Every finding on record at Concord Health & Rehab CTR

Based on medical record review and staff interview, the facility failed to develop a baseline plan of care for Resident #87 upon admission who was admitted with a gastrostomy tube. This affected one resident (#87) of 20 residents reviewed for care plans. The facility census was 74.Findings include:Record review for Resident #87 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Guillain Barre syndrome, chronic obstructive pulmonary disease, dysphagia, gastro-esophageal reflux disease, hematemesis, depression, gastrostomy, anxiety, depression, irritable bowel syndrome, and spinal stenosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 had intact cognition.Review of Resident #87's current baseline care plan, last revised on 06/26/26, revealed there was no care plan put into place to address Resident #87's care needs related to her gastrostomy tube and tube feedings. Interview with the Director of Nursing (DON) on 06/29/26 at 4:11 P.M. verified the facility did not develop a baseline care plan to address Resident #87's care needs related to her gastrostomy and tube feeding.

Based on medical record review and staff interview, the facility failed to properly submit a discharge assessment following its completion. This affected one resident (#1) of three residents reviewed for discharge assessments. The facility census was 74.Findings include:Record review for Resident #1 revealed the resident was admitted to the facility on [DATE] and discharged home on [DATE]. Diagnoses included acute respiratory failure, COVID-19, muscle weakness, dysphagia, lumbar compression fracture, low back pain, gastro-esophageal reflux disease, and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition.Review of Resident #1's Discharge Return Not Anticipated assessment revealed a start date of 02/02/26 and a completion date of 02/13/26. The current status was not accepted at the time of survey. Interview with the MDS Registered Nurse #950 on 06/29/26 at 10:34 A.M. verified the assessment was not properly submitted to be accepted.

Based on observation, medical record review, interview and facility policy review, the facility failed to ensure care planned fall prevention interventions were in place. This affected one resident (#12) of two residents reviewed for falls. The facility census was 74.Findings Include:Review of the medical record for Resident #12 revealed an admission date of 03/13/26 with a readmission date of 05/29/26. Diagnoses included chronic obstructive pulmonary disease (COPD), vascular dementia, depression, generalized muscle weakness, abnormalities of gait and mobility, symbolic dysfunction, dysphagia, adult failure to thrive, protein calorie malnutrition, peripheral vascular disease, adjustment disorder with mixed anxiety and depressed mood, hypertension, insomnia, hypothyroidism, mixed anxiety disorders and chronic respiratory failure.Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had a severe cognitive deficit. Review of the mood and behavior revealed the resident had no indicators of depression and wandered. The assessment indicated the resident was dependent on staff for transfers. Review of the care plan dated 04/01/26 revealed Resident #12 was at risk for falls related to dementia, impaired balance, impaired cognition, memory impairments, personal history of falls, poor decision-making skills, use of psychotropic medications, attempts to get up unassisted lacks safety awareness. Interventions included anti-tippers to wheelchair, anti-rollback to wheelchair, ensure environment is free of clutter, maintain a clear pathway, have commonly used articles within reach, monitor/anticipate/intervene for causative factors, personal sensitivity alarm (PSA) to bed, check placement and function every shift, PSA to chair, check placement and function every shift, remain in wheelchair while in dining room as she will allow, resident to be in common area when awake, verbal reminders and visual reminders, Call don't fall. On 06/29/26 at 1:48 P.M., an observation of the resident's wheelchair revealed the anti-rollbacks were in place; however the anti-tippers were not on the wheelchair. Interview with Licensed Practical Nurse (LPN) #460 verified the anti-tippers were not in place. Review of the facility policy titled, Fall Management, last revised 01/23/25, revealed each resident will be assessed throughout the course of treatment for different parameters such as cognition, safety awareness, fall history, mobility, medications or predisposing health conditions that may contribute to fall risk. An interdisciplinary plan of care will be developed, implemented, reviewed and updated as necessary to reflect each resident's current safety needs and fall reduction interventions.

Based on interview and record review, the facility failed to have parameters for administration of two as needed pain medications for Resident #33. This affected one resident of five reviewed for unnecessary medications. The facility census was 73. Findings include: Review of the medical record for Resident #33 revealed an admitted [DATE]. Diagnoses included chronic pain. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively intact. Resident #33 had occasional moderate pain interfering with her activities of daily living. Review of the pain assessments dated 08/28/24 and 09/04/24 revealed Resident #33 had moderate pain described by the resident. Review of the plan of care revealed Resident #33 had pain related to recent re-fracture of right hip and surgery. The interventions included to assess/monitor pain and provide pain medication as ordered. Review of the physician orders dated 09/2024 revealed on 08/09/24, Resident #33 had an order for Ibuprofen (non-narcotic pain medication) 800 milligrams (mg) by mouth every eight hours as needed for mild pain and on 08/12/24, hydrocodone-acetaminophen (narcotic pain medication) 5/325 mg by mouth every six hours as needed for pain. Neither pain medication had description of mild pain, or numerical identification of pain level. Review of the Medication Administration Record for 09/2024 revealed Resident #33 received no doses of Ibuprofen however, received hydrocodone-acetaminophen 5/325 mg by mouth every six hours as needed for pain was administered 20 times for pain ranging from three to six on a pain scale of one to ten along with non-pharmacological interventions. Interview with Licensed Practical Nurse (LPN) #560 on 09/11/24 at 3:42 P.M. confirmed that a resident ordered two pain medications as needed would need parameters to help the nurse decide which medication to administer based on the resident's level of pain. Interview with Director of Nursing (DON) on 09/12/24 at 1:44 P.M. confirmed as needed pain medications required level of pain parameters to ensure the nurse administered the appropriate pain medication.

Based on record review and staff interview, the facility failed to ensure Resident #31 had appropriate clinical reason/diagnosis for the use of an antipsychotic medication. This affected one (#31) of five residents reviewed for unnecessary medications. The facility census was 73. Findings include: Review of the medical record for Resident #31 revealed an admitted [DATE] with diagnoses including dementia with psychotic disturbance, anxiety disorder, major depressive disorder, psycho-physiologic insomnia, hallucinations, and delirium. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was cognitively impaired with signs and symptoms of delirium, hallucinations, delusions and verbal behaviors directed to others. Resident #31 received antipsychotic medication seven of seven days during the look back period. The antipsychotics were reviewed on a routine basis with no gradual dose reduction attempted. Review of the plan of care for Resident #31 revealed no plan of care specifically for hallucinations. The plan of care addressed dementia and it did not list hallucinations as a symptom or problem. Review of the nursing progress notes from 07/01/24 to 09/12/24 revealed occasional documentation Resident #31 had hallucinations. Review of the physician orders dated 09/2024 indicated Resident #31 was ordered and received quetiapine fumerate (Seroquel) (antipsychotic medication) 100 milligrams (mg) by mouth daily for hallucinations. Interview with Regional Clinician #999 on 09/12/24 at 9:09 A.M. confirmed hallucinations was not an appropriate diagnosis for the use of antipsychotic medication Seroquel for Resident #31.

Based on closed medical record review, staff interviews and facility policy review, the facility failed to ensure the Power of Attorney (POA) was notified of a change in condition in the area of skin tears for one resident (#74). This affected one (Resident #74) of three residents reviewed for notification. The facility census was 73. Findings Include: Review of the closed medical record for Resident #74 revealed an initial admitted [DATE] with the diagnoses including encounter for orthopedic aftercare, displaced intertrochanteric fracture of the right femur, chronic obstructive pulmonary disease (COPD), Parkinsonism, generalized muscle weakness, abnormalities of gait and mobility, dysphagia, other symbolic dysfunctions, dysarthria and anarthria, repeated falls, protein-calorie malnutrition, chronic kidney disease, dementia, hypertension, gastro-esophageal reflux disease, hyperlipidemia, insomnia, depression, anxiety disorder, chronic pain syndrome, dementia with behavioral disturbances, abnormal weight loss, psychotic disorder and urinary tract infection (UTI). The resident expired in the facility on [DATE]. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the resident had delusions, displayed verbal and physical behaviors directed towards others and rejected care. The resident required was dependent on staff for activities of daily living (ADL). The resident was always incontinent of both bowel and bladder. The assessment indicated the resident had no falls since admission to the facility. The resident was assessed as being at risk for skin breakdown and had no skin issues. Review of the behavior note dated [DATE] at 1:10 A.M. revealed the resident was combative with staff and attempting to get out of bed. Review of the progress note dated [DATE] at 1:15 A.M., revealed the resident had two skin tears on the right and left wrist/lower hand area after resident was being combative with staff and hitting hands of bed railings. Staff was attempting to keep resident from falling out of bed. The resident was assisted with putting pants on and assisted into her wheelchair to help calm resident down. The skin tears were cleansed with wound cleanser, antibiotic ointment was applied and covered with band-aid. The resident was taken to the nurses station and given juice. Review of the progress note dated ,d+[DATE] 24 at 10:08 A.M. revealed the resident's daughter requested to see the nurse. The resident daughter was upset about the skin tears to the left and right hand/wrist. The daughter informed the nurse on one had informed her of the skin tears occurring. The nurse notified the Director of Nursing (DON) of the situation. Review of the skin grid non-pressure dated [DATE] revealed the resident was found to have a skin tear to the left wrist. The wound measured 1.0 centimeters (cm) by 1.0 cm. The assessment indicated the physician and the family were notified of the incident. Review of the skin grid non-pressure dated [DATE] revealed the resident was found to have a skin tear to the right wrist measuring 1.0 cm by 1.0 cm. The assessment indicated the physician and the family were notified of the incident. On [DATE] at 8:29 A.M., interview with the DON verified the resident's POA was not notified when the incident occurred. The DON revealed when the POA came to the facility on [DATE] she noted the skin tears and was notified at that time. On [DATE] at 1:16 P.M., interview with Licensed Practical Nurse (LPN) #183 verified she had not notified the POA at the time of the occurrence of the skin tears. Review of facility policy titled Change of Condition, dated [DATE], revealed a change of condition is defined as deterioration in health, mental or psychosocial status of a resident related to a life threatening condition, a significant alteration in treatment or a significant change in the resident's clinical condition or status. The unit manager or charge nurse will notify the resident, physician and guardian/interested family member of all changes as stated above and of any other situations requiring notification. This deficiency represents non-compliance investigated under Complaint Number OH00150843.

Based on closed medical record review, interviews, facility investigation review and facility policy review, the facility failed to report an allegation of abuse to the required state agency for one resident (#74). This affected one (Resident #74) of three residents reviewed for abuse. The facility census was 73. Findings Include: Review of the closed medical record for Resident #74 revealed an initial admitted [DATE] with the diagnoses including encounter for orthopedic aftercare, displaced intertrochanteric fracture of the right femur, chronic obstructive pulmonary disease (COPD), Parkinsonism, generalized muscle weakness, abnormalities of gait and mobility, dysphagia, other symbolic dysfunctions, dysarthria and anarthria, repeated falls, protein-calorie malnutrition, chronic kidney disease, dementia, hypertension, gastro-esophageal reflux disease, hyperlipidemia, insomnia, depression, anxiety disorder, chronic pain syndrome, dementia with behavioral disturbances, abnormal weight loss, psychotic disorder and urinary tract infection (UTI). The resident expired in the facility on [DATE]. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the resident had delusions, displayed verbal and physical behaviors directed towards others and rejected care. Review of the behavior note dated [DATE] at 1:10 A.M. revealed the resident was combative with staff and attempting to get out of bed. Review of the progress note dated [DATE] at 1:15 A.M., revealed the resident had two skin tears on the right and left wrist/lower hand area after resident was being combative with staff and hitting hands of bed railings. Staff was attempting to keep resident from falling out of bed. The resident was assisted with putting pants on and assisted into her wheelchair to help calm resident down. The skin tears were cleansed with wound cleanser, antibiotic ointment was applied and covered with band-aid. The resident was taken to the nurses station and given juice. Review of the progress note dated ,d+[DATE] 24 at 10:08 A.M. revealed the resident's daughter requested to see the nurse. The resident daughter was upset about the skin tears to the left and right hand/wrist. The daughter informed the nurse on one had informed her of the skin tears occurring. The nurse notified the Director of Nursing (DON) of the situation. Review of the skin grid non-pressure dated [DATE] revealed the resident was found to have a skin tear to the left wrist. The wound measured 1.0 centimeters (cm) by 1.0 cm. The assessment indicated the physician and the family were notified of the incident. Review of the skin grid non-pressure dated [DATE] revealed the resident was found to have a skin tear to the right wrist measuring 1.0 cm by 1.0 cm. The assessment indicated the physician and the family were notified of the incident. Review of the facility's self-reported incident (SRI) list revealed no reported SRI related to the allegation of abuse alleged by the resident's POA. On [DATE] at 8:29 A.M., interview with the DON revealed the Power of Attorney (POA) was very accusatory and tried to say the staff held the resident down and that is what caused the skin tears. The DON revealed the POA accused the staff of abusing the resident at that point. The DON verified the facility had not completed a self-reported incident notifying the state agency of the allegation of abuse. Review of facility policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated [DATE], revealed it is the facility's policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident or Misappropriation of Resident Property, including injuries of unknown source. Additionally, the facility should immediately report all such allegations to the Administrator and to the Ohio Department of Health (ODH). This deficiency represents non-compliance investigated under Complaint Number OH00150843.

Based on closed medical record review, interviews, facility investigation review and facility policy review, the facility failed to complete a thorough investigation for an allegation of abuse for one resident (#74). This affected one (Resident #74) of three residents reviewed for abuse. The facility census was 73. Findings Include: Review of the closed medical record for Resident #74 revealed an initial admitted [DATE] with the diagnoses including encounter for orthopedic aftercare, displaced intertrochanteric fracture of the right femur, chronic obstructive pulmonary disease (COPD), Parkinsonism, generalized muscle weakness, abnormalities of gait and mobility, dysphagia, other symbolic dysfunctions, dysarthria and anarthria, repeated falls, protein-calorie malnutrition, chronic kidney disease, dementia, hypertension, gastro-esophageal reflux disease, hyperlipidemia, insomnia, depression, anxiety disorder, chronic pain syndrome, dementia with behavioral disturbances, abnormal weight loss, psychotic disorder and urinary tract infection (UTI). The resident expired in the facility on [DATE]. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the resident had delusions, displayed verbal and physical behaviors directed towards others and rejected care. Review of the behavior note dated [DATE] at 1:10 A.M. revealed the resident was combative with staff and attempting to get out of bed. Review of the progress note dated [DATE] at 1:15 A.M., revealed the resident had two skin tears on the right and left wrist/lower hand area after resident was being combative with staff and hitting hands of bed railings. Staff was attempting to keep resident from falling out of bed. The resident was assisted with putting pants on and assisted into her wheelchair to help calm resident down. The skin tears were cleansed with wound cleanser, antibiotic ointment was applied and covered with band-aid. The resident was taken to the nurses station and given juice. Review of the progress note dated ,d+[DATE] 24 at 10:08 A.M. revealed the resident's daughter requested to see the nurse. The resident daughter was upset about the skin tears to the left and right hand/wrist. The daughter informed the nurse on one had informed her of the skin tears occurring. The nurse notified the Director of Nursing (DON) of the situation. Review of the skin grid non-pressure dated [DATE] revealed the resident was found to have a skin tear to the left wrist. The wound measured 1.0 centimeters (cm) by 1.0 cm. The assessment indicated the physician and the family were notified of the incident. Review of the skin grid non-pressure dated [DATE] revealed the resident was found to have a skin tear to the right wrist measuring 1.0 cm by 1.0 cm. The assessment indicated the physician and the family were notified of the incident. Review of the facility's self-reported incident (SRI) list revealed no reported SRI related to the allegation of abuse alleged by the resident's POA on [DATE]. On [DATE] at 8:29 A.M., interview with the DON revealed the Power of Attorney (POA) was very accusatory and tried to say the staff held the resident down and that is what caused the skin tears. The DON revealed the POA accused the staff of abusing the resident at that point. The DON provided no additional investigative information other than the three State tested Nursing Assistants (STNA) statements. Review of facility policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated [DATE], revealed it is the facility's policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident or Misappropriation of Resident Property, including injuries of unknown source. Additionally, the facility should immediately report all such allegations to the Administrator and to the Ohio Department of Health (ODH). This deficiency represents non-compliance investigated under Complaint Number OH00150843.

Based on interviews, record reviews, and review of video camera footage, the facility failed to ensure a resident was treated in a dignified, professional manner by staff. This affected one resident (#46) with the potential to affect all residents residing in the facility. The facility census was 72. Findings include: Record review for Resident #46 revealed this resident was admitted to the facility on [DATE] and had diagnoses including chronic respiratory failure with hypoxia, obstructive sleep apnea, epilepsy, heart failure, and muscle weakness. Review of the annual Minimum Data Set (MDS) assessment, dated 07/07/23, revealed this resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 10 out of 15. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting and to be independent with setup help only for eating. Review of the video camera footage, dated 06/28/23 and timed 6:13 A.M., revealed Licensed Practical Nurse (LPN) #200 was observed placing her hands together by her face, mimicking a sleeping position, and stated Sleeping like a baby, I'm gonna wake up every two hours hungry and wet. Resident #46 responded I'm not to which LPN #200 further replied I know you are. Review of the video camera footage, dated 08/07/23 and timed 11:07 P.M., revealed LPN #200 is instructing the resident to breathe while standing beside her bed. LPN #200 then begins walking around the residents bed and loudly and sternly states I'm not leaving, calm down!. Interview with the Director of Nursing (DON) on 08/22/23 at 10:00 A.M. verified the manner in which LPN #200 spoke to Resident #46 in the video camera footage was not professional. Telephone interview with LPN #200 on 08/22/23 at 12:55 P.M. revealed the manner in which the LPN interacted with the resident was intended to be joking and disrespect or harm was not intended. This deficiency was a result of the investigation of Complaint OH00145461.

Based on review medical record review, policy and procedure review and interview the facility failed to ensure Resident #45's medical record contained evidence of contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, advance directive information, all special instructions or precautions for ongoing care, as appropriate, and comprehensive care plan goals when the resident was discharged to the hospital. This affected one resident (#45) of one resident reviewed for hospitalization . Findings include: Review of Resident #45's medical record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #45's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/27/2022 revealed the resident's speech was clear, he made himself understood, he understands others and his cognition was moderately impaired. Review of Resident #45's progress note, dated 07/04/2022 revealed Resident #45's daughter in-law was contacted, and she informed the nurse Resident #45 had called her and he was talking about hurting himself. Resident #45 thought he was on a bus in West Virginia. Resident #45's daughter in-law wanted the resident sent to the emergency department. Resident #45 was asked if he wanted to go to the emergency room for evaluation and he said yes. Resident #45 was sent to the emergency department and was admitted to the hospital. Further review of Resident #45's medical record revealed no evidence the emergency department and/or the hospital was provided with information for Resident #45's including contact information of the resident's physician, resident representative contact information, advance directive information, and comprehensive care plan goals as required. On 07/14/22 at 1:55 P.M. interview with the Director of Nursing (DON) confirmed there was no evidence in Resident #45's medical record of physician contact information, Resident #45's representative information including contact information, advance directive information, all special instructions or precautions for ongoing care, and comprehensive care plan goals when the resident was discharged to the hospital. The DON revealed she send a copy of the resident's face sheet, history and physical, and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility Transfer to Hospital for Admission policy, revised April 2002 revealed a completed transfer form was to be sent with the resident.

Based on medical record review, facility policy and procedure review and interview the facility failed to ensure bed hold information was provided to Resident #45 and/or the resident's representative at the time of transfer to the hospital. This affected one resident (#45) of one resident reviewed for hospitalization . Finding include: Review of Resident #45's medical record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #45's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/27/2022 revealed the resident's speech was clear, he made himself understood, he understands others and his cognition was moderately impaired. Review of Resident #45's progress note, dated 07/04/2022 revealed Resident #45's daughter in-law was contacted, and she informed the nurse that Resident #45 had called her and he was talking about hurting himself. Resident #45 thought he was on a bus in West Virginia. Resident #45's daughter in-law wanted the resident sent to the emergency department. Resident #45 was asked if he wanted to go to the emergency room for evaluation and he said yes. Resident #45 was sent to the emergency department and was admitted to the hospital. Further review of Resident #45's medical record revealed no evidence Resident #45 or his responsible party were provided or notified of the facility bed hold policy/information at the time of his transfer. On 07/14/22 at 1:55 P.M. interview with the Director of Nursing (DON) confirmed neither Resident #45 or his responsible party were provided required bed hold information at the time of transfer/discharge. Review of the facility Bed Hold Policy, revised 11/30/2018, revealed before a nursing facility transferred a resident to a hospital or the resident goes on a therapeutic leave, the nursing facility must provide written information to the resident or the resident representative related to bed hold.

Based on review of resident personal funds accounts, policy and procedure review and interview the facility failed to ensure residents who were within $200.00 of the Social Security Income (SSI) resource limit of $2,000.00 were assisted in spending down the money so the resident did not lose their Medicaid eligibility. This affected two residents (#32 and #60) of five residents reviewed for personal funds. Findings include: 1. Review of Resident #60's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident did not have a financial power of attorney or legal guardian. Review of Resident #60's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/13/2022 revealed the resident's speech was impaired and she was severely cognitively impaired. Review of Resident #60's personal funds account on 07/11/2022 revealed she had $9,179.76 in her personal funds account. As of 03/25/2022 Resident #60's account exceeded the $2,000.00 SSI resource limit. On 07/14/22 at 12:58 P.M. interview with Business Office Manager (BOM) #700 confirmed Resident #60 exceeded the $2,000.00 SSI resource limit. BOM #700 indicated she had notified Resident #60 quarterly her personal funds account exceeded the SSI resource limit. However, the resident was non-verbal and was unable to participate in conversations regarding the funds. BOM #700 was unaware of anything Resident #60 needed. BOM #700 revealed she also had spoken with Resident #60's brother (specific dates not provided), but stated he had not done anything with her money. On 07/14/22 at 1:08 P.M. interview with Social Service Designee (SSD) #240 revealed she was not aware Resident #60's personal funds account exceeded the SSI resource limit. SSD #240 indicated Resident #60 had personal needs the money could be used for. Review of the undated Resident Trust Fund Accounting and Records policy revealed the provider shall give written notification to each resident who received Medicaid benefits and whose funds were managed by the provider, when the amount in the resident's account reached $200.00 or less than the resource limit. 2. Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #32's annual MDS 3.0 assessment, dated 05/16/2022 revealed the resident's speech was rarely/never understood and he had severely impaired cognition. Review of Resident #32's personal funds account revealed on 07/11/2022 Resident #32 had $5,939.31 in his personal funds account. As of 03/25/2022 Resident #32's account exceeded the $2,000.00 SSI resource limit. On 07/14/22 at 12:58 P.M. interview with BOM #700 verified Resident #32 exceeded the $2,000.00 SSI resource limit. BOM #700 revealed she had spoken with Resident #32's brother (date not provided), and he was supposed to work on spending the money, but stated he had not had time to do so. BOM #700 revealed she was unaware of anything the resident might need. On 07/14/22 at 1:08 P.M. interview with Social Service Designee (SSD) #240 revealed she was not aware Resident #32's personal funds account exceeded the SSI resource limit. SSD #240 indicated Resident #32 had personal needs the money could be used for. Review of the undated Resident Trust Fund Accounting and Records policy revealed the provider shall give written notification to each resident who received Medicaid benefits and whose funds were managed by the provider, when the amount in the resident's account reached $200.00 or less than the resource limit.

Based on medical record review, review of Centers for Medicare and Medicaid (CMS) guidance and interview the facility failed to timely complete and submit a Minimum Data Set (MDS) assessment for Resident #63, who had been discharged from the facility. This affected one resident (#63) of 20 residents whose MDS 3.0 assessments were reviewed. Findings include: Review of Resident #63's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged from the facility on 05/13/22. Review of a nursing progress note, dated 05/13/22, revealed the resident was discharged to a Hospice house. Review of the MDS 3.0 assessments completed for Resident #63 revealed there had not been a discharge MDS assessment completed related to the resident's discharge from the facility as of 07/13/22. On 07/14/22 at 11:10 A.M. interview with the Director of Nursing (DON) verified there had not been a discharge MDS assessment completed for Resident #63 since her discharge on 05/13/22. Review of the online CMS guidance titled Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 (https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf), dated 10/2019 revealed a discharge assessment-return not anticipated must be completed when the resident was discharged from the facility and the resident was not expected to return to the facility within 30 days, must be completed 14 days after the discharge date , and must be submitted within 14 days after the MDS completion date.

Based on observation, medical record review, review of Centers for Medicare and Medicaid (CMS) guidance and interview the facility failed to ensure Resident #14's Minimum Data Set (MDS) 3.0 assessments were accurate to reflect the resident's limitations in functional mobility/range of motion. This affected one resident (#14) of 20 residents whose MDS 3.0 assessments were reviewed. Findings include: Record review revealed Resident #14 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessments, dated 01/08/22 and 04/07/22 revealed Resident #14 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15. The resident was assessed to be dependent on two staff members for bed mobility, transfers and toileting and was dependent on one staff member for eating. Section G0400 of the assessment was marked as not assessed for functional limitation in range of motion to upper extremities and lower extremities. Review of the Physical Function Observation form, dated 03/30/22 revealed the resident had functional limitation in range of motion to the bilateral upper and lower extremities. On 07/12/22 at 9:25 A.M. Resident #14 was observed in bed with obvious contractures of both the upper and lower extremities present. On 07/12/22 at 4:07 P.M. interview with MDS Nurse #370 verified the MDS assessments, dated 01/08/22 and 04/07/22 had been marked as the resident not being assessed for limited range in motion. MDS Nurse #370 revealed this was due to nursing staff not having documented an assessment of the limited range of motion during the seven day lookback period for the MDS assessment. MDS Nurse #370 verified Resident #14 had limited range of motion present to both upper and lower extremities since being admitted to the facility which should have been coded on both of the above MDS assessments. On 07/13/22 at 8:40 A.M. interview with Certified Occupational Therapy Assistant #470 verified Resident #14 had contractures present to both upper and both lower extremities since being admitted to the facility. Review of the online CMS guidance titled Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 (https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf), dated 10/2019 revealed coding for functional Range of Motion (ROM) was a three step process which included testing the resident's upper and lower extremity ROM. If the resident was noted to have limitation of upper and/or lower ROM, review G0110 and/or directly observe the resident to determine if the limitation interfered with function or placed the resident at risk for injury. Code G0400 A/B as appropriate based on the assessment.

Based on medical record review and staff interview the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) assessment for Resident #23 was accurately completed upon admission to the facility. This affected one resident (#23) of three residents reviewed for timely and accurate PASARR assessments. Findings include: Record review revealed Resident #23 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the PASARR, dated 09/06/21 revealed the assessment was not accurate as it did not include the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/21/22 revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 14 out of 15. The assessment revealed the resident required extensive assistance from two staff members for bed mobility and toileting and extensive assistance from one staff member for eating. On 07/13/22 at 3:30 P.M. interview with the social service designee verified the PASARR assessment completed for Resident #23 on 09/06/21 had not been filled out accurately as it did not include the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, record review and interview the facility failed to ensure comprehensive care plans were developed and implemented for Resident #14 and Resident #29 related to functional mobility/contractures. This affected two residents (#14 and #29) of three residents reviewed for range of motion. Findings include: 1. Record review revealed Resident #29 had an initial admitted [DATE] and re-admission on 06/15/22. Resident #29 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physical Function Assessments, dated 05/11/22 and 06/15/22 revealed the resident had impairment to both upper extremities and hands. Record review revealed no comprehensive care plan had been developed for Resident #29 to identify and provide an individualized plan to address the resident's impairments (range of motion needs) to the bilateral upper extremities and hands. On 07/14/22 at 9:28 A.M. observation of Resident #29 with the Director of Nursing (DON) verified the resident had limitations in range of motion and bilateral hand contractures. The DON also verified the facility had not developed a comprehensive and individualized plan of care to address and provide interventions related to range of motion/contractures. 2. Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physical Function Observation form, dated 03/30/22 revealed the resident had functional limitation in range of motion to the bilateral upper and lower extremities. Review of the quarterly MDS 3.0 assessment, dated 04/07/22 revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15. The assessment revealed the resident was dependent on two staff members for bed mobility, transfers and toileting and dependent on one staff member for eating. Record review revealed no comprehensive care plan had been developed for Resident #14 to identify and provide an individualized plan to address the resident's impairments (range of motion needs) to the bilateral upper and lower extremities. On 07/12/22 at 9:25 A.M. Resident #14 was observed in bed. The resident as observed with obvious contractures to both the upper and lower extremities present. On 07/12/22 at 4:07 P.M. interview with MDS Nurse #370 verified Resident #14 had contractures present to both the upper and lower extremities. MDS Nurse #370 also verified the facility had not developed and implemented a comprehensive plan of care to address and provide intervention for the contractures/limitations in range of motion.

Based on medical record review and interview the facility failed to ensure residents and/or their responsible party were invited and participated in quarterly care conferences/interdisciplinary team meetings. This affected two residents (#20 and #25) of three residents reviewed for care conferences. Findings include: 1. Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/29/22 revealed Resident #20 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15 our of 15. The assessment revealed the resident required extensive assistance from one staff member for bed mobility and toileting, limited assistance from one staff member for transfers and was independent with no setup or physical help from staff for eating. Review of the social service progress notes, dated 01/01/22 through 07/11/22 revealed no evidence of care conferences being conducted for the resident. On 07/12/22 at 9:35 A.M. interview with Resident #20 revealed the resident denied being invited to or attending care conferences with facility staff to discuss his care. On 07/12/22 at 4:05 P.M. interview with Regional Director of Clinical Operations (RDCO) #990 verified there was no evidence of care conferences being held for Resident #20 in 2022. 2. Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment, dated 04/29/22 revealed the resident had moderately impaired cognition evidenced by a BIMS assessment score of 02 out of 15. This assessment revealed the resident was assessed to exhibit rejection of care one to three days, required extensive assistance from two staff members for bed mobility, toileting, and transfers and required supervision with setup help only for eating. Review of the social service progress notes, dated 07/17/21 through 07/05/22 revealed no documentation of care conferences being conducted for the resident to include the resident's responsible party. On 07/12/22 at 4:05 P.M. interview with Regional Director of Clinical Operations (RDCO) #990 verified there was no evidence of care conferences being held for Resident #20 between 07/2022 and 07/05/22. This deficiency substantiates Complaint Number OH 505.

Based on observation, record review and interview the facility failed to develop and implement comprehensive and individualized range of motion treatment and services for Resident #29 to address contractures/limitations in range in motion to the resident's bilateral upper extremities/hands. This affected one resident (#29) of three residents reviewed for range of motion. Findings include: Record review revealed Resident #29 had an initial admitted [DATE] and re-admission on 06/15/22. Resident #29 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physical Function Assessments, dated 05/11/22 and 06/15/22 revealed the resident had impairment to both upper extremities and hands. Record review revealed no comprehensive care plan had been developed for Resident #29 to identify and provide an individualized plan to address the resident's impairments (range of motion needs) to the bilateral upper extremities and hands. Review of daily task documentation for Resident #29 revealed no evidence the resident was provided range of motion exercises or use of splinting devices to address the bilateral upper extremity impairments. On 07/13/22 at 11:30 A.M. observation of Resident #29 revealed the resident's hands were contracted into closed fists. When asked if he could open his hands, the resident was unable to do so. On 07/13/22 at 2:45 P.M. interview with Regional Director of Clinical Services #990 verified the resident had bilateral contractures to both upper extremities with no splint devices or services in place. On 07/14/22 at 9:28 A.M. observation of Resident #29 with the Director of Nursing (DON) verified the resident had limitations in range of motion and bilateral hand contractures. The DON also verified the facility had not developed a comprehensive and individualized plan of care to address and provide interventions related to range of motion/contractures.

Based on medical record review and interview the facility failed to ensure appropriate diagnoses/justification for the use of psychoactive medications for Resident #16. This affected one resident (#16) of five residents reviewed for unnecessary medication use. Findings include: Record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including COVID-19, muscle weakness, dysphagia, dementia, [CONDITION(S)], depression, anxiety, [CONDITION(S)] and disorders of the bladder. Review of physician's medication orders revealed the resident had orders for psychoactive medications, including the anti-psychotic medication, [MEDICATION(S)] ([MEDICATION(S)]) 10 milligrams by mouth daily and the anti-convulsant medication, [MEDICATION(S)] 125 mg twice daily. Review of the resident's current diagnoses revealed no evidence the resident had a diagnosis of [CONDITION(S)] or other appropriate diagnosis to ensure the justified use of the [MEDICATION(S)] or [MEDICATION(S)]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/11/22 revealed the resident had severe cognitive impairment. On 07/13/22 at 10:01 A.M. interview with Regional Director of Clinical Services #990 verified the lack of evidence to support the justified use of [MEDICATION(S)] ([MEDICATION(S)]) or [MEDICATION(S)] for Resident #16.

Based on record review, facility policy and procedure review, Centers for Medicare and Medicaid (CMS) Quality Safety and Oversight (QSO) 22-09-ALL review and interview the facility failed to implemented their COVID-19 vaccination plan and failed to ensure 100 percent of staff were fully vaccinated against COVID-19, were temporarily delayed or had been granted a medical or religious exemption as required. This had the potential to affect all 60 residents residing in the facility. Findings include: On 01/14/22 CMS issued QSO Memo 22-09-ALL requiring all providers ' and suppliers ' staff to have received the appropriate number of (COVID-19 vaccine) doses by the timeframes specified unless exempted as required by law, or delayed as recommended by the Centers for Disease Control (CDC). CMS provided guidance effective 90 days after the issuing of the QSO memo (April 2022), facility staff vaccination rates under 100% constituted non-compliance under the rule. On 07/11/22 review of the facility undated COVID Vaccine Matrix Log revealed two of 95 employees, State tested Nursing Assistant (STNA) #650 and STNA #850 were not fully vaccinated against COVID-19. Both employees were noted to be partially vaccinated against COVID-19. Neither STNA had documented evidence of having a granted medical or religious exemption or as being temporarily delayed in receiving the COVID-19 vaccination. This resulted in the staff vaccination rate being 97.9 percent. Review of the COVID-19 Vaccination Record Card for State tested Nursing Assistant (STNA) #650 revealed documentation the STNA had received the first dose of the Pfizer COVID-19 vaccine on 12/22/21. There was no documentation of the second dose of the vaccine being administered. Review of the COVID-19 Vaccination Record Card for STNA #850 revealed documentation the STNA had received the first dose of the Moderna COVID-19 vaccine on 01/27/22. There was no documentation of the second dose of the vaccine being administered. Review of the facility daily staffing schedules for nursing staff, dated 06/14/22 through 07/14/22 revealed STNA #650 and STNA #850 worked multiple shifts in a position which required providing direct care to residents. On 07/14/22 at 2:52 P.M. interview with the Director of Nursing (DON) verified STNA #650 and STNA #850 were not fully vaccinated, newly hired and did not have a granted medical or religious exemption. Review of the facility policy titled COVID-19 Vaccine Plan, Exemptions/Accommodations/Temporary Delays & Tracking, most recently revised on 02/15/22 revealed all employees were required to be considered fully vaccinated by the deadline as stated in the provided regulations.

Based on record review, review of admitting hospital medical record documentation, review of the facility's policy and procedure for gastrostomy tubes and staff interview the facility failed to ensure Resident #78, who received all of her nutrition and hydration via gastrostomy tube received adequate nutrition/fluids to prevent dehydration. This resulted in harm to Resident #78, who was dependent on staff for all of her nutrition/hydration needs via a gastrostomy tube, when on 01/19/14 the resident was admitted to the hospital with [REDACTED].#78) of three residents reviewed for quality care and treatment. Findings include: Resident #78 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission nursing assessment, completed by licensed practical nurse (LPN) #2, dated 12/31/13 revealed the resident was awake, alert and oriented. The assessment also reflected the resident's vital signs and indicated the resident did not have any type of pressure or non-pressure related skin abnormalities. Under the section nutrition, the assessment revealed the resident had a feeding tube and a special diet. Record review revealed on 12/31/13 an order was in place to cleanse the resident's gastrostomy tube site with soap and water and apply zinc oxide twice a day. However, there was no written assessment of the resident ' s skin or gastrostomy tube patency /functionality at that time. Review of the laboratory testing, dated 01/03/14 revealed the resident's blood urea nitrogen (BUN) was elevated at 46 (normal 7-18) and creatinine was 1.1. The resident's sodium level was normal at 141. Record review revealed the resident's diet order was for a regular diet with mechanical soft texture and nectar thick liquids. On 01/03/14 a new order was obtained for the resident to have nothing by mouth (NPO). From 12/31/13 until 01/09/14 the resident had a physician order [REDACTED]. Review of the dietary assessment narrative, completed by Dietician #1, dated 01/05/14 revealed Resident #78 was admitted on a mechanical soft diet with nectar thick liquids and had a speech evaluation completed on 01/02/14. The note revealed the resident was ordered nothing by mouth (NPO), had a jejunostomy tube and was receiving 100% of her estimated nutrition from the feeding tube. The current order for enteral feeding was Fibersource at 60 milliliters (mls) per hour continuous feeding with water flushes of 300 mls every six hours. The dietary assessment revealed this provided the resident with 1728 kilocalories (kcals), 78 grams protein and 2366 milliliters (mls) of water which was assessed to exceed the resident's estimated needs. Record review revealed a nutritional assessment note, also dated 01/05/14 and completed by Dietitian #1 which revealed a clarification for the tube feeding to be Fibersource HN at 70 mls continuous for 22 hours to provide 1848 kcals, 83 grams of protein and 1247 mls of free water with goal weight maintenance of 125-135 pound range. The free water was to be changed to 240 mls three times a day for 720 mls and total free water 1967 mls. No additional dietary progress notes or assessments were completed following the notes dated 01/05/14. Review of the admission Minimum Data Set (MDS) 3.0 dated 01/07/14 revealed the resident was cognitively intact. The MDS revealed the resident was totally dependent on one staff member for eating and had an ostomy in place. The MDS assessment revealed the resident was 67 inches tall and weighed 128 pounds. It also identified she had an abdominal (PEG) tube with 51% or more of her total calories provided by the tube and 501 milliliters (ml) average fluid intake received per day by the tube. The MDS assessment reflected the resident also received and a mechanical soft diet. On 01/10/14 the nursing assessment revealed the resident did not have any pressure or non-pressure related skin abnormalities. Review of nursing progress notes, dated 01/19/14 at 3:35 A.M. revealed the resident was not responsive and lethargic. Vital signs revealed the resident ' s blood pressure was 88/55, pulse 72 beats per minutes and oxygen saturation 85%. The resident was noted to have feces seeping out around her feeding tube. The resident was transferred to the emergency room . Review of hospital documentation, dated 01/19/14 revealed the resident had been sent to the emergency department and was admitted with hypotensive septic shock, acute kidney injury on top of [MEDICAL CONDITIONS] from profound dehydration and probable health care associated pneumonia. The emergency room documentation revealed the resident required intravenous hydration with fluid resuscitation. Laboratory values, completed at the hospital and dated 01/19/14 revealed the resident's sodium level was elevated at 163 HH which indicates it was critically high, potassium level was elevated at 6.4 HH which indicates it was critically high, BUN was elevated at 243 H which indicates it was high and creatinine was elevated at 8.4 H which indicated it was high. On 02/04/14 at 12:53 P.M. interview with State tested nursing assistant (STNA) #7 revealed she was aware Resident #78 had a gastrostomy ([DEVICE]) tube in place. The STNA indicated staff were keeping a [MEDICAL CONDITION] bag over the [DEVICE] site because the site was leaking so much, the bag was required to catch the contents that were leaking. The STNA indicated the resident's [DEVICE] site was leaking all the time. On 02/04/14 at 12:59 P.M. interview with licensed practical nurse (LPN) #6 revealed Resident #78 had a [DEVICE] in place for nutrition/hydration. The LPN indicated the resident's [DEVICE] site had been leaking copious amounts. He stated it leaked to the point that he was doing dressing changes constantly. He stated they had put a bag over the [DEVICE] to catch the drainage and indicated the facility was using a [MEDICAL CONDITION] bag to catch the drainage. He also stated they used the stoma paste to attach the bag to protect her skin. However, the resident's skin surrounding the gastrostomy tube site had become irritated and inflamed. Record review revealed no written documentation during the resident ' s stay related to her gastrostomy tube leaking, although staff were aware, via interview of it leaking so badly that it had to be covered with a [MEDICAL CONDITION] bag. There was no written evidence the amount or consistency of output was monitored. Additionally, there was no written indication the resident ' s physician or dietitian were notified of the increased leakage from the resident ' s gastrostomy tube to evaluate if the resident was receiving sufficient nutrition/hydration from the enteral product being used. The resident subsequently ended up admitted to the hospital with [REDACTED]. On 02/04/14 at 4:57 A.M. an interview with the facility's medical director revealed he was aware the resident's gastrostomy tube was leaking when he assessed her on 01/06/14. The medical director stated he did not know what had been done for the leaking [DEVICE]. He also stated the staff had not notified him of the copious amounts of leakage and he was not aware the facility was using a [MEDICAL CONDITION] bag to catch the contents that were leaking from the [DEVICE]. The medical director verified he had not evaluated the resident ' s nutrition/hydration as it related to the leaking gastrostomy tube. On 02/04/14 at 5:15 P.M. interview with social service director from local hospital verified Resident #78 had been admitted to their facility and had come through the emergency department on 01/19/14. The social service director verified the resident was admitted to the hospital with [REDACTED]. On 02/05/14 at 9:59 A.M. interview with the director of nursing (DON) revealed Resident #78's gastrostomy tube had been leaking when the resident was admitted . The DON indicated a [MEDICAL CONDITION] bag was placed over the gastrostomy tube to capture the leakage. The DON verified there was no monitoring or assessing of the content that was leaking to ensure the resident was receiving adequate nutrition/hydration. The DON indicated she was aware staff were covering the site with a [MEDICAL CONDITION] bag to contain the leakage, although there was no order for such. The DON also acknowledged the facility had not completed skin/wound assessments of the skin surrounding the resident's [DEVICE] site. On 02/05/14 at 12:07 P.M. interview with Dietitian #1 revealed she had no knowledge that Resident #78's gastrostomy tube was leaking or there was a possibility that the resident was not receiving the enteral feeding that was ordered because the gastrostomy tube was leaking. The dietitian indicated she had not been asked to reassess Resident #78, nor had staff alerted her to any concerns, problems or issues with the resident ' s gastrostomy tube. The dietitian was unaware that staff had placed a [MEDICAL CONDITION] bag over Resident #78's gastrostomy tube to collect the copious amounts of liquid drainage that was coming from the resident's [DEVICE] site. This deficiency substantiates Complaint Number OH 541.

Based on observation, medical record review, incident report review, policy review and staff interview, the facility failed to ensure a diabetic resident received appropriate nail care. This affected one of three residents reviewed for accidents (Resident #67). The facility census was 66. Harm resulted to Resident #67 when a State tested Nurse Aide (STNA) cut the resident's toenails and the resident received three lacerations to two toes that required treatment in the emergency room that included application of surgical glue and a compression bandage. Findings include: Medical record review revealed Resident #67 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment (dated 10/28/11) revealed Resident #67 was severely impaired for daily decision making and required extensive assist from staff for personal hygiene. Review of the Monthly Physician order [REDACTED]. Review of the Progress Note (dated 12/12/11 at 10:21 A.M.) revealed Resident #67 was still bleeding and sent out to the emergency room for evaluation. Review of the medical record revealed no documented evidence of what caused the resident's bleeding, where the resident was bleeding, or when the incident occurred. Review of the Progress Note (dated 12/12/11 at 2:23 P.M.) revealed Resident #67 returned from the emergency room with a compression dressing. Review of the medical record revealed no documented evidence of the location of the compression dressing. Review of the General Investigation of Incident Report (dated 12/11/11) revealed on 12/11/11 at 10:00 P.M., STNA #1 was cutting Resident #67's toenails when the resident jerked causing a laceration to the great left toe and two lacerations to the second left toe. The great left toe laceration measured 0.9 centimeters (cm) in length by 1.0 cm width (w). The two lacerations to the second left toe measured 0.2 cm (l) by 0.1 cm depth (d), and 0.3 cm (l) by 0.2 cm (w) by 0.1 cm (d). On 12/22/11 at 2:40 P.M., observation of Resident #67's left great toe revealed a laceration that measured 1.0 cm (l) by 0.3 cm (w) by 0.1 cm (d), the wound bed was red with a black scab that measured 0.1 cm (l) by 0.1 cm (w). Observation of the second left toe laceration revealed a purplish bruise at the base of the nailbed and a black scabbed area that measured 1.0 cm (l) by 0.2 cm (l). Review of the Care of Fingernails/Toenails policy (revised July 2006) revealed unless otherwise permitted, do not trim the nails of a diabetic resident. On 12/22/11 at 2:12 P.M., interview with the Director of Nursing (DON) verified the medical record revealed no documented assessment of Resident #67's laceration, and no evidence of when or how the incident occurred. On 12/22/11 at 2:25 P.M., interview with Licensed Practical Nurse (LPN) #3 revealed on 12/12/11 the resident's dressing to the left great and second toe were saturated with a moderate amount of blood. The dressing was changed and the lacerations continued to bleed. LPN #3 verified the resident was sent to the emergency room for treatment that included surgical glue to the lacerations and a compression dressing. On 12/22/11 at 3:00 P.M., interview with LPN #3 verified STNAs were not to cut nails of a diabetic resident. LPN #3 stated Resident #67 was not diabetic. On 12/22/11 at 3:25 P.M., interview with the DON verified Resident #67 did have a [DIAGNOSES REDACTED]. This deficiency was an incidental finding during the investigation of Complaint Number OH 611.

Based on record review, observations, review of policies and procedures, review of fall investigations, and staff interview, the facility failed to ensure a resident was assisted appropriately by staff and the use of a gait belt, and failed to ensure a resident had safety interventions in place to prevent a fall. This affected two of three residents reviewed for falls (Residents #47 and #49). There was a total of 67 residents residing in the facility. Harm occurred to Resident #49 when facility staff failed to provide the appropriate number of staff and the use of a gait belt which resulted in the resident falling and sustaining a fractured hip requiring surgical repair. Findings include: 1. Record review revealed Resident #49 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] status [REDACTED]. Resident #49 had [DIAGNOSES REDACTED]. Review of Resident #49's record revealed a fall risk assessment dated [DATE], and identified the resident at high risk for falls. Review of Resident #49's Minimum Data Set (MDS) quarterly assessment, dated 07/07/11, revealed the resident required extensive assistance of two people for transfers and required extensive assistance of one person for toilet use. When moving on and off the toilet and walking, the resident was not steady and only able to stabilize with human assistance. Review of the MDS assessment revealed the resident used a walker or a wheelchair as a mobility device and had a personal history of falls. Review of the plan of care for At Risk for Falls (dated 11/27/09) revealed the resident was to have a call bell within reach, have commonly used articles within easy reach, have a mat to floor at bedside, monitor/anticipate/intervene for causative factors, and staff were to provide assistance of 1-2 with all transfers. Review of Resident #49's nurses' notes revealed on 09/04/11, an entry by Registered Nurse (RN) #2 stated the nurse was called to the room by a State-tested nurse aide (STNA) and observed the resident on the floor in front of the recliner lying on her back. RN #2 assessed the resident for injuries, complaints of pain to the head, back, and right hip. RN #2 initiated neuro checks and attempted vital signs but the resident refused. RN #2 contacted Emergency Medical Systems (EMS) for transport to the hospital for evaluation. RN #2 notified the physician as well as the resident's daughter. Review of the fall investigation dated 09/04/11, revealed the resident returned from the bathroom, let go of the walker prematurely, lost balance, and was lowered to the ground by STNA #3. The investigation described the fall scene as the resident was observed on the floor in front of chair, shoes on, walker present, and floor clear. Review of the fall investigation revealed the new intervention was for a two-person assist. Review of a statement by STNA #3 stated, "I took Resident #49 to bathroom at 11:00 P.M., got her off the toilet about 15 minutes later. When I was walking her back to her room, she was leaning forward and didn't have very good control of her walker. When Resident #49 got into her room, she ran over the pillow beside her recliner with the front left wheel of the walker and pushed the walker out of reach. I asked her what she was doing, and she said she didn't know what she was doing. Then, before I could get her walker, she took a step and started going forward to the floor. So I got under her arm and turned her around, sat her on the floor and layed her down. Finally I got the nurse." Review of the Rehabilitation History and Physical and post-admission assessment dated [DATE] from the hospital revealed Resident #49 suffered a right hip fracture. An x-ray was performed and revealed a closed displaced comminuted subtrochanteric fracture of the right hip, and the resident received an open reduction and internal fixation of the right hip. On 09/20/11 at 1:30 P.M., interview with the Director of Nursing (DON) revealed STNA #3 stated to her she wanted to keep Resident #49 from falling face-first, so she put her arms under hers, turned her quickly around, and sat Resident #49 down. The DON stated the pillow was beside Resident #49's recliner on the floor and not directly in the pathway, but the resident veered to the side, and the walker caught the pillow. The DON stated STNA #3 was behind the resident while she was using the walker and not beside of her. The DON stated STNA #3 did not use a gait belt when transferring the resident from the bathroom back to her room. The DON stated STNA #3 was educated to use a gait belt on hire and after this incident. The DON confirmed the MDS assessment dated [DATE] revealed the resident required extensive assistance of two people for transfers. The DON confirmed STNA #3 was the only staff in the room at the time. Review of the facility's Fall Prevention Program (dated 10/18/01), revealed it was the responsibility of all associates to have preventative fall precautions taken for all residents admitted to the facility. Intervention measures would include but were not limited to: orientation to surrounding, instruction concerning toileting, ensuring call light, water, tissues, and other personal items were within reach of resident, dry floors, and no obstacles in pathways. Review of the facility's Gait Belt policy and procedure (dated 10/18/01), revealed the purpose was to promote safe resident mobility and transfers and the nursing staff was responsible. The facility policy stated gait belts were to be used on all residents who required "hands on" assistance to transfer or ambulate. Review of the policy revealed a gait belt would be issued to each new STNA during Nursing Department orientation. A gait belt was required for use by licensed nurses. A gait belt was available at each nursing unit for this purpose. Nursing staff were responsible for having their assigned gait belt with them for use during their shift. The policy stated nurses or nursing assistants who were not using their gait belt when transferring/ambulating residents may be subject to corrective action. On 09/20/11 at 2:25 P.M., interview with the Director of Nursing (DON) confirmed the policy and procedure for gait belts was not followed by STNA #3, and Resident #49 had a fall resulting in a fractured right hip. 2. Record review for Resident #47 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #47's September 2011 physician orders [REDACTED]. Review of Resident #47's plan of care for At Risk For a Fall Related to Unsteady Gait, Debilitation, Weakness, Dementia, and Anxiety Medication (dated 01/20/10) revealed the resident was to have an alarm to chair and bed to alert staff of unassisted transfers. Review of a fall risk assessment dated [DATE] revealed Resident #47 was at high risk for falls. Review of Resident #47's nurses' notes revealed the resident had a fall on 06/02/11. The resident was found on the floor, lying on her right side. Review of the nurses' notes revealed no documented evidence the resident's alarm was in place or sounding. Review of the fall investigation completed on 06/02/11 revealed the resident fell out of bed. The current ordered intervention was to have bed and chair alarm in place. Review of the investigation revealed the alarm was not sounding and was not turned on by staff. On 09/20/11 at 5:50 P.M., observation revealed Resident #47 was in her room, sitting in a recliner, with no one in her room and with no alarm on, or in place. At 7:00 P.M., observation of Resident #47 revealed the resident was up in her recliner with the sensor pad alarm not turned on. On 09/20/11 at 4:45 P.M., interview with the DON confirmed the alarm was not turned on when Resident #47 had a fall on 06/02/11. On 09/20/11 at 7:00 P.M., interview with RN #4 confirmed Resident #47's alarm was not turned on. This certification deficiency substantiates Complaint Number OH 278.