Every finding on record at Crestwood Care Center

Based on observation, medical record review, interview, and review of the facility policy, the facilty failed to ensure medications were administered per physician's orders. This affected one (#15) of three residents reviewed for medication administration. The facility census was 113. Review of the medical record for Resident #15 revealed this resident was admitted to the facility on [DATE]. Diagnoses included fracture of unspecified part of neck of left femur. Review of the care plan dated 07/09/26 revealed Resident #15 had complaints of acute and chronic pain and was at risk for pain. Interventions included administering non-pharmacological interventions and evaluating the effectiveness of interventions, observing for pain each shift, and following physician's orders for complaints of pain. Review of the physician's order revealed an order on 07/09/26 for oxycodone 5 milligrams (mg); give one tablet every four hours as needed for pain; Melatonin Oral Capsule 5 mg, give one capsule by mouth at bedtime for sleep aide, Fluticasone Propionate Diskus Inhalation Aerosol Powder Breath Activated 250 mg per actuation (act) 1 puff inhale orally two times a day for COPD; gabapentin 100 mg, give one capsule by mouth every 12 hours for pain; and oxcarbazepine 150 mg, give one tablet by mouth two times a day for epilepsy. Review of the nurse progress note dated 07/08/26 at 5:32 P.M. revealed Resident #15 was transported to the facility via Emergency Medical Squad (EMS) from the hospital. Resident #15 was alert and oriented times four and was aware of medical condition and surroundings and was okay with the admission. admission vitals were blood pressure of 98/64, pulse rate of 111, temperature of 98.2, respiratory rate of 20, and oxygen level of 86 on 2 liters of oxygen via nasal cannula. Resident #15 stated that was her baseline oxygen level. Interview on 07/09/26 at 8:57 A.M. with Resident #15 revealed she was admitted to the facility on [DATE] at approximately 5:00 P.M. Resident #15 stated she had surgery on her leg and hand, and had not had any medication since being admitted to the facility. Resident #15 stated she was up throughout the night due to being in pain, and asked staff for relief, however none was provided. Resident #15 stated at this time her pain was beyond a 10 on a scale of one being none and 10 being the worst. Resident #15 additionally stated she was supposed to start therapy however if she did not have pain medication, she would not be able to complete it. Interview on 07/09/26 at 9:10 A.M. with Licensed Practical Nurse (LPN) #202 revealed Resident #15 arrived at the facility yesterday at approximately 5:00 P.M. to 5:30 P.M. LPN #202 stated Resident #15 did not have orders signed for the medications, therefore none of her night medications were given. LPN #202 verified Resident #15 missed Melatonin Oral Capsule 5 mg, Fluticasone Propionate Diskus Inhalation Aerosol Powder Breath Activated, gabapentin 100 mg, and oxcarbazepine 150 mg. LPN #202 further confirmed Resident #15 had an order for oxycodone 5 mg. LPN #202 further confirmed Resident #15 stated she was in pain throughout the night. LPN #202 stated that the nurse who admitted Resident #15 should have called the on-call physician to get orders, and the medications could have been pulled from the contingency supply or could have been expressed shipped from the pharmacy, including the pain medication. Interview on 07/09/26 at 9:15 with Assistant Director of Nursing (ADON) #277 confirmed if a resident does not have orders in the system the staff should have called the physician on call to pull the medications from the contingency supply. ADON #277 further stated the facility had oxycodone 5 mg available in the contingency supply. Review of the facility policy titled, Medication Administration, not dated, revealed it was policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. This deficiency represents non-compliance investigated under Complaint Number 1357978.

Based on record review, review of the late administration medication report, interview, and facility policy review the facility failed to ensure medications were administered per physician order. This affected three (#11, #16, and #51) of seven residents reviewed for medications. The facility census was 86. Findings include: 1. Review of medical record for Resident #11 revealed admitted [DATE]. Diagnoses included but not limited to peripheral vascular disease, type two diabetes, fracture of third and fourth lumbar vertebra, fracture of one rib, chronic obstructive pulmonary disease, malignant neoplasm of left bronchus, secondary malignant neoplasm of bone, and hypertension. Review of Minimum Data Set (MDS) dated [DATE] (Medicare 5-day) revealed resident was cognitively intact. Review of current physician orders revealed Hydroxyzine (antihistamine) 25 milligrams (mg) three times daily. Review of late medication report revealed Hydroxyzine 25 mg was ordered at 9:00 P.M. and administered at 11:49 P.M. on 03/24/25, and Hydroxyzine 25 mg was ordered at 2:00 P.M. and it was administered at 5:41 P.M. on 03/23/25. 2. Review of medical record for Resident #16 revealed admitted [DATE]. Diagnoses included malignant neoplasm of upper lobe left bronchus or lung, chronic obstructive pulmonary disease, anxiety, insomnia, major depressive disorder, and muscle weakness. Review of Minimum Data Set (MDS) dated [DATE] (Admission) revealed resident was cognitively intact. Review of current physician orders revealed Calcium (supplement) 500 plus D3 500-15 milligrams (mg)-micrograms (mcg) twice daily, Mometasone Furo-formoterol fum inhalation aerosol (steroid) 200-5 mcg/ACT twice daily, Pantoprazole (proton pump inhibitor) 40 mg twice daily, Tylenol (analgesic) extra strength 500 mg twice daily, Review of late medication report revealed on 03/23/25 Calcium 500 plus vitamin D3 500/15 mg/mcg , Tylenol extra strength 500 mg, Pantoprazole 40 mg, and Mometasone Furo-Formoterol Fum Inhalation Aerosol 200/5 mcg/act two puffs orally twice daily, scheduled at 7:30 A.M. were administered at 9:52 A.M. 3. Review of medical record for Resident #51 revealed admitted [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, type two diabetes, metabolic encephalopathy, nontraumatic intracerebral hemorrhage, and hypertension. Review of Minimum Data Set (MDS) dated [DATE] (Medicare 5-day) not completed revealed resident was cognitively intact. Review of MAR for March 2025 revealed medications were given except for bedtime (HS) meds on 03/13/25 Atorvastatin (statin) 80 mg, Carvedilol (lowers heart rate and blood pressure) 25 mg, Clopidogrel (platelet inhibitor)75 mg, Dicyclomine (relieves muscle spasms in the gastrointestinal tract) 20 mg, Evolocumab subcutaneous solution auto-injector ( used to treat high cholesterol) 140 mg/ml 1 ml SQ at bedtime every 14 days for high cholesterol, Gabapentin ( anticonvulsant) 300 mg, Hydralazine (vasodilator) 50 mg, Lantus Solostar SQ solution pen-injector 100 unit/ml 45 units at bedtime, Macrobid (antibiotic) 100 mg for 4 days, Sodium Bicarbonate (antacid) 650 mg, Tamiflu (used to lessen influenza symptoms) 30 mg (not given on 03/14/25) started 03/15/25 for 8 days,. Review of late med report revealed on 03/23/25 Humulin R (insulin) injection solution 100 unit/milliliter (ml) per sliding scale 150-200 2 units, 201-250 4 units, 251-300 6 units, 301-350 8 units, 351-400 10 units, 401-500 12 units recheck blood glucose in 30 minutes, if still above 400 call provider before meals (7:30 A.M.) and it was not administered until 9:31 A.M. after breakfast. Review of contingency med list revealed the following medications were available to be pulled and administered on 03/13/25 on admission Atorvastatin 40 mg tablet (2 tabs to make 80 mg), Clopidogrel 75 mg, Gabapentin 300 mg, Hydralazine 25 mg tablet (2 tabs to equal 50 mg), Insulin Glargine 100 unit/ml pen. Observation on 03/25/25 from 8:19 A.M. to 8:30 A.M. of medication pass for three residents revealed no concerns. Interview on 03/25/25 at 2:43 P.M. with the Director of Nursing (DON) verified the medications listed above could have been pulled from the contingency supply for Resident #51. DON verified Residents #11, #16, and #51 had not received their medications timely. Review of policy titled Medication Administration not dated revealed general procedures included administer medication only as prescribed by the provider. Medications will be administered within the time frame of one hour before up to one hour after time ordered. Before meals provide medications thirty minutes prior to meal time. This deficiency represents non-compliance investigated under Complaint Number OH00163843.

Based on record review, admission agreement review, and interview the facility failed to ensure the consent to treat was signed timely. This affected one (#89) of three residents reviewed for consent to treat. The facility also failed to ensure admission agreements were signed timely. This affected one (#51) of three residents reviewed for admission agreements. The facility census was 86. Findings include: 1. Review of medical record for Resident #89 revealed an admitted [DATE] and discharge date of [DATE] with diagnoses including but not limited to fracture of unspecified part of the neck of left femur, metabolic encephalopathy, nonrheumatic mitral valve insufficiency, chronic atrial fibrillation, dementia, rheumatic tricuspid valve insufficiency, and thrombocytopenia. Review of minimum data set (MDS) 3.0 assessment dated [DATE] revealed the resident was severely impaired with cognition and was rarely/never understood. Resident #89 was dependent for all activities of daily living. Review of nurses note dated 03/11/25 at 3:06 A.M. revealed resident arrived at 7:35 P.M. via emergency medical services (EMS). Family in not long after the resident arrived and at the bedside. Review of Care Conference Note dated 03/12/25 at 1:51 P.M. revealed the Power of Attorney daughter was in attendance. Review of PHP progress note dated 03/14/25 at 7:42 P.M. revealed the resident is comfort care. Oxygen level 84 percent on two liters. Death Rattle present per nurse. Per the nurse family is on their way to the facility. Atropine drops ordered. Review of nurses note dated 03/14/25 at 7:50 P.M. revealed the writer contacted the daughter about change in condition. Daughter stated she would be in as soon as possible. Review of nurses' note dated 03/14/25 at 11:40 P.M. revealed the resident was found absent of vital signs. Confirmed by two nurses. Family and physician notified. Review of the consent to treat revealed the form was signed on 03/14/25. Interview on 03/24/25 at 3:32 P.M. with the Director of Nursing (DON) verified that Resident #89's consent to treat was not signed until 03/14/25. DON verified the nursing staff were responsible for getting the consent to treat signed by the resident or their representatives upon admission. 2. Review of medical record for Resident #51 revealed admitted [DATE] with diagnoses including but not limited to cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, type two diabetes, metabolic encephalopathy, and nontraumatic intracerebral hemorrhage. Review of MDS dated [DATE] revealed the resident was cognitively intact. Review of consent to treat revealed the form was signed by the resident on 03/13/25. Review of the admission agreement revealed the resident signed on 03/24/25. Interview on 03/25/25 at 7:44 A.M. with Director of Public Relations (DPR #212) revealed the facility will typically get the admission agreements signed within three days of admission. DPR #212 verified she did not get Resident #51's paperwork signed until 03/24/25 which was 11 days after admission. DPR #212 stated when she met with the resident on 03/14/24 he did not feel up to doing paperwork. DPR #212 stated when she came back to the resident on Monday 03/17/25 he was in therapy. DPR #212 stated she is out of the building 90 percent of the time for marketing. DPR #212 verified she forgot that Resident #51 had not signed his paperwork. This deficiency represents noncompliance investigated under Complaint Number OH00163843.

Based on record review, interview, and facility policy review the facility failed to ensure wound treatment orders were obtained in a timely manner. This affected three (#11, #51, and #89) of three residents reviewed for wounds. The facility census was 86. Findings include: 1. Review of medical record for Resident #11 revealed an admitted [DATE] with diagnoses including but not limited to peripheral vascular disease, type two diabetes, fracture of third and fourth lumbar vertebra, fracture of one rib, chronic obstructive pulmonary disease, malignant neoplasm of left bronchus, secondary malignant neoplasm of bone, and hypertension. Review of minimum data set (MDS) dated [DATE] revealed the resident was cognitively intact. Resident #11 had one stage three pressure ulcer present on admission and one unstageable pressure ulcer presenting as deep tissue injury present on admission. Review of Nursing Admission Evaluation dated 03/03/25 documented the following non pressure skin issues; right lower leg front scratch, and left lower leg dry thick patchy skin. Treatment order in place for each skin area are marked as not applicable. Review of current physician orders revealed there were no treatments or monitoring implemented for the non pressure skin wounds documented on the nursing admission evaluation. Review of Treatment Administration Record (TAR) for March 2025 confirmed no treatment or monitoring was implemented for the right lower leg or the left lower leg. 2. Review of medical record for Resident #51 revealed admitted [DATE] with diagnoses including cerebral infarction, hemiparesis and hemiplegia following cerebral infarction affecting unspecified side, type two diabetes with foot ulcer, metabolic encephalopathy, nontraumatic intracerebral hemorrhage, and chronic kidney disease stage three. Review of MDS dated [DATE] not completed revealed the resident was cognitively intact. Review of Resident #51's Nursing Admission Evaluation dated 03/13/25 documented the following non pressure skin issues: left toes surgical incision measuring 6.0 cm by 0.1 cm by 0.0 with a treatment order in place. Review of the wound assessment completed by the wound NP dated 03/18/25 reveaeld the resident had the following wounds: Left great toe skin tear/laceration acquired not in house on 03/13/25, measured 0.4 cm by 4.20 cm by 0.1 cm, edges were documented as sutured and approximated well, there was scant serosanguineous exudate. Treatment was documented as cleanse with wound cleanser, cover with oil emulsion, pad with gauze and Kerlix, complete daily and as needed. Right great toe abrasion acquired not at the facility on 03/13/25, measured 0.6 cm by 0.6 cm by 0.1 cm the wound was 100% epithelial tissue with no drainage or exudate. Treatment was documented as cleanse with wound cleanser, apply betadine and leave open to air, complete twice daily. Right second toe abrasion acquired not at the facility on 03/13/25, documented as improving without complications and measured 0.7 cm by 1.2 cm by 0.0 cm. The wound was 100 % epithelial with no exudate or drainage. The treatment was documented as cleanse with wound cleanser apply betadine and leave open to air, complete twice daily. Review of current physician orders revealed left great toe cleanse with wound cleanser, apply oil emulsion to the base of the wound, pad with gauze and secure with Kerlix daily started 03/15/25, right great toe cleanse with wound cleanser, apply betadine to base of the wound twice daily and leave open to air started 03/15/25, and right second toe cleanse with wound cleanser, apply betadine to the base of the wound twice daily and leave open to air started 03/15/25. Review of TAR for March 2025 revealed treatments were started on 03/15/25 and not the day acquired 03/13/25. 3. Review of medical record for Resident #89 revealed admitted [DATE] and discharge date of [DATE] with diagnoses including but not limited to fracture of unspecified part of the neck of left femur, metabolic encephalopathy, nonrheumatic mitral valve insufficiency, chronic atrial fibrillation, dementia, rheumatic tricuspid valve insufficiency, and thrombocytopenia. Review of MDS dated [DATE] revealed the resident was severely impaired with cognition and was rarely/never understood. Resident was dependent for all activities of daily living. Review of Nursing Admission Evaluation dated 03/10/25 documented the following non pressure skin issues; left arm skin tear, hematoma to right forehead, and red sacrum. Treatment order was marked as not applicable for all areas. Review of wound assessment completed by wound NP on 03/14/25 reveaeld the resident had the following skin wounds: Left buttock abrasion acquired not at the facility on 03/10/25, measured 6.5 cm by 1.5 cm by 0.1 cm documented as 100% epithelial with scant amount of serosanguineous exudate. Treatment was documented as cleanse with wound cleanser, apply oil emulsion and bordered foam, complete daily and as needed. Review of skin and wound note dated 03/14/25 at 8:23 P.M. revealed skin tear noted to left buttock present on admission with partial thickness measuring 6.5 cm by 1.5 cm by 0.1 cm and treatment ordered. Review of physician orders revealed an order dated 03/15/25 to cleanse left buttock with wound cleanser, apply oil emulsion to base of the wound and cover with bordered gauze daily. No treatment order to left buttock prior to 03/15/25. Interview on 03/25/25 with the Director of Nursing (DON) verified the wound treatment orders for Residents (#11, #51, and #89) were not put into place when the wounds were identified and were not implemented timely. DON stated that the wound nurse was responsible for getting the orders for the wounds upon admission and she quit without notice. DON verified that this represented a delay in treatment. Review of policy titled Skin Care and Wound Management not dated revealed residents admitted with or develop skin integrity issues will receive treatment as indicated based on location, stage and drainage. This deficiency represents on going non-compliance from the survey dated 02/27/25 and represents non-compliance investigated under Complaint Number OH00163843.

Based on record review, interview, and policy review the facility failed to ensure pressure ulcer wound treatment orders were obtained in a timely manner. This affected one (#11) of three residents reviewed for wounds. The facility census was 86. Findings include: Review of medical record for Resident #11 revealed an admitted [DATE] with diagnoses including but not limited to peripheral vascular disease, type two diabetes, fracture of third and fourth lumbar vertebra, fracture of one rib, chronic obstructive pulmonary disease, malignant neoplasm of left bronchus, secondary malignant neoplasm of bone, and hypertension. Review of minimum data set (MDS) dated [DATE] revealed the resident was cognitively intact. Resident #11 had one stage three pressure ulcer present on admission and one unstageable pressure ulcer presenting as deep tissue injury present on admission. Review of Nursing Admission Evaluation dated 03/03/25 revealed the following skin issues coccyx stage two pressure measuring 2.0 centimeters (cm) by 0.3 cm, right toes (unspecified) pressure ulcer with no stage or measurements provided, and right lateral foot pressure ulcer with no stage and no measurement provided. Treatment order in place for each skin area noted is marked as not applicable. Review of wound assessment completed by the nurse practitioner (NP) dated 03/18/25 revealed Resident #11 had a stage III pressure ulcer on the sacrum that was acquired on 03/04/25 and measured 1.8 cm by 0.4 cm by 0.6 cm. The wound was described as improving without complications with 20 percent (%) epithelial tissue, 80% granulation tissue with moderate serosanguineous drainage. The wound was to be cleansed with wound cleanser apply medical grade honey, calcium alginate, and cover with Border foam. Right great toe pressure ulcer deep tissue injury, acquired on 03/04/25 and measured 0.6 cm by 0.6 cm by 0.0 cm the wound was documented as improving without complications dark purple maroon non blanching. The treatment was cleanse with wound cleanser, treat with betadine and cover with a bordered gauze daily and as needed. No other pressure wounds were documented in the assessment. Review of current physician orders revealed treatment to right great toe to cleanse with wound cleanser, apply betadine to the base of the wound and cover with bordered gauze daily started on 03/07/25 and sacrum wound cleanse with wound cleanser, apply medical grade honey and calcium alginate to the base of the wound and cover with bordered foam daily started on 03/05/25. Review of discontinued medications revealed no treatment orders prior to 03/05/25. Review of Treatment Administration Record (TAR) for March 2025 revealed treatment to sacrum was not started until 03/08/25 and was not marked as completed on 03/14/25 and 03/21/25. Interview on 03/25/25 with the Director of Nursing (DON) verified the wound treatment orders for Residents #11 were not timely obtained and implemented. DON stated that the wound nurse was responsible for getting the orders for the wounds upon admission and she quit without notice. DON verified Resident #11 had a delay in treatment. Review of policy titled Skin Care and Wound Management not dated revealed residents admitted with or develop skin integrity issues will receive treatment as indicated based on location, stage and drainage. This deficiency represents non-compliance investigated during Complaint Number OH00163843.

Based on observations, review of facility policy, and staff interviews, the facility failed to ensure clean food service areas and beard restraints were worn during food preparation. This had the potential to affect all 96 residents who received meals from the kitchen. The facility did not identify any residents who received nothing by mouth. Findings include: Observation and interview on 02/24/25 at 8:30 A.M. of the secured unit pantry revealed the microwave had dried food splatter in the inside of the microwave. This was verified by Dietary Aide #344. Observation and interview on 02/24/25 at 8:32 A.M. of the snack refrigerator located behind the nurses' station in the secured unit revealed there were dried liquid spills on the bottom of the refrigerator. The freezer had dried frozen liquid at the bottom of the freezer, protein balls were on a tray not covered, labeled or dated. There was a package of veggie burgers that did not have an open date. This was verified by Licensed Practical Nurse (LPN) #359 verified at 8:32 A.M. Observation on 02/25/25 at 4:03 P.M., revealed [NAME] #396 had a full beard that went past his chin (approximately half inch of facial hair) and was not wearing a beard net while cooking. [NAME] #396 stated he forgot to put a beard net on when he came in to work. Dietary Manager (DM) #316 gave [NAME] #396 a beard net to wear at time of observation. Review of the facility policy titled, Environment dated 09/2017 revealed all food preparation areas, food service areas, and dining areas will be maintained in a clean sanitary condition.

Based on observation, staff interview, medical record review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy, the facility failed to ensure glucometers were properly disinfected, failed to implement enhanced barrier precautions (EBP) by donning personal protective equipment (PPE) when completing wound care, and failed to change gloves properly during wound care This affected one (Resident #57) of four residents observed for medication administrations and one (#54) of two residents observed for wound care. The facility identified five residents receiving blood glucose monitoring on the unit. The facility census was 96. Findings include: 1. Review of the medical record for Resident #57 revealed an admitted [DATE] with a diagnosis including type II diabetes mellitus (DM) with hyperglycemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 had intact cognition. Review of the physician order dated 02/09/25 revealed an order for accu check twice daily and notify the physician (MD)/certified nurse practitioner (CNP) if greater than 200. Resident #57's finger stick blood sugar (FSBS) was four times a day for insulin to be administered four times daily via sliding scale insulin. Observation and interview on 02/26/25 at 7:52 A.M. revealed Licensed Practical Nurse (LPN) #310 obtained Resident #57's FSBS prior to administering morning insulin. LPN #310 then came back to the nurses' cart and placed the glucometer on the medication cart, took an alcohol wipe and cleaned the front and back of the glucometer. She then placed the glucometer back into the storage pouch. When asked if the glucometer was used for other residents, LPN #310 confirmed it is used for other residents on the hallway. LPN #310 confirmed she used an alcohol wipe to sanitize the glucometer. LPN #310 stated she cleaned it with alcohol to sanitize the glucometer. Interview with Licensed Practical Nurse Unit Manager (LPNUM) #359 on 02/26/25 at 8:18 A.M. verified the nurse should clean the glucometer with bleach sanitizer wipes and set it in a cup or on a clean towel, making sure it is wet for two minutes, and air dries completely before using again. Review of the undated policy titled Cleaning & Disinfection of Glucose Meter revealed shared glucometers must undergo cleaning and disinfection after each resident use. Use an Environmental Protected Agency (EPA) approved disinfectant that is effective against HIV, Hepatitis C and Hepatitis B to thoroughly wet all surfaces for the time recommendation on the product. Alcohol wipes are not appropriate for cleaning/disinfecting a used glucometer. 36650 2. Review of the medical record for Resident #54 revealed an admitted [DATE]. Diagnoses included type II diabetes mellitus, morbid obesity, and stage IV chronic kidney disease. Review of the treatment order dated 12/16/24 revealed an order for the right posterior thigh to cleanse with wound cleanser, apply Hydrocolloid (a type of wound dressing that provide a moist, protective environment for wound healing) to base of the wound. Change every other day and as needed. Enhanced barrier precautions (EBP) related to wounds when providing dressing change dated 06/19/24. The treatment order for the bilateral posterior leg ulcers dated 02/22/25 was to apply Aquaphor to bilateral leg, apply Dakin's soaked two by two (2x2) gauze pads. Secure with Kerlix and ace bandage bilaterally. Change dressings daily. Observation on 02/26/25 at 5:04 P.M. of Resident #54 dressing treatments with Licensed Practical Nurse (LPN) #303 revealed LPN #303 put gloves on and did not wear a gown that was required for a resident that was on EBP. The EBP sign on Resident #54's door stated when providing personal care and wound care staff are to complete hand washing, wear gloves and gown. The old dressing was removed from Resident #54's bilateral legs. LPN #303 continued with wound care without removing the dirty gloves. LPN #303 then put triple antibiotic ointment on the dirty glove and applied it to the wounds on the left lower leg. LPN #303 did not change gloves and then continued to apply Aquaphor cream to Resident #54's left calf. After applying Aquaphor, she removed her gloves and used hand sanitizer and reapplied gloves. LPN #303 finished wrapping Resident#54's left leg and then continued to remove the old dressing from Resident #54's right lower leg, again LPN #303 did not change her glove or wash her hands after removing the old dressing. LPN #303 then applied triple antibiotic ointment to the wounds on Resident #54's right leg wound with the dirty glove and applied Aquaphor to Resident #54's right leg. LPN #303 took off the dirty gloves and applied new gloves after using hand sanitizer. LPN #303 continued to remove the dirty dressing from Resident #54's posterior thigh and knee. LPN #303 needed assistance with turning Resident #54 and put the call light on for assistance. Certified Nurses Assistant (CNA) #327 came into the room to assist LPN #303, CNA #327 did not don a gown before she assisted with the dressing change. CNA #327 assisted with turning and holding Resident #54 while LPN #303 continued to remove the dirty dressing. LPN #303 did not clean the wound prior to applying the Hydrocolloid dressing to the posterior thigh wound and wound behind the knee. After Resident #54's treatments were completed, LPN #303 and CNA #327 did not remove their gloves, and they repositioned Resident #54. CNA #327 took off their gloves when leaving Resident #54's room. LPN #303 left the room with her gloves on, and put her supplies back into the treatment cart with her gloves still on. Interview on 02/26/25 at 5:56 P.M. with LPN #303 verified she did not put on the appropriate PPE when providing wound care for Resident #54. She stated she should have put on a gown and gloves when a resident was on EBP. LPN #303 verified she did not change her gloves and wash her hands between removing the old dressing and new dressing. Review of CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. Review of CDC guidance titled Clinical Safety: Hand Hygiene for Healthcare Workers found at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html and dated 02/27/24 revealed hand hygiene protects both healthcare personnel and patients. Cleaning your hands reduces the potential spread of deadly germs to patients. Recommendations included on know when to wear (and change) gloves stated gloves are not a substitute for hand hygiene. If your tasks requires gloves, perform hand hygiene before donning gloves and touching the patient or the patients surroundings; always clean your hands after removing gloves. When to change gloves and clean hands included if gloves become soiled with blood or body fluids after a task, if moving from work on a soiled body site to a clean body site on the same patient or if clinical indication for hand hygiene occurs, and before exiting a patient room.

Based on observation, record review, resident and staff interview, and policy review, the facility failed to ensure that residents were free from significant medication errors. This affected one (Resident #57) of four residents reviewed for medication administration. The facility census was 96. Findings include: Review of the medical record for Resident #57 revealed an admitted [DATE] with a diagnosis including type II diabetes mellitus (DM) with hyperglycemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 had intact cognition. Review of the physician order dated 02/10/25 revealed an order for Lantus SoloStar subcutaneous solution pen-injector 100 unit per milliliter (ml), inject 50 units subcutaneous twice daily for DM. (Lantus is a long-acting insulin used to control high blood sugar). The scheduled times for this medication were 7:30 A.M. and 4:00 P.M. Additional insulin orders with a start date of 02/13/25 was Insulin Aspart FlexPen 100 unit per ml solution pen-injector (Insulin Aspart was a fast acting insulin). Inject per sliding scale intradermally before meals and at bedtime for DM. Observation on 02/26/25 at 7:52 A.M. of medication administration for Resident #57 revealed Licensed Practical Nurse (LPN) #310 obtained a finger stick blood sugar (FSBS) for the resident with a FSBS result of 435 (normal range is less than 100). LPN #310 then removed from the medication cart a glass vial with the label Lispro (fast acting insulin and not physician ordered for Resident #57), and the Insulin Aspart FlexPen (fast acting insulin). LPN #310 then stated she was going to give 12 units of the Aspart FlexPen per the resident's sliding scale. LPN #310 then took the glass vial labeled Lispro and stated the resident gets 50 units at this time. LPN #310 then took an insulin syringe and withdrew 50 units of Lantus from the bottle and verified the correct dosage was 50 units. LPN #310 then went into Resident #57's room and injected both medications (Lantus and Insulin Aspart) into Resident #57's lower right abdomen. Interview on 02/26/25 at 9:56 A.M. with Director of Clinical Operations #502 verified LPN #310 gave Lispro 50 units (fast acting insulin) to Resident #57 instead of the prescribed Lantus 50 units (long-acting insulin). LPN #310 verified with Director of Clinical Operations #502 the vial of Lispro along with the Aspart FlexPen was administered to Resident #57. Interview with LPN #310 on 02/26/25 at 10:00 A.M. verified she withdrew 50 units of Lispro from the vial, and dialed the Aspart FlexPen to 12 units totaling 62 units of fast acting insulin administered to Resident #57. Certified Nurse Practitioner (CNP) #503 was in the facility at this time and went to Resident #57's room and obtained her FSBS with a result of 411. Interview on 02/26/25 at 11:05 A.M. with Resident #57 stated she was told that she was given the wrong insulin. Resident #57 stated she felt tired and out of breath and her left arm was numb, shortly after getting the insulin, more than normal and had not had anything to eat since breakfast. Resident #57 further stated she has been having crazy thoughts and was loopy, and shaky when eating breakfast, having to use her fingers to pick up food but after 20 minutes it stopped. Interview on 02/26/25 at 11:23 A.M. with CNP #503 stated Resident #57 has a history of numbness in her left arm due to a pinched nerve and Resident #57 told CNP #503 when she was in with her that she did not sleep well last night and was tired. CNP #503 further stated Resident #57 told her she was a little shaky this morning. CNP #503 said they would check Resident #57 FSBS every 15 minutes for three times, and then continue every hour for 24 hours. CNP #503 stated Resident #57 was insulin resistant and the extra fast acting insulin has not had an effect on her. Interview on 02/26/25 at 12:09 P.M. with LPN #310 stated CNP #503 placed an order to hold noon insulin at this time. FSBS was 366. Interview on 02/26/25 at 12:55 P.M. with Unit Manager #359 stated Resident #57's blood sugar was dropping so she was sitting with Resident #57 for the rest of the day. Review of the undated policy titled Medication Administration revealed licensed and authorized personnel may administer prescribed medication and observe the five rights in giving each medication which include: the right medicine, and the right dose. The licensed personnel must read medication labels three times before administering medication. This deficiency represents non-compliance investigated under Complaint Number OH00161215.

Based on observation, resident and staff interview, medical record review, and facility policy review, the facility failed to ensure medications were administered according to physician orders resulting in a medication error rate which exceeded five percent (%). 27 opportunities were observed with two medication errors resulting in a 7.41% error rate. This affected two (Resident #57 and #69) of four residents observed for medication administration. The facility census was 96. Findings include: 1. Review of the medical records for Resident #57 revealed an admitted [DATE] with a diagnosis including type II diabetes mellitus (DM) with hyperglycemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 had intact cognition. Review of the physician order dated 02/10/25 revealed an order for Lantus SoloStar subcutaneous solution pen-injector 100 unit per milliliter (ml), inject 50 units subcutaneous twice daily for DM. (Lantus is a long-acting insulin used to control high blood sugar). The scheduled times for this medication were 7:30 A.M. and 4:00 P.M. Additional insulin orders with a start date of 02/13/25 was Insulin Aspart FlexPen 100 unit per ml solution pen-injector (Insulin Aspart was a fast acting insulin). Inject per sliding scale intradermally before meals and at bedtime for DM. Observation on 02/26/25 at 7:52 A.M. of medication administration for Resident #57 revealed Licensed Practical Nurse (LPN) #310 obtained a finger stick blood sugar (FSBS) for the resident with a FSBS result of 435 (normal range is less than 100). LPN #310 then removed from the medication cart a glass vial with the label Lispro (fast acting insulin and not physician ordered for Resident #57), and the Insulin Aspart FlexPen (fast acting insulin). LPN #310 then stated she was going to give 12 units of the Aspart FlexPen per the resident's sliding scale. LPN #310 then took the glass vial labeled Lispro and stated the resident gets 50 units at this time. LPN #310 then took an insulin syringe and withdrew 50 units of Lantus from the bottle and verified the correct dosage was 50 units. LPN #310 then went into Resident #57's room and injected both medications (Lantus and Insulin Aspart) into Resident #57's lower right abdomen. Interview on 02/26/25 at 9:56 A.M. with Director of Clinical Operations #502 verified LPN #310 gave Lispro 50 units (fast acting insulin) to Resident #57 instead of the prescribed Lantus 50 units (long-acting insulin). LPN #310 verified with Director of Clinical Operations #502 the vial of Lispro along with the Aspart FlexPen was administered to Resident #57. Interview with LPN #310 on 02/26/25 at 10:00 A.M. verified she withdrew 50 units of Lispro from the vial, and dialed the Aspart FlexPen to 12 units totaling 62 units of fast acting insulin administered to Resident #57. Certified Nurse Practitioner (CNP) #503 was in the facility at this time and went to Resident #57's room and obtained her FSBS with a result of 411. Interview on 02/26/25 at 11:05 A.M. with Resident #57 stated she was told that she was given the wrong insulin. Resident #57 stated she felt tired and out of breath and her left arm was numb, shortly after getting the insulin, more than normal and had not had anything to eat since breakfast. Resident #57 further stated she has been having crazy thoughts and was loopy, and shaky when eating breakfast, having to use her fingers to pick up food but after 20 minutes it stopped. Interview on 02/26/25 at 11:23 A.M. with CNP #503 stated Resident #57 has a history of numbness in her left arm due to a pinched nerve and Resident #57 told CNP #503 when she was in with her that she did not sleep well last night and was tired. CNP #503 further stated Resident #57 told her she was a little shaky this morning. CNP #503 said they would check Resident #57 FSBS every 15 minutes for three times, and then continue every hour for 24 hours. CNP #503 stated Resident #57 was insulin resistant and the extra fast acting insulin has not had an effect on her. Interview on 02/26/25 at 12:09 P.M. with LPN #310 stated CNP #503 placed an order to hold noon insulin at this time. FSBS was 366. Interview on 02/26/25 at 12:55 P.M. with Unit Manager #359 stated Resident #57's blood sugar was dropping so she was sitting with Resident #57 for the rest of the day. 2. Review of the medical record for Resident #69 revealed a diagnosis of paroxysmal atrial fibrillation, essential hypertension, and hyperlipidemia. Resident #69 had severe cognitive impairment. Review of the physicians order dated 01/30/25 revealed Resident #69 had an order for Diltiazem HCL ER (treats high blood pressure) 180 milligrams (mg) coated beads give one capsule in the morning. Hold if systolic blood pressure is less than 120, and hold if heart rate is less than 60. On 02/26/25 at 8:22 A.M., Resident #69's heart rate was documented as 56. Observation on 02/26/25 at 7:38 A.M. revealed Licensed Practical Nurse (LPN) #310 prepared Resident #69's medication and administered the Diltiazem HCL ER 180 mg along with Resident #69's other medication. No vital signs were obtained during this time. Interview on 02/26/25 at 10:08 A.M. with LPN #310 confirmed she had documented Resident #69's heart rate at 56 and verified the Resident #69's physician orders read to hold the medication if the heart rate was below 60. Review of the undated policy titled Medication Administration revealed licensed and authorized personnel may administer prescribed medication and observe the five rights in giving each medication which include: the right medicine, and the right dose. The licensed personnel must read medication labels three times before administering medication. Record pertinent information prior to giving medication if appropriate, which include: blood pressure recorded, apical pulse recorded, and blood sugar recorded. This deficiency represents non-compliance investigated under Complaint Number OH00161215.

Based on resident and staff interviews, record review, and review of facility policy, the facility failed to monitor weights and vital signs before and after dialysis and maintain adequate communication with the outside dialysis center for Resident #66. This affected one (Resident #66) of one resident reviewed for dialysis. The facility identified four residents receiving dialysis. The facility census was 96. Findings include: Review of the medical records for Resident #66 revealed an admitted [DATE]. Diagnosis included stage III kidney disease and hemodialysis. The medical record for November 2024, December 2024, and January 2025 revealed there were no routine vital signs, pre or post dialysis assessments were completed. There was no dialysis communication noted in the medical record either. Review of the physician order dated 02/06/25 revealed to assess the resident upon return from dialysis in the afternoon every Monday, Thursday and Saturday. Complete a pre-dialysis assessment prior to dialysis on Tuesday, Thursday and Saturday. Interview on 02/25/25 at 1:24 P.M. with Resident #66 stated he has a port for dialysis on right chest and fistula in left arm. He goes to dialysis three times a week. Resident #66 stated he does not take any communication with him to dialysis and does not bring any communication back to the facility. Resident #66 stated the staff usually does not weigh him pre and post and staff do not complete vital signs on his dialysis days. Interview on 02/25/25 at 1:41 P.M. with Licensed Practical Nurse (LPN) #337 stated if a resident has changes while at dialysis, the dialysis staff will send it back with resident or call facility. Dialysis does all of their labs. LPN #337 verified pre and post assessment were to be done for all dialysis residents. LPN #337 verified the nursing staff does not send any paperwork with Resident #66 when he goes to dialysis. Interview on 02/26/25 at 2:00 P.M. with Regional Nurse #501 verified there was no documentation of pre, and post assessments being completed in the months of November 2024, December 2024, and January 2025. Regional Nurse #501 verified the facility does not communicate with dialysis on a regular basis. Review of the facility policy titled Hemodialysis Care and Monitoring dated 2017 revealed pre-dialysis evaluation completed within four hours of transportation to dialysis to include but not limited to, accurate weight, blood pressure, perspirations and temperature. Send a copy of nursing evaluation with resident to dialysis center along with MAR and emergency contact and facility contact information. Post-dialysis the nurse is to review notes from dialysis center and should be put into medical record. Nurse is to complete the post-dialysis evaluation upon return and dialysis center.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure oxygen was administered per physician orders and further failed to ensure oxygen tubing was routinely changed. This affected two (Resident #12 and #18) of two residents reviewed for oxygen administration. The facility identified 11 residents who received oxygen therapy. The facility census was 96. Findings include: 1. Review of the medical record for Resident #12 revealed an admission of 07/19/17. Diagnoses included acute and chronic respiratory failure with hypoxia, atrial fibrillation, morbid obesity, and hypertensive heart disease with heart failure. Review of the Minimum Data Set (MDS) assessment revealed Resident #12 had intact cognition and required assistance with activities of daily living (ADLs). Review of the physician orders for Resident #12 dated 09/02/24 revealed an order for oxygen two to three liters ER minute (LPM) via nasal cannula continuous every shift with oxygenation saturations. The oxygen order was discontinued on 01/11/25. Observation on 02/24/25 at 9:28 A.M. revealed Resident #12 laying in bed with the head of bed elevated. Oxygen via nasal cannula was running from an oxygen concentrator at two LPM. The oxygen tubing was dated 02/10/25, with no date noted on the humidification. Resident #12 stated he was on oxygen all the time. Interview with Licensed Practical Nurse (LPN) 395 on 02/24/25 at 10:12 A.M. verified Resident #12 did not have an order for oxygen administration in the electronic medical record (EMR) and there were no orders for how often to change oxygen tubing and humidification. LPN #395 stated oxygen tubing should be changed weekly and verified Resident #12 oxygen tubing had a date of 02/10/25. 2. Review of the medical record for Resident #18 revealed a diagnosis of Arnold Chiari Syndrome without Spina Bifida or Hydrocephalus and cerebral palsy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact and required assistance with activities of daily living. Review of the physician orders dated 12/12/23 revealed Resident #18 had an order to provide supplemental oxygen at two liters per minute (LPM) via nasal cannula to keep oxygen saturation greater than 94 percent. Review of Resident #18's treatment administration record for February 2025 revealed there was no oxygen saturation documented Under vital signs, there was only one documentation of oxygen saturation at 98% on room air. Observation on 02/25/25 at 8:21 A.M. revealed an oxygen concentrator behind Resident #18's bed with oxygen tubing connected to the concentrator that was not dated. Resident #18 stated he wears oxygen at night when he feels short of breath, which was typically every night. Interview with Licensed Practical Nurse (LPN) #395 on 02/25/25 at 8:21 A.M. confirmed there were no orders for oxygen as needed unless oxygen saturation drops below 94% and there was only one instance on 02/09/25 where his oxygen saturation was obtained. LPN #395 stated the oxygen tubing was typically changed weekly and verified there were no orders for how often to change it in the EMR. Review of the policy titled Oxygen- Medical Gas Use undated, revealed oxygen will be ordered by a physician or other authorized provider. Oxygen will be provided under the supervision of a licensed professional. Residents will have a physician/provider's order for the oxygen including route of administration, liters per minute and frequency of use.

Based on review of the medical record, observation, staff interview, and policy review, the facility failed to ensure the residents received appropriate catheter care. This affected two (#46 and #69) of two residents reviewed for catheter care. The facility identified seven residents with catheters. The facility census was 96. Findings include: 1. Review of the medical record for Resident #46 revealed an admitted [DATE]. Diagnoses included chronic diastolic heart failure and neuromuscular dysfunction of bladder. Review of the annual Minimum Data Set (MDS) assessment revealed Resident #46 had cognitive impairment and had an indwelling catheter. Review of the care plan last revised 02/27/22 revealed Resident #46 had an indwelling catheter for neurogenic bladder. Interventions included to secure catheter to the leg with security device. Review of the physician orders dated 05/15/24 revealed Foley catheter care every shift and as needed with soap and water. Secure straps if applicable, document output every shift. Observation on 02/24/25 at 1:16 P.M. revealed Resident #46 had an indwelling urinary catheter. The catheter tubing was not secured to the resident's leg with security device. Interview on 02/24/25 at 1:16 P.M. with Licensed Practical Nurse (LPN) #400 verified the urinary catheter tubing was not secured to Resident #46's leg with security device. 2. Review of the medical record for Resident #69 revealed an admitted [DATE]. Diagnoses included chronic cystitis, dementia, and obstructive and reflux uropathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had impaired cognition and had an indwelling catheter. Review of the care plan initiated on 02/04/25 revealed Resident #69 had a catheter related to obstructive reflux uropathy. Interventions included to secure catheter to the leg with security device. Review of a physician order dated 02/04/25 revealed Foley catheter care every shift and as needed with soap and water. Secure straps if applicable. Document output every shift. Observation on 02/24/25 at 11:10 A.M. revealed the resident's catheter was not secured to the resident's leg. Interview on 02/24/25 at 11:10 A.M. with Licensed Practical Nurse (LPN) #400 verified the resident's catheter was not secured. Review of the policy Catheter Care, revealed the catheter would be secured to the leg with a device or tape.

Based on review of the medical record, observation, resident and staff interview, and policy review, the facility failed to ensure wound treatments were completed per physician orders. This affected two (#28 and #54) of three residents reviewed for wounds. The facility identified 21 residents with non-pressure wounds. The facility census was 96. Findings include: 1. Review of the medical record revealed Resident #28 had an admitted [DATE]. Diagnoses included type two diabetes mellitus, chronic obstructive pulmonary disease, and pulmonary fibrosis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had intact cognition. Review of a nurse practitioner wound note dated 02/18/25 revealed the resident had a non-pressure neuropathic wound to the left inner ankle. The wound measured 1.5 centimeters (cm) in length by 1.6 cm in width, 0.2 cm in depth. The wound base was 50% epithelial and 50% granulation tissue with attached wound edges. The surrounding skin was fragile and there was a moderate amount of serosanguineous drainage. Review of the physician orders dated 02/18/25 revealed an order to cleanse the left inner ankle with wound cleanser, apply calcium alginate with silver, cover with silicone bordered dressing, change daily and as needed daily on day shift for wound care and as needed for soiled/displaced dressing. Review of the treatment administration record dated February 2025 revealed there was no documentation the wound treatment was completed on 02/10/25 and 02/21/25. There was documentation the treatment was completed 02/22/25 and 02/23/25. Observation on 02/24/25 at 10:56 A.M. of Resident #28 revealed the resident's wound dressing on the left inner ankle was dated 02/20/25. Interview on 02/24/25 at 10:56 A.M. with Licensed Practical Nurse (LPN) #400 verified Resident #28's wound dressing was dated 02/20/25. LPN #400 stated the resident's wound dressing should have been changed daily. Interview on 02/24/25 at 1:08 P.M. with Resident #28 stated the nurses had not been completing the daily dressing change to his left ankle. Interview on 02/26/25 at 10:00 A.M. with Unit Manager Licensed Practical Nurse (UMLPN) #359 verified there was no documentation the resident's wound treatments were completed on 02/10/25 and 02/21/25. UMLPN #359 verified staff had incorrectly documented the resident's wound dressing change as completed on 02/22/25 and 02/23/25. Review of the undated policy Monitoring A Wound, revealed the facility would conduct daily rounds to verify the appropriate wound treatments were completed and documented and implement wound treatments as ordered. 36650 2. Review of the medical record for Resident #54 revealed an admitted [DATE]. Diagnoses included type II diabetes mellitus, morbid obesity, and stage IV chronic kidney disease. Review of the treatment order dated 12/16/24 for the right posterior thigh revealed to cleanse with wound cleanser, apply Hydrocolloid (a type of wound dressing that provide a moist, protective environment for wound healing) to base of the wound. Change every other day and as needed. Enhanced barrier precautions (EBP) related to wounds when providing dressing change dated 06/19/24. There was a treatment order for the bilateral posterior leg ulcers dated 02/22/25 to apply Aquaphor to bilateral leg, apply Dakin's soaked two by two (2x2) gauze pads. Secure with Kerlix and ace bandage bilaterally. Change dressings daily. Observation on 02/26/25 at 5:04 P.M. of Resident #54's wound care with Licensed Practical Nurse (LPN) #303 revealed LPN #303 removed the old dressing from bilateral lower leg wounds and right posterior thigh. LPN #303 did not clean the wound beds and applied triple antibiotic ointment to all the wound beds, and then applied the new dressings. Interview on 02/26/25 at 5:56 P.M. with LPN #303 verified she applied triple antibiotic ointment to the bed of all wound beds. LPN #303 verified she did not follow the physician orders when completing the wound dressing treatments.

Based on observations, staff, family, and resident interview, review of facility policy, and record review, the facility failed to ensure activities were offered and provided to all the residents routinely. This affected two (Residents #15 and #79) of three residents reviewed for activities. The facility census was 96. Findings include: 1. Review of the medical record for Resident #15 revealed admitted [DATE]. Diagnoses included sequela of cerebral infarction, type II diabetes mellitus, and dementia. Resident #15's birthday was in the month of February. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had significant cognitive impairment. Resident #15 was dependent on staff for upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Review of the care plan for Resident #15 revealed the facility will assist with transport to activities as needed and ensure activities were compatible with resident's physical and cognitive capabilities. Resident #15 would be invited to scheduled activities and provided one-to-one in room visits if unable to attend out of room events. Review of the activities progress note from 01/29/25 for Resident #15 revealed activity staff will continue to invite/encourage, transfer to/from, offer independent/leisure supplies, offer one-on-one activities as the resident tolerates. Review of the activity logs from 11/23/24 to 02/23/25 revealed Resident #15 was not offered activities on 11/25/24, 11/30/24, 12/03/24, 12/04/24, 12/05/24, 12/07/24, 12/08/24, 12/11/24, 12/14/24, 12/15/24, 12/18/24, 12/20/24, 12/21/24, 12/24/24, 12/25/24, 12/28/24, 12/29/24, 12/31/24, 01/01/25, 01/02/25, 01/03/25, 01/04/35, 01/05/25, 01/06/25, 01/07/25, 01/08/25, 01/13/25, 01/14/25, 01/15/25, 01/16/25, 01/18/25, 01/19/25, 01/21/25, 01/22/25, 01/23/25, 01/24/25, 01/25/25, 01/27/25, 01/28/25, 01/29/25, 01/30/25, 01/31/25, 02/01/25, 02/02/25, 02/03/25, 02/05/25, 02/06/25, 02/07/25, 02/08/25, 02/09/25, 02/13/25, 02/15/25, 02/16/26, 02/18/25, 02/22/25, and 02/23/25. Review of one-on-one activity documentation in the last three months for Resident #15 revealed one-on-one facility visits were offered six times on 12/03/24, 12/10/24, 01/07/25, 01/24/25, 02/04/25, and 02/12/25. There was no other documentation Resident #15 received one-on-one visit activities during this time period. Review of the February Activity Calendar revealed a Birthday Bash was taking place on 02/26/25 at 2:00 P.M. and they had a drink cart on 02/26/25 at 4:00 P.M. Observations on 02/26/25 at 9:14 A.M. and 10:36 A.M. revealed Resident #15 was in her bed asleep during an activity. On 02/26/25 at 2:40 P.M., Resident #15 was in her room awake while an activity was going on three rooms down in the activity room and Resident #15 stated wanted to talk to somebody and have them stay with her. On 02/26/25 at 4:29 P.M., Resident #15 was in bed and did not get a drink from the drink cart. Resident #15 was unaware of a drink cart that came around. Interview on 02/26/25 at 10:48 A.M. with Licensed Practical Nurse (LPN) #303 stated the facility could do more activities and they do not provide activities for residents with a lower cognition. Interview on 02/26/25 at 4:32 P.M. with Activity Leader #398 stated she passed out the drinks during the drink cart activity and she was completed. Activity Leader #398 stated she did not go to Resident #15's room as she usually doesn't want it. Activity Leader #398 confirmed she did not offer Resident #15 a drink. At 4:46 P.M., Activity Leader #398 stated residents were offered activities every day and it was marked in the electronic activity log. Interview on 02/26/25 at 4:52 P.M. with Activities Director #385 stated activities were offered to residents daily and each resident was invited daily. Activities Director #385 confirmed activities offered were tracked on the activity log. At 5:15 P.M., Activities Director #385 verified the activity log showed Resident #15 was offered activities sporadically. Review of the facilities undated policy titled Activities Program revealed it is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. 39333 2. Review of the medical record for Resident #79 revealed an admitted [DATE] with diagnoses including diabetes mellitus, vascular dementia, and hyperlipidemia. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #79 was severely impaired cognition and required substantial assistance with activities of daily living. Review of Resident #79's activity tracking from 01/25/25 to 02/26/25 revealed there was no activity tracking documented for 01/29/25, 01/30/25, 01/31/25, 02/01/25, 02/02/25, 02/03/25, 02/05/25, 02/06/25, 02/07/25, 02/08/25, 02/09/25, 02/10/25, 02/11/25, 02/12/25, 02/18/25, 02/20/25, 02/21/25, 02/22/25, and 02/23/25. Interview on 02/24/25 at 12:34 P.M. with the wife of Resident #79 stated there were not many activities offered to her husband or available for her husband to attend. Interview on 02/26/25 at 5:15 P.M. with Activity Director (AD) #385 stated there was no specific calendar for the residents who resided on the secure unit but there was a guide for staff to utilize. The guide shows activity aids what they can do and puts scheduled activities on a whiteboard. AD #385 verified there multiple missing activities offered to Resident #79 from 01/25/25 to 02/26/25. Interview on 02/27/25 at 1:36 P.M. with Activity Aide (AA) #367 stated she was part-time activity aide for the secure unit. AA #367 stated her shift was from 9:00 A.M. through 4:00 P.M. and sometimes 3:30 P.M. to 6:00 P.M. AA #367 stated she does not work past 6:00 P.M. usually. She stated she gets a feeling from what the residents do and then does the activity. AA #367 stated today they wanted to continue with BINGO instead of singing along. AA #367 stated she documents if a resident attends activities. Review of the secure unit's activity guide revealed it looked like a calendar dated February 2025 which had blocks that were numbered like a calendar with times and activities listed on them. There were activities scheduled starting at 10:00 A.M. through 6:00 P.M.

Based on staff interview, review of facility policy, and record review, the facility failed to ensure baseline care plans were developed and/or summaries of the baseline care plan were provided to the residents and/or their representatives. This affected two (#79 and #81) of five residents who were reviewed for baseline care plans. The facility census was 96. Findings include: 1. Review of the medical record for Resident #79 revealed an admitted [DATE] with diagnoses including diabetes mellitus, vascular dementia, and hyperlipidemia. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #79 was severely impaired cognition and required substantial assistance with activities of daily living. Review of the medical record revealed no evidence of a baseline care plan was established to address Resident #79's care needs. There was no evidence Resident #79's resident representative was provided with a copy of the baseline care plan. Interview with the Administrator on 02/27/25 at 3:26 P.M. verified there were no baseline plans established for Resident #79 and no evidence the representatives were given a copy. 2. Review of the medical record for Resident #81 revealed an admitted [DATE] with diagnoses including major depressive disorder, unspecified dementia, and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #81 was severely impaired cognition and required moderate assistance with activities of daily living. Review of the medical record revealed no evidence of a baseline care plan was established to address Resident #81's care needs. There was no evidence Resident #81's resident representative was provided with a copy of the baseline care plan. Interview with the Administrator on 02/27/25 at 3:26 P.M. verified there were no baseline plans established for Resident #81 and no evidence the representatives were given a copy. Review of the facility policy titled Baseline Care Plan dated 06/01/24 revealed a baseline care plan will be developed within 48 hours of a resident's admission which would include minimum information, a written summary of the baseline care plan will be provided to the resident and representative. There must be documentation in the medical record that the baseline care plan was provided to the resident and resident representative, either in a progress note or by utilizing a signature page.

Based on staff and resident interview, medical record review, and review of facility policy, the facility failed to ensure personal property was secured and returned timely to the resident. This affected one (Resident #18) of one resident reviewed for missing personal property. The facility census was 96. Findings include: Review of the medical record for Resident #18 revealed diagnoses including generalized anxiety and cerebral palsy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had intact cognition and required assistance with activities of daily living (ADLs). Interview with Resident #18 on 02/24/25 at 12:26 P.M. revealed Resident #18 had multiple clothing items (shirts, pants, and socks) that were sent to laundry and never returned, including a comforter. Resident #18 stated the comforter has been missing for around two weeks now. There were approximately four T-shirts, three pairs of sweatpants, and an unknown number of socks missing. Resident #18 stated he often receives other residents' clothing. Interview with Laundry Aide #505 on 02/25/25 at 11:18 A.M. revealed laundry staff does not properly put clean clothes into the correct designated room area when hanging laundry to be delivered back to the residents. Laundry Aide #505 stated he has addressed this multiple times with the housekeeping supervisor. The laundry room has a list of residents rooms with names which Laundry Aide #505 said was not properly updated therefore leading to clothing being delivered to the wrong residents. Laundry Aide #505 stated he was unable to locate Resident #18's comforter and remembers when Resident #18 reported it missing to laundry. Interview with the Administrator on 02/25/25 at 2:34 P.M. stated if a resident has something missing, they were to report it to staff and then it was reported to corporate and then the items can be replaced. Review of the policy titled Personal Laundry Handling & Processing Policy, undated, revealed delivery times of laundry should meet the needs of the residents. The environment supervisor should ensure that documentation is maintained for all linens that are cleaned and ready for delivery.

Based on record review and staff interview, the facility failed to ensure annual performance evaluations were completed as required for certified nursing assistants (CNAs). This affected three of three CNAs reviewed for annual performance evaluations. This had the potential to affect all 96 residents residing in the facility. Findings include: Review of the personnel file for CNA #302 revealed a hire date of 08/10/22. The employee's personnel file revealed no annual performance evaluation had been completed for 2024. Review of the personnel file for CNA #304 revealed a hire date of 11/19/19. The employee's personnel file revealed no annual performance evaluation had been completed for 2024. Review of the personnel file for CNA/Medication technician (MT) #360 revealed a hire date of 01/05/22. The employee's personnel file revealed no annual performance evaluation had been completed for 2024. On 02/25/25 at 8:20 A.M. with Human Resource Director (HR) #307 verified no 2024 annual performance evaluation had been completed for CNA #302, CNA #304, and CNA/MT #360.

Based on interviews, record reviews, and policy review, the facility failed to ensure resident's advance directives were readily available and communicated to the interdisciplinary team. This affected one (#100) of three residents reviewed for advance directives. The facility census was 86. Findings include: Review of the medical record for Resident #100 revealed an admitted [DATE]. Diagnosis included dementia and stated Do Not Resuscitate- Comfort Care (DNR-CC). Under the tab advance directive, it stated DNR-CC dated [DATE]. There was no DNR uploaded in Resident #100's medical record. Review of the plan of care dated [DATE] for advance directive for DNR-CC. Interventions included obtain copies of advanced directives from resident/resident representative to have on file, dated provider order for code status and obtain the state specific DNR form. Review of the physician orders for [DATE] revealed no order related to resident's code status. Code status for DNR-CC was discontinued on [DATE]. Review of the face sheet on the electronic charting revealed no advance directive. Review of the hard chart revealed Face sheet [DATE] revealed Resident #100 was a DNR-CC and was current and verified on [DATE]. Review of the progress note dated [DATE] at 7:42 P.M. revealed Resident #100 had a change in condition. The nurse took vital signs, and they were critical, and squad was called. Resident #100 was unable to be resuscitated. Interview on [DATE] at 11:37 A.M. with Certified Nurse's Assistant (CNA) #301 stated she went to look for the DNR paper for Resident #100 and she was unable to find it. She took the chart to Licensed Practical Nurse (LPN) #390. LPN #390 looked in the chart also and was unable to find the signed DNR paper, but she did find on a hospital note that Resident #100 was a DNR. By the time the squad got to her, Resident #100 had passed away. Interview on [DATE] at 2:51 P.M. with LPN #390 stated she was the nurse on when Resident #100 passed away. She did not start CPR because Resident #100 was a DNR-CC. She had CNA #301 go get the hard chart and she was unable to find the copy of the DNR, but she did find hospital paperwork that stated she was a DNR. LPN #390 stated she had no idea what her code status was only what she found in the chart and there was no face sheet in hard chart, and it was not on the orders. Interview on [DATE] at 3:40 P.M. with the Director of Nursing (DON) verified the advance directive paper should be accessible to all nursing staff and there should be a valid DNR in residents advance directive tab in the hard chart if a resident is a DNR. The DON stated the DNR paper was in the chart but the nursing staff was unable to find it. Review of the facility policy Advance Directive (Resident's Right to choose), dated [DATE] revealed upon admission, should the resident have an Advance directive, copies will be made and placed on the hard chart medical record as well as communicated to the staff. This deficiency represents non-compliance investigated under Complaint Number OH00159896.

Based on resident and staff interviews, record review and observation, the facility failed to ensure Resident #78's continuity of care was reviewed and implemented timely. This affected one (#78) of three residents reviewed for medications. The facility census was 86. Findings include: Review of the medical record for Resident #78 revealed an admitted [DATE]. Diagnoses included heart disease, diabetes mellitus, and lymphedema. Review of the after-visit summary for obstetrics and gynecology dated 10/24/24 revealed a medication order changed for megestrol (hormone therapy) 40 milligrams (mg) two tablets twice a day to four tablets twice a day. Review of the Nurse Practitioner (NP) #300 dated 10/25/24 revealed Resident #78 reported she had a procedure in the gynecology office that left her really sore. Resident #78 stated she has had some relief with ibuprofen. Resident #78 has history of abnormal uterine bleeding and had a uterine scraping and was waiting to hear back if she needs a dilation and curettage (D&C) (a surgical procedure that involves dilating the cervix and using a spoon-shaped instrument to remove tissue from the uterus). Resident #78 stated she may just tell them to go ahead and perform a hysterectomy because she was tired of bleeding. Megestrol Acetate (hormone therapy) tablet 20 mg, give two tablets by mouth in the morning for postmenopausal bleeding and give two tablets by mouth in the evening for postmenopausal bleeding. On 11/11/24, the NP note revealed Resident #78 was waiting for referral to gynecology in at hospital to be seen for a hysterectomy. Resident #78 most recent hemoglobin/hematocrit (H/H) was low at 8.5/29.2 but was supposed to have been treated by gynecology. Resident #78 was not currently on an iron supplement and was agreeable to starting three times a day dosing regimen and have her blood work repeated. Significant anemia from blood loss could contribute to a tachy heart rhythm and lower blood pressure. Resident #78 otherwise reported she was sleeping well and reported her bowels and bladder were good as well as her appetite when she likes the food. She continues on Megestrol Acetate Tablet 20 mg, give two tablets by mouth in the morning for postmenopausal bleeding and give two tablets by mouth in the evening for postmenopausal bleeding Review of the progress note dated 11/13/24 at 3:29 P.M. revealed labs were drawn early morning and lab called to notify nurse that her hemoglobin was low 6.8. Resident #78 was sent to hospital for a transfusion due to Resident #78 was still bleeding from the vaginal area. Review of the physician orders and Medication Administration Record for November 2024 revealed Resident #78 was taking Megestrol 20 mg two tablets twice a day and was discontinued on 11/14/24. On 11/14/24, Megestrol 40 mg four tablets twice a day was started. Megestrol 40 mg four tablets twice a day was started 21 days after Resident #78's physician at obstetrics and gynecology appointment recommendation dated 10/24/24. Review of the NP #300 progress note dated 11/18/24 revealed Resident #78 received one unit of blood and returned to the facility with no new orders. Resident #78 was however, started on Ferrous Sulfate 325 mg by mouth three times a day just prior to her blood transfusion. Resident #78's gynecology was contacted to expedite her follow-up to discuss hysterectomy due to increased bleeding. Resident #78's Megestrol had also been doubled to 40 mg by mouth three times a day (at her last visit on 10/24/24) but was not started long prior to her transfusion. Resident #78's hemoglobin was rechecked that morning (11/18/24) and was 7.2 but was not available prior to her leaving for her three o'clock appt. Resident #78 reported she was still dizzy and was slightly hypotensive despite her Metoprolol being held for low blood pressure. Interview on 12/12/24 at 2:17 P.M. with Licensed Practical Nurses (LPN) #380 stated Resident #78 has been having bleeding concerns since the beginning of the year. Do not know when her order increased. LPN #380 stated order was changed on 10/14/24 she was looking at paperwork and saw the order had been changed and was not changed on her orders on 11/14/24 so she changed the order. The orders had been scanned into the computer and that was where she found the original order for the medication change. LPN #380 stated sometimes Resident #78 does not give her orders to the nurses when she comes back from appointments. LPN #380 stated the nurse on duty was to follow up with the physician if the paperwork was not brought back to the facility to see if there were any new orders. Interview on 12/12/24 at 3:40 P.M. with the Director of Nursing (DON) stated Resident #78 had an appointment on 10/24/24 with her gynecologist. The DON stated she was not sure if Resident #78 gave the nurse the paperwork when she returned to the facility. Resident #78 was seen by the NP #300 the next day and did not mention any medication change. NP #300 looked for notes from the appointment but was unable to find any. The Gynecologist did not sign the paperwork until 11/01/24 and this was when the notes were uploaded to Resident 78's medical record. The DON verified that if Resident #78 came back from an appointment without physician notes, the nurse on duty should have contacted the doctor to ensure there were no new orders. Interview on 12/16/24 at 9:18 A.M. with Registered Nurse (RN) #310 (surgeons office nurse) stated Resident #78 was referred to them for a hysterectomy. Resident #78 received a hysterectomy on 12/12/24. RN #310 stated she had been bleeding for 10 months and increase in the medications would not have kept her from having the hysterectomy, it was to help slow the bleeding down until she could have the hysterectomy. Interview on 12/16/24 at 9:28 A.M. with Resident #78 stated she had her hysterectomy on 12/12/24 and was doing well, a little sore. Resident #78 stated she could not remember if she had given the nurse the paperwork from the 10/24/24 appointment, which had the new order on it to increase the megestrol. Resident #78 stated it was in inevitable that she was going to have to have the hysterectomy, she had been bleeding for ten months. Attempted to reach the gynecologist about the ordered for megestrol during the survey was unsuccessful. This deficiency represents non-compliance investigated under Complaint Number OH00159899.

Based on medical record review, resident and staff interviews, and policy review, the facility failed to provide effective pain control relief to a resident. This resulted in Actual Harm to Resident #100 when her physician discontinued the use of a narcotic pain medication (Oxycodone) without notifying the resident resulting in Resident #100 experiencing withdrawal symptoms including nausea and trembling hands and Resident #100 experiencing severe pain. This affected one (Resident #100) of three residents reviewed for pain management. The facility census was 91. Findings include: Review of the medical record for Resident #100 revealed an admitted [DATE]. Diagnoses included diabetes mellitus type two with diabetic neuropathy, osteoarthritis, and chronic pain syndrome. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 had intact cognition. Resident #100 had pain occasionally in the last five days of the assessment reference period to which she received pain medication scheduled and as needed and did not receive non-medication interventions for pain. Review of Resident #100's plan of care with revision date of 04/01/24 revealed the resident had complaints of pain related to osteoarthritis and chronic pain syndrome. Interventions included observation for pain every shift and administering non-pharmacological interventions. The goal for Resident #100 was to be able to verbalize relief of pain. Review of Nurse Practitioner (NP) #03's note dated 08/20/24 revealed Resident #100's chief complaint was swelling and erythema to right lower leg. Resident #100 found lying supine in bed in no obvious discomfort. Resident #100 denied increased pain. Review of Resident #100's August 2024 physician orders revealed an order for Percocet oral tablet 5/325 milligrams (mg) (pain medication) administer one tablet by mouth every eight hours as needed for moderate to severe pain. An order for Acetaminophen tablet 325 mg administer two tablets by mouth every six hours as needed for mild to moderate pain, not to exceed three grams acetaminophen in 24 hours started on 06/11/24. An order for Oxycodone HCL (pain medication) oral tablet 10 milligrams (mg) administer one tablet by mouth two times a day for pain with a start date of 06/23/24. Oxycodone HCL was discontinued on 08/20/24. There was no documentation in the medical record Resident #100 was notified the Oxycodone was discontinued until four days later on 08/24/24. Review of Resident #100's Medication Administration Record (MAR) for August 2024 revealed from 08/20/24 to 08/27/24, Resident #100 received as needed Percocet 5/325 mg on 08/20/24 at 10:09 P.M. for a pain level of seven (pain scale from zero indicating no pain and ten being worse pain ever); on 08/21/24 at 7:08 A.M. for a pain level at seven; at 9:30 P.M. for a pain level of six; on 08/23/24 at 7:04 A.M. for a pain level of seven; on 08/24/24 at 7:38 A.M. for a pain level 10; on 08/24/24 at 3:45 P.M. for a pain level of 10; on 08/24/24 at 11:50 P.M. for a pain level of eight; on 08/25/24 at 9:50 A.M. for a pain level of 10; on 08/25/24 at 8:50 P.M. for a pain level of seven; on 08/26/24 at 1:15 P.M. for a pain level of seven; and on 08/27/24 at 6:35 A.M. for a pain level of six. Resident #100 received Oxycodone 10 mg at 8:00 A.M. on 08/20/24 for pain level of zero. Review of the nursing progress notes dated 08/24/24 at 3:09 P.M. revealed Resident #100 spent most of the shift in tears, unable to rest due to complaints of pain. Resident #100 stated Percocet was not effective for her pain but will take it due to not having anything else for pain. Review of the medication administration progress note dated 08/24/24 at 3:48 P.M. revealed Resident #100 had been complaining of general pain rating it 10 out of 10 and stated Percocet was not effective. The progress note lacked evidence of any documentation of alternative pain solutions provided. The nursing progress note dated 08/25/24 at 9:50 A.M. revealed Resident #100 was lying in bed crying and hands trembling. Resident #100 stated she was having so much pain she could not get comfortable and was unable to sleep most of the night. Resident #100 stated she reached out to her son due to not being able to have her Oxycodone, and she stated again the Percocet was not effective. Residents' son did reach out to this nurse asking why the facility has not administered his mother her pain medication. The nurse instructed the son to call the facility and reach out to social services, as she may have some ideas that would be helpful. The medication administration progress note dated 08/25/24 at 4:40 P.M. documented Resident #100 rated her pain five out of ten and stated the Percocet was not effective. The progress note lacked evidence of documentation of alternative pain solutions provided. Review of the social services progress notes dated 08/26/24 at 11:01 A.M. revealed Resident #100's son contacted the social services director (SSD) regarding medication changes. The son requested the Oxycodone medication to be re-instated. The Director of Nursing (DON) and the Administrator were made aware. The DON to contact the physician and follow up with the son. The nursing progress note dated 08/26/24 at 11:48 A.M. revealed Resident #100 was sitting up in her wheelchair watching television and she became tearful. Resident #100 was very tearful stating she just needed her pain medication (Oxycodone) back to make her feel better. The nurse reminded the resident that her son had called into facility and then she was less tearful at that time. The nursing progress note dated 08/26/24 at 12:54 P.M. revealed the nurse contacted Physician #01 regarding resident's complaint of uncontrolled pain. Resident was previously ordered Oxycodone HCL 10 mg twice a day; however, the medication was discontinued on 08/20/24 due to the Pharmacy and Therapeutics (P&T) meeting (a meeting to discuss the resident's medications and usage). Resident/family concerned the current order was not controlling pain. Physician #01 informed this nurse to request NP #03 to discontinue Oxycodone-acetaminophen as needed and restart routine Oxycodone. Review of NP #02's note dated 08/26/24 revealed Resident #100's chief complaint was chronic pain. Resident #100 had a past medical history of chronic pain due to spinal fracture, after a fall, causing severe nerve pain. Resident #100 was currently receiving Neurontin 600 mg four times daily, Acetaminophen 650 mg four times daily as needed and was on Oxycodone 10 mg for approximately 25 to [AGE] years, after seeing multiple specialists. The dose was changed to Percocet five mg/325 mg which was not providing adequate pain control. Resident #100 reported she used to exercise to reduce her depression symptoms and was not able to perform her exercise therapy while experiencing increased pain. The plan was to increase Oxycodone to 10 mg to twice a day and continue PRN (as needed) Acetaminophen. Resident #100 to return to normal exercise therapy once pain was reduced to baseline. The social services progress notes dated 08/27/24 at 9:08 A.M. revealed Resident #100 shared she has not received her medication that was discussed yesterday. The physician order for Oxycodone HCL tablet every 12 hours abuse-deterrent 10 mg give one tablet by mouth every 12 hours for moderate to severe pain was started on 08/27/24. The MAR for 08/27/24 and 08/28/24 revealed Oxycodone HCL ER tablet every 12 hours abuse-deterrent 10 mg was documented on 08/27/24 at 9:00 A.M as a 9 which indicated the medication not provided, and there was no pain level or corresponding nursing note. On 08/27/24 at 8:00 P.M., the MAR indicated the medication was provided with a pain level seven and on 08/28/24 at 8:00 A.M., it was documented a 5 which indicted the medication on hold/see nursing note. However, there was no corresponding pain level or nursing note. Interview on 09/25/24 at 8:30 A.M. with Resident #100 stated her pain was out of control when the facility physician stopped her Oxycodone 10 mg without her knowledge or family's knowledge for a week in August 2024. She started to feel ill with aching, nausea, shaking and increased pain in her legs and back to which she discussed with Licensed Practical Nurse (LPN) #03. Resident #100 stated LPN #03 suggested she was going through withdrawal because of the Oxycodone 10 mg being discontinued a few days before. Resident #100 stated she was never informed of the medication being discontinued nor that she had been given Percocet 5/325 mg instead of the Oxycodone 10 mg (that she had taken for years that controlled her chronic pain). Resident #100 stated she requested to speak to her physician and to call and explain the severity of the pain she was experiencing. Resident #100 stated the nurses said they called the physician on multiple occasions and was unwilling to provide additional medications or any alternative treatments or intervention. Resident #100 stated for four to five days she suffered, she had the shakes, anxiety, excruciating pain in back, legs and feet that was not controlled by the Percocet, Tylenol, or distractive activity. Resident #100 stated she finally called her son for help after being advised by nursing home staff, because of the unwillingness of the physician to provide relief. Only after her son called, her medication was restored, and she began to have pain relief. Interview with LPN #03 on 09/25/24 at 9:20 A.M. verified the MAR with a 5 and 9 indicated the medication was not provided and verified Resident #100 did not receive Oxycodone on 08/27/24 at 9:00 A.M. and 08/28/24 at 8:00 A.M. Physician #01 was called by her and other nurses on multiple occasions notifying him of the severity of Resident #100's pain, with withdrawal symptoms when the Oxycodone was discontinued. LPN #03 verified Physician #01 refused to provide any alternative to help control Resident #100's pain until Resident #100's son got involved. LPN #03 stated she had never known Resident #100 to attempt to abuse narcotics, ask for more than prescribed, appear to be under the influence nor a medication seeker which was concerning because all the residents have the potential to have pain and even when a physician was presented with the nurses' assessment of a resident's pain, the physician was not prescribing any interventions. Interview with SSD #10 on 09/25/24 at 11:20 A.M. verified Resident #100 did express to her the distrust Resident #100 had regarding Physician #01 after his refusal to address her pain, refusal to talk with her and that no alternative physician had been discussed. SSD #10 verified Resident #100 could make her own health decisions, was not cognitively impaired, and should be informed of all medical decisions. Interview with the DON on 09/25/24 at 12:30 P.M. verified there was no documentation of alternative pain-relieving measures/non-pharmacological interventions provided to Resident #100 from 08/20/24 through 08/28/24. The DON verified Resident #100's plan of care was not updated reflecting any alternative measures to help with pain relief. The DON stated Resident #100's Oxycodone 10 mg was discontinued on 08/20/24 during a facility group meeting with Physician #01. The DON verified Resident #100, nor her family were in attendance during this facility meeting and was unable to provide documentation regarding notification of Resident #100 being notified of Oxycodone 10 mg being discontinued on 08/20/24. Attempts to interview Physician #01, NP #02 and NP #03 during the survey were unsuccessful. Review of the facility policy titled Pain Management and Assessments dated 04/16/24 revealed neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility must ensure the residents receive the treatment and care in accordance with professional standard of practice, the comprehensive care plan and the resident's choices related to pain management. There is no objective test that can measure pain, the clinician must accept the resident report of pain. This deficiency represents non-compliance investigated under Complaint Number OH00157343.

Based on medical record review, resident and staff interview, and review of a facility policy, the facility failed to ensure medications were administered as ordered. This affected two (#14 and #110) of five residents reviewed for medications. The facility census was 104. Findings include: 1. Review of Resident #14's medical record revealed admission to the facility occurred on [DATE] with diagnoses including rheumatoid arthritis, diabetes, chronic pain, and chronic obstructive pulmonary disease. Review of a comprehensive assessment dated [DATE] revealed Resident #14 was assessed as completely alert and oriented. Review of Resident #14's medical record revealed a physician order for the immunosuppressive medication to treat arthritis Humira subcutaneous (SQ) every 14 days. Review of Resident #14's medication administration record (MAR) for [DATE] revealed Licensed Practical Nurse (LPN) #232 documented on the MAR that Resident #14 received his Humira injection on [DATE]. There was no other documentation of the medication being administered during the month. Interview with Resident #14 on [DATE] at 8:24 A.M. confirmed there was a nurse recently who came in to administer the Humira injection and was not able to figure out how to do it correctly, so she threw the medication in the trash. Resident #14 confirmed this occurred on [DATE] and stated he spoke with the Director of Nursing (DON) regarding the situation. Interview with the Director of Nursing (DON) on [DATE] at 10:46 A.M. confirmed LPN #232 did not provide Resident #14 his Humira injection on [DATE] and signed off the [DATE] MAR as if she administered it. The interview confirmed Resident #14 originally told the Social Services Director on [DATE] about what happened and the facility started an investigation. Interview with LPN #233 on [DATE] at 10:46 A.M. stated after identifying Resident #14 did not receive his Humira injection on [DATE] another nurse gave Resident #14 his injection on [DATE]. The interview confirmed there was no documented evidence Resident #14 received the injection on the [DATE] MAR or in the progress notes. 2. Review of Resident #110's medical record revealed admission to the facility occurred on [DATE]. Diagnoses included dementia, chronic kidney disease and anxiety. Review of Resident #110's nursing progress notes dated [DATE] revealed Resident #110 had a decline in condition and the family gave consent for a hospice consult. Review of a nursing progress notes for Resident #110 dated [DATE] at 4:30 P.M. revealed family was notified of the continued health decline and Resident #110 was to be admitted to hospice in the morning. Review of a nursing progress note dated [DATE] at 11:42 P.M. revealed Resident #110 was assessed with mottling to bilateral feet and uneven increased abdominal respirations. Further review of nursing progress notes from [DATE] revealed Resident #110 was moaning and appear uncomfortable. The nurse called the physician who ordered the narcotic pain medication morphine and/or the antianxiety medication Ativan for comfort measures. Review of Resident #110's medication administration record (MAR) for [DATE] revealed the resident was ordered Morphine 20 milligrams per milliliter (mg/mL) to give 0.5 mLs by mouth every one hour as needed. The order had a start date of [DATE] at 12:19 A.M. and ended on [DATE] at 1:07 A.M. The same order was entered again with a start date of [DATE] at 1:33 A.M. and ended on [DATE] at 4:12 P.M. Further review of the [DATE] MAR revealed Resident #110 received no morphine during the month. Review of a nursing progress note dated [DATE] at 1:39 A.M. revealed the nurse was waiting on the pharmacy to call back with authorization to pull morphine for Resident #110. The resident appeared more comfortable and relaxed. Further review revealed Resident #110 expired on [DATE] at 1:55 A.M. Review of a nursing progress note dated [DATE] at 5:14 A.M. revealed the pharmacist called the facility that morning in regards to Resident #110's morphine order. The note identified the nurse informed the pharmacist Resident #110 had expired and had waited for over an hour, and would be placed on a call back list to receive authorization to pull the morphine from the facility's stock items. Further review of the note revealed the pharmacist apologized and indicated it had been a long night and they had technical issues that night and just was able to call the facility back. Interview with Cooperate Registered Nurse #231 on [DATE] at 2:14 P.M. verified Resident #110 did not received morphine as ordered when it was needed due to signs of discomfort. Review of a facility policy titled, Medication Administration, dated 2013, revealed it was the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Medications should be administered only as prescribed by the provider. This deficiency represents non-compliance investigated under Complaint Number OH00151892.

Based on observation, record review, job description review, staff interviews and policy review, the facility failed ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by effectively implementing their plan of correction. This resulted in Immediate Jeopardy when on-going non-compliance was identified during an on-site complaint and post-survey revisit, with previous deficiencies centering around appropriate supervision to prevent and address resident-to-resident physical and verbal abuse by Resident #100 to five residents (97, #98, #80, #83, and #101) who resided on the Memory Care Unit (MCU). Additionally, the facility failed to ensure Resident #100, and Resident #91 were free from significant medication errors, failed to accurately maintain resident records to accurately record resident-to-resident altercations, and failed to correct the frequency of physician visits. The facility failed to effectively implement their previous plans of corrections to achieve compliance with the regulations which had the potential to affect all residents residing in the facility. The facility census was 107. On 05/10/24 at 9:43 A.M., the Administrator, Director of Nursing (DON), Regional Director of Clinical Operations (RDCO) #250 and Divisional Director of Clinical Operations (DDCO) #310 were notified that Immediate Jeopardy began on 02/12/24 when Resident #100, who was known to have an extensive history of aggressive behavior, had his antipsychotic medication erroneously omitted by a facility nurse while transcribing a consultant provider ' s new medication orders. On 04/24/24, Resident #100 began having increased aggressive behaviors towards residents and staff, with numerous incidents being reported by staff and few documented in the residents ' medical records. These behaviors included punching other residents, pulling hair in an upward motion lifting a resident up out of the chair, forceful grabbing of arms resulting in skin issues, and verbal threats of physical harm. The facility failed to implement their approved plan of corrections regarding enhanced supervision to prevent resident-to-resident altercations, failed to appropriately audit medical records for resident-to-resident altercations and significant medication errors, and failed to achieve compliance with the frequency of physician visits. The Immediate Jeopardy was removed on 05/16/24 when the facility implemented the following corrective actions: On 05/07/24, laboratory testing and urinalysis was obtained for Resident #100 to rule out medical reasoning for increased agitation. On 05/07/24, all self-reported incidents were completed and submitted to the Ohio Department of Health (ODH) by the Administrator. On 05/07/24, an investigation of all incidents was conducted and completed by RDCO #250. At the time of the incidents, Residents #97, #98, #80, #83, and #101 were interviewed and assessed by SSD #300 with no apparent adverse effect. On 05/07/24, notification to the physician and families of the involved residents were completed by the DON. On 05/07/24, the police department was notified of the resident-to-resident incidents by the Administrator. On 05/07/24, Corporate Nurse #330 obtained staff statements regarding the resident-to-resident incidents, and anyone involved in the state reportable incidents. On 05/08/24, Resident #100 was sent for an inpatient psychiatric evaluation. On 05/08/24 (no time provided), Resident #100 ' s plan of care was updated with all interventions provided by RDCO #250. On 05/10/24, a timeline of events was completed by the DON or designee. On 05/10/24, an initial audit of all psychiatric progress notes received since 02/12/24, and all other physician notes since 04/10/24, was completed by Corporate Nurse #330. On 05/10/24, an initial audit of all progress notes for the last 30 days for all residents was completed to identify any potential incidents that should be reported to ODH as a self-identified, state reportable, with proper investigation and notifications made and documented. This was completed by Corporate Nurse #330. On 05/10/24, an audit of all resident-to-resident incidents was conducted to identify trends with residents and address increased behaviors, or risk for increased behaviors, and completion of interventions. This was completed by Corporate Nurse #330. On 05/10/24, any residents found to be with trends of aggression or increased agitation will be referred for inpatient psychiatric evaluation and treatment by the Administrator. On 05/10/24, education was provided to facility leadership on the abuse policy, risk management, investigation, supervision, behavior management policy, implementation of interventions, order transcription, and the risk escalation process. This education was completed by DDCO #310 and RDCO #250. On 05/10/24, education was provided to all staff on the abuse policy, risk management and investigation, supervision, behavior management policy, order transcription. This was completed by RDCO #250. On 05/10/24, education was provided to Psychiatric Nurse Practitioner #604, who will write all orders as telephone orders and communicate to nursing leadership in person prior to leaving the facility upon completion of rounds. This training was provided by RDCO #250. On 05/10/24, an audit was conducted to ensure all residents had been evaluated by a physician. This was completed by Corporate Nurse #330. On 05/10/24, Education was provided to the Administrator and DON on ensuring plans of correction are completed as written to achieve ongoing compliance. This was completed by DDCO #310. An ongoing audit will be conducted weekly for psychiatric and physician progress notes received, observing for any noted orders that were not properly transcribed. This will be completed weekly by RDCO #250 beginning on 05/11/24. An ongoing audit of resident ' s progress notes will be completed to identify any potential incidents that should be reported to ODH as a state reportable, with proper investigations and notifications made and documented will be completed by RDCO #250 or designee three times weekly for four weeks starting on 05/11/24. An ongoing audit of all resident-to-resident interactions will be conducted to identify trends with residents, and address increased behaviors or risk, to assist in accurately maintaining the resident ' s record or record instances of resident-to-resident altercations. This will be completed by RDCO #250 or designee weekly for four weeks starting on 05/11/24 with oversight from [NAME] President of Risk Management #680. Beginning 05/11/24, staff interviews will be conducted by RDCO #250 five days per week, one staff per unit, and three staff members per day on random shifts, to determine if any resident behaviors were identified. An ongoing audit of the daily clinical meeting and its operations, with attention to the implementation, effectiveness of interventions, and to ensure all incidents are recorded accurately in the resident record will be conducted by RDCO #250 and Regional Director of Operations (RDO) #530 five times weekly for four weeks beginning on 05/13/24. An ongoing audit of the frequency of physician visits, to ensure regulatory compliance, will be completed by RDCO #250 weekly. The results of the audit observations will be reported, reviewed, and trended for compliance through the facility Quality Assurance Committee for a minimum of six months, then randomly thereafter for further recommendations. Ad hoc Quality Assurance and Performance Improvement meetings were conducted on 05/13/24, 05/14/24, and 05/15/24 by the facility ' s interdisciplinary team. On 05/16/24, behavior training specific to dementia and memory care, provided by an outside licensed behavioral specialist, was completed for all staff who work on the memory care unit. Although the Immediate Jeopardy was removed on 05/16/24, the deficiency remained at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: During an interview on 05/08/24 at 9:01 A.M., the Administrator stated he had only been employed at the facility for approximately one month. The Administrator recognized the facility was out of compliance and his highest priority was getting the facility back into compliance. The Administrator stated the concerns were getting the facility back into compliance and achieving staff stability. The Administrator was unable to state how the facility was achieving compliance with previously cited deficiencies. He stated he would have to check the survey binders to familiarize himself to what areas the facility was out of compliance. During the on-site complaint and post-survey revisit, continued non-compliance was identified by the survey team. The facility ' s failure to effectively audit, monitor, and correct previously cited deficiencies resulted in the potential for serious harm or injury to all residents. 1. Review of the Facility Assessment, revised on 04/04/24 and reviewed with the Quality Assurance and Performance Improvement (QAPI) committee on 04/25/24, revealed the facility provided mental health and behavior management. Specific care provided to this population of residents included managing the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identifying, and implementing interventions to help support individuals with issues such as dealing with anxiety, cognitive impairment, residents with depression, trauma/post-traumatic stress disorder (PTSD), other psychiatric diagnoses, and intellectual or developmental disabilities. The facility identified it was able to provide medication administration by various routes. The section of the facility assessment which discussed working with medical providers in describing the facility ' s plan to recruit and retain enough medical practitioners and how the facility collaborates with the providers to meet the medical needs of the population was blank. 2. The facility failed to ensure Resident #100, who had a history of physical aggression towards other residents and staff, had appropriate supervision, monitoring, and services rendered to manage his behaviors, supervise his actions, and protect other residents of the facility. Resident #100 was assessed to have severely impaired cognition, an extensive history of aggressive behaviors, and resided on a secured MCU. On 02/12/24, Resident #100 was seen by the psychiatrist for a medication adjustment/follow-up and the resident was ordered Seroquel to be stopped and Risperdal started. The Seroquel was discontinued; however, the Risperdal was never started. Review of Resident #100's Medication Administration Record (MAR) indicated he received no antipsychotic medication from 02/12/24 until Resident #100 was seen by a visiting physician on 05/07/24 due to multiple instances of aggression and behaviors and his Seroquel was restarted. As a result, Resident #100 was off his antipsychotic medications for 85 days. In this time frame, Resident #100 began having increased physical behaviors as well as verbal threats of physical harm towards other residents in the Memory Care Unit (MCU). On or about 04/24/24, Resident #100 started having increased aggressive behaviors towards the residents and staff. The resident has numerous incidences of aggressive behaviors involving other residents, with few being documented in the residents ' medical record. The resident's behaviors included punching other residents in the stomach, pulling residents hair and pulling them upwards out of a chair, forcefully grabbing others ' arms causing skin issues and verbally threatening residents with harm. Resident #100's care plan has not been revised to reflect his behaviors and/or any interventions to monitor and address his pattern of behavior. There is limited documentation about his behaviors, despite the staff interviews reporting the behaviors, and no evidence of preventative measures or increased supervision to ensure the safety of other residents on the unit. The resident was noted to have potential to experience increased agitation and/or threatens violence, refuses care, and refuses medications at times of increased agitation. This resulted in Resident #100 being physically aggressive with numerous other residents because of not having proper interventions and adequate supervision in place. Review of facility SRIs, medical records, and staff interviews regarding Resident #100 revealed the resident had five resident-to-resident altercations with five different residents between 04/24/24 and 05/06/24 in the MCU: On 04/24/24, Resident #100 was observed by facility staff attempting to strike Resident #97 in the face. Staff was unsure if Resident #100 struck Resident #97 ' s face with his hand, but Resident #100 was observed throwing juice in Resident #97 ' s face. On or about 04/25/24, Resident #100 was observed by facility staff using his forearm in a backwards, reflexive type motion and pushed Resident #98 in the abdomen. Interviews conducted on 05/06/24 with a family member of Resident #98 revealed she was told the resident was punched in the stomach by Resident #100. Interviews conducted on 05/07/24 with State tested Nursing Assistant (STNA) #252 and STNA #262 revealed both witnessed the event in the MCU dining room and reported Resident #100 punched Resident #98 in the stomach. On 04/28/24, Resident #100 was observed by facility staff yelling, cursing, and making verbal threats of harm and attempted to physically lunge towards Resident #80. LPN #406 intervened and as a result was physically struck by Resident #100. On 05/03/24, Resident #100 was involved in a verbal and physical altercation in the dining room with Resident #83. Resident #83 had stated Resident #100 hit him, and following the event was observed with bruising and a skin tear to his left arm. On 05/06/24, Resident #100 was observed by facility staff to grasp a handful of Resident #101 ' s hair and forcefully lift her up off the seat of a chair. Resident #100 then dropped the resident back down before staff responded to separate the two residents. 3. Review of the facility ' s plan of correction for the survey dated 01/08/24 revealed the facility implemented an ongoing audit of residents involved in resident-to-resident altercations without provocation, to ensure interventions were in place for the involved residents. The audit tool noted the need for monitoring to ensure staff are implementing the interventions to prevent the same actions, situations, and/or practices from occurring in the future. This audit tool was to be completed by the DON or designee. Resident #100 was not listed on the audit tool upon initiation of the audit on 01/02/24 through the most recent entry on the log dated 04/29/24. For the week of 04/22/24 to 04/29/24, RDCO #250 recorded there had been no resident-to-resident altercations. During an interview on 05/08/24 at 7:56 A.M., Corporate Nurse #330 verified the resident-to-resident altercation audit was incorrect, as there were three resident-to-resident interactions, all involving Resident #100 during that time frame. Corporate Nurse #330 verified Resident #100 ' s altercations should have been noted on the audit and that the audit tool had not yet been completed for the week of 04/29/24 to 05/06/24. Review of the facility ' s plan of correction to the survey dated 03/04/24 revealed RDCO #250 provided education to the DON, the Administrator, Medical Director (MD) #750, and the former Nurse Practitioner (NP) #475 on 02/28/24. An initial audit was completed of the last physician visit for all residents by the DON or designee by 03/20/24. The facility alleged compliance by 03/26/24. Review of the running list of residents with their most recent physician visit dates revealed approximately 90 residents with no evidence of a current physician visit on the audit log. Review of a statement dated 04/25/24 authored by Corporate Nurse #330 stated she spoke with MD #750 and educated him on the status of resident physician visits and established a plan for compliance. The statement stated MD #750 will see all residents who have not had a visit documented in the electronic medical record on record. MD #750 was provided an excel spreadsheet with the last physician visit documented and will see residents in reverse chronological order from the oldest date last seen to current to establish compliance. The statement indicated MD #750 had seen several individuals but had not documented the visit in a physician ' s progress note but will try to get the notes in the proper format. During an interview on 05/07/24 at 8:13 A.M., Licensed Practical Nurse (LPN) #325 stated she rarely sees MD #750 at the facility. The facility previously had a full-time Nurse Practitioner, but she was removed from the building two months ago. When MD #750 is at the facility, the nurses are not told he is here, rather if something medically is needed for a patient, the facility nursing staff must use the after-hours telehealth provider who are unfamiliar with the residents. During an observation on 05/07/24 at 10:20 A.M., the DON was performing rounds with visiting Physician #800. The DON stated Physician #800 was the assistant Medical Director for the corporation and had been called in to get physician visits current. During an interview on 05/08/24 at 7:56 A.M., Corporate Nurse #330 stated she had previously had a discussion with MD #750 and documented the conversation. MD #750 had submitted his resignation, citing he had not been aware of the time commitment required, but stated he would stay on until a new Medical Director was found. Corporate Nurse #330 reviewed the facility audit tool and verified the significant number of residents who remained out of compliance for physician visits. Review of the Medical Director Agreement form between the facility and MD #750, dated 12/11/23, revealed the agreement contained the Medical Director ' s duties and responsibilities which included: developing policies and procedures in concert with the facility, the facility ' s administration, and the medical staff to assure quality patient care, active treatment, appropriate level of professional and technical staff and personnel and will review professional standards of practice within the facility. Additionally, duties included to provide medical supervision for treatment modalities within the facility, ensuring compliance with the medical staff bylaws of the facility, providing the facility with timely information and reports, and providing all other services required to ensure the facility is run in an efficient, prudent manner to provide the facility ' s patients with the best possible care. 4. Review of the facility ' s plan of correction for the survey dated 04/11/24 revealed the facility did an audit of all residents ' Medication Administration Records (MAR) to observe for potential issues related to documentation of medications, with no issues or concerns found. Facility nursing staff were re-educated on medication administration and the documentation of medication administration. Review of a facility audit, completed between 04/23/24 and 05/01/24, revealed the DON audited all residents ' MAR to ensure all medications were administered as ordered. Resident #91 was included in this audit. Review of Resident #91 ' s physician ' s orders revealed an order dated 03/25/24 for dextromethorphan-quinidine (Neudexta, a central nervous system agent used to treat pseudobulbar affect) 20-10 milligram (mg) one capsule by mouth twice daily. Review of Resident #91 ' s April 2024 and May 2024 MAR records revealed the resident missed a total of 30 doses of her ordered Neudexta between 04/18/24 and 05/10/24. Review of Resident #91 ' s interdisciplinary progress notes, dated 04/01/24 to 05/10/24, revealed frequent entries noting the resident ' s Neudexta medication was on order, still not available, or there was none on hand. A note dated 05/10/24 at 12:55 P.M. revealed a conversation with a pharmacy representative indicating that Resident #91 ' s ordered Neudexta would be delivered that night. The note indicated the resident ' s physician was notified and provided an order to hold the medication. During an interview on 05/13/24 at 5:24 P.M., the DON stated there had been an issue with getting Resident #91 ' s Neudexta medication covered through insurance, as it required a prior authorization prior to the pharmacy being able to dispense and deliver the medication. The DON verified Resident #91 ' s missing doses and confirmed there was no evidence of the provider being aware of the missing doses until she contacted the provider on 05/10/24. The DON stated the process had been started to obtain the prior authorization, but there was an assumption amongst the nurses that someone else had ordered the medication and notified the provider. During an interview on 05/15/24 at 3:10 P.M., RDCO #250 verified the DON audited each resident ' s MAR records. RDCO #250 verified the facility should have identified Resident #91 ' s missed Nuedexta doses during that audit. RDCO #250 confirmed the previous audit performed was ineffective. Review of the Executive Director ' s (Administrator) job description, dated 05/28/18, revealed the position of Executive Director provides leadership to all staff to assure that care standards are met, and the highest degree of quality resident care is provided at all times. The Executive Director has the authority, responsibility, and accountability for the overall operation and financial success of the center. Job duties included to efficiently manage facility resources and operations to ensure that the needed resources will be available to provide quality care and a safe, homelike environment for all residents, maintain and work within established policies, procedures, objectives, and quality improvement programs, and to provide leadership to the staff. Review of the Director of Nursing job description, dated May 2022, revealed the DON position provides leadership to the nursing staff to assure that care standards are met and the highest degree of quality resident care is provided at all times. Job duties included to assist in developing, implementing, and coordinating department policies and procedures, resident care plans, and nursing procedure manuals, executing resident care policies, assuming authority, responsibility, and accountability of directing the nursing service department, and making daily rounds to assure that department personnel are performing required duties and to assure that appropriate resident care is being rendered. Additional job duties listed included supervising and maintain resident documentation, records, and charts to ensure an accurate, up to date record of the resident ' s medical records. This included reviewing care plans as needed for any changes, using monitoring tools consistently and correctly, and recording all resident information as required.

Based on observation, record review, job description review, staff interviews and policy review, the facility failed ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by effectively implementing their plan of correction. This resulted in Immediate Jeopardy when on-going non-compliance was identified during an on-site complaint and post-survey revisit, with previous deficiencies centering around appropriate supervision to prevent and address resident-to-resident physical and verbal abuse by Resident #100 to five residents (97, #98, #80, #83, and #101) who resided on the Memory Care Unit (MCU). Additionally, the facility failed to ensure Resident #100, and Resident #91 were free from significant medication errors, failed to accurately maintain resident records to accurately record resident-to-resident altercations, and failed to correct the frequency of physician visits. The facility failed to effectively implement their previous plans of corrections to achieve compliance with the regulations which had the potential to affect all residents residing in the facility. The facility census was 107. On 05/10/24 at 9:43 A.M., the Administrator, Director of Nursing (DON), Regional Director of Clinical Operations (RDCO) #250 and Divisional Director of Clinical Operations (DDCO) #310 were notified that Immediate Jeopardy began on 02/12/24 when Resident #100, who was known to have an extensive history of aggressive behavior, had his antipsychotic medication erroneously omitted by a facility nurse while transcribing a consultant provider ' s new medication orders. On 04/24/24, Resident #100 began having increased aggressive behaviors towards residents and staff, with numerous incidents being reported by staff and few documented in the residents ' medical records. These behaviors included punching other residents, pulling hair in an upward motion lifting a resident up out of the chair, forceful grabbing of arms resulting in skin issues, and verbal threats of physical harm. The facility failed to implement their approved plan of corrections regarding enhanced supervision to prevent resident-to-resident altercations, failed to appropriately audit medical records for resident-to-resident altercations and significant medication errors, and failed to achieve compliance with the frequency of physician visits. The Immediate Jeopardy was removed on 05/16/24 when the facility implemented the following corrective actions: • On 05/07/24, laboratory testing and urinalysis was obtained for Resident #100 to rule out medical reasoning for increased agitation. • On 05/07/24, all self-reported incidents were completed and submitted to the Ohio Department of Health (ODH) by the Administrator. • On 05/07/24, an investigation of all incidents was conducted and completed by RDCO #250. • At the time of the incidents, Residents #97, #98, #80, #83, and #101 were interviewed and assessed by SSD #300 with no apparent adverse effect. • On 05/07/24, notification to the physician and families of the involved residents were completed by the DON. • On 05/07/24, the police department was notified of the resident-to-resident incidents by the Administrator. • On 05/07/24, Corporate Nurse #330 obtained staff statements regarding the resident-to-resident incidents, and anyone involved in the state reportable incidents. • On 05/08/24, Resident #100 was sent for an inpatient psychiatric evaluation. • On 05/08/24 (no time provided), Resident #100 ' s plan of care was updated with all interventions provided by RDCO #250. • On 05/10/24, a timeline of events was completed by the DON or designee. • On 05/10/24, an initial audit of all psychiatric progress notes received since 02/12/24, and all other physician notes since 04/10/24, was completed by Corporate Nurse #330. • On 05/10/24, an initial audit of all progress notes for the last 30 days for all residents was completed to identify any potential incidents that should be reported to ODH as a self-identified, state reportable, with proper investigation and notifications made and documented. This was completed by Corporate Nurse #330. • On 05/10/24, an audit of all resident-to-resident incidents was conducted to identify trends with residents and address increased behaviors, or risk for increased behaviors, and completion of interventions. This was completed by Corporate Nurse #330. • On 05/10/24, any residents found to be with trends of aggression or increased agitation will be referred for inpatient psychiatric evaluation and treatment by the Administrator. • On 05/10/24, education was provided to facility leadership on the abuse policy, risk management, investigation, supervision, behavior management policy, implementation of interventions, order transcription, and the risk escalation process. This education was completed by DDCO #310 and RDCO #250. • On 05/10/24, education was provided to all staff on the abuse policy, risk management and investigation, supervision, behavior management policy, order transcription. This was completed by RDCO #250. • On 05/10/24, education was provided to Psychiatric Nurse Practitioner #604, who will write all orders as telephone orders and communicate to nursing leadership in person prior to leaving the facility upon completion of rounds. This training was provided by RDCO #250. • On 05/10/24, an audit was conducted to ensure all residents had been evaluated by a physician. This was completed by Corporate Nurse #330. • On 05/10/24, Education was provided to the Administrator and DON on ensuring plans of correction are completed as written to achieve ongoing compliance. This was completed by DDCO #310. • An ongoing audit will be conducted weekly for psychiatric and physician progress notes received, observing for any noted orders that were not properly transcribed. This will be completed weekly by RDCO #250 beginning on 05/11/24. • An ongoing audit of resident ' s progress notes will be completed to identify any potential incidents that should be reported to ODH as a state reportable, with proper investigations and notifications made and documented will be completed by RDCO #250 or designee three times weekly for four weeks starting on 05/11/24. • An ongoing audit of all resident-to-resident interactions will be conducted to identify trends with residents, and address increased behaviors or risk, to assist in accurately maintaining the resident ' s record or record instances of resident-to-resident altercations. This will be completed by RDCO #250 or designee weekly for four weeks starting on 05/11/24 with oversight from [NAME] President of Risk Management #680. • Beginning 05/11/24, staff interviews will be conducted by RDCO #250 five days per week, one staff per unit, and three staff members per day on random shifts, to determine if any resident behaviors were identified. • An ongoing audit of the daily clinical meeting and its operations, with attention to the implementation, effectiveness of interventions, and to ensure all incidents are recorded accurately in the resident record will be conducted by RDCO #250 and Regional Director of Operations (RDO) #530 five times weekly for four weeks beginning on 05/13/24. • An ongoing audit of the frequency of physician visits, to ensure regulatory compliance, will be completed by RDCO #250 weekly. • The results of the audit observations will be reported, reviewed, and trended for compliance through the facility Quality Assurance Committee for a minimum of six months, then randomly thereafter for further recommendations. • Ad hoc Quality Assurance and Performance Improvement meetings were conducted on 05/13/24, 05/14/24, and 05/15/24 by the facility ' s interdisciplinary team. • On 05/16/24, behavior training specific to dementia and memory care, provided by an outside licensed behavioral specialist, was completed for all staff who work on the memory care unit. Although the Immediate Jeopardy was removed on 05/16/24, the deficiency remained at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: During an interview on 05/08/24 at 9:01 A.M., the Administrator stated he had only been employed at the facility for approximately one month. The Administrator recognized the facility was out of compliance and his highest priority was getting the facility back into compliance. The Administrator stated the concerns were getting the facility back into compliance and achieving staff stability. The Administrator was unable to state how the facility was achieving compliance with previously cited deficiencies. He stated he would have to check the survey binders to familiarize himself to what areas the facility was out of compliance. During the on-site complaint and post-survey revisit, continued non-compliance was identified by the survey team. The facility ' s failure to effectively audit, monitor, and correct previously cited deficiencies resulted in the potential for serious harm or injury to all residents. 1. Review of the Facility Assessment, revised on 04/04/24 and reviewed with the Quality Assurance and Performance Improvement (QAPI) committee on 04/25/24, revealed the facility provided mental health and behavior management. Specific care provided to this population of residents included managing the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identifying, and implementing interventions to help support individuals with issues such as dealing with anxiety, cognitive impairment, residents with depression, trauma/post-traumatic stress disorder (PTSD), other psychiatric diagnoses, and intellectual or developmental disabilities. The facility identified it was able to provide medication administration by various routes. The section of the facility assessment which discussed working with medical providers in describing the facility ' s plan to recruit and retain enough medical practitioners and how the facility collaborates with the providers to meet the medical needs of the population was blank. 2. The facility failed to ensure Resident #100, who had a history of physical aggression towards other residents and staff, had appropriate supervision, monitoring, and services rendered to manage his behaviors, supervise his actions, and protect other residents of the facility. Resident #100 was assessed to have severely impaired cognition, an extensive history of aggressive behaviors, and resided on a secured MCU. On 02/12/24, Resident #100 was seen by the psychiatrist for a medication adjustment/follow-up and the resident was ordered Seroquel to be stopped and Risperdal started. The Seroquel was discontinued; however, the Risperdal was never started. Review of Resident #100's Medication Administration Record (MAR) indicated he received no antipsychotic medication from 02/12/24 until Resident #100 was seen by a visiting physician on 05/07/24 due to multiple instances of aggression and behaviors and his Seroquel was restarted. As a result, Resident #100 was off his antipsychotic medications for 85 days. In this time frame, Resident #100 began having increased physical behaviors as well as verbal threats of physical harm towards other residents in the Memory Care Unit (MCU). On or about 04/24/24, Resident #100 started having increased aggressive behaviors towards the residents and staff. The resident has numerous incidences of aggressive behaviors involving other residents, with few being documented in the residents ' medical record. The resident's behaviors included punching other residents in the stomach, pulling residents hair and pulling them upwards out of a chair, forcefully grabbing others ' arms causing skin issues and verbally threatening residents with harm. Resident #100's care plan has not been revised to reflect his behaviors and/or any interventions to monitor and address his pattern of behavior. There is limited documentation about his behaviors, despite the staff interviews reporting the behaviors, and no evidence of preventative measures or increased supervision to ensure the safety of other residents on the unit. The resident was noted to have potential to experience increased agitation and/or threatens violence, refuses care, and refuses medications at times of increased agitation. This resulted in Resident #100 being physically aggressive with numerous other residents because of not having proper interventions and adequate supervision in place. Review of facility SRIs, medical records, and staff interviews regarding Resident #100 revealed the resident had five resident-to-resident altercations with five different residents between 04/24/24 and 05/06/24 in the MCU: On 04/24/24, Resident #100 was observed by facility staff attempting to strike Resident #97 in the face. Staff was unsure if Resident #100 struck Resident #97 ' s face with his hand, but Resident #100 was observed throwing juice in Resident #97 ' s face. On or about 04/25/24, Resident #100 was observed by facility staff using his forearm in a backwards, reflexive type motion and pushed Resident #98 in the abdomen. Interviews conducted on 05/06/24 with a family member of Resident #98 revealed she was told the resident was punched in the stomach by Resident #100. Interviews conducted on 05/07/24 with State Tested Nursing Assistant (STNA) #252 and STNA #262 revealed both witnessed the event in the MCU dining room and reported Resident #100 punched Resident #98 in the stomach. On 04/28/24, Resident #100 was observed by facility staff yelling, cursing, and making verbal threats of harm and attempted to physically lunge towards Resident #80. LPN #406 intervened and as a result was physically struck by Resident #100. On 05/03/24, Resident #100 was involved in a verbal and physical altercation in the dining room with Resident #83. Resident #83 had stated Resident #100 hit him, and following the event was observed with bruising and a skin tear to his left arm. On 05/06/24, Resident #100 was observed by facility staff to grasp a handful of Resident #101 ' s hair and forcefully lift her up off the seat of a chair. Resident #100 then dropped the resident back down before staff responded to separate the two residents. 3. Review of the facility ' s plan of correction for the survey dated 01/08/24 revealed the facility implemented an ongoing audit of residents involved in resident-to-resident altercations without provocation, to ensure interventions were in place for the involved residents. The audit tool noted the need for monitoring to ensure staff are implementing the interventions to prevent the same actions, situations, and/or practices from occurring in the future. This audit tool was to be completed by the DON or designee. Resident #100 was not listed on the audit tool upon initiation of the audit on 01/02/24 through the most recent entry on the log dated 04/29/24. For the week of 04/22/24 to 04/29/24, RDCO #250 recorded there had been no resident-to-resident altercations. During an interview on 05/08/24 at 7:56 A.M., Corporate Nurse #330 verified the resident-to-resident altercation audit was incorrect, as there were three resident-to-resident interactions, all involving Resident #100 during that time frame. Corporate Nurse #330 verified Resident #100 ' s altercations should have been noted on the audit and that the audit tool had not yet been completed for the week of 04/29/24 to 05/06/24. Review of the facility ' s plan of correction to the survey dated 03/04/24 revealed RDCO #250 provided education to the DON, the Administrator, Medical Director (MD) #750, and the former Nurse Practitioner (NP) #475 on 02/28/24. An initial audit was completed of the last physician visit for all residents by the DON or designee by 03/20/24. The facility alleged compliance by 03/26/24. Review of the running list of residents with their most recent physician visit dates revealed approximately 90 residents with no evidence of a current physician visit on the audit log. Review of a statement dated 04/25/24 authored by Corporate Nurse #330 stated she spoke with MD #750 and educated him on the status of resident physician visits and established a plan for compliance. The statement stated MD #750 will see all residents who have not had a visit documented in the electronic medical record on record. MD #750 was provided an excel spreadsheet with the last physician visit documented and will see residents in reverse chronological order from the oldest date last seen to current to establish compliance. The statement indicated MD #750 had seen several individuals but had not documented the visit in a physician ' s progress note but will try to get the notes in the proper format. During an interview on 05/07/24 at 8:13 A.M., Licensed Practical Nurse (LPN) #325 stated she rarely sees MD #750 at the facility. The facility previously had a full-time Nurse Practitioner, but she was removed from the building two months ago. When MD #750 is at the facility, the nurses are not told he is here, rather if something medically is needed for a patient, the facility nursing staff must use the after-hours telehealth provider who are unfamiliar with the residents. During an observation on 05/07/24 at 10:20 A.M., the DON was performing rounds with visiting Physician #800. The DON stated Physician #800 was the assistant Medical Director for the corporation and had been called in to get physician visits current. During an interview on 05/08/24 at 7:56 A.M., Corporate Nurse #330 stated she had previously had a discussion with MD #750 and documented the conversation. MD #750 had submitted his resignation, citing he had not been aware of the time commitment required, but stated he would stay on until a new Medical Director was found. Corporate Nurse #330 reviewed the facility audit tool and verified the significant number of residents who remained out of compliance for physician visits. Review of the Medical Director Agreement form between the facility and MD #750, dated 12/11/23, revealed the agreement contained the Medical Director ' s duties and responsibilities which included: developing policies and procedures in concert with the facility, the facility ' s administration, and the medical staff to assure quality patient care, active treatment, appropriate level of professional and technical staff and personnel and will review professional standards of practice within the facility. Additionally, duties included to provide medical supervision for treatment modalities within the facility, ensuring compliance with the medical staff bylaws of the facility, providing the facility with timely information and reports, and providing all other services required to ensure the facility is run in an efficient, prudent manner to provide the facility ' s patients with the best possible care. 4. Review of the facility ' s plan of correction for the survey dated 04/11/24 revealed the facility did an audit of all residents ' Medication Administration Records (MAR) to observe for potential issues related to documentation of medications, with no issues or concerns found. Facility nursing staff were re-educated on medication administration and the documentation of medication administration. Review of a facility audit, completed between 04/23/24 and 05/01/24, revealed the DON audited all residents ' MAR to ensure all medications were administered as ordered. Resident #91 was included in this audit. Review of Resident #91 ' s physician ' s orders revealed an order dated 03/25/24 for dextromethorphan-quinidine (Neudexta, a central nervous system agent used to treat pseudobulbar affect) 20-10 milligram (mg) one capsule by mouth twice daily. Review of Resident #91 ' s April 2024 and May 2024 MAR records revealed the resident missed a total of 30 doses of her ordered Neudexta between 04/18/24 and 05/10/24. Review of Resident #91 ' s interdisciplinary progress notes, dated 04/01/24 to 05/10/24, revealed frequent entries noting the resident ' s Neudexta medication was on order, still not available, or there was none on hand. A note dated 05/10/24 at 12:55 P.M. revealed a conversation with a pharmacy representative indicating that Resident #91 ' s ordered Neudexta would be delivered that night. The note indicated the resident ' s physician was notified and provided an order to hold the medication. During an interview on 05/13/24 at 5:24 P.M., the DON stated there had been an issue with getting Resident #91 ' s Neudexta medication covered through insurance, as it required a prior authorization prior to the pharmacy being able to dispense and deliver the medication. The DON verified Resident #91 ' s missing doses and confirmed there was no evidence of the provider being aware of the missing doses until she contacted the provider on 05/10/24. The DON stated the process had been started to obtain the prior authorization, but there was an assumption amongst the nurses that someone else had ordered the medication and notified the provider. During an interview on 05/15/24 at 3:10 P.M., RDCO #250 verified the DON audited each resident ' s MAR records. RDCO #250 verified the facility should have identified Resident #91 ' s missed Nuedexta doses during that audit. RDCO #250 confirmed the previous audit performed was ineffective. Review of the Executive Director ' s (Administrator) job description, dated 05/28/18, revealed the position of Executive Director provides leadership to all staff to assure that care standards are met, and the highest degree of quality resident care is provided at all times. The Executive Director has the authority, responsibility, and accountability for the overall operation and financial success of the center. Job duties included to efficiently manage facility resources and operations to ensure that the needed resources will be available to provide quality care and a safe, homelike environment for all residents, maintain and work within established policies, procedures, objectives, and quality improvement programs, and to provide leadership to the staff. Review of the Director of Nursing job description, dated May 2022, revealed the DON position provides leadership to the nursing staff to assure that care standards are met and the highest degree of quality resident care is provided at all times. Job duties included to assist in developing, implementing, and coordinating department policies and procedures, resident care plans, and nursing procedure manuals, executing resident care policies, assuming authority, responsibility, and accountability of directing the nursing service department, and making daily rounds to assure that department personnel are performing required duties and to assure that appropriate resident care is being rendered. Additional job duties listed included supervising and maintain resident documentation, records, and charts to ensure an accurate, up to date record of the resident ' s medical records. This included reviewing care plans as needed for any changes, using monitoring tools consistently and correctly, and recording all resident information as required.

Based on observation, review of open and closed medical records, hospital record review, review of self-reported incidents (SRI), resident and staff interviews, and review of facility policies, the facility failed to ensure residents were adequately supervised and interventions were put in place to prevent a resident-to-resident altercation. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death when, on 10/19/23, one resident (#06) was involved in an altercation with another resident (#100) which resulted in Resident #06 being pushed to the floor by Resident #100 who had a documented history of aggression and past incidents of physical altercations with other residents. The facility's failure to have appropriate supervision and interventions in place for Resident #100 resulted in Resident #06, who was previously able to self-ambulate, sustaining sacrum and pubic fractures because of the fall, and have rendered the resident unable to freely walk and has significantly affected the resident's activities of daily living. This affected two (#06 and #100) of three (#99) residents reviewed for supervision. Additionally, the facility failed to ensure resident's smoking materials were safely secured per facility policy which placed the resident at risk for the potential for more than minimal harm that was not Immediate Jeopardy. This affected one (#79) of three residents reviewed for smoking. The facility census was 94. On 12/28/23 at 2:17 P.M., the Administrator, Director of Nursing (DON), Therapy Director #700, Licensed Practical Nurse (LPN) #800, Regional Director of Clinical Operations (RDCO) #150, and Regional Director of Operations (RDO) #160 were notified that Immediate Jeopardy began on 10/19/23 when Resident #06 returned from an outing with family and the resident engaged Resident #100 on the secured unit. Resident #06 and Resident #100, both assessed with impaired cognition, were walking in the hallway when Resident #06, formerly a nurse with a history of assisting other residents, approached Resident #100, and attempted to link arms. Per Resident #06's family interview, Resident #100 lifted Resident #06 off the ground and threw the resident to the ground. Resident #06 had complaints of pain and was sent to the hospital for evaluation on 10/19/23 with no concerns noted. Resident #06 returned to the facility and had additional diagnostic imaging completed on 10/20/23 with no issues noted. Resident #06 continued to complain of pain and discomfort so, on 10/25/23 Resident #06 was taken to the hospital and was diagnosed with sacral and pubic fractures which have prevented the resident from being able to walk. The Immediate Jeopardy was removed on 10/20/23 when the facility implemented the following corrective actions: On 10/19/23 at 7:40 P.M., Resident #06 and Resident #100 were immediately separated following the incident. On 10/19/23 at 7:45 P.M., Resident #100 was assessed, the physician was notified, and the resident was placed on increased supervision to ensure the safety of all residents. On 10/19/23 at 8:00 P.M., Resident #06 was assessed and sent to the hospital for evaluation with no adverse findings noted. Resident #06 returned to the facility on [DATE] at 11:00 P.M. On 10/19/23 at 8:40 P.M., staff statements were obtained related to the incident. On 10/19/23 at 10:09 P.M., the police were notified of the incident. On 10/19/23, all residents residing on the secured unit were assessed with skin assessments completed. There were no negative findings noted. On 10/20/23 at 9:20 A.M., Resident #06 had diagnostic images completed by an in-house provider out of an abundance of caution with no negative findings noted. On 10/20/23 at 11:43 A.M., Social Service Designee (SSD) #850 assessed Resident #100 who had no recollection of the events of 10/19/23 and no psychosocial changes. On 10/20/23 at 1:43 P.M., SSD #850 spoke with Resident #06 and the resident's niece who voiced concerns regarding Resident #100. On 10/20/23 at 3:48 P.M., a room change was completed for Resident #06 who was moved off the secured unit away from Resident #100 per request. On 10/20/23 at 6:00 P.M., Resident #100 was placed on one-to-one supervision. On 10/20/23, Certified Nurse Practitioner (CNP) #850 was updated on the situation and gave orders for an in-patient stay, medication review, and psychiatric review for Resident #100. On 10/20/23, SSD #850 sent two referrals for Resident #100 to local psychiatric facilities and was denied by both. Resident #100 was to remain on one-to-one observation until a psychiatric evaluation was completed. On 10/20/23, education was provided to all staff members regarding the facility's abuse policy and procedures by the DON. All staff were educated on 10/20/23. On 10/24/23 at 2:00 P.M., Psychiatric Nurse Practitioner (PNP) #860 performed an assessment of Resident #100, including a medication review, with no concerns and no incidents of increased behavior. Resident #100's care plan was updated, and the resident was removed from one-to-one observation. Resident #100 remained free of incidents involving other residents. On 10/25/23, ongoing audits to assess three residents for skin abnormalities weekly for six weeks to be completed by the DON/designee was initiated. The results of the audit observations were to be reviewed and trended for compliance through the facility's Quality Assurance Committee for a minimum of six months. No further skin abnormalities were identified. On 12/28/23 at 10:35 P.M., nursing management was re-educated on resident supervision and the guidelines related to it by the DON. On 12/28/23, all staff were re-educated by the DON on supervision and the guidelines related to it. On 12/29/23 at 3:00 P.M., an initial audit of residents was completed by reassessing residents for the last 90 days who may have a history of resident-to-resident altercations, without provocation, and have interventions in place specific to those residents and monitor to ensure staff are implementing those interventions to prevent the same actions, situations, and/or practices from occurring in the future. This was completed by RDCO #150 with no negative findings. Beginning 12/29/23, ongoing audits will be performed to ensure supervision is adequate on locked dementia unit daily for six weeks completed by the DON/or designee. Beginning the week of 01/01/24, the Administrator will hold specialized Quality Assurance and Performance Improvement (QAPI) meetings weekly for six weeks for the duration of the ongoing audits to review results and review effectiveness of education. This will continue weekly for six weeks. Beginning 01/02/24, ongoing audits of staff knowledge regarding the abuse policy and procedure, and supervision and guidelines will be conducted three times per week with three different staff members by the DON/designee. Beginning 01/02/24, ongoing audits of residents to be completed by assessing residents moving forward involved in any resident-to-resident altercations, without provocation, and have interventions in place specific to those residents and monitor to ensure staff are implementing those interventions to prevent the same actions, situations, and/or practices from occurring in the future to be completed by DON/designee. On 01/02/24, the Administrator/designee held a QAPI meeting to review the results of all initial audits to be provided by the DON. Interviews on 12/29/23 and 01/02/24 between 9:00 A.M. and 3:00 P.M. with State tested Nurse Aide (STNA) #300, STNA #310, STNA #320, STNA #330, LPN #140, LPN #400, and Registered Nurse (RN) #120 all verified they were educated regarding the facility abuse policy and reporting procedure as well as guidelines for resident supervision. All staff members interviewed were knowledgeable regarding the content of the education. Although the Immediate Jeopardy was removed on 10/20/23, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of Resident #06's medical record revealed an admitted [DATE]. Diagnoses included cerebral infarction, delirium, Alzheimer's disease, chronic obstructive pulmonary disease, and a transient alteration of awareness. Review of Resident #06's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate decline of cognitive function. The resident was assessed to require supervision with bed mobility, transfers, dressing, and personal hygiene, and required an extensive one person assist with toilet use. A walker, cane, or wheelchair were utilized as she was fully ambulatory. Review of the medical record for Resident #100 revealed an admitted [DATE]. The diagnoses included cerebral vascular accident, psychoactive substance abuse, dysphagia, and schizoaffective disorder. Review of Resident #100's quarterly MDS assessment dated [DATE] revealed the resident had a severe cognitive decline and the only behavior charted was rejecting care. Review of Resident #100's most recent care plan revealed he had a behavior problem at times due to impulsive behavior related to a stroke. The resident was known to lay on the floor at times, and wander into other resident's rooms and take their belongings. The resident experienced increased agitation, threatened violence, refused care, and refused medications when experiencing increased agitation. The care plan updated on 10/24/23 revealed the resident received a medication review with psychiatry. Review of a physician's application for emergency admitted d 08/29/20 revealed Resident #100 was admitted to a psychiatric hospital due to bizarre and aggressive behavior toward staff and other residents. The resident was yelling and threatening and involved in a physical altercation with another female resident that resulted in a fall and mild head trauma. Review of a self-reported incident (SRI) dated 08/26/21 revealed a female resident (#150) was walking down the hall of the memory care unit knocking on resident's doors. When Resident #150 came to Resident #100's door he pushed the female resident causing her to fall and hit her head. Resident #150 was transferred to the hospital for evaluation and found no injuries. Review of a physician's application for emergency admitted d 08/27/21 revealed Resident #100 had an ongoing psychiatric disorder and was at risk of harm to others and in need of inpatient psychiatric care. The resident was noted to be at risk of harming others and had assaulted a co-resident without any reason. Resident #100 had also tried to elope and required 24-hour supervision due to his behaviors. Review of an SRI dated 08/18/22 revealed Resident #100 was sitting at a table eating dinner when a female resident (#105) approached him and attempted to take his meal tray. Resident #100 stood up, grabbed her arm, and pushed her. There were no injuries. Review of an SRI dated 11/18/22 revealed Resident #100 and a female resident (#103) were walking through the memory care unit when Resident #100 became agitated. Resident #100 began yelling at Resident #103 to leave him alone, then pushed her which resulted in Resident #103 falling to the floor. Resident #103 received a bruise to the elbow. Review of Resident #100's progress note dated 02/22/23 revealed the resident was having increased behaviors and elevated vital signs. The resident was verbally and physically aggressive, and a physician order was received to send Resident #100 to a local psychiatric hospital. Review of an interdisciplinary team note dated 04/03/23 revealed an unnamed staff member observed Resident #100 kick another resident in the ankle with no injuries noted. Review of an SRI dated 10/19/23 revealed Resident #100 was ambulating independently in the memory care unit hallway when Resident #06 approached him and attempted to link arms. Resident #06 was formerly a nurse and had a history of assisting other residents in various ways. Per staff report, Resident #100 then moved away from Resident #06, pulling his arm away from her arm and grasp causing Resident #06 to lose balance and fall to the floor. Resident #06 had complaints of pain in her hip and was sent to a local hospital for evaluation and treatment. The niece of Resident #06 stated she witnessed the incident and Resident #100 pushed Resident #06 to the ground. Notifications were made to the Director of Nursing (DON) and Executive Director (ED) and an investigation was initiated. Statements were collected, and per staff report, Resident #100 was without any increased agitation, or recollection of events when interviewed. Immediately following the incident, Resident #100 was assessed, and the physician was notified and placed with increased supervision as an immediate intervention to ensure safety of all residents. Resident #06 returned to the facility on the same date from the emergency room (ER) without any injuries. On 10/20/23 the SSD #850 assessed Resident #100 who had no recollection of the event, and no adverse psychosocial effect. On that date the ED and SSD #850 interviewed Resident #06 and her niece, who were concerned regarding Resident #100. Resident #100 was known to wander in and out of rooms at times so a room change was requested. The facility nurse practitioner was updated on the investigation and orders were received to send a referral for inpatient medication and psychiatric review for Resident #100. Referrals were sent to two local facilities, and both were denied per SSD #850. In an abundance of caution, orders were received for one-to-one monitoring for Resident #100 until a psychiatric evaluation could be completed. On 10/24/23 a psychiatric consultation occurred, and Resident #100 was removed from one-to-one observation. A medication review was completed. Resident #100 remained without increased agitation or anxiety at that time and without any psychosocial impact. Resident #06 was assessed for further psychosocial adversities from baseline daily for 72 hours post-incident after a room change, and no further adverse effects were observed. Further review of the SRI dated 10/19/23 revealed after completing a full comprehensive investigation into this incident, Resident #100 was placed on increased supervision, a psychiatric evaluation was completed, and psychiatric referrals were made to two locations and were denied. A medication review was also completed for Resident #100 with no changes noted, the care plan was updated, and like residents had skin assessments completed by the nurse with no concerns. Review of Resident #06's ER report dated 10/19/23 revealed she was examined due to a fall. A computed tomography (CT) scan of her cervical spine, head, and brain revealed no concerns. An x-radiation (x-ray) of the left elbow and left femur also were negative. Diagnoses included a fall with a contusion of the left lower extremity and contusion of the left elbow. Review of Resident #06's social service note dated 10/20/23 revealed she did not feel safe residing near Resident #100. SSD #850 requested staff to keep Resident #100 away from Resident #06 and allow her to keep her door closed. Resident #06 was moved to a room outside of the memory care unit. Review of Resident #06's nursing notes dated 10/20/23 revealed due to continued pain, the physician ordered further testing for the resident. Review of Resident #06's x-ray results dated 10/20/23 revealed x-rays of the left shoulder, left arm, left leg, and left hip were negative for fractures. Review of Resident #06's medication administration record (MAR) dated 10/21/23 through 10/25/23 revealed the pain medication Tramadol 25 milligrams (mg) was prescribed for the resident due to pain. The medication was to be administered every six hours as needed for moderate to severe pain for five days. Documentation revealed on 10/21/23 the resident's pain level was rated a six on a ten-point scale with ten being the highest level of pain. On 10/23/23, Resident #06's pain was rated a seven, on 10/24/23 the resident's pain level was rated an eight, and on 10/25/23 the resident received three doses of pain medication for pain levels of 10, eight, and nine on a ten-point pain scale. Review of Resident #06's hospital notes dated 10/25/23 revealed the resident presented to the hospital for evaluation of left hip pain, and stated she sustained a fall last week and sought out care for this at a local hospital. Resident #06's niece stated the fall occurred in the nursing home due to her being pushed by another resident one week ago. Resident #06 denied any falls since that time. Resident #06 had continued pain in her lower back, left ribs, left hip, and the pain was worsening. The pain was present without walking or ambulation and when coughing and deep breathing. Review of a CT image of the left hip without contrast revealed fractures of the left sacrum (a bony structure located between the left and right hip bones forming the back of the pelvis) and left superior pubic ramus (pubic bone) and left inferior pubic ramus. These conditions have prevented the resident from walking since her fall on 10/19/23. Review of a CT image of the chest and abdomen revealed Resident #06 had a possible sternal fracture, however, this could be an artifact (a deviation of the visual integrity of an anatomic structure) of motion. Further documentation revealed Resident #06 had no tenderness over the sternum, so the physician believed the finding from the chest CT image to be an artifact for the possible sternal fracture. Resident #06 was in stable condition in the ER, although the resident was mildly hypoxic (low oxygen saturation) and was diagnosed with pneumonia of the right middle lobe. The resident was to be admitted to the hospitalist service for intravenous antibiotics for pneumonia as well as pain control and physical therapy for the fractures. Interview on 12/21/23 at 12:55 P.M. with the previous Administrator revealed Resident #100 did have issues in the past with aggression toward others, but he had not had any negative behaviors recently. The former Administrator stated Resident #06's family accused Resident #100 of pushing Resident #06 to the ground on 10/19/23, but due to a staff witness (STNA #330) having a statement of an accidental fall no ongoing precautions were put into place. The previous Administrator stated after the incident on 10/19/23 Resident #100 was placed on one-to-one observation and was seen by the facility psychiatric nurse practitioner who released him from close observation status. Observation on 12/27/23 at 9:10 A.M. and on 12/28/23 at 8:49 A.M. revealed Resident #100 was walking freely up and down the hallway in the memory care unit. The resident was walking alone. Staff were observed down the hallway caring for other residents. Interview with LPN #400 on 12/27/23 at 9:18 A.M. revealed Resident #100 did refuse care and would become verbally aggressive with staff. LPN #400 was aware of Resident #100's prior behaviors of aggression but denied any recent issues. There were no plans in place regarding Resident #100's aggression toward others. Interview with STNA #320 on 12/27/23 at 9:51 A.M. revealed Resident #100 walked freely about the memory care unit daily. STNA #320 denied seeing Resident #100 be aggressive toward other residents, but the resident would be aggressive toward staff and called staff inappropriate names. STNA #320 denied Resident #100 requiring any restrictions or plans regarding his previous behaviors. Interview with Resident #06's niece on 12/29/23 at 12:20 P.M. revealed she witnessed the incident on 10/19/23 between Resident #06 and Resident #100. Resident #06's niece stated she and Resident #06 returned to the facility from an outing. The niece and STNA #330 were in the hallway standing together when they witnessed Resident #100 shuffling down the hall. Resident #06's niece stated Resident #06 (a retired nurse and care giver) then informed Resident #100 that he should hold onto the handrail so he would not fall. Resident #100 grabbed Resident #06's shirt, lifted her off the ground, and threw her across the hallway. As Resident #06 fell , she hit her head on the handrail, and her buttocks bounced off the floor once and back down again. Resident #06's niece stated she screamed, and the nurse came running. Both Resident #06 and Resident #100 were assessed, and emergency medical services (EMS) was called for Resident #06. Resident #06's niece stated the resident was found to have no injuries with the testing that was done in the hospital, and five days after the fall the family felt Resident #06 was in too much pain, so with staff assistance the family transported Resident #06 to a different hospital. Resident #06's niece confirmed Resident #06 was then diagnosed with several sacral fractures, a breastbone fracture, and pneumonia due to not being able to ambulate or take deep breaths due to the pain and injuries. At the time of the interview Resident #06 continued to be non-ambulatory due to the injuries suffered in the fall on 10/19/23. Telephone interview with STNA #330 on 01/02/24 at 2:28 P.M. stated on 10/19/23, Resident #06 and her niece returned from an outing and the niece asked STNA #330 to get a sheet for the resident's bed. As STNA #330 and Resident #06's niece were walking down the hall, Resident #06 walked up to Resident #100, and she weaved her arm into his and was holding onto him. STNA #330 stated he then saw Resident #06 fall to the floor, and stated he did not see Resident #100 push Resident #06. STNA #330 stated he did witness Resident #100 push another resident previously for taking his comb which agitated Resident #100. Review of the undated facility policy titled, Unit Supervision, revealed it was the policy of the facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety is a primary concern for our residents, staff, and visitors. 2. Review of Resident #79's medical record revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction, chronic obstructive pulmonary disease, atrial fibrillation, contractures of the left wrist and right hand, and epilepsy. Review of Resident #79's MDS assessment dated [DATE] revealed the resident had an intact cognitive function. He had an upper body impairment on both sides. Review of Resident #79's most recent care plan revealed he utilized nicotine products. The resident was educated on the smoking policy. The care plan revealed he was independent and was in need of updating since his cerebral vascular accident and return from the hospital. Observation of Resident #79 on 12/21/23 at 8:59 A.M. revealed the resident was laying in his bed. On the floor to the left side of his bed was a lighter and also noted was a pack of cigarettes on top of his dresser which was situated at the foot of the bed. Interview with Resident #79 on 12/21/23 at approximately 9:00 A.M. revealed he was allowed to have his cigarettes and lighter on his person. Interview with STNA #300 on 12/21/23 at 9:01 A.M. verified that Resident #79 had a lighter and cigarettes in his room and that was not allowed per facility policy. Review of the undated facility policy titled, Resident Smoking Guidelines, revealed the facility staff will secure smoking material in a locked area when not in use by the resident/patient for both independent and supervised smokers. This deficiency represents non-compliance investigated under Complaint Number OH00149010.

Based on medical record review, observation, staff interview, review of the fall evaluation, and review of the staff schedules, the facility failed to provide the necessary supervision for a resident to prevent avoidable falls with injury. This resulted in Actual Harm when Resident #72 was left alone in a shower room, on the toilet, fell on the floor, and complained of hip pain. Subsequently, the resident was sent to the hospital and required surgical repair of the right hip. This affected one resident (#72) out of three residents reviewed for falls. The facility census was 95. Findings include: Review of the medical record revealed Resident #72 admitted to the facility on [DATE]. Diagnoses included dementia, mood disorder and chronic obstructive pulmonary disease (COPD) and resided on the facility secured dementia unit. Review of the quarterly minimum data (MDS) assessment dated [DATE] revealed Resident #72 had severe cognitive impairment, required extensive assistance of two staff for transferring, toilet use and walking due to not steady. Review of Resident #72's annual MDS dated [DATE] revealed under the care area assessment (CAA) documented Resident #72 was at risk for falls, needs assistance for transfers and was on psychotropic medication. Review of Resident #72's progress notes dated 12/13/22 at 4:31 P.M. revealed the resident was observed on the floor by the nurse. The notes identified Resident #72 had an unwitnessed fall they believed she tried to transfer herself from the wheelchair to recliner. The notes identified x-rays were completed and were negative for injury. Review of the progress notes dated 12/20/22 at 3:47 P.M. revealed Resident #72 was found laying on the floor in the room; the resident said she was trying to lay herself on the bed. No injury noted. Review of the physician progress notes dated 12/15/22 revealed Resident #72 continued to have increased behaviors including attempting to self transfer which has resulted in multiple falls over the last several days and the resident was to continue to have 24 hour supervision as she was a high fall risk. Review of the progress notes dated 01/18/23 at 8:15 P.M., written by Licensed Practical Nurse #400, revealed the resident had an unwitnessed fall at 8:15 P.M. Resident #72 was toileted due to the need to have a bowel movement. The State tested Nursing Assistant (STNA) left the shower room to get the resident clean clothes. The nurse heard the resident yelling and upon entering the shower room the resident was found in a supine (on her back) position next to the toilet. Resident #72 complained of bilateral hip and wrist pain. The resident was sent to the hospital for an evaluation. Review of the post fall evaluation dated 01/18/23 revealed Resident #72 had an unwitnessed fall in the shower room. The facility intervention was to educate the staff not to leave the resident alone in the bathroom. The medical record revealed Resident #72 returned from the hospital on 01/24/23 at 1:35 P.M. with a new medical diagnosis of a fractured right hip with a surgical repair. Resident #72 had 22 staples in the right hip. Resident #72 was hospitalized from 01/18/23 through 01/24/23 for a surgical repair of the right hip fracture. Observation of the secured unit shower room was completed on 02/09/23 at 11:19 A.M. The room was located in the center of the hallway on the secured unit. The room was a large area with a toilet in the center on the wall. The toilet had assist bars on both sides. The floor was tile throughout. Resident #72's room was at the end of the hallway and some distance from the shower room. Review of the staff schedule working on the secured unit on 01/18/23 at 8:15 P.M. identified STNA #310, #320, and #330 and LPN #400 was assigned the secured unit on 01/18/23 at the time of Resident #72's fall with injury. Interview with LPN #400 on 02/09/23 at 3:24 P.M., verified she worked the evening of 01/18/23 and around 8:15 P.M. she heard yelling from down the hallway. LPN #400 said she went down to the shower room and found Resident #72 alone on the bathroom floor. LPN #400 said the STNA #330 had said he left the resident alone, on the toilet, in the shower room, when he left to get clothing for her, from her room. LPN #400 verified the STNA #330 should not have left Resident #72 alone and he should have known her fall risk. Interview with STNA #330 on 02/09/23 at 5:36 P.M., STNA #330 verified he left Resident #72 on the toilet alone in the shower room on 01/18/23 while he left to get new clothing for her. STNA #330 verified Resident #72 should not have been left alone. This deficiency represents non-compliance investigated under Master Complaint Number OH00139887.

Based on observations, review of medical records, Self-Reported Incidents (SRI) review, witness statement review, staff schedule review, police call report review, review of the Centers for Medicare and Medicaid (CMS) guidance related to sexual activity and consent, facility policy review and interviews with staff, residents, and a resident's legal representative, the facility failed to ensure five cognitively impaired residents (#98, #81, #101, #13, #15) were free from resident-to-resident sexual abuse. This resulted in Immediate Jeopardy and the potential for serious physical, mental and/or psychosocial harm, when on 12/20/22 at 10:25 P.M., State tested Nurse Aide (STNA) #94 observed two residents (#98 and #81) naked in bed with Resident #81 thrusting on top of Resident #98; on 12/21/22 at approximately 4:15 P.M., Scheduler #36 observed Resident #15's hand moving in an up and down motion in Resident #13's pants while sitting in the common area by Station One nursing station; and on 12/24/22 a staff member reported to Regional Director of Operations (RDO) #100 that Resident #101 stated sometimes Resident #81 came into her room at 4:00 A.M. and touched her vagina. This affected five residents who were involved in sexual encounters which included three of 26 residents on Station Three secured unit (#98, #81, #101) and two of 38 residents on Station One non-secured unit (#13 and #15). On 12/28/22 at 2:34 P.M., the Administrator, the Director of Nursing (DON) and RDO #100 were notified Immediate Jeopardy began on 12/20/22 at 10:25 P.M. when STNA #94 observed Residents #98 and #81, both cognitively impaired residing on the secured memory care unit, naked in Resident #81's bed with Resident #81 thrusting on top of Resident #98. One-to-one staff monitoring for Resident #81 and #98 was ordered by the nurse practitioner after the sexual encounter; however, the one-to-one staff monitoring for each resident was not completed. Additionally, the police were not accurately notified of the sexual encounter, and Residents #81 and #98 did not have a timely medical and/or psychiatric follow-up evaluation, Residents #81 and/or #98 did not have sexual transmitted infection (STI) testing, care plans were not updated to reflect sexual behaviors for Residents #81 or #98 and skin assessments of all residents residing on Station Three were not immediately completed by a licensed nurse to ensure a thorough investigation was completed. Additionally, on 12/21/22 at approximately 4:15 P.M., Scheduler #36 observed Resident #15's hand moving in an up and down motion in Resident #13's pants while sitting in the common area by Station One nursing station. Both residents were cognitively impaired. There had been other indications of possible sexual interactions between Residents #13 and #15; however, there was no evidence in the medical records of the occurrences. There was no evidence in the medical record of the sexual encounter between Residents #13 and #15 on 12/21/22, Self-Reported Incidents (SRI's) were not submitted to the State Agency, the police were not notified, a thorough investigation was not completed, and care plans were not updated to reflect the sexual behaviors for Resident #13 and #15. Furthermore, on 12/24/22, Resident #101, who was cognitively impaired residing on the secured memory care unit, stated sometimes Resident #81 entered her room at 4:00 A.M. and touched her vagina. A skin assessment of Resident #101 was not timely completed, all witnesses who worked the night of the allegation were not interviewed and skin assessments of all residents residing on Station Three were not immediately completed by a licensed nurse to ensure a thorough investigation. The Immediate Jeopardy was removed on 01/04/23 when the facility implemented the following corrective actions: On 12/28/22 at 11:13 A.M., RDO #100 and the Administrator implemented a hall monitor to Station Three where Resident #81, #98 and #101 resided. At 3:30 P.M., the Administrator and DON devised a plan for an around-the-clock hall monitor at Station Three to monitor residents for the foreseeable future. The Administrator was responsible for ensuring this was completed. On 12/28/22 at 11:15 A.M., a skin assessment was performed for all residents who resided on Station Three by Unit Manager (UM) #23 and UM #05 with no negative findings. On 12/28/22 at 11:39 A.M., RDO #100 notified and discussed with Medical Director (MD) #112 the hall monitors on Station Three. On 12/28/22 at 2:55 P.M., RDO #100 reviewed the facility's abuse policy. No changes were made. On 12/28/22 at 3:00 P.M., RDO #100 educated the Administrator and DON regarding how to complete a thorough investigation of Self-Reported Incidents. By 12/28/22 at 3:06 P.M., the Administrator educated all staff via an on-line training system on the facility's abuse policy specifically addressing who the staff report abuse allegations to. All staff who weren't educated would be educated before their next scheduled shift. On 12/28/22 at 3:10 P.M., RDO #100 notified and discussed with MD #112 the Immediate Jeopardy notification for resident abuse, the abatement plan, and the resident-to-resident sexual abuse for Resident #81 and #98 on 12/20/22, Resident #81 and #101 on 12/24/22, and Resident #13 and #15 on an unknown date. MD #105 ordered laboratory work for sexual transmitted diseases, human immunodeficiency virus (HIV) and rapid plasma regain (RPR) for Residents #81 and #98. MD #112 was made aware of the skin assessments and did not request Resident #81 and #98 to be sent to the hospital for further examination. On 12/28/22 at 3:20 P.M., the Administrator notified the police of resident-to-resident sexual abuse for Residents #81 and #98 on 12/20/22, Resident #81 and #101 on 12/24/22, and Resident #13 and #15 for unknown date and time. On 12/28/22 at 4:00 P.M., Social Services Director (SSD) #89 spoke with Resident #15 and Resident #15's representative. Resident #15 had a room change from Station Two to Station Three to be monitored by the hall monitor. On 12/28/22 at 4:11 P.M., the Administrator submitted a facility Self-Reported Incident to the State agency regarding sexual abuse involving Residents #13 and #15. On 12/28/22 at 4:15 P.M., SSD #89 interviewed all residents residing on Station Three using an abuse questionnaire without any negative findings. On 12/28/22 at 4:15 P.M., Registered Nurse (RN) #106 updated the care plans for sexual behaviors for Resident #15, Resident #81, and Resident #98. On 12/28/22 at 4:45 P.M., SSD #89 interviewed all residents residing on Station One and Station Two using an abuse questionnaire with two negative findings. Two SRIs were initiated. On 12/28/22 at 4:45 P.M., a skin assessment was performed for all residents who resided on Station One and Station Two by UM #23 and UM #05 without any negative findings. On 12/29/22, the Administrator began an audit to occur three times a week for four weeks of the hall monitor report. On 12/29/22, RDO #100 and Regional Director of Clinical Operations #107 began an audit to occur three times a week for four weeks to ensure a thorough investigation was completed for SRI's and accurate police reporting. Findings will be reviewed in the Quality Assurance Performance Improvement (QAPI) meetings for three months. On 12/29/22 at 2:50 P.M., RDO #100 discussed with Resident #13 and Resident #13's representative about moving Resident #13 to Station Three to be monitored by the hall monitor; Resident #13 was moved to Station Three. On 12/29/22 at 2:50 P.M., the Administrator educated all assigned staff regarding the duties of the hall monitor. On 01/04/23 at 3:00 P.M., the DON put into writing specific instructions for the hall monitors responsibilities and reeducated all staff on the hall monitors responsibilities. Although the Immediate Jeopardy was removed on 01/04/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: 1) Review of the medical record for Resident #81 revealed an admitted [DATE] with diagnoses of metabolic encephalopathy, alcohol abuse, cognitive communication deficit, anxiety disorder and dementia associated with alcoholism. Resident #81 resided on the secured memory care unit (Station Three) and had a legal guardian. Review of the Pre-Admission Screen and Resident Review (PASRR) determination letter dated 10/07/22 revealed Resident #81 experienced confusion and forgetfulness, mood changed frequently, and was released from prison in the past six months. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #81 was severely cognitively impaired, required supervision to walk in his room and corridor, and did not use a mobility device. Review of the nurses note dated 08/13/22 timed at 5:41 P.M. revealed Resident #81 was moved to a different room at this time due to another female resident continued to go into his room. Resident #81 agreed with the room change. UM #05 spoke with Resident #81's daughter who also agreed to the room change. Review of the late entry nurses note documented on 08/18/22, effective for 08/15/22, revealed an interdisciplinary team note indicating on 08/13/22, female resident [Resident #101], observed by State-tested Nurse Aides (STNAs), sitting on resident's bed attempting to disrobe. After interviewing STNAs and residents, both STNA's and resident deny any physical contact was observed or taking place. STNAs immediately intervened, assisted the female resident to exit the room, and notified the unit manager and the nurse. The family and physician were notified, and no new orders were received. In discussion with family, UM #05 suggested to move Resident #81 to the end of the hall to deter further issue, family in agreeance. The room move was completed, and no further issues were observed. Review of the late entry nurse practitioner progress note documented on 11/12/22, effective for 11/10/22, revealed Resident #81 was unable to make sound decisions. His judgement was poor along with his mentation, judgment, and the resident was deemed incompetent. He had alcohol induced dementia and would require long term care. He was alert and oriented to self and situation when spoken to, otherwise disoriented. He had poor recollection of past events. Review of the incident note dated 12/21/22 timed at 2:00 A.M., authored by Licensed Practical Nurse (LPN) #06 revealed at 10:25 P.M. on 12/20/20, this male resident (Resident #81) was observed in his room with female patient (Resident #98) lying in his bed with both having their clothes off. Staff redirected both residents and redirected the female resident out of the male resident's room. The female resident (Resident #98) was observed in the lounge area by the nurses' desk between five-to-10 minutes before the occurrence. Vital signs were within normal limits. The on-call nurse, UM #22, and the Administrator were notified. The Convergence (a contracted telehealth company) was also notified. Convergence stated there was not much to be done at this point as both were in an Alzheimer's dementia unit, and to defer to the facility for protocol. A new order for one-to-one supervision with Resident #81 until further notice was received. Also, management notified the local police department and Resident #81's guardian of the occurrence. Review of the physician orders from December 2022 revealed an order dated 12/20/22, timed 10:25 P.M. for Resident #81 to be on one-to-one supervision until further notice. The order was given by Convergence Nurse Practitioner (NP) #108. Review of the nurses note dated 12/21/22 timed 6:34 A.M. revealed Resident #81 continued to be on one-to-one supervision, was resting in bed, and this nurse notified the day shift nurse that Resident #81 was to be on one-to-one supervision until further notice. Review of the nurses note dated 12/21/22 timed 11:19 A.M. documented Resident #81 continued to be monitored resulting from a situation with another resident and denied having any needs, concerns, or pain at present. Resident #81 was spending most of the time in his room and not interacting with staff or other residents. Resident #81's niece called in requesting to know what if any actions were going to be taken. Staff advised Resident #81's niece that presently both residents (Residents #81 and #98) were monitored by staff members at all times until additional orders were received. Review of the nurses note dated 12/21/22 timed 2:17 P.M. revealed Convergence was called to request complete blood count (CBC), comprehensive metabolic panel (CMP), urinalysis (UA) and culture and sensitivity (C&S) for episode last night with another resident (Resident #98). Review of the nurses note dated 12/23/22 timed 6:48 P.M. revealed many times today Resident #81 attempted one-on-one with another female resident, [Resident #98]. He was redirected many times by staff. He became belligerent using curse words at staff saying he can talk to and do whatever he wants. Staff continued to redirect Resident #81. Review of the nurses note dated 12/24/22 timed 4:40 A.M. revealed Resident #81 was witnessed walking into female resident's (Resident #101) room despite staff trying to redirect. Resident #81 was sitting on Resident #101's bed when this nurse entered the room. Resident #81 was redirected back to the common area. Resident #81 was yelling at staff and stated, I can go check on my friend if I want. Resident #81 was advised that at this time he was not to be in the room and Resident #81 screamed that this nurse was Hitler. Review of the Treatment Administration Record (TAR) from December 2022 revealed nurses were initialing twice a day (each shift) acknowledging Resident #81 was on one-to-one staff monitoring from night shift on 12/20/22 through 12/27/22. Review of the 15-minute checks paper documentation for Resident #81 dated 12/20/22 revealed Resident #81 was observed at 15-minute intervals starting at 10:25 P.M. through 6:00 A.M. by STNA #20, STNA #94 or LPN #06, verifying with their initials. There was no other documented evidence of 15-minute checks for Resident #81 from 12/21/22 through 12/28/22. Review of Resident #81's care plans revealed there was no evidence of Resident #81 displaying sexual behaviors nor any interventions addressing the sexual behaviors. Review of the nurses note dated 01/02/23 timed 8:50 A.M. revealed hall monitors report she heard this resident [Resident #81] telling a female resident that, if you want to join me, I'll be in my room. The female resident instead went to her room in the opposite direction. Resident #81 was reminded that he cannot be alone in any private room with any female resident. Review of the medical record for Resident #98 revealed an admitted [DATE] with diagnoses of Alzheimer's disease, anxiety disorder, cognitive communication deficit, and insomnia. Resident #98 resided on the secured memory care unit (Station Three) and Resident #98's son was her power of attorney (POA). Review of the MDS 3.0 quarterly assessment dated [DATE] revealed Resident #98 was severely cognitively impaired, required supervision to walk in her room and corridor, didn't use any mobility devices, had verbal behaviors, other behavioral symptoms and wandered one to three days during the assessment reference period. Review of the Convergence narrative note dated 12/21/22 timed 12:26 A.M. authored by Convergence NP #108 revealed staff found this female resident (Resident #98) in male resident's (Resident #81) room both had clothes off. She was lying flat on her back, and he was on his right side. Resident #98 became upset when staff removed her from Resident #81's room. Resident #98 said to the nurse, it's my husband I can do what I want. When questioned, Resident #81 said she caught me off guard and put her hand on my leg and then down my pants rubbing on my penis. Resident #81 said he couldn't get hard. Plan: Deferring to facility protocol. Maintain residents on one-to-one until further instruction from the DON. Review of the incident note dated 12/21/22 timed 1:28 P.M. authored by LPN #06 revealed at 10:25 P.M on 12/20/22, Resident #98 and Resident #81 were in Resident #81's room lying in bed both having all their clothes off. When redirecting Resident #98 out of Resident #81's room, she was very upset yelling at staff. Resident #98 said, it's my husband I can do what I want. Vital signs were within normal limits. LPN #06 notified the on-call UM #22, the Administrator, and Convergence NP #108 of the occurrence, who said not much to be done at this point, and to defer to facility protocol. LPN #06 also notified Resident #98's son/POA. The local police department was notified of the occurrence by management. Resident #98 has been on one-to-one supervision since the occurrence and a new order was written for Resident #98 to be on one-to-one supervision until further notice. Review of the physician orders from December 2022 revealed an order dated 12/20/22 timed 10:25 P.M. for Resident #98 to be on one-to-one supervision until further notice. The order was given by Convergence NP #108. Review of the nurses note dated 12/21/22 timed 6:33 A.M. authored by LPN #06 revealed Resident #98 was sitting in a recliner in the lounge area with bilateral feet elevated resting, remains on one-to-one supervision and kept track on paper. LPN #06 passed on in report Resident #98 was to be on one-to-one supervision until further notice. Review of the nurses note dated 12/21/22 timed 11:11 A.M. revealed Resident #98 continued to be monitored by staff post incident. Resident #98 denied having any needs, pain, or concerns. Resident #98 was sitting at a table in the dining room with activities decorating cookies and making Christmas decorations and had no complaints or no signs or symptoms of distress, discomfort, or pain. Resident #98's son was in to visit with his mother and expressed concerns over the situation that occurred with Resident #81. Resident #98's son expressed that he does not feel she is safe and will be looking into finding another facility to move her to. Comfort and reassurance were offered. Social Services Director (SSD) #89 was on the unit and introduced herself to Resident #98's son stating she may be able to help him better with the relocation process. No other issues or concerns were expressed at that time. Review of the nurses note dated 12/21/22 timed 2:08 P.M. revealed Convergence was contacted to request order for CBC, CMP, UA and C&S. Review of the social services note dated 12/22/22 timed 2:02 P.M revealed SSD #89 returned a call to Resident #98's son. SSD #89 reported that the one-on-one supervision would remain in place. SSD #89 reported that the one-on-one or close watch will remain in place due to Resident #98 continuing to call another resident her husband. SSD #89 also reported behavior training will be provided for station aides and nurses. Review of the interdisciplinary team (IDT) follow-up dated 12/28/22 timed 10:01 A.M. authored by the DON revealed Resident #98 was no longer showing any attraction to male residents. Resident #98 has a history of mistaking male residents for her spouse. Interventions put into place: goal will redirect resident if she shows any interest in male residents, staff will continue to consistently redirect and intervene. Resident #98 had not shown any further behavior showing interest in male residents since the occurrence. Review of the TAR from December 2022 revealed nurses were initialing twice a day (each shift) acknowledging Resident #98 was on one-to-one staff monitoring from night shift on 12/20/22 through 12/27/22. Review of the 15-minute check paper documentation for Resident #98 dated 12/20/22 revealed Resident #98 was observed at 15-minute intervals starting at 10:25 P.M. through 6:00 A.M. by STNA #20, STNA #94 or LPN #06, verifying with their initials. There was no other documented evidence of 15-minute checks for Resident #98 from 12/21/22 through 12/28/22. Review of the facility's SRI to the State agency dated 12/21/22 timed 12:48 A.M. revealed Resident #98 was found unclothed in the room of Resident #81, and he was also unclothed. Review of the witness statement dated 12/20/22, authored by STNA #94 revealed, was taking another resident to bathroom and when I was done, I came to dining room and asked where Resident #98 was. I went looking for her and opened Resident #81's door and saw Resident #98 naked laying on his bed with Resident #81 over top of her thrusting (did not see him physically penetrating her). I alerted nurse and she came down and separated them. I assisted in dressing and removing Resident #98 and she was very irritated and angry. She said it was her husband she could do what she wanted. We bagged up all linen. I approached Resident #81 to ask what happened and he said she came into his room and rubbed his leg and then put her hand in his pants and it escalated from there. He said he couldn't penetrate her because he couldn't get fully erect, but he tried. We monitored both residents for the rest of the night. Review of the witness statement dated 12/20/22 timed 10:25 P.M., authored by LPN #06 revealed, STNA #94 alerted this nurse to [Resident #81's room] when this nurse entered room, observed Resident #98 laying on her back in bed [Resident #81's room number] and Resident #81 laying on his right side with back to door in same bed, both patients had all their clothes off. When this nurse redirected female patient out of male patient's room, she became very upset yelling at staff and said, It's my husband, I can do what I want. This nurse redirected patient it was not her husband with female patient still saying it was. Took female patient to her room and did skin assessment. This nurse then had staff one-to-one female patient and male patient from time observed until further notice by management. This nurse then went in and talked to male patient, Resident #81. Asked Resident #81 why he was naked in bed with female patient. Resident #81 stated, she caught me off guard, it won't happened again, I'm sorry. This nurse redirected male patient of the inappropriateness. This nurse then had STNA #94 ask male patient what happened while this nurse stood at doorway and heard Resident #81 say, she came into my room and rubbed my thigh and then put her hands in my pants and it escalated from there. Resident #81 then said he couldn't get it in because he couldn't get it hard, but he tried. All linen and both patients' clothes put in bags. Notified on-call UM #22. I spoke with the Administrator. Called Convergence and reported occurrence. Management said they notified the police department and this nurse notified both patients guardians. When this nurse entered room and had both patients sit up and removed female patient from the room, male patient was not hard (penis). This nurse asked UM #22 and Administrator if female patient needed to be sent to ER (emergency room ) for evaluation. Administration said corporate person said, no unless if Convergence doctor gives order to send her to the ER which she did not. Review of the witness statement dated 12/20/22, authored by STNA #20 revealed, while monitoring residents on Station Three, STNA #94, the other nurse aide working with me, asked where Resident #98 went to. He then went down to Resident #81's room, opened the door, then came down to alert the nurse that Resident #81 was on top of Resident #98 thrusting himself against her in his bed. LPN #06 promptly walked down to Resident #81's room to remove Resident #98 from the situation and from Resident #81's room. I was asked by LPN #06 to assist STNA #94 in helping dress Resident #98 and bring her out for an evaluation in a private setting. Once she was removed from the room. her clothing and Resident #81's clothing and bedding were stripped from the bed, bagged, and put behind the nurse's station. Nurse followed up per protocol. Review of the police call report dated 12/21/22 timed 12:15 A.M. revealed UM #22 is calling to report that Resident #98 and #81 was found in the same bed unclothed. UM #22 stated it was consensual but needs to report it. Unknown age of the male and female at this time. Call was logged and told if further needed investigated to call in. Review of the nurse and STNA staff schedule from 12/20/22 through 12/28/22 revealed there were only two STNA's and one nurse assigned to the secured memory care unit except on 12/24/22 from 6:00 P.M. to 6:00 A.M. when there was only one STNA and one nurse. There was no staff specifically assigned/scheduled to do one-to-one staff monitoring for Resident #81 and Resident #98. Interview on 12/27/22 at 8:17 A.M. with STNA #94 regarding the sexual encounter between Resident #81 and #98 revealed he was working with a new STNA [STNA #20] that night. STNA #94 had taken a resident to the toilet and came out of the restroom asking STNA #20 where the other resident from the room had gone. STNA #94 located Resident #98 in Resident #81's room. STNA #94 observed both residents completely unclothed, and Resident #81 was on top of Resident #98 making thrusting movements. STNA #94 reported he did not actually visualize vaginal penetration. He reported there was a similar incident approximately two weeks ago involving Resident #81. STNA #94 reported Resident #81 was sexually aggressive. Observation on 12/27/22 at 12:08 P.M. of the secured memory care unit revealed there were two STNA's (STNA #13 and STNA #98) and one LPN (LPN #04) working on the unit. LPN #04, STNA #13, and STNA #98 were standing by/at the nursing station. There were 26 residents residing on the unit. Observation on 12/28/22 at 8:40 A.M. of the secured memory care unit revealed STNA #99 standing at the nursing station observing the residents in the common area. Resident #81 was lying in bed, sleeping. There was not a staff member monitoring Resident #81. Interview, during the observation, with STNA #99 revealed she did not know where Resident #81 was. STNA #99 verified Resident #81 was supposed be monitored one-to-one by staff however, there were only two STNA's assigned for the whole unit for 26 residents from 6:00 A.M. to 6:00 P.M. so the one-to-one staff monitoring with Resident #81 was not being completed. STNA #99 stated the other aide on the unit (STNA #58) was giving a shower to Resident #78 in the shower room and LPN #04 had stepped off the unit, so STNA #99 verified she was the only staff on the unit supervising all 26 residents (besides Resident #78) at that time. Observation on 12/28/22 at 8:54 A.M. revealed Resident #98 was sitting in a wheelchair in the common area. At 8:56 A.M., UM #05 was sitting in her office on the telephone. At 8:57 A.M., Resident #98 was walking westward in the hall towards Resident #81's room. There was not one-to-one staff monitoring of Resident #98. At 8:59 A.M., Resident #81 continued to lay in bed, sleeping without one-to-one staff monitoring. Interview on 12/28/22 at 8:59 A.M with LPN #04 revealed Resident #81 was ambulatory and tried to hang around the women. Lately, Resident #98 had been trying to go to Resident #81's room. LPN #04 verified Resident #81 had a one-to-one staff monitoring physician order however, administration didn't schedule a staff member to only monitor Resident #81 for one-to-one monitoring, so the staff were doing 15-minute checks on Resident #81 and documenting on a paper document. LPN #04 didn't know where the paper documentation was when the surveyor asked to review it. Interview on 12/28/22 at 10:15 A.M. with Resident #98's POA revealed the facility notified him of Resident #98's sexual encounter with another resident. Resident #98's POA revealed that Resident #98 had always been a good, discrete lady and would have never been unclothed in someone else's bed. Resident #98's POA revealed he did not give consent for Resident #98 to engage in sexual activity with other residents. During the surveyor's interview with Resident #98's POA, it was apparent Resident #98's POA was uncomfortable discussing the sexual activity involving Resident #98 as he would not reveal what the facility notified him of on 12/21/22 at 12:30 A.M. Interview on 12/28/22 at 11:23 A.M. with LPN #06 revealed the night of 12/20/22 into 12/21/22, there were two STNA's and herself working on the secured memory care unit. STNA #20 was monitoring the hallway and STNA #94 was taking a resident to the bathroom. STNA #94 came back to the nursing station and asked where Resident #98 was since Resident #98 wandered in and out of rooms all the time. STNA #94 reported to LPN #06 that Resident #98 was in Resident #81's room. LPN #06 entered Resident #81's room and observed Resident #98 lying flat on her back and Resident #81 laying on his right side with his back facing the door. Both residents weren't clothed. LPN #06 educated the residents on the inappropriateness and Resident #98 was fighting while putting her clothes back on. LPN #06 notified the on-call nurse, the Administrator, and both families. The Administrator told LPN #06 that the police had been notified. LPN #06 notified Convergence NP #108 of sexual activity between Resident #81 and #98 and NP #108 ordered to follow the facility's protocol and implement one-to-one staff monitoring of Residents #81 and #98. NP #108 did not order Resident #98 to be sent to the emergency department for examination. LPN #06 notified the Administrator the staff were going to do one-to-one monitoring. Resident #98 wouldn't go to bed and kept looking down the hallway the rest of the night. Observation on 12/28/22 at 4:20 P.M. of the secured memory care unit revealed Resident #81 walked out of his room into the hallway then into the common area. Interview, during the observation, with Resident #81 revealed a female resident had come into his room and wanted something sexual but he kicked her out because he didn't need any more trouble. Resident #81 stated nothing sexual occurred between them. Resident #81 was asked by the surveyor what the day of the week it was, and Resident #81 was unaware of the day of the week. An interview on 12/28/22 at 4:25 P.M. with Resident #98 was attempted; however, Resident #98 was unable to form a purposeful sentence. Resident #98 just muttered undiscernible words. Observation on 12/28/22 at 4:29 P.M. of the secured memory care unit revealed Resident #81 was sitting in a dining room chair and Resident #98 was standing in the dining room close to Resident #81. The residents were chatting with each other. Interview on 12/28/22 at 5:00 P.M. with the Administrator, DON, and RDO #100 verified one-to-one staff monitoring was not completed for Resident #81 or Resident #98, verified the police were inaccurately notified of the extent of the sexual encounter between Resident #81 and Resident #98, verified Resident #98 was not sent out to the emergency room for an examination, verified sexual transmitted infections (STI) testing was not completed for Resident #81 or Resident #98, verified there was no follow up from Residents #81 and #98's nurse practitioner and/or physician or psychiatric services after the sexual encounter, verified Residents #81 and #98's care plans were not updated to reflect sexual behaviors and verified all residents residing on Station Three did not have a skin assessment completed by a licensed nurse after Resident #81 and #98's sexual encounter. RDO #100 also verified the telehealth services (Convergence) that LPN #06 notified of the sexual encounter, does not follow up at the facility. Interview on 01/04/23 at 9:50 A.M. with LPN #101 revealed she worked on the secured unit during day shift on 12/23/22 and observed Resident #81 atte [TRUNCATED]

Based on medical record review, review of hospital records, review of the facility's investigation and staff interview, the facility failed to treat Resident #120's pain in a timely manner. This resulted in actual harm for Resident #120 who complained of pain upon admission and was not administered pain medication resulting in the resident crawling out of her window to go to the emergency room for pain control. This affected one (#120) of three residents reviewed for pain. The facility identified 17 residents on a pain management program. The facility census was 118. Findings include: Review of Resident #120's medical record revealed the resident was admitted to the facility on [DATE] at 5:40 P.M., following a hospitalization for pleurisy (infection in the lining of the lungs). The hospital discharge orders included [MEDICATION NAME] 5/325 (narcotic pain medication), with instructions to take on tablet every six hours as needed for pain. Review of the telephone physician orders, dated 12/28/19, revealed an order for [REDACTED]. Review of the facility's admission assessment, dated 12/28/19 at 5:40 P.M., identified Resident #120 was cognitively intact. It revealed the resident verbalized and/or exhibited non-verbal pain. The assessment did not have evidence of any further evaluation of the pain level or type. Review of the progress notes, dated 12/29/19 at 8:46 [NAME]M. (15 hours after the resident's admission to the facility) revealed Licensed Practical Nurse (LPN) #46 called the physician to notify them Resident #120 was admitted from the hospital without narcotic prescriptions and the facility was unable to administer the pain medications until they had one. The notes identified the physician told the staff to call the hospital to obtain the prescriptions. The notes revealed LPN #120 called the discharging hospital on [DATE] at 10:00 [NAME]M. whom faxed the prescriptions to the facility at 10:24 [NAME]M. The notes further identified on 12/29/19 at 3:43 P.M. LPN #120 called the pharmacy for notification the facility had not received the resident's narcotic medications. There were no notes that identified what the pharmacy ' s response was. The progress note, dated 12/29/19 at 8:43 P.M. (27 hours after admission), revealed Resident #120 was upset her narcotics were not in the building from the pharmacy yet. The nurse called the pharmacy to get an authorization to pull the narcotics and was told they would send the code when approved. The notes identified an hour later the nurse called the pharmacy back and was told the medications were sent out in the delivery tote and could not be pulled from the emergency box. The notes identified Resident #120 remained very upset and stated she will call 911 or have her son take her to the hospital next door to receive her narcotics. The notes identified the nurse offered to call the physician to obtain an order to go to the hospital and the resident identified she would take care of this herself. The nurse stated she tried to calm the resident and offered her Tylenol (treats mild pain) and [MEDICATION NAME] (treats nausea and vomiting). The resident responded if they don't have the narcotics, she will not take them. The progress note, dated 12/29/19 at 11:20 P.M., revealed the facility received a phone call from the emergency room (ER), that was next door to the facility. The emergency room reported Resident #120 was there. The facility had determined Resident #120 crawled out of her window and walked herself over to the emergency room . Review of the resident's Medication Administration Record, [REDACTED]. one tablet every six hours as needed for pain was not administered to the resident on 12/28/19 or 12/29/19. Review of the hospital records, dated 12/30/19, revealed the ER had medicated Resident #120 with her [MEDICATION NAME] and [MEDICATION NAME] (anti-anxiety) medication and would be returning her to the facility. The resident told the ER she was having chest pain and abdominal pain and the nursing home would not administer her pain medications to her. She stated she crawled out her window and came to the ER to get her medications. The progress note, dated 12/30/18 at 3:30 [NAME]M. revealed Resident #120 returned to the facility. The resident asked the nursing staff if her narcotics were now available in the building. The staff did let the resident know they now have access to her narcotics. Review of the facility's investigation into the incident with Resident #120 revealed the resident requested pain medications on 12/28/19 at 8:00 P.M., the morning (no time specified) of 12/29/19, 12/29/19 at 4:15 P.M., 6:30 P.M. and 7:30 P.M. The investigation identified Resident #120 wanted to call 911 at 7:30 P.M. The records identified no evidence of pain evaluations being completed at those times. Interview with the Director of Nursing (DON) on 01/13/20 at 10:13 [NAME]M. confirmed the nursing staff should have made sure Resident #120 had a prescription for the narcotic pain medication at the time of admission. The DON confirmed Resident #120 did not have access to her narcotic pain medication for longer than 24 hours following her admission to the facility and the facility conducted an investigation into the incident. The DON confirmed the [MEDICATION NAME] was available in the facility in the emergency box. The DON revealed the facility was required to have permission (a code) from the pharmacy to remove the narcotic pain medication from the box. The DON confirmed Resident #120 should have had access to her pain medications upon admission and there was a system breakdown. This deficiency substantiates Complaint Number OH 198.

Based on medical record review, review of self-reported incident (SRI), hospital record review, staff interview, and facility policy review, the facility failed to provide timely care and treatment for one resident (#11) of three reviewed for timeliness of care. This resulted in actual harm when Resident #11 had a fall, was left for over eight hours without any treatment, and subsequently required surgical intervention for a left elbow fracture and a [MEDICAL CONDITION]. The facility census was 122. Findings include: Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/19, revealed Resident #11 had severe impaired cognition. The resident required supervision for walking. Review of Resident #11's nurses notes dated 06/09/19 at 10:35 P.M., revealed the resident was found on the floor. The physician was notified via text message at 10:45 P.M. The physician did not respond to the text. Mobile x-ray was notified five hours later, and x-rays were completed on 06/10/19 at 3:45 [NAME]M. The results of the x-rays were sent via text to the physician. Again, the physician did not respond to any texts. Per the nurse's judgement emergency services was called and the resident was transported to the hospital on [DATE], at 7:10 [NAME]M., over eight hours after the fall. Review of the x-ray results dated 06/10/19 revealed Resident #11 had a left elbow displaced [MEDICAL CONDITION] of the olecranon. Overlying soft tissue [MEDICAL CONDITION] and swelling with mild elbow joint effusion. The resident's hip x-ray revealed a displaced [MEDICAL CONDITION] femoral neck and changes of [MEDICAL CONDITION] joint disease. Review of the hospital records dated 06/11/19 revealed Resident #11 had surgical intervention including a hemiarthroplasty of the left hip and open reduction internal fixation of the left elbow. The hospital record indicated the resident was in pain with any movement of her hip. Review of the SRI (# 8) dated 06/11/19 revealed facility staff had reported they did not believe Licensed Practical Nurse (LPN) #56 gave proper care when Resident #11 had fallen on 06/10/19. Review of the witness statement, undated completed by State tested Nursing Assistant (STNA) #51 revealed the STNA arrived at the facility at 2:00 [NAME]M., on 06/10/19 and as she was going up the hall, she could hear Resident #11 crying out. She stopped in the resident's room and asked her what she needed. She said she was in pain and grabbed her left elbow. The STNA then pulled back her covers and found a lot of bruising with the elbow so swollen it looked like a softball was hanging off it. The STNA went to the nurse's station and was told the resident had fallen on 06/09/19 at 10:15 P.M. The STNA told LPN #56 it looked like the resident's elbow was broke and asked the nurse if she was sending her out. The nurse told the STNA she couldn't until she got an order to do so. Then about 2:30 [NAME]M., the mobile x-ray showed up and said the resident's elbow and hip were broken. The STNA again asked LPN #56 if she was going to send her out and she said she had to wait until she received the official fax from the physician before she could send her out. The witness statement further revealed the resident had been crying ever since she arrived at the facility at 2:00 [NAME]M., and was not sent to the hospital until 7:00 [NAME]M., on 06/10/19. Review of the witness statement dated 06/12/19, completed by STNA #62 revealed on 06/09/19 at 10:30 P.M., she heard a resident yell for help. When the STNA arrived at Resident #11's room the resident was on the floor and was complaining of arm and hip pain. LPN #56 insisted they had to get the resident back in bed even though the resident was complaining of pain. After the resident was placed back in bed she was continuously complaining of pain, especially after she was moved. The witness statement further revealed Resident #11 laid in bed all night after the fall and was yelling in pain. STNA #62 reported you could not touch the resident's arm or leg without her screaming. Review of LPN #56's statement, undated, revealed she had heard a yell for help from Resident #11 and when she arrived at her room, the resident was found on the floor. She was complaining of her elbow hurting. It was already starting to bruise. LPN #56 sent a text to the physician. The physician never answered the text. The LPN then called mobile x-ray to come and take x-rays. LPN #56 reported she checked on Resident #11 every 15 minutes and the resident would yell, however was asleep most of the time. She reported there was not a Registered Nurse (RN) on duty, just her, one other LPN, two STNAs, and two STNAs who were in orientation. The witness statement further revealed the charge nurse never responded to her texts until 6:24 [NAME]M., on 06/10/19 and she had already called for transport for Resident #11. Review of the Corrective Counseling Report dated 06/18/19, revealed LPN #56 was terminated for not following proper fall protocol and for not responding or providing care to Resident #11. Interview on 07/23/19 between 11:00 [NAME]M. the 11:30 [NAME]M, with STNA #51 and #58 confirmed they were working the night of 06/09/19 when Resident #11 fell . They both confirmed the resident fell around 10:30 P.M. and was not sent to the emergency room until the next morning. Both STNA's confirmed what was written in their witness statements and confirmed the resident was in pain all night. Interview with the Administrator on 07/23/19 at 8:30 [NAME]M., confirmed LPN #56 was terminated for not following the fall protocol. Phone interview on 07/23/19 at 1:20 P.M., with LPN #59 confirmed she was working on 06/09/19 when Resident #11 fell , however revealed LPN #56 did not notify her of the fall. An attempt to interview LPN #56 via telephone on 07/23/19 at 8:47 [NAME]M. and 1:08 P.M. was unsuccessful. Review of the facility titled, Fall Prevention Program Guidelines dated 06/24/14 under the post fall protocol revealed staff were to make sure every employee that were in the vicinity are interviewed and are asked specific questions, so everyone's input is received. Document in the resident's record all the specifics. This deficiency substantiates Control Number OH 110.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of a self-reported incident (SRI), medical record review, facility investigation, and staff interviews, the facility failed to ensure one (#120) of three sampled residents received proper assistive devices to prevent accidents. Actual harm occurred when Resident #120 suffered a fractured femur following an improper transfer by facility staff. The facility census was 118. Findings include: Review of Resident #120's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a facility quarterly Minimum Data Set (MDS) assessment, dated 12/31/17, identified Resident #120 had severe cognitive deficits and was totally dependent on staff for transfers and bathing. Review of the nursing assistant's Kardex (care information card) identified Resident #120 required the use of a mechanical Hoyer left for all transfers. A report sheet, dated 02/25/18, also identified Resident #120 required the use of a Hoyer lift for all transfers. Review of the resident's progress notes, dated 02/24/18 at 2:15 P.M., written by RN #300 identified Resident #120 had abnormal right lower leg positioning; observed resident lying in bed with right knee cap swollen and did not line with left knee cap; residents right lower leg from knee down had abnormal positioning. The note identified calling the physician and receiving an order for [REDACTED].#300 documented notifying x-ray company of ordered x-ray. Progress notes, dated 02/25/18 at 9:32 A.M., identified the radiology company was in the facility to complete Resident #120's x-ray. On 02/25/18 at 11:49 A.M., Resident #120 x-ray results were reported to the physician, whom ordered for Resident #120 to go to the hospital. Review of the hospital records, dated 02/25/18, identified a closed [MEDICAL CONDITION] end of the femur. The hospital completed a CAT scan dated 02/26/18, to further evaluate the fracture, which revealed an acute periprosthetic [MEDICAL CONDITION] metaphysis of the right femur with 4.2 centimeter (cm.) of posterior displacement, 2 cm. of medial displacement and 4.4 cm. of overlap of the distal condylar fracture fragment. Review of the facility's SRI Control Number 2, dated 02/25/18 submitted at 4:22 P.M., identified an injury of unknown origin was reported. The report identified Resident #120 had a [MEDICAL CONDITION]. The investigation included a written statement from Licensed Practical Nurse (LPN) #1. LPN #1 revealed on the morning of 02/24/18 at 4:30 A.M., she overheard State tested Nursing Aide (STNA) #800 and #900 in Resident #120's room saying she needed to sit up and help them. LPN #1 identified STNA #800 and #900 had the sit-to-stand lift, laying across the bed. LPN #1 stated she asked the nursing assistants what they were doing and they identified Resident #120 was getting up for a shower and the resident would not help them and she would not stand. LPN #1 then stated she told the nursing assistants Resident #120 required lifting with a Hoyer lift, and STNA #800 replied no she was not and stated she was a two-person assist with a stand lift. LPN #1 then identified she repeated she was pretty sure she was a Hoyer lift and that she would check. LPN #1 stated she told the nursing assistants not to transfer the resident and to complete a bed bath. LPN #1 documented the nursing assistants did not report to her Resident #120 had fallen, and the LPN did not see Resident #120 on the ground, that she only saw the stand lift in front of Resident #120, while the resident was in bed. Review of a written statement from Registered Nurse (RN) #300, dated 02/25/18, identified she was notified by LPN #5 that she needed to assess Resident #120's knee. RN #300 documented Resident #120's right knee cap was swollen and did not line up with left knee cap; right lower leg had abnormal positioning. RN #300 documented she was told Resident #120 was transferred with a stand up lift on 02/24/18 and was a two-person lift with no mechanical lift being used. RN #300 documented after receiving all this information she got an order from the physician for an x-ray. RN #300 confirmed she called the x-ray company and told them it needed to be done on Saturday (02/24/18). Further review of the facility's investigation revealed the Director of Nursing (DON) interviewed STNA #800 on 02/25/18 at 3:22 P.M., on the phone, to investigate the incident with Resident #120. The DON identified STNA #800 and STNA #900 were in the room with Resident #120 on 02/24/18 at 4:30 A.M. and attempted to transfer her but her knees gave out. STNA #800 then identified she attempted to use the stand lift because she was too weak to transfer with two person assists. The DON identified a follow up phone call investigation occurred on 02/25/18 at 4:16 P.M. and STNA #800 identified Resident #120 did not fall and stated they literally had a hold of her the entire time and indicated the resident's knees touched the floor. The DON interviewed STNA #900 on 02/25/18 at 5:39 P.M. to continue the investigation. STNA #900 identified STNA #800 requested her assistance to transfer Resident #120, and they did so with two-person assist and did not use mechanical lift. STNA #900 identified Resident #120's knees buckled, they lowered the resident to her knees and scooped her back onto the edge of her bed. STNA #900 reported the sit-to-stand lift was obtained and used to move Resident #120 to the center of the bed. Interview with the DON and Administrator, on 04/03/18 at 2:10 P.M., confirmed STNA #800 and #900 improperly transferred Resident #120 by not using the mechanical lift. The STNAs used a sit-to-stand lift, which required the resident to place weight on her lower legs on 02/24/18 at 4:30 A.M. As a result of the incident, the facility took the following action to correct the deficient practice by 02/27/18: · STNA #800 was terminated on 02/25/18; and STNA #900 received education and had to complete a return demonstration of mechanical lifts prior to working in the facility again. · On 02/25/18, the DON conducted an entire in-house audit of all residents to ensure no unreported injuries. · On 02/25/18, audits to ensure all Kardex and report sheets had residents properly identified with type of mechanical lift to be used. · On 02/25/18, therapy re-evaluated all residents using mechanical lifts to ensure identified properly. · By 02/27/18, all nursing staff were educated on the use of mechanical lifts, where to locate the information in resident's plan of care including transfer care, and all nursing staff had return demonstration of mechanical lift use prior to caring for any residents. · By 02/27/18, the facility educated all staff to ensure any change in condition were immediately reported to the licensed nurse. If fractures were suspected, the physician orders [REDACTED]. · On 02/27/18, the facility conducted audits to ensure timely notification of changes in conditions, timely follow up on resident conditions, and proper documentation. This deficiency substantiated Complaint Number OH 010.