Every finding on record at Ayden Healthcare of Toledo

Based on observation, interview, and policy review, the facility failed to maintain the reach in refrigerator and oven in a clean and sanitary manner. Also, the facility failed to ensure food items were covered, labeled, and dated. Additionally, the facility failed to ensure staff wore hairnets while in the kitchen and while preparing meal trays. This affected all 72 residents. The facility identified 72 residents as receiving meals from the kitchen. The resident census was 72. Findings include:Observations on 08/05/26 beginning at 10:43 A.M. in the kitchen with Dietary Manager (DM) #210 revealed in the reach-in refrigerator there were two bottles of ketchup and two bottles of mustard not dated when opened. Further observation revealed a large uncovered rectangular pan containing an unidentified brown food item which was not labeled and dated. Also, there was a tray of prepared sandwiches which were not labeled and dated. Additionally, there was a brown paper sack with a to-go meal with no label and no date on it. There was a large spill of yellow substance on the bottom of the reach-in refrigerator. Further observation of the free-standing oven revealed there was a large buildup of black grime on the inside bottom of the oven and a buildup of grease drips on the sides of the oven doors.Interview on 08/05/26 beginning at 10:43 A.M., DM #210 verified the ketchup, mustard, sandwiches, to go meal in the brown paper bag should have been labeled and dated. DM #210 verified the large pan containing a brown food substance was uncovered and not labeled and dated. DM #210 verified the buildup of black grime on the inside bottom of the free-standing oven. DM #210 revealed the oven should be cleaned weekly, and it had not been cleaned in a couple of weeks. Observation on 08/05/26 at 11:07 A.M. revealed [NAME] #200 was in the kitchen without a hairnet.Interview on 08/05/26 at 11:07 A.M., Dietary Manager (DM) #210 verified no staff should be in the kitchen without a hairnet. Observation on 08/05/26 at 11:08 A.M. revealed Dietary Aide (DA) #201 was prepping meal trays by the steam table with napkins and silverware. DA #201 was not wearing a hairnet. Interview on 08/05/26 at 11:08 A.M., DM #210 verified DA #201 was not wearing a hairnet and stated DA #201 was walking out of the room to put on a hairnet. Observation on 08/05/26 from 11:43 A.M. through 12:17 P.M. revealed [NAME] #204 was plating lunch meals. [NAME] #204 had her hair pulled back into a bun at the back of her head. Further observation revealed [NAME] #204 had a hairnet only covering the bun on the back of her head leaving the rest of her hair on the top and sides of her head uncovered. Interview on 08/05/26 at 12:17 P.M., [NAME] #204 verified the hair net was only covering the hair in the bun on the back of her head. [NAME] #204 revealed the hairnet would fall back when wearing it. Review of the daily/weekly cleaning checklist revealed the morning and evening cooks should clean and sanitize all equipment used including wiping down the oven doors, wiping down the reach in refrigerator inside and out and discarding out-of-date items. There were no specific guidelines for cleaning inside the oven. Review of the facility policy General Kitchen Sanitation, dated 11/22/20 revealed cleaning and sanitation tasks for the kitchen would be outlined in a written cleaning schedule. Review of the facility policy Employee Sanitary Food Practices, dated 03/07/21 revealed all employees would wear hair restraints to prevent hair from contacting exposed food. Review of the facility policy, Food Safety and Sanitation, dated 03/07/21 revealed staff members of the culinary services department were required to wear hair restraints. The hair restraints should cover all hair on the head. Stored food was handled to prevent contamination and growth of pathogenic organisms. All time and temperature control for safety (TCS) foods including leftovers should be labeled, covered, and dated when stored. When a food package was opened, the food item should be marked to indicate the open date. This date would be used to determine when to discard the food. This deficiency represents non-compliance investigated under Complaint Number 3131134.

Based on observation, staff interview, review of the food temperature logs, and policy review, the facility failed to ensure food temperatures were maintained during food plating and meal delivery. This affected six of nine residents interviewed regarding food temperatures and had the potential to affect all residents. The facility identified all 72 residents receiving meals from the kitchen. The facility census was 72. Findings include:Review of the food temperature log for the lunch meal on 08/05/26 revealed the food temperatures prior to the food leaving the kitchen in the basement revealed the Salisbury steak was 188 degrees Fahrenheit (F), the mashed potatoes were 183 degrees F, and the mixed vegetables were 180 degrees F. Observation on 08/05/26 at 11:09 A.M. revealed Dietary Manager (DM) #210 obtained the temperatures of the food items on the steam table in an upstairs room next to the dining room. The Salisbury steak was 186 degrees F, the mashed potatoes were 187 degrees F, the gravy was 157 degrees F, and the mixed vegetables were 167 degrees F. Further observations revealed the kitchen staff plated the lunch meals for the residents from the steam table on 08/05/26 from 11:40 A.M. through 12:18 P.M. The food temperatures were not checked just prior to plating the meals. The steam table was located underneath a ceiling air conditioning vent. The plated meals were placed on a plastic plate base with a plastic cover then placed on a food cart for transportation to the dining room and resident hallways. Observation on 08/05/26 at 12:18 A.M. of a test tray placed on the last hall cart revealed the meal cart was immediately placed in the hallway at 12:18 P.M. Three staff delivered the meal trays to the resident rooms. The last meal tray was delivered at 12:28 P.M. Observation on 08/05/26 at 12:31 P.M. of the meal test tray with DM #210 and Dietary Director (DD) #212 revealed the Salisbury steak was 136 degrees F, the potatoes were 135 degrees F, and the mixed vegetables were 111 degrees F. Further observation revealed the temperature of the mixed vegetables and the Salisbury steak were not warm enough and not at an appetizing temperature when tasted. The mashed potatoes were acceptable to taste and temperature. Interview on 08/05/26 at 12:31 P.M., with DM #210 and DD #212 revealed the temperatures of the Salisbury steak and mixed vegetables were not warm enough. Interview on 08/05/26 at 12:39 P.M., Resident #2 revealed the food was always cold including the Salisbury steak, mashed potatoes, and vegetables just served at lunch. Resident #2 revealed he had not asked staff to reheat his food because he would have to ask for the food to be reheated at every meal. Interview on 08/05/26 at 12:43 P.M., Resident #46 revealed the food at lunch today should have been warmer. Interview on 08/05/26 at 12:41 P.M., Resident #47 stated the lunch meal served today was cold per usual. Interview on 08/05/26 at 1:55 P.M. Resident #54 revealed the lunch meal today could have been hotter. Interview on 08/05/26 at 4:16 P.M., Resident #10 revealed her vegetables and potatoes at lunch were not warm enough. Resident #10 also revealed her juice at breakfast was frozen. Resident #10 revealed the food was usually not warm enough. Resident #10 stated sometimes the staff would reheat the food when asked. Resident #10 also revealed sometimes the staff would say the food was served at a safe temperature and could not be reheated. Interview on 08/06/26 at 8:16 A.M., Resident #39 revealed the lunch meal on 08/05/26 was not hot enough. Resident #39 revealed the food was never warm enough and had not been warm enough for years. Review of the facility policy Food Temperatures, dated 03/07/21 revealed the temperatures of all food items would be taken and properly recorded prior to service of each meal. All hot food items would be served at a temperature of at least 135 degrees F. Temperatures should be taken periodically to assure hot foods stay above 165 degrees F during the holding and plating process and until food leaves the service area. This deficiency represents non-compliance investigated under Complaint Number 3067264.

Based on observation, staff interview, and review of a facility policy, the facility failed to ensure medications were securely stored and not maintained in stock past the expiration date. This had the potential to affect all 75 residents residing in the facility. The facility census was 75.Findings include:1. Observation on 05/07/26 at 7:23 A.M. of the medication room revealed expired facility stock over-the-counter (OTC) medications that were available in a bin on a shelf mixed in with un-expired OTC medications. The expired medications observed were Geri-Lanta (antacid) with an expiration date of 07/25, fish oil 1200 milligrams (mg) with an expiration date of 02/25, melatonin three (3) mg with an expiration date of 10/25, two bottles of oyster shell with calcium 250 mg plus vitamin D with an expiration date of 07/25, two bottles of calcium carbonate 500 mg with an expiration date of 01/26, sodium bicarbonate five (5) grams with an expiration date of 05/25, two bottles of allergy relief 25 mg with an expiration date of 12/25, bisacodyl (stool softener) 5 mg with an expiration date of 02/26, antacid tablets (used for acid reflux) 500 mg chewable with an expiration date of 09/25, and bisacodyl suppositories 10 mg with an expiration date of 01/25. Concurrent interview at the time of the observation with Licensed Practical Nurse (LPN) #132 verified the expired medication in the medication room and further stated night shift was responsible for disposing of expired medication. Review of the facility policy titled, Medication Storage in the Facility, dated January 2026, revealed medications and biologicals are stored safely, securely, and properly following manufacturers recommendations or those of the supplier. Outdated, contaminated or deteriorated medications are immediately removed from stock. 2. Observation on 05/07/26 at 4:10 P.M. of a medication cart located in the hallway outside of room [ROOM NUMBER] revealed the cart was unlocked and unattended for approximately two minutes. Interview on 05/07/26 at 4:12 P.M. with LPN #256 confirmed she walked away from her medication cart and the cart was unattended and unlocked. 3. Observation on 05/11/26 at 9:15 A.M. in the hallway outside of room [ROOM NUMBER] revealed a white oval pill on the floor. Interview on 05/11/26 at 9:15 A.M. with Certified Nurse Aide (CNA) #109 confirmed there was a white oval pill on the floor outside of room [ROOM NUMBER]. Concurrent observation revealed CNA #109 picked the pill up and took it to LPN #256. LPN #256 asked Unit Manager (UM) #263 to assist with identification of the pill. Interview on 05/11/26 at 9:17 A.M. with UM #263 revealed the white oval pill found on the floor outside of room [ROOM NUMBER] was identified as 50 mg of the diuretic spironolactone. Review of facility policy titled, Medication Storage in the Facility, dated January 2026, revealed the facility would ensure medication was accessible only to licensed personnel authorized to administer medications.

Based on observation, resident interview, staff interview, review of facility menus and spreadsheets, and policy review, the facility failed to follow scheduled menus and failed to ensure portion sizes were served per spreadsheets. This had the potential to affect all 74 residents who the facility identified as receiving food from the kitchen. The facility identified one (#85) resident with orders for nothing by mouth. The facility census was 75. Findings include:Review of the lunch menu for the week of 05/04/26 through 05/06/26 revealed for lunch on 05/04/26 the facility was scheduled to serve chicken tenders, dipping sauce, potato salad, mixed vegetables, chocolate pudding, and milk, coffee, or hot tea. Further review revealed on 05/05/26, the facility was scheduled to serve tomato soup, saltine crackers, ham and cheese sandwich, marinated cucumber salad, confetti cake, and milk, coffee, or hot tea; and on 05/06/26, the facility was scheduled to serve chicken and biscuits, marinated green bean salad, tropical fruit cup, and milk, coffee, or hot tea.Review of the facility spreadsheet for the week of 05/04/26 through 05/06/26 revealed for lunch on 05/04/26 the facility was scheduled to serve four chicken tenders, one ounce of dipping sauce, half a cup of potato salad, half a cup of mixed vegetables, half a cup of chocolate pudding, and eight fluid ounces of milk, coffee, or hot tea. Further review revealed on 05/05/26 for lunch, the facility was scheduled to serve six ounces of tomato soup, one packet of saltine crackers, one ham and cheese sandwich, three-fourths cup of marinated salad, a two inch by three inch piece of confetti cake, and eight ounces of milk, coffee or hot tea; and on 05/07/26 for lunch, the facility was scheduled to serve a serving of chicken and biscuits, half a cup of marinated salad, a two inch by three inch piece of bar chocolate cake, and eight fluid ounces of milk, coffee, or hot tea.Interview on 05/04/26 at 10:04 A.M. with Resident #4 revealed portion sizes were too small especially regarding meat. Resident #4 stated they only received one slice of bacon for breakfast.Interview on 05/04/26 at 10:54 A.M. with Resident #7 revealed portion sizes were too small. Resident #7 stated they only got two tablespoons of eggs for breakfast.Interview on 05/04/26 at 11:28 A.M. with Resident #17 revealed food portions were very small. Resident #17 stated they never served strawberries or grapes and those were her favorite foods.Observation and concurrent interview on 05/04/26 at 11:45 A.M. with [NAME] #233 verified the facility was having chicken tenders, dressing (stuffing), and peas in gravy for lunch. [NAME] #233 stated the regular portion for chicken tenders was two tenders and a double portion was three tenders. [NAME] #233 gave a four-ounce scoop of dressing and a four-ounce serving of peas in gravy.Observation and concurrent interview on 05/05/26 at 11:10 A.M. with [NAME] #233 verified the facility was having tomato soup, chicken noodle soup, broccoli cheddar soup, ham and cheese sandwiches and fruit. [NAME] #233 verified the facility did not have marinated cucumber salad and could not serve it.Interview on 05/06/26 at 10:23 A.M. with Dietary Manager (DM) #172 verified for lunch on 05/04/26, the residents received two chicken tenders and residents who required double portions received three chicken tenders. Furthermore, DM #172 verified residents should have received four chicken tenders and residents who required double portions should have received eight chicken tenders. Additionally, DM #172 verified they did not serve marinated cucumbers on 05/05/26 as they did not have them.Observation and concurrent interview on 05/06/26 at 11:32 A.M. with [NAME] #233 verified the facility was serving chicken and biscuit, beets, marinated cucumber salad, and apple crumble dessert.Review of the facility policy titled Portion Control, updated 03/07/21, revealed individuals will receive the appropriate portions of food as outlined on the menu spreadsheets. Control at the point of service was necessary to assure that accurate portion sizes are served.

Based on observation, medical record review, resident interview, staff interview, and policy review, the facility failed to ensure measures developed for Legionella control measures were fully implemented, failed to ensure enhanced barrier precautions were in place for residents with indwelling medical devices, and failed to ensure proper infection control measures were maintained during administration of a subcutaneous medication. This had the potential to affect all 75 residents except one (#85) resident identified with orders for nothing by mouth, and directly affected one (#66) of one residents reviewed for dialysis and one (#68) of four residents observed for medication administration. The facility census was 75.1. Interview on 05/06/26 at 7:50 A.M. with Maintenance Supervisor (MS) #260 revealed Legionella control measures being completed and documented included water temperature checks, flushing logs, and hot water tank servicing. No further documentation was provided for Legionella control measures. MS #260 verified there was no documentation for ice machine or shower head cleaning. Interview on 05/06/26 at 8:36 A.M. with Housekeeping Supervisor (HS) #219 revealed housekeeping staff complete monthly deep cleans of shower rooms which included shower head cleaning. HS #219 verified housekeeping was not responsible for ice machine cleaning. Observation of a service log located on the inside area of the ice machine located in the main dining area on 05/06/26 at 10:09 A.M. with MS #260 revealed service dates were in 2025, with the last two services completed in April 2025 and May 2025. Review of the document titled, Risk Management Plan for Legionella Control, dated 02/07/25, revealed control and monitoring measures included facility flushing, measure temperatures weekly, hot water tank inspected and cleaned annually, clean sinks, basins and shower heads monthly, clean ice machine quarterly and weekly flushing of water in low use areas and annual inspection. 2. Review of the medical record for Resident #66 revealed an admission date of 01/23/26. Diagnoses included cerebral infarction, type two diabetes mellitus, end stage renal disease, hypertension, and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 had intact cognition. The resident was receiving dialysis services. Review of the care plan initiated 01/24/26 revealed Resident #66 received hemodialysis three times per week. Interventions included monitoring of the dialysis access site for signs and symptoms of infection or bleeding. The type of dialysis access site the resident was utilizing was not specified in the care plan. Further review of the care plan revealed there was no interventions in place for enhanced barrier precautions. Review of Resident #66's physician orders dated 01/26/26 revealed an order to observe the hemodialysis catheter in the right upper chest for signs or symptoms of infection, infiltration, and bleeding every day and night shift and as needed. The order was discontinued on 03/16/26. There was no documentation in the medical record that the resident's hemodialysis catheter had been removed. Further review of the physician orders revealed there were no orders for enhanced barrier precautions. Interview on 05/04/26 at 1:13 P.M., with Resident #66 revealed he had an arteriovenous (AV) fistula in his left arm that the dialysis center had not used yet. Resident #66 revealed he was receiving dialysis using the catheter in his chest. Resident #66 revealed the nurses looked at his hemodialysis catheter on dialysis days. The resident revealed he was unaware if he was on enhanced barrier precautions and could not recall if staff wore personal protective equipment (PPE) when providing care. Observation on 05/04/26 at 1:13 P.M. revealed there was no signage of Resident #66's door indicating the resident was on enhanced barrier precautions. Observation on 05/04/26 at 4:25 P.M. with Registered Nurse (RN) #238 revealed Resident #66 had a hemodialysis catheter located in the right upper chest area. Further observation revealed there was no sign posted noting the resident was requiring enhanced barrier precautions. Interview on 05/04/26 at 4:32 P.M. with Unit Manager Licensed Practical Nurse (UM LPN) #201 and Regional Registered Nurse (RRN) #295 revealed a physician order was not required for enhanced barrier precautions. UM LPN #201 verified Resident #66 had no care plan in place for enhanced barrier precautions and there was no sign for enhanced barrier precautions posted on the resident's door. RRN #295 verified Resident #66 should be on enhanced barrier precautions. Review of the facility policy titled, Enhanced Barrier Precautions, dated 08/2022, revealed enhanced barrier precautions (EBP) were an infection control intervention designed to reduce transmission of resistant organisms requiring staff to use gowns and gloves during high contact resident care for residents with wounds and/or indwelling medical devices. Further review of the policy revealed clear signage would be posted on the door or wall outside the resident room indicating the type of precautions and required PPE. 3. Review of the medical record for Resident #68 revealed an admission date of 08/08/25. The resident had a diagnosis of diabetes mellitus type two. Review of the current physician orders from May 2026 for Resident #68 revealed an order for Lantus Solostar 15 units (U) administered subcutaneously. Review of the care plan revised March 26 for Resident #68 revealed she was care planned at risk of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) with interventions in place for administration of medications as ordered by the physician. Observation on 05/06/26 at 8:46 A.M. revealed LPN #115 administered insulin to Resident #68 without the use of gloves. Interview on 05/06/26 at 8:57 A.M. with LPN #115 verified she administered long acting insulin to Resident #68 and she did not wear gloves when she administered the insulin. LPN #115 further stated she usually wore gloves to administer insulin. Review of the undated facility policy titled, Medication Administration and General Guidelines, revealed the person administering medications adheres to universal precautions, using proper hand hygiene and gloves when appropriate. This deficiency represents non-compliance investigated under Complaint Number 1365104.

Based on observation, staff interview, and policy review, the facility failed to ensure resident were provided a respectful and dignified dining experience. This affected one (#56) of four residents observed seated at the same table during meal service. The facility census was 75.Findings include:Observation on 05/04/26 at 12:08 P.M. during lunch mealtime revealed approximately 32 residents in the main dining room. Resident #56 was observed at a table with three other residents and standing to the left of Resident #56 was a Certified Nurse Aide (CNA) assisting Resident #56 with feeding the resident lunch. Interview on 05/04/26 at 12:10 P.M. with CNA #130 verified she was standing next to Resident #56 and assisting her with lunch. CNA #130 stated she was not aware she should not be standing when assisting residents with meals. Review of the facility policy titled, Resident Rights, dated 10/2022, revealed residents have the right to be treated with respect, dignity, and care to enhance quality of life and individuality. This deficiency represents non-compliance investigated under Complaint Number 2728038, Complaint Number 2603494, and Complaint Number 1365012 (OH00165158).

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, review of facility investigation documents including written statements, review of pharmacy manifest documents, review of staffing schedules, review of narcotic count sheets, staff interview, policy review, and review facility corrective action, the facility failed to prevent the misappropriation of resident narcotic medications. This affected one (#86) of five residents reviewed for abuse, neglect, and misappropriation. The facility census was 75.Findings Include:Review of the medical record for Resident #86 revealed an admission date of 09/15/25 and a discharge date of 04/14/26. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure, anxiety, and cancer of the pharynx.Review of Resident #86's physician orders for active in April 2026 revealed she was prescribed the narcotic pain medication oxycodone 10 milligrams (mg) every four hours as needed, the narcotic pain medication morphine sulfate 20 milligrams per milliliter (mg/ml) with instructions to give 0.25 ml every hour as needed for pain or shortness of breath (SOB), and the antianxiety medication Ativan one (1) mg every four hours as needed for anxiety or SOB, and admission to hospice program.Review of the care plan for Resident #86 revealed she was a focus area for pain related to generalized pain, left foot pain, lung pain, and cancer pain with interventions in place to administer medications as prescribed.Review of the pharmacy manifest for Resident #86 dated 02/14/26 and timed at 1:06 P.M. revealed Licensed Practical Nurse (LPN) #290 signed for the delivery of oxycodone 10 mg with a total of 60 tablets.Review of the daily nursing schedule for 02/14/26 revealed LPN #290 was scheduled to work and assigned to the North unit.Review of the narcotic count sheet for 02/14/26 for the North unit revealed no narcotic count sheets were added for the day of the arrival of Resident #86's oxycodone medication.Review of the written statement dated 02/18/26 at 5:30 P.M., authored by Registered Nurse (RN) #249, revealed she was working with LPN #138 when LPN #138 asked for assistance related to Resident #86's oxycodone that was allegedly delivered to the facility on [DATE] and she was not able to locate it. RN #249 further indicated both nurses looked for the medication, were not able to find it, and requested a copy of the pharmacy manifest be faxed to the facility. RN #249 revealed stated upon receipt of the copy of the pharmacy manifest the Director of Nursing (DON) was notified of the incident.Review of the written statement dated 02/16/26, authored by LPN #138, revealed she was getting pain medication ready for Resident #86 and had to call the pharmacy for permission to pull the oxycodone 10 mg from the Cubex machine (machine that holds commonly used medication for quick access, usually holds common pain medication and antibiotics for ease of access). LPN #138 indicated the pharmacy advised the medication was just delivered with a card of 60 tablets. LPN #138 documented the pharmacy granted permission for administration of the medication from the Cubex machine.Review of the statement from a telephone interview with RN #150 revealed she worked on 02/14/26 and observed LPN #290 interact with the pharmacy delivery person, and LPN #290 delivered the medication to RN #150 that belonged to her for the medication cart.Review of the telephone statement obtained from LPN #290 dated 02/16/26 revealed LPN #290 did not know what occurred with the oxycodone 10 mg card and did not recall receiving the narcotics in question. LPN #290 stated she signed the paperwork from the pharmacy technician and further stated she did not look at or verify the medications at the time she signed for them. LPN #290 further stated she was in a rush to leave the facility for her lunch break.Review of the written statement dated 02/17/26 authored by LPN #290 revealed she signed for medication from the pharmacy delivery driver, she did not verify what medication she was signing for, and was going on break while receiving orders from her unit manager and the DON regarding a different medication. LPN #290 stated she was not sure if she took possession of the narcotics or if they were left on the nurses station.Interview on 05/11/26 at 3:48 P.M. with the DON confirmed the information contained in the facility self-reported incident related Resident #86's oxycodone medication. The DON stated LPN #290 signed for Resident #86's oxycodone on 02/14/26, confirming receipt of the medication, but the medications were never found in the facility. The DON stated the facility completed a thorough investigation and ultimately terminated LPN #290's employment from the facility.Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 10/22, revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation.The deficient practice was corrected on 02/23/26 when the facility implemented the following corrective actions: - On 02/16/26, the DON and unit managers searched all medication carts, the nursing units, and the medication room for the missing narcotics and the medications was not found.- On 02/16/26, the DON/designees conducted interviews with all staff members involved in the missing medication. - On 02/16/26, the DON began an investigation and filed a self-reported incident to the State Survey Agency. - On 02/16/26, the DON completed interviews with all residents on the North unit and all residents were assessed for pain management with no concerns noted.- On 02/16/26, per direction from the DON, Resident #86 was administered oxycodone as ordered following notification to the pharmacy for permission to dispense the medication STAT (immediately). The facility paid for replacement of the missing narcotics.- On 02/16/26, notification was made to the physician and the hospice provider for the missing narcotics. Orders were received for Resident #86 to continue pain control until the replacement medication was received.- On 02/16/26, the Administrator and the DON contacted LPN #290 for a statement and completed a urine toxicology screening which was negative. LPN #290 was suspended for performance failure to follow duties in job description and adhering to policies and procedures according to pharmacy standards and practice. - On 02/16/26, a police report was filed with the local police department by the DON for suspicion of drug theft by LPN #290.- On 02/16/26, a report was filed with the pharmacy by the DON.- On 02/16/26, the State Board of Nursing was notified of the alleged narcotic theft by the DON.- On 02/18/26, the DON completed all staff education on abuse, neglect, and misappropriation. Nurse education was completed on 02/18/26 which included instructions that two nurses must sign narcotic medication manifests as well as shift-to-shift narcotic sheet counts.- On 02/20/26, the facility initiated audits of resident narcotics through review of the shift-to-shit sheets and pharmacy manifests with no concerns noted. The audits consisted of review for two nurse signatures and initials, audits of the spenddown sheets for two nurse signatures when accepting narcotics from delivery, and narcotics removed and added to shift-to-shift narcotic count sheets with review completed twice weekly. Additionally, the shift-to-shit narcotic sheets were audited three times weekly by facility nurses. The audits were completed through 04/28/26 with no additional concerns identified.- On 02/23/26, LPN #290 was terminated by the DON.- On 04/30/26, the Quality Assurance and Performance Improvement (QAPI) committee met and made no changes to the processes put in place for the receipt of narcotic medications into the facility. - Review of four (#12, #82, #83, and #85) additional resident medical records for abuse, neglect, and misappropriation on 05/12/26 revealed no further concerns related to misappropriation of medications.- Interviews on 05/12/26 from 8:49 A.M. to 9:01 A.M. with RN #117, RN #257, LPN #169, LPN #201, and LPN #277 verified they received education on abuse, neglect, and misappropriation. All nurses also confirmed they received education on the process to sign in narcotic medications, the requirement of two nurses to sign the pharmacy manifest, and the requirement to have two nurses sign the narcotic sheet count at each shift change.This deficiency represents non-compliance investigated under Complaint Number 2804787, Complaint Number 2786880, Complaint Number 1365108 (OH00166363), and Complaint Number 1365106 (OH00166222).

Based on observation, medical record review, resident interview, staff interviews, and review of a facility policy, the facility failed to ensure residents received appropriate assistance from staff to maintain adequate personal and oral hygiene. This affected two (Residents #38 and #42) of four residents reviewed for activities of daily living. The facility census was 75.Findings include:1. Review of the medical record for Resident #38 revealed he was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, type two diabetes mellitus, antisocial personality disorder, anxiety, delusional disorders, paranoid personality disorder, and schizophrenia.Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/06/26, for Resident #38 revealed he experienced mild cognitive impairment, did not experience behaviors toward himself or others, and he refused care on four to six days during the assessment period. Resident #38 required set up and clean up assistance with oral care.Review of the care plan for Resident #38 revealed a focus area for activities of daily living self-care performance deficit and an intervention dated 08/15/24 indicating he required supervision with oral hygiene.Review of the task sheet dated 04/08/26 through 05/07/26 for Resident #38 revealed oral care was offered three times daily and he received oral care three times on 05/04/26.Observation on 05/05/26 at 8:50 A.M. of Resident #38 sitting up in bed revealed a white debris buildup on his upper and lower front teeth visible from approximately four feet away while he spoke. Concurrent interview with Resident #38 revealed he had not eaten breakfast yet, pointing to the untouched tray of food on his bedside table, could not recall the last time his teeth had been brushed, and was displeased that he had not been offered assistance with brushing his teeth.Interview on 05/05/26 at 9:05 A.M. with Licensed Practical Nurse (LPN) #231 confirmed Resident #38 had a white debris buildup on his upper and lower front teeth while standing approximately four feet away.2. Review of the medical record for Resident #42 revealed she was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis affecting her right dominant side, muscle weakness, and dementia.Review of the care plan for Resident #42 revealed a focus area for activities of daily living self-care performance deficit and an intervention dated 06/25/24 indicating she required supervision with personal hygiene. Observation on 05/05/26 at 8:55 A.M. of Resident #42 in her room revealed she was dressed, sitting up in her wheelchair, and the back of her hair was disheveled, flat, and swirled sticking outward.Interview on 05/05/26 at 9:06 A.M. with LPN #231 confirmed Resident #42's hair was not brushed.Review of facility policy titled, Activities of Daily Living (ADLs), Supporting, dated March 2018, revealed the facility would provide services to maintain good oral hygiene and grooming for those residents identified as unable to complete these tasks independently.This deficiency represents non-compliance investigated under Complaint Number 2687112.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure physician orders regarding wound treatments were followed. This affected one (#28) of three residents reviewed for wound care. The facility census was 75.Findings include: Review of Resident #28's medical record revealed an initial admission date of 04/29/25 and a re-entry date of 02/02/26. Diagnoses included nontraumatic subarachnoid hemorrhage, acute respiratory failure with hypoxia, viral hepatitis C, disruption of external operation of surgical wound, and hypertension. Review of Resident #28's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition, had a surgical wound, and did not require surgical wound care. Additionally, applications of ointments/medications were required. Review of Resident #28's care plan dated 03/06/26 revealed the resident had a surgical wound on the frontal scalp with interventions that included to follow facility protocols for treatment of the injury, wound consultations as ordered, and weekly treatment documentation should include measurements of each area of skin breakdown including width, length, depth, type of tissue and exudate, and any other notable changes or observations. Review of Resident #28's physician orders revealed an order with a start date of 05/05/26 to treat a scalp incision with saline moistened gauze to the open wound, cover with abdominal (ABD) pad, and hold in place with roll gauze and change the dressing daily.Observation and concurrent staff interview on 05/07/26 at 8:51 A.M. of wound care for Resident #28 completed by Registered Nurse (RN) #257 revealed Resident #28 received a shower and needed to have wound care completed. RN #257 did not remove the old dressing and the nurse was not aware if the doctor just stuffed the dressing into the wound because there was a hole. RN #257 applied triple antibiotic ointment to the healed incisional scars. Upon observation of wound care for Resident #28, RN #257 did not remove the old gauze, did not apply an ABD pad, and wrapped Resident #28's head with gauze. Interview on 05/07/26 at 10:03 A.M. with RN #257 verified she only re-wrapped Resident #28's head and did not change the saline moistened gauze or apply an ABD pad per the physician's orders. Review of the facility policy with a last revision date of September 2013 titled, Dressings, Dry/Clean, revealed the nurse should verify there was a physician's order for the procedure and to apply the ordered dressing and secure with tape or bordered dressing per the order.

Based on observation, medical record review, resident interview, staff interview, and review of a facility policy, the facility failed to ensure residents assessed as unsafe to store smoking materials and ordered supplemental oxygen did not possess lighters. This affected one (Resident #43) of one residents reviewed for smoking. The census was 75. Findings include: Review of the medical record revealed Resident #43 was admitted to facility on 11/19/25. Diagnoses included chronic obstructive pulmonary disease, diabetes mellitus, pulmonary embolism, alcohol dependence, major depressive disorder, generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #43 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Behaviors included physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes one to three days a week. Functional abilities included supervision or touching assistance with toileting hygiene, shower/bathing, and upper and lower body dressing. Review of the care plan for Resident #43 dated 03/06/26 revealed an intervention to administer oxygen as ordered via nasal canula. Further review of Resident #43's care plan revealed smoking items were to be kept at the nurse's station. Review of physician orders entered on 11/18/25 for Resident #43 revealed an order for oxygen at two to three liters per minute continuous every day and night shift. Review of the smoking assessment dated [DATE] revealed Resident #43 was unable to safely store his own smoking materials. Interview and observation on 05/05/26 at 11:25 A.M. with Resident #43 verified nasal oxygen tubing was in place for supplement oxygen. Resident #43 stated his oxygen was set at three liters per minute. Resident #43 was asked about his lighter, and he stated his lighter was currently in his shirt pocket. Interview and subsequent observation on 05/05/26 at 11:36 A.M. with Unit Manager (UM) #201 verified Resident #43 was on oxygen. Resident #43 was then observed removing a lighter from his shirt pocket. Interview on 05/05/26 at 11:36 A.M. with UM #201 revealed the facility was unable to continually remove Resident #43's lighter due to it being against resident rights. UM #231 and the Director of Nursing (DON) arrived at Resident #43's room and the DON also stated removing the lighter from Resident #43 was against resident rights. Interview on 05/05/26 at 11:40 A.M. with the DON verified even though Resident #43 was currently on oxygen he was allowed to have his lighter, and stated education on oxygen safety had been provided. Review of the policy titled, Oxygen Administration, revised on 10/2010, revealed all potentially flammable items, such as lotions, oils, alcohol and smoking articles, are to be removed from the immediate area where oxygen was to be administered.

Based on medical record review, staff interview, and policy review, the facility failed to ensure monitoring of fluid intake for residents with fluid restrictions and orders for daily weights were completed. This affected two (#50 and #66) of five residents reviewed for nutrition. The facility identified nine residents with fluid restrictions. The facility census was 75. Findings include:1. Review of the medical record for Resident #66 revealed an admission date of 01/23/26. Diagnoses included cerebral infarction, type two diabetes mellitus, end stage renal disease, hypertension, and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 had intact cognition. The resident was receiving dialysis services. Review of the care plan last revised 05/02/26 revealed Resident #66 had the potential for alteration in nutrition/hydration related to aphasia, Barrett's esophagus, heart failure, anemia, malnutrition, end stage renal disease with need for hemodialysis, diuretic therapy, and fluid restrictions. Interventions included a 1500 milliliter (ml) fluid restriction every 24 hours. Dietary would provide 720 ml with meals and nursing would provide 780 ml divided between shifts. There was to be no water pitcher in resident's room. Review of a physician order dated 03/17/26 revealed Resident #66 had an order for a regular diet with regular texture and thin consistency. The resident had orders for a 1500 ml daily fluid restriction, 720 ml per day from dietary or 240 ml cup per meal; nursing on day shift to administer 320 ml from 6:00 A.M. to 2:00 P.M., give 260 ml from 2:00 P.M. to 10:00 P.M., and 200 ml on night shift from 10:00 P.M. to 6:00 A.M. Review of the medication administration record (MAR) and treatment administration record (TAR) dated 04/01/26 through 05/04/26 revealed no documentation of fluid intake monitoring for Resident #66. Interview on 05/11/26 at 2:51 P.M. with the Director of Nursing (DON) revealed Resident #66 had an order for a fluid restriction and the nurses could read the order and give the amount of fluid ordered. The DON revealed staff would not need to monitor or document Resident #66's fluid intake when the nurses could just read the order. The DON stated the amount ordered was the amount of fluid the resident received. 2. Review of the medical record for Resident #50 revealed an admission date of 03/13/23. Diagnoses included chronic kidney disease stage three, quadriplegia, congestive heart failure, and tubulo-interstitial nephritis (inflammation of the tubules of the kidneys-the filters of the kidneys). Review of the current physician orders for May 2026 for Resident #50 revealed a regular diet with thin liquids with a fluid restriction of 1200 ml per day; 720 ml per day from dietary and 480 ml per day from nursing; 120 ml per day for each shift 6:00 A.M. to 2:00 P.M., 2:00 P.M. to 10:00 P.M. and 10:00 P.M. to 6:00 A.M.; was ordered to receive the diuretic Lasix 20 milligrams (mg) daily, and have daily weights obtained. Review of the care plan revised 05/26 for Resident #50 revealed he was care planned for the potential for alteration in nutrition and hydration related to a 1200 ml fluid restriction per day with interventions in place to monitor daily weight as ordered and monitor for signs and symptoms of dehydration. Review of the MAR and TAR for Resident #50 for March 2026, April 2026, and May 2026 revealed no monitoring or documentation of the about of fluid that was consumed per day. Review of the nursing progress note dated 05/02/26 at 9:50 A.M. for Resident #50 revealed the resident remained on daily weights to monitor fluid shift. Further review of the TAR for Resident #50 revealed daily weights were not obtained on the following days including 03/01/26, 03/02/26, 03/03/26, 03/04/26, 03/06/26, 03/08/26, 03/13/26, 03/16/26, 03/19/26, 03/21/26, 03/26/26, 03/30/26, 04/02/26, 04/08/26, 04/13/26, 04/16/26, 04/17/26, 04/21/26, 04/22/26, 04/23/26, 04/24/26, 04/25/26, 04/26/26, 04/28/26, 04/31/26, 05/03/26, and 05/05/26. Interview on 05/11/26 at 12:20 P.M. with Licensed Practical Nurse (LPN) #201 stated the facility did not document fluid intake and only give what was on the tray card for dietary. LPN #201 stated nursing only gave the allowable about that was reflected in the breakdown in the orders and that was all the staff gave. LPN #201 verified there was no other documentation the facility completed for documenting fluid intake and further verified daily weights for Resident #50 were not obtained as ordered for the above mentioned dates. Interview on 05/11/26 at 2:52 P.M. with the DON stated when there was an order for fluid restrictions, the nurses can read the order and the facility did not document the intake amount for those residents, including Resident #66 and Resident #50, on fluid restriction. Review of the facility policy titled, Resident Hydration and Prevent of Dehydration, revised 10/17, revealed the facility will strive to provide adequate hydration and to prevent and treat dehydration. Nursing will monitor and document fluid intake and the dietician will be kept informed of status. The interdisciplinary team will update the care plan and document resident response to interventions until the team agrees that fluid intake and relating factors are resolved.

Based on observation, review of the medical record, staff interview, resident interview, and policy review, the facility failed to ensure a hemodialysis catheter was monitored every shift for signs of infection and bleeding. This affected one (#66) of one residents reviewed for dialysis services. The facility identified three residents receiving dialysis services. The facility census was 75. Findings include:Review of the medical record for Resident #66 revealed an admission date of 01/23/26. Diagnoses included cerebral infarction, type two diabetes mellitus, end stage renal disease, hypertension, and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 had intact cognition. The resident was receiving dialysis services. Review of the care plan initiated 01/24/26 revealed Resident #66 received hemodialysis three times per week. Interventions included monitoring of the dialysis access site for signs and symptoms of infection or bleeding. Review of Resident #66's physician orders dated 01/26/26 revealed an order to observe the hemodialysis catheter in the right upper chest for signs or symptoms of infection, infiltration, and bleeding every day and night shift and as needed. The order was discontinued on 03/16/26. There was no documentation in the medical record the resident's hemodialysis catheter had been removed. Review of Resident #66's physician order dated 04/14/26 revealed an order to observe the arteriovenous (AV) fistula in the left forearm for bleeding or infection and abnormalities every day and night shift. Review of Resident #66's progress notes from 04/06/26 through 05/04/26 revealed the resident's hemodialysis catheter was monitored on dialysis days on 04/06/26, 04/08/26, 04/10/26, 04/13/26, 04/15/26, 04/17/26, 04/20/26, 04/22/26, 04/24/26, 04/27/26, 04/29/26, and 05/01/26. Further review of the progress notes revealed no documentation the hemodialysis catheter had been monitored on 04/09/26, 04/11/26, 04/12/26, 04/14/26, 04/16/26, 04/18/26, 04/19/26, 04/21/26, 04/23/26, 04/25/26, 04/26/26, 04/28/26, 04/30/26, 05/02/26, and 05/03/26. Review of Resident #66's medication administration record (MAR) and treatment administration record (TAR) from 04/06/26 through 05/03/26 revealed no documentation for monitoring of the hemodialysis catheter. Interview on 05/04/26 at 1:13 P.M., with Resident #66 revealed he had an AV fistula in his left arm the dialysis center had not used yet. Resident #66 revealed he was receiving dialysis using the catheter in his chest. Resident #66 revealed the nurses looked at the hemodialysis catheter on dialysis days. Observation on 05/04/26 at 4:25 P.M. with Registered Nurse (RN) #238 revealed Resident #66 had a hemodialysis catheter located in the right upper chest area. Interview on 05/11/26 at 8:55 A.M., with Unit Manager Licensed Practical Nurse (UM LPN) #201 revealed Resident #66's hemodialysis catheter should be monitored daily on each shift. UM LPN #201 verified there was no documentation in the medical record of the resident's hemodialysis catheter being monitored on non-dialysis days. Review of the facility policy titled, End-Stage Renal Disease, Care of a Resident With, dated 09/2010, revealed the resident's comprehensive care plan would reflect the resident's needs related to end stage renal disease/dialysis care. Further review of the policy revealed no guidelines for monitoring the hemodialysis catheter access site.

Based on medical record review, staff interview, resident interview, and review of facility standards for trauma-informed care, the facility failed to ensure trauma-informed care and related interventions were provided to residents with a history of post-traumatic stress disorder. This affected one (Resident #12) of one residents reviewed for trauma-informed care. The facility census was 75.Findings include:Review of the medical record for Resident #12 revealed she was admitted on [DATE] with diagnoses including chronic respiratory failure with hypoxia, abnormalities of gait and mobility, paraplegia, venous insufficiency, bipolar disorder, schizophrenia, depression, anxiety, panic disorder, and post-traumatic stress disorder (PTSD).Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #12 revealed she was cognitively impaired, exhibited behavioral symptoms toward others, and did not refuse care. Resident #12 utilized a manual wheelchair and was dependent for mobility. She required maximal assistance to dependence with activities of daily living. Resident #12 had a diagnosis of PTSD.Review of the care plan for Resident #12 revealed a focus area dated 05/04/26 for a mood problem related to PTSD. There were no resident specific trauma-informed care interventions.Interview on 05/11/26 at 2:35 P.M. with MDS Licensed Practical Nurse (LPN) #141 confirmed Resident #12 had PTSD, she was unaware of specific triggers related to Resident #12's PTSD, and the care plan did not include resident specific interventions to aid with providing trauma-informed care for Resident #12.Interview on 05/11/26 at 2:40 P.M. with Resident #12 confirmed she had experienced childhood trauma and the facility had not spoken to her about trauma-informed care nor what triggers she experienced while receiving care at the facility.Interview on 05/11/26 at 2:50 P.M. with Certified Nurse Aide (CNA) #104 revealed she was currently assigned to provide care to Resident #12, was not aware Resident #12 had PTSD, was unable to identify in the electronic health record if Resident #12 had PTSD, and was not able to locate any resident-specific care needs related to PTSD and trauma-informed care for the resident.Interview on 05/12/26 at 12:05 P.M. with the Director of Nursing (DON) revealed there was no facility policy for providing trauma informed care and the facility utilized the curriculum of their trauma-informed care training. Review of the facility's trauma-informed care training curriculum revealed the facility would ensure residents who were trauma survivors would receive culturally competent trauma-informed care. Further review of the training curriculum revealed PTSD was trauma and care provided would account for resident preferences and experiences to mitigate triggers that may cause re-traumatization.

Based on review of the medical record, resident interview, staff interview, and policy review, the facility failed to ensure routine dental services were provided. This affected one (#65) of two residents reviewed for dental services. The facility census was 75. Findings include:Review of the medical record for Resident #65 revealed an admission date of 08/02/24. Diagnoses included chronic kidney disease stage three, hypertension, depression, bipolar disorder, and schizophrenia.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had impaired cognition. The resident required supervision for oral hygiene. Review of the care plan dated 08/02/24 revealed Resident #65 was at risk for oral/dental health problems related to dental caries and a history of dental infections and pain. Interventions included for staff to coordinate arrangements for dental care and transportation as needed/ordered. Review of an attending physician request for services/consultation order dated 10/21/24 revealed the physician ordered Resident #65 to see the dental provider due to the resident's being unable to care for his teeth. Review of dental service records revealed Resident #65 was not seen by the dentist from 10/21/24 through 02/26/26. Review of the resident's dental treatment history revealed the resident initial dental exam occurred on 02/27/26. Interview on 05/04/25 at 11:43 A.M., Resident #65 revealed he had only seen the dentist once since his admission to the facility. Resident #65 revealed he had asked staff if he could see the dentist. Interview on 05/06/26 at 11:28 A.M. and on 05/11/26 at 8:37 A.M., Social Service Designee (SSD) #242 revealed residents with Medicaid coverage could see the dentist up to two times a year. SSD #242 revealed there was no documentation Resident #65 was seen by the dentist from 08/02/24 through 02/26/26. SSD #242 revealed the dental provider was provided with a list of residents who needed to be seen and was unaware why the resident was not seen by the dentist until 02/27/26. SSD #242 revealed she could not find any documentation Resident #65 had refused dental services. Review of the facility policy titled, Referrals, Social Services, revised 12/2008, revealed social services personnel would coordinate most resident referrals. Social services would collaborate with the pertinent discipline to arrange for services ordered by the physician and document the referral in the resident's medical record.

Based on medical record review, observation, resident interview, staff interview, interview with the local health department, and review of facility policy the facility failed to assist dependent residents with activities of daily living (ADL) care. This affected three (#26, #78, and #94) of four residents reviewed for ADL care. The facility census was 86. Findings include: 1. Review of the medical record revealed Resident #26 was admitted on [DATE]. Diagnoses included nontraumatic subarachnoid hemorrhage, dementia in other diseases, hyperlipidemia, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 02/21/25, revealed the resident was severely cognitively impaired and required partial/moderate assistance with personal hygiene. Review of the care plan, dated 09/09/22, revealed Resident #26 required one person assist with bathing/showers and supervision to one person assist with dressing. Review of progress note, dated 02/20/25, revealed the nurse was informed by Certified Nursing Assistant (CNA) that Resident #26 asked for help stating something was biting her. The CNA assisted the resident in getting ready for bed and as the staff was taking off the resident's shirt stated there were bites all over the resident as the resident started itching herself. The CNA continued to assist the resident by taking off her bra and saw multiple small bugs in the resident's bra. Resident #26 was assessed and observed multiple bug bites on the resident's arms, chest, underneath her breast, back, legs, and feet. Redness and bite marks were observed to bilateral hips. The marks appeared reddened and discolored and some appeared healed over. Resident #26 was showered and all linen was bagged. The physician was notified. Resident #26 was placed in a new room for isolation as the bugs appeared to be body lice. Review of progress note, dated 02/20/25, revealed notification to the resident's Power of Attorney (POA) of the room move for isolation due to signs and symptoms of body lice. Review of Skin Alteration Assessment, dated 02/20/25, revealed Resident #26 had multiple bug bites, and scattered scratches from the resident itching on her chest, arms, legs, back, and underneath breast. Areas appeared reddened and some scabbed over. Review of progress note, dated 02/23/25, revealed Resident #26 had dead nets in her hair. Review of progress note, dated 02/24/24, revealed Resident #26's skin is noted to have some red marks and areas noted to be in different stages of healing that have scabbed over. Review of Weekly Wound Round Assessment, dated 02/25/25, revealed a rash due to lice infestation on the chest and upper-mid vertebrae. Interview on 03/26/25 at 10:43 A.M. with CNA #224 revealed she had assisted Resident #26 when the lice was discovered. CNA #224 stated Resident #26 had her bra in her hand, stated something was biting her, and asked for help. CNA #226 stated she picked up the bra and saw a whole lot of bugs in the bra and also on the floor. CNA #224 stated once the bedding was removed there were dead bugs in a perimeter around the bed. CNA #224 confirmed there were bites on the resident's ankles, back, and under the breast. Interview on 03/26/25 at 12:30 P.M. with Registered Nurse (RN) Unit Manager #262 verified Resident #26 would often refuse showers and the CNA's would accept the first no. RN Unit Manager #262 verified prior to finding the lice it had been a while since Resident #26 received a bath or a shower. The timeframe was unknown and stated again that it had been a while. Interview on 03/27/25 at 4:48 P.M. with Health Department Epidemiologist #500 verified it would take six to nine days for lice eggs to hatch and if there were nits on the hair and bites on the body it was most likely combination of head and body lice that affected the resident. 2. Review of the medical record revealed Resident #78 was admitted on [DATE]. Diagnoses included diffuse traumatic brain injury without loss of consciousness, major depressive disorder recurrent, essential hypertension, quadriplegia, and bipolar disorder. Review of the MDS assessment, dated 02/16/25, was cognitively intact and required partial/moderate assistance with eating. Review of the care plan, dated 12/10/24, revealed Resident #78 required assistance with ADL care due to weakness, non-ambulatory, contractures, and limited range of motion. Resident #78 required one person assistance with eating. Observation on 03/26/25 at 12:42 P.M. revealed the lunch meal served in the dining room with thirteen residents present. Resident #78 was observed to have two hot dogs in a bun on the lunch tray. CNA #206 passed trays and assisted other residents. While walking by Resident #78, CNA #206 would offer him a bite of the hotdog. Resident #78 was observed to watch CNA #206 deliver trays and assist other residents while waiting for his next bite of food. Resident #78's tablemate, Resident #50 was observed to take approximately one-third of a hotdog in a bun from Resident #78's plate and lob it in the Resident #78's mouth. Resident #78 leaned his head back to take in the food and was observed chewing with with a full mouth of food. Resident #50 was observed to continue to feed Resident #78 when CNA #206 was assisting other residents in the dining room. Interview on 03/26/25 at 12:50 P.M. with Resident #50 stated she assists Resident #78 with his meals at lunch and dinner when they are in the dining room. Resident #50 and Resident #78 stated they have never been informed another resident cannot not feed him. Resident #50 stated aides will often ask if she plans to feed him and count on her to do it. Interview on 03/26/25 at 12:56 P.M. with CNA #206 verified Resident #50 fed Resident #78 when she was assisting other residents. CNA #206 stated she has never told Resident #50 to not assist Resident #78 with eating and has never been told Resident #50 could not assist Resident #78. Interview on 03/26/25 at 2:15 P.M. with the Administrator and Director of Nursing (DON) verified no residents are approved or trained to feed other residents. 3. Review of the medical record revealed Resident #94 was admitted on [DATE]. Diagnoses included acquired fibrokeratoma, cellulitis of the right lower leg, opioid use, cerebral infarction, asthma, and epilepsy. Review of the MDS assessment, dated 12/27/24, revealed the resident was cognitively intact. Resident #94 required substantial/maximal assistance with bathing/showering. Review of the care plan, dated 12/23/24, revealed Resident #94 was at risk for ADL self-performance deficit due to weakness, difficulty ambulating, spasticity, cognitive deficits, asthma, pain, fall risks, anxiety, and history of stroke. The resident required one person assistance with bathing/showering and personal hygiene. Interview on 03/25/25 at 9:15 A.M. with Resident #94 revealed she is not always receiving showers. Resident #94 states she stinks. Resident #94 stated she did receive a shower on Saturday (3 days ago) however they did not use any shampoo on her hair or deodorant on her body. Interview on 03/25/25 at 9:21 A.M. with CNA #206 revealed Resident #94's hair does appear greasy. CNA #206 began to assist Resident #94 and stated that she does have a body odor. CNA #206 stated aides do not use soap and shampoo even though it is available. Observation on 03/25/24 at 9:25 A.M. revealed Resident #94 did have body odor under her armpits and her hair appeared greasy and unkempt. Review of policy, Support Activities of Daily Living, dated March 2018, revealed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADL's. Residents who are unable to carry out ADL care independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Review of policy titled Food and Nutrition Services, dated October 2017, verified food and nutrition staff will be available and adequately staffed to assist residents with eating as needed. Nurse aides and feeding assistants will provide support to enhance the resident experience, but not as a critical component to the functioning of the department. This deficiency represents non-compliance investigated under Complaint Number OH00163959, Complaint Number OH00163167, Complaint Number OH00162850, and Complaint Number OH00163858.

Based on medical record review, resident interview, staff interview, and review of policy the facility failed to provide treatment for pressure ulcers. This affected two (Resident #43 and Former Resident #9) of three residents reviewed for pressure ulcers. The facility census was 86. Findings include: 1. Review of the medical record revealed Resident #43 was admitted on [DATE]. Diagnoses included paraplegia, chronic osteomyelitis, pressure ulcer right buttock stage 4, pressure ulcer sacral region stage 4. Review of the Minimum data Set (MDS) assessment, dated 03/18/25, revealed the resident was cognitively intact, always incontinent of urine and stool, and two stage four pressure ulcers. Review of wound care notes, dated 03/14/25, revealed Resident #43 has a stage four sacral decubitus ulcer and right buttock ulcer with bone exposure, no necrotic tissue or purulent drainage. Review of physician order, dated 03/11/25, revealed an order for wound care to the right thigh with instructions to cleanse with liquid antibacterial soap and water rinse well, apply collagen then silver alginate cover with tape, assess for pain prior to wound treatment and medicate per order as indicated. Observation on 03/25/25 at 11:26 A.M. revealed the wound care treatment cart outside Resident #43's resident room. Interview on 03/25/25 at 12:03 P.M. with Resident #43 revealed since approximately 3:30 A.M. that morning he did not have a wound dressing on his thigh wound and there was fecal matter in his wound. Resident #43 stated the dressing came off during incontinence care, the aide reportedly informed the nurse, however the dressing was not reapplied. Resident #43 stated the wound care nurse just applied a new dressing. Interview on 03/25/25 at 12:20 P.M. with Licensed Practical Nurse (LPN) #205 verified when completing wound care rounds today Resident #43 did not have dressing to his right thigh and there was fecal matter in the wound. 31638 2. Review of Former Resident (FR) #9 revealed an admitted [DATE]. Diagnoses included paraplegia, alcohol use with withdraw, and myocardial infarction. Review of FR # 9's admission MDS dated [DATE] revealed the resident had impairment on both upper and lower extremities. He was dependent on staff for all activities of daily living. Review of FR #9's care plan revealed the resident was at risk for impaired skin integrity related to weakness, paraplegia, alcoholism, numbness, urinary catheter, incontinence, dermatitis, cognitive deficits, behaviors, and smoking. Interventions included inspecting skin daily during routine care, apply barrier cream/ointment after each incontinent episode as needed, dietary evaluation, explain all procedures prior to care, and to provide a pressure reducing mattress. Review of FR #9's facility wound care note dated 03/04/25 revealed the note was absent regarding wounds of the heel and foot. Review of FR #9's progress note revealed on 03/05/25 the resident went out to a physician's appointment and demanded to be sent to the emergency room instead of back to the facility. The record was absent regarding the reason for the hospital admission. Review of FR #9's Wound Ostomy Continence Nursing Consult Note from the local hospital dated 03/05/25 revealed the resident was admitted with a pressure injury to the left lateral heel. The wound measured 3.8 centimeters (cm) long by 3.1 cm wide by 0.3 cm deep and had serosanguinous drainage. The wound was described as subcutaneous, pink/red in color with devitalized tissue, dusky in color and with slough. The peri-wound was hypopigmented. The patient also had a pressure injury to the right ankle. The wound measured 0.9 cm long by 0.5 cm wide by 0.3 cm deep. The wound was pink/red with serosanguinous drainage. The peri-wound was hyperpigmented and edematous. Both wounds were described as painful. Review of FR #9's hospital physician's note dated 03/13/25 revealed he developed a stage three pressure ulcer to the left lateral heel. The wound was present on admission to the hospital. Review of FR #9's after visit summary dated 03/13/25 revealed treatment to the left lateral heel and right ankle which were stage 3 pressure ulcers. Treatment included applying a foam dressing. Review of FR # 9's facility physician assistant note dated 03/13/25 revealed the resident was readmitted from the hospital. The resident had a left heel and right ankle pressure wound. Continue local wound care. Review of FR #9's medical record dated 03/13/25 revealed the Physician Assistant ordered wound care for the resident's left heel and right ankle wounds per hospital after visit summary (AVS). The order was incomplete as to treatment. Review of FR # 9's physician note dated 03/18/25 revealed the resident was disoriented and being sent out to the hospital. The resident had chronic pressure ulcers. Review of FR # 9's treatment administration record dated March 2025 revealed the record was absent of wound care to the left lateral heel and the right ankle. Telephone interview with the Corporate Nurse #400 and the DON on 03/26/25 at 11:07 A.M. verified the facility failed to obtain orders for FR #9's wounds to the left lateral heel and right ankle after his return from the hospital on 03/13/25. Corporate Nurse #400 stated she knew the staff completed wound care on the resident even though there were no orders nor documentation regarding care. Review of the facility policy titled Skin Management Program undated revealed initial admission assessment included review of hospital records, transfer documents, etc., to understand the resident's history of or risk factors for pressure injuries. Assess resident for other skin conditions. If an alteration in skin integrity is identified the charge nurse will do the following: notify/document the physician and obtain order for treatment. This deficiency represents non-compliance investigated under Master Complaint Number OH00164030, Complaint Number OH00163959 and Complaint Number OH00162616.

Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure adequate toenail care. This affected two (#15 and #94) of four residents reviewed for activities of daily living. The facility census was 86. Findings include: 1. Review of the medical record revealed Resident #15 was admitted on [DATE]. Diagnoses included lymphedema, venous insufficiency, myiasis, essential hypertension, personal history of transient ischemic attack and cerebral infarction without residual deficits, paroxysmal atrial fibrillation, heart failure, non-pressure chronic ulcer of other part of right and left lower leg with necrosis of muscle. Review of the Minimum Data Set (MDS) Assessment, dated 01/28/25, revealed the resident was cognitively intact and required set-up/clean up assistance with personal hygiene and partial/moderate assistance with footwear. Review of the care plan, dated 10/25/24, verified Resident #15 was at risk for activities of daily living (ADLs) self-performance due to weakness, difficulty ambulating, fall risk, and wounds. Resident #15 required one person assist with bathing/showering, dressing, and personal hygiene. Review of request for services documentation, signed 03/24/25, revealed signed consent for eye care and podiatry care. The checkbox for the reason for a podiatry visit was listed as thickened, dystrophic, and/or painful nails with increased risk of infection. Observation on 03/25/25 at 2:40 P.M. of Resident #15 revealed resident was in her resident room and her toes were exposed. The toe nails were observed to be long, thick, and discolored. Interview on 03/25/25 at 2:42 P.M. with Licensed Practical Nurse (LPN) #221 verified Resident #15's toe nails were too long and overdue to be trimmed. 2. Review of the medical record revealed Resident #94 was admitted on [DATE]. Diagnoses included acquired fibrokeratoma, cellulitis of the right lower leg, opioid use, cerebral infarction, asthma, and epilepsy. Review of the MDS assessment, dated 12/27/24, revealed the resident was cognitively intact. Resident #94 required substantial/maximal assistance with bathing/showering. Review of the care plan, dated 12/23/24, revealed Resident #94 was at risk for ADL self-performance deficit due to weakness, difficulty ambulating, spasticity, cognitive deficits, asthma, pain, fall risks, anxiety, and history of stroke. The resident required one person assistance with bathing/showering and personal hygiene. Review of request for services documentation, signed 03/25/25, revealed signed consent for eye care and podiatry care. Observation on 03/25/25 at 9:14 A.M. revealed Resident #94 in the resident room with no socks on. Resident #94 toe nails were all long and jagged with rough edges. Interview on 03/25/25 at 9:15 A.M. with Resident #94 verified her toe nails are uncomfortable and snag on everything. Interview on 03/25/25 at 9:21 A.M. with Certified Nursing Assistant (CNA) #206 verified Resident # 94's toe nails were long and stated she should be on the podiatry list. Interview on 03/26/25 at 12:23 P.M. with Social Services #309 verified Resident #15 and Resident #94 have not been on the podiatry list. The residents were approved for podiatry services effective 03/24/25 and 03/25/25. Review of the Podiatry List, scheduled 04/10/25, revealed Resident #15 had been add to the list by hand and Resident #94 had not been added to the list. This deficiency represents non-compliance investigated under Complaint Number OH00163817, Complaint Number OH00162850, and Complaint Number OH00163167.

Based on record review, staff interview, and policy review the facility failed to ensure medical records were properly documented. This affected one resident (#73) of three reviewed for skin issues. The facility census was 86. Findings include: Review of Resident #73's medical record revealed an admitted [DATE]. Diagnoses included schizophrenia and metabolic disorders. Review of Resident #73's Minimum Data Set, dated dated dated [DATE] revealed he had an intact cognition. He was independent for dressing and required supervision or touch assistance for hygiene. No skin conditions were noted. Review of Resident #73's most recent care plan revealed he was at risk for impaired skin integrity related to weakness, difficulty ambulating, refusing showers, refusing to take off layers of clothing, refusing skin checks, schizophrenia, and cognitive deficits. Interventions included to inspect the skin during routine daily care. The resident was non-compliant related to refusals of personal care/showers, refusing to change clothing, layering clothing, and refusing skin checks. Review of Resident #73's weekly body audits dated 02/03/25, 02/07/25, 02/14/25, 02/21/25, 03/01/25, 03/08/25, and 03/15/25 revealed the resident's skin was intact and there were no new concerns. Review of Resident #73's progress note dated 02/04/25 revealed the resident refused weekly showers and skin sweeps. The provider was made aware. Review of Resident #73's progress note dated 02/20/25 revealed the physician's assistant gave a verbal order for Permethrin (antiparasitic) to be used for lice and possible scabies. Review of Resident #73's progress note dated 03/25/25 revealed the resident continued refusal to comply with treatment for body lice. The resident continued to refuse treatments and to bathe. Telephone interview with the Corporate Nurse #400 the Director of Nursing (DON) on 03/26/25 at 11:07 A.M. revealed Resident #73 had continually refused bathing and skin assessments for quite a while and failed to comply with treatment of bedbugs and scabies. Interview on 03/27/25 at 2:40 P.M. with the Administrator and Director of Nursing (DON) revealed facility staff declined to verify inaccurate skin assessments for Resident #73. Review of the facility policy titled Skin Management Plan undated revealed skin evaluations will be completed on a weekly basis for all residents. The results will be documented in the electronic medical record using the weekly skin assessment documentation tool. Any new skin alterations will be followed up on as described in this guide. This deficiency represents non-compliance investigated under Complaint Number OH00163858.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure infection control standards were maintained during medication administration. This affected one resident (#60) of four residents (#16, #37, #40, and #60) observed for medication administration. The facility census was 86. Findings include: Review of the medical record for Resident #60 revealed an admitted [DATE] with diagnoses of chronic respiratory failure, cerebral vascular accident (CVA), quadriplegia, and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #60 revealed he was cognitively intact. Observation on 03/27/25 at 8:10 A.M. of Licensed Practical Nurse (LPN) # 221 completed medication administration for Resident #63. Concurrent observation during medication observation revealed LPN #221 moved her medication cart across the hall and began medication preparation for Resident #60 without performing hand hygiene. Continued observation of LPN #221 during medication administration revealed she prepared the prescribed oral medication for Resident #60 which included 11 pills. Observation on 03/27/25 at 8:15 A.M. of LPN #221 revealed she counted the number of pills by dumping the entire medication cup of 11 pills into her ungloved hand, counted the pills for administration and returned them to the medication cup for administration. Observation on 03/27/25 at 8:17 A.M. Resident #60 was presented with his medication cup of pills and he consumed all the medication. Interview on 03/27/25 at 8:18 A.M. with LPN #221 verified she did not complete hand hygiene following medication administration to Resident #63 and prior to preparing medication for Resident #60. Concurrent interview with LPN #221 verified she dumped the medication cup of pills into her ungloved, uncleaned, hand and counted the pills and then administered them to Resident #60. Review of the facility policy titled Medication Administration and General Guidelines dated 2022 revealed medications are administered as prescribed, in accordance with state regulations using good nursing principles and practices. The person administering medications adheres to universal precautions, using proper hand hygiene, gloves when appropriate, before beginning a medication pass, prior to handling any medication, and after coming into direct contact with a resident.

Based on review of personnel files, staff interview, review of the employee handbook, and review of facility policy, the facility failed to ensure state tested nurse aides (STNAs) received twelve hours of training annually and performance reviews were completed at least once every 12 months. This had the potential to affect all 67 residents in the facility. The census was 67. Findings include: 1. Review of the personnel file for STNA #113 revealed a hire date of 02/09/23 and had seven hours of annual training. 2. Review of the personnel file for STNA #116 revealed a hire date of 08/02/22 and had seven hours of annual training. The personnel file was absent of a performance evaluation. 3. Review of the personnel file for STNA #119 revealed a hire date of 02/21/23 and had five hours of annual training. STNA #119 had a performance evaluation completed on 06/17/24. Interview on 07/11/24 at 2:12 P.M. with Human Resource Director (HRD) #160 verified STNA #113, STNA #116, and STNA #119 did not have the required twelve hours of annual training, and verified STNA #116 and STNA #119 did not have annual performance reviews completed within required timeframes. Review of the Employee Handbook, dated January 2021, revealed the job description forms the bases of each employee's annual performance evaluation to review job performance. Employees will also be evaluated following their introductory/probationary period. An employee that provides direct patient care will be required to have at a minimum an annual skills evaluation and competency check. Review of the policy titled, Nurse Aide In-Service Training Program, revised October 2017, revealed all nurse aide personnel shall participate in regularly scheduled in-service training classes. The annual in-service must be no less than 12 hours per employment year. In addition, the facility will complete a performance review of nurse aides at least every twelve months. In-service training will be based on the outcome of the annual performance reviews, addressing weaknesses identified in the reviews.

THIS DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, staff interview, and facility investigation review, the facility failed to ensure appropriate staff supervision/assistance was provided when Resident #6 was rolled out of bed by an State tested Nursing Assistant (STNA) during bathing. Actual harm occurred when STNA #400 completed a bed bath for Resident #6, who was totally dependent on staff for bathing with two person physical assist, and Resident #6 fell from the bed and sustained a closed fracture of the right tibial plateau and fractured the right sixth tooth. This affected one (Resident #6) of three sampled residents reviewed for bed mobility and transfer assistance. The facility census was 70. Findings include: Resident #6 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, paralytic syndrome following cerebral infarction, quadriplegia, dysphagia, urinary retention, hypertension, chronic kidney disease stage 3, anemia, and left elbow contracture. Review of the Minimum Data Set (MDS) assessment, dated 09/27/23 revealed Resident #6 was cognitively intact and required the extensive assistance of two plus staff for bed mobility and personal hygiene. Resident #6 was dependent on staff for bathing with two person physical assist and functional limitation in range of motion impairment affecting upper and lower extremities bilaterally. Review of the plan of care, dated 03/14/23, documented Resident #6 was at risk for activities of daily living (ADL) self-care performance related to weakness, limited mobility, quadriplegia, cardiac impairments, respiratory failure, and cerebral vascular accident (CVA). Interventions included requires one person assist with bathing/showering and bed mobility requires two person assist. On 10/04/23, the plan of care was updated to require two staff members at all times when providing care. Review of the Kardex care detail noted on 10/04/23 the resident required the assistance of two persons for bed mobility and transfers. The transfer required a Hoyer lift. Review of the nursing notes dated 10/31/23 at 5:32 A.M. documented Licensed Practical Nurse (LPN) #800 was standing at the nursing cart and heard someone yell help. LPN #800 and an STNA began to run down the hall. Upon entering Resident #6's room, LPN #800 noticed Resident #6 laying on his side next to the bed. STNA #400 was kneeling down next to Resident #6. LPN #800 noticed blood was coming from the resident's mouth. LPN #800 applied a cold towel to the resident's mouth and began to assess vital signs. Resident #6's blood pressure was 122/82 millimeters of mercury (mm/Hg), pulse 78 beats per minute and oxygen saturation of 100 percent on room air. More staff entered the room to assist. Resident #6 was safely transferred back into bed via Hoyer lift with the assistance of four other staff members. LPN #800 noticed the resident was bleeding from his gums at the top of his mouth and was missing a tooth. The tooth was found on the floor. Resident #6 stated when he fell he hit his mouth on the garbage can. Resident #6 also complained of right knee pain with some swelling noted. Staff got the resident dressed and LPN #800 called 911 at approximately 5:10 A.M. Emergency Medical Services (EMS) arrived about 5:20 A.M. and Resident #6 left the facility via EMS at 5:30 A.M. The physician and family were notified. According to hospital emergency room documentation dated 10/31/23 Resident #6 was evaluated for fall from bed. A Computed Tomography (CT) Scan of the right knee discovered a closed fracture of right tibial plateau and irregularity in right anterior maxilla with absent right sixth tooth and associated fracture of tooth. Review of the facility investigation noted a dictated statement dated 11/01/23 from Resident #6 that documented STNA #400 was providing care alone. STNA #400 rolled Resident #6 to the side and he rolled out of the bed. Review of the statement from STNA #400 documented she was washing Resident #6's back while he was in bed. He slipped from the bed and fell to the floor. STNA #400 indicated she looked at the care plan and it said Resident #6 was a one person assist with bathing and two person assist with transfers. Review of a corrective action form dated 10/31/23 documented STNA #400 was suspended pending investigation for creating and contributing to unsafe working conditions. On 11/07/23, a second corrective action resulted in STNA #400 being terminated. from employment. During an observation on 12/06/23 at 2:15 P.M., Resident #6 was in bed on an air mattress with a splint to the left upper and lower extremity. Resident #6 stated in late October he was getting a bed bath by STNA #400 and was turned to the side. He slid from the bed and sustained a fractured left leg and lost a tooth. Resident states at that time he was one assist with bathing; however, two staff when being transferred. During interview on 12/07/23 at 11:04 A.M., the Administrator and Director of Nursing (DON) confirmed STNA #400 failed to follow Resident #6's plan of care and associated Kardex related to supervision and support. Resident #6 required two staff members with all care and bed mobility as of 10/04/23. On 10/31/23, STNA #400 provided Resident #6 with a bed bath and associated bed mobility alone. This resulted in Resident #6 falling from the bed and sustaining a fractured tooth and right tibial fracture. Review of the facility's corrective action plan revealed the following actions were implemented and the deficiency corrected as of 11/27/23: On 10/31/23, STNA #400 was suspended by the Administrator pending investigation and subsequently terminated employment on 11/07/23. On 10/31/23, the facility obtained a larger bed for Resident #6. On 11/02/23, the DON assessed all residents to ensure two assists with ADL care as required. On 11/02/23, the DON verified plans of care and Kardex information were correct and updated regarding required supervision during ADLs. Beginning on 10/31/23, nurses and state tested nurse aides received education from the DON regarding Kardex information for assistance status with ADL care beginning each shift. Education was completed on 11/03/23. Beginning 11/07/23, the DON and/or designee conducted audits including two residents with ADL care, twice a week for 4 weeks to ensure they were following the plan of care and Kardex information. This was completed by 11/27/23. The DON and/or designee will bring completed audits to the Quality Assurance Performance Improvement (QAPI) committee for review and recommendations. This was completed 11/28/23. During interviews on 12/07/23, STNAs #402 and #403, and LPN #802 confirmed knowledge of corrective action and in-service education content. This deficiency represents non-compliance investigated under Master Complaint Number OH00148208 and Complaint Number OH00147975.

Based on staff interview, medical record review, policy review, review of hospital records, and interview with an outside surgeon's office nurse, the facility failed to report a change in a surgical wound condition to the physician. This resulted in actual harm when one resident (#88) did not have her increased complaints of pain and changes in surgical wound reported to the surgeon upon occurrence and as ordered by the Nurse Practitioner. The resident required admission to the hospital for two surgical debridement of an infected wound, surgical removal of her prior surgical hardware, and excessive time spent with increased levels of pain. This affected one (#88) out of two residents reviewed for surgical wounds. The facility identified three current residents with surgical wounds. The census was 79. Findings include: Review of the medical record for Resident #88 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The resident was admitted for post-operative care following spinal surgery that included placement of internal hardware. The resident had a 14-centimeter (cm) surgical wound to the lumbar region of the back. Resident #88 was discharged [DATE]. Review of Resident's #88 admission Minimum Data Set (MDS) assessment, dated 01/26/18, revealed no cognitive impairment. Review of physician orders [REDACTED]. The orders further revealed [MEDICATION NAME] 20 mg twice daily was added 01/21/18 for ongoing pain, at which time the [MEDICATION NAME] was decreased from every three hours as needed, to every four hours as needed for pain. On 01/24/18, the [MEDICATION NAME] dosage was increased from 20 mg twice daily, to 40 mg twice daily. Review of the plan of care dated 01/20/18 revealed Resident #88 had a surgical incision to the mid back with a goal to heal within the limits of the disease process and show no signs of infection to the surgical incision. Interventions to meet this goal included follow-up with the physician as ordered, and reporting of signs of infection such as purulent drainage, swelling, localized heat, and/or increased pain. The plan of care also included an identified risk for an alteration in skin integrity with interventions to observe the skin condition daily during care, and report abnormalities. Additionally, the plan of care included pain management with a goal to be free from discomfort, with an intervention to report ongoing pain as needed. Review of the nurses' notes on 01/29/18 at 1:15 P.M. revealed the resident had complained of pain to right thigh area feeling like it has been kicked or hit by a car, rating the pain a nine to ten on a pain scale of one to ten with ten being worse pain. The pain does not radiate and has been getting increasingly worse over the past couple of days. Any movement of this extremity or even the left extremity exacerbates this pain. Pain is more intense in anterior thigh area. Denies lower abdominal pain. The resident's right thigh was noted to be [MEDICAL CONDITION] and slightly warmer than the left thigh. Resident denies trauma to this area. The resident's attending physician was called and new orders received. Review of the nurses' notes on 02/01/18 at 7:15 A.M. revealed the resident stated her pain level was five out of ten on the pain scale. The physician has been notified of the resident's pain levels and there are no new orders at this time. Review of Resident #88's medical record revealed a written order, dated 02/01/17, to call neurosurgeon surgeon in regards to increased pain. Review of progress notes confirmed this call was not made. Review of the nurses' notes on 02/09/18 at 10:30 A.M. noted the dressing to Resident #88's lumbar back was changed and small amount of serosanguineous- drainage was noted on the dressing. The upper part of incision had the appearance of a slit and the upper incision was pinkish, with no warmth and not painful to touch. The resident stated her pain was a seven out of ten on the pain scale with no relief from any interventions. The resident stated the pain will go to a five out of ten for a short while. There was no evidence the physician or surgeon were notified of the change to the incision at this time. Review of the nurses' notes on 02/12/18 at 4:53 P.M. revealed Resident #88 went to the neurosurgeon's office for a follow up appointment. The resident was admitted to the hospital and was scheduled for surgery on 02/13/18. Review of neurosurgeon progress notes, dated 02/12/18, revealed Resident #88's lumbar wound was dehisced (separated and opened up) at the upper end of the wound. The wound was malodorous with purulent drainage noted on the dressing. The notes ordered Resident #88 be admitted to the hospital for evaluation of a need to remove the hardware due to the dehiscence. The notes further ordered cultures be performed to rule out infection. Resident #88 had a low-grade fever and elevated heart rate. Review of an neurosurgeon operative note, dated 02/13/18, revealed the upper portion of the wound was dehisced approximately 1.5 to 2 cm of the 14 cm, and the wound was debrided (cleaned). The surgeon documented Resident developed lumbar wound dehiscence and I was not notified. She came to the clinic necrotized and with altered sensorium. Review of a second operative note by the neurosurgeon, dated 02/15/18, listed a post-operative [DIAGNOSES REDACTED]. The report noted the internal hardware was removed and the wound was debrided a second time. Interview on 02/27/18 at 9:20 A.M., Nurse Practitioner (NP) #3 confirmed Resident #88 was admitted to the facility for post-operative care following spinal surgery. NP #3 reported Resident #88 began asking for more pain medication and was assessed for pain control before [MEDICATION NAME] 20 mg was ordered to be given twice daily. NP #3 reported that when the facility nurse again requested an increase in pain medication for Resident #88's continuing pain, NP #3 increased the [MEDICATION NAME] dosage from 20 mg to 40 mg, and verbally instructed the nurse to contact the neurosurgeon's office to report the increased pain level. NP #3 felt the pain was excessive considering the duration of time that had passed since Resident #88's surgery. NP #3 stated three to five days later, she returned to the facility for routine rounds and inquired about Resident #88, at which time the nurse on duty reported the neurosurgeon had not been contacted in accordance NP #3's instruction several days prior. NP #3 stated she instructed the nurse to immediately contact the neurosurgeon's office to report the resident's ongoing pain and increase in pain medication, as well as a small area of the surgical wound that had dehisced. NP #3 reported the nurse called the neurosurgeon's office that day, scheduled an appointment, and Resident #88 was seen the following day. Interview on 02/27/18 at 2:55 P.M. with NP #7 revealed she is a nurse practitioner at Resident #88's neurosurgeon's office. NP #7 confirmed on 02/12/18, Resident #88 came to the office for a pre-scheduled second post-operative examination, at which time the wound was discovered to have dehisced, be malodorous, with purulent drainage indicative of infection, and the resident reported ongoing pain to the surgeon. NP #7 further confirmed the resident was subsequently admitted to the hospital where wound cultures confirmed the presence of a bacterial infection that resulted in a need to debride the wound twice, remove the hardware, and provide intravenous antibiotics. NP #7 reported the facility did not report the complications to the surgeon and failed to send any form of communication with the resident to the follow-up evaluation. NP #7 reported the resident arrived for the evaluation with a list of medications, a blank physician order [REDACTED]. Interview on 02/27/18 at 5:48 P.M., the Administrator and Director of Nursing (DON), confirmed the facility did not contact the neurosurgeon's office in accordance with NP #3's instruction, after Resident #88 experienced ongoing pain and the wound dehisced. Review of a policy titled Change in Condition, dated November 2016, revealed the facility shall immediately inform the resident, and consult with the physician when there has been a significant change in the resident's physical, mental or psychosocial status, including a deterioration in health that results in clinical complications. Further, the policy stated immediate notification is recommended for any marked change in relation to usual symptoms and signs, or is unrelieved by measures already prescribed. This deficiency substantiates Complaint Number OH 246.

Based on staff interview, medical record review, review of hospital documentation, and interview with an outside surgeon's office nurse, the facility failed to monitor a surgical wound for signs and symptoms of infection as ordered, failed to report changes in the surgical wound to the physician, and failed perform dressing changes as ordered. This resulted in actual harm when one resident (#88) required admission to the hospital for two surgical debridement of an infected wound and surgical removal of her prior surgical hardware. This affected one (#88) out of two residents reviewed for surgical wounds. The facility identified three current residents with surgical wounds. The census was 79. Findings include: Review of the medical record for Resident #88 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The resident was admitted for post-operative care following spinal surgery that included placement of internal hardware. The resident had a 14-centimeter (cm) surgical wound to the lumbar region of the back. Resident #88 was discharged [DATE]. Review of Resident's #88 admission Minimum Data Set (MDS) assessment, dated 01/26/18, revealed no cognitive impairment. Review of the plan of care dated 01/20/18 revealed Resident #88 had a surgical incision to the mid back with a goal to heal within the limits of the disease process and show no signs of infection to the surgical incision. Interventions to meet this goal included follow-up with the physician as ordered, and reporting of signs of infection such as purulent drainage, swelling, localized heat, and/or increased pain. The plan of care also included an identified risk for an alteration in skin integrity with interventions to observe the skin condition daily during care, and report abnormalities. Additionally, the plan of care included pain management with a goal to be free from discomfort, with an intervention to report ongoing pain as needed. Review of physician orders [REDACTED]. Additionally, on 01/26/18 Resident #88 was evaluated by the neurosurgeon who wrote an order on that date, to change the incision dressing daily and as needed, after cleaning the wound with wound cleaner and patting it dry. Review of the Treatment Administration Record (TAR) for Resident #88 revealed monitoring for signs and symptoms of infection to the incision, was not documented as performed by the nurse on third shift on 01/25/18, 01/26/18, 01/27/18, 01/28/18, 02/02/18, 02/03/18, 02/07/18, and 02/11/18, on first shift on 01/20/18, 01/21/18, 01/22/18, 01/28/18, 01/29/18, 01/30/18, 01/31/18, 02/02/18, 02/06/18, 02/09/18 and 02/10/18, or on second shift on 01/24/18, 01/25/18, 01/27/18, 01/29/18, 01/20/18, 01/31/18, 02/01/18, and 02/04/18. Additionally, the daily wound dressing change was not documented as performed on 01/28/18, 01/29/18, 01/30/18, 01/31/18, or 02/02/18. Review of the nurses' notes on 02/09/18 at 10:30 A.M. noted the dressing to Resident #88's lumbar back was changed and small amount of serosanguinous drainage was noted on the dressing. The upper part of incision had the appearance of a slit and the upper incision was pinkish, with no warmth and not painful to touch. The resident stated her pain was a seven out of ten on the pain scale with no relief from any interventions. The resident stated the pain will go to a five out of ten for a short while. There was no evidence the physician or surgeon were notified of the change to the incision at this time. Review of the nurses' notes on 02/12/18 at 4:53 P.M. revealed Resident #88 went to the neurosurgeon's office for a follow up appointment. The resident was admitted to the hospital and was scheduled for surgery on 02/13/18. Review of neurosurgeon progress notes, dated 02/12/18, revealed Resident #88's lumbar wound was dehisced (separated and opened up) at the upper end of the wound. The wound was malodorous with purulent drainage noted on the dressing. The notes ordered Resident #88 be admitted to the hospital for evaluation of a need to remove the hardware due to the dehiscence. The notes further ordered cultures be performed to rule out infection. Resident #88 had a low-grade fever and elevated heart rate. Review of an neurosurgeon operative note, dated 02/13/18, revealed the upper portion of the wound was dehisced approximately 1.5 to 2 cm of the 14 cm, and the wound was debrided (cleaned). The surgeon documented Resident developed lumbar wound dehiscence and I was not notified. She came to the clinic necrotized and with altered sensorium. Review of a second operative note by the neurosurgeon, dated 02/15/18, listed a post-operative [DIAGNOSES REDACTED]. The report noted the internal hardware was removed and the wound was debrided a second time. Review of progress notes on Resident #88 by a nurse practitioner following the resident's admission to the hospital, revealed the resident was diagnosed with [REDACTED]. The notes further revealed the wound required debridement (cleaning) 02/13/18 and 02/15/18, and placement of a [DEVICE] to help with delayed healing as a result of the infection. Interview on 02/27/18 at 9:20 A.M., Nurse Practitioner (NP) #3 confirmed she instructed the nurse to immediately contact the neurosurgeon's office to report a small area of the surgical wound that had dehisced. NP #3 reported the nurse called the neurosurgeon's office that day, scheduled an appointment, and Resident #88 was seen the following day. Interview on 02/27/18 at 2:55 P.M. with NP #7, a nurse practitioner at Resident #88's neurosurgeon's office, revealed that on 02/12/18, Resident #88 came to the office for a second post-operative examination, at which time the wound was discovered to be malodorous with purulent drainage indicative of infection. NP #7 further reported the resident was subsequently admitted to the hospital where wound cultures confirmed the presence of a bacterial infection that resulted in a need to debride the wound twice, remove the hardware, and provide intravenous antibiotics. Interview on 02/27/18 at 5:48 P.M., the Administrator and Director of Nursing (DON) confirmed monitoring of Resident #88's surgical wound every shift, as ordered by the physician, was not documented as performed by the nurse on 27 occasions between 01/19/18 and 02/12/18. They also confirmed the resident's surgeon was not notified when the surgical wound opened up. This deficiency substantiates Complaint Number OH 246.

Based on medical record review, staff interview, review of hospital records, and review of the facility policy regarding physician orders, the facility failed to ensure a resident was free from a significant medication error when Registered Nurse (RN) #1 failed to transcribe physician orders for a resident upon readmission to the facility following a hospitalization for the placement of two cardiac stents. This resulted in Immediate Jeopardy for one (#1) of three residents reviewed for implementation of physician ordered medication following admission to the facility. Consequently, Closed Record (CR) Resident #1 suffered actual harm when she did not receive the physician ordered medications, which included two anti-platelets (to prevent blood clots), and suffered [MEDICAL CONDITION] (blood clots) in the area of the stents, which led to a [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]) and the need for surgery to remove the blood clots. The Administrator and Director of Nursing (DON) were notified on 02/22/16 at 5:00 P.M. the Immediate Jeopardy began on 01/28/16 at 6:30 P.M. when CR #1 returned from the hospital following cardiac stent placement with new physician orders for two anti-platelet medications and a cardiac medication. On 02/01/16 at 5:22 P.M., CR#1 was observed with a blank stare and [MEDICAL CONDITION] activity. The resident was subsequently transported to the hospital via emergency transport and was diagnosed with [REDACTED]. The Immediate Jeopardy was removed on 02/09/16 at 12:00 P.M. when all residents residing in the facility had their physician orders checked to ensure all medications were transcribed accurately and being administered as ordered. The deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 02/23/16 when the facility implemented the following corrective actions: * On 02/02/16 at 8:45 A.M., RN #1, who failed to transcribe the physician orders for the anti-platelet medications, was suspended pending investigation. RN #1 did not return to work and resigned from employment on 02/16/16. * On 02/02/16, an investigation was initiated the Administrator to determine corrective action required to be taken by the facility. * On 02/02/16, the facility Quality Assurance (QA) Committee met and made recommendations to prevent any further medication errors for residents newly admitted to the facility or readmitted to the facility. These recommendations included the facility would complete an audit of 100 percent of the current residents' medical records to ensure medications were being administered accurately, the procedure for new order processing was changed to include two licensed nurses were to validate the transcription of physician orders with each admission and readmission, and the night shift nurses were to ensure any new physician orders were transcribed accurately on a daily basis. Additionally, the nurse managers were to validate the accuracy of transcribed orders five times a week and this information would be reviewed Monday through Friday during the daily clinical meetings. The QA Committee also recommended the Unit Managers to complete a comprehensive chart review on all new admissions and readmissions to ensure the accuracy of the physician orders. * On 02/02/16, the medical records of residents receiving anticoagulation medications were audited to ensure these medications were being administered as ordered by the physician. * On 02/02/16 at 1:00 P.M., in-servicing was initiated by the DON for licensed nurses in regards to the admission process which included: utilizing the admission checklist, transition of care, review of acute care transfer forms, review of documentation to be sent to an acute care center during a transfer, and review of the medication reconciliation process. The in-service education was completed for all licensed nurses employed by the facility on 02/06/16 at 3:00 P.M. * On 02/02/16 during the QA Committee meeting, the medical director was notified of the medication/transcription error for CR #1 and recommendations which have been implemented by the facility. * On 02/06/16 at 10:00 A.M., all medical records of residents currently residing in the facility and not receiving anticoagulation medications were reviewed for proper transcription of medication orders. On 02/09/16 at 12:00 P.M., the medical records of all residents in the facility had been reviewed to ensure the physician ordered medications were being administered accurately. * On 02/06/16 monitoring of resident medical records, physician orders, and medication administration was initiated and continued to occur daily through 02/23/16. * On 02/22/16 between 7:45 A.M. and 8:20 A.M., RN #4 was observed administering medications to Residents #3, #4 and #5. These medications were administered without error. * On 02/22/16 between 7:00 A.M. and 4:30 P.M., interviews with Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12 and #13, revealed the residents were receiving their medications as ordered by the physician. * On 02/22/16, review of the current medical records for Resident #13, admitted on [DATE], and Resident #2, admitted [DATE], revealed the admitting physician orders were transcribed correctly to the Medication Administration Record [REDACTED]. * On 02/23/16 between 7:00 A.M. and 8:00 A.M., RN #4, RN #6, RN #7 and Licensed Practical Nurse (LPN) #5 were interviewed regarding the in-service they received regarding the admission process. All staff interviewed were able to correctly articulate the information provided in the in-service. Findings include: Review of the medical record of CR #1 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the nurses' notes dated 01/27/16 at 07:14 A.M., documented as a late entry, revealed CR #1 was transferred to the hospital vascular center for a heart catheterization. The note documented the nurse received communication from the hospital indicating CR #1 had received stents as a result of the heart catheterization. The resident was admitted to the hospital for observation after stent placement and upcoming surgery. Review of the nurses' notes dated 01/28/16 at 6:30 P.M. document the resident returned to the facility from the hospital. The resident was noted to be alert and oriented times three. The note documented the left femoral site of the cardiac catheter remained without redness swelling or pain. No dressing was noted to the area. The resident's femoral pulses were palpable and equal. The resident's respirations were regular. The resident denied shortness of breath or chest pain. There was no documentation regarding the primary care physician being notified of the resident's return. Review of the hospital history and physical completed by the cardiologist indicated CR #1 had undergone a cardiac catheterization on 01/27/16. As a result of this catheterization, bare metal stents (to improve blood flow through blocked coronary arteries) were placed in the right coronary artery and the obtuse margin. Review of the hospital community referral form, dated 01/28/16, indicated CR #1's [DIAGNOSES REDACTED]. The hospital community referral form documented post stent orders which included the addition of the anti-platelet [MEDICATION NAME] 75 milligrams (mg) daily, the anti-platelet aspirin 325 mg daily and the antihypertensive medication [MEDICATION NAME] 25 mg twice a day. Review of the admission physician orders, dated 01/29/16, and documented by RN #1, did not contain the orders for the [MEDICATION NAME], aspirin and [MEDICATION NAME], which were included on the hospital community referral form. Review of the MAR for January 2016 and February 2016 did not contain documentation indicating the [MEDICATION NAME] 75 mg, the aspirin 325 mg, or the [MEDICATION NAME] were added to CR #1's daily medication regimen. The medical record contained no documentation these medications were administered to CR #1 between 01/28/16 and on 02/01/16 when the resident was transferred to the hospital. Review of the nurses' notes on 02/01/16 at 5:22 P.M. documented CR #1 was last observed at 4:30 P.M. Documentation revealed the resident stated to State tested Nurse Aide (STNA) #200 she felt warm. STNA #200 provided the resident with a cool wash cloth. The resident then went into a blank stare and leaned forward in the wheel chair. The resident had both arms drawn in towards her body. The nurses' note documented the nurse contacted Emergency transport (911) to transfer the resident to the hospital. The documentation revealed the nurse assessed the resident's vital signs and noted the resident's blood pressure measured 144/71 millimeters of mercury (mm/Hg), respirations were 25 per minute, axillary temperature was 98.2 degrees Fahrenheit, the heart rate was 96 beats per minute, and the pulse oxygen saturation was 90% on room air. Review of the cardiologist consultation report, dated 02/01/16, revealed CR #1 was admitted to the hospital for a [MEDICAL CONDITION] infarction. The note documented the resident was status [REDACTED]. The report documents upon review of the resident's medical records from the nursing home, specifically the MAR, the record did not indicate the resident was taking any dual anti-platelet therapy. The cardiologist ' s plan of treatment included a cardiac catheterization. Review of the hospital cardiac catheterization report dated 02/01/16, documented CR #1's right coronary artery and obtuse margin were each 100 percent blocked by the presence of a thrombus. The report indicated a thrombectomy (removal of the blood clot) and a percutaneous [MEDICATION NAME] coronary angioplasty (opening of blocked cardiac arteries) were successfully performed on both the right coronary artery and the second obtuse margin. Interview on 02/22/16 at 10:25 A.M., with the DON revealed an investigation was conducted regarding a medication error involving CR #1. The investigation discovered CR #1 was admitted to the hospital for observation on 01/27/16 and readmitted to the facility following a cardiac stent placement on 01/28/16. The readmitting nurse (RN #1) did not process a new physician order for [REDACTED].#2 did not review the medical record of CR #1 following readmission on 01/28/16 to verify possible physician orders which may have been overlooked by RN #1. The DON stated the second review was a facility procedure for all new admissions or readmissions. Interview on 02/22/16 at 10:55 A.M., with Unit Manager RN #2 revealed CR #1 had been at the hospital for the placement of cardiac stents on 01/27/16. The resident returned to the facility on [DATE]. The unit nurse, RN #1, readmitted the resident and did not complete a full readmission assessment until 01/29/16, when directed to do so by Unit Manager RN #2. Unit Manager RN #2 stated he did not discover any new physician orders following a review of the medical record on 01/29/16. Interview on 02/22/16 at 11:20 A.M., with the Administrator and DON revealed during the investigation of the medication error, an interview was conducted with RN #1 on 02/02/16. During this interview it was discovered when CR #1 was readmitted to the facility on [DATE], the ambulance transport service provided RN #1 with a packet of paperwork from the hospital pertaining to CR #1, which included physician orders from the resident's medical procedure. The DON stated RN #1 indicated she had reviewed the paperwork at approximately 10:00 P.M. on 01/28/16 and did not notice any new physician orders. However, RN #1 was presented with the physician order for [REDACTED]. During interview on 02/22/16 at 12:10 P.M., LPN #3 revealed she was CR #1's nurse on 02/01/16. At approximately 5:30 P.M., STNA #4 summoned LPN #3 to CR #1's room indicating the resident was not looking well. LPN #3 stated she assessed the resident with a blank look on her face and what appeared to be [MEDICAL CONDITION] activity. The resident subsequently vomited bile like contents and returned to her normal self. LPN #3 immediately called emergency transport services (911) and the resident was transported to the hospital. Later in the evening, a family member of CR #1 called the facility and informed LPN #3 the resident had not been given her prescribed anti-platelet medications. LPN #3 was unable to discover a physician order for [REDACTED]. The orders were located in the back of the medical record revealed three new medications which were not on the current MAR. These medications were [MEDICATION NAME], aspirin, and [MEDICATION NAME]. LPN #3 verified she was unaware these medications were to be administered to the resident until 02/02/16. Review of the personnel record for RN #1 revealed the nurse was suspended on 02/02/16 due to the investigation of CR #1's medication error. RN #1 did not return to work and resigned her position on 02/16/16. Review of the facility policy titled Requirements and Guidelines for Clinical Record Content, dated 2015, under the heading Physician Orders, subheading Transcribing or Noting Orders, revealed physician orders that are written, telephoned or faxed are noted by a licensed nurse. The nurse is responsible for the accuracy of transcription and signs and dates the orders as noted. The licensed nurse, noting the order, transcribes the new medication or treatment onto the patient's Medication Administration Record [REDACTED]. The policy indicated under the heading Physician Orders, subheading Orders Upon Readmission or Return From hospitalization , upon patient readmission or return from hospitalization , a new order sheet is created. Each new and continued order is documented on the new order sheet and transcribed on a new MAR, or TAR and other required documents. This deficiency substantiates Complaint Number OH 721.

This deficiency represents an incident of past non-compliance. Based on medical record review, staff interview, observation, resident interview, review of inservices, review of a personnel record and review of the facility's fall policy, it was determined the facility failed to ensure one resident was transferred properly to prevent an avoidable fall. This resulted in actual harm for Resident #30 who sustained a left knee and femur fracture that required surgical intervention. This affected one (#30) of three residents reviewed for in-house falls with fractures of a total of four residents who experienced in-house falls with fractures. The facility census was 82. Findings include: Review of Resident #30's medical record revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The minimum data set (MDS) assessment dated [DATE] indicated the resident required extensive assistance with two person physical assistance for transfers. She was not observed to ambulate in her room/corridor during the assessment period. Review of the care plan for at risk for falls developed on 01/10/07 noted the resident was at risk for falls due to physical deficits, medication, depression and a history of falls. Interventions included assist to the toilet frequently, provide assistance to transfer and ambulate as needed and encourage and assist as needed to wear proper and non-slip footwear (shoes only, no socks). Review of nurses' notes revealed an entry dated 12/19/10 at 2:00 P.M. that indicated Resident #30 had difficulty bearing weight on her right leg. On 12/23/10 at 11:00 A.M., the nurse practitioner was notified the resident had increased confusion and decreased weight bearing on her right leg (should be left leg). The nurse documented an x-ray order was obtained for the right knee (should be left knee). Review of the left knee x-ray dated 12/23/10 revealed Resident #30 had an acute fracture of the distal left femur involving a previous total left knee replacement with lateral displacement of the distal fracture fragments. Small fracture fragments were displaced both on the front and back side of the femur. Resident #30 had surgery to repair the fractures on 01/11/11. Review of the facility's form entitled "Fall", completed 12/27/10, revealed Resident #30 experienced a fall on 12/14/10 at 8:30 P.M. when the state tested nurse aide (STNA) assisted the resident to the toilet. The form noted Resident #30 "went down on floor on left knee". The form also contained documentation that Resident #30 had difficulty maintaining a sitting balance, difficulty maintaining a standing position, impaired balance during transitions, had fatigue/weakness and chronic back and knee pain. The resident requires the assist of two staff with transfers. On 05/12/11 at 9:40 A.M., the Director of Nursing (DON) and Regional Nurse #1 revealed STNA #1 took Resident #30 to the bathroom by herself. The STNA received a written reprimand for the improper transfer and the need to use a gait belt with difficult transfers. They also verified the resident required the assistance of two staff for transfers. Resident #30 was interviewed on 05/12/11 at 11:00 A.M. regarding her fall on 12/14/10. She stated an STNA took her to the bathroom and she fell and broke her left leg. She indicated the cast was just removed a couple of weeks ago. Resident #30 informed the surveyor that since the fall she has difficulty bending her left knee and is unable to stand for long periods of time. Review of STNA #1's personnel record revealed an "Employee Warning Notice" dated 12/28/10. The notice indicated that on 12/14/10, the STNA got the resident up alone. The STNA was educated to transfer people with a gait belt and ask for assistance with difficult transfers. Review of inservice records revealed mandatory inservices were held from 03/15/11 through 04/21/11 for all staff regarding gait belts, two person resident transfers and standard fall prevention. Random observations during the survey, 05/10/11 through 05/12/11, revealed residents being transferred properly with the correct number of staff.