Every finding on record at Best Care Health and Rehabilitation

Based on medical record review and staff interview, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASARR) were completed and updated to accurately reflect all resident information. This affected four (#1, #4, #35 and #68) of eight residents reviewed for PASARR accuracy. The facility census was 89. 1. Record review for Resident #1 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disorder, schizoaffective disorder, diabetes mellitis type II, anxiety, depression, mood disorder(03/30/26), and insomnia. Review of an updated diagnosis list revealed a new diagnosis of mood disorder was added on 03/30/26. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had minimally impaired cognition. Review of the most recent PASARR documentation provided by the facility for Resident #1 revealed it was completed on 03/04/25, with no further documentation which reflected the addition of the new diagnosis. Interview with the Director of Nursing and Social Services Designee #268 on 07/29/2026 at 1:26 P.M. verified a new PASARR had not been completed following the addition of the new diagnosis for Resident #1. 2. Record review for Resident #68 revealed the resident was admitted to the facility on [DATE]. Diagnoses included atrial fibrillation, atherosclerosis, hypertension, Bipolar disorder, asthma, depression, Mood Disorder(09/16/25), bronchitis, Schizoaffective disorder(10/24/24), and atherosclerosis.A new diagnosis of Mood Disorder was added on 09/16/25. A new diagnosis of Schizoaffective Disorder was added on 10/24/24. Review of the quarterly MDS assessment dated [DATE] revealed Resident #68 had no cognitive impairments. Review of the most recent PASARR documentation provided by the facility for Resident #68 revealed it was completed prior to admission on [DATE], with no further documentation which reflected the addition of the new diagnosis. Review of current medications for this resident revealed currently receiving the following medications that were not captured on the most recent PASARR review: Lexapro Oral Tablet 20 MG (Escitalopram Oxalate) Give 1 tablet by mouth one time a day for depression, anxiety. Start Date on 06/10/2026. TraZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 2 tablet by mouth at bedtime for Insomnia and depression. Start Date 10/24/2025. Vraylar Oral Capsule 6 MG (Cariprazine HCl) Give 6 mg by mouth at bedtime for schizophrenia. Start Date 12/30/2024. BusPIRone HCl Oral Tablet 5 MG (Buspirone HCl) Give 3 tablet by mouth three times a day for anxiety. Start Date 03/26/2026. Interview with the Director of Nursing and Social Services Designee #268 on 07/29/2026 at 1:26 P.M. verified a new PASARR had not been completed following the addition of the new diagnosis for Resident #68 and did not accurately reflect the appropriate medications for Resident #68. 3. Review of the medical record for Resident #4 revealed an admission date 11/05/25. Diagnoses included chronic obstructive pulmonary disease, hypothyroidism, gout, retention of urine, hypertension, bipolar disorder, depression, anxiety disorder, insomnia, major depressive disorder, dementia, schizoaffective disorder, bipolar type and hallucinations. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Further review of the assessment indicated dementia, bipolar disorder, anxiety disorder, depression and schizoaffective disorder was a current diagnosis. Review of the PASARR dated 11/05/36 revealed the resident had only mood disorder indicated as a current diagnosis. Review of the resident's diagnoses list revealed on 11/06/25 the diagnoses of anxiety disorder and major depressive disorder was added as a current diagnosis. Review of the medical record revealed no significant change PASARR being completed to reflect the newly added diagnoses of anxiety disorder and major depressive disorder. Review of the resident's diagnoses list revealed on 11/21/25 the diagnoses of schizoaffective disorder, bipolar type, was added as a current diagnosis. Review of the medical record revealed no significant change PASARR being completed to reflect the newly added diagnoses of anxiety disorder and major depressive disorder. Review of the resident's diagnoses list revealed on 03/19/26 the diagnosis of dementia was added was added as a current diagnosis. Review of the medical record revealed no significant change PASARR being completed to reflect the newly added diagnoses of anxiety disorder and major depressive disorder. On 07/30/26 at 12:10 P.M., Social Service Designee (SSD) #268 verified the significant change PASARR were not completed as required to reflect the newly added diagnoses. 4. Review of the medical record for Resident #35 revealed an admission date of 11/15/25. Diagnoses included cerebral infarction, quadriplegia, hypertension, psychoactive substance abuse, obstructive sleep apnea, depression, major depressive disorder, hyperlipidemia, duodenal ulcer, chronic pain, polyneuropathy, insomnia, anxiety disorder, dysphagia and mood disorder. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Further review of the assessment indicated anxiety disorder, depression and psychoactive substance abuse were active diagnoses. Review of the resident's diagnoses list revealed on 11/17/26 the diagnosis of anxiety disorder was added was added as a current diagnosis. Review of the medical record revealed no significant change PASARR being completed to reflect the newly added diagnosis of anxiety disorder. Review of the resident's diagnoses list revealed on 02/26/26 the diagnosis of mood disorder was added as a current diagnosis. Review of the medical record revealed no significant change PASARR being completed to reflect the newly added diagnosis of mood disorder.

Based on resident record review, staff interview, and resident interview, the facility failed to ensure medication orders were obtained and implemented in a timely manner. This affected one resident (#18) out of the five residents reviewed for unnecessary medications. The facility census was 89. Findings include:Record review for Resident #18 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included need for assistance with personal care, muscle weakness, and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/27/26, revealed the resident was assessed to have intact cognition. Review of the urology appointment progress note, dated 07/15/26, revealed the resident was to begin being administered 100 milligrams (mg) of Macrobid (an antibiotic medication) twice a day for four days for treatment of a urinary tract infection, 75 mg of Vibegron once daily for treatment of overactive bladder, and estradiol cream vaginally for treatment of postmenopausal atrophic vaginitis. Review of the nurse progress note, dated 07/21/26, revealed Resident #18 stated she was told by urology team she was supposed to have a prescription for a cream sent with her from her previous appointment on 07/15/26. The urology team was contacted and stated they will fax over the prescription. Review of the physicians orders for Resident #18 revealed orders for Macrobid, Vibegron, and estradiol cream were not implemented until 07/23/26, 8 days after the residents urology appointment. Interview with Resident #18 on 07/27/26 at 12:29 P.M. confirmed the resident had not received prescribed medications and cream from the facility until days after it was ordered by the urologist. Interview with the Director of Nursing (DON) on 07/29/26 at 8:18 A.M. confirmed Resident #18 received new orders for medications and medicated cream to be administered on 07/15/26 by the urologist but the orders were not received by the facility due to the printer being out of ink.

Based on observations, staff and resident interviews, resident record reviews, and review of facility policy, the facility failed to ensure showers and nail care were provided timely and appropriately for residents who required assistance from staff with Activities of Daily Living (ADLs). This affected two residents (#6 and #18) out of the four residents reviewed for ADL care. The facility census was 89. Findings include:Record review for Resident #18 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included need for assistance with personal care, muscle weakness, and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/27/26, revealed the resident was assessed to have intact cognition. Review of the care plan, dated 01/21/26, revealed the resident required assistance with ADLs. Interventions included to assist with shower twice weekly or per residents preference. Review of the paper shower sheets and electronic shower documentation for Resident #18 from 07/01/26 through 07/29/26 revealed the resident was documented to have declined a shower on 07/01/26 and 07/04/26 and to have only received a shower on 07/05/26, 07/09/26, and 07/14/26, and 07/21/26. Interview with Resident #18 on 07/27/26 at 12:29 P.M. confirmed the resident believed she had not had a shower in a week and a half and stated her hair was greasy and needed washed. Resident #18 confirmed she would prefer to have a shower and have her hair washed at least two to three times a week. Observation of the resident at the time of the interview revealed the residents hair was greasy near the roots and appeared to need washed. Interview with Certified Nursing Assistant (CNA) #275 on 07/28/26 at 12:49 P.M. confirmed there was not always enough time to complete showers for all residents scheduled or asking to receive one due to staff being too busy. Review of the facility policy titled Bath, Shower/Tub, revised 02/2018, revealed the purpose of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the residents skin. 2. Record review for Resident #6 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included hemiplegia and hemiparalysis following cerebral infarctin affecting the right side, psychosis, and anxiety disorder. Review of the significant change MDS assessment, dated 06/22/26, revealed the resident was assessed to have impaired cognition. Review of the care plan, dated 02/05/26, revealed the resident required assistance with ADLs. Interventions included nail care as needed. Observation on 07/27/26 at 2:45 P.M. revealed Resident #6 was lying in bed listening to music. The residents fingernails were long and had dark brown debris caked underneath them. Observation on 07/28/26 at 12:44 P.M. revealed Resident #6 was lying in bed consuming his lunch meal. The residents fingernails continued to be long and had dark brown debris caked underneath them. Interview with the resident at the time of the observation confirmed his nails needed to be cleaned and trimmed and he believed someone was coming in that day to do so. Interview with CNA #275 on 07/28/26 at 12:49 P.M. confirmed residents nails were to be trimmed and cleaned on shower days and as needed but staff were not always able to do so when needed due to being too busy. CNA #275 confirmed Resident #6's fingernails were long and dirty and needed to be trimmed and cleaned. Review of the facility policy titled Fingernails/Toenails, Care of, revised 02/2018, revealed the purpose of the procedure was to clean the nail bed, keep nails trimmed, and prevent infections.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on closed record review, staff interviews, policy review, and review of hospital documentation, the facility failed to ensure a resident received adequate assistance during a transfer to prevent an avoidable fall. This resulted in Actual Harm to Resident #95 when on 12/21/25 she fell on to the floor in the bathroom while being assisted with toileting by one staff member. Resident #95 sustained a fracture of the right femoral head and the left distal femur. This affected one (Resident #95) of three residents reviewed for falls. The facility census was 90.Findings include:Record review for Resident #95 revealed an admission date of 05/02/25. Diagnoses included congestive heart failure, polyneuropathy, difficult ambulation, muscle weakness, and chronic obstructive pulmonary disease. Review of the Lift, Transfer, Reposition Assessment, dated 05/16/25, revealed Resident #95 was at risk for falls and required two-persons substantial/maximal assist for transfers with the use of a gait belt.Review of the care plan, dated 06/18/25, revealed Resident #95 had intact cognition, and she was at risk for falls due to weakness and poor balance. The interventions included encouraging proper footwear when out of bed. Review of the care plan, dated 10/09/25, revealed Resident #95 required a functional maintenance program for transfers to restore their ability to assist with transfers between surfaces. Interventions included utilizing a gait bait belt with moderate-maximum assistance.Review of the Minimum Data Set (MDS) assessment, dated 12/01/25, revealed Resident #95 was cognitively intact. Resident #95 required substantial/maximal physical assistance for all transfers. Resident #95 was not steady and was unable to stabilize without staff assistance for moving from a seated to standing position, walking, and surface to surface transfer. Review of the progress note, dated 12/21/25 at 1:05 P.M. by Licensed Practical Nurse (LPN) #600, revealed Certified Nursing Assistant (CNA) #920 walked up to the nursing station for LPN #600 to come to Resident #95's room. Upon entry, LPN #600 observed Resident #95 sitting on the bathroom floor, complaining of left knee pain with multiple abrasions. Resident #95 was assisted to bed by the nurse and CNA #920. At 1:30 P.M. a STAT (without delay) order for imaging was obtained for both lower extremities including both hips. Fifteen-minute checks and neurological checks were initiated, with all being completed.Review of the Imaging Report dated 12/21/25 revealed a study time of 5:28 P.M. The facility was notified of the results at 7:34 P.M. The results of this imaging showed severe right hip degenerative changes with deformity in the right femoral neck. The left femur showed an acute distal femoral metadiaphysis fracture (the anatomical region of a long bone that encompasses the junction between the widened end and the shaft) with generalized osteopenia. The progress note dated 12/21/25 at 7:28 P.M. revealed notification to the physician of preliminary imaging reports and an order was obtained to send Resident #95 to the emergency room via emergency medical system (EMS) transport.The progress note dated 12/22/25 at 1:01 A.M. revealed Resident #95 was being admitted to the hospital with active diagnoses of a right hip fracture along with a fracture to the left femur.The progress note dated 12/22/25 at 6:38 A.M. revealed the receiving hospital was transferring Resident #95 to another hospital due to compartment syndrome (severe, often acute, condition where high pressure builds with muscle compartment, restricting blood flow and causing oxygen deprivation) related to the left femur fracture. Review of the Fall Assessment Quality Assurance Performance Improvement (QAPI) report revealed Resident #95 had a fall on 12/21/25 at approximately 1:05 P.M. in the bathroom and sustained a major injury and was sent to the emergency room. The investigation stated the care plan interventions/strategies were in place. Resident #95 fell during transfer to the toilet, and the possible root cause was knee giving out. The QAPI action plan was to utilize the sit-to-stand lift to transfer Resident #95. The investigation did not address that Resident #95 required two persons to transfer and during this incident, only one person transferred Resident #95. The investigation did not address that CNA #920 did not utilize a gait belt which was part of the resident's plan of care. The report did not include any staff names involved with the QAPI action plan.The witness statement (undated) by CNA #920 revealed on12/21/25 at 1:05 P.M., CNA #920 was taking Resident #95 to the restroom and the resident stated that her knee was hurting her. Resident #95 was holding on to the bar in the bathroom. CNA #920 moved the wheelchair and was behind Resident #95 when Resident #95 began falling to her side. Resident #95 fell backwards toward the other bathroom door. Nurse was notified.Review of Resident #95's hospital records from Hospital #1, dated 12/22/25, revealed Resident #95's imaging showed a left distal femur fracture and a right hip fracture. This resident also arrived at the hospital being hypotensive (low blood pressure) with no external signs of bleeding or hemorrhage. The discharge plan was a closed left femoral fracture, fracture of right hip, anemia, and acute hypotension. Resident #95's condition at discharge was serious. Resident #95 was transferred to a Level One Trauma Center at Hospital #500 due to suspicions of internal bleeding of the left thigh. The family elected hospice services on 12/31/25.Review of Hospital #500's records revealed Resident #95 was treated for hemorrhagic shock and acute on chronic shock. The physician stated the left femur fracture was pathological due to a combination of osteopenia and trauma and that alone would not have resulted in fracture.Review of the death certificate and coroner's report dated 01/09/26 revealed Resident #95's cause of death to be medical decline following a left distal femur fracture with surgical therapy as a consequence of a ground level fall.During an interview on 02/13/26 at 2:34 P.M., LPN #600 stated Resident #95 fell on [DATE] while CNA #920 was assisting her to the toilet by herself. LPN #600 stated CNA #920 came to get him at the nursing station and said Resident #95 had fallen. LPN #600 stated Resident #95 required a two-person assist and this transfer was completed by only CNA #920. During an interview on 02/17/26 at 12:31 P.M., the Director of Nursing (DON), Assistant Director of Nursing (ADON) #330, [NAME] President of Clinical Operations #900, and Regional Resource Nurse #910 verified CNA #920 improperly transferred Resident #95 alone without the use of a gait belt for a safe transfer. They verified Resident #95 sustained a right hip fracture and a left femur fracture because of the transfer, with CNA #920 being terminated on 12/29/25 for inadequate work performancesReview of the policy titled Falls/Accidents/Incidents, dated 07/17/23, revealed the intent of this requirement is to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. An avoidable accident means the accident occurred the facility failed including implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice to eliminate the risk, if possible, and, if not, reduce the resident of an accident.The deficient practice was corrected on 02/06/26 when the facility implemented the following corrective actions:-On 12/21/25, Resident #95 was sent to the hospital and did not return to the facility.-On 12/22/25, a QAPI meeting was conducted following identification of the incident and ongoing four weeks with all required individuals in attendance to ensure compliance.-Beginning 12/22/25, all falls will be reviewed Monday-Friday in the clinical whiteboard meeting by the interdisciplinary team (IDT) with detailed investigation to ensure the event was completed correctly, a root cause analysis was conducted, with all care plans updated, interventions implemented, physician and family notifications completed.-Beginning 12/22/25, members of the IDT team will observe staff completing activities of daily living (ADLs) for five residents to ensure all are provided per plan of care and Kardex on each shift daily for two weeks, then five daily on Monday-Friday for four weeks on different shifts.-By 12/24/25, all current residents had a new fall risk assessment completed to ensure proper identification of all residents who are at risk for falls. The facility identified 38 residents at risk for falls.-By 12/26/25, all 38 residents who were identified for falls had care plans reviewed to ensure that all falls care plans were up to date with current interventions. This included the type of assistance the residents required with ADL.-By 12/26/25, all 38 residents who have fall prevention interventions present on care plans were assessed to ensure the interventions were in place for residents and available for resident utilization. were assessed to ensure all fall interventions on the care plan were implemented.-By 12/26/25, the DON, Assistant Director of Nursing (ADON) #330, Staff Development Coordinators (SDC) #650, Unit Manager #790, and/or Administrator educated all staff on accident and incident policies and procedures, following care plans, utilization of assistive devices and use of gait belts. Post-education test was given until 100% passing score for all staff. -Beginning 12/22/25, members of the IDT will review five residents total per day on all units on all shifts to ensure all fall interventions are in place. This was daily for two weeks, then Monday-Friday for two weeks, then weekly for six weeks.-Beginning the week of 12/27/25, a post-test will be conducted for five random staff members weekly starting on 12/27/25 to ensure retention of education. This was ongoing for four weeks. -On 12/29/25, CNA #920 was terminated for poor work performance.-On 02/13/26, record reviews for Residents #27, #38, and #64 who had a fall history with major injury revealed no concerns relates to their falls.-Observation on 02/13/26 revealed Resident #38 was transferred safely to wheelchair from bed by staff.-Interviews on 02/13/25 with LPN #600, LPN #740, CNA #470, and CNA #630 revealed staff were educated on the facility's policies and procedures related to accidents and incidents, following care plans, and utilizing assistive devices and use of gait belts.This deficiency substantiates Complaint Number 2714886.

Based on observation, staff interview and medical record review the facility failed to ensure physician orders were in place for Resident #68 foley catheter. This affected one (Resident #68) of one resident resident reviewed for foley catheters. The facility census was 79.Findings include: Review of the medical record for Resident #68 revealed an admission date of 08/21/25 with diagnoses including atrial fibrillation, congestive heart failure, liver cirrhosis, diabetes mellitus type two, chronic kidney disease with dialysis. Review of the physician orders dated 09/25 revealed no orders in place for Resident #68 indwelling foley catheter.Review of the discharge return not anticipated Minimum Data Set (MDS) most recent completed, dated 08/28/25 revealed Resident #68 was cognitively intact with no behaviors. Resident #68 was dependent on staff for toileting hygiene, bed mobility, and transfers and required substantial assistance with bathing. Resident #68 had an indwelling catheter.Review of the nursing progress notes for Resident #68 revealed no documentation of physician orders for Resident #68 indwelling foley catheter.Review of the Certified Nursing Assistant documentation revealed care was provided for Resident #68 indwelling foley catheter. Review of the plan of care revealed no plan of care for Resident #68 indwelling foley catheter.Interview on 09/17/25 at 2:55 P.M. with the Director of Nursing confirmed Resident #68 had no physician orders for indwelling foley catheter.Observations made during the survey revealed Resident #68 had an indwelling foley catheter to bedside drainage bag with privacy cover.The facility did not have a policy related to physician orders for indwelling foley catheter.This was an incidental finding discovered during investigation of Master Complaint Number 2603203 and Complaint Number 1382712.

Based on medical record review , interview, and facility policy review, the facility failed to ensure medications on admission were received from pharmacy and administered to the residents timely. This affected three Residents (#42, #68 and #120) of five residents reviewed for medication administration. The facility census was 79.Findings include:1.Review of the closed medical record for Resident #120 revealed an initial admission date of 08/12/25 with diagnoses including pleural effusion, chronic kidney disease stage three, cirrhosis of the liver, atrial fibrillation diabetes mellitus type two and Clostridium difficile (C-diff). Review of the Medication Administration Record (MAR) dated 08/25 revealed Resident #120 was ordered on 08/12/25 Vancomycin hydrochloride capsule 125 milligrams (mg) by mouth four times daily for C-diff, Sulcralfate 1 gram by mouth four times daily for gastroesophageal reflux disease (GERD), and Gabapentin 100 mg by mouth three times daily for pain. The MAR indicated Resident #120 did not receive the Sulcralfate and Gabapentin until the morning dose on 08/14/25. The MAR indicated Resident #120 did not receive the Vancomycin 125 mg by mouth up to her discharge back to the hospital on [DATE] for chest pain. Review of the nursing progress notes revealed a note dated 08/13/25 at 9:39 A.M. awaiting pharmacy, a note dated 08/13/25 at 4:29 P.M. awaiting pharmacy, a noted dated 08/13/25 4:29 P.M. Sulcralfate 1 gram by mouth four times day for GERD, awaiting pharmacy, a note dated 08/13/25 at 4:29 P.M. Gabapentin 100 mg by mouth three times day for pain, awaiting pharmacy, a note dated 08/13/25 4:30 P.M. Vancomycin hydrochloride (hcl) oral capsule 125 mg by mouth four times a day for infection for four days, awaiting pharmacy, a note dated 08/14/25 at 6:02 P.M. Vancomycin hcl 25 mg per milliliter (ml) solution reconstituted, give 5 ml by mouth four times day for C-diff for 8 days, awaiting on pharmacy, and no documentation the physician or Nurse Practitioner (NP) was notified for instructions. Review of the Minimum Data Set (MDS) revealed Resident #120 had two admission assessments (limited information) and two discharge return not anticipated assessments. Interview on 09/17/25 at 12:54 P.M. with Licensed Practical Nurse (LPN) #21 confirmed there was a problem getting medications from pharmacy timely especially with admissions. LPN #21 confirmed Resident #120 missed doses of medication for several days after admission. LPN #21 stated if a resident missed a medication the procedure was to call the pharmacy, notify the Nurse Practitioner (NP) or physician, and document. The facility has a Pixus system with medications on hand but does not always have what the resident was ordered. LPN #21 stated the facility was working on a new pharmacy. Interview on 09/17/25 at 1:15 P.M. with NP (on site) revealed Resident #21 had no adverse effects from missing the medications.Interview on 09/17/25 at 2:55 P.M. with the Director of Nursing (DON) confirmed Resident #21 did not receive the medication Vancomycin oral tablets for three days after admission. DON confirmed there was no documentation in nursing progress notes the physician or NP was notified.2.Review of the medical record for Resident #42 revealed an admission date of 09/03/25 with diagnoses including weakness, chronic obstructive pulmonary disorder cirrhosis of liver, chronic viral Hepatitis C, diabetes mellitus type two and congestive heart failure.Review of the MAR dated 09/25 for Resident #42 revealed the following orders dated 09/03/25 on admission: Clopidogrel bisulfate 75 milligrams (mg) by mouth daily not administered until 09/05/25, Lantus insulin Solostar injector pen 100 units/milliliter (ml) inject 8 units subcutaneously daily not administered until 09/05/25, Nicotine patch 21mg/24 hours apply in the morning and remove in the evening not administered until 09/05/25, Sertraline hydrochloride 100 mg by mouth daily not administered until 09/05/25, Trelegy ellipta inhalation powder 100-62.5-25 micrograms one puff daily for 90 days not administered until 09/05/25, Cefazolin intravenous 2.0-0.9 grams/100 ml every 8 hours for 15 days not administered until 09/05/25, and Creon 36000-114000 units give 2 capsules by mouth three times daily not administered until 09/15/25.Review of the nursing progress notes for Resident #42 revealed the following: 09/03/25 at 8:39 P.M. the physician and family was notified of Resident #42 admission to the facility. The resident had no known allergies. Resident #42 tolerated transfer well, oriented to call light, bed controls and television remote. The resident had a midline intravenous site to left upper extremity and a supra pubic catheter. Also noted a wound to coccyx covered with mepilex. The skin assessment was completed. Resident #42 was a full code and was alert and oriented to person, place and time. A note dated 09/04/25 at 4:54 P.M. medications not delivered by pharmacy. A note dated 09/04/25 at 11:46 A.M. Cefazolin in sodium chloride intravenous solution 2.0-0.9 grams/100 ml was not available. A note dated 09/05/25 1:21 P.M. Creon oral capsule delayed release 36000-114000 units give two capsules by mouth three times daily was on order. A noted dated 09/05/25 at 3:25 P.M. Creon capsule delayed release 36000-114000 units 2 capsules by mouth three times daily was on order. A note dated 09/06/25 9:33 A.M. Creon capsule delayed release 36000-114000 units 2 capsules by mouth three times daily was on order. A note dated 09/07/25 at 7:15 A.M. Creon capsule delayed release 36000-114000 units 2 capsules by mouth three times daily was on order. A noted dated 09/09/25 at 3:05 P.M. Creon capsule delayed release 36000-114000 units was not provided. A note dated 09/10/25 at 8:38 A.M. Creon capsule delayed release 36000-114000 units 2 capsules by mouth three times daily was on order. A note dated 09/11/25 at 7:11 A.M. Creon capsule delayed release 36000-114000 unit give 2 capsules by mouth three times daily was on order. A note dated 09/12/25 at 7:27 A.M. Creon oral capsule delayed release 36000-114000 unit 2 capsules by mouth three times daily was on order. A note dated 09/12/25 7:27 A.M. Creon oral capsule delayed release 36000-114000 unit give 2 capsules by mouth three times daily, the nurse received an order to hold the medication until arrival from pharmacy.Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #42 was cognitively intact with no behaviors. Interview on 09/17/25 at 9:20 A.M. with Resident #42 revealed there was a medication she did not receive after being admitted . Resident #42 stated the nurse explained that she had contacted the pharmacy and was waiting on the pharmacy to bring it. Resident #42 stated she now received the medication and has no problems with getting her medications. Interview on 09/17/25 at 12:46 P.M. with LPN # 68 confirmed Resident #42 did not receive scheduled medication Creon as ordered for several days. The medication was then placed on hold. Resident #42 now receives the medication. Interview on 09/17/25 at 1:15 P.M. with NP (on site) revealed Resident #42 had no adverse effects from missing the medications. The NP stated she was not notified of the missing doses of medication until 09/12/25 and she gave the order to hold the Creon until available from the pharmacy. The medication Creon has since been started and administered as ordered. Interview on 09/17/25 at 2:55 P.M. with the Director of Nursing (DON) confirmed Resident #42 did not receive the medications Plavix, Lantus insulin, Nicotine patch, Sertraline, Trelegy inhaler, Cefazolin and Creon for several days until it was place on hold. 3.Review of the medical record for Resident #68 revealed an admission date of 08/21/25 with diagnoses including atrial fibrillation, congestive heart failure, liver cirrhosis, diabetes mellitus type two, chronic kidney disease with dialysis. Review of the MAR dated 08/25 revealed on admission Resident #68 was ordered lactulose solution 10 grams/15 ml give 30 ml by mouth two times daily for cirrhosis. The medication was not administered on the following dates: 08/22/25 and 08/23/25.Review of the discharge return not anticipated Minimum Data Set (MDS) most recent completed, dated 08/28/25 revealed Resident #68 was cognitively intact with no behaviors.Review of the nursing progress notes for Resident #68 revealed the following: a note dated 08/21/25 at 6:05 P.M. admit [AGE] year old male to room [ROOM NUMBER] A from local hospital and arrived at the facility via ambulance on a stretcher. The resident was assisted from stretcher onto the bed with assistance of five people. Resident was oriented to room, call light and bed controls. A note dated 08/22/25 at 11:16 A.M. lactulose solution 10 grams/15 milliliters (ml) give 30 ml by mouth two times daily, awaiting from pharmacy. A note dated 08/23/25 at 8:56 A.M. lactulose solution 10 grams/15 ml give 30 ml by mouth two times daily, not available will call the pharmacy for delivery of medication. Interview on 09/17/25 at 9:45 A.M. with Resident #68 revealed no concerns with medication now, however, when the resident was first admitted he did not receive the medication he takes for his bowels. Resident #68 denied any adverse effects from not having the medication.Interview on 09/17/25 at 12:46 P.M. with LPN #68 confirmed Resident #68 did not receive scheduled lactulose medication for two days after admission. LPN #68 stated he called the pharmacy about the medication and was not sure it was documented in nursing notes. Interview on 09/17/25 at 12:54 P.M. with LPN #21 confirmed there was a problem getting medications from pharmacy timely especially with admissions. LPN #21 stated if a resident missed a medication the procedure was to call the pharmacy, notify the Nurse Practitioner (NP) or physician, and document. The facility has a Pixus system with medications on hand but does not always have what the resident was ordered. LPN #21 stated the facility was working on a new pharmacy. Interview on 09/17/25 at 1:15 P.M. with NP (on site) revealed Resident #68 had no adverse effects from missing the medication.Interview on 09/17/25 at 2:55 P.M. with the Director of Nursing (DON) confirmed Resident #68 did not receive the medication lactulose for three days after admission. The DON confirmed there was no documentation in the nursing progress notes the physician or NP were notified. Observation of Resident #68 on 09/17/25 at 9:45 A.M. revealed no concerns related to not receiving medication upon admission.Review of the facility policy titled Medication Administration with effective date of 06/17/17 revealed during medication administration if the medication was unavailable, the nurse would contact the pharmacy and document accordingly.This deficiency represents non compliance investigated under Master Complaint Number 2603203.

Based on medical record review, interview, and facility policy review, the facility failed to notify the Ombudsman of discharge. This affected three Residents (23, #68 and #120) of four reviewed for discharge. The facility census was 79.Findings include:1.Review of the medical record for Resident #23 revealed an admission date of 08/21/25, discharged to the hospital on [DATE] and readmitted to the facility on [DATE] with diagnoses including chronic lymphocytic leukemia of B cell type in remission, chronic kidney disease stage four, cirrhosis of the liver, diabetes mellitus type two, fibromyalgia and mood disorder. Review of the discharge return not anticipated Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was cognitively intact with verbal behaviors towards others. Resident #23 required assistance from the staff to complete activities of daily living. Review of the nursing progress notes revealed no documentation the facility notified the Ombudsman of Resident #23 discharge on [DATE]. 2.Review of the medical record for Resident #68 revealed an admission date of 08/21/25, discharged to hospital on [DATE] and readmitted to the facility on [DATE] with diagnoses including atrial fibrillation, congestive heart failure, liver cirrhosis, diabetes mellitus type two, chronic kidney disease with dialysis. Review of the discharge return not anticipated Minimum Data Set (MDS) most recent completed, dated 08/28/25 revealed Resident #68 was cognitively intact with no behaviors. Review of the nursing progress notes for Resident #68 revealed no documentation the Ombudsman was notified of resident's discharge on [DATE].3.Review of the closed medical record for Resident #120 revealed an initial admission date of 08/12/25, discharged to the hospital on [DATE], readmitted to the facility on [DATE] and discharged to hospital on [DATE] with diagnoses including pleural effusion, chronic kidney disease stage three, cirrhosis of the liver, atrial fibrillation diabetes mellitus type two and Clostridium difficile (C-diff). Review of the Minimum Data Set (MDS) revealed Resident #120 had two admission assessments (limited information) and two discharge return not anticipated assessments. Review of the nursing progress notes revealed no documentation the Ombudsman was notified of Resident #120 discharges to the hospital.Review of the 48 hour plan of care revealed no concerns. Interview on 09/17/25 at 2:55 P.M. with the Director of Nursing confirmed the facility had not notified or had been notifying the Ombudsman of discharges from the facility. Interview on 09/17/25 at 3:20 P.M. with Social Services Director #40 revealed it was a new position and did not know of the notification of the Ombudsman regarding discharge. The Social Services Director #40 stated she called the Ombudsman and received information related to notification of resident discharge.Review of the facility policy titled Bed Hold and Return to Center policy dated 04/20/18 revealed if the facility determined that it can no longer provide the needed services for the resident and was unable to accept the resident in return after transfer, then refer to the Notice of Transfer Discharge policy. That policy was not provided by the facility.This deficiency represents non-compliance investigated under Complaint Number 1382712.

Based on review of the Resident Council meeting minutes, staff interview, and resident interview, the facility failed to ensure concerns discussed during the meetings were adequately addressed. This had the potential to affect five facility-identified residents ( #10, #27, #44, #47, #65) who consistently attended the Resident Council meetings. The facility census was 66 residents. Findings include: Review of the Resident Council meeting minutes dated 04/15/24 revealed the social worker had looked into free phones but had been unable to secure any. The department response documented on the form read the social worker would meet with the residents regarding free phones. Review of the Resident Council meeting minutes dated 08/26/24 revealed residents asked if there were free government phones available. There was no documented response for the concern noted on the form. Review of the Resident Council meeting minutes dated 09/16/24 revealed residents asked again if the social worker could check on free government phones. The department response documented on the form read the social worker had checked and was unable to find any avenues for residents to receive free government phones. Interview on 10/03/24 at 2:05 P.M. with Social Service Director (SSD) #75 confirmed she had been working at the facility since August 2024 and no requests from residents regarding free government phones had been brought to her attention. Interview on 10/03/24 at 2:20 P.M. with Activities Director (AD) #53 on 10/03/24 confirmed residents had requested information and assistance with obtaining government phones during several Resident Council meetings. AD #53 confirmed she was present at Resident Council meetings and wrote the concerns down on a piece of paper and then gave the paper to the Administrator who then typed out the meeting minutes and returned them to her. AD #53 further confirmed the Administrator was responsible to address the concerns and she was unsure how and if the residents' concerns were addressed. Interview on 10/03/24 at 2:30 P.M with Resident #10 on 10/03/24 confirmed residents had requested information about government phones during the last resident council meeting, but the facility had not provided with a response to the concern. This deficiency represents noncompliance investigated under Complaint OH00158289.

Based on observation, staff interview and review of the facility policy, the facility failed to ensure medication carts on the front hall were locked and secured. This had the potential to affect seven facility-identified cognitively impaired and independently mobile residents of 22 residents residing on the front hall. The facility census was 66 residents. Findings include: Observation on 09/30/24 at 8:05 A.M. revealed the two medication carts on the front hall were unlocked and unattended by staff. Interview on 09/30/24 at 8:14 A.M. with Licensed Practical Nurse (LPN) #49 confirmed the front hall medication carts were unlocked and left unattended. LPN #49 confirmed the medication carts should be locked when not attended by staff. Review of the facility policy titled Storage of Medications dated November 2020 revealed drugs and biologicals used in the facility should be stored in locked compartments under proper temperature, light and humidity controls and unlocked medication carts should not be left unattended.

Based on medical record review and the staff interview the facility failed to update resident Preadmission Screening and Resident Reviews (PASARRs) for residents with new diagnoses and/or treatment with psychotropic medications. This affected two (Residents #39 and #52) of four residents reviewed for PASARR completion. The facility census was 66 residents. Findings include: 1. Review of the medical record for Resident #39 revealed an admitted [DATE] with diagnoses including depression, anxiety, diabetes mellitus type two, hypertension and congestive heart failure. Review of the PASARR for Resident #39 dated 07/21/23 revealed the resident did not have a dementia diagnosis or any indications of serious mental illness such as psychosis, depression and anxiety and was not prescribed any psychotropic medications. Review of the diagnosis list for Resident #39 revealed dementia was added as a diagnosis on 08/22/23. Review of the diagnosis list for Resident #39 revealed psychosis was added as a diagnosis on 11/23/23. Review of the care plan for Resident #39 dated 08/02/24 revealed the resident had altered psychosocial needs related to dementia, depression, psychosis and anxiety. Interventions included the following: administer medications as ordered, provide nonpharmacological interventions such as redirect with an activity, offer food and or fluids, offer reassurance, offer conversation and provide one on one care. Review of the annual Minimum Data Set (MDS) assessment for Resident #39 dated 08/15/24 revealed the resident had cognitive impairment with no behaviors and was dependent on the staff for personal care and mobility. Review of the physician's orders for Resident #39 for October 2024 revealed the resident had orders for the following psychotropic medications: Seroquel (antipsychotic medication) 50 milligrams (mg) by mouth three times daily for terminal agitation, Ativan (antianxiety medication) one mg by mouth every eight hours for anxiety, Trazodone (antidepressant medication) 50 mg by mouth at bedtime for terminal agitation and sleep, Paxil (antidepressant medication)10 mg by mouth daily for depression. Interview on 10/03/24 at 2:25 P.M with Social Services Director (SSD) 75 confirmed the facility should have completed a new PASARR for Resident #39 in conjunction with the new diagnoses and the addition of psychotropic medications. 2. Review of the medical record for Resident #52 revealed an admitted [DATE] with a diagnosis of bipolar disorder. Review of the PASARR for Resident #52 dated 06/07/24 revealed the resident was not prescribed any antipsychotic medications. Review of the care plan for Resident #52 dated 08/02/24 revealed the resident had altered psychosocial needs related to bipolar disorder, trouble sleeping, feeling down at times, feeling bad about self and trouble concentrating on things. Interventions included the following: encourage the resident to attend activities of his choice, medications as ordered, monitor for behaviors every shift and document if noted, provide nonpharmacological interventions such as offer food and or fluids, offer reassurance, offer conversation, provide one on one care, offer music of choice. Review of the quarterly MDS assessment for Resident #52 dated 09/19/24 revealed the resident was cognitively intact with no behaviors and required supervision with activities of daily living. Review of the physician's orders for Resident #52 for October 2024 dated 10/24 revealed the resident had orders for the following psychotropic medications: Paxil (antidepressant medication) 40 mg by mouth daily for anxiety dated 07/12/24, Trazadone (antidepressant medication) 50 mg by mouth at bedtime for insomnia dated 07/12/24, Vraylar (antipsychotic medication to treat bipolar disorder) 1.5 mg by mouth daily dated 09/25/24. Interview on 10/03/24 at 2:25 P.M. with SSD #75 confirmed the facility should have completed a new PASARR for Resident #52 with the addition of psychotropic medications. SSD #75 further confirmed the facility did not have a written policy regarding PASARR completion.

Based on record review, observation, resident interview, ombudsman interview, and staff interview, the facility failed to ensure residents were not discharged without a justified and documented reason. This affected one (Resident #20) of three residents reviewed for discharge rights. The facility census was 66 residents. Findings include: Review of the medical record for Resident #20 revealed an admitted [DATE] with the diagnoses including cellulitis, Parkinson's disease, cerebral infarction, bipolar disorder, anxiety, hypertension, dementia, polyneuropathy, depression, asthma, hemiplegia and hemiparesis, hyperlipidemia, and traumatic subdural hemorrhage. Review of the medical record for Resident #20 revealed the resident signed a copy of the facility smoking policy upon admission on 02/29/20. Review of the nurse progress note for Resident #20 dated 06/10/24 revealed the resident was educated on signing himself out of the facility as he was known to leave and purchase cigarettes and lighters while he was out of the facility. The resident returned to the facility with a pack of cigarettes which were turned over to the Administrator. Resident #20 was observed sitting on the front patio smoking cigarettes. Review of the Minimum Data Set (MDS) assessment for Resident #20 completed on 09/18/24 revealed the resident was cognitively intact. Review of the 30-day Notice of Discharge and Transfer of Resident #20 dated 09/27/24 revealed the resident was being discharged from the facility due to noncompliance with the facility smoking policy. The notice was sent to the resident's representative via certified mail and hand-delivered to the resident on 09/27/24. Resident #20 had signed the notice which included information regarding the resident's right to appeal. Interview on 10/02/24 at 10:00 A.M. with the Ombudsman confirmed she spoke to Resident #20 on 09/27/24 regarding the 30-day discharge notice. Further interview with the Ombudsman confirmed the only documented instance of Resident #20 violating the smoking policy was on 06/10/24, and she did not feel the facility had a strong case for an involuntary discharge. Interview on 10/03/24 at 01:46 P.M. with Resident #20 confirmed he did not want to be discharged from the facility. Interview on 10/03/24 at 02:43 P.M. with Social Service Director (SSD) #75 confirmed the facility issued Resident #20 a 30-day discharge notice on 09/27/24 for noncompliance with the facility smoking policy, because the facility did not allow smoking on facility grounds. SSD #75 further confirmed the only documented instance of noncompliance with the smoking policy for Resident #20 occurred on 06/10/24. There were no instances of noncompliance noted in July, August, September, or October 2024.

Based on medical record review and staff interview, the facility failed to provide regular care plan conferences to residents and their representatives. This affected one (Resident #20) of three residents reviewed for care conferences and care planning. The facility census was 66 residents. Findings include: Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses including cellulitis, Parkinson's disease, cerebral infarction, bipolar disorder, hypertension, and dementia. Review of the Minimum Data Set (MDS) assessment for Resident #20 dated 09/18/24 revealed the resident was cognitively intact. Review of the medical record for Resident #20 revealed it did not include documentation of a care conference for the resident since his admission to the facility. Interview on 10/02/24 at 09:46 A.M. with Social Services Director (SSD) 75 confirmed the facility had not conducted a care conference for Resident #20 since the resident's admission in 2020.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure skin alterations were adequately monitored and treated. This affected one (Residents #1) of 23 residents sampled. The facility census was 66 residents. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE] with diagnoses including Parkinson's disease, dysphagia, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #1 dated 07/16/24 revealed the resident was cognitively impaired. Review of the progress notes for Resident #1 dated 07/22/24 revealed the resident had a precancerous lesion on her foreahed and the resident's representative did not want to pursue treatment of the area. Review of the monthly physician's orders for Resident #1 dated October 2024 revealed there were no orders for application of a bandage to the resident's forehead. Observation on 09/30/24 at 10:34 A.M. revealed Resident #1 had a soiled white bandage applied over a skin alteration to her forehead. The bandage was undated and there were no initials to indicate the individual who had applied it. Observation on 10/01/24 at 8:14 A.M. revealed Resident #1 continued to have a soiled white bandage applied over a skin alteration to her forehead. Observation on 10/01/24 at 1:48 P.M. revealed Resident #1 was lying in bed asleep. The soiled white bandage which had been on the resident's forehead had fallen off and was lying on the resident's left shoulder. There was a half-dollar sized lesion with dried blood to the resident's forehead. Interview on 10/01/24 at 1:50 P.M with Licensed Practical Nurse (LPN) 49 confirmed Resident #1 had a precancerous lesion to her forehead which frequently bled. LPN #49 confirmed staff sometimes placed a bandage over the area. Further interview with LPN #49 confirmed there was no order for a bandage to be applied to the skin alteration on the resident's forehead and the area had not been assessed since 07/22/24.

Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure adequate care and services for residents requiring oxygen. This affected one (Resident #8) of 20 residents with orders for oxygen therapy. The facility census was 66. Findings include: Review of the medical record for Resident #8 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), and hypertension. Review of the care plan for Resident #8 dated 01/12/24 revealed the resident had altered respiratory status and difficulty breathing related to COPD. Interventions included the following: administer medications as ordered, observe abnormal breathing patterns, observe for signs and symptoms of respiratory distress, report to the physician as needed. Review of the Minimum Data Set (MDS) assessment for Resident #8 dated 09/19/24 revealed the resident had intact cognition and was coded as not having received oxygen therapy during the review period. Review of the monthly physician's orders for Resident #8 for October 2024 revealed there were no orders in place for the administration of oxygen. Review of the vital signs record for Resident #8 from June 2024 to October 2024 revealed there had been no oxygen saturation levels or respiratory rate recorded since 06/08/24. Observation on 10/01/24 at 3:19 P.M. revealed there was an oxygen in use sign posted on the frame of Resident #8's door. Resident #8 was lying in bed with oxygen being delivered through a nasal cannula at a rate of two liters per minute. Interview on 10/01/24 at 3:20 P.M. with Resident #8 confirmed she utilized oxygen when she was short of breath. Interview on 10/01/24 at 3:58 P.M with Licensed Practical Nurse (LPN) #49 confirmed Resident #8 was receiving oxygen at two liters per minute via nasal canula. LPN #49 further confirmed Resident #8 did not have a physician's order for oxygen therapy and the resident's record did not include oxygen saturation levels or respiratory rates since 06/08/24. Review of the facility policy titled Oxygen Administration revised October 2010 revealed the facility would follow guidelines for safe oxygen administration which included verifying there was a valid physician's order for oxygen therapy. Prior to oxygen administration, the nurse should review the resident's orders, review the facility protocol for oxygen administration, and should monitor the resident's vital signs and oxygen saturation levels in response to oxygen therapy.

Based on medical record review and staff interview, the facility failed to ensure a resident with post-traumatic stress disorder (PTSD) were appropriately assessed to identify the cause of the residents PTSD and minimize triggers and/or re-traumatization. This affected one (Resident #5) of one resident identified by the facility as having PTSD. The facility census was 66 residents. Findings include: Review of the medical record for Resident #5 revealed an admitted [DATE] with diagnoses including cirrhosis of the liver, acute and chronic respiratory failure, diabetes mellitus type two, chronic obstructive pulmonary disease, congestive heart failure, Crohn's disease, chronic kidney disease, depression, and PTSD. Review of the Minimum Data Set (MDS) assessment for Resident #5 dated 09/17/24 revealed the resident was cognitively intact and had a diagnosis of PTSD. Review of the care plan for Resident #5 initiated 09/25/23 revealed the plan did not address the following: the cause of the resident's PTSD, triggers which might cause re-traumatization, interventions to reduce the risk of re-traumatization, how to provide care for a resident with PTSD. Review of the medical record for Resident #5 revealed the record did not include an assessment to identify the cause of the resident's PTSD and the potential triggers which might cause re-traumatization. Interview on 10/02/24 at 12:16 P.M. with the Director of Nursing (DON) confirmed Resident #5 was admitted with a diagnosis of PTSD on 09/25/23, but the facility had not completed an assessment of the cause of the PTSD and the possible triggers which could cause re-traumatization. The DON further confirmed Resident #5's care plan did not address the following: the cause of the resident's PTSD, triggers which might cause re-traumatization, interventions to reduce the risk of re-traumatization, how to provide care for a resident with PTSD.

Based on medical record review, staff interview, review of the facility policy, the facility failed to ensure residents were free of significant medication errors. This affected one (Resident #228) of 13 facility-identified newly admitted residents and one (Resident #45) of five residents reviewed for unnecessary medications. The facility census was 66 residents. Findings include: 1. Review of the medical record for Resident #228 revealed an admitted [DATE] with diagnoses including end stage renal disease, diabetes mellitus type two, chronic obstructive pulmonary disorder and fracture of right lower leg. Review of the admitting physician orders for Resident #228 dated 09/13/24 revealed Resident #228 was ordered Admelog insulin inject 30 units subcutaneously before meals and Tresiba inject 80 units subcutaneously two times daily. Review of the care plan for Resident #228 dated 09/13/24 revealed the resident had diabetes mellitus. Interventions included the following: administer medications as ordered, dietary consultation for nutritional regimen as needed, observe for any signs and symptoms of hyperglycemia and hypoglycemia, obtain blood sugars as ordered, notify physician of abnormal blood sugars as indicated. Review of the Medication Administration Record (MAR) for Resident #228 dated September 2024 revealed the resident should have received Admelog insulin before meals on 09/14/24, but the resident did not receive his first dose of Admelog insulin until 8:00 P.M. on 09/14/24. Resident #228 should have received Tresiba at 8:00 A.M. on 09/14/24, but he did not receive his first dose of Tresiba until 8:00 P.M. on 09/14/24. Interview on 09/30/24 at 2:28 P.M. with Resident #228 confirmed he was admitted to the facility on [DATE] but he missed two doses of Admelog insulin and one dose of Tresiba on 09/14/24 because the medications were not available. Interview on 10/3/24 at 10:02 A.M. with Registered Nurse (RN) #120 confirmed Resident #228 missed two doses of Admelog insulin and one dose of Tresiba for treatment of diabetes mellitus on 09/14/24 because the medications were not available. Interview on 10/04/24 at 9:00 A.M. with the Director of Nursing (DON) confirmed Resident #228 arrived at the facility on new insulins which the facility did not keep in emergency stock. DON confirmed Resident #228 missed two doses of his Admelog insulin and one dose of Tresiba on 09/14/24. 42728 2. Review of the medical record for Resident #45 revealed the resident was admitted on [DATE], transferred to the hospital on 06/19/24, was discharged from the facility on 07/03/24 and was readmitted to the facility on [DATE] with diagnoses including low back pain, seizures, and restlessness and agitation. Review of the admission Minimum Data Set (MDS) assessment for Resident #45 dated 09/25/24 revealed the resident had moderately impaired cognition. Review of the active and discontinued physician's orders for Resident #45 revealed there were no orders for the administration of naloxone (an opioid antagonist). Review of the nurse progress note for Resident #45 dated 06/19/24 and timed 6:26 P.M. revealed Resident #45 was found on her bed, nonresponsive but breathing, and was barely able to be roused with a sternal rub. The resident's blood pressure and pulse were elevated, and the nurse administered a 0.4 milligram (mg) dose of naloxone. Resident #45's responsiveness was somewhat increased after naloxone administration, and the resident was sent to the hospital for an evaluation. Interview on 10/03/24 at 11:45 A.M with the Director of Nursing confirmed Resident #45 did not have an order to be administered naloxone on 06/19/24 and there was no documented history of substance abuse for the resident indicating the need for naloxone to be administered on 06/19/24. The DON confirmed the medication was administered in error for Resident #45. Review of the facility policy titled Medication Administration dated 6/21/17 revealed medications were to be administered in accordance to applicable state, local, and federal laws and consistent with accepted standards of practice and per the prescriber's order.

Based on record review, staff interview, review of online resources per the Centers for Disease Control (CDC) regarding pneumococcal vaccinations, and review of facility policy, the facility failed to ensure residents were offered and received up to date pneumococcal vaccinations. This affected two (Residents #3 and #43) of five residents reviewed for vaccinations. The facility census was 66 residents. Findings include: 1. Review of the medical record for Resident #43 revealed an admitted [DATE] with diagnoses including hypertension, presence of cardiac pacemaker, and intellectual disabilities. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #43 dated 08/19/24 revealed the resident had intact cognition. Review of the vaccination record for Resident #43 revealed the resident received one dose of Pneumovax 23 on 10/01/18. No other pneumococcal vaccines were documented as being offered or administered. 2. Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease and muscle weakness. Review of the quarterly MDS assessment for Resident #3 dated 09/02/24 revealed the resident had moderately impaired cognition. Review of the vaccination record for Resident #3 revealed the resident had received one dose of Pneumovax 23 on 09/08/14. No additional pneumococcal vaccines were documented as being offered or administered. Interview with the Director of Nursing on 10/04/24 at 10:45 A.M. confirmed Residents # had been offered or received PCV15 or PCV20. Review of online guidance per the CDC updated 09/12/24 at https://www2a.cdc.gov/vaccines/m/pneumo/pneumo.html revealed residents should be offered and receive one dose of PCV15 (a pneumococcal vaccine) or PCV 20 (a pneumococcal vaccine) at least one year after the last dose of Pneumovax 23. Review of the facility policy titled Pneumococcal Vaccine revised March 2022 revealed administration of the pneumococcal vaccines were made in accordance with the CDC recommendations in place at the time of the vaccination.

Based on medical record review, observation, resident interview, staff interviews, and review of facility policy, the facility failed to ensure adequate monitoring of a resident pain. This affected one (Resident #45) of four residents reviewed for pain management. The facility census was 66 residents. Findings include: Review of the medical record for Resident #45 revealed the resident an admitted [DATE] with diagnoses including low back pain, restlessness and agitation, and need for assistance with personal care. Review of the admission physician's orders for Resident #45 dated 09/18/24 revealed the resident was ordered to receive the medications Zanaflex, gabapentin, and hydrocodone for pain. Review of the care plan for Resident #45 dated 09/18/24 revealed the resident had actual pain and potential for pain related to chronic low back pain. Interventions included the following: pain assessment quarterly and as needed, monitor for side effects of medications, monitoring what makes the pain worse. Review of the Minimum Data Set (MDS) assessment for Resident #45 dated 09/25/24 revealed the resident had moderately impaired cognition and had daily indicators of pain during the review period. Review of the Resident #45's medical record revealed no pain assessments or pain levels had been obtained since 09/24/24. Observation on 09/30/24 at 8:40 A.M. revealed Resident #45 was yelling out loudly enough to be heard several feet from her room. The resident was lying in bed grimacing and was holding the left side of her ribcage towards her back. Interview on 09/30/24 at 8:41 A.M. with Resident #45 confirmed she was yelling because her back hurt. Interview on 09/30/24 at 8:42 A.M. with Licensed Practical Nurse (LPN) #49 confirmed Resident #49 yelled frequently throughout the day and often complained of pain to the left side of her back. LPN #49 confirmed the resident received several medications for the treatment of the pain which did not seem to help. Observation on 09/30/24 at 3:10 P.M. revealed Resident #45 was yelling out loudly and grimacing. Observation on 10/01/24 at 8:20 A.M. revealed Resident #45 was again yelling out loudly enough to be heard throughout the hallway on which she resided. Observation on 10/02/24 at 3:15 P.M. revealed Resident #45 was again yelling out loudly enough to be heard throughout the hallway on which she resided. Interview on 10/02/24 at 3:15 P.M. with Resident #45 confirmed she was yelling because her back hurt. Observation on 10/03/24 at 9:45 A.M. revealed Resident #45 was again yelling out loudly enough to be heard throughout the hallway on which she resided. Interview on 10/03/24 at 9:45 A.M. with Resident #45 confirmed she was yelling loudly because her back hurt. Interview on 10/03/24 at 10:35 A.M. with LPN #21 confirmed Resident #45 yelled out a large portion of the day and also voiced complaints of pain to the lower back. LPN #21 confirmed the resident was receiving multiple medications for the treatment of pain which seemed to have minimal effectiveness. Interview on 10/03/24 at 11:45 A.M. with the Director of Nursing (DON) confirmed Resident #45 yelled out frequently and complained of back pain. The DON confirmed there were no assessments of the resident's pain levels since 09/24/24 and there was no documentation of nonpharmacological interventions for Resident #45's chronic back pain. Review of the facility policy titled Pain Assessment and Management revised March 2020 revealed pain management was a multidisciplinary process which included recognizing the presence of pain, identifying the characteristics of pain, and monitoring the effectiveness of interventions for pain. Staff should monitor the resident by performing by performing a basic assessment with enough detail and as needed, with standardized assessment tools (approved pain scales, etc.) and relevant criteria for measuring pain management (target signs and symptoms).

Based on observations, staff interview, and policy review, the facility failed to ensure only authorized personnel had access to the medication storage room. This had the potential to affect 80 of 80 residents residing in the facility. Findings include: Interview with Licensed Practical Nurse (LPN) #124 on 01/31/24 at 7:40 A.M. revealed the business office was supposed to place a petty cash box in the medication room each day when they left so that residents had access to petty cash in the evening or on weekends. Observations on 01/31/24 at 7:40 A.M. revealed there was a key pad lock on the medication room door on Station 1. Interview with the Director of Nursing on 01/31/24 at 7:45 A.M. confirmed the business office was to put the money box in the medication room every day so that money was available for residents in the evening and on weekends. Interview with Business Office Manager #201 on 01/31/24 at 7:50 A.M. revealed that she placed the money box in the Station 1 medication room every day when she leaves. At that time, she stated that she had the code to the medication room door. Observations on 01/31/24 at 8:00 A.M. revealed there were unlocked medications in the Station 1 medication room to access if you had the code to the medication room door. Medications included phenergan, insulin, IV antibiotics, buspar, eliquis, venlafaxine, and flexaril. Review of the facility policy titled Storage of Medications (dated November 2020) revealed only persons authorized to prepare and administer medications have access to locked medications. Interview with the Director of Nursing on 01/31/24 at 8:00 A.M. confirmed only nurses should have access to the medication room. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number OH00149842.

Based on observations, staff interview, resident interview, and policy review, the facility failed to ensure residents had access to their personal funds during times the business office was not open (evenings and weekends). The facility handled funds for 47 of 80 residents. This had the potential to affect any resident whose funds were handled by the facility. Findings include: Interview with Licensed Practical Nurse (LPN) #124 on 01/31/24 at 7:40 A.M. revealed the business office was supposed to place a petty cash box in the medication room each day when they left so that residents had access to petty cash in the evening or on weekends. She stated this was not always done. Observations of the medication room, at that time, with LPN #124 confirmed the petty cash box was not in the specified locked location. Interview with the Director of Nursing (DON) on 01/31/24 at 7:45 A.M. confirmed the business office was to put the money box in the medication room every day so that money was available for residents in the evening and on weekends. Interview with Business Office Manager #201 on 01/31/24 at 7:50 A.M. revealed that she had taken the money box out of the locked medication room that morning at 7:30 A.M. Then she stated maybe she did not put it in the medication room last night. Interview with LPN #124 on 01/31/24 at 7:55 A.M. confirmed she had the keys that Business Office Manager #201 would have needed to get the money box out of the locked location in the medication room and confirmed she did not get the box out for Business Office Manager #201 on that day. Interview with Resident #51 on 01/31/24 at 11:50 A.M. revealed the facility handles her funds (verified by facility list). She stated you can't get any of your money after 5:00 P.M. She stated she was not aware of any money being kept at the facility in the evening or on weekends. Interview with Resident #43 on 01/31/24 at 12:00 P.M. revealed the facility handles her funds (verified by facility list). She stated there had been times she had asked for money and they did not have any available in the evenings. Review of the facility policy titled Deposit of Residents' Personal Funds (revised March 2021) revealed if a resident chooses for the facility to hold, safeguard, and manage his/her personal funds, the facility provides the resident access to funds of one hundred dollars (fifty dollars for Medicaid residents) or less within 24 hours and access to funds in excess of one hundred dollars (fifty dollars for Medicaid residents) within three banking days. The policy did not address having petty cash available at times the business office was not open. Interview with the Administrator on 01/31/24 at 10:00 A.M. confirmed the facility policy did not address residents having access to petty cash in the evening or on weekends when the business office was not open. This deficiency represents non-compliance investigated under Complaint Number OH00149842.

Based on staff interview, record review, and observation, the facility failed to ensure that residents received adequate supervision to prevent accidents. Actual Harm occurred to Resident #115 when she was not under staff supervision at the nurse station and she fell in her room resulting in multiple fractures. This affected two (Resident #115, and #144) of four residents reviewed for accidents. The facility failed to ensure hot water temperatures were maintained at a safe level. This occurred in four resident rooms. Findings include: 1. Review of the medical record revealed Resident #115 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a care plan dated 06/01/17 revealed the resident was at risk for falls related to poor safety awareness, increased confusion, history of falls, convulsions and medication use. Interventions were to assist with one or two staff members for ambulation, wear tennis shoes, bed in low position, and keep room free from clutter. A care planned intervention dated 06/03/17 revealed the resident was to be in staff's view at the nurses station when up. Review of a Fall Analysis dated 06/03/17 revealed the resident attempted to stand on her own without asking for assistance. She had a 1.5 centimeter (cm) by 1.5 cm skin tear to her right elbow. The facility's intervention to prevent a re-occurence was for the resident to sit at the nurses station while she was up. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #115 was moderately cognitively impaired and required extensive assistance of two people for bed mobility, transfer, walk in room and corridor, dressing, toilet use and personal hygiene. The resident had a fall history, used a walker and a wheelchair to aid in mobility, was occasionally incontinent of bladder and always continent of bowel. Review of a Departmental Note dated 07/01/17 revealed at 5:50 P.M. Resident #115 fell in her room in the bathroom and complained of pain to the right side of her head, right shoulder, and right hip. The resident was sent to the Emergency Department for evaluation. Review of a Fall Analysis dated 07/01/17 revealed the resident was in her room and fell in the bathroom. Review of hospital records dated 07/01/17 at 7:31 P.M. revealed Resident #115 had several fractures of her right arm. Observation on 07/25/17 at 2:43 P.M. revealed Resident #115 was in a right arm sling and had a bruised face. Interview with the Director of Nursing (DON) on 07/27/17 at 10:26 A.M revealed on 07/01/17, State tested Nurse Aide (STNA) #65 thought Resident #115 did not have to be at the nurse station, so she had the resident in a chair in her room. The DON verified that Resident #115 had a fall in her room and should of been at the nurse station being observed. The DON verified that the resident had a fractured wrist and arm from the fall on 07/01/17. 2. Review of Resident #144's medical record revealed an original admission date of [DATE] with the latest readmission on 06/06/17. Admitting [DIAGNOSES REDACTED]. Review of the resident's Activities of Daily Living plan of care dated 08/10/16 indicated the resident required a mechanical lift for transfers. Review of the resident's MDS 3.0 assessment dated [DATE] indicated the resident has clear speech, usually understands others, usually makes himself understood and had moderate cognitive impairment. The MDS 3.0 assessment indicated the resident required extensive assistance of two staff members for transfers. Review of the resident's progress note dated 06/25/17 at 8:39 P.M. revealed a late entry for 06/24/17 at 10:15 P.M. indicating the registered nurse (RN) was notified to come and assess the resident. The staff said that during a transfer the resident slipped out of the lift pad on the mechanical lift. The entry documented blood was noted on the floor behind the resident's head. A pillow was slid under the resident's head to help stabilize the resident's head and to provide pressure to stop the bleeding. Review of the progress note dated 06/25/17 at 7:23 A.M. documented the resident returned from the local ER with the final [DIAGNOSES REDACTED]. Review of the emergency department discharge instructions dated 06/24/17 revealed the resident was treated for [REDACTED]. Review of the Investigation Template dated 06/27/17 indicated the investigation summary concluded the nurse became distracted when she realized the feeding tube was tangled and let go of the handle on the sling causing the resident to shift in the sling. STNA #30 lifted the resident's legs instead of guiding them during the transfer at the same time the nurse let go of the handle of the sling. The actions of both staff members resulted in the fall. On 07/27/17 at 11:06 A.M. interview with the DON verified the resident fell from the mechanical lift due to staff error. 3. Review of the facility's Hot Water Temperature Log Sheets from 06/08/17 through 07/24/17 revealed the hot water temperature for Room 24 was 132 degrees F on 07/11/17 and 133 degrees F on 07/13/17. The hot water temperatures for Room 25 was 133 degrees F on 07/18/17. The hot water temperature for Room 26 was 132 degrees F on 07/06/17. The hot water temperature for Room 28 was 135 degrees F on 06/08/17. Staff #19 noted at the bottom of each finding of high water temperatures that maintenance was notified. On 07/24/17 the hot water temperature in Room 24 was 127 degrees Fahrenheit (F) at 2:28 P.M., Room 25's hot water temperature was 129 degrees F at 2:46 P.M., Room 26's hot water temperature was 127 degrees F at 2:30 P.M., and Room 28's hot water temperature was 130 degrees F at 2:35 P.M. and 2:57 P.M. Nurse Practitioner (NP) #19 confirmed the hot water temperatures were elevated and stated she had notified maintenance to adjust the hot water temperatures. Interview of NP #19 on 07/24/17 at 3:05 P.M. revealed part of her job was to check water temperatures every week in various rooms on each hall. If she found any water temperatures above 120 degrees F she would immediately report this to the maintenance director and he would adjust the water temperatures to stay between 95 degrees F and 118 degrees F. During an interview with the Administrator on 07/24/17 at 4:39 P.M. she confirmed NP #19's job included to monitor hot water temperatures in various rooms on each hall weekly. The Administrator stated if the water temperature was above 120 degrees F, NP #19 would notify Maintenance Director #113 and he would adjust the hot water tank and assure water temperature in resident rooms were below 120 degrees F. The Administrator said she received a copy of the weekly report within 24 hours of completion. The Administrator confirmed that Maintenance Director #113 did not document on the report the temperature of the hot water in the individual rooms after adjusting the water heater. Interview of Maintenance Director #113 on 07/24/17 at 5:20 P.M. revealed NP #19 obtained weekly hot water temperatures and when a temperature was above 120 degrees F she would notify him and he would adjust the water temperatures to assure all were below 120 degrees F. Maintenance Director #113 confirmed he did not record the temperature of the water after adjusting the hot water tank. Review of the Facility Policy Tels Masters (no date) indicated if water was noted to be over 115 degrees F the water heater should be adjusted and retested as necessary. This deficiency substantiates Complaint Number OH 588.

Based on observation, staff interview, review of the facility's Abuse policy, review of a facility self-reported incident (SRI), and review of facility abuse investigation notes, the facility failed to immediately report verbal and physical abuse to the Administrator thereby delaying the investigation and protection of residents from further abuse. This resulted in Immediate Jeopardy for two of two residents reviewed for abuse (Residents #57 and #65) when staff witnessed State tested Nurse Aide (STNA) #108 being physically and verbally abusive to Resident #57 and verbally abusive to Resident #65 and failed to immediately report the abuse to the Administrator thereby delaying the investigation and protection of residents from further abuse. This had the potential to affect all 107 residents in the facility. On 01/27/16 at 11:45 A.M., the Administrator was notified that Immediate Jeopardy began on 01/22/16 at 10:00 P.M. when STNA #108 asked Resident #65 why she was (expletive) crazy. This was observed by STNA #109. STNA #108 also responded to Resident #65 that she was a nut case and she wished she would die. This was observed by STNA #110. On 01/23/16 between 6:00 P.M. and 10:30 P.M., STNA #108 had a hold of Resident #65's wrist and said, stop your (expletive) (expletive); I am not putting up with you tonight. This was observed by STNA #111. On 01/24/16 around 2:00 A.M., STNA #108 slapped Resident #57 twice on the forehead with her open hand and asked him why he was so stupid when he would not straighten his legs in bed. Later in the morning on 01/24/16, STNA #108 asked Resident #65 why she was crazy and told her to shut up. This was observed by STNA #109. On 01/25/16 at 4:00 A.M. STNA #108 yelled at Resident #57 to put his (expletive) feet down during care. This was observed by Licensed Practical Nurse (LPN) #113. Also, sometime during the night of 01/23/16 or 01/24/16, STNA #108 called an unnamed resident a (expletive) demon. This was observed by STNA #112. STNA's #110, #111, and #112 did not report observing abuse. STNA #109 reported verbal and physical abuse to Registered Nurse (RN) Supervisor #114 sometime between midnight and 6:00 A.M. on 01/25/16. However, RN Supervisor #114 did not report the abuse until 3:25 P.M. on 01/25/16, at which time he sent a text message to the Staff Development Licensed Practical Nurse (LPN) #115. The Administrator was not aware of the abuse until Resident #57's daughter called her on 01/25/16 at 1:15 P.M. and stated that STNA #109 had told her that Resident #57 had been abused by STNA #108. Immediately after the Administrator was notified, STNA #108 was suspended from duty pending investigation. The Immediate Jeopardy was removed on 01/25/16 at 3:00 P.M. when STNA #108 was suspended and an investigation initiated. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 02/11/16 when the facility implemented the following corrective actions: · On 01/25/16 at 3:00 P.M. STNA #108 was suspended from duty (was not working at the time). · On 01/25/16 Resident #57 had a skin assessment completed by the Director of Nursing (DON), RN Supervisor, and Nurse Practitioner (NP) #117 with no suspicious injuries noted. · On 01/26/16 Resident #65 had a skin assessment completed by the DON with no suspicious injuries noted. · On 01/26/16 the six interviewable residents on the dementia unit were interviewed with no issues related to abuse identified. · Body audits were completed by multiple nursing staff including the ADON, DON, and NP #117 for the other 105 residents in the facility between 01/26/16 and 01/27/16 with no suspicious bruising noted. · Starting on 01/26/16 and completed on 01/27/16, in-service training was conducted by Staff Development Nurse #115 for all staff including all disciplines in all areas on the facility abuse policy procedure and resident rights with special emphasis placed on the definitions of abuse, the protection aspect of the policy, and the reporting aspect including the fact of reporting suspected abuse immediately. · On 01/27/16 the 44 additional interviewable residents were interviewed with no issues noted. · On 01/27/16 pain assessments were completed by the MDS Nurse on the 20 residents on the dementia unit who were not interviewable with no issues related to abuse noted. · STNA #108 was terminated from employment on 01/27/16. · LPN #113 was terminated from employment on 01/27/16. · On 01/28/16 a resident council meeting was held by the Administrator, Social Service Director, and Activity Director to determine residents felt safe in the facility and residents were permitted and encouraged to express and report any concerns regarding behaviors displayed by staff, residents, family members or visitors. No issues were noted. Resident council meetings will be held weekly for four weeks. · On 01/31/16 STNA #111 received a written warning for failure to report abuse. · On 01/31/16 STNA ' s #109 and #110 were notified by telephone by the Administrator that they were receiving written warnings for failure to report abuse. As of 02/01/16, the employees had not been in to sign their disciplinary forms. · On 01/31/16 RN Supervisor #114 was notified by telephone by the Administrator that he would receive a one day suspension for failure to notify the administrator of abuse. The suspension had not yet taken place. · On 01/30/16 through 02/03/16 Staff Development Coordinator #115 completed 15 staff abuse questionnaires regarding the resident abuse policy to ensure staff was able to correctly answer questions regarding resident abuse. Eleven of 15 staff were re-educated regarding resident abuse during the time frame of 01/30/16 through 02/03/16. · On 02/02/16, STNA #109 signed her written warning for not reporting resident abuse timely. · On 02/04/16, STNA #110 signed her written warning for not reporting resident abuse timely. · On 02/05/16 through 02/10/16 the ADON completed 15 staff abuse questionnaires regarding the resident abuse policy to ensure staff was able to correctly answer questions regarding resident abuse. No staff re-education was required as a result of these abuse questionnaires. · On 02/11/16, RN Supervisor #114 was suspended from duty during 6 PM- 6:30 AM shift · On 02/16/16 interviews with Licensed Practical Nurses (LPN) #121, #122, and #123 and STNAs #124 and #125 confirmed they were able to articulate the resident abuse policy including protection of residents and reporting abuse. Findings include: Review of the medical record for Resident #57 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was receiving hospice services. Review of the comprehensive assessment dated [DATE] assessed Resident #57 as being severely cognitively impaired and requiring extensive assistance of two staff for bed mobility, transfers, and toileting. Review of the medical record for Resident #65 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. An assessment completed 01/20/16 indicated Resident #65 was severely cognitively impaired, had behaviors towards others, and rejected care. The assessment further indicated Resident #65 required extensive assistance of two staff for bed mobility, transfers, and toileting. Review of an SRI revealed that an allegation of physical abuse was discovered on 01/25/16. A brief description stated that it was reported on 01/26/15 (the date was entered in error and should be 01/25/16 per the Administrator) STNA #108 slapped Resident #57 on the forehead. On 01/26/16 when the surveyor arrived at the facility, the facility had not completed their investigation. Interview with the Administrator on 01/26/16 at 10:30 A.M. revealed on 01/25/16 at 1:15 P.M. she received a telephone call from Resident #57's daughter. The daughter stated she been made aware by STNA #109 that Resident #57 had been abused by STNA #108 over the weekend. The Administrator confirmed she was not aware of the allegation of abuse until notified by Resident #57's daughter. Interview with STNA #109 on 01/27/16 at 9:03 A.M. revealed she worked on the dementia unit with STNA #108 on 01/22/16 from around 10:00 P.M. until 6:00 A.M. on 01/23/16. She stated around 10:00 P.M. on 01/22/16 she observed STNA #108 be verbally abusive to Resident #65. She stated STNA #108 called Resident #65 crazy and asked her why she was so (expletive) crazy. STNA #109 did not report the abuse. STNA #109 stated she again worked with STNA #108 on 01/23/16 from 10:30 P.M. until 6:00 A.M. on 01/24/16. She stated around 2:00 A.M. on 01/24/16, she and STNA #108 went into Resident #57's room to provide care. She stated Resident #57 pulled his legs up and STNA #108 was mad because he would not put his legs down. She stated STNA #108 then slapped Resident #57 twice on the forehead with an open hand and asked him why he was so stupid. STNA #109 stated later in the morning on 01/24/16, STNA #108 was verbally abusive to Resident #65. STNA #108 asked Resident #65 why she was so crazy and told her to shut up. STNA #109 stated she left the facility at 6:00 A.M. and did not report the abuse. STNA #109 stated she came to work at 6:00 P.M. on 01/24/16 but did not work with STNA #108, who was working on the dementia unit from 6:00 P.M. until 6:00 A.M. STNA #109 stated that sometime before midnight on 01/24/16, she notified RN Supervisor #114 regarding the physical and verbal abuse that she had witnessed by STNA #108 on 01/23/16. Interview with RN Supervisor #114 on 01/26/16 at 3:38 P.M. revealed on 01/25/16 at 5:00 A.M. STNA #109 reported to him that STNA #108 was being really mean with residents and cussing at them. STNA #109 had witnessed STNA #108 smack Resident #57 on the forehead repeatedly and ask him why he was so stupid. On 01/26/16 at 4:50 P.M., RN Supervisor #114 confirmed he did not report the abuse until he sent a text message to Staff Development LPN #115 on 01/25/16 at 3:00 P.M. He stated he did not report this to the Director of Nursing or Administrator as he knew STNA #108 was off for a couple of days. Review of a facility investigation note revealed on 01/25/16 STNA #110 was interviewed by Staff Development LPN #115. STNA #110 stated she worked with STNA #108 on 01/22/16. STNA #110 stated Resident #65 was combative, hitting, kicking, and spitting. She stated STNA #108 responded verbally saying that Resident #65 was a nut case and she wished she would die. STNA #110 had not reported this until contacted by the facility on 01/25/16. Interview with STNA #111 on 01/26/16 at 2:00 P.M. revealed on 01/23/16 between 6:00 P.M. and 10:30 P.M. he worked on the dementia unit with STNA #108. He stated STNA #108 was verbally abusive to Resident #65. He stated Resident #65 swatted at STNA #108 and he observed STNA #108 holding the resident's wrist, stating stop your (expletive)[***] I am not putting up with you tonight . He stated he thought LPN #113 heard. STNA #111 stated he did not report the incident because he knew LPN #113 heard STNA #108 and did not do anything. During an interview with STNA #112 on 01/26/16 at 3:31 P.M. she stated STNA #108 was verbally abusive. STNA #112 stated she witnessed this over the weekend on either 01/23/16 or 01/24/16. STNA #112 stated she went to the dementia unit to get some milk and observed STNA #108 in the dining room with residents. She stated STNA #108 was angry and saying a resident was a (expletive) demon. STNA #112 stated this was directed at a resident but she did not know the resident ' s name. STNA #112 stated she did not report what she heard to a supervisor. An interview was conducted with LPN #113 on 01/26/16 at 2:29 P.M. LPN #113 worked 6:00 P.M. to 6:00 A.M. on the dementia unit on 01/22/16, 01/23/16, and 01/24/16. LPN #113 indicated he had heard STNA #108 be verbally abusive to Resident #57. LPN #113 stated while STNA #108 was changing Resident #57, she yelled at him to put his (expletive) feet down. This occurred around 4:00 A.M. on 01/25/16. LPN #113 confirmed he did not report the abuse to anyone. On 02/01/16 at 3:40 P.M., interview with the Administrator revealed that if the first employee (STNA #109) that witnessed abuse had reported it immediately then it would have prevented further instances of abuse of residents and would have initiated the investigation. Review of the facility Abuse policy and procedure dated 03/01/14 revealed it was the policy to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident property and to ensure that all alleged violations of Federal or State laws which involved mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of resident property were reported immediately to the Administrator of the center. The policy further stated that if the suspected perpetrator was an employee, the Administrator or designee shall place the employee on immediate investigatory suspension while completing the investigation. This certification deficiency substantiates Complaint OH 437.

Based on observation, staff interview, review of the facility's abuse policy, review of a facility self-reported incident (SRI), and review of facility abuse investigation notes, the facility failed to follow their abuse policy and procedure and immediately report verbal and physical abuse of two residents. This resulted in Immediate Jeopardy for two of two residents reviewed for abuse (Residents #57 and #65) when State tested Nurse Aide (STNA) #108 was witnessed by staff as being physically and verbally abusive to Resident #57 and verbally abusive to Resident #65. Staff failed to follow their abuse policy and procedure and did not immediately report the abuse to the Administrator. This resulted in a delay in the investigation and the protection of residents. This had the potential to affect all 107 residents. On 01/27/16 at 11:45 A.M., the Administrator was notified that Immediate Jeopardy began on 01/22/16 at 10:00 P.M. when STNA #108 asked Resident #65 why she was (expletive) crazy. This was observed by STNA #109. STNA #108 also responded to Resident #65 that she was a nut case and she wished she would die. This was observed by STNA #110. On 01/23/16 between 6:00 P.M. and 10:30 P.M., STNA #108 held Resident #65's wrist and said, stop your (expletive) (expletive); I am not putting up with you tonight. This was observed by STNA #111. On 01/24/16 around 2:00 A.M., STNA #108 slapped Resident #57 twice on the forehead with her open hand and asked him why he was so stupid when he would not straighten his legs in bed. Later in the morning on 01/24/16, STNA #108 asked Resident #65 why she was crazy and told her to shut up. This was observed by STNA #109. On 01/25/16 at 4:00 A.M. STNA #108 yelled at Resident #57 to put his (expletive) feet down during care. This was observed by Licensed Practical Nurse (LPN) #113. During the night of 01/23/16 or 01/24/16 TNA #112 indicated STNA #108 called an unnamed resident a (expletive) demon. STNAs #110, #111, and #112 did not report their observation of physical and verbal abuse. STNA #109 reported verbal and physical abuse to Registered Nurse (RN) Supervisor #114 sometime between midnight and 6:00 A.M. on 01/25/16. However, RN Supervisor #114 did not report the abuse until 3:25 P.M. on 01/25/16, at which time he sent a text message to Staff Development Licensed Practical Nurse (LPN) #115. The Administrator was not aware of the abuse until Resident #57's daughter called her on 01/25/16 at 1:15 P.M. and stated that STNA #109 had told her that Resident #57 had been abused by STNA #108. Immediately after the Administrator was notified, STNA #108 was suspended from duty pending investigation. The Immediate Jeopardy was removed on 01/25/16 at 3:00 P.M. when STNA #108 was suspended and an investigation initiated. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 02/11/16 when the facility implemented the following corrective actions: · On 01/25/16 at 3:00 P.M. STNA #108 was suspended from duty (was not working at the time). · On 01/25/16 Resident #57 had a skin assessment completed by the Director of Nursing (DON), RN Supervisor, and Nurse Practitioner (NP) #117 with no suspicious injuries noted. · On 01/26/16 Resident #65 had a skin assessment completed by the DON with no suspicious injuries noted. · On 01/26/16 the six interviewable residents on the dementia unit were interviewed with no issues related to abuse identified. · Body audits were completed by multiple nursing staff including the ADON, DON, and NP #117 for the other 105 residents in the facility between 01/26/16 and 01/27/16 with no suspicious bruising noted. · Starting on 01/26/16 and completed on 01/27/16, in-service training was conducted by Staff Development Nurse #115 for all staff including all disciplines in all areas on the facility abuse policy procedure and resident rights with special emphasis placed on the definitions of abuse, the protection aspect of the policy, and the reporting aspect including the fact of reporting suspected abuse immediately. · On 01/27/16 the 44 additional interviewable residents were interviewed with no issues noted. · On 01/27/16 pain assessments were completed by the MDS Nurse on the 20 residents on the dementia unit who were not interviewable with no issues related to abuse noted. · STNA #108 was terminated from employment on 01/27/16. · LPN #113 was terminated from employment on 01/27/16. · On 01/28/16 a resident council meeting was held by the Administrator, Social Service Director, and Activity Director to determine residents felt safe in the facility and residents were permitted and encouraged to express and report any concerns regarding behaviors displayed by staff, residents, family members or visitors. No issues were noted. Resident council meetings will be held weekly for four weeks. · On 01/31/16 STNA #111 received a written warning for failure to report abuse. · On 01/31/16 STNAs #109 and #110 were notified by telephone by the Administrator that they were receiving written warnings for failure to report abuse. As of 02/01/16, the employees had not been in to sign their disciplinary forms. · On 01/31/16 RN Supervisor #114 was notified by telephone by the Administrator that he would receive a one day suspension for failure to notify the administrator of abuse. The suspension had not yet taken place. · On 01/30/16 through 02/03/16 Staff Development Coordinator #115 completed 15 staff abuse questionnaires regarding the resident abuse policy to ensure staff was able to correctly answer questions regarding resident abuse. Eleven of 15 staff were re-educated regarding resident abuse during the time frame of 01/30/16 through 02/03/16. · On 02/02/16, STNA #109 signed her written warning for not reporting resident abuse timely. · On 02/04/16, STNA #110 signed her written warning for not reporting resident abuse timely. · On 02/05/16 through 02/10/16 the ADON completed 15 staff abuse questionnaires regarding the resident abuse policy to ensure staff was able to correctly answer questions regarding resident abuse. No staff re-education was required as a result of these abuse questionnaires. · On 02/11/16, RN Supervisor #114 was suspended from duty during 6 PM- 6:30 AM shift · On 02/16/16 interviews with Licensed Practical Nurses (LPN) #121, #122, and #123 and STNAs #124 and #125 confirmed they were able to articulate the resident abuse policy including protection of residents and reporting abuse. Findings include: Review of the medical record for Resident #57 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was receiving hospice services. Review of the comprehensive assessment dated [DATE] assessed Resident #57 as being severely cognitively impaired and requiring extensive assistance of two staff for bed mobility, transfers, and toileting. Review of the medical record for Resident #65 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. An assessment completed 01/20/16 indicated Resident #65 was severely cognitively impaired, had behaviors towards others, and rejected care. The assessment further indicated Resident #65 required extensive assistance of two staff for bed mobility, transfers, and toileting. Review of an SRI revealed that an allegation of physical abuse was discovered on 01/25/16. A brief description stated that it was reported on 01/26/15 (the date was entered in error and should be 01/25/16 per the Administrator) STNA #108 slapped Resident #57 on the forehead. On 01/26/16 when the surveyor arrived at the facility, the facility had not completed their investigation. Interview with the Administrator on 01/26/16 at 10:30 A.M. revealed on 01/25/16 at 1:15 P.M. she received a telephone call from Resident #57's daughter. The daughter stated she been made aware by STNA #109 that Resident #57 had been abused by STNA #108 over the weekend. The Administrator confirmed she was not aware of the allegation of abuse until notified by Resident #57's daughter. Interview with STNA #109 on 01/27/16 at 9:03 A.M. revealed she worked on the dementia unit with STNA #108 on 01/22/16 from around 10:00 P.M. until 6:00 A.M. on 01/23/16. She stated around 10:00 P.M. on 01/22/16 she observed STNA #108 be verbally abusive to Resident #65. She stated STNA #108 called Resident #65 crazy and asked her why she was so (expletive) crazy. STNA #109 did not report the abuse. STNA #109 stated she again worked with STNA #108 on 01/23/16 from 10:30 P.M. until 6:00 A.M. on 01/24/16. She stated around 2:00 A.M. on 01/24/16, she and STNA #108 went into Resident #57's room to provide care. She stated Resident #57 pulled his legs up and STNA #108 was mad because he would not put his legs down. She stated STNA #108 then slapped Resident #57 twice on the forehead with an open hand and asked him why he was so stupid. STNA #109 stated later in the morning on 01/24/16, STNA #108 was verbally abusive to Resident #65. STNA #108 asked Resident #65 why she was so crazy and told her to shut up. STNA #109 stated she left the facility at 6:00 A.M. and did not report the abuse. STNA #109 stated she came to work at 6:00 P.M. on 01/24/16 but did not work with STNA #108, who was working on the dementia unit from 6:00 P.M. until 6:00 A.M. STNA #109 stated that sometime before midnight on 01/24/16, she notified RN Supervisor #114 regarding the physical and verbal abuse that she had witnessed by STNA #108 on 01/23/16. Interview with RN Supervisor #114 on 01/26/16 at 3:38 P.M. revealed on 01/25/16 at 5:00 A.M. STNA #109 reported to him that STNA #108 was being really mean with residents and cussing at them. STNA #109 had witnessed STNA #108 smack Resident #57 on the forehead repeatedly and ask him why he was so stupid. On 01/26/16 at 4:50 P.M., RN Supervisor #114 confirmed he did not report the abuse until he sent a text message to Staff Development LPN #115 on 01/25/16 at 3:00 P.M. He stated he did not report this to the Director of Nursing or Administrator as he knew STNA #108 was off for a couple of days. Review of a facility investigation note revealed on 01/25/16 STNA #110 was interviewed by Staff Development LPN #115. STNA #110 stated she worked with STNA #108 on 01/22/16. STNA #110 stated Resident #65 was combative, hitting, kicking, and spitting. She stated STNA #108 responded verbally saying that Resident #65 was a nut case and she wished she would die. STNA #110 had not reported this until contacted by the facility on 01/25/16. Interview with STNA #111 on 01/26/16 at 2:00 P.M. revealed on 01/23/16 between 6:00 P.M. and 10:30 P.M. he worked on the dementia unit with STNA #108. He stated STNA #108 was verbally abusive to Resident #65. He stated Resident #65 swatted at STNA #108 and he observed STNA #108 holding the resident's wrist, stating stop your (expletive)[***] I am not putting up with you tonight . He stated he thought LPN #113 heard. STNA #111 stated he did not report the incident because he knew LPN #113 heard STNA #108 and did not do anything. During an interview with STNA #112 on 01/26/16 at 3:31 P.M. she stated STNA #108 was verbally abusive. STNA #112 stated she witnessed this over the weekend on either 01/23/16 or 01/24/16. STNA #112 stated she went to the dementia unit to get some milk and observed STNA #108 in the dining room with residents. She stated STNA #108 was angry and saying a resident was a (expletive) demon. STNA #112 stated this was directed at a resident but she did not know the resident ' s name. STNA #112 stated she did not report what she heard to a supervisor. An interview was conducted with LPN #113 on 01/26/16 at 2:29 P.M. LPN #113 worked 6:00 P.M. to 6:00 A.M. on the dementia unit on 01/22/16, 01/23/16, and 01/24/16. LPN #113 indicated he had heard STNA #108 be verbally abusive to Resident #57. LPN #113 stated while STNA #108 was changing Resident #57, she yelled at him to put his (expletive) feet down. This occurred around 4:00 A.M. on 01/25/16. LPN #113 confirmed he did not report the abuse to anyone. On 02/01/16 at 3:40 P.M., interview with the Administrator verified the facility policy was to report abuse immediately. The administrator verified the facility policy was not followed when the facility staff witnessed verbal and physical abuse and did not report it immediately. Review of the facility Abuse policy and procedure dated 03/01/14 revealed it was the policy to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident property and to ensure that all alleged violations of Federal or State laws which involved mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of resident property were reported immediately to the Administrator of the center. The policy further stated that if the suspected perpetrator was an employee, the Administrator or designee shall place the employee on immediate investigatory suspension while completing the investigation. This certification deficiency substantiates Complaint OH 437.

Based on observation, staff interview, review of the facility's Abuse policy, review of a facility self-reported incident (SRI), and review of facility abuse investigation notes, the facility failed to prevent staff to resident physical and verbal abuse. This resulted in Immediate Jeopardy for two of two residents reviewed for abuse (Residents #57 and #65) when State tested Nurse Aide (STNA) #108 was physically and verbally abusive to Resident #57 and verbally abusive to Resident #65. The facility census was 107. On 01/27/16 at 11:45 A.M., the Administrator was notified that Immediate Jeopardy began on 01/22/16 at 10:00 P.M. when STNA #108 asked Resident #65 why she was (expletive) crazy. This was observed by STNA #109. STNA #108 also responded to Resident #65 that she was a nut case and she wished she would die. This was observed by STNA #110. On 01/23/16 between 6:00 P.M. and 10:30 P.M., STNA #108 held Resident #65's wrist and said, stop your (expletive) (expletive); I am not putting up with you tonight. This was observed by STNA #111. On 01/24/16 around 2:00 A.M., STNA #108 slapped Resident #57 twice on the forehead with her open hand and asked him why he was so stupid when he would not straighten his legs in bed. Later in the morning on 01/24/16, STNA #108 asked Resident #65 why she was crazy and told her to shut up. This was observed by STNA #109. On 01/25/16 at 4:00 A.M. STNA #108 yelled at Resident #57 to put his (expletive) feet down during care. This was observed by Licensed Practical Nurse (LPN) #113. Also, sometime during the night of 01/23/16 or 01/24/16, STNA #108 called an unnamed resident a (expletive) demon. This was observed by STNA #112. STNA's #110, #111, and #112 did not report observing abuse. STNA #109 reported verbal and physical abuse to Registered Nurse (RN) Supervisor #114 sometime between midnight and 6:00 A.M. on 01/25/16. However, RN Supervisor #114 did not report the abuse until 3:25 P.M. on 01/25/16, at which time he sent a text message to the Staff Development LPN #115. The Administrator was not aware of the abuse until Resident #57's daughter called her on 01/25/16 at 1:15 P.M. and stated that STNA #109 had told her that Resident #57 had been abused by STNA #108. Immediately after the Administrator was notified, STNA #108 was suspended from duty pending investigation. The Immediate Jeopardy was removed on 01/25/16 at 3:00 P.M. when STNA #108 was suspended and an investigation initiated. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 02/11/16 when the facility implemented the following corrective actions: · On 01/25/16 at 3:00 P.M. STNA #108 was suspended from duty. · On 01/25/16 Resident #57 had a skin assessment completed by the Director of Nursing (DON), RN Supervisor, and Nurse Practitioner (NP) #117 with no suspicious injuries noted. · On 01/26/16 Resident #65 had a skin assessment completed by the DON with no suspicious injuries noted. · On 01/26/16 the six interviewable residents on the dementia unit were interviewed by Guest Relations Staff #118 and no issues related to abuse identified. · Body audits were completed by multiple nursing staff including the ADON, DON, and NP #117 for the other 105 residents in the facility between 01/26/16 and 01/27/16 with no suspicious bruising noted. · Starting on 01/26/16 and completed on 01/27/16, in-service training was conducted by Staff Development Nurse #115 for all staff including all disciplines in all areas on the facility abuse policy and procedure and resident rights with special emphasis placed on the definitions of abuse, the protection aspect of the policy, and the reporting aspect including the fact of reporting suspected abuse immediately. · On 01/27/16, 44 additional interviewable residents were interviewed by Guest Relations Staff #118, Admissions Coordinator #119, and Social Worker #120 with no issues noted. · On 01/27/16 pain assessments were completed by the MDS Nurse on the 20 residents on the dementia unit who were not interviewable with no issues related to abuse noted. · On 01/17/16 STNA #108 was terminated from employment. · On 01/27/16 LPN #113 was terminated from employment. · On 01/28/16 a resident council meeting was held by the Administrator, Social Service Director and Activity Director to determine if residents felt safe in the facility. Residents were encouraged to express and report any concerns regarding behaviors displayed by staff, residents, family members or visitors. No issues were noted. Resident council meetings will be held weekly for four weeks. · On 01/31/16 STNA #111 received a written warning for failure to report abuse. · On 01/31/16 STNA's #109 and #110 were notified by telephone by the Administrator that they were receiving written warnings for failure to report abuse. As of 02/01/6, the employees had not been in to sign their disciplinary forms. · On 01/31/16 RN Supervisor #114 was notified by telephone by the Administrator that he would receive a one day suspension for failure to notify the administrator of abuse. The suspension had not yet taken place. · On 01/30/16 through 02/03/16 Staff Development Coordinator #115 completed 15 staff abuse questionnaires regarding the resident abuse policy to ensure staff was able to correctly answer questions regarding resident abuse. Eleven of 15 staff were re-educated regarding resident abuse during the time frame of 01/30/16 through 02/03/16. · On 02/02/16, STNA #109 signed her written warning for not reporting resident abuse timely. · On 02/04/16, STNA #110 signed her written warning for not reporting resident abuse timely. · On 02/05/16 through 02/10/16 the ADON completed 15 staff abuse questionnaires regarding the resident abuse policy to ensure staff was able to correctly answer questions regarding resident abuse. No staff re-education was required as a result of these abuse questionnaires. · On 02/11/16, RN Supervisor #114 was suspended from duty during 6 PM- 6:30 AM shift. · On 02/16/16 interviews with Licensed Practical Nurses (LPN) #121, #122, and #123 and STNAs #124 and #125 confirmed they were able to articulate the resident abuse policy including protection of residents and reporting abuse. Findings include: Review of the medical record for Resident #57 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident was receiving hospice services. Review of the comprehensive assessment dated [DATE] assessed Resident #57 as being severely cognitively impaired and requiring extensive assistance of two staff for bed mobility, transfers and toileting. Review of the medical record for Resident #65 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. An assessment completed 01/20/16 indicated Resident #65 was severely cognitively impaired, had behaviors towards others, and rejected care. The assessment further indicated Resident #65 required extensive assistance of two staff for bed mobility, transfers, and toileting. Review of an SRI revealed that an allegation of physical abuse was discovered on 01/25/16. A brief description stated that it was reported on 01/26/15 (the date was entered in error and should be 01/25/16 per Administrator) STNA #108 slapped Resident #57 on the forehead. On 01/26/16 when the surveyor arrived at the facility, the facility had not completed their investigation. Interview with the Administrator on 01/26/16 at 10:30 A.M. revealed on 01/25/16 at 1:15 P.M. she received a telephone call from Resident #57's daughter. The daughter stated she been made aware by STNA #109 that Resident #57 had been abused by STNA #108 over the weekend. The Administrator confirmed she was not aware of the allegation of abuse until notified by Resident #57's daughter. Interview with STNA #109 on 01/27/16 at 9:03 A.M. revealed she worked on the dementia unit with STNA #108 on 01/22/16 from around 10:00 P.M. until 6:00 A.M. on 01/23/16. She stated around 10:00 P.M. on 01/22/16 she observed STNA #108 be verbally abusive to Resident #65. She stated STNA #108 called Resident #65 crazy and asked her why she was so (expletive) crazy. STNA #109 did not report the abuse. STNA #109 stated she again worked with STNA #108 on 01/23/16 from 10:30 P.M. until 6:00 A.M. on 01/24/16. She stated around 2:00 A.M. on 01/24/16, she and STNA #108 went into Resident #57's room to provide care. She stated Resident #57 pulled his legs up and STNA #108 was mad because he would not put his legs down. She stated STNA #108 then slapped Resident #57 twice on the forehead with an open hand and asked him why he was so stupid. STNA #109 stated later in the morning on 01/24/16, STNA #108 was verbally abusive to Resident #65. STNA #108 asked Resident #65 why she was so crazy and told her to shut up. STNA #109 stated she left the facility at 6:00 A.M. and did not report the abuse. STNA #109 stated she came to work at 6:00 P.M. on 01/24/16 but did not work with STNA #108, who was working on the dementia unit from 6:00 P.M. until 6:00 A.M. STNA #109 stated that sometime before midnight on 01/24/16, she notified RN Supervisor #114 regarding the physical and verbal abuse that she had witnessed by STNA #108 on 01/23/16. Interview with RN Supervisor #114 on 01/26/16 at 3:38 P.M. revealed on 01/25/16 at 5:00 A.M. STNA #109 reported to him that STNA #108 was being really mean with residents and cussing at them. STNA #109 had witnessed STNA #108 smack Resident #57 on the forehead repeatedly and ask him why he was so stupid. On 01/26/16 at 4:50 P.M., RN Supervisor #114 confirmed he did not report the abuse until he sent a text message to Staff Development LPN #115 on 01/25/16 at 3:00 P.M. He stated he did not report this to the DON or Administrator as he knew STNA #108 was off for a couple of days. Review of a facility investigation note revealed on 01/25/16 STNA #110 was interviewed by Staff Development LPN #115. STNA #110 stated she worked with STNA #108 on 01/22/16. STNA #110 stated Resident #65 was combative, hitting, kicking and spitting. She stated STNA #108 responded verbally saying that Resident #65 was a nut case and she wished she would die. STNA #110 had not reported this until contacted by the facility on 01/25/16. Interview with STNA #111 on 01/26/16 at 2:00 P.M. revealed on 01/23/16 between 6:00 P.M. and 10:30 P.M. he worked on the dementia unit with STNA #108. He stated STNA #108 was verbally abusive to Resident #65. He stated Resident #65 swatted at STNA #108 and he observed STNA #108 holding the resident's wrist, stating stop your (expletive) s__t. I am not putting up with you tonight . He stated he thought LPN #113 heard. STNA #111 stated he did not report the incident because he knew LPN #113 heard STNA #108 and did not do anything. During an interview with STNA #112 on 01/26/16 at 3:31 P.M. she stated STNA #108 was verbally abusive. STNA #112 stated she witnessed this over the weekend on either 01/23/16 or 01/24/16. STNA #112 stated she went to the dementia unit to get some milk and observed STNA #108 in the dining room with residents. She stated STNA #108 was angry and saying a resident was a (expletive) demon. STNA #112 stated this was directed at a resident but she did not know the resident's name. STNA #112 stated she did not report what she heard to a supervisor. An interview was conducted with LPN #113 on 01/26/16 at 2:29 P.M. LPN #113 worked 6:00 P.M. to 6:00 A.M. on the dementia unit on 01/22/16, 01/23/16 and 01/24/16. LPN #113 indicated he had heard STNA #108 be verbally abusive to Resident #57. LPN #113 stated while STNA #108 was changing Resident #57, she yelled at him to put his (expletive) feet down. This occurred around 4:00 A.M. on 01/25/16. LPN #113 confirmed he did not report the abuse to anyone. On 1/26/16 at 12:52 P.M. Resident #57 was observed in bed on his back with his knees drawn up towards his chest, his eyes were mostly closed. Resident #57 did not respond to verbal questions. Resident #57's right arm had a clear, occlusive dressing on his right elbow and the right upper backside of the arm. No redness or bruising was noted to Resident #57's head and face. 1/26/16 at 5:30 P.M. Resident #65 was observed seated in the dining room and had just finished with supper. Resident #65 had a swollen area on her forehead. Resident #65 spoke words but said things that didn't make sense. The resident was not able to be interviewed. Review of the facility Abuse Policy and Procedure, dated 03/01/14, revealed it was the policy to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident property and to ensure that all alleged violations of Federal or State laws which involved mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of resident property were reported immediately to the Administrator of the center. This certification deficiency substantiates Complaint OH 437.

Based on clinical record reviews, review of fall tracking, investigation review, review of performance evaluation, observation, facility policy review and staff interview, the facility failed to provide care and supervision of care to prevent the harm of fractures to three of five residents reviewed for fractures which occurred in the facility (Residents #201, #49, #11). The facility identified four residents with fractures that occurred in the facility. The facility census was 107. Harm occurred to Resident #201 when the facility assessed the resident at high risk for falls and failed to develop and implement interventions to assist the resident with fall prevention resulting in the resident having a fall and sustaining a fractured collar bone. Harm occurred to Resident #49 when the facility assessed the resident at high risk for falls and failed to develop and implement interventions resulting in the resident falling and sustaining fractures of the right shoulder and right femoral head requiring surgical intervention. Harm occurred to Resident #11 when the facility staff failed to transfer the resident using a mechanical lift resulting in the resident sustaining a fractured ankle. 1. Review of the closed clinical record for Resident #201 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The only minimum data set (MDS) assessment was a five day assessment related to the discharge of the resident on 01/31/12 after one of three falls which resulted in a fracture. The assessment revealed a need for extensive assist of two for ambulation and the resident had a fall since admission on 01/28/12. Noted interventions were to re-educate the resident to ask for assist with ambulation. The assessment identified the resident sometimes understood and had problems with short term memory and decision making abilities. No interventions were put in place to prevent the resident from ambulating unassisted. The initial nursing assessment for Resident #201, completed on 01/24/12, revealed the resident required assist of two persons for ambulation. The assessment indicated poor balance sitting and standing with an unsteady gait. The cognitive assessment did not match the MDS assessment of cognition. The resident required two person assist to go to the bathroom. The nursing assessment completed on 01/26/12 revealed the resident had problems with short term memory and could not recall after 5 minutes. The assessment evidenced the resident was disoriented to place, time and situation. The assessment indicated the resident's gait was unsteady, balance problem and weakness. The nursing assessment note on 01/27/12 revealed the resident was very confused and had no idea where he was or why he was here. The note documented the plan for the resident was to return to home. The nursing assessment completed on 01/28/12 revealed the resident was disoriented with short term memory, disoriented to place, time, situation and was restless. The resident had an unsteady gait, poor balance and weakness with decreased movement of the right and left lower extremities. The note documented the resident was confused looking for cats and dogs, and the need to get the carburetor off the stand and fix his car. The resident was documented as restless. No additional interventions were put in place to provide a safe environment with the changes noted in the resident's cognition and decreased ambulation ability. Review of the Departmental Notes for 01/28/12 at 3:03 A.M., revealed at 2:00 A.M., a crash was heard from the resident's room. The resident was found on the floor. A new fall assessment was not completed. The note documented the resident had been up several times prior to this fall in other residents rooms. The intervention to prevent unassisted ambulation was resident instruction to use the call light for help. Review of the POC after the fall on 01/28/12 revealed an intervention to put a yellow band on the resident's wrist, re-educate to use call light, check oxygen level and review medications with physician for possible changes. No interventions were put in place to prevent the confused resident from ambulating unassisted. Review of the nursing assessment completed 01/30/12, revealed the resident continued with short term memory, inability to recall information more then 5 minutes, disoriented to person, place, time and situation. The resident was described as restless and required extensive assist with transfers and ambulation. No additional interventions were put in place related to the assessment to provide a safe environment. Review of the Departmental Notes dated 01/30/12 at 2:38 P.M. revealed the resident was found sitting on the floor at 2:10 P.M. The resident reported getting up to turn the TV on and lost his balance and sat down on the floor. The TV remote was noted to be on the table beside the bed. The note documented the resident was observed previous to the incident up ambulating in the hallway pushing a wheelchair with an unsteady gait and was assisted back to a bedside chair. No additional precautions or interventions were implemented to prevent the resident from ambulating unassisted. A note on 01/30/12 indicated the family expressed concern about the resident being lethargic at times. The physician was notified of the concern and an order was received to check oxygen saturation four times a day x 48 hours and discontinue Remeron (a medication given at night). Review of the plan of care for Resident #201 revealed the intervention to prevent the resident from ambulating unassisted and prevent falls was to place the TV remote on the bedside table. According to the review of the Departmental Notes of 01/30/12, the remote was documented as on the bedside table at the time of the fall on 1/30/12. No other interventions were put in place to prevent the resident from ambulating unassisted and prevent falls. Review of the clinical record revealed Resident #201 had a fall on 01/31/12 at 5:15 P.M. The resident was found on the floor and noted to have skin tears to the left elbow, along with redness and swelling to the left collar bone area. The resident was documented as expressing complaints of pain to the left shoulder and unable to move. The resident's vital signs were taken and was noted to have a blood pressure of 153/78, pulse of 83, temperature of 98.1, respirations of 20 and oxygen saturation level of 93%. The physician was notified and an order received to send the resident to the local emergency room for evaluation and a possible fractured clavicle. The resident was transported at 5:35 P.M. Review of a Fall and Critical Incident checklist completed on 01/31/12 revealed the resident was transferred from the local emergency room to the hospital with a fracture of the collar bone. Review of the "Fall Reduction Program" dated 12/01/10 revealed a fall assessment was to be completed on admission, with significant change and after a fall. If a resident had a score of 10 or above the resident was considered a high fall risk. The program required the assessing nurse to provide an interim plan of care to identify the resident at risk for falls. Once the plan of care was completed an activity of daily living (ADL) flow sheet was to be put in place as follows: Section V: After occurrence of fall, (e): Licensed nurse will revise interventions for the resident previously identified as "at risk". There was no documentation by the nurse on duty at the time of the fall that this had occurred for Resident #201. The Departmental Notes, fall investigations and the plan of care to provide interventions for Resident #201 was reviewed with registered nurse (RN) #6 on 02/22/12 at 3:00 P.M., and verified the interventions to provide a safe environment were ineffective. Review of the nursing documentation of the change in the resident status in cognition and observation of unassisted ambulation on multiple occasions revealed the nurse failed to implement interventions to provide additional safety measures to prevent unassisted ambulation which resulted in the fall on 01/30/12 and a fractured collar bone. This was verified during interview of RN #6 on 02/22/12 at 3:00 P.M. 2. Review of the clinical record for Resident #49 revealed the resident was admitted to the facility on [DATE], with readmission on 02/13/12 with a fracture of the right shoulder, and right femoral neck with surgical intervention of an open reduction and internal fixation. The resident had [DIAGNOSES REDACTED]. The MDS assessment completed on 01/04/12 required physical assist of one for ambulation in the room and ambulation did not occur in the corridor. The MDS assessment completed on 02/20/12 revealed the resident required an assist of two for ambulation in the room. Review of fall tracking for Resident #49 revealed four falls from 12/11/11 to 02/08/12 with the last fall resulting in fractures which required surgical intervention. Review of the POC dated 03/24/11 for Resident #49 revealed the resident was identified as a fall risk. The POC identified the resident required extensive assist of two for all ambulation. The POC identified the resident required staff to observe for changes in condition that may warrant increased supervision and assistance. The resident was to wear a yellow fall risk bracelet to alert staff the resident was at risk for falls. The resident had a POC related to restlessness and anxiety which was initiated on 03/24/11 and identified the resident as requiring 1 on 1 observations when anxious. Review of incident tracking of falls for Resident #49 revealed a fall on 12/11/11 in the hallway at 3:30 P.M. The investigation revealed the resident was ambulating unassisted and the intervention was to give the resident Fiber Lax Tabs, and every 15 minute checks x 24 hours. Review of the POC revealed no interventions were implemented to ensure the safety of the resident to prevent unassisted ambulation. The resident had a fall on 01/17/12 at 2:28 A.M. The investigation revealed the resident was heard to call for help. The resident was found in another resident's room on the floor. The resident suffered skin tears and bruising and complained of pain. Review of the fall investigation revealed the fall was related to unassisted ambulation. The intervention was to obtain a urine analysis and place on every 15 minute checks for 24 hours. Review of the POC revealed the intervention was to obtain a urinalysis and to refer to physical therapy evaluation as needed. There were no notes that evidenced this occurred after this fall. The POC also identified to refer the resident to restorative services for treatment as ordered. There was no evidence in the notes this occurred after this fall. Review of the Department Note dated 01/24/12 at 7:38 A.M. revealed the resident continued to get up unassisted. Review of the POC for falls revealed no additional interventions were put in place to prevent the resident from ambulating unassisted. Review of the clinical record revealed the resident had a fall on 02/01/12 at 8:00 P.M. in the bathroom. The investigation revealed while the nurse aide took the resident to the bathroom, the resident was left unsupervised and fell on the floor. Review of the POC revealed an intervention was to obtain urinalysis and add a defined perimeter mattress. This intervention was not relevant to the resident being left unsupervised in the bathroom. Review of a therapy note on 02/03/12 revealed the resident ambulated five feet with maximum assist of two persons. No additional interventions were put in place to ensure the resident did not ambulate without assist of two. The POC indicated the need to ambulate with one assist. Review of the incident tracking for Resident #49 noted a fall on 02/08/12 at 5:30 A.M. related to unassisted ambulation. The interventions noted were to obtain a x-ray of the right hip and right shoulder, place on every 15 minute checks for 24 hours and evaluate for a bed alarm. Documentation in the Departmental Notes on 02/08/12 (late entry for 5:30 A.M.), revealed the resident was found on the floor with blood to the right side of the forehead. The resident was documented as stating "she thought it was time to get up". The resident was transported to the hospital related to x-ray results of fractures of the right shoulder and right femoral head. The noted fractures required surgical intervention. The resident returned to the facility on [DATE]. An assessment was completed on 2/20/12 and there were no changes in the POC related to prevention of falls. Observation of Resident #49 on 02/21/12 at 10:20 A.M. revealed the resident did not have the yellow bracelet on per the Fall POC. This was verified by RN #6 at the time of the observation. Review of the POC for falls, fall investigations and Departmental Notes for Resident #49 with RN #6 on 02/21/12 at 2:30 P.M., verified the interventions were not appropriate and were ineffective to prevent the resident from continued unassisted ambulation. This resulted in the resident falling and sustaining fractures which required surgical interventions. 3. Review of the clinical record for Resident #11 revealed the resident was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the MDS assessment completed on 01/06/12 revealed the resident was totally dependent of two for transfer and was non-ambulatory. The resident was totally dependent on staff for toileting and had occasional incontinence of bladder. The resident did not have a history of falls. Review of the POC for Resident #11 revealed the instruction under self care deficit (initiated 04/08/11), required the transfer of the resident with full lift and two persons. The POC was updated 12/29/11 for care of a fracture to the left ankle. Review of Departmental Notes for Resident #11 revealed an entry dated 12/29/11 at 6:44 A.M. that the resident had complaints of left ankle pain. The left ankle was observed to have edema and painful to touch with pain assessment score of 10 on a 1-10 scale. The resident received Percocet (narcotice pain medication) 10-325 mg. The reassessment of pain at 7:15 A.M. revealed pain continued at a level 8. An entry on 12/29/11 at 9:05 A.M. documented the nurse was called to Resident #11's room at 6:30 A.M. The resident was noted to have increased pain and edema to left ankle. The resident stated she twisted her ankle last night in the bathroom. The physician was notified and an order was received to obtain an x-ray. A late entry in the notes at 3:19 P.M. (for 10:00 A.M.) revealed an x-ray result of an acute fracture to the left distal tibia/fibula, non-displaced. The physician was notified and an order was received to transport the resident to the local emergency room . A note on 12/29/11 at 7:18 P.M. (a late entry for 5:00 P.M.), revealed the resident returned to the facility with orders to see a physician on 01/02/12. The resident had increased complaints of pain to the left lower extremity. The Percocet was given as per order. The left lower leg was elevated and ice applied as needed. The resident had a splint/ace wrap to the left lower extremity. The resident was noted to have decreased movement to the left lower extremity. The order for placement of the splint to the left lower extremity was ongoing at the time of the survey. Interview and observation of Resident #11 on 02/22/12 at 10:55 A.M. confirmed the incident which occurred on 12/29/11. The resident stated the red headed girl didn't use a lift. The girl stood her up and turned her to sit her down in the chair and she heard a pop of her ankle. The resident was noted to be up in the wheelchair in her room. The resident stated she had some pain and took her pain medicine. The splint to the left lower extremity was not in place. This was confirmed during interview with RN #6 on 02/22/12 at 11:58 A.M. Review of the investigation completed by the facility related to the injury of Resident #11 revealed the investigation was started on 12/29/11 and completed 12/30/11 as an injury of unknown origin. The report documented the State tested Nurse Aide (STNA) #20 worked on 12/29/11 the 6:00 P.M. to 6:00 A.M. shift and transferred the resident from the wheelchair to the toilet with no assist or lift. STNA #20 transferred Resident #11 by standing the resident and turning the resident's body. STNA #20 transferred the resident from the toilet back to the chair in the same manner. The report indicated a pop of the left ankle. The report documented a physician's orders [REDACTED]. The report concluded the resident's fracture was caused by the inappropriate transfer of the resident on 12/29/11 by STNA #20. Review of the performance evaluation for STNA #20 related to the injury of Resident #11 revealed the STNA confirmed the mechanical lift was not used. STNA #20 confirmed the resident flow sheet was not checked for instruction on the proper transfer of the resident. Interview of the facility Administrator on 02/22/12 at 3:00 P.M. verified Resident #11 sustained a fractured ankle when STNA #20 transferred the resident without the use of a lift. This deficiency substantiates Complaint Number OH 522