Every finding on record at Beachwood Pointe Care Center

Based on medical record review, observations, interview and facility policy review, the facility failed to ensure a sanitary resident environment. The affected two (Residents #17 and #30) of three residents observed for environment. This had the potential to affect all residents residing on the first and second floor who utilized the second-floor shower. The facility census was 101.Findings include:Review of the medical record for Resident #17 revealed an admission date of 12/24/25. Diagnoses included type two diabetes, chronic pain, anxiety disorder, muscle weakness, and age-related nuclear cataract, bilateral.Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/06/26, revealed Resident #17 had intact cognition. The resident required substantial assistance for bed mobility and transfers. Resident #17 utilized an electric wheelchair.Observations of the facility on 02/03/26 at 8:08 A.M. noted the hallway for rooms 110 through 122 were heavily soiled with salt from snow, gum, dried stains, and other miscellaneous debris. These findings were verified by Certified Nurse Assistant (CNA) #366.Observations on 02/03/26 at 3:15 P.M. noted the second-floor main shower had two used bars of soap lying on the shower floor and three used bottles of body soap on the shelf in the shower stall. The floor of the shower stall was covered with rust stains and mold, the shower chair and bed had dried stains on the seat and frame. These findings were verified by Unit Manager #329.Interview on 02/03/26 at 10:04 A.M., Resident #17 stated the shower was very dirty, and she didn't want to shower in there.Interview on 02/03/26 at 1:18 P.M., Resident #30 stated she will not shower because the only working shower is on the second floor, and it was disgusting. Resident #30 stated the shower chairs were covered in feces and urine.Review of the facility policy titled Homelike Environment, dated 2001, noted facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting including a clean, sanitary and orderly environment.This deficiency represents non-compliance investigated under Complaint Number 2732435.

Based on record review, interview and facility policy review, the facility failed to ensure plans of care were created and/or revised in a timely manner. This affected one (Resident #17) of three residents reviewed for care plans. The facility census was 101.Findings include:Review of the medical record for Resident #17 revealed an admission date of 12/24/25. Diagnoses included type two diabetes, chronic pain, anxiety disorder, muscle weakness, and age-related nuclear cataract, bilateral.Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/06/26, revealed Resident #17 had impaired cognition and required substantial assistance for bed mobility and transfers. Resident #17 utilized an electric wheelchair. Resident #17 experienced frequent incontinence of bowel and bladder.Review of the plans of care noted the facility created plans of care dated 12/24/25 for malnutrition and activities.Interview on 02/05/26 at 3:50 P.M., the MDS Nurse #406 stated the plans of care should be created when the resident is admitted .Further review of plans of care dated 02/03/26 for Resident #17 noted the facility created plans of care for diabetes mellitus, polypharmacy, hypertension, use of antidepressant, and activities of daily living. No plan of care for transfers via a mechanical lift, resident had verbal aggression toward staff and peers, and incontinence of bowel and bladder.Interview on 02/05/26 at 11:30 A.M., the Director of Nursing (DON) verified the lack of plans of care for Resident #17.Review of the undated facility policy titled Care Plans, Comprehensive Person-Centered noted the Interdisciplinary Team, in conjunction with the resident and his/her family will develop and implement a comprehensive, person-center care plan for each resident.This deficiency was an incidental finding identified during the complaint investigation.

Based on medical record review, interview and facility policy review, the facility failed to ensure incontinence care was completed as ordered and as needed. This affected two (Resident #5 and Resident #17) who were dependent on staff for care of three residents reviewed for incontinence care. The facility census was 101.Findings include:1. Review of the medical record for Resident #5 revealed an admission date of 02/23/24. Diagnoses included spastic hemiplegia affecting right dominant side, osteoarthritis and hypertension.Review of the plan of care dated 12/11/24 noted Resident #5 had episodes of incontinence related to aging process. Interventions included checking resident every two hours and assisting with toileting as needed and providing peri-care after each incontinent episode.Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/11/25, revealed Resident #5 had impaired cognition. The resident was dependent on staff for all activities of daily living. Resident #5 utilized an electric wheelchair. Resident #5 experienced frequent incontinence of bowel and bladder.Review of the incontinence sheets dated 01/06/26 through 02/03/26 for Resident #5 noted, on average, staff changed Resident #5 twice a day.Interview on 02/03/26 at 8:17 A.M., Resident #5 stated she had to wait a long time to get changed if staff showed up at all. Resident #5 could not provide specific times or dates when she waited long periods of time.2. Review of the medical record for Resident #17 revealed an admission date of 12/24/25. Diagnoses included type two diabetes, chronic pain, anxiety disorder, muscle weakness, and age-related nuclear cataract, bilateral.Review of the quarterly MDS assessment, dated 01/06/26, revealed Resident ##17 had intact cognition. The resident required substantial assistance for bed mobility and transfers. Resident #17 utilized an electric wheelchair. Resident #17 experienced frequent incontinence of bowel and bladder.Revie of the plan of care dated 02/04/26 noted Resident #17 had episodes of incontinence and depends on staff for assistance. Interventions included applying skin moisturizers/barrier creams as needed and providing assistance with toileting/incontinent care as needed.Review of the incontinence sheets dated 01/06/26 through 02/03/26 noted, on average, staff changed Resident #17 twice a day.Interview on 02/03/26 8:23 A.M. Licensed Practical Nurse (LPN) #435 stated sometimes staffing is short and it takes longer to get residents changed. LPN #305 stated staff try their best to complete tasks promptly.Interview on 02/03/26 at 8:42 A.M. Certified Nurse Assistant (CNA) #302 stated residents have longer wait times when the facility is short staffed.Interview on 02/03/26 at 10:04 A.M., Resident #17 stated she had been left in a soiled brief for hours throughout the week. Interview on 02/05/26 at 11:30 A.M., the Director of Nursing (DON) verified the lack of documentation indicating incontinence care was completed as ordered and as needed.This deficiency represents non-compliance investigated under Complaint Number 2732435.

Based on medical record review, interview and facility policy review, the facility failed to ensure physician orders were updated and blood glucose levels were monitored appropriately. This affected one (Resident #17) of three residents reviewed for physician orders. The facility census was 101.Findings include:Review of the medical record for Resident #17 revealed an admission date of 12/24/25. Diagnoses included type two diabetes, chronic pain, anxiety disorder, muscle weakness, and age-related nuclear cataract, bilateral.Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/06/26, revealed Resident #17 had intact cognition. The resident required substantial assistance for bed mobility and transfers and utilized an electric wheelchair.Review of the plan of care dated 02/03/26 noted Resident #17 had diabetes mellitus two and was insulin dependent. Interventions included administering diabetes medications as ordered by the physician and monitoring side effects and effectiveness.Review of the December 2025 and January 2026 medication administration record (MARs) indicated an order for Humalog KwikPen solution per sliding scale dated 12/27/25 through 01/17/26 subcutaneously three times a day. Further review noted no new order for the sliding scale was provided. Resident #17 also had an order for a freestyle libre device for continuous blood glucose monitoring dated 12/31/25 through 01/13/26. No new order was provided.Review of blood glucose monitoring dated 01/19/26 through 02/02/26 noted staff checked Resident #17's blood sugar one time on 01/19/26, two times on 01/20/26 and 01/21/26, one time on 01/22/26, none on 01/23/26, and two times on 01/24/26, one on 01/27/26, none on 01/28/26, 01/29/26, 01/30/26, 01/31/26, 02/01/26, and 02/02/26.Interview on 02/03/26 at 10:04 A.M., Resident #17 stated staff were not checking her blood glucose levels throughout the day.Interview on 02/03/26 at 11:38 A.M., Licensed Practical Nurse (LPN) #333 stated she checked Resident #17's blood glucose level that morning but did not have an order to check it. LPN #333 stated it was very confusing because staff were checking the blood sugar randomly and not throughout the day. LPN #333 stated she would contact the physician to get verification of order.Interview on 02/03/26 at 12:09 P.M., with the physician revealed the physician was unaware that there was no order to check blood sugars before meals. The physician stated it made no sense to check when there was a plan in place, that he would put another order in that day. Resident #17 now has an order to check blood sugar levels before each meal.Interview on 02/03/26 at 12:25 P.M., the Director of Nursing (DON) verified no new order for a sliding scale or for staff to check Resident #17's blood glucose sugar three times a day.Review of the undated facility policy titled Insulin Administration provided little guidance related to the frequency at which residents should have blood glucose levels monitored.This deficiency represents non-compliance investigated under Complaint Number 2732435.

Based on observation, interview, and review of facility policy the facility failed to ensure appropriate monitoring and safe storage or outside foods for residents. This had the potential to affect 36 residents residing on the second floor (Residents #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #67, #68, #69, #70, #71, #72, #73, and #74) residing in the facility. The facility indicated Resident #66 received nothing by mouth. The facility census was 102. Observation on 09/09/25 at 11:17 A.M. of the second-floor resident lounge refrigerator revealed the front of the refrigerator was heavily soiled with dried food and fingerprints and the front of the door and handle were sticky. Inside of the resident refrigerator revealed a paper plate with two cheeseburgers with no name or date, an open package of microwavable chicken patties that did not have a resident name, an open date and the use by date was unable to be determined. The six chicken patties contained inside of the open bag had visible mold on each of the chicken patties and had a bad odor when the bag was moved.Observation and interview on 09/09/25 at 11:20 A.M. with Certified Nurse Aide (CNA) #316 confirmed the chicken patties were moldy and the burgers were not labeled with a name or date as required. CNA #316 stated dietary was supposed to monitor the unit refrigerator.Interview on 09/11/25 at 1:35 P.M. with Dietary Director #344 stated she thought the resident unit refrigerators were monitored by nursing staff on each floor. Review of the undated facility policy called; Foods Brought by Family/Visitors revealed perishable foods must be stored in a re-sealable container with tightly fitting lids in the refrigerator. Containers will be labeled with the residents' name, the item and the 'use by' date. The nursing staff is responsible for discarding perishable foods on or before the 'use by' date. The nursing and/or food service staff must discard any food prepared for the residents that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates.)

Based on observation ,staff interview and facility policy review, the facility failed to ensure the dumpster/refuse area was maintained in a clean and sanitary condition. This had the potential to affect all residents residing in the facility. The facility census was 102.Findings include:Observation on 09/09/25 at 10:45 A.M. of the facilities outside dumpster area revealed various loose rubbish around and underneath the stairs leading to the dumpster. The Administrator confirmed the observation and stated maintenance is supposed to clean the area week following the dumpster being emptied to prevent rodents.Review of the undated facility policy called; Disposal of Garbage and Refuse revealed the facility shall properly dispose of kitchen garbage and refuse. Storage areas, enclosures, and receptacles for refuse shall be maintained in good repair and cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming an attractant for insects and rodents.

Based on observation, interview and policy review, the facility failed to maintain a clean and homelike environment. This had the potential to affect all residents residing in the facility. The facility census was 102.Findings include:On 09/09/25 between 10:00 A.M. and 12:30 P.M. an initial tour of the building was conducted. room [ROOM NUMBER] was noted with visible dirt at the door threshold. The resident lounge on the second floor was noted to have a floor with visible dirt and debris. The garbage can was overflowing. The common bathroom on the second floor was noted to have caked hair and visible dirt under the sink in the back right hand side of the floor. There was a stained ceiling tile. There was plastic tape hanging from the overhead light. The mirror was chipped and broken. The elevator threshold was caked with visible dirt and debris. There was built up, visible dust on all baseboards on all units. room [ROOM NUMBER] was missing the baseboard behind the bed headboard exposing the wall. Peeling paint was noted under the air conditioning unit. The window seal in the common hall outside room [ROOM NUMBER] was noted to have built up visible dust and dead insects. The blinds on the window above outside room [ROOM NUMBER] were noted to have a build up of visible dust and dirt. room [ROOM NUMBER] was noted to have the corner of the wall outside of the bathroom torn away exposing the wall. The soap dispensers outside rooms [ROOM NUMBERS] were noted to not be filled. The threshold outside room [ROOM NUMBER] was noted to have built up dirt and debris. Maintenance Director #347 verified the aforementioned findings at the time of the observations. On 09/10/25 at 11:05 A.M. another tour of the building was conducted with Environmental Service Director (ESD) #346. Built up, visible dust was noted on all baseboards of all units. Windowsills at the end of each unit were noted to have visible dirt and dead insects. Blinds at the end of every hallway on all units were noted to have built up visible dust and dirt on them. ESD #346 verified the findings at the time of the tour. On 09/10/25 at 3:10 P.M. Visible dirt and dead insects was noted at the windowsills at the end of the halls on the 200 unit. Housekeeper #314 verified the findings at the time of the observation. A review of the policy titled; Homelike Environment with a revision date of 02/2021 revealed Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect personalized, home-like setting. These characteristics include a clean, sanitary and orderly environment. This deficiency represents non-compliance investigated under Complaint Numbers 1271397, 2589543, and 1271392.

Based on observation, interview, review of facility menus, and facility policy review, the facility failed to ensure the registered dietitian approved dietary menus were followed and the facility did not run out of menu items during service as required. This had the potential to affect 99 residents receiving meals from the facility. The facility indicated that three residents (Residents #6, #23, and #66) were receiving nothing by mouth from the kitchen. The facility census was 102.Findings include:Review of the facility provided menu for week three lunch for Thursday 09/11/25 revealed Chinese pepper steak, fried rice, oriental blend vegetables, iced mandarin orange cake and choice of milk and other beverage were being served.Observation on 09/11/25 at 12:13 P.M. of lunch tray line revealed pepper steak, oriental mixed vegetables, white rice mixed with peas, carrots and corn, ground chicken, pureed chicken, pureed vegetables, pureed bread, white rice, and diced chicken with mixed vegetables with chicken gravy. Review of menu production sheets revealed regular diets were to get six ounces (oz) of pepper steak with onion and green pepper, four ounces of fried rice, four ounces of oriental blend vegetables, and one slice (1 1/2 inch x 2-inch piece) of iced mandarin orange cake and 4 ounces of milk. Mechanical soft diets were supposed to receive a number eight scoop (1/2 cup) of ground Chinese pepper steak with the other menu items and the pureed diets were supposed to receive a number eight scoop (1/2 cup) of pureed Chinese pepper steak, a number eight scoop (1/2 cup) of seasoned cream of rice, a number eight scoop of pureed oriental vegetables and a number ten scoop (3/8 cup) of pureed iced mandarin orange cake.Observation on 09/11/25 at 12:18 P.M. revealed two different types of cake being served. Interview at the time with Foodservice Director (FSD) #344 revealed they only had enough mandarin orange cake for the first floor, so they substituted carrot cake for the second and third floor residents.Observation on 09/11/25 at 12:17 P.M. revealed the serving scoop used for the pepper steak was a four ounce not a six ounce as written in the approved production sheet. Interview at the time with [NAME] #294 confirmed he was using a four ounce rather than a six ounce as required.Observation on 09/11/25 at 12:30 P.M. revealed no seasoned cream of rice as a pureed modification for the fried rice. Interview at the time of the observation with FSD #344 revealed residents do not like regular cream of rice so they give them pureed wheat bread instead, had been doing it for a while, but had not discussed it with the Registered Dietitian. FSD #344 also stated since the meat is sometimes tough and will probably not puree well, they usually substitute baked chicken for beef in the mechanical soft and pureed diets on the menu. The mechanical soft diets get ground baked chicken, and the pureed diets get pureed baked chicken.Observation on 09/11/25 at 12:38 P.M. revealed no evidence of a pureed dessert. Interview at the time of the observation with FSD #344 stated because they ran out of orange cake, they are sending pudding for the pureed residents since the carrot cake would not puree smoothly.Observation on 09/11/25 at 12:55 P.M. revealed the cart for the second-floor residents began. Observation revealed [NAME] #294 ran out of fried rice and started sending white rice instead. FSD #344 confirmed they were out of fried rice and were sending white rice to finish out the carts for second floor residents. FSD #344 confirmed if residents did not like beef they received the chicken with vegetables in gravy.Phone interview on 09/15/25 at 1:33 P.M. with [NAME] #294 revealed he did not use a recipe for fried rice, he just made white rice and added various vegetables to it and did not realize the recipe included eggs. [NAME] #294 also confirmed he did not use the pepper steak for the pureed diets or mechanical soft diets as stated on the menu. [NAME] #294 confirmed he used chicken for the mechanical soft and pureed diets and did not taste them prior to serving them for taste or texture. [NAME] #294 also confirmed he did not use a recipe for chicken with vegetables mixed with chicken gravy. [NAME] #294 stated the menu recipes are in the book in the kitchen to use but since the meat was tougher, it was suggested to use the chicken instead and just made the chicken, vegetables and gravy without a recipe and was not listed on the facility approved menu.Interview on 09/15/25 at 1:38 P.M. with FSD #344 confirmed she did not have a substitution log for review prior to 08/01/25 and confirmed the substitution of the chicken with vegetables and gravy was not listed on the substitution list. FSD #344 confirmed it was not listed on the menu, and no recipe was followed. Observation on 09/11/25 at 1:41 P.M. revealed the tray for Resident #99, who is severely cognitively impaired and receives a pureed diet, received pureed chicken, pureed vegetables, pureed wheat bread and pudding. Interview at the time of the observation with Certified Nurse Aide (CNA) #251 confirmed the above listed items received for Resident #99 were already consumed with no swallowing concerns noted at the time.Phone interview on 09/11/25 at 2:07 P.M. with Registered Dietitian (RD) #362 confirmed she has not been doing test trays and stated she recently told the dietary staff that modified diets needs to get the items listed on the menu.Review of the 2023 facility policy called Standardized Recipes revealed standardized recipes will be used when preparing menu items. Standardized recipes for planned menu items will be maintained in the facility. Cooks/chefs are expected to use and follow the recipes provided.

Based on observation, interview and review of facility policies the facility failed to ensure palatable meals were served for resident meals. This had the potential to affect all residents receiving meals from the facility. The facility indicated three residents (Residents #6, #23, and #66 received nothing by mouth). The facility census was 102.Findings include:Review of the facility provided menu for week three lunch for Thursday 09/11/25 revealed Chinese pepper steak, fried rice, oriental blend vegetables, iced mandarin orange cake and choice of milk and other beverage.Observation on 09/11/25 at 12:13 P.M. of lunch tray line revealed pepper steak, oriental mixed vegetables, white rice mixed with peas, carrots and corn, ground chicken, pureed chicken, pureed vegetables, pureed bread, white rice, and diced chicken with mixed vegetables with chicken gravy. Review of menu production sheets revealed regular diets were to get six ounces (oz) of pepper steak with onion and green pepper, four ounces of fried rice, four ounces of oriental blend vegetables, and one slice (1 1/2 inch x 2-inch piece) of iced mandarin orange cake and 4 ounces of milk. Mechanical soft diets were supposed to receive a number eight scoop (1/2 cup) of ground Chinese pepper steak with the other menu items and the pureed diets were supposed to receive a number eight scoop (1/2 cup) of pureed Chinese pepper steak, a number eight scoop (1/2 cup) of seasoned cream of rice, a number eight scoop of pureed oriental vegetables and a number ten scoop (3/8 cup) of pureed iced mandarin orange cake.Observation on 09/11/25 at 12:13 P.M. of the lunch tray line temperatures with [NAME] #294 temperatures were as follows: pepper steak 178 F, oriental vegetables 195 F, fried rice 183 F, ground chicken 178 F, pureed chicken 172 F, pureed vegetable 179 F, pureed bread 165 F, white rice 170 F, diced chicken with vegetables and chicken gravy 169 F.Observation on 09/11/25 at 12:30 P.M. revealed no seasoned cream of rice as a pureed modification for the fried rice. Interview at the time of the observation with FSD #344 revealed residents do not like regular cream of rice so they give them pureed wheat bread instead, had been doing it for a while, but had not discussed it with the Registered Dietitian. FSD #344 also stated since the meat is sometimes tough and will probably not puree well, they usually substitute baked chicken for the beef in the mechanical soft and pureed diets. The mechanical soft diets get ground baked chicken, and the pureed diets get pureed baked chicken.Observation on 09/11/25 at 12:36 P.M. revealed the first-floor cart left the kitchen for the floor. Observation on 09/11/25 at 12:38 P.M. revealed no evidence of the pureed orange cake dessert. Interview at the time of the observation with FSD #344 stated because they ran out of orange cake, they are substituting carrot cake with cream cheese frosting. FSD #344 further stated they are sending pudding for the pureed diet residents since the carrot cake would not puree smoothly.Observation on 09/11/25 at 12:51 P.M. revealed the third-floor cart left for the floor.Observation on 09/11/25 at 12:55 P.M. revealed the cart for the second-floor residents began. Observation revealed [NAME] #294 ran out of fried rice and started sending white rice instead. FSD #344 confirmed they were out of fried rice and were sending white rice to finish out the carts for the 37 residents receiving meals on the second-floor residents.Observation on 09/11/25 at 1:15 P.M. revealed the last cart for the second floor left the kitchen. Upon arrival on the second floor three aides started passing resident meal trays. Last resident tray was passed at 1:30 P.M.A test tray initiated with FSD #344 on 09/11/25 at 1:32 P.M. Temperatures taken by FSD #344 were as follows: Chinese pepper steak was 119.5 F, chicken with vegetables in gravy 126.7 F, pureed bread 82 F, pureed vegetables 113.5 F, Oriental vegetables 113.4 F, and pureed chicken 107.6F. Taste test for each item was completed with FSD #344. FSD #344 confirmed the Chinese pepper steak was chewy with some notable gristle when chewing and was not warm enough. The oriental vegetables were watery, mushy and not warm enough to preference. The chicken with vegetables in gravy was not warm enough. The pureed chicken appeared to be more a mechanical soft consistency, was not a smooth consistency and tasted bland without seasoning. FSD #344 also noted the pureed bread was grainy, tasted pasty and was not a smooth consistency and the pureed vegetable had bean strings that were evident when chewing it. Following testing the above listed items, FSD #344 confirmed the tested items were not warm enough and she now understood resident complaints about food not being warm enough seeing the drop from the initial tray line temperature to the temperature of the test tray following the last passed resident meal tray. FSD #344 confirmed she does not usually complete test trays and had not tried the pureed food items. Phone interview on 09/15/25 at 1:33 P.M. with [NAME] #294 revealed he did not use a recipe for fried rice, he just made white rice and added various vegetables to it and did not realize the recipe included eggs. [NAME] #294 also confirmed he did not use the pepper steak for the pureed diets or mechanical soft diets as stated on the menu. [NAME] #294 confirmed he used baked chicken for the mechanical soft and pureed diets and did not taste them prior to serving them for taste or texture. [NAME] #294 also confirmed he did not use a recipe for the chicken with vegetables mixed with chicken gravy. [NAME] #294 stated the menu recipes are in the book in the kitchen to use but since the meat was tougher, it was suggested to use the chicken instead and just made the chicken, vegetables and gravy without a recipe and was not listed on the facility approved menu.Interview on 09/15/25 at 1:38 P.M. with FSD #344 confirmed she did not have a substitution log for review prior to 08/01/25 and confirmed the substitution of the chicken with vegetables and gravy was not listed on the substitution list. FSD #344 confirmed it was not listed on the menu, and no recipe was followed. Phone interview on 09/11/25 at 2:07 P.M. with Registered Dietitian (RD) #362 confirmed she has not been doing test trays at the facility, menus were to be followed, and stated she recently told the dietary staff that modified diets are supposed to get the items as written on the menu production sheets.Review of the 2023 facility policy called: The Dining Experience revealed the dining experience will be person centered with the purpose of enhancing each individual's quality of life and being supportive of each individual's needs during dining. Individuals will be provided with nourishing, palatable, attractive meals that meet daily nutrition and/or special dietary needs and food preferences and are served at a safe and appetizing temperature. Review of the 2023 facility policy called: Food Temperatures revealed foods sent to the units for distribution (such as meals, snacks, nourishments, oral supplements) will be transported and delivered to unit storage areas to maintain temperatures at or below 41 degrees Fahrenheit (F) for cold food and at or above 135 degrees F for hot foods.

Based on observation, interview and review of facility kitchen cleaning schedules, and facility policies the facility failed to ensure a clean and sanitary kitchen was maintained as required. This had the potential to affect 99 residents in the facility receiving meals from the kitchen. The facility identified three residents (Resident #6, #23, and #66) who received no food by mouth. The facility census was 102. Initial kitchen tour on 09/09/25 at 10:05 A.M. completed with Food Service Director (FSD) #344 revealed six packages of 12 count dinner rolls with best buy date of 09/06/25, 12 count hot dog buns with best buy date of 09/06/25. FSD #344 confirmed the bread should have been discarded over the weekend. Observation in the walk in refrigerator #1 revealed a one pound plastic container of diced tomatoes with a use by date of 09/01/25, a two pound plastic container of sliced onions with a use by date of 09/07/25, a leftover ham portion (approximately 2#) with a use by date of 08/25/25, and four packages of five pound Italian four cheese blend with a best by date of 08/29/25. FSD #344 confirmed the items should have been discarded and should not have still been in the refrigerator. Interview on 09/09/25 at 10:32 A.M. with FSD#344 confirmed she was unable to provide evidence of daily staff cleaning logs for August and had some sheets partially filled out for September but were not completed as required. FSD #344 stated each of the three scheduled dietary aides are supposed to complete a daily cleaning sheet and turn it in daily. FSD #344 also confirmed tray line food temperatures for the month of August 2025 were not available for review and the ones for September revealed dinner were not recorded on 09/06/25, no temperatures were recorded for 09/07/25 and dinner was not recorded on 09/08/25. Review of the 2023 facility policy called: Food Safety and Sanitation revealed all local, stated and federal standards and regulations will be followed to assure a safe and sanitary food and nutrition services department. Stored food will be handled to prevent contamination and growth of pathogenic organisms. Leftovers are to be used within 72 hours or discarded. Perishable foods with expiration dates should be used prior to the use by date on the package. All time and temperature control for safety (TCS) foods including leftovers should be labeled, covered and dated when stored.

Based on medical record review, observations, interviews, review of facility menus, spreadsheets, and facility policy revealed the facility failed to ensure four residents (Residents #36, #80, #82 and #99) received the physician ordered pureed diet as required. The facility indicated there were three residents (Residents #6, #23, and #66) who received nothing by mouth. The facility census was 102.Findings include:Review of the medical record for Resident #99 revealed and admission date of 01/31/22. Diagnoses included but were not limited to unspecified dementia with agitation and seizures. Review of the physician order dated 01/31/22 for Resident #99 revealed an order for a regular pureed diet with thin liquids.Review of the 08/16/25 quarterly Minimum Data Set (MDS) 3.0 for Resident #99 revealed severe cognitive impairment and she required maximum staff assistance for eating.Review of the facility provided menu for week three lunch for Thursday revealed Chinese pepper steak, fried rice, oriental blend vegetables, iced mandarin orange cake and choice of milk and other beverage.Review of menu production sheets revealed residents receiving a pureed diet were supposed to receive a number eight scoop (1/2 cup) of pureed Chinese pepper steak, a number eight scoop (1/2 cup) of seasoned cream of rice, a number eight scoop of pureed oriental vegetables and a number ten scoop (3/8 cup) of pureed iced mandarin orange cake.Observation on 09/11/25 at 12:13 P.M. of lunch tray line revealed pepper steak, oriental mixed vegetables, white rice mixed with peas, carrots and corn, ground chicken, pureed chicken, pureed vegetables, pureed bread, white rice, and diced chicken with mixed vegetables with chicken gravy. Observation on 09/11/25 at 12:30 P.M. revealed no seasoned cream of rice as a pureed modification for the fried rice. Interview at the time of the observation with FSD #344 revealed residents do not like regular cream of rice so they give them pureed wheat bread instead, had been doing it for a while, but had not discussed it with the Registered Dietitian. FSD #344 also stated since the meat is sometimes tough and probably not puree well, they usually substitute baked chicken for the beef for the mechanical soft and pureed diets. The mechanical soft diets get ground baked chicken, and the pureed diets get pureed baked chicken.A test tray was initiated with FSD #344 on 09/11/25 at 1:32 P.M. Temperatures taken by FSD #344 were as follows: Chinese pepper steak was 119.5 F, chicken with vegetables in gravy 126.7 F, pureed bread 82 F, pureed vegetables 113.5 F, Oriental vegetables 113.4 F, and pureed chicken 107.6F. Taste test for each item was completed with FSD #344. FSD #344 confirmed the Chinese pepper steak was chewy with some notable gristle with chewing and was not warm enough. The oriental vegetables were watery, mushy and not warm enough to preference. The chicken with vegetables in gravy was not warm enough. The pureed chicken appeared to be more a mechanical soft consistency, was not a smooth consistency and tasted bland without seasoning. FSD #344 also noted the pureed bread was grainy, tasted pasty and was not a smooth consistency and the pureed vegetable had bean strings that were evident when chewing it. Following testing the above listed items, FSD #344 confirmed the tested items were not warm enough and she now understood resident complaints about food not being warm enough seeing the drop from the initial tray line temperature to the temperature of the test tray following the last passed resident meal tray. FSD #344 confirmed she does not usually complete test trays and had not tried the pureed food items to ensure a safe texture or taste. Observation on 09/11/25 at 1:41 P.M. revealed the tray for Resident #99, who is severely cognitively impaired and receives a pureed diet, received pureed chicken, pureed vegetables, pureed wheat bread and pudding. Interview at the time of the observation with Certified Nurse Aide (CNA) #251 confirmed the above listed items received for Resident #99 were already consumed with no swallowing concerns noted at the time.Phone interview on 09/15/25 at 1:33 P.M. with [NAME] #294 revealed he did not use the pepper steak for the pureed diets or mechanical soft diets as stated on the menu. [NAME] #294 confirmed he used chicken for the mechanical soft and pureed diets and did not taste them prior to serving them for taste or texture. Phone interview on 09/11/25 at 2:07 P.M. with Registered Dietitian (RD) #362 confirmed she has not been doing test trays at the facility, menus were to be followed and stated she recently told the dietary staff that modified diets are supposed to get the items as written on the menu production sheets.Review of the undated facility policy called; Puree Food Preparation revealed puree means that all food has been ground, pressed an/or strained to a consistency of a soft, smooth, thick paste like a thick pudding. Pureed foods should be prepared in such a manner to prevent lumps or chunks. The goal is a smooth, soft, homogenous consistency like soft mashed potatoes. Review of the 2023 facility policy called Texture and Consistency Modified Diets revealed texture and consistency modified diets should be individualized with modifications made by the speech language pathologist (SLP) and physician in conjunction with the registered dietitian nutrition (RDN) or designee and director of food and nutrition services. A written order is needed. The food and nutrition services department will be responsible for preparing and serving the correct consistency of food and beverages as ordered.

Based on record review and interview, the facility failed to timely reorder medications to avoid missed doses. This affected one resident (Resident #32) of three residents reviewed for pharmacy services. The total census was 105. Findings include: Record review of Resident #32 revealed an admitted [DATE] with diagnoses including schizophrenia, diabetes, and breast cancer. Resident #32 had an order dated 12/13/24 and a previous order lasting from 09/05/23 to 12/13/24 for Verzenio (a medication for breast cancer) 150 milligram tablets to be given twice per day. Review of the December medication administration record revealed she did not receive doses of Verzenio on the mornings of 12/12/23 through 12/14/23. Progress notes on 12/12/24 and 12/13/24 revealed the medication was not at the facility. No physical effect on the resident was noted. Interview with Resident #32 on 01/15/25 at 9:44 A.M. revealed she had no knowledge of missed medications. Interview with Registered Nurse (RN) #202 on 01/15/25 at 9:54 A.M. revealed Resident #32's Verzenio was delivered from an outside pharmacy in opaque boxes. There was an event in December where an agency nurse stored empty boxes in the medication cart, and when RN #202 counted remaining doses she believed those boxes were full. Due to the resulting delay in reordering, this resulted in the resident missing roughly two days of doses. Interview with the Director of Nursing (DON) on 01/15/25 at 2:46 P.M. confirmed the above findings. She confirmed Resident #32 missed doses of Verzenio due to the facility running out of the medication. In response, the facility provided education and changed the order to clarify reordering procedures. This deficiency represents noncompliance investigated under OH00160400.

Based on observation, interview, and record review, the facility failed to provide privacy curtains in shared rooms. This affected two (Resident #5 and #82) of six residents reviewed for privacy. The total census was 105. Findings include: Record review of Resident #82 revealed he was admitted on [DATE] and resided in the same room since his admission. Record review of Resident #5 revealed he was admitted [DATE] and resided in the same room since his admission, with a room mate (Resident #82) Observation on 01/15/25 at 3:48 P.M. of Resident #82 and #5's room revealed it had no wall or other barrier between the residents' beds, and no privacy curtain or hooks on which one could be hung. Interview with the Administrator on 01/16/25 at 4:13 P.M. confirmed the above observations. Interviews with Resident #5 and Resident #82 on 01/16/25 from 9:23 A.M. to 9:32 A.M. revealed their room never had a privacy curtain throughout their stay. Both roommates entered the bathroom when changing clothes to preserve their own and each other's privacy. This deficiency represents noncompliance investigated under OH00160860.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure the kitchen was maintained in a safe and sanitary manner. This had the potential to affect all residents residing at the facility except two residents (Residents #88 and #94) identified by the facility as receiving nothing by mouth. The facility census was 102. Findings include: 1. Observation of the dishwasher on 10/24/24 from 8:38 A.M. till 8:45 A.M. revealed Dietary Aide #605 was actively cleaning breakfast dishes through the dishwasher. Observation of the gauges on the front of the dishwasher revealed the gauges did not move when she ran each cycle: the rinse gauge was set at 152 degrees Fahrenheit (F), and the sanitizer gauge was set at 154 degrees F. There was a back gauge on the dishwasher which also did not move that was at 156 degrees F during all cycles. Interview on 10/24/24 at 8:43 A.M. with Dietary Aide/Cook #604 verified during all three cycles, the three gauges did not move from the start of the cycle to the end. She revealed she was unsure how they measured the temperature of the rinse and sanitation cycle and/or how they knew if it reached a safe temperature for proper sanitation of the dishes. She was asked if they documented the temperatures anywhere and she stated, no, I do not see where we do that; I'm not sure what that is. Interview on 10/24/24 at 8:45 A.M. with Dietary Aide #605 who was the aide running the dishes through the dishwasher revealed she had worked at the facility for a couple months, and her routine job was running the dishes through the dishwasher. She revealed she had not received any training regarding looking at the gauges to know what the appropriate temperature for a rinse cycle and/or sanitation cycle. She had never checked the temperature by means of the gauges and/or any other means. She verified she had never documented the temperatures of the dishwasher on a log sheet. Interview on 10/24/24 at 8:52 A.M. with Food Service Director #606 revealed she had just started on 10/21/24. The dishwasher was a hi-low dishwasher and according to the manufacture's sign located on the dishwasher, the wash cycle was to be from 155 to 165 degrees F, and the rinse cycle was to be from 180 to 195 degrees F. Food Service Director #606 observed a cycle of dishes and verified the gauges on the outside of the dishwasher did not move: the rinse gauge was 152 degrees F, and the sanitizer gauge was at 154 degrees F. She was not aware the gauges were not working, and that staff were not utilizing a log sheet to record the dishwasher temperatures. Interview and observation on 10/24/24 at 9:27 A.M. after the entrance conference, the Administrator revealed that she had been the one completing audits regarding the dishwasher temperatures and verified that she thought the gauges were to remain where they were at and not supposed to move: the rinse gauge was at 152 degrees F and the sanitizer gauge was at 154 degrees F. She stated, to be honest I thought where they were at meant they were normal. She was never trained or knew what the temperatures of the dishwasher were to be, and she completed the audits. She had a staff member come from another facility, and they had never stated that the dishwasher gauges needed to move or that there was an issue if they did not. Observation with the Administrator revealed the gauges continued to be stuck at the same reading, and she verified for the past few weeks the gauges were like that each time she looked at them; she assumed that was normal. Interview on 10/28/24 at 9:30 A.M. with the Administrator revealed the dishwasher repair contractor was out on 10/24/24 and adjusted the water temperature and that currently they were utilizing a thermometer to measure the sanitation temperature while washing the dishes as the gauges continued to be broken. 2. Review of the facility form labeled, 3-Compartment Sink Chemical Concentration Level for September 2024 revealed the facility tested the three-compartment sink concentration levels for each meal by utilizing Quat testing strips, and the level was to be 200 parts per million (ppm) per manufacture guidelines. There was no form for October 2024 located in the kitchen. Observation and interview on 10/24/24 at 8:48 A.M. with Dietary Aide/Cook #604 revealed there was a bucket filled with sanitizer in the three-compartment sink that contained a washcloth inside the bucket. Dietary Aide/Cook #604 revealed they utilized the bucket to wash off the counter tops in the kitchen. She revealed she was unsure how to test the sanitation level of the bucket and the sanitizer that comes out of the three-compartment sink as there were no testing strips. Dietary Aide/Cook #604 revealed she had not seen testing strips for a while and that they had not been documenting the concentration levels of the sanitizer for the month of October 2024. Interview on 10/24/24 at 8:52 A.M. with Food Service Director #606 verified she did not have documented evidence that staff tested the concentration level of the three-compartment sink from 10/01/24 to 10/24/24. She also verified there were no testing strips to test the concentration level. 3. Review of the freezer temperature log from 10/01/24 to 10/24/24 revealed the freezer temperature was checked twice a day and ranged from eight to ten degrees F. On 10/24/24 the freezer temperature was recorded as eight degrees F. Observation on 10/24/24 at 8:56 A.M. with Food Service Director #606 verified the thermostat outside by the entrance to the freezer was 10 degrees F. The thermostat inside the freezer was 19 degrees F. Observation revealed the food inside the freezer was not frozen solid including four large ice cream containers were semi-liquid, ravioli and chicken in a bag when touched was mushy in nature, and pies on the back wall were not frozen. Interview on 10/24/24 at 8:56 A.M. with Food Service Director #606 verified the food in the freezer was not frozen solid. She revealed she started on 10/21/24 and was not aware this was an issue. Observation and interview on 10/24/24 at 9:30 A.M. with the Administrator verified the food in the freezer was not frozen as most of the food was either semi-liquid and/or mushy in nature. She verified she was not aware there was an issue regarding the food not being frozen solid. Interview on 10/28/24 at 9:09 A.M. with Maintenance Director #609 revealed there was an issue on 10/24/24 with the freezer maintaining proper temperature and keeping the food frozen solid. He stated the outside coil needed to be cleaned causing the freezer not to properly work. Review of the facility policy labeled, Refrigerators and Freezer, dated 2001, revealed the facility would ensure safe refrigerator and freezer maintenance, temperatures, and sanitation. The acceptable temperature of a freezer was to be less than zero degrees F. The policy revealed monthly tracking sheets would be posted, and employees would check and record the refrigerator and freezer temperatures daily. The supervisor would take immediate action if the temperature was out of range. Review of the facility policy labeled, Dish Machine Temperature Log, dated 2023, revealed dishwashing staff would monitor and record dish machine temperatures to assure proper sanitation of dishes. The policy revealed staff would be trained to report any problems with the dish machine to the Food Service Director. The Food Service Director would post a log near the dish machine for the staff to document temperatures. Review of the facility policy labeled, Cleaning Dishes- Manual Dishwashing, dated 2023, revealed dishes and cookware would be cleaned and sanitized after each meal. The policy revealed staff were to check the sanitation of the sink frequently using test strips to assure the level of sanitation solution was appropriate. This deficiency is an incidental finding identified during the complaint survey and is an example of continued non-compliance from the surveys completed on 07/23/24 and 09/25/24.

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure residents had a clean, comfortable, home-like environment due to a pervasive urine odor, the first-floor central bathroom was not maintained in a clean, sanitary manner, and failed to ensure door thresholds (a strip of wood, or metal forming the bottom of the doorway entering a room) were not missing. This affected all 40 residents on the first floor (#2, #5, #7, #12, #15, #16, #18, #21, #27, #28, #29, #32, #33, #35, #38, #39, #44, #46, #48, #50, #52, #53, #56, #57, #60, #63, #66, #68, #69, #70, #72, #76, #85, #86, #88, #91, #93, #95, #100, and #101). In addition, the facility failed to ensure door thresholds were not missing and the hallway handrail was not broken resulting in sharp edges on both sides which affected 37 residents on the second floor (#1, #3, #9, #13, #17, #19, #20, #22, #25, #26, #30, #31, #34, #42, #43, #45, #47, #49, #55, #58, #59, #61, #62, #73, #74, #75, #77, #78, #79, #80, #81, #92, #94, #97, #98, #99, and #102). The facility census was 102. Findings include: 1. Interview on 10/24/24 at 1:07 P.M. and 10/28/24 at 3:17 P.M. with Ombudsman #600 revealed she had one open case regarding Resident #1 stating she was not getting timely incontinence care. She revealed Resident #1 had stated at times she had not been changed for over 24 hours. She revealed approximately two to three weeks ago, she informed the facility, including the Director of Nursing (DON), of Resident #1's concerns, and they stated they would complete staff training on timely incontinence care. During her visits, she often found areas throughout the facility that smelled of urine. The smell of urine lingered throughout the hallways. Several residents voiced concerns regarding possible mold (black substance) in the first-floor central shower room. 2. Review of the medical record for Resident #15 revealed an admitted [DATE] with diagnoses including spastic hemiplegia affecting the right dominant side, hypertension, and osteoarthritis. Interview and observation on 10/28/24 at 11:18 A.M. with Resident #15 revealed there was a strong urine odor in the hallway outside of Resident #15's room that got stronger when entering her room. She was lying in bed with the top sheet partially pulled down and a brown dried urine ring to the bottom of her fitted sheet was observed. Resident #15 revealed she had not been provided with incontinent care since 1:00 A.M. She stated, so I would say the day is not going good, as I am a mess. Interview on 10/28/24 at 11:26 A.M. with Certified Nurse Aide (CNA) #611 verified there was a strong urine odor outside of Resident #15's room. Observation on 10/28/24 at 11:26 A.M. revealed CNA #611 provided incontinence care for Resident #15. Resident #15 was wearing a green incontinence brief that was soaked with urine. She had a bath blanket folded in four underneath her that was soaked with urine that was on top of a washable incontinence pad that was also soaked with urine. The washable incontinence pad and the bottom fitted sheet had multiple brown dried urine rings. CNA #611stated, it appeared she had not been provided with incontinence care for a prolonged time and verified that it was likely that Resident #15 was correct in stating she was last changed at 1:00 A.M. based on the condition she was in. She verified it appeared she had voided multiple times, especially since urine had soaked through the disposable incontinence brief, bath blanket, washable incontinence pad, and bottom fitted sheet. 3. Review of the medical record for Resident #48 revealed an admitted [DATE] with diagnoses including schizophrenia, dementia with agitation, diabetes, and frontotemporal neurocognitive disorder. Observation on 10/24/24 at 8:14 A.M. revealed a strong urine odor midway down the hallway towards Resident #48's room. Observation of Resident #48's room revealed he was not in his room. There was a bottom-fitted sheet on his bed that had large yellow and brown dried urine rings that covered almost the entire sheet; the sheet also had wet areas throughout. Observation revealed he had a urine-soaked top sheet lying on the floor that also had yellow stains throughout. There was a green incontinent brief opened, lying in the center of the floor that also contained urine. There was a garbage container next to his dresser that had a strong pungent smell of urine and fecal material as it contained three incontinent products (one green and two white). There was a pile of clothing lying against the wall containing three pants and three shirts that also smelled of urine. There was a urinal sitting on the dresser that was one third full of urine. Several flies were observed flying throughout the room, especially around the garbage container. Interview on 10/24/24 at 8:29 A.M. with Licensed Practical Nurse (LPN) #601 and LPN #602 verified the above findings and stated Resident #48 often refused care but were unable to identify when the last time staff had attempted and were unable to provide any documented evidence of attempts. Observation on 10/28/24 at 11:00 A.M. revealed a strong urine odor continued in the hallway leading to Resident #48's room. Resident #48 was not in his room, but the center of his room contained a large puddle of liquid that smelled of urine. His bed was unmade with a pile of urine-soaked sheets against the wall with dried yellow and brown rings throughout the sheets. Interview on 10/28/24 at 11:02 A.M. with Resident #46 revealed he was up in his wheelchair and resided across the hall from Resident #48's room. He stated, the smell of piss is all I smell all day long, and it is horrible. He felt staff did not do anything about it as they never go into Resident #48's room and clean, so he stated he was stuck smelling it 24-7. Interview on 10/28/24 at 12:25 P.M. and 10/29/24 at 11:20 A.M. with DON verified there was a strong urine smell throughout the hallway leading towards Resident #48's room. She verified there was a large puddle of urine in the center of Resident #48's room, and CNA #613 had just entered the room to pick up the urine-soaked sheets that were against the wall. 4. Review of the medical record for Resident #7 revealed an admitted [DATE] with diagnoses including diabetes, urinary incontinence, major depression, and hypertension. Observation on 10/28/24 at 12:01 P.M. as this surveyor walked by Resident #7's room, there was a strong urine odor lingering in the hallway outside of Resident #7's closed door. After knocking and receiving permission to enter from Resident #7, this surveyor observed Resident #7 sitting up in her wheelchair folding incontinent products on her over the bed table. Observation revealed a soiled washable incontinence pad lying in Resident #7's bed that had dried dark brown urine rings surrounding the length of the pad, and the top sheet also had yellow and brown stains. Interview on 10/28/24 at 12:01 P.M. with Resident #7 stated, the girl usually comes around and fixes the bed, but I have not seen her. Interview on 10/28/24 at 12:05 P.M. with LPN #610 verified the above findings that Resident #7's washable incontinent pad and top sheet had dried brown and yellow rings and stains caused by urine. She verified there was a strong urine smell in the hallway as well as in Resident #7's room. Interview and observation on 10/28/24 at 12:20 P.M. with the DON verified Resident #7's washable incontinent pad had dried brown rings, and her top sheet had yellow brown stains on it. She asked Resident #7 if staff could come in and change her bedding she stated, oh sure, they can come in. 5. Observation on 10/28/24 at 8:14 A.M. revealed the first-floor central bathroom shower had a black substance along the whole base of the left side of the shower approximately two inches in width. Interview on 10/28/24 at 8:14 A.M. with LPN/Unit Manager #607 verified there was a black substance along the entire left side of the base of the shower. She stated the substance looked like caked up Oreo cookies along the whole base. Interview on 10/28/24 at 9:09 A.M. with Maintenance Director #609 verified there was a large black substance along the base of the left side of the shower in the first-floor central bathroom. He applied a glove and began peeling off the black substance. He stated, that is just caked on dirt that needs a good cleaning which looks like has not been done for some time to have that much buildup of dirt. Interview on 10/28/24 at 11:02 A.M. with Resident #46 revealed the central bathroom shower was always dirty, and he refused to take showers in it because he believed the black substance was mold. 6. Observation on 10/28/24 at 9:09 A.M. the environmental tour revealed the second floor i hallway on both sides of the therapy door, the handrail was missing the end protective guard, and the handrail was cracked resulting in broken, sharp, jagged edges. Interview on 10/28/24 at 9:09 A.M. with Maintenance Director #609 verified the above findings and revealed he was not aware the handrail was broken. 7. Observation on 10/28/24 at 9:09 A.M. on environmental tour revealed the following door thresholds were missing: rooms 101, 108, 123, 125, 126, 127, 214, 218, first floor dining room entrance, shower room entrance, and second floor central bathroom entrance. Observation revealed there was dried black dirt the whole length of the threshold where the threshold was supposed to be. Interview on 10/28/24 at 9:09 A.M. with Maintenance Director #609 verified the above door thresholds were missing and stated they had been missing for a while now because as often as the residents' wheelchairs run over them, and they come loose and eventually fall off. Review of the facility policy labeled, Quality of Life- Homelike Environment, dated August 2009, revealed residents' were to be provided with safe, clean, comfortable, and homelike environment. The staff and management should maximize characteristics of the facility to reflect a personalized homelike setting including cleanliness, and pleasant neutral scents. This deficiency represents non-compliance investigated under Master Complaint Number OH00159140 and Complaint Number OH00158925.

Based on record review, interview, Ohio Department of Health Gateway review, and review of the facility abuse policy, the facility failed to implement their abuse policy including investigating and reporting Resident #22's allegation that Licensed Practical Nurse (LPN) #614 verbally abused her and withheld her pain medication out of retaliation. This affected one resident (#22) out of seven residents reviewed for abuse. The facility also failed to investigate and report Resident #104's daughter-in-law's allegation that Certified Nurse Aide (CNA) #615 was yelling at residents in the third-floor dining room. This had the potential to affect 25 residents (#4, #6, #8, #10, #11, #14, #23, #24, #36, #37, #40, #41, #51, #54, #64, #65, #67, #71, #82, #84, #87, #89, #90, #96, and #103) residing on the third floor. The facility census was 102. Findings include: 1. Review of the closed medical record for Resident #104 revealed an admitted [DATE] and she was discharged the same day against medical advice (AMA) to home. Her diagnoses included Alzheimer's disease, hypertension, and major depression. Review of the nursing note dated 10/10/24 at 6:10 P.M. authored by LPN #610 revealed Resident #104's daughter-in-law was taking Resident #104 out of the facility and Nurse Practitioner #901 was notified and stated if the resident left, she had to sign AMA papers. Resident #104's daughter-in-law signed the paper and took Resident #104 home. Review of the personnel file for CNA #615 revealed a hire date of 08/29/22. There was a disciplinary action form located in the file dated 10/16/24 that revealed on 10/10/24 a family member had stated she was rude. The disciplinary action revealed that it was a violation of customer service. There was nothing else regarding the incident in her file. Review of the timecard for CNA #615 revealed on 10/10/24 CNA #615 worked from 7:01 A.M. and punched out early at 6:37 P.M. There were no other time punches after 10/10/24 that CNA #615 worked at the facility. Review of the Ohio Department of Health Gateway from 10/10/24 to 10/28/24 revealed the facility had not filed a self-reported incident (SRI) of the allegation of staff-to-resident verbal abuse after Resident #104's daughter-in-law alleged CNA #615 was yelling at residents in the third-floor dining room on 10/10/24. Interview on 10/28/24 at 10:24 A.M. and on 10/28/24 at 2:36 P.M. with the Director of Nursing (DON) revealed on 10/10/24 she received a phone call from Resident #104's daughter-in-law who was upset and wanted to remove Resident #104 from the facility. She stated she heard CAN #615 yelling at residents in the dining room and did not feel safe leaving Resident #104 at the facility. Resident #104's daughter-in-law had not provided any details as to what CNA #615 yelled and/or specified a specific resident and/or residents CNA #615 yelled at. The nurse had immediately sent CNA #615 home, but she verified that she did not complete an investigation including interviewing and assessing residents on the third floor or obtaining witness statements of staff on duty during the incident. She revealed CNA #615 only worked at the facility as needed and had not picked up any further shifts since 10/10/24. The DON was asked why she did not complete an investigation regarding the above incident, and she revealed she only completed a full investigation and/ or filed a SRI when there was evidence that there was some truth to the allegation. Interview on 10/28/24 at 11:45 A.M. with LPN #610 revealed on 10/10/24 Resident #104's daughter-in-law was upset regarding CNA #615 yelling at residents on the third floor and telling the residents to shut up. Resident #104 was just admitted that same day and Resident #104's daughter-in- law did not feel comfortable leaving Resident #104 at the facility as she did not feel safe due to CNA #615's actions. Resident #104's daughter-in-law did not name specific residents that CNA #615 yelled at, just that it was at residents in the dining room. She sent CNA #615 immediately home. Resident #104's daughter-in-law removed Resident #104 from the facility AMA that same day, 10/10/24. An attempt to contact CNA #615 on 10/28/24 at 12:44 P.M. but the person who answered the phone stated it was the wrong number. Human Resource Director #608 revealed he had no other contact numbers. 2. Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, opioid abuse, and personality disorder. Review of the care plan dated 07/29/24 revealed Resident #22 refused care and wanted care only from one nurse. She was physically and verbally aggressive towards staff and made threats towards others. Interventions included attempting one on one to de-escalate verbal aggressive behavior, educate and encourage residents to be patient and allow nursing to provide care. Review of the care plan dated 09/05/24 revealed Resident #22 had a history of telling stories or making false allegations against staff and other residents. Interventions included documenting resident behavior, do not minimize residents' concerns, and referring to social services. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition. She had other behaviors documented one to three days of the seven-day assessment reference period. Review of the Ohio Department of Health Gateway from 08/01/24 to 10/28/24 revealed the facility had not filed an SRI regarding Resident #22's allegation that LPN #614 verbally abused her and withheld her pain medication out of retaliation Interview on 10/28/24 at 2:05 P.M. revealed Resident #22 requested to speak with this surveyor. She revealed LPN #614 had screamed and yelled at her multiple times, as well as denied her pain medication out of retaliation. She stated she was left in pain multiple times because LPN #614 refused to give her medications. She believed it was abusive and had reported it to the Administrator but that nothing was done except LPN #614 was now working on a different floor, but she was unsure how long that would last. Interview on 10/28/24 at 2:32 P.M. with Administrator verified Resident #22 told her LPN #614 walked up and down the hallway yelling and cussing at her and would not give her pain medications. She was unable to remember the date Resident #22 told her that. The Administrator revealed that she was new at the facility (less than three weeks), so she immediately talked with the DON and LPN/ Unit Manager #800 who stated Resident #22 had behaviors. She verified she had not investigated and/or reported the incident as she felt it was just behavioral. Interview on 10/28/24 at 2:36 P.M. with the Administrator and DON regarding Resident #22's allegation revealed the DON stated Resident #22 was very manipulative as she targeted and accused several nurses regarding not getting her as needed pain medication timely even if it was not due to be given. She stated this had been an ongoing pattern of Resident #22 making allegations and it was care planned as behaviors. She revealed at the time of the allegation, she had moved LPN #614 to a different floor to work but had not investigated or reported the incident because it was Resident #22's behavioral pattern that she demonstrated frequently. The DON revealed she only completed a full investigation and/or filed a SRI when there was evidence that there was some truth in the allegation. Review of the facility policy labeled, Abuse Prevention Program, dated December 2016, revealed the residents had the right to be free from abuse and neglect which included verbal abuse. The policy revealed the facility was to investigate and report any allegations of abuse within the time frames required by federal requirements. Review of the undated facility policy labeled, Abuse Investigations revealed all reports of resident abuse, and neglect shall be promptly and thoroughly investigated by facility management. The individual conducting the investigation as a minimum included interviewing the person reporting the incident, interviewing any witnesses to the incident, and interviewing the resident. The policy revealed witness reports would be obtained in writing and witnesses would be required to sign and date the reports. The results of the investigation would be recorded on approved documentation forms. The investigator would give a completed copy of the investigation to the Administrator within three working days of the incident. The administrator would provide a written report of the abuse investigation and appropriate actions taken to the state survey agency, local police, ombudsman, and others required by law within five days of the reported incident. This deficiency represents non-compliance investigated under Complaint Number OH00158925.

Based on record review, interview, Ohio Department of Health Gateway review, and review of the facility abuse policy, the facility failed to report Resident #22's allegation that Licensed Practical Nurse (LPN) #614 verbally abused her and withheld her pain medication out of retaliation. This affected one resident (#22) out of seven residents reviewed for abuse. The facility also failed to report Resident #104's daughter-in-law's allegation that Certified Nurse Aide (CNA) #615 was yelling at residents in the third-floor dining room. This had the potential to affect 25 residents (#4, #6, #8, #10, #11, #14, #23, #24, #36, #37, #40, #41, #51, #54, #64, #65, #67, #71, #82, #84, #87, #89, #90, #96, and #103) residing on the third floor. The facility census was 102. Findings include: 1. Review of the closed medical record for Resident #104 revealed an admitted [DATE] and she was discharged the same day against medical advice (AMA) to home. Her diagnoses included Alzheimer's disease, hypertension, and major depression. Review of the nursing note dated 10/10/24 at 6:10 P.M. authored by LPN #610 revealed Resident #104's daughter-in-law was taking Resident #104 out of the facility and Nurse Practitioner #901 was notified and stated if the resident left, she had to sign AMA papers. Resident #104's daughter-in-law signed the paper and took Resident #104 home. Review of the personnel file for CNA #615 revealed a hire date of 08/29/22. There was a disciplinary action form located in the file dated 10/16/24 that revealed on 10/10/24 a family member had stated she was rude. The disciplinary action revealed that it was a violation of customer service. There was nothing else regarding the incident in her file. Review of the timecard for CNA #615 revealed on 10/10/24 CNA #615 worked from 7:01 A.M. and punched out early at 6:37 P.M. There were no other time punches after 10/10/24 that CNA #615 worked at the facility. Review of the Ohio Department of Health Gateway from 10/10/24 to 10/28/24 revealed the facility had not filed a self-reported incident (SRI) of the allegation of staff-to-resident verbal abuse after Resident #104's daughter-in-law alleged CNA #615 was yelling at residents in the third-floor dining room on 10/10/24. Interview on 10/28/24 at 10:24 A.M. and on 10/28/24 at 2:36 P.M. with the Director of Nursing (DON) revealed on 10/10/24 she received a phone call from Resident #104's daughter-in-law who was upset and wanted to remove Resident #104 from the facility. She stated she heard CAN #615 yelling at residents in the dining room and did not feel safe leaving Resident #104 at the facility. Resident #104's daughter-in-law had not provided any details as to what CNA #615 yelled and/or specified a specific resident and/or residents CNA #615 yelled at. The nurse had immediately sent CNA #615 home, but she verified that she did not complete an investigation including interviewing and assessing residents on the third floor or obtaining witness statements of staff on duty during the incident. She revealed CNA #615 only worked at the facility as needed and had not picked up any further shifts since 10/10/24. The DON was asked why she did not complete an investigation regarding the above incident, and she revealed she only completed a full investigation and/ or filed a SRI when there was evidence that there was some truth to the allegation. Interview on 10/28/24 at 11:45 A.M. with LPN #610 revealed on 10/10/24 Resident #104's daughter-in-law was upset regarding CNA #615 yelling at residents on the third floor and telling the residents to shut up. Resident #104 was just admitted that same day and Resident #104's daughter-in- law did not feel comfortable leaving Resident #104 at the facility as she did not feel safe due to CNA #615's actions. Resident #104's daughter-in-law did not name specific residents that CNA #615 yelled at, just that it was at residents in the dining room. She sent CNA #615 immediately home. Resident #104's daughter-in-law removed Resident #104 from the facility AMA that same day, 10/10/24. An attempt to contact CNA #615 on 10/28/24 at 12:44 P.M. but the person who answered the phone stated it was the wrong number. Human Resource Director #608 revealed he had no other contact numbers. 2. Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, opioid abuse, and personality disorder. Review of the care plan dated 07/29/24 revealed Resident #22 refused care and wanted care only from one nurse. She was physically and verbally aggressive towards staff and made threats towards others. Interventions included attempting one on one to de-escalate verbal aggressive behavior, educate and encourage residents to be patient and allow nursing to provide care. Review of the care plan dated 09/05/24 revealed Resident #22 had a history of telling stories or making false allegations against staff and other residents. Interventions included documenting resident behavior, do not minimize residents' concerns, and referring to social services. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition. She had other behaviors documented one to three days of the seven-day assessment reference period. Review of the Ohio Department of Health Gateway from 08/01/24 to 10/28/24 revealed the facility had not filed an SRI regarding Resident #22's allegation that LPN #614 verbally abused her and withheld her pain medication out of retaliation. Interview on 10/28/24 at 2:05 P.M. revealed Resident #22 requested to speak with this surveyor. She revealed LPN #614 had screamed and yelled at her multiple times, as well as denied her pain medication out of retaliation. She stated she was left in pain multiple times because LPN #614 refused to give her medications. She believed it was abusive and had reported it to the Administrator but that nothing was done except LPN #614 was now working on a different floor, but she was unsure how long that would last. Interview on 10/28/24 at 2:32 P.M. with Administrator verified Resident #22 told her LPN #614 walked up and down the hallway yelling and cussing at her and would not give her pain medications. She was unable to remember the date Resident #22 told her that. The Administrator revealed that she was new at the facility (less than three weeks), so she immediately talked with the DON and LPN/ Unit Manager #800 who stated Resident #22 had behaviors. She verified she had not investigated and/or reported the incident as she felt it was just behavioral. Interview on 10/28/24 at 2:36 P.M. with the Administrator and DON regarding Resident #22's allegation revealed the DON stated Resident #22 was very manipulative as she targeted and accused several nurses regarding not getting her as needed pain medication timely even if it was not due to be given. She stated this had been an ongoing pattern of Resident #22 making allegations and it was care planned as behaviors. She revealed at the time of the allegation, she had moved LPN #614 to a different floor to work but had not investigated or reported the incident because it was Resident #22's behavioral pattern that she demonstrated frequently. The DON revealed she only completed a full investigation and/or filed a SRI when there was evidence that there was some truth in the allegation. Review of the facility policy labeled, Abuse Prevention Program, dated December 2016, revealed the residents had the right to be free from abuse and neglect which included verbal abuse. The policy revealed the facility was to investigate and report any allegations of abuse within the time frames required by federal requirements. Review of the undated facility policy labeled, Abuse Investigations revealed all reports of resident abuse, and neglect shall be promptly and thoroughly investigated by facility management. The individual conducting the investigation as a minimum included interviewing the person reporting the incident, interviewing any witnesses to the incident, and interviewing the resident. The policy revealed witness reports would be obtained in writing and witnesses would be required to sign and date the reports. The results of the investigation would be recorded on approved documentation forms. The investigator would give a completed copy of the investigation to the Administrator within three working days of the incident. The administrator would provide a written report of the abuse investigation and appropriate actions taken to the state survey agency, local police, ombudsman, and others required by law within five days of the reported incident. This deficiency represents non-compliance investigated under Complaint Number OH00158925.

Based on record review, interview, and review of the facility abuse policy, the facility failed to investigate Resident #22's allegation that Licensed Practical Nurse (LPN) #614 verbally abused her and withheld her pain medication out of retaliation. This affected one resident (#22) out of seven residents reviewed for abuse. The facility also failed to investigate Resident #104 daughter-in-law's allegation that Certified Nurse Aide (CNA) #615 was yelling at residents in the third-floor dining room. This had the potential to affect 25 residents (#4, #6, #8, #10, #11, #14, #23, #24, #36, #37, #40, #41, #51, #54, #64, #65, #67, #71, #82, #84, #87, #89, #90, #96, and #103) residing on the third floor. The facility census was 102. Findings include: 1. Review of the closed medical record for Resident #104 revealed an admitted [DATE] and she was discharged the same day against medical advice (AMA) to home. Her diagnoses included Alzheimer's disease, hypertension, and major depression. Review of the nursing note dated 10/10/24 at 6:10 P.M. authored by LPN #610 revealed Resident #104's daughter-in-law was taking Resident #104 out of the facility and Nurse Practitioner #901 was notified and stated if the resident left, she had to sign AMA papers. Resident #104's daughter-in-law signed the paper and took Resident #104 home. Review of the personnel file for CNA #615 revealed a hire date of 08/29/22. There was a disciplinary action form located in the file dated 10/16/24 that revealed on 10/10/24 a family member had stated she was rude. The disciplinary action revealed that it was a violation of customer service. There was nothing else regarding the incident in her file. Review of the timecard for CNA #615 revealed on 10/10/24 CNA #615 worked from 7:01 A.M. and punched out early at 6:37 P.M. There were no other time punches after 10/10/24 that CNA #615 worked at the facility. Interview on 10/28/24 at 10:24 A.M. and on 10/28/24 at 2:36 P.M. with the Director of Nursing (DON) revealed on 10/10/24 she received a phone call from Resident #104's daughter-in-law who was upset and wanted to remove Resident #104 from the facility. She stated she heard CAN #615 yelling at residents in the dining room and did not feel safe leaving Resident #104 at the facility. Resident #104's daughter-in-law had not provided any details as to what CNA #615 yelled and/or specified a specific resident and/or residents CNA #615 yelled at. The nurse had immediately sent CNA #615 home, but she verified that she did not complete an investigation including interviewing and assessing residents on the third floor or obtaining witness statements of staff on duty during the incident. She revealed CNA #615 only worked at the facility as needed and had not picked up any further shifts since 10/10/24. The DON was asked why she did not complete an investigation regarding the above incident, and she revealed she only completed a full investigation and/ or filed a SRI when there was evidence that there was some truth to the allegation. Interview on 10/28/24 at 11:45 A.M. with LPN #610 revealed on 10/10/24 Resident #104's daughter-in-law was upset regarding CNA #615 yelling at residents on the third floor and telling the residents to shut up. Resident #104 was just admitted that same day and Resident #104's daughter-in- law did not feel comfortable leaving Resident #104 at the facility as she did not feel safe due to CNA #615's actions. Resident #104's daughter-in-law did not name specific residents that CNA #615 yelled at, just that it was at residents in the dining room. She sent CNA #615 immediately home. Resident #104's daughter-in-law removed Resident #104 from the facility AMA that same day, 10/10/24. An attempt to contact CNA #615 on 10/28/24 at 12:44 P.M. but the person who answered the phone stated it was the wrong number. Human Resource Director #608 revealed he had no other contact numbers. 2. Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, opioid abuse, and personality disorder. Review of the care plan dated 07/29/24 revealed Resident #22 refused care and wanted care only from one nurse. She was physically and verbally aggressive towards staff and made threats towards others. Interventions included attempting one on one to de-escalate verbal aggressive behavior, educate and encourage residents to be patient and allow nursing to provide care. Review of the care plan dated 09/05/24 revealed Resident #22 had a history of telling stories or making false allegations against staff and other residents. Interventions included documenting resident behavior, do not minimize residents' concerns, and referring to social services. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition. She had other behaviors documented one to three days of the seven-day assessment reference period. Interview on 10/28/24 at 2:05 P.M. revealed Resident #22 requested to speak with this surveyor. She revealed LPN #614 had screamed and yelled at her multiple times, as well as denied her pain medication out of retaliation. She stated she was left in pain multiple times because LPN #614 refused to give her medications. She believed it was abusive and had reported it to the Administrator but that nothing was done except LPN #614 was now working on a different floor, but she was unsure how long that would last. Interview on 10/28/24 at 2:32 P.M. with Administrator verified Resident #22 told her LPN #614 walked up and down the hallway yelling and cussing at her and would not give her pain medications. She was unable to remember the date Resident #22 told her that. The Administrator revealed that she was new at the facility (less than three weeks), so she immediately talked with the DON and LPN/ Unit Manager #800 who stated Resident #22 had behaviors. She verified she had not investigated and/or reported the incident as she felt it was just behavioral. Interview on 10/28/24 at 2:36 P.M. with the Administrator and DON regarding Resident #22's allegation revealed the DON stated Resident #22 was very manipulative as she targeted and accused several nurses regarding not getting her as needed pain medication timely even if it was not due to be given. She stated this had been an ongoing pattern of Resident #22 making allegations and it was care planned as behaviors. She revealed at the time of the allegation, she had moved LPN #614 to a different floor to work but had not investigated or reported the incident because it was Resident #22's behavioral pattern that she demonstrated frequently. The DON revealed she only completed a full investigation and/or filed a SRI when there was evidence that there was some truth in the allegation. Review of the facility policy labeled, Abuse Prevention Program, dated December 2016, revealed the residents had the right to be free from abuse and neglect which included verbal abuse. The policy revealed the facility was to investigate and report any allegations of abuse within the time frames required by federal requirements. Review of the undated facility policy labeled, Abuse Investigations revealed all reports of resident abuse, and neglect shall be promptly and thoroughly investigated by facility management. The individual conducting the investigation as a minimum included interviewing the person reporting the incident, interviewing any witnesses to the incident, and interviewing the resident. The policy revealed witness reports would be obtained in writing and witnesses would be required to sign and date the reports. The results of the investigation would be recorded on approved documentation forms. The investigator would give a completed copy of the investigation to the Administrator within three working days of the incident. The administrator would provide a written report of the abuse investigation and appropriate actions taken to the state survey agency, local police, ombudsman, and others required by law within five days of the reported incident. This deficiency represents non-compliance investigated under Complaint Number OH00158925.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure timely incontinence care was provided to Residents #1, #7, #15, and #48. This affected four residents (#1, #7, #15, #48) out of five residents reviewed for incontinence care. This had the potential to affect 52 residents (#1, #3, #4, #6, #7, #8, #10, #13, #14, #15, #19, #23, #24, #26, #29, #30, #33, #37, #38, #41, #42, #43, #45, #46, #48, #52, #54, #55, #58, #59, #60, #64, #65, #66, #69, #70,#72, #73, #74, #75, #81, #82, #85, #88, #89, #91, #93, #96, #95, #99, #102, and #103) identified by the facility as incontinent. The facility census was 102. Findings include: 1. Review of the medical record for Resident #15 revealed an admitted [DATE] with diagnoses including spastic hemiplegia affecting the right dominant side, hypertension, and osteoarthritis. Review of the care plan dated 07/18/24 revealed Resident #15 had bladder incontinence related to the aging process. Interventions included checking Resident #15 every two hours and as needed, monitoring for signs of urinary tract infection, and changing clothing as needed after incontinent episodes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had impaired cognition with no behaviors identified. She required substantial to maximum staff assist with toileting hygiene and supervision or touch assist with rolling left and right. She was frequently incontinent of urine and always incontinent of bowel. Review of the Resident/Family/Staff Concern dated 10/10/24 revealed Resident #15's son filed a grievance that on the weekends, Resident #15 was not being provided care on a regular basis. The form revealed Licensed Practical Nurse (LPN)/ Unit Manager #607 spoke with Resident #15 on 10/10/24 who also stated she sometimes had to wait an extended time for her care to be completed. The concern form revealed an in-service would be provided to staff regarding timeliness of care which was completed on 10/10/24. There was no additional follow-up noted except asking the resident on 10/11/24, and she stated she was ok. Review of the Visual/Bedside Kardex Report dated 10/28/24 revealed Resident #15 was to be checked and changed every two hours and as needed and provided perineal care after each incontinent episode. Interview and observation on 10/28/24 at 11:18 A.M. with Resident #15 revealed there was a strong urine odor in the hallway outside of Resident #15's room that got stronger when entering her room. She was lying in bed with the top sheet partially pulled down and a brown dried ring of urine observed to her fitted sheet. Resident #15 revealed she had not been provided with incontinence care since 1:00 A.M. She stated, so, I would say the day is not going good, as I am a mess. Interview on 10/28/24 at 11:26 A.M. with Certified Nurse Aide (CNA) #611 verified there was a strong urine odor outside of Resident #15's room. Observation on 10/28/24 at 11:26 A.M. revealed CNA #611 provided incontinence care for Resident #15. Resident #15 was wearing a green incontinence brief that was soaked with urine. She had a bath blanket folded in four underneath her that was soaked with urine that was on top of a washable incontinence pad that was also soaked with urine. The washable incontinence pad and the bottom fitted sheet had multiple brown dried urine rings. CNA #611stated, it appeared she had not been provided with incontinence care for a prolonged time and verified that it was likely that Resident #15 was correct in stating she was last changed at 1:00 A.M. based on the condition she was in. She verified it appeared she had voided multiple times, especially since urine had soaked through the disposable incontinence brief, bath blanket, washable incontinence pad, and bottom fitted sheet. Interview on 10/28/24 at 11:44 A.M. with Licensed Practical Nurse (LPN) #614 (nurse assigned to Resident #15) revealed CNA #616 was assigned Resident #15's room but was not sure where she was. LPN #614 revealed she was not aware the facility had pulled CNA #616 or that the assignments had changed. Interview on 10/28/24 at 11:45 A.M. with LPN #610 revealed CNA #611 had just found out that she was assigned Resident #15 as they did not realize the other CNA was not on the floor. She stated, honestly, I do not know who was assigned to care for Resident #15 from 7:00 A.M. to 11:26 A.M. She was not aware that CNA #616 was pulled to the kitchen to work. She then stated, I guess CNA #619 was to take CNA #616's spot, but she had been sick in the bathroom. She revealed she was not aware CNA #619 was off the floor and not working as scheduled. Interview on 10/28/24 at 2:49 P.M. with CNA #616 revealed she was assigned to Resident 15's room from 7:00 A.M. till approximately 9:00 A.M. when she was pulled to work in the kitchen. She verified she had not communicated with nurses on the unit (LPNs #610 and #614) that she had been pulled and/or any of the other aides on the floor as she just figured management told them. She verified she had not provided incontinence care for Resident #15 from 7:00 A.M. to 9:00 A.M. Review of the daily staffing assignment sheet for 10/28/24 revealed the first-floor unit had scheduled LPN #610, LPN #614, CNA #611 and CNA #613 from 7:00 A.M. to 7:00 P.M. CNA #616 was assigned from 7:00 A.M. till 9:00 A.M. then was pulled to work in the kitchen. CNA #617 was scheduled to work from 10:00 A.M. to 7:00 P.M. and CNA #619 was scheduled 9:00 A.M. till 7:00 P.M. but was sent home. Interview on 10/29/24 at 11:49 A.M. with Scheduler/ CNA #620 verified she pulled CNA #616 to work in the kitchen at 9:00 A.M. She revealed usually the floor nurse or unit manager updated the staffing assignment as to which residents a staff was assigned. She revealed she was not aware CNA #619 was not on the floor working as scheduled and had heard she was sent home because she was arguing with management. 2. Review of the medical record for Resident #48 revealed an admitted [DATE] with diagnoses including schizophrenia, dementia with agitation, diabetes, and frontotemporal neurocognitive disorder. Review of the undated care plan revealed Resident #48 was non-compliant with personal care, incontinence care, and assistance with transfers. Interventions included attempting to educate in relation to compliance, educating the resident on negative outcomes related to noncompliance, notifying the physician of noncompliance, and explaining all procedures prior to starting. Review of the undated care plan revealed Resident #48 was at risk for alteration in elimination related to occasional incontinence of bowel and bladder and his need for assistance with toileting may fluctuate. Interventions included providing incontinence care as needed, monitoring for skin irritation and redness, and monitoring for signs of urinary tract infections. Review of the care plan dated 02/10/22 revealed Resident #48 had a behavior of urinating in inappropriate places in the facility. Interventions included educating him on infection control when urinating in inappropriate places, encouraging the resident to ask for assistance, offering toileting assistance every two hours and as needed, and showing the resident appropriate places to void. Review of the quarterly MDS assessment dated [DATE] revealed Resident #48 had cognitive impairment as his brief interview of mental status (BIMS) score was a five. There was nothing identified by the MDS that he rejected care. He required partial to moderate assistance with toileting hygiene, showering, lower body dressing, and transfers. He was always incontinent of urine and occasionally incontinent of bowel. Review of the nursing notes dated from 09/01/24 to 10/24/24 revealed there was no documented evidence of Resident #48 refusing care including toileting hygiene and cleaning of his room. Review of the toileting hygiene under the task section of the electronic medical record revealed from 10/01/24 to 10/29/24 there was no documented evidence that Resident #48 refused care. The only documentation on 10/24/24 revealed Resident #48 received toileting hygiene care at 6:59 P.M., and there was no other documentation he received care on 10/24/24. There was no documented evidence that Resident #48 received toileting hygiene assistance on 10/28/24. Observation on 10/24/24 at 8:14 A.M. revealed a strong urine smell midway down the hallway towards Resident #48's room. Observation of Resident #48's room revealed he was not in his room. There was a bottom-fitted sheet on his bed that had large yellow and brown dried urine rings that covered almost the entire sheet, and the sheet had wet areas throughout. Observation revealed he had a urine-soaked top sheet lying on the floor that also had yellow stains throughout. There was a green incontinent brief opened lying in the center of the floor that also contained urine. There was a garbage container next to his dresser that had a strong pungent smell of urine and fecal material as it contained three incontinent products (one green and two white). There was a pile of clothing lying against the wall containing three pants and three shirts that also smelled of urine. There was a urinal sitting on the dresser that was one third full of urine. Several flies were observed flying throughout the room, especially around the garbage container. Interview on 10/24/24 at 8:29 A.M. with LPN #601 and LPN #602 verified the above findings and stated Resident #48 often refused care but were unable to identify when the last time staff attempted and were unable to provide documented evidence of attempts. Interview and observation on 10/24/24 at 8:35 A.M. with Resident #48 revealed he was sitting in his wheelchair in the dining room without signs of incontinence as he appeared to have clean clothing on, but there was a urine smell noted upon interview. Interview with Resident #48 revealed he had cognitive impairment as he was unable to provide details regarding his care including how often incontinence care was provided and/or how often staff assisted with cleaning his room. Review of the Visual/Bedside Kardex Report dated 10/28/24 revealed Resident #48 was to receive a check and change every two hours and as needed, and staff were to show him appropriate places to void. Observation on 10/28/24 at 11:00 A.M. revealed a strong urine smell continued in the hallway leading to Resident #48's room. Resident #48 was not in his room but in the center of his room was a large puddle of liquid that smelled of urine. His bed was unmade with a pile of sheets against the wall that appeared urine soaked with dried yellow and brown rings throughout the sheets. Interview on 10/28/24 at 11:02 A.M. with Resident #46 revealed he was up in his wheelchair and resided across the hall from Resident #48's room. He stated, the smell of piss is all I smell all day long, and it is horrible. He felt staff did not do anything about it as they never go into Resident #48's room and clean, so he stated he was stuck smelling it 24-7. Interview on 10/28/24 at 12:25 P.M. and 10/29/24 at 11:20 A.M. with Director of Nursing (DON) verified there was a strong urine smell throughout the hallway leading towards Resident #48's room. She verified there was a large puddle of urine in the center of Resident #48's room and CNA #613 had just entered the room to pick up the urine-soaked sheets that were against the wall. The DON verified there was nothing documented in Resident #48's nursing notes and/or task bar that he had refused incontinence care. 3. Review of the medical record for Resident #1 revealed an admitted [DATE] with diagnoses including chronic respiratory failure with hypoxia, chronic pain, and muscle weakness. She was receiving hospice services. Review of the care plan dated 02/23/21 revealed Resident #1 had an alteration in elimination as she was incontinent of bowel and bladder. She was dependent on staff assistance to meet her toileting needs. Interventions included providing incontinence care as needed, monitoring for skin redness and irritation, and monitoring for signs of urinary tract infection. Review of the quarterly MD assessment dated [DATE] revealed Resident #1 had impaired cognition with no behaviors identified. She required substantial to maximum assistance with toileting hygiene and lower body dressing. She was dependent on staff for rolling left and right with bed mobility. She was always incontinent with bowel and bladder. Review of the Resident/Family/Staff Concern dated 10/09/24 revealed Resident #1 had communicated concerns to Ombudsman #600 that staff were on their cellphones while providing care, and staff were rough while completing bed baths. There was nothing identified on the grievance form regarding not receiving timely incontinence care. There was an in-service attached to the grievance form that included providing proper bed baths, and not being on personal phones, but there was no education regarding timely incontinence care. Interview on 10/24/24 at 1:07 P.M. and 10/28/24 at 3:17 P.M. with Ombudsman #600 revealed she had one open case regarding Resident #1 stating she was not getting timely incontinence care. She revealed Resident #1 stated at times she had not been changed for over 24 hours. She revealed approximately two to three weeks ago she informed the facility, including the DON, of Resident #1's concerns, and they stated they would complete staff training on timely incontinence care. Ombudsman #600 revealed on her visits, she often found that areas throughout the facility smelled of urine. She revealed the smell of urine lingered throughout the hallways. Review of Visual/Bedside Kardex Report dated 10/28/24 revealed Resident #1 was to be checked and changed every two hours and as needed. Interview and observation on 10/28/24 at 2:13 P.M. with Resident #1 revealed she was lying in bed covered with blankets. She revealed at times she was not provided with incontinence care for over 12 hours as she had gone whole shifts from 7:00 A.M. to 7:00 P.M. without being changed. She revealed the last time she was provided with incontinence care today, 10/28/24, was at 5:00 A.M. and had not been offered since. She revealed staff were to change her every two hours, but they did not. She stated, they will lie and say because I did not ring, but they should be changing me, not me telling them to change me. She felt it was wrong to lie in one spot and not be changed. She could feel that she was very wet at the time of the interview, but CNA #612 was her aide for the day, and she never changes her. Interview on 10/28/24 at 2:22 P.M. with CNA #612 revealed she was Resident #1's CNA from 7:00 A.M. to 7:00 P.M. She verified she had not changed Resident #1 since coming on duty at 7:00 A.M. and had not provided any morning personal care. Observation on 10/28/24 at 2:25 P.M. revealed CNA #612 provided incontinence care for Resident #1. Resident #1's incontinence brief contained dark brown, yellow urine with a strong urine smell. CNA #612 verified it appeared Resident #1 had voided multiple times. CNA #612 revealed Resident #1 usually asked when she wanted changed but verified, she had not asked her anytime from 7:00 A.M. to 2:25 P.M. if she wanted changed. Interview on 10/29/24 at 11:20 A.M. with the DON verified Ombudsman #600told her that Resident #1 had concerns regarding her care, including staff being rough with bed baths and staff on their cell phones. She revealed she was not aware Resident #1 had also voiced concern regarding not being provided with incontinence care timely but also verified she had not spoken with Resident #1 regarding the concerns. 4. Review of the medical record for Resident #7 revealed an admitted [DATE] with diagnoses including diabetes, urinary incontinence, major depression, and hypertension. Review of the care plan dated 12/27/23 revealed Resident #7 had an alteration in elimination related to occasional incontinence of bladder and her toileting assistance fluctuated. Interventions included providing incontinence care as needed, monitoring for signs of urinary tract infection, and monitoring for skin redness and irritation. Review of the task bar regarding bladder continence documentation for the last 30 days revealed from 09/30/24 till 10/28/24 it was documented Resident #7 was incontinent every day except 10/03/24, 10/08/24, and 10/15/24. There was no documented evidence Resident #7 refused incontinence care during this time frame. Review of the annual MDS assessment dated [DATE] revealed Resident #7 had impaired cognition. She required supervision to touching assistance with toileting hygiene, dressing, and transfers. She was occasionally incontinent of urine and frequently incontinent of bowel. Review of the Visual/Bedside Kardex Report dated 10/28/24 revealed Resident #7 was continent of bowel and bladder. Resident #7 was able to maintain her toileting hygiene with supervision and minimal assistance. Observation on 10/28/24 at 12:01 P.M. as this surveyor walked by Resident #7 room, there was a strong urine odor lingering in the hallway outside of Resident #7's closed door. After knocking and receiving permission to enter from Resident #7, this surveyor observed Resident #7 sitting up in her wheelchair folding incontinent products on her over the bed table. Observation revealed a soiled washable incontinence pad lying in Resident #7's bed that had dried dark brown urine rings surrounding the length of the pad and the top sheet was also stained with yellow and brown urine. Interview on 10/28/24 at 12:01 P.M. with Resident #7 stated, the girl usually comes around and fixes the bed, but I have not seen her. Interview on 10/28/24 at 12:05 P.M. with LPN #610 verified the above findings that Resident #7's washable incontinent pad and top sheet had dried brown and yellow rings and stains caused by urine. She verified there was a strong urine smell in the hallway as well as in Resident #7's room. Interview on 10/28/24 at 12:14 P.M. with CNA #611 revealed she was assigned to Resident #7, and Resident #7 does her own care, including taking herself to the toilet. She verified she had not completed any checks and changes for Resident #7 regarding incontinence care from the time she came on duty at 7:00 A.M. Interview and observation on 10/28/24 at 12:20 P.M. with the DON verified Resident #7's washable incontinent pad had dried brown rings, and her top sheet had yellow brown urine stains. She asked Resident #7 if staff could come in and change her bedding she stated, oh sure, they can come in. Interview on 10/29/24 at 11:24 A.M. with Registered Nurse (RN)/MDS #618 verified the care plan and MDS revealed Resident #7 was incontinent, but the Kardex stated Resident #7 was continent. Staff utilize the Kardex on the floor to know the care needs a resident, including incontinence care, and verified the Kardex was inaccurate. Review of the facility policy labeled, Perineal Care, dated October 2010, revealed the purpose was to provide cleanliness and comfort to the resident, prevent infections, prevent skin irritation, and observe resident's skin condition. The following information should be recorded in the resident's medical record: if the resident refused the procedure, the reason for the refusal, and the intervention taken. There was nothing in the policy regarding the frequency of the incontinence care. This deficiency represents non-compliance investigated under Master Complaint Number OH00159140.

Based on observation, record review, interview, Facility Assessment review, the facility failed to ensure they maintained sufficient and competent staff on the first floor on 10/28/24. This affected three residents (#1, #7, and #15) out of seven residents reviewed for staffing. This had the potential to affect 40 residents (#2, #5, #7, #12, #15, #16, #18, #21, #27, #28, #29, #32, #33, #35, #38, #39, #44, #46, #48, #50, #52, #53, #56, #57, #60, #63, #66, #68, #69, #70, #72, #76, #85, #86, #88, #91, #93, #95, #100, and #101) residing on the first floor. The facility census was 102. Findings include: 1. Review of the medical record for Resident #15 revealed an admitted [DATE] with diagnoses including spastic hemiplegia affecting the right dominant side, hypertension, and osteoarthritis. Review of the care plan dated 07/18/24 revealed Resident #15 had bladder incontinence related to the aging process. Interventions included checking Resident #15 every two hours and as needed, monitoring for signs of urinary tract infection, and changing clothing as needed after incontinent episodes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had impaired cognition with no behaviors identified. She required substantial to maximum staff assistance with toileting hygiene and supervision, or touch assist with rolling left and right. She was frequently incontinent of bladder and always incontinent of bowel. Review of the Resident/Family/Staff Concern dated 10/10/24 revealed Resident #15's son filed a grievance that on the weekends, Resident #15 was not being provided care on a regular basis. The form revealed Licensed Practical Nurse (LPN)/ Unit Manager #607 spoke with Resident #15 on 10/10/24 who also stated she sometimes had to wait an extended time for her care to be completed. The concern form revealed an in-service would be provided to staff regarding timeliness of care which was completed on 10/10/24. There was no additional follow-up noted except asking the resident on 10/11/24, and she stated she was ok. Review of the Visual/Bedside Kardex Report dated 10/28/24 revealed Resident #15 was to be checked and changed every two hours and as needed and provided perineal care after each incontinent episode. Interview and observation on 10/28/24 at 11:18 A.M. with Resident #15 revealed there was a strong urine odor in the hallway outside of Resident #15's room that got stronger when entering her room. She was lying in bed with the top sheet partially pulled down and a brown dried ring of urine observed to her fitted sheet. Resident #15 revealed she had not been provided with incontinence care since 1:00 A.M. She stated, so, I would say the day is not going good, as I am a mess. Interview on 10/28/24 at 11:26 A.M. with Certified Nurse Aide (CNA) #611 revealed the other aide she believed went on an appointment or something as she was not aware there had not been an aide assigned to Resident #15. CNA #611 revealed she did not know Resident #15 was her resident to care for until a few minutes ago when she was told. CNA #611 verified she arrived on duty at 7:00 A.M. but had not been in Resident #15's room to provide incontinence care. Observation on 10/28/24 at 11:26 A.M. revealed CNA #611 provided incontinence care for Resident #15. Resident #15 was wearing a green incontinence brief that was soaked with urine. She had a bath blanket folded in four underneath her that was soaked with urine that was on top of a washable incontinence pad that was also soaked with urine. The washable incontinence pad and the bottom fitted sheet had multiple brown dried urine rings. CNA #611stated, it appeared she had not been provided with incontinence care for a prolonged time and verified that it was likely that Resident #15 was correct in stating she was last changed at 1:00 A.M. based on the condition she was in. She verified it appeared she had voided multiple times, especially since urine had soaked through the disposable incontinence brief, bath blanket, washable incontinence pad, and bottom fitted sheet. Interview on 10/28/24 at 11:44 A.M. with Licensed Practical Nurse (LPN) #614 (nurse assigned to Resident #15) revealed CNA #616 was assigned Resident #15's room but was not sure where she was. LPN #614 revealed she was not aware the facility had pulled CNA #616 or that the assignments had changed. Interview on 10/28/24 at 11:45 A.M. with LPN #610 revealed CNA #611 had just found out that she was assigned Resident #15 as they did not realize the other CNA was not on the floor. She stated, honestly, I do not know who was assigned to care for Resident #15 from 7:00 A.M. to 11:26 A.M. She was not aware that CNA #616 was pulled to the kitchen to work. She then stated, I guess CNA #619 was to take CNA #616's spot, but she had been sick in the bathroom. She revealed she was not aware CNA #619 was off the floor and not working as scheduled. Interview on 10/28/24 at 2:49 P.M. with CNA #616 revealed she was assigned to Resident 15's room from 7:00 A.M. till approximately 9:00 A.M. when she was pulled to work in the kitchen. She verified she had not communicated with nurses on the unit (LPNs #610 and #614) that she had been pulled and/or any of the other aides on the floor as she just figured management told them. She verified she had not provided incontinence care for Resident #15 from 7:00 A.M. to 9:00 A.M. Review of the daily staffing assignment sheet for 10/28/24 revealed the first-floor unit had scheduled LPN #610, LPN #614, CNA #611 and CNA #613 from 7:00 A.M. to 7:00 P.M. CNA #616 was assigned from 7:00 A.M. till 9:00 A.M. then was pulled to work in the kitchen. CNA #617 was scheduled to work from 10:00 A.M. to 7:00 P.M. and CNA #619 was scheduled 9:00 A.M. till 7:00 P.M. but was sent home. Interview on 10/29/24 at 11:49 A.M. with Scheduler/ CNA #620 verified she pulled CNA #616 to work in the kitchen at 9:00 A.M. She revealed usually the floor nurse or unit manager updated the staffing assignment as to which residents a staff was assigned. She revealed she was not aware CNA #619 was not on the floor working as scheduled and had heard she was sent home because she was arguing with management. Interview on 10/29/24 at 12:00 P.M. with the Director of Nursing (DON) verified on 10/28/24 CNA #616 was pulled from the first floor to work in the kitchen. She verified CNA #619 was to take her assignment but CNA #619 was in the bathroom (ill). She verified she was not aware she was not completing her assignment as scheduled until she was notified of the condition Resident #15 was found in. 2. Review of the medical record for Resident #48 revealed an admitted [DATE] with diagnoses including schizophrenia, dementia with agitation, diabetes, and frontotemporal neurocognitive disorder. Review of the undated care plan revealed Resident #48 was non-compliant with personal care, incontinence care, and assistance with transfers. Interventions included attempting to educate in relation to compliance, educating the resident on negative outcomes related to noncompliance, notifying the physician of noncompliance, and explaining all procedures prior to starting. Review of the undated care plan revealed Resident #48 was at risk for alteration in elimination related to occasional incontinence of bowel and bladder and his need for assistance with toileting may fluctuate. Interventions included providing incontinence care as needed, monitoring for skin irritation and redness, and monitoring for signs of urinary tract infections. Review of the care plan dated 02/10/22 revealed Resident #48 had a behavior of urinating in inappropriate places in the facility. Interventions included educating him on infection control when urinating in inappropriate places, encouraging the resident to ask for assistance, offering toileting assistance every two hours and as needed, and showing the resident appropriate places to void. Review of the quarterly MDS assessment dated [DATE] revealed Resident #48 had cognitive impairment as his brief interview of mental status (BIMS) score was a five. There was nothing identified by the MDS that he rejected care. He required partial to moderate assistance with toileting hygiene, showering, lower body dressing, and transfers. He was always incontinent of urine and occasionally incontinent of bowel. Review of the nursing notes dated from 09/01/24 to 10/24/24 revealed there was no documented evidence of Resident #48 refusing care including toileting hygiene and cleaning of his room. Review of the toileting hygiene under the task bar in the electronic medical record revealed from 10/01/24 to 10/29/24 there was no documented evidence that Resident #48 refused care. There was no documented evidence Resident #48 received toileting hygiene assistance on 10/28/24. Review of the Visual/Bedside Kardex Report dated 10/28/24 revealed Resident #48 was to receive a check and change every two hours and as needed and staff were to show him the appropriate places to void. Observation on 10/28/24 at 11:00 A.M. revealed a strong urine smell continued to surround the hallway leading to Resident #48's room. Resident #48 was not in his room but in the center of his room was a large puddle of liquid that smelled of urine. His bed was unmade, and a pile of urine-soaked sheets were against the wall with dried yellow and brown rings throughout the sheets. Interview on 10/28/24 at 12:25 P.M. and 10/29/24 at 11:20 A.M. with the Director of Nursing (DON) verified there was a strong urine smell throughout the hallway leading towards Resident #48's room. She verified there was a large puddle of urine in the center of Resident #48's room and CNA #613 had just entered the room to pick up the urine-soaked sheets that were against the wall. The DON verified there was not documented evidence in Resident #48's nursing notes and/or task bar that he refused incontinence care. 4. Review of the medical record for Resident #7 revealed an admitted [DATE] with diagnoses including diabetes, urinary incontinence, major depression, and hypertension. Review of the care plan dated 12/27/23 revealed Resident #7 had an alteration in elimination related to occasional incontinence of bladder and her toileting assistance fluctuated. Interventions included providing incontinence care as needed, monitoring for signs of urinary tract infection, and monitoring for skin redness and irritation. Review of the task bar regarding bladder continence documentation for the last 30 days revealed from 09/30/24 till 10/28/24 it was documented Resident #7 was incontinent every day except 10/03/24, 10/08/24, and 10/15/24. There was no documented evidence Resident #7 refused incontinence care during this time frame. Review of the annual MDS assessment dated [DATE] revealed Resident #7 had impaired cognition. She required supervision to touching assistance with toileting hygiene, dressing, and transfers. She was occasionally incontinent of urine and frequently incontinent of bowel. Review of the Visual/Bedside Kardex Report dated 10/28/24 revealed Resident #7 was continent of bowel and bladder. Resident #7 was able to maintain her toileting hygiene with supervision and minimal assistance. Observation on 10/28/24 at 12:01 P.M. as this surveyor walked by Resident #7 room, there was a strong urine odor lingering in the hallway outside of Resident #7's closed door. After knocking and receiving permission to enter from Resident #7, this surveyor observed Resident #7 sitting up in her wheelchair folding incontinent products on her over the bed table. Observation revealed a soiled washable incontinence pad lying in Resident #7's bed that had dried dark brown urine rings surrounding the length of the pad and the top sheet was also stained with yellow and brown urine. Interview on 10/28/24 at 12:01 P.M. with Resident #7 stated, the girl usually comes around and fixes the bed, but I have not seen her. Interview on 10/28/24 at 12:05 P.M. with LPN #610 verified the above findings that Resident #7's washable incontinent pad and top sheet had dried brown and yellow rings and stains caused by urine. She was unsure why Resident #7 had not received care including incontinence care and a bed change. She verified CNA #611 had not communicated with her that Resident #7 refused care. Interview on 10/28/24 at 12:14 P.M. with CNA #611 revealed she was assigned to Resident #7, and Resident #7 does her own care, including taking herself to the toilet. She verified she had not completed any checks and changes for Resident #7 regarding incontinence care from the time she came on duty at 7:00 A.M. Interview and observation on 10/28/24 at 12:20 P.M. with the DON verified Resident #7's washable incontinent pad had dried brown rings, and her top sheet had yellow brown urine stains. She asked Resident #7 if staff could come in and change her bedding she stated, oh sure, they can come in. Interview on 10/29/24 at 11:24 A.M. with Registered Nurse (RN)/MDS #618 verified the care plan and MDS revealed Resident #7 was incontinent, but the Kardex stated Resident #7 was continent. Staff utilize the Kardex on the floor to know the care needs a resident, including incontinence care, and verified the Kardex was inaccurate. Review of the facility policy labeled, Perineal Care, dated October 2010, revealed the purpose was to provide cleanliness and comfort to the resident, prevent infections, prevent skin irritation, and observe resident's skin condition. The following information should be recorded in the resident's medical record: if the resident refused the procedure, the reason for the refusal, and the intervention taken. There was nothing in the policy regarding the frequency of the incontinence care. Review of the facility policy labeled, Facility Assessment, dated October 2018, revealed a facility assessment was to be conducted annually to determine and update the needs and competency care for the residents during day-to-day operations. The facility assessment was to include factors that affect the overall acuity of the residents including incontinence, need for assistance with activities of daily living, cognitive and behavioral impairments. The facility assessment also was to include a detailed review of resources available including staffing personnel (directors, managers, regular employees, contracted staff and volunteers). Review of the Facility Assessment, dated 01/18/24, revealed the facility would provide adequate staffing to meet the residents' needs, preferences and routines. This included an RN for at least eight consecutive hours a day, a designated licensed nurse to serve as a charge nurse on each tour of duty and adequate staffing on each shift to ensure residents' needs were met. There was no breakdown regarding how many nurses and direct care staff the facility would have except that the facility would not fall below the minimum daily average required by the law. This deficiency represents non-compliance investigated under Master Complaint Number OH00159140.

Based on observation, record review, interview, and facility policy review, the facility failed to timely provide care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in actual harm for Resident #96, who was readmitted to the facility on [DATE] from an acute hospital stay with a pressure ulcer. Resident #96 required two staff assist with bed mobility and was dependent on two staff for transfers and toileting. Resident #96 did not receive treatment to the pressure area until 05/12/22 when an ulcer debridement was required over an area of 120 square centimeters (cm). Following the debridement pressure ulcer care was not initiated until 05/16/22. This affected two of eight residents identified with pressure ulcers. The facility census was 95. Findings include: 1. Review of the medical record for Resident #96 revealed an admitted [DATE]. Resident #96 was transferred to the hospital on 04/20/22 and returned on 05/06/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MD'S 3.0 assessment dated [DATE] revealed Resident #96 had severe cognitive impairment with a BIMS score of 6 out of 15 possible. Resident #96 required extensive two staff assistance for bed mobility and was dependent on two staff assistance for transfers and toileting. The assessment indicated Resident #96 had a urinary catheter and was always incontinent of bowel. Review of the plan of care initiated 03/15/11 revealed Resident #96 was at risk for alteration in skin integrity related to diabetes, end-stage renal disease, peripheral vascular disease, and incontinence. Interventions included to administer preventative skin treatment as ordered; encourage and assist to reposition; and provide barrier cream after each incontinent episode as needed. Review of the hospital discharge instructions, dated 05/06/22, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress note dated 05/06/22 revealed Resident #96 was readmitted to the facility from an acute hospital stay and had an open area to the right buttocks with current dressing orders in the discharge paperwork. Review of the physician orders revealed there were no wound treatment orders implemented on 05/06/22 after Resident #96's re-admission from the hospital. Review of the medical record revealed there were no skin or wound assessments completed on 05/06/22 after Resident #96's re-admission from the hospital. The last assessment completed prior to Resident #96's hospital stay beginning 04/20/22 was dated 04/06/22 and revealed a bilateral gluteal wound with no measurements described as moist irritated skin covering the inner buttocks, gluteal folds, and inner thighs with extensive scarring. The wound bed involved skin only. Review of Wound Nurse Practitioner (NP) #800's progress notes dated 04/06/22 revealed Resident #96 had an area of concern on the bottom and was not examined due to being up in the wheelchair and was required to be transferred into the bed for the assessment with a mechanical lift. Resident #96 remained incontinent of bowel and bladder and wore protective briefs. Review of Wound NP #800 progress notes dated 05/12/22 revealed Resident #96 was examined as an initial evaluation after re-admission on 05/06/22. Area of concerns were identified on the bottom which nursing reported had deteriorated. Resident #96 required extensive assistance for repositioning and was incontinent of bowel and bladder. Moisture-associated skin damage was identified as present on admission to the facility to the gluteal folds and inner buttocks. Wound NP #800 ordered [MEDICATION(S)] cream every shift and as needed. A second wound was identified as a Stage 4 pressure ulcer (a deep wound involving the muscle, ligaments, or bone) on the sacrum which was present on admission to the facility. The Stage 4 pressure ulcer measured 10.9 centimeters (cm) (length) by 12.3 cm (width) by undetermined (depth) with wound undermining and required sharp/excisional debridement with scissors to remove slough and eschar (dead tissue). The depth of debridement was down to the fascia, 10.0 cm (length) x 12.0 cm (width) x undetermined (depth), with an area derided of 120 square cm. Wound NP #800 ordered to pack the Stage 4 pressure ulcer with Dakin's (antiseptic) soaked gauze as a wet to moist dressing, cover with absorbent dressing twice daily and as needed. Additional orders were to pack the open wound bed with Dakin's saturated gauze, use a Q-tip to pack into the undermining and apply calcium alginate to the superficial regions. Review of a nursing skin/wound note dated 05/12/22 revealed Resident #96 was examined by Wound NP #800 and incorrectly documented there were no new orders for treatment. Review of Resident #96's physician orders revealed Wound NP #800's orders documented on 05/12/22 were not transcribed until 05/16/22. Review of the TAR for May 2022 revealed Resident #96 received the initial treatment following re-admission on 05/06/22 for the gluteal folds and the Stage 4 sacral pressure ulcer on 05/16/22 during the day shift. Review of nursing progress notes dated 05/18/22 to 05/19/22 revealed Resident #96 had a critical blood lab result and was transferred to the local hospital for evaluation and treatment on 05/19/22. Interview on 06/03/22 at 11:51 A.M. with RN #254 verified there was no skin assessment completed for Resident #96 upon return from the hospital and there were no treatment orders implemented for Resident #96's pressure ulcer from the hospital discharge information. RN #254 indicated since Resident #96 had wounds prior to the hospital stay, Wound NP #800 checked her on 05/12/22. RN #254 confirmed Wound NP #800's orders were not implementedwhen ordered on 05/12/22 until 05/16/22 when RN #254 returned to work. RN #254 indicated it was difficult to monitor wounds, cover as floor nurse and do the unit manager duties. Interview on 06/03/22 at 1:05 P.M. with LPN #253 verified assessments including skin assessments, wound consults and an admission packet were completed with a re-admission including implementing and verifying all physician orders using the hospital paperwork. LPN #253 stated if there are any wounds the nursing assistants will report it to the nurses. LPN #253 recalled Resident #96 had moisture irritation prior to going the hospital in April 2022. Interview on 06/03/22 at 3:31 P.M. with the DON verified Resident #96 had a pressure ulcer upon re-admission on 05/06/22, and wound care treatment was not implemented as ordered on the hospital discharge orders. The DON confirmed even after seeing Wound NP #800 on 05/12/22, the first wound treatment was not provided until day shift on 05/16/22. The DON indicated Resident #96 was sent back to the hospital on 05/19/20 due to critical blood lab values. 2. 1. Review of the medical record for Resident #6 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) assessment, dated 03/10/22, revealed Resident #6 had severe cognitive impairment with a BIMS (Brief Interview for Mental Status) score of 0 out of 15 possible. Resident #6 was dependent on two staff assistance for bed mobility, was dependent on one staff assistance for toileting, and transfers occurred only once or twice with two staff assistance. The assessment indicated Resident #6 was always incontinent of bowel and bladder and had one unstageable pressure ulcer due to coverage of the wound bed by slough and/or eschar (dead tissue). Review of the plan of care, initiated 06/05/19, revealed an alteration in skin integrity and pressure ulcer development related to end-stage disease process, incontinence, and vitamin deficiency. Interventions included to assess for pain and provide treatment per physician orders; encourage and assist to turn and reposition as needed; and maintain low air loss mattress. Review of wound nurse practitioner (NP) progress notes, dated 05/12/22 and 05/26/22, revealed Resident #6 had a sacral unstageable pressure ulcer. On 05/12/22 the overall wound condition was improved and healing. The wound NP ordered to pack the wound with alginate, cover with absorbent dressing daily and as needed, and consider applying zinc to the surrounding skin with every dressing change. Again on 05/26/22, the NP requested the sacral wound packed with alginate, and covered with an absorbent dressing daily. Review of Resident #6's physician orders revealed an order dated 04/30/22 for the sacrum to clean with normal saline, apply Santyl (removes dead tissue), pack with silver Ag (provides antimicrobial action), then apply absorbent dressing and [MEDICATION(S)] to surrounding area daily which was discontinued on 06/01/22; and a new order started on 06/01/22 for the sacrum to cleanse with normal saline, pack with silver Ag, apply absorbent dressing and [MEDICATION(S)] to the surrounding area daily. There were no treatment orders changed for the sacrum on 05/12/22 or 05/26/22 as the wound NP requested until 06/01/22. Review of the Treatment Administration Record for May 2022 revealed the sacrum pressure ulcer treatment ordered on 04/30/22 was not documented as completed on 05/03/22, 05/04/22, 05/06/22, 05/08/22, 05/18/22, 05/24/22, 05/28/22 and 05/29/22. Observation on 06/03/22 at 9:20 A.M. with Licensed Practical Nurses (LPNs) #250 and #251 of wound care for Resident #6 revealed upon repositioning to the left side and removal of the incontinence brief, there was no wound dressing covering the sacral pressure ulcer for either treatment or protection. LPN #250 with the assistance of LPN #251 found no soiled dressing had fallen off the wound into the incontinence brief. Interview at the time of the observation with LPN #250 verified there was no wound dressing covering Resident #6's sacral pressure ulcer which was located inside the incontinence brief. LPN #250 confirmed not receiving a report from a nursing assistant of Resident #6's dressing falling off during incontinence care since the start of the shift at 7:00 A.M., and with the wound dressing changed once daily, it was unknown how long the wound was exposed and without the ordered treatment. Interview on 06/03/22 at 10:31 A.M. with State tested Nursing Assistant (STNA) #252 revealed wound dressings may come off during rounds at change of shift so it might not get passed on to the nurses and get missed. Interview on 06/03/22 at 2:28 P.M. with Registered Nurse (RN) #254 verified Resident #6's treatments were not documented as completed on 05/03/22, 05/04/22, 05/06/22, 05/08/22, 05/18/22, 05/24/22, 05/28/22 and 05/29/22. RN #254 indicated Resident #6 does not refuse treatments and verified the treatments were not completed as ordered. RN #254 confirmed Resident #6's treatment orders were not changed with the wound NP visits on 05/12/22 or 05/26/22. Interview on 06/03/22 3:31 P.M. with Director of Nursing (DON) verified Resident #6's treatments were not documented as completed on 05/03/22, 05/04/22, 05/06/22, 05/08/22, 05/18/22, 05/24/22, 05/28/22 and 05/29/22, and treatment orders were not changed as ordered by the wound NP on 05/12/22 or on 05/26/22. Review of the facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised April 2018, revealed the staff will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions and order pertinent wound treatments. Review of the facility policy titled Prevention of Pressure Injuries, revised April 2020, revealed a risk assessment was completed within eight hours on admission for existing pressure injury risk factors, and a comprehensive skin assessment upon admission or soon after with each risk assessment. This deficiency substantiates Complaint Number OH 863.

Based on record review and interview, the facility failed to maintain a safe environment for one cognitively impaired, dependent resident (Resident #59). Actual harm occurred when Resident #59 sustained a second degree burn to her lower leg from a baseboard heating unit that was too close to the bed. This affected one of one residents reviewed for hazards. The facility census was 75. Findings include: Record review revealed Resident #59 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #59's quarterly Minimum Data Set (MDS) assessment, dated 04/02/18, revealed Resident #59 had severe cognitive impairment and required extensive assistance of one to two staff for activities of daily living. Resident #59's nursing progress notes dated 02/01/18 at 4:23 A.M. revealed an unidentified state tested nursing assistant (STNA) found Resident #59 with her leg over the side of the of the bed and was found with a blister on her left lower leg. On 02/01/18 at 4:45 A.M. an unidentified floor nurse completed a full skin assessment and noted a blister to Resident #59's left lower leg. At 5:00 A.M., the nurse attempted to contact both the physician and Resident #59's daughter without success. At 7:30 A.M., Resident #59's physician was notified of the burn and treatment orders were received to cleanse the area with normal saline and apply a clean dry dressing. At 11:12 A.M., Resident #59's daughter was notified of the burn treatment ordered by the physician. At 12:39 P.M. on 02/01/18, the wound nurse, Licensed Practical Nurse (LPN) #101, completed an assessment of Resident #59's burn. It was described as a second degree burn with an open blister and a small amount of thin drainage. The burn measured 9.0 centimeters (cm) long, 8.0 cm wide and 0.1 cm deep. The most current skin assessment, completed 04/16/18 by LPN #101 described the burn as a second degree burn with an open blister with a small amount of thin drainage. The burn now measured 4.3 cm long, by 3.4 cm wide, and the depth was unmeasurable secondary to being covered in moist, dark yellow slough, which is dead or devitalized tissue. Staff interview with LPN #107 on 04/23/18 at 5:56 A.M. revealed Resident #59 was physically capable of throwing her legs over the edge of the bed. Staff interview with STNA #108 on 04/23/18 at 6:10 A.M. revealed Resident #59 was physically capable of throwing her leg over the edge of the bed. On 04/23/18 at 6:17 A.M., an interview with the Assistant Director of Nursing (ADON), LPN #106, confirmed the nurse's progress notes reflecting Resident #59's burn and verified at the time of the burn, Resident #59's bed was against the wall and close to the baseboard heating unit. Interview with the LPN #101 on 04/24/18 at 9:43 A.M. and again on 04/24/18 at 11:16 A.M. confirmed Resident #59's leg was burned by the baseboard heating unit when she put her leg over the side of the bed and it contacted the baseboard heating unit. LPN #101 said when she first saw the burn it was a blister. Resident #59 could not remember what happened when asked. Interview with the Maintenance Director (MAD) #109 on 04/24/18 at 12:14 P.M. revealed the facility uses boilers to heat the building and they change temperature according to the temperature outside. MAD #109 stated the resident rooms have radiators which are covered with a steel case that is approximately four inches from the actual heat source. MAD #109 stated they have never monitored the temperatures of the heating units. This deficiency substantiates Complaint Number OH 226.

Based on medical record review, review of a facility incident report, review of the facility's internal investigation, review of hospital documentation, staff interviews, review of personnel files, observation of the facility transport bus, and review of the facility policy for bus/van transportation revised March 2013, the facility failed to ensure Resident #101 received adequate supervision and assistive safety devices to prevent a fall during transport. This resulted in Immediate Jeopardy for one (#101) of two residents reviewed for the use of assistive devices during transport in the facility's bus. Resident #101 was not safely secured in the wheelchair with a seatbelt during transport resulting in a fracture to the left tibia when the bus made a sudden stop. The facility identified two residents who utilized the facility transportation bus and remained in a wheelchair during transportation. The facility census was 99. On 07/24/17 at 5:40 P.M., the administrator, director of nursing (DON), and Regional Director of Operations #2 were notified Immediate Jeopardy began on 07/11/17 at approximately 11:30 A.M. when Activity Director (AD) #3 and Activity Assistant (AA) #6 failed to ensure Resident #101 was properly secured in a wheelchair prior to transport on the facility bus. Resident #101's wheelchair was secured to the floor of the bus but the resident was not secured with a seat belt into the wheelchair. During transport, the bus made a sudden stop at a traffic light causing Resident #101 to fall out of the wheelchair onto the floor of the bus. AD #3 and AA #6 continued with the activity without notifying facility staff or having Resident #101 assessed until their return to the facility at 2:30 P.M. Resident #101 was sent to the hospital for evaluation and subsequently treated for [REDACTED]. The Immediate Jeopardy was removed on 07/13/17 when the facility implemented the following corrective actions: · On 07/11/17 at approximately 2:30 P.M., Resident #101 was assessed by Licensed Practical Nurse (LPN) #2. At 4:10 P.M., Resident #101 was transported to the hospital for evaluation. · On 07/11/17 at approximately 2:30 P.M., the facility bus was taken out of service until further notice. · On 07/11/17, Activity Director (AD) #3 was immediately suspended pending further investigation by the Administrator. · On 07/11/17, at 3:00 P.M., the DON educated five of five facility bus drivers regarding use of seatbelts. Seatbelts must be secured per the Bus/Van Transportation Policy (revised March 2013). · On 07/11/17 between 3:30 P.M. and 11:00 P.M., the DON educated 33 staff of 138 total staff on fall procedure and completing a nursing assessment prior to moving the resident following a fall. · On 07/12/17 at 7:00 A.M., 2:30 P.M., and 6:00 P.M., the administrator, DON, and Human Resources Director #4 educated 49 additional staff on falls protocol, post fall nursing assessment, and securing residents in facility vehicle with seatbelt. · On 07/13/17, the facility purchased two wheelchair seat belt sets and a training video for use of the seatbelt sets. The vendor installed the wheelchair seatbelt set the same day. · On 07/24/17 at 10:55 A.M., observation of the facility bus accompanied by Maintenance Director #7 revealed there was room to accommodate 12 mobile residents and two residents in wheelchairs. There were eight straps affixed to the floor at the back of the van to secure the frame of two wheelchairs. There were two straps affixed to the back wall near each corner with two shoulder harness/lap belt straps, enough to accommodate two wheelchairs. · On 07/25/17 at 12:30 P.M., the Administrator, Maintenance Director #7, Social Service Designee (SSD) #9, and Consultant Activity Director #12 provided training to 12 staff. The training included policies for Bus/Van Transportation Policy (revised March 2013) and Motor Vehicle Operator Qualification Policy (effective 12/01/08), as well as information on vehicle stopping distance and time, securing residents safely securing residents in wheelchairs, and a bus/van competency evaluation. · On 07/25/17 at 4:30 P.M., van/bus competency assessments were completed for nine staff. · On 07/25/17 at 4:36 P.M., SSD #9 demonstrated competency in using the facility bus wheelchair lift, securing the wheelchair to the floor with four straps, and securing the person in the wheelchair with a chest strap and pelvic strap. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate jeopardy), as all facility staff were not trained related to not moving a resident following a fall and prompt notification and assessment following a fall. Findings include: Review of the medical record for Resident #101 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the plan of care for falls initiated 05/21/15 revealed Resident #101 had a history of [REDACTED]. The risk factors were impaired balance, stroke with hemiparesis, does not walk, and history of syncope (fainting). The resident had interventions including Dycem (non-slip pad) to wheelchair, use Hoyer (mechanical lift) for transfers, and one-to-one supervision as needed for safety. Review of a Fall Risk assessment dated [DATE] indicated Resident #101 scored 10.0. A score of 10.0 or greater indicated high risk for potential falls. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101's Brief Interview for Mental Status (BIMS) was one indicating severe cognitive deficits. Further review of the MDS assessment revealed Resident #101 needed extensive assistance of two staff for transfers, had functional limitations in range of motion for the upper and lower extremities on one side and the resident utilized a wheelchair and needed extensive assistance of one staff for mobility. Review of the nursing progress note written by LPN #2 dated 07/11/17 at 2:30 P.M. indicated Resident #101 returned from an activity outing at this time. Activity Director (AD) #3 reported the resident slid from his wheelchair to the floor while on the bus. AD #3 reported Resident #101 denied pain and declined to return to the facility. Activity staff proceeded to the restaurant, where the resident ate lunch. LPN #2 immediately assessed the resident. Upon performing passive range of motion, Resident #101 winced, stating, Ouch. Swelling was noted to the left leg. LPN #2 immediately notified the responsible party and the nurse practitioner. The nurse practitioner ordered an x-ray of left leg. Review of the nursing progress noted written by LPN #2 dated 07/11/17 at 3:55 P.M. indicated the responsible party requested Resident #101 be sent to the hospital for evaluation. Review of the nursing progress written by LPN #2 dated 07/11/17 at 4:10 P.M. indicated the resident was transported to the hospital. Review of the hospital emergency department provider note dated 07/11/17 at 4:52 P.M. revealed Resident #101 was complaining of left leg pain. He reported the pain was mostly in the knee and anterior proximal tibia (front of lower leg just below the knee). Upon physical exam, the left leg was noted to be significantly contracted at the knee joint with increased swelling over anterior left proximal tibia. Range of motion of left lower extremity was significantly decreased secondary to pain and contracture. Review of the x-ray results dated 07/11/17 at 5:56 P.M. indicated Resident #101 had an oblique, nondisplaced fracture of proximal tibial shaft. Review of the Medical Decision Making/Emergency Department Course (no time) indicated resident given Tylenol and Percocet (narcotic) for pain. Orthopedics was consulted. Valium was given to properly sedate the resident for straightening of his left leg contracture so a long leg posterior slab splint could be placed. Review of the undated facility investigation by the DON related to the 07/11/17 11:30 A.M. fall revealed Resident #101 was out with the activity department for lunch. On the way to lunch the bus made a sudden stop and the resident fell from his wheelchair onto the floor. Activity staff did not witness the fall but noted the resident sitting on the floor in front of his wheelchair with his legs extended to the side. Resident #101 denied injury so Activity Director (AD) #3 and Activity Assistant (AA) #6 picked the resident up and returned him to his wheelchair. Staff continued to the restaurant. Upon returning to the facility at 2:30 P.M., the nurse was notified of the fall. The investigation noted Resident #101 was placed in the facility bus with his wheelchair strapped down and no seat belt. On 07/24/17 at 10:36 A.M., a phone interview with AD #3 revealed she was hired on 05/23/16. She reported the facility had not provided formal training on use of the facility bus. AD #3 indicated there were straps on the bus floor to secure wheelchairs. Resident #101 had no seat belt on his wheelchair. The bus contained no straps to secure the resident's upper body or to secure across his lap. AD #3 indicated Resident #101 denied pain so she continued with the activity. She could not state why she did not promptly notify the facility following the fall. On 07/24/17 at 1:14 P.M., an interview with AA #11 indicated he started working at the facility the beginning of February 2017. In either February or March 2017, AD #3 provided training for securing residents on the bus. He was not trained to use a shoulder harness or lap belt for residents in wheelchairs. The last time he was in the bus there were no shoulder harness/lap belt straps. AA #11 indicated Resident #50 was the only other resident who was dependent on a wheelchair during transport. On 07/24/17 at 1:24 P.M., an interview with the administrator revealed AD #3 was the staff responsible for training facility staff regarding bus safety. AD #3 never informed her that the appropriate equipment to secure residents in wheelchairs was not on the bus. On 07/24/17 at 1:35 P.M., a phone interview with AA #6 revealed she was the staff accompanying residents when Resident #101 fell . She has been employed at the facility for several years and transferred to the activity department in 2015. She accompanied residents during activities but did not drive. She reported never receiving training on bus safety or securing residents in the bus. Resident #101 had no seat belt in his wheelchair. There was no harness/lap belt attached to the wall to secure him. On 07/24/17 at 4:05 P.M., an observation of Resident #101 revealed he had a hard cast on his left leg extending from the mid thigh area to the foot. He was pleasantly confused and had no recollection of how he injured his leg. Review of the facility policy Bus/Van Transportation Policy (revised March 2013) included training requirements. Drivers and transporters must be educated on the use of wheelchairs and if available electronic lifts. This was to include return demonstrations. Wheelchairs should be checked for fitness and safe operation and with all components attached. All residents transported in wheelchairs must have lap-belt applied before moving the resident in the wheelchair. The lap-belt must remain in place until arrival at destination and unloaded from bus. Review of the personnel files for AD #3, AA #6 and AA #11 revealed no evidence of training on the Bus/Van Transportation Policy or competency evaluations. On 07/24/17 at 5:37 P.M., the administrator confirmed the personnel file for AD #3, AA #6 and AA #11 had no evidence the facility provided training on the facility bus transportation policy or did a competency evaluation. The administrator indicated AA #6 and #11 were transporters and did not drive the bus. She confirmed the staff should have been trained on resident transport and safety. On 07/25/17 at 2:05 P.M., the administrator confirmed the facility did not have the needed equipment to safely secure residents in wheelchairs on the bus or evidence of training/competency evaluations. This deficiency substantiates Complaint Number OH 473.

Based on record review and staff interview the facility failed to ensure skin assessments, care and treatment was provided resulting in the development of Stage IV and Stage III pressure ulcers on the right leg of Resident #110. This affected one of ten residents the facility identified with pressure ulcers. Harm resulted when the facility failed to assess Resident #110's skin integrity until the development of Stage IV and Stage III pressure ulcers. Findings include: Resident #110 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with a right knee immobilizer and a soft cast/splint to the right lower extremity. Review of a nurse's note dated 02/18/13 revealed the skin assessment for Resident #110 indicated admission with a deep tissue injury to the right heel and a large scab to the right great toe. No other skin impairments were revealed, Pressure ulcer risk assessments dated 08/17/12, 11/17/12 and 02/12/13 assessed Resident #110 as being at high risk for the development of pressure ulcers. Review of a nurses note dated 03/14/13 timed 12:20 P.M. documented the wound nurse was notified by therapy that Resident #110 had a scab on the right knee. The wound nurse assessed the resident's knee and found a Stage IV pressure ulcer on the right knee that measured 2.0 centimeters (cm) in length by 2.0 cm in width by 0.1 cm depth. The area was noted with soft black eschar and slough. The National Pressure Ulcer Advisory Panel (NPUAP) defines a Stage IV pressure ulcer as full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Eschar is described as thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual properties and biological activity. Eschar may be loose or firmly adhered to the wound. Slough is necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft , moist, and stringy (at times). In addition the wound nurse also noted a Stage III pressure ulcer to Resident #110's posterior thigh that measured 1.5 cm length by 9.0 cm width by 0.1 cm depth. The area was noted with slough and pink tissue. The NPUAP defines a Stage III pressure ulcer as full thickness tissue loss. Subcutaneous fat mat be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. During an interview conducted on 04/18/13 at 2:30 P.M. the facility wound nurse (WN#1) stated that she initially discovered the resident's Stage III and Stage IV pressure ulcers on 03/14/13. WN#1 verified that there was no documentation Resident #110 had the wounds prior to 03/14/13. WN#1 stated that the state tested nursing assistants (STNA) were to do a daily skin check of the resident and inform the nurse of any skin issues or changes. WN #1 stated that the STNAs were to document any skin issues or changes. WN#1 verified this was not done. During an interview conducted on 04/18/13 at 2:45 P.M. the above information was verified with the director of nursing (DON). The DON verified that the daily skin checks required to be done by the STNAs were not done. This deficiency substantiates Complaint Number OH 702.

Based on observation, record review and interview, the facility transferred a resident using one staff member instead of the required two staff members for one resident (Resident #108), resulting in a fractured left ankle, and failed to maintain assessed interventions to prevent falls for one resident (Resident #49) out of three residents identified as having falls/fractures. Findings include: 1. Resident #108 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. An interim plan of care dated 11/18/10 revealed the resident required two staff assistance for mobility, which included positioning in the bed and transferring. A Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident was cognitively impaired for decision-making and required an extensive assistance by two staff members for bed mobility and transferring. Nursing notes dated 07/10/11 at 7:16 P.M., revealed that at approximately 5:00 P.M., Licensed Practical Nurse (LPN) #2 transferred Resident #108 from chair to bed by herself. Upon reaching the bed, the resident stated her left foot hurt. LPN #2 repositioned the foot and put a pillow under the foot. Approximately one hour later, the resident stated she was in a lot of pain and any time anyone touched her foot it hurt worse. The physician was notified and an x-ray was ordered. The x-ray was completed with results showing possible fracture of the lower leg. The physician was notified and ordered an ace wrap to be placed on the left foot for two weeks and to change it every day. The physician also ordered the resident to receive Tylenol 500 milligrams (mg) every four hours as needed. Nursing notes dated 07/14/11 at 11:02 A.M., revealed that Resident #108 displayed facial grimacing and excessive moving due to the foot discomfort. The family came to visit and voiced concern that the resident was still experiencing pain after days of pain medications and requested the resident to be sent to the hospital. Resident #108 was sent to the hospital and admitted with a fractured left ankle. Review of the facility's investigation report dated 07/10/11 revealed that Resident #108 required two to four person assistance with activity of daily living events, including transferring and that the resident was transferred from the chair to the bed by one staff member. Included in the investigation was an Employee Warning Notice dated 07/14/11 for LPN #2. The warning revealed that LPN #2 failed to gather information pertaining to the resident before giving care. An employee statement from LPN #2 dated 07/11/11 indicated the resident requested to go to bed. She informed the resident that the state tested nurse aides (STNA's) were providing care to other residents and could she wait. The resident replied "yes" but later rang again to request to go back to bed and that she "cannot wait no more." LPN #2 told the resident that she would put her back to bed. The resident questioned the LPN that she could not do it by herself but the nurse informed the resident "yes, I can." LPN #2 transferred the resident by herself. LPN #2 stated that she did not see the resident's leg during the transfer and assumed that no problem occurred. Review of LPN #2's personnel file revealed it contained a copy of the written warning regarding the transfer of Resident #108. 2. Review of Resident #49's medical record revealed the resident to be admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] revealed the resident was severely impaired in cognition and required a one-person staff assistance for all activity of daily living (ADL) activity including bed mobility, transferring, hygiene and toileting. The MDS revealed the resident had falls in the facility. A fall risk assessment dated [DATE] revealed the resident was a high risk for falls. Review of a fall risk plan of care for the resident dated 10/30/09 revealed interventions including bed and chair alarms. On 05/26/11 the alarms were changed to sensor alarms to the bed and chair. Nursing notes revealed the following falls: -On 01/07/11 at 9:16 P.M., an STNA notified the nurse that Resident #49 was observed lying on her right side on the floor. A wheelchair was facing the resident. The resident stated she was trying to go to the bathroom. The resident had no injury. The nursing note did not mention the ordered alarm device. -On 05/09/11 at 7:00 A.M., the nurse was walking into Resident #49's room and observed the resident standing in front of her bed getting ready to sit in the wheelchair when she slid down. The resident was able to brace herself with one hand on the bed and the other on the floor. The nurse grabbed the resident around her waist and sat her to the floor. The resident stated she was going to the bathroom. No injuries were noted. The nursing note did not mention if an alarm device sounded. -On 05/25/11 at 7:37 A.M., the nurse was called to Resident #49's room. The resident was sitting on her buttocks on the floor with her back against the bed. The notation indicated "no alarm was sounding." No injury was noted. The resident stated that "I slipped and fell getting out of bed." The resident was put back to bed by the nurse and a STNA. Review of the facility investigation reports regarding the above falls for Resident #49 revealed none of the investigations indicated if the ordered alarm device was on the resident prior to the fall or if it sounded. During tour of the facility on 07/15/11 at 9:05 A.M., accompanied by Registered Nurse (RN) #1, Resident #49 was observed in her room with a wheelchair facing her bed. She stood and then sat down on her bed. As she sat on the bed, she leaned toward her left into a side lying position on the bed. An alarm cord was on the wheelchair with no alarm box attached to it. The alarm box was attached to a cord coming from the bed onto a pressure pad. No alarm had sounded when the resident sat and moved sideways on the bed. The alarm box was examined and found to be in a turned-off position. This was verified by RN #1. On 07/15/11 at 3:15 P.M., RN #1 verified nursing notes and fall investigation reports did not indicated if Resident #49's alarms were on at the time of the falls. This deficiency substantiates Complaint Number OH 503.