Every finding on record at Ayden Healthcare of Madeira

Based on medical record review and staff interview, the facility failed to develop a plan of care related to resident leave of absences (LOA) and safety while on LOA. This affected one (Resident #29) of three residents reviewed for leave of absence. The facility census was 83 residents Findings Include:Review of the medical record for Resident #29 revealed an admission date of 05/06/26 with diagnoses including depression, epilepsy, anxiety disorder, cognitive communication deficit, unsteadiness on feet, difficulty in walking, muscle weakness. Review of the Minimum Data Set (MDS) assessment for Resident #29 dated 05/14/26 revealed the resident was cognitively intact. Review of the medical record for Resident #29, including progress notes, incident reports, and physician orders, revealed it did not include documentation of an incident in which the resident reportedly left the faciity on LOA and entered the grounds of a private citizen's house to look for rocks and fossils. There was also no documentation of the facility's provision of education to the resident regarding safety measures while on LOA such as not going into yards of unknown private citizens. Review of the current care plan for Resident #29 revealed it did not include care areas and/or interventions related to resident safety while going on LOA. Interview on 08/14/26 at 2:10 P.M. with the Director of Nursing (DON) confirmed on 07/21/26 a private citizen unrelated to or associated with Resident #29 called the facility to report the resident was in the citizen's yard uninvited and without permission, and Resident #29 said he was in the yard looking for rocks and fossils. The DON stated the facility went to pick Resident #29 up from the private citizen's property and brought him back to the facility. The DON verified the facility had no documentation of the incident, no documentation of education provided, and the facility had not developed a plan of care regarding LOA safety following the incident.

Based on medical record review and staff interview, the facility failed to adequately assess residents for appropriateness to be on leave of absence (LOA). This affected one (Resident #29) of three residents reviewed for leave of absences. The facility census was 83 residents. Findings Include:Review of the medical record for Resident #29 revealed an admission date of 05/06/26 with diagnoses including major depressive, epilepsy, anxiety disorder, cognitive communication deficit, adult failure to thrive, unsteadiness on feet, difficulty in walking, and muscle weakness. Review of the elopement risk assessment for Resident #29 dated 05/10/26 revealed the resident was not deemed to be an elopement risk, but the assessment did not determine if the resident was safe to be outside of the facility on LOA without supervision. Review of the Minimum Data Set (MDS) assessment for Resident #29 dated 05/14/26 revealed the resident was cognitively intact. Review of the medical record for Resident #29, including progress notes, incident reports, and physician orders, revealed it did not include documentation of an incident in which the resident reportedly left the faciity on LOA and entered the grounds of a private citizen's house to look for rocks and fossils. There was also no documentation of the facility's provision of education to the resident regarding safety measures while on LOA such as not going into yards of unknown private citizens. Review of the current care plan for Resident #29 revealed it did not include care areas and/or interventions related to resident safety while going on LOA. Interview on 08/14/26 at 2:10 P.M. with the Director of Nursing (DON) confirmed on 07/21/26 a private citizen unrelated to or associated with Resident #29 called the facility to report the resident was in the citizen's yard uninvited and without permission, and Resident #29 said he was in the yard looking for rocks and fossils. The DON stated the facility went to pick Resident #29 up from the private citizen's property and brought him back to the facility. The DON stated the facility did not have a formal LOA assessment but instead looked at a resident's score on the Brief Interview for Mental Status (BIMS) score along with their mental health diagnoses to help determine if a psychiatric evaluation is needed for a secured unit and if the resident is safely able to leave the facility unattended. The DON confirmed there were residents with a BIMS score high enough to be considered to be cognitively intact but some of these residents had mental health diagnoses that prevented them from being able to go on an LOA unsupervised. When asked if Resident #29's diagnoses of epilepsy, anxiety disorder, adult failure to thrive, and major depressive disorder would be considered safe to be in the community unsupervised, she stated they take all of that information into consideration, but gave no definitive answer regarding the resident's safety to go an independent LOA. Interview on 08/14/26 at 2:12 P.M. with the Administrator confirmed the facility had no formal process to determine which residents were safe to go on LOA unsupervised.

Based on observation, interview and record review, the facility failed to prepare and store food in a manner to prevent foodborne illness. This affected all 86 residents who the facility identified as receiving food from the kitchen. The total facility census was 86. Findings Include:Observation of the kitchen during the initial tour on 12/08/25 at 9:09 A.M. with Dietary Manager (DM) #04, revealed the following:1) At the dietary employee handwashing sink there was no soap in the dispenser, and the hand drying towels were not in a hands-free dispenser. 2) Inside the walk-in refrigerator there was an undated open container with orange liquid labeled water. There was a packaged coleslaw with an expired label of best used by 10/02/25, and an expired opened container of boiled eggs dated 12/01/25. There was an uncut watermelon which was blacked throughout the exterior. 3) There were opened thawing pie shells with no open date and dated an arrival of 11/11/25. There were undated thawing items, including three bags of pork loin, a bag of chicken pieces, and two packages of hamburger.4) Inside the walk-in freezer, there was no thermometer and several food debris items on the floor. 5) Inside the refrigerator, there was no internal thermometer. There was an open container of cheese with a use by date of 12/01/25, an open container of cottage cheese with a use by date of 11/17/25 and sliced cheese with a use by date of 12/07/25. There were three open containers of relish with no use by date or open date. 6) Inside the dry food storage area, there were two bags of breadcrumbs with a use by date of 11/07/25. The door into the dry food area was propped open with a can of food. The door was an automatic closure door.7) The ice machine scoop was directly on top of the ice machine, with scoop side up. There was no drainage pan. Interview with DM #04 immediately following these observations, verified the orange liquid was in a mislabeled container and had should have had an open date, and the coleslaw, boiled eggs and watermelon should have been discarded. DM #04 verified the thawing meat should be dated at the date of being pulled from the freezer, the freezer should have an internal thermometer, and the freezer floor needed cleaned of debris. DM #04 verified all opened containers needed an open date and when they expired. DM #04 stated it was a new ice machine and verified there was no ice scoop holder to permit water drainage.Observation on 12/10/25 at 7:38 A.M, [NAME] #103 picked up a biscuit and put it on a resident meal plate with gloved hands. [NAME] #103 touched countertop surfaces, drawers and utensils and then picked up a second biscuit and put it on a resident's plate with the same gloved hand.Interview on 12/10/25 at 8:45 A.M., [NAME] #103 and DM #04 verified during serving biscuits, [NAME] #103 did not change gloves between different tasks. [NAME] #103 and DM #04 stated the gloves needed changed between each task or a utensil should be used to pick up the biscuits. Observation on 12/10/25 at 10:15 A.M, [NAME] #103 was observed to prepare the puree foods for the lunch meal. [NAME] #103 prepared macaroni and cheese, stewed tomatoes and cauliflower separately in a blender bowl. [NAME] #103 rinsed out the blender bowl with only water between pureeing each of the three foods. Interview with [NAME] #103 after the observation, verified he had only rinsed out the blender bowl between pureeing each of the foods. He stated he should have either used the dishwasher or used the three-compartment sink processing, which included sanitizing the bowl. Review of the October, November and December 2025 dishwasher logs on 12/11/25 at 9:50 A.M., revealed there was no monitoring documentation of the level of sanitizer in the final rinse.Observation of dishwasher's identifier plate on 12/11/25 at 9:55 A.M. with DM #04 revealed the dishwasher was a low temperature machine requiring a chemical sanitizer in the rinse cycle to sanitize the dishes. Interview with DM #04 following the observation verified there had been no documentation of the final rinse sanitizer levels for October, November and through 12/15/25. Observation on 12/11/25 from 2:25 P.M. to 2:45 P.M. of food storage in the resident's refrigerators revealed the following:1)In the resident refrigerator on 500 unit, revealed there were two unlabeled and undated containers of food. There was a sign posted on the refrigerator Label, Date and Resident Name on all Foods. CNA #38 verified all foods should only be resident food and must be labeled and dated.2) In the residents' refrigerator on the Memory Care unit (MCU), revealed there two containers of milk dated 12/10/25 and there was a buildup of ice, approximately one-half inch thick, on the sides and bottom of freezer shelf, and a water leak inside the refrigerator compartment. CNA #60 verified the findings and stated there should not be ice and a water leak in the refrigerator, and the milk was expired.3) In the residents' refrigerator on the 100 unit, revealed two containers of milk dated 12/10/25, two unlabeled and undated containers of food and a container of yogurt with no name. The freezer had buildup of ice, approximately one-half inch thick, on the sides and bottom of freezer shelf. Assistant Director Nursing (ADON) #88 verified the milk was expired and foods stored in the resident refrigerator should be labeled with the resident name. Review of facility policy, Food Safety and Sanitation, dated 2001, revealed state and federal regulations will be followed to assure a safe and sanitary food and nutrition department, including opened foods are labeled, and dated, and record sanitizer parts per million on sanitation a log. Review of facility policy, Ice Machine Storage and Use, undated, revealed the ice machine scoop are stored in a closed and clean container.

Based on observation and staff interview, the facility failed to ensure the garbage cans were covered when not in use. This affected all 86 residents receiving food from the kitchen. The total facility census was 86.Findings Include:Observation of the kitchen during the initial tour on 12/08/25 at 9:09 A.M. with Dietary Manager (DM) #04 revealed there were four garbage cans in the dish machine area and in the food preparation area of the kitchen which were not covered. The containers were nearly full of food and garbage, and the kitchen staff were not actively using the garbage containers. Interview at the same time with DM #04, verified the cans were nearly full, were not in active use and should be covered. Observation of the kitchen on 12/15/25 at 10:30 A.M., with DM #04 revealed there were four garbage cans in the dish machine area and in the food preparation area of the kitchen which were not covered. The containers contained food and garbage and the staff were not actively using the garbage containers. Interview at the same time with DM #04, verified the cans should be covered and the cans contained food and garbage. DM #04 stated there were lids available for the garbage cans. Review of facility policy, Food Safety and Sanitation , dated 2001, revealed the facility will follow all state and federal regulation in order to assure a safe and sanitary food department.

Based on observations, and staff interviews, the facility failed to ensure menus were preplanned and followed for daily meals and emergency meals. This affected all 86 residents who the facility identified as receiving meals from the kitchen. The facility census was 86.Findings Include:1) Observations on 12/08/25 at 9:09 A.M. (breakfast meal), on 12/10/25 at 7:38 A.M. (breakfast meal), and 12/11/25 at 1:05 P.M. (lunch meal), revealed there were no meal spreadsheets used during the tray line meal service for residents on therapeutic diets.Review of the diets ordered listing provided by the facility on 12/10/25 at 7:38 A.M., revealed there were six residents on controlled carbohydrate diet restrictions, three residents on low sodium diet restrictions, and two residents on renal diet restrictions,Interview on 12/10/25 at 7:39 A.M., [NAME] # 103 verified there was no spreadsheet of planned meals for the concentrated controlled, low sodium and renal diets. [NAME] #103 stated he did not know the specific food items to avoid or the portions to serve for the physician ordered therapeutic diets. [NAME] #130 stated he served the food and portions of the regular diet to the residents with therapeutic diet. Interview on 12/15/25 at 11:38 A.M., Dietary Manager (DM) #04 verified there had been no planned meal spreadsheets for therapeutic diets on 12/08/25, 12/10/25, and 12/11/25. There was no information for [NAME] #103 to know what specific foods and portions each resident on the concentrated controlled, low sodium and renal diets were to receive.Interview on 12/16/25 at 10:38 A.M., DT #315 verified [NAME] #103 should have had a menu spreadsheet to provide the foods and portions for the therapeutic diets.2) Observation on 12/10/25 at 7:15 A.M. of the breakfast meal, revealed the puree food portion served was hot cereal of four ounces, scrambled eggs with cheese one ounce, and sausage with biscuit four ounces.Review of the diets ordered listing provided by the facility on 12/10/25 at 7:30 A.M. with DM #04 and [NAME] #103, revealed there were four residents who had physician orders for puree consistency diet. Review of the menu sheet for puree diets at the same time, revealed the foods consisted of hot cereal of six ounces, scrambled egg with cheese two ounces, and sausage with biscuit six ounces. Interview with DM #4 and [NAME] #103 at the same time, verified the puree portions served were smaller than the menu directed.3) Observation on 12/08/25 at 9:09 A.M. with DM #04, revealed no designated storage of emergency foods and there was not a sufficient food quantity storage of food for a three-day emergency.Interview on 12/08/25 at 9:10 A.M., DM #04 verified there was no designated emergency food storage and not sufficient food in storage in the quantity for a three-day emergency.Interview on 12/15/25 at 11:38 A.M, DM #4 verified there was no planned menu for emergencies for three to seven days. Review of the facility policy, Accuracy of Quality of Trayline Service, undated, revealed the menu extensions display foods items and amounts for each regular or therapeutic diet. The meal will be checked against the therapeutic diet spreadsheet to assure that foods are served as listed on the menu.Review of Emergency and Disaster Planning and Disaster Menu policy, revealed the facility would have food supplied for the planned menu for a minimum of three to seven days. The facility maintained sufficient inventory of par stock items to meet current menu needs plus emergency menu needs.

Based on observations, staff interviews, and policy review, the facility failed to maintain a safe, functional, and sanitary environment. This directly affected two Residents (#56 and #59) and had the potential to affect 11 additional residents housed in the 500 hall out of 13 residents reviewed for environment. The facility census was 86.Findings include: Review of the medical record for Resident #56 revealed an admission date of 07/03/24. Diagnoses included unspecified dementia, unspecified severity, with other behavioral disturbance, unspecified protein-calorie malnutrition, encephalopathy, acute kidney failure, type two diabetes mellitus without complications, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had severely impaired cognition. Resident #56 was assessed to require supervision for eating and bed mobility, partial/moderate assistance for oral hygiene and toileting, and substantial/maximal assistance for bathing, dressing, and personal hygiene. Review of the medical record for Resident #59 revealed an admission date of 10/14/21. Diagnoses included Alzheimer's disease with late onset, unspecified severe protein-calorie malnutrition, cerebrovascular disease, and anxiety disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #59 had severely impaired cognition. Resident #59 was assessed to require setup assistance for eating, partial/moderate assistance for bed mobility, and was dependent on staff for oral hygiene, toileting, bathing, dressing, personal hygiene, and transfer. Observation on 12/08/25 at 12:00 P.M. revealed the carpet in the hallway of the 500 unit to be heavily soiled at each entrance to rooms 501, 502, 503, 504, 505, 509, 510, 513, 514 and 515. There was a three-foot-long stain at the start of the hallway carpet, near room [ROOM NUMBER]. There were three ceiling vents in the 500 hallway with the grids with heavily soiled brown debris hanging down from the grids. Observation on 12/11/25 at 1:01 P.M. in the room shared by Residents #56 and #59 revealed a baseball sized hole in the lower section of the wall near the bathroom door. The baseboard was also missing along the walls in the room in several areas. Interview at the time of the observations with State Tested Nursing Assistant (STNA) #60 verified the findings. Interview on 12/11/25 at 3:10 P.M., Environmental Director (ED) #03 verified the unit 500 hallway carpet was heavily soiled, and the hallway ceiling vents were heavy soiled with brown debris. ED #03 stated there was no carpet machine to clean the carpets. There was only a vacuum to clean the carpets. He had no knowledge of when the carpets were last shampooed to remove the heavily soiled area. Review of the facility policy titled Homelike Environment, revised 05/2017, revealed residents would be provided with a safe, clean, comfortable and homelike environment. This deficiency represents non-compliance investigated under Complaint Numbers 2627584, 1264367, and 1264367.

Based on observation, staff interview, and policy review, the facility failed to ensure handrails on the Memory Care Unit (MCU) were secured to the wall. This had the potential to affect all 20 Residents (#07, #22, #25, #27, #38, #41, #43, #44, #54, #56, #58, #59, #64, #69, #75, #77, #80, #82, #85, and #88) who the facility identified as being independently mobile and residing on the MCU. The facility census was 86.Findings include:Observation on 12/11/25 at 12:55 P.M. on the MCU, revealed the handrail between the nursing station and the hallway leading to the outdoor smoking area was not secured to the wall. The handrail on the right side of the hallway leading to the outdoor smoking area was also not properly secured to the wall.Interview on 12/11/25 at 12:59 P.M. with State Tested Nursing Assistant (STNA) #60 verified the handrails were not secured to the wall.Review of the facility policy titled Resident Environmental Quality, dated 08/2022, revealed the facility should equip corridors with firmly secured handrails.

Based on observation, record review, and interview, the facility failed to ensure a clean, comfortable and homelike environment for residents. This affected six residents (#04, #11, #15, #19, #39, and #86) out of 15 residents reviewed for physical environment. The facility census was 86.Findings include:1. Review of the medical record of Resident #19 revealed an admission date of 10/10/24. Diagnoses included chronic obstructive pulmonary disease, urinary tract infection, and chronic respiratory failure with hypoxia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require setup or cleanup assistance for eating, setup or cleanup assistance for oral hygiene, substantial/maximal assistance for toileting, substantial/maximal assistance for shower/bathing, dependent for dressing, and substantial/maximal assistance for personal hygiene. Observation on 12/10/25 at 8:40 A.M revealed Resident #19 had a dirty brief laying on the floor next to her bed. Interview on 12/10/25 at 8:45 A.M with Resident #19 confirmed Resident #19 took her brief off and left it on the floor around 7:00 A.M. Interview on 12/10/25 at 8:50 A.M with Licensed Practical Nurse (LPN) #28 confirmed Resident #19 had a dirty brief lying next to her bed. 2. Record review for Resident #39 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: type two diabetes mellitus with diabetic neuropathy, diabetes mellitus, and unsteadiness of feet. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require a wheelchair of mobility. Observation on 12/09/25 at 12:00 P.M. revealed Resident #39's room had a window curtain that was hooked randomly on the curtain rod, creating loose gaps at the top. The curtain lining was not attached at the side and lower seams, with the hem of the curtain hanging loose in random areas along the bottom edge. The curtain was faded and wrinkled. There was a drawer front missing on a dresser, a broken glass picture frame on the wall with shards of glass within the frame. There was unattached wallpaper in the bathroom of about six feet long along the baseboard. There was a two-foot-long plastered area directly above the resident's bed, unpainted. Interview on 12/09/25 at 12:00 P.M. with Resident #39 stated the worn curtain, broken glass picture frame ,unpainted wall area and missing drawer front made for an unsightly and unhomelike room. Interview on 12/11/25 at 3:10 P.M. with Environmental Director (ED) #3 verified Resident #39 had unpainted plastered wall, loose wallpaper in bathroom, missing dress drawer front and broken glass picture frame on the wall with shards of loose glass. He further verified the curtains were so worn the hem stiches were no longer attached, that the curtains were on the curtain rod incorrectly and were very wrinkled. The ED #3 stated the curtains needed replaced or repaired. 3. Record review for Resident #15 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: lymphedema, gastro-esophageal reflux disease without esophagitis, morbid obesity and hyperlipemia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. The resident used a walker and wheelchair for mobility. Observation on 12/09/25 at 12:15 P.M. revealed Resident #15's room had a window curtain that was hooked randomly on the curtain rod, creating loose gaps at the top. The curtain lining was not attached at the side and lower seams, with the hem of the curtain hanging loose in random areas along the bottom edge. The curtain was faded and wrinkled. Interview on 12/09/25 at 12:015 P.M. with Resident #15 stated the worn and wrinkled curtain was unsightly and felt like the staff didn't care to take the time to make it look right. Interview on 12/11/25 at 3:10 P.M. with Environmental Director (ED) #3 verified the curtains in Resident #15's room were so worn the hem stiches were no longer attached, that the curtains were on the curtain rod incorrectly and were very wrinkled. The ED #3 stated the curtains needed replaced or repaired. 4. Record review for Resident #86 revealed the resident was admitted to the facility 09/20/24. Diagnoses included chronic obstructive pulmonary disease, diabetes, morbid obesity, hypertension, and atrial fibrillation. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE], revealed the resident had intact cognition and required maximal assistance. Observation on 12/09/25 at 12:25 P.M. revealed Resident #86's room had a window curtain that was hooked randomly on the curtain rod, creating loose gaps at the top. The curtain lining was not attached at the side and lower seams, with the hem of the curtain hanging loose in random areas along the bottom edge. The curtain was faded and wrinkled. Interview on 12/09/25 at 12:25 P.M. with Resident #86 revealed the wrinkled and unattached curtain was unsightly and not like he would have had at home. Interview on 12/11/25 at 3:10 P.M. with Environmental Director (ED) #3 verified the curtains in Resident #86's room were so worn the hem stiches were no longer attached, that the curtains were on the curtain rod incorrectly and were very wrinkled. The ED #3 stated the curtains needed replaced or repaired. 5. Review of the medical record of Resident #04 revealed an admission date of 07/23/20. Diagnoses included paraplegia, bipolar disorder, anxiety, depression, panic disorder, nicotine dependence, schizophrenia, opioid dependence, cocaine abuse. Review of the quarterly Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition. The resident was independent with eating, required substantial/maximal assistance with bed mobility and was dependent with transfers, bathing, and dressing. Observation on 12/08/25 at 3:09 P.M. in Resident #04's room, revealed two fabric softener sheets in the vents of the air conditioning unit. Further observation revealed varying sizes of food debris within the air conditioning unit. Continued observation revealed brownish/red splatters, measuring approximately 0.5 to 2.0 inches on the walls near the resident's television stand. Some of the areas were breaking down, exposing dry wall. The back of the door to the resident's room contained numerous areas of brown splattered material. There was an area on the floor in the corner of the room near the television stand, measuring approximately 6 inches by 4 inches, of a black substance. Interview at the time of the observations with Resident #04 stated the fabric softener sheets were a little trick his mom taught him. Resident #04 stated the splatters throughout the room had been that way since he moved into the room and he had attempted to clean some of the areas on the wall by himself, which caused the wall to breakdown and expose the drywall. Resident #04 stated staff told him a resident who previously resided in the room often spit blood on the floor, contributing to the black area on the floor. Interview on 12/08/25 at 3:29 P.M. with Maintenance Technician (MT) #137 and Maintenance Director (MD) #138 verified the splattered areas, exposed areas of drywall throughout the room, and black area in the corner. Interview on 12/10/25 at 2:16 P.M. with Licensed Practical Nurse (LPN) #28 verified the fabric softener sheets and food debris in Resident #04's air conditioning unit. 6. Review of the medical record of Resident #11 revealed an admission date of 04/15/21. Diagnoses included dysphagia, type two diabetes mellitus, dementia with behavioral disturbance, hypothyroidism, hypertension, and gastro-esophageal reflux disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident required setup/cleanup assistance with eating, substantial/maximal assistance for bed mobility and transfers, and was dependent for toileting and bathing. Observation on 12/08/25 at 11:17 A.M. revealed areas of brown splatter throughout the window shade in Resident #11's room. Interview on 12/10/25 at 2:15 P.M. with Resident #11 stated the brown splatter on his window shade had been like that since he moved into the room over four years ago. The resident stated nobody ever cleaned his window shade. Interview on 12/10/25 at 2:15 P.M. with Licensed Practical Nurse (LPN) #28 verified the brown splatter throughout the shade on Resident #11's window. This deficiency represents non-compliance investigated under Complaint Numbers 2627584, 2590032, 1264367, and 1264360.

Based on record review, staff interviews, and policy review, the facility failed to update care plans following a change in condition. This affected four Residents (#02, #10, #25, and #60) out of 24 residents reviewed for care planning. The facility also failed to ensure care conferences were completed. This affected six Residents (#04, #09, #10, #11, #13, and #39) out of 24 residents reviewed for care planning. The facility census was 86.Findings include: 1) Review of the medical record for Resident #02 revealed an admission date of 07/10/25. Diagnosis included traumatic brain injury, psychosis, Barrett's esophagus, and dysphagia. Review of the Incident Report dated from 10/09/24 through 12/09/25, revealed Resident #02 fell on the following dates: 06/23/25, 06/24/25, 07/05/25, 07/29/25, and three separate falls on 08/07/25. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #02 had severe cognitive deficits and required total dependence with care from staff for activities of daily living (ADL). Review of the care plan for Resident #02 dated 06/14/25 and canceled on 08/25/25, revealed the care plan was not updated after the falls documented on 06/23/25, 06/24/25, 07/05/25, 07/29/25, and three separate falls on 08/07/25. An interview on 12/16/25 at 12:54 P.M., the DON verified that the care plan had not updated after Resident #02's falls. The DON stated after a resident fell, the staff should update the care plans. Review of the medical record of Resident #10 revealed an admission date of 10/10/12. Diagnoses included multiple sclerosis, aphasia, pulmonary embolism, depression, dementia, and protein-calorie malnutrition. Review of documented weights for Resident #10, revealed, on 02/03/25, the resident weighed 141.2 pounds. On 03/05/25, the resident weighed 143 pounds. On 04/04/25, the resident weighed 141.6 pounds. On 05/08/25, the resident weighed 137.3 pounds. On 06/05/25, the resident weighed 137.8 pounds. On 07/02/25, the resident weighed 130.8 pounds. On 08/02/25, the resident weighed 127.3 pounds. On 09/09/25, the resident weighed 132.5 pounds. On 10/06/25, the resident weighed 130.7 pounds. On 11/02/25, the resident weighed 125.2 pounds. Review of nutrition progress notes for Resident #10 dated 07/04/25, 08/06/25, and 08/22/25, revealed the resident triggered for significant weight loss. Review of a Nutrition assessment dated [DATE], revealed Resident #10's weight was showing a gradual downward trend. Review of the nutrition care plan for Resident #10 dated 11/03/25, revealed there was no documentation of the resident experiencing a recent weight loss. Review of the quarterly MDS assessment dated [DATE], revealed the resident had moderately impaired cognition Interview on 12/10/25 at 1:19 P.M., Regional Director of Clinical Operations (RDCO) #300 verified Resident #10's nutrition care plan did not address her recent weight loss. Review of the medical record for Resident #25 revealed an admission date of 10/22/25. Diagnoses included fracture of unspecified part of neck of left femur subsequent encounter for closed fracture with routine healing, Parkinson's disease with dyskinesia without mention of fluctuations, Alzheimer's disease, unspecified protein-calorie malnutrition, and congestive heart failure. Review of the five-day MDS assessment dated [DATE], revealed Resident #25 had severely impaired cognition. Review of the plan of care initiated on 08/22/25, revealed Resident #25 was at risk for falls related to impaired cognition and physical mobility. Interventions, all dated 08/22/25, included keeping bedside table within reach, keeping call light within reach, keeping room free of clutter, medication review, non-skid footwear in place at all times, and therapy to evaluate and treat as needed. The care plan was not updated following the resident's falls on 09/19/25, 10/09/25, and 10/19/25. Review of the facility's incident reports revealed Resident #25 had falls on 09/19/25, 10/09/25, and 10/19/25. Interview on 12/10/25 at 1:15 P.M., Regional Director of Clinical Operations (RDCO) #300 confirmed the care plan for Resident #25 had not been updated since 08/22/25. Review of the medical record for Resident #60 revealed an admission date of 04/04/24. Diagnoses included Alzheimer's disease with late onset, unspecified protein-calorie malnutrition, generalized anxiety disorder, hypertension, and unspecified intrascapular fracture of right femur subsequent encounter for closed fracture with routine healing. Review of the facility's incident reports revealed Resident #60 had falls on 03/21/25, 04/11/25, 08/29/25, and 11/04/25. Review of the plan of care initiated on 04/09/24 and resolved on 08/06/25, revealed Resident #60 was at risk for falls related to Alzheimer's disease, dementia, impaired balance, impaired cognition, unsteady gait, and psychoactive medication use. Interventions dated 04/09/24, included: encourage the resident to use call light, encourage staff to perform frequent checks and provide assistance as needed, fall assessments per facility policy, have commonly used articles within easy reach, monitor for side effects of psychotropic medications and notify physician of any irregularities, and therapy to evaluate as needed. Review of the plan of care revised on 08/26/25, revealed Resident #60 was at risk for falls related to impaired cognition and physical mobility. Interventions included keeping the bedside table within reach, keeping the call light within reach, keeping the room free of clutter, medication review, non-skid footwear at all times, and therapy to evaluate and treat as needed. Review of the quarterly MDS assessment dated [DATE], revealed Resident #60 had severely impaired cognition. Interview on 12/15/25 at 12:56 P.M., the Director of Nursing (DON) verified Resident #60's care plan had not been updated following the falls. Review of the policy titled Falls and Fall Risk, Managing Policy) dated 04/28/25, revealed, based on previous evaluations and current data, the staff will identify interventions related to the resident's risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the attending Physician/Nurse Practitioner (NP) as needed, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. 2) Review of the medical record of Resident #04 revealed an admission date of 07/23/20. Diagnoses included paraplegia, bipolar disorder, anxiety, depression, panic disorder, nicotine dependence, schizophrenia, opioid dependence, and cocaine abuse. Review of the quarterly MDS assessment dated [DATE], revealed the resident had intact cognition. Review of the medical record on 12/09/25 at 4:35 P.M., revealed Resident #04's last care conference was held on 12/06/24. Interview on 12/09/25 at 4:35 P.M., the Administrator verified Resident #04's last care conference was on 12/06/24 and care conferences were to be held quarterly. Review of the medical record for Resident #09, revealed the resident was admitted to the facility on [DATE]. Diagnoses included cellulitis, type 2 diabetes mellitus, and bilateral primary osteoarthritis of knee. Review of the most recent MDS assessment dated [DATE], revealed Resident #09 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Review of medical record for Resident #09 on 12/09/25 at 3:47 P.M., revealed Resident #09 did not have an initial care conference. Interview on 12/09/25 at 3:47 P.M., the Administrator confirmed Resident #09 did not have an initial care conference and was supposed to have one within seventy-two hours of admission. Review of the medical record of Resident #10, revealed an admission date of 10/10/12. Diagnoses included multiple sclerosis, aphasia, pulmonary embolism, depression, dementia, and protein-calorie malnutrition. Review of the quarterly MDS assessment dated [DATE], revealed the resident had moderately impaired cognition. Interview on 12/08/25 at 2:12 P.M., Resident #10 stated she had not had a recent care conference. Review of the medical record on 12/09/25 at 4:36 P.M., revealed Resident #10 had care conferences on 02/18/25 and 07/16/25. There was no additional care conferences documented. Interview on 12/09/25 at 4:37 P.M., the Administrator verified Resident #10's last care conference was held 07/16/25 and care conferences were supposed to be held quarterly. Review of the medical record of Resident #11, revealed an admission date of 04/15/21. Diagnoses included dysphagia, type 2 diabetes mellitus, dementia with behavioral disturbance, hypothyroidism, hypertension, and gastro-esophageal reflux disease. Review of the quarterly MDS assessment dated [DATE], revealed the resident had moderately impaired cognition. Interview on 12/08/25 at 11:09 A.M., Resident #11 stated he had not had a recent care conference. Review of the medical record on 12/09/25 at 4:33 P.M., revealed Resident #11's last documented care conference was on 02/11/25. Interview on 12/09/25 at 4:33 P.M., the Administrator verified Resident #11 had not had a care conference since 02/11/25 and care conferences were supposed to be held quarterly. Record review for Resident #13, revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Acute and Chronic Respiratory Failure with hypoxia, Ventral Hernia without obstruction or gangrene, and dependence on respirator (ventilator) status. Review of the most recent MDS assessment dated [DATE], revealed Resident #13 had intact cognition evidenced by a BIMS score of 15. Review of care conference meeting log on 12/09/25 at 4:29 P.M., revealed the last care conference for Resident #13 was held 01/14/25. Interview on 12/09/25 at 4:29 P.M., the Administrator verified Resident #13's last care conference was on 01/14/25. and care conferences were to be held quarterly. Record review for Resident #39, revealed the resident was admitted to the facility on [DATE] Diagnoses included type 2 diabetes mellitus with diabetic neuropathy, and unsteadiness of feet. Review of the most recent MDS assessment dated [DATE], revealed Resident #39 had intact cognition evidenced by a BIMS score of 15. Review of care conference meeting log on 12/09/25 at 4:33 P.M., revealed the last care conference for Resident #39 was held 01/28/25. Interview on 12/09/25 at 4:33 P.M., the Administrator verified Resident #39's last care conference was on 01/28/25. and care conferences were to be held quarterly.

Based on medical record review, review of fall investigations, observation, resident interview, staff interview, and policy review, the facility failed to ensure adequate supervision for residents who smoke. This affected three Residents (#12, #57, and #61) of three residents reviewed for smoking. The facility also failed to thoroughly investigate falls and implement appropriate fall interventions following falls to reduce and/or eliminate future falls. This affected five Residents (#01, #02, #25, #60, and #66) of five residents reviewed for falls. The facility census was 86. Findings include:1) Review of Resident #12's medical record revealed an admission date of 12/30/21. Diagnosis included end stage renal disease, dependence on renal dialysis, anxiety disorder and tobacco use. Review of the care plan dated 09/15/25, revealed Resident #12 was at increased risk of injury related to smoking cigarettes. Interventions include providing supervision at all times while smoking, smoking assessment upon admission, quarterly and as needed, smoking items to be kept at the nurse's station, and the resident verbalized adherence to facility smoking policy and validated resident concerns. Review of the most recent Minimum Data Set (MDS) dated [DATE], revealed Resident #12 was cognitively intact. Review of the physician orders for Resident #12 dated 12/03/25, revealed the resident used tobacco products and the resident was to follow the facility's policy on location and time of smoking. Observation on 12/08/25 from 2:15 P.M. to 2:20 P.M., revealed Resident #12 was outside the facility at the end of the 100-hall seated in a wheelchair and smoking a cigarette with no staff present. Resident #12 started knocking on the door. Interview on 12/08/25 at 2:21 P.M., Certified Nursing Assistant (CNA) #65 confirmed Resident #12 was smoking outside the door of 100-hall and the door was locked to where the resident could not get back in the building. CNA #65 stated the smoking area was closed right now due to activities. CNA #65 stated she let Resident #12 outside to smoke and was going to let him in after she went to check on another resident. CNA #65 stated Resident #12 was an independent smoker. Review of the medical record for Resident #57 revealed an admission date of 09/18/25. Diagnoses included emphysema, heart disease, diabetes, and depression. During record review, there was no documented evidence of a care plan being developed for Resident #57. Review of the modification to the Quarterly MDS dated [DATE], revealed Resident #57 had no cognitive deficits and required minimum assistance with activities of daily living (ADL). Review of the medical record for Resident #61 revealed an admission date of 07/20/23. Diagnoses included sciatica, carpel tunnel, diabetes, anxiety, and depression. Review of a care plan dated 08/26/25, revealed Resident #61 was at increased risk of injury related to smoking cigarettes. Interventions included providing supervision at all times while smoking and a smoking apron was to be worn while smoking. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #61 had no cognitive deficits and required supervision with ADL. Review of the undated Smoking Times paper hanging up in the facility on 12/09/25 at 1:14 P.M., revealed the residents can smoke with supervision at 7:30 A.M., 9:30 A.M., 11:30 A.M., 1:30 P.M., 3:30 P.M., 6:00 P.M., 8:30 P.M., and 10:30 P.M. An observation on 12/09/25 at 1:15 P.M. of the smoking area revealed two Residents (#57 and #61) were outside smoking without supervision and Resident #61 was not wearing an apron. During the observation, Receptionist #132 came to the door and instructed Residents (#57 and #61) to put out their cigarettes out since there was no staff to supervise. An interview on 12/09/25 at 1:40 P.M., Activities Aide #124 stated that the residents were not allowed to go outside to smoke without supervision, but they went out and smoked anyway. Review of the Smoking Policy dated 02/2024, revealed any smoking related privileges, restrictions, or concerns will be noted in the resident's care plan and any resident who has restricted smoking privileges may be required to be monitored by staff, a family member, or visitors while smoking. Review of the policy named Buckeye Forest at [NAME] Smoking Times dated 02/2024, revealed smoking was only permitted on the porch outside of the dining room. Smoking times are not to be changed unless approved by the Administrator. Smoking times listed are: 7:30 A.M.-8:00 A.M., 9:30 A.M.-10:00 A.M., 11:30 A.M.-12:00 P.M., 1:30 P.M.-2:00 P.M., 3:30 P.M.-4:00 P.M., 6:00 P.M.-6:30 P.M., 8:30 P.M.-9:00 P.M., 10:30 P.M.-11:00 P.M. Residents are to smoke only in outside designated smoking areas.2) Review of the medical record revealed Resident #01 was admitted to the facility on [DATE]. Diagnoses included Generalized anxiety, auditory hallucinations, major depressive disorder, unspecified dementia, cognitive communication deficit, bipolar disorder and unspecified psychosis. Review of the physician progress note for Resident #01 dated 03/24/25, revealed the resident was found on the floor beside her bed when the CNA was doing rounds. The resident stated she fell because the floor was slippery due to housekeeping recently in the room. Review of the fall investigation report for Resident #01 dated 03/24/25, revealed the resident was assessed with no bruising, open areas or swelling. Vital signs were taken and were within normal limits. The resident stated the floor was slippery because housekeeping was recently in the room. There was no documented fall interventions implemented to prevent and/or aid in future falls. Review of the progress note for Resident #01 dated 05/13/25, revealed the resident had complaints of back pain related to a fall she had yesterday. There was no documented evidence of a thorough investigation being completed to determine a root cause analysis and there was no documented fall interventions implemented to prevent and/or aid in future falls. Review of the progress note for Resident #01 dated 09/23/25, revealed the resident was yelling for help and staff found the resident on the floor next to the bed. The resident stated she fell onto her buttocks and attempted to get up. All parties were notified. A new intervention was for the resident to call staff before doing self with transfers; however, there was no documented evidence of a thorough investigation being completed to determine a root cause analysis. Review of the progress note for Resident #01 dated 10/22/25, revealed the nurse was notified by the oncoming nurse that the resident was on the floor in her room. The resident was sent to the emergency room for further evaluation. Review of the fall investigation report for Resident #01 dated 10/22/25, revealed there were no documented fall interventions implemented to prevent and/or aid in future falls. Review of the most recent MDS assessment dated [DATE], revealed Resident #01 had moderately impaired cognition and was dependent with ADL. Interview on 12/15/25 at 1:05 P.M., the DON confirmed there was no documentation of any new fall interventions being implemented for Resident #01's falls on 03/24/25, 05/12/25, and 10/22/25 and no documented evidence of a thorough fall investigation being completed for the resident's falls on 05/12/25 and 09/23/25. Review of the medical record for Resident #02 revealed an admission date of 07/10/25. Diagnosis included traumatic brain injury, psychosis, Barrett's esophagus, and dysphagia. Review of the fall report dated 06/24/25 for Resident #02, revealed the resident had an unwitnessed fall. There was no documented evidence of a thorough investigation being completed to determine a root cause analysis and there was no new fall interventions implemented to reduce and /or eliminate future falls. Review of the fall report dated 06/27/25 for Resident #02, revealed the resident had an unwitnessed fall. There was no documented evidence of a thorough investigation being completed to determine a root cause analysis and there was no new fall interventions implemented to reduce and /or eliminate future falls Review of fall report dated 07/29/25 for Resident #02, revealed the resident had a witnessed fall. There was no documented evidence of a thorough investigation being completed to determine a root cause analysis and there was no new fall interventions implemented to reduce and /or eliminate future falls. Review of the Incident Log from 10/09/24 through 12/09/25, revealed Resident #02 had falls on the following dates 06/24/25, 06/27/25, 07/05/25, 07/29/25, and three separate falls on 08/07/25. Review of the Quarterly MDS dated [DATE], revealed Resident #02 had severe cognitive deficits and required total dependence with care for ADL. Review of the fall reports on 12/10/25 at 1:30 P.M., revealed there were no fall reports completed for Resident #02's falls on 07/05/25 and the three falls on 08/07/25. There was also no documented evidence of thorough investigations being completed to determine a root cause analysis and there was no new fall interventions implemented to reduce and /or eliminate future falls. An interview on 12/10/25 at 1:34 P.M., the DON verified the resident had falls on 06/24/25, 06/27/25, 07/05/25, 07/29/25, and three separate falls on 08/07/25. The DON verified there were no fall reports for Resident #02's falls on 07/05/25 and 08/07/25. The DON also verified there was no documented evidence of thorough investigations being completed to determine a root cause analysis and there was no new fall interventions implemented to reduce and /or eliminate future falls. During a subsequent interview on 12/16/25 at 12:54 P.M., the DON stated after a resident fell, the staff were expected to complete a post-fall assessment, investigate to find out why and how the fall happened, come up with a new fall intervention to help prevent future falls, and update the care plan. Review of the medical record for Resident #25 revealed an admission date of 10/22/25. Diagnoses included fracture of unspecified part of neck of left femur subsequent encounter for closed fracture with routine healing, Parkinson's disease with dyskinesia without mention of fluctuations, Alzheimer's disease, unspecified protein-calorie malnutrition, and congestive heart failure. Review of the plan of care initiated on 08/22/25 revealed Resident #25 was at risk for falls related to impaired cognition and physical mobility. Interventions included having the bedside table within reach, call light within reach, keeping room free of clutter, medication review, non-skid footwear at all times, and therapy to evaluate and treat as needed. Review of the progress note for Resident #25 dated 09/19/25, revealed the resident had a fall while attempting to sit in a chair. There was no new documented fall interventions implemented to reduce and /or eliminate future falls. Review of the progress note dated 10/09/25, revealed Resident #25 was found on the floor next to a chair and reported that she slipped on a wet spot. There was no new documented fall interventions implemented to reduce and /or eliminate future falls. Review of the progress note dated 10/19/25, revealed Resident #25 bumped into the meal tray cart and fell. There was no new documented fall interventions implemented to reduce and /or eliminate future falls. Review of the five-day MDS assessment dated [DATE], revealed Resident #25 had severely impaired cognition. Resident #25 was assessed to require partial/moderate assistance for eating, oral hygiene, and toileting, substantial/maximal assistance for bed mobility and transfer, and was dependent on staff for bathing and dressing. Interview on 12/15/25 at 1:03 P.M., the DON verified Resident #25 had falls on 09/19/25, 10/09/25, and 10/19/25. The DON verified there were no new documented fall interventions implemented to reduce and /or eliminate future falls following the falls on 09/19/25, 10/09/25, and 10/19/25. Review of the medical record for Resident #60 revealed an admission date of 04/04/24. Diagnoses included Alzheimer's Disease with late onset, unspecified protein-calorie malnutrition, generalized anxiety disorder, hypertension, and unspecified intrascapular fracture of right femur subsequent encounter for closed fracture with routine healing. Review of the progress notes for Resident #60 from 04/11/25 to 12/15/25, revealed no documentation related to any changes to or review of fall interventions. Review of the progress note dated 04/11/25, revealed Resident #60 was found on the floor near his bed and was wrapped up in his blanket. There was no new documented fall interventions implemented to reduce and /or eliminate future falls. Review of the plan of care revised on 08/06/25, revealed Resident #60 was at risk for falls related to Alzheimer's disease, dementia, impaired balance, impaired cognition, unsteady gait, and psychoactive medication use. Interventions included encouraging the resident to use call light, encouraging the staff to perform frequent checks and provide assistance as needed, fall assessments per facility policy, have commonly used articles within easy reach, monitoring for side effects of psychotropic medications and notifying physician of any irregularities, and therapy to evaluate as needed. Review of the quarterly MDS assessment dated [DATE], revealed Resident #60 had severely impaired cognition. Resident #60 was assessed to require setup assistance for eating, supervision for oral hygiene, toileting, dressing, bed mobility, and transfer, partial/moderate assistance for personal hygiene, and was dependent on staff for bathing. Interview on 12/15/25 at 12:56 P.M., the Director of Nursing (DON) verified Resident #60 had a fall on 04/11/25 and there was no new documented fall interventions implemented to reduce and /or eliminate future falls. Review of the medical record of Resident #66 revealed an admission date of 10/09/24. Diagnoses included right hip fracture, chronic obstructive pulmonary disease (COPD), hypothyroidism, unsteadiness on feet, depression, cognitive communication deficit, and restless legs syndrome. Review of the progress note for Resident #66 dated 01/14/25, revealed the resident was found lying on the floor near her bed with her pants down. The resident stated she had just left the bathroom. The resident was assessed for pain and bruising, vitals were obtained, and the resident was assisted back to bed. Neurological checks were started, notifications made, and 911 was called for transfer to the hospital. Review of the Post Fall Evaluation for Resident #66 dated 01/14/25 revealed the resident experienced an unwitnessed fall. The fall occurred in the resident's room when she was walking from her bathroom to her bed with her pants around her ankles and without a walker. The resident was wearing non-skid footwear at the time of the fall but was not using her cane/walker at the time of the fall. The resident sustained a swollen knot to the back of the head and was sent to the hospital for evaluation. Review of the fall investigation dated 01/14/25, revealed Resident #66 had an unwitnessed fall. The immediate actions taken included assessing for pain and bruising, assessing vitals, and assisting the resident back into bed, euro checks were started, notifications made, and 911 called for transfer to the hospital. There was no new documented fall interventions implemented to reduce and /or eliminate future falls. Review of the progress note for Resident #66 dated 08/01/25 at 1:38 A.M., revealed the resident had an unwitnessed fall in the bathroom. The resident was assessed and assisted back to bed and provided with as needed pain medication. The resident stated her right buttock hurt from the fall; however, there was no bruising noted. Review of the Post-Fall Evaluation, for Resident #66 dated 08/01/25, revealed the resident experienced an unwitnessed fall in the bathroom while attempting to ambulate to the toilet by herself. The resident fell trying to stand up from the toilet. The resident was using her cane/walker at the time of the incident; however, was ambulating in bare feet. Review of the progress note for Resident #66 dated 08/01/25 revealed the resident continued with pain throughout the shift. The physician was contacted and ordered the resident to receive a right hip x-ray and continue non-weight bearing status. The x-ray was completed and a right hip fracture was noted. The resident was sent to the hospital for evaluation and treatment. Review of the fall investigation dated 08/01/25 revealed Resident #66 was heard yelling for help. The resident was found sitting in front of the toilet and stated she fell while trying to get up from the toilet. The resident was assessed and assisted back to bed. The resident complained of pain in her right hip and buttocks. There was no redness or bruising. An as needed pain medication was provided. There was no new documented fall interventions implemented to reduce and /or eliminate future falls. Review of a progress note for Resident #66 dated 11/18/25, revealed the resident was noted sitting on the edge of her bed while the nurse was passing medications and then noted sliding to the floor. The resident stated she was sliding on the floor and could not hold herself up. The resident was assessed and had no visible injuries or pain. Review of the fall investigation for Resident #66 dated 11/18/25, revealed the resident was noted sliding to the floor from her bed. The resident stated she could not hold herself up. The resident was assessed and had no visible injuries and no pain. There was no new documented fall interventions implemented to reduce and /or eliminate future falls. Review of the comprehensive MDS assessment dated [DATE], revealed Resident #66 had severely impaired cognition. The resident required supervision for eating, substantial/maximal assistance for bed mobility, was dependent for transfers, toileting and bathing. Interview on 12/15/25 at 1:10 P.M., the Director of Nursing (DON) verified there were no new documented fall interventions for Resident #66's falls on 01/14/25, 08/01/25, and 11/18/25. Review of the facility policy titled Managing Falls and Fall Risk, reviewed 04/28/25, revealed staff would identify interventions related to the resident's risks and causes to try to prevent the resident from falling. The policy also indicated if a resident continued to fall, staff would re-evaluate the situation and decide whether it would be appropriate to continue or change interventions. Review of the policy named, Falls and Fall Risk, Managing Policy dated 04/28/25 revealed, based on previous evaluations and current data, the staff would identify interventions related to the resident's risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the attending Physician/Nurse Practitioner (NP) as needed, would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. If falling reoccurs despite initial interventions, staff may implement additional or different interventions or indicate why the current approach remains relevant. If the resident continued to fall, staff would re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. This deficiency represents non-compliance investigated under Complaint Number 1264360.

Based on observation, interview and record review, the facility failed to ensure therapeutic diets were received, as ordered by the physician. This affected four Residents (#48, #51, #53 and #01) of four residents reviewed for therapeutic diets. The total facility census was 86.Findings Include:1) Record review of Resident #48 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #48 include cerebral infarction, malnutrition, and end stage renal disease. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE], revealed Resident #48 had intact cognition and required supervision with meals. The resident received dialysis treatments three times a week at a dialysis center. The resident received a renal diet, with double portions of protein at breakfast. Observation of Resident #48's breakfast tray and review of the meal ticket on 12/11/25 at 8:10 A.M., revealed an order for renal diet. Resident #48 received one portion of egg with cheese, eight ounces of milk and one portion sausage patty. Interview at the same time, Resident #48 verified he received one portion of egg and cheese, sausage and milk. He stated there were no restrictions that he knew of on his diet, including snacks. He stated for snack time, he received packaged potato chips. Resident #48 stated he was not aware of being on a renal diet. Interview on 12/11/25 at 8:11 A.M., Certified Nursing Assistant, (CNA) #42 verified the Resident #48's meal ticket listed renal diet with double portions at breakfast. CNA #42 verified the resident did not receive double portion protein and received cheese, milk and sausage. CNA #42 stated she did not know what foods were restricted on a renal diet Review of therapeutic diet definition sheet provided by the facility on 12/11/25 10:00 A.M., revealed the renal diet was to avoid milk, cheese, potatoes, tomatoes, vegetable juice and sausage. Observation of Resident #48's lunch tray on 12/11/25 at 1:15 P.M., revealed the resident received a ham and cheese sandwich and vegetable soup for lunch. The resident consumed all the food. Interview on 12/11/25 at 1:25 P.M., CNA # 42 verified Resident #48 received a ham and cheese sandwich and vegetable soup. CNA #42 verified the resident consumed the ham and cheese sandwich and vegetable soup. Interview on 12/11/25 at 1:30 P.M., Resident #48 verified he received and consumed the ham and cheese sandwich and vegetable soup. Resident #38 stated he did not know what foods were restricted to a renal diet. Interview on 12/16/25 at 10:38 A.M., Dietary Technician, (DT) #315 verified Resident #48 had physician orders for a renal diet which restricted sausage, ham, cheese, vegetable juice, and milk. DT #315 verified Resident #48 was ordered to receive double portions of protein at breakfast and should have foods on the renal diet at snack time. 2) Record review of Resident #51 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #51 include diabetes, morbid obesity, malnutrition, tachycardia, and hypertension. Review of the MDS comprehensive assessment dated [DATE], revealed Resident #51 had intact cognition and required set up assistance with eating. Observation on 12/10/25 at 8:45 A.M., revealed the Resident #51 received scrambled eggs with cheese, eight ounces of milk and sausage gravy. Resident #51's meal ticket revealed an order for renal diet with dislikes listed as milk, and orange juice. Interview with Resident #51 at the same time verified she received eggs and cheese, sausage gravy and milk. The resident stated she did not know why she was on a renal diet. Resident #51 stated for snack time, she had no choices of a renal diet food item and snacks included high sodium prepackaged snacks, including potato chips. Interview on 12/10/25 at 8:46 A.M., Licensed Practical Nurse, (LPN) # 46 verified Resident #51 was on a renal diet and received eggs and cheese, sausage gravy and milk. Observation on 12/11/25 at 8:15 A.M., revealed Resident #51 received one portion of eggs with cheese, eight ounces of milk and one portion sausage patty. Interview with Resident #51 at the same time verified she received an egg and cheese omelet, sausage and milk. She stated she often received orange juice. Interview on 12/11/25 at 8:16 A.M., LPN # 46 verified the Resident #51's meal ticket listed renal diet and the resident received an egg and cheese omelet, sausage and milk. Observation on 12/11/25 at 1:25 P.M., Resident #51 received a ham and cheese sandwich and vegetable soup at lunch. The resident consumed all the food. Interview on 12/11/25 at 1:25 P.M., LPN # 51 verified Resident #51 received and consumed ham and cheese sandwich and vegetable soup. Review of therapeutic diet definition sheet provided by the facility on 12/16/25 at 10:38 A.M., revealed the renal diet was to avoid milk, cheese, potatoes, tomatoes, vegetable juice and sausage. Interview with DT #315 at the same time, verified Resident #51 had physician orders for a renal diet which restricted sausage, ham, cheese, vegetable juice, milk and salty snacks. DT #315 verified Resident #51 was ordered to receive double portion proteins at breakfast and should have food on the renal diet at snack time. Review of the active December 2025 physician orders, revealed Resident #51 was ordered for renal diet with listing of limit bananas, tomato, potato and orange juice. 3) Record review of Resident #53 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #53 include dementia, malnutrition, nonceliac gluten sensitivity, abdominal distension, symptoms involving the digestive system and abdomen. Resident #53 resided in the secured Memory Care Unit. Review of the MDS comprehensive assessment dated [DATE], revealed Resident #53 had intact cognition and required set-up assistance for eating. Interview on 12/11/25 at 7:38 A.M., [NAME] #103 verified he had no knowledge of the specific foods that were restricted on Residents #51 and #48's renal diets and had not prepared alternates for the egg and cheese food. [NAME] #103 stated he had no knowledge of Resident #53's special diet and did not prepare gluten and lactose free foods. Observation on 12/11/25 at 8:25 A.M., revealed Resident #53 received one portion of eggs with cheese and eight ounces of a nutritional supplement. The supplement listed milk protein concentrate as a main ingredient. Resident #53's meal ticket revealed a regular diet. There were no food restrictions except chocolate, peanuts and popcorn. There was no notation of any restricted foods due to gluten and lactose intolerance. Interview on 12/11/25 at 8:28 A.M, Resident #53 verified she received eggs and cheese, sausage and the supplement. She stated she had been gluten and lactose sensitive for years and knew she could not have milk products and wheat products, including cheese, toast, and milk. She stated that after she consumes her supplement, she had strong pain in her abdomen. She stated she gets similar food served to her all the time and her family brought in gluten and lactose free foods. Resident #53 stated she did not want to eat the food provided by the facility. Interview on 12/11/25 at 8:30 A.M., LPN #46 verified Resident #53's meal ticket did not list gluten and lactose restricted foods or listed as a part of the diet order. LPN #46 verified the facility serves Resident #53 gluten and lactose type foods daily. LPN #46 verified Resident #53's supplement ingredients listed milk protein concentrate as a main ingredient, and Resident #53 at time reported some abdominal discomfort after drinking the supplement. Observation on 12/11/25 at 1:25 P.M. with LPN #46, revealed Resident #53 received a ham and cheese sandwich and vegetable soup for lunch. The resident refused the ham sandwich and stated she knew not to consume milk and wheat products. Interview with LPN #46 and CNA #52 at the same time, verified Resident #53 received ham and cheese sandwich. Interview on 12/11/25 at 1:30 P.M, Resident #53 verified she received the ham and cheese sandwich and refused it. Interview on 12/16/25 at 10:38 A.M., DT #315 verified Resident #53 had physician orders for a regular gluten and lactose free diet due to allergy. DT #315 verified the residents should not receive wheat and milk products, including a supplement listed as milk protein concentrate. Review of the active December 2025 physician orders revealed Resident #53 was ordered to receive a regular diet with gluten and lactose free diet for allergies. 4) Review of the medical record revealed Resident #01 was admitted to the facility on [DATE]. Diagnoses included generalized anxiety, auditory hallucinations, major depressive disorder, unspecified dementia, cognitive communication deficit, bipolar disorder and unspecified psychosis. Review of the care plan for Resident #01 dated 08/22/25, revealed the resident was at risk for malnutrition/alteration in nutritional status and was ordered a mechanically altered diet/thickened liquids related to dysphagia. Interventions included monitoring the resident's ability to chew/swallow, reporting any changes to nurse and medical provider, providing and serve diet as ordered and the Registered Dietician (RD) to evaluate and make diet change recommendations as needed (PRN). Review of the physician orders dated 11/03/25, revealed Resident #01 was ordered to receive a regular diet, mechanical soft, cut up foods texture, nectar thickened - no straws consistency. Review of the most recent MDS assessment dated [DATE], revealed Resident #01 had moderately impaired cognition, supervision with eating, dependent with toileting and bathing. Observation of Resident #01 on 12/10/2025 at 10:44 A.M. with CNA #42, revealed the resident was sitting up in bed with a can of soda sitting on the bedside table with a straw inside. CNA #42 stated Resident #01 had been drinking out of straws for weeks, and she had not been thickening the resident's liquids. Resident #01 stated she had been using straws for weeks and no one had been thickening her liquids that she is consuming. Interview on 12/10/25 at 10:53 A.M. with LPN #81, confirmed Resident #01 had an order for thickened liquids and no straws but LPN #81 stated she was not aware of the order for no straws. Observation and interview on 12/11/2025 at 9:58 AM with LPN #81, confirmed the staff must follow the physicians order for Resident #01 not to have straws and confirmed there was a straw in the resident's cup sitting on her bedside table at the time of this observation. Observation and interview on 12/11/25 at 1:15 P.M., revealed Resident #01 was sitting up in bed and had two cups sitting on her bedside table with straws in the cups. CNA #42 verified Resident #01 had straws in her drinks. Review of the physician orders dated 12/11/25, revealed Resident #01 had an order for therapy to do a one-time speech evaluation for diet. Review of the nurse's progress note for Resident #01 dated 12/11/25, revealed a nurse spoke with a Hospice nurse and informed her that the resident has been non-compliant with the current diet order and a new order was received for a one-time speech therapy evaluation. The Nurse Practitioner (NP) and the resident were notified, and the order had been entered and implemented. Interview on 12/15/25 at 1:15 P.M., the Director of Nursing (DON) confirmed that all staff should document if a resident was refusing to follow diet orders and to set up a care conference. Review of the medical record revealed there was documentation of Resident #01 refusing to follow diet orders. Review of facility policy, Accuracy of Quality of Tray Line Service, undated, revealed the meal will be checked against the therapeutic diet spreadsheet to assure that the foods are served as listed on the menu. The staff will refer to the meal identification ticket for food dislikes, allergies and other details. Each meal would be checked for proper portion sizes. Review of facility policy, Therapeutic Diets, undated revealed a tray identification system is established to ensure each resident receives his or her diet.as ordered.

Number of residents sampled: Number of residents cited: 6 Based on chart review, observation, interview, and policy review revealed the facility failed to ensure proper infection control practices. This affected four Residents (#11, #19, #88, and #86) reviewed for infection control in the initial pool. The facility also failed to ensure hand hygiene was performed during medication administration and incontinence care. This affected two Residents (#45 and #85) out of four residents observed for medication administration and one Resident #85 out of two Residents (#09 and #85) observed for incontinence care. The in-house facility census was 86.Findings include: 1) A chart review revealed Resident #19 was admitted on [DATE] with diagnoses including urinary tract infection, generalized anxiety, anemia, colostomy status, and bipolar disorder. Review of the Quarterly Minimum Data Set (MDS) dated for 10/14/25 revealed Resident #19 had no cognitive deficits and required substantial to moderate assistance with activities of daily living (ADL). An observation of Resident #19's room on 12/08/25 at approximately 10:15 A.M. revealed there was no posted sign to indicate the resident was in EBP. Observation also revealed there was no Personal Protective Equipment (PPE) cart near the resident's room. An interview on 12/09/25 at 9:47 A.M. the Assisted Director of Nursing (ADON) #01 stated she was the Infection Preventionist for the facility and verified that there should have been personal protection equipment (PPE) and a sign to indicate Resident #19 was in EBP. Review of the medical record for Resident #88 revealed an admission date of 12/29/23. Diagnoses included diabetes mellitus with diabetic polyneuropathy, moderate protein-calorie malnutrition, non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle, anxiety disorder, schizoaffective disorder, vascular dementia unspecified severity with agitation, mixed hyperlipidemia, other chronic pain, hyperglycemia, peripheral vascular disease, and hypertension. Review of the active physician orders for Resident #88 revealed an order dated 09/03/25 for the resident to be EBP for a foot wound. Review of the annual MDS assessment dated [DATE] revealed Resident #88 had moderately impaired cognition. Review of the plan of care initiated on 11/05/25 revealed Resident #88 required EBP related to an open wound that required a dressing. Interventions included: implement contact precautions, keeping EBP in place until wound was healed, have a sign posted on the door or the wall outside the resident's room to identify the need for EBP, and supply gowns and gloves outside the resident's room. Observation on 12/08/25 from 11:00 A.M. to 11:30 A.M. revealed no sign on the Resident #88's door to identify the need for EBP and no cart of PPE outside of the room. Observation and Interview on 12/09/25 at 9:49 A.M. with ADON #01 verified there was no sign on Resident #88's door for EBP and no cart of PPE available outside of the room. 2) Review of the medical record for Resident #85 revealed an admission date of 10/26/20. Diagnoses include Alzheimer's disease, depression, nicotine dependence, and dementia. Review of the Annual MDS dated [DATE] revealed Resident #85 had severe cognitive deficits, is incontinent, and is total dependence on staff for toileting. An observation on 12/11/25 at 10:00 A.M. with Certified Nursing Assistant (CNA) #52 providing incontinence care on Resident #85 revealed CNA #52 did not wash hands prior to and after providing care to the resident. An interview on 12/11/25 at 10:10 A.M. with CNA #52 who stated she forgot to wash her hands prior to and after providing incontinence care. CNA #52 verified that she forgot to wash her hands prior to and after providing incontinence care to Resident #85. Review of the Infection Control-Precaution Types Policy (dated 08/2024) revealed staff must perform hand hygiene (even if gloves were used) before and after contact with a resident. Review of the webpage (https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html#cdc_generic_section_2-definition-and-scope-of-enhanced-barrier-precautions) revealed EBP are an infection control intervention designed to reduce transmissions of multidrug-resistant organisms (MDROs) in nursing homes. EBP involves gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (residents with wounds or indwelling medical devices). This deficiency represents non-compliance investigated under Complaint Numbers 1264367 and 2590032.

Based on staff interview and record review, the facility failed to provide/offer the pneumococcal vaccine to all residents. This affected five Residents (#19, #02, #04, #88, and #90) of the five residents reviewed for pneumococcal vaccines. The facility further failed to provide/offer the influenza vaccine to all residents. This affected three Residents (#19, #04, and #90) of the five residents reviewed for influenza vaccines. The facility further failed to provide/offer the Coronavirus (COVID) vaccine to all residents. This affected four Residents (#02, #19, #04, and #88) of the five residents reviewed for COVID vaccines. The facility census was 86.Findings includeReview of the medical record of Resident #19 revealed an admission date of 10/10/24. Diagnosis included chronic obstructive pulmonary disorder, respiratory failure, asthma, colostomy status, anxiety, and anemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was cognitively intact. Review of Resident #19's immunization medical record revealed no vaccinations given or documented. Review of the medical record of Resident #02 revealed an admission date of 7/10/25. Diagnosis included psychosis, diabetes, malnutrition, sleep apnea, insomnia, and muscle disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #2 had severe cognitive deficits and dependent on staff for activities of daily living (ADL). Review of Resident #02's immunization medical record revealed no pneumococcal or COVID vaccines given or documented. The influenza vaccine was documented as being given on 10/05/25. Review of the medical record of Resident #04 revealed an admission date of 07/23/20. Diagnoses included paraplegia, bipolar disorder, anxiety, depression, panic disorder, nicotine dependence, schizophrenia, opioid dependence, cocaine abuse. Review of the quarterly MDS assessment dated [DATE] revealed Resident #04 had intact cognition. Review of Resident #04's immunization medical record revealed no pneumococcal, no influenza or COVID vaccines given or documented. Review of the medical record of Resident #88 revealed an admission date of 12/29/23. Diagnoses included type one diabetes mellitus with diabetic polyneuropathy, moderate protein-calorie malnutrition, non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle, anxiety disorder, schizoaffective disorder, vascular dementia unspecified severity with agitation, and peripheral vascular disease. Review of the annual MDS assessment dated [DATE] revealed Resident #88 had moderately impaired cognition. Review of Resident #88's immunization medical record revealed no pneumococcal or COVID vaccines given or documented. The Influenza vaccine was documented as being refused 09/09/25. Record review for Resident #90 revealed the resident was admitted to the facility on [DATE]. Diagnoses included osteomyelitis, diabetes Mellitus with Foot Ulcer, and bipolar disorder. Review of the MDS assessment dated [DATE] revealed Resident #90 had moderate intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 12. Review of Resident #90's immunization medical record revealed no pneumococcal or influenza vaccines given or documented. The COVID vaccine was documented as being refused on 12/08/23. Interview on 12/15/25 at 8:45 A.M. with the Director of Nursing (DON) confirmed all vaccines listed above were missing. The DON stated all vaccines were documented under the immunizations tab in the medical record. The DON revealed the facility does not have a specific policy regarding COVID vaccines related to the residents.Review of the policy named, Influenza and pneumococcal disease prevention policy dated 04/28/25 revealed, in order to reduce the disease morbidity and mortality associated with influenza and pneumococcal disease, influenza and pneumococcal vaccines are offered to all residents.

Based on observation, staff interviews and record review, the facility failed to provide varied activities to meet the needs and interests of residents. This affected three Residents (#15, #13 and #39) of five residents reviewed for activities. The total facility census was 86.Findings Include: Review of the activity calendars for October, November and December 2025 revealed from 9:30 A.M. to 11:30 A.M., there were three activities consisting of exercise, hydration cart, and table games for seven days of the week. Two to three times a week there was a 5:00 P.M. activity. There were no activities listed after 5:00 P.M. There was no religious program listing on Sundays or any other days of the week. Review of activity participation logs of 12/01/25 through 12/10/25 revealed 10 to 20 of the same residents attending all activities. There was no participation in the morning exercise class. There were no one-on-one participation logs provided for December 2025. Record review for Resident #13 revealed the resident was admitted to the facility on [DATE]. Diagnoses included acute and chronic Respiratory failure with hypoxia, ventral hernia without obstruction or gangrene, and dependence on respirator (ventilator) status.Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Interview on 12/09/25 at 8:46 A.M., Resident #13 stated she received an activity calendar, but she liked group evening activities and there are only a few days of the week when a group activity was planned at 5:00 P.M. and that is the time the dinner meal was being served. Resident #13 stated there were no additional activities planned after 5:00 P.M. She stated she had been told by activity staff there is no staff that is available for additional group evening activities. Record review for Resident #15 revealed the resident was admitted to the facility on [DATE]. Diagnoses included lymphedema, gastro-esophageal reflux disease without esophagitis, morbid obesity and hyperlipemia.Review of the most recent MDS assessment dated [DATE], revealed Resident #15 had intact cognition evidenced by a BIMS score of 15. Review of the Activity assessment dated [DATE], revealed Resident #15 often felt socially isolated.Interview on 12/08/25 at 10:46 A.M., Resident #15 stated she liked group outings because she felt lonely. Resident #15 was informed by the staff that the facility's bus needed repaired several months ago and there had been no other arrangements for her to go on outings. Record review for Resident #39 revealed this resident was admitted to the facility on [DATE]. Diagnoses included type 2 diabetes mellitus with diabetic neuropathy, diabetes mellitus, and Unsteadiness of feet. Review of the most recent MDS assessment dated [DATE] revealed this resident had intact cognition evidenced by a BIMS score of 15. This resident was assessed to require a wheelchair of mobility. Review of the Activity assessment dated [DATE], revealed Resident #39 wanted socialization and being outside.Interview on 12/08/25 at 11:46 A.M., Resident #39 stated the activities were boring and not varied. He stated he liked group outings because he liked to be with others. He stated the bus was not working and there had been no outings for nearly a year. Interview on 12/11/25 at 2:15 P.M., Activity Director (AD) #07 stated she completes the monthly activity calendars for Residents #13, #15 and #39. She stated many of the residents have requested bus outings and evening activities after 5:00 P.M. due to many of the residents are younger in age. She stated the bus had been broken down for two years and no other alternatives for outings had been made. She was unaware she could borrow a sister facility's bus until two months ago and had not requested the use of it. AD #07 verified there were no activities scheduled after 5:00 P.M. and only two days a week. She stated she had one staff member available after 5:00 P.M., which was during the dinner meal being served. AD #07 verified the morning activities have remained the same for the past three months despite only five to 10 residents attending and none attending the exercise group. There was no one-to-one documentation provided for the month of December 2025. AD #07 verified there were residents with a high interest in religious activities and verified there were no religious programs on Sundays or other days. Review of facility policy, Activities, dated 2020, revealed activity programs were designed to meet the interest of the residents and encourage interaction in the community. Activity participation is documented in the medical record.

Based on medical record review, staff interview, and policy review, the facility failed to ensure weights were completed as ordered. This affected three (Residents #04, #10, and #48) of five residents reviewed for nutrition. The facility census was 86.Findings include:1) Review of the medical record of Resident #04 revealed an admission date of 07/23/20. Diagnoses included paraplegia, bipolar disorder, anxiety, depression, panic disorder, nicotine dependence, schizophrenia, opioid dependence, and cocaine abuse. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 had intact cognition. Review of weights for Resident #04 revealed the following: On 03/05/25, the resident weighed 163.2 pounds, on 04/18/25, the resident weighed 161.2 pounds, on 05/08/25, the resident weighed 157.4 pounds, on 07/02/25, the resident weighed 144.6 pounds, on 08/06/25, the resident weighed 144.2 pounds, on 09/06/25, the resident weighed 145 pounds, on 10/06/25, the resident weighed 146 pounds, on 11/01/25, the resident weighed 146.1 pounds. Review of a weight change note dated 07/06/25 for Resident #04 revealed the resident triggered for a 16.6 pound weight loss since the previous weight. Recommendations were to reweigh the resident and obtain weekly weights on the resident if the weight loss was verified. Review of the Individual Nutrition Recommendations/Response dated 07/06/25 for Resident #04 revealed the physician was notified of the significant weight loss and recommended the resident to be reweighed and add to weekly weights if loss is verified. The form was signed by the physician on 07/23/25, indicating agreement with the recommendations. Review of the medical record on 12/10/25 at 1:00 P.M., revealed no documented evidence of Resident #04 being reweighed nor any weekly weights being completed. Interview on 12/10/25 at 1:11 P.M., Regional Director of Clinical Operations (RDCO) #300 verified a reweight was not obtained in a timely manner and weekly weights were not completed. 2) Review of the medical record of Resident #10 revealed an admission date of 10/10/12. Diagnoses included multiple sclerosis, aphasia, pulmonary embolism, depression, dementia, and protein-calorie malnutrition. Review of the quarterly MDS assessment for Resident #10 dated 11/06/25, revealed the resident had moderately impaired cognition. The resident fed self with supervision and was dependent on staff for all other ADL. Review of documented weights for Resident #10 revealed the following: On 02/03/25, the resident weighed 141.2 pounds, on 03/05/25, the resident weighed 143 pounds, on 04/04/25, the resident weighed 141.6 pounds, on 05/08/25, the resident weighed 137.3 pounds, on 06/05/25, the resident weighed 137.8 pounds, on 07/02/25, the resident weighed 130.8 pounds, on 08/02/25, the resident weighed 127.3 pounds, on 09/09/25, the resident weighed 132.5 pounds, on 10/06/25, the resident weighed 130.7 pounds, on 11/02/25, the resident weighed 125.2 pounds. Review of nutrition progress notes for Resident #10 dated 07/04/25, 08/06/25, and 08/22/25 revealed the resident triggered for a significant weight loss. Recommendations were made to start weekly weights on the resident. Review of the Individual Nutrition Recommendations/Response for Resident #10 dated 07/04/25, revealed the physician was notified of the significant weight loss and ordered weekly weights for the resident. The form was signed by the physician on 07/23/25, indicating agreement with the recommendations. Review of the medical record for Resident #10 on 12/10/25 at 1:05 P.M., revealed no documented evidence of weekly weights being completed. Interview on 12/10/25 at 1:11 P.M., RDCO #300 verified weekly weights were not completed on Resident #10 as ordered. 3) Record review of Resident #48 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, malnutrition, and end stage renal disease. Review of the physician order dated 08/09/25, revealed Resident #48 was ordered to receive a renal diet, regular, thin consistency diet related to ESRD. Review of the physician order dated 08/11/25, revealed Resident #48 received dialysis treatment three times a week (Monday, Wednesday and Friday). Review of the physician order dated 08/30/25, revealed Resident #48 was ordered to receive double protein portions with breakfast meals. Review of the physician order dated 10/04/25, revealed Resident #48 was ordered to be weighed daily weights every night shift. Record review of the weight summary for Resident #48, revealed the resident was not weighed daily as ordered. The only weights recorded for the resident were 10/13/25, 10/20/25, 10/27/25, 11/05/25, 11/14/25, 11/17/25, 11/20/25, 11/23/25, 11/24/25, 12/03/25, and 12/08/25 Review of the October, November and December 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR), revealed no additional weights or resident refusals documented. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE], revealed Resident #48 had intact cognition and required supervision with meals. Interview on 12/15/25 at 4:48 P.M., the Director of Nursing (DON) verified Resident #48 was not weighed daily as ordered. Review of the facility policy titled, Weight Management Program and Weight Gain/Loss, dated 08/2024, revealed all residents would have their weight and nutritional status monitored and addressed. All residents would be weighed monthly and as ordered. If there is a 5 percent (%) or greater change from the previous month, the resident will be reweighed

Based on observation, interview and record review, the facility failed to provide reasonable accommodations to allow residents appropriate access to handwashing facilities. This affected three resident (Residents #13, #15 and #55) of five residents reviewed. The total facility census was 86. Findings Include:1. Record review for Resident #13 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Morbid obesity, Acute and Chronic Respiratory Failure with hypoxia, and Ventral Hernia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require setup or clean-up assistance for personal hygiene. The resident could transfer self and ambulate a few feet independently. The resident used a bariatric wheelchair for mobility.Review of the weight log revealed the Resident #13 weighed 496 pounds on 11/18/25.Interview on 12/09/25 at 8:45 A.M. with Resident #13 revealed she could not get herself into her bathroom to wash her hands. She could not ambulate enough to get to the sink, and her bariatric wheelchair could not fit through the doorway. She was provided with hand sanitizer to use after toileting herself on the bedside commode. She stated the nearest shower and bathing area was one hallway away and she could not get to it to wash her hands after using the hand sanitizer three times. She stated she would have to wait to get a shower two times a week to get her hands washed and she wanted to be able to wash her hands after using the commode. 2. Record review for Resident #15 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: lymphedema, gastro-esophageal reflux disease without esophagitis, and hyperlipemia.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require setup or cleanup assistance for eating, setup or clean up assistance for oral hygiene, dependent for toileting, substantial/maximal assistance for shower/bathing, and substantial/maximal assistance for personal hygiene. The resident could transfer self and ambulate a few feet independently. The resident used a bariatric wheelchair for mobility.Review of the weight log revealed the Resident #15 weighed 301 pounds on 11/03/25.Interview on 12/08/2025 at 10:07 A.M. with Resident #15 verified she could not get into her room bathroom with her bariatric wheelchair. The bathroom door entry was too small, and she could not always walk to the sink safely to wash her hands. She stated there was no other way to wash her hands except to go to the main shower room during her biweekly shower days. 3. Record review of Resident #55 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #55 included diabetes, respiratory failure, morbid obesity, and hypertension. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #55 had intact cognition and required maximal assistance for personal hygiene and, once standing, required moderate assistance to walk a few feet. The resident used a bariatric wheelchair for mobility.Interview on 12/08/25 at 1205 P.M. with Resident #55 revealed he could not get himself into the bathroom to wash his hands because he could not walk that far and be steady, and his bariatric wheelchair would not fit through the bathroom doorway. He was provided hand sanitizer but said it wasn't like washing your hands. He stated he could not get to the shower room to wash his hands an often as he would want to and was not provided any other means to wash his hands except a bed bath twice a week.Interview on 12/011/25 at 9:50 A.M. with Therapy Director (TD) #9 verified Residents #13, #15 and #55 could not safely walk into or use the bariatric wheelchair into the bathroom safely to wash their hands in their in-room bathrooms. She stated she had had reports from Residents #13, #15 and #55 of their dissatisfaction of having hand sanitizer and no daily hand-washing alternative. She stated it was not feasible to have the residents have the shower room as an option to wash their hands daily, due to the far distance from the residents' rooms. She stated for some time the bathrooms small door size had been an issue for the bariatric residents due to having to use a bedside commode and not having a hand sink readily available.Interview on 12/15/25 at 1:05 P.M. the Director of Nursing (DON) verified the Residents #13, #15 and #55 did not have access to their in-room bathroom hand washing sink due to their bariatric wheelchair would not fit through the doorway. The DON verified Residents #13, #15 and #55 could not ambulate safely independently into the bathroom and the closest handwashing for the residents was one hallway away in the shower room. She confirmed the use of the shower room option would not accommodate the residents' frequent handwashing needs.

Based on medical record review, interview, and policy review the facility failed to ensure a discharge summary was completed. This affected one resident (Resident #94) out of three residents reviewed for discharged summaries. The facility census was 86. Findings Include:Record review for Resident #94 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Unspecified combined systolic (congestive) and diastolic (congestive) heart failure, and venous insufficiency (chronic) (peripheral). Resident #94 had a planned discharge home on [DATE].Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was assessed to require setup or clean-up assistance for eating, setup or clean-up assistance for oral hygiene, setup or clean-up assistance for toileting, setup or clean-up assistance for shower/bathing, setup or clean-up assistance for dressing, and setup or clean-up assistance for personal hygiene. It noted the resident was occasionally incontinent of bowel and bladder.Review of the medical record for Resident #94 revealed Resident #94's discharge summary was not completed. Resident #94's discharge summary was filled out by social services and therapy. It was not filled out by dietary, activities, or the nursing team. Interview on 12/09/25 at 5:06 A.M with the Administrator confirmed the discharge summary was not completed. Review of facility policy titled, Transfer and Discharge dated on 04/28/25 revealed the nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete.

Based on medical record review and staff interview, the facility failed to develop and implement a fall care plan for a resident who was at risk for falls. This affected one (Resident #66) of five residents reviewed for falls. The facility census was 86. Findings include:Review of the medical record of Resident #66 revealed an admission date of 10/09/24. Diagnoses included right hip fracture, chronic obstructive pulmonary disease, hypothyroidism, unsteadiness on feet, depression, cognitive communication deficit, and restless legs syndrome.Review of the Fall Risk Evaluation dated 12/10/24 revealed the resident was at risk for falls.Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #66 had severely impaired cognition. The resident was dependent on staff for transfers, toileting and bathing Review of the progress note dated 01/14/25, revealed Resident #66 experienced an unwitnessed fall. The fall occurred in the resident's room when she was walking from her bathroom to her bed with her pants around her ankles and without a walker. The resident sustained a swollen knot to the back of the head and was sent to the hospital and returned 01/17/25 with a diagnosis of sepsis. Review of the medical record on 12/15/25 at 1:10 P.M., revealed a fall care plan was not initiated until 08/04/25. The care plan was discontinued on 08/25/25 and a new fall care plan was started on 08/25/25. Interview on 12/15/25 at 1:10 P.M., the Director of Nursing (DON) verified Resident did not have a fall care plan developed until 08/04/25. Review of the facility policy titled, Care Planning, dated 04/28/25, revealed a comprehensive care plan would be developed within seven days of the completion of the resident assessment (MDS).

Based on medical record review, resident interview, and staff interview, the facility failed to arrange vision services outside of the facility as requested. This affected one (Resident #04) of one resident reviewed for vision services. The facility census was 86. Findings include:Review of the medical record of Resident #04 revealed an admission date of 07/23/20. Diagnoses included paraplegia, bipolar disorder, anxiety, depression, panic disorder, nicotine dependence, schizophrenia, opioid dependence, and cocaine abuse. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had intact cognition. The resident was independent with eating, required substantial/maximal assistance with bed mobility and was dependent with transfers, bathing, and dressing. Interview on 12/08/25 at 3:21 P.M., Resident #04 stated he was unable to see out of his left eye and was unable to get someone in the facility to make him an eye appointment. Review of an Eye Care Chart note dated 07/24/25 revealed Resident #04 was seen by the facility's optometry provider. Recommendations were made for the use of corrective lenses; however, Resident #04 refused to fill the new prescription because he wanted to have another eye doctor do another exam outside of the facility. Review of the medical record revealed no documented evidence of an appointment being scheduled for Resident #04 to obtain vision services outside of the facility. Interview on 12/10/25 at 1:15 P.M., RDCO #300 verified there was no record of any follow-up regarding Resident #04's request to see an optometrist in the community.

Based on interview and record review the facility failed to ensure care and services were provided as planned and ordered. This affected one (Resident #15) out of three reviewed. The facility census was 86.Findings include: Record review for Resident #15 revealed the resident was admitted to the facility on [DATE]. Diagnoses included lymphedema, gastro-esophageal reflux disease without esophagitis, and hyperlipemia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Review of active physician orders revealed Resident #15 was ordered to have lymphedema boots placed on the resident by nursing staff for one hour two times a day for swelling reduction. Review of the October, November and December 2025 Medication Administration Record, (MAR), revealed there were two time slots for documentation for morning and nighttime. The slots did not have a time duration of one hour and there was random documentation of either on or off in the documentation slots. Review of the physician visit note dated 11/06/25, revealed Resident #15 had a diagnosis of lymphedema and reported her lymphedema boots were not being applied consistently. The physician's recommendation was to ensure the use of lymphedema boots. Observation on 12/08/25 from 8:00 A.M. through 4:00 P.M., revealed Resident #15 had no lymphedema boots applied during day shift. Interviews on 12/08/25 at 4:00 P.M., 12/09/25 at 4:05 P.M., and 12/10/25 at 3:25 P.M., Resident #15 verified she had no lymphedema boots applied during day shift or the previous night shift twice daily for one hour on 12/08/25, 12/09/25 or 12/10/25. She stated she could not put the boots on herself, and she had to be in bed near the lymphedema boot machine to receive the treatment. She stated she never has the boots applied on the evening shift or during the night. She stated sometimes the Certified Nursing Assistants (CNA) apply the boots without the nurse. Resident #15 stated she never refused the boot application. Observation on 12/09/25 from 8:00 A.M. through 4:00 P.M., revealed Resident #15 had no lymphedema boots applied during day shift. Observation on 12/10/25 from 6:10A.M. through 11:30 A.M., revealed Resident #15 had no lymphedema boots applied. At 11:40 A.M., after the surveyor brought it to the attention of Licensed Practical Nurse (LPN) # 37, then LPN #37 applied the lymphedema boots. Interview on 12/15/25 at 10:30 A.M., Resident #15 revealed she had no lymphedema boots applied on 12/13/25 and 12/14/25. Interview on 12/10/25 at 11:30 A.M., LPN #37 verified Resident #15 had no lymphedema boots on in the morning of 12/10/25 between 7:00 A.M and 11:00 A.M. Interview on 12/10/25 at 12:30 P.M., the Director of Nursing, (DON) stated the physician orders in the MARs were not set up properly to permit the proper documentation as ordered. The DON verified the MAR had no documented evidence that the lymphedema boots were applied twice daily for an hour as ordered. The DON stated she expected the morning shifts would be between 7:00 A.M to 11:00 A.M. and the afternoon from 1:00 to 4:00 P.M. The DON verified the boots should not be applied overnight. The DON verified there was no documented evidence in any documentation that the lymphedema boots had been applied as ordered or the Resident #15 had refused. Interview on 12/11/25 at 11:45 A.M. Certified Nursing Assistant, (CNA) #61 stated she often worked with Resident #15, and had worked 12/07/25, 12/08/25, and 12/09/25. She stated she rarely observed the resident with the lymphedema boots applied and did not see the evening or night shift staff had applied the boots. The CNA # 61 stated she last applied the boots on 12/07/25 during day shift and verified the boots had not been applied on 12/08/25 and 12/09/25. This deficiency represents non-compliance investigated under Complaint Number 1263891.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on medical record review, observation, review of a Self-Reported Incident (SRI), review of the facility investigation and witness statements, and policy review, the facility failed to ensure one resident (#67) was free from physical abuse by a facility resident. This resulted in Actual Physical and Psychosocial Harm, based on a reasonable person's response of fear and anxiety, for Resident #67, who has impaired cognition, when Resident #85 bit her right forearm and her left breast, requiring Resident #67 to be placed on prophylactic antibiotic medication. This affected one resident (#67) out of three residents reviewed for physical abuse. The facility census was 85. Findings include: 1. Review of the medical record for Resident #67 revealed an admitted [DATE]. Diagnoses included COVID-19, major depressive disorder, anemia, pain in the right hip, dementia, mental disorders, and hyperparathyroidism. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 had impaired cognition. Resident #67 required supervision for bed mobility, transfers, eating and toilet use. The resident was coded as receiving an antidepressant and an antipsychotic medication during the assessment period. Resident #67 had no increased behaviors or moods and was unchanged from the 10/08/22 assessment. Review of the plan of care, dated 12/03/20 and revised on 08/15/22 for Resident #67, revealed impaired cognitive function/dementia or impaired thought process related to Alzheimer's. Interventions included administer medications as ordered; use resident preferred name; cue, reorient and supervise as needed; keep resident routine consistent; try to provide consistent caregivers to decrease confusion; and monitor, document and report any changes in cognitive function. Review of Resident #67's progress note dated 11/26/22 at 7:32 P.M. revealed Resident #67 had a physical altercation with another resident, Resident #85. Staff was sitting in the nurse's station with Resident #67. Resident #67 complained of pain where she was bit, with as needed Tylenol given which relieved the pain. A skin assessment was completed and noted a bite mark to the right forearm and a bruise noted to the left breast. No other injuries were noted. Resident #67 was unable to describe the incident in detail related to her mental status. Resident #67 appeared to calm down when dinner arrived, and no further distress was noted. The physician, the power of attorney (POA), the Administrator, and the Director of Nursing (DON) were notified. New orders were received for a prophylactic antibiotic. Review of a weekly skin assessment dated [DATE] revealed Resident #67 had a bite mark to the right forearm with bruising two centimeters (cm) by three cm and a bruise to the left breast that measured two cm by two cm. 2. Review of the medical record for Resident #85 revealed an admitted [DATE]. Diagnoses included dementia, delirium, hypertension, and schizophrenia. Resident #85 was discharged from the facility on 12/30/22. Review of the quarterly MDS assessment dated [DATE] revealed Resident #85 had severely impaired cognition. The resident required one-person extensive assistance with transfers, dressing, and toilet use, supervision with eating, and one-person dependence with bathing. Section E of the MDS related to behaviors dated 10/13/22 revealed Resident #85 had physical behaviors directed towards others (hitting, kicking, pushing, scratching, grabbing, and abusing others sexually) revealed behavior of this type occurred four to six days. Verbal behaviors occurred one to three days. Review of a progress note dated 11/26/22 at 7:13 P.M. revealed Resident #85 had initiated aggression on another resident. Resident #85 was standing in the hallway with Registered Nurse (RN) #30. Resident #85 was immediately placed on one-to-one observation and 15-minute checks. A skin assessment was completed with no new skin issues noted. Resident #85 was unable to provide details of the incident due to mental status. Emergency services were called, and Resident #85 was transferred to the hospital. Review of a Self-Reported Incident (SRI), dated 11/26/22 at 5:23 P.M. revealed the facility reported an incident of physical abuse involving Resident #67 and Resident #85. The SRI noted Resident #67's diagnoses included major depressive disorder, and dementia with behavioral disturbances. Resident #85's diagnoses included schizophrenia, altered mental status, and hypertension. The incident occurred on 11/26/22 at 4:00 P.M. in the hallway when Resident #85 walked up to Resident #67, grabbed her arm, and bit her in two areas. Both residents were separated immediately and Resident #85 was placed on one-to-one observation and 15-minute checks until emergency services arrived and transported her to the hospital. Review of the facility investigation dated 11/26/22 revealed all like residents residing on the memory care unit were assessed for injury or wrongdoing. Staff interviews and witness statements were completed. On 12/12/22 social services made a referral for a behavioral unit for Resident #85. Review of State tested Nurse Aide (STNA) #13's witness statement dated 11/26/22, revealed STNA #13 reported she came to help on the secured dementia unit related to the incident. Resident #85 had Resident #67's breast in her mouth while holding a fork to her neck. Resident #85 voiced she could kill her. STNA #13 and other staff got Resident #67's breast dislodged from Resident #85's teeth. Resident #85 was taken to her room and Resident #67 was taken to the nurse's station for further evaluation. Review of STNA #14's witness statement dated 11/26/22, revealed STNA #14 reported the attack started around 3:00 P.M. and continued through 4:30 P.M. STNA #14 stated she left the unit to get the nurse. STNA #14 got help from STNA #13. STNA #14 explained when STNA #13 and herself walked through the doors, Resident #85 was after Resident #67 again. Resident #85 was biting Resident #67 and would not let her go. It took STNA #13 and STNA #14 to remove Resident #85 from Resident #67. STNA #13 and STNA #14 took Resident #85 to her room. STNA #13 and STNA #14 took Resident #67 to the nurse's station, where the doors lock. Resident #85 was pushing and banging on the door trying to get in to attack Resident #67 again. Resident #85 attacked Resident #67 three different times. Review of RN #30's witness statement dated 11/26/22 revealed she was summoned by staff on the secured dementia unit related to a resident biting another resident in two areas. Resident #85 was abusive to staff, hitting and noncompliant. Resident #67 was sitting at the nurse's station with staff. RN #30 stayed with Resident #85 in the hallway until the police and the ambulance arrived at 5:16 P.M. and a 15-minute observation sheet was completed. Resident #85 was assisted to stretcher for transport to the hospital. Resident #67 had a bite mark visible to her right forearm and no visible injury noted on breast. Review of Licensed Practical Nurse (LPN) #22's witness statement dated 11/26/22 revealed Resident #85 had bit Resident #67. LPN #22 found Resident #67 in the nurse's station with staff. Resident #85 was walking in the hall with RN #30. RN #30 and LPN #22 initiated one-to-one supervision with Resident #85. Resident #67 was assessed and was noted to have a bite mark on her right forearm and left breast. Emergency services were called. Resident #85 was taken to the hospital for evaluation. Observation on 02/21/23 at 2:41 P.M. revealed Resident #67 was sitting in the dining room in a chair of the memory care unit. Staff were trying to get her to go to her room to be changed, Resident #67 became agitated and walked to her room and slammed the door. Resident #67 was unable to be interviewed related to cognition. Resident #85 no longer resided in the facility and was unable to be observed or interviewed. Telephone interview on 02/23/23 at 6:34 P.M., with STNA #13 revealed STNA #14 asked STNA #13 for help related to Resident #67 and Resident #85 altercations. STNA #13 stepped onto the unit as STNA #14 left to find a nurse. STNA #13 reported Resident #67 and Resident #85 were in the dining room. Resident #67 was screaming and saying get off me to Resident #85. Resident #85 was grabbing Resident #67. STNA #13 explained she asked Resident #85 to let go of Resident #67. STNA #13 stated Resident #85 let go of Resident #67 and turned towards and came at STNA #13 and threatened her. STNA #13 reported she kept her distance from Resident #85. STNA #13 explained Resident #67 was holding her head and went to her room and shut the door. STNA #13 reported other staff members arrived at the unit and asked what had happened. STNA #13 explained to staff what happened and went back to her assigned unit. She had not recalled writing about a fork or the threatening remarks. Interview on 03/07/23 at 12:52 P.M. with STNA #14 revealed she was in room [ROOM NUMBER] assisting another resident when she heard Resident #67 hollering out, Why are you doing this? STNA #14 reported she saw Resident #85 hitting and pulling Resident #67's hair. STNA #14 took Resident #85 to her room. STNA #14 placed Resident #67 in the nurse's station. STNA #14 explained Resident #85 came out of her room and started banging and kicking on the nurse's station door trying to get in. STNA #14 stated she left the nurses station and redirected Resident #85 to her room again. STNA #14 revealed she was trying to page and call LPN #22 but was unable to reach her. STNA #14 explained Resident #67 exited the nurse's station and walked in the opposite direction. STNA #14 escorted Resident #67 to her room. Resident #85 was heading towards Resident #67 again, but STNA #14 walked Resident #85 to her room. STNA #14 reported she went to find help and found STNA #13 on the adjacent unit. STNA #13 and STNA #14 found Resident #85 attacking Resident #67. Resident #85 was biting Resident #67's shirt, near her left breast. STNA #14 revealed Resident #67 wore multiple layers of clothes. STNA #14 stated STNA #13 and herself had to maneuver Resident #85 off of Resident #67. When STNA #13 and STNA #14 removed Resident #85 from biting Resident #67's shirt, Resident #85 bit Resident #67 in the arm. Resident #67 was placed back in nurse's station and STNA #13 stayed with Resident #85. STNA #14 reported she went to find LPN #22 because she was not on the unit. She said at no time had she seen Resident #85 have a fork to Resident #67's neck during the incidents. STNA #14 said the incidents happened quick and they were not happening continuously for an hour and a half. Telephone interview on 03/08/23 at 8:55 A.M., with LPN #22 revealed she was on another unit taking care of residents when the incident happened between Resident #67 and Resident #85. Telephone interview on 03/08/23 at 1:39 P.M. with the former Administrator #100 revealed the investigation was uploaded into the system prior to her departure from the facility and given to the current Administrator. The former Administrator #100 reported she spoke with staff regarding the incident. She reported LPN #22 was placed on suspension related to not providing supervision on the unit. The Former Administrator #100 stated all staff present in the building on 11/26/22 were educated on abuse. All staff were educated on abuse on 11/28/22. Skin checks were completed on all residents on the dementia unit, where the abuse occurred. The former Administrator #100 also revealed Resident #85 was taken off the unit during the day to participate in activities and this kept her busy. The former Administrator #100 said they had a hard time finding a behavior unit for Resident #85 but one was willing to accept her on 12/30/22. She said her investigation showed the incidents happened in a short time period, not ongoing abuse for hours. They provided on-going monitoring of abuse on the unit. Review of facility policy titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated 10/06/22 revealed the residents had the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. It was the facility's policy to investigate all alleged violations involving abuse, neglect, misappropriation of resident property, exploitation, or mistreatment, including injuries of unknown origin. Facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health in accordance with the procedures in this policy. Staff were required to identify, correct, and intervene in situations in which abuse, neglect, exploitation and/or mistreatment of resident property was more likely to occur in accordance with the facility's quality assurance and performance improvement (QAPI). If a resident was accused or suspected, the facility would ensure other residents are protected as determined by the circumstances, which may include but are not limited to, increased supervision of the alleged perpetrator and/or other residents, room, or staffing changes, and immediate transfer or discharge, if indicated. As a result of the incident, the facility took the following actions to correct the deficient practice as of 12/30/22: On 11/26/22, the former Administrator #100 and designee educated all staff who were on the schedule and working on 11/26/22 on abuse. On 11/26/22, Registered Nurse #30 completed skin sweeps on all residents who resided on the dementia unit where Resident #85 resided. No residents were found with any new skin issues or suspected abuse. On 11/26/22, Resident #85 and Resident #67 were both placed on increased supervision. On 11/26/22, Resident #85 was sent out to the local hospital for evaluation. On 11/28/22, the former Administrator #100 and the Director of Nursing (DON) provided abuse education/in-service all staff either in person or via telephone was completed 11/28/22. On 11/28/22, the former Administrator #100 suspended LPN #22 pending the outcome of the investigation. LPN #22 then wrote a formal complaint against the former Administrator #100 and never returned to work. On 11/28/22, Resident #85 was escorted out of the unit for activities during the day. On 12/12/22, the Social Service Designee made a referral for all behavior units in the area. None were willing to take Resident #85. Placement on a women's behavioral unit was found on 12/30/22 for Resident #85. The former Administrator #100 and/or the DON/Designee completed audits to ensure the interventions and supervision levels were in place. The audits were taken to the Quality Assurance Performance Improvement (QAPI) committee for review. Review of the audits discussed with former Administrator #100 revealed they began the week of 11/28/22 and revealed a second incident occurred on 12/27/22 where Resident #85 ran in Resident #67's room and bent her thumb despite increased supervision levels. No injuries occurred during this incident. This deficiency represents non-compliance investigated under Master Complaint Number OH00139812 and Control Number OH00138276.

Based on medical record review, review of the local hospital record, review of a Self-Report Incident (SRI), staff interviews, local hospital staff interviews, and policy review the facility failed to ensure wounds were not infested with maggots. This resulted in actual harm for Resident #95 when a surgical wound on her neck became infested with non medical maggots found by the local hospital which required surgical debridement. In addition the facility failed to complete physician ordered wound treatments. This affected two Residents (#49, and #121) of three reviewed. The facility identified 20 residents with wounds. The facility census was 91. Findings include: 1. Medical record review revealed Resident #95 was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. Review of the plan of care dated 11/06/19 revealed Resident #95 had actual impairment to skin integrity related to a surgical neck wound. The resident frequently refused care to the area. Review of the wound note dated 12/31/19 revealed Resident #95 had a surgical wound to the right neck measuring 1.0 centimeter (cm) length by 2.7 cm width by 0.1 cm depth. The Physician ordered to cleanse the wound with normal saline or sterile water, apply alginate to the wound bed and cover with a dry clean dressing every day. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #95 had severe cognitive deficits, required extensive assistance with activities of daily living, was totally dependent for transfers, eating, and was frequently incontinent of bladder and always incontinent of bowel. Review of the SRI dated 07/26/20 revealed State tested Nursing Assistant (STNA) #103 notified Licensed Practical Nurse (LPN) #104 there was black drainage around the residents [DEVICE] site as well as bleeding from the scabbed wound on the neck. STNA #103 reported to LPN #104 the resident had been refusing to allow the neck wound site to be cleaned and was becoming aggressive with STNA #103 during her attempt to cleanse the neck area. LPN #104 assessed the resident, noted the black drainage from the gastromony site and became immediately concerned regarding a gastro-intestinal (GI) bleed. LPN #104 also assessed the neck wound and noted the resident had scratched the scab off causing the bleeding. The resident continued to be aggressive towards the nurse, swinging at her as she attempted to investigate the neck wound. The Director of Nursing (DON) was notified immediately and instructed LPN #104 to send Resident #95 out emergently due to the possible GI bleed and to notify hospice and family of the situation. The DON also instructed the nurse to cleanse the neck wound with normal saline, paint with [MEDICATION NAME], and cover with a dry sterile dressing as this was her prescribed wound dressing at the time. Resident #95 was transported emergently via emergency medical squad to a local hospital. LPN #104 later received a phone call from a nurse at the local hospital Emergency Department (ED) informing her Resident #95 had maggots coming from her neck wound. The hospital nurse informed LPN #104 the resident had to tilt her head a certain direction in order to detect the maggots as they tunneled further up her neck. She stated they found three however were concerned there may be more hidden, so the resident was going to undergo surgical debridement. The nurse at the local hospital also expressed to LPN #104 they had difficulty getting the resident to comply with wound investigation and treatment due to her combativeness. The DON received a call the same day from the hospital charge nurse claiming this was a case of neglect. Review of the local hospital ED provider notes dated 07/26/20 at 1:30 P.M., for Resident #95 revealed a large neck wound to right anterior there appeared to be several maggots within the wound, no active bleeding, gross [DIAGNOSES REDACTED], or purulent discharge, the resident denied pain or tenderness at site, does not appear to have difficulty speaking. Attempted to clean and debride at the bedside, however, the wound was extensive and the infestation was significant. It was evaluated and discussed with general surgery who had evaluated her at the bedside and recommended operating room debridement as well as one-time dose of [MEDICATION NAME] (antibiotic) which was provided. Review of local hospital ED nursing note dated 07/26/20 at 4:09 P.M., revealed when the resident had returned from her computed tomography (CT) scan Hydrogen peroxide (antiseptic) soaked gauze was placed in the wound. Multiple maggots were noted in the wound during replacement of the dirty dressing. Review of History and Physical performed by hospital physician dated 07/26/20 revealed Resident #95 had a history of [REDACTED]. The resident was severely demented at baseline, care discussed with the residents son; the local hospital was taking appropriate measures to report elderly neglect; the wound was grossly infested with maggots and this was most likely a case of neglect due to the extent of infestation. The medial aspect of wound had a large amount of maggots present both tunneling under the skin and at the skin margin. Review of operative notes dated 07/27/20 revealed the surgeon used DeBakery forceps to pick out the superficial maggots and suction was also used to assist with this. A 15-blade was used to excise circumferentially the borders of the wound and a tunnel was seen along the subcutaneous tissue down to the platysma muscle, just anterior to the sternocleidomastoid muscle. Very meticulous dissection was done to open this wound along the anterior border of the muscle and bovi electrocautery was used to maintain hemostasis. The tunnel was completely opened, and no obvious purulence or remaining maggots were seen. Review of Pathology report dated 07/27/20 revealed the specimen removed from Resident #95's neck wound was a maggot. Gross Description as follows: submitted fresh and subsequently fixed in [MEDICATION NAME] with correct patient labeling as maggot is a 1.0 cm long by 0.2 cm in diameter white larva suggestive of maggot. Review of post-operative note dated 07/27/20 revealed findings as multiple maggots removed. Wound base with healthy bleeding, small amount of tissue debrided from edges of wound to level of subcutaneous tissue. Telephone interview on 10/05/20 at 1:46 P.M., the local hospital Registered Nurse (RN) #100 verified when she saw the dressing on Resident #95 neck it was just gauze with a piece of tape barely holding it in position. The dressing was changed prior to the resident going to the CT scan. She reported when she removed the gauze there were maggots crawling around the wound. She verbalized there was no scabbing on the wound and the resident had not refused care and was not combative during the dressing change. Telephone interview on 10/05/20 at 2:15 P.M. the local hospital charge RN #101 verified there was no scab over the wound when Resident #95 arrived at the ED, however there was a flimsy dirty piece of gauze taped in place. Charge RN #101 reported when she looked under the gauze there were multiple maggots moving around. She verbally described them in various stages such as: larvae, formed maggots, and cocooned. She stated she called the nursing home to inform them the report of neglect, however she never said there were just three maggots and she did not say Resident #95 was combative or refusing care provided to the wound. Interview on 10/05/20 at 4:21 P.M., LPN #104 stated that when the nursing aide reported to her that Resident #95's [DEVICE] was leaking a black substance and that the neck wound was bleeding, she went to do an assessment on the [DEVICE], she noted the dressing was off the neck wound so she cleansed it with normal saline, painted it with [MEDICATION NAME], and placed the gauze on it. She stated the [DEVICE] was more of a priority due to a possible GI bleed. When asked, LPN #104 stated that the wound on Resident #95's neck did not have a scab in place, and it was open to air. Interview on 10/14/20 at 2:24 P.M., the DON reported the resident had always refused care, however upon review of the Treatment Administration Record (TAR) dated from 07/01/20 through 07/26/20 revealed treatments were completed without refusals. Review of the policy titled Skin Practice Guidelines dated 2020 provided by the facility revealed the goal of a wound management team was to assist with ongoing wound management and monitoring. Patients have the right to refuse the care designed in the care plan. In this case, staff performs several tasks including: documenting patient's refusal, try to discover basis for patient's refusal, presenting a rational for why the intervention is important, designing and alternate plan, offering alternatives and documenting the patient's comprehension of options presented. This revised strategy needs to be described in the care plan and documented in the patient's medical record. Update the care plan to reflect any changes in the patient's risk status. 2. Record review revealed Resident #49 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the wound care notes from Wound Care Physician #565 dated 06/30/20 revealed resident had a skin tear on the right gluteal fold that was 0.4 centimeters (cm) x 2 cm by 0.1 cm and had 80 percent granulation and 20 percent slough with the wound onset date being 06/30/20. Resident #49 was ordered to cleanse the wound with normal saline or sterile water and cover with dry dressing as instructed every three days. Wound Care Physician #565's note dated 07/07/20 revealed resident had a skin tear on her right gluteal fold that had declined. The wound onset date was 06/30/20 and was 11.5 cm by 3.5 cm by 0.1 cm with 60 percent granulation and 40 percent slough. Resident #49 was ordered to cleanse wound with normal saline or sterile water, apply alginate to wound bed and cover with dry clean dressing every day. Wound Care Physician #565's note dated 07/14/20 revealed resident had a skin tear on her right gluteal fold that had declined with a wound onset date of 06/30/20. The wound was 15.5 cm by 6 cm by 0.1 cm and had 60 percent granulation and 40 percent slough. Resident #49 was ordered cleanse wound with normal saline or sterile water, apply alginate to wound bed and cover with dry clean dressing every day. Wound Care Physician #565's note dated 07/21/20 revealed resident had a skin tear on her right gluteal fold that was healing. The wound was 8.5 cm by 4.5 cm by 0.1 cm with 60 percent granulation and 40 percent slough. Resident #49 was ordered to cleanse wound with normal saline or sterile water, cover with dry clean dressing as instructed. Apply santyl a nickel thick layer and cover with moist gauze every day. Review of Wound Care Physician #565's note dated 07/28/20 revealed resident had a skin tear on her right gluteal fold that was healing. The wound was measured at 6.5 cm by 4.5 cm by 0.1 cm with 80 percent granulation and 20 percent slough. Resident #49 was ordered to cleanse wound with normal saline or sterile water, cover with dry clean dressing as instructed. Apply santyl and nickel think layer and cover with moist gauze every day. Review of Wound Care Physician #565's note dated 08/04/20 revealed resident had a skin tear on her right gluteal fold that was healing. The wound was 5.5 cm by 2 cm by 0.2 cm and had 100 percent granulation. Resident #49 was ordered to cleanse wound with normal saline or sterile water and cover with a dry clean dressing every day. Resident #49 was also noted to have a skin tear on the right groin that was in the healing stage with a wound onset of 07/14/20 that measured 0.4 cm by 7.5 cm by 0.1 cm with 100 percent granulation. Resident #49 was ordered to cleanse the area with normal saline or sterile water and to cover with dry clean dressing one time per day. Review of Wound Care Physician #565's note dated 10/20/20 revealed Resident #49's skin tear on her right gluteal fold was healed. Review of Resident #49's MDS assessment dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance with bed mobility, transfers, dressing, toileting, eating and personal hygiene. Further review of Resident #49's MDS also revealed the resident did not have any pressure ulcers. Review of the TAR from 08/01/20 to 10/19/20 revealed Resident #49's order to cleanse wounds to right gluteal fold with normal saline, pat dry and apply zinc barrier cream 20 percent or greater every shift was blank on the following dates 08/17/20, 08/18/20, 08/21/20 09/01/20, 09/16/20, 10/14/20, 10/17/20 and 10/18/20 on day shift and on 09/01/20, 09/02/20, 09/03/20, 09/10/20, 09/23/20, 09/25/20, 09/26/20, 09/27/20, 10/07/20, 10/16/20 and 10/18/20 on night shift. Interview on 10/19/20 at 1:26 P.M. the DON verified Resident #49 had not received her treatment to cleanse wounds to right gluteal fold with normal saline, pat dry and apply zinc barrier cream 20 percent or greater on the TAR on 08/17/20, 08/18/20, 08/21/20 09/01/20, 09/16/20, 10/14/20, 10/17/20 and 10/18/20 on day shift and on 09/01/20, 09/02/20, 09/03/20, 09/10/20, 09/23/20, 09/25/20, 09/26/20, 09/27/20, 10/07/20, 10/16/20 and 10/18/20 on night shift. Review of the facility's undated skin practice guidelines revealed the licensed nurse provides wound treatments as ordered by the physician and documents completion of the treatments on the TAR. 3. Record review revealed Resident #121 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #121 discharged from the facility on 05/02/20. Review of Resident #121's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and required extensive assistance with bed mobility, dressing, toileting and personal hygiene. Further review revealed resident required supervision with eating and total dependence with transfers and bathing. Review of Wound Care Physician #565 revealed resident was seen on 12/31/19 and was reported to have an former abscess that was 0.2 cm x 0.3 cm x 0.1 cm with 100 percent granulation. The wound was reported to have a wound onset date on 12/31/19 and had an order to use barrier wipes and spray daily and as needed. Resident #121 was also seen for moisture associated skin damage to her bilateral breasts and right abdominal pannis with a wound onset date of 12/31/19. The areas were noted to be unmeasurable. An order was put in place to cleanse the area, pat dry and apply antifungal powder every shift and as needed. Review of Wound Care Physician #565 revealed resident was seen on 04/28/20 and was reported to have moisture associated skin damage to her bilateral breasts, lower leg and right abdominal pannis with a wound onset date of 12/31/19. Both areas were listed as healing and were noted to be unmeasurable. An order was put in place to cleanse the area, pat dry and apply antifungal powder every shift and as needed. Resident #121 also had moisture associated skin damage to the back of the neck that was unmeasurable and healed on 04/28/20. Resident #121 also had [MEDICAL CONDITION] on the left lower leg posterior with a wound onset date of 04/21/20 that was unmeasurable and listed as healed. Resident was also seen for wound care on 04/21/20, 04/07/20, 03/31/20, 03/24/20, 03/17/20, 03/10/20, 03/03/30, 02/18/20, 02/11/20 and 01/13/20. Review of Resident #121's March TAR revealed resident was ordered to apply [MEDICATION NAME] ointment topically to buttock twice a day was blank on the TAR on 04/13/20, 04/20/20, 04/21/20, 04/22/20, 04/30/30 and 04/31/20 on night shift and 04/15/20 on day shift. Review of Resident #121's April 2020 TAR revealed resident was ordered to cleanse folds with soap and water, pat day well, apply antifungal powder to folds and place abdominal pads in all the folds twice a day and as needed was blank on the TAR on 04/20/20, 04/21/20, 04/22/20 04/29/20 and 04/31/20 on night shift. Interview on 10/22/20 at 9:47 A.M., the DON verified Resident #121's order to apply [MEDICATION NAME] ointment topically to buttock twice a day was blank on the TAR on 04/13/20, 04/20/20, 04/21/20, 04/22/20, 04/30/30 and 04/31/20 on night shift and 04/15/20 on day shift. The DON also verified Resident #121's order to cleanse folds with soap and water, pat day well, apply antifungal powder to folds and place abdominal pads in all the folds twice a day and as needed was blank on the TAR on 04/20/20, 04/21/20, 04/22/20 04/29/20 and 04/31/20 on night shift. This deficiency substantiates Complaint Number OH 261, OH 567, OH 728 and OH 887.

Based on review of facility medical records, review of hospital records, staff interviews, interview with Certified Nurse Practitioner (CNP) #05, review of personnel records, and review of facility policies regarding medication reconciliation and medication administration, the facility failed to ensure a resident was free from significant medication errors when Registered Nurse (RN) #07 transcribed the wrong medication orders on a resident's physician order sheet and Medication Administration Record (MAR). This resulted in Immediate Jeopardy and serious life-threatening harm when Resident #36 received 18 different medications that were not prescribed for this resident over the course of three days. Consequently, the resident experienced low blood pressure, elevated heart rate, low blood sugar, and complaints of dizziness requiring hospitalization . This affected one (#36) of three residents reviewed for medication reconciliation following admission to the facility. The facility census was 109. On 07/18/18 at 12:28 P.M., the Administrator, Director of Nursing (DON), and Quality Assurance Consultant (QAC) #10 were notified Immediate Jeopardy began on 06/23/18 when RN #07 transcribed medication orders on Resident #36's physician order sheet and MAR from Resident #60's physician orders which included diuretics, a blood thinning medication, multiple antihypertensives (blood pressure lowering medications), an oral antidiabetic agent and short and long acting insulins. On 06/25/18 at 10:15 A.M., Resident #36 reported feelings of dizziness, visual disturbances (seeing black curtains closing from the side of the eyes) and had a blood pressure reading of 81/49 millimeters of mercury (mm Hg), with a heart rate in the 130s (measuring beats per minute-bpm). The resident was transported to the hospital via 911 emergency transport and was assessed with [REDACTED]. The resident was hospitalized for [REDACTED]. The Immediate Jeopardy was removed on 06/25/18 when all licensed nurses currently working in the facility were in-serviced regarding the admission process, including medication administration and medication reconciliation guidelines, and the facility implemented the following corrective actions: · On 06/25/18 at 12:00 P.M., Resident #53, who was the only new admission from 06/21/18 through 06/25/18, had their medical record audited by RN #03 to ensure admission medications were being administered as ordered by the physician with no errors found. · On 06/25/18 at 2:40 P.M., RN #07, the admitting nurse that transcribed the medications on the physician's order sheet and MAR, was suspended pending the outcome of the investigation. An investigation was initiated by the Administrator. · On 06/25/18, the facility implemented a new order processing procedure to include having two licensed nurses review new admission orders [REDACTED]. · On 06/25/18 at 6:00 P.M., in-servicing was initiated by the Unit Managers and/or DON for licensed nurses regarding the admission process including medication administration and medication reconciliation guidelines which defined the roles and responsibilities of nursing staff involved in the process of transcribing an accurate list of the patient's medications upon admission to the facility. Staff unable to participate in the education will receive education prior to providing patient care and will be removed from the schedule until such education has been completed. · On 06/25/18, the DON and/or Unit Manager began auditing all new admission physician orders through the morning interdisciplinary team (IDT) meeting daily for 14 days, then Monday through Friday ongoing with areas of deficiency corrected immediately and submitted to the Quality Assessment and Assurance (QAA) Committee. · On 06/26/18 at 11:00 A.M., RN #07 received education by the DON on the facility's Medication Administration and Medication Reconciliation policies. RN #07 did not return to work, and employment was terminated on 06/29/18. · On 06/26/18 at 3:00 P.M., RN #03 completed a review of the medical records of all eight (#34, #79, #101, #102, #103, #104, #105, #106) newly admitted residents since 06/01/18 to ensure the physician ordered medications were being administered accurately. No errors were found. · On 06/26/18 at 6:11 P.M., a QAA Committee meeting was held and was attended by the administrator, DON, and Medical Director (MD). The MD was notified of recommendations which had been implemented by the facility and the plan was reviewed and accepted. · On 07/16/18 between 8:42 A.M. and 9:17 A.M., LPN #01 was observed administering medications to Residents #37, #38 and #39. These medications were administered without error. · On 07/16/18 at 9:26 P.M., the DON notified the Ohio Board of Nursing by e-mail of RN #07's transcription medication order error. · On 07/17/18 between 12:00 P.M. and 1:00 P.M., RN #09 and LPN #08 were interviewed regarding the in-service they received on the admission process and medication reconciliation process. Both staff interviewed were able to correctly articulate the information provided in the in-service. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record of Resident #36 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. There was no comprehensive Minimum Data Set (MDS) assessment completed due to the resident's recent admission. Review of Resident #36's After Visit Summary document from the referring facility dated 06/22/18 indicated the residents medication orders included the following: [MEDICATION NAME] (antibiotic) 875-125 milligrams (mg) twice daily for 14 days, [MEDICATION NAME] 100 mg three times a day as needed for cough, [MEDICATION NAME] Sodium 1% gel every six hours for 14 days, [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg every six hours as needed for pain, Tolvaptan (used to treat low sodium levels) 15 mg by mouth daily, [MEDICATION NAME] HFA 108 (90 Base) MCG (microgram) inhaler two puffs every six hours as need for wheezing, [MEDICATION NAME] 300 mg three times daily, [MEDICATION NAME] 600 mg daily, [MEDICATION NAME] 100 mg daily, Pantoprazole 40 mg daily, [MEDICATION NAME] 100 mg daily, [MEDICATION NAME] 18 mcg daily, [MEDICATION NAME] 100 mg nightly, and Vitamin D3 50,000 units daily. Review of Resident #36's admission physician's order sheet dated 06/23/18 documented by RN #07, did not contain the orders for [MEDICATION NAME] HFA, [MEDICATION NAME], Pantoprazole, [MEDICATION NAME], Vitamin D3, and contained twice the ordered dose of [MEDICATION NAME]. The admission physician orders also contained the following medications for which there were no orders on the After Visit Summary form dated 06/22/18: [MEDICATION NAME] 600 mg three times daily, [MEDICATION NAME] (diuretic) 20 mg daily, [MEDICATION NAME] 40 mg daily, Potassium Extended Release (ER) 20 milliequivalents (mEq) three times daily, [MEDICATION NAME] 80 mg daily, [MEDICATION NAME] (blood thinner) 3.5 mg daily, [MEDICATION NAME] (antihypertensive) 10 mg daily, [MEDICATION NAME] (antihypertensive) 12.5 mg twice daily, Calcium 500 mg daily, [MEDICATION NAME] (diuretic) 2.5 mg daily, [MEDICATION NAME] (diuretic) 30 mg daily, Calcium [MEDICATION NAME] 500 mg daily, [MEDICATION NAME] (antibiotic) 250 mg twice daily, [MEDICATION NAME] 12 mcg/hour every third day, [MEDICATION NAME] 325 mg daily, [MEDICATION NAME] 54 mg daily, [MEDICATION NAME] (diabetic medication) 500 mg daily, Calcium-Vitamin D 500-200 mg twice daily, [MEDICATION NAME] (antihypertensive) 50 mg three times daily. [MEDICATION NAME] 8.6-50 mg two tabs twice daily as needed, [MEDICATION NAME] 4 mg every six hours as needed, [MEDICATION NAME] 2.5 mg/3 milliliter (ml) 0.083% inhalation 2.5 mg every six hours as needed, [MEDICATION NAME] 17 grams daily as needed, Tylenol 650 mg as needed for mild pain, Basaglar (insulin) Kwikpen 100 units/ml 12 units at bedtime, and Humalog (insulin)100 units/ml four units three times daily before meals. Review of the MAR for (MONTH) (YEAR) contained documentation the following medications were written on Resident #36's MAR without a physician's order. There were 18 medications administered to the resident between 06/23/18 and 06/25/18 that the resident did not have a physician order for [REDACTED]. doses), Calcium [MEDICATION NAME] 500 mg (three doses), [MEDICATION NAME] 250 mg (four doses), [MEDICATION NAME] 325 mg (one dose), [MEDICATION NAME] 54 mg (two doses), [MEDICATION NAME] 500 mg (three doses), Calcium-Vitamin D 500-200 mg (four doses), [MEDICATION NAME] 50 mg (three doses), Basaglar Kwikpen 100 units/ml 12 units (two doses), Humalog 100 units/ml four units (seven doses). Review of Resident #36's progress notes dated 06/25/18 revealed the resident was sent to the hospital emergently after complaints of confusion, dizziness, and visual disturbances along with a low blood pressure reading of 81/49 mm HG (normal 120/80 mm HG), and an elevated heart rate of 130 bpm (normal resting between 60 and 100 bpm). Review of the hospital Emergency Department Attending Physician note dated 06/25/18 at 11:03 A.M. revealed the Emergency Medical Service (EMS) providers reported upon arrival to the nursing home facility, Resident #36 was hypotensive with blood pressures in the 60's and 70's and was found to by hypoglycemic with fingerstick blood sugar in the 30s. The note indicated after the resident had been present in the emergency department for about an hour, they began to receive calls from nursing staff and nursing home administrators at the facility which informed them the resident had been receiving the wrong medications throughout her stay at the nursing facility. The note further indicated among the medications the resident had received but were not prescribed were diabetic medications including [MEDICATION NAME] and both long-acting and short-acting insulin, several antihypertensive medications, and [MEDICATION NAME]. This appeared to be the most likely explanation for both the resident's [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. The note indicated the resident was being admitted to the hospital due to requiring careful blood pressure and glucose monitoring. Review of the hospital Internal Medicine History and Physical dated 06/25/18 at 3:08 P.M. revealed the resident had iatrogenic (medical treatment induced) [MEDICAL CONDITION] to 60s systolic secondary to iatrogenic causes, patient was given another patient's [MEDICATION NAME] and diuretics; iatrogenic [DIAGNOSES REDACTED] to 30's secondary to being given another patient's Humalog, Basalgar and [MEDICATION NAME]; [MEDICAL CONDITION], worsened by diuretics; [DIAGNOSES REDACTED] and [DIAGNOSES REDACTED], likely secondary to being given diuretics incorrectly in setting of diarrhea; and elevated INR, secondary to receiving [MEDICATION NAME] incorrectly. The resident was hosptalized on [DATE] and discharged to another nursing home facility from the hospital on [DATE]. During an interview on 07/16/18 at 12:15 P.M., CNP #05 reported Resident #36 was sent to the emergency roiagnom on [DATE] with complaints of dizziness, visual changes, low blood pressure and elevated heart rate. CNP #05 reported having compared the resident's medication orders to the hospital discharge medications and noted the medications did not match. Interview on 07/16/18 at 1:20 P.M. with the DON revealed a facility investigation was conducted on 06/25/18. The DON verified RN #07 incorrectly transcribed another resident's medication orders onto the resident's admission orders [REDACTED]. The DON verified Resident #36 received the incorrect medications and was sent to the hospital thereafter. The DON further reported that RN #07's employment was terminated as a result. Interview on 07/19/18 at 9:18 A.M. with RN #07 verified transcribing a different resident's medication orders onto Resident #36's physician's order sheet and verified the admission orders [REDACTED]. Review of the personnel record for RN #07 revealed the employee received education on 09/22/17 on medication administration and 12/01/17 on medication administration; avoiding common errors. Further review of the personnel record revealed RN #07's employment was suspended on 06/25/18 related to the investigation of Resident #36's medication error. RN #07 did not return to work and employment was terminated on 06/29/18 for failure to comply with all health and safety rules, including rules prohibiting unsafe conduct or unsafe acts that jeopardize the health and safety of self or others or result in serious injury. Review of the facility policy titled Medication Reconciliation dated (MONTH) (YEAR) revealed that, upon admission, the facility was to review the medication list obtained from the referral source (hospital), identify medications that were discontinued at the time of the transfer to the facility, identify medication that the patient reported to have been taking prior to admission from referring facility, review any discrepancies with admitting attending physician for disposition and reconciliation, and document orders in the patient's clinical record. Review of the facility policy titled Medication Administration and Treatment Administration dated (MONTH) (YEAR) revealed medication errors are documented in the facility's Incident Management System, that all orders are to be prescribed by a medical practitioner, and that licensed nurses are oriented upon hire and evaluated annually in medication and treatment administration techniques and medication and treatment documentation requirements. The policy further indicated a current INR level was to be validated prior to the administration of [MEDICATION NAME] and documented on the MAR. This deficiency substantiates Complaint Number OH 918.

Based on medical record review, resident interview, staff interview and review of information from Medscape, the facility failed to ensure a residents pain was adequately managed. This resulted in harm when the facility failed to administer as needed (prn) pain medication and/or adequately manage Resident #410's pain resulting in unrelieved severe pain. This affected one (#410) resident out of 22 sampled residents. The facility census was 111. Findings include: Review of the medical record for Resident #410 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) was not available as the resident was just admitted [DATE]. Interview on 02/11/18 at 9:31 A.M. with Registered Nurse (RN) #10 revealed that Resident #410 had a temporary prescription when she arrived for [MEDICATION NAME] five to ten milligrams (mg) every six hours as needed for pain relief the quantity was 10. RN #10 further revealed that Resident #410 had not gotten any pain medications the evening before and had gotten no pain medication overnight. RN #10 revealed the evening shift nurse had paged the physician overnight. RN #10 revealed she had paged the physician this morning twice but had not received an answer yet. RN #10 revealed she could not pull this medication from the emergency box because she didn't have a valid order to do so. Interview on 02/11/18 at 9:44 A.M. with Resident #410 revealed she had received no pain medication the day prior and had not received any pain mediation as of the time of this interview. Resident #10 stated her current pain level was a 10 out of 10, with 10 being the most severe pain. Review of progress notes dated 02/10/18 at 2:32 A.M. revealed Resident #410 had been given pain medication, [MEDICATION NAME] five milligrams (mg) earlier in shift and would need a prescription for more [MEDICATION NAME]. The doctor on call was informed. Awaiting response. Review of the controlled substances record shows a last dose given on 02/09/18 at 9:00 P.M. of one tablet [MEDICATION NAME] five mg. Review of progress notes dated 02/10/18 at 3:10 P.M. revealed Resident #410 was experiencing some significant pain, eight out of 10 so the physician would need to be contacted for orders for pain medication and an anti-nausea medication was given at that time. Review of progress notes dated 02/11/18 at 8:15 A.M. and 11:10 A.M. revealed RN #10 called and left message for the physician regarding orders for pain medication for Resident #410. Review of progress notes dated 02/11/18 at 12:07 P.M. revealed orders were obtained for pain medication, [MEDICATION NAME] five mg and the quantity was six. Interview on 02/12/18 at 9:25 A.M. with Resident #410 revealed her pain medication had been filled on 02/11/18 and she received her first dose after lunch. Resident #410 stated she took two pills (10 mg) to bring the pain down, then two more at dinner time, one pill overnight and one this morning. Resident #410 stated her current pain level was six out of 10. Interview on 02/14/18 at 9:12 A.M. with Resident #410 revealed that during the time the resident was out of pain medication the facility offered her nothing for pain relief and that the only medications she received were her scheduled medications. Review of information from Medscape revealed [MEDICATION NAME] is an opiod [MEDICATION NAME] that is indicated to treat moderate to severe pain. Further review revealed precise and systematic pain assessment is required to make the correct [DIAGNOSES REDACTED]. During a Pain Assessment the residents pain is assessed on a zero to 10 scale with zero being no pain and 10 being the most severe pain.

Based on medical record review, staff interviews, review of the Emergency Medical Service (EMS) report, review of personnel records, interview with the Medical Director, and facility policy review, the facility failed to appropriately respond to a resident's change in condition by timely notifying the resident's physician and failed to provide the necessary care and services when staff delayed the immediate initiation of Cardiopulmonary Resuscitation (CPR) for one (#121) resident who was found unresponsive, without a pulse and respirations, and who was a Full Code status. This resulted in Immediate Jeopardy when facility staff failed to respond appropriately to Resident #121's change in condition (i.e. labored breathing, abnormal lung sounds and dark brown phlegm) by timely notifying the resident's physician and subsequently failed to provide timely emergent medical treatment when the resident was found unresponsive, without a pulse or respirations. CPR was not immediately initiated, and the resident did not respond once resuscitative measures were eventually started. The resident was subsequently pronounced dead at the facility. This affected one resident (#121) of one reviewed who required CPR in the event of a cardiopulmonary arrest. The facility identified a total of 75 residents who were a Full Code status. The facility census was 115. On [DATE] at 4:58 P.M., the Administrator, Director of Nursing (DON), Quality Assurance Consultant (QAC) #400, Regional Director (RD) #401 and Regional Consultant #402 were notified Immediate Jeopardy began on [DATE] at 9:15 A.M. when Resident #121 was found unresponsive, without a pulse or respirations, and Licensed Practical Nurse (LPN) #103 failed to immediately initiate CPR or call 911. The Immediate Jeopardy was removed on [DATE] at 7:48 P.M. when the facility implemented the following corrective actions: · On [DATE] at 1:00 P.M., education began for all staff on the Emergency Management Guidelines by Staff Development Nurse (SDN) #406, Unit Managers #211 and #221 and the DON. This included defining roles and responsibilities of nursing staff involved in the care of a patient in an emergent situation. Staff unable to participate will be removed from the schedule until such education has been completed. · On [DATE] at 3:45 P.M., Human Resource Director (HRD) #9 began an audit of personnel files to validate active licenses and CPR certification for all nursing staff. · On [DATE] at 5:30 P.M., the administrative staff completed a chart audit of all current residents residing in the facility to ensure the correct code status was on the chart and also in the electronic chart to ensure valid physician orders were in place. This task was completed at 7:48 P.M. · On [DATE], RD #401 educated Licensed Social Worker (LSW) #304 on the social service manual related to advance directives. · On [DATE] at 6:00 P.M., in-service education for all nursing staff regarding the Emergency Procedure-Cardiopulmonary Resuscitation (CPR) policy was completed. · On [DATE] between 6:23 P.M. and 6:51 P.M., interviews with LPN #95, Registered Nurse (RN) #46, RN #231, LPN #87, RN #211, LPN #223, RN #108 and LPN #234, revealed they were knowledgeable regarding the procedure of where to check for a resident's code status and the procedure for initiating CPR. · On [DATE] at 7:00 P.M., SDN #406 provided education for LPN #103 for not initiating CPR immediately on Resident #121 and on the Emergency Management Guidelines which included the process of defining roles and responsibilities of nursing staff involved in the care of a patient in an emergent situation. · On [DATE] at 3:48 P.M., a random interview with State tested Nurse Aide (STNA) #74 revealed she had training with SDN #406 on what to do in an emergency situation. She was knowledgeable regarding the procedure for emergency care. · On [DATE], the DON and/or Administrator will monitor code status through the morning Interdisciplinary Team (IDT) daily for the next 14 days, then Monday through Friday on-going. Areas of deficiency identified will be submitted to the Quality Assurance (QA) committee and corrected immediately. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (No actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan to investigate all deaths and monitor to ensure on-going compliance. Findings include: Review of Resident #121's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #121's signed physician order (PO) dated [DATE] Resuscitation Identification was located in her medical record and indicated her code status was handwritten on the order as being a Full Code. Review of Resident's #121 electronic record indicated the resident's code status on the advanced directives assessment was also a full code. Review of the PO dated [DATE] documented the resident had two breathing treatments ordered for administration. The orders included a routine [MEDICATION NAME] (which came with a manufacturer warning to not use this medication during an acute attack) 0.5 milligrams per Liter (mg/L), twice daily and [MEDICATION NAME] (a short acting [MEDICATION NAME][MEDICATION NAME]) 5 mg/L, every four hours, as needed. Review of the nurse's note dated [DATE] at 10:30 A.M., written by LPN #103 documented at approximately 7:15 A.M., Resident #121 had experienced respiratory issues with labored breathing. She noted the resident has having dark brown colored phlegm. Resident #121 was given a routine nebulizer treatment at 7:15 A.M., and the phlegm seemed to loosen and the resident was able to cough very slightly. At approximately 7:45 A.M., she was reassessed with [REDACTED]. Resident respirations were even and continued slightly labored. At approximately 8:45 A.M., LPN #103 noted the resident was up in bed in a sitting position with eyes open, at baseline, and did not respond to verbal stimuli. At approximately 9:00 A.M., LPN #103 entered the room to reassess Resident #121 and found her eyes slightly open, skin cold, clammy, lower extremities with noted mottling, fingertips slightly bluish in color, and she checked for a radial and carotid pulse which was unattainable. LPN #103 immediately called for the 500 hall nurse LPN #87 to assess the resident and LPN #103 left the room to check the chart. Resident #121 was a full code, so she called for a code blue. All nurses responded to the residents' room and the full code protocol was initiated. Emergency Medical Services (EMS) was called and given information. At approximately 9:15 A.M., EMS arrived and took over the code. The EMS staff stated due to her overall condition and possibly deceased , they would continue CPR for 20 minutes and then if no response from the resident, the code would be terminated. At approximately 9:58 A.M., the EMS staff stopped the code and pronounced the time of death. Review of the EMS incident detail report dated [DATE] documented they were called at 9:26 A.M. by STNA #112 for a female resident who was unresponsive and not breathing. The EMS arrived on site at 9:32 A.M. Review of the Patient Care Report/Detailed form revealed the EMS responded to the 911 call for Resident #121 regarding a [MEDICAL CONDITION]. The form indicated the fire department/EMS received a call on [DATE] at 9:26 A.M. The call was dispatched at 9:27 A.M. EMS arrived in Resident #121's room at 9:32 A.M. to find Resident #121 without a pulse and unresponsive. EMS found the patient lying in bed unconscious and unresponsive with no nursing home staff members performing CPR. EMS instructed a nursing home staff member if the patient does not have a pulse to start CPR which they did. The Automated Electronic Defibrillator (AED) was on the patient and instructed no shock advised. The AED was removed and EMS lifepack 15 pads were placed on the patient which showed asystole (a [MEDICAL CONDITION] rhythm in which there is no discernable electrical activity or sometimes called a flat line). EMS took over CPR from staff and discontinued care at 9:58 A.M. An interview on [DATE] at 12:16 P.M. with LPN #103 and the DON was conducted. LPN #103 stated as she was walking to the medication cart with the night shift nurse RN #47, they could hear a certain sound coming from Resident #121's room. It was a gurgling sound and she had brown colored phlegm like someone had given her a piece of chocolate. She stated RN #47 and LPN #103 swabbed her mouth out and she seemed to be doing a little better. LPN #103 then thought because it was close to medication time, she would give Resident #121 her routine breathing medication. LPN #103 stated she was unsure of the exact time, but a little while later, she gave the resident her as needed breathing treatment. She stated she did not get vital signs and stated RN #47 did those as she was still responsible for the resident. LPN #103 stated she finished her medication pass and went into the room between 8:00 A.M. and 8:45 A.M. LPN #103 stated she went into Resident #121's room and found the resident without a pulse. LPN #103 yelled for LPN #87 to come to the residents' room to verify the resident's condition. LPN #103 did not start CPR, and left the room to call the family. She then found out the resident was a full code, went into full code mode and got on the phone to call the code blue. She stated she stayed at the nurses' station and notified 911 and went to get the crash cart. LPN #103 stated LPN #87 was a new nurse and was flustered for a moment, but LPN #95 showed up and he took over and directed the code. LPN #103 verified she did not perform CPR at any time on Resident #121 including when the resident was found to be without a pulse. LPN #103 also verified she never called the doctor to notify of the residents earlier change in condition. During an interview on [DATE] at 12:43 P.M. with LPN #87 revealed LPN #103 yelled for her and told her to bring her electronic vital sign machine to Resident #121's room. LPN #87 came in and Resident #121 was very pale and cold to the touch. She was unsure what time all this was but she was in the middle of her medication pass when LPN #103 called for her. She told LPN #103 she thought the resident had passed away and LPN #103 said she was leaving the room to go call RN #47 and find out what she should tell the family. LPN #87 verified LPN #103 and LPN #87 did not initiate CPR immediately. LPN #87 stated a little time passed as they were trying to figure out what the next step was. She said LPN #103 then yelled to her the resident was a full code at which time LPN #87 started chest compressions. LPN #87 stated it was sometime after 9:00 A.M. but she was unsure of the exact time. During an interview on [DATE] at 1:30 P.M., the Administrator and DON verified they did not investigate the events surrounding Resident #121's death. They verified there was little documentation to support what time CPR was initiated and there was lack of documentation of the status of the resident. The DON stated she thought she was unresponsive around 9:00 A.M., and EMS arrived around 9:15 A.M., but she did not know specifics. They also stated they would expect their nurses to initiate CPR immediately depending on the code status. During an interview on [DATE] at 2:10 P.M., LPN #95 revealed he had just finished medication pass when code blue came across the intercom to respond. He entered Resident #121's room and there were three nurses (LPN #103, LPN #87 and LPN #80) standing around the resident. He was not sure what they were doing, and stated the resident was lying flat in the bed and the crash cart was in the room. LPN #95 stated he grabbed the AED and was trying to figure out the placement of the pads and the others were standing watching the resident. The AED advised to shock and then he began compressions until EMS arrived and they took over her care. During a telephone interview on [DATE] at 4:07 P.M., RN #47 revealed she was helping LPN #103 pass medications for some of the residents early because she was going to get admissions. She stated she was getting ready to leave around 8:00 A.M. or 8:30 A.M. and she heard Resident #121 breathing from the doorway and it sounded as though she had something in her mouth. RN #47 and LPN #103 went into the room to check on Resident #121 and put her up high. She instructed LPN #103 to go get a suction machine and she began cleaning out her mouth with swabs. She had a brown phlegm like substance in her mouth. She stated she had never had to clean the resident's mouth before. She got her mouth clear and gave her a breathing treatment. RN #47 obtained lung sounds which revealed she was wheezing and obtained respirations which she reported to LPN #103 who was on duty for this resident. She told LPN #103 she was wheezing and sounded like she needed a chest x-ray. She stated she did not call the doctor and she reported all of this to LPN #103. She stated about 25 minutes after she left the building, LPN #103 called her to tell her Resident #121 had passed and was not breathing and asked if she should call the family and the doctor. She instructed LPN #103 to check her code status because she thought she was a full code. Review of the time detail for RN #47 documented she punched out at 9:02 A.M. on [DATE]. During an interview and review of the personnel file information concurrently with the Administrator on [DATE] at 1:05 P.M., verified LPN #103 did not have a current CPR certification document in her employee file. Further interview with the Administrator verified LPN #103 in fact, did not have a current CPR certification. During a telephone interview on [DATE] at 3:35 P.M., Medical Director (MD) #404 stated he would expect the nurses to start CPR immediately and if they did not know the code status they should start it anyway until the status could be verified. If there was a clinical change in the residents' condition, he would expect the nurses to notify a physician so they could make decisions based on a clinical assessment of the resident. The facility identified there were no other residents with a Full Code status who had expired since [DATE]. Review of the facility policy titled Emergency Management revised ,[DATE], provided specific guidelines for documentation after the provision of emergency services to a patient in the section identified as DOCUMENTATION OF EMERGENCY SERVICES PROVIDED. Facility staff are directed to document the following in a progress note after a patient emergency event: patient status, time medical emergency identified and type of emergency care initiated, evaluation of patients level of consciousness, circulation, airway, and breathing, verification of patients code status, occurrence and time code called, time and person contacting EMS, step by step description of care provided , physician notification, response received, orders obtained, family notification, response received, EMS arrival and transfer of care, time and patient status upon transfer from the center,, and any additional applicable information. Under the section EMERGENCY RESPONSE GUIDELINES, the facility policy describes the establishment of a process defining the roles and responsibilities of nursing staff involved in the care of a patient in an emergent situation. The policy directs the first person to arrive at the scene calls for assistance either by voice or emergency call light system to notify the nurse immediately, if first staff to arrive is not a nurse, do not leave patient alone unless immediate response is anticipated. The first licensed nurse that arrives on the scene evaluates patient level of consciousness, circulation, airway and breathing, directs additional licensed nurse to review chart for living will or do not resuscitate (DNR) documentation, physician orders and patients additional wishes. The policy directs additional responder to page emergency code per center established process, e.g., Code Blue ., etc., and the page is repeated at least two times. The policy further directs additional licensed nurse or staff member to phone EMS. The licensed nurse or other designated staff member reports to the nurses ' station and completes the following: notifies attending physician, on-call physician or medical director, notifies patients family or legal representative, initiates transfer form and other paper work that may be needed, and assigns a staff member to wait by the center's emergency entrance in order to direct EMS to the scene. Center staff continue management of the emergency until directed otherwise by physician or upon arrival of EMS team personnel on site. Documentation of interventions implemented, notifications made, and other relevant information identified is entered in a progress note by the licensed nurse. The policy directs staff to consider a debriefing session, including staff members involved, following the emergent situation to verify sequence of actions steps, time steps implemented and other observations. Review of the facility policy titled Cardio-Pulmonary Resuscitation revised ,[DATE], revealed the purpose is to attempt to restore cardio-pulmonary circulation to a patient without a pulse or respirations. Under the section Key Points it indicates CPR is performed only by individuals who have been trained. Review of the procedures revealed upon discovering unresponsive patient with no breathing or no normal breathing call for help, palpate for pulse and if no pulse is felt within 10 seconds, place back board or head of bed under upper body to provide a flat rigid surface, and to initiate compressions. The policy further directs if available, attach and use AED per manufacturer recommendations. Continue CPR until relieved, spontaneous breathing and or heart rate resumes or emergency medical personnel arrive and assume control of situation. Review of the facility policy titled Change in Condition dated ,[DATE] revealed the purpose was to provide guidance in the identification of clinical changes that may constitute a change in condition and require intervention and notifications. The policy defines Acute Changes in Condition in the Long-Term Care Setting in accordance with the American Medical Directors Association Clinical Practice Guidelines and recommends immediate notification for any symptoms, sign or apparent discomfort that is acute or sudden in onset and a marked change in relation to usual symptoms and signs, or is unrelieved by measures already prescribed. This deficiency substantiates Complaint Number OH 342.

Based on medical record review, review of a facility Self-Reported Incident (SRI), review of the facility's investigation, observations, interviews with residents, staff and local police officers, and review of the facility's policy on Abuse, the facility failed to ensure Resident #84 was free from physical abuse by State tested Nurse Aide (STNA) #13. This resulted in Immediate Jeopardy for one (#84) of three sampled residents from a total of nine residents identified with verbally abusive behaviors. The facility's census was 127. On 09/27/12 at 3:18 P.M., the Administrator, Administrative Director of Nursing (DON), Regional Director of Operations, and Clinical Service Coordinator were notified Immediate Jeopardy began on 09/24/12 at 10:30 A.M. when Resident #84 alleged STNA #13 punched him three times. Resident #84 sustained a laceration on the right eyebrow and a swollen black eye. Resident #84 became agitated and was sent to the hospital on [DATE] for a physical and psychiatric evaluation. The Immediate Jeopardy was removed on 09/24/12 at 10:50 A.M. when the DON escorted STNA #13 out of the facility. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 09/28/12 when the facility implemented the following corrective actions. ? On 09/24/12 through 09/29/12, and on 10/01/12, the DON and Assistant Director of Nursing (ADON) in-serviced staff on the abuse protocol and reporting. ? On 09/26/12 at 4:00 P.M., a Quality Assurance meeting was held by the Administrator, the DON, and the Medical Director to discuss the initial incident, immediate actions taken, the ongoing investigation of the incident, and additional steps for the action plan were developed. ? On 09/26/12 at 4:00 P.M., measures were put in place for ongoing monitoring by identified staff that included the ADON, Director of Care Delivery, Nursing Supervisors, and Minimum Data Set (MDS) nurses or Social Workers. Random interviews were to be conducted with five residents and five family members of cognitively impaired residents weekly utilizing the Quality Assurance Resident/Family Interview tool to determine if there were any concerns with staff related to the provision of care and services. ? On 09/26/12, the Quality Assurance (QA) committee began to monitor for concerns and identified trends daily and develop a plan of action, if needed, for follow-up and resolution. Monitoring went to five days a week on 10/04/12. ? On 09/27/12, all cognitively alert residents were interviewed by the Licensed Social Worker (LSW) #34, Licensed Practical Nurse (LPN) #69, LPN #92 and LPN #49 utilizing the Quality Assurance Resident Interview tool, to determine if there were any concerns with staff related to care and services. No concerns were identified. ? On 09/27/12, responsible parties for all cognitively impaired residents, were interviewed by LPN #69, LPN #92 LPN #49, MDS nurse #45, MDS nurse #189, LSW #34 and LSW #139 utilizing the Quality Assurance Family Interview tool to determine if there were any concerns with any staff related to care and services. There were no concerns identified. ? On 09/27/12 at 4:00 P.M., a Quality Assurance meeting was held with the Administrator, DON, all unit managers and the Medical Director to review the status of the investigation, progress on action steps, and any additional recommendations. ? On 09/27/12 at 4:00 P.M., the Interdisciplinary Team was educated on the facility's abuse guidelines, the process for investigation and reporting allegations of abuse by the Clinical Services Consultant. ? On 09/28/12 starting at 4:00 P.M., all employees were educated on Patient Protection: Abuse, Neglect and Misappropriation Prevention by the Administrator, ADON, Nursing Supervisors, Human Resources Director, and Department Managers. Employees that were unavailable for training will not be allowed to work until this training is completed. ? Interviews between 09/26/12 thru 10/04/12, with ten nurses including the DON, LPNs, #208, #105, #49, #69, #41, #118, and #11; Registered Nurses (RN) #189 and #80; Six STNAs #174, #13, #115, #68, #1, and #196; LSW #139; Residents #84, #99,#107, #83, #88, #2 and #6 revealed staff were educated on the abuse policy and procedure. All were knowledgeable on the abuse protocol and procedure. Resident interviews did not reveal any resident concerns with abuse. ? As of 10/04/12, all staff with the exception of five as needed staff, had completed the abuse training. The five as needed staff will not be allowed to work until they have completed the training. Findings include: Review of the medical record of Resident #84 revealed [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] noted the resident had good recall and was cognitively intact. The assessment identified the resident with daily verbal behaviors directed toward others. The impact of behaviors included: significantly interferes with resident care, puts others at risk for physical injury, intrudes on privacy of others, and significant disruption of care. Resident #84 required extensive assistance for all functional tasks. Review of the plan of care verbal/physical agitation/aggression noted Resident #84 had been yelling at staff, yelling profanity and had made what the staff perceived as threats related to pain, change in routine, and residents expectations. The goal of the plan of care was the resident will not verbally abuse others. Interventions included: allow the resident to respond to directions or requests, evaluate for pain, if strategies are not working, leave, if safe to do so, and re-approach later. Review of a facility SRI dated 09/24/12 at 10:30 A.M., revealed STNA #13 hit Resident #84 in the face. Review of an investigation of staff to resident abuse revealed a typed statement of witness from housekeeper (HSK) #1 dated 09/24/12, which documented HSK #1 was in a resident's room when she heard Resident #84 calling STNA #13 a "[***] ass n----". HSK #1 did not hear STNA #13's comment due to Resident #84 being so loud. HSK #1 did not see who started what first. When HSK #1 walked out of the door of the resident room she was in, Resident #84 and STNA #13 were witnessed hitting each other. HSK #1 went around the corner and told the DON there was a fight. Review of a typed statement from the DON dated 09/24/12, noted the DON was on her way out to the front of the building and heard HSK #1 yell, "fight, a fight." When the DON got around the corner on the 300 hall, Resident #84 was two to three feet away from STNA #13 and had his foot pedal off his wheel chair and swinging it towards STNA #13's face. At that point the DON sent STNA #13 to the ADON's office with a nurse manager. Resident #84 stated he hit me three times. The DON went into the ADON's office to speak with STNA #13 for three to four minutes. STNA #13 was asked to give a statement. Review of a typed statement by STNA #13 dated 09/24/12, revealed he stated Resident #84 had been harassing him all day and would call STNA #13 names every time he saw him. In the typed statement STNA #13 noted he would walk away down the hall but Resident #84 kept trying to provoke him. When this incident happened, STNA #13 documented he was going down the hall towards room [ROOM NUMBER] when Resident #84 approached STNA #13 and started calling him names and said he was going to get his people on him (STNA #13). STNA #13 documented he tried to ignore him, walked past Resident #84, then looked over his shoulder because Resident #84 was approaching him. "He came at me and swung at me and hit me in the lip and tried to re-approach me to hit me again and even took his foot rest off to try and hit me. I tried to defend myself and ended up hitting him in the face, at that point staff intervened and we were separated." Review of a typed statement from STNA #174 dated 09/25/12, documented Resident #84 and STNA #13 did not get along. On a few occasions STNA #174 had conversations with STNA #13 and told him to just leave it alone, just walk away. There were a couple of times STNA #174 heard STNA #13 make statements to Resident #84 that would "get Resident #84 going." One time STNA #13 stated to Resident #84 "they should have shot you in the face". STNA #174 documented STNA #13 also made statements of "it's either going to be my job or it is going to be him." STNA #174 stated she never thought STNA #13 would react to this and she thought he was blowing off steam. What STNA #174 had noticed was if Resident #84 said something to STNA #13 around others, STNA #13 would respond back and STNA #174 said to let it go. Interview with the DON on 09/26/12 at 7:35 A.M., revealed the facility was currently investigating a physical abuse allegation between Resident #84 and STNA #13. The DON confirmed the altercation was witnessed and STNA #13 had punched Resident #84 in the face. The DON stated she responded when HSK #1 ran towards her to say there was a fight between the two. She stated STNA #13 confirmed he did hit Resident #84 in the face. Observation of Resident #84 on 09/26/12 at 11:10 A.M., revealed the skin color was naturally dark with a light purple discoloration under the right eye. No swelling or lacerations were noted. Interview with HSK #1 on 09/26/12 at 9:40 A.M., revealed on 09/24/12, not sure of the exact time, she witnessed Resident #84 and STNA #13 hitting each other. She stated Resident #84 was not on his unit but on the 300 unit. HSK #1 was cleaning room [ROOM NUMBER] and heard a noise like yelling. She heard Resident #84 say to STNA #13 that he was a "[***] ass ni-----." HSK #1 stated she came out of the room and saw Resident #84 and STNA #13 punching each other. She was unaware who threw the first punch. HSK #1's first reaction was to pull Resident #84 away but instead she ran to the nurse's station. The DON was told there was a fight. The hallway was empty at the time of the fight. She stated Resident #84 had a scratch above the eyebrow and his eyes were black and blue, swollen and busted. HSK #1 stated she heard complaints from Resident #84 that STNA #13 "picks on him a lot". She stated Resident #84 does not get along with anyone. HSK #1 clarified the scratch was above the right eyebrow and pointed to the left eye that was swollen and black and blue. Interview with Resident #84 on 09/26/12 at 11:10 A.M., revealed on 09/21/12 STNA #13 kept mumbling under his breath, "I am going to get you and whoever shot you should have killed you." Resident #84 stated he reported it to the DON that he was being harassed by STNA #13. He stated STNA #13 went home. On Monday 09/24/12, STNA #13 was cursing at him. Resident #84 started cursing at STNA #13 and pointed his finger at STNA #13. STNA #13 slapped Resident #84's finger away. Resident #84 stated he got upset and told STNA #13 he couldn't do that and cussed at him. Resident #84 confirmed he did get loud and STNA #13 punched him in the face after Resident #84 called him a name. Resident #84 stated he was defending himself, swung back at STNA #13, when STNA #13 punched him again. Resident #84 continued to say he was taking the footrest from his wheel chair to swing at STNA #13. He stated HSK #1 saw them fighting and the DON came running down the hallway. Resident #84 informed the DON that STNA #13 hit him three times. Interview with the DON and Administrator on 09/26/12 at 11:16 A.M., revealed STNA #13 had attended an in-service on Abuse during the first quarter and a recent in-service on caring for difficult residents. The documentation from the in-service showed STNA #13 had attended. Interview with Police Officers (PO) #204 and #205 on 09/26/12 at 2:48 P.M., revealed PO #204 stated another officer arrived first on 09/24/12, and was speaking with Resident #84 outside briefly. PO #204 arrived at the facility and went inside with the officer and Resident #84. Resident #84 stated he was assaulted by STNA #13. Resident #84 stated he called STNA #13 a "[***] ass dope fiend and a mother f-----". STNA #13 started to call him names first and Resident #84 put his finger in his face which was different than what was originally said outside. Resident #84 was agitated. PO #204 stated they have the film that was in the facility's camera. PO #204 stated Resident #84 was looking down the hall and STNA #13 walked past Resident #84. Resident #84 said something to STNA #13 and STNA #13 said something to Resident #84. Resident #84 threw his hand up and STNA #13 slapped at it, smacked his hand to move it out of his face. The film revealed Resident #84 struck STNA #13 twice before STNA #13 struck the resident. STNA #13 threw two punches and missed once. Interview with STNA #68 on 09/28/12 at 9:45 A.M,. revealed she was at the nurse's station when HSK #1 said there was a fight. STNA #68 ran down the hall just behind the DON and saw Resident #84 and STNA #13 arguing. STNA #13 stated "I'm tired of your sh--" to Resident #84. STNA #68 stood to demonstrate that STNA #13 was standing over Resident #84 leaning into him with his fist held up in a threatening manner about ready to hit Resident #84. STNA #174 grabbed STNA #13 and Resident #84 stated he was punched in his face three times. Interview with STNA #13 on 09/28/12 at 10:45 A.M., revealed STNA #13 gave a history of Resident #84 always being demeaning and using profanity every time he goes by Resident #84's room. He stated he is a therapy aide and transports residents to the therapy department. STNA #13 stated if he passes Resident #84's room a 100 times, Resident #84 is using profanity towards him. At the time of the incident, STNA #13 was coming down the hall and Resident #84 was facing him. STNA #13 stated Resident #84 said to him he was "ready to whoop his ass" and charged at STNA #13. STNA #13 stated he was worried about his safety so he was protecting himself and confirmed he hit Resident #84 in the face. Review of the facility's policy on Abuse, Neglect, and Misappropriation of Patient Property Prevention dated 04/21/06, revealed seven components of abuse, neglect and misappropriation prevention can potentially detect, reduce and prevent abuse from occurring. The components are part of the center's quality assessment and assurance process and, as outlined herein, form the basis of a proactive and interactive prevention system. The seven key components are screening, train, prevent, identify, investigate, protect and report/respond. The policy noted the resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. This certification deficiency substantiates Master Complaint Control Number OH 376 and Complaint Control Number OH 371.

Based on clinical record review, review of the facility self-reported incident (SRI), review of the facility's policy on Abuse Prevention, and staff interview, the facility failed to ensure staff immediately reported verbal abuse of Resident #84 by Stated tested Nurse Aide (STNA) #13 and failed to thoroughly investigate one Resident #99's injury of unknown origin. This resulted in Immediate Jeopardy for one (#84) of three sampled residents from a total of nine residents identified with verbally abusive behaviors. The facility's census was 127. On 09/27/12 at 3:18 P.M., the Administrator, Administrative Director of Nursing (DON), Regional Director of Operations, and Clinical Service Coordinator were notified Immediate Jeopardy began on 09/24/12 at 10:30 A.M. when Resident #84 alleged STNA #13 punched him three times. Resident #84 sustained a laceration on the right eyebrow and a swollen black eye. Resident #84 became agitated and was sent to the hospital on [DATE] for a physical and psychiatric evaluation. The Immediate Jeopardy was removed on 09/24/12 at 10:50 A.M. when the DON escorted STNA #13 out of the facility. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 09/28/12 when the facility implemented the following corrective actions. ? On 09/24/12 through 09/29/12, and on 10/01/12, the DON and Assistant Director of Nursing (ADON) in-serviced staff on the abuse protocol and reporting. ? On 09/26/12 at 4:00 P.M., a Quality Assurance meeting was held by the Administrator, the DON, and the Medical Director to discuss the initial incident, immediate actions taken, the ongoing investigation of the incident, and additional steps for the action plan were developed. ? On 09/26/12 at 4:00 P.M., measures were put in place for ongoing monitoring by identified staff that included the ADON, Director of Care Delivery, Nursing Supervisors, and Minimum Data Set (MDS) nurses or Social Workers. Random interviews were to be conducted with five residents and five family members of cognitively impaired residents weekly utilizing the Quality Assurance Resident/Family Interview tool to determine if there were any concerns with staff related to the provision of care and services. ? On 09/26/12, the Quality Assurance (QA) committee began to monitor for concerns and identified trends daily and develop a plan of action, if needed, for follow-up and resolution. Monitoring went to five days a week on 10/04/12. ? On 09/27/12, all cognitively alert residents were interviewed by the Licensed Social Worker (LSW) #34, Licensed Practical Nurse (LPN) #69, LPN #92 and LPN #49 utilizing the Quality Assurance Resident Interview tool, to determine if there were any concerns with staff related to care and services. No concerns were identified. ? On 09/27/12, responsible parties for all cognitively impaired residents, were interviewed by LPN #69, LPN #92 LPN #49, MDS nurse #45, MDS nurse #189, LSW #34 and LSW #139 utilizing the Quality Assurance Family Interview tool to determine if there were any concerns with any staff related to care and services. There were no concerns identified. ? On 09/27/12 at 4:00 P.M., a Quality Assurance meeting was held with the Administrator, DON, all unit managers and the Medical Director to review the status of the investigation, progress on action steps, and any additional recommendations. ? On 09/27/12 at 4:00 P.M., the Interdisciplinary Team was educated on the facility's abuse guidelines, the process for investigation and reporting allegations of abuse by the Clinical Services Consultant. ? On 09/28/12 starting at 4:00 P.M., all employees were educated on Patient Protection: Abuse, Neglect and Misappropriation Prevention by the Administrator, ADON, Nursing Supervisors, Human Resources Director, and Department Managers. Employees that were unavailable for training will not be allowed to work until this training is completed. ? Interviews between 09/26/12 thru 10/04/12, with ten nurses including the DON, LPNs, #208, #105, #49, #69, #41, #118, and #11; Registered Nurses (RN) #189 and #80; Six STNAs #174, #13, #115, #68, #1, and #196; LSW #139; Residents #84, #99,#107, #83, #88, #2 and #6 revealed staff were educated on the abuse policy and procedure. All were knowledgeable on the abuse protocol and procedure. Resident interviews did not reveal any resident concerns with abuse. ? As of 10/04/12, all staff with the exception of five as needed staff, had completed the abuse training. The five as needed staff will not be allowed to work until they have completed the training. Finding include: Review of the medical record of Resident #84 revealed [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] noted the resident had good recall and was cognitively intact. The assessment identified the resident with daily verbal behaviors directed toward others. The impact of behaviors included: significantly interferes with resident care, puts others at risk for physical injury, intrudes on privacy of others, and significant disruption of care. Resident #84 required extensive assistance for all functional tasks. Review of the plan of care verbal/physical agitation/aggression noted Resident #84 had been yelling at staff, yelling profanity and had made what the staff perceived as threats related to pain, change in routine, and residents expectations. The goal of the plan of care was the resident will not verbally abuse others. Interventions included: allow the resident to respond to directions or requests, evaluate for pain, if strategies are not working, leave, if safe to do so, and re-approach later. Review of a facility SRI dated 09/24/12 at 10:30 A.M., revealed STNA #13 hit Resident #84 in the face. Review of an investigation of staff to resident abuse revealed a typed statement of witness from housekeeper (HSK) #1 dated 09/24/12, which documented HSK #1 was in a resident's room when she heard Resident #84 calling STNA #13 a "[***] ass n----". HSK #1 did not hear STNA #13's comment due to Resident #84 being so loud. HSK #1 did not see who started what first. When HSK #1 walked out of the door of the resident room she was in, Resident #84 and STNA #13 were witnessed hitting each other. HSK #1 went around the corner and told the DON there was a fight. Review of a typed statement from the DON dated 09/24/12, noted the DON was on her way out to the front of the building and heard HSK #1 yell, "fight, a fight." When the DON got around the corner on the 300 hall, Resident #84 was two to three feet away from STNA #13 and had his foot pedal off his wheel chair and swinging it towards STNA #13's face. At that point the DON sent STNA #13 to the ADON's office with a nurse manager. Resident #84 stated he hit me three times. The DON went into the ADON's office to speak with STNA #13 for three to four minutes. STNA #13 was asked to give a statement. Review of a typed statement by STNA #13 dated 09/24/12, revealed he stated Resident #84 had been harassing him all day and would call STNA #13 names every time he saw him. In the typed statement STNA #13 noted he would walk away down the hall but Resident #84 kept trying to provoke him. When this incident happened, STNA #13 documented he was going down the hall towards room [ROOM NUMBER] when Resident #84 approached STNA #13 and started calling him names and said he was going to get his people on him (STNA #13). STNA #13 documented he tried to ignore him, walked past Resident #84, then looked over his shoulder because Resident #84 was approaching him. "He came at me and swung at me and hit me in the lip and tried to re-approach me to hit me again and even took his foot rest off to try and hit me. I tried to defend myself and ended up hitting him in the face, at that point staff intervened and we were separated." Review of a typed statement from STNA #174 dated 09/25/12, documented Resident #84 and STNA #13 did not get along. On a few occasions STNA #174 had conversations with STNA #13 and told him to just leave it alone, just walk away. There were a couple of times STNA #174 heard STNA #13 make statements to Resident #84 that would "get Resident #84 going." One time STNA #13 stated to Resident #84 "they should have shot you in the face". STNA #174 documented STNA #13 also made statements of "it's either going to be my job or it is going to be him." STNA #174 stated she never thought STNA #13 would react to this and she thought he was blowing off steam. What STNA #174 had noticed was if Resident #84 said something to STNA #13 around others, STNA #13 would respond back and STNA #174 said to let it go. Interview with the DON on 09/26/12 at 7:35 A.M., revealed the facility was currently investigating a physical abuse allegation between Resident #84 and STNA #13. The DON confirmed the altercation was witnessed and STNA #13 had punched Resident #84 in the face. The DON stated she responded when HSK #1 ran towards her to say there was a fight between the two. She stated STNA #13 confirmed he did hit Resident #84 in the face. Observation of Resident #84 on 09/26/12 at 11:10 A.M., revealed the skin color was naturally dark with a light purple discoloration under the right eye. No swelling or lacerations were noted. Interview with HSK #1 on 09/26/12 at 9:40 A.M., revealed on 09/24/12, not sure of the exact time, she witnessed Resident #84 and STNA #13 hitting each other. She stated Resident #84 was not on his unit but on the 300 unit. HSK #1 was cleaning room [ROOM NUMBER] and heard a noise like yelling. She heard Resident #84 say to STNA #13 that he was a "[***] ass ni-----." HSK #1 stated she came out of the room and saw Resident #84 and STNA #13 punching each other. She was unaware who threw the first punch. HSK #1's first reaction was to pull Resident #84 away but instead she ran to the nurse's station. The DON was told there was a fight. The hallway was empty at the time of the fight. She stated Resident #84 had a scratch above the eyebrow and his eyes were black and blue, swollen and busted. HSK #1 stated she heard complaints from Resident #84 that STNA #13 "picks on him a lot". She stated Resident #84 does not get along with anyone. HSK #1 clarified the scratch was above the right eyebrow and pointed to the left eye that was swollen and black and blue. Interview with Resident #84 on 09/26/12 at 11:10 A.M., revealed on 09/21/12 STNA #13 kept mumbling under his breath, "I am going to get you and whoever shot you should have killed you." Resident #84 stated he reported it to the DON that he was being harassed by STNA #13. He stated STNA #13 went home. On Monday 09/24/12, STNA #13 was cursing at him. Resident #84 started cursing at STNA #13 and pointed his finger at STNA #13. STNA #13 slapped Resident #84's finger away. Resident #84 stated he got upset and told STNA #13 he couldn't do that and cussed at him. Resident #84 confirmed he did get loud and STNA #13 punched him in the face after Resident #84 called him a name. Resident #84 stated he was defending himself, swung back at STNA #13, when STNA #13 punched him again. Resident #84 continued to say he was taking the footrest from his wheel chair to swing at STNA #13. He stated HSK #1 saw them fighting and the DON came running down the hallway. Resident #84 informed the DON that STNA #13 hit him three times. Interview with the DON and Administrator on 09/26/12 at 11:16 A.M., revealed STNA #13 had attended an in-service on Abuse during the first quarter and a recent in-service on caring for difficult residents. The documentation from the in-service showed STNA #13 had attended. Interview with Police Officers (PO) #204 and #205 on 09/26/12 at 2:48 P.M., revealed PO #204 stated another officer arrived first on 09/24/12, and was speaking with Resident #84 outside briefly. PO #204 arrived at the facility and went inside with the officer and Resident #84. Resident #84 stated he was assaulted by STNA #13. Resident #84 stated he called STNA #13 a "[***] ass dope fiend and a mother f-----". STNA #13 started to call him names first and Resident #84 put his finger in his face which was different than what was originally said outside. Resident #84 was agitated. PO #204 stated they have the film that was in the facility's camera. PO #204 stated Resident #84 was looking down the hall and STNA #13 walked past Resident #84. Resident #84 said something to STNA #13 and STNA #13 said something to Resident #84. Resident #84 threw his hand up and STNA #13 slapped at it, smacked his hand to move it out of his face. The film revealed Resident #84 struck STNA #13 twice before STNA #13 struck the resident. STNA #13 threw two punches and missed once. Interview with STNA #68 on 09/28/12 at 9:45 A.M,. revealed she was at the nurse's station when HSK #1 said there was a fight. STNA #68 ran down the hall just behind the DON and saw Resident #84 and STNA #13 arguing. STNA #13 stated "I'm tired of your sh--" to Resident #84. STNA #68 stood to demonstrate that STNA #13 was standing over Resident #84 leaning into him with his fist held up in a threatening manner about ready to hit Resident #84. STNA #174 grabbed STNA #13 and Resident #84 stated he was punched in his face three times. Interview with STNA #13 on 09/28/12 at 10:45 A.M., revealed STNA #13 gave a history of Resident #84 always being demeaning and using profanity every time he goes by Resident #84's room. He stated he is a therapy aide and transports residents to the therapy department. STNA #13 stated if he passes Resident #84's room a 100 times, Resident #84 is using profanity towards him. At the time of the incident, STNA #13 was coming down the hall and Resident #84 was facing him. STNA #13 stated Resident #84 said to him he was "ready to whoop his ass" and charged at STNA #13. STNA #13 stated he was worried about his safety so he was protecting himself and confirmed he hit Resident #84 in the face. Review of the facility's policy on Abuse, Neglect, and Misappropriation of Patient Property Prevention dated 04/21/06, revealed seven components of abuse, neglect and misappropriation prevention can potentially detect, reduce and prevent abuse from occurring. The components are part of the center's quality assessment and assurance process and, as outlined herein, form the basis of a proactive and interactive prevention system. The seven key components are screening, train, prevent, identify, investigate, protect and report/respond. The policy noted the resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. 2. Record review for Resident #99 of the accumulative [DIAGNOSES REDACTED]. The minimum data set assessment dated [DATE], noted the resident had recall difficulty and was moderately cognitively impaired. The resident required limited to extensive assistance for all functional tasks. Review of a fall report noted on 07/01/12 at 2:30 P.M., the resident was found sitting in the entry way, stated he was walking to the patio and lost his balance and fell . Range of motion was within normal limits for the resident and no complaints were voiced. The physician and family were notified. After speaking with the son of the resident, the staff removed the walker until the resident could be re-assessed by therapy for safety. After reviewing documentation of the two falls, the resident did not receive any injuries. Review of nurses notes dated 07/03/12 at 10:34 A.M., noted the resident complained of mid to lower back pain and gave Tylenol 650 milligram of Tylenol earlier before therapy. The resident was in bed and stated the pain is still there and spoke with the physical therapist. The physical therapist was concerned maybe something was going on with the back. Review of nurses notes dated 07/03/12 at 12:03 P.M., noted the nurse spoke with the physician and obtained an order for [REDACTED].M., the x-ray revealed no fractures. Review of the MRI of the L spine dated 07/10/12, 10 days after the fall, noted the impression of findings compatible with a recent L2 compression fracture with minimal loss of height, subacute to chronic severe compression fracture of L3 with mild [MEDICAL CONDITION], severe remote compression fracture of L1, moderate subacute to remote superior endplate compression fracture of L5, findings compatible with a recent sacral insufficiency fracture with fractures involving the inferior aspects of the sacrum extending across the midline at the level of S2-S3, this would be amendable to sacroplasty, multiple lumbar spondylosis. Interview with the Director of Nursing (DON) and Administrator on 10/02/12 at 7:15 A.M., confirmed Resident #99 had only two falls with no injuries, scrapes or bruising. Interview with the DON on 10/02/12 at 4:30 P.M., confirmed the recent vertebral fractures of unknown origin were not investigated. She confirmed after the last fall on 07/01/12, the x-ray was negative and the MRI of the spine was not completed until 10 days later. She confirmed the MRI showed recent fractures and thought maybe it had something to do with the fall and did not investigate. Review of the facility's policy on Abuse, Neglect, and Misappropriation of Patient Property Prevention dated 04/21/06, noted seven components of abuse, neglect and misappropriation prevention can potentially detect, reduce and prevent abuse from occurring. The components are part of the center's quality assessment and assurance process and, as outlined herein, form the basis of a proactive and interactive prevention system. The seven key components are screening, train, prevent, identify, investigate, protect and report/respond. The center must ensure that all alleged violations involving mistreatment,neglect or abuse, including injuries of unknown source are reported immediately to the Administrator of the center and to other officials in accordance with state law. This certification deficiency substantiates Master Complaint Control Number OH 376 and Complaint Control Number OH 371.

Based on record review, review of the facility's policy on Abuse, Neglect, and Misappropriation of Patient Property Prevention, and staff interviews, the facility failed to ensure staff followed their Abuse policy and reported potential verbal abuse of a resident by a State tested Nurse Aide (STNA). This resulted in Immediate Jeopardy for one (#84) of three sampled residents from a total of nine residents identified with verbally abusive behaviors. The facility's census was 127. On 09/27/12 at 3:18 P.M., the Administrator, Administrative Director of Nursing (DON), Regional Director of Operations, and Clinical Service Coordinator were notified Immediate Jeopardy began on 09/24/12 at 10:30 A.M. when Resident #84 alleged STNA #13 punched him three times. Resident #84 sustained a laceration on the right eyebrow and a swollen black eye. Resident #84 became agitated and was sent to the hospital on [DATE] for a physical and psychiatric evaluation. The Immediate Jeopardy was removed on 09/24/12 at 10:50 A.M. when the DON escorted STNA #13 out of the facility. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 09/28/12 when the facility implemented the following corrective actions. ? On 09/24/12 through 09/29/12, and on 10/01/12, the DON and Assistant Director of Nursing (ADON) in-serviced staff on the abuse protocol and reporting. ? On 09/26/12 at 4:00 P.M., a Quality Assurance meeting was held by the Administrator, the DON, and the Medical Director to discuss the initial incident, immediate actions taken, the ongoing investigation of the incident, and additional steps for the action plan were developed. ? On 09/26/12 at 4:00 P.M., measures were put in place for ongoing monitoring by identified staff that included the ADON, Director of Care Delivery, Nursing Supervisors, and Minimum Data Set (MDS) nurses or Social Workers. Random interviews were to be conducted with five residents and five family members of cognitively impaired residents weekly utilizing the Quality Assurance Resident/Family Interview tool to determine if there were any concerns with staff related to the provision of care and services. ? On 09/26/12, the Quality Assurance (QA) committee began to monitor for concerns and identified trends daily and develop a plan of action, if needed, for follow-up and resolution. Monitoring went to five days a week on 10/04/12. ? On 09/27/12, all cognitively alert residents were interviewed by the Licensed Social Worker (LSW) #34, Licensed Practical Nurse (LPN) #69, LPN #92 and LPN #49 utilizing the Quality Assurance Resident Interview tool, to determine if there were any concerns with staff related to care and services. No concerns were identified. ? On 09/27/12, responsible parties for all cognitively impaired residents, were interviewed by LPN #69, LPN #92 LPN #49, MDS nurse #45, MDS nurse #189, LSW #34 and LSW #139 utilizing the Quality Assurance Family Interview tool to determine if there were any concerns with any staff related to care and services. There were no concerns identified. ? On 09/27/12 at 4:00 P.M., a Quality Assurance meeting was held with the Administrator, DON, all unit managers and the Medical Director to review the status of the investigation, progress on action steps, and any additional recommendations. ? On 09/27/12 at 4:00 P.M., the Interdisciplinary Team was educated on the facility's abuse guidelines, the process for investigation and reporting allegations of abuse by the Clinical Services Consultant. ? On 09/28/12 starting at 4:00 P.M., all employees were educated on Patient Protection: Abuse, Neglect and Misappropriation Prevention by the Administrator, ADON, Nursing Supervisors, Human Resources Director, and Department Managers. Employees that were unavailable for training will not be allowed to work until this training is completed. ? Interviews between 09/26/12 thru 10/04/12, with ten nurses including the DON, LPNs, #208, #105, #49, #69, #41, #118, and #11; Registered Nurses (RN) #189 and #80; Six STNAs #174, #13, #115, #68, #1, and #196; LSW #139; Residents #84, #99,#107, #83, #88, #2 and #6 revealed staff were educated on the abuse policy and procedure. All were knowledgeable on the abuse protocol and procedure. Resident interviews did not reveal any resident concerns with abuse. ? As of 10/04/12, all staff with the exception of five as needed staff, had completed the abuse training. The five as needed staff will not be allowed to work until they have completed the training. Findings include: Review of the medical record of Resident #84 revealed [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] noted the resident had good recall and was cognitively intact. The assessment identified the resident with daily verbal behaviors directed toward others. The impact of behaviors included: significantly interferes with resident care, puts others at risk for physical injury, intrudes on privacy of others, and significant disruption of care. Resident #84 required extensive assistance for all functional tasks. Review of the plan of care verbal/physical agitation/aggression noted Resident #84 had been yelling at staff, yelling profanity and had made what the staff perceived as threats related to pain, change in routine, and residents expectations. The goal of the plan of care was the resident will not verbally abuse others. Interventions included: allow the resident to respond to directions or requests, evaluate for pain, if strategies are not working, leave, if safe to do so, and re-approach later. Review of a facility SRI dated 09/24/12 at 10:30 A.M., revealed STNA #13 hit Resident #84 in the face. Review of an investigation of staff to resident abuse revealed a typed statement of witness from housekeeper (HSK) #1 dated 09/24/12, which documented HSK #1 was in a resident's room when she heard Resident #84 calling STNA #13 a "[***] ass n----". HSK #1 did not hear STNA #13's comment due to Resident #84 being so loud. HSK #1 did not see who started what first. When HSK #1 walked out of the door of the resident room she was in, Resident #84 and STNA #13 were witnessed hitting each other. HSK #1 went around the corner and told the DON there was a fight. Review of a typed statement from the DON dated 09/24/12, noted the DON was on her way out to the front of the building and heard HSK #1 yell, "fight, a fight." When the DON got around the corner on the 300 hall, Resident #84 was two to three feet away from STNA #13 and had his foot pedal off his wheel chair and swinging it towards STNA #13's face. At that point the DON sent STNA #13 to the ADON's office with a nurse manager. Resident #84 stated he hit me three times. The DON went into the ADON's office to speak with STNA #13 for three to four minutes. STNA #13 was asked to give a statement. Review of a typed statement by STNA #13 dated 09/24/12, revealed he stated Resident #84 had been harassing him all day and would call STNA #13 names every time he saw him. In the typed statement STNA #13 noted he would walk away down the hall but Resident #84 kept trying to provoke him. When this incident happened, STNA #13 documented he was going down the hall towards room [ROOM NUMBER] when Resident #84 approached STNA #13 and started calling him names and said he was going to get his people on him (STNA #13). STNA #13 documented he tried to ignore him, walked past Resident #84, then looked over his shoulder because Resident #84 was approaching him. "He came at me and swung at me and hit me in the lip and tried to re-approach me to hit me again and even took his foot rest off to try and hit me. I tried to defend myself and ended up hitting him in the face, at that point staff intervened and we were separated." Review of a typed statement from STNA #174 dated 09/25/12, documented Resident #84 and STNA #13 did not get along. On a few occasions STNA #174 had conversations with STNA #13 and told him to just leave it alone, just walk away. There were a couple of times STNA #174 heard STNA #13 make statements to Resident #84 that would "get Resident #84 going." One time STNA #13 stated to Resident #84 "they should have shot you in the face". STNA #174 documented STNA #13 also made statements of "it's either going to be my job or it is going to be him." STNA #174 stated she never thought STNA #13 would react to this and she thought he was blowing off steam. What STNA #174 had noticed was if Resident #84 said something to STNA #13 around others, STNA #13 would respond back and STNA #174 said to let it go. Interview with the DON on 09/26/12 at 7:35 A.M., revealed the facility was currently investigating a physical abuse allegation between Resident #84 and STNA #13. The DON confirmed the altercation was witnessed and STNA #13 had punched Resident #84 in the face. The DON stated she responded when HSK #1 ran towards her to say there was a fight between the two. She stated STNA #13 confirmed he did hit Resident #84 in the face. Observation of Resident #84 on 09/26/12 at 11:10 A.M., revealed the skin color was naturally dark with a light purple discoloration under the right eye. No swelling or lacerations were noted. Interview with HSK #1 on 09/26/12 at 9:40 A.M., revealed on 09/24/12, not sure of the exact time, she witnessed Resident #84 and STNA #13 hitting each other. She stated Resident #84 was not on his unit but on the 300 unit. HSK #1 was cleaning room [ROOM NUMBER] and heard a noise like yelling. She heard Resident #84 say to STNA #13 that he was a "[***] ass ni-----." HSK #1 stated she came out of the room and saw Resident #84 and STNA #13 punching each other. She was unaware who threw the first punch. HSK #1's first reaction was to pull Resident #84 away but instead she ran to the nurse's station. The DON was told there was a fight. The hallway was empty at the time of the fight. She stated Resident #84 had a scratch above the eyebrow and his eyes were black and blue, swollen and busted. HSK #1 stated she heard complaints from Resident #84 that STNA #13 "picks on him a lot". She stated Resident #84 does not get along with anyone. HSK #1 clarified the scratch was above the right eyebrow and pointed to the left eye that was swollen and black and blue. Interview with Resident #84 on 09/26/12 at 11:10 A.M., revealed on 09/21/12 STNA #13 kept mumbling under his breath, "I am going to get you and whoever shot you should have killed you." Resident #84 stated he reported it to the DON that he was being harassed by STNA #13. He stated STNA #13 went home. On Monday 09/24/12, STNA #13 was cursing at him. Resident #84 started cursing at STNA #13 and pointed his finger at STNA #13. STNA #13 slapped Resident #84's finger away. Resident #84 stated he got upset and told STNA #13 he couldn't do that and cussed at him. Resident #84 confirmed he did get loud and STNA #13 punched him in the face after Resident #84 called him a name. Resident #84 stated he was defending himself, swung back at STNA #13, when STNA #13 punched him again. Resident #84 continued to say he was taking the footrest from his wheel chair to swing at STNA #13. He stated HSK #1 saw them fighting and the DON came running down the hallway. Resident #84 informed the DON that STNA #13 hit him three times. Interview with the DON and Administrator on 09/26/12 at 11:16 A.M., revealed STNA #13 had attended an in-service on Abuse during the first quarter and a recent in-service on caring for difficult residents. The documentation from the in-service showed STNA #13 had attended. Interview with Police Officers (PO) #204 and #205 on 09/26/12 at 2:48 P.M., revealed PO #204 stated another officer arrived first on 09/24/12, and was speaking with Resident #84 outside briefly. PO #204 arrived at the facility and went inside with the officer and Resident #84. Resident #84 stated he was assaulted by STNA #13. Resident #84 stated he called STNA #13 a "[***] ass dope fiend and a mother f-----". STNA #13 started to call him names first and Resident #84 put his finger in his face which was different than what was originally said outside. Resident #84 was agitated. PO #204 stated they have the film that was in the facility's camera. PO #204 stated Resident #84 was looking down the hall and STNA #13 walked past Resident #84. Resident #84 said something to STNA #13 and STNA #13 said something to Resident #84. Resident #84 threw his hand up and STNA #13 slapped at it, smacked his hand to move it out of his face. The film revealed Resident #84 struck STNA #13 twice before STNA #13 struck the resident. STNA #13 threw two punches and missed once. Interview with STNA #68 on 09/28/12 at 9:45 A.M.,. revealed she was at the nurse's station when HSK #1 said there was a fight. STNA #68 ran down the hall just behind the DON and saw Resident #84 and STNA #13 arguing. STNA #13 stated "I'm tired of your sh--" to Resident #84. STNA #68 stood to demonstrate that STNA #13 was standing over Resident #84 leaning into him with his fist held up in a threatening manner about ready to hit Resident #84. STNA #174 grabbed STNA #13 and Resident #84 stated he was punched in his face three times. Interview with STNA #13 on 09/28/12 at 10:45 A.M., revealed STNA #13 gave a history of Resident #84 always being demeaning and using profanity every time he goes by Resident #84's room. He stated he is a therapy aide and transports residents to the therapy department. STNA #13 stated if he passes Resident #84's room a 100 times, Resident #84 is using profanity towards him. At the time of the incident, STNA #13 was coming down the hall and Resident #84 was facing him. STNA #13 stated Resident #84 said to him he was "ready to whoop his ass" and charged at STNA #13. STNA #13 stated he was worried about his safety so he was protecting himself and confirmed he hit Resident #84 in the face. During interview on 10/03/12 at 8:20 A.M., STNA #174 stated she did not witness the abuse but had heard STNA #13 in the past when he was angry past and heard him say to Resident #84 "they should have shot you in the face" and "it's going to be him or my job." She confirmed she did not report what she heard to anyone. STNA #174 stated she did not report it because it was a weekend and the facility's abuse coordinator was not in the building. She then stated maybe she reported it to the social worker but she was not sure. Review of the facility's policy on Abuse, Neglect, and Misappropriation of Patient Property Prevention dated 04/21/06, revealed seven components of abuse, neglect and misappropriation prevention can potentially detect, reduce and prevent abuse from occurring. The components are part of the center's quality assessment and assurance process and, as outlined herein, form the basis of a proactive and interactive prevention system. The seven key components are screening, train, prevent, identify, investigate, protect and report/respond. The policy noted the resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The center must ensure that all alleged violations involving mistreatment,neglect or abuse, including injuries of unknown source are reported immediately to the Administrator of the center and to other officials in accordance with state law. This certification deficiency substantiates Master Complaint Control Number OH 376 and Complaint Control Number OH 371.