Every finding on record at Crestwood Ridge Skilled Nursing and Rehab

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on resident record review, staff interview, review of hospital records, and review of facility policy, the facility failed to ensure a resident was transferred in a manner which prevented accidents. This affected one resident (#16) out of the four residents reviewed for falls. The facility census was 47. Findings include:Record review for Resident #16 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included osteopenia, age-related osteoporosis with current pathological fracture, functional quadriplegia, epilepsy, and cerebral palsy. Review of the 5-Day Minimum Data Set assessment, dated 06/14/26, revealed the resident was assessed to have impaired cognition. Review of the care plan, revised 10/30/23, revealed the resident required assistance with Activities of Daily Living (ADLs). Interventions included hoyer lift for all transfers. Review of the nurses progress note, dated 05/28/26, revealed on 05/27/26 staff nurse was alerted to residents room after two staff members were transferring the resident back into bed with a mechanical lift. Noted lift pad not properly placed and resident was lowered to floor. Wheelchair and bed breaks were both locked. Resident assessed by staff nurse, range of motion completed with complaints of pain to left lower extremity. Physician notified and resident was transferred to the hospital for evaluation. Review of the hospital visit notes, dated 05/27/26, revealed active problem osteoporosis with current pathological fracture. Resident complaining of pain to right knee. Telephone interview on 07/07/26 at 4:37 P.M. with Certified Nursing Assistant (CNA) #206 confirmed on 05/27/26 Resident #16 was being transferred from the wheelchair to the bed by herself and CNA #291 using a hoyer lift. CNA #206 confirmed the two CNAs placed the four loops on the corners of the lift pad onto the hooks of the hoyer lift and began raising Resident #16 up when the loop supporting the left lower side of the resident popped off the hook and the resident began sliding off the lift pad. CNA #206 confirmed she immediately caught the resident and CNA #291 rushed over to help her gently lower the resident to the floor. CNA #206 confirmed Resident #16 did not hit any part of her body on anything during the incident. CNA #206 confirmed the lift pad and hoyer lift were not broken before or after the incident. Telephone interview on 07/07/26 at 4:48 P.M. with CNA #291 confirmed she was assisting CNA #206 to transfer Resident #16 from the wheelchair to the bed using a hoyer lift on 05/27/26. CNA #291 confirmed the lift pad loops were placed on the hoyer lift hooks appropriately and as they began to raise the resident up in the air one of the loops popped off the hook causing the resident to begin to slide towards the floor. CNA #291 confirmed CNA #206 immediately caught the resident, preventing her from falling to the floor roughly, and she rushed over to help CNA #291 gently lower the resident to the floor. CNA #291 confirmed Resident #16 did not hit any part of her body on anything during the transfer. CNA #291 confirmed the lift pad and hoyer lift were not broken before or after the incident. Interview on 07/08/26 at 8:40 A.M. with the Administrator and Director of Nursing (DON) confirmed on 05/27/26 Resident #16 was lowered to the floor by CNA #206 and CNA #291 after a lift pad loop came loose from the hook of the hoyer lift causing the resident to begin falling to the floor. They confirmed both CNA #206 and CNA #291 denied Resident #16 hitting any part of her body on any machines or furniture in the room as they were able to catch her and gently lower her to the floor. They confirmed the resident was sent to the hospital and x-rays were taken which showed the resident had a pathological fracture of the left femur. They confirmed the resident had osteopenia and osteoporosis and a history of previous fracture of the left femur. The deficient practice was corrected on 05/28/26 when the facility implemented the following corrective actions: On 05/27/26 at 7:00 P.M. Registered Nurse (RN) #409 completed a head-to-toe assessment of Resident #16. The resident was subsequently sent to the hospital for examination.On 05/27/26 at 7:08 P.M. RN #409 notified the DON of the incident.On 05/27/26 at 7:19 P.M. RN #409 notified the Administrator of the incident.On 05/27/26 at 7:20 P.M. RN #409 notified the residents physician and the residents guardian of the incident.On 05/27/26 at 8:00 P.M. the DON inspected the hoyer lift pad used to transfer Resident #16 and found it was in good repair.On 05/27/26 from 8:00 P.M. to 8:30 P.M. the DON provided education to all CNAs and licensed nurses regarding the proper use of the hoyer lift, inspection of the hoyer pad to ensure it is in good repair, and ensuring the hoyer lift was functioning properly.On 05/27/26 and 05/28/26 Maintenance Director #600 completed a house-wide audit on all hoyer pads in the facility to ensure they were all in good repair. Any hoyer pads deemed unsafe/in poor repair were taken out of service.On 05/28/26 at 7:40 A.M. Maintenance Director #600 completed a house-wide audit of all mechanical lift in the facility to ensure proper function and safety with no concerns identified.On 05/28/26 at 10:00 A.M. a root-cause analysis of the incident was completed by the DON, the Administrator, and Medical Director #503.On 05/28/26 at 1:00 P.M. the DON finished completing competencies with all CNAs and licensed nurses on transferring a resident with a mechanical lift. The DON will conduct weekly audits for four weeks, then randomly thereafter, of five residents who are transferred using a mechanical lift to ensure transfers are completed safely and per policy and to ensure at least two staff are present and participating in the transfer of a resident using a mechanical lift. Any non-compliance will result in Ad-hoc education.Maintenance Director #600 will conduct weekly audits for four weeks, then randomly thereafter, of the hoyer pads in house and mechanical lifts to ensure they are all in good repair and functioning properly. Any hoyer pads or mechanical lifts found not to be in good repair will immediately be taken out of service.The DON will complete an audit on all residents requiring a mechanical lift, then make a color chart to go with it matching lift size based on manufacturing instructions.Housekeeping Supervisor #700 will complete education with all housekeeping staff on 05/28/26 regarding daily sling inspections as they come through the laundry. Results of the audits will be reviewed during the facility QAPI meetings to ensure compliance. A one-time QAPI meeting was held in house on 05/28/26 at 10:00 A.M.This deficiency represents non-compliance investigated under Complaint Number 3054605.

Based on record review, interview and policy review, the facility failed to ensure residents were free from abuse. This resulted in an Actual Harm when Resident #12 was assaulted by Resident #39 on 01/11/25. Resident #12 was punched in the face and was temporarily unconscious. Resident #12 was evaluated at the local hospital, diagnosed with mild closed head injury, lip abrasion, and cervical strain. This affected one (Resident #12) of three residents reviewed for abuse. The facility census was 47. Findings include: Review of the medical record for Resident #12 revealed an admitted on 03/22/24. Diagnoses included intracranial injury with loss of consciousness on 06/29/23, major depressive disorder, dementia, personality disorder, generalized anxiety disorder, borderline personality disorder, bipolar two disorder, and post-traumatic stress disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/14/24, revealed that Resident #12 was cognitively intact. Resident #12 used a wheelchair to self-propel in the facility. Review of medical record for Resident #39 revealed an admitted [DATE]. Diagnoses included unspecified focal traumatic brain injury without loss of consciousness, paranoid schizophrenia, epilepsy, hemiplegia, panic disorder, extrapyramidal and movement disorder, Schizoaffective disorder depressive type, pseudobulbar affect, general anxiety disorder, attention deficit hyperactivity disorder, psychotic disorders with delusions due to known physiological condition, auditory hallucinations, visual hallucinations (09/08/22), suicidal ideations (09/08/22), homicidal ideations (09/22/22), and post-traumatic stress disorder chronic (09/08/22). Review of the quarterly MDS assessment, dated 12/24/24, revealed Resident #39 was cognitively intact. Review of the plan of care dated 12/24/24 revealed that Resident #39 had behaviors and problems related to profanity, fabricating stories, angry verbal outbursts towards others, spitting on staff, throwing things at staff, refusing care, aggression towards others, attention seeking, stating that he had been misdiagnosed , physical behaviors towards inanimate objects, kicking things, refuse vitals, inappropriate sexual behaviors towards staff, resident referred to therapy multiple times related to falls, history of refusals to medication and physical assessments, and requesting more anxiety medications. Interventions included one on one at times of agitation, administer medications, provide risks and benefits during refusals of care, intervention due to physical outburst on 01/01/23 to 01/02/23 shift, monitor and assess for behaviors, physical outbursts over shower times that he agrees upon then suddenly changes his mind, provide a calm and relaxing environment, refer to psych, and resident was educated to ask for assistance when he was in a difficult situation. Resident #39 used a wheelchair to self-propel in the facility. Further review of the plan of care dated 12/24/24 revealed Resident #39 was at risk for alteration in cognitive function related to anxiety, depression, traumatic brain injury, paranoid schizophrenia, panic disorder, schizoaffective disorder, pseudobulbar affect, ADHD, psychotic disorder, hallucinations, delusions, and post-traumatic stress disorder. Interventions included allow resident time to remember and respond, be as consistent as possible with daily routine, be patient with resident, continue to converse and communicate with resident daily despite cognitive deficits, ensure resident's physiological needs are met, formulate plan for hospital admission if condition warrants, medication as ordered, provide a calm and relaxing environment, provide activities of choice, repeat directions as needed, report any changes to physician, and speech therapy as ordered. Review of a progress note dated 01/11/25 by Registered Nurse (RN) #290 documented Resident #12 and Resident #39 were in a verbal exchange as they were outside for a smoke break. Resident #39 called Resident #12 names, and Resident #12 told him to shut up. Resident #39 swung at Resident #12. Resident #12 swung her arm sideways to keep from being hit. Resident #39 wheeled himself to get in front of her and connected with her face again. Resident #39 continued to curse at Resident #12. Resident #39 stated he didn't care if it was female, male or child he would hit whomever he felt needed it. Resident #12 was removed from the smoking patio and immediately taken with staff to the nursing station and was supervised through the rest of the night. RN #290 stated she notified the physician and responsible party. Review of the local police incident report dated 01/11/25 at 7:26 P.M. documented Resident #39 was the suspect who was being investigated for disorderly conduct. Residents were fighting and one resident had possibly been assaulted. Resident #12 had suffered minor injuries. Currently still under investigation. Review of a skin assessment dated [DATE] revealed Resident #12 had an abrasion to the upper inner lip measuring 0.2 centimeter (cm) by 0.1 cm and a purplish area to the lower inner lip. Resident #12 had scant amount of bleeding and a cool wet cloth was applied to the area. Resident #12's teeth were intact. There was redness to the upper right cheek and no bruising. Review of a hospital document dated 01/11/25 revealed Resident #12 was sent to the hospital to be evaluated after another resident (Resident #39) struck her in the right side of the face with a fist. Resident #12 was diagnosed with assault with minor closed head injury, lip abrasion, and cervical strain. She had perhaps lost consciousness for two minutes. She was alert and oriented to her name and place and situation. She admits to some discomfort in her mouth where it appears that she had an abrasion to her right upper lip. She complains of discomfort to the right side of her head but had no bruising. She was positive for neck pain. A Computed Tomography (CT) scan to head demonstrated no evidence of midline shift mass effect, acute bleeding, fracture, or hematoma. Resident #12 seems to be back to her baseline at this point. She was alert and knew where she was at. Resident #12 remembered the event that resulted in her being struck to the face. Discussed the case with the Medical Director, who returned Resident #12 to the facility with an order for neurological checks every four hours for 24-hours. During an interview on 01/14/25 at 3:21 P.M., RN #290 stated Resident #12 was hit by Resident #39, and she was standing behind them. RN #290 stated Resident #39 was cursing and yelling at staff to be on the smoke break on time. RN #290 stated they were getting residents out the smoke patio door when a verbal altercation between Resident #12 and Resident #39 broke out. Resident #12 had tried to stand up for staff in saying they were busy and was only a few minutes short in getting a timely smoke break. RN #290 stated that Resident #12 threw an arm up to block Resident #39 from hitting her, and was struck in the face by his hand. RN #290 was coming from behind her to break Resident #39 from hitting Resident #12. Resident #39 hit Resident #12 a second time in the face, and she went slumped over unconscious in her wheelchair. RN #290 got to Resident #12 to support her limp body to make sure she was safe. RN #290 stated she directed Resident #39 to another part of the smoke patio. RN #290 stated Resident #39 was calling Resident #12 a faker, and stating he would hit any woman, man, or child if need be. Resident #12 was unconscious for a few seconds because yelling her name did not arouse here. Resident #12 woke up as they were getting her inside the building. Her bottom lip was purple and bleeding. Resident #12 repeated he hit me. RN #290 stated Resident #12 went to the emergency room to be assessed. RN #290 stated to the physician she thought Resident #12 was knocked out. During an interview on 01/14/25 at 5:34 P.M., STNA #237 stated she ran to Resident #12 and saw her eyes closed and she was slumped over in the wheelchair. Resident #39 was yelling on the other side of the patio, saying she was faking. She was moved back in the facility, and startled and started to cry, and was upset. She was taken to the nursing station. Review of facility policy titled Abuse Prohibition dated unknown stated that residents will not be subjected to abuse, neglect, exploitation, mistreatment, or misappropriation of property by anyone. This deficiency represents non-compliance investigated under Complaint Number OH00161543.

Based on observation, review of dietary menus, and staff interview, the facility failed to serve all food items from the preplanned menu during meal service. This had the potential to affect all 44 residents in the facility. The census was 44. Findings include: Review of the dietary menu for week one, which contained the date of 12/11/24, revealed the meal was to include spaghetti sauce with meatballs, pasta, green beans, wheat bread, margarine, and cake. Observation on 12/11/24 at 11:32 P.M. revealed the cook was preparing the meals which included spaghetti sauce with meatballs, pasta, green beans, and cake. Further observation revealed the cook was not serving bread with the meals as indicated on the menu. Interview with Dietary Manager (DM) #167 on 12/11/24 at 2:07 P.M. verified the menu for 12/11/24 was to have wheat bread included with the meal and confirmed the facility did not serve bread on the lunch trays. DM #167 stated they just forgot to add the bread to the meal trays.

Based on review of Quality Assurance and Performance Improvement (QAPI) staff sign-in sheets and staff interview, the facility failed to have QAPI meetings at least quarterly and failed to have all required members in attendance. This had the potential to affect all 44 residents in the facility. The census was 44. Findings include: Review of the QAPI meeting sign-in sheet dated 01/11/24 revealed the facility's administrator, owner, board member, or other individual in a leadership role was not in attendance for this meeting. Further review of the QAPI sign-in sheets revealed a meeting was held 03/12/24 and the next meeting was not held until 08/22/24. There was no documentation of a second quarter (April, May, or June) QAPI meeting occurring in 2024. Interview with the Administrator on 12/12/24 at 1:40 P.M. verified the facility did not have the administrator, owner, board member, or other individual in a leadership role attend the QAPI meeting on 01/11/24. The Administrator also verified the facility did not hold QAPI meetings at least quarterly as the facility had a meeting on 03/12/24 and did not have another meeting until 08/22/24.

Based on observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure a resident's dignity was maintained by placing a cover over a urinary catheter drainage bag. This affected one (#28) of three residents the facility identified as having indwelling urinary catheters. The facility census was 44. Findings include: Record review for Resident #28 revealed the resident was admitted to the facility on [DATE] and had diagnoses including muscle weakness, neuromuscular dysfunction, and spastic diplegic cerebral palsy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was assessed to have intact cognition and to have an indwelling urinary (Foley) catheter. Review of an active physician order dated 10/03/24 reveled Resident #28 was to have a 16 French Foley catheter in place. Observation on 12/09/24 at 12:40 P.M. revealed Resident #28 was lying in bed with the door open. The resident's Foley catheter drainage bag was hanging on the side of the bed visible from the doorway. No dignity bag was in place over the bag and yellow urine was visible in the tubing and drainage bag. Observation on 12/10/24 at 12:55 P.M. revealed Resident #28 was lying in bed with the door open. The resident's Foley catheter drainage bag was hanging on the side of the bed visible from the doorway. No dignity bag was in place over the bag and yellow urine was visible in the tubing and drainage bag. Observation on 12/11/24 at 9:30 A.M. revealed Resident #28 was lying in bed with the door open. The resident's Foley catheter drainage bag was hanging on the side of the bed visible from the doorway. No dignity bag was in place over the bag and yellow urine was visible in the tubing and drainage bag. Interview with Activity Director #118 at the time of the observation confirmed there was not a dignity bag in place but there should have been. Review of the undated facility policy titled, Foley Catheter Care, revealed staff would place the Foley catheter drainage bag inside of a Foley catheter privacy bag.

Based on medical record review and staff interview, the facility failed notify a physician of resident blood glucose levels when the level was above 400 milligrams per deciliter (mg/dL) as ordered. This affected one (#20) of five residents reviewed for unnecessary medications. The facility census was 44. Findings include: Review of Resident #20's medical record revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, unspecified severe protein calorie malnutrition, respiratory failure, major depressive disorder, generalized anxiety disorder, and dysphagia. Review of Resident #20's physician order dated 03/29/24 revealed the resident was ordered Humalog Kwikpen subcutaneous (SQ) solution pen-injector 100 unit/ml to be injected as per sliding scale before meals and at bed time for diabetes as followed: for blood glucose levels between zero (0) and 149 mg/dL, notify the physician and administer no insulin; between 150 mg/dL and 199 mg/dL, give two (2) units of insulin; between 200 mg/dL and 249 mg/dL, give four (4) units of insulin; between 250 mg/dL and 299 mg/dL, give six (6) units of insulin; between 300 mg/dL and 349 mg/dL, give eight (8) units of insulin; between 350 mg/dL and 399 mg/dL, give 10 units of insulin; and blood glucose levels above 400 mg/dL, give 12 units of insulin and notify the physician. Further review of Resident #20's medical record revealed from 11/10/24 to 12/09/24 Resident #20's blood glucose was over 400 mg/dL 12 times and the physician was only notified on four occasions. The physician was not notified on 11/12/24 with a blood glucose level of 432 mg/dL, 11/15/24 with a blood glucose level of 500 mg/dL, on 11/17/24 with a blood glucose levels of 408 mg/dL and 426 mg/dL, on 11/21/24 with a blood glucose level of 567 mg/dL, 11/22/24 with a blood glucose level of 498 mg/dL, 11/25/24 with a blood glucose level of 520 mg/dL, 11/27/24 with a blood glucose level of 450 mg/dL, on 11/28/24 with a blood glucose level of 411 mg/dL, on 12/02/24 with a blood glucose level of 418 mg/dL, on 12/04/24 with a blood glucose level of 488 mg/dL, and on 12/05/24 with a blood glucose levels of 511 mg/dL. Interview with Regional Nurse #200 on 12/12/24 at 10:20 A.M. verified Resident #20's blood glucose level was above 400 mg/dL on 11/12/24, 11/15/24, 11/17/24, 11/21/24, 11/22/24, 11/25/24, 11/27/24, 11/28/24, 12/02/24, 12/04/24, and 12/05/24 and the physician was not notified as ordered.

Based on medical record review and staff interview, the facility failed to complete a Significant Change in Status Assessment for a resident enrolled in a hospice program. This affected one (#44) of three residents reviewed for Minimum Data Set assessments. The facility census was 44. Findings include: Record review for Resident #44 revealed the resident admitted to the facility on [DATE]. Diagnoses included dyskinesia, psychosis, essential primary hypertension, dementia, carbuncle, gout, depression, and adult failure to thrive. Review of Resident #44's progress notes dated 09/04/24 revealed the facility called to notify Resident #44's family of a change in condition. Further review of the progress notes confirmed Resident #44 was admitted to hospice services effective 09/12/24. Review of Resident #44's contract for hospice confirmed hospice services were effective on 09/12/24. Further review of Resident #44's medical record revealed no Significant Change in Status Minimum Data Set (MDS) assessment was completed when the resident received hospice services. Interview with MDS Licensed Practical Nurse (LPN) #134 confirmed Resident #44 was under hospice care effective 09/12/24 and remained on hospice until Resident #44's death at the facility on 10/27/24. MDS LPN #134 confirmed the facility failed to complete a Significant Change in Status MDS assessment for Resident #44 and state the assessment should have been completed within 14 days of hospice enrollment.

Based on staff interview and medical record review, the facility failed to to ensure Pre-Admission Screening and Resident Review (PASARR) documents were accurate regarding resident current conditions and diagnoses. This affected two (#23 and #27) of two residents reviewed for PASARR documents. The census was 44. Findings include: 1. Review of Resident #27's medical record revealed an admitted [DATE]. Diagnoses included nephropathy induced by other drugs, type two diabetes mellitus with diabetic neuropathy, cellulitis, adult failure to thrive, hyperlipidemia, gout due to renal impairment, anxiety disorder, and bipolar disorder manic without psychotic features. Review of Resident #27's medical record revealed on 05/15/24 the resident had a new diagnosis of bipolar disorder manic without psychotic features. Review of Resident #27's most current PASARR dated 09/08/23 revealed there was no updated diagnosis of bipolar disorder manic without psychotic features. Interview with Regional Nurse #200 on 12/12/24 at 12:39 P.M. verified there was not an updated diagnosis of bipolar disorder manic without psychotic features on Resident #27's most recent PASARR, and an updated PASARR should of been completed with the new diagnosis. 42728 2. Record review for Resident #23 revealed the resident was admitted to the facility on [DATE] and had diagnoses including anxiety disorder, senile degeneration of the brain, and dissociative identity disorder. The resident had a new diagnosis of schizoaffective disorder added on 11/14/23. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was rarely/never understood. Review of the completed PASARR assessments for Resident #23 revealed no updated PASARR was completed after the addition of the diagnosis of schizoaffective disorder was added on 11/14/23. Interview with Regional Nurse #200 on 12/11/24 at 3:15 P.M. confirmed a new PASARR assessment was not completed for Resident #23 following the addition of a new mental health diagnosis.

Based on medical record review and staff interview, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) after receiving Medicare Part A services at the facility as required. This affected three (#04, #28, and #40) of three residents reviewed. The facility census 44. Findings include: 1. Record review for Resident #04 revealed the resident admitted to the facility on [DATE]. Diagnoses included diabetes mellitus, essential primary hypertension, schizoaffective disorder, major depressive disorder, anxiety disorder, and schizophrenia. Review of Resident #04's Minimum Data Set (MDS) assessment dated [DATE] revealed she was mildly cognitively impaired. Review of Resident #04's Medicare cut letter dated 09/20/24 revealed she was cut for Medicare skilled services effective 09/23/24; however, the facility failed to provide Resident #04 a SNF ABN. 2. Record review for Resident #28 revealed the resident admitted to facility on 11/28/24. Diagnoses included urinary tract infection, asthma, aphasia, dysarthria, dysphasia, anemia, anxiety disorder, and major depressive disorder. Review of Resident #28's MDS assessment dated [DATE] revealed she was mildly cognitively impaired. Review of Resident #28's Medicare cut letter dated 11/05/24 revealed she was cut from Medicare skilled services effective 11/07/24; however, the facility failed to provide Resident #28 a SNF ABN. 3. Record review for Resident #40 revealed the resident admitted to the facility on [DATE]. Diagnoses included hyperlipidemia, peripheral vascular disease, dementia, adjustment disorder, essential primary hypertension, insomnia, and anxiety disorder. Review of Resident #40's MDS assessment dated [DATE] revealed he was cognitively impaired. Review of the Resident # 40's Medicare cut letter dated 12/04/24 revealed he was cut from Medicare skilled services, effective 12/06/24; however, the facility failed to provide Resident #40 a SNF ABN. Interview on 12/12/24 at 10:04 A.M. with Regional Nurse (RN) #200 confirmed Resident #04, Resident #28, and Resident #40 remained in the facility after their Medicare skilled services were cut and the facility failed to provide each resident a SNF ABN as required.

Based on medical record review and staff interview, the facility failed develop a plan of care to address a resident's post traumatic stress disorder. This affected one (#31) of one residents reviewed for behavior and emotional needs. The facility identified five residents with a diagnosis of post traumatic stress disorder. The facility census was 44. Findings include: Review of Resident #31's medical record revealed an admitted [DATE] with diagnoses including traumatic brain injury, paranoid schizophrenia, hemiplegia affecting the left non-dominant side, psychotic disorder with delusions, auditory and visual hallucinations, suicidal ideations, paranoid personality disorder, major depressive disorder, hereditary and idiopathic neuropathy, post traumatic stress disorder, homicidal ideations, edema, and hyperlipidemia. Review of the 11/08/24 quarterly Minimum Data Set (MDS) assessment revealed Resident #31 was cognitively intact and used a wheelchair to aid in mobility. The resident was coded as having a diagnosis of post traumatic stress disorder (PTSD). Further review of Resident #31's medical record on 12/10/24 revealed there was no care plan to address the resident's PTSD and identified triggers. Interview with Regional Nurse #200 on 12/10/24 at 3:37 P.M. verified Resident #31 did not have a care plan for PTSD that identified triggers.

Based on record review, hospital record review and interview, the facility failed to allow Resident #49 to return to the facility upon discharge from the hospital. This affected one resident (#49) of three residents reviewed for hospitalization . The facility census was 47. Findings include: Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including unspecified psychosis, post-traumatic stress disorder, Bipolar disorder, schizoaffective disorder, chronic obstructive pulmonary disease, suicide attempts, and intellectual disabilities. Review of admission records revealed this resident had a court appointed guardian, with an effective date of 06/13/22. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had a Brief Interview Mental Status (BIMS) score of ten out of 15 which indicated she had moderate cognitive impairment. Review of a nursing progress note dated 07/26/24 at 9:50 P.M. revealed the resident was sent to the emergency room after confiding in this nurse that she swallowed two AAA batteries. Room checked and found remote on bed without batteries, trash checked, drawers checked. Resident adamant about swallowing batteries. The note indicated the physician and Assistant Director of Nursing (ADON) were notified. An attempt to reach the resident's legal guardian revealed the guardian's number was disconnected. A nursing progress note dated 07/29/24 at 4:04 A.M. revealed resident had batteries removed via scope. Nurse stated she should be returning back to the facility today. Record review revealed no additional progress notes related to why the resident did not return to the facility as planned/noted in the above note on 07/29/24. Interview with Licensed Practical Nurse #20 on 08/10/24 at 11:20 A.M. revealed Resident #49 was residing in the facility until 07/26/24. The resident was transferred to the hospital emergency room due to an acute change in condition with concerns related to the resident ingesting batteries. Interview with Licensed Practical Nurse #10 on 08/10/24 at 11:30 A.M. revealed Resident #49 was sent to the hospital and did not return. Interview with the Administrator on 08/10/24 at 11:45 A.M. revealed Resident #49 was transferred to the hospital from the facility on 07/26/24. Resident #49 was then sent from the first hospital to a second hospital for removal of a foreign body following ingestion (that had occurred at the nursing home). The Administrator stated the second hospital allowed Resident #49 to leave their facility against medical advice (AMA) and she went out in the community. The Administrator stated after the resident left the hospital AMA and was out in the community, he believed they did not have to take her back. During the interview, the Administrator verbalized awareness of the resident being taken back to the hospital/emergency room after she left the second hospital AMA due to concerns of her ingesting another substance at a local store. Review of hospital medical record documentation, dated 07/31/24 at 12:15 P.M. and completed by case management staff revealed the case manager/social worker was advised the resident was in the emergency department (ED) and the facility was refusing to accept her back. The note indicated the resident had a legal guardian. The note revealed the social worker was advised the resident had been in the ED earlier in the week and was transferred to another hospital (name provided of second hospital). While she was at this other hospital, she was allowed to sign out against medical advice (AMA) despite having a legal guardian. The resident found a ride and emergency medical services were subsequently called to a Walmart the resident was at as she (the resident) reported to someone there she had taken a bottle of Benadryl. After receiving treatment in the ED, hospital staff contacted the nursing home to advise them that due to the resident not having the capacity to sign herself out AMA, she was still their resident. The Administrator indicated he refused to allow the resident to return, stating she was a community member and not their problem. The Administrator confirmed the resident had resided in the facility for approximately two months prior to being transferred to the hospital for acute medical care (after swallowing batteries). The hospital medical record included the Administrator advised he wasn't taking the resident back, it didn't matter what was said. Hospital staff informed the Administrator he would be required to issue the resident a 30 day discharge notice, which the Administrator stated he did not. The hospital staff involved with the situation indicated the Ombudsman would be notified and the Administrator indicated he did not care and then he abruptly ended the call. On 07/31/24 at 2:26 P.M. the case manager/social worker spoke with the discharge planner at the other hospital involved with resident's care. The discharge planner revealed Resident #49 had received care, was stabilized, ready for discharge back to the nursing home and she had communicated this to the nursing home (date not provided). The discharge planner had started the prior authorization process for the resident to return and were only waiting on an occupational therapy (OT) evaluation. The discharge planner revealed she was unaware the resident was tired of waiting so the staff inappropriately allowed her to sign an AMA. On 07/31/24 at approximately 3:53 P.M. hospital staff reached out the facility medical director to discuss the situation with him including the facility was refusing to allow Resident #49 to return. The note indicated the medical director stated he could see both views on the situation and he'd call the NH Administrator to reconsider. The medical director text back shortly thereafter advising the administrator would not reconsider. On 07/31/24 at 4:24 P.M. the hospital case manager/social worker spoke with the Ombudsman regarding the situation and refusal of the facility to allow the resident to return. The note indicated the Ombudsman was also in agreement that refusing to allow the resident to return was a violation of her rights and indicated she would reach out to the facility to let them know they would have to accept the resident back. Continued review of hospital notes from 08/01/24 indicated hospital staff were actively working on trying to find a new discharge location that was appropriate for the resident as the facility continued to refuse to allow her to return. A note dated 08/01/24 at 3:43 P.M. revealed staff at the facility had been instructed not to talk to anyone calling from the hospital regarding Resident #49 and that they would have to speak to the Administrator. Hospital staff had reached out to the facility in an attempt to get a copy of the resident's Pre-Admission Screening and Resident Review (PASRR) documents. Hospital discharge planning continued on 08/02/24 for the resident who had been ready to discharge back to the facility on [DATE]. The resident was ultimately discharged from the hospital to an appropriate facility for ongoing care and treatment post hospitalization . This deficiency represents non-compliance investigated under Complaint Number OH00156427.

Based on record review and interview the facility failed to provide a written bed-hold notice to Resident #49 and Resident #49's legal guardian at the time of the resident's transfer to the hospital as required. This affected one resident (#49) of three residents reviewed for hospitalization . The facility census was 47. Findings include: Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including unspecified psychosis, post-traumatic stress disorder, Bipolar disorder, schizoaffective disorder, chronic obstructive pulmonary disease, suicide attempts, and intellectual disabilities. Review of admission records revealed this resident had a court appointed guardian, with an effective date of 06/13/22. The resident also had a Medicaid payor source. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had a Brief Interview Mental Status (BIMS) score of ten out of 15 which indicated she had moderate cognitive impairment. Review of a nursing progress note dated 07/26/24 at 9:50 P.M. revealed the resident was sent to the emergency room after confiding in this nurse that she swallowed two AAA batteries. Room checked and found remote on bed without batteries, trash checked, drawers checked. Resident adamant about swallowing batteries. The note indicated the physician and Assistant Director of Nursing (ADON) were notified. An attempt to reach the resident's legal guardian revealed the guardian's number was disconnected. Record review revealed a document titled Transfer/Discharge Notice. The document included the resident's name and listed the date of discharge/transfer as 07/27/24. The reason for discharge/transfer included the resident was discharged to the hospital due to possible self-harm (swallowed batteries times two). The notice was documented to be reviewed by the facility social service director (SSD) and reviewed with the resident. There was no evidence the resident's legal guardian was provided this notice or included in a review of the notice. The notice also contained information related to bed holds including but not limited to: All residents or resident representatives will be notified in regards to the number of bed hold days available for the use of the resident on the first business day following a transfer from the facility. Notification to be completed by the Business Office Manager. Record review revealed no evidence the resident's legal guardian was provided information related to the number of bed hold days the resident had available as required. There was no evidence the legal guardian was provided a written bed hold notice at the time of the resident's transfer or on the first business day following the transfer from the facility as required. Record review revealed the facility failed to permit Resident #49 to return to the facility following her hospitalization . Interview with the Administrator on 08/10/24 at 11:45 A.M. verified Resident #49's legal guardian was not provided a bed hold notice as required. This deficiency represents non-compliance investigated under Complaint Number OH00156427.

Based on record review and interview the facility failed to ensure Resident #49's legal guardian was provided, in writing a transfer/discharge notice at the time the resident was transferred to the hospital as required. This affected one resident (#49) of three residents reviewed for hospitalization . The facility census was 47. Findings include: Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including unspecified psychosis, post-traumatic stress disorder, Bipolar disorder, schizoaffective disorder, chronic obstructive pulmonary disease, suicide attempts, and intellectual disabilities. Review of admission records revealed this resident had a court appointed guardian, with an effective date of 06/13/22. The resident also had a Medicaid payor source. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had a Brief Interview Mental Status (BIMS) score of ten out of 15 which indicated she had moderate cognitive impairment. Review of a nursing progress note dated 07/26/24 at 9:50 P.M. revealed the resident was sent to the emergency room after confiding in this nurse that she swallowed two AAA batteries. Room checked and found remote on bed without batteries, trash checked, drawers checked. Resident adamant about swallowing batteries. The note indicated the physician and Assistant Director of Nursing (ADON) were notified. An attempt to reach the resident's legal guardian revealed the guardian's number was disconnected. Record review revealed no written evidence the resident's legal guardian was reached/notified of the resident's transfer to the hospital by facility staff at the time of the transfer. Record review revealed a document titled Transfer/Discharge Notice. The document included the resident's name and listed the date of discharge/transfer as 07/27/24. The reason for discharge/transfer included the resident was discharged to the hospital due to possible self-harm (swallowed batteries times two). The notice was documented to be reviewed by the facility social service director (SSD) and reviewed with the resident. There was no evidence the resident's legal guardian was provided this notice or included in a review of the notice. Record review revealed the facility failed to permit Resident #49 to return to the facility following her hospitalization . Interview with the Administrator on 08/10/24 at 11:45 A.M. revealed Resident #49 was transferred to the hospital from the facility on 07/26/24. Resident #49 was then sent from the first hospital to a second hospital for removal of a foreign body following ingestion (that had occurred at the nursing home). During the interview, no additional information was provided to indicate Resident #49's legal guardian had been provided written notice of the resident's transfer to the hospital. This deficiency represents non-compliance investigated under Complaint Number OH00156427.

Based on record review, policy review, review of the weather condition, review of Centers for Disease Control and Prevention (CDC) guidance, and resident and staff interviews, the facility failed to ensure staff provided adequate supervision to prevent a resident from be treated for hyperthermia during extreme weather conditions. This affected resident (Resident #8) of three residents reviewed for accidents. The facility census was 48. Findings include: Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, asthma, muscle wasting and atrophy, muscle weakness, and bipolar disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 was cognitively intact, required supervision with wheeling 150 feet, and rejected care. Resident #8 felt it was somewhat important to go outside and get fresh air when the weather was nice. Review of the care plan dated 06/20/24 revealed Resident #8 has a history of refusing medication and treatment. Interventions included staff were required to provide drinks frequently, monitor and assess for behaviors, document and notify physician of increased behaviors. Review of the focus alteration in mood with depression/anxiety found staff were required to ensure the resident's psychological needs were met. The resident was non-complaint with safety measures. Interventions included to document educational attempts made with resident and inform of negative outcomes related to non-compliance, and notify the medical doctor or nurse practitioner of non-compliance. Review of the medical record from 06/18/24 to 07/13/24 revealed there was minimal documentation regarding Resident #8's refusal of care and education of the health risks with refusal of specific care. On 06/19/24 and 06/20/24, Resident #8 refused morning medications. On 06/25/24, it was documented that Resident #8 was offered sunscreen several times but declined each time. On 07/01/24, Resident #8 refused Eliquis (a medication to that thins blood). On 07/02/24, Resident #8 refused morning medications. There was no documentation of the resident refused to come inside during extreme weather conditions and/or education to come inside if there was extreme weather conditions. There was no documentation to support staff provided increased supervision and fluids during extreme weather conditions. Review of the plan of care (POC) records for Resident #8 for 07/13/24 revealed specific timings documented as seen at 11:20 A.M. for hygiene (POC), and 12:41 P.M. for Bowel Movement (POC) and 3:59 P.M. for eating (POC). No additional encounters were found for 07/13/24 Review of the progress notes dated 07/13/24 at 5:24 P.M. indicated Resident #8 exhibited altered mental status, confusion, low blood pressure (134/44), and high temperature (103 Fahrenheit (F)). A medical doctor was promptly notified and ordered the transfer of the resident out of the building by 5:35 P.M. Further notes at 9:57 P.M. reported that the resident was flown to the local hospital due to urosepsis. Review of the physician orders dated 07/13/24 revealed instructions to send to the emergency room due to elevated temperature, low blood pressure, and altered mental status. Review of the pre-hospital care report dated 07/13/24 revealed Medic 223 was called to Resident #8's room for fever and low blood pressure with confusion. Staff member informed crew that she believes the resident was having a stroke or a heat stroke. Staff were unable to provide detailed events leading up to episode, last known well estimated as approximately one hour prior to calling Emergency Medical Services (EMS) (07/13/24 at 4:20 P.M.). Resident #8 was found to be confused, incoherent, speaking in short phrases, her skin was extremely hot, with remarkable erythema (skin redness) throughout and especially in face. Temporal artery obtained as 108.1 F, second attempt taken with read at 106.6 degrees F. The emergency room (ER) called EMS and asked EMS if they have the sunburn patient. The ER reported the facility called in report and stated Resident #8 was left outside for undetermined amount of time and may be having a heat stroke and sun poisoning. Review of the hospital records dated 07/13/24 for admission and discharge on 07/16/24 indicated Resident #8 arrived at the hospital with hyperthermia (106.6 F), confusion, deficits in bilateral lower extremities, and possible new hand contractures. Diagnoses included hyperthermia, urinary tract infection, left lower lobe pulmonary nodule, and hypotension. ER course included active cooling measures which included cooling blankets, status post one liter of cool water through intravenous and temperature decreased from 104 F to 100 F. The resident was reportedly outdoors for unknown amount of time on an extremely hot day with outdoor temperature at 90 F or higher. The resident presented with severe hyperthermia (temperature greater than 104 F), which improved and eventually resolved following multiple treatments. The physician documented although urosepsis can incite fever, temperatures to this severity and with such acuity in unlikely due to infection alone. Resident #8 was treated for urinary tract infection (UTI). Fever present upon admission more likely due to heat-related illness than infection due to rapid resolution. Interview on 07/18/24 at 9:17 A.M. with Licensed Practical Nurse (LPN) #17 confirmed staff should increase supervision and hydration when residents were sitting outside in the sun all day. Interview on 07/18/24 at 9:19 A.M. with Resident #8 stated she was outside everyday, and was able to self propel in the wheelchair. Resident #8 does not remember anything from 07/13/24. Observation on 07/18/24 between 11:00 A.M. and 11:06 A.M. with Resident #1, Resident #7 and Resident #8 revealed no staff members were outside with residents. Interview on 07/18/24 at 11:00 A.M. with Resident #1 stated Resident #8 was acting normal on 07/13/24 before and after she was sent inside. Resident #1 stated staff did not check on them for over two and a half hours on 07/13/24. However, she stated the staff typically come out every hour to check on residents. Interview on 07/18/24 at 11:06 A.M. with Resident #7 confirmed Resident #8 was outside most of the day on 07/13/24. Interview on 07/18/24 at 10:33 A.M. with Licensed Practical Nurse (LPN) #24 confirmed Resident #8 was outside in the courtyard on 07/13/24 for a significant amount of time. The resident received a medication at 5:17 P.M., and was sent out to the hospital at 5:47 P.M. LPN #24 suspected heatstroke when the Medication Aide requested her help in the resident's room. After assessing the resident, LPN #24 notified the physician, who promptly ordered the resident to be transferred to the hospital. During the assessment, LPN #24 observed that the resident was not sweating and had excessively hot skin. Interview on 07/18/24 at 12:30 P.M. with Dietary Aide (DA) #5 stated he was responsible for the 07/13/24 at 2:00 P.M. smoke break which lasted about 25 minutes. DA #5 stated Resident #8 was already outside when he went to start the smoke break. DA #5 offered to assist all residents inside after the break. Resident #8 refused. DA #5 was concerned with Resident #8's energy, attitude, and overall appearance. He stated she looked and acted off. He denied notifying nursing staff of this change. DA #5 denied seeing Resident #8 after he came back inside from smoke break. Interview on 07/18/24 at 12:49 P.M. with State tested Nursing Assistant (STNA) #38 stated she was not concerned with Resident #8 until she came up to this STNA sometime after the 2:00 P.M. smoke break voicing she was tired and was not feeling herself. STNA #38 asked STNA #41 for assistance with getting Resident #8 changed and back to bed which was around 3:50 P.M The medication aide was the staff member who notified nursing staff of a change in condition, she stated the resident felt like her skin was on fire. Resident #8's vital signs were taken and it was found her temperature was at 103 degrees F. Interview on 07/18/24 at 12:50 P.M. with STNA #41 confirmed she changed and assisted Resident #8 to bed with the assistance of STNA #38. During this encounter, STNA #41 stated she didn't observe any health concerns. Interview on 07/18/24 at 1:04 P.M. with Medication Aide #28 confirmed she was assigned to Resident #8. She identified the change in condition for Resident #8 around 5:22 P.M. where she looked weaker and was showing sign of a stroke. The nurse assessed her and found she had a temperature of 104.9 degrees F. The nurse notified the doctor who sent orders to send the resident out for further evaluation. Interview on 07/18/24 at 1:20 P.M. with Corporate Nurse #200 stated Resident #8's main diagnosis was urosepsis and the high fever could be from urosepsis alone. Corporate Nurse #200 verified there was no documentation of increased supervision levels during extreme weather conditions for Resident #8, no documentation of education to Resident #8 for extreme weather conditions, and no documentation of Resident #8's request to stay outdoors despite education. Corporate Nurse #200 verified the facility did not complete an investigation into the incident on 07/13/24 for Resident #8 being left outdoors for an unknown amount of time in extreme weather and being treated for hyperthermia in the ER. Corporate Nurse #200 explained they did not do an investigation because the primary diagnosis was urosepsis in the hospital. Interview on 07/18/24 at 1:41 P.M. with Medical Director #101 confirmed the resident has a history of non-compliance. He stated he was not notified Resident #8 refused to come inside on 07/13/24 and he was only notified of the change in condition. Nursing staff reported an elevated temperature of 103 degrees F and said she was sitting outside and would not come in. With Resident #8's presentation of symptoms, he was initially concerned she way exhibiting neuroleptic malignant syndrome which can mimic heatstroke. He placed an order for nursing staff to send to the hospital for further evaluation. His professional opinion felt Resident #8's diagnosis of urosepsis was an appropriate diagnosis for Resident #8 signs and symptoms exhibited on 07/13/24. Review of the weather report dated 07/13/24 for Hillsboro revealed between 12:55 P.M. to 3:55 P.M. found temperatures outside ranged between 88-90 degrees F. Review of the facility's Accidents/Hazards policy, undated, revealed the interdisciplinary team will implement interventions to reduce hazards that are consistent with a residents needs, goals, plan of care, and will include adequate supervision based on residents needs. Review of CDC guidance titled Heat and Chronic Condition dated 02/15/24 and found at https://www.cdc.gov/extreme-heat/risk-factors/extreme-heat-and-chronic-conditions.html revealed extreme heat can be dangerous for anyone, but it can be especially dangerous for those with chronic medical conditions. People with chronic medical conditions are more vulnerable to extreme heat because they may be less likely to sense and respond to changes in temperature, they maybe taking medications that can make the effect of extreme heat worse, and conditions like heart disease, mental illness, poor blood circulation, and obesity are risk factors for heat-related illness. This deficiency represents non-compliance investigated under Complaint Number OH00155804.

Based on observation and staff interview, the facility failed to ensure a safe environment when furniture obstructed the view of hallway's call lights and the handrails on both sides of the 100-unit hallway. This affected 24 residents, (#01, #02, #07, #08, #09, #10, #11, #12, #13, #14, #21, #22, #23, #24, #25, #26, #27, #28, #31, #32, #35, #40, #41 and #45) for call light obstruction and five residents (#14, # 22, #24, #25, and #40) who required the use of the handrails. The total facility census was 45. Findings Include: Observation on 08/14/23 at 5:30 P.M. and on 08/15/23 at 8:12 A.M. to 4:00 P.M., revealed wardrobe furniture, measuring approximately three feet wide and seven feet tall, were on both sides of the resident occupied 100-unit hallway. The call lights were obstructed from sight and the handrails were blocked from the resident's usage. Review of the resident census listings dated 08/14/23, revealed there were 24 residents, (#01, #02, #07, #08, #09, #10, #11, #12, #13, #14, #21, #22, #23, #24, #25, #26, #27, #28, #31, #32, #35, #40, #41 and # 45), who resided on the 100-unit hallway. Interview on 08/15/23 at 8:12 A.M. the Maintenance Director, (MA) #12 verified the call lights were obstructed from view and the handrails were obstructed from use due to the wardrobe furniture placement on the 100-unit hallway. MA #12 revealed the wardrobes were delivered on 08/10/23 and he was not in the facility to direct the delivery. Interview on 08/15/23 at 4:00 P.M. with the Director of Nursing (DON) and the Assistant Director of Nursing, (ADON), #04 verified there were five residents who were dependent on the handrails on 100-unit hallway. The DON and ADON #04 verified the hallway call lights were obstructed and the handrails were not available for the resident use. Review of the resident listing dated 08/15/23, provided by DON, revealed there were five residents, (#14, # 22, #24, #25, and #40), who required the use of the handrails on unit 100. This deficiency represents non-compliance investigated under Complaint Number OH00145480.

Based on document review, staff interview, and review of the facility policy, the facility failed to ensure a Registered Nurse (RN) worked in the facility for eight consecutive hours daily. This had the potential to affect all residents residing in the facility. The census was 42 residents. Findings include: Review of the staffing schedules revealed the facility did not have an RN working on 06/17/23, 06/18/23, and 07/01/23. Interview on 07/05/23 at 3:15 A.M. with the Director of Nursing (DON) confirmed the facility did not have a RN working on 06/17/23, 06/18/23, and 07/01/23. Review of the facility policy titled Nursing Staffing Services undated revealed the facility would ensure licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services.

Based on observation, resident interview, staff interview, record review and review of facility policy, the facility failed to ensure group activities were offered and provided per the resident's preferences and the activity calendar. This had the potential to affect all residents residing in the facility except for residents (#2, #6, #7, #8, #9, #11, #14, #20, #21, #23, #31, #34, and #43) who the facility identified as residents who did not participate in any group activities. The facility census was 42. Findings include: Review of the facility activity participation records for 06/01/23 to 07/06/23, revealed there was no record of activities from 06/13/23 to 07/06/23. Review of a copy from a text message Activities Director (AD) #245 sent to the facility's management dated 06/16/23 revealed the staff member was resigning her position effective immediately. Review of the facility activity calendar dated June 2023, revealed the calendar featured a variety of activities seven days per week. There was no calendar available for July 2023. Random observations of the resident care environment on 07/05/23 from 8:35 A.M. to 4:49 P.M. and on 07/06/23 from 6:20 A.M. to 12:00 P.M., revealed the June 2023 activity calendar was posted in the common area, and there were no activity programs observed taking place. Interview on 07/05/23 at 8:48 A.M. with the Director of Nursing (DON) indicated former AD #245 had resigned without notice a couple weeks ago, and they had no activities since AD #245 left. DON confirmed the facility had hired a new AD; however, she was not going to start work till 07/07/23. Interview on 07/05/23 at 11:15 A.M. with Housekeeper #235, confirmed the facility had not had any activity programs since AD #245 resigned a couple weeks ago. Housekeeper #235 confirmed she worked on the fourth of July 2023, and there were no activities related to the holiday. Interview on 07/05/23 at 11:17 A.M. with residents (#1, #10, and #38), confirmed AD #245 quit without notice a couple weeks ago and they would not have any activities until the new AD started. Residents confirmed they were particularly bothered that the facility had not offered any activities to celebrate the fourth of July 2023. Interview on 07/05/23 at 11:20 A.M. with the DON, confirmed AD #245 was the only activity staff person and the facility had not appointed anyone to carry out the activities in her absence. Interview on 07/05/23 at 2:35 P.M. with Regional Quality Assurance Nurse (RQAN) #250 confirmed AD #245 had resigned her position without notice via text message dated 06/16/23. RQAN #250 confirmed AD #245's last day worked was 06/15/23. Interview on 07/06/23 at 9:35 A.M. with the DON, confirmed former AD #245 recorded activity participation in the facility electronic medical record. DON confirmed the facility had no documentation of resident activities from 06/13/23 to 07/07/23. DON confirmed the facility identified 13 residents who did not participate in any group activities related to preference, behaviors, medical or cognitive status. DON further confirmed AD #245 had prepared the June 2023 activity calendar. Review of facility list dated 07/06/23, revealed there were 13 residents (#2, #6, #7, #8, #9, #11, #14, #20, #21, #23, #31, #34, and #43) identified by the facility who did not participate in group activities: Review of the facility policy titled Activity Programming undated revealed the Activities Director shall and organize a program of activities for residents on a group level and for individuals to meet the resident's interests and preferences. This deficiency represents non-compliance investigated under Complaint Number OH00144137.

Based on medical record review, staff interview, review of the facility's Self-Reported Incidents (SRI), review of employee punch detail, review of employee schedules, and policy review, the facility failed to ensure a staff member was removed from duty to potentially prevent further abuse following an allegation of abuse. This affected one (#39) of three residents reviewed for abuse. The facility census was 40. Findings include: Review of the medical record for Resident #39 revealed an admitted [DATE]. Resident #39 admitted to the facility from a hospital Geriatric Psych unit. Diagnoses included parkinson's disease, violent behavior, dementia with behavioral disturbance, major depressive disorder, anxiety disorder, essential hypertension, hyperlipidemia, disorientation, and unspecified mood disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/02/23 revealed the resident's cognition was not assessed. The resident was assessed as exhibiting fluctuating disorganized thinking, hallucinations, delusions, and one to three days of physical and verbal behavioral symptoms directed towards others during the assessment period. The resident required extensive assistance of two for bed mobility, transfers, and toileting. The resident required supervision for eating. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #39 had intact cognition. Review of the nursing progress note dated 12/15/22 at 2:20 A.M. revealed Resident #39 was up walking in the hallway unassisted throughout the night. Resident #39 was noted to be confused. Review of the nursing progress note dated 12/15/22 at 11:09 P.M. revealed Resident #39 was found by a State tested Nursing Assistant (STNA) in another resident's room, hiding behind the door. When the STNA attempted to get Resident #39 to come out of the room, Resident #39 became aggressive and grabbed the STNA's arms and twisted them. STNA yelled for help and another STNA and Registered Nurse (RN) #300 came to assist. Resident #39 punched the second STNA in the right shoulder. Staff attempted to get Resident #39 back to his room and Resident #39 was swinging and kicking at staff. The two STNA's and RN #300 were attempting to get Resident #39 to sit down when he kneed RN #300 in the mouth. A third STNA arrived in the room to assist. Director of Nursing (DON) was notified and instructed staff to call 911 and have a police escort. During that time, Resident #39 hit and scratched two of the STNA's. Staff were eventually able to get Resident #39 to sit down in his bed. Resident #39 became less aggressive when the police and paramedics arrived. Police and paramedics were able to get Resident #39 onto a stretcher and out of the facility. Review of the plan of care dated 12/29/22 revealed Resident #39 had an alteration in thought process related to dementia. Interventions included to administer medications per physician order, approach calmly, reapproach as necessary, and avoid change to environment. Review of the SRI dated 12/16/22 at 9:01 A.M. revealed RN #300 informed DON that, while attempting to manage a resident's behaviors, the resident struck her in the face and, when attempting to hit her again, she reflexively put her hand up in self-defense. While putting her hand up, she stated she came into contact with the resident. The resident was sent to the hospital for psychiatric evaluation and the nurse was sent home pending investigation by the facility. Review of the facility investigation dated 12/16/22 at 10:00 A.M., revealed statements were obtained from staff present during the incident. Resident interviews and skin checks were completed with no findings. All facility staff were educated on the facility abuse policy, crisis prevention management, non pharmacological interventions for behaviors, and resident aggression training. RN #300 did not return to the facility. The allegation was inconclusive due differing statements from the STNA's, no physical evidence of any marks or injuries on Resident #39 , and the investigation uncovered dynamics between RN #300 and STNA #315 related to a loan not being repaid by RN #300 to STNA #315. Review of the punch detail revealed RN #300 worked a full night shift (12.5 hours) on 12/15/22. Interview on 01/19/23 at 10:09 A.M. STNA #305 stated, on the night of 12/15/22, at approximately 10:45 P.M., Resident #37 activated her call light. When STNA #305 arrived in Resident #37's room, Resident #37 stated there was someone behind her door. STNA #305 found Resident #39 hiding behind the door. STNA #305 stated Resident #39 grabbed her arms, so she yelled for help. STNA's #310 and #315 responded to the call for help. Resident #39 stated he was scared someone was trying to kill him. STNA #305 stated she and the other two STNA's were able to lead Resident #39 back into his room, sat him on his bed and had him calmed down. STNA #305 stated RN #300 then arrived in Resident #39's room and, without warning, went to lift the Resident #39's legs up (attempting to pivot him into the bed). Resident #39 kneed RN #300 in the face. RN #300 then punched Resident #39 in the mouth and called him a Stupid [explicit term]. STNA #305 stated there was bleeding from the Resident #39's lip immediately. STNA #305 stated she knew the DON and Administrator were supposed to be notified immediately, however their phone numbers were located behind the nurse station and RN #300 was sitting behind the nurse station and would not move to allow the STNA's to get the phone numbers. STNA #305 stated she reached out to the DON via Facebook Messenger, but did not hear back for the rest of the shift. STNA #305 stated RN #300 remained in the facility for the remainder of her shift. Interview on 01/19/23 at 9:56 A.M., STNA #310 stated, the night of 12/15/22, she heard STNA #305 holler for help because Resident #39 was behind the door in another resident's room. Resident #39 stated he was scared because someone was coming to get him. STNA #310 stated she and STNA #315 responded immediately and assisted STNA #305 in getting Resident #39 back to his room. STNA #310 stated the resident was then calmed down and the situation was under control and RN #300 came into the room yelling and cussing and began pulling on Resident #39 's feet. Resident #39 then kneed RN #300 in the mouth and RN #300 then pushed Resident #39 and punched him between the neck and chest twice and once in the mouth and said, How do you like that you [explicit term]. STNA #310 stated Resident #39 had blood on his mouth. STNA #310 stated RN #300 stated she did not punch Resident #39, but she hit him. STNA #310 stated she knew the DON and Administrator should be notified of the incident, however their phone numbers were located at the nurse station and RN #300 did not move from behind the nurse station for the rest of that night. STNA #310 stated she utilized Facebook Messenger and sent a message to the DON, asking her to call her back on her personal phone regarding the nurse on shift that night. STNA #310 stated she did not hear from the DON until hours later. Interview on 01/19/23 at 10:24 A.M., STNA #315 stated, on the night of 12/15/22, she and STNA #310 heard STNA #305 called for help and had Resident #39 in another resident's room. STNA #315 stated Resident #39 was grabbing STNA #305's arm. STNA #315 stated she and STNA's #305 and #315 calmly walked Resident #39 back into his room and sat him at the edge of the bed. STNA #315 stated RN #300 then came into the room screaming and grabbed the Resident #39's feet, while calling him filthy names. STNA #315 stated Resident #39 kneed RN #300 in the chest and she observed RN #300 punch Resident #39 twice, once in the chest and once in the mouth. STNA #315 stated she noticed a small amount of blood on the Resident #39's lip after RN #300 punched him. STNA #315 stated RN #300 called Resident #39 a Stupid [explicit term] several times. STNA #315 stated she was unable to get to the DON and Administrator's phone numbers because they were at the desk of the nurse station and RN #300 did not leave the desk. Interview on 12/15/22 at 11:02 A.M., the Administrator stated, on 12/16/22, the STNA's on night shift alleged RN #300 hit Resident #39. The Administrator stated the STNA's had different accounts of the number of times and where Resident #39 was punched. The Administrator stated Resident #39 was sent to the hospital due to his behaviors and returned from the hospital the same day. The Administrator stated RN #300 stated, when she got hit, she reactively pushed him away. The Administrator stated RN #300 stated she knew she made contact with Resident #39 but was unable to say if she hit him. The Administrator stated RN #300 was suspended and the DON called the hospital and alerted them to the incident. The Administrator verified RN #300 worked the rest of the night and stated she would have been sent home immediately if he had known about the incident earlier. Interview on 01/19/23 at 2:18 P.M., the DON stated the STNA's sent her messages that night (on 12/16/22) at 12:19 A.M., stating they needed to talk to her about the nurse on duty, but she did not see the messages at that time because she was sleeping. The DON stated RN #300 called her at 6:00 A.M. with a question about staffing and then told her about the situation involving Resident #39 and said the STNA's may say she punched Resident #39. The DON stated she then read the messages from the STNA's and told RN #300 to immediately clock out and leave. The DON stated, had she known what happened earlier, she would have immediately come to the facility and sent RN #300 home. Interview on 01/19/23 at 2:43 P.M., Corporate Nurse #330 confirmed RN #300 clocked out on 12/16/22 at 6:30 A.M. and worked an entire shift that night. Review of staffing schedules on 12/15/22 revealed RN #300, STNA #305, STNA #310, and STNA #315 were the only staff present the night of the incident. Review of facility policy titled Abuse, Neglect, Exploitation of Residents, and Misappropriation of Property, dated 09/2020, revealed all alleged violations concerning abuse, neglect, misappropriation of property, and injuries of unknown origin are reported immediately to the Administrator/Designee. An investigation procedure begins immediately by the Administrator or facility designee. The facility will maintain the resident's protection during the investigation. To assure resident safety during and after the investigation, if the alleged abuser is an employee, the employee will be removed from the facility and suspended pending the results of the facility's investigation. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, staff interview, review of the facility's Self-Reported Incidents (SRI), review of employee punch detail, review of employee schedules, and policy review, the facility failed to immediately report an allegation of abuse to the Administrator/Designee and to the Ohio Department of Health (ODH) as required. This affected one (#39) of three residents reviewed for abuse. The facility census was 40. Findings include: Review of the medical record for Resident #39 revealed an admitted [DATE]. Resident #39 admitted to the facility from a hospital Geriatric Psych unit. Diagnoses included parkinson's disease, violent behavior, dementia with behavioral disturbance, major depressive disorder, anxiety disorder, essential hypertension, hyperlipidemia, disorientation, and unspecified mood disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/02/23 revealed the resident's cognition was not assessed. The resident was assessed as exhibiting fluctuating disorganized thinking, hallucinations, delusions, and one to three days of physical and verbal behavioral symptoms directed towards others during the assessment period. The resident required extensive assistance of two for bed mobility, transfers, and toileting. The resident required supervision for eating. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #39 had intact cognition. Review of the nursing progress note dated 12/15/22 at 2:20 A.M. revealed Resident #39 was up walking in the hallway unassisted throughout the night. Resident #39 was noted to be confused. Review of the nursing progress note dated 12/15/22 at 11:09 P.M. revealed Resident #39 was found by a State tested Nursing Assistant (STNA) in another resident's room, hiding behind the door. When the STNA attempted to get Resident #39 to come out of the room, Resident #39 became aggressive and grabbed the STNA's arms and twisted them. STNA yelled for help and another STNA and Registered Nurse (RN) #300 came to assist. Resident #39 punched the second STNA in the right shoulder. Staff attempted to get Resident #39 back to his room and Resident #39 was swinging and kicking at staff. The two STNA's and RN #300 were attempting to get Resident #39 to sit down when he kneed RN #300 in the mouth. A third STNA arrived in the room to assist. Director of Nursing (DON) was notified and instructed staff to call 911 and have a police escort. During that time, Resident #39 hit and scratched two of the STNA's. Staff were eventually able to get Resident #39 to sit down in his bed. Resident #39 became less aggressive when the police and paramedics arrived. Police and paramedics were able to get Resident #39 onto a stretcher and out of the facility. Review of the plan of care dated 12/29/22 revealed Resident #39 had an alteration in thought process related to dementia. Interventions included to administer medications per physician order, approach calmly, reapproach as necessary, and avoid change to environment. Review of the SRI dated 12/16/22 at 9:01 A.M. revealed RN #300 informed DON that, while attempting to manage a resident's behaviors, the resident struck her in the face and, when attempting to hit her again, she reflexively put her hand up in self-defense. While putting her hand up, she stated she came into contact with the resident. The resident was sent to the hospital for psychiatric evaluation and the nurse was sent home pending investigation by the facility. Review of the facility investigation dated 12/16/22 at 10:00 A.M., revealed statements were obtained from staff present during the incident. Resident interviews and skin checks were completed with no findings. All facility staff were educated on the facility abuse policy, crisis prevention management, non pharmacological interventions for behaviors, and resident aggression training. RN #300 did not return to the facility. The allegation was inconclusive due differing statements from the STNA's, no physical evidence of any marks or injuries on Resident #39 , and the investigation uncovered dynamics between RN #300 and STNA #315 related to a loan not being repaid by RN #300 to STNA #315. Review of the punch detail revealed RN #300 worked a full night shift (12.5 hours) on 12/15/22. Interview on 01/19/23 at 10:09 A.M. STNA #305 stated, on the night of 12/15/22, at approximately 10:45 P.M., Resident #37 activated her call light. When STNA #305 arrived in Resident #37's room, Resident #37 stated there was someone behind her door. STNA #305 found Resident #39 hiding behind the door. STNA #305 stated Resident #39 grabbed her arms, so she yelled for help. STNA's #310 and #315 responded to the call for help. Resident #39 stated he was scared someone was trying to kill him. STNA #305 stated she and the other two STNA's were able to lead Resident #39 back into his room, sat him on his bed and had him calmed down. STNA #305 stated RN #300 then arrived in Resident #39's room and, without warning, went to lift the Resident #39's legs up (attempting to pivot him into the bed). Resident #39 kneed RN #300 in the face. RN #300 then punched Resident #39 in the mouth and called him a Stupid [explicit term]. STNA #305 stated there was bleeding from the Resident #39's lip immediately. STNA #305 stated she knew the DON and Administrator were supposed to be notified immediately, however their phone numbers were located behind the nurse station and RN #300 was sitting behind the nurse station and would not move to allow the STNA's to get the phone numbers. STNA #305 stated she reached out to the DON via Facebook Messenger, but did not hear back for the rest of the shift. STNA #305 stated RN #300 remained in the facility for the remainder of her shift. Interview on 01/19/23 at 9:56 A.M., STNA #310 stated, the night of 12/15/22, she heard STNA #305 holler for help because Resident #39 was behind the door in another resident's room. Resident #39 stated he was scared because someone was coming to get him. STNA #310 stated she and STNA #315 responded immediately and assisted STNA #305 in getting Resident #39 back to his room. STNA #310 stated the resident was then calmed down and the situation was under control and RN #300 came into the room yelling and cussing and began pulling on Resident #39 's feet. Resident #39 then kneed RN #300 in the mouth and RN #300 then pushed Resident #39 and punched him between the neck and chest twice and once in the mouth and said, How do you like that you [explicit term]. STNA #310 stated Resident #39 had blood on his mouth. STNA #310 stated RN #300 stated she did not punch Resident #39, but she hit him. STNA #310 stated she knew the DON and Administrator should be notified of the incident, however their phone numbers were located at the nurse station and RN #300 did not move from behind the nurse station for the rest of that night. STNA #310 stated she utilized Facebook Messenger and sent a message to the DON, asking her to call her back on her personal phone regarding the nurse on shift that night. STNA #310 stated she did not hear from the DON until hours later. Interview on 01/19/23 at 10:24 A.M., STNA #315 stated, on the night of 12/15/22, she and STNA #310 heard STNA #305 called for help and had Resident #39 in another resident's room. STNA #315 stated Resident #39 was grabbing STNA #305's arm. STNA #315 stated she and STNA's #305 and #315 calmly walked Resident #39 back into his room and sat him at the edge of the bed. STNA #315 stated RN #300 then came into the room screaming and grabbed the Resident #39's feet, while calling him filthy names. STNA #315 stated Resident #39 kneed RN #300 in the chest and she observed RN #300 punch Resident #39 twice, once in the chest and once in the mouth. STNA #315 stated she noticed a small amount of blood on the Resident #39's lip after RN #300 punched him. STNA #315 stated RN #300 called Resident #39 a Stupid [explicit term] several times. STNA #315 stated she was unable to get to the DON and Administrator's phone numbers because they were at the desk of the nurse station and RN #300 did not leave the desk. Interview on 12/15/22 at 11:02 A.M., the Administrator stated, on 12/16/22, the STNA's on night shift alleged RN #300 hit Resident #39. The Administrator stated the STNA's had different accounts of the number of times and where Resident #39 was punched. The Administrator stated Resident #39 was sent to the hospital due to his behaviors and returned from the hospital the same day. The Administrator stated RN #300 stated, when she got hit, she reactively pushed him away. The Administrator stated RN #300 stated she knew she made contact with Resident #39 but was unable to say if she hit him. The Administrator stated RN #300 was suspended and the DON called the hospital and alerted them to the incident. The Administrator verified RN #300 worked the rest of the night and stated she would have been sent home immediately if he had known about the incident earlier. Interview on 01/19/23 at 2:18 P.M., the DON stated the STNA's sent her messages that night (on 12/16/22) at 12:19 A.M., stating they needed to talk to her about the nurse on duty, but she did not see the messages at that time because she was sleeping. The DON stated RN #300 called her at 6:00 A.M. with a question about staffing and then told her about the situation involving Resident #39 and said the STNA's may say she punched Resident #39. The DON stated she then read the messages from the STNA's and told RN #300 to immediately clock out and leave. The DON stated, had she known what happened earlier, she would have immediately come to the facility and sent RN #300 home. Interview on 01/19/23 at 2:43 P.M., Corporate Nurse #330 confirmed RN #300 clocked out on 12/16/22 at 6:30 A.M. and worked an entire shift that night. Review of staffing schedules on 12/15/22 revealed RN #300, STNA #305, STNA #310, and STNA #315 were the only staff present the night of the incident. Review of facility policy titled Abuse, Neglect, Exploitation of Residents, and Misappropriation of Property, dated 09/2020, revealed all alleged violations concerning abuse, neglect, misappropriation of property, and injuries of unknown origin are reported immediately to the Administrator/Designee. An investigation procedure begins immediately by the Administrator or facility designee. The facility will maintain the resident's protection during the investigation. To assure resident safety during and after the investigation, if the alleged abuser is an employee, the employee will be removed from the facility and suspended pending the results of the facility's investigation. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review, facility policy and procedure review and interview the facility failed to ensure quarterly care conferences were held and included the resident. This affected one resident (#25) of three residents reviewed for care conferences. Findings include: Record review for Resident #25 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's electronic medical record revealed Minimum Data Set (MDS) 3.0 assessments were completed on 10/21/21, 11/19/21, 02/19/22, 03/24/22 and 04/05/22. Record review revealed the last documented care planning conference was held on 10/29/21. Review of the 04/05/22 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the Resident was cognitively intact. On 05/02/22 at 9:16 A.M. interview with Resident #25 revealed she had not had a care conference in a long time. On 05/05/22 at 8:42 A.M. interview with the Director of Nursing (DON) verified the most recent care conference for Resident #25 was held on 10/29/21. Review of the undated facility plan of care meetings policy revealed plan of care meetings would be held for each resident upon admission, quarterly and as needed. The meeting minutes would be recorded in the electronic health records during or after the plan of care meeting.

Based on review of a closed medical record, review of hospital records, review of ambulance reports, review of facility investigation documentation, review of a death certificate, interviews with staff and the physician, and review of facility policies, the facility failed to provide adequate care and treatment to facilitate continuity of care to monitor a resident's condition after readmission from the hospital, provide ordered respiratory equipment, and timely notify the physician of a change in condition for one Resident (#01) who was a Full Code status. This resulted in Immediate Jeopardy and serious life-threatening harm when Resident #01 experienced a change in condition without proper assessment upon readmission to the facility from a hospital stay and following a fall. The resident was noted with continued lethargy, drowsiness, and increased confusion. There was no notification to the physician of the resident's status and condition changes until Resident #01 was found unresponsive with an absence of respirations and pulse and subsequently expired at the hospital. This affected one Resident (#01) of four residents reviewed for change in condition. The facility census was 44. On [DATE] at 11:43 [NAME]M., the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) #55, and two Quality Assurance Regional Registered Nurses (QARRN) #80 and #81 were notified Immediate Jeopardy began on [DATE] at 9:06 P.M., when Licensed Practical Nurse (LPN) #85 failed to complete a thorough assessment and notify the physician upon Resident #01's readmission to the facility, when they did not have his ordered medical equipment available, and the resident was presenting with a change in condition. On [DATE], the resident sustained [REDACTED]. LPN #85 did notify the physician of Resident #01's fall; however, did not indicate what his condition was before, during, and after his fall. Resident #01 was found unresponsive in bed with an absence of vital signs. Cardiopulmonary Resuscitation (CPR) was initiated per facility staff until the Emergency Medical Service (EMS) arrived and took over the resuscitation efforts. The resident was pronounced dead on [DATE] at 4:30 [NAME]M. at the hospital. The Immediate Jeopardy was removed on [DATE] at 4:10 P.M. when the facility implemented the following corrective actions: · On [DATE] at 12:15 P.M., an audit was conducted by ADON #55 of all current residents for Bilevel Positive Airway Pressure ([MEDICAL CONDITION])/Continuous Positive Airway Pressure ([MEDICAL CONDITION]) equipment use. Two residents (#06 and #08) were identified with [MEDICAL CONDITION] machines which were in place per physician's orders [REDACTED]. · On [DATE] from 1:00 P.M. to 3:20 P.M., all licensed nursing staff were in-serviced and re-educated by the DON and QARRN #80 on proper physician notification of a resident's health status/condition of all resident's immediately upon admission/readmission, physician's orders [REDACTED]. The DON/ADON will audit all admissions within 24 hours of arrival ongoing. · On [DATE] at 1:00 P.M., Admission Coordinator (AC) #33 was educated by QARRN #80 on the facility preadmission evaluation screening tool to be put into place and utilized from [DATE] moving forward. This screening tool identifies residents' active diagnoses, current health status, prior function, and all needed equipment to appropriately care for that specific resident. This audit tool will be given to the DON and the DON will arrange and verify all resident's needs are able to be met prior to admission/re-admission. · On [DATE] at 1:00 P.M., the DON was educated by QARRN #80 on the preadmission screening tool which is to be completed on all admissions. · On [DATE] from 1:45 P.M. to 5:00 P.M., all current residents were assessed by the DON, ADON #55, Registered Nurse (RN) #71, and LPN #70, for any recent change in condition and all current physician orders. There were no discrepancies noted. · All current residents will be assessed for change in condition on a weekly basis by licensed nursing staff. The DON will audit these assessments weekly for four weeks, then monthly for three months, and as needed thereafter. · On [DATE] at 2:00 P.M., all admissions within the past 60 days were audited for physician notification and appropriate assessment performed upon admission by the Administrator. No discrepancies were noted. · On [DATE] at 2:50 P.M., RN #57 and LPN #85 were educated by QARRN #80 related to the change in condition policy, equipment to be provided as ordered, admission assessments/procedures. · On [DATE] at 3:20 P.M., all nursing staff, including nurse aides were reeducated on their role in resident change of condition notification, appropriate persons to notify and on the change in condition policy by the Administrator and DON. · On [DATE] at 3:25 P.M., interview with AC #33 verified she was in-serviced on the preadmission form and screening tool and to notify the DON of all needed equipment and resident needs for admission. · On [DATE] at 3:32 P.M., interviews with LPN #70 and RN #71 verified they were in-serviced on resident change in condition assessments and notification as well as on the new admission process including to complete an assessment and fill out admission assessment paperwork. · On [DATE] at 3:34 P.M., interviews with STNA #73 and STNA #77 verified they were in-serviced on the change in condition policy including notification to their nurse immediately of any changes in a resident's status. · On [DATE] at 4:15 P.M., a Quality Assurance (QA) committee meeting was held to review findings of all audits, deficiencies noted, and corrections needed/implemented. · All findings from audits will be reviewed during monthly QA meetings and any deficiencies noted will be immediately corrected and reviewed by the QA team. Although the Immediate Jeopardy was removed, 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 in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #01's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #01 was sent to the hospital on [DATE] due to low oxygen saturations and was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #01's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficits and received oxygen therapy. Review of Resident #01's physician orders [REDACTED]. Review of Resident #01's hospital history and physical dated [DATE], revealed the resident had shortness of breath and [MEDICAL CONDITION]. He was currently on a [MEDICAL CONDITION] machine in the hospital. Per Resident #01's wife, the resident lived in a nursing home and for the past few days, felt short of breath. That morning his oxygen saturations were low in the 60's and they were unable to get it up. When he presented to the emergency room (ER), his oxygen saturation was 55 percent on six liters of oxygen and per medical record he was on two liters of oxygen normally. Assessment revealed the principal problem included bacterial pneumonia, acute chronic [MEDICAL CONDITION] with [MEDICAL CONDITION] and hypercapnia, and [MEDICAL CONDITION] hypertension. The plan for hospitalization revealed Resident #01 had a [MEDICAL CONDITION] exacerbation and would be on a [MEDICAL CONDITION] machine with adjustments to his [MEDICAL CONDITION] settings as indicated. Review of Resident #01's nurses notes dated [DATE] revealed the hospital called to inform the facility the resident would be returning to the facility and would require a [MEDICAL CONDITION] machine. Review of the ambulance report dated [DATE] revealed, from the hospital to the nursing facility, Resident #01's vital signs were obtained and closely monitored. Resident #01 was given oxygen at 4 liters per minute (lpm) for slightly low oxygen saturation, was later reassessed, and showed improvement. He was alert and oriented to his name, was unable to verbally respond to prompts and showed limb weakness. Resident #01 remained stable during transport and report was passed onto the facility. Review of Resident #01's hospital continuity of care paperwork dated [DATE] revealed the resident was a full code, had the primary [DIAGNOSES REDACTED]. There was also an order [REDACTED].#01 required five lpm of oxygen (O2) to keep O2 saturations above 90 percent (%). Review of Resident #01's nurses notes completed by LPN #85, dated [DATE] at 9:06 P.M., revealed the resident arrived at the facility on four liters of oxygen and had increased confusion and lethargy. At 9:11 P.M., Resident #01's blood pressure was ,[DATE], pulse 74, respirations 16, temperature 97.3 and oxygen saturation was 96 percent on four liters of oxygen per nasal cannula. He was experiencing a new onset of confusion and his speech was incoherent. Resident #01 was usually able to make himself understood. He had non-[MEDICAL CONDITION] to the lower extremities. He had difficulty breathing with respirations shallow, shortness of breath while lying flat and with activity. His lung sounds were diminished on auscultation. Review of the Resident #01's medical record revealed the facility did not have current physician orders [REDACTED]. There was also no admission packet completed for the resident upon his readmission. Further review of Resident #01's medical record revealed there was no documented evidence the physician was notified of Resident #01's readmission to the facility, orders were not verified and reconciled by the physician, the physician was not made aware of Resident #01's condition upon readmission and there was no indication the physician was notified that the facility did not have a [MEDICAL CONDITION] machine in place for the orders as per the hospital continuity of care. Review of Resident #01's medical record revealed his O2 saturations were taken on [DATE] at 9:12 P.M. and 9:34 P.M. and were at 96%. There was no documented evidence of any additional O2 saturation levels completed by the facility staff. Review of Resident #01's care plans revealed there was no baseline care plan after readmission. He did have an immediate needs post fall care plan dated [DATE] which indicated he had fallen with no injury except for a reddened area to the forehead and left side of the eye which was noted one hour after the incident. Resident #01 was at risk for falls related to debility, weakness, medications, and unsteady gait. Resident #01 had the following care plans in place prior to hospitalization on [DATE]: Care plan in place for risk for alteration in respiratory function related to [MEDICAL CONDITIONS], oxygen use, and history of pneumonia. Interventions included to administer oxygen as ordered, monitor oxygen saturations, observe for signs and symptoms of dyspnea, labored respirations, low oxygen saturation, cyanosis, tachypnea, and changes in mental status. Care plan in place for risk for alteration in oxygen exchange and perfusion related to [MEDICAL CONDITION] and pneumonia and included interventions to assure set up of all required equipment. Review of Resident #01's fall investigation report dated [DATE] revealed the resident had fallen on [DATE] at 11:50 P.M. STNA #60 informed LPN #85, the resident was lying on the floor. When the nurse entered the room, he was noted lying in a prone position (a body position in which the person lies flat with the chest down and the back side up) with his head under the bed, legs and arms outstretched by his sides, skin was dusky in color, and oxygen was not in place. He was assisted back into bed and the bed was placed in low position with a fall mat next to the bed. Neuro checks and 15-minute checks were initiated. Resident #01 was confused and disoriented. There was no documented oxygen saturation with the assessment after the fall. He was lethargic (drowsy), confused, disoriented and noted to have a red area to the forehead and left side of the eye. The physician and DON were notified on [DATE] at 12:00 [NAME]M. The cause of the fall was documented as Resident #01 had increased confusion, rolled out of bed and landed on the floor. New interventions included the bed in low position with a bedside mat and 15-minute checks. Review of Resident #01's skilled evaluation form dated [DATE] at 1:02 [NAME]M., completed by LPN #85, included vitals which had been taken at 9:11 P.M. (blood pressure ,[DATE] with an abnormality noted that his systolic was less than 90, and O2 saturations at 96%). The skilled evaluation form indicated Resident #01 did not obey commands, was confused and lethargic with abnormality noted of new onset confusion, was incoherent, and lethargic. He had unclear speech and new onset of bladder incontinence. His skin color was pale, and he had difficulty breathing with shallow respirations, shortness of breath while lying flat and upon exertion, diminished lung sounds throughout and was on oxygen at four liters. Review of Resident #01's neuro checks revealed they were all completed and indicated he continued to be lethargic. The last check was completed on [DATE] at 2:35 [NAME]M. and indicated he was drowsy. No O2 saturations were taken. Review of documentation of Resident #01's 15-minute checks revealed nursing documented they were completed with the last one on [DATE] at 3:00 [NAME]M. Review of the ambulance report dated [DATE] revealed they received a 911 call from the facility at 3:06 [NAME]M. that Resident #01 was having breathing problems. The ambulance arrived at 3:14 [NAME]M. on [DATE] and CPR was in progress. The ambulance crew attempted ventilation and initiated chest compressions and left the facility to go to hospital at 4:19 [NAME]M. Review of the death certificate revealed Resident #01 expired at the hospital on [DATE] at 4:30 [NAME]M. The immediate cause of death was noted as sudden cardiac death due to or as consequence of cardiopulmonary arrest and [MEDICAL CONDITION]. Other significant conditions contributing to death but not resulting in the underlying cause was listed as [MEDICAL CONDITION]. Telephone interview with LPN #85 on [DATE] at 12:35 P.M. revealed she was the nurse that admitted Resident #01 on [DATE] and was his nurse when he fell as well. LPN #85 stated Resident #01 was not himself upon admission. She verified his blood pressure was low, he was worse then before he was sent out, and he only knew his name upon return. She stated she could not send him back to the hospital because she thought she had to take him since she had report from the hospital, and he was on a stretcher. LPN #85 stated she did not know Resident #01 was supposed to have a [MEDICAL CONDITION] machine in place and she did not see an order for [REDACTED].#85 verified she did not contact the physician to make him aware Resident #01 had been readmitted to the facility and his current condition upon return, stating the physician knew earlier that day the resident was coming back. She stated the aide reported that evening the resident had fallen. LPN #85 indicated the resident was dusky in color and she stated they started 15-minute checks. She stated she did check his oxygen saturation and it was below 90 but she could not remember what it was exactly, only that it came back up on a 15-minute check. She stated he had no injuries at first, then later had a reddened area to the forehead and eye. She stated she did call the physician to notify him of the fall and verified she only told him Resident #01 had fallen, nothing additional. LPN #85 stated during one of the 15-minute checks, Resident #01 was found with no pulse and no respirations and they called 911 and started CPR. Interview on [DATE] at 12:45 P.M. with ADON #55 revealed she received a phone call on [DATE] from the hospital that Resident #01 needed a [MEDICAL CONDITION] machine and stated the [MEDICAL CONDITION] machine would not be at facility until the next day. ADON #55 verified Resident #01 returned to the facility on [DATE] at 9:00 P.M., and the facility did not have a [MEDICAL CONDITION] machine available for the resident. Telephone interview with Physician #99 on [DATE] at 1:05 P.M. revealed he was not aware Resident #01 did not have his ordered [MEDICAL CONDITION] machine upon readmission to facility. Physician #99 verified he did get a call around 2:00 [NAME]M. or 3:00 [NAME]M. on [DATE] that Resident #01 had fallen but was not told about any changed or current condition of Resident #01, only that he fell . Physician #99 verified he was not made aware when Resident #01 returned to the facility that evening. He stated his first call was about the fall and then he was notified the resident was found without a pulse and respirations and CPR was in process. A second telephone interview was conducted with Physician #99 on [DATE] at 1:48 P.M. indicating he did not recall any information being relayed to him regarding Resident #01 being lethargic and drowsy with increased confusion upon admission, that it continued throughout the evening and night, or that Resident #01 was dusky following his fall. Physician #99 verified he only knew the resident had fallen and then was notified when CPR was in process. Physician #99 stated it was hard to say the [MEDICAL CONDITION] machine being in place would have made a difference, however, he did state it was possible as Resident #01 had chronic [MEDICAL CONDITION]. Interview was conducted on [DATE] at 3:01 P.M. with the DON and QARRN #80 and they verified there was not a [MEDICAL CONDITION] machine available as ordered for Resident #01. The DON stated she would expect the nurse to notify the physician of a change in condition. Telephone interview with RN #57 on [DATE] at 3:21 P.M. revealed she worked from 6:00 P.M. on [DATE] to 6:00 [NAME]M. on [DATE]. RN #57 stated she did take care of Resident #01 along with LPN #85. She stated LPN #85 took report from the hospital and she did see Resident #01 when he arrived. She stated the ambulance driver told her Resident #01's oxygen was in the low 90's and he was confused and had pneumonia. She stated she did not notify the physician of Resident #01's return or his condition. She stated she knew nothing about the [MEDICAL CONDITION] machine or if he was supposed to have one or not. She stated Resident #01's blood pressure was low upon admission but came up later that evening. RN #57 stated after his fall that night, they did check his oxygen but she could not recall what it was, only that it was in the 90's. She stated the resident had no injuries at first, then later had a reddened area to his forehead and eye. RN #57 verified she did not notify the physician of the reddened areas noted following the fall or his continued confusion and lethargy. She stated they checked on him every fifteen minutes after his fall. She stated during one of his checks he was found not breathing and they called 911 and started CPR. Interview with the DON on [DATE] at 9:01 [NAME]M. verified there was no admission packet filled out for Resident #01. The DON verified the nurse did not reconcile the resident's orders, did not notify the physician upon admission or of any change in condition for the resident. Interview on [DATE] at 9:50 [NAME]M. with QARRN #80 revealed they did not have an actual nursing admission policy but the nurses were required to fill out the admission packet, go off of the admission check list, and complete an assessment upon admission. Telephone interview with STNA #60 on [DATE] at 10:15 [NAME]M. revealed she was Resident #01's aide on [DATE] and [DATE]. She stated when she came on duty he was already back from the hospital and was in bed. She stated she received report from LPN #85 who told her Resident #01's oxygen saturation was low, she was concerned about him, and to watch him. STNA #60 stated Resident #01 was not good at all. She stated she had him covered up and his call light pinned to him. When she found him on the floor, she thought he had either passed out or his oxygen was low. STNA #60 indicated the resident's oxygen was half off and his oxygen tubing was only around one ear when he was found. She also stated he was also very pale in color. She stated she then asked for help to the room. STNA #60 stated later, the nurses were doing CPR on the resident and the squad came and took him out. Review of the facilities Change in Condition policy (dated [DATE]) revealed the purpose was to maintain open communication and continuity of care between nursing staff and the resident's physician as it related to the change in the resident's medical condition. A significant change in condition may include a decline in decision making ability, balance and safety awareness that results in a fall, deterioration in overall condition, and emergence of unstable condition or disease. The charge nurse would notify the resident, physician, and responsible party of all changes immediately. Review of the facilities Respiratory Assessment Policy (undated) revealed the facility was to determine the resident's respiratory status so that if necessary, appropriate interventions could be initiated. Review of the facilities Post Fall Policy (dated (MONTH) (YEAR)) revealed the facility was to promote proper post fall interventions in place and to ensure safety and well being of residents at risk for falls. The nurse was to notify the physician and if an injury had occurred, the physician was to be notified immediately, the DON and responsible party was to be notified and a fall investigation would be completed by the DON following the fall. This deficiency substantiates complaint number OH 47