Every finding on record at Buckeye Care and Rehabilitation

Based on closed record review, and interview the facility failed to ensure a wound treatment was implemented timely. This affected one (Resident #93) of three residents reviewed for wounds. The facility census was 91. Findings include:Review of the closed medical record revealed former Resident #93 was admitted on [DATE] with diagnoses that included Parkinson's disease with dyskinesia, dementia, congestive heart failure, dysphagia, and adult failure to thrive. Resident #93 expired at the facility on [DATE]. A plan of care dated [DATE] revealed Resident #93 was at risk for pressure ulcers (development). Interventions included to encourage and assist the resident with turning and repositioning upon rounds and as needed. If an ulcer developed, the wound nurse, Director of Nursing (DON), family, and medical doctor would be notified. Incontinence care as indicated to be provided, and weekly nursing assessments completed to observe for skin breakdown.The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #93 had severe cognitive impairment. Resident #93 was dependent on staff for toileting, hygiene, bathing, rolling side to side, and sitting to laying. Resident #93 was always incontinent with bowel and bladder. The MDS revealed the resident had no skin concerns. A skin tear/laceration form dated [DATE] at 10:35 A.M. revealed Resident #93 had a skin tear that measured 1.49 centimeters (cm) long and 1.11 cm wide to the right hip. It was believed to be caused by the resident scratching himself. The wound was cleansed with wound cleanser, and a dressing was applied per physician order. Resident #93's nails were to be trimmed to avoid skin issues in the future. Review of the treatment administration record (TAR) for February 2026 revealed no treatments were in place or completed for the area to Resident #93's right hip/trochanter. The skin issues evaluation dated [DATE] at 3:37 P.M. revealed the abrasion to Resident #93's right trochanter/hip wound had deteriorated. The wound measured 2.94 cm long and 1.76 cm wide. The dressing was intact and there was not saturation.Review of the TAR revealed on [DATE] a treatment to Resident #93's right hip was started. The wound was to be cleansed with Dakins (broad-spectrum, antiseptic, antimicrobial cleanser) wound cleanser (DWC), patted dry, with Mesalt (sodium chloride dressing used to stimulate the cleansing of moist necrosis in draining and infected wounds) applied, and covered with a dry clean dressing every day until healed. The treatment was completed from [DATE] through [DATE].The skin issues evaluation dated [DATE] at 1:15 P.M. revealed the abrasion to Resident #93's right trochanter wound had deteriorated. The wound measured 3.53 cm long and 3.53 cm wide. Signs of infection included erythema/edema (redness may be intense bright red to dark red or purple), and the peri wound temperature was warm.Review of the Medication Administration Record (MAR) and TAR revealed on [DATE] a treatment to Resident #93's right hip was changed. The new treatment revealed the resident's right hip was to be cleansed with DWC, patted dry, a nickel thick amount of Santyl (breaks down dead tissue in skin ulcers) applied to slightly moistened (with normal saline) gauze, and applied to the wound bed. The wound was to be covered with a dry, clean dressing daily until healed.An interview on [DATE] at 12:58 P.M. Registered Nurse (RN) #147 verified she was the facility wound nurse. RN #147 stated she felt the wound was due to an abrasion or skin tear from Resident #93 scratching himself. RN #147 stated there was just a layer of skin gone so it was classified as a skin tear/abrasion and not a pressure wound. RN #147 verified an outside wound physician, and hospice did not assess the wound at any time. RN #147 verified the wound was discovered on [DATE] and treatments were not put in place until [DATE]. The following deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review, review of facility risk management investigations, interview, and policy review, the facility failed to ensure allegations/ incidents of potential resident to resident physical abuse were reported to the State survey agency as required. This affected one (Resident #1) of two residents reviewed for abuse. Findings include: Review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified psychosis, dementia, generalized anxiety disorder, major depressive disorder, Parkinson's disease, and a history of a fractured upper end of the right humerus (11/21/25). Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had minimal difficulty with her hearing and clear speech. She was usually able to make herself understood and was usually able to understand others. She was cognitively intact and not known to have displayed any behaviors during the seven day assessment period. She had a functional limitation in her range of motion of one side of her upper and lower extremities. A wheelchair was used as a mobility device. Review of Resident #1's nurses' progress notes revealed a nurse's note dated 12/15/25 at 2:44 P.M. that indicated the resident reported to an aide that another resident had hit her. The nurse was immediately notified and entered the resident's room. The resident was alert and oriented times three (person, place, and time) and was able to provide credible information. The resident reported another resident wheeled by her and smacked her arm. The nurse's note was struck out for a correction on 12/21/25 at 5:53 P.M. An amended note dated 12/21/25 at 5:53 P.M. added social services provided evaluation as an immediate intervention to prevent further occurrences. Further review of Resident #1's nurses' progress notes revealed a nurse's note dated 12/24/25 at 4:12 P.M. indicated the nurse was alerted by staff the resident was hit by another resident on the left arm three times with a carrying bag. The residents were immediately separated and the resident's safety was ensured. A head to toe assessment was completed on the resident with no apparent injuries at that time. Resident #1's cognition was intact and she was able to provide credible information regarding the incident. The resident would be closely monitored for any further inappropriate interactions and would use the sitting room at the end of her hall away from the other resident. On 01/05/26 at 9:59 A.M., an interview with Resident #1 revealed another resident (Resident #90) hit her on the left arm with a bag. She alleged the incident had happened about a month ago and she was hit three times with the bag. She alleged she continued to have issues with that resident, who still resided in the facility. She reported other incidents in the past with the same resident.Review of the Ohio Department of Health (ODH) Certification and Licensing (CAL's) application (a system used by the facility to report allegations of abuse/ neglect/ misappropriation to the State survey agency) revealed there was not any self-reporting incidents (SRI's) that reported any allegations of potential physical abuse of Resident #1 by Resident #90. Findings were verified by the Director of Nursing (DON) on 01/08/26 at 2:39 P.M.On 01/08/26 at 2:40 P.M., an interview with the facility's DON revealed the facility did not submit a SRI for either incident occurring between Resident #1 and #90 that occurred on 12/15/25 and again on 12/24/25. She acknowledged both incidents involved Resident #1 being hit by Resident #90 and they should have been reported to the State survey agency as possible physical abuse. She reported the facility had completed an investigation through their risk management team, but did not feel it was something that had to be reported to the State survey agency. She was asked, why she did not feel the physical altercations between Resident #1 and #90 did not need to be reported to ODH, and replied the facility did not feel Resident #90 had any malicious intent to harm Resident #1. She did not feel Resident #90 was willful in her attempt to harm Resident #1, due to Resident #90's known developmental disability. She further acknowledged the definition of willful was a deliberate act and there did not need to be the intent to inflict harm. One resident hitting another resident was a deliberate act and should be reported even if the alleged abuser had a developmental disability. Review of the facility's policy on Abuse/ Neglect revised April 2021 revealed residents had the right to be free from abuse. That included but was not limited to physical abuse. They were to protect residents from abuse by anyone, including other residents. They were to investigate and report any allegations within the timeframes required by federal requirements.

Based on medical record review, resident and staff interviews, and policy review, the facility failed to ensure resident-centered care plans were individualized and comprehensively addressed all areas of the residents' care this affected two residents (Residents #17 and #65) of 28 residents reviewed for care plans. The facility census was 88.Findings Include: 1. Review of the medical record for Resident #17 revealed an admission date of 04/05/2024 with diagnoses including Ogilvie syndrome (intestinal pseudo-obstruction), schizoaffective disorder, major depressive disorder, suicidal ideations, insomnia, hypertensive heart disease, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment completed on 12/22/25 revealed Brief Interview for Mental Status (BIMS) score of 15 indicating he was cognitively intact. Additionally, he was dependent on staff for toileting, personal hygiene/grooming, and positioning in his bed; required moderate assistance with dressing his upper and lower body; and required supervisory assistance with eating, oral care, showering, and mobility in his manual wheelchair. Review of the nurse's progress notes revealed Resident #17 began exhibiting signs of depression and suicidal ideations beginning on 09/01/25. He was evaluated and treated at the hospital and returned to the facility on the same day. He received counseling services in the community on 09/02/25, and his physician adjusted his psychoactive medications on 09/04/25 with instructions to provide him with daily notifications on how the resident was tolerating the new dosage adjustments. On 09/05/25, Resident #17 returned to the hospital after displaying symptoms associated with serotonin syndrome and continued suicidal ideations. He was admitted to the hospital on [DATE] and remained hospitalized until 09/18/25. Review of Resident #17's active care plan revealed his care plan was revised on 09/25/25 to reflect he was at risk for decreased psychosocial well-being and adjustment issues, emotional distress and ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual well-being related to mood interview triggered and diagnosis of schizoaffective disorders, depression, suicidal ideations, insomnia, and anxiety. The goal was to assess clinical issues that may contribute to his mood pattern; encourage the expression of his feelings and concerns, participation in activities of interest; maintaining a calm, understandable approach; observe for signs and symptoms of depression and emotional distress and notify the physician as needed; referring to psychiatry/psychology as ordered; and for social services to visit and evaluate as needed. The care plan did not comprehensively address specific behaviors, triggers, or interventions to properly manage his depression and/or suicidal ideations. Interview on 01/06/26 at 12:29 P.M. with Resident #17 revealed he has an average of weekly appointments with his community psychiatric nurse practitioner and counselor, the facility-contracted psychiatrist, and his primary medical doctor who worked together to treat his psychiatric symptoms. He stated his current medication regimen addressed his symptoms. Interview on 01/08/25 at 9:14 A.M. with Social Services Director (SSD) #650 stated she is responsible for assessing the psychosocial needs of residents in the facility and updating care plans to address specific needs. SSD #650 confirmed Resident #17's care plan did not specifically address suicidal ideation. 2. Observation on 01/05/26 at 11:31 A.M. revealed Resident #65 had very poor dentition. He was missing teeth and the teeth present had visible decay. Review of Resident #65's medical record revealed an admission date of 04/27/25 with diagnoses including bipolar disorder, moderate protein-calorie malnutrition, major depressive disorder, anxiety disorder, orthostatic hypotension, and other seizures. Review of Resident #65's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had moderately impaired cognition. Review of Resident #65's plan of care dated 05/06/25 revealed the resident was at risk for oral issues. He needed assistance with oral care and had his own teeth. Interventions included dental consultation as indicated, oral exam and intervention as indicated, and notifying the physician of symptoms of dental infection or complications. Interview on 01/08/26 at 10:59 A.M. with the Director of Nursing (DON) verified Resident #65 had poor dentition and his dental condition was not in his care plan, with goals to manage his individualized needs. Review of the facility policy titled, Comprehensive Person-Centered Care Plans, (revised March 2022) confirmed the comprehensive, person-centered care plan should include measurable objectives to meet the resident's physical, psychosocial, and functional needs. The policy states the care plan was to be revised as information about the resident and the resident's conditions change. The policy also states the interdisciplinary team reviews and updates the care plan when the resident has been readmitted to the facility from a hospital stay.

Based on record review, observations and interviews the facility failed to ensure residents were provided with timely hygiene care to removing facial hair. This affected two residents (Residents #36 and #55) of the four residents reviewed for activities of daily living. The facility census was 88.Findings include:1. Review of Resident #36 ' s medical record revealed an admission date of 03/07/25 with diagnosis to include but not limited too Parkinson's disease, pain in right shoulder, difficulty in walking, unsteadiness on feet, chronic obstructive pulmonary disease, hyperlipidemia, bipolar, obesity, osteoarthritis, gastro-esophageal reflux disease, major depressive disorder, anxiety, heart failure, seizures, hypertensive heart disease, and anemia.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Resident #36 required required touching assistance for personal grooming to include shaving. Review of the care plan focus initiated 03/12/25 and revised on 10/03/25 revealed Resident #36 had an actual risk for Activities of Daily Living (ADL) decline and required staff assistance related to impaired mobility related to right shoulder pain with interventions which to included resident required staff assistance with hygiene. Observation of Resident #36 who was sitting in a wheelchair in a common area on 01/05/26 at 1:44 P.M. revealed the resident had multiple white hairs on her chin which were long and noticeable. Interview with Resident #36 on 01/05/26 at 1:44 P.M. revealed the resident stated I can not find tweezers to get rid of the chin whiskers, the girls usually shaved them, but they did not today.Interview on 01/05/26 at 1:51 P.M. with License Practical Nurse (LPN) #480 confirmed and verified Resident #36 had multiple long white hairs on her chin and Resident #36 had asked for them to be removed but they remained. 2. Review of Resident #55 ' s medical record revealed an admission date of 04/14/21 with diagnosis to include but not limited to atrial fibrillation, hypertension, osteoarthritis, anxiety disorder, hypothyroidism, major depressive disorder, ischemic heart disease, anemia, hypo-osmolality and hyponatremia.Review of the quarterly MDS dated [DATE] revealed a BIMS score of 11 which indicated a moderate cognitive impairment. Resident #55 required moderate assistance for showering and personal hygiene which included shaving. Review of the shower sheet dated 01/03/26 for Resident #55 revealed a blank space where it should be documented if Resident #55 had a shower or not. Review of the care plan forResident #55 revealed a focus which stated Resident #55 had an ADL self-care performance deficit related to impaired mobility with interventions revised on 02/10/23 to include Resident #55 required staff assistance for showering and personal hygiene to include shaving. Observation on 01/05/26 at 1:22 P.M. of Resident #55 revealed she had multiple black hairs on her upper and lower lips which had the appearance of a mustache. Interview on 01/05/26 at 1:22 P.M. with Resident #55 confirmed the black hair on her upper and lower lips bothered her because it does not look good.Interview on 01/05/26 at 1:27 P.M. with LPN #480 revealed the female residents have their facial hair shaved on shower days and when it is noticeable. Additionally, LPN #480 stated the expectation is for the Certified Nursing Assistants (CNAs) to shave the female residents who have facial hair even if it is not their shower day. Interview on 01/05/26 at 1:33 P.M. with LPN #480 who confirmed and verified Resident #55 had multiple black hairs on her upper and lower lips and Resident #55 asked for it to be shaved but it remained. Review of the facility policy Activities of Daily Living (ADL), Supporting revision dated 03/2018 stated that residents who are unable to carry out activities of daily living independently will receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Furthermore, the facility policy Activities of Daily Living (ADL), Supporting revision dated 03/2018 stated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care).This deficiency represents non-compliance investigated under Complaint Number OH002706168.

Based on record review, observation, policy review, and staff interview, the facility failed to ensure a wound was properly identified as a pressure ulcer. This affected one (Resident #4) of three residents reviewed for pressure ulcers. The facility census was 88.Findings Include:Review of the medical record for Resident #4 revealed an admission date of 06/06/25 with diagnoses including inflammatory disorders of scrotum, gangrene Fournier, dementia, and cerebral infarction.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 was at risk for pressure ulcers and the resident had one or more pressure ulcers.Review of the care plan dated 06/09/25 and revised on 01/05/26 revealed Resident #4 was at risk for pressure ulcer/skin breakdown related to impaired mobility, medication, fragile skin, diagnosis, Diabetes Mellitus (DM), hyperlipidemia, cerebral vascular accident (CVA), obstructive sleep apnea, osteoarthritis, acute kidney injury, rhabdomyolysis, right hip pain, depression, insomnia, chronic obstructive pulmonary disease (COPD), dysphagia, dementia, urinary retention, hyponatremia, anemia, mitral endocarditis, malnutrition, history of Fournier gangrene, and resident can be non-compliant with safety, mobility, activities of daily living (ADL's), care, showers, and preventative skin measures.Subsequent review of the care plan revealed Resident #4 had a resolved stage II pressure ulcer (partial-thickness skin loss, appearing as a shallow, open sore, blister, or crater, with a pink/red wound bed, but no visible fat or deeper tissue) to sacrum, a stage II pressure ulcer to left gluteus, surgical wound to scrotum, an intact blister to left heel, and a blister to rear left knee.A skin and wound evaluation dated 10/08/25 revealed a wound to left heel identified as a blister. The wound measured 4.6 centimeters (cm) long, 3.5 cm wide and depth not applicable.A progress note dated 12/03/25 with wound nurse practitioner revealed an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) to left heel and wound was covered with 100% eschar (a dark patch of dead skin that forms over a wound acting as a hard scab).Further review of wound evaluations revealed an assessment dated [DATE] identifying the left heel wound as a blister and no unstageable pressure ulcers identified.Observation on 01/07/26 at 2:47 P.M. of wound care on Resident #4 with RN #690 revealed an unstageable pressure ulcer to the left heel, covered with eschar.Interview on 01/07/26 at 2:50 P.M. with RN #690 revealed Resident #4 's left heel wound started as an intact fluid filled blister and is now an unstageable pressure ulcer. RN #690 confirmed an intact fluid filled blister can be identified as a stage II pressure ulcer according to the facility's pressure ulcer policy citing the National Pressure Injury Advisory Panel Classification System and the wound was not documented properly.Review of the facility's policy titled Pressure Injuries Overview, dated March 2020 revealed a pressure ulcer/ injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medial or other device. Stage 2 pressure injury: The wound is viable, pink or red, moist and may also present as an intact or ruptured serum-intact blister.

Based on record review, observation, staff interview, and policy review, the facility failed to ensure residents did not smoke in an area that also had residents with portable oxygen on. This affected one (Resident #23) of one residents reviewed for smoking. The facility also failed to ensure fall prevention interventions were implemented as per the plan of care for a resident with the history of falls. This affected one (Resident #35) of four residents reviewed for falls. Findings include:1. Review of Resident #23's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included dementia, schizo-affective disorder, multiple rib fractures on the left and right side, fracture of the sacrum, chronic obstructive pulmonary disease (COPD), difficulty walking, and muscle weakness.Review of Resident #23's smoking observation assessment dated [DATE] revealed the resident was a smoker and was known to smoke cigarettes. She had cognitive impairment and was able to light her own cigarette. The assessment determined she could smoke but required supervision. Review of Resident #23's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate difficulty with hearing and clear speech. She was usually able to make herself understood and was usually able to understand others. Her cognition was moderately impaired. Review of Resident #23's active care plans revealed she had a care plan in place for the potential for injury related to smoking, desires to smoke, and may smoke with supervision per the facility's smoking policy. The care plan originated on 10/10/25. The goal was for the resident's safety to be maintained every shift through the review date. The interventions included educating the resident on the facility's smoking policy and oxygen safety requirements, precautions, and, if on oxygen, remove oxygen before taking the resident out to smoke. Those on oxygen were to maintain a safe distance from designated smoking areas. She was to be supervised at all times by staff while in the courtyard. Review of Resident #23's physician's orders revealed the resident had an order for continuous oxygen at three liters per minute (LPM) per nasal cannula. The order for the oxygen use originated on 12/04/25. As of 12/10/25, she had an order to wean oxygen as the resident never wore oxygen at home. Her orders also included the need for her to be supervised in the courtyard at all times. On 01/05/2026 at 1:36 P.M., an observation noted Resident #23 to be sitting by the door to the facility's courtyard/ designated smoking area. She was noted to be wearing oxygen per nasal cannula that was connected to an e-tank on the back of her wheelchair. Housekeeper #425 was observed to approach Resident #23 and informed her she needed to take her oxygen off before going outside to smoke. Housekeeper #425 was observed assisting the resident with removing the nasal cannula from the resident's nares before placing the oxygen tubing across the back of the wheelchair the resident was sitting in. Seven residents went out to smoke in the enclosed courtyard/ designated smoking area to include Resident #23. Housekeeper #425 had a tackle box that contained the residents' smoking materials and she passed them out to the residents one at a time. Resident #23 was noted to have her oxygen tank still on the back of her wheelchair and it remained on at three LPM. Air was able to be felt coming out of the end of the oxygen tubing from the nasal cannula by placing your hand over the end of the tubing that was draped over the back of the wheelchair. Housekeeper #425 approached Resident #23 to light the cigarette the resident was given at 1:42 P.M. The surveyor had to intervene and stop the housekeeper from lighting the resident's cigarette while the oxygen tank remained on the back of her wheelchair and turned on. LPN #145 was also in the designated smoking area, as she was completing a smoking assessment on another resident (Resident #73) at that time. She had previously been noted to remove Resident #73's oxygen from his nares placing his e-tank in his room before allowing him to go outside to smoke. LPN #145 was in close proximity of Resident #23, but did not recognize Resident #23 still had her oxygen tank on the back of her wheelchair and her oxygen tank turned with the oxygen tubing draped over the back of the wheelchair. On 01/05/26 at 1:49 P.M., an interview with LPN #145 revealed the facility's normal process was not to allow residents with oxygen tanks to be out in the designated smoking area when residents were smoking. She commented oxygen should never be on the back of a chair outside, ever. On 01/05/26 at 2:00 P.M., an interview with Housekeeper #425 revealed she was normally the staff member that took residents outside to smoke. It was usually just her unless there was an aide out there with her. The aide was busy working the hall that day and was not able to accompany her for that smoking time. She denied Resident #23 had been out to smoke the past couple of days. She had not known her to have a portable oxygen tank on the back of her wheelchair when out to smoke in the past. She stated it would be her responsibility to ensure residents did not go out to smoke with oxygen on. An aide brought Resident #23 down by the door to the designated smoking area and she would have assumed the aide had already taken Resident #23's oxygen off or at least turned the oxygen off at the tank. She acknowledged she should have ensured the oxygen tank was left inside the building and not allowed to be on the back of her wheelchair when the resident went out to smoke. She was not familiar with oxygen tanks and did not know how to turn them off. She confirmed they were not supposed to allow an oxygen tank to go out with a resident when going out to the smoking area with the intent to smoke. She stated it was her bad that she did not catch it, and she was aware of the safety risk of a potential burn injury with smoking near/ or around oxygen. Review of the facility's Smoking Policy revised 05/05/25 revealed it was the policy of the facility to accommodate their smoking and non-smoking residents. The goal was for the residents to be able to smoke safely per policy after passing a smoking assessment. The purpose of the policy was to ensure the residents of the facility, who smoke, to have a comfortable and safe environment in which to smoke. The use of oxygen while smoking was strictly prohibited. 2. Review of Resident #35's medical record revealed he was admitted to the facility on [DATE] with the diagnoses of dementia, anxiety disorder, major depressive disorder, insomnia, and hypotension (low blood pressure). Review of Resident #35's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had adequate vision, adequate hearing, and clear speech. He was usually able to make himself understood and was usually able to understand others. His cognition was moderately impaired. He was not known to have displayed any behaviors and was not known to reject care. He had a functional limitation in his range of motion of his bilateral lower extremities. He required substantial/ maximum assist with bed mobility and was dependent on staff for transfers. Review of Resident #35's care plans revealed he had a care plan in place for being at risk for falls related to impaired safety awareness, medication use, impaired mobility, and diagnoses that increased his risk for falls. The goal was for the resident to be compliant with fall interventions through next review. The interventions included the need for his bed to be in low position. That intervention was added on 04/05/25. Review of Resident #35's physician's orders revealed an order for him to have the use of a perimeter mattress. His orders also included the need for his bed to be in low position. That order originated on 04/20/25. Review of Resident #35's progress notes revealed a nurse's note dated 04/20/25 at 3:24 A.M. that indicated the resident rolled out of bed while sleeping. The new intervention added to prevent additional falls was for a low bed to be put in place. On 01/06/2026 11:22 A.M. an observation of Resident #35 noted him to be in bed in a supine position. He had a perimeter mattress on his bed, but his bed was not in it's lowest position. On 01/06/26 at 2:21 P.M., a follow up observation of Resident #35 noted him to remain in bed with his bed raised and not in it's lowest position. His bed was about 24 inches from the bottom of the bedframe to the floor. On 01/06/26 at 2:25 P.M., an interview with LPN #160 revealed she did not consider Resident #35 to be a fall risk as he does not move. She confirmed the resident has fallen in the past, but it was not enough to consider him a fall risk at that time. He was always in bed and denied that he got up. She was asked what fall prevention interventions were in place for the resident. She stated she did not know without checking his orders. She denied any problems with Resident #35 and had not known him to use his own bed controls to raise or lower his bed. She was asked to go to his room to verify the bed not being in it's lowest position. She verified the bed was up about 18 inches higher than it should have been. She lowered the bed from being about 24 inches from bed frame to floor to only being six inches off the floor. She confirmed his active care plans and physician's orders included the need for the bed to be in the lowest position for safety/ fall risk.

Based on interview, record review, and review of facility policy the facility failed to timely complete an ordered urinalysis laboratory test and appropriately address a urinary tract infection (UTI) for Resident #52. This affected one resident (#52) of three residents reviewed for UTI's. The facility census was 88.Findings include: Review of Resident #52's medical record revealed an admission date of 05/28/21 with diagnoses including Parkinson's disease, Type II Diabetes Mellitus, progress multiple sclerosis, unspecified protein-calorie malnutrition, dysphagia, legal blindness, and dementia.Review of Resident #52's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition.Review of Resident #52's physician note dated 11/10/25 revealed the resident complained of lower abdominal pain. The physician wanted an urinalysis (UA) with culture and sensitivity and recommended encouraging fluids while the results were pending.Review of Resident #52's physician order dated 11/11/25 revealed an order for urinary analysis with culture and sensitivity.Review of Resident #52's progress note dated 11/12/25 revealed the UA was not collected.Review of Resident #52's physician order dated 11/18/25 revealed an order for urinary analysis with culture and sensitivity.Review of Resident #52's physician order dated 11/18/25 revealed an order for Ciprofloxacin Hcl (an antibiotic) 250 milligrams one tablet to be given by mouth every 12 hours for three days for infection.Review of Resident #52's progress note dated 11/19/25 revealed the UA was not collected.Review of Resident #52's progress note dated 11/20/25 revealed the resident showed up in the laboratory's system for a UA, however, she had been on an antibiotic for two days. The physician was asked if he still wanted a UA and on 11/21/25 he reported the order could be discontinued.Review of Resident #52's medical record from 11/10/25 to 11/20/25 revealed no further documentation related to her UTI.Interview on 01/08/26 at 8:42 A.M. with the Director of Nursing verified Resident #52's UA was not completed timely as ordered. She was unsure why it was not completed, and verified there was no documentation on 11/18/25 to indicate why an antibiotic was ordered, or what symptoms she still had. She additionally verified an antibiotic was ordered without a UA, she reported due to the continued symptoms the physician did not wait for the results.Review of the policy 'Antibiotic Stewardship', revised December 2016 revealed when a culture and sensitivity is ordered, the lab results and current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be continued or modified.This deficiency represents non-compliance investigated under Complaint Number 2706168.

Based on record review, staff interview, and policy review, the facility failed to adequately monitor the nutritional status of a resident with the history of a significant weight loss. This affected one (Resident #37) of one residents reviewed for nutrition. The census was 88. Findings include:Review of Resident #37's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included progressive multiple sclerosis, mild dementia, schizo-affective disorder, major depressive disorder, adult onset Diabetes Mellitus, dysphagia (difficulty swallowing), Vitamin B and D deficiencies, anemia, hyperlipidemia (high cholesterol), hypokalemia (low potassium), moderate protein calorie malnutrition, and constipation. Review of Resident #37's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was usually able to understand others and was usually able to make herself understood. Her cognition was moderately impaired and mood indicators included a poor appetite. Her height was 65 inches and her weight was 128 pounds. She was known to have a significant weight loss without being on a physician prescribed weight loss program. Review of Resident #37's active care plans revealed she had a care plan in place for being at nutritional risk secondary to her diagnoses, medication use, and a history of significant weight loss. Her goal was to consume at least 75% of most meals to maintain weight. Interventions included the need to monitor/record/report to the physician any signs or symptoms of malnutrition. They were to offer substitute meals if the resident consumed less than 50%, provide and serve diet as ordered, and administer supplements (House Supplement 237 milliliters (ml) twice daily. The registered dietitian (RD) was to evaluate and make diet change recommendations as needed (PRN). Review of Resident #37's physician's orders revealed she was to be on a regular diet. She was to receive a house nutritional supplement 237 ml twice a day for oral consumption. The house supplement was initiated on 10/24/25. Review of Resident #37's weight history revealed the resident weighed 145 pounds on 06/24/25. Her weight reduced to 129.6 pounds on 12/09/25 reflecting a significant weight loss of 10.62% in six months. Her last weight obtained on 01/02/26 had her weight as 126 pounds. She was noted to have a significant weight loss at 1, 3 and 6 months, since 06/24/25, reflecting a loss of 6.9% in one month, 8.5% at 3 months and 10.62% at six months. Review of Resident #37's meal intakes for the past 30 days (12/09/25- 01/06/26) revealed the resident did not have any of her three meals consumed recorded on 12/11/25, 01/02/26, or 01/04/26. There was only one of the three meals recorded on 12/31/25, and only two of the three meals recorded on 12/16/25 and 01/06/26. It was not clear what percentage of the meals the resident consumed on those days or if she had received a meal at all. Review of Resident #37's medication administration record (MAR) for December 2025 and January 2026 revealed the nurses were documenting the resident's acceptance of her house nutritional supplement when offered twice daily. The nurses were inconsistent in the manner in which they were recording the resident's supplement acceptance. Some nurses were documenting the percent of the supplement consumed while others were putting a Y on the MAR to indicate that the supplement was accepted but not the percentage consumed. There were five times between 12/01/25 and 01/06/26 that the nurse just entered a Y, without documenting the percentage consumed. On 01/07/26 at 12:35 P.M., an interview with the facility's Director of Nursing (DON) revealed it was an expectation that the nurses documented the percentage of the house nutritional supplement that the resident consumed when given twice a day as ordered. She acknowledged the nurses were not always specifying the percentage of the supplement the resident consumed as there were five times in the past two months they just added a Y. She confirmed, by the nurses entering a Y, that just indicated the house supplement had been given. It was not clear how much of the house supplement had been taken when it was just marked as a Y. She further confirmed the resident's meal intakes were not consistently being recorded under the task tab of the EMR. She acknowledged there were three days in the past 30 days where the resident's meal intake was not recorded for any of the three meals served that day. She further acknowledged there was only one of the three meals recorded on 12/31/25, and only two of the three meals recorded on 12/16/25 and 01/06/26. She acknowledged, by not recording the resident's supplement acceptance and not recording meal intakes for all three meals received daily, they were not showing evidence of the resident's nutritional status being adequately monitored, after the resident was known to have had a significant weight loss. It would also make it hard to determine if the house nutritional supplement was an effective nutritional intervention, if it was not known how much the resident was consuming. Review of the facility's policy on Food and Nutrition Services revised October 2017 revealed each resident was to be provided with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Meals and/ or supplements would be provided within 45 minutes of either resident request or scheduled meal time. Nursing personnel would evaluate and document food and fluid intake of residents with, or at risk for, significant nutritional problems.

Based on interview and record review the facility failed to prevent duplicate pain medication orders and when administering as needed medications they failed to attempt nonpharmacological interventions and describe the pain for Resident #2 and #5. This affected two residents (#2 and #5) of one of five residents reviewed for unnecessary medications and one of one resident reviewed for pain. The facility census was 88.Findings include:1. Review of Resident #2's medical record revealed an admission date of 04/02/24 with diagnoses including paranoid personality disorder, Post-traumatic stress disorder (PTSD), mood disorder, Parkinson's disease, epilepsy, personality disorder, bipolar disorder, dementia, unspecified psychosis, mild cognitive impairment, depressive disorder, Type II Diabetes Mellitus, and chronic kidney disease.Review of Resident #2's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. The resident received insulin, antipsychotics, antianxiety medication, antidepressants, diuretics, opioids, anticonvulsants, and hypoglycemics.Review of Resident #2's plan of care dated 10/28/25 revealed the resident was at risk for pain or discomfort related to diagnoses, her pain was excepted to fluctuate. Interventions included administering medications and treatments as ordered, assessing pain every shift, assessing for non-verbal indicators of pain, and dimming light for photosensitivity.Review of Resident #2's physician order dated 06/30/25 revealed an order for Dilaudid (opioid) four milligrams (mg) one tablet by mouth every four hours as needed for pain.Review of Resident #2's physician order dated 12/21/25 revealed an order for Dilaudid Oral Tablet four mg one tablet by mouth every four hours as needed for pain one through ten.Review of Resident #2's Medication Administration Record for December 2025 and 01/01/26 through 01/05/26 revealed Dilaudid was given on 12/02/25 once, on 12/04/25 twice, on 12/05/25 once, on 12/06/25 once, on 12/07/25 twice, on 12/08/25 once, on 12/11/25 twice, on 12/12/25 twice, on 12/14/25 once, on 12/15/25 once, on 12/16/25 once, on 12/17/25 once, on 12/20/25 twice, on 12/27/25 once, on 12/29/25 twice, on 12/31/25 once, on 01/01/25 once, and on 01/04/25 once. Both orders of Dilaudid were used.Review of Resident #2's progress notes dated 12/01/25 through 01/05/26 revealed on 12 occasions she was given as needed pain medication without nonpharmacological methods being attempted and without a description of her pain. On two occasions she was given as needed pain medication without a description of her pain.Interview on 01/08/26 at 10:14 A.M. with the Director of Nursing (DON) verified nursing is supposed to attempt and document nonpharmacological interventions prior to administering as needed pain medication, she additionally verified the nursing staff was not documenting descriptions of her pain. The DON verified there were two orders of Dilaudid in use for Resident #2 and there should not have been.2.Review of Resident #5's medical record revealed an admission ate of 05/21/25 with diagnoses including cerebral palsy, cerebral infarction, dementia, osteoarthritis, neoplasm of unspecified behavior of brain, major depressive disorder, abnormal posture, and spinal stenosis.Review of Resident #5's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition.Review of Resident #5's plan of care dated 11/07/25 revealed the resident exhibited or was at risk for alteration in comfort related to generalized discomfort and diagnoses. Interventions included evaluating pain characteristics, utilizing pain scale, completing pain assessment per protocol, medications as ordered, nonmedication interventions including relaxation, repositioning, and redirection. Review of Resident #5's physician order dated 11/11/25 revealed an order for Oxycodone (opioid)-Acetaminophen (analgesic) five-325 milligrams (mg) one tablet by mouth every six hours as needed for pain.Review of Resident #5's Medication Administration Record (MAR) for December 2025 and 01/01/26 through 01/05/26 revealed he received Oxycodone-Acetaminophen on 12/01/25 three times, on 12/02/25 twice, on 12/3/25 once, on 12/04/25 twice, on 12/05/25 once, on 12/06/25 once, on 12/07/25 twice, on 12/08/25 once, on 12/09/25 twice, on 12/10/25 twice, on 12/11/25 twice, on 12/12/25 twice, on 12/13/25 twice, on 12/14/25 twice, on 12/15/25 twice, on 12/16/25 twice, on 12/17/25 twice, on 12/20/25 twice, on 12/21/25 three times, on 12/22/25 twice, on 12/23/25 twice, on 12/24/25 three times, on 12/25/25 twice, on 12/26/25 three times, on 12/27/25 twice, on 12/28/25 twice, on 12/29/25 twice, on 12/30/25 once, on 12/31/25 once, on 01/01/26 twice, on 01/02/26 once, on 01/03/26 once, on 01/04/26 three times, and on 01/05/26 twice.Review of Resident #5's progress notes revealed on 35 occasions he was given as needed pain medication without nonpharmacological methods being attempted and without a description of his pain.Interview on 01/08/26 at 10:14 A.M. with the Director of Nursing (DON) verified nursing is supposed to attempt and document nonpharmacological interventions prior to administering as needed pain medication. She additionally verified the nursing staff was not documenting descriptions of his pain.

Based on observation, medical record review, staff interview, manufacturer guide review, and facility policy review, the facility failed to ensure medication error rate was less than five percent. There were two observed medication errors of 28 opportunities observed, resulting in a 7.14 percent medication error rate. This affected one Resident (#103) out of three residents reviewed for medication administration and had the potential to affect 15 residents who received insulin at the facility. Facility census was 88.Findings Include:Review of the medical record for Resident #103 revealed an admission date of 12/31/25 with diagnoses including alcoholic hepatitis without ascites, Type II Diabetes Mellitus, and heart failure. Review of physicians orders dated 12/31/25 revealed an order for Insulin Glargine (long acting insulin) subcutaneous solution Pen-Injector 100 unit/ML (milliliter), inject 20 units subcutaneous (sq) two times a day for diabetes mellitus and Insulin Aspart (fast acting insulin) subcutaneous solution Pen-Injector 100 unit/ML, inject per sliding scale before meals and at bedtime for diabetes mellitus.Observation on 01/07/26 at 8:13 A.M. with Registered Nurse (RN) #660 of medication administration revealed RN #660 prepared Resident #103's Insulin Glargine and Insulin Aspart and did not prime the insulin pens prior to administration. Interview on 01/07/26 at 8:17 A.M. with RN #660 verified the insulin pens were not primed prior to dialing up the dose administered to the resident. RN #660 stated he thought the insulin pens only needed primed after opening the insulin for the first time. Review of Insulin Aspart step-by-step manufactures guide verified a safety test (airshot) must be performed before each injection by dialing a test dose of two units, hold the pen with the needle pointing up lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. Review of Insulin Glargine step-by-step manufactures guide verified a safety test must be performed before each injection by dialing a test dose of two units, hold the pen with the needle pointing up lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. Review of facility policy titled Administering Medications dated April 2019 revealed medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview and record review, the facility failed to follow enhanced barrier precautions (EBP) as guided by the Centers for Disease Control and Prevention (CDC) for Resident #4 and failed to ensure hand hygiene was performed during catheter care for Resident #9. This affected two of five residents reviewed for infection control. The facility census was 88.Findings include: 1.Review of the medical record for resident #4 revealed an admission date of 06/06/25 with diagnoses including inflammatory disorders of scrotum, gangrene fournier, dementia, and cerebral infarction. Review of physician's orders dated 10/04/25 revealed an order for enhanced barrier precautions during high contact resident care two times a day for foley catheter. Observation on 01/08/26 at 1:28 P.M. revealed a bed bath being performed by CNA #665 with Resident #4. Interview on 01/08/26 at 1:31 P.M. with CNA #665 verified the signage was posted on the door for enhanced barrier precautions due to resident having a catheter and she was not following enhanced barrier precautions, as required by CDC guidance. Review of facility policy titled Enhanced Barrier Precautions dated December 2024, revealed examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include: dressing, bathing/showering, providing hygiene or grooming, changing briefs or assisting with toileting, transferring, providing bed mobility, changing linens, prolonged high-contact with items in the residents room, with residents equipment, or with residents clothing or skin, device care or use and wound care. 2.Review of Resident #9's medical record revealed an initial admission date of 10/30/25 and a re-entry admission dated of 11/11/25 with diagnosis to include but not limited to acute and chronic respiratory failure, calculus of kidney, disorders of the kidney and ureter, Type II Diabetes Mellitus, obstructive and reflux uropathy, acute kidney failure, encephalopathy, dementia, abdominal pain, sepsis, urinary tract infection, hydronephrosis, elevation of levels of liver transaminase, retention of urine, atrial fibrillation, anxiety disorder, and overactive bladder. Review of an order dated 11/11/25 stated enhanced barrier precautions during high contact resident care every day and night shift for preventative. Review of an order dated 11/11/25 stated catheter care every shift. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was dependent (staff does all the effort) on staff for toileting hygiene and showering. Review of the care plan last revised on 12/18/25 for Resident #9 revealed a focus for an indwelling foley catheter related to obstructive uropathy with inventions to include provide catheter care and empty catheter every shift and as needed, perform catheter care and as needed following protocols to maintain cleanliness and reduce infection risk, and provide catheter care and hygiene practices with cleaning daily and as needed and as need after bowel movements per policy to reduce infection risk. Additionally, the care plan for Resident #9 revealed a focus for enhanced barrier precautions during high-contact resident activities due to the presence of an indwelling device not known to be infected or colonized with any multi-drug resistant organism (MDRO) with interventions to include utilize protective personal equipment (PPE) (gown, gloves, and face-shield as indicated) during high-contact resident care activities (dressing, bathing/showering, transferring, hygiene, line changes, brief changes, toileting assistance, device care, wound care). Observation on 01/06/26 at 3:40 P.M. of catheter care for Resident #9 performed by Certified Nurse Assistant (CNA) # 500 revealed CNA #500 did not perform hand hygiene before donning gown and gloves prior to starting catheter care. The CNA was observed to leave the resident room twice during the catheter care and when she returned to the room she did not perform hand hygiene prior to donning gloves. The CNA was then observed to moved Resident #9's trash can from one side of the bed to the other side of the bed with her gloved hand and then with the same hand was observed to reached inside her pocket and get a trash bag. CNA #500 was observed to place the trash bag on the floor and without doffing gloves, performing hand hygiene, and donning gloves CNA #500 was observed to perform catheter care on Resident #9. Interview on 01/06/26 at 4:15 P.M. at the end of the observation of catheter care with CNA #500 it was confirmed and verified she did not wash her hands before donning gown and gloves before catheter care, or when she returned to the room after she left on two different occasions. Additionally, CNA #500 confirmed and verified she had no open trash bags to place dirty linen or trash in and had gloves on to take the trash bags from her pocket and then placed the trash bags on the floor, and did not change her gloves before touching and performing catheter care on Resident #9. Review of the facility policy Catheter Care, Urinary dated 08/2022 stated for routine perineal hygiene wash and dry hands thoroughly, put on gloves, provide privacy. Review of the facility policy Handwashing/Hand Hygiene dated 10/2023 stated hand hygiene is indicated immediately before touching a resident, before performing an aseptic (free from contamination caused by harmful bacteria, viruses, or other microorganisms) task (for example, placing an indwelling catheter or handling and invasive device medical device), after contact with blood, body fluids, or contaminated surfaces, after touching a resident, after touching a residents environment, before moving from work on a soiled body site to a clean body site on the same resident, and immediately after gown removal. Review of the facility policy Enhanced Barrier Precautions dated 12/2024 stated enhanced barrier precautions (EBPs) are utilized to prevent the spread of MDROs to residents. EBPs apply when a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical devices (including urinary catheters), and does not have secretions or excretions that are unable to be covered or contained. EBPs employ targeted gown/glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Examples of high contact resident care activities requiring the use of gowns and gloves for EBPs include device care or use (urinary catheter). Furthermore, the facility policy Enhanced Barrier Precautions dated 12/2024 stated staff are trained prior to caring for residents on EBPs.

Based on observation and interview the facility failed to ensure Resident #52 ' s wheelchair was maintained in a clean and sanitary manner. This affected one resident (#52) of three residents reviewed for environment. The facility census was 88.Findings include:Review of Resident #52's medical record revealed an admission date of 05/28/21 with diagnoses including Parkinson's disease, Type II Diabetes Mellitus, progress multiple sclerosis, mild cognitive impairment, unspecified protein-calorie malnutrition, legal blindness, dementia, and major depressive disorder.Review of Resident #52's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition.Observation on 01/06/26 at 2:50 P.M. and on 01/08/26 at 10:05 A.M. revealed Resident #52's wheelchair had a large build up of dirt, food, stains, and splatters along the sides and edges.Interview on 01/08/26 at 10:05 A.M. with the Director of Nursing (DON) verified Resident #52's wheelchair needed cleaned, she reported it was on the schedule for night shift. This deficiency represents non-compliance investigated under Complaint Number 2706168.

Based on observations, medical record review, staff interview, and facility policy review, the facility failed to report an alleged violation to the state department of health in a timely manner. This affected one (Resident #43) of three incidents reviewed. The census was 93.Findings Include: Observation on 11/17/25 at approximately 11:55 A.M. revealed Resident #43 lying in bed with a white towel lying over her right shoulder/upper arm area. She was observed with a slight grimace as if in pain. Resident #43 was admitted to the facility on [DATE]. Her diagnoses were Parkinson's disease, abnormal posture, mild cognitive impairment, muscle weakness, dementia, unspecified protein calorie malnutrition, herpes-viral vesicular dermatitis, dysphagia, mixed hyperlipidemia, major depressive disorder, obesity, anxiety disorder, hydrocephalus, psychosis, hypertension, obstructive sleep apnea, Type II Diabetes, vitamin D deficiency, chronic ischemic heart disease, mood disorder, weakness, drug induced subacute dyskinesia, and constipation. Review of her minimum data set (MDS) assessment, dated 11/05/25, revealed she was cognitively intact. Review of Resident #43's nurse's notes, dated 11/16/25, revealed an entry at 8:10 P.M. that stated resident was being transferred from her bed to her wheelchair when she felt weakness in her legs and was unable to hold on to the sit to stand machine. Staff placed her back into her bed. They noted on the progress note there were no injuries/issues. Review of Resident #43's nurse's note, dated 11/16/25, revealed an entry at 8:28 P.M., another recount of the incident with the sit to stand machine and stated Resident #43 was not in pain at this time. Review of Resident #43's nurse's note, dated 11/16/25, revealed an entry at 10:15 P.M., resident reported to the nurse her arm was hurting. Moderate swelling noted in the right shoulder/arm region. She stated there was pain in that area and it hurt when she moved it. Physician was contacted and a stat X-ray was ordered. Review of Resident #43 nurse's note, dated 11/17/25, revealed an entry at 10:24 A.M. that was an interdisciplinary note which documented a review of the incident with the sit to stand machine. The note documented there was no injury or complaint of pain from the resident. There was no mention of an X-ray being ordered or completed. Review of Resident #43's nurse's note, dated 11/17/25, revealed an entry at 12:13 P.M. that an X-ray was completed for Resident #43 and an order to send her to the emergency room for further evaluation. Review of Resident #43's X-ray result, dated 11/17/25, revealed the results arrived at the facility at approximately 11:45 A.M. and documented the resident had a fractured neck of the humerus, which is why she was ordered to be sent to the emergency room for further evaluation. Review of Resident #43's Witness Fall report, dated 11/16/25, revealed the narrative for the incident was a replication of the progress notes listed above from 11/16/25. The notifications were made by facility staff on 11/16/25 at 8:09 P.M., but at the top of the witness fall form, it stated the incident happened on 11/16/25 at 11:40 A.M. Review of facility investigative documents for Resident #43's incident, dated 11/16/25, revealed there was an interview statement from Resident #43, who stated she felt the fracture of her arm came from the incident with the sit to stand machine on 11/16/25. There were no interview statements from the two aides who provided the physical assistance with the sit to stand machine to determine how the incident occurred, or if the nurse's notes were an accurate description of what happened. Review of facility reported incidents (FRI), dated 11/01/25 to 11/17/25, revealed no FRI reported regarding this incident. The facility was made aware of the fracture on 11/17/25 at 11:45 A.M., and as of 1:45 P.M., there was no FRI filed as required. Interview with Director of Nursing on 11/17/25 at 2:55 P.M. and 3:35 P.M. confirmed they were made aware of Resident #43's fracture on 11/17/25 at 11:45 A.M. She confirmed they immediately reached out to the physician, and they got an order to send the resident to the emergency room for further monitoring and observation. The DON confirmed they did not file an FRI, further stating they knew the injury occurred the day before when Resident #43 had an incident they considered a fall, using the sit to stand machine. When asked how she knew this, the DON confirmed there was a nurse's note about the incident and stated she spoke with Resident #43 who stated she felt the injury occurred during the incident with the sit to stand machine. The DON confirmed she had not spoken with the two aides who were assisting Resident #43 with the transfer to determine what happened, and if they had used the sit to stand machine appropriately. She also confirmed the nurse's notes in the electronic medical records were not written by the two aides who were in the room at the time of the incident. The DON also confirmed the incident report and nurse's notes were not written until nine hours after the incident occurred; confirming the incident occurred on 11/16/25 at 11:40 A.M., and it was not documented until 8:10 P.M. She confirmed they were planning to interview the two aides later in the day. Review of facility Reporting and Investigating Abuse, Neglect, Exploitation, or Misappropriation policy, dated September 2022, revealed all reports of abuse, (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The administrator or individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility. Immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure wound care treatment and assessments were appropriately implemented and completed. This affected one resident (#76) out of three residents reviewed for wound care. The facility census was 93.Record review for Resident #76 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Parkinsonism, dementia, and dysphagia.Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/25, revealed the resident was assessed to have impaired cognition.Review of the nurses' progress note, dated 04/07/25, revealed right thigh healed. Treatment orders discontinued.Review of the care plan, revised 06/25/25, revealed the resident was at risk for impaired skin integrity. Interventions included blister to right thigh (05/10/25).Review of the facility eINTERACT SBAR (Situation, Background, Appearance, Review) form, dated 05/09/25, revealed the resident was assessed to have a new blister present to the right thigh with green and yellow drainage present. The physician was notified and new orders for laboratory testing and Levaquin (an antibiotic medication) were given and implemented.Review of the physicians orders for Resident #76 revealed no wound care treatment for the blister on the residents right thigh were implemented from 05/09/25 through 08/17/25.Review of the facility assessments from 05/09/25 through 08/17/25 revealed no assessment indicating the presence or description of the blister to Resident #76's right thigh was present.Observation on 08/18/25 at 2:14 P.M. revealed Resident #76 was lying in bed asleep with his pants removed for comfort. A small white bandage was in place to the residents right thigh which contained the initials of Licensed Practical Nurse (LPN) Manager #164. Interview with LPN Manager #164 at the time of the observation confirmed a small scab was observed on the residents right thigh and treatment orders were obtained from the physician and implemented. LPN #164 confirmed no new skin areas were present to her knowledge prior to 08/18/25.Observation on 08/19/25 at 9:15 A.M. with LPN Manager #164 revealed wound care was provided to the area on Resident #76's right thigh. A small open area approximately the size of a dime was present. The skin surrounding the open area was pink and no signs of infection were noted.Interview with LPN #262 on 08/19/25 at 10:47 A.M. confirmed Resident #76 had a small burn present to his right thigh which had healed around 04/07/25. LPN #262 confirmed she was working and providing care for Resident #76 on 05/09/25 and noticed a new blister to the residents right thigh which had green and yellow drainage present. LPN #262 confirmed she had notified the physician and obtained new orders for Levaquin to be administered and laboratory testing to be conducted. LPN #262 confirmed she notified Registered Nurse (RN) #166 of the presence of the wound and was told to clean the wound, apply Medi-honey (an ointment to treat wounds), apply a bandage and check on the wound as often as possible. LPN #262 confirmed wound care treatment orders were never implemented and wound assessments had never been conducted or documented. LPN #262 confirmed herself and RN #166 had been changing the bandage to the residents thigh when working in the facility and the area had continued to be present from 05/09/25 through 08/19/25.Interview with Certified Nursing Assistant (CNA) #268 on 08/18/25 at 1:02 P.M. confirmed Resident #76 had a wound present to his right thigh which had been there for a while. CNA #268 confirmed LPN #262 changed the bandage to the wound and had been doing so for a while.Interview with Assistant Director of Nursing (ADON) #263 on 08/19/25 at 11:57 A.M. confirmed the facility should implement and follow wound care treatment orders obtained by the physician and wounds were to be assessed and documented weekly. ADON #263 confirmed no wound care treatment orders had been implemented for the blister to Resident #76's right thigh from 05/09/25 through 08/17/25 and also confirmed no assessment of the wound had been completed or documented from 05/09/25 through 08/17/25.Review of the facility policy titled Wound Care, revised 10/2010, revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. Verify there is a physician's order for this procedure. The following information should be recorded in the resident's medical record: The type of wound care given, the date and time the wound care was given, the name and title of the individual performing the wound care, any change in the residents' condition, all assessment data obtained when inspecting the wound, and how the resident tolerated the procedure.This deficiency represents non-compliance identified during the investigation of Complaint 1386024.

Based on record reviews and staff interview, the facility failed to ensure residents remained free from burns. This affected one resident (#76) out of three residents reviewed for accidents. The facility census was 93.Record review for Resident #76 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Parkinsonism, dementia, and dysphagia.Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/25, revealed the resident was assessed to have impaired cognition.Review of the nurses progress note, dated 02/20/25, revealed Resident #76 had spilled coffee on himself during lunch. The resident would not allow staff to remove his pants to assess the area where coffee had spilled.Review of the nurse progress note, dated 02/20/25, revealed Resident #76 had been brought back from the dining area after he had spilled coffee on himself. The nurse completed a head-to-toe assessment, and a blister was present to the right outer leg with some redness noted. The immediate intervention was use of restrictive flow cup for hot liquids. The physician and responsible party were notified of the area and new intervention.Review of the Interdisciplinary Team (IDT) Note, dated 02/22/25, revealed the IDT met to review related to occurrence on 02/20/25. All aspects of the plan of care were in place at the time of occurrence. All safety interventions were in place and functional at time of occurrence. Resident was brought back from the dining area and had spilled coffee on himself. His liquids were in a lidded cup with handles at the time of the occurrence. The nurse completed a head-to-toe assessment with a blister noted to the right outer leg with some redness present. The immediate intervention was use of restrictive flow cups with hot liquids. Provide and responsible party notified. IDT in agreement with intervention and orders and updated POC (Plan of Care).Review of the facility Skin and Wound Evaluation, dated 02/24/25, revealed there was a second degree burn to the right thigh assessed. The wound measured 10.5 centimeters (cm) long by 6.6 cm wide. No pain was assessed to be present related to the wound, and no signs or symptoms of infection were noted.Interview with Assistant Director of Nursing (ADON) #263 on 08/19/25 at 11:57 A.M. confirmed Resident #76 sustained a burn from spilling hot coffee on himself on 02/20/25. ADON #263 confirmed the resident had been assessed by Occupational Therapy (OT) prior to the incident and was recommended to have a two handled cup with spouted lid used while consuming liquids to prevent spillage and burns, and the resident was using the cup as ordered at the time of the incident. ADON #263 confirmed treatment orders for the burn were obtained and implemented and the burn was resolved without infection or complications on 04/07/25. ADON #263 confirmed a restrictive flow cup was implemented for use with all hot liquids after the incident on 02/20/25 to further decrease the risk for spills or burns for Resident #76. This deficiency represents noncompliance investigated under Complaint Number 1386024.

Based on interview and closed medical record review, the facility failed to ensure blood draw orders were obtained for Resident #110 who was receiving Vancomycin (strong antibiotic) intravenously per standards of care. This affected one (Resident #110) of three residents reviewed for intravenous medication administration. The facility census was 97. Findings include: Review of the closed medical record for Resident #110 revealed an admission date of 03/20/25, discharged to hospital on [DATE], returned to facility on 05/07/25 and discharged home on [DATE]. Diagnoses included acute osteomyelitis of right ankle and foot, peripheral vascular disease, diabetes mellitus type two, abscess tendon sheath of right ankle and foot. Upon return from hospital stay resident was diagnosed with metabolic encephalopathy and altered mental status. Review of the physician orders upon admission revealed Resident #110 was ordered Vancomycin hydrochloride intravenous solution 1250 milligrams/250 milliliters, use 250 milliliters (ml) once daily for osteomyelitis. The start date was 03/21/25 and was discontinued on 4/11/25. There were no orders for Vancomycin peak and or trough levels. Review of the nursing progress notes for Resident #110 revealed no documentation related to Vancomycin trough levels being completed. Review of the admissions Minimum Data Set (MDS) dated [DATE] revealed Resident #110 was cognitively intact with no behaviors. Resident #110 required maximum assistance from staff to complete activities of daily living. Resident #110 received intravenous medications, antibiotics, insulin and antiplatelet medications. Review of the 48 hour baseline plan of care and comprehensive plan of care revealed Resident #110 received intravenous antibiotics related to osteomyelitis of right foot and ankle. However, no laboratory interventions related to Vancomycin. Interview on 06/23/25 at 11:46 A.M. with Licensed Practical Nurse (LPN) #170 revealed Vancomycin antibiotic intravenous should have labs drawn often for peak and trough. The results would be called to the physician and pharmacy, as pharmacy helped with dosing. LPN #170 stated Resident #110 did not have any peak or trough levels drawn for three weeks in March 2025. Interview on 06/24/25 at 12:44 P.M. with Physician Assistant (PA) #410, who had provided care for Resident #110, revealed the expectation for residents admitted on the medication Vancomycin would be to have trough levels drawn regularly or as ordered by physician. The PA stated he expected the nursing staff to notify the physician if no lab orders upon admission or with any start of intravenous Vancomycin. PA #410 stated he was not aware Resident #110 had went three weeks without labs. PA #410 stated Resident #110 hospitalization did not have anything to do with not having lab values for Vancomycin. Interview on 06/24/25 at 12:51 P.M. with Consult Pharmacist #411 revealed residents receiving Vancomycin intravenously should have peak and trough levels regularly based on physician orders. Pharmacist #411 stated he reviewed Resident #110 medication the day after he was admitted and there were not any labs to review at that time. Pharmacist #411 stated there were orders from the hospital that stated to draw a trough every Monday and he reviewed Resident #110 medications on Friday. Therefore, he did not make a recommendation for labs to be drawn. Pharmacist #411 stated the level of the trough varied per the diagnosis. Interview on 06/24/25 at 2:12 P.M. with the Director of Nursing (DON) confirmed Resident #110 did not have Vancomycin trough levels drawn for three weeks prior to rehospitalization. Upon return from hospital, Resident #110 received weekly trough levels as ordered and as needed per the physician. The facility did not have a policy pertaining to lab draws and values for antibiotics. This deficiency represents non-compliance investigated under Complaint Number OH00166429.

Based on observation, medical record review, policy review and interview, the facility failed to ensure residents were treated with dignity and respect. This affected three residents (#12, #30 and #31) observed for incontinence care and one resident (#45) of one resident self-propelling in the hallway. The facility census was 87. Findings include: 1. Medical record review revealed Resident #31 was admitted on [DATE] with diagnoses including multiple sclerosis, Parkinson's disease, altered mental status and urge incontinence. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #31 was cognitively intact for daily decision-making and was frequently incontinent of urine. Medical record review revealed Resident #30 was admitted on [DATE] with diagnoses including dementia, urinary tract infections, cognitive communication disorder, contractures and bipolar disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #30 was cognitively intact for daily decision-making, always incontinent of bowel and bladder. On 05/01/25 at 6:00 A.M., observation from the hallway revealed Resident #30 was positioned on her left side and Certified Nurse Assistant (CNA) #237 was observed providing incontinence care to the resident. Resident #30's buttocks and legs were exposed as the door to the room was open and the privacy curtain was not pulled shut. Observation of the floor revealed an incontinence product containing brown stool was observed on the floor without a barrier. Resident #31 was observed sitting on the toilet naked with her head lowered to her chest. Interview with CNA #237 and CNA #238 verified the above observations and the dignity of the residents were not maintained while providing morning care. 3. Medical record review revealed Resident #45 was admitted on [DATE] with diagnoses including heart failure, mild cognitive impairment, dementia, cognitive communication deficit and anxiety disorder. Review of the annual MDS assessment dated [DATE] revealed Resident #45 was cognitively intact for daily decision-making and required supervision or touching assistance with shower/bathe self. On 05/01/25 at 7:15 A.M., observation revealed Resident #45 was self-propelling in a wheelchair by the nurses' station wearing a pair of slippers and one, white bath towel was observed to be draped across her torso and groin. The resident's hair was wet and her shoulders and upper thighs to her feet were exposed. CNA #223 was following behind the resident from the shower room and was carrying the resident's bath supplies. At the time of the above observation, Activities #224 was passing out activity calendars and verified the above. Activities #224 stated the resident needed to be covered and went towards the resident to assist. While Resident #45 was still in the hallway, Resident #50 was coming out of his room to go to the dining room and looked down the hallway towards Resident #45. On 05/01/25 at 7:19 A.M., interview with CNA #223 stated she had assisted Resident #45 with her shower that morning and verified the resident was not completely covered when she left the shower room to go back to her room. CNA #223 verified the resident's dignity was not maintained. 4. Medical record review revealed Resident #12 was admitted on [DATE] with diagnoses including pneumonia, adult failure to thrive, dysphagia, cardiomyopathy, protein-calorie malnutrition and anxiety disorder. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #12 was cognitively intact for daily decision-making and was frequently incontinent of bowel and bladder. On 05/01/25 between 10:07 A.M. and 10:07 A.M., observation revealed CNA #226 gathered supplies to complete incontinence care for Resident #12 whose bed was next to a large window with the blinds open. An adjacent business parking lot and sidewalk were observed outside the resident's window. CNA #226 raised the resident's bed and rolled the resident onto her left side, removed her incontinence product revealing a large amount of loose brown stool and began incontinence care. At no time did CNA #226 close the blinds to maintain Resident #12's dignity during incontinence care. Interview on 05/01/25 at 10:24 A.M. with CAN #226 verified the blinds were left open during incontinence care for Resident #12. Review of the policy: Dignity revised February 2021 revealed residents were to be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. This included staff were to promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and treatments. This deficiency represents noncompliance investigated under Complaint Number OH00165005.

Based on observation, medical record review, controlled drug sheet review, policy review and interview, the facility failed to ensure a comprehensive program to safeguard controlled substances and ensure medications were administered as ordered. This affected four residents (#18, #21, #38 and #102) sampled during reconciliation of controlled substances and one resident (#36) of three residents reviewed for infection. The census was 87. Findings include: 1. On 05/01/25 between 6:15 A.M. and 6:45 A.M., observation of reconciliation of controlled drugs for the Maple Avenue Hall and Main Street Hall revealed the following: a. Reconciliation of controlled medications with Registered Nurse (RN) #235 and Licensed Practical Nurse (LPN) #236 for Maple Avenue Hall revealed RN #235 opened the medication cart and unlocked the narcotic drawer. The locked narcotic drawer contained bubble packs of medications, transdermal patches, a community-filled prescription bottle and a disposable water cup that contained two pill-crusher pouches (pouch to put medications into prior to the crushing process to help eliminate cross contamination) stapled shut with an unknown amount of round, blue-scored tablets. The pouches were full and at the time of the observation, RN #235 stated she was unable to complete an accurate count of how many tablets were in the pouches without removing the staple, and there was no name of the drug or resident name on the pill-crusher pouches. RN #235 stated she had notified the Director of Nursing (DON) of her concerns when reconciling at the beginning of her shift and earlier this morning when she arrived. The disposable plastic drinking cup was observed to have Resident #21's name and oxycodone 5 milligrams (mg) written in black marker on the cup. The pouches of the blue-scored tablets did not include a pharmacy label or proper identification only handwritten initials and the number '30'. There was no pharmacy label or identifying information of what medication was in the sleeves, drug name, strength, ordering physician or expiration date. On 05/01/25 between 6:52 A.M. and 7:00 A.M., observation and interview with the DON verified the locked narcotic drawer contained two pill-crusher pouches, the pouches were not labeled with required information, and she did not know how long they had been in there. The DON stated she had just become aware of the situation prior to the surveyor's arrival at the facility this morning. The DON stated the resident had the prescription filled in the community prior to her admission and brought them to the facility in the original prescription bottle. The DON stated she believed the unlabeled pills were Resident #21's oxycodone (opioid) as the prescription bottle (also located in the locked narcotic drawer of the medication cart) was for oxycodone and the pills looked the same. The DON stated she does not know why anyone would remove them from the original prescription bottle and separate them out like that, but that was what she believed had happened. The DON verified the two pouches of blue tablets could be something else since not labeled but felt they were the resident's oxycodone. Review of the Controlled Drug Receipt/Record/Disposition Form (CDR) with the DON revealed there should be 65 tablets of oxycodone available for use; however, there were only five tablets in the prescription bottle. The DON stated there were probably '30' tablets in each pouch as there was the number '30' written on each pouch but the pouches were not labeled, and the disposable cup did not meet the criteria of proper labeling. b. On 05/01/25 at 6:25 A.M., observation during reconciliation with RN #235 and LPN #236 revealed Resident #18 had a CDR for Norco 5/325 mg (opioid) indicating there should be six tablets of Norco 5/325 mg available for use. Observation of the Norco 5/325 mg bubble pack with RN #235 and LPN #236 revealed there were five tablets in the bubble pack. At the time of the observation, RN #235 stated she administered Norco 5/325 mg tablet to Resident #18 at 5:00 A.M. and had forgotten to sign out the medication. RN #235 and LPN #236 verified the above at the time of the observation. c. On 05/01/25 at 6:30 A.M., observation during reconciliation with RN #235 and LPN #236 revealed Resident #102 had an order to administer oxycodone 5/325 mg every six hours as needed for pain. Review of the CDR at the time of the observation revealed there were seven tablets available for use. Observation of the oxycodone 5/325 mg bubble-pack revealed six tablets were available for use. At the time of the observation, RN #235 stated she administered the oxycodone to Resident #102 at 6:00 A.M. but forgot to sign it out. RN #235 and LPN #236 verified the above at the time of the observation. d. Reconciliation of controlled medications with RN #235 and LPN #236 for Main Street Hall revealed there were 25 bubble pack cards of controlled medications, and the Controlled Medication Shift Change Log revealed there were 24 count sheets. Review of the Controlled Medication Shift Change Log dated 04/27/25 through 04/30/25 revealed the following: On 04/28/25, the Total Count Sheets were 24. On 04/29/25 at 11:00 P.M., five sheets were added, and six sheets were removed leaving a Total Count Sheet of 23. On 04/30/25 at 7:00 A.M., three sheets were added leaving a Total Count Sheet of 26. On 04/30/25 at 1:37 P.M., one card was removed (discharged home) leaving 25 (signed by on-coming nurse). On 04/30/25 at 10:00 P.M., two cards were removed, and Total Count Sheets was 24. On 05/01/25 at 6:40 A.M., interview with RN #235 and LPN #236 verified the total count sheets did not match the number of controlled bubble packs. The Total Count Sheets should have been 23 instead of 24 on 04/30/25 at 10:00 P.M. At the time of the observation, the Total Count Sheets was 23 and there were 25 medication cards. RN #235 and LPN #236 verified the above was not discovered during reconciliation at the start of their shift on 04/30/25 at 10:00 P.M. when reconciliation was done. 2. Medical record review revealed Resident #21 was admitted on admitted on [DATE] with diagnoses including osteoporosis, spinal stenosis, chronic pain, osteoarthritis and joint pain. Review of the electronic Physician Orders dated 05/01/25 revealed Resident #21 was ordered oxycodone 5 mg every eight hours PRN (as needed) for pain rated on a scale of one to 10. Review of the electronic Medication Administration Record (eMAR) dated April 2025 revealed Resident #21 was administered oxycodone 5 mg PRN as follows: On 04/25/25 at 5:37 A.M. On 04/26/25 at 9:37 A.M. and 6:10 P.M. On 04/27/25 at 5:01 A.M., 1:00 P.M. and 9:05 P.M. On 04/28/25 at 5:05 A.M. On 04/29/25 at 5:20 A.M. On 04/30/25 at 1:12 A.M. Review of Resident #21's oxycodone 5 mg CDR dated 04/25/25 revealed a supply of 79 tablets were received. On 05/01/25 at 6:17 A.M., Resident #21's CDR for oxycodone 5 mg indicated 65 tablets were available for use and had received oxycodone per the CDR as follows: On 04/25/25 at 5:37 A.M. and 3:20 P.M. On 04/26/25 at 9:37 A.M. and 6:10 P.M. On 04/27/25 at 5:00 A.M., 1:00 P.M. and 9:05 P.M. On 04/28/25 at 5:05 A.M. and 6:40 P.M. On 04/29/25 at 5:20 A.M. and 2:30 P.M. On 04/30/25 at 1:13 A.M., 9:10 A.M. and 6:10 P.M. On 05/01/25 at 11:00 A.M., interview with Assistant Director of Nursing (ADON) #198 verified Resident #21's eMAR indicated nine doses were administered between 04/25/25 and 05/01/25, and the CDR indicated 14 doses were administered within the same timeframe. ADON #198 stated the nurses do forget to document on the eMAR which makes it look like more doses of oxycodone were dispensed and not administered to the resident (five doses) but felt it was more of a documentation error than someone taking them. 3. Medical record review revealed Resident #38 was admitted on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage, dementia, contracture of other specified joint and hemiplegia. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #38 was severely impaired for daily decision-making, did not complain of pain and received scheduled pain medications. Review of the Order Summary Sheet dated April 2025 revealed Resident #38 was ordered to receive oxycodone 5 mg three times a day for pain. Review of the CDR dated 04/08/25 revealed Resident #38 received oxycodone 5 mg once on 04/19/25 at 9:45 A.M., once on 04/20/25 at 9:45 A.M., twice on 04/24/25 at 9:30 A.M. and 5:45 P.M., and once on 04/25/25 at 9:30 A.M Review of the eMAR dated April 2025 revealed Resident #38 was administered oxycodone 5 mg three times a day as ordered including 04/19/25, 04/20/25, 04/24/25 and 04/25/25. Review of the care plan: At Risk for Pain due to problems including but not limited to contractured joints, chronic pain, craniectomy and hydrocephalus with shunt revised 07/09/24 revealed interventions including to administer pain medications as ordered and monitor for effectiveness. On 05/01/25 at 2:00 P.M., interview with ADON #198 verified after review of the CDR for Resident #38 that there was a discrepancy in the eMAR and CDR for Resident #38. ADON #198 stated the Controlled Medication Shift Change Log did not reflect the discrepancies. ADON #198 stated RN #197 did not administer the scheduled pain medications because she did think the resident needed it. ADON #198 denied any side effects or concerns with the current dose ordered and administered routinely to the resident stating it was the nurse's belief system that kept her from administering the medications to the resident. ADON #198 stated the nurse had been re-educated at least twice regarding the administration of medications per physician orders, and she would have to educate her again. 4. Medical record review revealed Resident #36 was admitted on [DATE] with diagnoses including respiratory failure, atrial fibrillation, heart failure and anxiety. Review of the quarterly MDS assessment dated [DATE] revealed Resident #36 was moderately impaired for daily decision-making and had been receiving antibiotics. Review of the electronic Physician Orders dated February 2025 revealed Resident #36 was ordered to receive Augmentin 875-125 mg (antibiotic) every 12 hours for six days for pneumonia. Review of the eMAR dated February 2025 revealed Augmentin 875-125 mg was administered between 02/19/25 and 02/25/25 for 11 of 12 ordered doses. There was no evidence Resident #36 had received the 12th dose of Augmentin. On 04/30/25 at 2:17 P.M., interview with LPN #227 verified Resident #36 was not administered Augmentin as ordered as indicated above. Review of the policy: Administering Medications revised April 2019 revealed medications were to be administered in a safe and timely manner, and as prescribed. The procedure included the individual administering the medication was to check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. If a dosage was believed to be inappropriate, excessive or identified as having potential adverse consequences for the resident, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. Review of the policy: Controlled Substances revised November 2022 revealed the facility complied with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of controlled medications. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: records of personnel access and usage, MAR, declining inventory records and destruction, waste and return to pharmacy records. Nursing staff was to count controlled medication inventory at the end of each shift using these records to reconcile the inventory count. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the DON. The consultant pharmacist or designee routinely monitors controlled storage records. This deficiency represents noncompliance investigated under Complaint Number OH00165005.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, self-reported incident (SRI) review, medical record review, policy review and interview, the facility failed to safeguard controlled substances to prevent misappropriation. This affected one resident (Resident #13) of three residents identified in a self-reported incident. The facility census was 87. Findings include: Medical record review revealed Resident #13 was admitted on [DATE] with diagnoses including diabetes mellitus, fracture of left tibia and fibula, benign prostatic hyperplasia, heart failure and urinary tract infection. Review of the SRI tracking number 258836 dated 03/30/25 revealed when the facility tried to reorder Resident #13's oxycodone (opioid), the pharmacy indicated that the medication could not be refilled as it was too soon. The pharmacy reported that 60 tablets of oxycodone 5 milligrams (mg) had been delivered to the facility on [DATE]. A review of the delivery receipt and the Controlled Drug Administration Record (CDR) confirmed that the medication had been received and registered in the facility's narcotic count. A comprehensive facility-wide search was conducted, including all medication carts and medication storage areas. Despite these efforts, facility staff were unable to locate the missing card of oxycodone, or the control sheet associated with Resident #13's oxycodone. The attending physician was immediately informed of the incident and the assessment findings. Licensed nurses have been reminded of the requirement to perform thorough shift change narcotic counts and report discrepancies immediately. A licensed pharmacist was reviewing CDR records and evaluating facility narcotic count protocols to identify potential areas for improvement in preventing future medication diversions. The Director of Nursing (DON) and designee were reviewing all current residents with oxycodone prescriptions, cross-referencing control sheets, pharmacy packing slips, and medication administration records to determine the root cause of the issue. The facility unsubstantiated misappropriation but indicated it was suspected. On 05/01/25 at 10:41 A.M., interview with Assisted Director of Nursing (ADON) #198 verified she was not aware there were unidentified controlled drugs being stored in the medication controlled lock box as discovered on 05/01/25. ADON #198 stated this was not an acceptable or approved practice at the facility. On 05/01/25 at 10:43 A.M., interview with ADON #198 verified misappropriation of Resident #13's controlled substance was identified when a missing bubble-pack card of 60 tablets of oxycodone 5 mg for Resident #13 when the pharmacy denied a request to refill the medication due to being refilled 10 days prior. ADON #198 stated she was very involved in this investigation especially reviewing the CDR and controlled substances. ADON #198 stated to her knowledge the facility has not been able to determine who or when the medications were misappropriated and/or removed from the facility. ADON #198 acknowledged there have been continued concerns identified through audits, as well as observations made during the current survey of documentation concerns related to signing out controlled substances and reconciliation sheets. 2. On 05/01/25 at 6:25 A.M., observation during reconciliation with Registered Nurse (RN) #235 and Licensed Practical Nurse (LPN) #236 revealed Resident #18 had a CDR for Norco 5/325 mg (opioid) indicating there should be six tablets of Norco 5/325 mg available for use. Observation of the Norco 5/325 mg bubble pack with Registered Nurse (RN) #235 and LPN #236 revealed there were five tablets in the bubble pack. At the time of the observation, RN #235 stated she administered Norco 5/325 mg tablet to Resident #18 at 5:00 A.M. and had forgotten to sign out the medication. RN #235 and LPN #236 verified the above at the time of the observation. 3. On 05/01/25 at 6:30 A.M., observation during reconciliation with RN #235 and LPN #236 revealed Resident #102 had an order to administer oxycodone 5/325 mg every six hours as needed for pain. Review of the CDR at the time of the observation revealed there were seven tablets available for use. Observation of the oxycodone 5/325 mg bubble-pack revealed six tablets were available for use. At the time of the observation, RN #235 stated she administered the oxycodone to Resident #102 at 6:00 A.M. but forgot to sign it out. RN #235 and LPN #236 verified the above at the time of the observation. 4. On 05/01/25 at 6:40 A.M., reconciliation of controlled medications with RN #235 and LPN #236 for Main Street Hall revealed there were 25 bubble pack cards of controlled medications, and the Controlled Medication Shift Change Log revealed there were 24 count sheets. Review of the Controlled Medication Shift Change Log dated 04/27/25 through 04/30/25 revealed the following: On 04/28/25, the Total Count Sheets were 24. On 04/29/25 at 11:00 P.M., five sheets were added, and six sheets were removed leaving a Total Count Sheet of 23. On 04/30/25 at 7:00 A.M., three sheets were added leaving a Total Count Sheet of 26. On 04/30/25 at 1:37 P.M., one card was removed (discharged home) leaving 25 (signed by on-coming nurse). On 04/30/25 at 10:00 P.M., two cards were removed, and Total Count Sheets was 24. On 05/01/25 at 6:40 A.M., interview with RN #235 and LPN #236 verified the total count sheets did not match the number of controlled bubble packs. The Total Count Sheets should have been 23 instead of 24 on 04/30/25 at 10:00 P.M. At the time of the observation, the Total Count Sheets was 23 and there were 25 medication cards. RN #235 and LPN #236 verified the above was not discovered during reconciliation at the start of their shift on 04/30/25 at 10:00 P.M. when reconciliation was done. Review of the policy: Abuse Prevention dated 10/02/19 revealed the facility will prohibit abuse, mistreatment, neglect, misappropriation of resident property and exploitation for all residents. The deficient practice was corrected on 04/09/25 when the facility implemented the following corrective actions: On 03/30/25, the DON/designee completed a count of all controlled substances, and no additional issues were identified. On 03/30/35, the DON/designee contacted the county police department and filed a report with associated case #25-16450. On 03/30/25, the DON/designee initiated re-education to all current licensed nurses regarding the receipt process and accurate counts during shift changes of controlled medications. On 03/30/25, the pharmacy was notified of the incident and was to send a licensed pharmacist by 04/08/25 to evaluate the current controlled medication validation process and staff education. On 03/31/25, the DON/designee notified the Ohio Department of Health of the incident. On 03/31/25, the DON/designee initiated daily audits for five days, then weekly for four weeks and PRN (as needed) thereafter. On 04/03/25, the DON/designee initiated re-education with nursing clinical managers of the importance of consistent and organized oversight of the controlled documentation administration records. On 04/04/25, the DON/designee notified the pharmacy that any bills were to be directed to the facility to ensure the residents were reimbursed for the potentially misappropriated medications. On 04/04/25, RN #400 remained under suspension. On 04/04/25, the county sheriff was notified of the investigation findings. A full review of licensed nursing staff credentials were completed and confirmed all licenses remained in good standing. On 04/07/25, the pharmacy initiated new measures to monitor controlled medications more closely including all controlled medication invoices were to be signed by two nurses, completed controlled medication cards and count sheet were to be placed in a binder and double checked by the unit manager and held until the pharmacist's next visit for his review on 04/22/25. On 04/09/25, RN #400 employment was terminated. On 04/22/25, pharmacy returned to review previous measures implemented and no concerns were identified. This deficiency represents past noncompliance investigated under Complaint Number OH00165005.

Based on observation, medical record review, policy review and interview, the facility failed to timely assess an indwelling catheter, treat urinary tract infections and provide adequate incontinence care. This affected one resident (#13) of three residents reviewed for urinary tract infections and one resident (#12) of one resident observed for incontinence care. The facility census was 87. Findings include: 1. Medical record review revealed Resident #13 was admitted on [DATE] with diagnoses including left fibula and tibia fracture, heart failure, chronic kidney disease, benign prostatic hyperplasia (BPH) without lower urinary tract symptoms, and urinary tract infection (UTI). Review of the Foley Catheter Evaluation dated 02/28/25 revealed Resident #13's indwelling catheter was being utilized for better pain control and mobility. The evaluation was to be completed upon admission, weekly for four weeks and then quarterly thereafter. The goal was to minimize the invasive methods used for resident safety, health, and overall wellbeing. Further review of the medical record revealed no evidence of a comprehensive evaluation of Resident #13's indwelling catheter between 02/28/25 and 04/30/25. Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident had an indwelling catheter and no UTI in the last 30 days. Review of the quarterly MDS assessment dated [DATE] revealed Resident #13 was cognitively intact for daily decision-making, did not utilize an indwelling catheter, was frequently incontinent of urine and had a UTI in the last 30 days. Review of the electronic Physician Orders dated 02/27/25 to 04/11/25 revealed the resident utilized an indwelling urinary catheter. An order for a trial removal of the indwelling catheter was completed on 04/11/25, and the resident's indwelling catheter was discontinued. Review of the Progress Notes dated 04/11/25 revealed Resident #13 requested his indwelling catheter to be removed and to evaluate if he really needed it. Physician Assistant #304 evaluated the resident, and an order was received to remove the indwelling catheter, obtain a urinalysis and start an antibiotic pending urine result. The resident voided cloudy urine, and the urine sample was obtained; however, there was no evidence the urine sample was sent to the laboratory. Review of the Physician Assistant #304's Progress Note dated 04/14/25 revealed Resident #13 was reassessed and complained of back pain and dysuria (difficulty urinating) over the weekend. The resident's urine was noted to be cloudy, and he stated he felt a little better this morning. Continue antibiotic pending urinalysis results and encourage fluids. Review of the Culture, Urine report dated 04/18/25 revealed Resident #13's urine specimen was collected on 04/14/25 and final results were reported on 04/18/25. The urine culture was positive for Escherichia coli (e-coli) greater than 100,000 CFU/mL (colony-forming-units per milliliter), and enterococcus faecalis 26-30,000 CFU/mL. The urinalysis included 2+ blood, 4+ leukocytes, six to 20/HPF (high power field) red blood cells, and greater than 50 HPF white blood cells. Review of the Antibiotic Sensitivity revealed e-coli was sensitive to Bactrim (antibiotic) but not enterococcus faecalis. Review of the electronic Medication Administration Record (eMAR) dated April 2025 revealed Resident #13 was administered Bactrim DS 800-160 milligrams mg between 04/11/25 and 04/18/25 for infection and Cipro 500 mg (antibiotic) between 04/21/25 and 04/28/25 for UTI. Review of the resolved care plan: Indwelling Foley Catheter: Skin breakdown/discomfort/diagnosis BPH/pain management initiated 02/27/25 and discontinued 04/15/25 revealed interventions included to monitor/record/report signs and symptoms of UTI to physician. On 05/04/25 at 3:02 P.M., interview with Licensed Practical Nurse (LPN) #227 verified Resident #13's indwelling catheter was only assessed upon admission and had been utilized due to the difficulty using a urinal due to his leg brace. LPN #27 verified the resident had not been seen by a urologist, was symptomatic of a possible UTI prior to the catheter being discontinued, the urinalysis was obtained not sent timely to the lab and the resident had taken two different antibiotics to treat the diagnosed UTI due to the first antibiotic was not sensitive to one of the two organisms. LPN #227 stated she has spoken to PA #304 regarding ordering antibiotics prior to urinalysis/culture but he continues to write it in his progress note and order the antibiotics to start treatment without urine test results. On 05/05/25 at 3:50 P.M., an electronic interview with the Administrator verified the urinalysis/culture was ordered on 04/11/25; however, the lab will not do STAT (immediate) urinalysis, the lab didn't pick up the sample on 04/11/25 and the earliest they would come was on 04/14/25. The Administrator stated the facility had limited options, as far as, labs in their geographical location. 2. Medical record review revealed Resident #12 was admitted on [DATE] with diagnoses including pneumonia, adult failure to thrive, dysphagia, cardiomyopathy, protein-calorie malnutrition and anxiety disorder. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #12 was cognitively intact for daily decision-making and was frequently incontinent of bowel/bladder. On 05/01/25 between 10:07 A.M. and 10:35 A.M., observation revealed CNA #226 gathered supplies to complete incontinence care for Resident #12 whose bed was next to a large window with the blinds open. An adjacent business parking lot and sidewalk were observed outside the resident's window. CNA #226 raised the resident's bed and rolled the resident onto her left side, removed her incontinence product revealing a large amount of loose brown stool and began incontinence care. CNA #226 was observed using multiple disposable incontinence wipes in a circular motion on the resident's buttocks, legs and groin in attempts to clean the excessive amount of soft, loose stool. CNA #226 placed a clean incontinence product under the resident while brown stool was still observed on her buttocks and rectum. CNA #226 turned the resident onto her back and stool was observed on the resident's groin and clean incontinence product under the resident. CNA #226 continued to use the disposable incontinence wipes and then fastened the incontinence product to the resident. On 05/01/25 at 10:24 A.M., an interview with CNA #226 verified there was stool on both the resident's groin/peri-area and the clean incontinence product that was placed on the resident during incontinence care. CNA #226 stated Resident #12 consistently had loose stool and staff would have to check her every 20-minutes, and they would clean her again at that time. On 05/01/25 at 10:35 A.M., interview with Assistant Director of Nursing (ADON) #198 verified CNA #226 had not provided appropriate incontinence care and should not have left the resident soiled. Review of the policy: Urinary Continence and Incontinence - Assessment and Management revised August 2022 revealed indwelling urinary catheters were to be used sparingly for appropriate indications only. Identification and management of UTI will follow relevant clinical guidelines and antibiotics will be used appropriately. If a resident was admitted from the hospital with a newly placed indwelling catheter, the attending physician and staff were to evaluate the potential for removing it, depending on the current condition and rationale for its original placement. Where indicated, the staff and physician will treat symptoms of a UTI. The physician will identify situations in which an indwelling urethral catheter was indicated and document why other alternative were not feasible. If used, the physician and staff will document the clinical indications for use of the catheter and utilize a standardized tool to document its ongoing need. If an indwelling catheter is needed, staff will monitor for and report complications such as evidence of a symptomatic infection. This deficiency represents noncompliance investigated under Complaint Number OH00165005. This deficiency substantiates Complaint Number OH00165005.

Based on observation, clinical record review, review of hospital progress notes, staff interview, resident interview, resident representative interview, and review of facility policy, the facility failed to maintain a safe outdoor smoking area for residents assessed to be independent with smoking, failed to ensure Resident #100 was accurately assessed for the ability to safely smoke without supervision, failed to ensure Resident #100 was appropriately assessed for the ability to extinguish herself in the event of a fire (she had hemiplegia and hemiparalysis of the left arm and leg and required assistance from two staff members for transfers), failed to ensure the resident had reasonable access to a fire blankets and/or fire extinguisher, and failed to ensure the resident had the means to obtain assistance in the event of a fire. This resulted in Immediate Jeopardy and serious physical harm on 05/12/24 when Resident #100, who was smoking in the facility designated smoking area caught on fire from an ash of her cigarette sustaining severe third degree burns to her upper body/face requiring hospitalization and surgical intervention. A visitor observed the resident to be on fire and utilized the sleeve of her shirt to extinguish the fire when the visitor was unable to locate a fire blanket in the designated smoking area. The resident was subsequently transferred to the hospital where she received treatment for the third degree burns to her upper body which required skin graft surgery. This affected one resident (#100) of three residents reviewed for safe smoking. The facility identified six additional residents (#2, #25, #26, #34, #47, and #78) who were assessed to be able to smoke independently. The facility census was 90. On 06/04/24 at 10:48 A.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 05/12/24 when the facility failed to maintain a safe smoking area for Resident #100 when the resident caught on fire while smoking. A visitor who responded after seeing the resident on fire had to utilize the sleeve of her sweatshirt to extinguish the resident because there was no fire blanket readily accessible in the designated smoking area. The Immediate Jeopardy was removed on 06/04/24 when the facility implemented the following corrective actions: On 05/12/24 Licensed Practical Nurse (LPN) #242 responded to Resident #100 after being notified the resident had caught fire. LPN #242 assessed Resident #100 for pain which the resident initially denied and refused a transfer to the emergency room . Later Resident #100 agreed to the hospital transfer, the transfer was facilitated, and the resident's representative was notified of the incident. On 05/12/24 after the incident occurred, the Administrator called Resident #100's representative and discussed the incident. On 05/12/24 the Administrator visited Resident #100 in the hospital. The Administrator stated the resident voiced concerns about losing her smoking privileges and also stated the wind blew amber out of her cigarette and caught her clothes on fire. The resident stated she had been wearing loose fitting clothing at the time of the incident and she thought she had swatted the amber off her but later realized she had not done so. On 05/12/24 Licensed Practical Nurse (LPN) #242 reviewed the current smoking residents in the facility with no injuries noted. All smoking evaluations were reviewed for accuracy and the plans of care was updated if needed for the residents reviewed. LPN #242 also instructed the residents on the location of the fire safety equipment, fire blanket, and ensured they understood how to use it. On 05/12/24 the Director of Nursing (DON) reviewed skin evaluations on all current residents and there were no signs of any injuries of unknown origin or injuries consistent with a smoking injury. On 05/12/24 LPN #242 observed independent smokers' clothing and no signs of damaged clothing consistent with a smoking incident were noted. On 05/12/24 LPN #242 re-educated current smoking residents on the importance of informing staff of any potential fire hazards immediately to prevent similar incidents from occurring. On 05/12/24 LPN #242 re-educated the current staff on the updated facility smoking policy. On 05/12/24 the Administrator met with the resident council to review the smoking policy, and to receive feedback from the residents related to the possibility of transitioning the facility to supervised smoking in the future. On 05/12/24 Regional Nurse Consultant (RNC) #800 incorporated fire safety equipment checks immediately, daily for four days, then monthly and as needed thereafter to ensure appropriate fire safety equipment was present and in functional order. On 05/12/24 Activities Director (AD)#294 started random audits on a minimum of five residents per week for four weeks then as needed to ensure residents were appropriately assessed and were smoking safely independently, avoiding loose and flammable clothing, and were taking appropriate precautions related to weather conditions. Any issues identified within the audits were to be forwarded to the Quality Assurance (QA) committee for immediate follow-up. On 05/12/24 Registered Nurse (RN) #319 provided staff, residents, and visitors with education regarding placement of the fire extinguisher and fire blanket. On 05/13/24 the Administrator obtained a quote for a gazebo to be placed in the smoking courtyard. On 05/15/24 Regional Nurse Consultant (RNC) #800 updated the smoking policy to include additional fire safety measures, such as having fire extinguisher in the smoking area, training residents on basic fire safety, and inspection and maintenance of fire safety equipment. On 05/15/24 AD#294 educated current smokers on the updated smoking policy, the current smokers were provided with a copy of the policy and signed an attestation of understanding. On 05/15/24 AD#294 placed signage on the facility doors informing and reminding residents and staff of the smoking rules and fire safety practices. On 05/15/24 the Administrator held a meeting with the Ombudsman and all independent smoking residents regarding the smoking policy, placement of the fire extinguisher, placement of the fire blanket, and the importance of verbalizing the need for assistance. On 05/30/24 a gazebo was placed within the courtyard by Maintenance Director (MD) #281. On 06/03/24 MD #281 placed a fire blanket on the gazebo. On 06/04/24 MD #281 moved the fire extinguisher to the designated smoking area. On 06/04/24 Occupational Therapist (OT) #318 assessed all independent smokers to ensure they were able to follow safety precautions related to fire safety and ensured residents were able to remove the fire blanket and understood how to use a fire extinguisher. The facility implemented a plan that on 06/04/24 by 11:59 P.M., the DON would educate all licensed nurses on how to complete a smoking assessment to ensure consistency. Licensed nurses would be responsible for completing smoking assessments moving forward. The education would include the new location of the smoking blanket in the designated smoking area. No agency staff were being utilized and no licensed nurses were on leave at the time of the training. On 06/04/24 AD #294 hung signs on the two handicapped accessible doors leading to the smoking area to ensure staff, residents, and visitors had knowledge of where the smoking blanket and fire extinguisher were located. On 06/04/24 the Administrator fastened a walkie talkie to the smoking gazebo for communication in the event of an emergency. The walkie talkie would be changed out daily to ensure it was charged. Beginning on 06/04/24 the DON or designee would complete weekly audits for four weeks and as needed to ensure the completed smoking observation/assessments were accurate and reflected the medical record. Beginning on 06/04/24 the DON or designee would complete weekly audits for four weeks and as needed to ensure the fire blanket, fire extinguisher, and walkie talkie were in place. Results of the audits would be reviewed during monthly Quality Assurance (QA) meetings to determine if the current action plan was effective or if additional interventions would need to be added. Any issues identified within the audit would be forwarded to the QA committee for immediate follow-up. Interviews on 06/04/24 from 3:35 P.M. to 3:50 P.M. with three licensed nurses (#242, #248, and #246) confirmed they had received education regarding the accurate completion of resident smoking assessments. Although the Immediate Jeopardy was removed on 06/04/24, the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #100 revealed the resident was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparalysis affecting the left non-dominant side, dysphagia, weakness, seizures, and need for assistance with personal care. The resident was transferred to the hospital on 05/12/24 and did not return to the facility. Review of the care plan for Resident #100 initiated 05/19/20 revealed the resident was a cigarette smoker and was safe to smoke independently per the smoking assessment. Interventions included staff were to complete smoking assessment prior to initiating smoking independently, quarterly, and as needed. Review of the care plan for Resident #100 initiated11/24/20 revealed the resident had an activities of daily living (ADL) self-care performance deficit and was noncompliant with safety interventions and mobility. Interventions included staff to provide assistance with transfers, bed mobility, personal hygiene, and dressing. Review of the care plan for Resident #100 initiated 11/17/21 revealed the resident had impaired visual function related to limited vision in the left eye. Interventions included reminding resident to wear glasses. Review of the care plan for Resident #100 initiated 07/21/23 revealed the resident had a diagnoses of seizure disorder and was at risk for complications. Interventions included the following: place the call light within reach and answer promptly and to maintain a safe environment, instruct resident on smoking risks and hazard, therapy as ordered to improve mobility, keeping smoking materials stored appropriately in the lock box, smoking at designated times per the facility policy. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #100 dated 04/11/24, revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15 (out of 15). The assessment indicated Resident #100 utilized a manual wheelchair for mobility and had functional limitation in range of motion present on one side of the upper and lower extremities. Record review revealed the Resident #100 required substantial/maximum assistance from staff for transfers. Review of the smoking observation/assessment for Resident #100 dated 05/03/24 completed by Activities Director #294 revealed the resident was a smoker or user of tobacco products. The resident was assessed to have no cognitive loss, visual deficits, or dexterity problems. The resident was assessed to be safe to smoke without supervision. Review of the physician's order for Resident #100 dated 05/12/24 revealed the resident was to be provided assistance from two staff members with use of a gait belt for transfers. Review of the nursing progress note for Resident #100 dated 05/12/24 at 12:31 P.M. and authored by Registered Nurse (RN) #319 revealed Resident #100 was outside smoking unsupervised in the smoking area. Someone yelled fire while standing by the windows to the courtyard. The nurse approached Resident #100 and a visitor was using the sleeve of her sweatshirt to put out the fire. Resident #100 was brought back inside and the Registered Nurse (RN) on shift was notified. The RN assessed Resident #100 and noted burns to both breasts, chest, neck, jaw, and face and the left side of the resident's face and her hair was burnt. The resident's shirt and bra had significant damage and staff removed them and placed a sheet over the resident. Staff called 911 due to the severity of the burns. Emergency medical service (EMS) personnel arrived at the facility and assessed the resident. Resident #100's representative was notified of the incident and the transfer, and the resident was taken to the hospital. Review of the Emergency Medical Services (EMS) report for Resident #100 dated 05/12/24 timed at 11:30 A.M. revealed upon (EMS) arrival to the facility the resident had sustained multiple first, second, and possibly even third degree burns to her chest, shoulders, neck, and the lower part of her face when her clothing caught fire while smoking the facility courtyard. The resident rated her pain as an eight on a scale of 1 to 10 with 10 being the worst pain and was administered intravenous Fentanyl (an opioid pain medication) at the facility with her pain level unchanged upon transfer to the emergency room . Resident #100 reported to EMS personnel that she was smoking when ashes from her cigarette caught her nylon sweater on fire. Review of the hospital progress note for Resident #100 dated 05/12/24 revealed the resident presented to this hospital with a chief complaint of significant burns. The resident stated she was on the porch smoking when her sweater burst into flames causing burns to her upper chest, neck, face, and shoulders. The resident had damage to her nasal hair, eyebrows, and hair on the scalp line. Resident #100 was borderline hypoxic upon arrival and was complaining of pain to her chest and face with burn to an estimated 15 to 18 percent (%) of her total body. Resident #100 was transferred to the emergency department of another hospital once stable for further treatment of the burns. Review of the hospital progress notes for Resident #100 dated 05/12/24 revealed the resident was transferred to this hospital for admission and treatment of burn injuries to the bottom half of face, anterior chest, and anterior bilateral upper extremities. Resident #100 reported at approximately 11:00 A.M. on 05/12/24 she was smoking a cigarette outside when a burning ash blew off in the wind and caught her nylon shirt on fire. Upon arrival to the hospital the resident was complaining of a pain level of 8 on a scale of 1 to 10. Resident #100 presented to the emergency department with burns to approximately 15 to 18 percent of her total body surface area with superficial and partial-thickness burns. Resident #100 had scattered blistering, some skin sloughing, and singed nasal hairs. The burn team evaluated the resident. Review of the [NAME]-[NAME] Total Burn Surface Area Chart revealed 0.5 percent of head burns were second degree burns, 0.5 percent of head burns were third degree burn, 0.5 percent of neck burns were second degree burns, 0.5 percent of neck burns were third degree burns, 10 percent of anterior trunk burns were second degree burns, two percent of anterior trunk burns were third degree burns, one percent of right upper arm burns were second degree burns, and one percent of left upper arm burns were second degree burns for a total burn area of 16 percent of the resident's body. Resident #100 underwent surgical excision and skin grafting of the face, anterior chest, chin, and neck on 05/15/24. Resident #100 was in the hospital for a total of 26 days undergoing post-operative treatment for her burns sustained while at the facility and was discharged to a new skilled nursing facility on 06/07/24. Resident #100 was scheduled for ongoing follow-up care of her burn injuries with the hospital burn clinic, and her first post-discharge visit was scheduled for 06/21/24. Review of a written statement completed by the Administrator dated 05/12/24 regarding an interview with Representative #500 revealed on 05/12/24 she was visiting in Resident #54's room when she saw smoke emanating from the facility courtyard and she realized Resident #100's clothing had caught on fire. Representative #500 yelled fire and ran to the courtyard. Representative #500 reported she extinguished the fire using the representative's own clothing. The statement did not indicate why Representative #500 used her clothing to extinguish the fire, nor did it include information regarding the location of the fire blanket and its proximity to the fire. On 06/03/24 at 10:10 A.M. observation of the facility designated area provided for residents who smoked revealed it was located on concrete pad in the middle of the facility courtyard. The concrete pad was surrounded by grass and had a concrete sidewalk leading around the side of the courtyard which looped back to the concrete pad. The designated smoking area included an ash tray and a red receptacle with a self-closing lid. There was no fire extinguisher or fire blanket observed in the designated smoking area. The fire extinguisher and fire blanket were in the courtyard hanging on a brick wall by the double glass doors. Maintenance Director #281 measured the fire extinguisher and fire blanket to be 85 feet away from the designated smoking area when taking the concrete sidewalk and 46 feet away when going through the grass. Interview with Ombudsman #901 on 06/03/24 at 10:30 A.M. revealed the ombudsman had concerns related to the extent of Resident #100's injuries (that occurred during the smoking incident on 05/12/24) and felt the incident needed to be investigated closely. Interview with Activities Director (AD) #294 on 06/03/24 at 12:15 P.M. revealed the facility smoking assessment was completed based on observation of residents' ability to get outside of the facility, accessing smoking materials in the locked boxes in the facility courtyard, safely lighting their own cigarettes, and safely smoking their cigarettes. The AD denied receiving any type of formal training on how to complete the assessments prior to the incident involving Resident #100. AD #294 confirmed record reviews were not utilized as part of the completion of the facility smoking assessment. AD #294 confirmed Resident #100 was documented on the assessment to not have any visual deficits or dexterity problems based on the observation at the time of the assessment. However, AD #294 confirmed Resident #100 had hemiplegia and hemiparalysis affecting her left side and likely would not have been able to wheel herself quickly to where the fire blanket was located in the event of a fire. Interview with State tested Nursing Assistant (STNA) #299 on 06/03/24 at 12:25 P.M. confirmed Resident #100 utilized a wheelchair for mobility, had hemiplegia and hemiparalysis of the left arm and hand, and required extensive assistance from two staff members for transfers and bed mobility. STNA #299 confirmed on 05/12/24 someone yelled fire and the STNA responded to find the fire (involving Resident #100) had already been put out. STNA #299 confirmed Resident #100 had burns all over her chest caused by her shirt catching on fire while smoking a cigarette and was sent to the hospital for evaluation. STNA #299 confirmed Resident #100 had no use of her left arm or leg and required assistance from two staff members for transfers. Interview with Registered Nurse (RN) #319 on 06/03/24 at 12:32 P.M. revealed on 05/12/24 she was notified by an STNA that Resident #100 was on fire. RN #319 confirmed she arrived to the resident's room to find the residents bra, shirt, and skin were burnt. RN #319 confirmed, prior to the incident, Resident #100 had been assessed to have visual deficits in her left eye and did not have use of her left arm, hand, or leg. Observation on 06/03/24 at 1:45 P.M. revealed Resident #26 had finished smoking independently in the facility courtyard and was propelling herself backwards in her wheelchair on the sidewalk towards the facility doors. During the onsite investigation, interview on 06/03/24 at 1:47 P.M. with Resident #26 revealed the resident utilized a wheelchair for mobility and could not safely propel herself through the grass toward the facility doors or location of the fire blanket. During the interview, Resident #26 stated it would take too long to propel in the manual wheelchair to the location of the fire blanket if she was on fire and stated she would burn up before she got there. Resident #26 confirmed there was no way to call for staff assistance from the designated smoking area in the event of a fire. In addition, an interview with Resident #78 on 06/03/24 at 2:05 P.M. revealed the resident utilized a wheelchair to propel on the sidewalk through the courtyard to the smoking area. Resident #78 confirmed the location of the fire blanket was not convenient to a resident who was on fire and there was no way to call for help from the smoking area in the event of a fire. A telephone interview with Representative #500 on 06/03/24 at 2:23 P.M. revealed on 05/12/24 the representative was visiting with a resident, Resident #54 in Resident #54's room which had a window facing the facility courtyard when she observed smoke coming from the area. Representative #500 stated she knew the area was utilized for smoking and did not immediately believe it was cause for concern. Representative #500 stated a couple minutes later she observed what appeared to be a resident (identified to be Resident #100) on fire in the designated smoking area of the courtyard, and there was a significant amount of smoke coming from the resident. Representative #500 stated she ran out of the room and into the courtyard to where the resident was located and observed the resident's shirt had flames emanating from it. Representative #500 stated the resident was wide-eyed and appeared fearful. Representative #500 stated she looked around for a fire blanket and was not able to locate one. Representative #500 stated she pulled the sleeve to her sweatshirt over her hand and utilized it to put out the flames coming from the resident. Representative #500 stated facility staff arrived outside immediately after she put out the flames to assist the resident as the representative had instructed another resident to get help. Representative #500 stated on the way back inside the facility, she did observe the fire extinguisher and fire blanket next to the facility doors fastened to the brick wall. Representative #500 confirmed the fire extinguisher and fire blanket were not visible from the designated smoking area. Interview with Occupational Therapist (OT) #318 on 06/04/24 confirmed Resident #100 did not have use of her left hand or arm due to hemiplegia and hemiparalysis affecting the left side. A telephone interview with Representative #700 (for Resident #100) on 06/05/24 at 9:35 A.M. revealed Resident #100 suffered third degree burns as a result of catching on fire while smoking at the facility on 05/12/24 and required skin graft surgery on 05/14/24. Representative #700 revealed Resident #100 remained hospitalized as of this date (06/05/24) as a result of the injuries sustained on 05/12/24. Representative #700 confirmed Resident #100 utilized a manual wheelchair with a footrest for mobility and the resident had no use of her left arm and left leg. Further interview with Representative #700 revealed Resident #100 had required a blood transfusion on or about 06/03/24 and was exhibiting confusion which was abnormal for the resident following the incident. During the interview, Representative #700 revealed she was under the impression staff were supposed to be supervising Resident #100 when she smoked. Review of the facility smoking policy, revised 09/20/23 revealed the purpose of the policy was to ensure residents who smoke had a comfortable and safe environment in which to smoke. The policy indicated a fire blanket should be available in the smoking area to wrap around a resident whose clothes had caught alight. Review of the facility smoking policy, revised on 05/12/24 (following the incident with Resident #100), revealed the purpose of the policy was to ensure residents of the facility who smoked had a comfortable and safe environment in which to smoke. Smoking would be permitted in the courtyard's designated smoking area only, by the old brick grill. Fire safety measures, such as having a fire extinguisher in the smoking area and training residents on basic fire safety, were in place. There was to be a fire blanket available at the smoking area, which could be used to wrap around a resident whose clothes had caught fire. The policy contained an area for the resident and a facility representative to sign and date. This deficiency represents noncompliance investigated under Complaint Number OH00154361.