Every finding on record at Avenue at Brooklyn

Based on medical record review, Self-Reported Incident (SRI) investigation review, video surveillance review, police report review, Ohio Board of Nursing complaint information, interviews, and facility policy review, the facility failed to implement adequate interventions to prevent a fall, prevent accident hazards to prevent injury, conduct a safe resident transfer to prevent injury, provide appropriate assessment and care after a fall, and complete timely and accurate fall assessments, investigations and care plans. This affected five residents (Residents #6, #24, #56, #113 and #115) of seven residents reviewed for accidents. The facility census was 95.Actual harm occurred on 06/03/26 when Resident #56 who was cognitively impaired and dependent on staff for activities of daily living (ADLs), was observed to have bruising and a chest hematoma (pooling of blood that forms outside of broken blood vessels in the skin, soft tissue or organs). By 06/06/26 the hematoma worsened, and the resident had redness and edema to the right hand with increased pain. Subsequently, Resident #56 was admitted to the hospital and diagnosed with multiple right and left side rib fractures, a hematoma to the right chest wall, bruising to the chest across the breasts and on the right-side flank, back, and multiple bruising to both arms, right and left side ribs, and both legs. Additional Actual Harm occurred on 07/02/26 when Resident #113 who received hospice care, had severe cognitive impairment, and required two-person assistance and a mechanical lift for transfers, was in bed without physician ordered fall interventions in place and fell out of bed onto a floor mat adjacent to the bed. Without assessing for injury, Licensed Practical Nurse (LPN) #930 lifted Resident #113 by placing one hand in the middle of Resident #113's back near her neck and the other hand behind her left knee and threw her onto the bed. LPN #930 then exited the room and left the resident alone without providing any other assistance. Resident #113 developed a swollen right arm and hand and was hospitalized from [DATE] until 07/11/26 with a thoracic burst fracture (a severe spinal injury where a middle-back vertebra shatters under heavy vertical force, sending bone fragments into the spinal canal), and multiple ecchymoses (bruising) on bilateral hands, wrists, forearms and upper extremities.Findings include: 1. Review of the closed medical record for Resident #113 revealed an admission date of 02/06/26 and discharge date of 07/03/26 with diagnoses including unspecified dementia, anxiety disorder and spinal stenosis. Review of Resident #113's x-ray of the lumbosacral spine three-view dated 02/06/26 revealed no evidence of fracture or subluxation. Moderate to severe spondylotic changes were seen in the lumbar spine as described. Review of Resident #113's fall care plan dated 02/07/26 revealed the resident was at risk for falls with interventions dated 02/20/26 for bed bolsters (long, firm, cylindrical or wedge-shaped cushions used on beds for body positioning and support), an intervention dated 02/07/26 for the bed in the lowest position when occupied, and an intervention dated 02/07/26 for call light within reach. Review of Resident #113's physician orders revealed an order dated 02/13/26 for bilateral half side rails to bed for mobility and positioning; an order dated 02/17/26 for a perimeter mattress to properly identify bed borders and for comfort every shift; an order dated 02/17/26 for floor mats to exit side of bed; an order dated 02/20/26 to admit to hospice services with a diagnosis of protein malnutrition; an order dated 02/20/26 for bed bolsters every shift; an order dated 02/23/26 for two staff to assist at all times every shift; an order dated 06/19/26 for a mechanical lift with two staff assistance for all transfers; and an order dated 07/20/26 to admit to the secured unit. Review of Resident #113's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment and was dependent to roll left and right. Review of Resident #113's fall risk assessment dated [DATE] revealed the resident was at risk for falls. Review of Resident #113's medication administration records (MARS) and treatment administration records (TARS) from 06/01/26 to 07/03/26 revealed documentation the fall interventions including bilateral half side rails, perimeter mattress, and bed bolsters were in place. Review of video surveillance dated 07/02/26 at 9:57 A.M. provided by Resident #113's daughter revealed the resident was on the floor with her head facing the bottom of the bed and her feet towards the top of the bed. The resident was on a floor mat. The nurse (LPN #930) was observed picking the resident up from the floor under her right shoulder and under the left knee. He then threw the resident in bed with her head towards the foot of the bed and her legs towards the top of the bed. Resident #113 was slightly sideways in bed and had no gown on. The video surveillance confirmed the resident did not have a perimeter mattress, bed bolsters, or bilateral half side rails in place per physician's orders. The resident did have a floor mat to the exit side of the bed. Twelve seconds into the video surveillance, the nurse was observed walking out of the room and leaving the resident alone. The video surveillance did not reveal evidence that the nurse had assessed the resident after the fall and prior to transferring her and did not assist in putting Resident #113's gown back on. Review of Resident #113's Self-Reported Incident (SRI) investigation for physical abuse dated 07/02/26 revealed on 07/02/26, Resident #113's daughter and hospice nurse reported to the Administrator about the nurse's (LPN #930) technique used for Resident #113's transfer to bed. The nurse in question was immediately pulled from the floor and suspended pending an investigation. A skin assessment was performed on the resident with no apparent injuries noted. Statements were gathered and interviews conducted. The SRI was unsubstantiated. Review of Resident #113's Un-Witnessed Fall investigation dated 07/02/26 at 11:00 A.M. revealed the resident was found on the floor mat next to her bed by the charge nurse. No injuries or pain were noted during the assessment. The power-of-attorney (POA) and physician were notified. The resident was transferred back into bed. The resident was unable to give a description of the incident. Injuries reported post fall include hematomas to the right elbow and right forearm. Review of Resident #113's progress note dated 07/02/26 at 12:55 P.M. authored by LPN #930 revealed the resident rolled onto the floor mat off her bed and was found by the nurse and assisted back in bed with one assist. The nurse practitioner, Director of Nursing (DON) and power-of-attorney were made aware. No injuries were found. Review of Resident #113's police report dated 07/02/26 at 2:27 P.M. revealed the police were dispatched on an abuse complaint. Upon arrival, the police spoke with the facility Administrator who stated on 07/02/26, he received an abuse complaint about Resident #113. The Administrator stated Resident #113 was a resident in the memory care unit and that she was in the late stages of dementia. The Administrator received the complaint from the resident's daughter. The daughter had a motion activated camera in Resident #113's room and provided the Administrator with footage that showed a nurse throwing the resident in bed. The Administrator provided the police with a copy of the footage. The Administrator further stated he reported the incident to the health department and was provided with an intake number of #276364. On 07/02/26 at approximately 9:57 A.M., Resident #113 fell out of bed. The nurse that responded to help her was LPN #930. LPN #930 placed his right hand on the middle of Resident #113's back near her neck and his left hand behind her left knee. He then picked her up and threw her on the bed. Resident #113's feet were near the headboard and her head near the end of the bed. LPN #930 then left the room. Resident #113 was wearing what appeared to be a hospital gown that fell off the resident. LPN #930 then left the room without attempting to put the resident's gown back on. On 07/02/26 at approximately 3:50 P.M., LPN #930 responded to the police station. He stated that he had no intent to harm Resident #113. He stated that after he left the room, he went to get another aide to help rearrange the resident. He further stated that he did not follow some of the protocols that were in place and was fired from the facility. The police advised him that the investigation was not complete and the police were to contact him if further information was needed. The officer attempted to gather further information from Resident #113 regarding the incident, and she did not recall this incident due to her dementia. On 07/03/26 at approximately 12:51 P.M., the officers spoke to Resident #113's power-of-attorney who wanted an update and to provide the police with video footage of the incident. At approximately 1:50 P.M. the officer called the daughter and asked if the resident had any injuries. The daughter stated that a private ambulance was going to transport the resident to the hospital to assess for injuries. The daughter reviewed the footage and told the officer that the resident was thrown into bed at 9:57 A.M. and at 10:00 A.M., a different aide came in and correctly rearranged the resident in bed. On 07/15/26, the officer received discharge paperwork from the daughter. The paperwork showed Resident #113 was admitted to the hospital on [DATE] and that she was discharged on 07/11/26. The injuries listed on the discharge paperwork was a closed stable burst fracture of the seventh thoracic vertebrae. On 07/15/26, a follow-up with the daughter revealed the doctor said a vertebra in the resident's neck was also injured. Review of Resident #113's progress note authored by the DON as a late entry on 07/02/26 at 2:52 P.M. revealed the resident's range of motion (ROM) was assessed. No issues or concerns were noted. Resident #113 was able to move extremities without pain or discomfort. Review of Resident #113's progress note dated 07/03/26 at 1:41 P.M. authored by LPN #716 revealed Resident #113's daughter came in along with the grandson. The resident's right arm and hand were swelled. The Certified Nursing Assistant (CNA) (unnamed) reported that the resident's Tubigrip (elasticated tubular support bandage) was pulled up on her arm, and the arm was swollen up. The Tubigrip was removed. The family requested the resident to be transferred to the emergency room (ER). Hospice was notified and transport was called. The Certified Nurse Practitioner (CNP) (unnamed) was also called. The resident was transferred to the hospital and did not return to the facility. Review of the Ohio Board of Nursing Complaint Information form dated 07/06/26 at 11:39 A.M. revealed LPN #930 was quite rough when picking up a resident who had fallen and putting her back to bed. Telephone interview on 07/22/26 at 8:59 A.M. with LPN #930 revealed he thought Resident #113 was a one person assist for transfers and he had observed the resident fall on the fall mat, so he picked her up and put her back in bed. He denied that he intentionally abused her and just thought she was a one person assist. He denied seeing the video surveillance of the incident on 07/02/26. LPN #930 stated he recalled walking by the resident's room and saw her roll off the bed with the bed in low position, then she turned and rolled into the bed. When he could not find an aide to help, he thought she was one assist and believed she rolled onto the mat which would not be classified as a fall, so he decided to cradle transfer her. He picked her up and she ended up sideways on the bed and admitted that he should have gotten her up but went out of the room and told an aide coming down the hall that he found her and transferred her back to bed and for the aide to get her up and dressed. LPN #930 confirmed in hindsight he should have obtained staff assistance and confirmed an assessment was not completed following the resident's fall. He denied being aware of the resident having spinal fractures and stated that the facility contacted him about two hours after he left the facility and terminated him for not following policy and procedure by getting another staff member to help transfer her. LPN #930 stated it was not his intention to pick up Resident #113 and put her in bed like a sack of potatoes and realized replaying it back in his mind that he did not have the control he wanted to have. Interview on 07/22/26 at 9:55 A.M. with Regional Registered Nurse (RRN) #935 confirmed Resident #113 was ordered a perimeter mattress, bed bolsters, and bilateral grab bars for the bed which were not implemented as seen on the video surveillance provided by the family members of Resident #113. Interview on 07/22/26 at 11:08 A.M. with DON revealed Resident #113's family came in from 12:00 P.M. to 12:30 P.M. and stated she took resident into the shower room on 07/02/26 around 1:30 P.M. to 2:30 P.M. to assess Resident #113 and no injuries were noted at that time. The DON confirmed the video surveillance showed the resident on the floor on her right arm on the floor mat, and she was not sure whether the fall caused the pain to the resident's right arm status post fall. Telephone interview on 07/22/26 at 2:38 P.M. with CNP #931 revealed he reviewed Resident #113's hospital paperwork and the resident had a T7 (seventh thoracic bone) burst fracture which could have been from the fall or from prior falls. NP #931 confirmed the paperwork said acute or subacute fracture with brittle bones. NP #931 confirmed the resident had multiple ecchymotic areas on the bilateral hands, wrists, forearms and upper extremities with mixed levels of bruising. Telephone interview on 07/28/26 at 8:39 A.M. with Administrator verified LPN #930 had 100 percent inappropriately transferred Resident #113, and that there were so many things wrong with what he did. He further stated that it was awful, and not the appropriate way of transferring someone back in bed, and it was clearly and obviously not done in a gentle or compassionate manner. Administrator stated that it was the reason why they terminated him and reported him to the state Board of Nursing and included the video surveillance. Review of the Fall Management policy revised October 2022 revealed the facility will identify each resident who was at risk for falls and will develop a plan of care and implement interventions to manage falls. The facility will provide an environment free from potential hazards. The licensed nurse will perform a Fall Risk Assessment immediately if the resident was deemed to be at risk for falls. 2. Review of the medical record for Resident #56 revealed she was admitted to the facility on [DATE], discharged to the hospital on [DATE] and then readmitted to the facility on [DATE]. Diagnoses included dementia, and transient cerebral ischemic attack. Review of the care plan dated 10/22/25 revealed Resident #56 had an activity of daily living (ADL) self-care performance deficit with interventions that included two staff assist for ADLs, and an addition on 12/03/25 for mechanical lift transfers with two staff assistance. Review of the physician orders dated 10/24/25 revealed Resident #56 required a mechanical lift with two staff assisting for transfers. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had short-term and long-term memory problems and was severely impaired regarding decisions of daily life. She had impaired upper and lower bilateral extremities and was dependent on staff for ADLs. Review of Resident #56's progress notes dated 05/16/26 through 06/01/26 revealed no progress notes were documented within that time frame. Review of the weekly skin check assessment dated [DATE] revealed Resident #56 had a new skin problem of a chest hematoma. Review of the progress note dated 06/03/26 at 5:33 P.M. revealed Resident #56 had bruising under her right breast, right nipple and in the middle of her chest. Resident #56 received a new order for a stat (immediate) x-ray of the chest for bruising. Review of the radiology report dated 06/03/26 revealed Resident #56 had a single view chest x-ray that revealed bruising of the chest, bilateral linear atelectasis (partial collapse of small areas in both lungs), and tortuous of the aorta (main artery of your body has abnormal twists, loops, or sharp curves instead of a straight path). Review of the progress note dated 06/04/26 at 6:10 A.M. revealed Resident #56's x-ray results were reported to the physician with no new orders. Review of the progress note dated 06/05/26 at 8:16 P.M. revealed Resident #56's bruising spread to her right upper extremities, shoulder and breast. Resident #56 displayed signs of pain and upon assessment, new edema was observed. Resident #56 received new orders to be sent to the hospital for further evaluation. Review of the progress note dated 06/05/26 at 8:29 P.M. revealed Resident #56's family was notified that she was being transported to the hospital for further evaluation. Review of the progress note dated 06/06/26 at 2:20 A.M. revealed Resident #56 was transported to the hospital. Review of the nursing resident transfer form dated 06/06/26 revealed Resident #56 was transferred to the hospital for worsened hematoma, redness, and edema to the right hand with increased pain. Review of the resident acute change in condition assessment dated [DATE] revealed Resident #56 had a change in condition. Resident #56's symptoms had worsened since it started on 06/03/26, but the assessment did not specify those symptoms. Review of the progress note dated 06/06/26 at 6:12 P.M. revealed Resident #56 was admitted to the hospital, but the hospital would not provide an admitting diagnosis at that time. Review of SRI #275412 dated 06/06/26, approximately three days after the first observed bruising revealed the facility initiated an incident of injury of unknown origin due to a growing hematoma on Resident #56's arm and a fracture identified after being sent to the hospital. On 06/06/26, Resident #56 was sent to the hospital due to a growing bruise on her chest. Resident #56's emergency room x-ray revealed multiple bilateral rib fractures with no report of any recent falls or incidents to explain the injuries. Reviews of the staff interviews revealed no explanation for injuries and staff were educated on mechanical lift transfers and transfers according to care plans. Review of the SRI revealed the facility unsubstantiated the allegation due to the evidence being inconclusive and reported the incident to the local police. A timeline of events related to Resident #56's injury of unknown origin revealed on 06/03/26, at approximately 5:00 P.M., Resident #56 had bruising under her right breast and mid chest and an x-ray was ordered. On 06/03/26, between approximately 8:00 P.M. to 8:15 P.M., an x-ray was completed with no new orders. On 06/05/26, at between approximately 8:00 P.M. to 8:30 P.M., Resident #56's bruising had spread to her right upper extremity, shoulder and breast so she was sent to the hospital emergency room for evaluation. On 06/06/26, Resident #56 was admitted to the hospital with fractured ribs, so an SRI was initiated, and audits and education were initiated. Review of the witness statement dated 06/07/26 by Licensed Practical Nurse (LPN) #718 revealed she last worked with Resident #56 on 06/03/26, and she was unaware of any bruising, but had learned during a report that Resident #56 had bruising and a chest x-ray. LPN #718 then observed the bruising on Resident #56's right side which expanded to her upper chest area. Review of the police incident report dated 06/08/26, five days after the first observed bruising, revealed at 7:54 A.M., the police received a call. A unit was dispatched to the facility at 3:58 P.M. for a report of personal injury. The facility reported Resident #56 sustained broken ribs while in the care of the facility and they were unsure of how the injuries occurred. There was no other information documented. Review of the hospital paperwork dated 06/08/26 revealed Resident #56 presented to the trauma intensive care unit (TICU) for multiple rib fractures and a large intramuscular hematoma. Resident #56 had multiple bilateral nondisplaced rib fractures including right third through fifth and left second, third, sixth and seventh ribs, possibly acute or subacute with concerns of neglect and/or abuse. Review of the hospital paperwork revealed Resident #56 bruising started 06/02/26, one day prior to what the facility documented, and had worsened over the next few days until she was seen in the emergency room on [DATE]. Review of the progress note dated 06/09/26 at 10:54 P.M. revealed Resident #56 was readmitted back to the facility at 10:20 P.M. Review of the nursing admission assessment dated [DATE] revealed Resident #56 was re-admitted back to the facility with multiple right and left side rib fractures, a hematoma to the right chest wall, bruising to the chest across the breasts and on the right-side flank, back, and right upper arm, and multiple bruising of both arms, right and left side ribs and both legs. Review of the witness statement dated 06/09/26 by LPN #607 revealed she noticed Resident #56 had edema to her right upper extremity toward her inner chest area and upper arm. Resident #56's physician was notified and she received new orders to be sent to the emergency room for evaluation. Review of the witness statement dated 06/09/26 by Certified Nursing Assistant (CNA) #900 revealed her last working with Resident #56 was on 06/03/26. CNA #900 noticed bruising later in her shift when she laid Resident #56 down and changed her clothes. CNA #900 was informed that the bruise had already been reported. Review of the witness statement dated 06/09/26 by LPN #806 revealed being informed of Resident #56's bruising on her right breast and nipple and middle chest during report. LPN #806 informed Resident #56's physician assistant who was present in the facility and a new order for a chest x-ray was given. LPN #806 revealed he informed Assistant Director of Nursing (ADON) #713. Review of the witness statement dated 06/10/26 by LPN #702 revealed her last working with Resident #56 was on 06/02/26 from 6:00 P.M. to 6:00 A.M. During her medication pass (time not specified), the two CNAs working (not specified) were putting Resident #56 to bed when they came out of the room asking LPN #702 to look at Resident #56's skin. LPN #702 observed bruising under Resident #56's right breast, around her right nipple, and in the center of her chest. LPN #702 reported it to the unit manager LPN #705. Review of the physician orders dated 07/01/26 revealed an order for a mechanical lift for all transfers. Interview on 07/22/26 at 1:45 P.M. with the unit manager, LPN #705 revealed Resident #56's bruising (the side of her breast and underneath her arms) was noticed about two days prior to being sent out to the hospital and denied noticing any fractures. LPN #705 revealed she reported it to the Director of Nursing (DON) the following morning because she was working nights at the time. Resident #56 received an x-ray the next morning with no findings. A few days later, the bruising had spread and she was sent to the hospital and admitted for fractures. LPN #705 revealed the facility did not initiate an investigation until after receiving the admitting diagnosis. LPN #705 revealed the facility reported Resident #56's injury of unknown origin on 06/06/26, approximately three days after the first sign of injury. LPN #705 confirmed and verified the above findings at the time of the interview. Interview attempts with LPN #607 (who worked Resident #56 around the time of the incident) on 07/23/26 at 9:30 A.M. and 4:30 P.M. were unsuccessful. Interview attempts with LPN #806 (who worked Resident #56 around the time of the incident) on 07/23/26 at 9:41 A.M. and 2:15 P.M. were unsuccessful. Interview on 07/23/26 at 12:18 P.M. with the Administrator revealed after investigating, the facility was unable to determine the cause of Resident #56's injuries. The Administrator revealed Resident #56 was unable to communicate what occurred and no one witnessed or knew of any incidents related to the injuries. Following the injury, the Administrator stated staff were educated and audits performed of mechanical lift techniques. The Administrator revealed he did not report the incident to the survey agency until 06/06/26 and to the police until 06/08/26. There was no immediate reporting of Resident #56's injuries, and no investigation was started until after she was admitted to the hospital. The Administrator confirmed and verified the above findings at the time of the interview. Interview attempts with CNA #900 (who worked Resident #56 around the time of the incident) on 07/27/26 at 10:30 A.M. and 1:00 P.M. were unsuccessful. Interview attempts with CNA #702 (who worked Resident #56 around the time of the incident) on 07/27/26 at 10:32 A.M. and 1:05 P.M. were unsuccessful. 3. Review of Resident #115's medical record revealed the resident was admitted on [DATE] with diagnoses including vascular dementia with severe behavioral disturbance, cerebral infarction and chronic obstructive pulmonary disease. Review of Resident #115's fall care plan revealed the resident was at risk for falls related to impaired decision making, impaired safety awareness and history of falls. Review of Resident #115's interventions include an intervention dated 11/18/25 for anti-rollbacks to the wheelchair; an intervention dated 11/18/25 for anti-tippers to the wheelchair; an intervention dated 12/19/25 to bring the resident to the common area while awake and an intervention dated 11/11/24 to have call light within reach and encourage the resident to use it. Review of Resident #115's Significant Change MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment, the resident used a walker and required supervision walking ten feet. Review of Resident #115's Weekly Skin Check dated 11/12/25 revealed the resident did not have skin problems. Review of Resident #115's progress note dated 11/13/25 at 12:39 P.M. authored by LPN #710 revealed the resident got up for lunch and the nurse observed the resident standing at the door. A bruise was noted under the resident's right eye, and the resident was unable to tell the nurse what happened to her face. The Assistant Director of Nursing (ADON) and son were notified. Review of Resident #115's progress note dated 11/13/25 at 12:56 P.M. revealed the son reported the resident had said she fell on [DATE] but she did not remember how she fell. The son confirmed no staff had called him and staff usually called for falls. Review of Resident #115's progress note dated 11/13/25 at 2:01 P.M. revealed the resident fell within the last two hours with a time unknown. The CNP was notified and wanted the resident sent to the emergency department (ED). Family were made aware. Review of Resident #115's progress note dated 11/13/25 at 2:27 P.M. revealed the resident got up for lunch and the resident was standing at the doorway. A bruise was noted under the resident's eye, and the resident was unable to report what happened. The ADON and son were notified. Review of Resident #115's progress note authored by the DON dated 11/13/25 at 9:28 P.M. revealed the clarification note stated the resident had fallen the night before and told the staff that she did not tell anyone. The resident was in the doorway without an assistive device and unsteady. The CNP was notified of the unwitnessed fall, and the resident was sent to the emergency room. Review of Resident #115's progress note authored by LPN #605 dated 11/13/25 at 11:11 P.M. revealed the resident was transported to the hospital. A right eye bruise was noted and no complaints of pain. Review of Resident #115's Fall Risk assessment dated [DATE] revealed the resident was at risk for falls. Interview on 07/23/26 at 12:37 P.M. with RRN #935 confirmed the resident record showed a large black eye on the right eye. Interview on 07/27/26 at 3:00 P.M. with the Administrator confirmed Resident #115's unwitnessed fall did not have an adequate investigation to determine what caused the fall with injury, what interventions were in place prior to the fall and what new interventions were implemented following the fall. The investigation also did not contain staff statements to determine the events that led to the fall. Review of the Fall Management policy revised October 2022 revealed the facility will identify each resident who was at risk for falls and will develop a plan of care and implement interventions to manage falls. The facility will provide an environment free from potential hazards. The licensed nurse will perform a Fall Risk Assessment immediately if the resident was deemed to be at risk for falls. 4. Review of the medical record for Resident #6 revealed an admission date of 07/11/25. Diagnoses included but were not limited to stage IV chronic kidney disease, atrioventricular block, type II diabetes mellitus, unspecified protein-calorie malnutrition, acquired absence of left great toe, partial traumatic amputation of left great toe, displaced fracture of proximal phalanx of left great toe, and osteoarthritis. Review of the 01/16/26 Quarterly MDS 3.0 assessment for Resident #6 revealed a moderate to severe cognitive impairment and was noted to be dependent on rolling left and right and ADLs. Review of the physician orders for Resident #6 revealed a 10/30/25 order to turn and reposition with care round and as needed. No additional orders were noted related to fall interventions prior to the 01/21/26 fall. Review of the 10/29/25 admission assessment for Resident #6 revealed his last fall was indicated as 10/19/25 and no fall risk score was noted. No evidence of a fall risk assessment was found prior to 01/21/26. Review of 07/22/26 care plan for Resident #6 revealed the fall care plan was initiated on 08/06/25 and indicated resident was at risk for falls related to impaired mobility and weakness. Interventions listed were call light within reach, encouraging resident to use call light, encouraging non-skid footwear when out of bed to minimum slipping as tolerated, following facility fall protocol, and therapy to evaluate and treat as ordered or as needed. Review of the nursing progress note dated 01/21/26 timed at 5:51 A.M. for Resident #6 revealed (unspecified) CNA called nurse to resident room, and she had found resident on the floor between his bed and the window. Resident #6 was lying face down parallel between the bed and the window, and his right leg was straight, and his left leg was bent at the knee under the right leg. Resident #6's bed was noted to b

Based on record review, interview, and facility policy review, the facility failed to ensure effective administration staff. This affected 30 residents (Residents #6, #9, #12, #13, #16, #24, #25, #29, #30, #32, #39, #40, #45, #49, #56, #61, #72, #80, #82, #83, #86, #88, #93, #96, #99, #106, #110, #113, #115 and #117) and had the potential to affect all residents residing in the facility. The facility census was 95.Findings include:During review of the annual and complaint survey, the following concerns were identified which resulted from ineffective administration including:The facility failed to implement an effective system to prevent injuries from falls and accident hazards which included following fall interventions and facility smoking policy, and completing accurate fall assessments, investigations and care plans which affected Residents #6, #9, #24, #56, #113 and #115. Actual harm occurred to Resident #56 who sustained multiple right and left side rib fractures, a hematoma to the right chest wall, bruising to the chest across the breasts and on the right-side flank, back, and multiple bruising to both arms, right and left side ribs, and both legs with no actual determination as to the cause of injuries. Additional actual harm occurred to Resident #113 when after falling out of bed staff inappropriately transferred her and she was thrown onto the bed. The resident sustained a thoracic burst fracture (a severe spinal injury where a middle-back vertebra shatters under heavy vertical force, sending bone fragments into the spinal canal), and multiple ecchymoses (bruising) on bilateral hands, wrists, forearms and upper extremities. Residents #6, #9, #24 and #115 had falls with inadequate investigations to implement corrective measures, incomplete documentation and updated care plans, and inaccurate assessments. The facility failed to implement effective dietary services to ensure substantial snacks for the secured memory care unit, the honoring of food preferences, and providing necessary adaptive equipment which affected Residents #29, #49, #80, #83, #86, #96 and #99. Residents #49, #96 and #99 did not receive substantial nutritional evening snacks when mealtimes were greater than 14 hours. Resident #83 was served food listed as an allergy, and Residents #29, #80 and #86 did not receive adaptive equipment during meal service.The facility failed to implement effective nursing services to ensure adequate and appropriate staffing by not having registered nurse (RN) coverage at least eight hours daily and not providing sufficient staffing to meet resident needs which resulted in inadequate and untimely provision of activities of daily living care or assistance affecting Residents #6, #12, #13, #16, #39, #40, #45, #88, #93, #99 and #110. Nursing staff did not implement care planned interventions for Resident #45, follow discharge instructions and provide timely incontinence care for Resident #13, ensure transport to dialysis treatment for Resident #106, accurately and consistently document advance directives in the medical record for Resident #93, accurately transcribe a physician order to prevent a significant medication error for Resident #88, and refrain from falsifying bathing documentation for Resident #88. The facility failed to implement an effective immunization program to ensure residents or resident representatives received education regarding the benefits and potential side effects of the COVID-19, influenza and pneumococcal vaccinations affecting Residents #9, #24, #32 and #72.The facility failed to implement an effective program for abuse, neglect, misappropriation and exploitation by ensuring Resident #93 was free from staff-to-resident verbal abuse, Resident #61 was free from misappropriated resident funds, Resident #117 was free from misappropriated personal property, Residents #25 and #30 were free from unnecessary medications, and timely abuse reporting and investigations for Residents #56, #82, #93 and #117.Review of the undated Administrator job description revealed the primary purpose of the job position was to direct the overall operation of the facilities activities in accordance with current applicable Federal, State and local standards, guidelines and regulations and to assure that the highest degree of quality resident care was maintained at all times. Major duties and responsibilities included but were not limited to help to establish and direct the implementation of written policies and procedures that reflect the goals and objectives of the facility. Review of the Director of Nursing (DON) job description signed on 09/12/24 revealed the purpose of the position was to provide complete supervision and management of the nursing department through the implementation of policies and procedures and adherence to quality standards. Review of the Assistant Director of Nursing (ADON) job description signed on 11/03/25 revealed the ADON supports the DON in supervising and managing the nursing department to ensure high-quality resident care. This position helps implement policies and procedures, maintains compliance with federal and state regulations and ensure staffing levels meet resident needs. Interview on 07/28/26 at 1:46 P.M. with Administrator confirmed during the quality assurance (QA) meetings, the department heads meet every other month with the Medical Director, and the ancillary services send reports quarterly. Administrator confirmed the facility had concerns with the above findings.Review of facility policy for the Quality Assurance Performance Improvement (QAPI) Guidelines dated 03/2024 revealed a process that allowed for continuous identification of opportunities for enhancement and improvement by addressing gaps in the systems through planned interventions to improve overall quality of patient care and facility services. This deficiency represents non-compliance investigated under Complaint Number 1405090 (OH00167146).

Based on the nursing staffing schedule, staff time punches and staff interview, the facility failed to maintain the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. This had the potential to affect all 95 residents residing in the facility.Findings include: Review of the nursing staff schedule and staff time punches for 06/06/26 revealed there was no RN present working in the facility.Interview on 07/28/26 at 10:18 A.M. with Administrator confirmed he was unable to provide evidence that an RN was working for at least eight consecutive hours on 06/06/26.This deficiency represents non-compliance investigated under Complaint Numbers 2735166, 2715490 and 1405090 (OH00167146).

Based on observations, resident and staff interviews, record reviews of nursing staff schedules, timecards, facility assessment and Payroll Based Journal, the facility failed to maintain sufficient staffing levels to ensure residents received timely care and services. This affected eight residents (Resident #6, #12, #13, #16, #39, #40, #93 and #99) and had the potential to affect all 95 residents residing in the facility. Findings include: 1. Review of the Payroll Based Journal report revealed the facility had a one-star staffing rating and was identified with low weekend staffing for the second fiscal year quarter from 01/01/26 through 03/31/26. Interviews with residents during the survey revealed they had concerns with staffing. Residents stated they had to wait too long for their call lights to be answered and receive timely assistance with incontinence care and activities of daily living (ADLs). The interviews included the following: Interview on 07/20/26 at 9:14 A.M. with Resident #16 revealed call lights were not always answered timely. Interview on 07/20/26 at 9:49 A.M. with Resident #40 revealed there was not enough staff for her mechanical lift transfer and frequently had to wait to get up due to lack of staff to assist her. Interview on 07/20/26 at 10:23 A.M. with Resident #39 revealed on first shift and weekends there were not enough staff, and staff were not always timely with care. Interview on 07/20/26 at 10:41 A.M. with Resident #12 revealed the facility was short-staffed for aides on all shifts and call lights took at least an hour and a half for staff to answer. Interview on 07/20/26 at 11:01 A.M. with Resident #99's daughter revealed she had staffing concerns related to care not being provided timely. Interview on 07/20/26 at 2:30 P.M. with Resident #6 revealed that it took a long time for care to be given. Resident #6 stated staff say they will come back and they do not come back for a long time, sometimes several hours. Resident #6 also stated that night shift was really bad and took a long time and stated that the Director of Nursing stated they would get help but does not provide help. Interview on 07/21/26 at 5:43 A.M. with Certified Nursing Aide (CNA) #912 stated there was not enough staff scheduled for nights. There were typically four to five aides and five nurses, so they were not always able to finish assigned showers and tasks. Interview on 07/21/26 at 6:02 A.M. with CNA #625 stated there was not usually enough staff and did not feel the facility always tried to cover call offs. CNA #625 also stated being not always able to complete showers due to staffing. CNA #625 tried to do checks and changes but was not always able to complete them every two hours if there was only three CNAs and not able to complete timely mechanical lift transfers with only three aides due to waiting for another aide to assist with the transfer. Interview on 07/21/26 at 6:31 A.M. with CNA #703 revealed there was not always enough staff scheduled and call-offs were not always covered. Interview on 07/23/26 at 6:43 A.M. with CNAs #631 and #807 stated when there were call-offs they were not always able to complete their two-hour checks and changes and not always able to complete all their scheduled showers, and management did not usually come in to assist staff. 2. Observation and interview on 07/22/26 at 7:37 A.M. revealed Resident #13 was lying in bed pointing to her brief. Resident #13 revealed she was wet and needed to be changed and cleaned up. Resident #13 stated she was last changed the night prior and it had been a long time. Observation and interview on 07/22/26 at 7:39 A.M. with Licensed Practical Nurse (LPN) #705 in Resident #13's room, revealed Resident #13 was lying in bed and informed LPN #705 she was wet, needed to be changed and had not been changed since the night before. LPN #705 checked Resident #13's brief and stated, she is wet. LPN #705 then was observed fastening Resident #13 brief back together, then pulled up her covers, washed her hands and exited the room. LPN #705 stated I'll be back. LPN #705 was then observed standing next to a medication cart watching a current medication pass by an alternate surveyor. LPN #705 was not the designated staff member for the medication pass and left Resident #13 unchanged. LPN #705 confirmed and verified she did not check and change Resident #13 at the time of the interview. 3. Observation and interview on 07/22/26 at 9:42 A.M. of Unit Manager (UM)/LPN #705 revealed she was gathering supplies to provide Resident #16's incontinence care. UM/LPN #705 gathered the supplies she needed and proceeded to Resident #16's room to provide his incontinence care. Resident #16 told UM/LPN #705 he had been waiting a long time to have his incontinence brief changed. Resident #16 stated he told other staff he needed changed, including UM/LPN #705 and he did not know why they did not come back to provide his care. Resident #16 indicated he frequently waited a long time to be changed, and he asked UM/LPN #705 to change him before he ate because he did not like to eat when his incontinence brief was soiled. UM/LPN #705 verified that it was true, but the staff were instructed not to change residents' soiled incontinence briefs when they had food in the room because it was an infection control issue and Resident #16's meal tray was in the room when he asked to be changed. Resident #16's incontinence brief was saturated with urine. Resident #16 stated he wanted changed before he ate and told staff about it, but no one came into his room to provide his care before the meal came. He said he waited about two to three hours before he was changed. Interview on 07/22/26 at 10:26 A.M. with CNA #900 and #717 revealed there were just two of them assigned to the nursing unit Resident #16 resided on and it was not enough to meet the care needs of the residents. CNA #900 indicated some residents required two staff assistance and call lights were going off at the same time they were providing care for those residents and it made it hard for them to get to everyone in a timely matter. Interview on 07/22/26 at 10:47 A.M. of CNA #717 revealed she had just found out about a half hour prior that her assignment changed and she now had resident rooms 119 through 129 and 135 through 145. CNA #717 indicated she was not told she had the residents in rooms 135 through 145, so she had not made rounds or changed incontinence briefs for those residents including Resident #16 because she did not know she had them. CNA #717 stated communication was not always good when there was not enough staff, and it was stressful when there weren't enough aides. CNA #717 indicated she did not feel she could take breaks including a lunch break when there wasn't enough staff because she wanted to make sure the residents were taken care of. CNA #717 revealed she did not have enough time to sit with residents and listen to them. CNA #717 stated about half the time there was not enough staff to care for the residents. 4. Interview on 07/22/26 at 2:36 P.M. of Occupational Therapy Assistant (OTA) #944 revealed she just spoke with Resident #93, he was not feeling well enough for therapy today and he had his call light on to have his aide clean him up. Observation on 07/22/26 at 2:42 P.M. revealed Resident #93's light above the door to his room was blinking, indicating his call light was activated. Observation on 07/22/26 at 2:45 P.M. revealed Assistant Director of Nursing (ADON) #713 answered Resident #93's call light and walked out of the room without doing anything and left the call light blinking. Observation on 07/22/26 at 2:47 P.M. revealed Certified Nursing Assistant (CNA) #629 walked into Resident #93's room to answer his call light. Resident #93 indicated he was waiting an hour to an hour and a half to have his incontinence brief changed. Resident #93 revealed the staff came to his room to answer his call light and said they would come back if no one changed him, but no one came back. Resident #93 indicated the aides were busy and unable to change him when they answered his call light. CNA #629 provided incontinence care and observation of Resident #93's buttocks, upper thighs and hips revealed multiple healed open areas. Resident #93 indicated one of the healed areas by his left lower buttock still hurt and he could not sit very long because of it. Resident #93's incontinence brief was very wet with urine. Interview on 07/22/26 at 3:15 P.M. with CNA #629 revealed Resident #93's call light was activated and she answered it. CNA #629 indicated she was giving another resident a shower and was unable to change Resident #93's incontinence brief when she answered his call light but told him to activate his call light in 15 minutes if no one came in to change him. CNA #629 indicated about 25 minutes later when she was finished with the shower Resident #93's call light was on and that is when she went to his room to change him. CNA #629 revealed Resident #93 did not tell her how long his call light was on when she first answered it. 5. Review of the facility assessment dated [DATE] showed the assessment did not identify specific staffing numbers required per unit. During an interview on 07/28/26 at 9:48 A.M., the Administrator confirmed the facility assessment reflected only the minimum staffing levels and was based on patient per day (PPD) calculations. He stated CNA numbers were based on census, and the facility aimed to operate at a PPD of 3.0 (the amount of care time per resident in a 24 hour period). During an interview on 07/28/26 at 9:35 A.M., Unit Manager #827 stated staffing levels were dependent on census. She explained that assignment sheets generally showed between four and eight CNAs scheduled, and she assigned CNAs to their units when they arrived for their shift. She stated the facility tried to schedule five to six CNAs per day shift. The memory care unit was consistently staffed with one nurse and two aides per shift. Review of the daily assignment sheet for day shift on 07/22/26 showed: CNA #913 (Assignment 1) was responsible for rooms 101–118 and 130–134, totaling 18 residents. CNA #717 (Assignment 2) was responsible for rooms 119–129 and 135–145, totaling 19 residents. CNA #911 (Assignment 3) was responsible for rooms 146–148 and 200–219, totaling 20 residents. CNA #900 (Assignment 4) was responsible for rooms 149–170, totaling 22 residents. Review of the assignment sheets and timecards confirmed CNA #911 was responsible for 20 residents on 07/22/26, and CNA #717 was responsible for 19 residents. Additional review showed CNA #909 arrived at 2:48 P.M. on 07/22/26 to assist when the census was 79 residents. During an interview on 07/28/26 at 11:32 A.M., the Administrator confirmed that the staffing records for 07/22/26 showed five aides scheduled on night shift and four aides scheduled on day shift. He stated these were the only dated assignment sheets he located. This deficiency represents non-compliance investigated under Complaint Numbers 2735166, 2715490 and 1405090 (OH00167146).

Based on record review, observation, staff interview, video surveillance review, police report review, and review of the facility's policies, the facility failed to implement care planned interventions and provide required assistance for multiple activities of daily living (ADL). Specifically, the facility failed to provide timely incontinence care for Residents #16, #45, #93, and #110; failed to ensure Resident #45's fingernails were trimmed appropriately; failed to ensure Resident #16's mattress remained properly positioned; failed to ensure Resident #110 received needed meal assistance; and failed to ensure scheduled showers were provided for Residents #45 and #88. This deficient practice affected five residents (#16, #45, #88, #93, and #110) out of seven residents reviewed for ADL. The facility census was 95.Findings include: 1. Review of Resident #45's medical record revealed an admission date of 06/17/26 with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebellar artery, unspecified protein-calorie malnutrition, and adult failure to thrive. Review of Resident #45's care plan dated 06/18/26 included Resident #45 had an alteration in elimination of bowel and bladder. Resident #45 would continue to remain clean, dry, and free of odors on a daily basis through the review date of 09/28/26. Interventions included assisting with toileting needs throughout the day; checking and changing as required for incontinence, washing, rinsing and drying perineum, changing clothing as needed after incontinence episodes, and providing incontinence care with care rounds. Review of Resident #45's care plan dated 06/18/26 included Resident #45 had an ADL self-care performance deficit related to diagnoses. Staff assisted with completion of Resident #45's needs throughout the day. Resident #45 would continue to have needs met daily; remaining clean, dry, dressed, groomed and free of odors through the review date of 09/28/26. Interventions included checking fingernail length and trimming and cleaning on bath days and as necessary. Review of Resident #45's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] included Resident #45 had severe cognitive impairment. Resident #45 required substantial to maximal assistance with toileting hygiene, bathing, upper and lower body dressing and personal hygiene. Resident #45 was occasionally incontinent of urine and bowel. Resident #45 did not reject care during the seven-day assessment look-back period. Observation on 07/20/26 at 9:24 A.M. of Resident #45 revealed there was a large area of dried urine on his sheet and a large area of dried urine on his bedspread. Resident #45 was unable to verbalize when he was last changed. Observation revealed a large puddle of what appeared to be spilled water on the floor under Resident #45's bedside table, near the foot of his bed. A communication board was lying in the puddle of liquid on the floor. An interview on 07/20/26 at 9:24 A.M. of Unit Manager/Licensed Practical Nurse (UM/LPN) #705 confirmed Resident #45 had large, dried urine areas on his sheet and bedspread, and there was a large puddle of what appeared to be spilled water on the floor with a communication board lying in the middle of the puddle. UM/LPN #705 revealed it looked like the sheets and bedspread had not been changed in quite a while. UM/LPN #705 had housekeeping mop the floor to clean the spilled liquid. Observation on 07/20/26 at 9:36 A.M. of UM/LPN #705 revealed she gathered incontinence supplies to provide Resident #45's incontinence care and found UM/LPN #827 to assist her. UM/LPN's #705 and #827 proceeded to provide Resident #45's incontinence care and his sleep pants were wet with urine; the fitted sheet and regular sheet were wet with urine, and the sheets and bedspread had large areas of dried urine on them. Resident #45 had a moderate bowel movement of formed brown stool, and his incontinence brief was wet with urine. Further observation revealed Resident #45's fingernails on both hands were about a half inch long, yellow and had brownish-black colored material under the nails. UM/LPN #705 confirmed Resident #45's fingernails were long, dirty, needed cut, and the aides were supposed to cut the residents fingernails when they had showers. UM/LPN #705 indicated Resident #45 did not talk but would nod his head or shake his head when asked questions. An interview on 07/20/26 at 10:19 A.M. of Certified Nursing Assistant (CNA) #801 revealed he was assigned to Resident #45 but had not changed his incontinence brief or provided care this morning. An interview on 07/22/26 at 8:13 A.M. with the Director of Nursing (DON) revealed shower sheets were completed and were used for logging showers. After the showers were completed ,the shower sheets were given to the Unit Managers. The DON indicated showers could be documented in the electronic record, but the paper shower sheets were what was used to ensure showers were completed. An interview on 07/23/26 at 2:40 P.M. with the DON confirmed not all showers were completed, and she did not have shower sheets for Resident #45 for 06/17/26 through 07/20/26. An interview on 07/27/26 at 9:36 A.M. of Regional Director of Clinical Operations (RDCO) #940 revealed shower sheets were expected to be filled out when residents had showers, and the facility was working on getting into compliance with the aide documentation in the electronic record. RDCO #940 indicated both were supposed to be completed, but it did not always happen. RDCO #940 revealed hair washing and clipping fingernails should be done by the aides as needed and per resident preference. 2. Review of Resident 16's medical record revealed an admission date of 11/29/23 with diagnoses including hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the right non-dominant side, HIV (human immunodeficiency virus), neuromuscular dysfunction of the bladder, and neurogenic bowel. Review of Resident #16's care plan revised 07/08/24 included Resident #16 was incontinent of bladder and bowel due to diagnoses. Staff assisted with completion of his toileting and incontinence care needs. Resident #16 would remain clean, dry, and free of odors through the review date. Interventions included checking and changing during care rounds and as required/needed for incontinence. Washing, rinsing, and drying perineum, applying an adult brief or pad with each incontinence episode and as needed, and changing clothing as needed after incontinence episodes. Review of Resident #16's Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #16 was cognitively intact. Resident #16 required supervision or touching assistance with eating, and substantial to maximal assistance with toileting hygiene, bathing, and personal hygiene. Resident #16 was frequently incontinent of urine and occasionally incontinent of bowel. Resident #16 did not reject care during the seven-day assessment look-back period. Review of Resident #16's nurse aide charting on 07/22/26 revealed his incontinence brief was changed at 5:20 A.M. There was no evidence Resident #16's incontinence brief was changed on 07/22/26 between 5:20 A.M. and 9:42 A.M. Observation on 07/22/26 at 8:43 A.M. revealed Resident #16's call light was activated, and UM/LPN #705 answered the call light. Resident #16 told UM/LPN #705 his incontinence brief needed changed. An interview on 07/22/26 at 8:43 A.M. with UM/LPN #705 indicated Resident #16 said he needed changed, and she told him when he was done eating, he would have his incontinence brief changed. UM/LPN #705 indicated she told Certified Nursing Assistant (CNA) #629 to change Resident #16's incontinence brief when he finished eating. An interview on 07/22/26 at 9:19 A.M. of CNA #717 revealed her resident assignment included rooms 119 through 134 (which did not include Resident #16's room), and she did not know who was assigned to Resident #16's room. CNA #717 indicated CNA #629 was in the dining room assisting residents with their breakfast meal. Observation on 07/22/26 at 9:38 A.M. revealed Resident #16's call light was activated, and it was answered by UM/LPN #705. Resident #16 said he needed changed. Resident #16 was lying in bed, and his pillow had fallen into an open area between the headboard and the mattress, and there was a gap of about 12 inches where the pillow was laying. Resident #16 kept pulling up on the pillow and fluffing it to make it high enough to be comfortable for his head to lay on. Resident #16 stated the mattress slid every day like this, and the mattress could be seen hanging over the foot of the bed by at least 12 inches. UM/LPN #705 indicated she would have maintenance fix the bed, so it did not do that anymore. Observation on 07/22/26 at 9:42 A.M. of UM/LPN #705 revealed she was gathering supplies to provide Resident #16's incontinence care. UM/LPN #705 gathered the supplies she needed and proceeded to Resident #16's room to provide his incontinence care. Resident #16 told UM/LPN #705 he had been waiting a long time to have his incontinence brief changed. Resident #16 stated he told other staff he needed to be changed, including UM/LPN #705, and he did not know why they did not come back to provide his care. Resident #16 indicated he frequently waited a long time to be changed, and he asked UM/LPN #705 to change him before he ate because he did not like to eat when his incontinence brief was soiled. UM/LPN #705 revealed that was true, but the staff were instructed not to change the residents soiled incontinence briefs when they had food in the room because it was an infection control issue, and Resident #16's meal tray was in the room when he asked to be changed. Resident #16's incontinence brief was saturated with urine. Resident #16 stated he wanted to be changed before he ate and told staff about it, but no one came in his room to provide his care before the meal came. He said he waited about two to three hours before he was changed. An interview on 07/22/26 at10:26 A.M. with CNAs #900 and #717 revealed there were just two of them assigned to the nursing unit Resident #16 resided on, and it was not enough to meet the care needs of the residents. CNA #900 indicated some residents required two-staff assistance, and call lights were going off at the same time they were providing care for those residents, and it made it hard for them to get to everyone in a timely matter. An interview on 07/22/26 at 10:47 A.M. of CNA #717 revealed she just found out a half an hour ago that her assignment changed, and she now had resident rooms 119 through 129 and 135 through 145 (this included resident #16's room). CNA #717 indicated she was not told she had the residents in rooms 135 through 145 until a half an hour ago, and she had not made rounds or changed incontinence briefs for those residents, including Resident #16, because she did not know she had them on her assignment. CNA #717 stated communication was not always good when there were not enough staff, and it was stressful when there weren't enough aides. CNA #717 indicated she did not feel she could take breaks including a lunch break when there wasn't enough staff because she wanted to make sure the residents were taken care of. CNA #717 revealed she did not have enough time to sit with residents and listen to them. CNA #717 stated there was not enough staff to care for the residents about half of the time. An interview on 07/28/26 at 8:32 A.M. with Resident #16 confirmed no one had been in to fix the gap between his mattress and the headboard since he reported it last week. An interview on 07/28/26 at 8:37 A.M. with Maintenance Director #707 confirmed no one had informed him of the repair needed for Resident #16's bed until the surveyor pointed it out to him. He stated the bed bolsters need to be moved up closer to the head of the bed to keep it from sliding. He stated a work order was not created, and he had not been made aware of it prior to this morning. An interview on 07/28/26 at 10:56 A.M. of RDCO #940 revealed there was no written policy stating residents were not to have soiled incontinence briefs changed during mealtimes. RDCO #940 indicated the facility did not want the resident's food sitting in the room not attended to, but the residents could have their soiled incontinence briefs changed around mealtimes. RDCO #940 indicated there was no infection control issue preventing residents from having their incontinence briefs changed around mealtimes. 3. Review of Resident #93's medical record revealed an admission date of 09/19/25 with diagnoses including acute and chronic respiratory failure with hypoxia and hypercapnia, heart failure, acquired absence of the right leg above the knee, and peripheral vascular disease. Review of Resident #93's care plan revised 04/21/26 included Resident #93 had an alteration in elimination related to incontinence of bowels. Staff assisted with completion of Resident #93's toileting and incontinence needs throughout the day. Resident #93 would continue to remain clean, dry, and free of odors through the review date of 09/07/26. Interventions included assisting with toileting needs throughout the day, disposable briefs, checking and changing as required for incontinence, washing, rinsing, and drying perineum, and changing clothing as needed after incontinence episodes. Review of Resident #93's Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #93 was cognitively intact. Resident #93 had upper and lower extremity impairment on both sides. Resident #93 used a wheelchair and was dependent on staff for toileting hygiene, bathing, dressing and personal hygiene. Resident #93 was always incontinent of urine and bowel. Resident #93 did not reject care during the seven-day assessment look-back period. An interview on 07/21/2026 at 10:36 A.M. with Resident #93 revealed the physician told him his skin was fragile and to make sure he was changed as soon as had a bowel movement or urinated. An interview on 07/22/26 at 2:36 P.M. of Occupational Therapy Assistant (OTA) #944 revealed she just spoke with Resident #93, he was not feeling well enough for therapy today, and he had his call light on to have his aide clean him up. Observation on 07/22/26 at 2:42 P.M. revealed Resident #93's light above the door to his room was blinking, indicating his call light was activated. Observation on 07/22/26 at 2:45 P.M. revealed Assistant Director of Nursing (ADON) #713 answered Resident #93's call light and walked out of the room without doing anything and left the call light blinking. Observation on 07/22/26 at 2:47 P.M. revealed CNA #629 walked into Resident #93's room to answer his call light. Resident #93 indicated he was waiting an hour to an hour and a half to have his incontinence brief changed. Resident #93 revealed the staff came to his room to answer his call light and said they would come back if no one changed him, but no one came back. Resident #93 indicated the aides were busy and unable to change him when they answered his call light. CNA #629 provided incontinence care. Observation of Resident #93's buttocks, upper thighs and hips revealed multiple healed sites from prior breakdown. Resident #93 indicated one of the healed areas by his left lower buttock still hurt, and he could not sit very long because of it. Resident #93's incontinence brief was very wet with urine. An interview on 07/22/26 at 3:15 P.M. with CNA #629 revealed Resident #93's call light was activated and she answered it. CNA #629 indicated she was giving another resident a shower and was unable to change Resident #93's incontinence brief when she answered his call light but told him to activate his call light in 15 minutes if no one came in to change him. CNA #629 indicated about 25 minutes later when she was finished with the shower, Resident #93's call light was on and that was when she went to his room to change him. CNA #629 revealed Resident #93 did not tell her how long his call light was on when she first answered it. 4. Review of the medical record for Resident #88 revealed an admission of 02/13/24 with diagnoses including Cerebral Palsy, morbid obesity, type II diabetes, paraplegia, and scoliosis. Review of the MDS 3.0 assessment dated [DATE] Resident #88 revealed a BIMS of 15/15 indicating intact cognition. Resident #88 was noted to require moderate assistance of staff with bathing. Review of the shower sheets provided by the facility for the past three months revealed out of 18 shower opportunities, shower sheets were only provided for 05/06/26, 05/19/26, 05/20/26, 06/13/26, 06/17/26, and 06/27/26 which revealed evidence of six out of 18 bathing opportunities. An interview on 07/23/26 at 2:40 P.M. with the DON confirmed not all shower sheets were completed as required for Resident #88. 5. Review of Resident #110's medical record revealed the resident was admitted on [DATE] with diagnoses including quadriplegia, diabetes and depression. Review of Resident #110's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition, was dependent on staff for eating, oral hygiene, toileting, bathing, and personal hygiene. Review of Resident #110's physician orders revealed an order dated 02/25/26 for regular diet, regular texture, thin liquids consistency. Review of Resident #110's video surveillance dated 02/27/26 at 3:24 P.M. provided by the resident's daughter revealed Registered Nurse (RN) #818 came into the room at 3:24 P.M. and asked the resident if he was hungry. The food was sitting on the overbed tray. Per the video surveillance, it was unable to be determined the resident's response to the question. The nurse picked up the lid of the meal tray, sat the lid back down and told Resident #110 that you don't want to eat that now fine, hang tight let me talk to them. The food tray was sitting on an overbed table away from the resident. The nurse walked out of the room. Review of Resident #110's video surveillance dated 02/27/26 at 7:13 P.M. revealed staff, who appeared to be the nighttime receptionist, came into the room with food and left it on the overbed table. The staff asked the resident if he wanted the nurse. The tray from 3:24 P.M. appeared to be sitting on the overbed table. Review of Resident #110's Police Incident/Offense Report form 20-26204735 revealed the allegation was received on 02/27/26 at 8:12 P.M., the police were dispatched on 02/27/26 at 8:14 P.M., and the police arrived at the facility on 02/27/26 at 8:22 P.M. The narrative revealed on 02/27/26 a report was taken at the facility for suspected adult neglect. A report was forwarded to Adult Protective Services. An email interview on 07/27/26 at 5:19 A.M. with Resident #110's daughter revealed the video surveillance camera was event based and would activate if anyone entered the resident's room. The daughter confirmed the nurse was in the room at 3:24 P.M. and then no one came back into the room until the nighttime receptionist brought food into the resident's room at 7:13 P.M. An interview on 07/27/26 at 7:02 A.M. with the Administrator confirmed RN #818 was the nurse in the video surveillance who went into Resident #110's room on 02/27/26 at 3:24 P.M. The Administrator stated he was not aware the police department was looking into this resident's care on 02/27/26. The Administrator stated he was aware the resident's daughter demanded to talk to the administrative staff on 02/27/26 although he said he was not aware of the police coming in for a welfare check on the resident based on a report of neglect. The Administrator confirmed he did not initiate a self-reported incident (SRI) for abuse per the daughter's report of neglect or the police report of not providing timely resident care and neglect. The Administrator confirmed the video surveillance showed the resident in bed with the meal tray on the table against the wall in both video surveillance clips, and no staff were assisting the resident with the meal. A telephone interview on 07/27/26 at 7:42 A.M. with RN #818 revealed he did not remember the specific incident on 02/27/26. A telephone interview on 07/27/26 at 3:55 P.M. with Officer #942 revealed he came into the facility on [DATE] based on an allegation of neglect for Resident #110. Officer #942 stated the resident was supposed to be fed lunch and dinner, and that never happened and confirmed he had reviewed the video surveillance supplied by the resident's daughter. Officer #942 revealed Resident #110 was hard to understand, but he was pretty sure the resident had reported to him that he had not been fed his meal. He could not remember if it was the lunch meal or the dinner meal. Officer #942 confirmed he spoke to RN Assistant Director of Nursing (ADON) #713 on the phone concerning Resident #110's allegation of neglect. Review of the facility policy called Bathing-Personal Care, revised 08/2022, revealed resident will receive personal care in the facility according to the resident's plan of care to promote dignity, cleanliness and general well-being. Under procedure; shower bath or tub will be offered to the resident twice a week, as needed and as often as the resident would like per choice. The resident's care plan will be updated to document the resident's bathing needs. Review of the facility policy titled Activities of Daily Living, dated 03/2023, included a resident who was unable to carry out ADL would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility policy titled Incontinence Care dated 12/2022 included the purpose was to ensure a resident who was incontinent of bowel and/or bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. This deficiency represents non-compliance investigated under Complaint Numbers 3021865, 2799196, 2742587, 2735166, 2656594, and 2582257.

Based on record review and interview, the facility failed to document education provided to residents or resident representatives regarding the benefits and potential side effects of the influenza and pneumococcal vaccines. This affected four residents (Residents #9, #24, #32 and #72) of five residents reviewed for immunizations. The facility census was 95.Findings include:1. Review of Resident #9's medical record revealed an admission date of 02/13/25. Diagnoses included paraplegia, protein-calorie malnutrition, and cervical spine injury.Review of Resident #9's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition.Review of Resident #9's immunization documentation in the Electronic Medical Record (EMR) revealed Resident #9 refused both the influenza and pneumococcal vaccinations.Further review of Resident #9's medical record revealed there was no documented evidence of education provided to Resident #9 or the resident's representative regarding the benefits and potential side effects to the vaccines.2. Review of Resident #24's medical record revealed an original admission date of 01/04/24 with a re-admission date after hospitalization on 04/23/26. Diagnoses included left side hemiplegia, cerebral infarction due to embolism of right carotid artery, diabetes, asthma, contracture of muscle left upper arm, repeated falls, paroxysmal atrial fibrillation, hypertension, chronic pain, disorder of kidney and ureter, obstructive sleep apnea, and neurogenic bladder.Review of Resident #24's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had slight impairment to her cognition.Review of Resident #24's immunization documentation in the EMR revealed the resident received an influenza vaccination on 09/11/25.Further review of Resident #24's medical record revealed there was no documented evidence of education provided to Resident #24 or the resident's representative regarding the benefits and potential side effects to the vaccine.3. Review of Resident #32's medical record revealed an admission date of 12/26/25. Diagnoses included Alzheimer's disease, protein-calorie malnutrition, type II diabetes, interstitial pulmonary disease, chronic bronchitis, dementia, cerebral ischemia, atherosclerosis, and legal blindness.Review of Resident #32'a Quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition.Review of Resident #32's immunization documentation in the EMR revealed the resident received the influenza vaccination on 10/10/25 and refused (undated) the pneumococcal vaccination.Further review of Resident #32's medical record revealed there was no documented evidence of education provided to Resident #32 or the resident's representative regarding the benefits and potential side effects to the vaccines.4. Review of Resident #72 medical record revealed an admission date of 01/02/26. Diagnoses included dementia, kidney disease stage III, non-traumatic subarachnoid hemorrhage, and visual loss.Review of Resident #72's Quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition.Review of Resident #72's immunization documentation in the EMR revealed the resident refused the influenza and pneumococcal vaccinations (undated).Further review of Resident #72's medical record revealed there was no documented evidence of education provided to Resident #72 or the resident's representative regarding the benefits and potential side effects to the vaccines.Interview on 07/28/26 at 1:45 P.M. with the Regional Registered Nurse #935 and the Regional Director of Clinical Operations (RDCO) #940 verified there was no documented influenza or pneumococcal education provided for Residents #9 #24, #32 and #72.

Based on record review and interview, the facility failed to document education provided to residents or resident representatives regarding the benefits and potential side effects of the COVID-19 vaccine. This affected three residents (Residents #24, #32 and #72) of five residents reviewed for immunizations. The facility census was 95.Findings include:1. Review of Resident #24's medical record revealed an original admission date of 01/04/24 with a re-admission date after hospitalization on 04/23/26. Diagnoses included left side hemiplegia, cerebral infarction due to embolism of right carotid artery, diabetes, asthma, contracture of muscle left upper arm, repeated falls, paroxysmal atrial fibrillation, hypertension, chronic pain, disorder of kidney and ureter, obstructive sleep apnea, and neurogenic bladder.Review of Resident #24's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had slight impairment to her cognition.Review of Resident #24's immunization documentation in the Electronic Medical Record (EMR) revealed the resident received a COVID-19 vaccination on 01/22/26.Further review of Resident #24's medical record revealed there was no documented evidence of education provided to Resident #24 or the resident's representative regarding the benefits and potential side effects to the vaccine.2. Review of Resident #32's medical record revealed an admission date of 12/26/25. Diagnoses included Alzheimer's disease, protein-calorie malnutrition, type II diabetes, interstitial pulmonary disease, chronic bronchitis, dementia, cerebral ischemia, atherosclerosis, and legal blindness.Review of Resident #32'a Quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition.Review of Resident #32's immunization documentation in the EMR revealed the resident received the COVID-19 vaccination on 01/27/26.Further review of Resident #32's medical record revealed there was no documented evidence of education provided to Resident #32 or the resident's representative regarding the benefits and potential side effects to the vaccine.3. Review of Resident #72 medical record revealed an admission date of 01/02/26. Diagnoses included dementia, kidney disease stage III, non-traumatic subarachnoid hemorrhage, and visual loss.Review of Resident #72's Quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition.Review of Resident #72's immunization documentation in the EMR revealed the resident refused (undated) the COVID-19 vaccination.Further review of Resident #72's medical record revealed there was no documented evidence of education provided to Resident #72 or the resident's representative regarding the benefits and potential side effects to the vaccine.Interview on 07/28/26 at 1:45 P.M. with the Regional Registered Nurse #935 and the Regional Director of Clinical Operations #940 verified there was no documented COVID-19 education provided for Residents #24, #32 and #72.

Based on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure residents were provided with adaptive equipment to maintain independence. This affected three residents (Residents #29, #80 and #86) of four residents who received adaptive equipment for drinking. The facility census was 95.Findings include:1. Review of the medical record for Resident #86 revealed an admission date of 10/15/25. Diagnoses included but not limited to unspecified protein-calorie malnutrition, depression, and diverticulitis of intestine.Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #86 had severely impaired cognition and required supervision or touching for eating.Review of Resident #86's physician orders for July 2026 revealed a diet order for regular diet, regular texture with thin consistency liquids and disposable silverware for resident safety.Review of the daily diet ticket for Resident #86 revealed that Resident #86 was supposed to receive disposable silverware. Observation and interview on 07/21/26 at 4:16 P.M. revealed Resident #86's tray was prepared and placed into the food cart for delivery and then Dietary Aide (DA) #910 started preparing the next resident's tray. Resident #86's tray had regular silverware on it and not the plastic silverware per her diet order. This was verified by DA #910 at the time of the observation. 2. Review of the medical record for Resident #80 revealed an admission date of 07/18/24. Diagnoses included but not limited to Parkinson's Disease, Alzheimer's Disease, and anxiety disorder.Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #80 had severely impaired cognition and required supervision or touching for eating.Review of Resident #80's physician orders for July 2026 revealed a diet order for regular diet, regular texture with thin consistency liquids.Review of the daily diet ticket for Resident #80 revealed that Resident #80 was supposed to receive her meals on a divided plate. Observation and interview on 07/21/26 at 4:17 P.M. revealed Resident #80's meal was plated and placed inside the food cart, then DA #910 started preparing the next resident's tray. DA #910 was asked to remove Resident #80's tray from the food cart which revealed Resident #80's diet ticket which stated that she should have her food on a divided plate. Resident #80's entree was on a regular plate with no dividers. This was verified by DA #910 at the time of the observation. 3. Review of the medical record for Resident #29 revealed an admission date of 07/18/24. Diagnoses included but not limited to bipolar disorder, unspecified protein-calorie malnutrition, and Alzheimer's Disease.Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #29 had severely impaired cognition and required moderate assistance for eating.Review of Resident #29's physician orders for July 2026 revealed a diet order for regular diet, and mechanical soft (minced and moist) texture with thin consistency liquids.Review of the daily diet ticket for Resident #29 revealed that Resident #29 was supposed to receive no butter knife. Observation and interview on 07/21/26 at 4:22 P.M. revealed Resident #29's meal was plated and placed inside the food cart, then DA #910 started preparing the next resident's tray. Resident #29's diet ticket stated that he should have not have a butter knife. Resident #29's tray had a butter knife on it. This was verified by DA #910 at the time of the observation. Review of the undated facility policy titled, Assistive Devices revealed that adaptive assistive eating devices shall be provided to residents who need them for all meals.

Based on record review, observation, interview, and review of the facility policy, the facility failed to ensure Resident #93's advance directive was accurate and consistently documented in his care plan and medical record. This affected one resident (Resident #93) out of seven residents reviewed for advance directives. The facility census was 95. Findings include: Review of Resident #93's medical record revealed an admission date of [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia and hypercapnia, heart failure, acquired absence of right leg above the knee, and peripheral vascular disease.Review of Resident #93's Advance Directive found in his hard chart and dated what appeared to be [DATE] (note: the writing was hard to read) revealed DNRCC-Arrest (a medical order meaning you receive all life-saving care until your heart or breathing stops, after which only comfort measures were given).Review of Resident #93's care plan dated [DATE] included Resident #93 expressed wishes to have his code status as DNRCCA (Do Not Resuscitate Comfort Care Arrest). Resident #93's code status wishes would be honored. Interventions included maintaining a copy of Resident #93's code status on the chart at all times; update Resident #93's code status as needed.Review of Resident #93's physician orders dated [DATE] revealed Resident #93's code status was DNRCCA, no compression.Review of Resident #93's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #93 was cognitively intact. Resident #93 had upper and lower extremity impairment on both sides and used a wheelchair. Resident #93 was dependent on staff for toileting hygiene, bathing, dressing and personal hygiene and was always incontinent of urine and bowel. Resident #93 did not reject care during the seven-day assessment look-back period.Review of Resident #93's physician orders dated [DATE] revealed Resident #93's code status was CPR/Full Code (means medical teams would use every tool and CPR (cardiopulmonary resuscitation) to try and save your life at any time).Observation on [DATE] at 9:30 A.M. of Resident #93 revealed he was lying in bed, did not have a shirt on, and the room was on the cool side. Resident #93 indicated his preference was for the room to be cool because he was always hot, and he did not want to wear a shirt.Review of Resident #93's advance directive with Unit Manager/Licensed Practical Nurse (UM/LPN) #705 on [DATE] at10:37 A.M. revealed Resident #93's Electronic Health Record (EHR) had documentation that Resident #93's advance directive was a Full Code. Resident #93's hard chart located on the nursing unit he resided on had documentation that Resident #93's advance directive was DNRCCA. UM/LPN #705 confirmed the advance directives were different and stated she was going to clarify his code status.An interview on [DATE] at 3:42 P.M. with UM/LPN #705 revealed she talked to Resident #93, and he wanted his code status to be DNRCCA. UM/LPN #705 confirmed a physician order for a Full Code was written on [DATE] and she would have to reach out to LPN #605. UM/LPN #705 indicated LPN #605 documented the order in Resident #93's HER, and she would contact her to find out why she wrote the order.An interview on [DATE] at 5:00 P.M. of UM/LPN #705 revealed she spoke to LPN #605, and LPN #605 did not remember why she wrote an order for a Full Code for Resident #93. UM/LPN #705 indicated she asked LPN #605 if the order was supposed to be for a different resident, and LPN #605 could not remember.Review of the undated facility policy titled Do Not Resuscitate (DNR) Policy included facility staff should verify the presence of advance directives or the residents' wishes regarding CPR, upon admission. If the resident's wishes were different than the admission orders, or if the admission orders do not address the resident's code status and the resident did not want to receive CPR facility staff should immediately document the resident's wishes in the medical record and contact the physician to obtain the order. The care plan and MDS would indicate the resident had an advance directive.

Based on resident record review, staff interviews and facility policy review, the facility failed to ensure Resident #87 was given appropriate notice regarding financial liability. This affected one (Resident #87) of three residents reviewed for beneficiary notification. The facility census was 95.Findings include:Review of the medical record for Resident #87 revealed he was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, malnutrition, and cerebral infarction.Review of the care plan dated 05/28/26 revealed Resident #87 planned to remain in the facility for long-term placement.Review of the progress note dated 07/13/26 at 10:50 A.M. revealed the facility issued Resident #87 a Notice of Medicare Non-Coverage (NOMNC) with a Last Covered Day (LCD) of services dated 07/15/26. Resident #87 signed and dated the NOMNC and planned to remain in the facility for long-term care.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #87 had a Brief Interview for Metal Status (BIMS) score of 3/15, indicating he had short- and long-term cognitive impairment. Resident #87 was dependent on staff for activities of daily living (ADL).Review of the progress note dated 07/21/26 at 12:36 P.M. revealed Resident #87's wife stated she would be at the facility on 07/22/26 to sign the Advance Beneficiary Notice of Non-Coverage (ABN).Review of the ABN revealed Resident #87's wife signed and dated form on 07/22/26, approximately seven days after the LCD.An interview on 07/23/26 at 10:49 A.M. with Social Services Designee (SSD) #903 revealed NOMNCs and ABNs were issued 48 hours prior to the LCD. SSD #903 revealed once a resident decides that they will remain in the facility, NOMNCs and ABNs were issued and completed in a timely manner to ensure transparency related to financial liability. SSD #903 revealed after she audited the tracking system, she realized she did not issue Resident #87's ABN in a timey manner. SSD #903 revealed Resident #87's wife would sign the form on 07/22/26. SSD #703 confirmed and verified the above findings at the time of the interview.Review of the facility document titled Resident Rights dated 10/03/23, revealed the facility had a policy in place to be fully informed of charges for services not covered under the Medicare or Medicaid program. Review of the document revealed the facility did not implement the policy.

Based on record review, observation, interview, review of a concern form, and review of the facility policy, the facility failed to ensure Resident #93 was free from staff-to-resident verbal abuse. This affected one resident (Resident #93) out of four residents reviewed for abuse. The facility census was 95. Findings include:Review of Resident #93's medical record revealed an admission date of 09/19/25 and diagnoses included acute and chronic respiratory failure with hypoxia and hypercapnia, heart failure, acquired absence of right leg above the knee, and peripheral vascular disease.Review of Resident #93's care plan revised 04/21/26 included Resident #93 had an alteration in elimination related to incontinence of bowels. Staff assisted with completion of Resident #93's toileting and incontinence needs throughout the day. Resident #93 would continue to remain clean, dry and free of odors through the review date of 09/07/26. Interventions included assisting with toileting needs throughout the day; Resident #93 used disposable briefs; checking and changing as required for incontinence, washing, rinsing, drying perineum and changing clothing as needed after incontinence episodes.Review of Resident #93's Braden Scale for Predicting Pressure Sore Risk dated 06/02/26 included Resident #15 was at mild risk for developing a pressure sore.Review of Resident #93's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #93 was cognitively intact. Resident #93 had upper and lower extremity impairment on both sides. Resident #93 used a wheelchair and was dependent on staff for toileting hygiene, bathing, dressing and personal hygiene. He was always incontinent of urine and bowel and did not reject care during the seven-day assessment look-back period.Review of Resident #93's Grievance/Concern form dated 07/21/26 written by Central Supply Clerk #803 included the concern occurred on 07/20/26 and no time was documented. The Concern form stated Resident #93 did not like the way Certified Nursing Assistant (CNA) #801 speaks to him, and CNA #801 made comments about the smell of his bowel movements. CNA #801 also made a comment that Resident #93 was lucky to stay in bed, soiled himself and have someone like CNA #801 take care of him. Resident #93 did not want CNA #801 caring for him any longer.Observation on 07/21/26 at 9:30 A.M. of Resident #93 revealed he was lying in bed, did not have a shirt on, and the room was on the cool side. Resident #93 indicated his preference was for the room to be cool because he was always hot, and he did not want to wear a shirt. An interview on 07/21/26 at 9:30 A.M. with Resident #93 revealed CNA #801 had a smart mouth and doesn't know when to shut up. Resident #93 indicated it was his turn to have his incontinence brief changed and he told CNA #801 the doctor told him he should be changed as soon as possible after he was incontinent of urine or bowel. Resident #93 revealed CNA #801 said it must be nice to be lying in bed [expletive] yourself and waiting for me to clean you up. Resident #93 indicated if he could have got out of bed he would have wrung his neck and stated emphatically he felt like okay [NAME] you don't know how bad I feel about that, I already feel bad enough and you are making me feel worse. Resident #93 stated CNA #801 was always in a hurry, did not do a good job and wanted him to use a urinal or a bedpan, but Resident #93 stated he always wore a brief and did not know when he was going to have a bowel movement. Resident #93 stated CNA #801 used paper towels and even took the pillowcase off his pillow to use for incontinence care when Resident #93 had a bowel movement. Resident #93 revealed CNA #801 was always commenting on how much he goes and how bad it smelled. Resident #93 indicated he told Activity Director (AD) #711 and Central Supply Clerk #803 what happened. Resident #93 revealed the situation happened on 07/20/26.An interview on 07/21/26 at 9:45 A.M. of AD #711 confirmed Resident #93 told her about his concerns with CNA #801, but as soon as he started telling her what happened, she told him he needed to speak with Social Worker Designee (SWD) #903.An interview on 07/21/26 at 12:44 P.M. with the Administrator revealed it was brought to his attention that Resident #93 was upset by CNA #801 who provided care for him. CNA #801 openly complained about the smell of Resident #93's bowel movement. The Administrator indicated he discussed the situation with the Director of Nursing (DON), and CNA #801 was sent home while the concern was looked into. The Administrator revealed he talked to staff including Unit Manager/Licensed Practical Nurse (UM/LPN) #705 who brought the concern to him and told him what CNA #801 said to Resident #93. The Administrator stated it sounded like CNA #801 was rude to Resident #93. The Administrator revealed he was not given a concern form on 07/20/26 when the incident happened but had notes given to him today about the interaction. The Administrator indicated he had not interviewed Resident #93 about the situation.An interview on 07/22/26 at 8:07 A.M. of SWD #903 revealed Resident #93 came to her, and he was upset. SWD #903 indicated Resident #93 told her CNA #801 said he [expletive] a lot, it smelled and he could lay there and [expletive] and [expletive] all day and have someone like CNA #801 clean him up all day. SWD #903 revealed as soon as Resident #93 told her this, she reported it to the Administrator, and CNA #801 had to go. SWD #903 revealed CNA #801 talking to Resident #93 that way set him over the edge. SWD #903 indicated it hurt her heart that CNA #801 would treat Resident #93 that way and stated, why was CNA #801 in health care if he was going to treat residents like that? An interview on 07/22/26 at 9:30 A.M. of UM/LPN #705 revealed she did not have complaints about CNA #801 until 07/21/26 when he was sent home. An interview on 07/22/26 at 4:07 P.M. with the Administrator and DON revealed the Administrator spoke with Resident #93 about the situation and Resident #93 was informed CNA #801 was suspended, and at the minimum, he would receive discipline for customer service. The Administrator revealed he had not initiated an investigation with CNA #801 or other residents. The DON indicated she spoke briefly with CNA #801 the day he went home, and CNA #801 was told there were customer service issues, and the facility would follow up for next steps. The DON revealed up to this point the facility had not followed up with residents. The DON indicated she spoke with Resident #93, and he told her the same thing about CNA #801 commenting on the smell, he did not care for Resident #93 properly, and Resident #93 told her he would have wrung CNA #801's neck if he could have reached him. Resident #93 told the DON that CNA #801 used paper towels and a pillowcase to clean him up. The Administrator revealed he did not think the situation was abusive, but it was definitely rude behavior and poor customer service. Review of the undated facility policy titled Abuse Prohibition included abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also included the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. This deficiency represents non-compliance investigated under Complaint Numbers 3069997, 3031303, 3021865, 2670307, 2582257, and 1405090 (OH00167146).

Based on record review, review of the Medicaid Information Technilogy System (MITS), review of the Ohio Department of Medicaid Bureau of Long-Term Services and Supports application of Shared of Cost/Patient Liability for Nursing Facilities, review of Ohio Department of Health (ODH) documentation, review of a facility Self-Reported Incident (SRI), and interview, the facility failed to ensure Resident #61 was free from misappropriation of resident funds and Resident #117 was free from misappropriation of personal property. This finding affected two (Residents #61 and #117) of ten residents reviewed for abuse. The facility census was 95. Findings include: 1. Review of the medical record for Resident #61 revealed he was admitted to the facility on [DATE] with diagnoses including major depressive disorder, heart failure, and diabetes mellitus. Review of the resident fund management services (RFMS) authorization and agreement to handle resident funds document revealed Resident #61 opened a resident funded account on 09/12/23. Review of the document revealed Resident #61 opted to have direct deposit of income with a monthly allowance. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #61 had a Brief Interview for Mental Status (BIMS) score of 13/15 indicating he was alert and oriented to person, place, and time. Resident #61 was dependent on staff for activities of daily living (ADL). Review of the patient liability submitted in the MITS from the Ohio Department of Medicaid (ODM) revealed Resident #61 had a patient liability of $672.00 for the period of 03/01/25 through 07/01/26. Review of the facility's trial balance dated 07/20/26 regarding resident funds accounts revealed Resident #61 had a current balance of $34,245.19 with a designated established monthly allowance of $75.00. Review of the quarterly statement dated 04/01/26 through 06/30/26 revealed Resident #61 had deposits from Social Security in the amount of $2,169.00 on 04/03/26, 05/01/26, and 06/03/26 and a pension deposit of $722.50 on 04/01/26, 05/01/26, and 06/01/26. Further review of the quarterly statement revealed care cost auto withdrawal of $672.00 on 04/01/26, $2169.00 on 05/01/26, $647.50 on 05/01/26, $647.50 on 06/01/26 and $2,169.00 on 06/03/26. Further review of Resident #61's financial records revealed that she received spend-down letters monthly since 07/25/25. An interview on 07/21/26 at 9:14 A.M. with Business Office Manager (BOM) #622 revealed that Resident #61's RFMS account was very high because the county Medicaid Benefits Center (CMBC) did not get her income correctly. The CMBC received an email weekly, and you must inform them when a resident has a problem, so the problem can be resolved. Resident #61's MITS stated that her monthly income was lower than it actually was, because Resident #61 gets a pension and social security, which increased when her husband passed away. BOM #622 stated that patient liability was determined by adding all income and subtracting $75.00, which was an increased from $50.00 in January 2026. An interview on 07/23/26 at 8:52 A.M. with Medicaid Supervisor (MS) #939 revealed that she spoke to the RBOM #938 on 07/21/26. MS #939 stated that the facility does not have the right to adjust the amount of patient liability submitted in the MITS. MS #939 stated that she spoke to the facility in December 2025 and sent a form and a checklist for them to fill out, but it was not returned. She stated she forwarded it to the facility on Tuesday, 07/21/26. Review of the Ohio Department of Medicaid Bureau of Long-Term Services and Supports application of Shared of Cost/Patient Liability for Nursing Facilities dated 05/11/22 revealed a Medicaid-certified nursing home in Ohio cannot charge more than your calculated patient liability. Under Ohio Medicaid rules, the nursing facility's reimbursement rate plus your required monthly patient liability (share of cost) constitutes payment-in-full. They are prohibited from seeking additional payments for covered services. 2. Review of Resident #117's medical record revealed the resident was admitted on [DATE] (discharged on 04/27/26) with diagnoses including chronic obstructive pulmonary disease, dependence on supplemental oxygen and heart failure. Review of employee files revealed Activity Aide (AA) #941's date of hire was on 07/12/23. The Employee Corrective Action Form (in the employee file) dated 02/19/25 revealed AA #941 was terminated for performance/policy violation. The violation statement indicated AA #941 was terminated for unauthorized possession or use of property belonging to the facility. Review of the facility SRI Investigation tracking number 257852 dated 03/04/25 revealed at 3:00 P.M., Resident #117 reported that he recently found out the private bank account he used was overdrawn. He had an account at an outside bank that he stated was used regularly. An SRI was initiated. Resident #117 was alert and oriented and able to make decisions. During the investigation, Resident #117 stated at times he would give money or the bank card to a former AA #941 to make purchases for him. Resident #117 stated in 04/20/24, the bank debit card was given to AA #941 to purchase a list of items the resident wanted that would also assist in the resident's spend-down to meet resource limits per Medicaid guidelines. On 03/04/25, the Administrator contacted the police department to report potential theft. The SRI was unsubstantiated. Review of Resident #117's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of the Ohio Department of Health (ODH) Journal Entry form dated 06/10/26 with Case Number M257852 revealed previously, on 12/18/25, a notification was issued to AA #941 advising the employee that an investigation was initiated for an allegation of misappropriation which had a reasonable basis. Specifically, the allegation was made that between 08/01/24 and 02/28/25, AA #941 had misappropriated personal property by wrongfully making fraudulent purchases with Resident #117's bankcard. After reviewing the Report and Recommendation, the recommendation was a Finding of Misappropriation against AA #941. The finding will be sent to the Attorney General's office, the prosecutor's office and the Ohio Nurse Aid Registry. Review of the ODH letter dated 07/09/26 to AA #941 for Case Number M257852 revealed the Director adopted the Hearing Officer's Report and Recommendation and found that you did misappropriate funds from a long-term care resident. Interview on 07/27/26 at 12:56 P.M. with Regional Registered Nurse (RRN) #940 confirmed the misappropriation of Resident #117's funds by AA #941. Review of the undated Abuse Prohibition policy revealed each resident had the right to be free from abuse, neglect, and corporal punishment of any type by anyone. The health care center's management prohibits neglect, mental or physical abuse, including mental abuse associated with the unauthorized use of photographs and recording that were used in a manner to demean or humiliate a resident including, but not limited to photographs and recordings uploaded to social media, involuntary seclusion, misappropriation of resident property and/or funds. This deficiency represents non-compliance investigated under Complaint Number 2656594.

Based on resident record review, staff interviews, Self-Reported Incident (SRI) review, review of the police report, review of hospital paperwork, and facility policy review, the facility failed to implement the abuse policy related to an injury of unknown origin for Resident #56. This affected one (Resident #56) of one resident reviewed for injuries of unknown origins. The facility census was 95.Findings include: Review of the medical record for Resident #56 revealed she was admitted to the facility on [DATE] with diagnoses including dementia and transient cerebral ischemic attack. Review of the medical record revealed Resident #56 had new upgraded diagnoses of multiple fractures of the left side ribs and contusion of the right front wall of thorax dated 06/09/26.Review of the care plan dated 10/22/25 revealed Resident #56 had an activity of daily living (ADL) self-care performance deficit with interventions including two-staff assistance for ADL and a new care plan entry dated 06/18/26, after an injury of unknown origin, to have a fixed monitoring system put in her room per family request.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 had a Staff Assessment for Mental Status (SAMS) score that indicated she had a short term and long-term memory problem and was severely impaired regarding decisions of daily life. Review of the MDS assessment revealed she had impairment of the upper and lower bilateral extremities and was dependent on staff for ADL.Review of the progress notes dated 05/16/26 through 06/01/26 revealed no progress notes documented within that time frame.Review of the pain summary dated 05/25/26 through 06/12/26 revealed Resident #56 had a pain rating of zero except on 06/02/26, which she reported a pain level of five on a zero to 10 pain scale.Review of the weekly skin check assessment dated [DATE] revealed Resident #56 had a new skin problem of a hematoma to the chest.Review of the progress note dated 06/03/26 at 5:33 P.M. revealed Resident #56 had bruising under her right breast, right nipple and in the middle of her chest. Resident #56 received a new order for a STAT (immediate) x-ray of the chest for bruising.Review of the radiology report dated 06/03/26 revealed Resident #56 had a single view chest x-ray that revealed bruising of the chest, bilateral linear atelectasis (partial collapse of small areas in both lungs), tortuous of the aorta (main artery of your body has abnormal twists, loops, or sharp curves instead of a straight path) with no acute findings identified.Review of the progress note dated 06/04/26 at 6:10 A.M. revealed Resident #56's x-ray results were reported to the physician with no new orders.Review of the progress note dated 06/05/26 at 8:16 P.M. revealed Resident #56's bruising spread to her right upper extremities, shoulder and breast. Resident #56 displayed signs of pain and upon assessment, new edema was observed. Resident #56 received new orders to be sent to the hospital for further evaluation.Review of the progress note dated 06/05/26 at 8:29 P.M. revealed Resident #56's family was notified and she was being transported to the emergency room (ER) for further investigation.Review of the MDS 3.0 assessment dated [DATE] revealed Resident #56 discharged from the facility and was anticipated to return.Review of the nursing resident transfer form dated 06/06/26 revealed Resident #56 was transferred to the local ER for increased hematoma, redness, edema to the right hand, and increased pain.Review of the progress note dated 06/06/26 at 2:20 A.M. revealed Resident #56 was picked up and taken to the ER for evaluation.Review of the progress note dated 06/06/26 at 9:50 A.M. revealed Resident #56 had a change in condition.Review of the progress note dated 06/06/26 at 6:12 P.M. revealed Resident #56 was being admitted to the local hospital, but the hospital would not provide admitting diagnosis until she arrived in a different unit.Review of the SRI tracking number 275412 revealed on 06/06/26 Resident #56 was sent to the hospital due to a growing bruise on her chest. Resident #56 emergency room x-ray revealed multiple bilateral rib fractures with no report of any recent falls or incidents to explain injuries. Reviews of the staff interviews revealed no explanation for injuries and were educated on mechanical lift transfers and transfers according to care plans. Review of the SRI revealed the facility unsubstantiated the allegation due to the evidence being inconclusive and reported the incident to the Local Police Department (LPD).Further review of the SRI revealed a timeline of events related to Resident #56's injury of unknown origin. Review of the timeline revealed on 06/03/26, at approximately 5:00 P.M., revealed Resident #56 had bruising under her right breast and mid chest and an x-ray was ordered. On 06/03/26, at approximately between 8:00 P.M. to 8:15 P.M., revealed the x-ray was completed with no new orders. On 06/05/26, at approximately 8:00 P.M. to 8:30 P.M., revealed Resident #56's bruising spread to her right upper extremity, shoulder and breast and was sent to the ER for evaluation. On 06/06/26, Resident #56 was admitted to the hospital with fractured ribs, an SRI was initiated, and audits and educated initiated.Review of the SRI tracking number 275412 dated 06/06/26, approximately three days after the first observed skin change, revealed the facility initiated an incident of injury of unknown origin due to a growing hematoma on Resident #56 arm and a fracture identified after being sent to the ER.Review of the progress note dated 06/07/26 at 2:00 P.M. revealed the hospital requested facility ordered x-rays to be faxed for review after speaking with Resident #56s daughter and informed of the x-ray.Review of the LPD incident report dated 06/08/26, five days after first observed skin change, revealed at 7:54 A.M., the LPD received a call and a unit was dispatched to the facility at 3:58 P.M. for a report of personal injury. Review of the incident report revealed the facility reported Resident #56 sustained broken ribs while in the care of the facility and were unsure of how the injuries occurred. Review of the incident revealed no other information documented.Review of the hospital paperwork dated 06/08/26 revealed Resident #56 presented to the trauma intensive care unit (TICU) for multiple rib fractures and large intramuscular hematoma. Resident #56 had multiple bilateral nondisplaced rib fractures including right third through fifth and left second, third, sixth and seventh ribs, possibly acute or subacute with concerns of neglect and/or abuse. Review of the hospital paperwork revealed Resident #56's bruising started 06/02/26, one day prior to what the facility documented, and worsened over the next few days until she was seen in the ER on [DATE].Review of the nursing readmission assessment dated [DATE] revealed Resident #56 was admitted back to the facility with multiple fractures of the rib, right and left side, and a hematoma to the right chest wall. Further review of the assessment revealed Resident #56 had bruising to the chest across breasts and on the right-side flank, back, and right upper arm, multiple bruises of the arms, right and let side ribs and legs.Review of the progress note dated 06/09/26 at 10:54 P.M. revealed Resident #56 was readmitted to the facility at 10:20 P.M.An interview on 07/22/26 at 1:45 P.M. with Unit Manager Licensed Practical Nurse (LPN) #705 revealed she did not notice Resident #56's fractures until two days before she was sent out to the ER because of bruising to the side of her breast and underneath her arms. LPN #705 revealed she reported it to the Director of Nursing (DON) the following morning because she was working nights at the time. LPN #705 revealed Resident #56 received an x-ray the next morning with no findings. LPN #705 revealed a few days later, the bruising spread and she was sent to the ER and admitted with fractures. LPN #705 revealed the facility did not initiate an investigation until after receiving the admitting diagnosis. LPN #705 stated the facility staff were educated on transfers after Resident #56 became a mechanical lift of two staff for transfers after her hospital stay. LPN #705 revealed the facility believed that during repositioning, Resident #56 was transferred using the bear-hug technique from the back and was pulled upward. LPN #705 revealed the bear-hug technique was not a transfer technique utilized or taught to staff for transferring residents. LPN #705 revealed the facility reported Resident #56's injury of unknown origin on 06/06/26, approximately three days after the first sign of injury. LPN #705 confirmed and verified the above findings at the time of the interview.An interview on 07/23/26 at 12:18 P.M. with the Administrator revealed after investigating, the facility was unable to determine the cause of Resident #56's injuries. The Administrator revealed Resident #56 was unable to communicate what occurred and no one witnessed or knew of any incidents related to the injuries. The Administrator revealed staff were educated and audits performed of mechanical lift techniques. The Administrator revealed he did not report the incident to the Ohio Department of Health (ODH) until 06/06/26 and to the LPD until 06/08/26. The Administrator revealed there was no immediate reporting of Resident #56's injuries, and no investigation was started until after she was admitted to the hospital. The Administrator confirmed and verified the above findings at the time of the interview.Review of the facility document titled Abuse Prohibition, revised 2022, revealed the facility had a policy in place that each resident had a right to be free from abuse including injuries of unknown origin. Review of the policy revealed the facility failed to keep Resident #56 free from abuse, report within a two-hour timeframe and implement the policy in totality. Review of the document revealed the facility did not implement the policy.This deficiency represents non-compliance investigated under Complaint Number 3041303.

Based on record review, observation, interview, and facility policy review, the facility failed to report abuse allegations to the State Agency. This affected three residents (Residents #82, #93 and #117) of ten residents reviewed for abuse. The facility census was 95.Findings include: 1. Review of former Resident #117's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), impulse disorder and major depressive disorder. Review of Resident #117's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #117's progress notes dated 04/11/26 at 5:26 A.M. revealed the resident was admitted to the hospital with COPD exacerbation. Resident #117 did not return to the facility. Review of Resident #82's medical record revealed the resident was admitted on [DATE] with diagnoses including COPD, essential hypertension and hyperlipidemia. Resident #82 still resides in the facility. Review of Resident #82's progress note dated 12/23/25 authored by Licensed Practical Nurse (LPN) Unit Manager (UM) #705 which was struck out as incorrect documentation indicated the nursing staff were notified that the resident stated an incident happened with another resident. Resident #82 stated another resident grazed her left foot. The nurse on staff along with the LPN UM #705 assessed the resident and no injuries were noted and no complaints of foot pain. The provider was notified and a new order for an x-ray was obtained. No bruising or redness was noted. The family was made aware. Review of Resident #82's radiology report dated 12/23/25 revealed the resident did not have a fracture, and a small plantar calcaneal spur was noted. Review of Resident #82's MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Interview on 07/22/26 at 7:36 A.M. with Resident #82 revealed the resident reported to the administration that Resident #117 ran over her feet with a wheelchair. Resident #82 stated the facility investigated and told her it did not happen. Interview on 07/23/26 at 10:31 A.M. with the Administrator revealed Resident #82 had a feud with another resident and that was why she had reported that the other resident who no longer resides in the building had run over her feet with a wheelchair. The Administrator confirmed the facility conducted a complete investigation and determined the incident did not occur but could not find the investigation. Interview on 07/23/26 at 10:49 A.M. with Social Service Designee (SSD) #903 confirmed Resident #82 had reported Resident #117 because the resident was a woman and she was black. SSD #903 revealed the facility did not find evidence that Resident #117 had run over Resident #82's feet with a wheelchair. An additional interview on 07/27/26 at 8:30 A.M. with the Administrator confirmed Residents #82 and #117's physical altercation was not reported to the State agency. 2. Review of Resident #93's medical record revealed an admission date of 09/19/25 and diagnoses included acute and chronic respiratory failure with hypoxia and hypercapnia, heart failure, acquired absence of right leg above the knee, and peripheral vascular disease. Review of Resident #93's care plan revised 04/21/26 included Resident #93 had an alteration in elimination related to incontinence of bowels. Staff assisted with completion of Resident #93's toileting and incontinence needs throughout the day. Resident #93 would continue to remain clean, dry and free of odors through the review date of 09/07/26. Interventions included assisting with toileting needs throughout the day; Resident #93 used disposable briefs; check and change as required for incontinence, wash, rinse, dry perineum and change clothing as needed after incontinence episodes. Review of Resident #93's Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #93 was cognitively intact. Resident #93 had upper and lower extremity impairment on both sides. Resident #93 used a wheelchair. Resident #93 was dependent on toileting hygiene, bathing, dressing and personal hygiene. Resident #93 was always incontinent of urine and bowel. Resident #93 did not reject care during the seven-day assessment look-back period. Review of Resident #93's Grievance/Concern form dated 07/21/26 written by Central Supply Clerk #803 included the concern occurred on 07/20/26 and no time was documented. The Concern form stated Resident #93 did not like the way Certified Nursing Assistant (CNA) #801 speaks to him and CNA #801 made comments about the smell of his bowel movements. CNA #801 also made a comment that Resident #93 was lucky to stay in bed, soiled himself and have someone like CNA #801 take care of him. Resident #93 did not want CNA #801 caring for him any longer. Review of facility Self-Reported Incidents (SRI) dated 07/20/26 through 07/24/26 did not reveal evidence Resident #93 had reported the allegation of verbal abuse to the State Agency. Observation on 07/21/26 at 9:30 A.M. of Resident #93 revealed he was lying in bed, did not have a shirt on and the room was cool. Interview at the time of the observation with Resident #93 indicated his preference was for the room to be cool because he was always hot and he did not want to wear a shirt. Resident #93 stated CNA #801 had a smart mouth and doesn't know when to shut up. Resident #93 indicated it was his turn to have his incontinence brief changed and he told CNA #801 the doctor told him he should be changed as soon as possible after he was incontinent of urine or bowel. Resident #93 revealed CNA #801 said it must be nice to be laying in bed (expletive) yourself and waiting for me to clean you up. Resident #93 indicated if he could have got out of bed he would have wrung his neck and stated emphatically he felt like okay [NAME] you don't know how bad I feel about that, I already feel bad enough and you are making me feel worse. Resident #93 revealed CNA #801 was always in a hurry, did not do a good job and wanted him to use a urinal or a bedpan, but Resident #93 stated he always wore a brief and did not know when he was going to crap. Resident #93 stated CNA #801 used paper towels and even took the pillowcase off his pillow to use for incontinence care when Resident #93 had a bowel movement. Resident #93 revealed CNA #801 was always commenting on how much he goes and how bad it smelled. Resident #93 indicated he told Activity Director (AD) #711 and Central Supply Clerk #803 what happened. Resident #93 revealed the situation happened on 07/20/26. Interview on 07/21/26 at 9:45 A.M. of AD #711 confirmed Resident #93 told her about his concerns with CNA #801 but as soon as he started telling her what happened she told him he needed to speak with Social Worker Designee (SWD) #903. Interview on 07/21/26 at 12:44 P.M. with the Administrator revealed it was brought to his attention that Resident #93 was upset by CNA #801 who provided care for him. CNA #801 openly complained about the smell from Resident #93's bowel movement. The Administrator indicated he discussed the situation with the Director of Nursing (DON) and CNA #801 was sent home while the concern was looked into. The Administrator revealed he talked to staff including Unit Manager/Licensed Practical Nurse (UM/LPN) #705 who brought the concern to him and told him what CNA #801 said to Resident #93. The Administrator stated it sounded like CNA #801 was rude to Resident #93. The Administrator revealed he was not given a concern form on 07/20/26 when the incident happened but had notes given to him today about the interaction. The Administrator indicated he had not interviewed Resident #93 about the situation. Interview on 07/22/26 at 8:07 A.M. of SWD #903 revealed Resident #93 came to her and he was upset. SWD #903 indicated Resident #93 told her CNA #801 said he (expletive) a lot, it smelled and he could lay there and (expletive) and piss all day and have someone like CNA #801 clean him up all day. SWD #903 revealed as soon as Resident #93 told her this she reported it to the Administrator and CNA #801 had to go. SWD #903 revealed CNA #801 talking to Resident #93 that way set him over the edge. SWD #903 indicated it hurt her heart that CNA #801 would treat Resident #93 that way and why was CNA #801 in health care if he was going to treat residents like that. Interview on 07/22/26 at 9:30 A.M. of UM/LPN #705 revealed she did not have complaints about CNA #801 until 07/21/26 when he was sent home. Interview on 07/22/26 at 4:07 P.M. with the Administrator and Director of Nursing (DON) revealed the Administrator indicated he spoke with Resident #93 about the situation and Resident #93 was informed CNA #801 was suspended and at the minimum he would receive discipline for customer service. The Administrator revealed he had not initiated an investigation with CNA #801 or other residents. The DON indicated she spoke briefly with CNA #801 the day he went home and CNA #801 was told there were customer service issues and the facility would follow up for next steps. The DON revealed up to this point the facility had not followed up with residents. The DON indicated she spoke with Resident #93, and he told her the same thing about CNA #801 commenting on the smell, he did not care for Resident #93 properly and Resident #93 told her he would have wrung CNA #801's neck if he could have reached him. Resident #93 told the DON CNA #801 used paper towels and a pillowcase to clean him up. The Administrator revealed he did not think the situation was abuse, but it was definitely rude behavior and poor customer service. The Administrator indicated he did not report the allegation to the required State Agency because he did not think it was abuse. Review of Resident #93's Self-Reported Incident (SRI) dated 07/24/26 at 4:15 P.M. included the category of allegation/suspicion was emotional/verbal abuse. The report stated there were no alleged perpetrators assigned to the case. The report was not completed. Review of the facility policy titled Abuse Prohibition undated included abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also included the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. The facility must ensure all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property were reported immediately but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to the State Agency in accordance with state law through established procedures. This deficiency represents non-compliance investigated under Complaint Number 3041303.

Based on record review and interview, the facility failed to ensure Resident #82's allegation of abuse by Resident #117 was thoroughly investigated. This affected one (Resident #82) of ten residents reviewed for abuse. The facility census was 95. Findings include:Review of Resident #117's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), impulse disorder, and major depressive disorder. Review of Resident #117's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #117's progress notes dated 04/11/26 at 5:26 A.M. revealed the resident was admitted to the hospital with COPD exacerbation. Resident #117 did not return to the facility.Review of Resident #82's medical record revealed the resident was admitted on [DATE] with diagnoses including COPD, essential hypertension, and hyperlipidemia. Resident #82 resides in the facility.Review of Resident #82's progress note dated 12/23/25 at 4:55 P.M. authored by Licensed Practical Nurse (LPN) Unit Manager (UM) #705 which was struck out as incorrect documentation indicated the nursing staff were notified that the resident stated an incident happened with another resident. Resident #82 stated another resident grazed her left foot. The nursing staff along with LPN UM #705 assessed the resident, and no injuries were noted and no complaints of foot pain. The provider was notified and a new order for an x-ray was obtained. No bruising or redness was noted. The family was made aware.Review of Resident #82's progress note dated 12/23/25 at 6:07 P.M. revealed the resident reported another resident ran over her sock with a wheelchair. The resident was assessed and there were no bruising, redness or signs of injury. An X-ray was ordered. The Nurse Practitioner and family were notified.Review of Resident #82's radiology report dated 12/23/25 revealed the resident did not have a fracture, and a small plantar calcaneal spur was noted.Review of Resident #82's MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.An interview on 07/22/26 at 7:36 A.M. with Resident #82 revealed the resident reported to the administration that Resident #117 ran over her feet with a wheelchair. Resident #82 stated the facility investigated and told her it did not happen.An interview on 07/23/26 at 10:31 A.M. with the Administrator revealed Resident #82 had a feud with another resident (Resident #117), and that was why she had reported that the other resident, who no longer resides in the building, ran over her feet with a wheelchair. The Administrator confirmed the facility conducted a complete investigation and determined the incident did not occur but could not find the investigation.An interview on 07/23/26 at 10:49 A.M. with Social Service Designee (SSD) #903 confirmed Resident #82 reported Resident #117 because the resident was a woman, and she was black. SSD #903 revealed the facility did not find evidence that Resident #117 ran over Resident #82's feet with a wheelchair.An additional interview on 07/27/26 at 8:30 A.M. with the Administrator confirmed the facility did not complete a comprehensive investigation for Residents #82 and #117's resident-to-resident altercation.Review of the undated Abuse policy revealed the health care center maintains that all allegations of abuse, neglect, misappropriation of property are immediately reported, thoroughly investigated, and appropriate actions were taken.

Based on medical record review, interview, and review of facility policy the facility failed to ensure physician orders were followed for appointments. This affected one resident (Resident #13) of three residents reviewed for coordination of care. The facility census was 95. Findings include: Review of the medical record for Resident #13 revealed she was admitted to the facility on [DATE] with diagnoses that included acute kidney failure, acute chronic diastolic congestive heart failure, and peripheral vascular disease. Review of the care plan dated 07/10/26 revealed Resident #13 had an altered cardiovascular status related to hypertension, peripheral vascular disease, and hyperlipidemia with interventions that included follow-up with cardiology as ordered. Review of the physician orders dated 07/10/26 revealed Resident #13 had a cardiology appointment scheduled for 07/14/26 at 8:00 A.M. Review of the progress note dated 07/10/26 at 12:03 P.M. revealed Resident #13's son contacted the facility regarding follow-up appointments, questions were answered and all needs were met. Review of the progress note dated 07/14/26 at 7:09 A.M. revealed Resident #13's son revealed he would not be able to go to the appointment and was in agreement to reschedule. Review of the progress note dated 07/14/26 at 8:11 A.M. revealed Resident #13's cardiology appointment on 07/14/26 at 8:00 A.M. was rescheduled. Interview on 07/20/26 at 11:48 A.M. with Resident's #13 son revealed being notified Resident #13 had missed the scheduled cardiology appointment for 07/14/26. The facility informed him that the follow-up appointment would be rescheduled but he was not provided with the new information. Interview on 07/21/26 at 3:30 P.M. with Registered Nurse (RN) #818, while actively reviewing Resident #13's medical record, revealed she had no upcoming follow-up appointments scheduled regarding cardiology. There was a progress note that stated the appointment was rescheduled; however, it was not rescheduled. RN #818 revealed the unit manager, Licensed Practical Nurse (LPN) #827 usually scheduled appointments, but at this time, there was nothing documented. RN #818 confirmed and verified the above findings at the time of the interview. Review of the facility document titled Bill of Rights effective 10/03/23, revealed the facility had a policy in place that all residents had a right to adequate and appropriate medical treatment and nursing care. This deficiency represents non-compliance investigated under Complaint Number 2656594.

Based on observations, resident record review, staff interviews, and facility policy review, the facility failed to provide timely incontinence care Resident #13. This affected one (Resident #13) of one resident reviewed for incontinence care. The facility census was 95.Findings include:Review of the medical record for Resident #13 revealed she was admitted to the facility on [DATE] with diagnoses including acute kidney failure, acute chronic diastolic congestive heart failure, and peripheral vascular disease.Review of the care plan dated 07/10/26 revealed Resident #13 had an activities of daily living (ADL) self-care performance deficit related to impaired mobility, had an alteration in elimination of bowel and bladder related to incontinence, was incontinent, and was not toileted. Interventions included assisting with toileting needs throughout the day, checking and changing as required as needed.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating she was alert and oriented to person, place, and time. Resident #13 was impaired on both upper and lower bilateral extremities and was dependent on staff for ADL.An interview and observation on 07/22/26 at 7:37 A.M. revealed Resident #13 was lying in bed pointing to her brief. Resident #13 revealed she was wet and needed to be changed and cleaned up. Resident #13 revealed she was last changed the night prior, and it had been a long time.An interview and observation on 07/22/26 at 7:39 A.M. with Licensed Practical Nurse (LPN) #705 in Resident #13's room, revealed Resident #13 was lying in bed and informed LPN #705 she was wet, needed to be changed and had not been changed since the night before. LPN #705 checked Resident #13's brief and stated, she is wet. LPN #705 was then observed fastening Resident #13 brief back together, then pulled up her covers, washed her hands and exited the room. LPN #705 stated I'll be back. LPN #705 was then observed standing next to a medication cart watching a current medication pass by an alternate surveyor. LPN #705 was not the designated staff member for the medication pass and left Resident #13 unchanged. LPN #705 verified she did not check and change Resident #13 at the time of the interview.Review of the facility document titled Incontinence Care, dated December 2022, revealed the facility had a policy in place to ensure residents who were incontinent of bowel and/or bladder received appropriate treatment and services. This deficiency represents non-compliance investigated under Complaint Number 3021865, 2742587, 2735166, 2656594, and 2582257.

Based on record review, observation, interview, review of hospital records, review of therapy records, and review of the facility policy, the facility failed to ensure Resident #45's care planned interventions were implemented and physician orders were followed for eating assistance and adaptive equipment. This affected one (Resident #45) out of three residents reviewed for feeding assistance. The facility census was 95.Findings include:Review of Resident #45's After Visit Summary for a hospital stay from 06/15/26 through 06/17/26 included Resident #45's discharge diagnoses were failure to thrive, unsteady gait, and severe malnutrition. Resident #45's diet should be soft, bite sized, thin liquids. Aspiration precautions included placing medications whole, in puree (pudding/applesauce). Swallow strategy recommendations were one-to-one supervision, alternate bites and sips, feed/eat at a slow rate, maintain an upright position 20 to 30 minutes following all oral intake, no straws, sit upright 90 degrees.Review of Resident #45's medical record revealed an admission date of 06/17/26 with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebellar artery, unspecified protein-calorie malnutrition, and adult failure to thrive.Review of Resident #45's physician orders dated 06/17/26 through 07/23/26 did not reveal orders to place Resident #45's medications whole, in applesauce or pudding.Review of Resident #45's physician orders dated 06/18/26 revealed Resident #45 needed assistance with all meals and no straws.Review of Resident #45's care plan dated 06/18/26 included Resident #45 had an activities of daily living (ADL) self-care performance deficit related to diagnoses. Staff assisted with completion of Resident #45's needs throughout the day. Resident #45 would continue to have needs met on a daily basis; remaining clean, dry, dressed, groomed and free of odors through the review date of 09/28/26. Interventions included checking fingernail length and trimming and cleaning on bath day and as necessary. Report changes to the nurse; eating, no straws; eating, assist with oral intake; therapy evaluation and treatment per physician orders.Review of Resident #45's care plan dated 06/23/26 included Resident #45 had the potential for altered nutrition/hydration related to diagnoses, mechanically altered diet and thick liquids. Resident #45 would safely consume meals without episodes of choking through the review date of 09/28/26. Interventions included encouraging Resident #45 to drink fluids provided at meals; observing as needed tolerance to diet and observing as needed for episodes of coughing/choking after trying to swallow, running nose during meals etcetera; refer to speech and language pathology (SLP) for evaluation/recommendations as needed.Review of Resident #45's Speech Therapy SLP Evaluation and Plan of Treatment dated 06/23/26 included Resident #45 was admitted to the facility on mechanical soft solids and thin liquids from the hospital. Resident #45 was referred to Speech Therapy for dysphagia service due to exacerbation of coughing/choking during oral intake, oral/pharyngeal function and signs/symptoms of dysphagia. Due to the documented physical impairments and associated functional deficit, without skilled therapeutic intervention Resident #45 was at risk for decreased leisure task participation and social isolation. Recommendations included nectar thick liquids and mechanical soft/ground textures.Review of Resident #45's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] included Resident #45 had severe cognitive impairment. Resident #45 required supervision or touching assistance with eating. Resident #45 required substantial to maximal assistance with toileting hygiene, bathing, upper and lower body dressing and personal hygiene. Resident #45 was occasionally incontinent of urine and bowel. Resident #45 did not reject care during the seven-day assessment look-back period.Review of Resident #45's Speech Therapy Treatment Encounter Notes dated 07/08/26 included Resident #45 was seen during the breakfast meal. Resident #45 had thin liquids (water) at the bedside table despite being on nectar-thick liquids. Education was provided to Resident #45 regarding following his diet/liquid recommendation in order to reduce the risk of aspiration. The thin liquid was removed, and education was provided to the nursing staff regarding liquid recommendation. Swallow dysfunction focused on body positioning to increase safety with intake, liquid delivery using small, controlled sips, intake, medication to bolus sizes and order, method of food, liquid presentation.Observation on 07/20/26 at 12:45 P.M. of Resident #45 revealed he was sitting upright in bed, and a meal tray was in front of him on the bedside table. There was no staff in the room assisting him with his meal.Observation on 07/21/26 at 4:57 P.M. of Resident #45 revealed he was sitting upright in his bed and his meal, a mechanical soft diet, was served to him. No staff stayed in the room to assist Resident #45 after Unit Manager/Licensed Practical Nurse (UM/LPN) #705 completed his meal set up. An interview on 07/21/26 at 4:58 P.M. with UM/LPN #705 revealed staff did not stay in the room to assist Resident #45 with eating after his meal was set up because he could feed himself. UM/LPN #705 indicated staff assisted Resident #45 with his meal set up then left the room.An interview on 07/22/26 at 11:12 A.M. with Director of Rehab (DOR) #945 revealed Resident #45 was currently receiving Speech Therapy for aphasia. An interview on 07/22/26 at 3:39 P.M. with DOR #945 revealed Resident #45 needed supervision at the time of the evaluation because he was not able to feed himself. DOR #945 indicated Resident #45 needed a lot of cueing for eating, needed to take small bites alternating with sips of liquid and it was not ideal to set up his meal tray and leave the room because he needed help. DOR #945 revealed Resident #45 was seen on 07/08/26 by therapy and when they entered his room, he had a straw and thin liquids.Observation on 07/22/26 at 4:10 P.M. revealed Resident #45 was sitting in a chair in his room. Resident #45 was holding a cup, and the cup had a lid with a straw in it and he took a sip of the drink with his straw. There were no staff in the room with Resident #45.Observation on 07/22/26 at 4:12 P.M. of Resident #45 with DOR #945 revealed Resident #45 was sitting in a chair in his room with an empty cup observed on the bedside table and the lid and straw were on the table next to the cup. DOR #945 confirmed Resident #45 had a straw, and he was not supposed to have straws.An interview on 07/22/26 at 4:21 P.M. with DOR #945 revealed DOR #945 reviewed Resident #45's notes and paperwork from the hospital and everything stated he should be supervised when eating. DOR #945 indicated Resident #45 could feed himself, but he needed nectar thick liquids, and he had trouble initiating and following through after his stroke. DOR #945 revealed staff should stay in Resident #45's room when he was eating his meals. DOR #945 indicated the straw put too much liquid back too quickly and increased the risk for aspiration. An interview on 07/22/26 at 4:30 P.M. with DOR #945 revealed Resident #45's care plan stated no straws and assist with oral intake. Resident #45's aide Kardex stated to assist with by mouth (po) intake and no straws. An interview on 07/23/26 at 9:18 A.M. of LPN #606 confirmed Resident #45's physician orders did not reveal an order to place whole pills in pudding or applesauce. LPN #606 indicated she admitted Resident #45 and knew his medications were supposed to be placed whole in applesauce or pudding and that was how she administered them. LPN #45 stated she must not have put the order in the system when she admitted Resident #45.Review of the facility policy titled Residents' Rights, effective 10/03/23, included residents upon admission and thereafter, had the right to adequate and appropriate medical treatment and nursing care and to other ancillary services that comprised necessary and appropriate care consistent with the program for which the resident contacted.This deficiency represents non-compliance investigated under Complaint Numbers 3021865, 2799196, and 2656594.

Based on medical record review, observation, interview, review of dialysis transfer agreement, and facility policy review, the facility failed to ensure residents were transported to dialysis treatments. This affected one resident (Resident #106) of one resident reviewed for dialysis services. The facility census was 95.Findings include:Review of the medical record for Resident #106 revealed he was admitted to the facility on [DATE] with diagnoses that included dependence on renal dialysis, end stage renal disease, type two diabetes mellitus with diabetic neuropathy, hypertensive heart and chronic kidney disease with heart failure and end stage renal disease. Review of the care plan dated 02/10/26 revealed Resident #106 was dependent on dialysis and received hemodialysis three times a week with interventions that included minimizing complications and follow physician orders. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #106 had a Brief Interview for Mental Status (BIMS) score of 13 that indicated he had no cognitive impairment. Resident #106 was impaired on both sides of upper and lower bilateral extremities, was dependent on staff for activities of living and was dependent on dialysis.Review of the nursing progress notes revealed on 07/05/26 Resident #106 was sent to the emergency room for an evaluation due to a change in condition and subsequently was admitted to the hospital and was re-admitted to the facility on [DATE]. Review of the physician orders dated 07/20/26 revealed Resident #106 was to receive hemodialysis three times a week, Monday, Wednesday, and Fridays with pick-up time of 6:15 A.M. Review of the order revealed Resident #106 was to be transported by local transport and to be in the facility lobby at 5:15 A.M. Observation and interview on 07/22/26 at 6:35 A.M. revealed Resident #106 was sitting in his wheelchair in the lobby located at the front entrance of the facility. Resident #106 stated I'm waiting for my dialysis transport. Observation and interview on 07/22/26 at 7:45 A.M. revealed Resident #106 in the hallway speaking with Social Services Designee (SSD) #903 discussing his dialysis transport not showing up. SSD #903 informed Resident #106 he missed his dialysis appointment due to not having transportation in place. SSD #903 revealed Resident #106 missed his dialysis transport because it was not set up due to his recent return from the hospital. Resident #106 asked SSD #903, What does that have to do with it? and SSD #903 replied that it did not matter whether he had just recently returned from a hospital stay, dialysis transport should be setup. Observation and interview on 07/22/26 at 7:52 A.M. revealed Resident #106 sitting near the entrance of the facility in his wheelchair, visibly upset. Resident #106 revealed something happened with his transportation to dialysis and now he had to sit in his wheelchair until 10:30 A.M. and he was very uncomfortable. Interview on 07/22/26 at 8:08 A.M. with SSD #903 revealed it was the facility's responsibility to call and alert the dialysis center of any updates regarding residents including hospitalizations. Interview on 07/22/26 at 8:09 A.M. with the Administrator revealed the facility had a transporter for residents needing transportation to and from appointments. Resident Transporter (RT) #629 was the facility driver and transporter. RT #629 set up transportation for all appointments including dialysis. Resident #106 was a long-standing dialysis resident with automatic transport in place, and he was unsure of what happened. Interview on 07/22/26 at 1:45 P.M. with unit manager Licensed Practical Nurse (LPN) #705 revealed Resident #106 was up and ready at 5:00 A.M. for his transport to dialysis. The staff thought he had already left the facility for his scheduled dialysis appointment and was not sure why transportation did not pick him up. Interview on 07/27/26 at 9:03 A.M. with RT #629 revealed she was responsible for setting up appointments for transportation to and from appointments for residents. Staff nurse's schedule appointments and then notified her to set up transport. RT #629 revealed his dialysis transport was automatic and when he transferred to the hospital the facility did not update the dialysis center. The dialysis center continued to attempt to pick up Resident #106 and after not being successful, they stopped coming. The facility was responsible for notifying the dialysis center of the residents' changes to ensure consistent care to and from the facility. RT #629 confirmed and verified the facility failed to update the dialysis center to ensure transportation to and from the facility for Resident #106's dialysis appointments. Review of the facility nursing home dialysis transfer agreement dated November 2023, revealed the facility had an agreement in place with the dialysis provider to provide dialysis services. The facility was responsible for arranging transportation of designated residents to and from the dialysis center including the mode of transportation and qualified personnel to accompany the resident. Review of the facility document titled Dialysis Monitoring revised December 2022, revealed the facility had a policy in place that the facility would maintain the safety and health of resident receiving dialysis services on a routine basis by ensuring each resident received care and services for the revision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice. This deficiency represents non-compliance investigated under Complaint Numbers 2582257 and 1405092 (OH00167225).

Based on medical record review and staff interview, the facility failed to ensure as needed (PRN) medications had a valid indication for use and non-pharmacological interventions were attempted. This affected two residents (Residents #25 and #30) of eight residents reviewed for unnecessary medications. The facility census was 95.Findings include:1. Review of the medical record for Resident #25 revealed an admission date of 10/02/23 and a readmission date of 06/19/25 with diagnoses including paranoid personality disorder, dementia, and restlessness and agitation. Review of the physicians' orders for July 2026 revealed Resident #25 was prescribed 25 milligrams (mg) of hydroxyzine orally every six hours PRN for agitation.Review of the electronic medication review note (e-MAR) dated 07/16/26 revealed that Resident #25 received the PRN 25 mg of hydroxyzine with no documentation of Resident #25 having behaviors prior to administration. Further review of the progress notes and MARS revealed that no behaviors were documented for Resident #25 on 07/16/26.Interview on 07/20/26 at 10:02 A.M. with Licensed Practical Nurse (LPN) #819 verified that Resident #25 had no documented reason for the administration of hydroxyzine PRN on 07/16/26.2. Review of the medical record for Resident #30 revealed an admission date of 10/25/23 and a readmission date of 06/19/25 with diagnoses including paranoid schizophrenia, dementia, and anxiety disorder. Review of the physicians' orders for July 2026 revealed Resident #30 was prescribed 25 mg of hydroxyzine orally every six hours PRN for agitation for 14 days with an end date of 07/17/26.Review of the e-MAR dated 07/07/26 revealed that Resident #30 received the PRN 25 mg of hydroxyzine with no documentation of Resident #30 having behaviors prior to administration. Review of the e-MAR dated 07/14/26 revealed that Resident #30 received the PRN 25 mg of hydroxyzine with no documentation of Resident #30 having behaviors prior to administration. Review of the e-MAR dated 07/15/26 revealed that Resident #30 received the PRN 25 mg of hydroxyzine with no documentation of Resident #30 having behaviors prior to administration. Further review of the progress notes and MARS revealed that no behaviors were documented for Resident #30 on 07/07/26, 07/14/26, and 07/15/26.Interview on 07/20/26 at 10:02 A.M. with Licensed Practical Nurse (LPN) #819 verified that Resident #30 had no documented reason for the administration of hydroxyzine PRN on 07/07/26, 07/14/26, and 07/15/26.Review of facility policy dated December 2017 labeled, Medication Monitoring Medication Management, revealed if a PRN medication was used to modify behavior, the indication(s) for use was clearly defined in objective terms for what specific symptom(s) was being addressed.

Based on closed medical record review, review of an Emergency Medical Services (EMS) report, facility policy review and interview, the facility failed to timely identify and provide adequate and necessary care for Resident #104, who experienced an acute change in condition. This resulted in Immediate Jeopardy and actual harm/death beginning on [DATE] when the facility failed to recognize and failed to timely and adequately respond to Resident #104's report of a low blood glucose level. On [DATE], at 12:18 A.M., Resident #104, who was known by staff to be a brittle diabetic, activated her call light and Certified Nursing Assistant (CNA) 636 responded. Resident #104 reported she needed a snack because her blood glucose level was low. CNA #636 reported she gave Resident #104 a snack and got side-tracked and did not report the change of condition to the nurse on duty, Licensed Practical Nurse (LPN) #637. CNA #636 did not round on Resident #104 after providing the snack. LPN #637 revealed she had last seen Resident #104 on [DATE] at approximately 9:50 P.M. when she administered her scheduled medications. Resident #104 had a Freestyle Libre System (continuous glucose monitoring (CGM) system that measures glucose levels through a small sensor worn on the arm, providing glucose readings without the need for finger pricks) and when administering her medications, LPN #637 based the amount of insulin administered on a verbal report (of the glucose level) from the resident. LPN #637 confirmed she did not make rounds on Resident #104 throughout the night, from 10:00 P.M. to 6:30 A.M. At approximately 6:30 A.M. Resident #104's husband arrived at the facility, found Resident #104 unresponsive, not breathing, and with no palpable pulse, and alerted the nurse. Resuscitative efforts began, Cardiopulmonary Resuscitation (CPR) was initiated, and Emergency Medical Services (EMS) were called. During resuscitative efforts, a blood glucose reading was obtained from the facility's glucometer which read registered low. Intramuscular (IM) glucagon (an emergency medicine used to treat severe hypoglycemia in diabetic patients, who cannot take some form of glucose by mouth) was administered during resuscitative measures with no noted effect. EMS arrived, determined Resident #104 had obvious signs of death including rigor and asystole (an arrythmia indicating the absence of electrical activity in the heart). Resident #104 was pronounced deceased at the facility. This affected one resident (#104) of three residents reviewed for changes in condition. The facility census was 103. On [DATE] at 11:39 A.M. the Administrator, Director of Nursing (DON), and Regional Clinical Nurse #640, were notified Immediate Jeopardy began on [DATE] at approximately 12:18 A.M. when Resident #104 reported her blood glucose was low, and the change of condition was not communicated to the nurse on duty for appropriate evaluation and timely intervention. Resident #104 received no further nursing care or monitoring from staff until Resident #104's spouse arrived at the facility at approximately 6:30 A.M. and was found Resident #104 unresponsive. Resident #104 was not breathing, and had no palpable pulse, and resuscitative efforts were attempted but unsuccessful. Resident #104 was pronounced deceased at the facility by EMS. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE] CNA #636 and LPN #637 were removed from the schedule pending an investigation into the events involving Resident #104. The investigation included interviewing staff regarding Resident #104's condition and staff interactions and reviewing Resident #104's medical record. • On [DATE] between 4:30 P.M. to 6:30 P.M. all 103 current residents of the facility were assessed for any changes in condition. This was completed by LPN Unit Manager (UM) #816 and LPN UM #904. • On [DATE], all 48 diabetic residents (#2, #5, #6, #7, #10, #11, #12, #13, #14, #15, #20, #22, #24, #25, #26, #27, #29, #30, #31, #32, #36, #38, #39, #40, #43, #45, #47, #52, #55, #56, #57, #61, #63, #64, #65, #69, #70, #71, #74, #75, #76, #79, #85, #88, #89, #95, #98, and #102) were assessed for changes in condition and blood glucose levels evaluated and verified for all residents with orders for blood glucose monitoring. Six of these residents (#10, #11, #22, #29, #63, and #89) were identified to have continuous glucose monitoring devices. This was completed by the DON. • On [DATE] between 4:00 P.M. and 11:00 P.M., all licensed nurses and Certified Nursing Assistants (CNAs) were educated on the facility's change in condition policy and procedure, including what constituted as a change in condition, timely reporting of changes in condition, and steps to take once a change is noted. This education was provided by the DON. • On [DATE] between 4:00 P.M. and 11:00 P.M., all licensed nurses and CNAs were educated on the facility's call light response policy which included answering call lights timely and routine resident rounding frequently during work shifts were provided. This education was provided by the DON. • On [DATE] between 4:00 P.M. and 11:00 P.M., all licensed nurses were educated on the facility's blood glucose monitoring policy, with specific components including following physician's orders for glucose testing and monitoring for signs and symptoms of hypoglycemia (low blood glucose level) and hyperglycemia (high blood glucose level). This education was provided by the DON. • On [DATE] LPN #637's employment was terminated for failing to meet performance standards related to attendance and frequent rounding on all residents, including Resident #104. • On [DATE] a Quality Assurance Performance Improvement (QAPI) meeting was held to discuss the events and investigation into the [DATE] incident with Resident #104. Present at the QAPI meeting were the Administrator, Director of Nursing, Medical Director #639, LPN UM #816, Human Resources Manager (HRM) #730, Rehabilitation Manager #643, and Activities Director #913. All findings, including incidental, were shared and discussed, as well as the facilities plan of action to correct any deficient practice. • Beginning on [DATE], an audit including visual observation of three licensed nurses performing glucose checks accurately, including the use of continuous glucose monitoring systems, began and would be completed weekly for four (4) weeks duration. This would be completed by the DON or designee. • On [DATE], CNA #636 was terminated for falsification of documentation related to her conflicting statements provided during the incident with Resident #104. • Beginning on [DATE], an audit was implemented to review blood glucose readings of five (5) diabetic residents three (3) times a week for four (4) weeks to ensure any readings outside of ordered parameters had physician notification. This audit would be completed by the DON or designee. • Beginning on [DATE], an audit was implemented to interview three CNA'S three times a week for four weeks regarding changes in condition with notification of nurse and physician. This would be completed by the DON or designee. • On [DATE], all licensed nurses were re-educated on blood glucose monitoring to include the continuous glucose monitoring system and that the nurse must verify the blood glucose reading by either visualizing the screen with the result or by utilizing the facility glucometer. This education was provided by the DON. • Beginning on [DATE], an audit was implemented to ensure staff were rounding and making visual observation of residents every two to four hours. The audit would include interviewing five residents and making visual observations of three staff members. The audit would be completed three times a week for four weeks and would include including both day and night shift. The Administrator would monitor the audits for ongoing compliance. • The results of all audits would be reviewed by the Administrator and the facility's QAPI committee for further review and prompt response and resolution. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of Resident #104's closed medical record revealed the resident was admitted to the facility on [DATE]. Resident #104 had medical diagnoses including type one diabetes mellitus (DM) with neuropathy and retinopathy, chronic pancreatitis, chronic kidney disease and dependence on renal dialysis and systolic congestive heart failure. Resident #104 was pronounced deceased at the facility on [DATE] at 6:52 A.M. Review of Resident #104's physician's orders revealed an order dated [DATE] for insulin glargine (long-acting insulin) 10 units subcutaneous in the morning for diabetes. Resident #104 also had an order dated [DATE] for insulin lispro (short-acting insulin) three units subcutaneous before meals in addition to sliding scale coverage. Resident #104's sliding scale insulin coverage included for a blood glucose of 151 to 200, give one unit of insulin. For a blood glucose result of 201 to 250, give 2 units. For a blood glucose result of 251 to 300, give 3 units. For a blood glucose result of 301 to 350, give 4 units. For a blood glucose result of 351 to 400, give five units. If blood glucose was less than 70 or greater than 401, notify the provider immediately. Review of the care plan initiated on [DATE] revealed the resident had a diagnosis of diabetes with hyperglycemia and hypoglycemia. The care plan noted Resident #104 utilized a FreeStyle Libre Continuous Glucose System. Listed interventions included utilizing the FreeStyle Libre per physician's orders, administer diabetes medication as ordered by the doctor, and to observe for side effects and effectiveness. Additional interventions included to observe as needed (PRN) for any signs or symptoms of hypoglycemia, including sweating, tremor, tachycardia (increased heart rate), pallor, nervousness, confusion, slurred speech, lack of coordination, and a staggering gait. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #104 had intact cognition. The assessment revealed Resident #104 was independent with all activities of daily living (ADL'S). Review of the facility's Alarm Event Report dated [DATE] to [DATE] revealed Resident #104's call light was activated on [DATE] at 12:18 A.M. The alarm was cleared by staff on [DATE] at 12:21 A.M. Record review revealed no corresponding nursing progress note completed at this time or at any time until a note entered by LPN Unit Manager (UM) #815 on [DATE] at 07:45 A.M. Review of a local EMS Prehospital Care Report Summary, dated [DATE] at 06:40 A.M. revealed EMS received a call from the facility and arrived at facility at 06:46 A.M. Review of the narrative history revealed Resident #104 was a full arrest. EMS providers asked facility staff when Resident #104 had last been seen normal, to which staff reported Resident #104 was found by the husband. Resident #104 was noted in her room with an automated external defibrillator (AED, a medical device used to treat cardiac arrest by delivering an electric shock to the heart, restoring a normal heart rhythm) applied. Manual Cardiopulmonary Resuscitation (CPR) was in progress, and manual respirations were being administered. The AED did not call for a shock. The EMS provider requested again when the resident was last seen normal, with staff reporting the resident was last observed normal the night prior, and Resident #104 was found unresponsive when the husband arrived to the facility and found her approximately 20-30 minutes prior. Resident #104 was noted with no pulse, she was not breathing, and the report noted Resident #104 was cold to the touch with rigor (condition that causes the muscles in the body to stiffen after death and typically begins two (2) to six (6) hours after death) noted in the resident's right arm. The EMS provider took over CPR, stopped for a rhythm check and again noted rigor was present. The EMS providers placed Resident #104 on the monitor with asystole (an arrythmia indicating the absence of electrical activity in the heart) noted in multiple leads. CPR was taken over by the fire department, stopped for rhythm check and rigor was noted. The EMS providers communicated with a physician at a local hospital, provided a report, and Resident #104's time of death was called as [DATE] at 6:52 A.M. Review of the death certificate dated [DATE] and signed by Physician #639 revealed Resident #104's causes of death to include End Stage Renal Disease (ESRD) on hemodialysis (HD), heart failure (HF) related to Ejection Fraction (EF), and diabetes mellitus Type 1. Review of the progress note dated [DATE] at 07:45 A.M. and authored by LPN UM #816 revealed Resident #104 was found unresponsive lying in bed. Resident #104 was a full code and a code was called. CPR was initiated and EMS was called. The AED machine was utilized, pads were placed, the AED machine indicated no shock was advised and to continue with CPR. CPR was continued. During resuscitative efforts, Resident #104's blood glucose was checked and read low on the machine. One dose (strength and amount not noted) of intramuscular glucagon was given. EMS arrived on scene at approximately 6:50 A.M. and took over CPR. Resident #104's heart rhythm was assessed by the EMS's monitor and showed asystole. The EMS providers contacted a local hospital and Resident #104 was pronounced at 6:52 A.M. by Physician #638. Resident #104's husband was present at the facility and notified of Resident #104's death. The DON was made aware of Resident #104's death. Interview on [DATE] at 1:12 P.M. with the DON revealed during the facility investigation of Resident #104's death, the facility determined CNA #636 responded to Resident #104's call light (on [DATE]) between 3:00 A.M. and 4:00 A.M. based on a telephone interview with CNA #636 the afternoon following Resident #104's death. (This was subsequently noted to be inaccurate during the State agency investigation as per the facility call light audit report and interview with CNA #636 the resident's call light had been activated at 12:18 A.M.). The DON reported when CNA #636 answered the light, Resident #104 reported she needed a snack because her blood glucose was low. The DON reported CNA #636 gave Resident #104 a snack but did not report Resident #104's change of condition, her report of the low blood glucose, to LPN #637. The DON reported CNA #636 was later terminated due to not reporting the resident's change in condition to the nurse. The DON reported she interviewed LPN #637 who stated she did not see Resident #104 after [DATE] at approximately 10:00 P.M. The DON reported LPN #637 was terminated due to issues identified during the investigation, including LPN #637's failure to round or check on Resident #104 from [DATE] at 10:00 P.M. to [DATE] at approximately 6:30 A.M. The DON reported the investigation identified the last time LPN #637 saw Resident #104 was on [DATE] before 10:00 P.M. The DON reported it was the expectation of staff to round on patients at least every two hours. Interview on [DATE] at 7:58 A.M. via phone with Certified Nursing Assistant (CNA) #636 revealed (on [DATE]) between approximately 12:30 A.M. to 1:00 A.M. she answered Resident #104's call light. Resident #104 reported she needed a snack because her blood glucose was low. CNA #636 reported she gave the resident a cream-filled oatmeal cookie for a snack. CNA #636 reported she got side-tracked and never reported the change in condition to LPN #637 as she should have. CNA #636 reported she was terminated following the incident and indicated she was supposed to notify the nurse immediately of a change in resident condition and was supposed to round on residents every two hours. Interview on [DATE] at 8:26 A.M. with LPN #637 revealed she attempted to give Resident #104 her medications (on [DATE]) at approximately 9:00 P.M. However, Resident #104 was busy and wanted her to return at a later time. LPN #637 reported she returned between approximately 9:45 P.M and 9:50 P.M. and administered Resident #104 her medications. LPN #637 reported Resident #104 checked her CBG device and reported her blood glucose level was 229. LPN #637 stated she did not verify the resident's blood glucose reading (by reviewing the device), as she was required to do. LPN #637 reported she administered two units of insulin lispro solution pen-injector per sliding scale as ordered. LPN #637 reported she was terminated following the incident for not checking Resident #104's CBG monitor result and not rounding on residents every two hours (as well as an issue with attendance). Interview on [DATE] at 9:57 A.M. with the Administrator verified on [DATE] at 12:18 A.M. Resident #104's call light was activated and was answered at 12:21 A.M. by CNA #636. The Administrator reported Resident #104 reported her blood glucose was low, and she needed a snack. The Administrator reported CNA #636 provided a snack but failed to notify the nurse of a change in condition, as required. The Administrator revealed the next time the resident's call light was activated on [DATE] was at 6:39 A.M. by staff during code in progress. The Administrator confirmed CNA #636 failed to notify LPN #637 of a change in condition and LPN #637 failed to check Resident #104's blood glucose, do an assessment for change in condition, and round on resident. The Administrator revealed the expectation was for CNA and LPN staff to round every two hours on residents, nurses to check the blood glucose reading of continuous monitoring devices and not take the word of the resident and CNA staff to report a change in condition timely to the nurse. Interview on [DATE] at 10:10 A.M. with Physician #639 revealed Resident #104 was a brittle diabetic and he expected nursing staff to check the continuous monitoring devices for blood glucose checks. Physician #639 reported Resident #104's diagnoses of ESRD and diabetes mellitus were major contributing factors in her death. Interview on [DATE] at 12:24 P.M. with LPN UM #816 revealed on [DATE] she overheard the nurse state Resident #104 was unresponsive and assisted with the code. LPN UM #816 reported CPR was initiated, and the resident's blood glucose level was checked. The blood glucose level read low on the glucometer. LPN UM #816 revealed if the result read low or lo on the glucometer, it meant the blood glucose level was 20 or below. LPN UM #816 reported intramuscular glucagon was administered, and CPR was continued. LPN UM #816 reported 911 arrived and took over CPR but Resident #104 was asystole on the monitor and was pronounced deceased by EMS at that time. LPN UM #816 confirmed the CNAs and LPNs were expected to round on residents every two hours. LPN UM #816 confirmed the expectation was for CNAs to notify the nurse immediately of a change in condition and the expectation was for the nurse to immediately assess any change in condition. LPN UM #816 confirmed LPN #637 should have confirmed the resident's evening blood glucose reading to verify accuracy and not take the residents verbal word before administering insulin. LPN UM #816 revealed she spoke with LPN #637 on [DATE] at approximately 7:30 A.M. to get a statement of what happened. LPN #637 confirmed the last time she saw Resident #104 was around [DATE] at 10:30 P.M. LPN UM #816 confirmed LPN #637 should have been checking on Resident #104 every two hours. LPN UM #816 revealed she spoke with CNA #636 on [DATE] at approximately 7:45 A.M. and confirmed last time CNA #636 saw the resident was on [DATE] between 12:00 A.M. and 1:00 A.M. LPN UM #816 reported she verbally notified the DON on [DATE] of the statement findings for CNA #636 and LPN #637. A telephone interview on [DATE] at 2:02 P.M. with Resident 104's husband revealed he arrived to the facility on [DATE] at 6:30 A.M. and found Resident #104 unresponsive. Resident 104's husband reported he last spoke with Resident #104 on [DATE] at 11:00 P.M. and stated the resident had reported at that time her blood glucose reading was in the 200's. Resident 104's husband reported Resident #104 was her normal self and there was nothing abnormal at that time. Resident 104's husband then stated he had concerns with the resident's care and how staff treated her. Resident 104's husband reported facility staff had not been very prompt and when the resident had blood glucose problems in the past, the resident would have to go and find staff to assist. Resident 104's husband reported he had concerns with staff not checking on Resident #104 frequently and if she needed medication or insulin she would have to find staff at time. Interview on [DATE] at 3:31 P.M. with LPN #717 revealed he did not receive education on continuous glucose monitoring (CGM) as part of the recent in-service on blood glucose checks. Interview on [DATE] at 3:41 P.M. with LPN #705 revealed she did not receive education on CGM as part of the recent in-service on blood glucose checks. An additional interview on [DATE] at 9:12 A.M. with Physician #639 revealed he was notified of the incident with Resident #104 at the facility's QAPI meeting when he was told of the low blood glucose which occurred on [DATE]. However, another physician was actually on-call at the time of the incident. Physician #639 reported he was unaware staff did not routinely round on Resident #104 on [DATE] and was unaware that CNA #636 had not reported a change in condition to the nurse on duty for a timely assessment of Resident #104 on [DATE]. Review of the MediVena One-Care PRO Blood Glucose Monitoring System Manufacturer Book, revealed on page 16, If a LO message appears on the display, your meter has detected your blood glucose level is lower than 20 milligrams per deciliter (mg/dl). It is suggested you review your testing procedure and test again with a new test strip to confirm the result. If the same result occurs, consult your healthcare professional immediately. Review of facility, Call Lights - Answering, revised [DATE], revealed staff would respond to resident's call light in a timely manner and throughout the shift nursing staff should periodically round the unit and visualize residents to ensure that the call light was in reach and needs were met. Review of facility policy, Blood Glucose Testing and Management revised [DATE], revealed the purpose was to determine a resident's blood glucose baseline, manage diabetes, prevention of complications and to identify variations in a resident's blood glucose levels. The licensed nurse would monitor the resident for signs or symptoms of hypoglycemia or hyperglycemia. Review of facility policy, Resident Change in Condition dated [DATE], revealed the purpose was to ensure staff provide timely and appropriate care and services when residents experience a change in condition that has or was likely to cause serious life-threatening harm or injuries and/or adverse negative health outcomes. The facility would notify the resident physician and responsible party of changes in the residents' condition and/or status. Licensed nurse would take immediate action to ensure timely and appropriate care and services were met when a resident change in condition was identified. Licensed nurse would notify the attending physician regarding the change in condition once an assessment of the resident had been completed. This deficiency represents the non-compliance investigated under Complaint Number OH00165604.

Based on closed medical record review, review of a Prehospital Care Report Summary/EMS Run report, review of the American Heart Association Cardiopulmonary Resuscitation (CPR) guidelines, facility policy review, interview with Emergency Medical Service (EMS) staff, staff interview and family interview, the facility failed to ensure all staff provided effective cardiopulmonary resuscitation (CPR). Additionally, the facility failed to ensure crash carts (a cart that holds equipment and includes a backboard, a hard, flat surface to facilitate effective chest compressions and an ambu bag, used to provide mechanical ventilation) in emergency resuscitation efforts were readily available and accessible during a cardiac emergency. This resulted in Immediate Jeopardy and actual harm/subsequent death when staff failed to initiate effective CPR for Resident #101 who experienced a cardiac emergency on [DATE]. At the initiation of the cardiac emergency, Resident #101 ' s family was with the resident in her room and yelled for help. Responding staff, Licensed Practical Nurse (LPN) #206 and State tested Nursing Assistant (STNA) #310, entered Resident #101 ' s room and found the resident was vomiting. LPN #206 left the room, indicating she was calling 911, and STNA #310 left to have LPN #207 print transfer documents (for the resident to go to the hospital). LPN #207 then returned to Resident #101's room at which time the resident was noted to lose consciousness and pulse. LPN #207 directed STNA #310 to get the crash cart and LPN #207 initiated CPR, with Resident #101 remaining in bed on her mattress. STNA #310 was unable to immediately locate the crash cart and EMS staff had arrived to the resident by the time STNA #310 located a crash cart on the secured unit of the facility and returned to Resident #101 ' s room. Without the presence of a crash cart, LPN #207 provided CPR to Resident #101 for approximately four minutes on her mattress (which decreased the effectiveness of CPR) and failed to provide any type of mechanical ventilation (via ambu bag) during this time. Upon EMS arrival, Resident #101 remained without a pulse or respirations. Resident #101 was moved to the EMS cot, a LUCAS device (provides mechanical chest compressions) was applied, and CPR was continued. Resident #101 was transferred to the hospital and subsequently expired on [DATE]. This affected one resident (#101) of one resident reviewed for CPR. The facility census was 95. On [DATE] at 12:44 P.M., the Administrator, Director of Nursing (DON), and Regional Registered Nurse (RRN) #920 were notified Immediate Jeopardy began on [DATE] when Resident #101 experienced a cardiac emergency. Facility staff left Resident #101 in her room, with her son, while LPN #206 called 911 and STNA #310 had LPN #207 print transfer documents. Resident #101 subsequently went into cardiac arrest. LPN #207 initiated CPR on a mattress without necessary supplies, including a backboard for support to provide good quality/effective chest compressions and an ambu bag to provide ventilation. Additional staff did not respond to provide assistance with CPR and staff were unable to immediately locate the crash cart. EMS arrived and assumed care for Resident #101, who was without a pulse or respirations. Resident #101 was admitted to the hospital and subsequently expired on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: Resident #101 was transferred to the hospital on [DATE] and expired on [DATE]. On [DATE], the Administrator, DON and RRN #920 conducted an investigation into the incident on [DATE] and determined the facility did not provide timely CPR. On [DATE], the DON provided education to all licensed nursing staff, including 10 Registered Nurses (RN) and 18 Licensed Practical Nurses (LPN), on crash cart locations and the Cardiopulmonary Resuscitation Policy and Procedure. This was completed in-person and via telephone. On [DATE], all residents with advance directives for a Full Code status had vital signs assessed by the DON or designee and found to be stable. Medical Director (MD) #500 was updated on resident status and no negative outcomes were identified. Further assessment on [DATE] by the DON of residents who expired in the past 60 days revealed no areas of concern related to CPR. On [DATE], the DON educated all non-licensed facility staff on the CPR policy and procedure and the location of crash carts. This education included 16 dietary staff, 12 housekeeping staff, two activities staff, five therapy staff, nine department heads and four receptionists. Beginning on [DATE], the DON or RRN #920 would ensure all agency staff were educated on the CPR policy and procedure and location of crash carts prior to working a shift. Beginning on [DATE], the DON or designee would audit all crash cart locations five times weekly, and with any use, for four weeks. Beginning on [DATE], the DON or designee would audit all residents who required CPR to ensure appropriate CPR procedures were followed per facility policy, five times weekly for four weeks. On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) committee meeting was held to review the CPR policy and procedure, education to be provided to facility staff and the location of crash carts. In attendance were the Administrator, DON, RRN #920 and MD #500. All audit findings of concern would be immediately addressed and reported to the QAPI committee for further review and prompt response and resolution. The Administrator and/or designee would monitor this area for ongoing compliance. Interviews on [DATE] between 5:25 P.M. and 5:31 P.M. with LPN #207, LPN #289, LPN #940, LPN #942 and STNA #942 confirmed they each received re-education on the facility's CPR policy and procedure and the locations of crash carts. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #101's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE]. Resident #101 had diagnoses including encounter for surgical aftercare following surgery on the digestive system and ileostomy. Review of the care plan dated [DATE] revealed Resident #101 had a Full Code status (advance directives). Interventions included performing CPR in the event of cardiopulmonary arrest. Review of the Medicare five-day Minimum Data Set (MDS) dated [DATE] revealed Resident #101 was cognitively intact. The assessment revealed Resident #101 was independent with eating, required substantial/maximum (staff) assistance with toileting, supervision or touch assistance with bed mobility and partial moderate assistance with sit to stand and chair transfers. The MDS identified Resident #101 had no condition or chronic disease that may result in a life expectancy of less than six months. Resident #101 had a recent surgery requiring active skilled nursing facility care. Review of the progress note dated [DATE] at 2:30 P.M. and created by LPN #206 revealed Resident #101's call light was ringing, staff member answered the light, resident stated she was okay and noted her son was present. This nurse was informed by another staff member that the resident was observed ambulating from the bathroom back to her bed at that time. Resident #101 was now sitting upright in bed. Review of the progress note dated [DATE], created at 7:17 P.M., with an effective time of 3:10 P.M. and completed by LPN #206 revealed Resident #101 emptied her ileostomy with no apparent issues. Around 3:25 P.M., Resident #101 was back in bed when the nurse heard yelling coming from the room. Resident #101's son was screaming. The nurse and another staff member ran into the room to assess the situation. Resident #101's son was holding the trash can up to the resident's mouth. Resident #101 was vomiting at this time. Resident #101 looked pale, so this nurse felt for a pulse. The note indicated the resident's pulse was weak and thready. LPN #206 sent another staff member out to get assistance. Other nurses assisted by placing a call to 911 and obtaining proper paperwork for EMS. The note indicated the resident lost consciousness, there was no pulse and CPR was initiated. EMS arrived and continued with CPR. Resident #101's pulse was restored as paramedics were leaving the facility. Physician (MD) notified of events. Review of the progress note dated [DATE] at 10:12 A.M. and completed by LPN #213, revealed a call was placed to the hospital and Resident #101 was admitted to telemetry unit (provides continuous cardiac monitoring). Review of the draft progress note dated [DATE] at 6:31 P.M. and completed by LPN #207, revealed an STNA came to the nursing desk and asked this nurse to print out paperwork and face sheet for a hospital transfer. After printing out papers, this nurse went to see if assistance could be provided. Upon entering Resident #101's room, the resident was found with her eyes closed and had a faint pulse. Resident #101 began to dry heave and the nurse placed the garbage can in front of the resident. After putting the garbage can in front of Resident #101, the resident became unresponsive, with no pulse. This nurse immediately put the head of the bed down and immediately started CPR, while another nurse called 911. This nurse, after starting CPR, yelled for the crash cart while CPR continued. Another nurse walked in the room for assistance while CPR continued. The crash cart arrived in the room. As the crash cart was in the room, EMS arrived at the facility. The draft progress note documented after paramedics assessed the resident for a pulse, Resident #101 had a faint pulse and no respirations. While this nurse and paramedics moved resident from the bed to the gurney, Resident #101 had no pulse. CPR continued on the gurney until paramedics put the LUCAS machine on and was doing compressions. Resident #101 left the facility with EMS and was transported to the hospital. Review of the Prehospital Care Report/EMS Run Report summary revealed EMS was called on [DATE] at 3:24 P.M. for Resident #101. The dispatch reason indicated provider impression was cardiac arrest. EMS was onsite at 3:32 P.M. Additional information indicated the healthcare provider (non 911 responder) first initiated CPR, manual compressions provided. The estimated time of arrest was 3:24 P.M. and the time of first CPR was 3:25 P.M. EMS left the scene at 3:45 P.M. and Resident #101 was receiving ongoing resuscitation in the Emergency Department (ED). Further review revealed EMS was dispatched for an unresponsive female who was vomiting. Upon arrival, nursing staff were performing CPR only on the resident. Resident #101 was apneic (a condition where a person involuntarily stops breathing) and pulseless. CPR with bag mask ventilation (BMV) was taken over by EMS. The resident's son stated the resident hit the call light an hour ago and complained of dizziness and nausea. As time went on, the resident became worse and started to vomit. Once Resident #101 vomited, she arrested per nursing staff. Nursing staff witnessed the arrest and started performing CPR. Resident #101 was moved over to the cot and the [NAME] device and monitor was applied to the resident. Resident #101 showed agonal breathing (when someone is not getting enough oxygen, not true breathing, natural reflex that happens when your brain is not getting needed oxygen to survive). CPR resumed. Resident #101 was loaded into the ambulance, CPR still in progress, intravenous (IV) access obtained, and Resident #101 was given epinephrine (epi) IV. Resident #101 was intubated (tube inserted through mouth or nose then down into trachea, allows air to get through), at pulse check the resident was in pulseless electrical activity (pea - no pulse), resident was given a second epi, CPR resumed, resident was given a third epi at the next pulse check and resident was in pea and CPR resumed. At the next pulse check, the resident had a pulse. As Resident #101 was taken in the ED room, the resident became pulseless, and CPR resumed. A telephone interview on [DATE] at 11:11 A.M. with Resident #101's husband revealed Resident #101 had passed away at the hospital on [DATE]. A telephone interview on [DATE] at 3:13 P.M. with Resident #101's son revealed he visited the resident the morning of [DATE] and when he left, around 11:30 A.M., he had no concerns. At approximately 3:00 P.M., Resident #101 called him, crying and asking for help because she told him her call light was not being answered. Resident #101's son stated he left home and arrived to the facility approximately five minutes later. Resident #101's son stated the resident complained of nausea. He assisted her with emptying her ostomy bag and going back to bed. Resident #101's son stated the resident was white as a ghost and very pale. Resident #101's son stated he gave the resident a few small sips of cranberry juice, she stated she was going to be sick, he picked up the trash can, and the resident began to vomit. Resident #101's son stated her head fell back, her eyes were very wide, and her breathing was rigid. Resident #101's son stated he began yelling for help. An STNA entered the room and the resident's son stated his mother needed help. Resident #101's son stated the STNA did not move. A nurse came in, touched Resident #101, stated she was ice cold and told the STNA to call 911. The STNA still did not move. The nurse was attending to Resident #101 and pulled a phone out of her pocket and called 911. After three to four minutes, a male nurse came in and began performing CPR on Resident #101. Resident #101's son stated the nurse performed CPR on the mattress, with no backboard, and yelled for a crash cart four or five times. Resident #101's son stated the crash cart got to the room at the same time as EMS. Resident #101's son stated he believed had staff checked on the resident, they would have seen how pale she was and could have done something sooner. Telephone interviews between [DATE] at 3:59 P.M. and [DATE] at 2:56 P.M. with First Responder Captain (FRC) #208 with the local fire department revealed upon EMS arrival on [DATE], facility staff were administering chest compressions only to Resident #101. FRC #208 stated there was no evidence the resident was breathing. During the interviews, FRC #208 voiced concerns related to how staff were performing CPR in that CPR was being administered on the resident's mattress and there was no backboard (or hard surface) under Resident #101. FRC #208 stated the crash cart arrived at Resident #101's room as EMS were coming up the hall. FRC #208 confirmed the facility staff did not have an ambu bag present to provide ventilation to the resident while performing chest compressions. While the facility nurse stated he felt a pulse, FRC #208 stated EMS never felt or observed a pulse or respirations prior to transferring Resident #101 to the cot, further stating that was why EMS needed to continue CPR. FRC #208 stated a hard surface provided better quality chest compressions, adding if chest compressions were provided on a bed, the energy was going into the bed instead of the chest. As a result of not having a backboard under Resident #101, the chest compressions administered were not as good of quality or effective CPR. Interview on [DATE] at 8:59 A.M. with STNA #310 revealed on [DATE], Resident #101's call light was on. STNA #310 stated she entered the resident's room and the resident's son stated he did not need her. STNA #310 stated she went to the nurse's station then heard loud screaming coming from Resident #101's room. STNA #310 stated she entered the resident's room and asked what was happening. Resident #101 was projectile vomiting. She stated she sat the resident up and LPN #206 entered the room. LPN #206 realized Resident #101 wasn ' t with it and walked out to call 911. STNA #310 stated Resident #101 was cold, blue, and in and out of consciousness. STNA #310 stated she left Resident #101's room to have LPN #207 print transfer documents. STNA #310 stated LPN #207 asked what was going on and after STNA #310 explained, he stated LPN #206 should have called a Code Blue. STNA #310 stated LPN #207 went to Resident #101's room and the resident was not breathing. STNA #310 stated LPN #207 began chest compressions and asked for a crash cart. STNA #310 stated she ran all over the building looking for a crash cart, including three nurse's stations, before locating one on the secured memory care unit. By that time, STNA #310 stated EMS were onsite. A telephone interview on [DATE] at 9:14 A.M. with LPN #207 revealed on [DATE], STNA #310 asked him to print papers to send Resident #101 out to the hospital. LPN #207 stated he went (to the resident ' s room) to see if he could help. LPN #207 stated when he entered Resident #101's room, the resident was breathing, with her head down. LPN #207 stated Resident #101 began to dry heave and he placed a trash can in front of her. LPN #207 stated Resident #101 then went limp, stopped breathing and had no pulse. The LPN stated he began chest compressions immediately and called for help. LPN #207 stated LPN #206 was there but then she went to call 911. LPN #207 stated he yelled for the crash cart, but it arrived at the room at the same time as EMS. LPN #207 verified Resident #101 was lying on a regular bed mattress, staff did not provide ventilation to Resident #101 during CPR and there was no backboard or hard surface used while he administered chest compressions. LPN #207 stated he believed he felt a faint pulse prior to EMS transferring Resident #101 but once transferred to the cot, Resident #101 lost the pulse again. While LPN #207 stated LPN #206 initially froze during the event, she (LPN #206) called 911. A telephone interview on [DATE] at 9:28 A.M. with LPN #206 revealed on [DATE] she heard Resident #101's son yelling. She was at the medication cart and went to see what was happening. LPN #206 stated Resident #101 was vomiting, her color was off, so she sent STNA #310 to get transfer paperwork, and she left to call 911. LPN #206 stated she checked Resident #101's vital signs and her pulse was weak. (The nurse did not document the vital signs in the resident's medical record). LPN #206 stated she was at the nurse's station calling 911 when LPN #207 went to Resident #101's room. LPN #206 stated, after calling 911, she went back to Resident #101's room and LPN #207 was doing chest compressions. Someone yelled to get the crash cart. LPN #206 confirmed the crash cart arrived at the room at the same time as EMS. Review of the American Heart Association (AHA) 2024 guidance for adult CPR included the following: Check for breathing, if the person is not breathing or only gasping, begin CPR; Chest compressions included to push down hard and fast at a rate of 100 to 120 compressions per minute; After every 30 compressions, give two rescue breaths; and make sure the person is on a firm surface. In 2008, after the publication of several studies looking at the rates of bystander CPR and public attitudes toward it, the AHA updated their guidance and decided to take out rescue breathing (mouth to mouth) for untrained or lay responders as a way to encourage and focus on hands only CPR. This updated guidance did not apply to trained healthcare professionals. Review of the facility policy titled Emergency Care/Code Management, revised [DATE], revealed the purpose was to ensure preparation for resident-specific emergency situations as they occur to promote the greatest optimal resident outcomes. The policy indicated CPR would be provided in accordance with the AHA guidelines. Review of the procedure included a crash cart would be maintained at each nursing unit and in the dining room. This deficiency is an incidental finding discovered during the course of the complaint investigation.

Based on closed medical record review, review of an Emergency Medical Services (EMS) Run report, review of the Health Care Summary, facility policy review, staff interview, physician interview and nurse practitioner (NP) interview, the facility failed to timely identify and provide adequate and necessary care for Resident #100, who experienced an acute change in condition. This resulted in Immediate Jeopardy and actual harm/serious health outcomes and potential for death beginning on 06/20/24 when the facility failed to recognize and adequately and timely respond to a decline in Resident #100's condition. Beginning on 06/20/24, Resident #100 was observed to have difficulty swallowing and his diet was downgraded to pureed. The physician was not notified of this change in condition. On 06/21/24 and 06/22/24, Resident #100 had poor oral intakes with no nursing assessments or monitoring completed and no evidence the physician was notified. On 06/22/24, at approximately 7:30 A.M., State tested Nursing Assistant (STNA) #202 identified Resident #100 was unresponsive to any stimuli. Licensed Practical Nurse (LPN) #203 was notified; however, failed to assess or notify the physician and took no action to address Resident #100's decline. Although Resident #100 was unresponsive, LPN #203 proceeded to place crushed medications mixed with chocolate pudding into the resident's mouth. At approximately 6:00 P.M., STNA #204 began her shift and found Resident #100 unresponsive to stimuli. STNA #204 notified LPN #203 of Resident #100's condition. LPN #203 stated Resident #100 had been that way all day and LPN #203 again took no action to address Resident #100's condition. Consequently, at approximately 9:00 P.M., STNA #204 returned to Resident #100's room and found the resident continued to be unresponsive. STNA #204 notified LPN #201, who assessed Resident #100 and found his vital signs to be unstable and the resident had a large amount of chocolate pudding and crushed medications in his mouth. On 06/23/24 EMS were called, and Resident #100 was sent to the hospital. Subsequently, Resident #100 was admitted to the hospital on 06/23/24 and admitted to hospice services on 07/01/24. The resident did not return to the facility. In addition, a concern that did not rise to Immediate Jeopardy occurred when the facility failed to timely respond to a change in condition for Resident #45, who experienced high blood pressure, rapid respirations, felt short of breath and received oxygen therapy outside of physician ordered parameters. This affected two residents (#100 and #45) of two residents reviewed for change in condition. The facility census was 95. On 07/30/24 at 12:54 P.M., the Administrator, Director of Nursing (DON), and Regional Registered Nurse (RRN) #920 were notified Immediate Jeopardy began on 06/20/24 when Resident #100 began experiencing a change in condition without adequate care/intervention. While the dietitian assessed the resident's diet texture, no nursing assessments were completed, and the physician was not notified. Resident #100's condition continued to decline throughout 06/21/24 and 06/22/24, without any nursing assessment, monitoring of vital signs or notification to the physician. Resident #100 was subsequently admitted to the hospital on 06/23/24 with a diagnosis of sepsis and transferred to hospice care on 07/01/24. The Immediate Jeopardy was removed on 07/30/24 when the facility implemented the following corrective actions: Resident #100 was admitted to the hospital on 06/23/24 and did not return to the facility. On 07/30/24, the Administrator, DON and RRN #920 conducted an investigation and determined the facility did not follow the Change in Condition Policy and Procedure for Resident #100. On 07/30/24, the DON issued disciplinary action to LPN #203 for failing to follow the Change in Condition Policy and Procedure. On 07/30/24, the DON and RRN #920 re-educated all licensed nursing staff on the Change in Condition Policy and Procedure, including ensuring staff provide timely and appropriate care and services when residents experience a change in condition that has or was likely to cause serious life-threatening harm or injuries and/or adverse negative health outcomes. On 07/30/24, Unit Manager LPN #213, LPN #263, LPN #239 and Registered Nurse (RN) #302 completed a head-to-toe assessment of all residents for a change in condition. All residents were assessed to be at baseline and no changes in condition were identified. All assessments were documented in the Electronic Medical Record (EMR) and Medical Director (MD) #500 was notified of the outcome of resident assessments. Beginning on 07/31/24, the DON or designee would conduct an audit of four random residents on each unit weekly for four weeks, then bi-weekly for two weeks, and then monthly. The audit would include compliance with providing timely and appropriate care and services when a resident experienced a change in condition. The audit tool would be used to validate resident status and appropriateness of care and included all pertinent information and actions needed to meet a residents medical, nursing, and mental and psychosocial needs if a change of condition was identified. On 07/30/24, an Ad Hoc Quality Assurance Performance Improvement (QAPI) committee meeting was held to review the policy and procedures for change in condition, education to be provided to nursing staff and a plan to complete assessments for all in facility residents for change in condition. All audit findings of concern would be immediately addressed and reported to the QAPI committee for further review and prompt response and resolution. The Administrator and/or designee will monitor this area for ongoing compliance. Interviews on 08/01/24 between 5:25 P.M. and 5:31 P.M. with LPN #207, LPN #289, LPN #940 and LPN #942 confirmed each received education on the facility ' s change in condition policy and procedures. Review of three (#8, #63 and #95) additional resident records revealed no additional related concerns. Although the Immediate Jeopardy was removed on 07/30/24, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of Resident #100's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE]. Resident #100 had diagnoses including type two diabetes mellitus, unspecified dementia, aneurism of the ascending aorta without rupture and hypertension. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #100 was severely cognitively impaired. The assessment revealed the resident had impairment to one side of the upper extremity, no impairment to the lower extremity, used a wheelchair for mobility, required supervision with eating, partial moderate assistance with personal hygiene and bed mobility and substantial maximum assistance with transfers. Review of the care plan initiated 05/22/24 revealed Resident #100 had functional bladder incontinence related to activity intolerance, dementia, and impaired mobility. Interventions included to monitor and document signs and symptoms of a urinary tract infection (UTI) to include increased pulse, increased temperature, altered mental status, change in behavior and change in eating patterns. Review of the progress note dated 06/07/24 at 12:39 P.M. and completed by LPN #213 revealed Resident #100 was alert and awake sitting at the dining table with lunch in front of him. Resident #100 was bent forward in the chair almost to where his head was touching his knees. He was eating lunch, but not using utensils. The resident was eating with his fingers at first then attempted to put his mouth on the table and food tray and eat his meal that way. The note documented, unable to get the resident to sit up in his chair. Further review revealed a Nurse Practitioner (NP) was notified and Resident #100 received an order for a urinalysis with culture and sensitivity. Further review of the medical record revealed no progress notes were completed on Resident #100 from 06/07/24 until 06/12/24. Review of the progress note dated 06/12/24 at 4:02 P.M. revealed Resident #100's urinalysis results came back positive and the resident was started on and antibiotic for a UTI. Review of the physician order/Medication Administration Record (MAR) revealed Resident #100 received Amoxicillin oral tablet 875-124 milligram (mg), one tablet by mouth two times a day for a UTI for seven days. Further review revealed Amoxicillin was initiated on 06/11/24 and completed 06/17/24. Additional review of the medical record revealed no evidence any assessments or monitoring was completed for Resident #100 during the course of treatment for the UTI. Review of the dietary note dated 06/20/24 at 3:19 P.M. completed by Registered Dietitian (RD) #501 revealed diet downgraded to puree per discussion with nursing, Resident #100 was pocketing and coughing with meals. Liberated therapeutic diet to aid with oral intakes. Discussed with the Interdisciplinary Team (IDT). Boost HVC eight ounces daily for added nutritional support. Will continue to monitor and coordinate for need of further intervention. Review of a nursing progress note dated 06/20/24 at 3:26 P.M. and completed by RN #224 revealed Resident #100 observed pocketing food and coughing during the breakfast meal. Diet downgraded to mechanical soft. Resident #100 continued to cough when fed during lunch. Resident did well with mashed potatoes. Resident #100's diet further downgraded to pureed. Review of the physician's orders revealed on 06/20/24, RD #501 created an order for a regular diet, pureed texture, and thin liquids. Review of the State tested Nurse Aide (STNA) tasks sheets revealed Resident #100 consumed 0% of his dinner meal on 06/20/24. On 06/21/24 the documentation indicated Resident #100 consumed 0 to 25% of breakfast and lunch and 0% for dinner. On 06/22/24 Resident #100 consumed 0 to 25% of breakfast and lunch and 0% of dinner. Further review of the medical record revealed no evidence of any assessments, monitoring of vital signs, or physician notification related to Resident #100's downgraded diet or change in condition during this time period. Review of an EMS run report revealed on 06/23/24 at 12:27 A.M., EMS received a call from the facility for Resident #100. EMS arrived on the scene at 12:35 A.M. Resident #100 was unresponsive and was placed on non-re-breather at 15 liters per minute (LPM) of oxygen. Resident #100 had unstable tachyarrhythmia and was cardioverted (shocks to restore heart rhythm) at 50 joules, then 100 then 200 joules. Resident #100 was taken to the trauma bay at the local hospital. Review of the progress note dated 06/23/24 1:39 A.M. and completed by LPN #201 revealed Resident #100 was observed unresponsive with blood pressure (BP) of 72/46 (hypotensive), blood sugar (BS) of 196, pulse of 115 (tachycardic), temperature of 99.6, respiration rate (RR) of 10 and oxygen saturation of 83% on room air. The note included Resident #100 had pudding residue in his mouth, unresponsive to stimuli. NP and family notified. The family requested Resident #100 be sent to the hospital. EMS was called and resident was sent to the hospital. Review of the hospital Health Issue Summary revealed Resident #100 was admitted to the hospital on 06/23/24 with a diagnosis of sepsis and transferred to hospice care on 07/01/24. Interview on 07/25/24 at 2:56 P.M. with STNA #204 revealed she worked with Resident #100 on 06/22/24, with her shift beginning at 6:00 P.M. STNA #204 revealed at the start of her shift, she went into Resident #100's room. Resident #100 was unresponsive. STNA #204 stated she turned him and called his name, but he would not respond. STNA #204 stated she went to get the nurse, LPN #203, who was still there from day shift. STNA #204 revealed she reported her findings to LPN #203, who stated Resident #100 had been like that all day. LPN #203 went on to state even when she gave the resident his medications, she had to shove them in his mouth. STNA #204 stated she had to provide care to other residents and did not return to Resident #100 until approximately 9:00 P.M. STNA #204 stated Resident #100 was still unresponsive. STNA #204 informed LPN #201 of Resident #100's condition. Together, STNA #204 and LPN #201 went to Resident #100's room. The resident was unresponsive. STNA #204 stated she and LPN #201 turned Resident #100 on his side and a brown substance came out of his mouth. LPN #201 opened the resident's mouth and found a glob of pudding with crushed medications in the back of the resident's throat. STNA #204 stated they used an entire box of toothettes to scoop the dried pudding and crushed medications from the back of Resident #100's mouth. STNA #204 stated LPN #201 checked the resident's vital signs, and his oxygen level and BP were low. Resident #100 was still not responding. STNA #204 stated there was confusion about the resident's advance directives/code status, so the nurse called family and the doctor, and the resident was then sent out to the hospital. STNA #204 stated she was so upset that she reported the incident to Unit Manager (UM) #205. STNA #204 stated she told UM #205 that Resident #100 was unresponsive and LPN #203 shoved pudding in his mouth. Review of the Medication Administration Record (MAR) for Resident #100 revealed on 06/22/24, LPN #203 administered the following morning medications to Resident #100: Eliquis tablet five milligrams (mg), Losartan 50 mg tablet, Metformin 750 mg tablet, Acidophilus one capsule, Depakote 125 mg tablet, Glimepiride two mg tablet, Quetiapine fumarate 25 mg and Risperidone one mg tablet. Interview on 07/25/24 at 3:15 P.M. with UM #205 confirmed STNA #204 reported (on 06/22/24) Resident #100 had a mouthful of pudding and medication and they sent him out. UM #205 further stated STNA #204 reported Resident #100 was not right when her shift began, and she tried telling the nurse. UM #205 stated there was not much she could do about it because Resident #100 was already sent to the hospital. UM #205 stated she was unsure if the DON was aware of the concern, and stated this DON was no longer employed by the facility. Interview on 07/25/24 at 3:36 P.M. with LPN #203 revealed Resident #100's diet texture was downgraded (in June) to pureed and he received his medications crushed in pudding. LPN #203 stated Resident #100 had been drinking fluids, but not much. LPN #203 stated she gave the resident his medications and she kept giving him fluids and he swallowed his medications. LPN #203 stated Resident #100 slept a lot on 06/22/24 but stated he did wake up a little bit. LPN #203 denied Resident #100 had a temperature and stated his vital signs were fine. LPN #203 verified she did not document any vital signs or assessments for Resident #100 on 06/22/24. LPN #203 also confirmed she did not notify the physician of a change in condition for the resident. LPN #203 stated Resident #100 had a UTI and denied anyone at the facility talked to her about Resident #100's condition. Interview on 07/29/24 at 11:25 A.M. with STNA #202 revealed she worked with Resident #100 on 06/22/24, beginning at 7:30 A.M. STNA #202 revealed she worked with Resident #100 many times and stated on 06/22/24, the resident had been knocked out all day. STNA #202 stated LPN #203 told her he had a UTI. STNA #202 stated she went to the resident's room at the start of her shift, and she could not wake Resident #100 up. STNA #202 stated she got LPN #203 and they both went back to the resident's room. STNA #202 stated LPN #203 tried to give Resident #100 his medication, but he would not swallow it and he already had pudding or some other substance in his mouth. STNA #202 stated Resident #100 would not wake up or respond to anything. STNA #202 stated she elevated the head of the resident's bed while LPN #203 put the medication crushed in pudding in his mouth and tried to get him to swallow. STNA #202 stated Resident #100 did not swallow his medications and was like that all day. STNA #202 stated Resident #100 usually moved around, would propel up and down the hall and feed himself. STNA #202 stated she was off for a few days and noticed a definite decline with the resident when she returned to work on 06/21/24. Interview on 07/29/24 at 1:49 P.M. with Agency LPN #201 revealed she checked on Resident #100 during rounds when she first arrived on 06/22/24. LPN #201 revealed Resident #100 just looked like he was sleeping. LPN #201 revealed she did not recall getting anything alarming about Resident #100's condition that day from LPN #203 during the nurse change in shift report. LPN #201 revealed after checking on the residents, she began medication pass. While LPN #201 could not recall the time STNA #204 came to get her, she did recall STNA #204 stating she needed to check on Resident #100 because he was unresponsive. LPN #201 revealed this was the first time she worked with Resident #100. LPN #201 stated she opened Resident #100's mouth and noted there was a lot of chocolate in his mouth. LPN #201 stated Resident #100 was breathing but he did not arouse or respond. LPN #201 stated she assessed Resident #100's vital signs, documented they were off, looked for his code status and then called the resident's family. LPN #201 stated the family requested Resident #100 be sent to the hospital. LPN #201 then notified the physician. LPN #201 stated EMS arrived, and Resident #100 was transported to the hospital. Interview on 07/29/24 at 3:09 P.M. with LPN #213 revealed typically when a resident was on an antibiotic, the nurses would monitor every shift for vitals, temperatures, and checking on the resident and this would be documented in the medical record. Additionally, the nurse would be monitoring for adverse reactions from the antibiotic. The surveyor indicated no assessments could be found for Resident #100 and requested LPN #213 locate the information. LPN #213 did not return at any point with the requested assessments or monitoring for Resident #100. Interview on 07/29/24 at 4:13 P.M. with MD #500 revealed he expected nursing staff to monitor vital signs and document on a resident who was diagnosed with a UTI and receiving antibiotics. If a resident had a change in condition, non-urgent, he would expect to be notified within 24 hours, at most. MD #500 stated if a resident was unresponsive, he should be notified immediately. MD #500 stated he should have been notified when Resident #100's change first occurred as he would have done blood work, a urinalysis and chest x-ray to rule out potential complications. MD #500 confirmed he was not notified of changes that occurred with Resident #100. Interview on 07/30/24 at 3:08 P.M. with NP #502 revealed he was not notified or called regarding Resident #100 having difficulty swallowing, having his diet order changed to pureed and was not made aware Resident #100 was not eating or unresponsive. NP #502 stated there would have been interventions implemented had he been aware of Resident #100's decline. Review of the facility policy titled, Resident Change in Condition dated 07/28/22 revealed Purpose: Ensuring staff provide timely and appropriate care and services when residents experience a change in condition that has or is likely to cause serious life-threatening harm or injuries and or adverse negative outcomes. The facility will promptly notify the resident, his or her attending physician, and responsible party of changes in the resident ' s condition and or status. The licensed nurse will take immediate action to ensure timely and appropriate care and services are met when a resident change in condition is identified. When a significant or an acute change is identified in resident ' s physical, mental, or psychosocial status. the licensed nurse will notify the attending physician regarding the change in condition once an assessment of the resident has been completed. 2. Record review for Resident #45 revealed an admitted [DATE] with diagnoses including orthostatic hypotension, syncope and collapse. Review of the admission Medicare five-day MDS revealed Resident #45 was cognitively intact. The assessment revealed Resident #45 required set up or clean up assist with meals, partial to moderate assist with personal hygiene, was independent with bed mobility, and required partial to moderate assistance with transfers. Resident #45 had occasional pain, had no shortness of breath or trouble breathing. Review of the care plan revealed Resident #45 had altered cardiovascular status related to hypertension, hyperlipidemia and congestive heart failure. Interventions included to monitor vital signs and lab work as ordered and notify the MD of significant abnormalities. Review of a physician order dated 07/25/24 revealed an order for oxygen at two liters via nasal cannula to keep oxygen saturation above 92% as needed. The order was dated 07/25/24. Observation on 07/29/24 at 8:37 A.M. with LPN #212 revealed Resident #45 complained of not feeling well. Continued observation revealed Resident #45 was breathing rapidly, was pale and his nose was dripping clear fluid. Resident #45 was receiving oxygen via nasal cannula at five LPM. Resident #45 stated again he was not feeling well, and he felt short of breath. Concurrent interview with LPN #212 revealed Resident #45's presentation was not typical. LPN #212 verified Resident #45's oxygen was set at five LPM and stated the resident was not able to adjust his own oxygen settings. LPN #212 assessed Resident #45's vital signs. Resident #45's oxygen saturation level was 95%. LPN #212 placed a wrist cuff on Resident #45 and obtained a blood pressure of 230/88. LPN #212 then obtained a manual blood pressure cuff and obtained a blood pressure in the right upper arm of 181/110. Resident #45 was afebrile and had a pulse of 81. Further observation revealed Resident #45 continued to have rapid respirations. LPN #212 revealed she counted respirations of 27 and stated she was not sure of the respiration count because she had to keep looking away to look at the clock on the wall while she was counting. LPN #212 stated this was a big change for Resident #45 and he was not usually like this. LPN #212 returned to the medication cart, reviewed the order for the oxygen and verified Resident #45 should be receiving oxygen at two LPM. LPN #212 then prepared and administered Resident #45's medications. LPN #45 left the room, did not adjust the oxygen level per the physician order, and continued going up the hall to administer additional residents' medications. Interview on 07/29/24 at 3:12 P.M. with LPN #212 revealed she rechecked Resident #45's vital signs at 1:00 P.M., nearly 4.5 hours after the initial assessment, and his blood pressure was 160/64. LPN #212 confirmed that was the only time she rechecked Resident #45's vital signs. LPN #212 confirmed she did not notify the physician of the change in condition and had only notified LPN #213. Interview on 07/29/24 at 3:40 P.M. with LPN #213 revealed the nurse on the floor would notify the physician of a residents change in condition. LPN #213 confirmed LPN #212 notified her of Resident #45's change in condition and revealed she did not notify Resident #45's physician or NP of Resident #45's change in condition, stating she was not asked to. LPN #213 confirmed the physician should have been notified of Resident #45's condition. Interview on 07/29/24 at 4:13 P.M. with MD #500 revealed he should have been notified of Resident #45's BP of 181/110. Additionally, MD #500 stated if Resident #500 required more oxygen than what was ordered, he should have also been notified of that. MD #500 verified he was not notified of concerns identified with Resident #45, but stated the NP may have been. Review of a progress note created on 07/30/24 at 8:07 A.M. with an effective date 07/29/24 at 3:30 P.M. by LPN #213 revealed NP #502 was notified of Resident #45's blood pressures. The documentation did not include notification of the oxygen level of five LPM. Interview on 07/30/34 at 3:08 P.M. with NP #502 confirmed he was notified on 07/29/24 of Resident #45's blood pressures. While NP #502 did not recall the exact time he ws notified, he confirmed it was sometime after 12:00 P.M. Review of the facility policy titled, Resident Change in Condition dated 07/28/22 revealed Purpose: Ensuring staff provide timely and appropriate care and services when residents experience a change in condition that has or is likely to cause serious life-threatening harm or injuries and or adverse negative outcomes. The facility will promptly notify the resident, his or her attending physician, and responsible party of changes in the resident ' s condition and or status. The licensed nurse will take immediate action to ensure timely and appropriate care and services are met when a resident change in condition is identified. When a significant or an acute change is identified in resident ' s physical, mental, or psychosocial status. the licensed nurse will notify the attending physician regarding the change in condition once an assessment of the resident has been completed. This deficiency represents the non-compliance investigated under Complaint Number OH00155297.