Every finding on record at Country Club Retirement Center

Based on record review and interview, the facility failed to ensure laboratory tests were obtained per physician's order. This affected one (Resident #42) of three residents reviewed for laboratory findings. The facility census was 67. Findings include: Record review for Resident #42 revealed an admission date of 06/14/24 with diagnoses including heart failure, atrial fibrillation, hypertension, cerebral infarction and dementia. Review of Resident #42's physician's orders revealed an order dated 06/14/24 for a prothrombin time and International Normalized Ration (PT/INR), a blood test that measures how many seconds it takes for your blood to clot. Review of the Coumadin and PT/INR flowsheet for Resident #42 revealed on 07/06/26 an order was obtained to recheck the PT/INR in one week (07/13/26). On 07/13/26, the date was errored with a line, and the number 14 was entered for the lab to be drawn on 07/14/26. Further review of Resident #42's medical record revealed no evidence the PT/INR lab was obtained on 07/13/26 as ordered. Interview on 08/26/26 at 1:45 P.M. with Administrative Lab Director from [NAME] County Hospital #503 revealed the laboratory did not receive an order for the PT/INR until 07/13/26. The Administrative Laboratory Director #503 further stated that the laboratory had an option to process the test as a STAT laboratory test and would have been able to obtain the PT/INR on 07/13/26; however, a STAT order was not received. Review of the facility policy titled Management of Coumadin Therapy dated 12/15/25, revealed to follow regulatory guidelines for the use of Coumadin. Lab work will be ordered per provider, adjustments to Coumadin doses will be made when provider order is received. Review of the facility policy titled Laboratory and Diagnostic Services dated 12/15/25, revealed all residents will receive diagnostic services and follow up care per clinical practitioner orders in accordance with federal and state requirements. This deficiency represents non-compliance investigated under Complaint Number 3092503.

Based on record review, interviews and review of facility policy, the facility failed to ensure Resident #42 was free from a significant medication error related to the administration of Coumadin (warfarin). This affected one resident (Resident #42) of three residents reviewed for medication error. The facility census was 67. Findings include:Record review for Resident #42 revealed an admission date of 06/14/24 with diagnoses including heart failure, atrial fibrillation, hypertension, cerebral infarction and dementia. Review of Resident #42's physician's orders revealed an order dated 06/14/24 for a prothrombin time and International Normalized Ration (PT/INR), a blood test that measures how many seconds it takes for your blood to clot.Review of the discontinued physician's orders for Resident #42 revealed an order dated 02/25/26 and discontinued on 07/14/26 for Coumadin 4 mg one time a day for preventing blood clots. Review of the Coumadin and PT/INR flowsheet for Resident #42 revealed on 07/06/26 an order was obtained to recheck the PT/INR in one week (07/13/26). On 07/13/26, the date was errored with a line, and the number 14 was entered for the lab to be drawn on 07/14/26. Review of Resident #42's Medication Administration Record (MAR) for July 20226 revealed on 07/13/26 the Coumadin 4 mg was administered by Licensed Practical Nurse (LPN) #117. Review of the progress notes for Resident #42 revealed no evidence of a missed PT/INR lab, no evidence of physician notification for a missed PT/INR lab, no evidence of LPN #117 obtaining further direction regarding administration of the Coumadin in the absence of the ordered PT/INR on 07/13/26. Further review of Resident #42's medical record revealed the PT/INR was obtained on 07/14/26 with an abnormal high result. Review of the progress notes dated 07/14/26 authored by LPN #210 revealed the Medical Director reviewed PT/INR results and new orders was received to hold the Coumadin medication on 07/14/26 and then start Coumadin 3 mg on 07/15/26 and keep current PT/INR lab orders for weekly on Mondays. Interview on 08/26/26 at 11:37 A.M. with LPN #117 revealed the physician should have been notified, she did not receive further direction prior to administration of the Coumadin on 07/13/26 and the missed PT/INR lab should have been documented. Review of the facility policy titled Medication Error Notification dated 02/26/26, revealed the facility will maintain safety standards designed to prevent medication errors and will respond promptly and appropriately when an error occurs. Medication errors will be reported to the medical director (MD), Director of Nursing (DON), and administrator upon discovery. Notifications to residents and resident representatives will be documented. Review of the facility policy titled Management of Coumadin Therapy dated 12/15/25, revealed to follow regulatory guidelines for the use of Coumadin, lab work will be ordered per provider, and adjustments to Coumadin doses will be made when provider order is received. This deficiency represents non-compliance investigated under Complaint Number 3092503.

Based on record review, interviews, and review of facility policy the facility failed to have an accurate medical record related to wound orders. This affected one (Resident #38) of three residents reviewed with wounds. The facility census was 67. Findings include: Review of the medical record for Resident #38 revealed an admission date of 04/26/24 with diagnoses including chronic atrial fibrillation, non-pressure chronic ulcer of other part of leg of left lower leg limited to breakdown of skin and non-pressure chronic ulcer of other part of leg of right lower leg limited to breakdown of skin. Review of the care plan dated 09/10/24 revealed Resident #38 has vascular areas to bilateral legs and goes to the wound center at [NAME] County Hospital. Interventions include apply treatments to areas as ordered including topical medications/antibiotics. Review of the physicians' orders for Resident #38 dated 04/23/26 revealed an order for all wounds being dressed at wound center. Cleanse with Debrisoft, apply vashe to moistened gauze and leave in place for 10 minutes prior to application of new dressing. If unavailable may use 0.9 Normal Saline to cleanse wound, apply Gentian [NAME] as directed, apply polyMem MAX non-adhesive, then Urgoclean ag with Hydra lock SA and layer compression. Further review of Resident #38's medical record revealed progress notes from the wound center dated 08/05/26 to cleanse wounds with Debrisoft, apply vashe to moistened gauze and leave in place for 10 minutes prior to application of new dressing. If unavailable may use 0.9 Normal Saline to cleanse wound. Apply Gentian [NAME] as directed. Apply DermaBlue plus Foam as directed. Apply Hydra lock SA as directed and layer compression. Then on 08/19/26, new orders from the wound center revealed to cleanse wounds with Debrisoft, apply vashe to moistened gauze and leave in place for 10 minutes prior to application of new dressing. If unavailable may use 0.9 Normal Saline to cleanse wound. Apply Gentian [NAME] as directed. Then apply UrgoClean ag, Hydra lock SA as directed and layer compression. Review of Resident #38's medical record revealed no evidence the resident's wound treatment orders were changed according to the wound center progress notes. Interview on 08/27/26 at 10:05 A.M. with Registered Nurse (RN) from [NAME] County Wound Center verified the order dated 04/23/26 in Resident #38's record is incorrect. The treatment order was changed on 08/05/26 and then discontinued on 08/19/26. Interview on 08/27/26 at 10:25 A.M. with the Director of Nursing (DON) verified the incorrect orders. This deficiency represents non-compliance investigated under Complaint Number 3092503.

Based on observation, interviews and review of facility policy, the facility failed to maintain a clean and homelike environment regarding sanitation and condition of residents rooms. This affected one resident (Resident #21) of 67 reviewed for environment. The facility census was 67. Record review for Resident #21 revealed an admission date of 08/19/26 with diagnoses including nondisplaced fracture of fifth metatarsal bone, left foot, type 2 diabetes mellitus without complications, difficulty in walking, muscle weakness, and repeated falls.Review of the care plan for Resident #21 dated 08/25/26 revealed he was incontinent of bowel and interventions included but limited to assist resident with toileting as needed and requested.Observation on 08/25/26 at 11:24 A.M. of Resident #21's room revealed a bedside commode bucket containing dried fecal matter sitting on the floor in the resident's room. In addition, a soiled incontinence brief (Depend) was observed hanging over the top of the trash receptacle.Interview on 08/25/26 at 11:26 A.M. with the Assistant Director of Nursing (ADON) #220 verified the bucket should not be sitting on the floor visible to the doorway for visitors to see and the incontinence brief should have been removed from the room.Interview on 08/25/26 at 11:30 A.M. with Resident #21 revealed he does not like it when the staff leave his bedside commode sitting in his room, due to the odor.Review of facility policy titled Homelike Environment dated 02/04/26, revealed residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary and orderly environment.This deficiency represents non-compliance investigated under Complaint Number 3107032, 3092126, and 3123869.

Based on observation and staff interview, the facility failed to clean dishes in a safe and sanitary manner. This affected all 68 residents residing at the facility.Findings include:Observation of breakfast dishes being washed on 06/22/26 at 8:15 A.M. with the high temperature sanitizing machine with Dietary Supervisor (DS) #215 revealed the machine rinse temperature reached approximately 148 degrees Fahrenheit (F) to rinse and sanitize the dishes. Digital temperature reading at the time of observation was 156. Review of June 2026 Main Kitchen Dish Machine Temperature Log on 06/22/26 at 8:18 A.M. revealed daily temperature checks were completed daily at breakfast, lunch and dinner. Further review revealed rinse temperatures reading 171 F on 06/01; 173 F on 06/05; 170 F on 06/08; 173 F on 06/09; 172 F on 06/10; 176 F on 06/16, 172 F on 06/19; 170 F on 06/20 and 130 F on 06/21. Temperature log also revealed to notify manager or person in charge immediately if dish machines are not reaching goal temp. Stop washing dished immediately until problem is resolved. Interview on 6/22/26 at 8:20 A.M. with DS #215 revealed goal temperature readings should be 160 F for wash and 180 F for rinse, to clean the dishes. DS #215 also verified high temperature machine did not reach 180 F at the time of observation for the rinse cycle and stated she was not aware of previous out of range temperatures documented on the June 2026 temperature log. DS #215 immediately stopped use of the high temperature dish washer and stated she would call for machine to be serviced. Review of facility policy titled dishwasher temperature dated 06/20/17 revealed the proper temperatures for high temperature sanitizing machines are rinse: 180 F degrees or above.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, review of Self-Reported Incident (SRI) and policy review, the facility failed to ensure residents' controlled substances were not misappropriated. This affected five (#40, #54, #85, #86 and #87) of 52 residents receiving controlled substances. The facility census was 68. Findings include: Review of Resident # 40's medical record revealed an admission date of 10/16/25 with diagnoses including bimalleolar fracture of the right lower leg, peripheral vascular disease, osteoarthritis of the right ankle and foot, pain in the right ankle and joints of the right foot and anxiety. Review of Resident # 40's Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and received antianxiety and opioid medications. Review of Resident # 40's physicians' orders for January 2026 revealed active orders for Alprazolam (Xanax) (antianxiety) and Hydrocodone-Acetaminophen (Norco) (opioid) for pain. Review of Resident # 54's medical record revealed an admission date of 04/16/24 with diagnoses including pain and anxiety. Review of Resident # 54's Minimum Data Set (MDS) dated [DATE] revealed she was cognitively impaired and received antianxiety medication. Review of Resident # 54's physicians' orders for January 2026 revealed orders for Clonazepam (antianxiety) and Morphine Sulfate (opioid). Review of Resident # 85's medical record revealed an admission date of 01/23/26 with diagnoses including right femur fracture. Review of Resident # 85's Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and received opioid medication. Review of Resident # 85's physicians' orders for January 2026 revealed orders for Oxycodone (opioid) with Acetaminophen (analgesic) (Endocet) for pain. Review of Resident # 86's medical record revealed an admission date of 01/13/26 with diagnoses including pain in the right leg and right heel deep tissue damage. Review of Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact. Review of Resident # 86's physicians' orders for January 2026 revealed an order for Hydrocodone-Acetaminophen for pain. Review of Resident # 87's medical record revealed an admission date of 01/13/26 with diagnoses including pressure ulcer of the left ankle. Review of Resident # 87's Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact and received opioid medications. Review of Resident # 87's physicians' orders for January 2026 revealed an order for Oxycodone with Acetaminophen (Endocet) for pain. Review of the facilities SRI dated 01/26/26 revealed on 01/26/26 Licensed Practical Nurse (LPN) #222 alerted the Director of Nursing (DON) #214 of LPN #580 acting out of character and finding discrepancies during narcotic count. DON #214 reported the incident to the Administrator and completed an audit of the narcotic sheets and discrepancies were found. DON # 214 and the Administrator attempted to contact LPN #580, but she did not respond to any calls or text. All nurses were immediately re-educated on the Narcotic Medication Policy, and all staff were re-educated on abuse, neglect and misappropriation. DON #214 completed an audit for 01/23/26 to 1/26/26 and discovered discrepancies with what residents' stated they requested and received, what was signed out on the narcotic sheets, and what was documented in the medication administration record; noting that one unidentified alert resident affected stated she requested one Norco and one Xanax on 01/23/26 before bedtime and no other time during the audit period however per the narcotic sheets four Norco and five Xanax were signed out as given from 01/24/26 to 01/26/26. Another unidentified alert affected resident stated during the audit period they requested Tylenol and did not request any of their prescribed Endocet/Oxycodone because they did not like how the medication made them feel, however per the narcotic sheet 10 Endocet/Oxycodone were signed out as given during the period and only four of the ten were documented as given on the resident's medication administration record. On 01/26/26 Local law enforcement was notified of the incident and on 01/29/26 the Ohio Board of Nursing was notified LPN #580 was suspected of drug diversion. The facilities investigation revealed misappropriation was substantiated. Review of the police report dated 01/26/26 at 11:53 A.M. revealed the facility reported several controlled substances missing and reported they believed LPN #580 took them. Interview on 06/25/26 at 7:38 A.M. with the DON #214 verified she found the controlled substance discrepancies in the medication administration record and narcotic sheets. She stated all residents were assessed with no concerns found. DON #214 confirmed the five residents # 40, #54, #85, #86 and #87's controlled substances were misappropriated as follows Resident #40 had four Norco and five Xanax misappropriated, Resident #54 had one Clonazepam misappropriated, Resident #85 had 14 Endocet misappropriated, Resident #86 had six Norco misappropriated, and Resident #87 had four Endocet misappropriated. Review of facility policy titled Abuse dated 01/31/20 revealed residents have a right to be free from, abuse, neglect, exploitation and misappropriation of resident property. Review of the policy titled Narcotic Medication dated 04/03/14 revealed that upon shift change, the incoming licensed nurse and outgoing licensed nurse will review the narcotics on the wing to ensure the count of narcotics is the same for the Medication Card and the controlled medication record. Further review revealed if the narcotic count is off, the incoming licensed nurse needs to notify the director of nursing as well as the administrator. No licensed nurse is to leave the facility until the issue is resolved. The deficient practice was corrected on 03/13/26 when the facility implemented the following corrective actions: On 01/26/26 the facility self-identified an area for improvement related to narcotic medications and nursing.On 01/26/26 an audit was completed by the DON on residents that received narcotics from LPN #580.On 01/26/26 a SRI was initiated on suspected drug diversion by LPN #580.On 01/26/26 residents that were affected were interviewed or family notified based on Brief interview of mental status score (BIMS)/resident cognitive function.On 01/26/26 Pharmacy was notified by the DON of narcotic discrepancies.On 01/26/26 Police notified of incident.On 01/26/26 Education was provided by the DON to all Nurses regarding the narcotic policy.On 01/26/26 Education was provided by the DON to all staff regarding abuse, neglect and misappropriation.On 01/26/26 LPN # 580 suspended pending investigation.On 01/26/26- 01/27/26 audits completed by DON or designee on residents in the facility.On 01/26/26-01/27/26 all medication carts were audited byt DON or designee for accuracy for medications and signatures.On 01/29/26 LPN # 580 was terminated.Weekly audit were completed by the DON of narcotics three times a week for six weeks, with no issues identified.

Based on interview and record review, the facility failed to ensure after visit summary (AVS) notes were obtained following a provider appointment and failed to initiate a new medication in a timely manner. This affected one, (Resident #7) out of two residents reviewed for urinary tract infections. The facility census was 68. Findings include:Review of the medical record for Resident #7 revealed an admission date of 02/02/24 with diagnoses of Type Two Diabetes Mellitus, chronic kidney disease, hypertension, psychotic disorder, dementia, obstructive and reflex uropathy, constipation, benign prostatic hyperplasia (BPH), and muscle weakness.Review of care plan dated 02/22/24 revealed resident was incontinent of bladder at times, with diagnosis of BPH. Interventions include assist resident to bathroom, provide privacy with incontinence care, assist with incontinence care, administer medications as ordered, obtain laboratory work/diagnostic testing as ordered, and follow up with urology as ordered/needed.Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 was moderately cognitively impaired, dependent upon staff assistance for toileting, partial/moderate assistance with shower/bathing, and frequently incontinent of urine and bowel.Review of Resident #7 urology after visit summary dated 06/03/26 at 2:00 P.M., received date of 06/23/26, revealed resident was seen for a follow up visit after renal ultrasound. Resident is known for having urinary retention but no longer requires a urinary catheter. Resident is currently on Tamsulosin (Flomax) 0.4 mg two times daily. Physician orders after visit include to continue Flomax two times per day and to follow up in one year with renal ultrasound and Basic Metabolic Panel (BMP) prior to visit.Interview on 06/23/26 at 12:37 P.M. with the Director of Nursing (DON) and Regional Nurse #174 requested clarification pertaining to the urology after visit summary and the order to continue tamsulosin two times per day. Regional Nurse #174 reported the facility did not receive the urology orders when the resident came back and confirmed the after visit summary was not obtained until 06/23/26. Regional nurse #174 confirmed the resident was not currently taking Tamsulosin two times per day and that the previous order had been discontinued on 02/25/26.Interview on 06/24/26 at 10:02 A.M. with Regional Nurse #174 revealed she could not confirm if Tamsulosin was to be ordered after the visit on 06/03/26 and was waiting to hear back from the urology office.Interview on 06/24/26 at 3:14 P.M. with Regional Nurse #174 confirmed urology ordered for resident to receive Tamsulosin HCl oral capsule 0.4 mg, give 1 capsule by mouth two times per day. Regional Nurse #174 stated the nurse on shift on 06/03/26 should have requested a copy of the after visit summary by calling the office after the appointment and documenting in the medical record that an attempt was made.Review of physician order start date 06/24/26 at 4:30 P.M. revealed Tamsulosin HCl oral capsule 0.4 mg, give 1 capsule by mouth two times per day.

Based on interview and record review the facility failed to ensure re-weights were obtained after significant weight loss and significant weight gain. This affected one, (Resident #22) out of four residents reviewed for nutrition. The facility census was 68. Findings include: Review of the medical record for Resident #22 revealed an admission date of 04/26/24 with diagnoses of hypertension, muscle weakness, age related osteoporosis, non pressure chronic ulcers of the left and right lower legs, vascular dementia, major depressive disorder and transient ischemic attack.Review of the care plan dated 05/05/24 revealed the resident was at risk for altered nutrition related to multiple medical conditions. The resident was identified as being at malnutrition risk with a basal metabolic rate of 18.5 with increased metabolic requirements. Interventions include following Nutritional At Risk (NAR) protocol, giving diet as ordered, and obtaining weights as ordered.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 was moderately cognitively impaired, required set up assistance with eating, and had not exhibited a weight loss at the time of assessment.Review of the weight summary dated 04/04/26 revealed the resident weighed 113.6 pounds. On 05/08/26, the resident weighed 107.9 pounds, which is a 5.02 percent loss.Review of the weight summary dated 05/08/26 revealed the resident weighed 107.9 pounds. On 05/18/26, the resident weighed 117 pounds, which is an 8.43 percent gain.Interview on 06/25/26 at 8:56 A.M. with dietician #171 revealed the resident was removed from Nutritional At Risk (NAR) monitoring on 06/18/26 due to stable weights. The dietician reported the 05/18/26 weight of 117 pounds was treated as a discrepancy, but no re-weight was completed. She confirmed she evaluated the resident three days later when the significant weight change was noted. The resident had been placed on NAR monitoring on 05/14/26 due to the weight loss from 113.6 pounds on 04/04/26 to 107.9 pounds on 05/08/26. She reported the resident often loses weight in warmer months due to frequent walking but confirmed she did not see any re-weights in the system to verify accuracy.Review of the medical record for Resident #22 revealed no documented re-weights after the significant weight loss identified on 05/08/26 or after the significant weight gain identified on 05/18/26.Interview on 06/25/26 at 9:26 A.M. with the Director of Nursing (DON) and Regional Nurse #174 requested a copy of the re-weights from 05/08/26 and 05/18/26.Interview on 06/25/26 at 9:38 A.M. with the DON confirmed re-weights were not completed after the significant weight changes. The DON stated aides are responsible for completing weights and she was not fully familiar with the entire weight obtaining procedure and re-weight policy.Interview on 06/25/26 at 1:13 P.M. with Certified Nursing Assistant (CNA) #145 reported aides receive lists of residents requiring daily, weekly and monthly weights. These are typically assigned to a bath aide or float aide. She reported the list does not include prior weights, so the aide obtaining the weight does not know if the value differs significantly. She stated the completed weights are handed directly to the dietician for review.Review of the weight management program and weight loss policy (undated) revealed that if there is a weight loss or gain of five or more pounds from the previous month, the resident will be re-weighed and the weight verified by the program nurse or designee before being entered into electronic medical record.

Based on observation, review of pest control work orders and invoices, interviews and facility policy review, the facility failed to maintain a pest-free environment. This deficient practice had the potential to affect all 68 residents receiving food from the kitchen. The facility census was 68.Findings include:Review of the facility's maintenance work order request dated 11/22/25 revealed cockroaches were observed under the dishwasher machine by staff. Further review of the maintenance work order request revealed on 03/03/26 staff observed a large number of cockroaches scattering on the floor in the dishwashing room when the lights were turned on.Review of the facility's pest control service logs revealed extra insect treatments were completed in the kitchen and dishwasher room including spray and dust applications on the following dates: 11/18/25, 11/22/25, 12/01/25, 12/08/25, 12/24/25, 01/01/26, 01/08/26, 01/12/26, 01/15/26, 01/28/26, 02/13/26, 02/24/26, 03/09/26, 03/19/26, 03/21/26. There extra insect treatments were applied by the facility's maintenance staff.Review of the pest control company's invoices dated 03/25/26, 04/03/26, and 04/08/26 revealed initial treatment for live cockroaches and cockroach eggs observed in the dishwashing room, with weekly follow-up treatment and replacement of monitoring traps in the dishwashing room related to continued live cockroach activity.Review of the local health department kitchen/food inspection dated 03/30/26 revealed during the observation of the dishwash machine, a live cockroach was observed running across the top of the dishwasher machine and back under the dishwasher machine components. There were also live and dead cockroaches observed in several insect glue traps located under the dishwasher and the drying racks.Review of the communication email dated 03/30/26 with the dishwasher company revealed there were no live cockroaches within the dishwasher machine and any of the components of the dishwasher machine.Observations on 04/14/26 from 8:05 A.M. to 8:25 A.M. during the kitchen tour revealed the room containing the dishwasher had several insect glue traps noted along the baseboard along the outside wall of the room and located under the dishwash machine and the drying rack area. In the insect glue trap closest to the door, there were eight to ten dead cockroaches noted. The insect glue trap located under the dishwasher machine was noted to have four dead cockroaches.An interview on 04/14/26 at 10:50 A.M. with Dietary Supervisor #256 revealed maintenance staff have been treating the dishwasher room/area off and on since last fall. In March is when there were a large number of cockroaches seen. Maintenance came in and treated the area like normal, but then it became too much and they called a pest control company to help with the pest control. Staff did a deep cleaning and moved everything out and away from the walls and power washed the dishwasher room and now clean the kitchen bi-weekly as a whole to help with preventative insect control.An interview on 04/14/26 at 11:20 A.M. with the Maintenance Supervisor #248 revealed the maintenance staff complete monthly pest control preventive treatments inside and outside of the facility with any extra treatment required documented on the pest control logs. Maintenance staff had been treating for cockroaches in the dishwashing room/area for about the last six months or so and it finally got to where the spray and dust were not effective. The facility contracted with a pest control company at that time. The insect glue traps currently in the dishwashing room belong to the pest control company as part of their on-going weekly treatment plan for the cockroaches.An interview on 04/14/26 at 11:45 A.M with Dietary Supervisor #256 confirmed there had been and continued to be cockroaches in the dishwashing room. Dietary Manager #256 stated the facility is using an outside pest control company to treat the cockroaches in the dishwasher room and since the company has been treating the area, the cockroaches have declined in the dishwashing room.Review of the facility's policy titled Pest Control, dated 01/01/17, revealed it is the policy of this facility to protect the quality of life for residents living in a communal setting by preventing the infestation of pests and/or other rodents.This deficiency represents non-compliance investigated under Complaint Number 2808976.

Based on observation and interview, the facility failed to post updated daily nursing staff form. This deficient practice had the potential to affect all 68 residents residing at the facility. Findings include:An observation on 04/14/26 at 7:50 A.M. revealed in a plastic stand-up frame at the main nurse's desk was the completed facility's daily nursing staff form with the date noted as 04/10/26.An interview on 04/14/26 at 7:55 A.M. with the Administrator confirmed the daily nursing staff form had not been updated since 04/10/26. The Administrator stated the nurse is to update that form daily; it just hadn't gotten changed yet this morning.An interview on 04/14/26 at 1:32 P.M. with the Director of Nursing (DON) revealed the DON is responsible for updating the daily nursing staff form each morning. The DON stated, I have been covering nursing shifts and just hadn't updated the form.This deficiency is an incidental finding identified during the complaint investigation.

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the facility Self-Reported Incident (SRI), staff interview, family interview and policy review, the facility failed to maintain a safe environment and provided adequate supervision to prevent Resident #10, who was cognitively impaired, from eloping from the facility without staff knowledge. This affected one (Resident #10) of three residents reviewed who were identified by the facility as having exit seeking and/or wandering behavior. The facility census was 65. Findings include: Review of the medical record for Resident #10 revealed an admission date of 12/23/24. Diagnoses included Wernicke's encephalopathy, with chronic alcohol use disorder, seizure disorder, history of urinary tract infection and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was mildly cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 11 out of 15. Resident #10 was independent with activities of daily living and required cueing and assistance at times. Review of the care plan dated 04/21/25 revealed Resident #10 was at risk for elopement. He walked throughout the facility independently with a Wanderguard (a safety bracelet to prevent residents from wandering into unsafe areas or leaving the facility unsupervised) on his right ankle. Review of the nurse's progress notes from 05/23/25 to 05/25/25 revealed Resident #10 somehow removed his Wanderguard on 05/23/25. Staff completed a search of Resident #10's room and belongings. Interviews conducted with other residents revealed no indication of how Resident #10 removed his alarm. Review of Resident #10's nurse's progress note dated 05/25/25 revealed Licensed Practical Nurse (LPN) #215 went to check on Resident #10 around 7:45 P.M. and noted he was missing. All staff were notified, and an elopement drill was announced, a search began, the Director of Nursing (DON) was notified immediately and arrived at the facility within ten minutes, 911 was called, police arrived and took report, and a community search began. Meanwhile the entire property was being searched in and out. The Assistant Director of Nursing (ADON) was in her car traveling around the area looking for the resident. At approximately 8:50 P.M., Resident #10's guardian was notified and reported Resident #10, her son, was sitting at her dining room table eating dinner. Resident #10's guardian did not call the facility to notify the staff when he arrived. Police were notified, and Resident #10 returned to the facility at 10:45 P.M. escorted by the police. A new Wanderguard was placed on the resident's right ankle, and he has had a one-on-one sitter since his return. It was unknown how he removed the monitor on 05/25/25. Review of Resident #10 Elopement Evaluation completed on 12/23/24 revealed he was at no risk for elopement. On 01/06/25 a score of seven indicated Resident #10 was at a high risk for elopement. Elopement Evaluations completed on, 01/06/25, 05/26/25 and 05/30/25 scores of six and five indicating Resident #10 continued to be a risk for elopement Review of SRI tracking number 260836 revealed on 05/25/25 approximately 8:00 P.M. Resident #10 was unable to be located within the facility. Elopement procedures were activated and a complete search in the facility and outside the facility began. 911 was called and the local police arrived at the facility. A missing person was activated in the community. Administration arrived, and the DON called the residents guardian/mother who reported he was at her house approximately two miles from the facility. The police escorted Resident #10 back to the facility without incident. The following was completed upon residents return to the facility: • Head-to-toe skin assessment and resident interview was initiated on Resident #10. • Resident's psychosocial needs were assessed by staff and counseling services were ordered. • The resident was placed on a one-on-one intervention and, a new Wanderguard was placed on his right ankle. • Facility staff searched Resident #10's room and all common areas for sharp objects resident could have used to remove the Wanderguard. Interview on 06/09/25 from 3:30 P.M. to 4:00 P.M. with Resident #10 and his family revealed Resident #10 was alert and oriented to person, place and time. He admitted he did leave the facility recently after taking his Wanderguard off. He refused to disclose how he was able to remove the Wanderguard. He explained I walked down the long drive, crossed the road walked down the sidewalk to a park, sat on the bench for a while, enjoyed the fresh air and walked across the high school's football field to his mother's house which was approximately two miles away, and I had dinner with my mother. I was returned to the facility by the police. During the interview, Resident #10's legal guardian/mother was not worried that her son left the facility, he called her every night and told her he doesn't like being in the facility. She believes Resident #10 needs more to do at the facility to keep him busy. Review of the undated facility policy titled Elopement Program Policy, revealed the facility will maintain an elopement program designed to prevent and manage incidents of elopement. The deficient practice was corrected on 05/26/25 when the facility implemented the following corrective actions: • When Resident #10 returned to the facility on [DATE] a head-to toe skin assessment and resident interview was initiated. • On 05/25/25 Resident #10 was placed on one-on-one intervention and a new Wanderguard was placed on the resident. • On 05/26/25 Resident #10 psychological needs were assessed by staff, and he was added to counseling services. • On 05/26/25 all like residents' care plans and orders were reviewed for those at risk for elopement and visualization placed on actual Wanderguards on their person completed • On 05/26/25 elopement risk assessments were completed for all current facility residents. • On 05/26/25 the previous 30 days of nurse's progress notes reviewed for all current facility residents to assess documentation of residents verbalized or attempted to leave. The intervention will be in real time, five times per week for four weeks. • On 05/25/25 Wanderguard system and all facility doors checked to ensure working within normal limits and then starting 05/26/25, the exit doors will be audited five times a week for one week, then weekly times three weeks to ensure the Wanderguard system and exit doors continue to work properly. • On 05/25/25 all residents with Wanderguards will be checked for proper placement and functionality. Audit will occur five times per week for four weeks. • On 05/25/25 night staff were educated on elopement policy when Resident #10 returned to the facility. • On 05/26/25 an elopement drill was completed, and additional elopement drills will be completed every shift for seven days, then two to three times per week, then weekly times two weeks. • On 05/26/25 and 05/27/25 all other staff were educated on the elopement policy and procedures. • On 5/26/25 all staff were educated to not leave objects in common areas one could use to remove a Wanderguard initiated and completed. Common areas will be monitored five times a week times two weeks, then two times a week, then weekly times four weeks to ensure there are not any objects that residents could use to remove a Wanderguard. • On 5/26/25 staff educated on the expectations of 15-minute checks on residents and policy and procedures of utilizing a one-on-one sitter. The DON or designee will audit the one-on-one sheet for Resident #10 five times a week for four weeks to ensure there are no gaps in coverage. This deficiency represents non-compliance investigated under Self-Reported Incident, Control Number OH00166053.

Based on observation, medical record review, review of emergency room records, review of the facility incident and accident logs, interview and facility policy review, the facility failed to develop and implement a comprehensive and individualized fall prevention program to prevent falls including a fall with major injury for Resident #60. Actual Harm occurred on 09/04/24 at 7:45 P.M. when Resident #60, who was identified as a high fall risk and experienced recent falls without individualized fall prevention interventions implemented to prevent further falls, climbed out of bed, unassisted and had to be lowered to the floor by State tested Nursing Assistant (STNA) #222 when she became unsteady and began to fall. The resident denied pain on 09/04/24 and was assisted back to bed; however, on 09/05/24 at 8:29 A.M. an order was received for an immediate (STAT) x-ray of the right hip, pelvis, femur and knee due to complaints of increased pain. On 09/05/24 at 1:00 P.M. the facility was notified the resident had acute fractures of the distal femur and proximal tibia (as a result of the incident on 09/04/24) and was transferred to the emergency room (ER) for further evaluation and treatment. This affected one resident (#60) of three residents reviewed for falls. Findings Include: Review of the medical record for Resident #60 revealed an admitted [DATE] with diagnoses including heart failure, muscle weakness, depression, dementia, osteoporosis, osteopenia, and syncope. Resident #60 was receiving hospice services for end stage heart failure. Review of Resident #60's at risk for falls/injury related to cognitive impairment, dizziness, history of falls, impaired balance, pain, osteoporosis, syncope related to aortic stenosis, poor safety awareness with impulsiveness noted at times care plan dated 01/06/20 revealed interventions including to encourage the resident to change positions slowly due to dizziness dated 01/06/20, room moved to a higher traffic area on 02/14/24, staff to anticipate needs dated 01/06/20, visual reminders to utilize call light for assistance dated 02/17/24, proper footwear to be worn at all times while out of bed dated 06/15/24, encourage non-skid/gripper socks when shoes are off dated 01/06/20, a personal alarm bed/chair to alert staff of unassisted transfer check for placement and function every shift was implemented on 07/07/24 and a fall intervention for a medication review completed by hospice was implemented on 07/29/24. Review of the physician orders dated 07/07/24 revealed an order for a personal alarm bed/chair to alert staff of unassisted transfers. Check for placement and function every shift (alarms to sound to walkies and computer only as to be non-disruptive.) Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] Resident #60 had severely impaired cognition and required minimal assistance with transfers, ambulated with the assist of a walker and stand-by assist from staff, and moderate assist with activities of daily living (ADL) tasks. Review of the facility incident logs dated 07/01/24 to 09/30/24 revealed Resident #60 had witnessed falls on 08/26/24 and 09/04/24, and unwitnessed falls on 07/07/24, 07/21/24, 07/28/24, and 07/29/24. Review of Resident #60's fall investigations revealed the following: A fall on 07/07/24 at 9:46 A.M. revealed Resident #60 was observed by a visitor to be sitting on the floor inside the room with her back against the side stand with the walker noted in the doorway to the bathroom. Resident #60 stated she struck her head on the side stand when she fell . There was no redness or swelling observed to the left side of the head. A fall intervention for the use of a bed/chair alert alarm pad was implemented. Review of the Post-Fall Risk assessment dated [DATE] revealed the resident was determined to be a high fall risk. A fall on 07/21/24 at 10:25 P.M. revealed Resident #60 was observed on her knees at her bedside. Resident #60 sated she had been ambulating and fell on to buttocks and bilateral knees. Resident #60 complained of pain to her bilateral knees and buttocks. Resident #60 was able to move all extremities. Resident #60 was placed into the recliner with the alert bed/chair alarm in place. There was no fall interventions implemented following the fall. A fall on 07/28/24 at 11:50 A.M. revealed Resident #60 was observed sitting on the floor beside the recliner with her back against a suitcase and the bookshelf. Resident #60 complained of pain to her back and a bruise was noted to be forming on the lower back from falling on the suitcase. There was no mention of the alert bed/chair alarm to be sounding at the time of the fall. A fall intervention for a medication review to be completed by hospice was requested. A fall on 07/29/24 at 3:44 P.M. revealed Resident #60 was observed sitting on the floor with her legs drawn up between the bookshelf and the recliner with her walker tipped over. Resident #60 was observed with a hematoma forming to the right side of her forehead. Resident #60 did not have appropriate footwear in place. The fall intervention implemented was for a medication review to be completed by hospice. The medication review was completed on 07/30/24 with no new orders or changes to the resident's medications. A fall on 08/26/24 at 11:20 P.M. revealed Resident #60 was ambulating unassisted with her walker, in the hallway. Resident #60 stopped ambulating and fell backwards onto the floor forcefully striking the back of her head on floor. Upon assessment a large lump was palpated to the left back of her head and her blood pressure and pulse were elevated. Resident #60 complained of pain to her head. Resident #60 had appropriate footwear in place. There was no mention of the alert bed/chair alarm sounding. Resident #60 was sent to the hospital for further evaluation and possible treatment. There was no fall interventions implemented following the fall. Review of Resident #60's emergency room paperwork dated 08/26/24 revealed Resident #60 was diagnosed with an acute right posterior head contusion and returned to the facility. A fall on 09/04/24 at 7:45 P.M. revealed Resident #60 was observed by State tested Nursing Assistant (STNA) #222 standing at her bedside, unassisted, with the alert alarm sounding. Resident #60 became unsteady and started to slide downwards. STNA #222 assisted Resident #60 down to the floor, in a seated position with her legs extended outwards. Resident #60 was assessed for injury by Registered Nurse (RN) #259. There were no indication of injury and Resident #60 denied pain. Resident #60 was assisted off the floor and into a wheelchair, taken to the restroom and then assisted back into bed. There was no fall intervention implemented following the fall. The facility was unable to provide evidence the falls were reviewed to determine a root cause, identify a trend or to ensure appropriate, individualized fall prevention interventions were added to the resident's plan of care for the falls dated 07/29/24 (a duplicate intervention to the fall that occurred on 07/28/24), 08/25/24 and 09/04/24. Review of the nurse progress note dated 09/05/24 at 8:29 A.M. (the first progress note entry after the resident's fall on 09/04/24) revealed an order was received for STAT x-rays to the right hip, pelvis, femur and knee due to complaints of increased pain. On 09/05/24 at 1:00 P.M. the facility was notified (by the x-ray company) the resident sustained acute fractures of the distal femur and proximal tibia and was transferred to the emergency room (ER) for further evaluation and treatment. Review of Resident #60's emergency room documents, dated 09/05/24, revealed Resident #60 was diagnosed with a displaced fracture the distal (lower) right femur, a fracture of the neck of the right fibula, and a possible fracture line of the right tibial plateau per x-ray of right leg and pelvis. Resident #60's Power of Attorney (POA) requested to not pursue any surgical intervention for the fractures given Resident #60's severe medical problems. Review of Resident #60's Treatment Administration Record dated 09/01/24 to 09/05/24 revealed documentation of completion for monitoring the personal alarm to the bed/chair to alert staff of unassisted transfers, check for placement and function every shift. Observation on 09/30/24 at 10:00 A.M. revealed Resident #60 resting in bed with an alert alarm pad in place, a visual reminder to use the call light, and her call light was within reach. Interview on 10/01/24 at 10:07 A.M. with the Director of Nursing (DON) revealed Resident #60 was at high risk for falls due to a history of falls, unsteady gait, dementia, and being restless at times. The DON stated Resident #60 was ambulatory with the use of a walker and would ambulate in the hallways of the facility with staff assistance. At times, Resident #60 would not be content to sit in the recliner or lay in bed and would be known to pack her suitcase with her belongings, verbally stating she wanted to leave the facility. She also shared the resident was known to have increased restlessness in the evening/nighttime and she had observed this when she sometimes worked the evening shift on the floor. The facility had moved Resident #60 from her original room on the back hallway to a room closer to the nurses' desk and on a higher trafficked hallway for better monitoring of Resident #60. The DON shared nurses were to assess the resident, check for injuries, complete paperwork and notifications. If the nurse could not determine an intervention to implement, they would contact the nurse on-call for ideas. The DON then stated the fall would be reviewed in the risk meeting to make sure the paperwork is completed, and an intervention had been implemented. Further interview revealed the resident had fallen on night shift, 09/04/24 and when she (the DON) worked the floor as an aide on 09/05/24, we (she did not indicate who the other staff was) went in to reposition Resident #60 for breakfast and she was complaining of her right leg hurting. The DON stated she had the nurse call (the physician) for X-ray orders. The X-rays were completed and that is how the facility learned the resident had fractures and she was sent to the ER for evaluation. Interview on 10/01/24 at 11:35 A.M. with RN #163 revealed the process for completing a post fall assessment, implementation of fall interventions and updating the fall care plans for residents had been the responsibility of RN #163 to help with the administrative nurse's workload but her administrative job responsibilities had been removed. Interview on 10/01/24 at 11:45 A.M. with the DON confirmed Resident #60 did not have fall interventions implemented for falls which occurred on 07/21/24, 07/28/24, 08/26/24 and 09/04/24. The DON stated there should be interventions implemented for each fall that occurs with a resident. Further interview with the DON revealed several nurses were assisting with the follow-up regarding falls and sometimes they did not have time to review the falls to ensure interventions are added to prevent future falls. During the onsite survey, attempts were made to reach STNA #222 via phone; however, no return call was provided. Review of the facility's policy titled, Accident/Incident Reporting last revised 08/13/14 revealed, Accidents and incidents are to be promptly and thoroughly reviewed and investigated. An incident is defined as an event, occurrence or happening that may result in actual or potential harm of a resident. The purpose of the incident reports are to facilitate the early detection problems or compensable events; to establish a foundation for early investigation of all potentially serious events; to develop a database for long-range problem detection, analysis and correction; to enable cross-reference with other risk detection systems; to investigate and respond to serious adverse events, in accordance with accrediting bodies standards. When an incident occurs, the individual discovering the incident will notify the supervisor immediately with observations or identification of the incident; follow-up with the resident and family/caregiver and resident's physician as indicated; Complete the Incident Report Form within 24 hours of the incident; the Administrator/Designee will review the incident report and request the necessary follow-up from the appropriate personnel. Corrective actions will be implemented and evaluated for effectiveness as indicated; A witness statement will be obtained, if applicable; Investigation will be completed, and findings will be documented.

Based on record review, review of a facility Self-Reported Incident (SRI), facility investigation review, personnel file review, facility policy review and interview, the facility failed to ensure Resident #51 was free from an incident of staff to resident physical abuse when State tested Nursing Assistant (STNA) #267 slapped the resident during the provision of care. This affected one resident (#51) of three residents reviewed for abuse. The facility census was 69. Findings Include: Review of the medical record for Resident #51 revealed an admitted [DATE] with diagnoses including unspecified dementia, high blood pressure, asthma, and muscle weakness. Review of Resident #51's bladder and bowel incontinence care task documentation dated 08/30/24 to 09/30/24 revealed Resident #51 was always incontinent of bowel and bladder, there were no refusal marked for care attempted by staff. Review of the facility's Self-Reported Incident (SRI) Tracking Number 251637 dated 09/07/24 revealed on 09/07/24 at approximately 10:00 P.M. it was reported that a facility State tested Nursing Assistant (STNA) (identified as STNA #267) slapped the hand of Resident #51 during the provision of care. The alleged perpetrator was suspended pending investigation. Resident #51's emergency contact and physician were notified. An investigation was initiated consisting of interview and skin assessment of Resident #51, interview of the reporting witness, interview of the alleged perpetrator, interviews of staff and interviews of residents within the same care section as Resident #51. During interview Resident #51 he was unable to recall the occurrence. The skin assessment performed revealed no signs of injury directly or indirectly related to the alleged incident. Interview of the reporting witness (staff) revealed that during the performance of care, Resident #51 was observed grabbing. According to the witness's recollection and perspective Resident #51 had been grabbing at his incontinence brief at the time of the occurrence. During interview the alleged perpetrator reported that Resident #51 grabbed her ' , very hard and that in response she smacked his hand. As a result of the investigation the facility concluded the alleged perpetrator's actions were not reflective of facility standards of conduct and the decision was made to terminate her employment. Review of the facility's investigation dated 09/07/24 revealed a statement dated 09/07/24, authored by STNA #267 (alleged perpetrator), stating STNA #267 was assisting Resident #51 when Resident #51 forcefully grabbed STNA #267. STNA #267 moved Resident #51's hand away and tapped/smacked Resident #51's hand as if to scold Resident #51 and said No, don't grab me. Further review revealed a statement dated 09/07/24 authored by STNA #177 stating STNA #267 was helping with changing Resident #51 when Resident #51 grabbed STNA #267, STNA #267 was witnessed smacking Resident #51's hand. STNA #177 asked STNA #267 to leave the room. STNA #177 reported the incident to Registered Nurse (RN) #213. Review of STNA #267's personnel file revealed a hire date of 12/2023 and she had received abuse and dementia education during orientation to the facility. Further review revealed the STNA was no longer an employee of the facility. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had severely impaired cognition and had impaired vision and hearing. The assessment revealed Resident #51 was always incontinent of bladder and bowel requiring total care by staff to complete incontinence care. Resident #51 required assistance from staff to complete activities of daily living (ADL) tasks. Review of Resident #51's resistive behavior care plan dated 09/17/24 revealed Resident #51 would be resistive to care related to dementia with interventions including if resident resists with ADLs, reassure resident, leave and return five to ten minutes later and try again. Further review of Resident #51's behavior management care plan dated 09/17/24 revealed interventions including attempt an alternate time to provide care refused, per resident's preference and ensure the safety of the resident and others. Interview on 10/01/24 at 3:08 P.M. with RN #213 revealed STNA #177 reported an incident to RN #213 related to Resident #51. In turn, RN #213 removed STNA #267 from the schedule and requested a statement to be written by STNA #267. Upon completion of the statement, STNA #267 was placed on suspension pending investigation and directed to leave the facility. RN #213 stated on the following Monday, 09/09/24, STNA #267 had sent a text message to the Director of Nursing (DON) which stated she was self-terming employment with the facility. Interview on 10/01/24 at 3:20 P.M. with the Administrator confirmed STNA #267 had smacked Resident #51's hand during care on the night of 09/07/24. Review of the facility's policy titled, Abuse dated 01/31/20 revealed, Residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint that is not required to treat the resident's medical symptoms. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology, such as through the use of photographs and recording devices to demean or humiliate a resident. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of a facility Self-Reported Incident (SRI), facility investigation review, medical record review, staff interviews, and facility policy review the facility failed to prevent misappropriation of resident narcotic medication. This affected one resident (Resident #12) of three residents reviewed for abuse The facility census was 69. Findings Include: Review of the medical record for Resident #12 revealed an admitted [DATE] with diagnoses including rheumatoid arthritis (RA), osteoporosis, gastric ulcer, and restless leg syndrome. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #12 required assistance from staff for activities of daily living (ADL) tasks including medication administration. The resident was cognitively intact. Review of the physician orders for Resident #12 revealed an order dated 06/27/24 for narcotic as needed pain medication, Percocet Oral Tablet 10-325 milligrams (mg), give one tablet by mouth every six hours as needed for pain. Review of Resident #12's Medication Administration Record (MAR) dated 08/01/24 to 08/31/24 revealed the as needed pain medication, Percocet Oral Tablet 10-325 mg, had been administered daily, at bedtime, for the month of August including the night of 08/16/24 at 8:04 P.M. Review of the facility Self-Reported Incident (SRI) Tracking Number 250912 dated 08/26/24 revealed on 08/17/24 facility staff identified that eight narcotic tablets were missing from the medication supply for Resident #12. The tablets in question were the remaining amount of an initial 30 tablet supply for Resident #12. A suspected perpetrator was identified and suspended pending investigation. Resident #12's physician and responsible party were notified. Interview with Resident #12 denied experiencing any recent change in health or symptom management as well as any knowledge of the missing tablets. During interview with the suspected perpetrator, she denied any knowledge of the missing medication but did not cooperate further with the investigation. The suspected perpetrator's employment was terminated. Review of the facility's investigation dated 08/18/24 revealed on the night of 08/17/24, during shift change and narcotic counting for A hallway, Resident #12's narcotic medication count sheet was discovered lying underneath the narcotic medication binder which was located on top of the medication cart. Registered Nurse (RN) #213 was notified by Licensed Practical Nurse (LPN) #197 of Resident #12's count sheet being found with a comment of completed written across the sheet and LPN #265's signature below the comment. The sheet indicated there were eight tablets remaining that had not been administered or signed out as being administered by the nursing staff. The Director of Nursing (DON) was notified by RN #213 and the DON immediately came to the facility to begin the investigation. LPN #265 had last worked the night shift of 08/16/24 on A hallway and during shift change for the morning of 08/17/24 and the shift change for the night shift on 08/17/24 the narcotic count of medication cards and count sheet was correct at 23 cards and 23 sheets. The DON contacted LPN #265 for an interview and LPN #265 denied knowledge of the removal of Resident #12's narcotic medication card or the count sheet and was placed on suspension pending investigation. LPN #265 agreed to meet with the DON on 08/18/24 for further investigation and statement. On the morning of 08/18/24, the DON returned to the facility and attempted to notify LPN #265 with no success. The DON then filed a police report with the local police department for the missing narcotic medication. Resident #12's empty narcotic card for Percocet Oral Tablet 10-325 mg was located in the paper shred box on A hallway, the card was noted to be empty of all tablets, which did not reflect the count sheet total of tablets left at being eight. The empty narcotic medication card matched the pharmacy prescription number located on the narcotic count sheet for Resident #12. Interview on 10/01/24 at 10:07 A.M. with the DON revealed Resident #12's missing eight tablets of narcotic pain medication, Percocet, had not been located during the facility investigation dated 08/18/24. The DON stated the facility immediately began education with the nurses on 08/18/24 to review the proper procedures for counting narcotic medications during shift change and to implement a new procedure to prevent missing narcotic medications in the future. This new procedure detailed two nurses were to verify and sign when a narcotic medication was completed and the count sheet was removed from the narcotic count binder, the count sheet would be signed by the two nurses, upon verification of the empty card, and the two nurses would sign the removal of the empty narcotic medication card and the completed count sheet removal from the narcotic count binder. The DON stated LPN #265 was eventually interviewed on 08/20/24 and denied removing Resident #12's narcotic medication tablets but could not defend the actions taken on the night of 08/17/24. LPN #265 was terminated employment at the facility. LPN #265 had been reported to the state Board of Nursing and the state Board of Pharmacy. Review of the Pharmcy Fill History report for Resident #12 revealed the prescription for 60 tablets of Percocet Oral Tablet 10-325 mg give one tablet by mouth every six hours as needed for pain had been initially filled and delivered to the facility on [DATE] and billed to Resident #12's insurance company. Upon notification of the missing remaining eight tablets on 08/17/23, the facility requested to be charged for a 30-day supply of Resident #12's Percocet Oral Tablets to cover the missing eight tablets and the insurance company for Resident #12 would be billed for the other 30-day supply of Percocet Oral Tablets. Interview on 10/01/24 at 11:35 A.M. with RN #163 revealed during shift change narcotic count the two nurses will count the narcotic cards and verify the amount of medication in the card matches the narcotic count sheet. If there is an empty card that required removal for the medication cart, the two nurses will verify the empty narcotic card with the completed count sheet, and both will sign to verify the completion of the narcotic medication. RN #163 confirmed the DON had provided education to the nurse on 08/18/24 for the new procedure. Interview on 10/01/24 at 11:45 A.M. with the DON confirmed Resident #12's narcotic medication Percocet had been missing on 08/17/24. The DON stated the facility had completed a through investigation of the incident and had educated the nurses on 08/18/24 for a new procedure to aid in the prevention of missing narcotic medications in the future. The DON stated the facility's regional nurse (RN #263) had notified the pharmacy following the incident and the facility had been charged for a 30-day supply of Resident #12's narcotic medication, Percocet, to cover the missing eight Percocet tablets. Review of the facility policy titled, Abuse revised on 01/30/20 revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint that is not required to treat the resident's medical symptoms. Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The deficiency was corrected on 08/18/24 when the facility implemented the following corrective actions: On 08/18/24 the DON educated 16 nurses on controlled substances procedures for receipt from pharmacy, administration of, shift to shift verification, and exhausting/removal of medications. On 08/18/24 the Regional Nurse Consultant notified pharmacy and requested for the 30-day supply dated 08/07/24 for Resident #12 be charged to the facility and the missing narcotic medication be replaced for Resident #12. On 08/18/24 the DON completed an audit for all residents receiving narcotic medications for verification of the medications remaining in the medication card is accurate with the corresponding signature count sheet. There were no discrepancies found. Beginning 08/22/24 the DON will audit narcotic count binder, narcotic medication cards and the corresponding narcotic signature count sheets for accuracy two times weekly times four weeks and then weekly times four weeks with the findings being reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) committee meeting. Between 08/18/24 and 10/01/24, there had been no additional allegations of narcotic misappropriation reported.

Based on observation, interview and facility policy review, the facility failed to ensure food was served at a palliative and warm food temperature. The deficient practice had the potential to affect all residents who received meals from the kitchen. The census was 60. Findings include: Interview on 05/13/24 at 10:32 A.M. with Resident #35 revealed sometimes the food was not very warm. Observation on 05/13/24 at 12:16 P.M. of the first lunch dining service revealed trays were being passed out of an open-air cart. Observation of the tray line was made on 05/14/24 at 10:46 A.M. with Dietary Supervisor #24 and Dietary Assistant Manager #16. The lunch menu consisted of corn, Spanish rice, and tacos. A test tray was requested on 05/14/24 at 11:52 A.M. with Dietary Supervisor #24 and Dietary Assistant Manager #16. Dietary Assistant Manager #16 started taking temperatures of the food being placed on the test tray. Dietary Assistant Manager #16 confirmed the corn measured 139 degrees Fahrenheit, Spanish rice 142 degrees Fahrenheit, and the tacos were 160 degrees Fahrenheit on the test tray. Observation on 05/14/24 at 11:54 A.M. revealed the test tray left the kitchen on the delivery cart. The cart was open to air and not insulated. Observation on 05/14/24 at 11:55 A.M. with Dietary Supervisor #24 revealed the delivery cart arrived on the hallway. Observation on 05/14/24 at 11:58 A.M. revealed all food trays have been served from the delivery cart. Dietary Supervisor #24 took temperatures of the test tray food items. Dietary Supervisor #24 verified the corn was 109 degrees Fahrenheit, Spanish rice was 118 degrees Fahrenheit, and the taco measured 115 degrees Fahrenheit. Interview and observation on 05/14/24 at 12:06 P.M. with Dietary Supervisor #24 revealed the Spanish rice, corn, and tacos were palatable but lukewarm and/or cold. Interview with Dietary Supervisor #24 revealed the tortilla used for the taco was cold. Interview on 05/16/24 12:50 P.M. with Corporate Nurse #100 revealed the facility does not have a tray delivery policy. Review of the Food Preparation policy dated 06/20/17 stated dietary staff will ensure that all foods are held at appropriate temperatures: greater than 135 degrees Fahrenheit for holding hot foods, under 41 degrees Fahrenheit for holding cold foods.

Based on record review and interview the facility failed to provide Resident #12, #22, #28, #30, and #43, who were dependednt on staff for care, with scheduled bathing. This affected five residents (#12, #22, #28 #30, and #43) out of six residents reviewed for activities of daily living (ADL). The facility census was 60. Findings include: 1. Resident #12 was admitted on [DATE] and readmitted on [DATE] with diagnoses including type II diabetes, heart failure, polyneuropathy, and chronic kidney disease. Review of the plan of care dated 10/13/23 revealed Resident #12 required assistance from staff to meet ADL needs. Interventions included assisting Resident #12 with bathing as needed and per Resident#12's requests. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12's Brief Interview Mental Status (BIMS) score was 12 of 15, which indicated cognitive impairment. Resident #12 required substantial/maximal assistance for bathing. Review of electronic documentation by State tested Nursing Assistants (STNAs) revealed Resident #12 was dependent on staff for bathing. Review of the electronic record and paper bathing sheets for the last 30-days revealed Resident #12 did not receive a shower or bed bath on 04/20/24, 04/24/24, 05/01/24, and 05/08/24. Interview on 05/13/24 at 1:27 P.M. Resident #12 revealed they received a shower once a week. Resident #12 stated they preferred showers and wanted a shower at least twice a week. Interview on 05/14/24 at 2:51 P.M. Corporate Nurse #100 verified Resident #12 was not bathed twice a week as scheduled/preferred. 2. Review of the medical record revealed Resident #22 was admitted on [DATE] with diagnoses including dementia, mood disorder, and anxiety disorder. Review of the plan of care dated 09/17/23 revealed Resident #22 required assistance from staff to meet ADL needs. Interventions included assisting Resident #22 with bathing as needed and per Resident #22's preference. Review of the quarterly MDS assessment dated [DATE] revealed Resident #22's BIMS score was 11 of 15, which indicated cognitive impairment. Review of electronic documentation by STNAs revealed Resident #22 required physical assistance with showers and was totally dependent for bed baths. Review of the electronic record and paper bathing sheets for the last 30-days revealed Resident #12 did not receive a shower or bed bath on 04/22/24, 05/02/24, 05/06/24, and 05/09/24. Interview on 05/13/24 at 10:11 A.M. Resident #22 revealed there was a sign in Resident #22's room that revealed showers were scheduled for Mondays and Thursdays. Resident #22 stated she did not always receive a shower twice a week. Interview on 05/14/24 at 2:51 P.M. Corporate Nurse #100 verified Resident #22 was not bathed twice a week as scheduled/preferred. 3. Review of the medical record revealed Resident #28 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included diverticulitis, type II diabetes, pleural effusion, and chronic kidney disease stage III. Review of the plan of care dated 11/22/23 revealed Resident #28 required assistance from staff to meet ADL needs. Interventions included assisting Resident #28 with bathing as needed and per Resident #28's preference. Review of the end of stay MDS assessment dated [DATE] revealed Resident #28 was cognitively intact. Resident #28 required supervision or touching assistance for bathing. Review of electronic documentation by STNAs on 04/18/24 revealed Resident #28 required physical assistance with a shower on 04/18/24. Review of the electronic record and paper bathing sheets for the last 30-days revealed Resident #28 received a shower on 04/18/24. Interview on 05/14/24 at 2:51 P.M. Corporate Nurse #100 verified Resident #28 was not bathed twice a week as scheduled/preferred. 4. Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnoses including chronic atrial fibrillation, type II diabetes, and pain. Review of the plan of care dated 01/07/24 revealed Resident #30 required assistance from staff to meet ADL needs. Interventions included assisting Resident #30 with bathing as needed and per Resident #30's request. Review of the quarterly MDS assessment dated [DATE] revealed Resident #30 was cognitively intact. Resident #30 required partial to moderate assistance for bathing. Review of electronic documentation by STNAs revealed Resident #30 required physical assistance with bathing. Review of the electronic record and paper bathing sheets for the last 30-days revealed Resident #30 was not bathed on 04/17/24, 04/19/24, 04/22/24, 04/24/24, 04/26/24, 05/01/24, 05/03/14, 05/08/24, and 05/10/24. Interview on 05/13/24 at 1:08 P.M. Resident #30 revealed they were scheduled to receive showers on Mondays, Wednesdays, and Fridays but did not received showers as scheduled. Interview on 05/14/24 at 2:51 P.M. Corporate Nurse #100 verified Resident #30 was not always bathed at least once a week. 41271 5. Review of the medical record for Resident #43 revealed an admitted [DATE] with diagnoses including dementia, abnormalities of gait and mobility, and adult to failure to thrive. Review of Resident #43's quarterly assessment dated [DATE] revealed a BIMS score of two of 15, indicating severely impaired cognition for daily decision-making ability. Resident #43 was noted to experience impairment to bilateral upper and lower extremities and required substantial to maximal staff assistance for toileting hygiene, bath and/or shower care, and dressing. Review of the plan of care dated 08/20/21 revealed Resident #43 required assistance from staff to meet ADL needs related to decreased mobility, history of a hip fracture, and impaired cognition. Review of the completed ADL for Resident #43 from 04/16/24 through 05/14/24 revealed the resident received a shower on 04/21/24 and 04/30/24 and refused a bath or shower on 05/14/24. Interview on 05/16/24 at 9:16 A.M. with the Director of Nursing (DON) revealed Resident #43 was supposed to receive a bath/shower on Sundays, Tuesdays, and Fridays, which was Resident #43's preference. Review of the completed shower sheets provided for Resident #45 revealed the resident received a bath/shower eight out of the 13 scheduled days for April 2024. A bath or shower was documented as being completed on 04/02/24 bed bath (Tuesday), 04/07/24 bath or shower was not indicated (Sunday), 04/12/24 Shower (Friday), 04/14/24 shower (Sunday), 04/16/24 Shower (Tuesday), 04/19/24 bed bath (Friday), 04/26/24 Shower Sunday), and 04/30/24 shower (Thursday). Interview on 05/16/24 at 9:16 A.M. with the DON revealed Resident #45 was supposed to receive a bath or shower every Sunday, Tuesday, and Friday. The DON verified that per documentation, Resident #45 was not receiving a bath or shower as per schedule/preference.

Based on observations, staff interviews, and facility policy review, this facility failed to ensure enhanced barrier precautions were implemented in a timely manner for Residents #50 #34, #58, #265, #35, and #119, who were noted to have indwelling medical devices. This affected six residents (#50 #34, #58, #265, #35, and #119) of the six residents reviewed for infection control. The facility census was 60. Findings include: Observation completed 05/13/24 from 8:00 A.M. through 4:30 P.M. of multiple residents revealed five residents (#50, #58, #265, #35, and #119) who were noted to have indwelling Foley catheters for bladder function and one (#34) was noted to have peritoneal dialysis site that required treatment care. All six residents did not have enhanced barrier precautions in place during this time. Interview on 05/15/24 12:48 P.M. with Cooperate Nurse #100 revealed education for enhanced barrier precautions was completed in April 2024. The official roll-out date was postponed until supplies became available. Cooperate Nurse #100 claimed the facility's commonly used supply company noted most isolation supplies, including isolation gowns and mask, were in low supply and could take longer to receive. The facility did have sister facilities they could borrow isolation supplies for COVID-19, but these sister facilities did not have enough isolation supplies now. The supplies the facility did have were from the Ohio Department of Health and were received around the third to fourth week of April. Cooperate Nurse #100 confirmed as of 05/15/24, enhanced barrier precautions had not been implemented for required residents. Interview on 05/16/24 at 12:45 P.M. with Supply Company Associate #600 claimed that the supply company had to switch manufactures due to items not being available and on back order. The supply company had received multiple complaints about this leading up to the switch including from this facility. Since April 2024 the facility ordered two cases of gowns and three cases of mask which were ordered on 04/03/24 and should have been delivered 04/07/24 but were not delivered until 04/15/24. Gloves were ordered weekly. Review of the untitled and undated facility policy revealed, it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resident organisms (MDROs). Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of MDROs in nursing homes. EBP involve gowns and gloves used during high-contact resident care activities for residents known to be colonized or infected with MDROs as well as those at increased risk for MDRO acquisition including resident with wounds or indwelling medical devices

Based on record review and interview, the facility failed to have the correct advance directives in Resident #22's medical record. This affected one resident (#22) out of three reviewed for advance directives. This had the potential to affect all 60 residents. The facility census was 60. Findings include: Review of the medical record revealed Resident #22 was admitted on [DATE] with diagnoses including dementia, hypertension, mood disorder, and anxiety disorder. Review of the scanned documents in the electronic medical record revealed on 06/15/23 Resident #22's advance directives were documented as a full code (all resuscitation procedures to be performed to keep a resident alive if their heart stops beating or their breathing stops). Review of the scanned documents in the electronic medical record revealed on 09/15/23 an order was signed to change Resident #22's code status to Do Not Resuscitate Comfort Care (DNRCC)-Arrest (can receive standard medical care until they experience a cardiac or respiratory arrest). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had a Brief Interview Mental Status (BIMS) score of 11 out of 15, which indicated cognitive impairment. Review of the medical record at the nurse's station on 05/14/24 revealed no evidence of advance directives. Interview on 05/14/24 at 8:58 A.M. Licensed Practical Nurse (LPN) #57 verified Resident #22 did not have advance directives in the medical record at the nurse's station. LPN #57 verified the electronic record revealed Resident #22 was a DRNCC-Arrest.

Based on record review, self-reported incident (SRI) review, facility policy review, and interviews, the facility failed to protect Resident #4 from staff-to-resident physical abuse and Resident #17 from staff-to-resident verbal abuse. This affected two residents (#4 and #17) out of two residents reviewed for abuse. This had the potential to affect all 60 residents. The facility census was 60. Findings include: 1. Review of the medical record revealed Resident #4 was admitted on [DATE] with diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and depression. Review of the plan of care dated 05/13/22 revealed Resident #4 required assistance from staff for activities of daily living. Interventions included to assist with toileting as needed. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had a Brief Interview Mental Status (BIMS) score of one out of 15 which indicated severe cognitive impairment. Resident #4 was dependent on staff for toileting. Review of SRI #246175 dated 04/09/24 revealed on 04/09/24 at approximately 7:20 P.M. State tested Nursing Assistant (STNA) #5 notified the Director of Nursing (DON) that STNA #102 slapped the back of Resident #4's hand. Resident #4 was unable to recall the incident. STNA #5 was interviewed and stated during incontinence care Resident #4 became agitated and began to scratch and hit STNA #5 and STNA #102. STNA #102 slapped the back of Resident #4's hand and stated not to do that. Resident #4 responded with that hurt. An interview with STNA #102 revealed Resident #4 became agitated and began scratching and hitting STNA #5 and STNA #102. STNA #102 stated when Resident #4 attempted to hit STNA #102, STNA #102 raised her hand to block Resident #4 which resulted in causing contact with Resident #4's hand. STNA #102 confirmed Resident #4 stated that hurt. Review of a typed statement dated 04/09/24 signed by the DON revealed an interview was conducted with STNA #102. STNA #102 reported care was being provided for Resident #4. Resident #4 was sitting on the toilet when Resident #4 became agitated and began hitting and scratching at STNA #5 and STNA #102. Resident #4 reached towards STNA #102 to hit her. STNA #102 stated she instinctively raised her hand to prevent Resident #4 from hitting her which caused contact between STNA #102 and Resident #4. STNA #102 did not recall Resident #4 reporting any discomfort from the incident. Review of a signed statement by STNA #5 dated 04/10/24 revealed they were assisting STNA #102 with providing incontinence care to Resident #4 on 04/09/24. Resident #4 was sitting on the toilet, and STNA #102 was in front of Resident #4 and STNA #5 was standing on Resident #4's left side. Resident #4 reached up to possibly scratch or hit STNA #102. STNA #102 slapped the top of Resident #4's hand and said I said not to do that. Resident #4 stated that hurt. STNA #5 notified the DON of the incident. Review of the police report dated 04/11/24 at 10:47 A.M. revealed a deputy was dispatched to investigate a complaint. Administrator #500 reported on 04/09/24 STNA #102 was cleaning Resident #4, and STNA #102 smacked Resident #4's hand. Administrator #500 stated STNA #5 witnessed the incident. STNA #5 told the police officer, Resident #4 had dementia and was trying to hit and kick staff during care. Resident #4 was very agitated and continued to hit and scratch STNA #5 and STNA #102. STNA #102 then swatted Resident #4's hand away. Review of the Employee Change of Status Notification dated 04/11/24 revealed STNA #102 was involuntarily terminated. There was not a description of the circumstances surrounding the involuntary termination. Interview on 05/15/24 at 2:45 P.M. STNA #5 verified STNA #102 did slap Resident #4's hand while Resident #4 was being combative with care. Interview on 05/16/24 at 8:33 A.M. Corporate Nurse #100 verified STNA #102 was interviewed but did not sign the statement. Corporate Nurse #100 stated he and the DON wanted to interrogate STNA #102, so a signed statement was not obtained by STNA #102. Corporate Nurse #100 verified the unsigned statement revealed Resident #4 did not report any pain or discomfort, but the SRI revealed STNA #102 reported Resident #4 did complain of pain. Review of the abuse policy revised on 01/31/20 revealed residents have the right to be free from abuse. It is the facility's policy to investigate all alleged violations involving abuse. Abuse is defined as the willful infliction of injury. Documentation in the nurses' notes should include the results of the resident's assessment, notification of the physician and the resident representative, and any treatment provided. Investigation protocol includes interviewing the resident, the accused, and all witnesses. In the case of staff-to-resident abuse, the facility will follow the facility's procedure for disciplining or dismissing an employee, depending upon the circumstances and results of the investigation. 48568 2. Review of medical record for Resident #17 revealed admitted [DATE] with diagnoses including polyneuropathy, unspecified fracture of lower end of left tibia, and morbid obesity. Review of the most recent quarterly MDS assessment dated [DATE] revealed Resident #17 was cognitively intact and required setup/clean up assistance for eating, oral hygiene, upper body dressing, personal hygiene, and rolling left and right. Interview on 05/14/24 at 1:31 P.M. at the Resident Council meeting revealed Resident #17 stated she was threatened with bodily harm by an aide. Interview on 05/15/24 at 12:49 P.M. with Resident #17 revealed she left the facility with a bone crack in her leg. When she returned to the facility, Resident #17 said STNA #40 came into her room with an attitude. Resident #17 told STNA #40 she was being rough with her, and STNA #40 said I will break your other leg. STNA #40 also yelled at her for going into another room. Resident #17 stated she was embarrassed when STNA #40 yelled at her in front of a family member from the room next door. Resident #17 said she reported this situation to a housekeeper, who is now STNA #42. Resident #17 said STNA #42 went to Social Service Director (SSD) #9. Resident #17 said she will not have STNA #40 take care of her anymore, and STNA #40 is not allowed in her room. Resident #17 stated both incidents happened last September. Resident #17 said she talked to the Ombudsman about this situation as well. She can't remember who or when she talked to the Ombudsman. Interview on 05/15/24 at 1:02 P.M. with SSD #9 revealed SSD #9 stated Resident #17 had an issue with an STNA. Resident #17 didn't tell her which one. SSD #9 was told by Resident #17 that an STNA was refusing to help her, and the aide said you can do this yourself. SSD #9 said it was that type of thing. She reported it to the Administrator at that time, but that Administrator does not work here anymore. This occurred close to the time Resident #17 was admitted . The current DON did an investigation, but she doesn't know what the result was. SSD #9 said she has met with Resident #17 since, and Resident #17 has not had complaints or further issues with her care. Interview on 05/15/24 at 01:13 P.M. with the DON revealed she didn't know off the top of her head if Resident #17 brought her any concerns about care provided by aides. When asked if a certain aide does not work with Resident #17, the DON stated not that I can think of. The DON was also questioned if SSD #9 brought anything like that to her attention, the DON said potentially if there would have been something. Interview on 05/15/24 at 3:20 P.M. with STNA #40 revealed she had issues with Resident #17 sometime last year. STNA #40 said she usually answers call lights as they go off to make it fair unless the resident is a fall risk. STNA #40 said she was in the room next to Resident #17 and talking to a resident and their family. STNA #40 said Resident #17 came into that room mad and upset that I answered his call light before hers. STNA #40 told Resident #17 that it would be a minute. STNA #40 said I guess that is what made Resident #17 mad. STNA #40 said Resident #17 wanted a gown before she got into bed. STNA #40 said Resident #17 was calling her all kinds of names. STNA #40 said to diffuse the situation she stepped out of the room and closed the door. STNA #40 said she heard loud banging coming from the room. STNA #40 said she got another aide to see what Resident #17 needed, and Resident #17 was nasty to them too. STNA #40 said she could not remember what aide she got to help her. STNA #40 said she reported it to her nurse at that time. She said she also messaged Assistant Director of Nursing (ADON) #47. STNA #40 said she was told not to go into Resident #17 's room to care for her anymore. STNA #40 said she remembered it happened towards the end of September. STNA #40 said she was not suspended and thinks the next-door family member wrote down statements. STNA #40 said Resident #17 did not say she was hurting her when providing care. STNA #40 said the DON and ADON #47 did the investigation. Interview on 05/15/24 at 04:32 P.M. with the DON who was accompanied by Corporate Nurse #100 revealed when the DON found out about the situation, she went to get a statement from the resident. The DON said Resident #17 told her STNA #40 ignored her call light. The DON said Resident #17 did not describe mistreatment. Resident #17 told the DON that STNA #40 wasn't receptive to her needs and ignored the call light. The DON stated it was more of a customer service thing. The DON said STNA #40 was talking to a family in the hallway. The DON said Resident #17 did allow STNA #40 to provide care. The DON said Resident #17 stated she was calling STNA #40 names, and STNA #40 went to get another STNA. The DON said when she was talking to Resident #17 there was no allegation of any type of mistreatment. The DON said if Resident #17 is alleging mistreatment now, they would do an SRI. When asked who made the decision that this incident was not reportable, the DON replied that it was the previous Administrator. When asked if an investigation was done, the DON replied that she does not know where they are. Interview on 05/16/24 at 01:04 P.M. with STNA #42 revealed Resident #17 told her about a situation last September with STNA #40. STNA #42 said STNA #40 got real smart with Resident #17 and didn't get her out of bed and took a tone with her. STNA #42 said she was visiting her dad next door when this occurred. STNA #42 explained that Resident #17 asked STNA #40 to change her bed, and STNA #40 took an inappropriate tone with her. STNA #42 said STNA #40 said she didn't have time for it, and she would get to it when she gets to it. STNA #42 said it wasn't physical, but STNA #42 talked to Resident #17 like a child. She belittled her and said it was a lack of respect. STNA #42 said she would consider the interaction verbal abuse. STNA #42 said she went to the DON and the previous Administrator. STNA #42 thinks she remembers filling something out. Interview on 05/16/24 at 1:19 P.M. revealed the Ombudsman was left a voicemail and a call was not returned. Interview on 05/16/24 1:34 P.M. with ADON #47 revealed she remembered an issue with STNA#40 and Resident #17 in September of last year. ADON #47 said it was reported that statements were made, and we went down and talked to Resident #17 and staff. ADON #47 said Resident #17 said STNA #40 was saying stuff to her. ADON #47 said when we talked to Resident #17, she said STNA #40 didn't make the statements Resident #17 said STNA #40 had made. When asked if ADON #47 has the statements, she said she would have to check. When asked if ADON #47 or the DON filled out a report, ADON #47 said we investigated it and talked to staff. When asked if any of this information was documented, ADON #47 said she does not remember. ADON #47 said a couple of call lights were going off in the area and the staff member chose the one that was a priority. ADON #47 said Resident #17 felt like STNA #40 chose that resident over her. When asked if she had proof that the resident said that ADON #47 said she would have to see if they had that statement. When asked if ADON #47 received complaints about STNA #40, she said I think sometimes STNA #40 gets overwhelmed. But at the end of the day, she does what she needs to do. She's a good aide. Interview on 05/16/24 at 03:43 P.M. with the DON revealed they do not have documentation from the September incident between Resident #17 and STNA #40. Review of the facility self-reported incidents to the State agency revealed no evidence this incident of abuse was reported to the agency as required. Review of the personnel record for STNA #40 revealed one written consultation from 08/02/23 revealed an unexpected absence and 12 call offs during her 90-day probationary period. Review of the abuse policy dated 01/31/20 revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property.

Based on record review, interview, review of the self-report incidents (SRI), and facility policy review, the facility failed to report an allegation of staff-to-resident verbal abuse against Resident #47 to the state agency as required. This affected one resident (#47) of two residents reviewed for abuse. The facility census was 60. Findings include: Review of medical record for Resident #17 revealed admitted [DATE] with diagnoses including polyneuropathy, unspecified fracture of lower end of left tibia, and morbid obesity. Review of the most recent quarterly MDS assessment dated [DATE] revealed Resident #17 was cognitively intact and required setup/clean up assistance for eating, oral hygiene, upper body dressing, personal hygiene, and rolling left and right. Interview on 05/14/24 at 1:31 P.M. at the Resident Council meeting revealed Resident #17 stated she was threatened with bodily harm by an aide. Interview on 05/15/24 at 12:49 P.M. with Resident #17 revealed she left the facility with a bone crack in her leg. When she returned to the facility, Resident #17 said STNA #40 came into her room with an attitude. Resident #17 told STNA #40 she was being rough with her, and STNA #40 said I will break your other leg. STNA #40 also yelled at her for going into another room. Resident #17 stated she was embarrassed when STNA #40 yelled at her in front of a family member from the room next door. Resident #17 said she reported this situation to a housekeeper, who is now STNA #42. Resident #17 said STNA #42 went to Social Service Director (SSD) #9. Resident #17 said she will not have STNA #40 take care of her anymore, and STNA #40 is not allowed in her room. Resident #17 stated both incidents happened last September. Resident #17 said she talked to the Ombudsman about this situation as well. She can't remember who or when she talked to the Ombudsman. Interview on 05/15/24 at 1:02 P.M. with SSD #9 revealed SSD #9 stated Resident #17 had an issue with an STNA. Resident #17 didn't tell her which one. SSD #9 was told by Resident #17 that an STNA was refusing to help her, and the aide said you can do this yourself. SSD #9 said it was that type of thing. She reported it to the Administrator at that time, but that Administrator does not work here anymore. This occurred close to the time Resident #17 was admitted . The current DON did an investigation, but she doesn't know what the result was. SSD #9 said she has met with Resident #17 since, and Resident #17 has not had complaints or further issues with her care. Interview on 05/15/24 at 01:13 P.M. with the DON revealed she didn't know off the top of her head if Resident #17 brought her any concerns about care provided by aides. When asked if a certain aide does not work with Resident #17, the DON stated not that I can think of. The DON was also questioned if SSD #9 brought anything like that to her attention, the DON said potentially if there would have been something. Interview on 05/15/24 at 3:20 P.M. with STNA #40 revealed she had issues with Resident #17 sometime last year. STNA #40 said she usually answers call lights as they go off to make it fair unless the resident is a fall risk. STNA #40 said she was in the room next to Resident #17 and talking to a resident and their family. STNA #40 said Resident #17 came into that room mad and upset that I answered his call light before hers. STNA #40 told Resident #17 that it would be a minute. STNA #40 said I guess that is what made Resident #17 mad. STNA #40 said Resident #17 wanted a gown before she got into bed. STNA #40 said Resident #17 was calling her all kinds of names. STNA #40 said to diffuse the situation she stepped out of the room and closed the door. STNA #40 said she heard loud banging coming from the room. STNA #40 said she got another aide to see what Resident #17 needed, and Resident #17 was nasty to them too. STNA #40 said she could not remember what aide she got to help her. STNA #40 said she reported it to her nurse at that time. She said she also messaged Assistant Director of Nursing (ADON) #47. STNA #40 said she was told not to go into Resident #17 's room to care for her anymore. STNA #40 said she remembered it happened towards the end of September. STNA #40 said she was not suspended and thinks the next-door family member wrote down statements. STNA #40 said Resident #17 did not say she was hurting her when providing care. STNA #40 said the DON and ADON #47 did the investigation. Interview on 05/15/24 at 04:32 P.M. with the DON who was accompanied by Corporate Nurse #100 revealed when the DON found out about the situation, she went to get a statement from the resident. The DON said Resident #17 told her STNA #40 ignored her call light. The DON said Resident #17 did not describe mistreatment. Resident #17 told the DON that STNA #40 wasn't receptive to her needs and ignored the call light. The DON stated it was more of a customer service thing. The DON said STNA #40 was talking to a family in the hallway. The DON said Resident #17 did allow STNA #40 to provide care. The DON said Resident #17 stated she was calling STNA #40 names, and STNA #40 went to get another STNA. The DON said when she was talking to Resident #17 there was no allegation of any type of mistreatment. The DON said if Resident #17 is alleging mistreatment now, they would do an SRI. When asked who made the decision that this incident was not reportable, the DON replied that it was the previous Administrator. When asked if an investigation was done, the DON replied that she does not know where they are. Interview on 05/16/24 at 01:04 P.M. with STNA #42 revealed Resident #17 told her about a situation last September with STNA #40. STNA #42 said STNA #40 got real smart with Resident #17 and didn't get her out of bed and took a tone with her. STNA #42 said she was visiting her dad next door when this occurred. STNA #42 explained that Resident #17 asked STNA #40 to change her bed, and STNA #40 took an inappropriate tone with her. STNA #42 said STNA #40 said she didn't have time for it, and she would get to it when she gets to it. STNA #42 said it wasn't physical, but STNA #42 talked to Resident #17 like a child. She belittled her and said it was a lack of respect. STNA #42 said she would consider the interaction verbal abuse. STNA #42 said she went to the DON and the previous Administrator. STNA #42 thinks she remembers filling something out. Interview on 05/16/24 at 1:19 P.M. revealed the Ombudsman was left a voicemail and a call was not returned. Interview on 05/16/24 1:34 P.M. with ADON #47 revealed she remembered an issue with STNA#40 and Resident #17 in September of last year. ADON #47 said it was reported that statements were made, and we went down and talked to Resident #17 and staff. ADON #47 said Resident #17 said STNA #40 was saying stuff to her. ADON #47 said when we talked to Resident #17, she said STNA #40 didn't make the statements Resident #17 said STNA #40 had made. When asked if ADON #47 has the statements, she said she would have to check. When asked if ADON #47 or the DON filled out a report, ADON #47 said we investigated it and talked to staff. When asked if any of this information was documented, ADON #47 said she does not remember. ADON #47 said a couple of call lights were going off in the area and the staff member chose the one that was a priority. ADON #47 said Resident #17 felt like STNA #40 chose that resident over her. When asked if she had proof that the resident said that ADON #47 said she would have to see if they had that statement. When asked if ADON #47 received complaints about STNA #40, she said I think sometimes STNA #40 gets overwhelmed. But at the end of the day, she does what she needs to do. She's a good aide. Interview on 05/16/24 at 03:43 P.M. with the DON revealed they do not have documentation from the September incident between Resident #17 and STNA #40. Review of the facility self-reported incidents to the State agency revealed no evidence this incident of abuse was reported to the agency as required. Review of the personnel record for STNA #40 revealed one written consultation from 08/02/23 revealed an unexpected absence and 12 call offs during her 90-day probationary period. Review of the abuse policy dated 01/31/20 revealed the administrator or his/her designee will notify The Ohio Department of Health of all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of property, and injuries of unknown origin as soon as possible, but in no event later than 24 hours from the time the allegation was made known to the staff member.

Based on observation, record review, policy review and staff interview the facility failed to implement adequate skin risk interventions and treatment for Resident #5, who was cognitively impaired, at risk for pressure ulcer development and dependent on staff for turning and repositioning, to prevent the development of a pressure ulcer to the resident's left heel. Actual harm occurred on 05/21/23 when an order for skin prep was obtained for Resident #5's heels with no corresponding assessment or information related to why. On 05/24/23 the wound Certified Nurse Practitioner (CNP) assessed Resident #5 to have a Stage III (full-thickness loss of skin, in which adipose (fat) is visible in the ulcer. Slough and/or eschar may be visible) pressure ulcer to the left heel. However, treatment orders were not implemented until 05/31/23 (ten days after the ulcer was potentially first identified). This affected one resident (#5) of three residents reviewed for pressure ulcers. Facility census was 67. Finding include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included fracture of left femur, pneumonia, type 2 diabetes mellitus, embolism and thrombosis of deep veins of left lower extremity, dementia, anxiety, and chronic kidney disease. Record review revealed a plan of care dated 02/03/21 reflecting Resident #5 was at risk for skin breakdown. Interventions included to encourage resident to turn and reposition, perform skin checks and report any new areas, assist with incontinence care, pressure redistribution mattress to bed, and apply treatment as ordered. The care plan did not include any pressure related interventions for the resident's heels. A Braden Scale for Predicting Pressure Ulcer Risk dated 03/16/23 revealed Resident #5 was at very high risk for the development of pressure ulcer. Clinical suggestions included to elevate heels off the bed, turn and reposition at least every two hours while in bed. Review of the treatment administration record (TAR) revealed on 05/21/23 the record was updated to include skin prep to be applied to Resident #5's heels and the resident's heels were to be floated. However, review of skin assessments and progress notes revealed no documentation/assessment(s) pertaining to Resident #5's heels at this time or any additional information related to why this order was initiated. A wound care note by the wound CNP dated 05/24/23 revealed Resident #5 had a new Stage III pressure ulcer to the left heel that measured 3.5 centimeter (cm) long and three cm wide. The note revealed the wound was to be cleansed and patted dry, and alginate (highly absorbent, antimicrobial dressing) was to cover the wound bed and then cover with adhesive foam dressing three times a week. Review of the TAR revealed no evidence of this treatment being initiated at that time. Review of a facility wound evaluation flow sheet completed by the Assistant Director of Nursing (ADON), dated 05/30/23 revealed Resident #5 had an in-house pressure ulcer to left heel that measured 3.2 cm long and 3 cm wide. The current treatment initiated on 05/30/23 revealed for silver alginate to be applied and the wound covered with an abdominal (ABD) dressing. The evaluation revealed Resident #5's heels were to be floated. Review of the TAR revealed the first treatment with alginate and was documented as being completed on 05/31/23. Review of the significant change Minimum Data Set (MDS) 3.0 assessment, dated 08/01/23 revealed Resident #5 had severe cognitive impairment and required extensive assistance from two staff for bed mobility and transfers. A plan of care, dated 08/09/23 revealed Resident #5 had open areas. Interventions included to apply treatment to area as ordered, encourage to elevate heels while in bed and encourage to turn and reposition. The most current wound care note, dated 08/15/23 revealed Resident #5 had an unstageable pressure ulcer to left heel that measured 1.2 cm long by one cm wide. An order for wound care revealed the area was cleansed and patted dry; apply alginate cut to cover the wound bed and then cover with an adhesive foam dressing three times a week on Tuesday, Thursday, and Saturday. On 08/24/23 at 8:21 A.M. Resident #5 was not observed in her room. An air mattress was observed and was in place and functioning to the resident's bed and pressure relieving boots were observed placed in a chair in the room. On 08/24/23 at 1:28 P.M. Resident #5 was observed laying in bed. One pressure relieving boot was noted to be in a chair in Resident #5's room. On 08/28/23 at 8:04 A.M. Resident #5 was observed in the dining room sitting in a wheelchair with pressure relieving boots in place to both feet. There was no physician order for the use of the pressure relieving boots and staff did not document the application of the boots on the administration record for the resident. Interview on 08/28/23 at 4:49 P.M. with the facility Corporate Nurse (CN) verified there was no documentation of Resident #5's heels being floated prior to 05/21/23. The CN verified there was no documentation of an assessment or what Resident #5's heels looked like on 05/21/23 when the order was received to apply skin prep and float heels. The CN also verified the order from the wound CNP on 05/24/23 was not implemented until 05/31/23. Review of the Wound and Skin Care Policy and Procedure dated 06/07/16 revealed treatment would be initiated as ordered by the physician. A Stage III pressure ulcer was defined as a full thickness of skin loss with exposed subcutaneous tissue with may include or be covered by necrotic tissue. The wound presents as a deep crater with or without undermining. This deficiency represents non-compliance investigated under Complaint Number OH00145762.

Based on record review, review of hospital records, review of a fall investigation, facility policy review and resident and staff interview the facility failed to provide timely and effective pain management for Resident #35 following a fall with injury. Actual harm occurred on 09/15/20 at 2:15 P.M. when Resident #35, who exhibited moderate cognitive impairment and required extensive staff assistance for activities of daily living, sustained a fall with verbalization of pain, guarding to the right hip and an inability to bear weight following the incident. The facility failed to provide effective pain management/pain medication to the resident following the incident or notify the physician of the pain level. The resident was assessed to have pain rated a seven out of 10 on a scale from one to ten with ten being the worst pain and did not consume dinner on 09/15/20. The resident was subsequently diagnosed with a displaced fracture to the right hip which required surgical intervention. The resident was transported to the hospital on 09/15/20 at 9:15 P.M. (seven hours after the fall occurred). Hospital records revealed the resident's pulse was elevated at 101 beats per minute on 09/15/20 at 11:09 P.M. and upon physical examination, the resident was noted to be uncomfortable with a complaint of right hip pain with any attempted motion. The resident was medicated with narcotic pain medication in the hospital. This affected one resident (#35) of one resident reviewed for pain management. Findings include: Review of Resident #35's medical record revealed an original admitted on 04/13/20 and readmission on 07/21/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #35's care plan, dated 07/24/20 and revised on 08/02/20 revealed the resident was at risk for pain. The plan revealed staff should administer medication as ordered and per the resident's preference and request. The resident should be assisted with repositioning as needed. Alternative pain relief measures should be attempted to include a back rub, relaxation, repositioning, exercise, or music prior to administering any PRN (as needed) medications. The physician should be consulted as needed related to the resident's pain. The resident should be observed for any signs or symptoms of pain, including any nonverbal signs of pain such as facial grimacing, restlessness, or grabbing an effected area. Therapy services as ordered by the physician. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 07/24/20 revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 11 which reflected mild cognitive impairment. The assessment revealed the resident required extensive assistance from two staff to complete tasks including bed mobility and toileting and was totally dependent on two staff to complete transfers. The resident was not assessed for walking in his room due to the activity not occurring however, the resident was assessed to be unsteady and required staff assistance to stabilize when he moved on and off the toilet or completed a surface-to-surface transfer, for example transferred from his bed to a chair or wheelchair. Review of physician's orders for Resident #35, for September 2020 revealed an order, initiated on 09/15/20 at 8:00 A.M. for [MEDICATION(S)] (a narcotic pain medication) 5-325 milligrams (mg) with instructions to administer the medication orally once daily for three days and then discontinue. The resident also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Lastly, the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had an additional order to be monitored for any signs or symptoms of verbal or nonverbal pain every shift. Review of Resident #35's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident also received three doses of Acetaminophen 650 mg as routinely ordered on 09/15/20. There was no additional pain medication administered to the resident on 09/15/20. There was no documentation confirming whether the medication was effective in controlling the resident's pain. The resident was monitored for signs and symptoms of verbal and nonverbal pain in the morning on 09/15/20 and reported a pain level of five out of ten with ten being the worst pain. The resident was noted to be hospitalized during the night shift observation. Review of Resident #35's nursing progress notes revealed on 09/15/20 at 2:15 P.M. the resident had a fall while attempting to ambulate to the restroom without assistance. The resident was assessed by Licensed Practical Nurse (LPN) #22. The resident was noted to be guarding the area and stated he was having pain in his right hip area. The resident was not able to bear a lot of weight to his right leg. Neurological checks were initiated. Additionally, red areas were noted to the resident's left temple and right side of his head at his hairline. The resident's sister, the Director of Nursing (DON), and physician were notified of the fall and a new order was received for a STAT (immediate) x-ray of the resident's right hip/femur (thigh bone) area. There was no additional documentation in the nurse's notes regarding resident's pain level or status. Review of a written statement from LPN #22 dated 09/15/20, no time provided revealed the nurse responded to Resident #35's room at approximately 2:15 P.M. Upon entering, the resident was found sitting on the floor. The resident stated he was going to the bathroom. The note revealed the resident complained of right hip pain but after he was repositioned in his recliner, facial grimacing and guarding subsided and the resident stated the pain lessened. The resident received routine [MEDICATION(S)] medication (earlier that morning as scheduled) and routine Tylenol on this date. There was no additional documentation showing the resident was repositioned (or any other non-pharmaceutical interventions were utilized) more than one time when the fall occurred. Review of Resident #35's vital signs on 09/15/20 at 3:03 P.M. revealed the resident was assessed by staff using the Wong-Baker faces pain scale (a nonverbal pain scale). The scale ranges from zero to two with two being the highest indication of pain. The resident was assessed at a one for negative vocalization (occasional moan or groan or low level of speech with a negative quality), a two for facial expression (facial grimacing), a two for body language (rigid, fists clenched, knees pulled up, pulling or pushing away, striking out), and a two for consolability (unable to console, distract or reassure). These scores added together determined a pain level of seven out of ten with ten being the worst pain. There was no additional pain level/assessment documented on 09/15/20 after 3:03 P.M. There was no evidence the physician was contacted to discuss the resident's pain level. Review of Resident #35's meal intakes on 09/15/20 revealed the resident ate 75% to 100% at breakfast and lunch (documented at 1:38 P.M. and 1:39 P.M.). The resident's intake decreased to zero to 25% at dinner (documented at 6:37 P.M.). Review of Resident #35's neurological checks on 09/15/20 from 2:20 P.M. to 8:05 P.M. revealed staff completed checks every 15 minutes for one hour, every 30 minutes for two hours, and every hour for three hours. The resident's blood pressure was 136/72 and his pulse was 86 at 2:20 P.M. At 4:05 P.M., the resident's blood pressure had increased to 144/72. At 5:05 P.M., the resident's blood pressure had increased to 146/66 and his pulse was 88. The resident's pain level was not assessed during any of the neurological checks. Review of Resident #35's fall scene investigation report, completed by LPN #8 and reviewed by the Assistant Director of Nursing (ADON), Social Services (SS) #77, Registered Nurse (RN) #6, the Administrator, and the Director of Nursing, dated 09/15/20 at 2:40 P.M., revealed on 09/15/20 at 2:15 P.M., the resident had an unwitnessed fall while ambulating alone to the bathroom in his room. The resident lost his balance, slipped, and appeared to become weak. The resident was alert and oriented. The investigation did not include any information related to addressing the resident's pain. The resident was not immediately taken to the hospital. The resident was educated on using his call light and waiting for staff to assist him. The Falls Team Meeting Notes at the end of the report stated a STAT (immediate) right lower extremity/hip x-ray was obtained and positive for a proximal femoral neck fracture. The resident was sent to the emergency room , admitted to the hospital, and was pending surgery. Record review revealed no Pain Assessment 3.0 was completed in the electronic charting system at the time of the incident. On 09/15/20 at 8:00 P.M. (nearly six hours after the resident's fall), the mobile x-ray provided arrived at the facility to complete the ordered hip and femur x-rays. Review of Resident #35's x-ray report, electronically signed on 09/15/20 at 8:32 P.M., revealed the findings included an oblique displaced fracture through the neck of the proximal right femur. There was limb retraction or cranial migration by approximately one centimeter (cm). On 09/15/20 at 8:50 P.M. (nearly seven hours after the resident's fall), a report was received from the mobile x-ray provider that confirmed the resident had a proximal right femur fracture and an order was received to send the resident to the emergency room . The Director of Nursing (DON), physician, and the resident's Power of Attorney (POA) were notified. On 09/15/20 at 9:15 P.M. Resident #35 was transferred to the hospital and remained hospitalized until 09/19/20. The resident returned to the facility on [DATE] at 1:50 P.M. with a 26 centimeter (cm) incision on his right hip with 17 staples. Review of the hospital information revealed the resident was administered [MEDICATION(S)] (used to treat moderate to severe pain) .5 mg per .5 milliliters (mL) intravenously one time. The resident had additional orders for [MEDICATION(S)] 5-325 mg every six hours as needed for pain, Acetaminophen 650 mg every four hours as needed for pain, and [MEDICATION(S)] 2 mg intravenously every three hours as needed for pain during his hospital stay. Review of Resident #35's hospital records, dated 09/15/20 at 11:37 P.M., revealed the resident was seen in the emergency room for an evaluation of a right hip fracture. The x-ray showed an acute displaced fracture of the right femoral neck fracture with proximal displacement. The fracture was discussed with an orthopedic surgeon. The resident was admitted to the hospital with a plan for surgical intervention. The resident's pulse was elevated to 101 on 09/15/20 at 11:09 P.M. and upon physical examination, the resident was noted to be uncomfortable with a complaint of right hip pain with any attempted motion. The resident received pain medication including [MEDICATION(S)] 0.5 mg per 0.5 mL intravenously one time and had additional orders for [MEDICATION(S)] 5-325 mg every six hours as needed, [MEDICATION(S)] two milligrams intravenously every three hours as needed, and Acetaminophen 650 mg every four hours as needed for pain. The resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] .M. On 05/17/21 at 5:29 P.M. and 05/20/21 at 1:04 P.M. interviews with Resident #35 revealed the resident had a fall at the facility and he broke his leg. The resident stated he was scheduled to go home the day after the fall occurred had tried to walk to the bathroom by himself and fell . The resident stated following the fall he was in a lot of pain but thought the staff had given him a pain pill. He stated he continued to have a lot of pain until the time he was sent to the hospital. On 05/19/21 at 4:24 P.M. interview with LPN #22 revealed she responded to a call for a nurse to Resident #35's room on 09/15/20. She had not been assigned to the resident that day. The nurse stated she remembered the resident attempted to walk to the bathroom by himself and fell . The fall resulted in a hip fracture. The nurse stated the fall was not witnessed and a state tested nursing assistant (STNA) had found the resident on the floor and called for a nurse to assist. Since the fall was unwitnessed, the facility policy was to start neurological checks. The nurse confirmed the resident did complain of right hip pain and was not able to bear weight on his right leg. The nurse revealed the resident had received a scheduled [MEDICATION(S)] medication that morning (before the fall) as well as Tylenol in the afternoon and evening time. The nurse confirmed there was no documentation of whether the medication was effective or not with controlling the resident's pain. The nurse confirmed she did reposition the resident at the time of the fall and it did help reduce the resident's pain but she could not recall how often the resident had been repositioned (or if that occurred at all) before he went to the hospital. The nurse confirmed the physician was notified of the fall and the results of the resident's x-ray but had not been contacted to discuss the resident's pain. On 05/20/21 at 10:43 A.M. and 05/20/21 at 12:26 P.M. interview with the Assistant Director of Nursing (ADON) revealed she thought there was a four hour window for STAT orders to be completed and if it was going to take the provider longer than four hours, they should inform the facility. Later, the ADON revealed there was not a set turn around time for completing a STAT (immediate) x-ray in the contract with the mobile x-ray provider. The ADON revealed the resident agreed to have the x-rays completed at the facility instead of going to the hospital. However, the resident was not told that it could take several hours for the mobile x-rays to be completed because the wait time varied depending on how many drivers the provider had. The ADON confirmed the resident's pain level was assessed at a seven out of ten at 3:03 P.M. and there were no additional pain assessments recorded or documentation about the resident's pain level from 3:03 P.M. until the resident went to the hospital at 9:15 P.M. The ADON confirmed there was no documentation showing whether the medication administered to the resident was effective for controlling the resident's pain. The ADON confirmed there was not any documentation to determine the physician or Certified Nurse Practitioner (CNP) had been contacted to discuss the resident's pain level after the initial notification about the fall. The ADON confirmed a pain assessment was not included as part of the neurological checks that were completed on the resident. Review of the facility policy, titled Pain Management Program, revised on 06/12/17 revealed all residents would be reviewed upon admission, quarterly and prn (as needed) for acute (described as passing in nature), chronic, or no pain.