Every finding on record at Cardinal Woods Skilled Nursing & Rehab CTR

Based on record review, facility self-reported incident (SRI) review and investigation, interviews and facility policy review, the facility failed to protect Resident #96's right to be free from physical abuse by another resident. Actual harm occurred on 06/23/26 when Resident #96 sustained a fall after being struck by Resident #87 resulting in rib fractures requiring hospitalization and treatment for a pneumothorax (collapsed lung). Resident #96 remained hospitalized through 07/01/26 and then was discharged to a different facility at the request of his family. This affected one (Resident #96) of three residents reviewed for abuse. The facility census was 95. Findings include Review of the closed medical record for Resident #96 revealed an admission date of 12/03/22 with diagnoses including dementia without behavior disturbance, osteoarthritis, hypertension, age related cataract, lack of coordination, and repeated falls.Review of Resident #96's Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed the resident had highly impaired hearing and sometimes understood others. Resident #96's cognition was severely impaired. Hallucination and delusions were present with no physical or verbal behaviors towards others exhibited. The assessment revealed Resident #96 required maximum assistance for bathing, and was independent for transfers from bed to chair, independent with sit to stand and independent to walk at least 150 feet once standing.Review of the plan of care dated 05/27/26 revealed Resident #96 had a communication problem related to hearing deficit. Interventions included anticipated needs, face resident when speaking so Resident #96 could see lips and use dry erase board to write messages or hand gestures.Review of a nurse's note for Resident #96 dated 06/23/26 at 3:09 P.M. authored by the Director of Nursing (DON) revealed a staff nurse was alerted to a problem that required help. The nurse witnessed another resident (Resident #87) swinging at Resident #96. Facility staff and residents guided the other resident away from Resident #96. Resident #96 stumbled backwards into a side table. Resident #96 was unable to verbalize incident details due to impaired cognition and communication difficulties. The note included there were no apparent injuries on Resident #96. Resident #96 was assisted back to his room.Further review of the medical record for Resident #96 revealed a progress note dated 06/25/26 at 3:29 P.M. written by Nurse Practitioner (NP) #592 that stated an acute change in mental status was reported by nursing today. New non-verbal pain behaviors and high pain score. On 06/25/26 nursing notes document increased pain (moaning, grimacing with movement and guarding). Review of systems shows decreased range of motion, and weakness. Assessment and Plan included altered mental status, address pain as a contributor to mental status change, continue scheduled Aleve 220 milligrams daily, monitor response and consider alternative or additional analgesia if pain persists. Monitor for worsening symptoms of acute illness.Review of physician orders dated 06/25/26 revealed Resident #96 had an order for x-ray to right lumber and thoracic spine, also right ribs for complaint of pain with decreased motion.Review of the Radiology Results Report, reported date 06/26/26 at 9:48 A.M., revealed Resident #96 had acute right fifth through ninth rib fractures. Up to two millimeters (MM) outward displacement distal fragments. No additional acute posterior seventh rib fracture with two MM downward displacement distal fragment. Lucency right CP (costophrenic) angle. Impression: Right pneumothorax (collapsed lung which can be caused by rib fractures) and rib fractures as stated.Review of a progress note dated 06/26/26 at 11:33 A.M. written by NP #593, revealed Resident #96's x-ray revealed rib fracture with two-millimeter displacement. Plan was to monitor vital signs every shift for three days. Schedule Tylenol 500 milligrams two tablets every eight hours for three days and send prescription Tramadol (narcotic pain medication) 50 mg every eight hours for three days.Review of the hospital records dated 06/27/26 at 6:54 P.M. revealed Resident #96 presented to the Emergency Department for altered mental status. Computed Tomography (CT) revealed large right-side pneumothorax with mild leftward shift of the midsternal contents concerning for tension pneumothorax. Small right pleural effusion with significant lung collapse of the right lung. Acute fracture of lateral right sixth rib, segmental fracture of the seventh, eight, and nineth ribs. No acute findings in the abdomen and pelvis. No intracranial hemorrhage. Resident #96 was diagnosed with tension pneumothorax (collapsed lung with tension) and altered mental status. High probability related to a fall. Resident #96 upon exam was difficult to arouse, in no apparent distress, and had a chest tube placed under moderate sedation due to the pneumothorax and some pleural effusion (fluid in the chest cavity). Pain medications and ceftriaxone and Zithromax antibiotics were given for pneumonia. The resident was discharged on 07/01/26 to another nursing facility.An interview on 07/08/26 with Resident #96's family member, (FM #586) revealed the family had Resident #96 transferred to another facility after Resident #96 was discharged from the hospital.An interview on 07/09/26 at 7:04 A.M. with Resident #96's Power of Attorney (POA) revealed the facility stated the resident who hit her husband was removed from the facility. When the family visited Resident #96 on 06/27/26 they observed Resident #96 to be lethargic so they requested Resident #96 to be sent to the hospital where he was treated for a punctured lung and broken ribs. The POA stated the Administrator told her Resident #96 was punched by Resident #87. Review of Resident #87's medical record revealed an admission date of 05/28/26 with diagnoses including dementia with behavioral disturbance, schizoaffective disorder, Parkinsonism, vascular dementia, major depressive disorder, insomnia, dementia in other disease classified elsewhere unspecified severity with other behavioral disturbance, mild neurocognitive disorder due to unknown psychological condition with behavioral disturbance, generalized anxiety disorder, and schizophrenia. Resident #87 resided on the secured unit due to wandering behaviors.Further review of the medical record for Resident #87 revealed admission documents to include a document titled Via [NAME] Psychiatric Note dated 04/23/26 from Resident #87's prior facility indicating Resident #87 had a history of behavior disturbance. Resident #87 had intermittent episodes of behavior disturbance such as agitation, verbal aggression and physical aggression towards staff that required emergency evaluation. The assessment and plan were for close interdisciplinary monitoring, behavior tracking for changes and agitation, and staff redirection strategies to maintain safety.Review of additional admission documents for Resident #87 included a care plan from the prior facility dated 12/31/25 indicating Resident #87 had a behavior problem of hitting other residents and refusing medications. Interventions included anticipating and meeting resident needs, educating the resident, explain procedures, and praise progress.Review of the comprehensive care plan for Resident #87, date revised 06/05/26 revealed Resident #87 had potential to demonstrate physically aggressive behaviors related to dementia, history of hitting other residents and taking other personal belongings. The goal was to not harm self or others. Interventions included analyzing key times, places, circumstances, triggers and what de-escalation behavior to document. Assess and address for contributing sensory deficits. Assess and anticipate resident needs. Provide physical and verbal cues to alleviate anxiety. Monitor and report to physicians of danger to self and others. Psych consult as indicated. When Resident #87 becomes agitated intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, staff to walk away and approach later if response was aggressive.Review of a nurse's note for Resident #87 dated 06/23/26 at 2:48 P.M. authored by the DON revealed a staff nurse was alerted to a problem that required help by an uninvolved resident. The nurse witnessed Resident #87 hitting staff and peers. Resident #87 began to approach others to continue aggression, the nurse intervened again. Resident #87 kept swearing and stated get these people out of my house. Resident #87 continued to escalate and tried to hit staff. Resident #87 was walked back to his room. NP #594 was notified who ordered a onetime dose of Olanzapine (Zyprexa) intramuscular (IM) that was administered. Staff stayed with Resident #87 for twenty minutes until resident was calm.Review of a facility Self-Reported Incident (SRI) dated 06/23/26 revealed staff reported residents on the locked unit getting into an altercation. Staff reported Resident #87 told Resident #96 not to look at him. Resident #96 looked at him so Resident #87 hit Resident #96. A nurse aide intervened and she was hit and her hair was pulled. Resident #86 pulled Resident #87 off the aide.Review of a staff witness statement dated 06/23/26 written by Unit Manager #568, revealed CNA #549 stated she was working at the time of the incident and Resident #87 pushed Resident #96 then came after her and pulled her hair.An interview on 07/09/26 at 12:46 P.M. with CNA #575 revealed she witnessed Resident #87 on top of Resident #96 and with Resident #87's hands swinging at Resident #96. CNA #575 stated Resident #96 was on the floor on his buttocks and LPN #565 had to remove him out of the dining room.An interview on 07/09/26 at 12:50 P.M. with LPN #565 revealed he was the nurse on the secured unit the day of the incident between Resident #87 and #96. LPN #565 stated the day of the incident he did not directly witness Resident #96 getting hit by Resident #87 but witnessed that Resident #87 needed to be held back to calm down because Resident #87 was dangerous. LPN #565 stated no bruising was assessed on Resident #96 during the head-to-toe assessment, but a bruise appeared a few days later. LPN #565 stated he observed Resident #96 at baseline but he was not as talkative or interactive with others after the incident.An interview on 07/09/26 at 1:00 P.M. with Resident #77 revealed Resident #87 always walked the hallway on the secured unit. Resident #77 stated (on 06/23/26) she observed Resident #96 holding his arms to his face to try to block Resident #87's punches. Resident #77 stated she was scared and yelled for help. Resident #77 stated she observed Resident #96 fall from his chair in the dining room onto the floor. Resident #77 stated it looked like he got pushed. An interview on 07/09/26 at 2:00 P.M. with CNA #549 revealed she was by the dining room the day of the incident involving Resident #96 and #87 when she heard commotion. CNA #549 stated she observed Resident #96 on the floor and Resident #87 standing by him because he knocked him down. CNA #549 stated Resident #96 landed on the floor after hitting the table and chair by him. CNA #549 stated when I went to check on [Resident #96], [Resident #87] came toward me to hit me. Another resident had to pull him off me and staff had to help me. CNA #549 stated Resident #87 tried to attack LPN #565 after the incident. CNA #549 stated Resident #87 was known to walk the hallways but she denied knowledge of him harming any other resident(s) before this incident. An interview on 07/09/26 at 3:00 P.M. with Resident #37 revealed (on 06/23/26) he observed Resident #87 walk in the dining room and Resident #96 was sitting in a chair by the dining room table. Resident #37 stated he saw Resident #87 take his fist to Resident #96. Resident #37 stated he did not know why Resident #87 acted like that. Resident #37 stated he then saw Resident #96 fall to the floor onto his back after getting hit by Resident #87.An interview on 07/10/26 at 2:03 P.M. with the DON revealed she heard there was a problem on the Memory Care Unit on 06/23/26 and observed Resident #87 to be agitated. The DON stated after the incident Resident #96's wife requested to have his room changed. Resident #87 was sent to a behavioral health hospital when the facility learned Resident #96 suffered an injury of rib fractures.An interview on 07/10/26 at 3:30 P.M. with the Administrator verified (on 06/23/26) Resident #87 hit Resident #96 and Resident #96 had been hospitalized with rib fractures and treated for pneumothorax.An interview on 07/15/26 at 12:45 P.M. with CNA #567 revealed (on 06/23/26) she observed Resident #87 attacking an aide and observed Resident #96 on the floor. CNA #567 stated Resident #96 looked like he was hit and looked scared, and Resident #87 continued to swing punches at staff and grabbed an aide's hair and tried to punch the aide after Resident #96 was knocked down. Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021, revealed residents had the right to be free from abuse this included freedom from physical abuse. Abuse was defined as willful infliction of injury and intimidation resulting in physical harm, or pain. Willful as used in the definition of abuse was defined as the individual must act deliberately (not an accident or involuntary movement), not that the individual must have intended to inflict injury or harm. The facility management and staff would initiate measures to address the needs of residents and minimize the possibility of abuse. The facility objective was to protect residents from abuse from other residents.This deficiency represents non-compliance investigated under Complaint Number 3072031, 3074721 and 3045955.

Based on record review, review of the facility self-reported incident investigation, interviews and review of facility policy, the facility failed to conduct a complete and thorough investigation for an allegation of resident-to resident physical abuse. This affected one (Resident #96) of three residents reviewed for abuse. The facility census was 95.Findings include:Review of the facility Self-Reported Incident (SRI) reported to the Ohio Department of Health by the Administrator on 06/23/26 at 12:29 P.M. and completed on 06/29/26 at 12:49 P.M. revealed Resident #87 was identified as the alleged perpetrator, Resident #87, #96 and #86 were identified as resident/victims and there were no witnesses identified. An allegation of physical abuse was sourced by staff when staff reported residents on the locked dementia unit were getting into an altercation. Staff reported Resident #87 told Resident #96 not to look at him. Resident #96 looked at him so Resident #87 hit Resident #96. A nurse aid intervened and she was hit and her hair was pulled. Resident #86 pulled Resident #87 off the aid. The facility separated the residents, placed the residents on 15-minute checks, and head-to-toe assessments were completed with no significant findings. The parties responsible were notified and no new orders were given. Staff and resident interviews were obtained. Skin, psychological and trauma assessments were completed with no negative findings. Abuse education was sent to staff. The facility unsubstantiated the allegation of physical abuse.Review of the facility SRI investigation provided by the Administrator revealed there were resident witness statements dated 06/23/26 in the investigation from Resident #44 and Resident #6. Both statements were written and signed by the Administrator. Resident # 44's statement revealed the incident happened in the dining room and the description of what happened stated they were fighting. Resident #6's statement revealed he was in his room and did not know what occurred.An interview on 07/09/26 at 12:50 P.M. with Licensed Practical Nurse (LPN) #565 revealed he was the nurse on the secured unit the day of the incident between Resident #87 and #96. LPN #565 stated the day of the incident he did not directly witness Resident #96 getting hit by Resident #87 but witnessed that Resident #87 needed to be held back to calm down because Resident #87 was dangerous. LPN #565 stated that Resident #37 was in the dining room when the incident happened and confirmed the resident was able to be interviewed. Review of the medical record for Resident #37 revealed an admission date of 10/30/24. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score (a score intended to determine the resident's attention, orientation, and ability to register and recall new information) of 11 indicating moderate cognitive impairment. The BIMS indicated the resident could remember the correct day, the correct year, and repeat three words after the first attempt.An interview on 07/09/26 at 3:00 P.M. with Resident #37 revealed he observed Resident #87 walking in the dining room and Resident #96 was sitting in a chair by the dining room table. Resident #37 stated he saw Resident #87 take his fist to Resident #96. Resident #37 stated he did not know why Resident #87 acted like that. Resident #37 stated he then saw Resident #96 fall to the floor onto his back after getting hit by Resident #87.An interview on 07/16/26 at 12:33 P.M. with the Administrator verified Resident #86 was interviewed for the facility SRI because Resident #86 pulled Resident #87 off the aid. The Administrator also verified Resident #44 and Resident #6 were the only other resident witness statements obtained for the investigation because of their Brief Interview for Mental Status (BIMS) score. The Administrator stated he only interviews residents with a BIMS of 13 or higher and all other residents had a skin check done.Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation, Reporting and Investigating, date revised 04/2021, revealed all allegations of abuse are thoroughly investigated by facility management. The administrator initiates the investigation, and the individual conducting the investigation at a minimum interview any witnesses to the incident and documents the investigation completely and thoroughly. Witness statements are obtained in writing, signed and dated. The witness may write his/her statement, or the investigator may obtain a statement.This deficiency represents non-compliance investigated under Complaint Number 3072031, 3074721 and 3045955.

Based on medical record review, observations, interviews, and policy review, the facility failed to implement a comprehensive, individualized, and effective nutrition program to prevent and address significant resident weight loss. Actual harm occurred on 03/20/26 when the facility identified Resident #75 experienced an unplanned significant weight loss of 22.6 percent (%) in approximately one month, and failed to implement appropriate interventions, provide continued monitoring of the resident's weight, or notify the physician of concerns. Subsequently, Resident #75 experienced a second unplanned weight loss of 6.82% approximately two months later. In total, Resident #75 experienced a significant weight loss of 27.8% in approximately three months. This affected one (#75) of three residents reviewed for nutrition. The facility census was 89.Findings include:Review of medical record revealed Resident #75 was admitted to the facility on [DATE]. Medical diagnoses included major depressive disorder, lymphedema, peripheral vascular disease, unspecified psychosis, bipolar disorder, morbid obesity, heart failure, dysphagia, dysfunction of bladder, anxiety disorder, and schizophrenia. Review of Resident #75's advanced directives dated 09/26/16, revealed the resident was documented as having a full code status (to receive all possibly life-saving measures in the event of a cardiac or respiratory arrest). Review of Resident #75's plan of care, revised 03/26/26, revealed the resident had the potential for altered nutrition and hydration due to heart failure with the need for diuretics, bipolar disorder, anxiety, lymphedema, edema, morbid obesity, nausea and vomiting, history of weight and laboratory (lab) refusals. Interventions included to elevate the head of bed when eating or drinking to reduce risk of aspiration, monitor for signs of edema, monitor/document and report to the physician refusals to eat, obtain weight per orders, encourage resident to be weighed, record meal intake every meal, and staff to assist with tray set up and provide further assistance as needed. Further review revealed no new interventions to address significant weight loss or decline in food intake. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #75 had a Brief Interview of Mental Status (BIMS) score of five, indicating severe cognitive impairment. Resident #75 required staff assistance with eating and the resident did not receive hospice services. Review of Resident #75's physician's order dated 04/20/21 revealed an order was initiated for a Hoyer lift for transfers with two staff members. An order dated 05/15/22 revealed Resident #75 was on a regular diet, regular texture and thin liquid consistency. Further review revealed an order dated 03/01/26 for monthly weights. Review of Resident #75's weights, located in the electronic medical record (EMR), revealed the resident weighed 278.9 pounds (lbs.) on 01/05/25. Further review revealed no evidence a weight was obtained again until 02/09/26, when the resident weighed 288.0 lbs. On 03/20/26, Resident #75 weighed 223.0 lbs., indicating a 22.6% weight loss in approximately one month. No additional weights were obtained until 05/25/26, when Resident #75 weighed 207.8 lbs., for an additional 6.82% weight loss and a total of 27.85% weight loss in approximately three months. Review of the Nursing and Dietary progress notes revealed Resident #75 refused food and weights on 01/12/26, 02/04/26, 04/07/26, 04/10/26, 04/13/26, 04/14/26 and 05/12/26.Review of the Dietary Note dated 04/02/26 at 3:10 P.M., authored by Registered Dietitian (RD) #604, revealed Resident #75 had a significant weight loss of 22% in one month. Meal intakes averaged less than 25%, providing about 531 calories and 21 grams of protein. Estimated needs were 1815 calories, 68 grams of protein and 1815 milliliters (ml) of fluids. Resident #75 was not meeting the estimated energy needs as evidenced by meal intake records, she was bedbound. RD #604 recommended a reweigh to ensure accurate weight. Resident #75 had nausea and vomiting and needed Zofran (anti-nausea medication). RD #604's intervention was to add Ensure Clear (dietary supplement) three times a day. Further review revealed no documented evidence RD #604 completed an in-person assessment of Resident #75 following the significant weight loss or recommended any further interventions. Review of Resident #75's physician order dated 04/02/26 revealed an order for Ensure Clear three times a day. Review of the meal intake documentation from 05/08/26 to 05/21/26 revealed, on average, Resident #75 consumed less than 50% of her meals. The facility failed to document meal intakes on 05/14/26 and 05/15/26.Review of the Dietary Note dated 05/26/26 at 1:10 P.M., authored by RD #604, revealed Resident #75's comparison weight was 223.0 pounds on 03/20/26 that revealed a 15.2 lbs., or 6.8%, weight loss and a 10% weight change with the comparison weight on 02/09/26 of 288.0 pounds, resulting in a 27.8% weight loss, or 80.2 lbs. weight loss. Two to three plus edema was documented. Resident #75 triggered for a significant weight loss, and the last weight was taken over a year prior. Resident #75 was not meeting sufficient energy needs as evidenced by meal intake records.Further review of Resident #75's medical record revealed no monitoring, reassessment, or new interventions were implemented regarding Resident #75's significant weight loss from 04/02/26, when RD #604 recommended Ensure Clear three times daily, until surveyor intervention on 05/27/26 at 7:32 A.M. The facility then approached Resident #75's legal guardian regarding alternative nutrition versus comfort care (Hospice services). Observation on 05/21/26 at 11:06 A.M. revealed Resident #75 was sleeping in bed with a breakfast tray that consisted of an untouched omelet, two sausage links, a full bowl of oatmeal and a full cup of Ensure Clear. Concurrent interview with Resident #75 revealed she did not eat breakfast because she did not wake up but was ready to eat if the staff assisted her. Interview on 05/21/26 at 11:09 A.M. with Certified Nursing Assistant (CNA) #262 revealed she delivered Resident #75's breakfast tray around 9:00 A.M., but the resident did not wake up to eat. CNA #262 stated Resident #75 only ate when she wanted to, and staff honored the resident's preference to sleep and did not wake her for meals. Observations on 05/21/26 at 12:23 P.M., 1:22 P.M., and 2:00 P.M. revealed Resident #75 had a full tray of food that consisted of a hot dog, peas, mashed potatoes, and juice. None of the food or beverages were consumed. Resident #75 was asleep in bed. No staff were observed to encourage the resident to eat or provide the resident with assistance.Interview on 05/21/26 at 11:12 A.M. with Registered Nurse (RN) #240 revealed Resident #75 was not consistently weighed because she was terrified of the mechanical lift.Interview on 05/21/26 at 11:15 A.M. with Director of Therapy (DOT) #304 revealed residents were reviewed during quarterly reviews but if the facility wished to have therapy see a particular resident, especially if there was a significant change, they could fill out a Therapy Referral Communication Sheet to notify the therapy department of a change in a resident's functional status to determine if therapy services could be beneficial. DOT #304 stated the facility did not request any evaluations outside of quarterly reviews for Resident #75 to potentially address Hoyer lift transfers or eating assistance. Interview on 05/21/26 at 12:15 P.M. with RD #604 revealed she tried to visit the facility once a week and was aware Resident #75 had a significant weight loss and had refused to be weighed in over a year. RD #604 stated she last assessed Resident #75 on 04/02/26 and had not visited the resident since or provided additional documentation/recommendations regarding the significant weight loss. RD #604 verified no physical assessment was completed to rule out malnutrition despite Resident #75 refusing weights and experiencing significant weight loss. A follow-up interview on 05/21/26 at 12:24 P.M. with RN #240 revealed Resident #75 refused to be weighed on a mechanical lift but a bed scale could be used if a resident was fearful of a mechanical lift scale. RN #240 stated she was not concerned about Resident #75 refusing weights or experiencing a significant weight loss.Interview on 05/21/26 at 12:34 P.M. with the Director of Nursing (DON) revealed Resident #75 refused to be weighed and the facility did not have a bed scale available to monitor Resident #75's weights, even though the resident was fearful of the mechanical lift transfer. The DON confirmed Resident #75 had not been weighed for monitoring for over one year (from 01/05/25 to 02/09/26) or after a significant weight loss had been identified on 03/20/26. The DON confirmed therapy was not consulted for possible interventions after the facility discovered Resident #75 experienced a significant weight loss. Interview on 05/26/26 at 10:00 A.M. with Resident #75's friend revealed he was concerned with the resident's food intake because he observed her meal tray sitting in front of her while she lay sleeping during his visits. He stated Resident #75 did not usually sleep this much and she used to eat good.Interview on 05/26/26 at 11:49 A.M. with CNA #262 revealed Resident #75 was terrified of the mechanical lift and refused to get weighed almost every week. CNA #262 stated, We usually skip her weight and mark refused because we do not have another way to weigh her. CNA #262 stated Resident #75 would not wake up to eat therefore her tray was left in the room if she was to wake up. Interview on 05/26/26 at 11:50 A.M. with CNA #256 revealed Resident #75 would not eat because she slept a lot. CNA #256 verified Resident #75 did not eat her eggs or pancakes on her breakfast tray this morning.Interview on 05/26/26 at 2:27 P.M. with Resident #75's legal guardian's paralegal, who attended the resident's care conferences, revealed the resident's significant weight loss was concerning, but the facility did not indicate they were concerned about it. Interview on 05/26/26 at 3:00 P.M. with Nurse Practitioner (NP) #605 revealed she assisted in the care of Resident #75. NP #605 stated she was aware the facility attempted to weigh Resident #75 using a mechanical lift, but the resident refused. NP #605 stated the facility did not notify her of the additional 15.2 lb. weight loss on 05/25/26 and confirmed no new orders were written to address Resident #75's refusals to monitor her weight. NP #605 stated she was unaware of the extended amount of time the facility had not obtained a weight on Resident #75. Interview on 05/26/26 at 3:05 P.M. with NP #606 revealed she usually cared for Resident #75 and was not notified of the additional 15.2 lb. weight loss on 05/25/26. NP #606 stated Resident #75 was at risk for weight loss because of not getting out of bed and had poor food intakes. NP #606 verified she was not reconsulted by the facility regarding the resident's refusals to be weighed and poor food intakes. While the resident had recent concerns for nausea, vomiting, and a urinary tract infection (UTI), which she was being treated for, NP #606 confirmed Resident #75 had no signs that the significant weight loss was unavoidable. A follow-up interview on 05/26/26 at 2:27 P.M. with RD #604 confirmed she was aware of Resident #75's significant weight loss and stated she was aware the resident refused weights due to the mechanical lift. RD #604 stated she was aware of Resident #75's nutrition risk factors that contributed to the resident's decline in food intake, which included her loss of appetite related to recent nausea and vomiting and depression. RD #604 confirmed that the resident's decline in food intake was a change in condition. RD #604 stated the last time she spoke with or observed Resident #75 was during the annual assessment in April 2026 and she could not remember what Resident #75 stated to her during the assessment. RD #604 verified she did not notify the physician of Resident #75's significant weight loss or decline in food intake. RD #604 stated the expectation was that if a resident had a significant weight loss with poor food intake and they were unsure if the weight was faulty, the facility would obtain weekly weights. While RD #604 stated Resident #75 was obese, the goal would have been for the resident to maintain a stable weight with no unplanned significant weight loss. RD #604 also stated she was aware Resident #75 refused weights for over a year and no interventions were implemented to prevent a significant weight loss.A follow-up interview on 05/26/26 at 3:20 P.M. with the DON verified Resident #75 experienced a significant weight loss and the facility did not pursue alternative methods for monitoring the resident's weights or initiate referrals to providers to potentially address the resident's fear of mechanical lift transfers or decreased food intakes. The DON further confirmed the facility did not implement updated interventions or proactively address Resident #75's weight refusals and poor food intakes until the resident was identified with an additional weight loss of 15.2 lbs. on 05/25/26. The DON stated it was the expectation of the facility to notify the physician if a resident refused three consecutive meals and documentation in the progress notes suggested the NP was notified, even though NP #605 and NP #606 both denied having knowledge. The DON verified Resident #75 experienced significant weight loss, and no interventions or monitoring were implemented to prevent further weight loss. The DON stated the resident lost weight due to a lack of appetite and stated the resident did not like the mechanical lift. Interview on 05/27/26 at 8:30 A.M. with the Administrator revealed Resident #75 had been bedbound for eight years because she was fearful of the mechanical lift. The Administrator stated the facility could have provided a bed scale, but they would have needed to slightly lift Resident #75 off the bed to zero out the scale, therefore the facility did not pursue an alternative method to obtain weights for Resident #75.Review of facility document titled, Therapy Referral Communication Form, undated, revealed staff could request an evaluation and screen by therapy for a resident who seemed to be experiencing a functional situation change. Areas for evaluation on the document included weight loss and eating/swallowing concerns. Review of facility policy titled, Weight Assessment and Intervention, revised March 2022, revealed weights were recorded in each unit's weight record chart and in the individual medical record. The threshold for significant unplanned weight change was based on the following criteria: greater than 5% in one month and greater than 10% in six months. The individualized care plan would address the cause of weight loss, goals and benchmarks for improvement with timeframes and parameters for monitoring and reassessment.

Based on observation, staff interview, review of maintenance records and review of facility policy, the facility failed to ensure foods were stored and served at appropriate temperatures to prevent foodborne illnesses. Additionally, the facility failed to ensure kitchen equipment was maintained in a clean and sanitary manner. This had the potential to affect all 89 residents in the facility who were identified to receive food from the kitchen. The facility census was 89.Findings include:1. Observation on 05/18/26 at 8:30 A.M. revealed the temperature in the facility's walk-in refrigerator was 49 degrees Fahrenheit (F). Concurrent interview with Food Service Manager (FSM) #601 verified the walk-in refrigerator temperature.Observation on 05/19/26 at 10:50 A.M. revealed the temperature in the facility's walk-in refrigerator was 49 degrees F. Concurrent interview with FSM #601 verified the walk-in refrigerator temperature.Review of facility policy titled, Food Storage, undated, revealed the food storage temperature for the refrigerator was between 37 degrees F to 40 degrees F.2. Observation on 05/20/26 at 1:21 P.M. with FSM #601of a lunch meal test tray revealed the meal was the last tray removed from the cart. Further observation of the food items, tested with a facility calibrated thermometer, revealed the hot foods maintained a safe temperature. However, the milk temperature was 48 degrees F. Concurrent interview with FSM #601 verified the temperature of the milk. FSM #601 stated dietary staff sent milk to the units around 11:30 A.M. on a beverage cart, before the lunch meal trays arrived. Review of facility policy titled, Food Safety and Sanitation, undated, revealed refrigerated food was to be stored at or below 41 degrees F.3. Observation on 05/18/26 at 8:37 A.M. of the kitchen ice machine revealed cracked plastic and a frayed seal on the ice machine door. The filter was observed to be full of dust, and the output vents had a coating of dust. Concurrent interview with FSM #601 verified the filter was dusty and the output fan had excess dust and stated the filter needed cleaned through the dish machine. Interview on 05/20/26 at 3:10 P.M. with Maintenance Supervisor (MS) #700 revealed it was maintenance's responsibility to clean the top part of the ice machine, such as the fan and filter, every six months.Review of facility document titled, Machine Activity Log, revealed the last documented ice machine cleaning was on 09/10/25, when the ice machine was sanitized and the descaling cycle was run. The facility performed a sanitization and descaling on 05/26/26, during the annual survey.This deficiency represents non-compliance investigated under Complaint Number 2710514.

Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure comprehensive care plans were developed and updated to address resident care needs. This affected one (#75) of three residents reviewed for care planning. The facility census was 89. Findings include:Review of Resident #75's medical record revealed an admission date of 09/26/16. Diagnoses included major depressive disorder, lymphedema, peripheral vascular disease, psychosis, bipolar, morbid obesity, heart failure, atrial fibrillation, hyperlipidemia, anxiety disorder, essential primary hypertension and schizophrenia.Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/01/26, revealed Resident #75 was severely cognitively impaired. Review of a physician order dated 04/20/21 revealed an order was initiated for Hoyer lift for transfers with two staff members. Further review of an order dated 03/01/26 revealed Resident #75 was to have monthly weights every day shift starting on the first and ending on the sixth of every month.Review of the Medication Administration Record (MAR) for March 2026 revealed Resident #75 was ordered Lasix (furosemide) 40 milligrams (mg) by mouth two times daily every other day related to morbid obesity. The medication had a start date of 02/27/24 and a discontinued date of 03/25/26. Review of Resident #75's weights, located in the electronic medical record (EMR), revealed the facility obtained a weight on 01/05/25. Further review revealed no evidence a weight was obtained again until 02/09/26.Review of the nursing and dietary progress notes revealed Resident #75 refused weights on 01/12/26, 02/04/26, 04/10/26, 04/07/26, 04/10/26, 04/13/26, 04/14/26 and 05/12/26.Review of the current care plan, initiated 09/22/17, revealed an absence of a care area, goal, or interventions regarding Resident #75's diagnosis of (congestive) heart failure (CHF) or the administration of the diuretic medication Lasix under the focused area of cardiovascular status. The care plan lacked instructions for staff to monitor clinical indicators for CHF complications or the clinical risks related to the resident's refusals of weights. Interview on 05/21/26 at 11:12 A.M. with Registered Nurse (RN) #240 revealed Resident #75 was not consistently weighed because she was terrified of the mechanical lift.Interview on 05/26/26 at 11:49 A.M. with CNA #262 revealed Resident #75 was terrified of the mechanical lift and refused to get weighed almost every week. Additional review of the current care plan revealed the Interdisciplinary Team (IDT) did not update or develop a care plan to address Resident #75's refusals of weights by a mechanical lift, no documented strategies, education efforts, or alternative methods to accommodate the resident's weight refusals due to the resident's fear of using a mechanical lift.Interview on 05/21/26 at 3:30 P.M. with MDS Coordinator (MDSC) #244 confirmed Resident #75 had a diagnosis of CHF and had received Lasix therapy but the care plan was not updated to address the resident's care needs. MDSC #244 also verified the care plan was not updated to address Resident #75's refusals of weights, due to fears of using a mechanical lift, to monitor her nutritional status. Interview on 05/21/26 at 4:10 P.M. with the Director of Nursing (DON) revealed Resident #75 had the right to refuse weights, so nursing staff would document the refusals in the progress notes. The DON verified a specific care plan was not created for the refusal to use the mechanical lift for weight status because the facility felt it was the resident's right to refuse. Review of facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was implemented and developed for each resident. The care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Interventions would address the underlying source of the problem, not just the symptoms or triggers.

Based on closed medical record review, staff interview and review of facility policy, the facility failed to ensure fall interventions were implemented. This affected one (#98) of four residents reviewed for falls. The facility census was 89.Findings include:Review of the closed medical record for Resident #98 revealed an admission date of 09/02/25. Diagnoses included senile degeneration of the brain, repeated falls, and unspecified dementia. Resident #98 discharged from the facility on 12/02/26.Review of the the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #98 had severe cognitive impairment and had one fall without injury since the last assessment period. Review of a physician order dated 09/09/25 revealed Resident #98 was to have a floor mat to the side of the bed with placement verification every shift and as needed.Review of the care plan, initiated 09/10/25, revealed Resident #98 was at high risk for falls related to decreased awareness to own safety, unsteady gait and effects from osteoarthritis and dementia. Interventions included ensure bed was kept in the lowest position and floor mat to the side of the bed. Review of a Post Fall Evaluation dated 01/07/26 revealed Resident #98 experienced an unwitnessed fall at approximately 9:15 A.M. while attempting to get out of bed. The document revealed the resident's bed was left in the high position and no mats were on the floor. The evaluation further revealed the bed was at an improper height and the floor mat was not in place at the time of the fall.Review of the facility's fall investigation, dated 01/07/26, revealed contributing factors related to Resident #98's fall included the resident's bed being left in the high position and the floor mat not positioned on the floor at bedside. Further review revealed the resident was attempting to get out of bed when the fall occurred. The investigation included staff witness statements corroborating the resident was found with the bed elevated and floor mat not positioned at bedside.Interview on 05/20/26 at 9:38 A.M. with Licensed Practical Nurse (LPN) #268 confirmed when Resident #98 fell on [DATE], the bed had been left in the high position and the floor mat was not at the side of the bed. LPN #268 stated it was believed the wound nurse and wound team left the room without notifying staff the bed remained elevated and the floor mat was not positioned next to the bed. Interview on 05/20/26 at 1:00 P.M. with Certified Nursing Assistant (CNA) #242 revealed on the day Resident #98 fell, she was preparing to provide care when the wound care team entered the resident's room and requested to complete wound care prior to her providing care. CNA #242 stated the bed was elevated and she briefly left the room. Upon returning, she observed Resident #98 on the floor with the bed still elevated and the floor mat positioned next to the other bed in the room. She stated she notified LPN #268, who assessed the resident.Interview on 05/20/26 at 1:19 P.M. with CNA #275 revealed she became aware of Resident #98's fall after CNA #242 requested the nurse come to the resident's room. CNA #275 stated she completed a witness statement indicating wound care staff had left the bed elevated.Review of the facility policy titled, Falls-Protocol, revised March 2018, revealed that after assessment, the staff and physician would identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. Additionally, the staff and physician would monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.This deficiency represents noncompliance investigated under Complaint Number 2710514.

Based on record review, review of facility Self-Reported Incidents (SRI), review of local law enforcement reports, interviews and facility policy review, the facility failed to protect Resident #71's right to be free from abuse by Resident #93 and failed to protect Resident #64's right to be free from abuse by Resident #88. This affected two residents (#71 and #64) of four residents reviewed for abuse. Actual Harm occurred on 11/13/25 when Resident #71 reported he had been inappropriately touched and choked by another Resident (#93). Upon assessment, Resident #71 was noted to have an abrasion to his lower neck and scratches to his left shoulder. Resident #71 complained of a sore throat and rectal tenderness. The resident's rectum was assessed to be reddened. The resident was transferred to the hospital for evaluation but subsequently declined having a rape assessment completed. Findings include:1. Review of the medical record for Resident #71 revealed an admission date of 09/02/25. Resident #71 had diagnoses including senile degeneration of the brain, unspecified dementia, and generalized muscle weakness.Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/08/25, revealed Resident #71 had impaired cognition and required supervision for bed mobility, transfers, and ambulation. Review of the behavior and mood section of the MDS revealed Resident #71 experienced hallucinations and wandering behaviors. Review of the plan of care dated 09/22/25 noted Resident #71 had impaired cognitive function/impaired thought process related to dementia. Resident #71 resided on the secured unit due to behaviors of elopement and lack of personal space regarding peers. Review of a nursing progress notes dated 11/13/25 at 3:20 A.M. noted Resident #71 reported inappropriate physical touch by another resident (Resident #93). The note included staff completed a thorough assessment noting Resident #71 had a slight abrasion on to the lower neck. Resident #71 also complained of a sore throat and rectal tenderness. A nursing progress note, entered in Resident #93's medical record dated 11/13/25 at 4:13 A.M. noted Resident #93 was observed by staff standing aggressively over Resident #71 and choking him.Review of a skin check evaluation dated 11/13/25 at 5:17 A.M. noted Resident #71 had a reddened rectum and scratches on the front of his left shoulder.Review of a nurse's progress note dated 11/13/25 at 9:20 A.M. noted Resident #71 reported his rectum was burning like fire. Resident #71 was transferred to the hospital for an evaluation. A nursing progress note dated 11/13/25 at 9:33 P.M. noted Resident #71 declined all rape assessments while at the hospital and would be returning to the facility. Review of the local hospital record dated 11/13/25 noted Resident #71 received a computerized tomography (CT) scan to brain, cervical (neck), face, chest, and right elbow. The hospital record noted Resident #71 declined rape assessments. Review of a facility SRI tracking number 267485 dated 11/13/25 noted Certified Nurse Assistant (CNA) #353 heard Resident #71 yell out and immediately went into the resident's room. CNA #353 stated she observed Resident #93 leaning over Resident #71. Resident#71 stated he was woken up when Resident #93 placed his right leg on his chest and started choking him. Resident #71 stated Resident #93 inserted his finger into his rectum. Both residents were placed on 1:1 observation for safety. The facility contacted all responsible parties including the local law enforcement agency. However, review of the SRI revealed the facility unsubstantiated an incident of physical abuse citing there was not enough evidence. Review of a local law enforcement report dated 11/13/25 at 4:52 A.M. noted a report of an assault was called in from the facility. Interview with law enforcement and Resident #71 noted Resident #71 was lying down in bed when his roommate Resident #93 tried to touch him. Resident #71 said he asked Resident #93 to go to bed. Resident #71 stated Resident #93 had his hand where it should not be, and he asked Resident #93 to stop. Resident #71 stated he again asked Resident #93 to stop and go to bed. Resident #71 stated Resident #93 kept standing over and touching him. Resident #71 stated Resident #93 got him down on the bed and started choking him. Resident #71 stated he had a difficult time breathing at that point. Resident #71 continued to say Resident #93 started using his finger on his butt when he was lying on his side for approximately 15 minutes. The law enforcement agency interviewed Resident #93 who had no memory of the incident. Interview with Resident #71 on 11/25/25 at 2:05 P.M. revealed Resident #93 wanted more than he was willing to give. Resident #71 stated Resident #93 wanted to have sex and was standing over him slapping him in the face and choking him. Resident #71 then stated Resident #93 pulled his pajamas down to stick his finger in his rectum. Resident #71 stated staff came in and separated them and then removed Resident #93 the following day. (Resident #71 and Resident #93 were roommates at the time of the incident). Attempts to interview CNA #353 during the onsite investigation were unsuccessful. Interview on 11/25/25 at 9:59 A.M., with the Administrator revealed the facility was unaware of any behaviors by Resident #93 until this incident on 11/13/25. Following the incident, the facility contacted Resident #93's parole officer and the resident was going back to prison. (Resident #93 had been incarcerated beginning in 1982 for aggravated murder, aggravated robbery, and felonious assault and was released from prison directly to the facility for admission on [DATE]).Interview on 12/03/25 at 12:48 P.M. with the Administrator revealed Resident #93's parole officer indicated the incident involving Resident #93 on 11/13/25 was a parole violation, therefore Resident #93 would be sent back to prison. Resident #93 was sent to the hospital after the incident on 11/13/25 and did not return to the facility.2. Review of the medical record for Resident #64 revealed an admission date of 05/28/21. Resident #64 had diagnoses including anxiety disorder, Alzheimer's disease, and unspecified dementia. Review of the plan of care dated 01/21/25 noted Resident #64 had behaviors of masturbation in an open setting.Review of the quarterly MDS assessment dated [DATE], revealed Resident #64 had intact cognition. The resident was independent with activities of daily living. Review of facility SRI tracking number 267239 dated 11/06/25 noted Licensed Practical Nurse (LPN) #368 reported Resident #88 was observed in Resident #64's room engaging in sexual activity. The SRI included both residents were separated immediately and placed on 15-minute checks for 72 hours. Interview on 11/24/25 at 4:04 P.M., with the Regional Director of Clinical Services # 391 and the Director of Nursing (DON) revealed Resident #88 had attempted to have sex with many male peers on the unit, but staff had (previously) been able to prevent that until 11/06/25. Both staff stated the facility purchased Resident #88 a pleasure device which was kept locked up. Staff also stated they changed Resident #88's medications to decrease her sexual behaviors. Interview on 11/25/25 at 11:06 A.M. with Resident #64 revealed (on 11/06/25) Resident #88 entered his room and closed the door. Resident #64 stated he told Resident #88 to leave his room, but she refused to leave stating she liked him and wanted to have sex. Resident #64 stated Resident #88 pulled his pants and underwear down before touching him. Resident #64 stated he did not like Resident #88 and did not want to have sex with her. Review of the facility policy titled Abuse and Neglect-Clinical Protocol, dated 2018, noted staff would assess all residents involved in allegations of abuse and/or neglect. The nurse would report all related findings to the physician. The staff, with the help of the physician's input, would investigate alleged abuse and neglect to clarify what happened and identify possible causes. The staff and the physician would monitor individuals who have been abused to address any issues regarding their medical condition, mood, and function. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. The policy defined sexual abuse as non-consensual sexual contact of any type with a resident. This deficiency represents noncompliance investigated under Master Incident Number 2676134, Complaint Number 2675465 and Incident Number 2671068.

Based on record review, review of the facility self-reported incident (SRI) and investigation, review of facility policy, observation and interview, the facility failed to ensure Resident #12 was free from physical abuse by Resident #40. Actual harm occurred on 03/16/25 when Resident #40, who had known verbal and physical aggressive behaviors towards others, punched Resident #12 in the face, head, and neck approximately 20 times resulting in facial and scalp contusions, headache and neck pain requiring evaluation and treatment in the hospital emergency room (ER). Resident #12 had X-rays, and a Computed Axial Tomography (CAT) scan performed while in the ER which indicated there were no broken bones. Resident #12 was diagnosed with physical assault, head, face, and neck contusions. Resident #12 returned to the facility on [DATE] with orders to see a concussion specialist on 03/26/25 at 2:30 P.M. This affected one resident (Resident #12) out of six residents reviewed for abuse. The facility census was 94. Findings include: 1. Review of the medical record for Resident #12 revealed an admitted [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), adult failure to thrive, chronic pain syndrome, neurogenic bladder, anxiety disorder, type two diabetes mellitus, opioid abuse, viral hepatitis, hypertension, and quadriplegia. Review of Resident #12's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition, required setup or clean up assistance for eating, and oral hygiene, required partial to moderate assistance for toileting hygiene and dressing, and required substantial to maximal assistance for showers, personal hygiene, and bed mobility. Resident #12 used a motorized wheelchair and required substantial to maximal assist for transfer into their wheelchair then were independent with wheelchair mobility. Review of the plan of care for Resident #12 dated 01/05/25 revealed Resident #12 was set up to dependent assist with their Activities of Daily Living (ADL), mobility and functions. Resident #12 utilized an electric wheelchair. Review of Resident #12's progress notes revealed on 03/16/25 at 1:47 A.M. Resident #12 was physically assaulted by Resident #40 when Resident #40 punched Resident #12 approximately 20 times in the head, neck and face. The two residents were separated, and 911 emergency services were called to the facility. Resident #12 stated he wanted to press charges against Resident #40. Resident #12 was sent to the ER for further evaluation and treatment of apparent facial and scalp contusions and reported headache and neck pain. Review of the hospital records dated 03/16/25 revealed Resident #12 had X-rays, and a CAT scan performed which indicated there were no broken bones. Resident #12 was diagnosed with physical assault, head, face, and neck contusions. Resident #12 returned to the facility on [DATE] with orders to see a concussion specialist on 03/26/25 at 2:30 P.M. Review of the pain scales (zero being no pain to 10 being the most severe pain on a scale of zero to 10) in the medical record for Resident #12 from 03/16/25 and 03/17/24 revealed after the assault on 03/16/25 Resident #12 had intermittent pain scores ranging from six to 10 with relief achieved after use of ordered pain medication as evidenced by scores of zero after the administration of oxycodone (narcotic pain medication) five milligrams (mg) every eight hours. 2. Review of the medical record for Resident #40 revealed an admitted [DATE] with diagnoses including COPD, vascular dementia with behavioral disturbances and agitation, Post-Traumatic Stress Disorder (PTSD), anxiety, and impulse disorder. Resident #40 was sent to the hospital on 03/16/25 for a psychiatric evaluation and did not return to the facility. Review of the emergency discharge notice dated 03/24/25 revealed Resident #40 was discharged from the facility as of 03/16/25 due to the welfare and needs of the resident could not be met in the facility. Review of the admission documentation dated 01/29/25 revealed Resident #40 had transferred to the facility from out of state and had known behaviors including confusion, mood swings, drug and alcohol use, physically abusive and aggression, wanders mentally and physically, short- and long-term forgetfulness and has difficulty concentrating. Resident #40 had diagnoses of PTSD, vascular dementia with behavioral disturbances and agitation, anxiety and impulse disorder. Review of Resident #40's baseline care plan dated 01/31/25 revealed under the Social Services section that mental health needs was checked but there was no additional information related to what the mental health needs were for Resident #40. The section for behavior concerns was also checked but there was no additional information related to what the behavioral concerns were for Resident #40. For both sections, no identified interventions were documented. The baseline care plan was silent for any plan of care, triggers or interventions for Resident #40's diagnoses of PTSD, impulse disorder or dementia with behavioral disturbances and agitation. Review of a progress note dated 02/05/25 at 2:36 A.M. revealed Resident #40 wanted to go smoke and when staff stated it was not time, he became aggressive and began yelling profanities and verbal threats to hurt staff. He was attempting to get to the nurse who told him it was not time for smoke break and additional nursing staff stood between the nurse and Resident #40 to protect the nurse. 911 emergency medical services (EMS) were called, and police arrived at the facility. The situation was explained to the police, and staff insisted the other residents and staff were not safe at the facility and Resident #40 needed to go to the hospital. Police then notified EMS they were needed to transport the resident to the ER for a psychiatric evaluation and treatment. The progress note dated 02/05/25 at 2:49 P.M. revealed Resident #40 returned to the facility with no new orders and was actively trying to exit the facility. Further review of progress notes indicated the resident calmed and was observed to be resting in bed at 6:11 P.M. Review of Resident #40's admission MDS 3.0 assessment dated [DATE] revealed the resident had impaired cognition, required supervision or touching assistance for showers and was independent with eating, oral hygiene, toileting hygiene, dressing, personal hygiene, bed mobility and walking. The behaviors noted on this MDS included physical behaviors including hitting, kicking, pushing, scratching, grabbing marked as behaviors occurring one to three days, verbal behaviors directed towards others including threatening others, screaming at others, cursing at others marked as behavior occurring one to three days, other behavioral symptoms not directed towards others including physical symptoms such as hitting or scratching self, pacing, rummaging, verbal/vocal symptoms like screaming or disruptive sounds and rejection of care occurring one to three days. Review of Resident #40's comprehensive care plan, date initiated 02/13/25, revealed Resident #40 had fluctuating behaviors related to affects of alcohol dependence, dementia, PTSD and impulse disorder. Resident #40 displayed both verbal and physical aggression towards staff and disrupted his environment. Interventions included administer medication as ordered and monitor for side effects, anticipate and meet needs as much as possible, assist to develop more appropriate methods of coping and interacting, caregivers to provide positive interaction by stopping to talk to him when passing by, explain all procedure before starting and allow time to adjust, discuss behavior and explain why inappropriate, intervene to protect the rights and safety of others by approach and speak in a calm manner, divert attention, remove from situation and take to alternate location, monitor behavior episodes and attempt to determine underlying cause. On 03/16/25 an additional intervention was added to include place resident on one-to-one during episodes of increased pacing and aggressive behaviors. Review of Resident #40's physician orders dated March 2025 revealed orders for Duloxetine 30 mg (selective serotonin and norepinephrine reuptake inhibitor) daily for depression, Chlorpromazine 25 mg (give three tablets to equal 75 mg) (antipsychotic) three times a day for impulse disorder, Propranolol 10 mg (beta blocker to treat high blood pressure) every 12 hours as needed for anxiety, Haloperidol 2 mg (antipsychotic) every eight hours as needed for anxiety/agitation, and Buspirone 15 mg (anxiolytic to treat anxiety) every 12 hours for anxiety. Review of progress notes for Resident #40 dated 03/16/25 revealed no documentation of the assault involving Resident #40 and Resident #12, however, there was a progress note entry on 03/16/25 at 4:01 P.M. stating the social worker from the hospital reached out to the facility and notified them Resident #40 was being transferred to Ohio Hospital for Psychiatry in Columbus. Review of the facility SRI and investigation dated 03/16/25 revealed the facility substantiated that resident-to-resident abuse had occurred with Resident #40 being listed as the perpetrator and Resident #12 the victim. Resident #40 made contact with his hand/fist to Resident #12's face and head. Resident #12 was transferred to a hospital ER for evaluation and treatment of apparent facial and scalp contusion and reported neck pain and headache. Resident #40 was transferred to an intensive psychiatric facility. Review of the witness statement dated 03/16/25 and authored by Certified Nurse Aide (CNA) #811 revealed CNA #811 was sitting at the nurses' station next to Resident #12. Resident #40 approached and asked for a sleeping pill. CNA #811 told Resident #40 she was just an aid so he would have to go back to his own unit and ask the nurse. Resident #12 stated yeah bud your nurse can help you. Resident #40 looked and pointed at Resident #12 then walked up to him and started punching him with a closed fist in his head. CNA #811 tried to intervene but could not get Resident #40 to stop hitting Resident #12. A nurse (not identified) came from a room and was able to get Resident #40 to stop. Review of the incident report dated 03/16/25 and authored by Licensed Practical Nurse (LPN) #808 revealed LPN #808 walked out of a resident room to find Resident #40 hitting Resident #12 with a closed fist and wrote he must have hit him at least 20 times. The residents were separated, and 911 EMS was called to the facility. Resident #12 had injuries to his scalp, right ear and face. Resident #12 indicated he wanted to press charges against Resident #40. Resident #40 was sent to the hospital. An interview with the Administrator and LPN #799 on 03/24/25 at 10:45 A.M. revealed Resident #40 was in the hospital and would not be returning to the facility due to his behaviors. They both confirmed Resident #40 assaulted Resident #12 on 03/16/25 causing facial and scalp contusions and reported headache and neck pain. They confirmed Resident #12 required an ER visit and follow up with a concussion specialist. Interviews were attempted with the responsible party for Resident #40 on 03/24/25 at 2:45 P.M. and 03/27/25 at 11:00 A.M. but no return contact was made. An interview on 03/24/25 at 10:45 A.M. with LPN #801 and LPN #802 revealed they were informed Resident #40 punched Resident #12 in the head, neck, and face approximately 20 times causing swelling and bruising and a possible concussion. They stated this was not the first time Resident #40 had been physically aggressive. They stated Resident #40 would become verbally and physically aggressive with staff. An interview on 03/26/25 at 12:55 P.M. with LPN #803 revealed Resident #40 was not appropriately placed in the facility and needed a facility that was better suited to handle his behaviors. Interviews on 03/26/25 at 2:15 P.M. with CNA #804 and CNA #806 revealed they were afraid of Resident #40 due to his aggressive behavior and verified he had a history of aggressive behaviors prior to the incident involving Resident #12. An interview on 03/27/25 at 11:39 A.M. with LPN #808 revealed they were working the night Resident #40 assaulted Resident #12. LPN #808 stated Resident #40 punched Resident #12 approximately 20 times in the head, neck and face. The two residents were separated and 911 was called. LPN #808 stated she notified the physician and responsible party for Resident #40. They stated Resident #12 was alert and oriented to person, place, time, and situation. LPN #808 stated Resident #12 was their own responsible party. Resident #12 stated to the nurse he wanted to press charges against Resident #40. Resident #12 was sent to the ER for further evaluation and treatment of apparent facial and scalp contusions and reported headache and neck pain. LPN #808 stated she was afraid of Resident #40, and this was not his first incident of physical aggression. An interview on 03/27/25 at 12:35 P.M. with the facility Psychiatric Nurse Practitioner (PNP) revealed she was aware Resident #40 was sent to theER on [DATE] due to a confrontation with another resident. The PNP verified Resident #40 punched Resident #12 approximately 20 times and required a discharge to a psychiatric hospital. When asked if she felt Resident #40's behaviors were well managed at the facility, the PNP stated it was hard to answer due to the situation that occurred on 03/16/25. Interview on 03/27/25 at 2:55 P.M. with LPN #805 and Registered Nurse (RN) #807 revealed Resident #40 assaulted Resident #12 causing visible bruising and swelling to his head, neck, and face. They stated Resident #12 had to go to the emergency room where he had X-rays and a CAT scan done which showed no broken bones, but he had to follow up with a concussion specialist. Observation was conducted and interviews attempted with Resident #12 on 03/24/25 at 12:38 P.M, 03/25/24 at 11:00 A.M. and on 03/27/25 at 2:35 P.M. who was alert and up in his motorized wheelchair. He had slight yellow bruising to his face. He demonstrated no signs of pain. During attempts to interview him, Resident #12 would start to drive off while yelling he contacted the police and they will handle it! An interview was conducted on 03/31/25 at 11:52 A.M. with Police Department Employee (PDE) #919 to try to obtain a copy of the police report related to the abuse incident on 03/16/25 involving Resident #12. PDE #919 stated they were unable to supply the police report associated with Resident #40 assaulting Resident #12 because it was an open investigation with Resident #12 wanting to press charges against Resident #40. Review of the facility policy titled Abuse and Neglect Clinical Protocol, date revised 03/2018, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. The policy stated facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse, and address appropriate causes of problematic resident behaviors. This deficiency represents non-compliance investigated under Complaint Number OH00163841 and OH00163683.

Based on observation, medical record review, review of the hospital records, review of the fall incident, facility policy review and family, staff and resident interview, the facility failed to ensure the physician was notified immediately of an unwitnessed fall with injury, and failed to timely update the physician on increased, severe pain and delay transferring the resident in and out of bed until further orders from the physician were obtained to prevent further injury and pain for Resident #57. Actual harm occurred beginning on 02/21/25 when Resident #57, who was severely cognitively impaired had an unwitnessed fall in his room with evidence of left foot rotation and increasing complaints of pain in his hips without timely and adequate treatment. The resident subsequently developed severe hip pain after being repeatedly transferred in and out of bed without obtaining orders from the physician throughout 02/21/25 and 02/22/25 with the resident yelling out, it hurts at the top while pointing to his bilateral hip area. The resident was also noted to have a problem bearing weight and had a decline in his ability to transfer from one person assistance to three-person assistance. On 02/22/25 at 2:44 P.M. Resident #57 was transported to the hospital emergency room (ER) per order by Physician #814 due to increased pain and difficulty with transfers where he was diagnosed with an acute displaced femoral neck fracture. Resident #57 had to be transferred from the ER to another hospital able to complete a left hip hemiarthroplasty surgery. Resident #57 was readmitted to the facility on [DATE] with orders for physical therapy, narcotic pain medication and treatments to the surgical incision. This affected one resident (#57) of six residents reviewed for pain/quality of care and treatment. The facility census was 94. Findings include: Review of the medical record for Resident #57 revealed an initial admitted [DATE] with diagnoses including chronic kidney disease, muscle wasting and atrophy, Alzheimer dementia, and type two diabetes mellitus. Resident #57 was discharged to a hospital on 02/22/25 after a fall incident occurring on 02/21/25 and readmitted to the facility on [DATE] with new diagnoses including displaced fracture of left femur and presence of left artificial hip joint. Review of the facility document titled Clinical Admission, dated 01/24/25 revealed Resident #57 was admitted from another facility, was alert to person with confusion, disorganized thinking and short-term memory loss. The resident had no pain upon admission, no functional limitations to his upper or lower extremities and used a walker and manual wheelchair for mobility devices. Review of the facility document titled Fall Risk Evaluation, dated 01/24/25, revealed the resident had no falls in the last three months. A predisposing factor to fall risk was that the resident had been hospitalized within the last 30 days. The fall risk score was two out of 10. Review of Resident #57's five-day admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition and required one-person physical assistance for bed mobility, toileting hygiene and transfers. Review of Resident #57's care plan, initiated on 01/24/25 revealed the resident had a high fall risk related to poor safety awareness due to dementia, unsteady gait and use of psychotropic medications. Goals included Resident #57 would be at a reduced risk for injury related to fall risk. Interventions included keep frequently used items in reach at bed side, maintain call light within reach at all times, monitor for acute signs and symptoms of infection or pain which may precipitate a fall, monitor for potential hazards such as untied shoes, spills on the floor, clutter and correct situation, monitor for signs of adverse effects of medication and notify physician, observe for decrease or loss of functional status and notify physician and observe for gait unsteadiness and intervene as necessary. Review of a physician's order dated 01/24/25 revealed an order for acetaminophen (non-narcotic pain medication) 325 milligram give two tablets by mouth every six hours as needed for pain and monitor for pain every shift. Further review of the care plan, initiated on 02/05/25 revealed Resident #57 had potential for pain related to age and diabetes. Goals included the resident would not have an interruption in normal activities due to pain. Interventions included administer analgesics per physician orders, anticipate needs for pain relief and respond immediately to any complaint of pain, encourage the resident to report pain, monitor/record/report to nurse any complaints of pain, notify physician if current interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Review of the progress notes for Resident #57 dated 01/24/25 through 02/09/25 revealed he had no indication of pain. There was no progress note entries documented for the date range of 02/11/25 to 02/20/25. Review of the February 2025 Medication Administration Record (MAR) revealed Resident #57 had no complaints of any pain from 02/01/25 through 02/20/25. Review of a facility document titled Fall, dated 02/21/25 at 12:00 A.M. and authored by Licensed Practical Nurse (LPN) #798 revealed an incident description including that a nurse aid informed the nurse she had seen Resident #57 by his counter trying to pull himself up. She did not witness him on the floor but treated it like a fall considering it was unwitnessed. The resident was in his chair sitting with both feet on the floor when the nurse entered the room. The resident stated he was alright and stated I fell . Immediate action taken was the nurse assessed vital signs and skin. A small skin tear was noted on the left elbow. When the nurse and aid asked the resident to stand the resident showed signs of pain and discomfort on his left side. The nurse assessed the left leg and noticed that while the resident was standing his left foot would go outward. The aid stated that was not normal for him. The resident's mental status was oriented to person and place. The physician was notified at 4:26 A.M., family was notified at 4:27 A.M. The document stated the Director of Nursing (DON) was notified but no time was noted. Review of the vitals and pain note dated 02/21/25 at 4:28 A.M. and authored by LPN #798 revealed Resident #57 was having aching pain in his left elbow and grimacing when he stood up. As needed, medication was administered. There were no details in the note regarding the fall incident. Review of a physician's order dated 02/21/25 at 8:00 A.M. revealed an order for an x-ray of the left femur due to complaint of pain after unwitnessed fall which was entered into the electronic medical record by LPN #798. Review of the x-ray report dated 02/21/25 and electronically signed at 10:04 A.M. by the interpreting physician revealed there was no acute visualized fracture of the left femur. Review of a nursing note dated 02/21/25 at 2:58 P.M. revealed the resident continued on neurological checks due to status post fall. The neurological checks were within normal limits for him. An x-ray completed showed no acute fracture visualized femur and was sent to the doctor with no new orders. The resident was able to sit up in his wheelchair. Tylenol was given with good effects for signs of pain. Spoke with son in New Mexico for update after x-rays. Review of a late entry nursing note with an effective date of 02/16/25 at 9:52 P.M. (this date is incorrect, as the fall occurred on 02/21/25) and created date of 02/23/25 at 10:14 P.M. and authored by LPN #808 revealed the resident complained of pain to his left hip when rolling resident to change him. X-ray was done today of femur per MDS but no hip x-ray was obtained. Left foot was turned out. Left hip x-ray was ordered at 7:00 P.M. with no ETA (estimated time of arrival). Another nurse (not identified) came and assessed the resident also, at this time, DON was called and did not want the resident sent out. Wanted a pain eval done (8) and wanted to give resident Tylenol. The resident was not transferred to the hospital for additional evaluation/care at this time. Review of a physician's order dated 02/21/25 at 7:45 P.M. revealed an order for a left hip x-ray due to pain after a fall. Review of a vitals and pain note entry dated 02/21/25 at 8:51 P.M. revealed Resident #57 was having severe pain (rated) of eight (on a scale of 1 to 10) in the left hip which worsened with any movement. The pain was constant and non-medication intervention did not provide relief. Scheduled medication was provided. Review of an orders administration note dated 02/22/25 at 8:40 A.M. and authored by LPN #809 revealed acetaminophen 325 mg two tablets given for pain. Resident had visual signs and symptoms of pain. He was guarding his left hip area and had a noted decrease in range of motion related to transferring into his wheelchair. Does have left hip x-ray scheduled to be completed today. Review of an orders administration note and nurse's note dated 02/22/25 at 9:40 A.M. and authored by LPN #809 revealed the acetaminophen was effective and the pain was now at a zero and resident showing no signs of pain. He was having problems transferring and weight bearing. Three staff were needed for transfers this morning. He ate his meals with good intake and fed himself with set-up. Care was ongoing. Review of a nursing note dated 02/22/25 at 10:48 A.M. and authored by LPN #809 revealed the resident was transferred back to bed with three staff assisting and he was yelling out in pain with the transfer it hurts at the top and pointing to his bilateral hip area. The nurse called ALL STAT X-ray Services who revealed this resident was on the schedule today for a left hip/pelvis x-ray but unable to give an estimated time of arrival. Call was placed to Physician #814 for further instruction as resident requested to go to the hospital. Review of a nursing note dated 02/22/25 at 1:12 P.M. and authored by LPN #809 revealed Physician #814 called back with new orders to send Resident #57 out to the ER. The resident had become non-weight bearing at this time and required three staff assistance for transfer. He had been medicated for his pain complaints per orders. Staff was laying him down after each meal this day to assist with pressure relief and pain control. Son was updated and notified of transfer. The ambulance service was called and will be at the facility approximately 2:00 P.M. Review of a nursing note dated 02/22/25 at 2:25 P.M. authored by LPN #809 revealed the resident had bilateral lower leg pitting edema times two and remains with pain and discomfort to hip area. Ambulance transport called with an arrival time of five minutes for transfer to ER. Review of a nursing note dated 02/22/25 at 2:44 P.M. authored by LPN #809 revealed Emergency Medical Services (EMS) arrived at the facility. LPN #809 and three paramedics lifted Resident #57 onto the gurney. Prior to leaving the resident room, the paramedics started an IV (intravenous line) and administered a dose of Fentanyl (narcotic used to treat pain) pain medication and completed an EKG (electrocardiogram test that measures heart activity) due to the severe pain of the resident. Review of hospital documentation dated 02/22/25 through 02/26/25 revealed the resident was diagnosed with an acute impacted femoral neck fracture with impaction and cephalad (toward the head/anterior) displacement of 1.2 centimeters after sustaining a fall at the facility. The operative note dated 02/24/25 listed the pre-operative diagnosis as closed the left displaced femoral neck fracture. Resident #57 was placed under general anesthesia and a left hip hemiarthroplasty was performed. The surgeon noted the resident tolerated the procedure well and was stable. An interview was conducted on 03/19/25 at 2:30 P.M. with Resident #57's son who reported the facility called to tell him Resident #57 fell at the facility. The son said his dad was sent to the hospital two days later and at the hospital he was diagnosed with a hip fracture and needed hip surgery. Interview on 03/24/25 at 10:45 A.M. with LPN #802 revealed they cared for Resident #57 on 02/21/25 from 7:00 A.M. to 7:30 P.M. and stated the resident's pain related to the fall was being treated with Tylenol. LPN #802 stated the resident would cry out anytime they had to move him with transfers or in bed to provide incontinence care. LPN #802 stated prior to the fall on 02/21/25 at 12:00 A.M. the resident required assist by one staff member for transfers to the wheelchair or bed. However, after the fall the resident was requiring maximal assistance by three to four staff members with a notable deformity of position on the left foot and when standing it would turn outward. LPN #802 stated it became more and more difficult to transfer the resident throughout the day until he was non-weight bearing on his left lower extremity. LPN #802 did not say why they continued to transfer the resident having pain with an outward turn of the left foot position. Interview on 03/26/25 at 2:15 P.M. with Certified Nursing Assistant (CNA) #806 revealed Resident #57 had complaints of left leg pain when transferring on 02/22/25 from his wheelchair to his bed. CNA #806 stated he screamed in pain with transfers, so they requested assistance by two additional staff members to get him in the bed. CNA #806 stated prior to the fall the resident was a minimal assist by one staff member for transfers to the wheelchair or the bed. CNA #806 stated they felt Resident #57's pain was not ceasing and should have been sent to the hospital sooner than he was. Interview on 03/27/25 at 11:26 A.M. with Resident #57 revealed when asked if he knew where he was, he stated no. When asked if he remembered falling, he stated yes and he was unsure what happened but his leg hurt after the fall. When asked what he was trying to do at the time of fall he stated, I do not know, I think I just fell over. Resident #57 did not show any verbal or nonverbal signs of pain during the interview. Interview on 03/27/25 at 11:39 A.M. with LPN #808 confirmed Resident #57 fell on [DATE] at 12:00 A.M. and that notification was not made to the Physician until 4:26 A.M. LPN #808 provided no explanation as to why the delay in notification. LPN #808 stated Resident #57 complained of left hip pain when rolling the resident to provide incontinence care. Resident #57's left foot was turned out. LPN #808 stated the left femur x-ray was negative for fracture and a left hip x-ray was ordered on 02/21/25 at 7:00 P.M. but was not completed yet and there was no estimated time of arrival for x-ray company. LPN #808 stated another nurse (not identified) came and assessed the resident also. At this time, they notified the DON who did not want the resident sent to the hospital instead instructed them to complete a pain evaluation with results of the resident's pain being an 8 out 10 on the pain scale and to medicate the resident with Tylenol. LPN #808 stated they did not feel Resident #57's pain was controlled on the Tylenol. LPN #808 gave no explanation of why they continued to move the resident before the hip x-ray was completed. Observation made on 03/27/25 at 11:45 A.M. and on 03/31/25 at 10:37 A.M. of Resident #57 revealed he was up in his wheelchair sitting with other residents in the dining room located on the secure dementia unit. There were no overt signs or symptoms of pain at the time of the observations. Interview on 03/27/25 at 2:15 P.M. with LPN #809 revealed the LPN was assigned to care for Resident #57 on 02/22/25 and had observed signs and symptoms of severe pain throughout their shift and had medicated the resident with Tylenol as needed for pain. LPN #809 confirmed Resident #57 was guarding his left hip area and noted a decrease in range of motion when transferring into their wheelchair. LPN #809 stated they notified the physician on 02/22/25 at 10:48 A.M. of the resident's continued pain, increase in need for assistance, swelling to legs, decrease in pedal pulses and wanted to notify the physician about the x-ray company unsure of when they would be out to do hip x-ray. LPN #809 stated the physician did not return the call until 02/22/25 at 1:12 P.M. and gave orders to transfer the resident to the local ER for evaluation and treatment. LPN #809 stated she notified EMS of need for transportation. EMS arrived around 2:44 P.M., assisted the staff with the transfer to the gurney. LPN #809 stated the paramedics immediately started an IV and medicated the resident with Fentanyl for pain prior to leaving the resident's room. LPN #809 stated Resident #57 was sent to the local ER where they found the resident had an acute displaced femoral neck fracture which required a left hip hemiarthroplasty. LPN #809 stated they had to transfer the resident from the local ER to a hospital equipped to complete the surgery. Interview attempts with LPN #798 were made on 03/27/25 at 11:37 A.M., on 03/27/25 at 2:58 P.M., on 04/09/25 at 11:23 A.M. and 04/09/25 at 1:45 P.M. but the calls were not answered, and no return call was received. A follow-up interview was conducted on 04/09/25 at 3:40 P.M. with LPN #808 who revealed the LPN spoke with the DON regarding Resident #57's pain, negative femur x-ray, and foot being rotated out. LPN #808 stated the DON instructed her to not send the resident to the hospital and gave orders for a hip x-ray. When asked why the DON instructed her to not send the resident to the hospital, LPN #808 stated the DON told her she was told by corporate to not send residents to the hospital that they would get in trouble for it. LPN #808 stated she was instructed to not call the physician by the DON. An interview on 04/09/25 at 3:49 P.M. with Physician #814 revealed the physician was not aware the facility waited four hours and 26 minutes after the fall to notify him. Physician #814 stated he was aware the resident was in pain but not that it continued or that Resident #57 was having difficulty with transfers. Physician #814 stated he was not informed the resident's foot was turned outward. Physician #814 stated it was not ok for the DON to instruct the staff to not send the resident to the hospital and it was not ok for the DON to order a hip x-ray. He stated the staff should have called him for further orders. Physician #814 stated the facility staff should not have been transferring the resident from his bed to his chair after the fall. The DON resigned employment with the facility on 03/24/25 with last day worked on 03/18/25 and was not available for an interview. Review of the facility policy titled Change in a Resident Condition or Status, revised 02/2021, revealed the facility promptly notifies the resident's attending physician of changes in the residents' medical condition or status. The nurse will notify the residents' physician or physician on call when there has been an accident or incident involving the resident. Review of the facility policy titled Falls Clinical Protocol, revised 03/2018, revealed the staff, with the physicians' guidance, with follow-up on any fall with an associated injury until the resident is stable and delayed complications such as late fracture have been ruled out or resolved. This deficiency represents non-compliance investigated under complaint number OH00163683.

Based on resident and staff interviews, record review, and review of the facility Self Reported Incident (SRI) and investigation, the facility failed to ensure the misappropriation of narcotic pain medication did not occur for Resident #80. This affected one resident (Resident #80) out of six residents reviewed for misappropriation. The facility census was 94. Findings include: Review of the medical record for Resident #80 revealed an admitted [DATE] with diagnoses including rheumatoid arthritis, chronic pain syndrome, peripheral vascular disease, history of morbid obesity, rheumatoid arthritis, and gout. Review of Resident #80's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. They required setup or clean up assistance with eating and were independent with all other Activities of Daily Living (ADLs) including toileting hygiene, showers, dressing, personal hygiene, bed mobility and transfers. Review of Resident #80's care plan dated 03/07/25 revealed Resident #80 had chronic pain related to peripheral vascular disease, history of morbid obesity, rheumatoid arthritis, and gout. Goals and interventions included the resident would voice that adequate comfort and pain control was maintained daily, staff would administer pain medications per physician orders, encourage activity and movement within tolerance, monitor, document side effects of pain medications, observe for constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness and falls. Staff to report any findings to the physician. Staff were to offer comfort measures every shift and as needed. Review of Resident #80's physician orders dated February 2025, revealed the resident was ordered Tylenol 650 milligrams (mg) every six hours for pain as needed, Baclofen 10 mg every 12 hours as needed for muscle pain, and Oxycodone (a narcotic pain medication) 5-325 mg every eight hours as needed for severe pain rated a seven or higher on the numerical pain scale. Review of Resident #80 Medication Administration Record (MAR) dated February 2025 revealed the resident received a dose of Oxycodone 5-325 mg on 02/11/25 at 6:00 P.M., 02/12/25 at 1:00 A.M., and on 02/12/25 at 6:20 A.M. administered by Licensed Practical Nurse (LPN) #797. There were no administrations of Tylenol documented for these dates. Review of the facility SRI dated 02/12/25 for misappropriation revealed Resident #80 accused LPN #797 of stealing remaining doses of Oxycodone 5-325 mg. The previous facility Administrator completed the investigation and unsubstantiated the allegation of misappropriation. After review of the investigation, it was determined that misappropriation occurred. Further review of the SRI investigation revealed a witness statement provided by LPN #797. LPN #797 stated he started his medication pass as usual with residents lined up at this cart. Resident #80 was at the cart and was medicated with his normal medications and a pain medication except his sleeping pill, which he usually requested around 10:00 P.M. to 10:30 P.M LPN #797 stated the resident was at his medication cart and witnessed him pull the medications and were given at this time. LPN #797 stated he completed his medication pass at approximately 9:30 P.M. to 9:45 P.M Resident #80 next came to the nurse's station and asked for his sleeping pill, which again the resident was present and witnessed the nurse pull the medication. LPN #797 stated he then was approached by Resident #80 around 6:00 A.M. to 6:15 A.M. on 02/12/25 asking for another pain pill which was the Oxycodone 5-325 mg. LPN #797 stated the resident was present when medications were pulled from the cart. LPN #797 stated he did tell Resident #80 this was his last pill in the card, and he was worried about this. LPN #797 stated he would re-order the medication. LPN #797 then pulled the empty card out of the cart, ripped off the top of the card, wrote down the prescription number, pulled the narcotic count sheet, and threw the card in the shred box. LPN #797 stated he placed the narcotic count sheet aside. LPN #797 stated the resident still seemed worried about not having his medication and explained it would be ok due to the fact they could call the pharmacy and get authorization to pull doses from the starter box if needed. LPN #797 stated he spoke with the other nurse on duty about Resident #80 not having any Oxycodone left, and the other nurse stated, didn't you order that last week?, LPN #797 stated yes, but it was not delivered yet. LPN #797 sent in an addendum to his original witness statement saying Resident #80 was up and about around 12:00 A.M. after his guest left and wanted medicated. LPN #797 thought this was odd because the lady guest was there late which she also seen him at the cart when she was leaving. Review of the witness statement provided by Resident #80's female guest revealed she visited with Resident #80 every evening at the facility and on 02/11/25 she visited from 8:00 P.M. to 11:30 P.M. and LPN #797 did not offer Resident #80 any medication. Review of the witness statement provided by LPN #815 revealed Resident #80 approached the nurse asking to call the pharmacy for authorization to pull Oxycodone because he was out and his nurse would pull it. When LPN #815 called the pharmacy they stated the Resident should have enough pills for the day, which would have been three pills and his next card was not due to be sent to the facility until 02/14/25. The resident stated to the nurse that he only asked for one Oxycodone during the 7:00 P.M. to 7:30 A.M. shift on 02/11/25. LPN #815 stated she saw the medication was signed out by LPN #797 three times, and Resident #80 stated he was given Tylenol instead of Oxycodone. LPN #815 looked for the narcotic count sheet and empty card, and neither could be located. The card was signed out of the cart as empty on 02/11/25 by LPN #797. Review of the witness statement provided by Registered Nurse (RN) #813 who relieved LPN #797 on 02/12/25 at 7:00 A.M. revealed she came in for her shift and spoke with LPN #797 who gave a hurried report, and appeared anxious to get out. Before they counted the narcotics LPN #797 stated Resident #80 was out of Oxycodone, it still had not come in from the pharmacy and LPN #797 stated he had to pull a dose from the starter box during the night shift. Review of the facility fax to the pharmacy revealed on 02/13/25 the facility contacted the pharmacy for authorization to pull three tablets of Oxycodone form the starter box for Resident #80. Review of the Shift Change Controlled Substance Inventory Count Sheet dated 02/09/25 to 02/12/25 revealed on 02/12/25 at 7:00 A.M. LPN #797 removed Resident #80's Oxycodone card and narcotic count sheet indicating they were empty. Interview on 03/26/25 at 2:49 P.M. with RN #813 revealed LPN #797 was in a hurry to leave on 02/12/25 and rushed through report, they counted the narcotics and count was correct. RN #813 stated before they counted the narcotics, LPN #797 pointed out Resident #80 was out of Oxycodone, and it had not come in from the pharmacy yet. RN #813 stated LPN #797 told her they had to pull a dose for the starter box during the night. Interview on 03/26/25 at 3:45 P.M. with Resident #80 revealed on 02/11/25 at approximately 10:15 P.M. he asked LPN #797 for his Oxycodone 5-325 mg pain medication and a sleeping pill. Resident #80 stated he received one pain medication and his sleeping pill. The resident stated he then went to sleep and slept until 6:00 A.M. on 02/12/25. He stated at 6:15 A.M. he asked LPN #797 for a pain pill and LPN #797 gave him a medication cup with two white tablets in them and then LPN #797 stated to him I threw a Baclofen in for you. Resident #80 stated he was surprised as he does not ask for Baclofen at that time. Resident #80 stated he knows what Tylenol looks like and stated the nurse gave him two Tylenol and not his Oxycodone as requested. Resident #80 stated he knew how he felt when he takes his Oxycodone, and he knows he did not get it as he did not have any pain relief. Resident #80 stated LPN #797 told him he was running out of his Oxycodone, Resident #80 stated he asked LPN #797 how many pills he had left, and LPN #797 stated he had two pills left. On 02/12/25 Resident #80 stated he asked Registered Nurse (RN) #813 for an Oxycodone and she replied, he did not have any left. Resident #80 stated he then went to go find the Director of Nursing (DON) to report the missing medications. Resident #80 stated he did not ask for or receive a dose of his Oxycodone at 6:00 P.M. on 02/11/25. Resident #80 stated he knows when his medications were given and knows he can only have his Oxycodone every eight hours, and it was not due at that time. Resident #80 stated he did not ask for a dose of Oxycodone at 12:00 A.M. either due to having it at 10:15 P.M. and it was not due to be taken. Interview on 03/27/25 at 12:15 P.M. with LPN #815 revealed Resident #80 approached her regarding his Oxycodone and wanted her to call the pharmacy for authorization to pull a dose of his medication from the starter box due to not having any at the facility. When LPN #815 called the pharmacy they stated the Resident should have enough pills for the day, which would have been three pills, and his next card was not due to be sent to the facility until 02/14/25. The resident stated to the nurse that he only asked for one Oxycodone during the 7:00 P.M. to 7:30 A.M. shift on 02/11/25. LPN #815 stated she saw the medication was signed out by LPN #797 three times, and Resident #80 stated he was given Tylenol instead of Oxycodone. LPN #815 looked for the narcotic count sheet and empty card, and neither could be located. The card was signed out of the cart as empty on 02/11/25 by LPN #797. Interview on 03/27/25 at 1:48 P.M. with the Regional Director of Clinical Operations (RDCO) revealed they had to replace three Oxycodone 5/325 mg tablets for Resident #80 due to LPN #797 stealing them. They stated LPN #797 denied stealing the medication when asked, however through investigation it was discovered there were three tablets unaccounted for, the narcotic count sheet was missing and was unable to be found. The RDCO stated there was an ongoing investigation with the Ohio Board of Nursing, Attorney General's Office, the Bureau of Regulatory Operations, and local Police Department. The RDCO stated the previous Administrator completed the SRI without the help or guidance of the Corporate team and unsubstantiated the SRI but should have Substantiated the allegation of Misappropriation. The RDCO stated Resident #80 did not miss a dose of their pain medication due to the facility replacing the three missing doses at no cost to the resident. An interview was not able to be conducted with LPN #797, as he no longer worked at the facility. Review of the undated facility policy titled Resident Right to Freedom of Abuse, Neglect, and Exploitation Policy and Procedure revealed the facility explicitly and expressly prohibits and will take steps to prevent, any associates from engaging in any behavior or actions that may result in the abuse, neglect, and exploitation of residents and misappropriation of resident's property. This deficiency represents non-compliance identified during investigation of Complaint Number OH00163841 and OH00163683.

Based on interviews and record reviews, the facility failed to develop and implement a baseline care plan that included instructions needed to provide effective and person-centered care for Resident #40. This affected one resident (Resident #40) out of six residents revealed for care plans. The facility census was 94. Findings include: Review of the Resident #40's medical record revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), vascular dementia with behavioral disturbances and agitation, Post-Traumatic Stress Disorder (PTSD), anxiety, and impulse disorder. Resident #40 was discharged to the hospital on 03/16/25 and did not return to the facility. Review of the admission documentation dated 01/29/25 revealed Resident #40 had transferred to the facility from out of state and had known behaviors including confusion, mood swings, drug and alcohol use, physically abusive and aggression, wanders mentally and physically, short- and long-term forgetfulness and has difficulty concentrating. Resident #40 had diagnoses of PTSD, vascular dementia with behavioral disturbances and agitation, anxiety and impulse disorder. Review of Resident #40's baseline care plan dated 01/31/25 revealed under the Social Services section that mental health needs was checked but there was no additional information related to what the mental health needs were for Resident #40. The section for behavior concerns was also checked but there was no additional information related to what the behavioral concerns were for Resident #40. For both sections, no identified interventions were documented. The baseline care plan was silent for any plan of care, triggers or interventions for Resident #40's diagnoses of PTSD, impulse disorder or dementia with behavioral disturbances and agitation. Review of a progress note dated 02/05/25 at 2:36 A.M. revealed Resident #40 wanted to go smoke and when staff stated it was not time, he became aggressive and began yelling profanities and verbal threats to hurt staff. He was attempting to get to the nurse who told him it was not time for smoke break and additional nursing staff stood between the nurse and Resident #40 to protect the nurse. 911 emergency medical services (EMS) were called, and police arrived at the facility. The situation was explained to the police, and staff insisted the other residents and staff were not safe at the facility and Resident #40 needed to go to the hospital. Police then notified EMS they were needed to transport the resident to the ER for a psychiatric evaluation and treatment. The progress note dated 02/05/25 at 2:49 P.M. revealed Resident #40 returned to the facility with no new orders and was actively trying to exit the facility. Further review of progress notes indicated the resident calmed and was observed to be resting in bed at 6:11 P.M. Review of Resident #40's admission MDS 3.0 assessment dated [DATE] revealed the resident had impaired cognition, required supervision or touching assistance for showers and was independent with eating, oral hygiene, toileting hygiene, dressing, personal hygiene, bed mobility and walking. The behaviors noted on this MDS included physical behaviors including hitting, kicking, pushing, scratching, grabbing marked as behaviors occurring one to three days, verbal behaviors directed towards others including threatening others, screaming at others, cursing at others marked as behavior occurring one to three days, other behavioral symptoms not directed towards others including physical symptoms such as hitting or scratching self, pacing, rummaging, verbal/vocal symptoms like screaming or disruptive sounds and rejection of care occurring one to three days. An interview on 03/24/25 at 10:45 A.M. with Licensed Practical Nurse (LPN) #801 and LPN #802 revealed baseline care plans were to be completed on the first day of admission. LPN #801 and #802 both revealed Resident #40 was verbally and physically aggressive. An interview on 03/26/25 at 12:55 P.M. with LPN #803 revealed Resident #40 was not appropriately placed in the facility and needed a facility that was better suited to handle his behaviors. LPN #803 verified a baseline care plan should have been completed for Resident #40 on his date of admission to the facility. LPN #803 confirmed Resident #40's baseline care plan was dated 01/31/25 and was not filled out appropriately to include information under the Social Services section to direct staff about Resident #40's mental health needs, and behavior concerns. LPN #803 stated there should have been information including diagnosis, goals and behavior interventions listed. Review of the facility policy titled Care Plans-Baseline, last revised March 2022, revealed the baseline care plan was to include instructions needed to provide effective, person-centered care of the resident which meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: A. initial goals based on admission orders and discussion with the resident/representative, B. physician orders, C. Dietary orders, D. therapy services, E. Social Services; and F. PASARR recommendations if applicable. This deficiency represents non-compliance investigated under Complaint Number OH00163841.

Based on medical record review, observation, interview and policy review, the facility failed to ensure Resident #53 received medications in a timely manner. This affected one resident (#53) of four residents reviewed for medication administration. The facility census was 91. Findings include: A review of medical records for Resident #53 revealed an admitted [DATE]. Significant diagnoses included schizoaffective disorder bipolar type, major depressive disorder, nicotine dependence, obesity due to excessive calories, bipolar disorder, unspecified, mild intellectual disability, type two diabetes mellitus, schizophreniform disorder, anxiety, Tourette's disorder, hypertension, and asthma. Significant orders included, Abilify 12 milligrams (mg) (antipsychotic), one tablet daily for schizoaffective disorder, bipolar type and schizophreniform disorder, acidophilus 100 mg (probiotic) one capsule orally one time a day for gastrointestinal health, Colace 100 mg (stool softener), one tablet one time a day to prevent constipation, Depakote 500 mg (anticonvulsant), two tablets by mouth one time a day at bedtime, Dupixent 300 mg per two milliliters (monoclonal antibody to treat severe eczema), inject one syringe subcutaneously every 14 days, Melatonin (hormone to treat insomnia) 5 mg, two tablets by mouth one time a day at bedtime for insomnia, Metformin 500 mg (antihyperglycemic), one tablet by mouth in the morning for diabetes, MiraLAX 17 grams (laxative), give 17 grams by mouth one time a day for constipation, Pravastatin 10 mg (statin to treat high cholesterol), give one tablet by mouth one time a day for hyperlipidemia, Propranolol 80 mg (beta blocker to treat hypertension), give one tablet by mouth one time a day for blood pressure, protoxin 40 mg proton-pump inhibitor to treat gastroesophageal reflux disease), give one tablet by mouth one time a day for gastrointestinal reflux for six weeks dated 01/09/25, Singulair 10 mg (medication to treat asthma), give one tablet by mouth daily for allergies, Trazodone 25 mg (antidepressant), give one tablet by mouth at bedtime for difficulty sleeping, vitamin D-125 micrograms (mcg) (supplement), give one capsule by mouth one time daily for vitamin deficiency, Vraylar 1.5 mg (antipsychotic), give one capsule by mouth daily for anxiety at bedtime, fish oil 1000 mg (supplement), give one capsule by mouth two times a day with breakfast and at bedtime., Fluticasone (steroid), one puff orally two times a day for asthma, Olmesartan 20 mg (medication to treat hypertension), give one tablet by mouth two times a day for hypertension at 9:00 A.M. and 9:00 P.M., Pepcid 20 mg (medication to treat gastroesophageal reflux disease), give one tablet by mouth two times a day for dyspepsia at breakfast and bedtime, Buspar 15 mg (antianxiety), give one tablet by mouth three times a day for anxiety at breakfast, lunch, and bedtime. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was cognitively intact. Review of the self-medication assessment dated [DATE] revealed Resident #53 was not capable of self-administering oral medications. Review of the medication administration record (MAR) dated 01/01/25 through 01/31/25 for Resident #53 revealed morning medications were Abilify 12 mg at breakfast, acidophilus 100 mg at breakfast, Colace 100 mg at breakfast, Metformin 500 mg at 8:00 A.M., MiraLAX 17 grams at breakfast, Propranolol 80 mg at breakfast, Singulair 10 mg at breakfast, vitamin-D 125 mcg at breakfast, fish oil 1000 mg at breakfast, Fluticasone inhalation at breakfast, Olmesartan 20 mg at 9:00 A.M., Pepcid 20 mg at breakfast and Buspar 15 mg at breakfast. On 01/21/25 at 11:45 A.M. an interview with Resident #53 revealed he had just received his morning medications. On 01/21/25 at 11:50 A.M. an interview with Licensed Practical Nurse (LPN) #267 revealed she had just given Resident #53 his morning medications. LPN #267 also verified that the medications were given late. A review of the facility listed medication times revealed one time a day medication should be administered between 4:00 A.M. and 10:00 A.M. Medications with meals should be administered at 8:00 A.M. A review of the policy titled Medication Administration dated December 2012 revealed medication shall be administered in a safe and timely manner and as prescribed. Sub point #4 states medications must be administered within one hour of their prescribed time unless otherwise specified. This deficiency represents non-compliance investigated under Master Complaint Number OH000161096.

Based on interview and observation the facility failed to ensure foods were served at a palatable temperature. This had the potential to affect 81 of the 83 residents in the facility. Two residents (#34 and #84) were identified by the facility as receiving nothing by mouth. The facility census was 83. Findings include: On 08/27/24 at 11:22 A.M. observation of the lunch tray line revealed all temperatures met or exceeded requirements. The baked ham was 202 degrees Fahrenheit (F), the buttered noodles were 184 degrees F, and the cabbage was 180 degrees F. On 08/27/24 at 12:44 P.M. a test tray was assembled. The tray left the kitchen at 12:35 P.M., arrived at the unit at 12:46 P.M. Nursing began passing the unit's lunch trays at 12:47 P.M. On 08/27/24 at 12:57 P.M. all the lunch trays had been passed and the food temperatures of the test tray were taken by Dietary Manager #354. The ham was 126 degrees F, the noodles were 108 degrees F, and the cabbage was 111 degrees F. The food items all had good flavor; however, the temperatures were too low for palatability. Dietary Manager #354 verified the tray temperatures at the time they were taken.

Based on review of Notice of Medicare Non-Coverage (NOMNC) letters and staff interview, the facility failed to provide required 48-hour notice for last covered day of therapy, failed to provide the correct last covered day, failed to provide appeal information, and did not place the resident name or identifying number on the on the NOMNC letter. This affected three residents (#342, #343 and #344) of three reviewed for liability notices. The facility census was 83. Findings include: 1. Review of Resident #342's medical record revealed an admitted [DATE]. A NOMNC letter revealed services were ended on 03/22/24, the last covered day (LCD). Resident #342 discharged on [DATE], the LCD should have been 03/21/24. The NOMNC did not have the appeal agency phone number listed and there was no resident name or identifying number on the notice. 2. Review of Resident #343's medical record revealed an admitted [DATE]. The resident started skilled therapy on 02/20/24. A NOMNC letter revealed services were ended on 04/19/24, the LCD. Resident #343 was discharged on [DATE], so the LCD should have been 04/18/24. Resident #343 signed the notice on 04/19/24 and did not receive the required 48-hour notice, to be able to appeal the discharge date . The NOMNC did not have the appeal agency phone number listed and there was no resident name or identifying number on the notice. 3. Review of Resident #344's medical record revealed an admitted [DATE]. The resident started skilled therapy on 01/25/24. A NOMNC letter revealed services were ended on 03/06/24. Resident #344 signed the notice on 03/06/24 and did not receive the required 48-hour notice, to be able to appeal the discharge date . The NOMNC did not have the appeal agency phone number listed and there was no resident name or identifying number on the notice. Interview on 08/26/24 at 1:02 P.M. Social Service Coordinator #352 verified the NOMNC letters contained the wrong dates for the last covered day, did not provide the residents the required time to appeal their discharge date , did not provide the contact information for the appeal agency, and did not contain the resident names or identifying information. Interview on 08/28/24 at 12:05 P.M. with Administrator #355 revealed there was no policy for beneficiary notices, the facility followed Medicare guidelines.

Based on record review, interview, and facility policy review the facility failed to follow recommendations to monitor weights after a significant weight loss for Resident #65. This affected one resident (#65) of two residents reviewed for weight loss. The facility census was 83. Findings include: Review of the medical record for Resident #65 revealed an initial date of admission of 10/15/22. Resident #65 was readmitted to the facility after a recent hospital stay on 04/26/24. Significant diagnoses included post-traumatic stress disorder, depression, presence of cerebrospinal fluid drainage device, anxiety, bipolar disorder, and congenital hydrocephalus. Significant orders included Invega six milligrams (mg) (antipsychotic) daily for psychosis, clonazepam 0.5 mg (benzodiazepine); give 0.25 mg by mouth every six hours as needed for anxiety, regular, no salt packet diet, mechanical soft/dental soft texture, thin consistency fluids and, Ensure (nutritional supplement) one can three times daily. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was cognitively intact. Review of the care plan dated 06/11/24 revealed Resident #65 was at risk for drug related side effects due to the use of psychoactive drug regime. Interventions included monitor for change in appetite or weight. The care plan also revealed on 12/08/23 Resident #65 had the behavior of binge eating and vomiting whole food items. Interventions included to encourage Resident #65 to eat slowly and chew her food and sit upright when eating. Review of Resident #65's weights revealed on 02/04/2024, the resident weighed 242 pounds. On 08/23/2024, the resident weighed 211 pounds which is a 12.81 percent weight loss in six months. Review of a dietary note dated 07/11/24 authored by Registered Dietitian/Licensed Dietitian (RD/LD) #367 revealed Resident #65 triggered for significant weight change. Meal intake varied averaging 50 percent. RD/LD #367 made the recommendation for Resident #65 to obtain weekly weights. Review of weight notes for Resident #65 revealed a weight of 211.2 pounds on 07/05/24 and a weight of 211.5 pounds on 08/23/24. There were no weekly weights noted in Resident #65 records. On 08/28/24 at 11:35 A.M. an interview with RD/LD #367 revealed Resident #65 did not have the weekly weights obtained as recommended on 07/11/24. RD/LD #367 stated she comes to the building weekly, and there were no weights for review for Resident #65. On 08/28/24 at 1:30 P.M. an interview with the Regional Director of Clinical Services (RDCS) #360 revealed there were no weekly weights obtained for Resident #65. RDCS #360 verified the facility did receive the recommendations from RD/LD #367 to obtain weekly weights for Resident #65 on 07/11/24. Review of the facility policy titled; Weight Assessment and Intervention, dated September 2008, revealed the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for residents.

Based on record review and interview the facility failed to provide adequate assistance/supervision to prevent a fall with injury for Resident #58. This affected one resident (#58) of three residents reviewed for accidents. The facility census was 88. Actual Harm occurred on 06/08/24 when Resident #58, who was assessed as requiring substantial/maximal assistance with showers, was left unattended in the shower, resulting in a fall with a right hip fracture. Findings include: Review of the medical record for Resident #58 revealed an admitted [DATE] with diagnoses including fracture of the left femur on 01/28/20, chronic pain syndrome, and difficulty walking. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/09/24, revealed Resident #58 had intact cognition. The assessment revealed the resident required substantial/maximal assistance for showers, upper body dressing, and lower body dressing. The assessment also noted the resident used a power wheelchair for mobility. Review of the plan of care (initiated 01/18/18) and last revised on 05/12/24 revealed the resident was at risk for falls due to a history of falls, poor safety awareness, and non-compliance with fall interventions. On 02/09/22 the care plan interventions were updated to include staff education to never leave the resident unattended during shower. Review of a nursing note dated 06/08/24 at 2:12 P.M. revealed Resident #58 had a fall in the shower. Agency Licensed Practical Nurse (LPN) #306 and Agency State tested Nursing Assistant (STNA) #305 were sitting at the nursing station and heard the resident call out for help. Agency STNA #305 went to check on the resident and came back to the nursing station and stated the resident was on the floor. When the nurse got into the shower room the resident was lying on her left side. The resident stated she was trying to fold a blanket that was on the floor and fell on to her right side. The resident stated she couldn't move her leg and that her hip was hurting her badly, rating her pain a ten, on a scale from zero to ten, ten being severe. The nurse gave the resident as needed (PRN) pain medication and called 911 for transport. Resident #58 was taken out via stretcher to the hospital. Review of the nursing note dated 06/08/24 at 6:23 P.M. revealed the nurse spoke with the hospital. Resident #58 had a right hip fracture. Review of the fall investigation dated 06/08/24 revealed the investigation reflected the contents of the corresponding nursing note. Witness statements from Agency STNA #305 and Agency STNA #307 confirmed they had not supervised or assisted Resident #58 with her shower or dressing afterwards. Interview on 06/28/24 a 9:50 A.M. with Resident #58 revealed she usually showered without (staff) assistance. The day of the fall, the resident stated she had already finished her shower and gotten dressed. The resident stated she was standing and had bent over to pick up one of the shower blankets when she fell . Interviews on 06/28/24 from 12:20 P.M. through 12:40 P.M. with Registered Nurse (RN) #302, STNA #303 and STNA #304 revealed Resident #58 wanted to remain as independent as possible and the resident did not like anyone helping with her shower. The resident would tell staff she could do it herself, so staff stated they would set the resident up and quietly check on her every three to ten minutes. Interview on 06/28/24 at 1:29 P.M. with Agency STNA #305, who was Resident #58's STNA on 06/08/24 at the time of the fall with injury, revealed when she had worked at the facility before, Resident #58 only needed for staff to get her towels and set her up. The Agency STNA revealed Resident #58 had been in the shower for about thirty minutes. Agency STNA #305 revealed she didn't go into the shower room during the resident's shower. When Agency STNA #305 then did go into the shower room (after hearing the resident call for help) the resident was on the floor in pain. Interview on 06/28/24 at 2:24 P.M. with the Administrator verified there was a care plan for Resident #58 to have supervision/assistance in the shower, and the resident was not supervised or assisted with a shower on 06/08/24 resulting in a fall with fracture/injury. This deficiency represents non-compliance investigated under Complaint Number OH00154828.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure residents with food allergies and/or food intolerances did not receive those foods at meals. This affected one resident (#15) out of three residents reviewed for food allergies/intolerances. The facility identified ten residents (#7, #8, #15, #41, #42, #44, #47, #60, #64, and #79) as having known food allergies. The facility census was 96. Findings include: Review of medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included type two diabetes with foot ulcer, chronic systolic (congestive) heart failure, essential hypertension (high blood pressure), and unspecified protein-calorie malnutrition. Resident#15 was on a regular diet with mechanical soft/dental soft texture. Resident #15 was cognitively intact and required setup or cleanup assistance for eating. Resident #15 had a known allergen to cheese. Review of care plan, initiated 02/28/24, revealed the Resident #15 had a potential for allergic reaction with a known allergy to cheese with a goal the resident would not receive substances known to cause an allergic reaction. Observation during lunch on 04/10/24 at 12:50 P.M. revealed Resident #15, who was allergic to cheese, was served mechanical soft chicken, lima beans and au gratin potatoes. The au gratin potatoes appeared untouched. Observation of Resident #15's meal ticket on the lunch meal tray revealed no indication of Resident #15 having a cheese allergy. Interview at the time of observation on 04/10/24 at 12:50 P.M. with Resident #15 confirmed his allergy to cheese with Resident #15 stating I told them and my sister told them I am allergic to cheese, and I get cheese items all the time. Observation of Resident #15's meal tray and interview on 04/10/24 at 12:55 P.M. with Licensed Practical Nurse #361 confirmed Resident #15 had received au gratin potatoes. Review of the facilities Fall and Winter week one menu for 2023 and 2024 revealed golden brown chicken, au gratin potatoes, buttered lima beans, and iced lemon sugar was to be served for lunch on 04/10/24. Review of the facility concern report, dated 03/13/24, initiated by Resident #15 revealed he was allergic to cheese and was still receiving cheese. The facility follow up on the concern report indicated the tray card had been updated. Interview on 04/10/24 during kitchen observation between 1:06 P.M. and 1:15 P.M. with Regional Dietary #374 revealed food allergies were loaded into the tray ticket system, and food allergies were indicated on the tray tickets. Periodically the food service manager would cross-reference the food allergies listed in the electronic medical record to ensure the two matched. Interview on 04/10/24 at 1:15 P.M. with Dietary Cook #376 confirmed the tray tickets were how dietary staff knew of a food allergy. Observation of Resident #15's lunch tray ticket for 04/10/24 and cheese allergy notation in the electronic medical record and interview on 04/11/24 at 9:29 A.M. with the Administrator, Regional Nurse #373, and Regional Dietary #374 confirmed Resident #15's food allergy to cheese was not listed on his tray card as it should be, and staff would have no idea Resident #15 was allergic to cheese. Review of the manufacturer box of Basic American Foods Au Gratin Potatoes Reduced Sodium (the au gratin potatoes which were served the previous day for lunch) with Regional Dietary # 374 revealed cheddar cheese was listed in the ingredient list and interview on 04/11/24 at 9:50 A.M. with Regional Dietary #374 confirmed au gratin potatoes should not have been served to a resident with a cheese allergy. Review of facility policy Food Allergies and Intolerances, revised October 2008, revealed residents with food allergies and/or intolerances will be identified upon admission and steps will be taken to prevent resident exposure to the allergen(s). This deficiency represents non-compliance investigated under Complaint Number OH00152203.

Based on observation, interview, record review and facility policy review revealed the facility failed to ensure resident room temperatures were maintained at a comfortable level for residents and between 71 to 81 degrees Fahrenheit as required. This had the potential to affect 49 residents (#1, #2, #4, #5, #6, #7, #8, #9, #12, #13, #16, #17, #19, #20, #21, #22, #24, #29, #30, #31, #32, #34, #35, #36, #37, #39, #43, #49, #55, #56, #58, #59, #62, #64, #65, #67, #71, #73, #74, #75, #77, #78, #81, #82, #84, #85, #95, and #97) who resided on the Elmwood and [NAME] units and one additional resident (#26) who resided on the Magnolia Unit identified through interview. The facility census was 99. Findings Include: Review of the facility room temperature logs revealed the following temperatures obtained on 02/04/24, 02/05/24 and 02/06/24: On 02/04/24 at 8:00 A.M. 37 residents (32 rooms) had room temperatures below 71.0 degrees F: room [ROOM NUMBER] - 66.6 degrees F room [ROOM NUMBER] - 66.2 degrees F room [ROOM NUMBER] - 66.4 degrees F room [ROOM NUMBER] - 65.7 degrees F room [ROOM NUMBER] - 65.3 degrees F room [ROOM NUMBER] - 62.8 degrees F room [ROOM NUMBER] - 63.7 degrees F room [ROOM NUMBER] - 61.5 degrees F room [ROOM NUMBER] - 69.3 degrees F room [ROOM NUMBER] - 66.4 degrees F room [ROOM NUMBER] - 67.6 degrees F room [ROOM NUMBER] - 67.3 degrees F room [ROOM NUMBER] - 68.5 degrees F room [ROOM NUMBER] - 68.5 degrees F room [ROOM NUMBER] - 65.1 degrees F room [ROOM NUMBER] - 64.4 degrees F room [ROOM NUMBER] - 65.8 degrees F room [ROOM NUMBER] - 65.3 degrees F room [ROOM NUMBER] - 68.9 degrees F room [ROOM NUMBER] - 68.3 degrees F room [ROOM NUMBER] - 68.5 degrees F room [ROOM NUMBER] - 66.0 degrees F room [ROOM NUMBER] - 67.2 degrees F room [ROOM NUMBER] - 68.7 degrees F room [ROOM NUMBER] - 69.6 degrees F room [ROOM NUMBER] - 66.7 degrees F room [ROOM NUMBER] - 69.0 degrees F room [ROOM NUMBER] - 67.4 degrees F room [ROOM NUMBER] - 68.3 degrees F room [ROOM NUMBER] - 68.3 degrees F room [ROOM NUMBER] - 68.0 degrees F room [ROOM NUMBER] - 69.0 degrees F room [ROOM NUMBER] - 67.8 degrees F On 02/05/24 temperatures taken at 1:00 P.M. revealed eight resident rooms were below 71 degrees F: room [ROOM NUMBER] - 68.8 degrees F room [ROOM NUMBER] - 70.5 degrees F room [ROOM NUMBER] - 70.0 degrees F room [ROOM NUMBER] - 70.3 degrees F room [ROOM NUMBER] - 70.0 degrees F room [ROOM NUMBER] - 70.9 degrees F room [ROOM NUMBER] - 69.6 degrees F room [ROOM NUMBER] - 69.3 degrees F On 02/06/24 temperatures taken at 8:30 A.M. revealed two resident rooms were below 71 degrees F: room [ROOM NUMBER] - 68.0 degrees F room [ROOM NUMBER] - 68.0 degrees F Interview on 02/06/24 at 12:50 P.M. with Interim Administrator #300 and Travel Director of Nursing (DON) #301 revealed in the older parts of the building there were registers that ran on a boiler system. The facility had identified an issue with these boilers approximately three to four weeks ago. The facility had repairs made but still had an air exchanger they were waiting on a part for. Interviews on 02/06/24 at 1:20 P.M. and 1:57 P.M. with Regional Maintenance Director #308 revealed the facility had a heat problem for the last three to four weeks. One boiler was working fine. The problem was with the air exchangers. There was one working now and they received quotes on the second one. They had been in contact with the company to get it fixed but had been unable to get the parts to fix it. The facility brought in four portable heat pumps. Interview on 02/06/24 at 3:31 P.M. with Resident #26, who resided on the Magnolia unit, stated her room was cold last night, and staff got her another blanket. The resident had a PTAC unit (individual heating unit) that broke, and she was moved to another room on the Magnolia unit. Interviews on 02/06/24 from 3:33 P.M. through 4:45 P.M. with residents from the [NAME] and Elmwood units revealed five residents, Resident #8 #16, #21, #22, and #77 voiced concerns with room temperatures/heat and indicated they felt their rooms were cold at night. On 02/07/24 from 7:45 A.M. through 7:56 A.M. observations of the resident room temperatures revealed two rooms on the Elmwood and [NAME] units were below 71 degrees F, the temperature in room [ROOM NUMBER] was 68.9 degrees F, and the temperature in room [ROOM NUMBER] was 69.4 degrees F. Interview on 02/07/24 at 11:38 A.M. with the Administrator verified the room temperature logs and temperatures taken during the survey identified resident room temperatures had not been maintained between 71 and 81 degrees Fahrenheit as required. Review of the facility undated policy and procedure for Extreme Cold Temperature defined optimal internal environment temperature range: (as defined by CMS) 71 degrees F and 81 degrees F. The policy revealed the facility would provide a safe, clean and comfortable and homelike environment including a comfortable and safe regulated temperature range of 71 degrees to 81 degrees within the facility. The policy included this ambient air temperature range minimized resident's susceptibility to loss of body heat and risk of hypothermia or hyperthermia and provides a comfortable homelike setting. This deficiency represents non-compliance investigated under Complaint Number OH00150821.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, review of an emergency medical service run report, review of hospital medical records, review of witness statements, review of a mechanical lift sling invoice, review of the mechanical lift instruction manual, review of the mechanical lift sling owner's manual, review of facility policy, and interview, the facility failed to ensure a mechanical lift and mechanical lift sling were used according to manufacturer's guidelines and failed to ensure proper mechanical lift transfer technique was used for Resident #58 to prevent a fall with injury. This affected one resident (#58) of three residents reviewed for falls. The census was 97. Actual harm occurred on 10/30/23 at approximately 10:58 A.M., when a mechanical lift was used with an incompatible mechanical lift sling and one of two staff members present during the mechanical lift transfer was not actively assisting with the transfer to guide Resident #58 from bed to wheelchair during the transfer resulting in Resident #58 sliding out of the mechanical lift sling, hitting his head on a nightstand and landing face down on the floor. Resident #58 sustained a closed head injury and subacute multifocal scapular fractures involving the acromion, coracoid and inferior tip. Subsequently, Resident #58 suffered from shoulder pain resulting in the need for topical gel for pain/inflammation, a topical Lidocaine patch and oral pain medications. Resident #58 also had a decrease in range of motion, strength and functional use to the right upper extremity as a result of the incident/injury. Findings include: Review of the medical record for Resident #58 revealed an admitted [DATE] with diagnoses of multiple sclerosis, morbid obesity, epilepsy, lymphedema, anxiety, osteoarthritis, disorders of bone density and peripheral vascular disease. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #58 was cognitively intact, was totally dependent on two-person staff for transfers and used a wheelchair for mobility. Review of the fall care plan updated 11/02/23 revealed Resident #58 was at moderate risk for falls related to being non-ambulatory status secondary to multiple sclerosis, seizures, required a Hoyer (mechanical lift) for transfers and used an electric wheelchair for mobility. Fall interventions included two-staff for bed mobility and transfers for safety and to Hoyer lift with two staff assistance. Review of the October 2023 physician orders revealed an order for transfers via Hoyer lift with assist of two staff. Review of the nursing note dated 10/30/23 timed 12:26 P.M. revealed at 10:58 A.M., the nurse was told by an STNA that Resident #58 had fallen out of the Hoyer pad onto the floor during transfer. Resident #58 was observed lying face down on the floor with his upper abdomen and legs across the legs of the Hoyer lift. The Director of Nursing (DON) and Administrator were notified. The STNA stated Resident #58 hit his head on the nightstand. No bleeding was observed. The Nurse practitioner (NP) was notified at 11:01 A.M. of the fall and Emergency Medical Services (911) was called at 11:05 A.M. Red marks were observed across upper abdomen area and left knee. Resident #58 was lifted off the floor onto the emergency department gurney. Resident #58 left the facility at 11:15 A.M. Review of an incident report dated 10/30/23 timed 11:00 A.M. revealed at 10:58 A.M., the nurse was told by a State tested Nurse Aide (STNA) that Resident #58 had fallen out of the Hoyer pad onto the floor during transfer. Resident #58 was observed lying face down on the floor with his upper abdomen and legs across the legs of the Hoyer lift. The STNA stated Resident #58 hit his head on the nightstand. No bleeding was observed. Resident #58 was alert and oriented to person, situation, place and time. Resident #58 rated pain to his right cheek and right shoulder a 10 out of 10 (zero being no pain and 10 being severe). There were red marks to his upper abdomen and left knee. Review of the weights/vitals tab in the electronic medical record revealed Resident #58 rated his pain at a 10 out of 10 on 10/30/23 at 12:13 P.M. Review of the advanced pain and vitals only note dated 10/30/23 timed 12:28 P.M. revealed Resident #58 had vocal complaints of pain to his right anterior shoulder with a pain score of six out of 10. Review of the Emergency Medical Services (EMS) run report dated 10/30/23 revealed EMS were dispatched to the facility for a male who fell . Upon arrival, Resident #58 was lying on the base of the Hoyer lift next to his bed. Staff stated that resident fell from the lift pad. Resident #58 was lying prone and was complaining of right shoulder pain and pain on the right side of his face. Resident #58 was alert and oriented times four spheres (person, time, place and situation). Resident #58 was slightly lifted to move the Hoyer lift out from underneath him. Resident #58 was rolled onto his back on a sheet and lifted off the ground to the cot and secured. The EMS report indicated Resident #58 was on blood thinner medication and hit his face when he fell . Resident #58 had notable injuries and continued to complain of right shoulder pain when moved. Review of the hospital emergency physician note dated 10/30/23 revealed Resident #58 presented with a fall. Resident #58 was being lifted with new sling and Hoyer lift and resident fell out of sling landing on face and right shoulder. Resident #58, a [AGE] year old male, presented to the emergency room with chief complaint of face pain. Resident #58 reported that he was on a Hoyer lift where he was accidentally dropped. Resident #58 was able to move his right shoulder but did complain of some pain. X-rays were negative. The plan was to discharge the resident back to the nursing home. The diagnosis was closed head injury. Review of the nursing note dated 10/30/23 timed 7:02 P.M. revealed the nurse called the hospital emergency department for an update. Resident #58 would be coming back to the facility. The hospital nurse stated all x-rays were negative (head, right arm and shoulder). Review of the witness statement dated 10/30/23 authored by STNA #8 revealed, we got the sling hooked up on the Hoyer, raised Resident #58 up over the bed when I started to move the resident in the Hoyer. The other aide was walking around the bed to come to assist me and before she made it there, Resident #58 fell over to the right and slipped out of the side of the sling falling face down. Review of the witness statement dated 10/30/23 authored by STNA #9 revealed, we got the sling hooked up on the Hoyer then raised Resident #58 up over the bed. The other aide then started to move Resident #58 in the Hoyer while I was walking around bed to assist her. Before I made it there, Resident #58 fell over to the right, slipped out the side of the sling falling face down. Review of the nursing note dated 10/31/23 timed 3:24 P.M. revealed Resident #58 had complaints of right shoulder pain. It was explained to Resident #58 the CT scan was negative. Resident #58 refused ice and heat. the NP was notified and new order received for Voltaren Gel (a topical medicated gel for muscle and joint pain) to the right shoulder every six hours for pain. Review of the late entry nursing note created 11/01/23, effective for 10/31/23 revealed an interdisciplinary team note indicating the fall on 10/30/23 was reviewed with an intervention for a new Hoyer sling. Review of the occupational therapy (OT) evaluation dated 11/01/23 revealed Resident #58 had a recent fall from Hoyer lift during staff transfer and now complained of right shoulder pain, decreased range of motion (ROM) and decreased functional use. Resident #58 reported pain of eight out of 10, was unable to operate joystick of wheelchair with right hand and had notable loss of ROM and strength in right upper extremity (RUE). Resident #58 referred to OT services to decrease pain in RUE and facilitate functional use of RUE and return to prior level of function. Review of the nurse practitioner (NP) progress note dated 11/01/23 revealed Resident #58 had a chief complaint of right shoulder pain. Resident #58 had a fall and was sent to the emergency department and x-rays were okay including scan to brain since on blood thinners. Resident #58 still complained of shoulder pain and was working with therapy despite pain medications ordered. He had no neurological changes and no vision changes or headaches from hitting head. Denied nausea and vomiting. Resident #58 appeared in mild moderate acute distress (shoulder pain). Unable to do good passive ROM to right shoulder due to pain. X-rays and scans were negative at hospital. On as needed pain medications. The note indicated Lidocaine patch (a medicated patch used to relieve the pain) to site would be added and if still pain working with therapy, could need further imaging like CT of shoulder. Review of the nursing note dated 11/03/23 timed 11:28 P.M. revealed the NP was in to see Resident #58. New order for Lidocaine patch 4% to right shoulder related to pain and discontinue Voltaren gel. Review of the nursing note dated 11/03/23 timed 11:31 P.M. revealed Lidocaine patch to be placed daily and removed at bedtime. Review of the nursing note dated 11/08/23 timed 9:48 A.M. revealed Resident #58 had complaints of pain to right shoulder post fall. New order per NP for x-ray to right shoulder. Review of the nursing note dated 11/09/23 timed 12:45 P.M. revealed x-ray of right shoulder done and sent to physician with no new orders. Impression: no acute fracture or dislocation. Review of the nursing note dated 11/15/23 timed 3:11 P.M. revealed the NP was in to see Resident #58 on this date. New order for CT scan with contrast of right shoulder related to pain to rule out rotator cuff tear status post fall. CT scan with contrast was scheduled for 11/28/23 at 12:00 P.M. Resident #58 had a pulmonary appointment on this same day. Per resident request, it was rescheduled. Review of the late entry lab note created 11/29/23, effective for 11/28/23 timed 3:04 P.M. revealed Resident #58 was taken to CT scan at hospital. Returned from scan without incident. Awaiting report. Review of the CT right shoulder without intravenous (IV) contrast radiology result dated 11/29/23 revealed Resident #58 had subacute multifocal scapular fractures involving the acromion, coracoid and inferior tip. Review of the nursing note dated 11/30/23 timed 7:59 A.M. revealed CT results of right shoulder revealed subacute multifocal fracture of the scapula, in the acromion, coracoid, and inferior tip of the scapula with comminution. No fracture or dislocation elsewhere. The findings were discussed with Resident #58. Resident #58 stated he continued to have pain in right shoulder which worsened with movement. Rated pain as a seven out of 10. Resident #58 was willing to try Percocet (an oral narcotic pain medication) for pain. The NP was aware and was getting STAT (immediate) order for Percocet. The NP contacted a shoulder specialist for further evaluation and management. Review of the November 2023 physician orders revealed Resident #58 was ordered Percocet oral tablet 5-325 milligrams (mg) give one tablet by mouth every six hours as needed for right shoulder pain. The order started on 11/30/23. Review of the November 2023 Medication Administration Record (MAR) revealed Resident #58 was administered Percocet oral tablet on 11/30/23 at 9:11 A.M. for a pain of eight out of 10. Review of the December 2023 MAR revealed Resident #58 was administered Percocet oral tablet on the following dates and times with corresponding pain level: on 12/01/23 at 8:02 A.M. with a pain level of six, on 12/01/23 at 4:54 P.M. with a pain level of eight, on 12/02/23 at 5:00 A.M. with a pain level of eight, on 12/02/23 at 11:00 A.M. with a pain level of eight, on 12/02/23 at 6:02 P.M. with a pain level of eight, on 12/03/23 at 9:53 A.M. with a pain level of nine and on 12/03/23 at 4:14 P.M. with a pain level of eight. Observation on 11/28/23 at 9:53 A.M. revealed Resident #58 was lying in bed. Resident #58 had a motorized wheelchair in his room. Interview, during the observation, with Resident #58 verified he was dropped from the mechanical lift to the floor during a transfer from his bed to his wheelchair. When Resident #58 was dropped, he landed on his right shoulder and was in a lot of pain. Resident #58 explained that the staff were using a new sling that crisscrossed and he slid out of the sling. STNA #8 and STNA #9 were the staff who transferred him that day. Resident #58 also stated since being dropped from the mechanical lift sling, he could not do therapy, lift weights and he tried to do ROM on his right shoulder and it didn't feel good. Interview on 11/28/23 at 10:45 A.M. with STNA #8 verified herself and STNA #9 were completing a mechanical lift transfer from Resident #58's bed to his wheelchair when Resident #58 slid out of the mechanical lift sling onto the floor. STNA #8 explained Resident #58 had a newer sling that crisscrossed at his legs which positioned the resident in a laidback position rather than sitting up. STNA #8 felt the sling was too big for Resident #58. STNA #8 revealed she was operating the mechanical lift, lifted Resident #58 approximately six inches away from the bed while STNA #9 was walking around the bed (at the bottom of the bed). At that time, STNA #8 pulled Resident #58 back (while gripping the sling) towards her when Resident #58 slid out of the sling between the top and middle portion of the sling, hitting his head on the nightstand and falling face down on the floor. STNA #8 verified Resident #58 continued to complain of pain to his right shoulder. Interview on 11/28/23 at 11:10 A.M. with STNA #9 verified herself and STNA #8 were completing a mechanical lift transfer from Resident #58's bed to his wheelchair when Resident #58 slid out of the mechanical lift sling onto the floor. STNA #9 explained the crisscross sling was used and all six hooks were hooked to the mechanical lift when STNA #8 used the mechanical lift to lift the resident off the bed while STNA #9 was walking around the bed when Resident #58 leaned to the right and slid out of the right side of the sling, between the top and middle portion of the sling, falling face down onto the floor. When the ambulance came and moved Resident #58, he yelled out in pain to his right shoulder. STNA #9 verified Resident #58 continued to complain of pain to his right shoulder. STNA #9 felt the newer crisscross sling was too big. During observation on 11/28/23 at 12:45 P.M. with STNA #8 and STNA #10, STNA #8 identified the mechanical lift on the hallway where Resident #58 resided as the mechanical lift that was used when Resident #58 slid out of the sling. It was a Joern's Hoyer HPL700 mechanical lift. There was a sticker on the boom or arm of the mechanical lift that read, Safety notice: not all slings are compatible with this lifting device. It is the policy of Joern's Healthcare to recommend that only Joern's slings be used with Joern's lifts. Interview on 11/28/23 at 3:00 P.M. with the Administrator, Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) #21 revealed they were not aware the sling was not compatible with the mechanical lift that was used to transfer Resident #58 when he slid out of the sling. In addition, the Administrator, DON and RDCS #21 verified STNA #8 should have waited to lift Resident #58 off the bed until STNA #9 was nearby. Observation on 11/28/23 at 3:30 P.M. of the sling used when Resident #58 slid out of the sling (with the Administrator present) revealed Resident #58's first name was written in black permanent marker at the head of the back of the sling. The sling was manufactured by Direct Supply. The label attached to the sling stated, WARNING: this sling is intended ONLY for use with lifts indicated in the most recent version of Compatibility Guide. Never alter slings, exceed weight limit, or use this sling with any other make or model resident lift. Interview on 12/04/23 at 9:00 A.M. with the Administrator and [NAME] President of Clinical Operations #22 verified the Direct Supply sling was not listed in the most recent Direct Supply Compatibility Guide and verified the facility's policy stated to follow the manufacturer's guidelines for mechanical lifts and mechanical lift slings. Interview on 12/04/23 at 3:50 P.M. with Joern's Healthcare Customer Service for Product Support Representative (CSPSR) #23 revealed when the surveyor asked if a Direct Supply sling could be used on a Joern's Healthcare Hoyer lift, CSPSR #23 stated, I can't speak to that. CSPSR #23 stated he could only speak to the Joern's Healthcare Hoyer company only recommended genuine Joern's Hoyer lift slings manufactured by Joern's be used on Joern's Healthcare Hoyer lifts. CSPSR #23 explained that the Joern's Hoyer HPL500 was a standard mechanical lift whereas the Joern's Hoyer HPL700 was a bariatric mechanical lift. The company recommended that only bariatric slings manufactured by Joern's be used on the HPL700 lift. CSPSR #23 stated that Joern's bariatric lifts (such as HPL700) had a different spreader and different cradle and was engineered and built differently than a standard lift (such as HPL500). Review of the Direct Supply invoice dated 10/03/23 revealed a Direct Supply Divided Leg Sling, Multi-Brand Compatible, size Large #GV249 was purchased. The sling was delivered on 10/05/23. Review of the Direct Supply Multi-Brand Compatible Slings Owner Manual dated March 2021 revealed, this sling is intended ONLY for use with lifts indicated in the most recent version of the Compatibility Guide. Never alter slings, exceed the weight limit, or use this sling with any other make or model of resident lift. Review of the Direct Supply Sling Compatibility Guide dated November 2022 downloaded from the Direct Supply website on 11/28/23, revealed Joern's Hoyer HPL700 was not listed on the guide to be compatible with any Direct Supply sling. Review of the Joern's Hoyer HPL700 User Instruction Manual dated 2016 revealed, WARNING: HOYER RECOMMENDS THE USE OF GENUINE HOYER PARTS. Hoyer slings and lifts are not designed to be interchanged with other manufacturer's products. Using other manufacturer's products on Hoyer products is potentially unsafe and could result in serious injury to patient and/or caregiver. Review of the facility's Using a Mechanical Lifting Machine policy revised July 2017 revealed the purpose of the procedure was to establish the general principles of safe lifting using a mechanical lifting device. It was not a substitute for manufacturer's training or instructions. Before using a lifting device, assess the resident's current condition including: measure the resident for proper sling size and purpose, according to manufacturer's instructions. The deficient practice was corrected on 11/14/23 when the facility implemented the following corrective actions: On 10/30/23, an investigation and root cause anaysis was completed by the Administrator, DON, Assistant Director of Nursings and RDCS #21. On 10/30/23, the [NAME] President of Operations, [NAME] President of Clinical Operations, Quality Assurance Compliance Officer, and Regional Director of Operations were notified of Resident #58's fall from Hoyer lift sling. An abatement plan was discussed approved and put into action. On 10/30/23, the sling utilized to transfer Resident #58 (Large #GV249 ) was taken out of serive and placed in storage. On 10/30/23, The DON/designee audited all residents' fall care plans, care Kardex, and tasks for accuracy. On 10/30/23, The DON provided education to STNA #8 and STNA #9 regarding mechanical lift safety. The training including review of the facility mechanical lift policy and procedure, care giver safety tips, knowing the lift, checking resident condition before using lift, selecting resident sling size, preparing the environment, preparing the equipment, placing resident in sling, performing safety checks, lifting the resident, and lowering the resident. On 11/02/23, an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held to inform all interdisciplinary team members of details of occurrence, investigation process, and work completed. Between 11/02/13 and 11/14/23 all nursing staff received training regarding mechanical lift competency. This one hour training included Hoyer/mechancal lift transferring, using the Kardex, transfers, falls, and pain. This training was confirmed as completed by in-service sign in sheets. On 11/02/23, auditing was initiated regarding type of Hoyer/mechanical lift used and if residents were transferred per policy and procedure. Auditing to continue three times a week for four weeks and ongoing. Auditing to be completed by DON/designee. Results of audits will be submitted to the QAPI committee for further review and recommendations. This deficiency represents non-compliance investigated under Complaint Number OH00148431.

Based on observation, record review, review of a facility investigation, review of a Materials Safety Data sheet and interviews with facility staff and Resident #10's daughter, the facility failed to ensure the environment on the memory care unit was free of accident hazards and failed to provide adequate supervision to prevent Resident #10, who was severely cognitively impaired and exhibited wandering behavior from obtaining and ingesting liquid from an unsecured bottle of all-purpose lemon scented cleaner with bleach. This resulted in Immediate Jeopardy on 12/22/22 at 12:30 A.M. when State tested Nursing Assistant (STNA) #214 placed a bottle of cleaner with bleach on the microwave oven in the dining room of the memory care unit. STNA #214 left the dining room to assist another resident, when STNA #214 returned, less than 20 minutes later, STNA #214 observed Resident #10 with the bottle to her lips and reported to Licensed Practical Nurse (LPN) #376 the resident may have consumed liquid from the bottle. Resident #10 was sent to the hospital for evaluation and treatment and returned the same day with no evidence of significant changes in her condition. The risk for serious harm, injury, death as a result of the consumption of cleaner with bleach occurred when staff left chemicals unsecured on the memory care unit resulting in Resident #10 accessing and potentially ingesting the cleaning solution which could have caused intraoral trauma, burning or swelling. This affected one resident (#10) and had the potential to affect 12 additional residents (#9, #11, #12, #14, #16, #43, #47, #54, #58, #66, #77 and #91) who resided on the memory care unit. The facility census was 89. On 02/07/23 at 9:00 A.M., the Administrator, Regional Operations Manager (ROM) #375, Assistant Director of Nursing (ADON) #347, and Minimum Data Set (MDS) Coordinator #331 were notified Immediate Jeopardy began on 12/22/22 at 12:30 A.M. when Resident #10, who had severely impaired cognition and was a known wanderer, obtained and ingested liquid from an unsecured bottle of all-purpose lemon scented cleaner with bleach. The cleaning solution had not been properly secured by staff and was left unattended in a common area of the unit. The facility failed to maintain a safe resident environment by not securing the cleaning supplies. Although the facility implemented corrective actions on 12/22/22 including immediate care for Resident #10, staff education and audits to ensure chemicals were properly secured; on 02/07/23 at 8:22 A.M. chemicals were observed unsecured on the memory care unit. This included one bottle of cleaner with bleach, one bottle of multipurpose cleaner, and one bottle of toilet bowel cleaner were observed in an unsecured cabinet above a utility/handwashing sink in the center of the hallway of the memory care unit. The cabinet had a locking mechanism in place to accommodate a lock to be applied, however there was no lock in place to prevent residents from obtaining or ingesting the cleaning supplies. At the time of the observation, there were no residents observed in the immediate area and no evidence the chemicals had been accessed by residents. The Immediate Jeopardy was removed on 02/07/23 at 3:00 P.M. when the facility implemented the following corrective actions: On 02/07/23 at 1:30 P.M., ADON #320 removed the doors from the cabinet located above the utility/handwashing sink in the memory care unit. The facility implemented a new plan for all cleaning supplies to be stored in room [ROOM NUMBER] (that automatically locked upon closure and required a code entered on a keypad to open) on the memory care unit and in the housekeeping storage area in the main area of the facility by the activity room. On 02/07/23 at 1:36 P.M., all staff were educated via Carefeed communication, sent through the Administrator, on the process of all cleaning supplies to be kept in room [ROOM NUMBER]. On 02/07/23 at 3:00 P.M., agency staffing companies were contacted by the facility's scheduler regarding education to be provided to all employees utilized by the facility for chemical storage to be provided prior to the staff working in the facility. Beginning 02/07/23, a plan for the DON/or designee to validate five times weekly for eight weeks to ensure that audits and interventions were completed related to chemical storage. The Administrator and/or designee would monitor for compliance and results of the audits will be trended and results discussed with the Quality Assurance (QA) committee. Interviews on 02/09/23 from 9:10 A.M. to 11:09 A.M. with STNAs #327, #337, #339, #346, #369, LPN #354, Registered Nurse (RN) #348, RN #372, and Administrator verified education was received on 02/07/23 regarding all chemicals being stored in the locked area of room [ROOM NUMBER] on the memory care unit and not to be left unattended or unsecured. Although the Immediate Jeopardy was removed on 02/07/23 at 3:00 P.M., the deficiency remains at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Review of Resident #10's closed medical record revealed the resident had an admitted [DATE] and discharge date of [DATE]. Diagnoses included multiple sclerosis, aphasia (loss of ability to understand or express speech), dementia, need for assistance with personal care, convulsions and seizures. Review of Resident #10's care plan, initiated 08/08/22 revealed the resident had behaviors including refusal of medications and being combative with hands on care. Interventions included to educate resident, family, and caregivers of the possible outcome(s) of not complying with treatment or care; and reassure resident, leave, and return five to ten minutes later and try again. Review of Resident #10's care plan, initiated 08/26/22 revealed the resident had poor safety awareness and a wheelchair for mobility. Interventions included to be up in wheelchair daily as tolerated and maintain call light within reach at all times. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/25/22 revealed Resident #10 had severely impaired cognition and was rarely or never understood. Resident #10 was assessed to require limited one staff assistance for transfers and staff supervision without setup for locomotion on and off the unit. Review of the Wandering/Elopement Risk Assessment, dated 11/04/22, revealed Resident #10 was a known wanderer. Review of a progress note, dated 12/21/22 revealed Resident #10 was re-evaluated by psychiatry services and assessed to be non-verbal, confused at times and unable to provide meaningful responses to questions. Resident #10 was reported by staff to have increased anxiety and restlessness particularly with hands on care and to be resistant to completing activities of daily living, notably showers, being more difficult to redirect. Review of progress note dated 12/22/22 at 12:38 A.M. revealed a nursing assistant from the memory care unit reported Resident #10 was found in the memory care unit common area drinking a bottle of all-purpose lemon scented cleaner with bleach while the nursing assistant was answering a call light and all other residents were in bed. The nurse practitioner (NP) and poison control were contacted. Resident #10 was transported to the hospital and left the facility without symptoms. Resident #10's daughter was notified of the incident. Review of a progress note, dated 12/22/22 at 3:39 A.M. revealed Resident #10 returned to the facility transported by Resident #10's daughter who reported the emergency room physician evaluated the resident's throat for burns and found no abnormalities, but provided intravenous (IV) fluids to the resident. The note indicated Resident #10 was stable without discomfort. Review of a progress note, dated 12/22/22 at 9:45 A.M. revealed Resident #10 ate two helpings of breakfast and consumed 420 milliliters of fluid including one container of milk and exhibited no signs or symptoms of pain or discomfort. Medications were consumed with four ounces of water. Review of a physician's order, dated 12/22/22 at 10:54 A.M. revealed an order for the medication, Protonix (pantoprozole) 40 milligram (mg) daily for acid reduction and prevention. Review of a physician's order, dated 12/22/22 at 10:55 A.M. revealed an order to monitor resident for nausea, vomiting and diarrhea. If any bleeding, send out to emergency department (ED) for evaluation of gastrointestinal system due to ingestion of chemicals. Review of a progress note, dated 12/22/22 at 1:41 P.M. revealed the Administrator, SSW #373, and representative from MDS contacted Resident #10's daughter to follow-up regarding the incident, and there were no concerns or questions voiced from the daughter. Review of Consumption of Foreign or Hazard Substance form, dated 12/22/22 revealed an incident occurred around 12:30 A.M. and affected Resident #10 who was in the memory care unit common area and while the aide on the unit was answering a call light; poison control was notified at 12:38 A.M.; the physician and family were notified and Resident #10 was transferred to the hospital; all residents in the facility were interviewed and if not able to be interviewed received skin checks; education was provided for staff; and a Quality Assurance Performance Improvement meeting was held. Review of incident report entitled other revealed an unnamed nursing assistant working on the memory care unit reported on 12/22/22 at 12:30 A.M. Resident #10 could have ingested all-purpose surface cleaner and was observed attempting to drink the cleaning solution; Resident #10 was transported to the hospital, returned to the facility at 3:39 A.M. and was stable. On 12/22/22, cleaning supplies or solutions were removed from the unit and housekeeping initiated rounds three times daily including education to clean up messes and notify housekeeping of additional cleaning. A facility sweep was completed on 12/22/22 to ensure all cleaning solutions and or toxins were removed or stored in secured areas. Housekeeping audits were initiated on 12/22/22 and would remain ongoing. Skin sweeps and interviews with residents were completed on 12/22/22 with no negative findings. Review of written witness statement by the Administrator, dated 12/22/22 revealed around 12:30 A.M. a call was received by LPN #376 who reported a nursing assistant (unnamed) was cleaning on the memory care unit and went to answer a call light, then when coming out of a resident room saw Resident #10 with a bottle of spray cleaner up to the mouth. LPN #376 stated Resident #10's daughter, nurse practitioner and poison control were notified, and Resident #10 was sent to the emergency room . Review of a written witness statement by STNA #214 revealed the all-purpose spray cleaner with bleach was setting on the microwave when he arrived, and he used it to clean off the tables then put it back where it was before going to answer a call light. About five to ten minutes later, he returned and saw Resident #10 put her head back and start drinking it. STNA #214 immediately removed it from the resident's mouth and indicated there was hardly any in the bottle when it was used and still a decent amount in there after it was removed from Resident #10's mouth. STNA #214 stated going immediately to the LPN #376 to report the incident. Review of a written witness statement by LPN #376 revealed about 12:38 A.M. on 12/22/22 STNA #214 approached LPN #376 at the nurse's station on Elmwood carrying a bottle of all-purpose cleaner with added bleach and stated, I just found [Resident #10] drinking this in the dining room. When questioned why the cleaner was left unattended and within Resident #10's reach, STNA #214 responded he had just finished rounds and everyone was sleeping so he felt it was an okay time to clean and then a call bell went off, so he went to answer it and left the bottle on top of the microwave rather than bringing it to the room with him. LPN #376 contacted the NP and poison control and sent Resident #10 to the hospital. Resident #10 did not have any vomiting or distress. At approximately 3:30 A.M., Resident #10 returned with her daughter. The hospital evaluated for burns and no abnormalities were found. Intravenous fluids were provided. Resident #10's daughter stated Resident #10 was agitated and continuously attempted to pull out the IV. No clinical paper was given, just education paperwork regarding accidental adult poisoning. Review of the Safety Data Sheet for Lemon Bright All Purpose Cleaner with Bleach, prepared on 11/13/18, revealed first aid measures were required for exposure to the eye, skin and with inhalation, and for ingestion to obtain medical attention. Review of the hospital documentation for the emergency services visit, dated 12/22/22 timed 1:08 A.M. revealed Resident #10 was sent to the ED for ingestion of bleach. Per report, Resident #10 ingested all-purpose cleaner with bleach. It was unclear how much was ingested but there was about one third of fluid left in the bottle. The amount in the bottle prior to the incident was unknown. Resident #10 was asymptomatic and was minimally verbal. There were no intraoral signs of trauma, burning or swelling. Poison control was contacted and recommended giving water orally but had no other recommendations if asymptomatic. Laboratory and imaging tests were reviewed with the family prior to discharge. Discharge planning with close outpatient follow-up was discussed and strict return precautions were given. Resident #10 was discharged back to the facility in stable condition. Review of Resident #10's care plan revealed it was updated on 12/22/22 to reflect the resident was sent to ED for potentially drinking a cleaning product. The care plan reflected discontinuation on 12/27/22 of 15-minute checks with no adverse effects and noted the resident had the potential for nausea, vomiting and gastrointestinal bleeding. Interventions included to call psychiatry hotline for emergency visit for any increased behaviors; monitor every 15 minutes and for any adverse reactions; administer medications and laboratory tests as ordered; encourage to drink water as tolerated; monitor for nausea, vomiting and diarrhea; and send to ED if any bleeding to evaluate gastrointestinal system due to ingestion of chemicals. Review of a progress note, dated 12/23/22 at 3:35 P.M. revealed Resident #10 had no signs or symptoms of distress, accepted medications without difficulty and consumed lunch and breakfast with a good appetite. Review of a fifteen- minute safety checks checklist revealed Resident #10 received safety checks every 15 minutes from 12/22/22 at 3:45 P.M. until 12/27/22 at 12:15 A.M. Review of a facility investigation, dated 12/22/22 revealed the Administrator and Housekeepers #318 and #319 searched resident rooms and areas to ensure cleaning supplies were secured, interviewed residents and conducted skin assessments on residents who were not interviewable with no adverse findings. On 01/10/23 Resident #10 was transferred to the emergency room due to a change in condition and treatment of seizures. The resident did not return to the facility following this date. Interview on 01/25/23 at 3:01 P.M. with the Administrator revealed (on 12/22/22) Resident #10 was observed drinking the cleaner. Resident #10 was sent to the hospital for an evaluation and returned to the facility a couple hours later. The Administrator revealed a plan of correction had been implemented following the incident, including to secure all cleaning supplies when not in use, educate staff and complete daily audits to monitor staff compliance. Interview on 01/25/23 at 3:52 P.M. with STNA #214 revealed on 12/22/22 he was exiting another resident's room and observed Resident #10 holding a bottle of cleaner to her lips. STNA #214 stated he was cleaning off tables earlier and had placed the bottle of cleaner on top of the microwave in the dining room. Interview on 02/07/23 at 11:44 A.M. with Resident #10's daughter revealed she was upset about the incident which occurred on 12/22/22. Resident #10's daughter stated about a week and a half after the incident Resident #10 stopped taking her medications and she believed it was because her throat was burned. A nurse had called to discuss the refusals with her, and she (the daughter) was going to come to the facility and encourage the resident to take her medications when she started having seizures (resident had a diagnosis of seizure disorder). Resident #10 went to the hospital and then was transferred to another hospital for additional care. Resident #10's daughter revealed it was then decided to choose Hospice care services and the resident did not return to the facility. Resident #10's daughter verified being at the hospital on 12/22/22, seeing the bottle of cleaner the facility sent which was a spray bottle and stated Resident #10 was very capable of twisting the sprayer top off and drinking it but indicated she would not be able to put the sprayer into the mouth and squeeze it repeatedly. Review of a progress note, dated 01/23/23 at 4:07 P.M. revealed an update on Resident #10's condition after the resident was transferred to the hospital for seizures. The daughter stated Resident #10 was in Hospice care now and would not be returning to the facility. Interview on 02/07/23 at 12:35 P.M. with the Regional DON and [NAME] President of Clinical Operations (VPCO) #377 revealed the DON was on-call on 12/22/22 when the incident occurred and stated STNA #214 observed Resident #10 put the squirt bottle to the mouth but did not know if any went into the mouth or not, and the bottle was intact as she was making a sucking motion as she tilted her head back. The physician stated if there was anything, there would be blistering, redness or changes, but none were noticed, and the daughter did not have any concerns. Resident #10 had an epileptic problem and was at a Hospice house. During a follow up interview on 02/07/23 at 2:54 P.M. with STNA #214, the STNA verified on 12/22/22, Resident #10 had the spray bottle container in her hand and upon returning from answering the call light he saw Resident #10 had removed the spraying apparatus from the top of the bottle and had set it on the counter-top and then tipped the container which had the chemical solution in it and her head backward to drink it. STNA #214 denied seeing solution dripping from the mouth but was uncertain if any had gone into the mouth. STNA #214 confirmed being gone at least up to ten minutes. The STNA revealed Resident #10 was in a wheelchair but could stand up which she was not supposed to do but made attempts which was how she reached the cleaner on top of the microwave which was located above the countertop in the common area on the memory care unit. STNA #214 indicated seeing Resident #10 again after returning from the hospital and stated she seemed alright, she was difficult to understand and was not talkative but would point out what she wanted. Resident #10 refused her snacks after the incident, but stated this was not something new. STNA #214 verified education was received after the incident to keep chemicals secured. Review of mandatory in-service of Cleaning Supplies - Handling and Storage, dated 12/23/22 revealed all cleaning supplies should be properly stored in non-resident areas and out of reach from residents at all times and if a staff member had cleaning supplies for any reason in a resident area, they needed to have it in their possession at all times. All cleaning supplies or materials needed to be kept in housekeeping closets and locked at all times, and housekeeping could lock any cleaning supplies in the storage room of the memory care unit (room [ROOM NUMBER]) for use. Rounds would be conducted three times daily by staff on the memory care unit to ensure no cleaning supplies/hazardous material were in resident areas or within reach of residents. There were no instructions specific to the cabinet above the utility/handwashing sink in the memory care unit hallway. The in-service was received by all staff between 12/22/22 and 12/26/22. Review of memory care unit cleaning supply rounds checklist revealed rounds were completed daily at 8:00 A.M., 2:30 P.M. and 8:00 P.M. from 12/23/22 until 02/06/23. On 02/07/23 at 8:00 A.M. the rounds checklist was initialed as completed. 2. Medical record review revealed Resident #16 had a diagnosis of dementia. Review of the quarterly MDS 3.0 assessment, dated 01/03/23 revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of one indicating severe cognitive impairment. The assessment revealed the resident required staff supervision with locomotion. The assessment also noted the resident had no impairment with range of motion. Resident #16's balance was not steady when moving from a seated to a standing position, with walking, or when turning around and facing the opposite direction while walking but was able to stabilize without staff assistance. Medical record review revealed Resident #9 had a diagnosis of dementia. Review of Resident #9's care plan with a review start date of 12/21/22 revealed Resident #9 required secure unit placement due to cognitive impairment secondary to diagnosis of Alzheimer's disease. Resident #9 was a moderate elopement risk/wanderer as evidenced by impaired cognition, poor safety awareness, and wandered aimlessly at times. Review of the quarterly MDS assessment dated [DATE] revealed Resident #9 had impaired vision, a Brief Interview Mental Status (BIMS) score of 10 indicating moderate cognitive impairment, moved between locations in her room and adjacent corridor on same floor with no physical assist from staff, and had no functional limit in range of motion to upper or lower extremities. Medical record review revealed Resident #14 had a diagnosis of dementia. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #14 had a BIMS score of three indicating severe cognitive impairment, walked in the corridor of the unit with no physical assist of staff and had no functional limitation in range of motion to upper or lower extremities. Resident #4 was independent with eating, toilet use, and her balance was steady at all times when walking and turning around. Observation on 02/07/23 at 8:22 A.M. during a tour of the memory care unit revealed one bottle of cleaner with bleach, one bottle of multipurpose cleaner, and one bottle of toilet bowel cleaner in an unsecured cabinet above a handwashing sink in the center of the hallway. The cabinet had a locking mechanism in place to accommodate a lock to be applied, however there was no lock in place to prevent residents from obtaining or ingesting the cleaning supplies. There were no residents observed in the immediate area at the time of the observation. Interview at the time of the observation with STNA #315 verified the cabinet contained the three bottles of cleaners and remained unlocked for use. STNA #315 stated no knowledge of a how the cabinet was to be locked despite a locking mechanism being in place to apply one. STNA #315 verified all three bottles of cleaners contained more than half of the cleaning solution. Observation on 02/07/23 at 8:29 A.M. during a tour of the memory care unit revealed Resident #16 was opening and closing all unlocked drawers and cupboards in the common dining area of the memory care unit rummaging through each before going to the next. There were no chemicals observed in the area of Resident #16. Interview at the time of the observation with STNA #315 confirmed the observation and behavior of Resident #16. Observation on 02/07/23 at 8:29 A.M. near the entrance of the memory care unit adjacent to room [ROOM NUMBER] revealed an isolation storage cabinet with a four-ounce bottle of instant hand sanitizer sitting on top of the storage cabinet. Interview at the time of the observation with STNA #315 verified the instant hand sanitizer bottle was left sitting on top of the isolation storage cabinet and indicated hand sanitizers were not to be left out due to the type of residents on the memory care unit. STNA #315 proceeded to pick up the instant hand sanitizer bottle and stated it would be put away. Observation on 02/07/23 at 9:46 A.M. of the memory care unit revealed the cabinet above the utility/handwashing sink in the center of the hallway was locked with a padlock at this time. Interview on 02/07/23 at 9:50 A.M. with STNA #378 on the memory care unit verified the facility provided education about chemicals needing secured and residents were not permitted to have shampoos or other items that were hazardous including hand sanitizer which was to be locked away or in a staff member's pocket. STNA #378 confirmed the cabinet above the utility/handwashing sink in the memory care unit hallway had to be locked but stated the padlock was lost about two days ago. Interview on 02/07/23 at 9:53 A.M. with ADON #320 verified the chemicals in the cabinet over the utility/handwashing sink on the memory care unit in the hallway were used by the nursing assistants to clean off the tables in the common area which was completed mostly by the night shift staff or after meals. The nursing assistants were responsible to make sure the lock was in place but there was no checklist or procedure to ensure it was completed, they were just supposed to check it especially at shift change and during the shift. ADON #320 stated the lock was lost about two days prior because an agency nurse took the lock home in their pocket, another lock was purchased, and it was replaced yesterday but the ADON was not sure why it was not in place this morning. ADON #320 verified the all-purpose cleaner with bleach in the cabinet was the same cleaner involved in the incident on 12/22/22. Interview on 02/07/23 at 10:04 A.M. with STNA #315 verified the cabinet above the utility/handwashing sink in the hallway of the memory care unit was not locked yesterday while working on her shift and stated it was supposed to be locked since there were cleaners inside the cabinet. STNA #315 confirmed receiving education about keeping chemicals secured after the incident happened. Interview on 02/07/23 at 10:09 A.M. with Director of Housekeeping (DOH) #319 revealed housekeeping staff used chemicals off the housekeeping carts and did not get into any cabinets but had access to the locks. DOH #319 confirmed being aware of the missing lock yesterday morning and believed it was replaced but was aware it was not on this morning. DOH #319 stated the nursing assistants helped clean the tables and DOH #319 was told one of the aides had the lock in their pocket. DOH #319 stated housekeeping made rounds, checking the cabinets two to three times daily and checking to ensure no chemicals were left out then signed off on the check off list. This started after the incident on 12/22/22. Interview on 02/07/23 at 10:17 A.M. with STNA #315 and STNA #378 denied the cabinet lock for the memory care unit cabinet above the handwashing sink in the hallway was left in their pockets and stated there was no lock available on this morning to put on the cabinet. Review of memory care unit cleaning supply rounds checklist revealed on 02/07/23 at 8:00 A.M. the rounds checklist was initialed as completed. Interview on 02/07/23 at 10:52 A.M. with DOH #319 verified the initials on the checklist were probably put in place because there were not chemicals seen out even though the cabinet was not locked at the time of the rounds. DOH #319 stated it was Housekeeper #318 who did the rounds check at the time. Interview on 02/07/23 at 11:08 A.M. with Housekeeper #318 revealed after the incident on 12/22/22 residents were not allowed to have anything like peri wash and shampoo, so all of it was moved to a storage area. Housekeeper #318 said they did rounds and checked to make sure no chemicals were out by going into resident rooms and the dining room area looking to ensure there were no chemicals. Housekeeper #318 stated not being aware the cabinet above the handwashing sink in the hallway as being part of the rounds but confirmed hand sanitizer was not to be setting out as a norm. Interview on 02/07/23 at 12:05 P.M. with Housekeeper #379 verified receiving education after the incident on 12/22/22 and conducting rounds as required to ensure all cleaning supplies were put away. Housekeeper #379 stated not being familiar with the cabinet over the handwashing sink in the memory care unit hallway but if the nursing staff used it then they would be responsible to ensure it was locked and housekeeping ensure no chemicals were left out/unsecured. Interview on 02/07/23 at 12:20 P.M. with ROM #375 revealed the facility policy on chemical storage was the education provided to staff on 12/22/22 with no revisions made to the policy. Interview on 02/07/23 at 12:35 P.M. with the Regional DON and [NAME] President of Clinical Operations (VPCO) #377 revealed all cleaning supplies were removed to secured areas and verified not providing education to the staff one way or the other regarding the cabinet above the utility/handwashing sink mid hallway on the memory care unit. VPCO #377 stated residents could not reach the cabinet, so it did not matter whether it was locked or unlocked, and rounds involved checking whether chemicals were left out and watching high risk areas. The DON stated residents on the memory care unit did not have the dexterity or height to reach the cabinet and there was open discussion and assessments completed regarding who could get into the cabinet. The DON verified there was no documentation regarding the referenced assessments. It was confirmed the nurses and housekeepers had a key to the lock on the cabinet above the utility/handwashing sink in the hallway of the memory care unit and there was no reference in the policy or education to staff regarding the cabinet or procedure for lock. VPCO #377 stated the items within the cabinet would be removed on this date and no longer used and new education provided to staff to only use room [ROOM NUMBER] for chemical storage. Observation on 02/07/23 at 1:22 P.M. revealed Resident #9 neatly dressed and groomed and ambulating about the hallway and dining/activity area of the memory care unit. Resident #9's gait was slow and steady as she stopped to talk to residents and staff in the memory care unit. Interview with Resident #9, at the time of the observation, revealed she was confused to person and time. Resident #9 was asked if she could reach the cupboard above the utility/handwashing sink in the hallway of the memory care unit and without hesitation Resident #9 reached up and pulled on the padlock repeatedly saying, it's locked, I can't open. This observation was observed and confirmed with STNA #215. Observation on 02/07/23 at 1:27 P.M. revealed Resident #14 walking independently in the hallway of the memory care unit. Resident #14 stopped to talk with Resident #9 asking Resident #9 to come to her room and visit. Residents #9 and #14 were standing in front of the utility/handwashing sink at the time of observation. Continued observation revealed ADON #320 removing the doors to the cabinet above the utility/handwashing sink, removing the contents of the cupboard and placing the contents in a plastic bag. Interview with ADON #320, at the time of the observation, revealed the doors to the cupboard were removed because it was determined having any type of closed storage above the utility sink was not a good idea because staff could store things that did not belong such as chemicals. Cleaning products were to be stored in the housekeeping department near the kitchenette located near the center of the building. The cabinet without the doors would remain in place for storage of gloves, paper towels and odds and ends. Observation on 02/09/23 at 8:57 A.M. of memory care unit revealed no unsecured chemicals or hazards. The cabinet above the handwashing sink [TRUNCATED]

Based on observation, interview, and record review, the facility failed to give medications according to physician orders. Harm occurred when Resident #38 did not receive [MEDICATION(S)] for which was ordered to treat long-term pain. This resulted in the resident experiencing and increased level of pain along with withdrawal, including trembling, feeling sick and sweaty, and being unable to sleep at all night. This affected one (Resident #38) of four residents reviewed for medication administration. The facility census was 89 residents. Findings include: Interview with Resident #38 on 12/09/21 at 8:45 A.M. revealed he said he was having withdrawal symptoms due to not getting his [MEDICATION(S)] (an opioid [MEDICATION(S)] used to treat long-term pain and opioid dependence) for over a day. He said he was up all night and felt hot and sick to his stomach and had trembling. He said he had gone through withdrawal before and these were familiar symptoms for him. He said this had happened before in November and he had to wait multiple days to get his [MEDICATION(S)] due to it not being reordered timely. He took [MEDICATION(S)] for pain for his spine injury and it had increased due to him being off the medication to a 8 out of 10 pain level. Observation of Resident #38 at the time of the above interview revealed him to appear sweaty and with a fan blowing on him in bed, and with an upset or worried facial expression. Interview with Licensed Practical Nurse (LPN) #568 on 12/09/21 at 8:55 A.M. revealed she was Resident #38's nurse and was waiting for the doctor to sign his [MEDICATION(S)] script. She could not receive it from pharmacy or pull from the starter box until this was done. She was told Resident #38 didn't get his [MEDICATION(S)] last night. Interview with LPN #568 on 12/09/21 at 12:58 P.M. revealed Resident #38's primary doctor said they could not prescribe [MEDICATION(S)], so she was trying to get in touch with the medical director. He still had not received his [MEDICATION(S)] dose as of yet. Interview with LPN #568 on 12/09/21 at 2:30 P.M. revealed she received an authorization to pull [MEDICATION(S)] from the starter box from the medical director, and a three-day supply was being sent from pharmacy. Record review of Resident #38 (on 12/09/21) revealed he was admitted [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had an order dated 07/17/21 for three tablets of [MEDICATION(S)] 10 milligrams to be given twice daily for pain. These were documented as not given from the 11/25/21 evening dose to the 11/27/21 morning dose, and from the 12/07/21 evening dose to the current time (12/09/21). Nursing progress notes at these times revealed the medication was unavailable at these times. Record review of Resident #38 on 12/13/21 revealed he received his morning dose of [MEDICATION(S)] on 12/09/21 at 1:50 P.M. He then received the medication as ordered until 12/12/21, where there was no documentation for his morning dose and a progress note in the evening noting the facility was awaiting delivery of the medication from pharmacy. Interview with the Director of Nursing (DON) on 12/13/21 at 9:11 A.M. confirmed the above findings, including that Resident #38 was again not receiving his ordered [MEDICATION(S)]. She said the facility was changing psych services and neither would agree to prescribe it, so they were trying to get in touch with a [MEDICATION(S)] clinic. These findings substantiate Complaint Numbers OH 903, OH 464, OH 829, and OH 419.

Based on observation, interviews with staff, residents and family, review of the medical record, police report and the facility Wandering, Unsafe Resident policy, the facility failed to provide adequate supervision to prevent the elopement of one resident (Resident #4), who had a court appointed guardian, impaired safety awareness and [DIAGNOSES REDACTED]. This resulted in Immediate Jeopardy when Resident #4 eloped from the facility on 04/01/19 at approximately 1:20 P.M. without staff knowledge until they were made aware by the resident's guardian at 6:50 P.M. The likelihood of Actual Harm occurred as Resident #4 has still not been located after spending the night on 04/01/19 at her daughter's house and leaving there in the morning, unknown to the daughter. This affected one of nine residents reviewed for elopement risk and wandering behaviors. The facility has identified five residents at high risk for elopement and 24 residents at moderate risk for elopement. The facility census was 98 residents. On 04/05/19 at 5:02 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 04/01/19 at 1:20 P.M. when Resident #4, who was at risk for elopement and exhibited a desire to leave the facility, arranged for public transportation and left the facility with her belongings and without staff knowledge. The Immediate Jeopardy was removed on 04/10/19 when the facility implemented the following corrective actions: · On 04/01/19 at 6:50 P.M., Licensed Practical Nurse (LPN) #15 initiated the facility elopement policy which included staff searching the facility and surrounding area for Resident #4. · On 04/01/19 at 7:00 P.M., LPN #9 notified the police Resident #4 was missing from the facility. · On 04/05/19 by 10:10 P.M., the Administrator and DON in-serviced all facility staff either in person or by phone regarding the facility policy and procedure for a missing resident/elopement; checking residents for safety every two hours; and reporting suspicious or unsafe activity to the Administrator, DON, or Nursing Supervisor immediately. · On 04/08/19 between 10:45 A.M. and 11:10 A.M., LPN #9, STNA #10, and STNA #11 demonstrated they were knowledgeable of the training they received on the facility missing resident/elopement policy, checking residents for safety, and reporting immediately any suspicious/unsafe activity to the Administrator, DON, or Nursing Supervisor. · On 04/08/19 by 2:20 P.M., LPN #16 and LPN #28 reassessed all facility residents for wandering/elopement risk. Twenty nine residents were assessed to be at moderate or high risk. · On 04/08/19 at 3:45 P.M., Environmental Service Assistant #26 activated 15 exit door alarms in the facility to ensure when an exit door was opened, an alarm would sound at an assigned nurses station. Staff at that nurses station would then communicate the number of the opened door by walkie talkie to the remaining facility staff so the door could be checked to see who left the facility · On 04/08/19 at 4:36 P.M., the Administrator and Scheduler #17 conducted an elopement drill for the day shift staff, which included four LPNs, eight state tested nursing assistants (STNAs), and three office staff. · On 04/08/19 at 8:07 P.M., the Administrator and Scheduler #17 conducted an elopement drill for the night shift staff including five LPNs, five STNAs, two office staff, and one laundry staff. · On 04/08/19 at 9:30 P.M. the facility implemented the At Risk for Wandering Resident Information notebooks which were placed at the three nurses stations and the front desk. This notebook identified 29 residents who were assessed as being at moderate or high risk for elopement, and included their picture, name, and relevant behavioral, medical and contact information. · On 04/09/19 at 3:30 P.M., the facility implemented a new procedure for the public transportation of residents. The driver is to come into the facility and check with the front desk staff to ensure the correct resident is being transported and the facility is aware the resident is leaving the facility. · On 04/09/19 at 4:30 P.M., the facility implemented scheduling a staff person at the front desk to monitor the lobby area and oversee residents who exit and enter the facility. The front desk will have a staff person present 24 hours a day. This staff person will also daily be given the names of residents who are going out by public transportation or taxi to an appointment and will communicate with transportation drivers regarding resident transport. · On 04/10/19 by 3:00 P.M. the facility educated all residents on the procedures for leaving the facility, including notifying their nurse and signing out when they plan to leave. The residents were also notified that a staff person will be at the front desk 24 hours a day to assist them if they need to leave the facility. · On 04/10/19 at 5:42 P.M., the facility installed additional alarms on all 15 exit doors, as well as the hallway door that entered the smoking room, so nursing staff would also hear an alarm at the door when the door was opened. This alarm system will operate as a secondary alarm system, providing two alarms for each door to notify staff that someone has opened an exit door or exited the facility. · On 04/10/19, the facility began monitoring their nursing and front door staff to ensure they were responding to the door alarms and following the facility policy for resident transport from the facility. Monitoring will continue five times a week for six weeks, and will include interviewing six staff members on each shift (12 staff) regarding the facility policy and responding to door alarms. Random checks will be completed thereafter. The monitoring will be done by the Administrator, DON, or designee. · On 04/10/19, the facility began auditing the door alarms to ensure they are all working properly. This monitoring will be completed daily by the Administrator or designee. Although the Immediate Jeopardy was removed on 04/10/18, the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was in the process of monitoring facility staff and exit doors to ensure compliance and determine if further action is required. Findings include: Review of Resident #4's medical record revealed an original admission date of [DATE] with [DIAGNOSES REDACTED]. Interview with the Administrator and Director of Nursing (DON) on 04/05/19 at 3:05 P.M. revealed when Resident #4 was admitted to the facility she had an emergency court appointed guardian. The facility thought the resident was homeless at one point prior to going to the hospital. Resident #4's medical record included progress notes describing the resident's history of making statements that she wanted to leave the facility or being exit seeking. In addition, a nursing note written by the DON on 03/27/18 at 10:56 A.M. revealed that at approximately 7:00 A.M., Resident #4 was observed outside at the end of the driveway carrying bags heading towards the two-lane road. Resident #4 was admitted to the secured unit on 03/27/18 after this attempt to leave the facility, however, she was moved off the secured unit to the unsecured area of the facility on 09/14/18. Review of the 10/16/18 statement of expert evaluation completed by Physician #18 revealed Resident #4 was mentally impaired due to [MEDICAL CONDITION], and had altered mental status and a depression diagnoses. Resident #4 had impairment in motor behavior, thought process, affect, memory, concentration, comprehension, and judgement during the evaluation. Physician #18 did not believe Resident #4 was capable of caring for her own activities of daily living or making decisions concerning medical treatment or living arrangements. Review of the 02/04/19 social service note written by Social Service Designee #27 at 2:16 P.M., revealed Resident #4 remained alert and oriented with impaired decision-making ability, and periods of mild confusion, inattention, disorganized thinking, or at times delusional ideations. Review of the 02/04/19 wandering/elopement risk assessment, completed by LPN #28 revealed Resident #4 was forgetful, had a short attention span, was independent with mobility without any assistance, and was taking anti-anxiety/hypnotic medications. This assessment did not identify Resident #4 as having a history of wandering and assessed the resident as a low-risk for wandering. Review of the care plan, updated on 03/22/19 by LPN #28, revealed Resident #4 was an elopement risk/wanderer as evidenced by attempts to leave the facility unattended by history and impaired safety awareness. Interventions included distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books; monitor for fatigue and weight loss; and provide structured activities of toileting, walking inside and outside, and reorientation strategies including signs, pictures, and memory boxes. Review of the 04/01/19 nursing note written by LPN #9 at 8:49 P.M., revealed at approximately 6:50 P.M., Guardian #3 called the facility to report Resident #4 had called her daughter's phone from an unknown number stating the resident was at an unknown location in a nearby city. After a search of the facility, and determining Resident #4 was not at the facility, LPN #9 called the police to report Resident #4 was missing from the facility. Review of the 04/01/19 missing person incident report written at 7:00 P.M. by Police Officer (PO) #31 from the local police, revealed on 04/01/19 at approximately 7:00 P.M., PO #31was dispatched to the facility for a missing elderly adult. Upon arrival, PO #31 spoke with LPN #9 who said that one of the residents was missing. PO #31 later interviewed Resident #4's daughter and Resident #4's sister. On 04/01/19 at approximately 10:50 P.M., Resident #4's daughter called the police dispatch and said Resident #4 was at her apartment. Review of the 04/03/19 missing adult police report written by PO #29 at 7:18 P.M. revealed the Administrator reported Resident #4, who has dementia, was missing from the facility. Resident #4 was last seen at Resident #4's daughter's apartment on 04/01/19. The Administrator received a phone call from Resident #4's daughter on 04/01/19 at 11:20 P.M. stating that Resident #4 showed up at the daughter's apartment and would be staying the night. Resident #4's daughter would arrange transportation back to the facility the next day. The Administrator contacted Resident #4's daughter on 04/02/19 at 4:00 P.M. The daughter said Resident #4 was not at the apartment when the daughter woke up, and she was not sure where Resident #4 had gone. Resident #4's daughter and son went to Resident #4's apartment building where she used to live in the past to look for her. The Administrator spoke to Resident #4's daughter on 04/03/19 and Resident #4 was not found and had not returned to the daughter's apartment. On 04/04/19 at 7:40 P.M., Resident #4's daughter went to the police station and said Resident #4 was last seen the morning of 04/03/19 on the first floor of Resident #4's former apartment building where she knew a lot of the residents. Resident #4 was not seen again. Resident #4's daughter said Resident #4 may be at a friend's apartment on the first floor and gave the name of the friend. Resident #4's daughter said when she last saw Resident #4, on 04/01/19, she was wearing black pants, black windbreaker jacket, black tennis shoes with a white stripe and a short wig that was honey blonde in the front and black on the back with a red scarf tied around her head. An interview on 04/04/19 at 6:15 P.M. with the Administrator and DON revealed they did not know where the resident was at that time. Resident #4's guardian (Guardian #3) was a court appointed guardian who did not want Resident #4 to go out on unsupervised outings. Interview on 04/04/19 at 7:01 P.M. with STNA #1, who worked on 04/01/19 from 7:00 A.M. to 7:00 P.M., revealed when Resident #4 could not be located, a Code Brown (missing person alert) was sent over the walkie talkie. STNA #1 checked all the resident rooms on her unit, as well as the bathrooms and other rooms and outside. When STNA #1 left at the end of her shift, Resident #4 was not found and the police were at the facility. Interview on 04/05/19 at 3:45 P.M. with STNA #2 revealed at times Resident #4 would say she didn't want to be at the nursing home anymore. STNA #2 said about a week before the resident left the facility she told STNA #2 that she was only supposed to be there for 90 days and it had been going on for almost a year. STNA #2 last saw Resident #4 on 04/01/19 before lunch when the resident was praying with Resident #98. Interview on 04/05/19 at 4:13 P.M. with Guardian #3 revealed on 04/01/19 at 6:15 P.M, Guardian #3 received a phone call from Resident #4's daughter asking if Guardian #3 gave Resident #4 permission to leave the facility. Resident #4 had called her daughter and the telephone number came up as unknown on the caller identification which was unusual as the nursing home's name and number always came up on the caller identification when Resident #4 called her. Resident #4 told her daughter that she was in a nearby city away from the facility but didn't know where she was. Guardian #3 then called the facility and asked LPN #15 if Resident #4 was in the building. LPN #15 told the guardian Resident #4 was in the building. Guardian #3 then called Resident #4's daughter back and said the facility said Resident #4 was at the facility. However, Resident #4's daughter insisted the resident was calling from somewhere away from the facility. Guardian #3 then called the DON and asked the DON to go to the facility to make sure Resident #4 was there. LPN #15 called Guardian #3 back and stated Resident #4 was not found and Resident #4's clothes were gone from her closet. The facility initiated a Code Brown and called the police. The Administrator called Guardian #3 about 7:30 P.M. and said the public transit company picked up a person (who had a different name than Resident #4) around 1:30 P.M. on 04/01/19 to go to a shopping mall. Resident #4 didn't have any money and told the driver a friend would pay for her transport, so the driver took her to the shopping mall. Sometime on 04/01/19 between 11:15 P.M. to 11:30 P.M., Guardian #3 received a call on her voicemail from Registered Nurse (RN) #30 saying Resident #4 went to her daughter's apartment at 11:15 P.M. and was safe. The guardian indicated on the evening of 04/03/19, the Administrator called Guardian #3 and said when Resident #4's daughter woke up on 04/02/19, Resident #4 was gone and was not at her apartment. Interview on 04/05/19 at 4:45 P.M. with the DON revealed she was not at the facility when she received the call from Guardian #3. The DON then came to the facility and looked for Resident #4. The police, Guardian #3, and Administrator were called when the staff could not find Resident #4. The DON said Resident #4 refused her 2:00 P.M. medications, which LPN #9 attempted to give her at 1:00 P.M., when she was last seen by staff. A follow-up interview on 04/05/19 with the Administrator and DON indicated Resident #60 observed Resident #4 get on the public transit bus in the afternoon. The Administrator called the public transit company and talked to a supervisor who said on 03/28/19 at 7:46 P.M., a person with a different name than Resident #4, called to arrange being picked up at the facility on 04/01/19. Interview on 04/05/19 at 5:32 P.M. with Road Supervisor #4 from the public transit company revealed on 04/01/19 at 1:20 P.M., their driver picked up a resident as scheduled at the facility. The name of the person to be picked up was different than Resident #4's name. Road Supervisor #4 contacted the driver, who was able to describe Resident #4 as the person he picked up. Resident #4 told the driver she was meeting friends from Florida and had no money, but they would pay him when she got to the mall. Resident #4 had a large black bag which the driver thought was strange, wore a black jacket, and had many folded papers in her purse. Resident #4 was sitting outside when he pulled up to the facility and had a scarf on her head. Interview on 04/05/19 at 5:15 P.M. with LPN #5 revealed Resident #4 always said she didn't want to be at the facility. Resident #4 was mad because her family left her there. On 04/05/19 at 5:50 P.M., observation of Resident #4's room with Admissions Coordinator (AC) #7 present revealed there was one black sweater lying at the bottom of the closet, one small coat, one pair of pants that had another resident's name inside the pants, and a broken religious statue in her nightstand drawer. Interview with AC #7 during this observation verified all of Resident #4's clothing, except the sweater and coat, was gone. She said there were usually one or two pictures on Resident #4's nightstand which were also gone. Interview on 04/08/19 at 10:24 A.M. with Resident #4's daughter revealed she has not heard from Resident #4 since 04/01/19. Resident #4's daughter stated Resident #4 was in and out with her mental status, however, she knew what she was doing and she felt captive in the facility. Interview on 04/08/19 at 10:41 A.M. with LPN #9 (who worked from 7:00 A.M. to 7:00 P.M. on 04/01/19) revealed Resident #4 had a history of [REDACTED]. Resident #4 was independent with all her activities of daily living and would walk to activities or around the facility to visit other residents. Resident #4 was a talker and the more Resident #4 talked, the more it was apparent she was confused. The last time LPN #9 saw Resident #4 was on 04/01/19 at 1:00 P.M. when she attempted to give Resident #4 her 2:00 P.M. medications, which she refused. LPN #9 said Resident #4 was wearing black clothes. Interview on 04/08/19 at 11:00 A.M. with Resident #60 revealed on 04/01/19 at approximately 10:00 A.M. to 11:00 A.M. or earlier, Resident #60 was sitting outside and Resident #4 asked him if the public transit had come by the facility yet. The public transit bus pulled up to the facility and Resident #4 attempted to get on the bus however it wasn't her bus. Resident #60 stated another public transit bus came to the facility and Resident #4 got on the bus and left the facility property. Resident #60 said he was not aware Resident #4 was a resident at the facility and thought she was a visitor. Interview on 04/08/19 at 11:05 A.M. with STNA #10 revealed Resident #4 always stated she wasn't supposed to be at the facility. Interview on 04/08/19 at 11:08 A.M. with STNA #11 revealed ever since Resident #4 lived at the facility, she would say she wasn't supposed to be at the facility and wanted to go home. Interview on 04/08/19 at 11:43 A.M. with LPN #13 revealed Resident #4 would say, I can't wait to be with my church group and she was leaving soon or going to get to leave soon. Interview on 04/08/19 at 3:38 P.M. with LPN #24 revealed a couple of weeks prior, Resident #4 said that she was leaving. On 04/08/19 at 3:50 P.M., interview with the Administrator revealed the facility exit door alarm system was activated that day at 3:45 P.M. He said that prior to 04/08/19, this exit door alarm system was not being used, and he did not know why it was deactivated. He confirmed that on 04/01/19 when Resident #4 left the facility the exit door alarm system was not being used at the facility. The system, if activated, would have sounded at the front door when someone exited the facility as Resident #4 did on 04/01/19. Interview on 04/08/19 at 4:00 P.M. with the DON revealed she was not aware Resident #4 was making comments to the staff about leaving the facility. The DON verified that by not marking on the Wandering/Elopement Risk assessment that a resident had a history of [REDACTED]. On 04/09/19 between 4:40 P.M. and 5:30 P.M., observation of the 15 facility exit doors with Maintenance Director #1 revealed when the doors opened they sounded at one of two nurses stations that had the alarm notification panel. While observing the doors, Maintenance Director #1 said prior to 04/08/19, this system was turned off, and he did not know why this door alarm system was not in use. The surveyor observed when an exit door was opened, an alarm would sound on the panel at the nurses station and a numbered button would light up that would tell the staff what door was opened. The staff person would then have to announce through the walkie talkie system the number of the door that was opened, someone would check that door area and determine if someone had left the building, and report that back through the walkie talkie system. However, a staff member was not always at the nurses station to look at the alarm panel when a door opened and sounded the alarm. Observation verified that the actual door did not have an alarming system when opened. In addition, the door that exited the resident's smoking room, led to the back of the facility which led to an open wooded area, as well as paved areas that led around the sides of the building to the front parking lot. This door was not alarmed. Maintenance Director #1 immediately notified the administrator. Staff were placed in the corridor outside of the smoking room to monitor the door until Maintenance Director #1 was able to secure this door with an alarm that sounded at the door, as well as ensuring it was connected to the alarm panel at the nurses station. On 04/10/19 at 5:42 P.M., the facility completed the installation of door alarms that would sound at the exit door when opened for the remaining 14 exit doors. The Administrator said these alarms were in addition to the alarm system that sounds at the nurses station, therefore, each exit door now had two alarms that would sound when the door was opened. This was confirmed by the surveyor through observation of each door alarm system on 04/15/19 between 12:40 P.M. and 1:10 P.M. Interview with the Administrator on 04/15/19 at12:35 P.M. revealed on 04/12/19, the facility discussed a new door security system with a vendor that would provide magnetic locks for all exit doors as well as an alarm/intercom system. The facility is currently waiting for a bid on the installation of this system. Review of the Wandering, Unsafe Resident policy, revised (MONTH) 2007, revealed the staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) and the staff will assess at-risk individuals for potentially correctible risk factors related to unsafe wandering. This deficiency substantiates Complaint Number OH 621.

Based on record review, observation, and interview, the facility failed to address and implement interventions for Resident #102's chronic back/leg pain. Actual Harm occurred when Resident #102 verbalized unrelieved pain at a level of an eight on a scale of zero to ten on 10/26/15 and 10/29/15, and pain at this level was recorded on her pain assessment from 08/22/15. This affected one of three residents reviewed for pain. The facility failed to complete an assessment and provide care when Resident #55 experienced a change in condition. This affected one of 21 residents whose records were reviewed. Findings included: 1. Review of the facility policy and procedure for Pain Management, dated October 2008, indicated that each resident who experiences pain will have a comprehensive assessment of pain and will have a treatment plan established to treat his/her pain. Things that would be considered included assessment of pain medications ordered and reassessment on an ongoing basis. This procedure indicated a pain assessment would be performed including behavior cues and possible environmental, positional or other causes of pain. The resident's current pain medication regimen should be reviewed to determine what medications they are receiving, how long the resident has been on the medication and the degree of relied experienced from the medication. Staff were to use the pain scale to describe her pain and amount of relief. In treating severe pain, the use of opioid narcotic is recommended. For moderate pain the use of medication containing [MEDICATION NAME] or [MEDICATION NAME] is recommended. Non-pharmacological interventions were also recommended. When treating pain, start with an appropriate dose and increase the dose until maximum benefit is reached. When no pain control is received, progress to to the next higher level of medication. This procedure indicated that when a resident's pain is not under control the attending physician and nursing supervisor should be notified. A pain control consultant may be contacted if indicated. Review of the medical record revealed Resident #102 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Review of a nursing admission assessment dated [DATE] indicated Resident #102 said she had back pain daily but it was not constant. No description of her pain intensity was marked but it did say she had back pain on admission. Review of the admission physician orders dated 08/21/15 revealed no ordered pain medications including [MEDICATION NAME], and a physician order for [REDACTED]. Review of a pain assessment dated [DATE] indicated Resident #102 had pain in her back and legs. This assessment indicated Resident #102 rated her present pain an 8 and she said her pain was a 10 at times. She indicated she used a [MEDICATION NAME], a topical narcotic pain reliever, to control her pain and has had this pain for [AGE] years. Her pain was documented on this assessment as sharp and throbbing and was made worse by walking, standing and carrying things. Resident #102 indicated her pain decreased her appetite, slowed her down, and affected her concentration, emotions and performance of her activities of daily living. The nurse completing this form indicated Resident #102 was observed grimacing, slightly agitated and with depression. Review of the history and physical completed on 08/24/15 by the nurse practitioner, Registered Nurse (RN) #11, documented Resident #102 had spine pain at times. An interim plan of care dated 08/24/15 was implemented and indicated Resident #102 was at risk for pain related to [MEDICAL CONDITION], back and leg pain, and a history of cervical spine surgery with hardware insertion. The intervention section indicated staff were to administer medications per current physician orders and offer non-medication interventions such as back rubs, holding her hand, one on one interaction, food/fluids and walks. On 08/24/15 an order was made for Tylenol 325 milligrams, two tablets, every four hours for pain or fever. No other pain medications were ordered for Resident #102 and there was no documentation that non-pharmacological pain relieving interventions were used. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was alert and oriented and cognitively intact, and frequently had moderate pain that interrupted her sleep. Review of a pain care plan initiated on 09/10/15 for Resident #102's history of cervical spine surgery with hardware in her back, spinal stenosis, pain in legs and back indicated she received Tylenol frequently with effect. Interventions on this care plan included staff to offer comfort measures every shift and as needed including environmental or position changes, reassurance, [MEDICATION NAME] and back rubs. The interventions also directed staff to administer medications/[MEDICATION NAME] as per physicians orders and to notify the physician if the interventions were unsuccessful or if current complaint was a significant change from the resident's past experience of pain. Review of the medical record revealed no documentation of pain scales completed after the initial pain assessment completed on 08/21/15. Review of a 10/04/15 note from Psychological Services, marked as a late entry for 09/29/15, indicated it was a psychotherapy session note with Resident #102. This note said Resident #102 admitted getting addicted to alcohol years ago because of her back pain. Review of the October 2015 Medication Administration Record [REDACTED]. An interview on 10/26/15 at 2:27 P.M. of Resident #102 indicated she did have discomfort such as pain, heaviness, burning, or hurting without relief. She said she had pain in her spine and needed some pain medication but was not getting anything. She stated she thought the facility staff were working on this for her. An interview with Licensed Practical Nurse (LPN) #23 on 10/28/15 at 2:45 P.M. verified she was aware that Resident #102 had said she had three previous spine surgeries. LPN #23 said nurses were to do pain assessments every shift and document them. She verified the nurse going off duty that morning had told her in report that a pain consult needed to be made. She was unsure what had occurred for this order to be written. Review of Resident #102's September and October 2015 medication administration records and treatment administration records with the Director of Nursing (DON) on 10/29/15 at 11:52 A.M. verified there was no documentation of a pain scale or pain assessment in the record. The DON verified the facility had not followed their pain management policy and procedure. The DON verified the only pain medication ordered for Resident #102 was as needed Tylenol and no doses were administered in October 2015. Resident #102 observed on 10/29/15 at 12:45 P.M. in her room, in bed with the lights off. She indicated she had back/spine issues since she was born and had three back surgeries. She stated she had pain from her neck to her hips and down her legs to her feet. She indicated the pain was currently an 8 on a scale of zero being no pain and 10 being the worst pain she ever had. She indicated her pain was constant and she also had numbness and tingling in her legs and feet. When asked if she was taking any medication for her pain she said she had to wait to go see the pain management doctor. She said her pain limited how much she could walk. She said she was told before that walking and swimming were good for her back and legs but she was in too much pain and was not able to do these things. She stated it would be fabulous and wonderful if she could get something now for her pain instead of waiting to see the pain management doctor. Interview on 10/29/15 at 1:55 P.M. of RN #11, and the DON revealed RN #11 said Resident #102 had never complained to her about pain. RN #11 verified she was aware that Resident #102 had chronic pain from a long time ago with her spine. RN #11 had completed the history and physical on 08/24/15 and documented Resident #102 complained of spine pain. They verified Resident #102 had pain since admission and the lack of documented pain assessments for Resident #102. 2. Review of the medical record revealed Resident #55 was admitted on [DATE] and [DIAGNOSES REDACTED]. The MDS 3.0 assessment dated [DATE] revealed no cognitive score was completed since Resident #55 was rarely/never understood. This assessment indicated she was totally dependent on staff for all of her activities of daily living. Review of the nurse's note dated 9/24/15 at 3:19 A.M. indicated Resident #55 was alert and responsive to stimuli. She was documented as having the 3+ [MEDICAL CONDITION] in both arms and her oxygen level while on the ventilator was 98%, within normal limits. This note indicated Resident #55 had been suctioned every two hours and as needed for thick beige sputum with a scant amount of streaks of bright red blood. She remained on [MEDICATION NAME], an antibiotic, for pneumonia. Her urinary catheter was draining without any issues and her tube feed was given as ordered and she was tolerating it well. This note indicated all of her medications were administered via her gastrostomy tube (GT) without any issues. Review of the nurse's note dated 09/24/15 at 1:02 P.M. revealed the nurse spoke to someone at the hospital and Resident #55 was admitted for [MEDICAL CONDITION]. There were no nurse's notes prior to this nurse's note to indicate what medical issues has occurred or what change in condition Resident #55 experienced. There was no documentation of any care or interventions provided to Resident #55 prior to her transfer to the hospital including what time that had occurred. The lack of documented care was verified with the DON on 10/29/15 at 9:20 A.M. The DON verified the nurse on the unit should document all information in the nurse's notes when there was a change in condition. On 10/29/15 at 11:44 A.M., the DON verified there was no other documentation found except the nurse's 24 hour report (not part of the resident's medical chart) that indicated Resident #55 had been sent to hospital for shortness of breath and her physician had been notified.

Based on record review and interview, the facility failed to have fall interventions in place. Actual harm occurred when Resident #137 sustained fractured ribs from a fall when his physician ordered non-skid socks as a fall prevention intervention were not in place. This affected two (Residents #137, #4) of three residents reviewed for accidents. Findings include: 1. Review of the medical record revealed Resident #137 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the falls risk assessment dated [DATE] revealed the resident was a high risk for falls. Review of the physician's orders [REDACTED]. Review of the plan of care stated the resident has a potential fall risk related to unsteady gait, poor safety awareness, ambulates using walker (forgets to use walker at times), and history of falls. Interventions included: 07/11/15 Non-skid socks 07/12/15 Pressure sensitive alarm to bed and chair to alert staff to unassisted transfers. Check application and function every shift 07/12/15 Stand by one assist for ambulation/ transfers 07/24/15 Resident given urinal to use at bedside - staff assist with using and emptying every shift 09/04/15 visual cue to remind resident to use call light for help with going to the bathroom Keep frequently used items within reach at bedside. Maintain call light within reach at all times. Observe for decrease or loss of functional status, notify physician. Physical therapy per physicians orders. Review of the falls risk assessment dated [DATE] revealed the resident was a high risk for falls. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment, required extensive assistance with bed mobility, transfers, locomotion on and off of the unit, dressing, toileting, and hygiene, required limited assistance with eating, and was occasionally incontinent of bowel and bladder. Review of a late entry health status note dated 09/04/15 at 6:00 P.M. stated at 5:35 P.M. a state tested nurse aide (STNA) heard Resident #137's bed alarm and found the resident on the floor next to his bed. The resident was laying on his left side with his left arm partially under him. The resident was assessed for injury, and was able to move arms and legs per his norm. The resident complained of pain to his left side abdominal area. The resident had bare feet at the time. Staff assisted the resident back into bed and placed non-skid socks on the resident's feet. The physician was notified with a new order received for a chest x-ray for complaint of left sided pain. Review of an orders administration note dated 09/07/15 at 1:36 A.M. stated that 650 milligrams (mg) was given for complaints of pain to left ribs. Review of a health status note dated 09/19/15 at 12:17 P.M. stated the nurse spoke with the resident's daughter and son-in law regarding the x-ray report showing rib fractures. The nurse explained to them that upon re-examination of the x-ray taken on 09/04/15, the rib fractures were present. Review of a health status note dated 09/22/15 at 9:12 P.M. stated the physician was in the facility and was notified of the family's concern of pain. A new order was received for Tylenol with codeine #3, one tablet by mouth every four hours as needed for pain. An interview with the Director of Nursing (DON) on 10/29/15 at 1:34 P.M. verified Resident #137 did not have on non-skid socks at the time of the fall on 09/04/15. She stated, I think he takes them off. There was no documented evidence in the medical record stating the resident removed his non-skid socks. 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the fall risk assessment dated [DATE] indicated Resident #4 was at high risk for falls. The resident had physician's orders [REDACTED]. The resident had a physician's orders [REDACTED]. Review of the care plan dated 09/30/15 indicated Resident #4 had a high risk for falls related to a history of falls, psychoactive drug use, impaired balance, [DIAGNOSES REDACTED], poor safety awareness, impulsiveness, forgetfulness and noncompliance with asking for help and using call his light. His fall interventions included an alarming seat belt to the wheelchair and recliner to alert staff of unassisted transfers due to poor safety awareness, to check the seat belt every 30 minutes, with a release and reposition every two hours for care and range of motion, a pressure sensitive alarm on the bed and recliner to alert staff to unassisted ambulation and transfers, to check the application and function of the alarm every shift, to position the alarm to prevent the resident from turning it off and to monitor the resident for restlessness in the recliner. Review of nurses notes dated 08/30/15 at 9:34 A.M. by Licensed Practical Nurse (LPN) #13 revealed Resident #4 fell on [DATE] at 1:00 A.M. The note said the resident wanted to turn his radio on, so he got out of his recliner and fell on to the floor, because his seat belt was not on. Upon investigation, LPN #13 was unable to determine whether the first or second shift staff was responsible for not securing the resident's seat belt. Review of the Physician's Notification Form dated 08/30/15 indicated Resident #4 sustained a reddened area to the left forehead and left elbow and a skin tear to the left knee from the fall. Review of the fall investigation report dated 08/30/15 revealed Resident #4 fell out of his recliner while trying to reach his radio. His seat belt was not on in the recliner. Staff were educated to place the seat belt when the resident was in the recliner and to provide a compact disc player with a remote. The statement from STNA #12 dated 08/30/15 indicated she entered the resident's room and Resident #4 was laying on his back next to his recliner. On 10/29/15 at 2:35 P.M. interview with the DON verified Resident #4 did not have his seat belt in place as ordered by the physician and sustained a fall with minor injury on 08/30/15.

Based on record review and interview, the facility failed to ensure immediate fall prevention measures were initiated after Resident #122 sustained a fall. Harm occurred when the facility failed to ensure a self release seat belt was applied and did not provide adequate supervision which resulted in Resident #122 falling and sustaining a subdural hematoma. This affected one of four residents reviewed for falls. Findings include: Resident #122 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 Assessment of 03/20/15 revealed the resident had severe cognitive deficits and required extensive assistance of staff for transfers and to meet his daily needs of hygiene and toileting. The resident had sustained a fall since admission and was assessed at high risk for further falls. The resident resided on a secured dementia unit. Record review of Progress Notes revealed on 02/04/15 the State-tested Nurse Aide (STNA) #1 called the Licensed Practical Nurse (LPN) #1 to the unit. The resident was on the floor in front of his room door with his back against the door, with his wheelchair located on his right side. The resident stated he was trying to stretch and fell down. He stated he hit his head and complained of mild pain. LPN #1 noted that Registered Nurse (RN) #2 assessed the resident and noted he had a light pink, nickel-sized area above his left eye. LPN #1 documented both she and RN #2 agreed that Resident #122 did not need an emergency room evaluation. A pressure sensitive alarm was placed for resident safety. She noted the resident turned off the alarms shortly after placement despite encouragement and education regarding safety. Record review of Progress Notes dated 02/10/15 at 12:00 P.M., revealed STNA #1 notified the nurse (unidentified) that the housekeeper (unidentified) observed the resident getting on the floor. The nurse noted the resident stated he fell and hit his left forehead. The nurse noted the resident's neurological checks and range of motion were within normal limits. At 1:52 P.M., the nurse noted she checked the resident and found the pressure sensitive alarm had been turned off. She noted the resident stated he did not care how often the nurse turned the alarm on, he would turn it off. He also stated that the nurse was going to be arrested. The nurse noted the one to one with the resident was not effective. Record review of the 02/10/15 Incident Investigation revealed at 7:30 A.M., Resident #122 was observed getting himself up off the floor and the pressure sensitive alarm was not sounding. The facility immediate interventions included educating the staff to check the alarm with every resident interaction and to move the alarm to where the resident could not reach it. Record review of the progress notes dated 02/16/15 revealed Resident #122 was found on the floor at 6:35 A.M., lying on his left hip with his wheelchair by the recliner chair. The resident stated he was going to the bathroom, but forgot to lock his wheelchair and it slipped out from under him. The nurse noted the resident had a current physician's orders [REDACTED]. She noted the alarm was lying on his bed with the sounds off. No injuries were noted. Review of the Incident Investigation dated 02/16/15 revealed the fall occurred at 6:35 A.M. The nurse noted the new intervention was to place an alarming seatbelt. Review of the form revealed instructions that all falls must have an immediate intervention put into place. There was no statement or documentation from the staff who found the resident on the floor or verification that the alarm had been placed when he was transferred to his chair. There was one staff statement submitted from an STNA who was in another resident room at the time of the fall. On 02/16/15 at 1:43 P.M., the progress notes revealed the nurse noted that Resident#122 had continued to receive neurological checks and fifteen minute checks due to his previous fall. At 9:10 A.M. she noted she was called to the resident's room and he was found sitting on the floor. She noted Resident #122 sustained two lacerations to his head and she applied pressure to the resident's forehead due to the bleeding. She documented the resident complained of lower back pain. Resident #122 was transferred to the hospital after a 911 call. Review of the Progress Notes revealed on 02/16/15 at 1:49 P.M. the nurse noted the resident was transferred to the hospital due to a brain bleed. Review of the Incident Investigation revealed on 02/16/15 at 9:10 A.M., Resident #122 was attempting to self transfer to the bathroom and fell to the floor. The alarm was sounding. He received a laceration to his forehead. Interventions noted to be currently in place included the pressure sensitive alarm to the chair and fifteen minute checks until seatbelt applied. The new intervention was to send the resident to the emergency room and place an alarming mat to the floor at the bedside. Review of the staff statement from STNA #1 revealed she was down the hall getting linen when the resident's alarm sounded and he was on the floor when she arrived at the room. STNA #2 noted she was across the hall caring for another resident when she hear the alarm and found the resident sitting on the floor. There was no documentation regarding what alarm was sounding. Review of Progress Notes revealed on 02/17/15 at 9:08 A.M., the nurse noted the resident was admitted to the hospital. On 02/17/15 at 11:02 A.M., the Director of Nursing (DON) documented in the Health Status Note that the resident's recent falls were reviewed. She noted the current interventions were not effective due to the resident continued non-compliance. She noted she talked to the power of attorney, who was in agreement to begin with a self releasing alarming seatbelt, and an order was obtained from the physician. On 02/17/15 at 6:25 P.M., the resident returned to the facility. The resident returned with sutures to his left hand which he sustained when he had become combative at the hospital. The nurse noted there were no new orders regarding the resident's subdural hemorrhage. She noted the resident was alert and oriented to self and was delusional. She also noted he required much redirection and one to one interventions were not effective. She noted the personal sensor alarm was placed in the wheelchair, but the resident continued to turn off the alarm. On 03/20/15 at 3:50 A.M. Resident #122 was found face down on the floor in his wheelchair with his seat belt intact. He sustained a laceration to his forehead and was transferred and admitted to the hospital with [REDACTED]. The DON was interviewed on 05/04/15 at 4:00 P.M. to review the resident's fall investigations. The DON verified the immediate intervention for the fall of 02/16/15 at 6:35 A.M., was not initiated. She stated that maintenance staff would have had to apply the seatbelt and probably was not available at that time. She verified that the seatbelt was the only immediate intervention the nurse had noted, but the staff did fifteen minute checks on the resident. She stated she was not sure why the staff did not initiate one on one observation of Resident #122 until the seat belt could be obtained and ordered. The DON verified the resident was at high risk for falls, and as noted on his care plans, he had a history of [REDACTED]. She also verified there was no evidence the nurse had obtained the order for the seatbelt and verified the order was not obtained until 02/17/15 at 11:02 A.M., when the resident was in the hospital. This deficiency substantiates Complaint Number OH 870.

Based on medical record review, staff interview, facility incident investigation reports and disciplinary records the facility failed to provide the proper assistance for one resident (Resident #19) when providing incontinence and bathing care. Actual harm occurred when Resident #19 rolled out of bed and sustained a lump on the middle of his chest and a laceration to his ear. This affected one of three residents reviewed. The facility census was 117. Findings include: Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set 3.0 ((MDS) dated [DATE] and 04/12/15 revealed Resident #19 was totally dependent for all activities of daily living and was severely cognitively impaired. The MDS revealed Resident #19 required the assistance of two staff members for bed mobility, bathing, transfers and toilet use. Review of Resident #19's fall assessments dated 01/14/15 and 04/13/15 revealed the resident was a high fall risk. Review of the state tested nurse aide (STNA) flow sheet care form revealed Resident #19 was totally dependent for transfers and bathing and needed a two person assist. Review of nurses' notes dated 06/07/15 at 1:30 P.M. revealed during personal care Resident #19 rolled over his bed rail while being changed. Resident #19 sustained a lump on the middle chest area from the bed railing and a cut on the ear from bed rail. Review of the fall investigation revealed a statement by STNA #8 in which she indicated she was providing care for Resident #19. STNA #8 indicated when she was turning Resident#19 over to change him; he went over the side of the bed and just kept going. STNA #8 indicated she tried to catch him but she wasn't fast or strong enough and Resident #19 fell on the floor. Observations of Resident #19 on 06/18/15 at 9:12 A.M. revealed he was seated in a specialized wheelchair with a self-releasing seat belt. Resident #19 was able to move his hand and arm slightly without purposeful movement and was able to move his head. He did not speak. Interview with Certified Nurse Practitioner (CNP) #1 on 06/18/15 at 1:50 P.M. revealed Resident #19 was totally dependent and unable to provide any assistance with care needs. CNP #1 indicated Resident #19 does not move his extremities. Interview with the director of nursing (DON) on 06/18/15 at 2:03 P.M. verified the accuracy of the MDS coding indicating Resident #19 required two staff to assist with bed mobility, bathing, and transfers. Interview with the MDS nurse, Licensed Practical Nurse (LPN) #9 on 06/18/15 at 3:34 P.M. revealed Resident #19 was totally dependent and was a two staff member assist as coded on the 01/13/15 and 04/12/15 MDS assessments. This deficiency is a recite to the complaint investigation completed on 05/04/15.

Based on record review and interview, the facility failed to adequate supervision to ensure planned fall interventions were in place to prevent a fall. This resulted in actual harm for one resident who fell and fractured his/her right arm. This affected one resident (Resident #30) of three residents reviewed for falls. The facility census was 103. Findings Include: Review of the medical record for Resident #30 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #30 as moderately cognitively impaired and required extensive one person assist for transferring. Resident #30 was observed at various times during the annual survey wearing a sling to the right arm. Review of a fall assessment dated [DATE] assessed Resident #30 as a high risk for falls. Review of a care plan for Resident #30 dated 08/22/13 and revised on 06/10/14 revealed Resident #30 was at increased risk for falls with a goal that the resident will be at reduced risk for injury related to high risk for falls. The care plan also included the following interventions; encourage one assist with transfers every shift, offer and encourage assist to bed for nap after breakfast and ensure non-skid socks on when in bed. Review of a nursing assistant flow sheet updated June 2014 for Resident #30 revealed the resident was to have a personal body alarm (an alarm with a clip that is attached to the resident to alert staff when a resident transfers unassisted) to the bed and the chair. Review of a resident treatment administration record for Resident #30 revealed an order to apply the personal body alarm to bed and chair every shift to alert staff of unassisted transfers with a start date of 02/21/14. Review of a progress note dated 07/12/14 revealed staff were alerted to Resident #30's room and found the resident lying on the floor. Resident #30 stated he/she had fallen asleep and in the chair and slipped to the floor. The progress note stated Resident #30 complained of right arm pain and was sent to the emergency room where he/she was found to have a fracture of the humerous bone. Review of a facility incident witness report provided by State tested Nursing Assistant (STNA) #200 concerning the fall by Resident #30 indicated the STNA came out of the bathroom, heard Resident #30 yelling, went to the resident's room and observed the resident laying on their right side near the sink. A telephone interview was conducted with STNA #200 on 07/23/14 at 10:59 A.M., the STNA stated she was alerted to Resident #30's room due to the resident yelling out. STNA #200 stated Resident #30's personal body alarm was not sounding at that time. The STNA found the resident lying on the floor and stated the alarm was not applied to Resident #30 at the time of the fall. Interview with the Director of Nursing (DON) on 07/23/14 at 11:48 A.M. confirmed Resident #30 had a fall with a fracture on 07/12/14. The DON was informed STNA #200 stated Resident #30's personal body alarm was not on at the time of the fall.