Every finding on record at Carecore at the Meadows

Based on observation, staff interview, review of the dish machine sanitization log, and policy review, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner to prevent the potential for a foodborne illness. This had the potential to affect all residents residing in the facility. The facility census was 85 residents. Findings include: 1.Observation on 08/24/26 at 9:23 A.M. revealed there was standing water on the floor near the dish machine. Interview on 08/24/26 at 9:23 A.M. with Dietary Manager (DM) #413 verified the standing water on the floor near the dish machine. DM #413 stated the garbage disposal next to the dish machine leaked water and it had been this way since he had been hired about a month prior to the survey. 2. Interview on 08/24/26 at 9:30 A.M with DM #413 verified the kitchen had a low temperature dish machine. DM #413 stated that he only monitored the temperature of the dish machine because the facility had not had chlorine test strips since he started working there about a month prior to the survey. Observation on 08/24/26 at 9:33 A.M. revealed that the dish machine sanitization logs had a section to document the chlorine parts per million (ppm) and the chlorine ppm had been documented every day for the month of August 2026 to date. Interview on 08/24/26 at 9:33 A.M. with DM #413 verified that the log was inaccurate as the facility has not had the ability to test the chlorine level in the dish machine. Review of the undated facility policy titled Sanitization revealed dishwashing machines are operated according to manufacturer's instructions with the general recommendation is for low temperature dish machines have a final rinse cycle of 50 ppm of chlorine. The chemical solution is maintained at correct concentration, based on periodic testing, at least once per shift. 3.Observation on 08/24/26 at 9:35 A.M. revealed at the bottom of the supplement freezer there was a build-up of ice on the walls and about half an inch of frozen water on the bottom of the freezer. Interview on 08/24/26 at 9:35 A.M. with DM #413 verified that there was a buildup of ice and the freezer should have been defrosted. 4.Observation on 08/24/26 at 9:39 A.M. revealed a knife with a damaged blade was stored in the clean knife holder. Interview on 08/24/26 at 9:39 A.M. with DM #413 verified the knife blade was damaged and should have been removed from the kitchen. Review of the undated facility policy titled Sanitization revealed damaged or broken equipment that cannot be repaired is discarded. 5. Observation on 08/14/26 at 9:43 A.M. of dry storage revealed there were bulk containers of flour, rice and sugar without a label or date. Interview on 08/14/26 at 9:43 A.M. with DM #413 verified the bulk containers were not labeled and dated and they should be labeled and dated when the items are opened and placed in the container. Review of the facility policy titled Food Receiving and Storage dated October 2017 revealed dry foods that are stored in bins will be removed from their original packaging, labeled, and dated. 6. Observation on 08/24/26 at 9:46 A.M. revealed buckets of detergent and sanitizer were stored on a shelf next to open bags of food. The open bags of chips, biscuit mix, cheese curls, and penne pasta did not have a date marked. Interview on 08/24/26 at 9:47 A.M. with DM #413 verified that the chemicals should be stored on a shelf away from open food, and the bags of open food should have been dated upon opening. Review of the facility policy titled Food Receiving and Storage dated October 2017 revealed all foods stored in the refrigerator or freezer will be covered, labeled, and dated. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly. 7. Observation on 08/24/26 at 9:48 A.M. revealed there was a build-up of dirt on the blade of the can opener. Interview on 08/24/26 at 9:48 A.M. with DM #413 verified the can opener blade was dirty and had a build-up of food debris. Review of the undated facility policy titled Sanitization revealed all kitchen areas, utensils, counters, shelves and equipment are kept clean. 8. Observation on 08/24/26 at 9:54 A.M. revealed there was an open and undated container of brown gravy stored in the walk-in cooler. Interview on 08/24/26 at 9:54 A.M. with DM #413 verified the brown gravy had been used in a meal last week and should have been dated. 9. Observation on 08/24/26 at 9:56 A.M. of the walk-in freezer revealed there were several pre-portioned sugar cookie dough balls stored on top of a box and there was an open and undated bag of pepperoni. Interview on 08/24/26 at 9:56 A.M. with DM #413 verified the cookie dough should have been placed in a container or bag and not stored directly on top of a box and the pepperoni should have been dated when it was opened. 10. Observation on 08/27/26 at 7:47 A.M. revealed DM #413 tested the dish machine with chlorine test strips. DM #413 used test strips intended for pool water testing which could not be used to measure chlorine levels within the required 50-100 ppm range for the dish machine. Interview on 08/27/26 at 7:47 A.M. with DM #413 verified the test strips were not designed for testing the dish machine. 11. Observation on 08/27/26 at 8:17 A.M. revealed DM #413 took the temperature of the hot food on the service line but was unable to take the temperature of the yogurt. Interview on 08/27/26 at 8:17 A.M. with DM #413 verified the lowest temperature the thermometer could reach was 50 degrees Fahrenheit (F). DM #418 verified cold food should be held below 41 degrees F and that he did not have a thermometer which could measure cold temperatures. 12. Observation on 08/27/26 at 8:21 A.M. revealed there were two large, uncovered containers of gelatin in the walk-in cooler. Interview on 08/27/26 at 8:21 A.M. with Registered Dietician (RD) #800 verified the containers of gelatin should be covered. 13. Observation on 08/27/26 at 8:29 A.M. revealed Dietary Aide (DA) #420 left the kitchen to serve a meal to a resident in the dining room, returned to the kitchen, donned gloves, and then began assembling breakfast trays. Interview on 08/27/26 at 8:32 A.M. with DA #420 verified she did not wash her hand when she returned to the kitchen and before donning gloves. 14.Observation on 08/27/26 at 9:05 A.M. revealed Activity Aide (AA) #502 entered the kitchen without a hair net or washing her hands. AA #502 entered the tray line area, grabbed a handful of sugar packets from the condiment container, and exited the kitchen. Interview on 08/27/26 at 9:07 A.M. with RD #800 verified only kitchen staff are supposed to be in the kitchen and anyone who entered the kitchen should be wearing a hair net and should wash their hands to prevent possible contamination. This deficiency represents noncompliance investigated under Complaint Number 2561614

Based on observation, staff interview, and policy review the facility failed to ensure that residents were able to receive telephone communications from outside the facility. This had the potential to affect all of the residents residing in the facility. The facility census was 85 residents.Findings include: Observation on 08/24/26 at 8:37 A.M. revealed the facility number (513) [PHONE NUMBER] was dialed. The voicemail greeting indicated to push 1 for nurses' station but it did not work. Observation on 08/24/26 at 1:30 P.M. revealed the facility number (513) [PHONE NUMBER] was dialed. The voicemail greeting indicated to push 1 for the nurses' station but it did not work. Interview on 08/24/26 at 1:45 P.M. with the Administrator verified there was no receptionist to answer outside phone calls, and the phones should be ringing to the nurses to answer. Review of the facility policy titled Long-Term Care Phone Answering Policy dated January 2026 revealed all incoming telephone calls were to be answered promptly, professionally, and courteously and staff should make reasonable efforts to respond to incoming calls in a timely and professional manner. This deficiency represents noncompliance investigated under Complaint Number 3178318 and Complaint Number 1285240.

Based on observation, staff interview, and policy review the facility failed to ensure personal protective equipment was available for staff in the laundry area. This had the potential to affect all of the residents residing in the facility. The facility census was 85 residents. Findings include: Observation on 08/26/26 at 2:20 P.M. revealed there was no PPE in the laundry area. Interview on 08/26/26 at 2:25 P.M. with Housekeeping Director (HD) #423 verified there was no PPE in the laundry room. HD #423 stated she was not aware there needed to be PPE in the laundry area. Review of the facility policy titled Standard Precautions dated September 2022 revealed linen soiled with blood, body fluids, secretions, excretions should be handled and processed in a manner that prevented skin and mucous membrane exposure, contamination of clothing, and avoids transfer of microorganisms to other residents and environments. This deficiency represents noncompliance investigated under Complaint Number 2960565 and Complaint Number 2805274.

Based on observation, resident interview, staff interview, and policy review, the facility failed to ensure a dignified dining experience for the residents. This affected seven (Residents #9, #27, #31. #44, #59, #79, and #80) of nine residents reviewed for dignity. The facility census was 85 residents. Findings include: 1. Review of the medical record for Resident #81 revealed an admission date of 01/01/25 with diagnoses including traumatic brain injury. Review of the Minimum Data Set (MDS) assessment for Resident #81 dated 06/30/26 revealed the resident had intact cognition. Review of the medical record for Resident #71 revealed an admission date of 03/10/23 with diagnoses including affective mood disorder, schizoaffective disorder, and psychoactive substance abuse. Review of the MDS assessment for Resident #71 dated 08/11/26 revealed the resident was cognitively intact. Observation on 08/24/26 at 12:11 P.M. revealed Residents #31, #44, #59, #71, #79, #80, and #81 were present in the dining room for lunch. Resident #71 was seated in a chair at a table with Resident #81, who was in a wheelchair. Resident #71 began leaning to her left, and Resident #81 moved his wheelchair closer to her. Both residents continued moving toward one another until Resident #71's head was positioned on Resident #81's lap. Interview on 08/24/26 at 12:18 P.M. with Dietary [NAME] (DC) #416 stated Residents #81 and #71 were in a relationship and the residents frequently displayed physical contact like this in common resident areas. Interview on 08/24/26 at 12:21 P.M. with Certified Nursing Assistant (CNA) #362 verified Residents #81 and #71 had an intimate relationship and have previously demonstrated behaviors that were not appropriate for a communal area. Both residents had been educated to maintain appropriate boundaries in shared spaces and to use private areas, such as their rooms, for interactions requiring additional privacy. CNA stated the physical contact between Resident #81 and #71 was inappropriate for a communal area. 2. Review of the medical record of Resident #44 revealed an admission date of 02/08/19 with diagnoses including nontraumatic subarachnoid hemorrhage, dementia, Alzheimer's disease, major depressive disorder, and unspecified mood disorder. Review of the MDS assessment for Resident #44 dated 07/01/26 revealed the resident was rarely/never understood and required maximal assistance for eating. Observation on 08/24/26 at 12:11 P.M. revealed seven residents were in the dining room with four residents who were actively eating their lunch. Resident #44 was sitting at a table by herself without any food in front of her. There were no staff present in the dining room Observation on 08/24/26 at 12:21 P.M. revealed CNA #362 entered the dining room. Interview on 08/24/26 at 12:30 P.M. with CNA #362 verified Resident #44 had not been served a meal yet, because the resident needed feeding assistance. CNA #362 stated Resident #44's tray had just been delivered, and she would go assist her with feeding. 3.Review of the medical record for Resident #9 revealed an admission date of 12/09/24 with diagnoses including type two diabetes mellitus. Review of the MDS assessment for Resident #9 dated 07/22/26 revealed the resident was cognitively intact and required set up and clean up assistance with eating. Review of the medical record for Resident #27 revealed an admission date of 08/05/26 with diagnoses including type two diabetes mellitus. Review of the MDS assessment for Resident #27 dated 08/12/26 revealed the resident was cognitively impaired and required set up and clean up assistance with eating. Observation on 08/27/26 at 9:11 A.M. revealed that residents were being served cereal in disposable plastic containers. Interview on 08/27/26 at 9:11 A.M. with Dietary Aide (DA) #422 verified he served Residents #9 and #27 cereal in disposable plastic bowls because the facility did not have clean bowls available at the time. Observation on 08/27/26 at 9:26 A.M. revealed Residents #9 and #27 had plastic forks on the meal trays. Interview on 08/27/26 at 9:26 A.M. with DA #422 verified Residents #9 and #27 had plastic forks because the kitchen had run out of clean metal forks. Interview on 08/27/26 at 9:54 A.M. with Resident #9 confirmed her biscuits and gravy were difficult to eat with a plastic fork, and the resident requested a metal fork. Interview on 08/27/26 at 9:57 A.M. with Resident #27 confirmed it was difficult for her to eat her meal with a plastic utensil. Resident #27 stated that she would prefer a metal fork, but she did not want to trouble anyone and would continue to use the plastic fork. Review of the facility policy titled Resident Rights dated December 2016 revealed residents had a right to a dignified existence. This deficiency represents noncompliance investigated under Complaint Number 3167891 and Complaint Number 3097754 and Complaint Number 2723806 and Complaint Number 2716752 and Complaint Number 2676763.

Based on medical record review, staff interview, and policy review, the facility failed to ensure residents were free of significant medication errors. This affected one (#71) of five residents reviewed for unnecessary medications. The facility census was 85 residents. Findings include: Review of the medical record revealed Resident #71 had an admissions date of 03/10/23 with diagnoses including unspecified mood affective disorder, schizoaffective disorder, psychoactive substance abuse, and opioid dependence. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 is cognitively intact. Review of the physician orders revealed Resident #71 had an order for Methadose Oral Concentrate 10 MG/ML (Methadone HCL) give 75 mg by mouth one time a day for opiod abuse. Review of the progress note written by Nurse Practitioner (NP) #682 on 01/16/26 revealed Resident #71 had a drug screen completed that came back positive for ecstasy. NP #682 ordered for methadone to be held and to follow up with the methadone clinic. Review of the Medication Administration Note dated 01/24/26 at 4:20 P.M. revealed Resident #71 has been constantly leaning to the side as if she's falling asleep while sitting and standing. Due to the possibility of resident falling, and known history of medication not prescribed being in her system. She informed Nursing Unit Manager #405 for further advice who stated a drug test was already obtained; methadone clinic was informed -but the MD never reached back out, our MD is aware and NP. She was informed to continue to redirect Resident #71 and monitor. Review of the Medication Administration Record for January 2026 revealed Resident #71 was administered Methadone on 01/18/26, 01/19/26, 01/20/26, 01/21/26, 01/22/26, 01/23/26, 01/24/26, 01/25/26, 01/26/26, 01/27/26, and 01/28/26. Review of the Methadone Clinic Physician Note date 01/28/26 revealed that the clinic was notified of the drug screen results and approved for Resident #71 to continue receiving her order for Methadone. Review of the progress note written by Nurse Practitioner #682 from 02/09/26 revealed there was concerns about Resident #71's behavior and recent drug screen. An order was given to hold all narcotics until a blood test was given. Review of the Medical Record revealed Resident #71 continued to recieve her order for Methadone after 02/09/26. Further review of the medical record revealed there was no follow up from the provider to continue administering narcotics. Interview on 08/31/26 at 8:12 A.M. with Administrator verified that NP #682 had put in her progress notes the order for Methadone to be held. He verified that an order to hold the medication failed to be put into the system and the medication continued to be administered. He verified that there was no follow up from the provider to continue the medication. Review of the facility policy titled, Administering Medications dated April 2019 revealed medications are administered in a safe and timely manner, and as prescribed. This deficiency represents noncompliance investigated under Complaint Number 3178318 and Complaint Number 3097754 and Complaint Number 3066402 and Complaint Number 3064752 and Complaint Number 1285238.

Based on record review, staff interview, facility policy review, and review of Self-Reported Incidents (SRIs) the facility failed to ensure allegations of misappropriation were investigated. This affected two (#70 and #71) of five residents reviewed for abuse and misappropriation. The facility census was 85 residents.Findings include: 1.Review of the medical record for Resident #71 revealed an admission date of 03/10/23 with diagnoses including unspecified mood affective disorder, schizoaffective disorder, psychoactive substance abuse, and opioid dependence. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the physician's orders for Resident #71 revealed an order dated 02/05/26 for methadone 75 milligrams (mg) by mouth one time a day for opioid abuse scheduled for 10:00 A.M Review of a lab report for Resident #71 dated 01/17/26 revealed the resident urine had a presumptive positive result for ecstasy and methadone. There was no documentation of additional test being conducted to verify the results. Review of a progress note written by Nurse Practitioner (NP) #682 from 02/09/26 revealed staff had concerns of misappropriation of medication for Resident #71 related to a recent screen. Review of the final lab report dated 02/23/26 revealed Resident #71 had presumptive positive results for ecstasy and methadone. Further review of the laboratory report revealed that the methadone panel was positive but flagged as inconsistent, and the ecstasy panel was negative. Interview on 08/26/26 at 9:00 A.M. with the Director of Nursing (DON) verified she was aware some staff had suspicions of misappropriation of Resident #71's medication, but the facility had not initiated an investigation of the concerns. Review of the facility SRIs dated 02/09/26 to 08/26/26 revealed there were no SRIs filed regarding possible misappropriation of medication for Resident #71. 2. Review of the medical record for Resident #70 revealed an admission date of 10/29/25 with diagnoses including type two diabetes and type one diabetes. Review of the MDS assessment for Resident #70 dated 07/08/26 revealed the resident was cognitively intact. Review of the physician's orders for Resident #70 revealed an order dated 05/12/26 for oxycodone 15 mg as needed for pain. Interview on 08/24/26 at 10:46 A.M. with Resident #70 confirmed there was an incident about a month and a half ago where Licensed Practical Nurse (LPN) #371 stated she had given the resident her oxycodone, but the resident denied receiving the medication. Resident #70 stated she reported her concern to Nursing Unit Manager (NUM) #405 but she was not satisfied the facility had investigated the issue. Interview on 08/26/26 at 11:10 A.M. with NUM #405 confirmed she could not remember the exact date when Resident #70 alleged she had not received her oxycodone from LPN #371 but thinks it happened in May or June 2026. NUM #405 did not report Resident #71's concerns to administration. Interview on 08/27/26 at 4:07 P.M. with the Administrator confirmed NUM #405 had not notified him of any concerns per Resident #70 regarding her medication. The Administrator verified the concerns Resident #70 had voiced could be interpreted as an allegation of misappropriation and the facility had not initiated an investigation of the resident's concerns. Review of the facility SRIs dated 05/01/26 to 08/27/26 revealed there were no SRIs filed regarding possible misappropriation of medication for Resident #70. Review of the facility policy titled Abuse, Neglect and Exploitation dated 01/22/25 revealed an immediate investigation was warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occurred.

Based on medical record review, staff interview, and policy review, the facility failed to ensure physician orders for safe resident transfers were followed. This affected one (Resident #6) of 15 facility-identified residents who required a mechanical lift for transfers. The facility census was 85 residents. Findings include:Review of the medical record for Resident #6 revealed an admission date of 11/13/13 with diagnoses including cerebral infarction, hemiplegia and hemiparesis, peripheral vascular disease, epilepsy, and osteoporosis. Review of the care plan for Resident #6 dated 10/09/25 revealed the resident should be transferred with the use of a Hoyer lift with the assistance of two staff. Review of the physician's orders for Resident #6 revealed an order dated 12/18/25 for Hoyer lift transfers due to decreased mobility related to hemiplegia. Review of a written statement per Certified Nursing Assistant (CNA) #700 revealed on 01/17/26 the aide transferred Resident #6 using a stand pivot transfer by one aide. Review of the Minimum Data Set (MDS) assessment for Resident #6 dated 06/04/26 revealed the resident had severely impaired cognition and was dependent on staff for transfers. During an interview on 08/25/2026 at 11:38 A.M., the Director of Nursing (DON) #407 confirmed on 01/17/26 CNA #700 put Resident #6 at risk for injury when she transferred the resident using a single caregiver stand pivot transfer. The DON verified Resident #6 had order for and was care planned for Hoyer lift transfers with the assistance of two staff for safe transfers. Review of the facility policy document titled Safe Lifting and Movement of Residents dated July 2017 revealed in order to protect the safety and well-being of staff and residents, and to promote quality care, the facility would use appropriate techniques and devices to lift and move residents. This deficiency represents noncompliance investigated under Complaint Number 3056447 and Complaint Number 3066402 and Complaint Number 3064752 and Complaint Number 2992861 and Complaint Number 2744978 and Complaint Number 1285240 and Complaint Number 1285237.

Based on observation, staff interview, and policy review, the facility failed to ensure a clean and comfortable resident environment. This affected three (Residents #30, #61 and #77) of 24 sampled residents. The facility census was 85 residents.Findings include: 1. Observation on 08/24/26 at 8:53 A.M. of Resident #77's bathroom revealed there was a dried brown substance on the outside of the toilet with a foul odor present. Interview on 08/24/26 at 11:40 A.M. with Housekeeper #423 verified there was dried stool on Resident #77's toilet. Interview on 08/26/26 at 9:45 A.M. with Licensed Practical Nurse (LPN) #358 verified with a dry brown substance was on the outside of Resident #77's toilet with a foul odor present. 2. Observation on 08/27/26 at 11:21 A.M. revealed there was a section of torn wallpaper of approximately three feet by six feet next to Resident #30's bed. Interview on 08/27/26 at 11:21 A.M. with LPN #350 confirmed the section of torn wallpaper next to Resident #30's bed. 3.Observation on 08/27/26 at 11: 28 A.M. revealed there was section of missing wallpaper approximately three feet in width near Resident #61's bed. Interview on 08/27/26 at 11:28 A.M. with LPN #350 confirmed the missing wallpaper near Resident #61's bed. Review of policy titled Quality of Life- Homelike Environment revised May 2017 revealed residents will be provided with a safe, clean, comfortable and homelike environment that was clean, sanitary, and had pleasant neutral scents. This deficiency represents noncompliance investigated under Complaint Number 1285235, Complaint Number 3167891, Complaint Number 3066402, Complaint Number 3064752, Complaint Number 2989434, Complaint Number 2960565, Complaint Number 2561614 and Complaint Number 3178318 and Complaint Number 2805761 and Complaint Number 2675886

Based on medical record review, staff interview, and policy review, the facility failed to maintain accurate medication records. This affected one (Resident #71) of 24 residents sampled. The facility census was 85 residents. Findings include: Review of the medical record for Resident #71 revealed an admission date of 03/10/23 with diagnoses including unspecified mood affective disorder, schizoaffective disorder, psychoactive substance abuse, and opioid dependence. Review of the physician's orders for Resident #71 revealed an order for methadone 75 milligrams (mg) daily for treatment of opioid dependence. Review of the Minimum Data Set (MDS) assessment for Resident #71 dated 08/11/26 revealed the resident was cognitively intact. Review of the facility-controlled substance log sheets dated January, February, and March 2026 revealed they did not include a record of the count sheets for Resident #71's methadone. Interview on 08/27/26 at 2:20 P.M. with Nurse Unit Manager (NUM) #405 confirmed Resident #71 had been on methadone for the months of January, February, and March 2026. NUM#405 verified the facility did not have copies of the narcotic count sheets for the resident's methadone for these months. Review of the facility policy titled Controlled Substance dated November 2022 revealed controlled substance inventory will be monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow up.

Based on observation, resident interview, staff interview, and policy review, the facility failed to ensure that residents were served meals at a palatable temperature. This affected two residents (#9 and #27) and had the potential to affect all residents residing in the facility. The facility census was 85 residents. Findings include: Interview on 08/24/26 at 2:53 P.M. with Resident #4 confirmed his meals were served cold at times when they should be served hot. Observation on 08/27/26 at 9:00 A.M. revealed residents had coffee or hot tea on their meal tickets, but staff had not placed it on the trays. Interview on 08/27/26 at 9:00 A.M. with Dietary Aide (DA) #420 verified the facility only had about 20 coffee cups and they were unable to add them to every tray. DA #420 stated they send the coffee and the cups on a cart before breakfast and the aides will pass the coffee or tea with the meal as residents request it. Observation on 08/27/26 at 9:34 A.M. revealed the kitchen had run out of normal-sized plates and had to switch to larger plates that did not fit inside the thermal insulated plate base. Interview on 08/27/26 at 9:34 A.M. with DA #420 verified the kitchen had run out of their normal plates and that they were having to use plates that did not fit in the thermal insulated base. Observation on 08/27/26 at 9:45 A.M. revealed that the last cart of meal trays was taken to the hall to be served to the residents. The cart in the hall had insulated pitchers containing coffee and hot water for tea. Coffee cups were stored on the lower shelf of the cart. Aides took residents their meals and poured cups of coffee or tea upon request. Interview on 08/27/26 at 9:54 A.M. with Resident #9 verified her food was delivered cold. Interview on 08/27/26 at 9:57 A.M. with Resident #27 verified her food was delivered cold. Observation on 08/27/26 at 10:00 A.M. revealed all meal trays had been passed. Registered Dietician (RD) #800 poured a cup of coffee and began taking the temperatures of the test tray. Interview on 08/27/26 at 10:01 A.M with RD #800 verified the coffee was 100 degrees Fahrenheit (F), the regular biscuits and gravy were 75 degrees F and the pureed biscuits and gravy was 85 degrees F. RD #800 verified the food was at an unpalatable temperature and that ideally the food and hot beverages should be at a minimum of 135 degrees F. Review of the facility policy titled Food and Nutrition Services dated October 2017 revealed each resident would be provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and dietary needs. This deficiency represents noncompliance investigated under Complaint Number 2983908.

Based on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure residents received regular podiatry services. This affected one resident (Resident #70) of 24 residents sampled. The facility census was 85 residents. Findings include: Review of the medical record for Resident #70 revealed an admission date of 10/29/25 with diagnoses including type two diabetes and type one diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 was cognitively intact. Review of the medical record revealed Resident #70 had a podiatry appointment scheduled for 07/28/26. Interview on 08/25/26 at 9:05 A.M. with Resident #70 confirmed she had been wanting a podiatry appointment for months to get her toenails trimmed and her nails are so long, it was painful. Observation on 08/25/26 at 9:12 A.M. revealed Certified Nursing Assistant (CNA) #362 removed Resident 70's socks. Resident #70's toenails were significantly overgrown and thick. Interview on 08/25/26 at 9:13 A.M. with CNA #362 verified Resident #70's toenails were overgrown. Interview on 08/26/26 at 1:36 P.M. with the Director of Nursing (DON) #407 verified Resident #70 had to have her nails cut by a podiatrist due to the resident's diabetes diagnoses. Interview on 08/27/26 at 10:15 A.M. with the DON verified Resident #70 had a podiatry appointment scheduled for 07/28/26, but the resident missed the appointment due to miscommunication and scheduling transportation. Interview on 08/27/26 at 10:17 A.M. with Social Services Director (SSD) #504 verified Resident #70 had not been seen by a podiatrist since admission to the facility. Review of the facility policy titled Activities of Daily Living (ADLs), Supporting dated March 2018 revealed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. This deficiency represents noncompliance investigated under Complaint Number 2960565 and Complaint Number 2723806.

Based on medical record review, staff interview, and policy review, the facility failed to initiate timely treatment for residents admitted with pressure ulcers. This affected one (Resident #90) of four residents reviewed for pressure ulcers. The facility census was 85 residents. Findings include: Review of the medical record for Resident #90 revealed an admission date of 04/15/26 with diagnoses including sepsis and acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity. Review of the progress notes for Resident #90 dated 04/15/26 to 04/17/26 revealed there was no documentation of treatments to the resident's pressure ulcer to the chest. Review of the physician's orders for Resident #90 revealed an order dated 04/17/26 to cleanse right side of the chest wall with normal saline, pat dry, apply Medi honey, alginate, and bordered foam daily and as needed for dislodgement. Review of the Treatment Administration Record for Resident #90 dated August 2026 revealed the resident began receiving wound treatment to right chest wound on 04/18/26. Review of the wound assessment report for Resident #90 dated 05/08/26 revealed the resident was admitted with an unstageable pressure ulcer to the right chest wall present on admission of 04/15/26. Review of the Minimum Data Set (MDS) assessment for Resident #90 dated 05/15/26 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Interview on 08/31/26 at 12:23 P.M. with the Director of Nursing (DON) confirmed Resident #90 was admitted on [DATE] with a pressure ulcer to the chest. The DON verified the facility did not initiate wound treatment until 04/18/26. The DON stated residents admitted with wound care needs should begin receiving wound care upon admission after assessment and per physicians orders. Review of facility policy titled Wound Care revised 2010 revealed the purpose of wound care was to promote healing, and wound care should be documented when it is completed. This deficiency represents noncompliance investigated under Complaint Number 1285239 and Complaint Number 3056447 and Complaint Number 2989434 and Complaint Number 2964830 and Complaint Number 2807561 and Complaint Number 2805274 and Complaint Number 2676763.

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to provide personal privacy to residents. This affected two (Residents #71 and #81) of nine residents reviewed for dignity. Based on medical record review and staff interview, the facility also failed to ensure the privacy of resident health information. This affected one (Resident #1) of 24 residents sampled. The facility census was 85 residents. Findings include: 1. Review of the medical record for Resident #81 revealed an admission date of 01/01/25 with diagnoses including traumatic brain injury. Review of the Minimum Data Set (MDS) assessment for Resident #81 dated 06/30/26 revealed the resident had intact cognition. Review of the medical record for Resident #71 revealed an admission date of 03/10/23 with diagnoses including affective mood disorder, schizoaffective disorder, and psychoactive substance abuse. Review of the MDS assessment for Resident #71 dated 08/11/26 revealed the resident was cognitively intact. Review of the medical record for Resident #68 revealed an admission date of 10/17/22 with diagnoses including schizoaffective disorder, schizophrenia, and anxiety disorder. Review of the MDS assessment for Resident #68 dated 07/15/26 revealed the resident was cognitively intact. Interview on 08/24/26 at 12:21 P.M. with Certified Nursing Assistant (CNA) #362 verified Residents #81 and #71 were in a consensual intimate relationship and had been instructed to go to either one of their rooms when they want to be intimate in private. CNA #362 state Resident #68 was Resident #81's roommate and he had expressed he was uncomfortable Residents #81 and #71 being intimate in the room. Interview on 08/26/26 at 4:15 P.M. with Social Services Director (SSD) #504 verified she was aware of the relationship between Residents #81 and #71. SSD #504 confirmed Resident #68 had expressed discomfort with Residents #81 and #71 having intimate relations in his room. SSD #504 confirmed the facility had encouraged Residents #81 and #71 to go into one of their respective rooms when they wanted to be intimate. SSD #504 verified he facility had not provided a private location for Residents #81 and #71 and that she had informed Resident #68 he had to be accepting of Resident #81 and #71's behavior. Interview on 08/27/26 at 11:18 A.M. with Resident #68 verified he shared a room with Resident #81 who was in an intimate relationship with Resident #71. Resident #68 stated that both residents are frequently in the shared room, and this makes him uncomfortable. He reported that when they are present, he feels unable to get out of bed because he does not want to inadvertently observe interactions that he feels are private. 2.Review of the medical record for Resident #1 revealed an admission date of 7/17/26 with diagnoses including cerebral infraction, borderline personality disorder, and post-traumatic stress disorder. Review of the MDS assessment for Resident #1 dated 07/24/26 revealed the resident was cognitively impaired. Review of the medical record for Resident #1 revealed the resident was his own responsible party and there was no documentation of a medical power of attorney on file. Review of the consent form for psychiatric services for Resident #1 revealed that it was signed by Social Services Director (SSD) #504 on 07/20/26 and indicated SSD #504 had spoken with Resident #1's mother by phone and obtained consent for psychiatric services. Interview on 08/26/26 at 2:40 P.M. with SSD #504 verified she contacted Resident #1's mother on 07/20/26 to obtain approval for psychiatric services, because the resident was tired at that time. SSD #504 verified there was no documentation authorizing Resident #1's mother to sign consent forms or to receive or provide medical information on his behalf.This deficiency represents noncompliance investigated under Complaint Number 1285237.

Based on observations, interviews, and record review, the facility failed to prepare food in a safe and sanitary manner. This had the potential to affect all residents with the exception of three Residents (#09, #19, and #39) who does not receive any food from the facility kitchen. The facility census was 83. Findings include: Observation of the kitchen on 10/23/24 at 11:54 A.M. with Dietary Manager (DM) # 195 revealed the following: a) The paint under the handwashing sink was bubbled up and peeling off. b) The soap dispenser near the handwashing sink was broken. c) The walls near the floor were heavily soiled with an unknown back and brown substance and pieces of the wall were missing. d) The ceiling near the walk-in refrigerator had an unknown brown colored substances splattered across it including on the light fixture. e) The appliances throughout the kitchen were heavily soiled with liquid splatter stains running down the sides. f) Multiple trash cans were heavily soiled with liquid splatter stains running down the sides. g) The counter near the sink contained an unknown brownish substance. h) There was a large white bath blanket with brown and yellow stains underneath the garbage disposal. The floor around the garbage disposal was heavily soiled with dirt and a black substance. i) A large while bath blanket with brown stains was stuffed under the three-compartment sink . j) The dish washer was heavily soiled with food debris, dirt, and crumbs across the top of it. Interview with DM #195 on 10/23/24 at 12:10 P.M. verified the current conditions in the kitchen. DM #195 stated the black substance throughout the kitchen was consistent with mold. DM #195 stated the bath blankets were under the garbage disposal and the three compartment sinks due to the pipes leaking DM #195 stated the kitchen was in need of a deep cleaning. Interview with Maintenance Supervisor (MS) #106 on 10/23/24 at 1:05 P.M. revealed the three-compartment sink was leaking a few weeks ago but he repaired it. MD #106 indicated he was not aware it was leaking again. MS #106 stated the black substance across the kitchen appeared to be mold.

Based on observations, interviews, and record review, the facility failed to maintain a clean and sanitary environment. This affected three (#10, #59, and #63) of the three residents reviewed. The facility census was 87. Findings include: 1) Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included vascular dementia, insomnia, diabetes mellitus (DM), obstructive sleep apnea, essential primary hypertension, anxiety disorder, chronic kidney disease, and hyperlipidemia. Review of the Minimum Data Set (MDS) assessment, for Resident #10, dated 08/09/24, revealed Resident #10 was cognitively intact. Interview with Resident #10 on 10/23/24 at 12:21 P.M., revealed the floors were so dirty in her room, she attempted to clean them herself with a cloth and soap. Observation of the resident's room at the same time revealed two large peeling black non-skid strips in front of Resident #10's bed. The floor in the resident's room and bathroom were very sticky. The bathroom walls were stained with brown splatter stains running down the walls. The floor in Resident #10's bathroom was lifted up around the toilet and the floor was soiled. Resident #10's toilet was soiled and heavily stained with an unknown brown substance. Interview with Licensed Practical Nurse (LPN) #161 on 10/23/24 at 12:23 P.M. verified the condition of the resident's room. LPN #161 stated the black strips on the floor were from a previous Resident's fall interventions. 2) Review of the medical record for Resident #59 revealed the resident was admitted to the facility on [DATE]. Diagnoses included, neurocognitive disorder with Lewy bodies, diabetes mellitus, history of Coronavirus 2019 (COVID-19), insomnia, edema, and major depressant disorder. Review of the MDS assessment, dated 10/01/24, revealed Resident #59 had impaired cognition. Observation of Resident #59's room on 10/23/24 at 12:14 P.M. with Housekeeping Director (HD) #179 revealed the resident's floor was sticky and soiled with a brown and black stain all around the walls. There was a bed frame with no mattress and missing a wheel which made the bed tilt to one side. There were two concrete bricks stacked next to the broken wheel on the floor. HD #179 verified the condition of the resident's room and the broken bed in the resident's room. HD #179 stated the two bricks stacked next to the bed was an attempt to fix the bed by maintenance staff. HD #179 stated the broken bed, and bricks were safety hazards for a memory care unit. Interview with Maintenance Supervisor (MS) #106 on 10/23/24 at 1:05 P.M., verified the broken bed frame and bricks located in Resident #59's room. MS #106 verified the concrete blocks lying on the floor next to the broken bed was an attempt to repair the broken bed frame. 3) Review of the medical record for Resident #63 revealed the resident was admitted to the facility on [DATE]. Diagnoses included ataxia, major depressant disorder, osteoarthritis, dementia, anxiety, Alzheimer's disease, kidney disease, and anxiety. The resident received Hospice services. Review of the MDS assessment, dated 09/03/24, revealed Resident #63 had severely impaired cognition. Observation of Resident #63's room on 10/23/24 at 12:11 P.M. with HD #179 revealed the cove base was hanging from the wall and the base of the wall had black spots throughout the resident's room. The floor was sticky and soiled, and a white towel stained with an unknown yellow substance which was pushed up against the television plug. HD #179 stated the towel was soaked with urine and the floor was sticky related to the resident's urine. Review of the facility policy titled, Quality of Life-Homelike Environment, dated May 2017, revealed the facility will provide residents with a clean, safe, and homelike environment. This includes a clean, safe, and orderly environment. This deficiency represents non-compliance investigated under Complaint Number OH00158493.

Based on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure medications were stored appropriately. This had the potential to affect all 77 residents residing in the facility. The facility census was 77. Findings Include: 1. During medication storage observation on [DATE] at 11:15 A.M. revealed the facility stock medication room was observed to contain expired stock medications. There were three bottles of mucus relief medication that expired on [DATE] (,d+[DATE]) and two bottles of an oral laxative (Bisacodyl) expired on February 2024 (,d+[DATE]). Interview with Registered Nurse (RN) #605 on [DATE] at 11:25 A.M. confirmed the medications were expired. 2. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] and had diagnoses including unspecified affective mood disorder, type II diabetes, and mild major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment completed [DATE] revealed Resident #40 was cognitively intact, had no behaviors, did not wander, and did not reject care. Review of the medical record revealed Resident #40 had current physician orders for medications including the pain medication aspirin 81 milligrams (mg) by mouth once daily, the supplement cyanocobalamin 1000 micrograms (mcg) by mouth once daily, the heart medication isosorbide mononitrate extended release (ER) 30 mg by mouth once daily, the blood pressure medications losartan potassium 25 mg by mouth once daily and Norvasc five (5) mg by mouth once daily, the psychoactive medication sertraline 50 mg by mouth once daily, the thyroid medication Synthroid 50 mcg by mouth once daily, the diabetic medication metformin 1000 mg by mouth twice daily, the blood pressure medication metoprolol tartrate 25 mg by mouth twice daily, and the narcotic pain medication Tylenol with codeine by mouth three times daily. Observation on [DATE] at 10:20 A.M. revealed Resident #40 had crushed medication mixed in chocolate pudding in a plastic medication cup with a spoon on her bedside table. During an interview on [DATE] at 10:20 A.M. Resident #40 stated the mediation cup had all of her morning medications in it including her Tylenol with codeine. The resident stated the staff leave her medications at bedside all the time. During an interview on [DATE] at 10:28 A.M. Licensed Practical Nurse (LPN) #400 asked Resident #40 why she had not taken her medication. LPN #400 verified she handed the medications to Resident #40 and had not watched her swallow the medications at the time of administration before leaving the room. LPN #400 confirmed the medications in the pill cup included all of Resident #40's morning medications. 3. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] and had diagnoses including type II diabetes, unspecified heart failure, stage II chronic kidney disease, unspecified anxiety disorder, and major depressive disorder. Review of the most recent MDS assessment completed [DATE] revealed Resident #11 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Review of the medical record revealed Resident #11 had physician orders for metformin 500 mg two tablets by mouth once daily, the supplement potassium chloride ER 20 milliequivalents (mEq) by mouth once daily, therapeutic multivitamin with minerals by mouth once daily, the blood pressure medication lisinopril 10 mg by mouth once daily, the anti-inflammatory medication diclofenac 50 mg by mouth once daily, aspirin 81 mg by mouth once daily, and urinary retention medication tamsulosin 0.4 mg by mouth once daily. During an observation on [DATE] at 8:02 A.M. LPN #603 exited Resident #11's room with a plastic cup containing medications and placed the medications in the top drawer of the medication cart. During an interview on [DATE] at 8:02 A.M. LPN # 603 stated Resident #11 did not want to take her medicine right now and she would re-attempt to administration them later. LPN #603 stated the medication cup contained Resident #11's medications and stated she could leave the medications in the drawer until the resident was ready to take them as long as the medication cart was locked at all times. During an additional interview on [DATE] at 8:37 A.M. LPN #603 stated she did not know you could not store medications in the cart after the resident refused to take them. Review of the facility policy titled, Storage of Medications, revised February 2023, revealed drugs and biological's used in the facility are stored in locked compartments under proper temperature, light and humidity controls; discontinued, outdated, or deteriorated drugs or biological's are returned to the dispensing pharmacy or destroyed; compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biological's are locked when not in use; and medications are stored separately from food and are labeled accordingly. The nursing staff was responsible for maintaining medication storage and preparation area in a safe, clean, and sanitary manner. Medications and biologicals were stored in the packing or containers in which they were received. 25908

Based on observation, staff interview, and review of equipment manuals, the facility failed to ensure kitchen equipment was maintained in working order. This had the potential to affect 76 residents in the facility. The facility identified one resident (#63) who did not receive food from the kitchen. The facility census was 77. Findings include: 1. Observation on 05/07/24 at 10:17 A.M. revealed the steamer in the kitchen was leaking water into a small reservoir connected to the steamer which was then leaking into a large bin. The bin measured approximately one foot long by two feet wide and had approximately four inches of white cloudy water inside. Interview at the time of the observation with Dietary Manager (DM) #346 verified water from the steamer was dripping into an overflowing reservoir and into a bin. DM #346 stated the steamer had been malfunctioning since he started working at the facility in October 2023. DM #346 stated someone came out to repair the steamer a few months prior and the steamer worked appropriately for a few days but then started leaking again. Review of the operation manual for the steamer, dated 09/18/19, revealed no mention of the need for a bin to collect water below the steamer. 2. Observation on 05/07/24 at 10:55 A.M., revealed DM #346 began the process of preparing pureed food for the upcoming meal. DM #346 scooped creamed corn into the food processor, placed the lid on top, stuck the prong of a thermometer into a hole on the food processor, and started to puree the creamed corn. Interview at the time of the observation with DM #346 stated he had to place the thermometer into the hole to get the food processor to work. DM #346 stated the food processor had been that way for approximately two weeks and would not work unless the thermometer prong was in the hole. Review of the undated food processor operation manual revealed no mention of the need to insert a thermometer prong into the machine for it to function. 3. Observation on 05/07/24 at 12:19 P.M., revealed the plate warmer sitting next to the counter. DM #346 was removing plates from the plate warmer and preparing plates for the lunch meal. The plate warmer was not observed to be hot nor warm to the touch. Further observation revealed the plate warmer was not plugged into any electrical source. Interview on 05/07/24 at 12:06 P.M., with DM #346 stated the plate warmer had not worked since he started working at the facility in October 2023. DM #346 stated he filled out a maintenance request form a while ago and filled another form out last week.

Based on observation, staff interview, and policy review, the facility failed to ensure food was stored and served in a safe and sanitary manner and failed to ensure clean dishes and eating utensils with handled in a manner to prevent contamination. This had the potential to affect 76 residents in the facility. The facility identified one resident (#63) who did not receive food from the kitchen. The facility census was 77. Findings include: 1. Observation on 05/05/24 at between 8:57 A.M. and approximately 9:10 A.M., of the facility kitchen, revealed the walk-in cooler had a large bag of brown salad, not wrapped, not sealed, and not labeled; a pan of an unidentified white substance, covered with plastic wrap, and dated 04/28/24; a large pan with unidentified food, covered loosely in foil, not labeled, and not dated; a pan of hot dogs in liquid, covered in plastic wrap, not labeled, and not dated; and a pan of macaroni and cheese, covered with plastic wrap, not labeled, and not dated. Observation of the dry storage area revealed a box of brownie mix, a box of fruit cocktail, and a box of stuffing mix all stored directly on the floor. Further observation revealed a box of rice on a shelf with a blue plastic bag sticking out of the top that was not sealed or dated. Observation of the general kitchen area revealed a ceiling ventilator, located directly above the pan storage area, was covered in a gray, fuzzy material. The gray, fuzzy material also surrounded the ventilator in an approximate three feet radius around the ventilator. A camera was also observed in the ceiling which was also covered in the gray, fuzzy material. Interview at the time of the observation of the kitchen with Dietary Cook (DC) #333 stated the white substance was butter, and verified the food items in the walk-in cooler were not properly stored as indicated. DC #333 verified all foods should be wrapped, sealed, labeled, and dated. DC #333 verified the boxes of food that were stored directly on the floor in the dry storage area and stated they should not be stored on the floor. DC #333 also verified the bag of rice was not sealed or dated. DC #333 verified the gray fuzzy material on the ventilator and ceiling surrounding the ventilator and stated the material was dust. 2. Observation on 05/05/24 at 9:10 A.M. revealed Dietary Aid (DA) #322 utilized the dishwasher to wash dishes from breakfast. DA #322 wore gloves as she cleaned off the plates, arranged the dishes and silverware in a rack, pushed the rack into the dishwasher, and retrieved and unloaded the clean dishes on the other end of the dishwasher wearing the same gloves she had used to clean off the dirty plates and handle the dirty dishes and silverware. DA #322 was observed over a period of approximately five minutes to repeat the process several times. Interview on 05/05/24 at 9:15 A.M. with DA #322 verified she handled the dirty dishes with gloves and unloaded the clean dishes without changing her gloves. DA #322 stated sometimes she changed her gloves between handling the dirty and clean dishes and sometimes she does not. 3. Observation on 05/05/24 at 9:10 A.M. revealed an approximate three feet long by six inch wide area directly above the counter of the loading side of the dishwasher with a black speckled substance. Further observation at 12:12 P.M. revealed the substance remained in place. Interview on 05/07/24 at 12:12 P.M., with Dietary Manager (DM) #346 verified the speckled black substance on the wall by the dish machine. 4. Observation on 05/07/24 at 10:13 A.M. revealed DM #346 prepared food for the lunch meal. Further observation revealed DM #346 had a beard which was not covered with any restraint. Interview at the time of the observation with DM #346 verified he was not wearing a restraint over his facial hair and stated the facility had just run out of beard restraints. Observations on 05/07/24 at 10:18 A.M., 11:12 A.M., 12:06 P.M., and 12:19 P.M., revealed DM #346 continued preparation of food without a beard restraint. Review of the facility policy titled, Food Receiving and Storage, dated 11/2022, revealed food in the dry storage area was kept at least six inches off the floor, dry foods are stored in a manner that maintains the integrity of the foods until they are ready to use, all foods stored in the refrigerator are covered, labeled and dated with a use by date, refrigerated foods are labeled, dated, and monitored so they are used by their use-by date. Review of the facility policy titled, Food Preparation and Service, dated 11/2022, revealed cross-contamination can occur when disease-causing microorganisms are transferred to food by hands (including gloved hands), and staff were to wear hair restraints (hair net, beard restraint, etc.) so that hair does not contact food.

Based on medical record review, resident and resident representative interview, staff interview, and policy review, the facility failed to conduct care conferences and failed to update care plan interventions in a timely manner. This affected seven (#4, #19, #22, #34, #40, #51, and #68) out of eight residents reviewed for care planning. The facility census was 77. Findings include: 1. Review of the medical record for Resident #51 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, major depressive disorder, unspecified dementia with unspecified severity, other behavioral disturbance, and other recurrent depressive disorders. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had severely impaired cognition. Resident #51 was assessed to require supervision for eating, bed mobility, and transfer, moderate assistance for oral hygiene, bathing, and upper body dressing, maximal assistance for lower body dressing and personal hygiene, and was dependent on staff for toileting. Review of the plan of care dated 02/27/20 revealed Resident #51 was at risk for falls related to balance deficit, cognitive deficits, disease progression, not waiting for assistance, impulsiveness, wandering, and history of falls. Interventions included to assist in position for comfort as needed, encourage non-skid footwear at all times, maintain an uncluttered environment, night light to room, non-skid strips to the bathroom floor, provide activities that minimize the potential for falls while providing diversion and distraction, and refer to therapy as needed. Review of a fall risk evaluation dated 12/03/23 revealed Resident #51 was at risk for falls. Review of the progress note dated 12/03/23 revealed Resident #51 was found on the floor near her bed. Review of the fall investigation dated 12/03/23 revealed Resident #51 had a fall and the intervention was non-skid strips to the floor. Review of the progress note dated 12/04/23 revealed the interdisciplinary team reviewed Resident #51's fall on 12/03/23 and added an intervention of non-slip strips to floor at bedside. Review of the progress note dated 03/17/24 revealed Resident #51 was found on the floor in front of her bed. Review of the fall investigation dated 03/17/24 revealed Resident #51 had a fall and the intervention was non-skid strips in front of the bed. Review of the progress note dated 03/27/24 revealed the interdisciplinary team reviewed Resident #51's fall on 03/17/24 and no new interventions were documented. Interview on 05/07/24 at 5:30 P.M. with Regional Business Office Manager #601 confirmed the fall interventions for non-skid strips to the flooring Resident #51's room were not added to the care plan following the falls on 12/03/23 and 03/17/24. 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] and had diagnoses including unspecified polyneuropathy, type II diabetes, chronic multifocal osteomyelitis of the left ankle and foot, and morbid obesity. Review of the most recent MDS assessment completed on 04/17/24 revealed Resident #4 was cognitively intact, had no behaviors, did not wander, and did not reject care. Review of the medical record revealed Resident #4 had one documented care conference held on 06/12/23 attended by the resident and social services. During an interview on 05/05/24 at 3:52 P.M., Resident #4 stated he had not had any care conferences since admission. During an interview on 05/07/24 at 3:48 P.M. Social Worker (SW) #316 verified Resident #4 had an initial care conference in June 2023 and had not had any quarterly care conferences since. 3. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] and had diagnoses including unspecified anxiety disorder, unspecified schizoaffective disorder, unspecified depression, unspecified hallucinations, and unspecified chronic obstructive pulmonary disease. Review of the most recent MDS assessment completed 02/02/24 revealed Resident #34 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Review of the medical record revealed Resident #34 had one care conference on 10/26/23. During an interview on 05/05/24 at 1:42 P.M. Resident #34 stated she did not receive routine care conferences. During an interview on 05/08/24 at 9:32 A.M. SW #316 verified she had no additional documentation of care conferences for Resident #34. 4. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] and had diagnoses including unspecified affective mood disorder, type II diabetes, and mild major depressive disorder. Review of the most recent MDS assessment completed 01/27/24 revealed Resident #40 was cognitively intact, had no behaviors, did not wander, and did not reject care. Review of the medical record revealed Resident #40 had two documented care conferences dated 10/27/23 and 04/27/24. During an interview on 05/05/24 at 10:10 A.M. Resident #40 stated staff talked to her individually about her care, but could not recall any formal care conferences with the interdisciplinary team. During an interview on 05/08/24 at 9:30 A.M. SW #316 verified Resident #40 had no other care conferences documented in the past twelve months except on 10/27/23 and 04/27/24. 5. Review of the medical record of Resident #22 revealed an admitted [DATE]. Diagnoses included type II diabetes mellitus, atherosclerotic heart disease of native coronary artery, schizoaffective disorder, bipolar type, bipolar disorder, adjustment disorder with mixed disturbance of emotions and conduct, anxiety disorder, congestive heart failure, hyperlipidemia, essential hypertension, major depressive disorder, gastro-esophageal reflux disease, and dysphagia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #22 had intact cognition. The resident was assessed as having fluctuating inattention and disorganized thinking and delusions during the assessment period. Interview on 05/05/24 at 10:07 A.M., Resident #22 stated he had not had a recent care conference. Review of the medical record of Resident #22 revealed the resident had care conferences on 12/22/22, 06/28/23, and 12/20/23. Interview on 05/07/24 at 12:34 P.M. SW #316 verified Resident #22's last care conference was 12/20/23. SW #316 stated care conferences were supposed to be completed on a quarterly basis. 6. Review of the medical record of Resident #68 revealed an admitted [DATE]. Diagnoses included anoxic brain damage, psychosis, psychotic disorder, psychoactive substance abuse, unspecified convulsions, unspecified mood disorder, anxiety, history of sudden cardiac arrest, and unspecified bilateral hearing loss. Review of the quarterly MDS assessment dated [DATE] revealed Resident #68 had severely impaired cognition. Interview on 05/05/24 at 4:48 P.M. Resident #68's responsible party stated she only had two care conferences since admission and had not had any recent care conferences. Review of the medical record revealed care conferences were held for Resident #68 on 06/27/23, 09/11/23, and 10/23/23. Interview on 05/07/24 at 12:34 P.M. with SW #316 verified Resident #68's last care conference was 10/23/23. SW #316 stated care conferences were supposed to be held quarterly. 7. Review of Resident #19's medical record revealed an admitted [DATE] and diagnoses of cerebral vascular disease and dementia. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #19 had severely impaired cognition. Review of the medical record revealed Resident #19 had a care conference on 03/28/24 which was the only care conference held during the past year. Interview on 05/06/24 at 10:09 A.M. with Resident #19's responsible party revealed he had not had any care conferences in the past two to three years. Interview on 05/08/24 at 9:31 A.M. with SW #316 verified there were no other care conference held in the past year for Resident #19. Review of a policy titled, Care Conference Procedure, dated 02/01/18, revealed care conferences were held quarterly to discuss diagnosis, condition, ancillary services, activities of daily living, rehabilitation, mood/behavior, falls/safety, nutrition, skin, medication issues, risks, discharge potential, review of code status, and additional topics as applicable. This deficiency represents non-compliance investigated under Complaint Number OH00152456. 42492 42731 50007

Based on observation, medical record review, resident and staff interview, and review of service invoices, the facility failed to maintain a homelike environment. This affected one (#329) of six residents reviewed for the physical environment. The facility census was 77. Findings include: Review of the medical record for Resident #329 revealed an admitted [DATE]. Diagnoses included diabetes mellitus, atheroscerotic heart disease of native coronary artery, and bipolar disorder. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #329 had intact cognition and required supervision with toileting. Observation on 05/05/24 at 10:29 A.M. of Resident #329's bathroom revealed an area below the sink where there was no drywall and the pipes in the wall were exposed. The area measured approximately two feet long by one and one-half feet wide Interview on 05/05/24 at 10:29 A.M., with Resident #329 stated the dry wall below the sink had been missing since she was admitted . Resident #329 further stated she talked with someone about having it repaired and was told it would be addressed, however nothing more happened with the repair. Interview on 05/07/24 at 1:00 P.M., with Maintenance Director (MD) #330 verified the dry wall was missing below the sink in front of the pipes in Resident #329's bathroom. MD #330 stated he had a plumber out to repair the pipes and had not had a chance to repair the dry wall after that was completed. MD #330 estimated the dry wall had been missing for a few weeks. Review of an invoice from the plumber revealed the pipes were repaired 01/23/24. Follow-up interview on 05/08/24 at 9:50 A.M., with MD #330 verified the invoice was dated 01/23/24, indicating the dry wall had not been replaced over three months.

Based on record review, staff interview, and review of the facility policy, the facility failed to monitor resident bowel functioning. This resulted in actual harm for Resident #45 when the resident went multiple days with no bowel movements and was subsequently treated at the hospital for severe fecal impaction. The facility also failed to ensure compression stockings were in place as ordered. This affected one resident (#45) out of three reviewed for bowel monitoring and one (#60) of five facility-identified residents with orders for compression stockings. The facility census was 63. Findings include: 1. Review of the medical record for Resident #45 revealed and admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .) Review of the Minimum Data Set (MDS) assessment, dated 07/07/22, revealed Resident #45 was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADLs), including toilet use. Resident #45 was incontinent of bowel. Review of physician orders dated 12/20/21 revealed senna tablets daily for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan for Resident #45, updated 05/23/22, revealed the resident had an alteration in bowel elimination; constipation related to immobility, pain medication use, and [CONDITION(S)] medication use. Interventions included: administer laxatives per physician orders, assist with toileting as needed, record all stools, report irregularities to charge nurse, encourage fluid intake as appropriate, note signs and symptoms of constipation, monitor stool frequency, and follow bowel regimen protocol as needed, encourage the resident to voice the need to have bowel movements, report to charge nurse any complaints of abdominal discomfort or difficulty having a bowel movement. Review of the nurse progress note dated 02/22/22 revealed the resident was found with her gastrostomy tube (g-tube) dislodged and the resident was unable to verbalize how long the tube had been out. Resident #45 was sent to the hospital via 911 due to g-tube dislodgement. Review of hospital records for Resident #45, dated 02/22/22, revealed the resident presented in the emergency room with a chief complaint of dislodged g-tube. Resident's abdomen was distended and rigid. The resident was noted with moderately severe constipation and severe fecal impaction causing partial obstruction of the colon. General surgery was consulted and recommended Resident #45 receive soapsuds enemas every four hours and [MEDICATION(S)] every six hours per g-tube. Review of nurse progress note for Resident #45 dated 02/23/22 revealed the facility received a report that resident was being admitted to the hospital for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .). Review of bowel record for Resident #45 for February 2022 revealed there were no bowel movements recorded for 02/01/22, 02/02/22, 02/03/22, 02/04/22, 02/05/22, 02/06/22, 02/07/22, 02/08/22, 02/09/22, 02/10/22, 02/12/22, 02/14/22, 02/15/22, 02/16/22, 02/17/22, 02/19/22, 02/20/22, 02/20/22, 02/21/22, 02/22/22. Review of bowel record revealed the resident was incontinent of a small amount of formed stool times one on the each of the following days: 02/11/22, 02/13/22, 02/18/22. Review of nurse progress note dated 02/2622 revealed Resident #45 was readmitted to the facility with no new orders. Interview on 08/02/22 at 3:59 P.M. with State tested Nursing Assistant (STNA) #410 confirmed Resident #45's bowel record for February 2022 revealed the resident did not have bowel movements on the following dates: 02/01/22, 02/02/22, 02/03/22, 02/04/22, 02/05/22, 02/06/22, 02/07/22, 02/08/22, 02/09/22, 02/10/22, 02/12/22, 02/14/22, 02/15/22, 02/16/22, 02/17/22, 02/19/22, 02/20/22, 02/20/22, 02/21/22, 02/22/22. STNA #410 confirmed Resident #45's bowel record for February 2022 indicated resident was incontinent of a small amount of formed stool times one on the following dates: 02/11/22, 02/13/22, 02/18/22. STNA #410 confirmed staff should inform the nurse if a resident goes three days or longer without a bowel movement (BM.) Interview on 08/03/22 at 8:14 A.M. with Licensed Practical Nurse (LPN) #285 confirmed if an aide says a resident has gone two to three days without a BM the nurse should assess the resident, check for as needed constipation medications, and call the physician if no results from the as needed medications. Interview on 08/03/22 at 9:16 A.M. with STNA #255 confirmed the computerized charting system gives the aide an alert if a resident has gone too long without a BM. STNA #255 confirmed she would notify the nurse if resident went more than two days without a BM or if they showed signs of abdominal pain. Interview on 08/03/22 at 12:44 P.M., Regional Director of Clinical Operations (RDCO) #580 confirmed the facility's bowel protocol per the medical director was if resident had no BM in three days the nurse should administer [MEDICATION(S)] or senna and if still no BM, notify the physician. Interview on 08/04/22 at 1:55 P.M. with the Director of Nursing (DON) confirmed Resident #45 was sent to the hospital for a dislodged g-tube on 02/22/22 and at the hospital they discovered the resident had a severe fecal impaction. The DON further confirmed the bowel record for Resident #45 for February 2022 showed the resident went multiple days without a BM and had only three small BMs recorded for the month of February 2022 prior to the resident's hospitalization . 2. Review of the medical record for Resident #60 revealed an admitted d of 12/13/19. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders dated 05/24/22 revealed Resident #60 was ordered to have ted hose to bilateral lower legs. Review of July and August 2022 treatment administration record (TAR) revealed no documented evidence of resident having ted hose in place. Observations on 08/01/22 at 3:00 P. M revealed Resident #60 was lying in bed with no ted hose in place. Interview with Stated tested Nurse's Aide (STNA) #220 at this time verified the resident had no ted hose in place. STNA #220 stated she had never seen Resident #60 wear TED hose. Interview 08/01/22 at 3:05 P.M. with Registered Nurse (RN) #565 verified Resident #60 was ordered ted hose and verified the resident had no ted hose in place. Observations on 08/02/22 from 6:30 A.M. to 12:30 P.M. reveled Resident #60 was seated in his wheelchair without ted hose in place. Interview on 08/02/22 at 12:36 P.M. with LPN #285 verified Resident #45 had no ted hose in place. LPN #285 was observed to look through resident's personal items and stated she could not find any ted hose. Interview on 08/02/22 at 1:05 P.M. with LPN #285 verified Resident#60 was ordered ted hose but the facility had nothing in place to record and monitor to ensure resident had ted hose placed and removed. LPN #285 stated she updated the physician orders and added ted hose to the TAR so application could be recorded. This deficiency substantiates Complaint Number OH 859.

Based on record review, staff interview, review of facility policy, and review of guidance from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to initiate prompt and timely treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in actual harm when Resident #71 was admitted with two stage II pressure ulcers (Stage II pressure ulcers are shallow with a reddish base. Adipose (fat) and deeper tissues are not visible, granulation tissue, slough and eschar are not present. Intact or partially ruptured blisters that are a result of pressure can also be considered stage II pressure ulcers) and the facility failed to initiate treatments, resulting in the wound significantly increasing in size. When the wound doctor assessed the wound four days after admission, the wound was assessed as an unstageable pressure ulcer (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed). This affected one Resident (#71) out of three residents reviewed for pressure ulcers. The census was 68. Findings include: Review of the medical record for Resident #71 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #71 discharged from the facility on 01/31/22. Review of the Minimum Data Set (MDS) for Resident #71 dated 01/26/22, revealed the resident was cognitively impaired, required extensive assistance of two staff with activities of daily living (ADLs), and was coded as being at risk for the development of pressure ulcers and had two unhealed stage II pressure ulcers which were present upon admission to the facility. Review of the hospital continuity of care (COC) paperwork for Resident #71 dated 01/21/22, revealed the resident had a stage II pressure ulcer to the coccyx which measured 1.0 centimeters (cm) by 0.5 cm and a stage II pressure ulcer to the buttocks which measured 1.5 cm by 1.0 cm. Treatment to ulcers included to cleanse with soap and water, apply zinc paste, and cover with a dry dressing. Review of admission nursing assessment for Resident #71 dated 01/22/22, revealed the resident had a stage II pressure ulcer to the coccyx which measured 0.5 cm by 0.5 cm and a stage II pressure ulcer to the right buttock which measured 1.5 cm by 1 cm. Review of the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the baseline care plan for Resident #71 dated 01/24/22, revealed the resident had current skin integrity issues and referred to the admission wound assessment. There were no wound treatment interventions listed on the baseline care plan. Review of the admitting history and physical per Resident #71's attending physician dated 01/27/22 revealed the resident was admitted with stage II pressure ulcers to the buttocks. Review of the wound physician's note for Resident #71 dated 01/26/22, revealed the resident was first seen by the wound physician on 01/26/22 and the wound was present upon admission on 01/22/22. Upon evaluation, the resident had an unstageable pressure ulcer to the sacrum/right buttock, which measured 5.8 cm by 3.8 cm and had 60 percent (%) slough observed in the wound bed. Further review revealed the wound physician recommended a daily treatment order and a low air loss mattress for the resident. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #71's Treatment Administration Record (TAR) for January 2022, revealed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatment was signed off as completed for 01/29/22 through 01/31/22. Interview on 04/13/22 at 1:30 P.M. the Director of Nursing (DON) confirmed the facility did not implement a wound treatment upon admission for Resident #71, who was admitted with pressure ulcers. The DON confirmed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility undated policy titled, Pressure Ulcer/Injury Risk Assessment, revealed the facility would assess resident's skin as soon as possible after admission and interventions to treat skin breakdown would be implemented based on current, recognized standards of care. Review of guidance from the National Pressure Injury Advisory Panel (NPIAP) dated 2014, revealed staff should assess the pressure ulcer upon discovery and at least weekly thereafter and should implement appropriate wound care. Further review revealed with each dressing change, staff should observe the pressure ulcer for signs that indicate if a change in treatment is required (e.g., wound improvement, wound deterioration, signs of infection, or other complications). Wound status could change rapidly. Wound improvement or deterioration indicated by change in wound dimensions, change in tissue quality, an increase or decrease in wound exudate, signs of infection or other complications all provided indications of the effectiveness of the current management plan. The person responsible for dressing changes should be educated regarding signs and symptoms of complications that should be reported to the health professional. This deficiency substantiates Complaint Number OH 705 and represents ongoing noncompliance from the survey dated 03/18/22.

Based on medical record review, review of hospital records, staff interview, and review of facility policy, the facility failed to ensure residents received adequate supervision and/or assistance when being provided with hot beverages. This resulted in Actual Harm when staff gave Resident #70 very hot water to mix with instant coffee powder and the hot coffee spilled on the resident resulting in a burn to the left hip which required an emergency room visit for evaluation/treatment. This affected one (#70) out of three residents reviewed for accidents. The facility census was 63. Findings include: Review of the medical record for Resident #70 revealed an admitted [DATE]. Resident #70 discharged home on 11/19/21. The resident had diagnoses which included [CONDITION(S)]. Review of the Minimum Data Set (MDS) assessment for Resident #70 dated 10/18/21 revealed the resident was cognitively intact and required extensive assistance of two staff with bed mobility, total dependence on two staff for transfer and toilet use and required extensive assistance of one staff with eating. Review of the care plan for Resident #70 dated 10/19/21 revealed the resident was dependent on staff for activities, cognitive stimulation, and social interaction related to immobility/bedbound status. Review of nurse progress note for Resident #70 dated 11/14/21 timed at 5:42 P.M. per Licensed Practical Nurse (LPN) #265 revealed the nurse was providing care and discovered a burn to the resident's left hip which the resident said had occurred earlier when she spilled coffee on herself. Further review of the note revealed Resident #70 said she did not feel hot and cold on her skin due to her diagnosis. LPN #265 notified the attending physician and Resident #70 was sent to the emergency room via nine-one-one (911) to be evaluated. Review of the hospital note dated 11/14/21 timed at 6:15 P.M. revealed Resident #70 was treated for a burn to her left hip which she sustained due to report of a coffee spill which occurred in the morning of 11/14/21. Review of a nurse progress note for Resident #70 dated 11/15/21 timed at 1:00 A.M. revealed the resident returned from the hospital and a burn was noted to her left hip. Review of a nurse progress note for Resident #70 dated 11/15/21 per the Director of Nursing (DON) revealed the DON met with the resident to discuss the incident resulting in a burn to resident's left hip. Resident #70 explained she preferred her own coffee instead of the facilities and while drinking it she dropped it causing a burn on her left hip. The DON said going forward Resident #70 needed to use a sippy cup that the facility would provide. Review of the care plan for Resident #70 dated 11/15/21 revealed the resident had impaired skin integrity related to the resident prefers to drink own coffee versus the facility coffee and the resident refuses adaptive equipment for meals and drops items. Interventions included the following: educated on risks of instant coffee at bedside, educated on importance of using adaptive equipment. Review of wound physician progress note for Resident #70 dated 11/17/21 revealed the resident had a partial and full thickness burn to her left hip sustained on 11/14/21 measuring 22.2 centimeters in length by 10.0 cm. in width by 0.2 cm. in depth. The composition of the wound bed was 35 percent (%) epithelial/64% granulation tissue/5.0% slough. Treatment order given to cleanse wound with normal saline, apply wound gel to wound bed, and cover with dry dressing once daily. Interview on 12/01/21 at 6:53 A.M. with the DON confirmed she met with Resident #70 on 11/15/21 regarding the situation that caused the burn to the residents left hip. The DON confirmed Resident #70 preferred to drink flavored instant coffee which she brought from home. The DON confirmed Resident #70 said a female State tested Nursing Assistant (STNA) brought her hot water in the morning of 11/14/21. The DON said Resident #70 was unsure which STNA brought her the hot water and also wasn't sure if it came from the facility kitchen or not. The DON confirmed Resident #70 said no one checked her for injury until LPN #265 came in to do wound care for a wound she was admitted with. The DON confirmed she spoke to Resident #70 about using a sippy cup for safety. Interview on 12/01/21 at 6:58 A.M. with the Administrator confirmed the staff were educated on 11/19/21 to make sure resident requests for hot water and food heated up all go through the kitchen. The Administrator further confirmed the facility did not know who brought the resident hot water on 11/14/21. Interview on 12/01/21 at 11:57 A.M. with LPN #265 confirmed on 11/14/21 at approximately 5:40 P.M. she went to do a treatment to Resident #70's right side and when she rolled the resident over, she saw a large burn on her left hip. LPN #265 said Resident #70's burn was red and blistered and the resident said she could not feel hot or cold on her skin due to her condition, so she was unaware she had a burn. LPN #265 further confirmed Resident #70 told the nurse one of the night shift aides that she didn't know had brought her hot water so she could mix it with instant coffee powder for her coffee. LPN #265 confirmed Resident #70 said she spilled the coffee on herself and an aide changed her bed linens, but no one had checked her skin for injury until LPN #265 came into her room at 5:40 P.M. Review of the facility policy titled Assistance with Meals dated July 2017 revealed residents shall receive assistance with meals in a manner that meets the individual needs of each resident. This deficiency substantiates Complaint Number OH 494.

Based on observation, interview and record review, the facility failed to ensure four residents (Residents #9, #15, #79 and #31) were free from resident to resident abuse. This resulted in Actual Harm for one resident (Resident #9) when Resident #39 pushed Resident #9, causing her to fall and sustain a laceration to her head that required five staples The facility census was 79. This affected four of seven residents reviewed. Findings include: 1. Record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION]. Review of Resident #9's quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, eating, toileting and personal hygiene. Record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #39's quarterly MDS assessment dated [DATE] revealed the resident was cognitively impaired and required supervision with bed mobility, transfers and eating and required extensive assistance with dressing, toileting and personal hygiene. Resident #39 was also reported to exhibit physical behaviors, verbal behaviors, rejection of care, wandering and other behaviors. Review of Resident #39's progress notes revealed on 07/16/19 Resident #39 was observed pacing the unit, hitting and pushing on staff, throwing ice water on staff and residents, charging staff members attempting to knock them over and being intrusive towards staff and other residents personal spaces. On 07/19/19 at 10:38 A.M., Resident #39 was aggressive towards residents and staff and was witnessed slapping another resident with no injury. At 1:00 P.M., Resident #39 threw milk onto a staff member while she was walking down the hallway. At 1:31 P.M., Resident #39 was extremely agitated. She came running out of her room, ran up to Resident #9 and pushed her, causing her to hit her head on the floor. Resident #39 was placed on one on one on 07/19/19. Review of Resident #9's progress notes revealed Resident #9 was pushed by another aggressive resident on 07/19/19, sustaining a laceration to the back of her head. Resident #9 was transported to the hospital for evaluation. The resident returned to the facility from the hospital on [DATE] with five staples to the top of her head and a [DIAGNOSES REDACTED]. Review of the facility's self reported incident (SRI), dated 07/19/19, revealed a staff member reported to Director of Nursing (DON) that there was a resident to resident altercation on the secured unit. Staff members interviewed reported that Resident #9 was standing in hallway with a staff member when Resident #39 ran out of bedroom and pushed Resident #9 onto the floor. Staff members immediately separated the two residents. Resident #9 acquired a small laceration to her head and was sent out to the hospital. Resident #39 was placed on one on one care until she was sent out to the hospital for a psychiatric evaluation. Review of the facility's investigation regarding the resident to resident abuse between Resident #39 and Resident #9 revealed Licensed Practical Nurse (LPN) #41 wrote a statement dated 07/19/19 that stated Resident #39 came out of the room agitated and aggressively pushed another resident, causing her to hit her head on the door frame and fall back onto the floor. Resident #39 was assisted to her room and placed on one on one. Review of LPN #23's statement dated 07/19/19 revealed Resident #39 was being aggressive with residents and staff. Redirection was given and was ineffective. Resident #39 ran out of the room and pushed another resident causing her to fall. Review of State tested Nurse Aide (STNA) #79's statement dated 07/19/19 revealed Resident #39 was combative and aggressive towards staff and other residents. Resident #39 charged out of the room and pushed another resident causing her to hit her head on the door frame and then fall onto the floor. Interview with the DON and the Administrator on 07/31/19 at 11:26 A.M. revealed Resident #39 charged at Resident #9 and caused her to fall. Staff immediately separated both residents and Resident #9 was sent out to the hospital. Resident #39 was placed on one on one and sent out to psychiatric services that day. The DON reported Resident #39 was placed back on one on one after she returned from the hospital. The DON stated Resident #9 had a laceration to her head with five staples as a result of the incident on 07/19/19. 2. Record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #15's quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and required supervision with eating, was independent with bed mobility, transfers and she required limited assistance with toileting, dressing and personal hygiene. Record review revealed Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #79's quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and require limited assistance with bed mobility and transfers, and required extensive assistance with dressing, eating, toileting and personal hygiene. Record review revealed Resident #236 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #236's discharge MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired and require limited assistance with toileting, personal hygiene and dressing and required supervision with transfers, bed mobility and eating. Review of Resident #236's progress notes revealed the resident had increased behaviors including cursing and hitting staff and other residents on 04/19/19. Review of Resident #15 and Resident #79's progress notes revealed both residents were ambulating in the corridor on 04/21/19 when Resident #236 physically assaulted both residents, hitting them both on the right side of their faces, resulting in bruising and swelling. Review of the facility's self reported incident (SRI) dated 04/21/19 revealed Resident #236 was sitting in the hallway while Resident #15 and Resident #79 were walking by her. Resident #236 hit both Resident #15 and Resident #79 in the face. Review of the facility's investigation regarding the incident revealed LPN #23's statement, dated 04/21/19, that Resident #236 walked up to Resident #79 and Resident #15 and slapped them both in the face. Review of STNA #800's statement revealed she observed Resident #236 punch Resident #15 in the face. Review of STNA #88's statement revealed Resident #236 punched Resident #15 in the right side of her face with her fists. Review of Laundry #21's statement dated 04/21/19 revealed Resident #79 and Resident #15 were walking down the hallway when Resident #236 came out of her room and walked by Resident #79 and punched her in the right side of her face. Resident #236 then walked up to Resident #15 and punched her in the right side of her face. Resident was #236 verbally abusive with staff and another resident threatening to strike the other resident on 04/22/19. Resident #236 had scissors and nail clippers stating she was going to kill them. Resident #236 was discharged to the psychiatric hospital on [DATE]. Interview with the Director of Nursing (DON) and the Administrator on 07/31/19 at 11:26 A.M. revealed Resident #236 hit Resident #15 and Resident #79 in the face on 04/21/19. Residents were separated and Resident #236 was sent out to the psychiatric hospital. 3. Record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #31's quarterly MDS assessment, dated 06/06/19, revealed the resident was severely cognitively impaired and required supervision with bed mobility and eating, and required limited assistance with transfers and extensive assistance with dressing, toileting and personal hygiene. Record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16's quarterly MDS assessment, dated 05/14/19, revealed the resident was severely cognitively impaired and required limited assistance with transfers, toileting and personal hygiene and was independent with bed mobility and required extensive assistance with dressing, supervision with eating. Review of the facility's SRI, dated 07/15/19, revealed Resident #16 struck Resident #15 in the mouth. Staff immediately separated residents and Resident #16 appeared calm. Resident #16 then pushed Resident #31 in the hallway. Review of the facility's investigation revealed STNA #88's statement reported she heard loud voices in the hallway on 07/15/19 and came out of a resident's room and saw one resident shaking another resident. STNA #88 stepped in the middle of the two and redirected one of the residents. Review of LPN #720's statement dated 07/14/19 revealed she was in another resident's room administering medications and did not see Resident #16 touch another resident. LPN #720's statement also reported that during the evening Resident #16 was verbally aggressive towards staff and other residents. All interventions were ineffective. Review of LPN #750's statement dated 07/14/19 revealed Resident #16 had a verbal and physical altercation with Resident #15 and Resident #31. Resident #16 struck Resident #15 near her mouth. Resident #15 and Resident #16 were immediately separated and Resident #16 appeared calm. Resident #31 was in the hallway and Resident #16 pushed Resident #31. Interview with the Director of Nursing (DON) and the Administrator on 07/31/19 at 11:26 A.M. revealed Resident #16 hit Resident #15 in the hallway. The DON stated Resident #16 was separated from Resident #15 and appeared calm. Resident #16 then hit Resident #31. Review of the progress notes for Resident #15, Resident #16 and Resident #31 's progress notes revealed no information regarding an incident of resident to resident abuse that occurred on 07/14/19. Review of the facility policy titled Abuse Investigation and Reporting, dated (MONTH) (YEAR), revealed residents have the right to be free from abuse, neglect and misappropriation. This includes the right to remain free from physical abuse.

Based on observations, medical record review, staff and resident interviews, review of the National Pressure Ulcer Advisory Panel (NPUAP) classification system for staging pressure ulcers and review of facility policy, the facility failed to assess and care plan for a newly applied leg brace for pressure areas for one (Resident #31) of three residents reviewed for pressure ulcers. This resulted in Immediate Jeopardy and a serious painful injury when Resident #31 developed an avoidable Stage IV pressure ulcer (full thickness skin loss with exposed bone, tendon, or muscle; slough may be present on some parts of the wound bed; and often includes undermining and tunneling.) to the right lateral calf. Additionally, the facility failed to ensure preventative measures were implemented for two (Residents #22 and #69) of the three residents reviewed for pressure ulcers that did not rise to the level of Immediate Jeopardy. The facility census was 91. On 04/18/19 at 12:55 P.M., the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON/Registered Nurse (RN) #79), and Regional Director of Nursing #201 were notified Immediate Jeopardy began on 03/09/19 when staff documented Resident #31 had an unstageable, painful pressure wound on her right leg, discovered after agency State tested Nurse Assistant (STNA) #103 removed the resident's leg brace. The leg brace had been placed on 02/21/19 status [REDACTED]. The Immediate Jeopardy was removed on 04/06/19 when the facility implemented the following corrective actions: · On 04/06/19, facility nurses were in-serviced on assessing skin integrity and circulation every shift for any resident with an immobilizer, brace, cast, or splint. · On 04/06/19, all residents were assessed for skin alterations. · On 04/06/19, all resident's pressure ulcer risk assessments were updated. · On 04/06/19, a physician order was implemented for weekly skin assessments on any resident who scored less than nine (9) on the Braden scale for pressure ulcer risk. A nine or below on the Braden scale indicates a very high risk for pressure ulcer development. Although the Immediate Jeopardy was removed on 04/06/19, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record of Resident #31 revealed an admission date of [DATE]. Review of the pressure sore risk assessment dated [DATE] indicated Resident #31 was not at risk for pressure sores. A quarterly comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31 had severe cognitive impairment and required limited assist of one to ambulate, and was supervision for eating, toileting, and hygiene. The assessment indicated the resident's skin was intact. Review of nurse's progress notes documented Resident #31 had a fall on 02/19/19 when attempting an independent transfer to the bathroom resulting in a two-day hospitalization for a fractured right hip. Review of a hospital Continuation of Care form dated 02/22/19 revealed Resident #31 was to wear a leg brace to the right leg for two weeks until an orthopedic follow up appointment. Review of the shower sheets dated 02/23/19, 03/02/19 and 03/06/19 revealed no skin issues were observed on Resident #31. Review of a nurse's progress note dated 03/09/19 revealed agency STNA #100 notified an agency Licensed Practical Nurse (LPN) #102 of finding a half dollar size open, red, painful wound when she had removed Resident #31's leg brace after complaints of pain. The physician was notified of the wound and the leg brace was removed. A dry dressing was ordered to the wound. A referral was made for Wound Physician #104 to see the patient on 03/11/19. The progress notes had no measurements of the wound. Review of the nursing progress note dated 03/11/19 revealed ADON/RN #79 documented a treatment was ordered to the wound and a referral to Wound Physician #104 was made, with rounds scheduled on 03/12/19. A progress note dated 03/12/19 indicated Wound Physician #104 assessed Resident #31's right calf with an unstageable pressure wound and changed the treatment orders. Review of the care plan, revised 03/12/19, revealed Resident #31 was at risk for skin impairment related to diabetes and incontinence, at risk for falls, and pain. The care plan contained no documentation about the [MEDICAL CONDITION] and leg brace. Review of Wound Physician #104's notes dated 03/12/19 revealed Resident #31 had an unstageable pressure ulcer which measured at 4.2 centimeters (cm) length (L) by 2.8 cm width (W) and a depth (D) not measurable due to 50 percent adherent black necrotic tissue and 50 percent adherent devitalized necrotic tissue. The wound was cleansed, numbed, and surgically excised of devitalized tissue, necrotic subcutaneous fat and surrounding connective tissue. The treatment ordered was Santyl ([MEDICATION NAME] agent) ointment and foam bordered dressing applied daily. Review of Wound Physician #104's notes dated 03/19/19 revealed the wound continued to be unstageable and the physician again cleansed, numbed, and surgically excised of devitalized tissue, necrotic subcutaneous fat, and surrounding connective tissue. On 04/05/19, an attempt was made to interview Resident #31; however, she was confused to time and unable to provide any details of the wound development. During an interview on 04/05/19 at 2:55 P.M., ADON/RN #79 reported Resident #31's leg pressure wound was found as an open, red, and painful area on 03/09/19 when the resident complained of pain and the leg brace was removed. ADON/RN #79 stated Wound Physician #104 assessed the wound on 03/12/19. ADON/RN #79 verified the medical record did not contain any documentation of skin assessments until after the right lateral calf pressure area was found. During an interview on 04/05/19 at 4:15 P.M., the DON stated nurses should check any immobilization devices for possible pressure areas. She stated the facility staff were not assessing Resident #31 while she was wearing the leg brace and the brace caused the pressure area. The DON reported the facility did not have a policy for skin checks, nor braces, and that STNAs were to perform skin checks when providing bathing. During an interview on 04/05/19 at 4:27 P.M., LPN #04 stated she would assess resident skin when the electronic health system triggered for her signature. LPN #04 stated she did not remember any triggers in Resident #31's treatment orders. A telephone interview on 04/05/19 at 5:00 P.M. with NP #101 revealed awareness of a pressure area on Resident #31's right lateral calf, stating she had given the initial treatment orders after viewing the wound on 03/11/19. NP #101 stated the area was a pressure sore attributed to a leg brace and the area should have been found prior to becoming a large open wound. She also stated she expects all residents wearing splints or braces would have an assessment for signs of developing pressure areas at least once per shift. 2. Review of Resident #22's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a skin risk assessment dated [DATE] indicated the resident was at moderate risk for skin impairment. Review of the most recent skin assessment dated [DATE] was documented with no new areas noted. Review of the comprehensive MDS assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors or refusals of care, and required extensive assist of two persons for bed mobility, transfers, toilet use, dressing, and transfer with extensive assist of one for hygiene and supervision for eating. The assessment also indicated one Stage IV pressure ulcer. Review of physician orders dated (MONTH) 2019 revealed a low air loss mattress, skin preparation to the right foot, protein powder, skin preparation to the left heel, and border dressing to the right heel daily. Review of the wound progress note dated 04/08/19 indicated Stage IV pressure wound to the right foot measuring 2 cm L by 3 cm W by 0.1 cm D, continue with current treatment, foam boots in place, and a low air loss mattress. Observation of Resident #22 on 04/18/19 at 8:07 A.M. revealed Resident #22 lying in bed on a low air loss mattress with his feet exposed below his sheet. Both feet were observed bare and lying directly on the mattress. During an interview on 04/18/19 at 9:30 A.M., STNA #46 stated she had just applied boots to Resident #22's feet since he did not have them on when she came on shift. 3. Review of Resident #69's medical record revealed an original admission date of [DATE] with [DIAGNOSES REDACTED]. The resident returned to the facility on [DATE] after a hospitalization for her [MEDICAL CONDITION] disorder. Review of a five-day admission comprehensive assessment dated [DATE] revealed severe cognitive impairment, behaviors not directed towards others that did not affect care, and no rejections of care. The assessment indicated Resident #69 was totally dependent on two staff for bed mobility, transfers, toileting; extensive assist of one for dressing, personal hygiene; dependent on one for eating; and was not ambulatory. A skin risk assessment dated [DATE] indicated Resident #69 was at risk for pressure wounds. Review of physician orders for Resident #69 revealed an order dated 03/08/19 for foam boots to both heels for pressure ulcers and an order dated 10/17/18 for cloth sleeves on both legs while out of bed to protect her skin. Nursing progress notes dated 03/20/18 revealed Resident #69 had a Stage II pressure area on her right heel measuring 2.7 cm L by 4 cm W by 0.1 cm D. The physician was notified, and an order was received for cleansing with normal saline solution, applying calcium alginate dressing and covering with border dressing. A progress note dated 04/14/19 indicated the right heel wound was healed. Observation of Resident #69 on 04/18/19 at 8:32 A.M. revealed her sitting in a wheeled recliner in a dining room. Resident #69 was wearing non-skid socks only with her feet resting directly on the footrest. During interview on 04/18/19 at 8:35 A.M., STNAs #34 and #202 verified Resident #69 was not wearing any foam boots and both STNAs denied awareness of any residents having orders for boots. Observation on 04/18/19 at 8:45 A.M. of Resident #69's heels revealed a dime size callus on her right heel. Review of the NPUAP revealed an unstageable pressure ulcer is defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. A review of the facility policy titled Prevention of Pressure Ulcers/Injuries, dated revised (MONTH) (YEAR), documented Risk Assessment: 1) Assess the resident on admission (within eight hours) for existing pressure ulcer/injury risk factors. Repeat checking skin weekly and upon any changes in condition; 2) Conduct a skin assessment upon admission, including: a. Skin integrity - any evidence of existing or developing pressure ulcers or injuries and b. Areas of impaired circulation due to pressure from positioning or medical devices; 3) Use a screening tool to determine if resident is at risk for under-nutrition or malnutrition; and 4) Inspect the skin on a weekly basis when performing or assisting with personal care or ADLs. The policy further addressed Monitoring: 1) Evaluate, report and document potential changes in the skin; and 2) Review the interventions and strategies for effectiveness on an ongoing basis. A review of the facility's policy titled Pressure Ulcer/Injury Risk Assessment, dated (MONTH) 2019, revealed risk factors included impaired/decreased mobility; the risk assessment should be conducted as soon as possible after admission; develop the resident centered care plan and interventions based on risk factors identified in the assessments, the condition of the skin, the resident ' s overall clinical condition; the interventions must be based on current, recognized standards of care; and the effects of the interventions must be evaluated. This deficiency substantiates Complaint Number OH 520.

Based on medical record review, observation, staff interview, and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to put interventions in place to prevent skin breakdown. This affected one Resident (#53) of four residents assessed for skin. Actual harm occurred to Resident #53 when the facility failed to put interventions in place after the resident was noted with a reddened coccyx. The area worsened and the resident developed an unstageable pressure ulcer to the coccyx within four days. The facility identified four residents with pressure ulcers. The census was 77. Findings include: Review of Resident #53's medical record revealed an admitted [DATE]. [DIAGNOSES REDACTED]. Review of a Braden Scale (used to assess a residents risk of developing a pressure ulcer) dated 01/09/18 revealed a score of 15 which indicated mild risk. Review of the Minimum Date Set ((MDS) dated [DATE] revealed a brief interview of mental status (BIMS) score of 6 which indicated severe cognitive decline. The MDS also indicated two staff were required for bed mobility and extensive assist of one staff for all other activities of daily living. The resident was incontinent of bowel and bladder. Review of the care plan interventions included to assist to the toilet every two hours to help prevent incontinent episodes; monitor skin condition with care; help to turn and reposition in bed as needed. The care plan was updated on 03/27/18 after the resident was identified with an unstageable pressure ulcer. The interventions included low air loss mattress, treatment to coccyx, stress tab and protein powder Review of a shower sheet dated 03/23/18 revealed Resident #53 had redness on the coccyx. Review of the progress notes dated 03/27/18 revealed the wound doctor saw Resident #53 for a pressure wound on her coccyx. The record did not reveal any previous documentation of skin concerns. Review of a nutritional assessment note dated 04/10/18 revealed an unstageable pressure area on coccyx, resident was seen by the physcian on 04/10/18 and noted the area was deteriorating. Review of a progress note dated 04/12/18 indicated the Hospice nurse was called to obtain an air mattress for Resident #53. During an interview conducted on 05/20/18 at 11:26 A.M., State tested Nurse Assistant (STNA) revealed Resident #53 was not on a turn and reposition schedule. During an interview conducted on 05/21/18 at 4:00 P.M. with Licensed Practical Nurse (LPN) #50 revealed Resident #53 could not turn herself in bed and staff would sometimes offer to assist her. Observation of Resident #53 on 05/22/18 at 9:18 A.M. revealed she was sitting in bed with her eyes closed. A gerichair (mobile recliner) was observed beside the bed and the gerichair did not have a pressure reduction cushion. During an interview conducted on 05/22/18 at 11:51 A.M. with Physician #101 revealed he began treating Resident #53 on 03/27/18 for a unstageable pressure injury to her coccyx. He reported performing an excisional debridement of the wound on 03/27/18 and made recommendations to include: limit sitting to 60 minutes, off load the wound, use a group two mattress, reposition per facility protocol, and apply a foam dressing daily. He verified on 03/27/18 the wound measured 1.2 centimeters (cm) in length (L) by 3.5 cm width (W) by unable to determine depth. He stated the wound required subsequent debridement on 05/01/18. Physician #101 indicated he was unfamiliar with the facility protocol for repositioning. Physician #101 indicated he had assesses the resident earlier today (05/22/18) and the area was improving. He indicated it was a Stage III and measured 1.6 cm L x 1.2 W cm x 0 D Observation of Resident #53 on 05/22/18 at 12:10 P.M. revealed she was lying on her back in bed. Observation of Resident #53 on 05/22/18 at 3:03 P.M. revealed she was lying on her back with the head of the bed elevated at approximately 45 degrees. During an interview conducted on 05/22/18 at 12:35 P.M., the Director of Nursing (DON) verified Resident #53's admission skin assessment dated [DATE] noted the residents skin was intact with a callus on her right great toe. The skin assessment dated [DATE] noted the resident's skin was intact. The DON indicated she had no clue how the resident's unstageable pressure ulcer was found. The DON indicated a Braden Scale was completed upon admission and the resident was at risk for skin breakdown. The DON indicated interventions to prevent skin breakdown included a side rail to reposition self and a pressure reduction cushion in the wheel chair, but the pressure reduction cushion was discontinued on 04/04/18. The DON indicated the resident used a gerichair for bingo attendance and verified no pressure reduction cushion was ordered. The DON indicated after the unstageable pressure ulcer was found interventions were added to include a low air loss mattress, wound care physician visits, wound treatments, pain medication was increased, and protein powder and a stress vitamin were ordered. Observation of Resident #53 on 05/23/18 at 9:04 A.M. revealed she was sitting in bed eating breakfast independently. During an interview conducted on 05/23/18 at 10:29 A.M. with LPN #6 during wound care observation revealed a STNA notified her of a skin problem with Resident #53 on 03/27/18. LPN #6 made rounds with the wound physician every week so she asked him to assess the resident. LPN #6 verified the wound was unstageable when identified. During a follow up interview conducted on 05/23/18 at 12:23 P.M. with the DON she verified the resident was noted with redness to her coccyx on 03/23/18 and no new interventions were added until the are was unstageable. Review of information from NPUAP revealed an Unstageable Pressure Injury is defined as an obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage III or Stage IV pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed.

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 in-service records, review of facility policies on Hoyer Lift Pad Care, Nursing Mechanical Lift Pad Monitoring and Using Portable Lifting Machine, review of witness statements, review of the facility's fall investigation, review of facility monitoring and tracking forms for Sit/Stand Mechanical Lift Competency Checklist and Laundry Mechanical Lift Pad Monitoring, manufacturer's product information sheet review and staff interviews, the facility failed to ensure a resident requiring transfers with a mechanical lift was transferred safely. This resulted in Immediate Jeopardy when Resident #98 experienced serious life threatening injuries during an avoidable fall from a mechanical lift when a lift pad/sling in poor condition tore resulting in the fall and the resident sustaining bilateral hip fractures. This affected one (#98) of three residents reviewed who required a mechanical lift for transfers. The facility identified a total of 19 residents who require the use of a mechanical lift with lift pad/sling for transfer. The facility census was 71. On [DATE] at 1:28 P.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on [DATE] at 5:10 P.M. when Resident #98 was being transferred using a mechanical lift from her specialized wheelchair to her bed, and the canvas pad used to lift the resident with the mechanical lift device had ripped on the bottom at the right corner causing the resident to slide out of the pad, feet first. The resident fell out of the full body lift pad/sling that was in poor condition landing on the leg of the mechanical lift and floor sustaining fractures to both hips. The resident was sent to the hospital for evaluation and treatment and expired two days after the fractures occurred. The Immediate Jeopardy was removed on [DATE] at 5:30 P.M. when the facility removed all the old lift pads/slings from service and replaced them with all new lift pads/slings for the lifts. The deficiency remained at Severity level 2 (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) until it was corrected on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 5:30 P.M., the DON disposed of all lift pads present in the facility used for transferring residents via the mechanical lift and full body shower lift pads in good condition were used in the interim. · On [DATE], beginning at 5:40 P.M. and completed on [DATE] at 8:00 P.M., the DON educated all facility nursing staff and routine agency staff, either in person or via telephone, regarding ensuring resident safety and proper integrity of the lift pad prior to, during, and following transfers when using mechanical lift devices. · On [DATE], beginning at 5:40 P.M. and completed on [DATE] by 8:00 P.M., the DON educated Director of Building Operations (DOBO) #52 and all Laundry personnel on the correct laundering procedures and routine inspection of mechanical lift pads. · On [DATE] at 5:40 P.M. and completed on [DATE] at 8:00 P.M., a new facility policy and procedure titled Hoyer Lift pad Care for mechanical lift pad care and condition tracking was developed. All nursing and laundry staff were in-serviced by the DON. · On [DATE] beginning at 5:45 P.M., total mechanical lift competency evaluations were started for each Stated tested Nurse Aide (STNA) and licensed nurses, and was completed for all nursing staff on [DATE] at 8:30 A.M. Each nursing staff's competency evaluation for use of a mechanical lift was recorded on an evaluation form titled Sit/Stand Mechanical Lift Competency Checklist. No nursing staff personnel was permitted to complete a mechanical lift transfer until they had been competency tested and passed, after the fall incident on [DATE]. · 0n [DATE] at 5:45 P.M., the mechanical lift policy titled Using a Portable Lifting Machine was revised and implemented requiring all agency STNAs working at the facility to only conduct mechanical lift transfers with a licensed nurse, and only after being competency tested by house staff. The charge nurse on duty is responsible for educating any agency nursing staff person called in to work at the facility on the policy upon their arrival and completing the competency testing. All facility nursing staff was trained on the revised policy by [DATE] at 8:00 P.M. · On [DATE], the facility ordered and scheduled overnight delivery of a new supply of 37 lift pads. · On [DATE] at 11:00 A.M., new full body lift pads arrived and were washed and labeled with a unique identifier number, and also labeled with the name of the resident who the lift pad was assigned to. · On [DATE], beginning at 11:30 A.M. and concluding at 2:30 P.M., the laundry staff began washing and monitoring the condition of each new lift pad in use at the time they were put in service, and subsequent daily monitoring each time a lift pad is laundered using a unique number assigned to the lift pad for tracking the condition of the lift pad when in the laundry. The monitoring is completed daily via a tracking sheet titled Laundry Mechanical Lift Pad Monitoring which included the number of the lift pad washed and inspected, including inspection of the padding, hooks and edging. · On [DATE], two current residents requiring a mechanical lift for transfers were observed during the transfer process. Resident #24 was observed at 11:15 A.M. and Resident #33 was observed at 2:26 P.M. Both residents were transferred with a mechanical lift device with two staff members present, utilizing the proper lift pads that were new, in good condition, labeled with their respective names and unique identification numbers for the lift pad. There were no identified problems observed during the mechanical lift transfers. · On [DATE] between 12:46 P.M. and 3:14 P.M., the following laundry and nursing staff were interviewed regarding the facility's new procedures regarding ensuring that lift pads were in an acceptable and safe condition, and their respective responsibilities: Registered Nurse (RN) #68, DOBO #52, Laundry Staff #46, STNA #62, agency STNA #80, and Licensed Practical Nurse (LPN) #29. All staff were able to verbalize the new procedures in place and their respective responsibilities regarding ensuring that lift pads were maintained in good and safe condition prior to use, or they were to be discarded. · On [DATE], review of monitoring and tracking documentation was completed with the facility implementing the new policies. Findings include: Review of Resident #98's closed medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive minimum data set (MDS) assessment dated [DATE] revealed Resident #98 was assessed as having good memory, recall, and cognitive skills, and requiring two nursing staff personnel for transfer and bed mobility, and having functional limitations in range of motion to both sides of her body. The resident did not/could not walk, and used a wheel chair for mobility. Resident #98 was discharged to the hospital on [DATE] after falling out of a lift pad during a transfer with a mechanical lift. The resident expired at the hospital on [DATE]. Review of the fall investigation dated [DATE] at 5:15 P.M., immediately after the fall incident, revealed the DON interviewed the staff present at the time of the fall, former STNA #83, agency STNA #80, and RN #68, who was the first nurse to respond to calls for help. Both STNA #83 and STNA #80 reported to the DON the resident fell due to the lift pad breaking/tearing. The DON noted the resident was being transferred using a mechanical lift from her specialized wheel chair to her bed, and the canvas pad used to lift the resident with the mechanical lift device had ripped on the bottom at the right corner causing the resident to slide out of the pad, feet first. She documented she examined the lift pad that was in use with the mechanical lift at the time of the fall. The DON documented upon visualization of the canvas lift pad, the piping along the edges of the pad was visually damaged. The bottom left corner of the pad also presented with a longitudinal tear just above the area where the Hoyer hooks are located. Review of the witness statements dated [DATE] (no time noted) by STNAs #83, #80 and #62 documented the cause of the fall was the mechanical lift pad failed/tore while the resident was being lifted causing the resident to fall to the floor. The witness statements from the STNAs did not include any information on the condition of the lift pad used to transfer Resident #98 on [DATE]. Review of the nurses ' notes dated [DATE] at 5:43 P.M. revealed RN #68 made a note regarding a fall incident which involved the resident on [DATE] at 5:10 P.M. RN #68 documented he was called to the resident's room and upon entering the room, the resident was noted sitting on the floor, being held up in a sitting position by two STNAs (STNA #83 and agency STNA #80). RN #68 noted the resident was also sitting upon one leg of the Hoyer (mechanical) lift, facing the window with her back towards the door with her electric wheel chair to the right of her, as she had just been lifted out of her chair. RN #68 documented hanging over Resident #98's head was the mechanical lift arm with the torn lift pad, torn in half, causing the resident's fall. RN #68 noted the resident stated she fell out of the mechanical lift when it tore. RN#68 documented the resident was then lifted off of the leg of the mechanical lift, and the lift was removed out from under her. RN #68 noted he completed a head to toe assessment and noted no apparent immediate injuries or deformities at that time, however the resident did complain of pain to her legs and back. RN #68 then noted emergency services via a 911 call were initiated to send Resident #98 out to the hospital for further evaluation. Interview with the DON on [DATE] at 12:24 P.M. regarding Resident #98 and the fall incident on [DATE] revealed the DON was in the facility at the time of the incident and got a call over the radio there was a fall and RN #68 had responded to Resident #98's room. There were two STNAs (STNA #83 and agency STNA #80) in the room as well. The DON stated Resident #98 was sitting on the floor and the left leg of the mechanical lift. RN #68 was behind the resident holding up her upper body; the resident had no use of her arms or legs, and the resident was complaining of pain. At that time, RN #68 stated he was going to send her out to the hospital. The DON reported the resident sustained [REDACTED]. The DON stated the root cause of the fall was the lift pad. The lift pad had ripped at one corner across the fabric allowing the resident to fall to the floor. On [DATE] at 3:24 P.M., the DON was asked to provide the lift pad that was involved in the fall incident with Resident #98 on [DATE]. She reported the facility no longer had the lift pad. The DON described the lift pad as having areas that were compromised/damaged along the piping/reinforced edge that were in poor condition. The DON stated the fabric of the lift pad had torn from one side of the lift pad to the other across a corner, in a triangular manner. She reported prior to the incident there was no formal maintenance/inspection plan in place to ensure that damaged or worn lift pads were disposed of and to ensure the integrity of the lift pad in use by residents. The DON shared when she started looking for all the lift pads in the facility after the incident she did find some older ones, not in good condition, that appeared to have been stashed away by staff for later use. Interview with RN #68 on [DATE] at 12:46 P.M. regarding the fall incident revealed STNA #62 heard someone nearby calling for help from Resident #98's room, and he went to the room. RN #68 stated when he arrived there was one facility STNA #83 and one agency STNA #80 in the room with the resident. RN #68 reported when he arrived at the room the resident was on the floor/lift leg, alert and conscious and stated to him that her butt was hurting really bad. He verbalized that one of the STNAs, he couldn ' t remember which one, told him the resident was complaining that one of her legs was hurting so they pulled it straight for her. RN #68 stated the STNAs shouldn ' t have pulled her leg and they shouldn ' t have moved her at all. Both aides reported to him that the resident fell from the mechanical lift when the lift pad ripped. He stated the lift pad was a four point lift pad and to the best of his recollection the lift pad ripped on the side at the corner supporting her right lower body/leg. RN #68 stated at that point, he lifted under her arms and had the STNAs pull the leg of the mechanical lift out from under her. He communicated the resident did not complain of any pain after the lift leg was removed from underneath her. Her vitals were obtained as stable. RN #68 stated the resident was repositioned for comfort until emergency services arrived. During a follow-up interview on [DATE] at 3:10 P.M., RN #68 was asked to clarify where the lift pad had ripped. He reported the lift pad ripped across the fabric of the lift pad toward the corner where it attached to the hook, not at the straps. Interview with STNA #62 on [DATE] at 2:33 P.M. revealed she arrived at Resident #98's room just after the incident, as she had heard staff calling for help. She stated she went to the room and saw the resident on the floor. STNA #62 stated there were two aides in the room; a facility aide and an agency aide who had worked at the facility often. She stated the agency STNA was #80, but could not recall the name of the facility STNA who no longer works at the facility. STNA #62 reported that two nurses were tending to the resident, LPN #29 and LPN #58, while RN #68 was calling 911. She stated at that time, the two STNAs that were completing the transfer left the room. STNA #62 stated she observed the lift pad was ripped and a corner of the lift pad was still hanging from the mechanical lift, about a half of a piece of paper in size. STNA #62 stated it was a lift pad that never should have been used and the fabric was faded and worn. STNA #68 stated the blue lift pads were worn down, some of them felt and looked worn, and when she came across them she never used them, prior to the incident. STNA #62 reported since the incident on [DATE], the facility got rid of every one of the old lift pads, and that every resident was assigned a new lift pad, with their name and number on it for tracking. She stated the facility policy is to always use two nursing staff personnel for a mechanical lift, and now if we have an agency STNA working they have to have a licensed nurse present and/or assisting with the transfer as the second person. Interviews with STNA #83 and agency STNA #80 were attempted on [DATE] with no answer. Review of the manufacturer's product information sheet titled Full Body Patient Sling dated 2016, documented a warning box. The warning box contained the statement: WARNING, Inspect sling for wear prior to each use, if signs of tearing, fraying or wear are found discard the sling immediately; worn out slings are not safe for use and may result in injury or death. The deficiency substantiates Complaint Number OH 490.