Every finding on record at Calcutta Health Care Center

THIS DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on observation, interview, record review, and policy review, the facility failed to provide adequate assistance and supervision for two dependent residents (Resident #8 and Resident #52) with activities of daily living (ADL's) resulting in preventable thermal burn injuries.Actual harm occurred on 12/09/24 when Resident #52, who had diagnoses of Alzheimer's disease and dementia and was assessed to require physical assistance from staff for meal set-up and assistance with ambulation in his wheelchair, spilled two cups of hot coffee (provided to him by dietary staff), sustaining second degree burns to his left thigh, right thigh, and abdomen. The resident required pain medication, wound care and oral antibiotics to aide in healing of the burns.Additionally, on 02/06/25 Resident #8, who was assessed to have severe cognitive impairment and required physical assistance from staff with eating /meals. spilled hot coffee on his person and sustained second degree burns to his right arm, right hip, and the right side of his abdomen. The resident required pain medication and wound care to aide in healing of the burns. This affected two residents (Resident #8 and Resident #52) of six residents reviewed for accidents. The facility census was 87.Findings include: 1. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, major depressive disorder, chronic kidney disease, chronic congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and edema. Review of Resident #52's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/10/24, revealed the resident had intact cognition and required physical staff assistance with activities of daily living (ADL's). Resident #52 required partial/moderate assistance with chair/bed-to-chair transfer and the resident's mobility device was a wheelchair. There were no mobility limitations or contractures noted to the resident's upper extremities. Review of Resident #52's Physical Therapy (PT) Evaluation and Plan of Treatment dated 10/17/24 revealed the current referral was due to Resident #52 exhibiting a new onset of compromised physical exertion level during activity, decreased functional mobility, decrease in strength, fall risk, functional limitation with ambulation, increased need for assistance from others, increased physical exertion during daily living tasks, reduced dynamic balance, and reduced static balance. Review of Resident #52's Care Plan, initiated date of 11/20/24, revealed the resident required assistance with most functional abilities due to decreased physical mobility with muscle weakness, difficulty walking, and poor endurance with lack of coordination at times secondary to diagnoses of multiple sclerosis and CHF and COPD. Resident #52 had altered cognition related to the diagnoses of Alzheimer's disease and dementia and seizures with potential for fluctuations. Interventions included the use of a mechanical lift with two staff members for transfers, staff to assist the resident while in his wheelchair with locomotion on and off unit as needed, to provide set up assistance with meals, and for dietary staff to deliver coffee to room upon request. Review of Resident #52's nursing progress note dated 12/09/24 at 6:20 P.M., revealed the kitchen staff came up to the nursing station and alerted the nurse that Resident #52 had spilled hot coffee on himself. The resident stated that they had just spilled (the resident confirmed the coffee cups fell over while he carried them) Areas assessed and cold cloth applied to all areas with red, blistered areas noted. Treatment orders were placed. The resident was educated on not carrying coffee from the kitchen by himself and had been told this several times before but continued to do so. Physician and wound care were notified. Review of Resident #52's physician order dated 12/09/24 revealed an order to cleanse front, right and left thigh blistered areas with normal saline solution (NSS) apply Silvadene and cover with dry clean dressing (DCD) every shift and as needed; monitor dressing every shift and as needed for soil or dislodgement; cleanse left abdomen/flank blistered area with NSS and apply Silvadene and cover with DCD every shift and as needed; monitor dressing every shift; apply Silver Sulfadiazine Cream 1% apply to bilateral thighs and abdomen topically every shift for burns. Review of Resident #52's Skin and Wound Evaluation V7.0 assessment dated [DATE] revealed Resident #52 had a new ruptured blister, onset 12/10/24, located on the left medial thigh, measuring 5.6 centimeters (cm) length (L) x 4.7 cm width (W) x 0 depth (D). The wound had a light amount of serous exudate. The physician was notified with treatment order obtained and initiated. Review of the MAR dated December 2024 revealed Resident #52 received Tylenol 325 mg two tablets by mouth on 12/09/24 at 10:34 P.M. for a pain level of four; on 12/11/24 at 10:14 P.M. for a pain level of two; on 12/12/24 at 5:21 A.M. for a pain level of five, and at 11:51 A.M. for a pain level of five, and at 9:52 P.M. for a pain level of three; and on 12/13/24 at 5:17 P.M. for a pain level of six. Review of a nursing progress note dated 12/14/24 at 1:55 P.M. revealed Resident #52 burned himself with coffee a few days ago on upper legs, thighs, and abdomen. Silvadene cream and dressings ordered daily and as needed (PRN) per wound care. The areas were more sensitive, reddish with discoloration, warm to touch, and looks worse than two days ago. There was no fever but a lot of drainage. The resident seemed a little more uncomfortable and Tylenol was given. Resident #52 was asked if he wanted something stronger for pain but denied at this time. Physician notified and awaiting new orders. Will continue to monitor. Call light in reach. Review of Resident #52's physician order dated 12/16/24 revealed an order for Norco 5-325 milligrams (mg) one tablet every six hours for pain for three days. Review of Resident #52's Skin and Wound Evaluation V7.0 assessment dated [DATE] revealed Resident #52 had a ruptured blister, onset 12/10/24, located on the left medial thigh, measuring 17.2 centimeters (cm) length (L) x 8.2 cm width (W) x undetermined. The wound was a non-intact blister noted to the left, medial thigh and has coalesced (come together to form a whole) with non-intact blister to right, front thigh, wound measurements have declined and wound bed 60% pink/red in color, 40% slough, moderate serous/yellow drainage noted. The true depth cannot be determined due to slough, peri-wound red/warm to touch. Physician was notified with an order given for Cefdinir capsule 300 mg twice daily for seven days. Wound care nurse practitioner (NP) consulted and will be in house on 12/30/24 to assess. Review of the Skin Injury Incident Report, dated 12/19/24, revealed kitchen staff informed the nurse that Resident #52 spilled hot coffee on himself. The resident was taken to his room and assessed with redness and blisters located on his left upper thighs and abdomen. The resident was educated to have staff assist or deliver coffee to him. He was educated in the past but stated he didn't want to bother the staff. Kitchen staff were instructed to summon nursing or deliver the coffee to the resident's room. Special mugs were obtained for the resident's safety. The physician was contacted and topical treatment was to be provided. The resident was alert and oriented, verbalized understanding and agreed he would let staff deliver the coffee to his room. Wound care would follow until the area was healed. Review of Resident #52's wound care NP progress note dated 12/30/24 revealed the resident was seen for an initial consult for wound care services. The resident stated he burned himself with hot coffee on multiple occasions, most recently a few weeks ago leading to blistering and a second degree burn prompting consult. He admitted he tried to hide his injuries from staff. The treatment has been silver cream for wounds. Wound #1: Burn, located on the left medial thigh, full thickness measuring 10.1 cm L x 19.3 cm W x undetermined D. 100% slough with no signs/symptoms of infection. Wound #1 Treatment: order to cleanse with normal saline (NS), apply oil emulsion gauze, calcium alginate, abdominal pad (ABD), wrap with Kerlex, secure with paper tape daily and prn. The treatment dressings were chosen for autolytic debridement, exudate management, pain management, barrier protection, granulation tissue promotion, antimicrobial activity have a promotion, and scar minimization. Wound #2: Burn, located on the right thigh, full thickness measuring 2.2 cm L x 5.6 cm W x undetermined D. The wound base is 20% pink and 80% scabbed, with no exudate. The peri-wound was dry with flaking skin, no signs/symptoms of infection. Wound #2 Treatment: order to cleanse with NS, apply oil emulsion gauze, calcium alginate, abdominal pad (ABD), wrap with Kerlex, secure with paper tape daily and prn. Wound #3: Burn, located on the left mid-abdomen, full thickness wound measuring 3.1 cm L x 7.5 cm W x undetermined D. Wound base with 100% slough and moderate serous exudate, no signs/ symptoms of infection. Wound #3 Treatment: order to cleanse with NS, apply oil emulsion gauze, calcium alginate, and silicone bordered foam dressing daily and prn. Continued review of the medical record revealed Resident #52's weekly wound care visits and treatments continued on 01/06/25, 01/13/25, 01/20/25, 01/27/25, 02/03/25, 02/10/25, 02/17/25, 02/24/25, 03/03/25, 03/10/25, 03/17/25, 03/24/25, 03/31/25, 04/07/25, 04/14/25, and 04/28/25 until all wounds were healed. Review of the wound care visit on 01/27/25 revealed upon examination, (Wound #2) burn located on the right thigh had complete healing and the wound was fully closed. Review of the wound care visit on 03/03/25 revealed upon examination, (Wound #3) burn located on the right thigh had complete healing and the wound was fully closed. Review of the wound care visit on 04/28/25 revealed wound #1 was healed. Interview on 06/15/26 at 12:40 P.M. with Resident #52 revealed he wasn't sure of the exact date but at least one year ago, he went to the kitchen in his wheelchair and asked for two cups of coffee. He stated one of the kitchen workers handed him two, 12-ounce Styrofoam cups filled with hot coffee, one stacked on top of the other. The resident stated that while attempting to hold both cups of coffee and propel in his wheelchair, both Styrofoam cups collapsed and the coffee spilled on his upper legs and stomach. Resident #52 stated it really hurt, and he did receive pain medication and dressing changes due to the burns. Interview on 06/15/26 at 12:56 P.M. with the Administrator revealed Resident #52 went to the kitchen to get a cup of coffee and while trying to return back to his room in his wheelchair, spilled the coffee on himself. The Administrator stated it was not a good idea for kitchen staff to hand him two cups of hot coffee and then allow him to try to wheel himself in his wheelchair, back to his room. The Administrator stated the coffee had been set at 180 degrees Fahrenheit (F) and he asked the kitchen to decrease the coffee to 165 degrees F. Interview on 06/15/26 at 2:15 P.M. with Dietary Manager (DM) #122 stated he had been employed in his current position for approximately six months and did not work at the facility when Resident #52's burn incident occurred. DM #122 stated the facility got a new coffee machine about two weeks ago and its temperature was at 155-160 degrees F. DM #122 stated the staff was familiar with the residents and know their capabilities related to carrying coffee and will carry coffee to their rooms if needed. Interview on 06/15/26 at 4:10 P.M. with Certified Nursing Assistant (CNA) #147 revealed a resident who was propelling themselves in a wheelchair would be unsafe trying to carry two cups of hot coffee. Interview on 06/15/26 at 4:11 P.M. with CNA #157 revealed if she saw a resident propelling self in wheelchair and they were holding two cups of hot coffee she would immediately remove the cups from the resident and carry the cups for them so they wouldn't spill the coffee. 2.Review of the medical record for Resident #8 revealed admission to facility on 11/13/24 with most recent reentry on 12/03/24 for diagnoses including chronic respiratory failure, lung disease, stroke affecting dominant right side, aphasia (difficulty speaking from stroke), Alzheimer's disease with late onset (brain disease affecting short and long term memory), malnutrition, blood clot in lung, depression and anxiety, enlarged prostate, high blood pressure, and gastric reflux. Review of the MDS 3.0 comprehensive assessment completed on 12/09/24 for Resident #8 revealed a BIMS score of 1/15 indicating cognitive impairment. Further review of the comprehensive assessment revealed Resident #8 had impairments on his right side and required partial to moderate assistance from staff for eating/feeding himself and was dependent of staff for oral hygiene, personal care, bathing, dressing, and mobility. The MDS 3.0 further revealed Resident #8's speech was unclear and slurred/garbled and difficult to understand at times. Review of the dietary orders dated 12/20/24 revealed Resident #8 was prescribed a regular diet with puree consistency and honey thickened liquids. Review of Resident #8's Documentation Survey Report V2 completed for the month of January 2025 provided by the facility Administrator revealed most meals Resident #8 was documented as a 1 (Dependent- helper does all the effort. Resident does none of the effort to complete the activity.) for eating assistance. Review of Resident #8's Documentation Survey Report V2 completed for the month of February 2025 provided by the facility Administrator revealed on day shift (7 A.M to 7 P.M) Resident #8 was marked as being a 2 (Substantial/maximal assistance, helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) for eating on 02/05/25. Further review revealed on night shift (7 P.M to 7 A.M.) Resident #8 was marked as being 2 for eating on 02/04/25. Review of the progress notes for Resident #8 revealed a nursing note dated 02/06/25 and timed 11:30 A.M. and authored by licensed practical nurse (LPN) #174. The nursing note revealed CNA #100 informed LPN #174 that Resident #8 had just spilled coffee on himself in the main dining room. LPN #174 noted Resident #8 appeared to be in pain with facial grimacing and yelling out. Further review of the nursing note revealed there was coffee visible on Resident #8 right arm (which had an ACE wrap present) and right side. LPN #174 and the wound care nurse removed the ACE wrap from the right arm and noted skin to be red with small, scattered blisters noted to right arm, right side, and right hip. The medical doctor (MD) was notified, and orders were obtained to give Resident #8 an injection (shot) of Toradol 60 milligrams (mg) for pain and begin Silvadene cream to burned areas. The MD further ordered for the Resident to be a total feed and all cups to have lids. Further review of the progress notes revealed the MD visited Resident #8 and gave an order for him to receive Toradol 60 mg injection 1 hour prior to wound care for 1 week. Review of the medical record for Resident #8 revealed a wound care consult note dated 02/17/26 and authored by a Nurse Practitioner (NP) from Wound Care revealed the burn to the right arm was healed but the burn on the right side of the abdomen remained full thickness and measured 2.0 centimeters (cm) long by 6.0 cm wide and depth undetermined due to presence of dead tissue and moderate thick tan drainage. The note further revealed Resident #8 was in mild transient pain during the dressing change. Interview on 06/15/25 at 11:04 A.M. with LPN #174 revealed she had worked at the facility for seven years and she recalled being summoned to the main dining room by CNA #100 due to Resident #8 spilling coffee on himself and getting burned. LPN #174 reported she did not witness the incident but CNA #100 who did witness the event did report to LPN #174 that Resident #8 was taking a drink of his coffee and dropped the cup. LPN #174 reported she immediately took him to his room addressed the burns. The burns were on his right upper arm around his armpit area and upper chest and on his right hip area. LPN #174 could not recall the stage of the burns but recalled Resident #8 was getting a cream and dressing to areas. LPN #174 could not recall any other residents being burned by coffee at the facility. Interview and observation on 06/15/26 at 11:08 A.M with Resident #8 revealed he confirmed by shaking his head yes and eyes opened wide when asked if he recalled being burned by coffee. Resident #8 motioned with his left hand toward his right shoulder and abdominal area and down to his hip. Interview on 06/15/26 at 12:28 P.M. with Registered Nurse (RN) #185 revealed she had worked at the facility for six years and she recalled Resident #8 being burned by coffee but also another resident she could recall being burned by coffee also, Resident #52. Further interview revealed RN #185 reporting that the facility got rid of the coffee machine and did require the staff to start adding a couple of ice cubes to the coffee to ensure it was not too hot after those incidents. Interview on 06/15/26 at 12:56 P.M. with the Administrator revealed confirmation that there were two separate incidents of Residents being burned. One on 12/09/24 related to Resident #52 and then on 02/06/25 related to Resident #8. The Administrator reported that the facility did not address the coffee temperatures at the time of Resident #52 incident on 12/09/24 but after Resident #8 was burned by coffee on 02/06/25 the facility did a quality assurance and performance improvement (QAPI) focused review to address the temperature of the coffee on 02/07/25 including adjusting the coffee machine temperature settings from 170-175 degrees Fahrenheit to 155-165 degrees Fahrenheit and monitoring the temperatures for six weeks after adjustments. The administrator also reported doing staff education regarding adding a couple of ice cubes to coffee made from the machine in the nutrition room to ensure it wasn't too hot. Observation on 06/15/26 at 2:15 P.M. of a temperature check of a cup of coffee obtained directly from the kitchen coffee machine by DS #122 revealed a temperature of 160.9 degrees Fahrenheit. Review of the facility policy titled, Safety and Supervision of Residents, and revised on 12/2007 revealed, when accident hazards are identified, the safety committee shall evaluate and analyze the causes of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. The deficient practice was corrected on 04/28/25 when the facility implemented the following corrective actions: -On 12/09/24, Resident #52 was assessed and wound care ordered. Resident #52 was educated about coffee safety. On 12/10/24 all dietary staff were educated about not handing residents' coffee through the dietary window, directly to residents. The education was completed by the Administrator. -On 12/10/24, Resident #52 was ordered a double handled cup with a tight-fitting lid. -On 02/07/25, Resident #8 was assessed and wound care ordered. -On 02/07/25 the facility held a Quality Assurance Performance Improvement Meeting focused review to address the temperature of the coffee including adjusting the coffee machine temperature settings from 170-175 degrees Fahrenheit to 155-165 degrees Fahrenheit. On 03/01/25, the coffee vendor came to the facility and was able to adjust the serving temperature of coffee to approximately 155 degrees F. Since the coffee pot in the B wing nutrition room could not be adjusted, it was removed from use, and coffee was only served from the kitchen. Staff are required to carry the coffee for residents to the location where they want to enjoy their coffee. -From 02/07/25 through 03/01/25, the Administrator educated all staff regarding adding a couple of ice cubes to coffee served until the vendor could make changes on 03/01/26. Signs were hung in the nutrition room and in the kitchen above all coffee machines to remind staff to add six ice cubes to every cup of coffee -Beginning 02/07/25, monitoring of the temperatures of coffee from the coffee pots in the kitchen during meal services was monitored for all three meals by dietary staff. Review of the QAPI Meeting documentation from February and March 2025 revealed the temperatures continued to be monitored for six weeks and no issues were identified. -On 02/07/25, Resident #8 was ordered a double handled cup. The resident was observed using the cup during the onsite survey. -On 04/28/25, Resident #52's wounds healed without additional complications. -Random staff interviews during the annual survey verified staff were provided education (after the incidents) about the coffee pots, and what to do if they felt coffee or other food/beverage items are too hot (add ice, don't serve to resident until cooled) -As of 06/17/26, there were no additional burns in the facility.

Based on record review and staff interview, the facility failed to ensure residents receiving psychotropic medications were educated on the risks/benefits associated with the use of psychotropic medications and failed to obtain informed consent from the resident and/or their representative prior to use. This affected four residents (Resident #2, #5, #11, and #106) of five residents reviewed for unnecessary medications. The facility identified 70 residents who received psychotropic medications. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 02/08/21 with diagnoses including Alzheimer's disease, dementia, generalized anxiety, major depressive disorder, excoriation disorder, and localized edema. Review of the Minimum Data Set (MDS) assessment, dated 02/24/26, revealed Resident #1 had moderately impaired cognition. Review of a physician order, dated 06/10/26, revealed the order for risperidone 0.5 milligrams (mg) one tablet by mouth twice daily for dementia. This was an increase from the previous order, dated 04/15/26, for Risperidone 0.25 mg one tablet by mouth twice daily for dementia. Review of Resident #11's Medication Administration Record (MAR), dated June 2026, revealed the resident received risperidone 0.5 mg twice daily beginning on 06/09/26 and risperidone 0.25 mg one table by mouth twice daily prior to the dosage increase. Interview on 06/10/26 at 11:15 A.M. with the Director of Nursing (DON) confirmed there was no documentation of Resident #11 and/or her responsible party being informed of the antipsychotic medication being administered and the risks and side-effects of its use prior to administration. 2. Review of the medical record revealed Resident #106 was admitted to the facility on [DATE] with diagnoses including non-ST elevation myocardial infarction, post-traumatic stress disorder, congestive heart failure, leukemia, diabetes mellitus, dementia, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 06/11/26, revealed Resident #106 had moderately intact cognition. Review of a physician order, dated 06/06/26, revealed the order for venlafaxine HCL (antidepressant medication) 75 mg one tablet by mouth in the morning for major depressive disorder. Review of Resident #106's Medication Administration Record (MAR), dated June 2026, revealed the resident received venlafaxine HCL 75 mg once daily as ordered by the physician. Interview on 06/10/26 at 11:15 A.M. with the Director of Nursing (DON) confirmed there was no documentation of Resident #106 and/or his responsible party being informed of the antidepressant medication being administered and the risks and side-effects of its use prior to administration. The DON further confirmed the facility did not have a policy in place regarding consents/authorizations for psychotropic medication use. 3. Review of Resident #5's medical record revealed diagnoses including vascular dementia, generalized anxiety disorder, insomnia, and major depressive disorder. On 06/05/25 an order was written for mirtazapine (antidepressant) 15 milligrams (mg) at bedtime. On 03/26/26 an order was written for trazodone (antidepressant) 50 mg at bedtime. Both orders remained current. There was no evidence of education related to the risks of antidepressant use. On 06/10/26 at 3:08 P.M., the Director of Nursing (DON) verified there was no documentation of Resident #5 and/or her responsible party being informed of the risks of antidepressant use prior to its administration. 4. Review of Resident #2's medical record revealed diagnoses including vascular dementia with agitation, generalized anxiety disorder, and major depressive disorder. On 01/05/26 an order was written for zoloft (antidepressant) 75 mg in the morning. The order remained current. There was no evidence of Resident #2 and/or her representative receiving education related to the risk of antidepressant use. On 06/10/26 at 3:08 P.M., the Director of Nursing (DON) verified there was no documentation of Resident #2 and/or her responsible party being informed of the risks of antidepressant use prior to its administration.

Based on review of facility policy, review of the Federal Food and Drug Administration (FDA) Food Code, observation of the pureed food preparation, and staff interview the facility failed to ensure the robot coupe blender was clean and dry prior to preparing pureed foods for meal service. This had the potential to affect seven residents who were ordered pureed diets, Residents #5, #16, #21, #75, #81, #88, and #96. The facility census was 87. Findings Include: Observation and interview on 06/10/26 at 10:43 A.M. during the puree preparation of the lunch meal revealed dietary cook (DC) #145 placed the robot coupe (a blender used in industrial kitchens to puree foods) bowl onto the robot coupe with water droplets noted on the lid and inside of the bowl. DC #145 then began to pour the roast beef into the bowl to puree and was stopped by surveyor to verify that there were water droplets in the bowl and on the lid. DC #145 verified there was water still in the bowl and on the lid and she was unsure of who had put the bowl away when it was wet and it would have been washed after the breakfast meal. DC #145 verified that equipment should be completely dry prior to use and then DC #145 stopped her preparation and removed the bowl and took it to be ran through the high temperature dishwasher to ensure sanitization of the bowl prior to use.Review of Federal Food and Drug Administration (FDA) Food Code 2022; with most recent updates on 12/09/25 revealed the following code 4-901.11 Equipment and Utensils, Air-Drying Required. Code 4-901.11 further revealed that after cleaning and sanitizing equipment and utensils they should be air-dried before contact with food and may not be clothed dried.Review of the facility policy titled Sanitization, dated 10/2008 revealed equipment that was manually washed should be air-dried. There was no evidence that all equipment washed and sanitized should be air-dried prior to coming in contact with foods.

Based on record review, interview, and policy review, the facility failed to ensure comprehensive baseline care plans and failed to ensure copies of baseline care plans were maintained in the medical record. This affected four residents (Resident #4, #12, #51, and #90) of 10 residents reviewed for baseline care plans. The facility census was 87.Findings include: 1. Review of Resident #51's medical record revealed an admission date of 05/07/26 with diagnoses including fracture of left femur, osteoporosis, fracture of first lumbar vertebra, seizures, pressure ulcer of right heel, retention of urine, and muscle wasting and atrophy. Review of the Resident #51's baseline care plan revealed only a scanned face sheet (admission record) and active physician orders. There was no signature of the resident and/or resident representative to indicate if the baseline care plan was reviewed with the resident and/or resident representative. Interview on 06/10/26 at 4:55 P.M. with Registered Nurse (RN) #196 verified Resident #51's baseline care plan was not comprehensive, only including the face sheet and physician orders. RN #196 stated the baseline care plan should additionally contain the resident and/or resident representative's signatures, care interventions and tasks, therapies, (as applicable), and the advance discharge plan. 2. Review of Resident #90's medical record revealed an admission date of 05/09/26 with diagnoses including artificial opening of digestive tract, malignant neoplasm of tongue, dysphagia, nausea and vomiting, and history of cerebral infarction. Review of the Resident #90's baseline care plan revealed only a scanned face sheet (admission record), active physician orders, and the Preadmission Screen and Resident Review (PASRR). There was no signature of the resident and/or resident representative to indicate if the baseline care plan was reviewed with the resident and/or resident representative. Interview on 06/10/26 at 5:10 P.M. with Registered Nurse (RN) #196 verified Resident #90's baseline care plan was not comprehensive, only including the face sheet, physician orders, and PASRR. RN #196 stated the baseline care plan should additionally contain the resident and/or resident representative's signatures, care interventions and tasks, and the advance discharge plan. 3. Review of Resident #4's medical record revealed an admission date of 04/27/26. Diagnoses included metabolic encephalopathy (brain dysfunction caused by underlying metabolic disturbances), chronic allergic conjunctivitis (allergens caused inflammation in the tissue that lined eyelids and the whites of the eyes), dysphagia (difficulty swallowing), dementia, osteoporosis, protein-calorie malnutrition, paroxysmal atrial fibrillation (when a person has occasional episodes of fast, chaotic heart rhythm that stops within seven days), anemia, cardiomegaly (enlargement of the heart_, atherosclerosis of aorta (gradual buildup of plaque in the aorta), insomnia, adult failure to thrive, thrombocytopenia (condition characterized by low blood platelet count which could lead to prolonged or excessive bleeding), and lymphocytopenia (condition characterized by an abnormally low level of lymphocytes, a type of white blood cell, in the blood). No baseline care plan (document that must be developed and implemented after a resident's admission to ensure continuity of care, promote safety and reduce the risk of adverse events shortly after admission) was able to be located. On 06/10/26 at 5:07 P.M., Registered Nurse (RN) #196 verified she had been able to locate a cover sheet dated 04/27/26 which had checkmarks beside admitting plan of care orders, advance discharge plan and Preadmission Screen and Resident Review (PASRR) (as applicable) with a statement indicating the baseline care plan was reviewed with the resident/family/representative. The form was signed by a nurse and Resident #4's representative. The form had a copy of Resident #4's face sheet attached. RN #196 stated she did not have all the information which had been developed/reviewed with Resident #4's representative. It was believed nurses were failing to keep copies of the baseline care plans and giving the originals to residents and/or their representatives. 4. Review of Resident #12's medical record revealed an initial admission date of 01/13/26. Diagnoses included chronic obstructive pulmonary disease, mild intermittent asthma, generalized anxiety disorder, schizoaffective disorder (bipolar type), intellectual disabilities, urinary retention, protein-calorie malnutrition, and allergic rhinitis. No baseline care plan was able to be located. On 06/10/26 at 4:00 P.M., RN #118 stated she had only been able to find a cover sheet indicating the baseline care plan was reviewed with Resident #12. RN #118 stated she thought some of the nurses must have given the residents and/or families the original copies of the baseline care plans. Review of the facility's admission Baseline Care Plan policy (not dated) revealed a baseline care plan was to be initiated for ever resident upon admission to identify immediate care needs, guide staff in delivering consistent care, and ensure continuity until a comprehensive care plan was completed. The baseline care plan must be accessible in the medical record or electronic health record.

Based on review of the medical record and staff and family interviews, the facility failed to notify the designated medical power of attorney and primary emergency contact of a change in condition of Resident #6. The affected one (Resident #6) of one record reviewed for notification of change in condition. The facility census was 87.Findings Include: Review of the medical record for Resident #6 revealed admission to the facility on [DATE] for diagnoses including epilepsy (seizure disorder), anoxic brain damage (damage caused by lack of oxygen for an extended period of time), high blood pressure, stage three pressure injury ulcer, dementia (confusion) with anxiety, colostomy status, and history of urinary tract infections.Review of the most recent quarterly minimum data set (MDS) 3.0 assessment completed on 05/26/26 for revealed Resident #6 had a brief interview for mental status (BIMS) score of 3/15 meaning severe cognitive impairment and was dependent on staff to complete all personal care, toileting hygiene, dressing, bathing, and transfers, as well as provide for mobility in a wheelchair.Review of the demographic information for Resident #6 revealed the primary emergency contact as Resident #6 eldest son, Son #1. The demographic information also indicated that the eldest son was noted to be the responsible party and care conference person and person to receive billing statements.Further review of the demographic information for Resident #6 revealed a second emergency contact as Resident #6 youngest son, Son #2 and his wife. Son #2 was not indicated to be responsible party of record, was not indicated as care conference person, and was not indicated to be person to receive billing statements.Review of the electronic medical record (EMR) for Resident #6 revealed the following banner on top of the screen titled special instructions, *BOTH SONS TO BE CALLED WHEN RESIDENT IS SENT OUT TO HOSPITAL*.Review of the facility, Change in Condition Evaluation- V5.1 form dated 05/30/26 and authored by licensed practical nurse (LPN) #138 and obtained from the facility Administrator revealed LPN #138 notified son #2, the secondary contact, and wife of resident being sent to the emergency room for change in condition. There was no evidence that the primary emergency contact, Son #1, was notified of the change in condition or need to be transported to the emergency room.Review of Resident #6 progress notes revealed a nursing progress note dated and timed 06/09/26 at 10:47 A.M. by LPN #138. The nursing progress noted indicated that son #2, the secondary contact, and his wife were notified of plan of care updates that included new orders from physical therapy for a tilt in space wheelchair.Review of Resident #6 progress notes revealed a nursing progress note dated and timed 06/09/26 at 2:54 P.M. by LPN #138. The nursing progress noted indicated that son #2, the secondary contact, and his wife were notified of plan of care updates that included new orders from physical therapy for use of a mechanical lift for all transfers and physical therapy would continue to see Resident #6 three times a week for treatments.Observation on 06/10/26 at 8:49 A.M. of Resident #6 revealed her sitting in a specialized wheelchair beside nurses' station with blanket draped over her lap. Resident #6 was dressed and groomed. Resident #6 was unable to answer questions and repeatedly asked how are you?Interview on 06/08/26 at 12:20 P.M. with Resident #6's primary emergency contact, Son #1 revealed he lived in Tennessee and was not local. Son #1 reported that the facility often called his brother Son #2 instead of him when Resident #6 became ill, needed to go to the hospital, or with any other concerns. Son #1 reported that he felt his brother was notified instead of him because his brother was more agreeable, asked less questions and lived locally to the facility. Son #1 reported that he was upset by this and his brother Son #2 was young, only [AGE] years old, and did not know how to handle his mother's care. Son #1 reported that he did not understand why his mother was being repeatedly sent to the ER for urinary tract infections and he often questioned the staff about his mother's care and he felt this was also why the facility was calling his brother and not him. Continued interview with Son #1 revealed that he was not notified of the recent change in condition of his mother, Resident #6 and her need to go to the emergency room last week for a breakthrough seizure on 05/30/26. Son #1 verified he was Resident #6's medical power of attorney and that he should be notified first of any changes or updates on his mother's condition.Interview on 06/15/26 at 2:30 PM with facility Administrator revealed that he and the DON had been reviewing resident records daily and thought the staff was calling son #1 with any concerns. Review of the policy titled Change in a Resident's Condition or Status, and dated 12/2016 revealed the nurse will contact the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status.

Based on record review, policy review, and interview, the facility failed to provide an appropriate diagnosis for a resident receiving an antipsychotic medication. This affected one (Resident #11) of five residents reviewed for unnecessary medications. The facility census was 87. Findings include: Review of the medical record for Resident #11 revealed an admission date of 02/08/21 with diagnoses including Alzheimer's disease, dementia, generalized anxiety, major depressive disorder, excoriation disorder, and localized edema. Review of the Minimum Data Set (MDS) assessment, dated 02/24/26, revealed Resident #11's Brief Interview for Mental Status (BIMS) score was 11, which indicated moderately impaired cognition. The resident did not have hallucinations, delusions, physical or verbal behaviors, or rejection of care. A diagnoses of dementia was indicated in the assessment and the resident received an antipsychotic medication. Review of a physician order, dated 06/10/26, revealed the order for risperidone 0.5 milligrams (mg) one tablet by mouth twice daily for dementia. This was an increase from the previous order, dated 04/15/26, for risperidone 0.25 mg one tablet by mouth twice daily for dementia. Review of Resident #11's Medication Administration Record (MAR), dated June 2026, revealed the resident received Risperidone 0.5 milligrams (mg) twice daily beginning on 06/09/26. Review of Resident #11's Care Plan, dated 06/05/26, revealed the resident received antidepressant, antianxiety, and antipsychotic medications per physician orders and is at risk for adverse side effects. She does not exhibit any side effects at this time. The physician trialed GDR with last reduction was on 05/02/22, leading to the discontinuation of the medication. The resident did experience increased anxiety after this final GDR. Review of a psychiatric progress note dated 05/13/26 revealed Resident #11 is calm and cooperative per staff report with coherent baseline dementia with no hallucinations. Interview on 06/15/26 at 11:27 A.M. with Pharmacist #251 revealed during her May 2026 monthly pharmacy review, she did note the resident was receiving an antipsychotic medication without an appropriate diagnosis; however, she did not receive a response from the physician, and the recommendation indicated a pending status in her computer. Pharmacist #251 stated her plan was to follow-up on this recommendation during her June review. Interview on 06/10/26 at 11:15 A.M. with the Director of Nursing (DON) confirmed the resident was receiving risperidone, an antipsychotic medication, and does have a diagnosis of dementia. The DON stated previous GDR attempts have failed, and the family would like the resident to continue the medication. The DON did confirm there was not a consent signed by the resident or resident representative and there was no evidence or documentation that the family had been educated on the side effects of the antipsychotic medication. Review of the facility's policy titled, Antipsychotic Medication Use, dated December 2016, revealed antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Antipsychotic medications shall generally be used only for the following conditions/diagnosis as documented in the record consistent with the definitions in the Diagnostic and Statistical Manual of Mental Disorders including psychosis in the absence of dementia.

Based on medical record review, policy review and interview, the facility failed to identify and report injuries of unknown origin to the State Survey Agency. This affected one (Resident #2) of two residents reviewed for abuse. Review of Resident #2's medical record revealed diagnoses including vascular dementia, osteonecrosis (bone disease that occurs when blood flow to a part of a bone is disrupted, leading to bone death and collapse), and fracture of the left patella. A nursing note dated 01/12/26 at 8:04 A.M. revealed Resident #2 had been complaining of left knee pain. The physician was made aware and a new order was received for a X-ray for the left knee due to pain and swelling. Mobile x-ray was made aware of the order. A nursing note dated 01/12/26 at 3:00 P.M. indicated the left knee x-ray revealed no acute fracture or dislocation, no definite joint effusion and no infiltrative or destructive process. The x-ray indicated moderately severe degenerative joint disease (DJD). Review of a nursing note dated 01/26/26 at 12:14 A.M. revealed Resident #2 was sent to the hospital due to uncontrolled pain to her left leg. A nursing note dated 01/16/26 at 3:55 A.M. indicated Resident #2 returned to the facility, having received a steroid shot at the hospital. X-rays of the left knee obtained at the hospital revealed osteoarthritis. On 01/27/26 an order was written for an elastic brace to the left knee for support with a notation therapy was ordering it. A nursing note dated 01/27/26 at 6:41 P.M. indicated Resident #2 was lowered to the floor during a transfer. No injuries were noted. A nursing note dated 01/30/26 at 1:50 P.M. revealed an appointment was made with an orthopedic doctor on 02/04/26 at 10:00 A.M. for left knee osteoarthritis and effusion with increased pain. A nursing note dated 02/04/26 at 11:15 A.M. indicated Resident #2 returned from the orthopedic doctor appointment. Resident #2 had received a cortisone injection in the left knee. The orthopedic doctor requested a x-ray of the left knee. X-ray results obtained of the left knee on 01/12/26 were sent to the orthopedic office and the physician was asked if he wanted a repeat x-ray obtained. A nursing note dated 03/02/26 at 11:00 P.M. indicated scattered purple bruising was noted from the left mid inner thigh to Resident #2's knee. Resident #2 stated the bruising was caused by staff not properly applying her knee brace. Staff were educated on proper knee brace placement to prevent further injuries. A nursing note entry titled SBAR (structured communication tool in nursing that stood for Situation, Background, Assessment and Recommendation) Summary for provider dated 03/08/26 at 12:12 P.M. indicated Resident #2 had edema (swelling) and pain. The response was send Resident #2 to the emergency room (ER). A nursing note dated 03/08/26 at 5:25 P.M. indicated Resident #2 returned with a diagnosis of suspected left patella fracture with joint effusion in the left knee and directions to follow up with ortho as soon as possible. Resident #2's daughter requested a x-ray be done in house. A nursing note dated 03/09/26 at 6:40 P.M. revealed the x-ray disc was received from mobile x-ray and was to be sent to the ortho appointment with Resident #2. Review of an ortho and spine office visit note dated 03/11/26 revealed Resident #2 denied any injury to the knee or fall. The examination of the left knee revealed a moderately large effusion with no clinical deformity. Resident #2 reported moderate pain with attempted range of motion. Resident #2 was assessed with a patellar sleeve fracture (characterized by the separation of the cartilage sleeve from the ossified patella) of the left knee and a large joint effusion which by aspirate was hemarthrosis (bleeding into a joint causing pain, swelling and limited movement). The left knee joint was aspirated for scant (less than 1 milliliter) of dark acute blood. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 was able to make herself understood and was usually able to understand others. Resident #2 was assessed as moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 11 (out of possible 15 points). On 06/11/26 at 4:09 P.M., the Director of Nursing (DON) stated he had not identified the bruising or fracture as an injury of unknown origin as Resident #2 had been voicing complaints of left knee pain and he assumed it was all related. However, the cause of the injuries were never definitively identified or investigated. Therefore, the injuries were not reported to the State Survey agency. On 06/15/26 at 9:06 A.M., the concerns related to lack of identifying Resident #2's injuries as injuries of unknown origin when she was identified with bruising then later with a patellar fracture without identifiable cause were discussed with the Administrator, who stated usually when there was bruising staff did an incident report. The Administrator verified without the injuries being identified as potential injuries of unknown origin, the information would not be reported to the State Survey Agency. On 06/15/26 at 12:40 P.M., Resident #2 stated she was confused at times but she recalled the bruise, pointing from the left mid inner thigh to the left knee. Resident #2 stated she had not had trauma to the left knee or leg. The only explanation she could think of was if the brace was not applied correctly. Resident #2 stated she did not know how the brace was supposed to be applied but she was trying to think of an explanation of how it could have occurred when asked. Resident #2 stated she might have forgotten but never recalled any nurses or therapy monitoring how nursing assistants applied the brace to her knee.Review of the facility's Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property policy (implementation date not recorded) revealed an injury of unknown source was identified as an injury in which the source of the injury was not observed by any person or the source of the injury could not be explained by the resident and the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time or the incident of injuries over time. The policy indicated all injuries of unknown source must be reported immediately to the Administrator or designee. Once the Administrator and State Survey agency were notified, an investigation of the alleged violation would be conducted.

Based on medical record review, policy review and interview, the facility failed to complete a thorough investigation for a resident who was identified with bruising and a patellar fracture without identifiable cause for the injuries. This affected one (Resident #2) of two residents reviewed for abuseReview of Resident #2's medical record revealed diagnoses including vascular dementia, osteonecrosis (bone disease that occurs when blood flow to a part of a bone is disrupted, leading to bone death and collapse), and fracture of the left patella. A nursing note dated 01/12/26 at 8:04 A.M. revealed Resident #2 had been complaining of left knee pain. The physician was made aware and a new order was received for a X-ray for the left knee due to pain and swelling. Mobile x-ray was made aware of the order. A nursing note dated 01/12/26 at 3:00 P.M. indicated the left knee x-ray revealed no acute fracture or dislocation, no definite joint effusion and no infiltrative or destructive process. The x-ray indicated moderately severe degenerative joint disease (DJD). Review of a nursing note dated 01/26/26 at 12:14 A.M. revealed Resident #2 was sent to the hospital due to uncontrolled pain to her left leg. A nursing note dated 01/16/26 at 3:55 A.M. indicated Resident #2 returned to the facility, having received a steroid shot at the hospital. X-rays of the left knee obtained at the hospital revealed osteoarthritis. On 01/27/26 an order was written for an elastic brace to the left knee for support with a notation therapy was ordering it. A nursing note dated 01/27/26 at 6:41 P.M. indicated Resident #2 was lowered to the floor during a transfer. No injuries were noted. A nursing note dated 01/30/26 at 1:50 P.M. revealed an appointment was made with an orthopedic doctor on 02/04/26 at 10:00 A.M. for left knee osteoarthritis and effusion with increased pain. A nursing note dated 02/04/26 at 11:15 A.M. indicated Resident #2 returned from the orthopedic doctor appointment. Resident #2 had received a cortisone injection in the left knee. The orthopedic doctor requested a x-ray of the left knee. X-ray results obtained of the left knee on 01/12/26 were sent to the orthopedic office and the physician was asked if he wanted a repeat x-ray obtained. A nursing note dated 03/02/26 at 11:00 P.M. indicated scattered purple bruising was noted from the left mid inner thigh to Resident #2's knee. Resident #2 stated the bruising was caused by staff not properly applying her knee brace. Staff were educated on proper knee brace placement to prevent further injuries. A nursing note entry titled SBAR (structured communication tool in nursing that stood for Situation, Background, Assessment and Recommendation) Summary for provider dated 03/08/26 at 12:12 P.M. indicated Resident #2 had edema (swelling) and pain. The response was send Resident #2 to the emergency room (ER). A nursing note dated 03/08/26 at 5:25 P.M. indicated Resident #2 returned with a diagnosis of suspected left patella fracture with joint effusion in the left knee and directions to follow up with ortho as soon as possible. Resident #2's daughter requested a x-ray be done in house. A nursing note dated 03/09/26 at 6:40 P.M. revealed the x-ray disc was received from mobile x-ray and was to be sent to the ortho appointment with Resident #2. Review of an ortho and spine office visit note dated 03/11/26 revealed Resident #2 denied any injury to the knee or fall. The examination of the left knee revealed a moderately large effusion with no clinical deformity. Resident #2 reported moderate pain with attempted range of motion. Resident #2 was assessed with a patellar sleeve fracture (characterized by the separation of the cartilage sleeve from the ossified patella) of the left knee and a large joint effusion which by aspirate was hemarthrosis (bleeding into a joint causing pain, swelling and limited movement). The left knee joint was aspirated for scant (less than 1 milliliter) of dark acute blood. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 was able to make herself understood and was usually able to understand others. Resident #2 was assessed as moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 11 (out of possible 15 points). On 06/11/26 at 4:09 P.M., the Director of Nursing (DON) stated the facility had not completed an investigation regarding the bruising or fracture of the left knee as Resident #2 had been complaining of knee pain prior to the diagnosed fracture. At 5:30 P.M., the DON provided copies of x-ray reports and ortho notes as requested and presented them as the facility's investigation. Upon addressing this with the DON he stated the x-ray at the hospital done on 03/08/26 was questionable so the facility did not add the diagnosis/confirm the fracture until Resident #2 was seen by the orthopedic doctor. It was not until the surveyor asked if any interviews were completed and addressed the nursing note revealing Resident #2 stated she believed the bruising was a result of the brace being applied incorrectly that the DON stated he had spoken to Resident #2 who denied abuse and he had the aide that was working that day demonstrate how she applied the brace and it was done correctly. The DON stated he also spoke to the nurse who wrote the note when the bruising was noted. He did not document any part of that investigation nor did he expand it to determine if other staff were applying the brace correctly or to verify there had been no accidents that were not recorded. On 06/15/26 at 9:06 A.M., the concerns related to lack of identifying Resident #2's injuries as injuries of unknown origin when she was identified with bruising then later with a patellar fracture without identifiable cause were addressed with the Administrator. The Administrator indicated he was not aware of the concern. No investigation was completed/provided. On 06/15/26 at 12:40 P.M., Resident #2 stated she was confused at times but she recalled the bruise, pointing from the left mid inner thigh to the left knee. Resident #2 stated she had not had trauma to the left knee or leg. The only explanation she could think of was if the brace was not applied correctly. Resident #2 stated she did not know how the brace was supposed to be applied but she was trying to think of an explanation of how it could have occurred when asked. Resident #2 stated she might have forgotten but never recalled any nurses or therapy monitoring how nursing assistants applied the brace to her knee.Review of the facility's Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property policy (implementation date not recorded) revealed an injury of unknown source was identified as an injury in which the source of the injury was not observed by any person or the source of the injury could not be explained by the resident and the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time or the incident of injuries over time. The policy indicated all injuries of unknown source must be reported immediately to the Administrator or designee. Once the Administrator and State Survey agency were notified, an investigation of the alleged violation would be conducted.

Based on review of the medical records, review of the facility infection control logs, facility policies, observation of incontinence care and hand hygiene practices, interviews and review of information from the Centers of Disease Control (CDC), the facility failed to prevent the recurrence of urinary tract infections for Resident #6. The affected one (Resident #6) of two residents reviewed for urinary tract infections. The facility census was 87.Findings Include: Review of the medical record for Resident #6 revealed admission not facility on 07/07/25 for diagnoses including epilepsy (seizure disorder), anoxic brain damage (damage caused by lack of oxygen for an extended period of time), high blood pressure, stage three pressure injury ulcer, dementia (confusion) with anxiety, a colostomy (bag secured to the abdomen over an surgically created opening of the bowel used to collect stool/feces), and history of urinary tract infections (UTI's)Review of the UTI care plan dated 05/04/2026 revealed Resident #6 was diagnosed with a UTI/cystitis related to E.Coli (common bacteria found in stool) and ESBL (a bacteria resistant to common antibiotics) and receiving antibiotics. Interventions included administering of antibiotics as ordered, encourage fluids, monitor for hematuria (blood in urine), fever, pian, increased urinary frequency, monitor for decreased oral intake, acute confusion, agitation, delusions, aggression, lethargy (excessive sleepiness), decreased sweating, low blood pressure, changes in blood pressure, high heart rate, sunken eyes, and generalized weakness. Further review revealed additional interventions to notify provider of any changes, monitor intake and outputs and refer to urologist as needed with doctor orders.Review of the most recent quarterly minimum data set (MDS) 3.0 assessment completed on 05/26/26 for revealed Resident #6 had a brief interview for mental status (BIMS) score of 3/15 meaning severe cognitive impairment and was dependent on staff to complete all personal care, toileting hygiene, dressing, bathing, and transfers, as well as provide for mobility in a wheelchair.Interview on 06/08/26 at 12:20 P.M. with Resident #6's primary emergency contact and eldest son, Son #1, revealed he lived in Tennessee and was not local to the facility. Son #1 reported that he did not understand why his mother, Resident #6, was being repeatedly sent to the emergency room (ER) for urinary tract infections and he often questioned the staff about his mother's care, including being cleaned good and getting enough fluids. Son #1 reported his mother was just in the ER last week on 05/30/26 for another UTI.Observation on 06/09/26 at 3:06 P.M. of incontinence care/peri-care of Resident #6 by certified nursing assistants (CNA) #100 and #120 revealed the following: Resident #6 was sleeping in bed and CNA #100 and #120 donned gloves and gowns to awake Resident #6 for incontinence check and change prior to preparing for the dinner meal at 4:30 P.M. CNA #100 then removed the adult brief from Resident #6 and used one disposable wet wipe to cleanse the front peri area of Resident #6 downward then continued to use the same wipe and cleaned in an upward motion. Resident #6 was then turned to side and CNA #120 cleaned the back peri area with another disposable wet wipe and applied moisture barrier cream to buttocks area and placed a new adult brief under Resident #6. Resident #6 was then positioned back on her back, and an anti-fungal powder was applied to front peri area. CNA #100 then straightened and positioned Resident #6 colostomy bag directly over the pubic area with the closed opening of the bag laying over the peri-area and secured the adult brief over the colostomy bag and pulled up her pants over the brief. Both CNA #100 and CNA #120 removed their gloves at that time and did not perform hand hygiene. CNA #100 and #120 positioned Resident #6 in the mechanical lift and transferred her to her specialty wheelchair. CNA #100 proceeded to comb Resident #6 hair while CNA #120 removed the mechanical lift from the room and placed it in the hallway. Neither CNA #100 or #120 had completed hand hygiene yet. CNA #100 proceeded to take Resident #6 out of her room in the wheelchair down the hall to the dining room. Interview on 06/09/25 at 3:20 P.M. with CNA #100 verified that she only used one disposable wet wipe to clean the front peri area of Resident #6 and may have cleaned her in the wrong direction but could not recall. CNA #100 also verified that she did not perform hand hygiene after peri-care and after removing gloves and then proceeded to comb the Resident #6 hair and remove her from the room in her wheelchair. Resident #120 also verified she did not perform hand hygiene after performing peri-care and removing her gloves and moved the mechanical lift into the hallway. Review of the facility infection control logs dated from 10/06/25 to 06/01/26 revealed Resident #6 had nine facility acquired urinary tract infections requiring antibiotic use. Further review revealed Resident #6 had five UTI's that cultured positive for E.Coli- ESLB (a bacteria found in the gut/stool).Interview on 06/10/26 at 9:15 A.M. with the infection preventionist nurse (IP) #252 and the Director of Nursing (DON) revealed that Resident #6 did have several UTI's in the past year and was prone to them. The DON reported that they did establish a urology consult for Resident #6 and she has been seen by urology with plans to have a cystoscopy (a medical procedure to insert a micro camera into the bladder to view for structural abnormalities and indicated for recurrent UTIs), but it had to be reschedule after Resident #6 had been hospitalized during the scheduled time. The DON did verify that the cystoscopy had been rescheduled for June 29, 2026. IP #252 verified the infection log from 10/06/25 to 06/01/26 indicating Resident #6 had nine UTIs. IP #252 further reported that she reviewed the monthly infection reports for trends related to organisms and locations of the residents in the facility and types of infections residents are having. IP #252 verified she did not trend out individual residents for reoccurrence or frequency of infections and she specifically had not reviewed Resident #6 for concerns for frequent UTI's. Further interview with IP # 252 revealed that if she had concerns with any specific trends related to UTI's, she would provide staff education related to things such as hand hygiene (hand washing) and ensuring appropriate peri-care (cleaning the genital area of a resident) being completed. IP #252 reported she had not done any recent staff education in the past 6 months related to hand hygiene or peri-care.Further interview with the DON revealed he agreed that if the colostomy bag opening was laying over the pubic area under the adult brief and was not thoroughly cleaned after emptying could increase risk of cross contamination of stool into the peri-area increasing risk for UTI's.Observation on 06/10/26 at 8:49 A.M. of Resident #6 revealed her sitting in a specialized wheelchair beside nurses' station with blanket draped over her lap. Resident #6 was dressed and groomed. Resident #6 was unable to answer questions and repeatedly asked how are you?Observation on 06/11/26 at 10:00 A.M. of Resident #6 resting in bed revealed her colostomy bag was now positioned laterally on her stomach to prevent it from lying on the pubic area and was not under the adult brief.Review of the facility policy titled Handwashing/Hand Hygiene, dated 04/2010 revealed staff are to perform hand hygiene before and after assisting Residents with personal care (toileting/bathing) and after removing gloves and gown.Review of the facility policy titled Perineal Care, undated revealed female residents' perineal area was to be washed downward and from front to back. Further review revealed not to reuse the same washcloth or water to clean the urethra or labia.Review of the Centers for Disease Control website titled ESBL-producing Enterobacterales found at About ESBL-producing Enterobacterales | ESBL-producing Enterobacterales | CDC revealed that ESBL are resistant to common antibiotics and ESBL infections are most commonly found in hospital or nursing home settings. Further review revealed ESBL can spread from person to person through dirty hands and surfaces and the best way to prevent the spread of infection was through hand hygiene.

Based on observation, policy review and interview, the facility failed to ensure expiration dates on stock medications were clearly legible and failed to ensure expired stock medications were disposed of. Expired medications were located in one of four medication storage rooms and a medication without a clearly labeled expiration date was located in one of three medication carts observed. The facility had one resident (Resident #106) who resided on the ortho hall and received the medication without a clear expiration date. On 06/10/2026 at 10:24 A.M.#191 observations of the ortho wing medication cart and medication room with Licensed Practical Nurse (LPN) #191 revealed one open bottle of ferrous sulfate in the medication cart with no expiration date found and a cabinet which contained one unopened bottle of vitamin B complex which expired March of 2026 and one unopened bottle each of lanthanum carbonate and bisacodyl tablets which expired May 2026. LPN #191 stated she did not know who was responsible for monitoring the stock meds in the cabinet to ensure they were not expired. The facility identified one (Resident #106) who had orders for ferrous sulfate and resided on the ortho wing. No residents on the ortho wing were identified as receiving vitamin B complex, lanthanum carbonate or bisacodyl tablets. Review of the facility's Storage of Medications (revised April 2007) policy revealed drug containers that had missing, incomplete, improper, or incorrect labels should be returned to the pharmacy for proper labeling before storing. The facility could not use discontinued, outdated or deteriorate drugs or biologicals. All such drugs should be returned to the dispensing pharmacy or destroyed.

Based on review of residents' personal funds accounts and interview, the facility failed to utilize a witness not associated with the facility when obtaining authorization to handle residents' funds. This affected six (Residents #13, #38, #44, #69, #93 and #110) of seven residents whose accounts were reviewed. The facility identified 44 residents who had personal funds accounts managed by the facility. Review of Residents' Personal Funds accounts with Business Office Manager (BOM) #158 on 06/15/26 between 1:29 P.M. and 2:40 P.M. revealed the facility used an authorization form for residents who wished for the facility to manage funds for them. The bottom of the form had an area for a witness to sign with a notation the witness must not be connected with the facility or the Administrator. 1.Review of Resident #13's Resident Personal Funds authorization signed by Resident#13's guardian on 11/18/22 revealed the witness was prior Business Office Manager #250. On 06/15/26 at 1:29 P.M., BOM #158 verified Resident #13's authorization was signed by BOM #250 and verified facility staff continued to witness the authorization forms for managing residents' funds accounts. 2.Review of Resident #44's resident personal funds authorization signed by the resident 05/18/23 indicated Resident #44 initialed she wanted to manage her own funds. The witness was prior BOM #250. During interviews of BOM #158 on 06/15/26 while reviewing funds between 1:29 P.M. and 2:40 P.M., she acknowledged previous BOM #250 had signed as a witness to manage Resident #44's personal funds. During an interview on 06/16/26 at 8:47 A.M., BOM #158 stated Resident #44 had opened her account with the facility prior to BOM #158's employment as BOM. BOM #158 acknowledged Resident #44 had placed her initials next to the section indicating she wanted to manage her own funds. The personal funds account was opened at the time of Resident #44's signature on 05/18/23. After reviewing the information, BOM #158 stated Resident #44 initialed the area indicating she wanted to manage her own funds to signify she wanted control of the funds in the account. BOM #158 indicated she would clarify Resident #44's wishes today and have her sign a new authorization. Resident #44 was aware of the facility holding her funds in a personal funds account and was active in managing her funds. 3.Review of Resident #110's resident personal funds authorization signed by her resident representative on 06/28/24 revealed it was witnessed by BOM #158. During review of accounts on 06/15/26 between 1:29 P.M. and 2:40 P.M., BOM #158 verified she had witnessed the authorization. 4.Review of Resident #69's resident personal funds authorization signed by Resident #69's representative on 04/04/25 had BOM #158 as the witness. During review of accounts on 06/15/26 between 1:29 P.M. and 2:40 P.M., BOM #158 verified she had witnessed the authorization. 5.Review of Resident #93's Resident Personal Funds authorization signed by the resident's POA on 05/27/25 revealed the witness was Business Office Manager #158. During review of accounts on 06/15/26 between 1:29 P.M. and 2:40 P.M., BOM #158 verified she had witnessed the authorization. 6.Review of Resident #38's Resident Personal Funds authorization signed by the resident on 01/01/26 revealed the witness was Business Office Manager #158. During review of accounts on 06/15/26 between 1:29 P.M. and 2:40 P.M., BOM #158 verified she had witnessed the authorization.

Based on closed medical record review, review of the ambulance run report, review of hospital records, review of death certificate, interviews with staff, physicians and resident power of attorney (POA), and review of facility policies, the facility failed to provide adequate monitoring and timely identification of an acute change in condition to prevent a delay in treatment for Resident #98. This resulted in Immediate Jeopardy and Actual Harm (subsequent death) beginning on 11/23/25 at approximately 1:40 A.M. when Resident #98, who had a known history of oral phase dysphagia, pneumonitis due to inhalation of food and vomit, use of antiplatelet therapy and was care planned for aspiration risk, and bleeding risk related to antiplatelet therapy, began to have brown emesis which continued throughout the midnight shift without proper assessment by the assigned nurse who proceeded to administer medications (on 11/23/25 RISE) via oral route without evidence of checking the oral cavity, completing a physical assessment, assessing the resident's vital signs or updating the physician of the ongoing emesis. On 11/23/25 at 8:44 A.M. Resident #98 was poorly responsive and was in respiratory distress requiring emergency transfer to the hospital where she was diagnosed with pneumonia, aspiration and gastrointestinal bleed. Subsequently Resident #98 was in need of mechanical ventilation and invasive testing to rule out the source of the bleed. However, the resident's family elected for Hospice care at this time and the resident expired on 11/24/25. The facility failure to implement appropriate monitoring and assessment, and failure to timely identify and treat an acute change in condition affected one resident (#98) of six residents reviewed for quality of care. The facility census was 97. On 03/30/26 at 11:54 A.M. the Administrator, Director of Nursing (DON), and Administrator in Training (AIT) #703 were notified Immediate Jeopardy began on 11/23/25 when Resident #98 was found in her room following an acute change in condition that resulted severe respiratory distress and emergency transfer to the hospital where she later expired on 11/24/25. The facility failed to ensure appropriate monitoring and assessment of the resident and failed to timely identify and treat an acute change in condition resulting in Resident #98's death. The Immediate Jeopardy was removed on 03/31/26 when the facility implemented the following corrective actions:On 3/30/26 the Director of Nursing (DON) contacted the Medical Director to inform him of the Immediate Jeopardy details involving Resident #98. The facility Quality Assurance Performance Improvement (QAPI) team and corporate staff met which included Corporate Registered Nurse (RN) #809, #900 and #901 and facility staff including the Director of Nursing (DON), Wound RN, RN Unit Manager, LPN Unit Manager, RN MDS/SS #902, RN MDS #903, RN/MDS #904, the Administrator, Social Services (SS), Activity Director, Dietary Director (DT). The discussion focused on review of the medical record for Resident #98 and collaboration on immediate educational materials and intervention to re-educate staff and assist administration in alternate ways to monitor documentation and the timely identification, intervention, assessment, documentation and notification of physician and family for any changes in a resident's condition. On 03/30/2026 the Administrator and Corporate RNs #809, #900 and #901 reviewed the facility Change in a Resident's Condition and the Acute Condition Changes policies the facility had in place and began re-educating all facility nurses and certified nursing assistants in-person. Additional in-person education included the following which was completed by 03/31/26: Education regarding proper timely identification of adequate interventions for and documentation of an identified change in condition.Education regarding proper timely notification of the physician and family of a change in condition and that accurate information is provided.Education regarding Certified Nursing Assistant (CNA) notification to nurse of concern in a residents change in condition. If the CNA feels the nurse the CNA reported to has not responded, the CNA should report the concerns to the supervisor or administration immediately.Education regarding physician notification of all changes in condition. If the primary care physician, or their on-call staff do not respond, the facility Medical Director should be called to report the change in condition.Education to nurses regarding reporting any concerns or possible concerns (i.e. emesis, new pain, change in mental status, new decrease in physical functioning, fever, cough, etc.) to the facility supervisor for assistance in ensuring staff is identifying, documenting, intervening and reporting changes in resident condition.The education identified above would also be included in the orientation packet for review with all new nurses and CNA staff effective 04/01/2026. On 03/30/2026 Corporate RNs #809, #900 and #901 re-educated administrative staff including the Administrator, DON, RN Unit Manager and LPN Unit Manager on reviewing the 24 hour/72 hour summary (summary of nursing notes) and other ways to monitor nurses' notes, changes in condition, discharges to the hospital, etc. The Administrator would now begin reading these summaries as well. On 03/30/2026, Corporate RN #809 and #900 completed record reviews of all residents sent to the hospital since 03/01/2026 to review for concerns related to identification, documentation and notification of changes in condition.On 3/30/2026 the facility administrative nurses (DON, RN Unit Manager, LPN Unit Manager) conducted nursing assessments (consisting of assessing residents head to toe, including vitals, lung sounds, bowel sounds and if any complaints noted) on all current residents to assess for any indications of a change in condition. Alert and oriented residents (those with a Brief Interview for Mental Status (BIMS) score of 10 or above) were asked during these assessments if they felt as though they have had a recent change in condition. Those residents who were not alert and oriented, the emergency contact/POA was contacted to review the assessments and asked if they felt as though the resident has had a recent change in condition. These assessments and responses from the resident and/or emergency contact/POA were documented in each resident's medical record in progress notes by the end of the day on 03/30/2026. Staff also reviewed with the emergency contact/POA, that when a change in condition was identified, the facility protocol was to contact the physician, then the emergency contact/POA. This was completed on 03/30/26, except for two residents on leave of absence which were completed on 03/31/26. For on-going monitoring, beginning on 03/30/26 the Administrator divided the facility into four sections and began the following: The Administrator, the DON, RN Unit Manager and LPN Unit Manager were assigned one of those four sections. Each would be responsible to read the 24-72-hour summary each morning for the assigned section of the facility. They will review these for any indications of a change in condition and how it was handled and documented. The Administrator, DON, RN Unit Manager and LPN Unit Manager would then meet after morning meeting to discuss any areas of concern. Any residents who were sent to the hospital would have a medical record review completed and the team would discuss any issues or concerns. This would be on-going. The facility QAPI team would then reassess the frequency of the morning meetings with the Administrator, DON and unit managers. For ongoing monitoring, beginning on 04/01/26, the Administrator, DON, RN Unit Manager and LPN Unit Manager would conduct chart reviews for three to four high risk residents daily for two weeks, then weekly for four weeks, then monthly for three months. The findings of the high-risk audits would be discussed with the QAPI team monthly. The QAPI team would discuss the findings and make any recommendations concerning the findings or need to adjust the frequency or extend the initially planned time frames for the audits. This will continue for at least three months, through 07/01/26. The summary reviews, high risk charts audited and morning meeting will be documented on forms for record of audits. Although the Immediate Jeopardy was removed on 03/31/26 the deficiency remains at 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 plan and monitoring to ensure on-going compliance. Findings include:Review of the closed medical record for Resident #98 revealed an admission date of 11/17/25 with diagnoses including but not limited to weakness, difficulty walking, oral phase dysphagia, muscle wasting, protein-calorie malnutrition, atherosclerotic heart disease, gastroesophageal reflux disease, pneumonitis due to inhalation of food and vomit, asthma, cardiac implant and viral meningitis. Resident #98 was emergency transferred from the facility to the hospital emergency room on [DATE] and expired in the hospital on [DATE]. Review of physician orders dated 11/17/25 revealed Resident #98 had a Do Not Resuscitate Comfort Care Arrest (DNRCC-A) order indicating standard care and life extending measures would to be used right up until the point of cardiac or respiratory arrest. Resident #98 was ordered vital signs every shift. Review of the admission assessment dated [DATE] at 5:01 P.M. authored by Licensed Practical Nurse (LPN) #400 revealed Resident #98 was admitted to the facility from a general hospital. Lifestyle prior to admission was semi-dependent, she used a walker to ambulate and needed some help with activities. Resident #98's diet consistency was mechanical soft, ground meat with thin liquids. Resident #98 was alert to person, place, time and situation. No cough was present, lung sounds were clear, no rhonchi ( thick mucus in airway), and no wheezes. Pulse was equal, bowel sounds present, soft abdomen, and continent of bladder. The assessment noted the resident had moderate pain in the right hip, and she used a walker for mobility. Resident #98 was pleasant, and cooperative.Review of a physician order dated 11/18/25 revealed to start Aspirin tablet chewable 81 milligrams (mg) by mouth in the morning (prophylactic) related to atherosclerotic heart disease.Review of the care plan date initiated 11/18/25 revealed Resident #98 was at risk for bruising/bleeding due to (prophylactic) antiplatelet therapy. Interventions included medications per physician order, monitor and report abnormal results to physician and monitor for side effects or adverse reaction of medications and report to physician. Monitor, document, and report as needed to physician any signs or symptoms of abnormal bleeding, bruising, black tarry stools, discolored urine, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, sudden changes in mental status, nose bleeds. Shortness of breath and hypotension. The care plan also included vital signs per order, document and report any significant abnormalities to physician.Review of the care plan date initiated 11/18/25 revealed Resident #98 was at risk for impaired air exchange due to asthma and aspiration pneumonia. Interventions included maintain saturations of oxygen greater than 88 percent, monitor for increased shortness of breath, cyanosis, increased edema, pallor or respiratory distress, administer medication per physician orders and monitor or adverse reactions, head of bed elevated.Review of the Physician Note dated 11/19/25 at 3:54 P.M. written by the Primary Care Physician (PCP) #701 revealed Resident #98 presented to the facility for therapy from the hospital (name provided). On examination Resident #98 was resting in bed, reported feeling sore and had occasional shortness of breath with scant phlegm production. She denied nausea and vomiting. Physical exam revealed lungs without wheeze, rales or rhonchi (rattling caused by fluid obstructing the airway). The plan was to continue occupational therapy and physical therapy, continue antibiotic for viral meningitis, continue aspirin for coronary artery disease and Protonix and Reglan for gastroesophageal reflux disease.Review of Resident #98's Treatment Administration Record dated November 2025, revealed Resident 98's vitals were taken once during the night on 11/22/25.Review of the vital records in the electronic medical record revealed vitals were recorded on 11/22/25 at 11:27 P.M. by LPN #619 that included a blood pressure reading of 153/84 mm/Hg, temperature 98 degrees Fahrenheit (F), pulse rate 88 beats per minute (bpm), respiration 18 breaths per minute, and oxygen saturation 94 percent room air. Review of the Medicare Five Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #98's Brief Interview for Mental Status (BIMS) score was 13 out of 15 indicating intact cognition. No indicator of psychosis, behavior symptoms and no rejection of care was present. The assessment revealed Resident #98 needed (staff) supervision to eat and maximal (staff) assistance for bathing. Moderate (staff) assistance was needed to transfer from bed to chair and to walk ten feet. Resident #98 had shortness of breath with exertion, while sitting and lying flat. Resident #98 did not have a chronic disease that would result in a life expectancy of less than six months. Problem conditions included vomiting and internal bleeding. Resident #98 had coughing or choking during meals or when swallowing medication and complained of difficulty or pain when swallowing. Resident #98 needed a mechanically altered diet that required a change in texture of food. Resident #98 had broken and loose fitting dentures and had discomfort when chewing. The assessment also noted Resident #98 received antiplatelet drug therapy.Review of a nursing progress note dated 11/23/25 at 1:40 A.M. authored by LPN #619 documented Resident #98 had an episode of dark watery emesis. No other assessment of the resident was included at this time. The note included the daughter/POA was notified and did not want to send resident to the emergency room (ER) at this time.Review of the resident's progress notes revealed no additional assessments, documentation of monitoring or notes after the note at 1:40 A.M. until the note authored by LPN #619 at 7:20 A.M.Review of Resident #98's Medication Administration Record (MAR), dated 11/23/25 revealed Resident #98 received the following mediation at Rise time by LPN #619 : Aspirin tablet chewable 81 milligrams (mg) by mouth, calcium citrate- Vitamin D oral tablet 200-6.25 milligrams (mg) one tablet by mouth, Cholecalciferol tablet 1000 unit two tablets by mouth, Glycolax powder 17 grams by mouth , levothyroxine 100 microgram (mcg) by mouth at 6:00 A.M., Metoprolol tablet 50 mg one tablet by mouth, multivitamin one tablet by mouth, Protonix 40 mg one tablet by mouth, Trospium chloride oral capsule 60 mg by mouth, Reglan 5 mg one tablet by mouth, and Sennoside tablet 8.6 mg by mouth.Review of the facility undated document titled Medication Pass revealed Rise medication pass was scheduled between the hours of 5:00 A.M. to 10:00 A.M.Review of the nursing progress note dated 11/23/25 at 7:20 A.M. authored by LPN #619 revealed Resident #98's daughter was notified of resident having more episodes of dark emesis this shift. The nurse documented the daughter wanted to wait to see what the doctor (Primary Care Physician (PCP) #701) wanted to do.Review of the nursing progress note dated 11/23/25 at 7:49 A.M. authored by LPN #619 revealed Resident #98 had more episodes of dark emesis this shift. There was no documentation of any type of assessment including vital sign monitoring of the resident at this time. PCP #701 was notified and a new order for a complete blood count (CBC) this morning and daughter (POA) notified.Review of Resident #98's Treatment Administration Record dated November 2025 revealed Resident 98's vital signs were taken once during the day on 11/23/25. Review of the vital records in the electronic medical record revealed on 11/23/25 at 8:42 A.M. LPN #518 documented the resident's vital signs included an oxygen saturation of 67 percent on room air, respiration rate of 40 breaths per minute (elevated), pulse rate 109 bpm (elevated/tachycardic), temperature 97.9 degrees (F), and blood pressure 88/92 mmHg (hypotensive). Review of the nursing progress note dated 11/23/25 at 8:44 A.M. authored by LPN #518 revealed she was in Resident #98's room to assess following an emesis. Upon assessment this nurse observed resident to have a dark brown/black emesis. Resident #98 did not respond to LPN #518 per baseline. Vitals were obtained that included a blood pressure 88/52 very faint, pulse 109, respirations 40, temperature 97.9 Fahrenheit (F) and oxygen (saturation) 67 percent. The note indicated supplemental oxygen was applied. Resident #98 did not respond via nasal cannula simple mask. Fifteen liters nonrebreather oxygen applied and oxygen went to 80 percent. Resident #98 still did not respond appropriately or open eyes. Abdomen was soft and non-tender. The note included the resident's daughter (POA) wanted the resident sent to Emergency Room. Ambulance contacted and made aware of need for transport. Hospital emergency room nurse to nurse given. Review of the Situation, Background, Assessment, Recommendation (SBAR) assessment form dated 11/23/25 at 8:44 A.M. authored by LPN #518 revealed a change in condition evaluation was done due to abnormal vital signs, altered mental status, functional decline, nausea or vomiting, shortness of breath, unresponsiveness, seems different than usual and confused at the time of evaluation. The SBAR included the resident's blood pressure was 88/52 lying down, pulse 109, respirations 40, pulse oximetry 67 percent room air. Code status DNRCC-A. Nursing observation included brown/black emesis. Resident not responding per baseline, confusion noted. Resident not opening eyes, mumbling. Vitals obtained, supplemental oxygen applied, physician notified, daughter (POA) notified. Sent to (ER) for evaluation for and treatment. PCP #701 responded with the following recommendations: send to ER.Review of the ambulance (name provided) Run Report dated 11/23/25 revealed a call came in to dispatch on 11/23/25 at 8:45 A.M. for Resident #98 who was short of breath with a pulse ox (oxygen) in the 60s. Emergency responders were dispatched to the facility, arriving onsite at 8:55 A.M. and to the resident at 8:55 A.M. Upon arrival, the resident was found in her room with nursing staff at bedside. Per nursing staff patient had multiple episodes of vomiting last night that was dark in color. Resident had a rapid decline on nursing staff and was on 15 liters oxygen with pulse ox of 82 percent. Resident complained of shortness of breath and had diminished lung sound to the right lower lobes. Resident also complained of right rib pain. A three lead (EKG) was placed prior to moving resident which showed sinus arrythmia with premature ventricular contractions (PVC) which are early heart beats disrupting the hearts normal rhythm). Resident #98 arrived to the emergency room at 9:26 A.M. Review of Hospital Emergency Department Report dated 11/23/25 at 9:36 A.M. revealed Resident #98 was sent to the emergency room (ER) for shortness of breath and low pulse ox at the nursing home. It was reported that Resident #98's pulse ox was 66 percent at the nursing home. It was reported Resident #98 was vomiting brown substance off and on all night. Resident #98 had a history of remote gastrointestinal bleed according to the family. Physical exam of head, eyes, ears, nose and throat revealed there was brown substance coating the resident's mouth and around the lips. Physical exam of the lungs revealed rales (crackles) apparent in the right lung upper and lower lobes. Differential diagnosis included pneumonia, aspiration and gastrointestinal (GI) bleed. Chest x-ray revealed infiltrate in the right upper and lower lobes consistent with pneumonia possible aspiration. Daughter was updated and Hospice was suggested due to sepsis criteria. Resident #98 was admitted to the hospital on [DATE] for critical care. On 11/24/26 Resident #98 transitioned to the care of Hospice for palliative care and Resident #98 expired on 11/24/25 at 2:58 P.M.Review of the nursing progress note dated 11/23/25 at 3:02 P.M. authored by LPN #518 revealed the hospital was contacted for an update. The ER nurse stated Resident #98 was admitted with diagnosis of gastrointestinal bleed, aspiration pneumonia and severe sepsis.Review of Ohio Department of Health Vital Statistics Certificate of Death dated 11/24/25 revealed Resident #98 place of death was inpatient hospital, immediate cause of death was severe sepsis and bilateral aspiration pneumonia on 11/24/25. Interview on 03/25/26 at 8:58 A.M. with Resident #98's daughter/Power of Attorney (POA) revealed the last time she saw her mother was on 11/21/25 during dinner time and there were no concerns with her mother's health at that time. The POA stated on 11/23/25 around 2:00 A.M. she received a phone call from LPN #619. The POA revealed LPN #619 told her Resident #98 was spitting up a little bit and asked if the POA wanted to send Resident #98 to the hospital. The POA stated she said yes if the nurse felt it was needed. The POA asked how much spit up and LPN #619 stated the spit up was a little bit and also stated the doctor would be in soon and to wait to see what the doctor thought. The POA stated she agreed to let the doctor look at her mother. The POA stated she received a second phone call around 7:00 A.M. on 11/23/25 from a different nurse stating her mother was in a bad condition and an ambulance was called. The POA stated when Resident #98 was in the emergency room she was told her mother had pneumonia, had aspirated and a possible bleed because of the coffee ground blood signs were in her mouth. The hospital gave her the option of placing Resident #98 on a ventilator to explore the source of the bleed or Hospice care. The POA stated she chose hospice care and Resident #98 passed away the next day in the hospital. Interview on 03/25/26 at 4:19 P.M. with LPN #518 revealed she worked day shift 11/23/25 and during report the outgoing nurse (LPN #619) reported Resident #98 was under the weather overnight, and she had called the POA who did not want to send Resident #98 to the hospital. The outgoing nurse (LPN #619) stated Resident #98 was stable at the time of report. LPN #518 stated she attended to two other residents and then was called to Resident #98's room because the lab tech could not draw blood from Resident #98. LPN #518 stated she stepped out of Resident #98's room to go to the medication cart and was notified Resident #98 was less responsive. LPN #518 obtained vitals and observed dark brown emesis on Resident #98. LPN #518 call the POA, physician and the ambulance. LPN #518 stated she did not pass medication to Resident #98 that morning, the outgoing nurse (LPN #619) had already administered the RISE medication pass to Resident #98 prior to ending her shift.Interview on 03/25/26 at 5:29 P.M. with the Director of Nursing( DON) revealed it was standard nursing practice to notify the physician if aspiration was suspected and vitals could be done more often than once a shift if the physician requested. The DON stated the night nurse (LPN #619) made the POA aware but not the physician because the POA did not want resident sent to the hospital; therefore, the nurse did not call the physician.Interview on 03/25/26 at 5:45 P.M. with LPN #619 verified she worked the night of 11/23/25 and stated Resident #98 had emesis that night but the POA did not want to send Resident #98 to the hospital. LPN #619 stated she observed the emesis to be a little dark brown but stated the emesis was enough Resident #98 needed her gown changed. LPN #619 verified she did not take additional vital signs that night and her intervention was to keep an eye on her. LPN #619 verified she did not call the physician after the brown emesis and revealed the resident had three to four emesis during the night to which she did not contact the physician. LPN #619 revealed she sent the PCP a text around 7:00 A.M. LPN #619 verified she passed medication to Resident #98 for the RISE medication pass time that could have been around 5:00 A.M. to 6:00 A.M. (unable to recall exact time). LPN #619 stated she provided Resident #98 fluids through the night but did not assess if her oral cavity was clear. LPN #619 verified vital sign monitoring should be done immediately with a change in condition and physician should be notified. LPN #619 stated she did not have concerns when speaking with the POA around 2:00 A.M. on 11/23/25 and suggested to wait until the physician was in the facility later that morning to see the resident. LPN #619 verified she did not call the POA again regarding the continued episodes of brown emesis that were significant enough to require gown changes.Interview on 03/26/26 at 11:19 A.M. with CNA #204 revealed she worked the morning shift on 11/23/25. CNA #204 stated she received report from the night CNA (CNA #704) stating Resident #98 was throwing up black all night. CNA #204 stated she observed Resident #98 around 8:00 A.M. moaning in bed and not responding and notified the nurse. CNA #204 stated she observed Resident #98 have a black emesis that was large enough Resident #98's bedding and gown needed changed.Interview on 03/26/26 at 1:58 P.M. with the DON revealed an investigation was not done related to Resident #98's change in condition and subsequent hospitalization. The DON verified LPN #619 did not document if or how many times the POA was called during the night. The DON verified the RISE medication was passed to Resident #98 during the morning of 11/23/25. The DON stated standard nursing practice was to call the physician if a resident had emesis and verified LPN #619 did not call the physician and additional vital sign monitoring or assessment were not completed or documented. The DON also verified no documentation existed regarding the times of emesis during the night or if the POA was additionally called.Interview on 03/26/26 at 3:13 P.M. with Medical Director #702 revealed it was the expectation of the facility to notify the physician any time of day or night if a resident had an acute change in condition. Medical Director #702 stated if the situation was critical the resident was to be sent to the ER and the physician and family called, and three or four brown/black emesis would be considered critical.Interview on 03/26/26 at 4:30 P.M. with Resident #98's PCP, PCP #701 revealed he received a text early in the morning on 11/23/25 and was not notified again until later in the morning around 7:00 A.M. by text that Resident #98 had brown like emesis. He stated an order for a CBC lab draw was made. PCP #701 stated it was his understanding the POA did not want the resident sent out to the hospital.Interview on 03/31/26 at 2:36 P.M. with CNA #704 revealed she worked the night shift on 11/22/25. CNA #704 reported she notified LPN #619 that Resident #98 had episodes of brown, mucus-like emesis and the resident needed gown changes. CNA #704 stated Resident #98 had approximately six episodes of emesis during the shift, including one large episode requiring a full bed change and CNA placed a towel by the resident's mouth. Review of the facility policy titled Acute Condition Changes Clinical Protocol, revised December 2015, revealed the nurse shall document and report vital signs, neurological status, pain, consciousness, onset duration and severity. Before contacting a physician about someone with an acute change of condition, the nursing staff would make detailed observations and collect pertinent information to report to the physician. The attending physician or practitioner providing back up coverage would respond in a timely manner (half hour or less) to notification of problems or changes in condition or status. The staff would notify the medical director for additional guidance or consultation if they did not receive a timely or appropriate response. The nurse and physician would discuss and evaluate the situation. The physician should ask questions to clarify the situation, for example, vitals signs, physical findings, and symptoms description. The physician would discuss with staff and/or resident families the benefits and risks of diagnosing and managing the situation in the facility versus the hospital. The physician would identify and authorize proper treatment. The staff would monitor and document responses to treatment and the physician with adjust treatment accordingly until the problem has been resolved or stabilized. Review of facility undated policy titled Quality of Care Policy revealed it was the policy of the facility that each resident received the necessary care to attain or maintain the highest practicable wellbeing, in accordance with the resident's comprehensive care plan. Also, each resident must receive, and the facility must provide the necessary care and services to attain and maintain the highest practicable well-being in accordance with the comprehensive assessment and plan of care. This deficiency represents noncompliance investigated under Complaint Number 2769707.

Based on record review, staff interviews, and review of facility policy the facility failed to ensure the physician was thoroughly informed and timely notified of a change of condition for Resident #98 in order to identify and authorize proper treatment. This affected one resident (#98) of six residents reviewed for change of condition. The facility census was 97. Findings include: Review of the closed medical record for Resident #98 revealed an admission date of 11/17/25 with diagnoses including but not limited to weakness, difficulty walking, oral phase dysphagia, muscle wasting, protein-calorie malnutrition, pneumonitis due to inhalation of food and vomit, asthma, cardiac implant and viral meningitis. Resident #98 was emergency transferred from the facility to the hospital emergency room on [DATE] and expired in the hospital on [DATE].Review of physician orders dated 11/17/25 revealed Resident #98 had a Do Not Resuscitate Comfort Care Arrest (DNRCC-A) order indicating standard care and life extending measures would to be used right up until the point of cardiac or respiratory arrest.Review of the admission assessment dated [DATE] at 5:01 P.M. written by Licensed Practical Nurse (LPN) #400 revealed Resident #98 was admitted to the facility from a general hospital. Lifestyle prior to admission was semi-dependent, she used a walker to ambulate and needed some help with activities. Resident #98's diet consistency was mechanical soft, ground meat with thin liquids. Resident #98 was alert to person, place, time and situation. No cough was present, lung sounds were clear, no rhonchi ( thick mucus in airway) , and no wheezes. Pulse was equal, bowel sounds present, soft abdomen, and continent of bladder. There was moderate pain in the right hip, and she used a walker for mobility. Resident #98 was pleasant, and cooperative.Review of the care plan date initiated 11/18/25 for Resident #98 revealed a risk for bruising/bleeding due to antiplatelet therapy related to prophylactic. Interventions included medications per physician order, monitor and report abnormal results to physician and monitor for side effects or adverse reaction of medications and report to physician. Monitor, document, and report as needed to physician any signs or symptoms of abnormal bleeding, bruising, black tarry stools, discolored urine, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, sudden changes in mental status, nose bleeds. Shortness of breath and hypotension. Finally, vital signs per order, document and report any significant abnormalities to physician.Review of the care plan date initiated 11/18/25 for Resident #98 revealed a risk for impaired air exchange due to asthma and aspiration pneumonia. Interventions included maintain saturations of oxygen greater than 88 percent, monitor for increased shortness of breath, cyanosis, increased edema, pallor or respiratory distress, administer medication per physician orders and monitor or adverse reactions, head of bed elevated.Review of Resident #98's Treatment Administration Record dated November 2025, revealed Resident 98's vitals were taken once during the night on 11/22/25.Review of the vital records in the electronic medical record revealed vitals were recorded on 11/22/25 at 11:27 P.M. by LPN #619 that included a blood pressure reading of 153/84 mm/Hg, temperature 98 degrees Fahrenheit (F), pulse rate 88 beats per minute (bpm), respiration 18 breaths per minute, and oxygen saturation 94 percent room air. Review of the Medicare Five Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #98's Brief Interview for Mental Status (BIMS) score was 13 out of 15 indicating intact cognition. No indicator of psychosis, behavior symptoms and no rejection of care was present. Resident #98 needed supervision to eat and maximal assistance for bathing. Moderate assistance was needed to transfer from bed to chair and to walk ten feet. Resident #98 had shortness of breath with exertion, while sitting and lying flat. Resident #98 did not have a chronic disease that would result in a life expectancy of less than six months. Problem conditions included vomiting and internal bleeding. Resident #98 had coughing or choking during meals or when swallowing medication and complained of difficulty or pain when swallowing. Resident #98 needed a mechanically altered diet that required a change in texture of food.Review of a nursing progress note dated 11/23/25 at 1:40 A.M. authored by LPN #619 documented Resident #98 had an episode of dark watery emesis. No other assessment of the resident was included at this time. The note included the daughter/POA was notified and did not want to send resident to the emergency room (ER) at this time. There was no documentation in the note to indicate the physician had been notified. Review of the resident's progress notes revealed no additional assessments, documentation of monitoring or notes after the note at 1:40 A.M. until the note authored by LPN #619 at 7:20 A.M.Review of Resident #98's Medication Administration Record (MAR), dated 11/23/25, revealed Resident #98 received the following mediation at Rise time by LPN #619 : Aspirin tablet chewable 81 milligrams (mg) by mouth, calcium citrate- Vitamin D oral tablet 200-6.25 milligrams (mg) one tablet by mouth, Cholecalciferol tablet 1000 unit two tablets by mouth, Glycolax powder 17 grams by mouth , levothyroxine 100 microgram (mcg) by mouth at 6:00 A.M., Metoprolol tablet 50 mg one tablet by mouth, multivitamin one tablet by mouth, Protonix 40 mg one tablet by mouth, Tropism chloride oral capsule 60 mg by mouth., Reglan 5 mg one tablet by mouth, and Sennoside tablet 8.6 mg by mouth.Review of the facility document titled Medication Pass, undated, revealed Rise medication pass was between the hours of 5:00 A.M. to 10:00 A.M.Review of the nursing progress note dated 11/23/25 at 7:20 A.M. authored by LPN #619 revealed Resident #98's daughter was notified of resident having more episodes of dark emesis this shift. The nurse documented the daughter wanted to wait to see what the doctor (Primary Care Physician (PCP) #701) wanted to do.Review of the nursing progress note dated 11/23/25 at 7:49 A.M. authored by LPN #619 revealed Resident #98 had more episodes of dark emesis this shift. There was no documentation of any type of assessment including vital sign monitoring of the resident at this time. PCP #701 was notified and a new order for a complete blood count (CBC) this morning and daughter (POA) notified.Review of Resident #98's Treatment Administration Record dated November 2025 revealed Resident 98's vital signs were taken once during the day on 11/23/25. Review of the vital records in the electronic medical record revealed on 11/23/25 at 8:42 A.M. LPN #518 documented the resident's vital signs included an oxygen saturation of 67 percent on room air, respiration rate of 40 breaths per minute (elevated), pulse rate 109 bpm (elevated/tachycardic), temperature 97.9 degrees (F), and blood pressure 88/92 mmHg (hypotensive).Review of the nursing progress note dated 11/23/25 at 8:44 A.M. authored by LPN #518 revealed she was in Resident #98's room to assess following an emesis. Upon assessment this nurse observed resident to have a dark brown/black emesis. Resident #98 did not respond to LPN #518 per baseline. Vitals were obtained that included a blood pressure 88/52 very faint, pulse 109, respirations 40, temperature 97.9 Fahrenheit (F) and oxygen (saturation) 67 percent. The note indicated supplemental oxygen was applied. Resident #98 did not respond via nasal cannula simple mask. Fifteen liters nonrebreather oxygen applied and oxygen went to 80 percent. Resident #98 still did not respond appropriately or open eyes. Abdomen was soft and non-tender. The note included the resident's daughter (POA) wanted the resident sent to Emergency Room. Ambulance contacted and made aware of need for transport. Hospital emergency room nurse to nurse given.Review of the Situation, Background, Assessment, Recommendation (SBAR) assessment form dated 11/23/25 at 8:44 A.M. authored by LPN #518 revealed a change in condition evaluation was done due to abnormal vital signs, altered mental status, functional decline, nausea or vomiting, shortness of breath, unresponsiveness, seems different than usual and confused at the time of evaluation. The SBAR included the resident's blood pressure was 88/52 lying down, pulse 109, respirations 40, pulse oximetry 67 percent room air. Code status DNRCC-A. Nursing observation included brown/black emesis. Resident not responding per baseline, confusion noted. Resident not opening eyes, mumbling. Vitals obtained, supplemental oxygen applied, physician notified, daughter (POA) notified. Sent to (ER) for evaluation for and treatment. PCP #701 responded with the following recommendations: send to ER.Interview on 03/25/26 at 8:58 A.M. with Resident #98's daughter/Power of Attorney (POA) revealed the last time she saw her mother was on 11/21/25 during dinner time and there were no concerns with her mother's health at that time. The POA stated on 11/23/25 around 2:00 A.M. she received a phone call from LPN #619. The POA revealed LPN #619 told her Resident #98 was spitting up a little bit and asked if the POA wanted to send Resident #98 to the hospital. The POA stated she said yes if the nurse felt it was needed. The POA asked how much spit up and LPN #619 stated the spit up was a little bit and also stated the doctor would be in soon and to wait to see what the doctor thought. The POA stated she agreed to let the doctor look at her mother. The POA stated she received a second phone call around 7:00 A.M. on 11/23/25 from a different nurse stating her mother was in a bad condition and an ambulance was called. The POA stated when Resident #98 was in the emergency room she was told her mother had pneumonia, had aspirated and a possible bleed because of the coffee ground blood signs were in her mouth. The hospital gave her the option of placing Resident #98 on a ventilator to explore the source of the bleed or Hospice care. The POA stated she chose hospice care and Resident #98 passed away the next day in the hospital.Interview on 03/25/26 at 4:19 P.M. with LPN #518 revealed she worked day shift 11/23/25 and during report the outgoing nurse (LPN #619) reported Resident #98 was under the weather overnight, and she had called the POA who did not want to send Resident #98 to the hospital. The outgoing nurse (LPN #619) stated Resident #98 was stable at the time of report. LPN #518 stated she attended to two other residents and then was called to Resident #98's room because the lab tech could not draw blood from Resident #98. LPN #518 stated she stepped out of Resident #98's room to go to the medication cart and was notified Resident #98 was less responsive. LPN #518 obtained vitals and observed dark brown emesis on Resident #98. LPN #518 call the POA, physician and the ambulance. LPN #518 stated she did not pass medication to Resident #98 that morning, the outgoing nurse (LPN #619) had already administered the RISE medication pass to Resident #98 prior to ending her shift.Interview on 03/25/26 at 5:29 P.M. with the Director of Nursing( DON) revealed it was standard nursing practice to notify the physician if aspiration was suspected and vitals could be done more often than once a shift if the physician requested. The DON stated the night nurse (LPN #619) made the POA aware but not the physician because the POA did not want resident sent to the hospital; therefore, the nurse did not call the physician.Interview on 03/25/26 at 5:45 P.M. with LPN #619 verified she worked the night of 11/23/25 and stated Resident #98 had emesis that night but the POA did not want to send Resident #98 to the hospital. LPN #619 stated she observed the emesis to be a little dark brown but stated the emesis was enough Resident #98 needed her gown changed. LPN #619 verified she did not take additional vital signs that night and her intervention was to keep an eye on her. LPN #619 verified she did not call the physician after the brown emesis and revealed the resident had three to four emesis during the night to which she did not contact the physician. LPN #619 revealed she sent the PCP a text around 7:00 A.M. LPN #619 verified she passed medication to Resident #98 for the RISE medication pass time that could have been around 5:00 A.M. to 6:00 A.M. (unable to recall exact time). LPN #619 stated she provided Resident #98 fluids through the night but did not assess if her oral cavity was clear. LPN #619 verified vital sign monitoring should be done immediately with a change in condition and physician should be notified. LPN #619 stated she did not have concerns when speaking with the POA around 2:00 A.M. on 11/23/25 and suggested to wait until the physician was in the facility later that morning to see the resident. LPN #619 verified she did not call the POA again regarding the continued episodes of brown emesis that were significant enough to require gown changes.Interview on 03/26/26 at 1:58 P.M. with the DON revealed an investigation was not done related to Resident #98's change in condition and subsequent hospitalization. The DON verified LPN #619 did not document if or how many times the POA was called during the night. The DON verified the RISE medication was passed to Resident #98 during the morning of 11/23/25. The DON stated standard nursing practice was to call the physician if a resident had emesis and verified LPN #619 did not call the physician and additional vital sign monitoring or assessment were not completed or documented. The DON also verified no documentation existed regarding the times of emesis during the night or if the POA was additionally called.Interview on 03/26/26 at 3:13 P.M. with Medical Director #702 revealed it was the expectation of the facility to notify the physician any time of day or night if a resident had an acute change in condition. Medical Director #702 stated if the situation was critical the resident was to be sent to the ER and the physician and family called, and three or four brown/black emesis would be considered critical.Interview on 03/26/26 at 4:30 P.M. with Resident #98's PCP, PCP #701 revealed he received a text early in the morning on 11/23/25 and was not notified again until later in the morning around 7:00 A.M. by text that Resident #98 had brown like emesis. He stated an order for a CBC lab draw was made. PCP #701 stated it was his understanding the POA did not want the resident sent out to the hospital.Interview on 03/31/26 at 2:36 P.M. with CNA #704 revealed she worked the night shift on 11/22/25. CNA #704 reported she notified LPN #619 that Resident #98 had episodes of brown, mucus-like emesis and the resident needed gown changes. CNA #704 stated Resident #98 had approximately six episodes of emesis during the shift, including one large episode requiring a full bed change and CNA placed a towel by the resident's mouth.Review of the facility policy titled Acute Condition Changes Clinical Protocol, revised December 2015, revealed the nurse shall document and report vital signs, neurological status, pain, consciousness, onset duration and severity. Before contacting a physician about someone with an acute change of condition, the nursing staff would make detailed observations and collect pertinent information to report to the physician. The attending physician or practitioner providing back up coverage would respond in a timely manner (half hour or less) to notification of problems or changes in condition or status. The staff would notify the medical director for additional guidance or consultation if they did not receive a timely or appropriate response. The nurse and physician would discuss and evaluate the situation. The physician should ask questions to clarify the situation, for example, vitals signs, physical findings, and symptoms description. The physician would discuss with staff and/or resident families the benefits and risks of diagnosing and managing the situation in the facility versus the hospital. The physician would identify and authorize proper treatment. The staff would monitor and document responses to treatment and the physician will adjust treatment accordingly until the problem has been resolved or stabilized.This deficiency represents noncompliance investigated under Complaint Number 2769707.

Based on observations, review of the medical record, interview with staff, and review of the facility policy, the facility failed to ensure physician orders were followed to adequately monitor and obtain a blood pressure and heart rate prior to the administration of medication for Resident #24. This affected one resident (Resident #24) of three residents reviewed for medication administration. Findings included: Review of the medical record revealed Resident #24 was admitted to the facility on [DATE]. Diagnoses included hemiplegia of right side following a cerebral infarction, aphasia, convulsions, atherosclerotic heart disease, hypertensive heart disease, chronic kidney disease, peripheral vascular disease, congestive heart failure, major depressive disorder, benign prostatic hyperplasia, generalized edema, gout, and insomnia. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #24 had moderately impaired cognition and he was nonverbal. Review of the March 2025 physician orders revealed Resident #24 had on order dated 08/02/22 for Carvedilol 6.25 milligram (mg) tablet with instructions to hold the medication if the residents systolic blood pressure was less than 110 millimeters of mercury (mmHg) or if the heart rate was less than 55 beats per minute. Review of the February 2025 medication administration record (MAR) revealed no documentation that Resident #24's blood pressure and heart rate were monitored or checked prior to the administration of Carvedilol 6.25 mg. Review of the March 2025 MAR revealed no documentation that Resident #24's blood pressure and heart rate were monitored or checked prior to the administration of Carvedilol 6.25 mg. Observation of medication administration on 03/05/25 at 9:00 A.M. revealed Registered Nurse (RN) #200 administered Carvedilol 6.25 mg to Resident #24 without obtaining a blood pressure or heart rate prior to the administration. On 03/05/25 at 9:05 A.M. an interview with RN #200 verified she had not checked the blood pressure or heart rate of Resident #24 prior to the administration of Carvedilol. On 03/05/25 at 12:30 P.M. an interview with the Director of Nursing confirmed the staff were not checking the blood pressure or heart rate of Resident #24 prior to the administration of the Carvedilol medication as ordered. He stated the nurse put the order back into the computer indicating the blood pressure and heart rate were to be taken prior to administration. Review of the undated facility policy titled, Medication Administration, revealed medications were to be administered as prescribed in accordance with good nursing principles and practices, and only by persons legally authorized to do so. This deficiency represents non-compliance investigated under Complaint Number OH00162269.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the Payroll-Based Journal Staffing Data Report (PBJ), review of staffing schedules, staff interviews, and review of a Facility Assessment, the facility failed to ensure adequate staffing ratios were maintained for the 4th Quarter of 2023. This had the potential to affect all 93 residents. Findings Include: 1. Review of the PBJ report revealed excessively low weekend staffing for the 4th quarter of 2023 was an area of concern. 2. Review of the staffing schedules for the nurses and State tested Nurse Aides (STNA) for October, November, and December of 2023 revealed the facility did not have consistent and adequate weekend staffing. Completion of the staffing tool revealed inadequate staffing levels for the following dates: 10/07/23 was at 2.10, 10/08/23 was at 2.42, 12/02/23 was at 2.37, 12/09/23 was at 2.45, and 12/10/23 was at 2.33. 3. Interview on 06/04/24 at 2:16 P.M. with the Director of Nursing (DON) confirmed he was aware that staffing levels were lower than normal for the 4th quarter but was doubtful the facility was out of compliance. 4. Interview on 06/06/24 at 11:35 AM with the Administrator confirmed the facility did not meet adequate staffing levels in the 4th quarter of 2023. The deficient practice was corrected on 04/01/24 when the facility implemented the following corrective actions: Nurse aide training was offered at no cost A recruiter was hired to focus solely on recruitment efforts New hire sign on bonus and retention bonuses were implemented Wages were increased across all departments The facility decreased its bed capacity to 107 beds Tuition reimbursement was offered The facility based staffing levels on resident population and acuity On 06/06/24 surveyor reviewed staffing schedules for the months of April, May and June of 2024 and confirmed adequate staffing levels were achieved and the facility was in compliance.

Based on observation, interview, and facility policy review, the facility failed to ensure food was prepared, served, and stored under sanitary conditions. This had the potential to affect 89 residents who received food from the kitchen. The facility identified four residents (#6, #32, #35, and #395) as receiving nothing by mouth. The facility census was 93. Findings include: 1. Observation during the kitchen tour on 06/03/24 from 8:10 A.M. to 8:45 A.M. with Dietary Supervisor (DS) #496 revealed the following concerns: -The floor of the walk-in freezer had a build of dirt and debris under the shelving units and frozen peas were scattered over the floor. -In the walk-in freezer, there was one gallon size storage bag with seven biscuits dated 05/30/24 unsealed and open to air. -In the walk-in cooler, there were two five-pound containers of sour cream with a best buy date of 06/01/24. -In the dry storage area, there was one ten-pound bag of dried angel hair pasta one fourth full open to air and not dated, and there was one two-pound bag of brown sugar opened and resealed with no date of when opened. -Observation of the fan mounted on the wall in the dish machine room and blowing towards the dish machine revealed there were visible fibers of black dust blowing from the metal guard. -Observation of the two-door reach in cooler located near the steam table revealed there were two containers of two-pound cottage cheese with a best buy date of 06/01/24. There was one opened and resealed factory plastic bag with 11 hotdog's sitting in a square metal container undated. There was one gallon storage container with approximately 12 slices of deli turkey undated. There was one factory five-pound factory bag of shredded cheddar cheese opened and resealed with no date. There was one gallon storage bag of seven cooked chicken breasts undated. There was approximately three-fourths of a one-pound opened and resealed factory bag of provolone sliced cheese undated. At the time of observation, DS #496 confirmed the areas of concern. Review of facility policy Food Receiving and Storage, revised July 2014, revealed food service personnel would maintain clean food storage areas at all times. All foods stored in the refrigerator or freezer would be covered, labeled, and dated. Review of facility policy Luncheon/Deli Meat Food Storage and Usage, reviewed 01/01/24, revealed any luncheon meat that was not consumed within five days of opening would be discarded no later than the sixth day. Packaging would be clearly marked with opening dated and use by date. 2. Observation on 06/04/24 from 8:21 A.M. to 8:29 A.M. of the running dish machine with Dietary Supervisor (DS) #458 revealed a plaque posted on the dish machine revealed a recommended sanitizing rinse temperature of 180 degrees F. Dishwashing racks full of dishes were being run through the machine, and there were two full racks of dishes sitting on the clean side of the dish machine. Observation of the dish machine at 8:21 A.M. with DS #458 revealed the temperature gauges on the dish machine indicated the sanitizing rinse temperature was 178 degrees F. Interview on 06/04/24 at 8:25 A.M. with Dietary Aide #400 stated he hadn't looked at the temperature gauges of the dish machine since he had been too busy running items through the dish machine. Observation of the dish machine at 8:25 A.M. with DS #458 revealed the temperature gauges on the dish machine indicated the sanitizing rinse temperature was 165 degrees F. Observation of the dish machine at 8:26 A.M. with DS #458 revealed the temperature gauges on the dish machine the sanitizing rinse temperature was 162 degrees F. Observation at 8:27 A.M. of Dietary Supervisor #458 using a TempRite dishwasher temperature test strip (another way to test the dish machine to ensure the temperature of the dish machine was reaching a sanitizing temperature) through the dish machine revealed the blue strip at the end of the test strip remained blue. Dietary Supervisor #458 confirmed at the time of observation there had been no change to the color strip at the end of the test strip. Review of the manufacturer's instructions printed on the bag where the TempRite dish washer temperature test strips were stored with Dietary Supervisor #458 revealed if the proper temperature for sanitation had been met, the blue strip at the end of the test strop would have changed to orange. Interview at 8:27 A.M. with Dietary Supervisor #458 confirmed the temperature of the rinse of the dish machine was not reaching the recommended sanitizing temperature of 180 degrees F was being met, and the TempRIte dish washer temperature test strip indicated sanitation was not being met. DS #458 stated dietary staff would stop using the dish machine until it could be fixed. Review of the facility policy Dishwashing, Machine Use, revised March 2010, revealed dishwashing machines that use hot water to sanitize may not be less than 180 degrees and no more than 194 degrees. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures would be reported to the supervisor and corrected immediately. If hot water temperatures do not meet requirements, the use of the dish machine would cease immediately until temperatures were adjusted. 3. Observation on 06/04/24 at 10:45 A.M. of Dietary Aide #458 washing the parts of the robo coupe (a type of commercial blender) in the three compartment sink revealed Dietary Aide #458 washed the blade of the unit in the first compartment with soapy water, rinsed it in the second compartment with clean water and then dipped the blade in the third compartment with the sanitizing solution and immediately lifted it out of the solution and shook the blade three times and then dipped the blade back into the sanitizing solution and immediately lifted the blade out of the solution and shook it three times and placed the blade on a drying rack. She then took the bowl of the unit and washed it in the first compartment with soapy water and rinsed it in the second compartment with clean water. Dietary Aide #458 then submerged the bowl into the sanitizing solution in the third compartment and rolled it around in the solution for approximately ten seconds and placed the bowl in the drying rack. Dietary Aide #458 then took the lid of the unit and washed it in the soapy water in the first compartment, rinsed the item in clean water in the second compartment, and then submerged the lid into the sanitizing solution in the third compartment and rolled the lid the solution for approximately 10 seconds and placed it in the drying rack. Observation of the chemical company's literature posted above the three-compartment sink revealed items should remain in the sanitizing solution for a minimum of 60 seconds. Interview on 06/04/24 at 10:46 A.M. with Dietary Aide #458 revealed when asked how long items need to stay in the sanitizing solution for the items to be considered sanitized, she replied I am not sure how long the items should stay in the sanitizer. Interview on 06/04/24 at 10:49 with Dietary Supervisor #496 revealed when asked how long items need to stay in the sanitizing solution for the items to be considered sanitized, she replied ten seconds. When reviewing the chemical company's literature posted above the three-compartment sink with Dietary Supervisor #496 at the time of interview, Dietary Supervisor #496 confirmed the roubo coupe parts hadn't stayed in the sanitizing solution for the required minimum of 60 seconds. 4. Observation on 06/04/24 from 11:56 A.M. to 12:33 P.M. of tray line revealed at 12:20 P.M. Dietary [NAME] #480 took his bare hand to remove from a rectangular silver storage container sitting on top of the cook top a baked potato. He then placed the potato on a plate and used his bare hand to hold the potato as he cut open the potato. At 12:24 P.M. Dietary [NAME] #480 Dietary [NAME] #480 took his bare hand to remove from a rectangular silver storage container sitting on top of the cook top a baked potato. He then placed the potato on a plate and used his bare hand to hold the potato as he cut open the potato. Interview on 06/04/24 at 12:32 P.M. with Dietary [NAME] #480 confirmed he had used his bare hands to cut open the baked potatoes. Interview on 06/04/24 at 12:34 P.M. with Corporate Chef #477 confirmed Dietary [NAME] #480 should have used a gloved hand to cut open the baked potatoes instead of using his bare hand.

Based on observation, interview, and review of facility menu and spread sheets, the facility failed to ensure the menu was followed and correct portion sizes were served for lunch on 06/04/24 for residents on a mechanical soft diet. This affected 13 residents (#3, #5, #14, #15, #24, #28, #52, #58, #68, #75, #84, #90, and #346) out of the 14 residents who the facility identified as being on a mechanical soft diet. This had the potential to affect 89 residents who received meals from the kitchen. The facility identified four residents (#6, #32, #35, and #395) as receiving nothing by mouth. The facility census was 93. Findings include: Review of the resident choice meal for lunch on 06/04/24 revealed pizza pasta casserole, Prince [NAME] vegetable medley, and lemon strawberry fluff dessert would be served. Review of spread sheets for the lunch meal on 06/04/24 revealed both the regular and the mechanical soft consistency diets would receive eight ounces of the pizza pasta casserole, 4 ounces of the Prince [NAME] vegetable medley, and a half a cup of lemon strawberry fluff dessert. The puree consistency diets would receive two number eight (four ounces) scoops, one number eight scoop of puree vegetables, and one number eight scoop for the puree lemon strawberry fluff. Observation of the tray line on 06/04/24 from 11:56 A.M. to 12:33 P.M. revealed Dietary [NAME] #480 was serving one green handled (three and one fourth ounce) scoop of carrots for the mechanical soft diets. Interview on 06/04/24 at 12:03 P.M. with Dietary [NAME] #480 confirmed he had been using a green handled scoop for the carrots, which he had been serving to the residents on a mechanical soft diet. Interview on 06/04/24 at 12:06 P.M. with Dietary Supervisor #496 confirmed the green handled scoop of vegetables for the mechanical soft diets fell short of the four-ounce portion per the spread sheet, and the mechanical soft diets should have received the same vegetable as the regular diets. After the interview, the mechanical soft diets began to receive four ounces of Prince [NAME] vegetables.

Based on observation, interview, and facility recipe, the facility failed to ensure food was served at an appetizing temperature and acceptable palatability. This had the potential to affect 89 residents who received meals in the facility. The facility identified four residents (#6, #32, #35, and #395) as receiving nothing by mouth. The facility census was 93. Findings include: Observation on 06/04/24 from 11:04 A.M. to 11:10 A.M. of Dietary [NAME] #480 taking the temperature of the food items on tray line revealed the pizza pasta casserole was 185 degrees Fahrenheit (F), Prince [NAME] Vegetables was 174 degrees F, the milk was 38 degrees F, and the lemon strawberry fluff dessert was 35 degrees F. Tray service for the dining rooms and hall trays began at 11:15 A.M. As the second to the last cart for 100 hall was finished being loaded, the surveyor requested at 12:20 P.M. a test tray be added at the end of the last cart for 200 hall. The test tray was plated at 12:31 P.M. and placed on the 200 hall cart. The cart was moved to the 200 hall and arrived at 12:34 P.M. After the last tray was passed to residents, the test tray was removed from the cart at 12:44 P.M. and was taken to a desk at the end of 200 hall next to exit door number four by Dietary Supervisor (DS) #496 along with Corporate Chef #477 and the surveyor. DS #496 checked the temperatures of the food using a facility thermometer as the surveyor tasted the food for temperature and palatability. The pizza pasta casserole was 143 degrees F, had a good flavor and tasted warm. The Prince [NAME] vegetable blend was 142 degrees F, had a good flavor, and tasted warm. The four-ounce carton of two percent milk was 63 degrees, tasted warm, and was unpalatable. The strawberry lemon fluff dessert was 61 degrees, tasted warm, and was unpalatable. DS #496 at 12:47 P.M. drank a sample of the milk and confirmed the milk was too warm and was not palatable. DS #496 then tasted the dessert and confirmed it was too warm since the dessert had cream cheese and whipped cream in it. Interview on 06/04/24 at 12:48 P.M. with Corporate Chef #477 stated at the point of service no cold item should be more than 50 degrees F and confirmed the milk at 63 was too warm and would be unpalatable and the dessert should have been below 50 degrees at the point of service. Review of facility recipe for lemon strawberry fluff dessert revealed the ingredients of the dessert were graham cracker crumbs, sugar, butter, gelatin, lemon juice, pureed strawberries, cream cheese and whipped topping.

Based on observation, resident and staff interviews, record review, and facility policy, the facility failed to ensure Resident #251's right to attend an activity program was honored. This affected one resident (#251) out of 28 residents reviewed for choices. The facility census was 93. Findings include: Review of Resident #251's medical record revealed an admitted [DATE]. Diagnoses included nondisplaced intertrochanteric fracture of left femur, difficulty in walking, unspecified fall, acute kidney failure with tubular necrosis (kidney tubules are damaged or destroyed), and type two diabetes without complications, muscle wasting and atrophy (reduced muscle mass) , essential hypertension (high blood pressure), and weakness. Review of Inspira- Activities Initial Review, dated 06/03/24, revealed Resident #251's past activity interests included reading, crocheting, crossword puzzles, solitaire, and bingo, and the resident wished to participate in activities while in the facility. Review of Resident #251's care plan dated 06/03/24 revealed the resident was a new admit to the facility and needed opportunities for recreational programs similar to those at home. Interventions included the resident will adjust to the facility, routine, and peers through participation in group activities of choice similar to home, assist and reassure resident as needed, discuss activity preferences and allow choices, and invite, and encourage and assist to group programs of resident's choice. Further review of Resident #251's medical record revealed a progress note, dated 06/03/24, timed 7:13 P.M., and authored by Licensed Practical Nurse (LPN) #483, revealed the resident was uncooperative with treatment that shift and was refusing to lay down each time LPN #483 asked to apply dressing. The resident then became angry when LPN #483 stated she could not go to the activity at 6:30 P.M. until the dressing change was completed. Interview on 06/04/24 at 11:36 with Resident #251 revealed the resident was upset since she couldn't go to bingo the previous day since the nurse was changing her bandages. Resident #251 stated bingo was one of her favorite activities. Observation of Resident #251 at the time of interview revealed the resident appeared visibly upset. Interview on 06/04/24 at 11:40 A.M. with Activities Staff #489 revealed Resident #251 had told the activity staff she had wanted to go to bingo on 06/03/24, but the resident ended up not attending the bingo activity since the nurse was changing her bandages. Interview on 06/04/24 at 4:24 P.M. with LPN#483 revealed Resident #251 had been noncompliant with having her dressings changed on 06/03/24. LPN #483 confirmed Resident #251 had wanted to go to bingo on 06/03/24 but LPN #483 told the resident she couldn't go to bingo until her dressing was changed. LPN #483 stated Resident #251 was upset about not being able to go to bingo, but LPN #483 didn't feel comfortable leaving the dressing change undone. Interview on 06/05/24 at 7:58 A.M. with Corporate Infection Control Preventionist #475 revealed LPN #483 should have educated Resident #251 of the importance of getting her treatments done, but Resident #251 does have the rights to refuse treatments and attend activities. Review of undated facility policy CHCC Companies Ohio Resident Rights & Facility Responsibilities revealed the residents have a right to have all reasonable requests responded to promptly and the right to participate in decisions that affect the resident's life.

Based on observation, medical record review, review of protocols, and interview, the facility failed to ensure interventions/orders were implemented to protect resident's skin from injuries. This affected one (Resident #50) of three residents reviewed for non-pressure skin related impairments. The facility census was 93. Findings include: Review of Resident #50's medical record revealed diagnoses including Alzheimer's disease, stage three chronic kidney disease, and protein-calorie malnutrition. Review of a care plan initiated 11/24/21 indicated Resident #50 had a potential for alteration in skin integrity related to decreased physical mobility. Skin was fragile, bruised and tore easily. Interventions included applying geri-sleeves to both upper extremities to be on at all times except for bathing and hygiene. Review of a skin and wound evaluation dated 05/31/24 revealed Resident #50 had a skin tear on the right outer forearm which was acquired in the facility on 05/24/24. The skin tear measured 6.1 centimeters (cm) in length and 4.3 cm in width. Review of a physician order dated 09/30/24 indicated geri-sleeves were to be applied at all times but may be removed for bathing and hygiene. Check skin integrity under sleeves every shift. Observation on 06/04/24 at 10:29 A.M., 12:52 P.M. and 1:10 P.M., revealed Resident #50 was observed without geri-sleeves on either arm. Observation on 06/04/24 between 1:10 P.M. and 1:25 P.M., revealed Registered Nurse (RN) #478 was observed changing the dressing to a skin tear on Resident #50's right arm. Once completed, RN #478 pulled the right sleeve down over part of the dressing. Approximately the bottom 1/3 of the forearms were uncovered (with the exception of the area covered by the dressing). Interview on 06/04/24 at 1:25 P.M., with RN #478 revealed he did not know why Resident #50 did not have the geri-sleeves applied. Interview on 06/04/24 at 1:37 P.M., with Licensed Practical Nurse (LPN) #483 stated nobody had reported Resident #50 refused to have the geri-sleeves applied. Review of the facility's State tested Nursing Assistant (STNA) protocol revealed instructions to apply geri-gloves as ordered (on at rise and off at bedtime).

Based on observation, medical record review, review of the facility's pain management protocol and staff interview, the facility failed to conduct a comprehensive pain assessment and provide interventions to prevent and/or alleviate pain for one resident (Resident #358). Actual Harm occurred for Resident #358 on 07/24/19 at 10:22 [NAME]M. when Resident #358 was grimacing, fidgeting, twisting his trunk around, yelling repeatedly this is terrible, and pulling on the hemi-tray on his wheelchair. This affected one (Resident #358) of one residents reviewed for pain. All 113 residents were screened for signs of unrelieved pain. Findings include: Review of Resident #358's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Skin and wound evaluations dated 07/13/19 indicated Resident #358 had unstageable pressure injuries (ulcers with obscured full-thickness skin and tissue loss) on the coccyx, left buttock and right buttock. The admission nursing assessment indicated Resident #358 had moderate pain in the lower back, hips and both arms which affected sleep, mood, socialization, activities of daily living and physical activity/mobility. The nurse documented not applicable for information regarding what non-pharmacological interventions alleviated the pain, what aggravated the pain and what medications and modalities had been effective in managing his pain. Resident #358's pain tolerance goal on a scale of 1-10 for comfort was a one. Resident #358 had a physician order [REDACTED]. On 07/16/19 an order was written for [MEDICATION NAME] 20 milligrams per milliliter (mg/ml), a narcotic pain medication: give 5 mg every three hours as needed for pain. On 07/17/19 an order was written to limit seating to three times a day no longer than 60-minute intervals. Review of Resident #358's (MONTH) 2019 Medication Administration Record [REDACTED].M., and [MEDICATION NAME] was administered 07/24/19 at 5:49 [NAME]M. On 07/24/19 at 8:34 [NAME]M., Resident #358 was propelled into his room in his wheelchair by therapy who updated his wife on Resident #358's progress and the difference wearing shoes made. Resident #358 had a left hemi-tray on his wheelchair. The therapist reported other than Resident #358 stating the gait belt was a little uncomfortable he denied pain. At 9:25 [NAME]M., Resident #358's wife continued to visit with Resident #358 sitting in the wheelchair while he ate breakfast. At 9:28 [NAME]M., Resident #358's wife informed Resident #358 she was leaving and would return that afternoon. Resident #358 was wearing tennis shoes on both feet and had [MEDICATION NAME] (a multi-purpose tubular bandage designed to provide tissue support in treating strains, sprains, soft tissue injuries, general [MEDICAL CONDITION], post-burn scarring, joint effusions and ribcage injuries) on both arms. A mechanical lift sling was under Resident #358. At 9:30 [NAME]M., Resident #358 was occasionally moaning out. When interviewed, Resident #358 stated he had pain all over, but he did not want pain medication at that time because he was not sure how much pain medication he had in his system and pain was part of the disease process. A prior request had been made to observe dressing changes to Resident #358's wounds. On 07/24/19 at 9:50 [NAME]M., Licensed Practical Nurse (LPN) #560 stated Resident #358 usually experienced a lot of pain with movement and she planned to wait until after Resident #358 was medicated for pain prior to changing his dressings. LPN #560 stated Resident #358 last received his pain medication at around 5:50 [NAME]M. On 07/24/19 at 10:11 [NAME]M., Resident #358 remained in his wheelchair in his room and continued to moan. At 10:22 [NAME]M., Resident #358 was sitting in his room in his wheelchair calling out repeatedly, This is terrible, this is terrible. and moving his trunk around. Resident #358 was grimacing and pulling at the hemi tray on his wheelchair. No staff were observed addressing the calling out and Resident #358 did not activate his call light. Resident #358 requested the surveyor tell someone he wanted something for pain. Registered Nurse (RN) #608 was observed sitting at the nursing station and was informed of Resident #358's request. RN #608 stated Resident #358's nurse was on break and should return at any time. At 10:26 [NAME]M., Resident #358 was moaning louder and was able to be heard five rooms down on the same side of the hall. Resident #358 was attempting to move the tray on the wheelchair so he could get out of the wheelchair independently. Resident #358 was encouraged to wait on staff for safety reasons. Resident #358 stated he would like to get his head down. Resident #358 stated he thought it would help if he could lie down. On 07/24/19 at 10:29 [NAME]M., LPN #520 arrived in Resident #358's room and asked Resident #358 if he was in pain. Resident #358 responded he was. When asked to rate the pain, Resident #358 responded about a 4 or 5 and described the pain as jagged. LPN #520 asked Resident #358 if he wanted a pain pill and he responded yes. After exiting Resident #358's room, LPN #520 stated she tried to get an increase in Resident #358's pain medicine on 07/23/19 but the doctor refused to increase the pain medication without the power of attorney's (POA) approval. The POA did not want Resident #358 to take the pain medication. LPN #520 was informed of Resident #358 stating he would like to lie down and of his behavior of attempting to get out of the wheelchair independently. LPN #520 walked down the hall and returned at 10:33 [NAME]M. and administered medication. LPN #520 offered to get someone to assist Resident #358 to bed. Resident #358 responded it was okay and that she did not need to bother anybody. At 10:39 [NAME]M., LPN #520 exited Resident #358's room and stated Resident #358 did not wish to go to bed. Safety concerns related to his behaviors were once again addressed with LPN #520 and she asked another staff member (unidentified) to find a nursing assistant and the mechanical lift. LPN #520 returned to Resident #358's room and told him staff were going to lay him down which he agreed to. LPN #520 monitored Resident #358 until other staff arrived in his room. Resident #358 was overheard moaning out and stating oh, this chair. On 07/24/19 at 10:45 [NAME]M., LPN #520 verified Resident #358 had a physician's orders [REDACTED]. LPN #520 stated Resident #358 usually received therapy for about a half hour. Sometimes therapy informed nurses when Resident #358 returned to his room and sometimes they did not. On 07/24/19 at 11:15 [NAME]M. Resident #358 was observed lying in bed with his eyes closed with no signs of distress. On 07/24/19 at 2:53 P.M., State tested Nursing Assistant (STNA) #626 stated she was not aware of any restriction to the time Resident #358 was permitted to be up in the chair. On 07/25/19 at 12:30 P.M., LPN #560 stated the order to limit Resident #358's time up in the chair for one hour three times a day was ordered due to wounds. On 07/25/19 at 4:00 P.M., RN #600 stated residents were assessed for pain during admission and then a minimum of every shift (twice a day) and with pain medication administration. RN #600 stated the doctor has refused to increase pain medication without Resident #358's wife's approval, and one time Resident #358's wife refused to have pain medication administered stating Resident #358 might just be bored. RN #600 verified the admission assessment was not comprehensive regarding alleviating or aggravating factors. At 4:35 P.M., RN #600 stated she interviewed Resident #358 about his pain and he reported rest and repositioning helped alleviate his pain and movement aggravated the pain. RN #600 stated Resident #358 told her the prescribed pain medication was effective in managing his pain. Review of the facility's pain management protocol indicated staff were to assess factors that may cause pain and administer [MEDICATION NAME] as prescribed to prevent severe pain from reoccurring and [MEDICATION NAME] prior to activities associated with discomfort such as therapy, consider around the clock basis for administration of [MEDICATION NAME] for continual pain as ordered by attending physician when necessary to meet resident's needs, provide individualized non-pharmacologic interventions such as, but not limited to, position change.

Based on record review, interview, observation, policy review, and manufacturer guidelines the facility failed to ensure Resident #94 was transferred properly and safely from the bed to the wheelchair. Harm occurred when Resident #94 fell from the mechanical lift device and sustained a right hip fracture. This affected one of three residents reviewed for falls. Findings include: Review of Resident #94's closed medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED].#94's most recent Minimum Data Set 3.0 ((MDS) dated [DATE] revealed Resident #94 was severely cognitively impaired. Review of the MDS revealed Resident #94 was totally dependent on two people physical assistance for transfers. Review of Resident #94's plan of care with a beginning date of 03/08/15 revealed Resident #94 had impaired physical mobility. The intervention for this problem was dated with a beginning date of 12/07/15 to transfer Resident #94 with a mechanical lift and two person assistance. Review of the fall risk assessment dated [DATE] revealed Resident #94 was at high risk for falls. Review of Resident #94's physician orders [REDACTED]. Review of Resident #94's nurse's note dated 06/09/16 at 4:50 P.M. revealed LPN #13 was notified at 4:30 P.M. by the STNA to come to Resident #94's room. The note indicated upon entering the room Resident #94 was observed lying on the floor on her right side under the Hoyer (a mechanical lift device) and between the Hoyer legs. The note indicated the STNAs stated Resident #94 slipped out of the Hoyer pad while they were transferring her form the bed to the chair. The note revealed the STNAs stated Resident #94 hit her head and the resident complained of right shoulder, right arm, left leg and right leg pain. Review of the fall investigation dated 06/09/16 at 4:30 P.M. revealed Resident #94 was sent to the emergency room for evaluation. The investigation revealed Resident #94 was admitted to the hospital with [REDACTED]. Review of the employee investigation statement dated 06/09/16 by STNA #15 revealed while in the middle of transporting Resident #94 with another staff member the resident slid out of the hoyer pad down to about her waist. The statement indicated the resident was being transferred from her bed to the wheelchair. The statement indicated after the resident had slid down she leaned forward falling completely out of the hoyer pad onto the floor. The statement indicated Resident #94 landed on her right side and face down between the hoyer legs. The statement indicated STNA #15 went to notify the nurse while STNA #12 stayed with the resident. Review of the employee investigation statement dated 06/09/16 by STNA #12 revealed during transferring Resident #94 with the Hoyer lift Resident #94 slipped out of the hoyer sling onto the floor landing on the right of her body and between the legs of the Hoyer lift. The statement revealed STNA #12 stayed with the resident while STNA #15 went to notify the nurse of the fall. Review of the Employee warning notice dated 06/09/16 at 4:30 P.M. revealed STNA #12 displayed poor technique using the Hoyer lift for transfer of the resident. The warning notice indicated the resident fell or slid out of the Hoyer sling resulting in the resident being injured and admitted to the hospital with [REDACTED]. Review of the Employee Warning Notice dated 06/09/16 at 4:30 P.M. revealed STNA #15 walked away from the Hoyer transfer to get a wheelchair. The notice revealed STNA #15 took her hands off the residents legs resulting in a resident fall. Review of Resident #94's X-ray results dated 06/09/16 at 6:23 P.M. revealed Resident #94 had X-rays of the pelvis and right hip. The X-ray was positive for a spiral fracture proximal diaphysis of the femur extending subtrochanteric/intratrochanteric. The X-ray indicated there was mild impaction, comminuting and override. Interview on 06/14/16 at 11:00 A.M. with STNA #12 revealed she was present and caring for Resident #94 when she fell from the Hoyer lift. STNA #12 stated she was operating the Hoyer and did not have her hands on Resident #94. STNA #12 stated Resident #94 was placed in the Hoyer pad appropriately for lifting. STNA #12 stated STNA #15 was holding Resident #94's legs. STNA #12 stated STNA #15 was responsible for guiding the resident to the chair. STNA #12 stated STNA #15 let go of Resident #94 and walked over to get the wheelchair. STNA #12 stated STNA #15 was not touching Resident #94. STNA #12 stated Resident #94 then slipped out of the hoyer pad onto the floor. STNA #12 stated STNA #15 then went to get LPN #13 who came in and assessed the resident. STNA #12 stated the resident complained her right arm hurt and she was sent to the hospital. Interview on 06/14/16 at 2:55 P.M. with the Director of Nursing revealed the wheelchair should of been there in place prior to transferring Resident #94 from the bed to the wheelchair. The DON indicated the resident was positioned in an upright position on the Hoyer inside the Hoyer pad. The DON revealed the loops were attached to the Hoyer machine and the Hoyer pad was placed in an acceptable position based on the way the resident was going to be seated. The DON stated Resident #94 being in the upright position and STNA #15 leaving the resident to get the wheelchair all contributed to the resident being able to slide out of the hoyer pad. The DON stated the facility's policy is to transfer residents with the Hoyer lift with two STNAs. The DON stated at least one STNA should have their hands on the resident at all times. Re-interview on 06/14/16 at 3:30 P.M. with STNA #12 revealed Resident #94 was facing away from the lifting column when she was moved away from the bed and that is the position she was in when she fell . STNA #12 indicated Resident #94's back was positioned toward the lifting column and her legs were facing out away from the Hoyer. Re-interview on 06/14/16 at 3:40 P.M. with the DON confirmed the manufactures guidelines indicated to face the resident toward the lifting column after lifting from the bed and prior to moving the lift away from the bed. Review of the lifting machine, using a portable policy revised April, 2007 revealed procedures including two nursing assistant will be required to perform the procedure. The procedure indicated steps for transferring a resident from a bed to a chair including to place the sling under the resident and be sure the top of the sling is at the head of the resident and the bottom at the residents knees. The procedure indicated when moving the lifter away from the bed be sure that the resident is turned in such a manner that she is facing you and do not pull the resident backwards. Review of the L1090 Bariatric patient lift user manual copyright date of 2013 revealed when lifting a patient from the bed procedures including to raise the patient until the buttocks are just above the mattress. Lift the patient's legs and turn the patient to face the lifting column. Move the patient lift away from the bed. When transferring the patient from a bed to a wheelchair the manual indicated for smooth, easy lifting, have the wheelchair in ready position with wheel locks in locked position This deficiency substantiates Complaint Number OH 948.