Every finding on record at Cridersville Nursing and Rehab

Based on medical record review, physician order, pharmacy recommendation, and staff interview, the facility failed to ensure an as needed (PRN) medication was ordered for 14 days. This affected one (Resident #01) out of five people reviewed for unnecessary mediations. The facility census was 39.Record review for Resident #01 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: anxiety disorder, chronic obstructive pulmonary disease, peripheral vascular disease and atrial fibrillation. Review of Minimum Data Set (MDS) Medicare 5-day assessment dated [DATE] revealed the resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 05. This resident was assessed to be moderate assistance with toileting, showering, and dressing. Review of the care plan dated 05/13/26 revealed Resident #01 uses anti-anxiety medication for anxiety. Physician order for lorazepam oral tablet to give 0.5 milligrams (mg) every twelve hours as needed for severe anxiety. Start date 07/06/26 and stop date 08/06/26. Pharmacy recommendation stated, According to the new CMS guidelines regarding as needed (PRN) Psychotropic medication, the Psychotropic medication must be reviewed after 14 days and can be extended if the time frame is specified and it is documented regarding why it is necessary. Further review of the medical record revealed no documentation from the physician providing rationale for the lorazepam to be ordered for 30 days. Interview on 07/28/26 at 8:01 A.M. with Administrator revealed lorazepam was dated for 30 days. Interview on 07/28/26 at 9:10 A.M. with Director of Nursing (DON) revealed DON was unaware of fourteen-day psychotropic CMS guidelines.

Based on medical record review, staff and Guardian interviews, and policy review, the facility failed to ensure residents had access to their medications upon discharge. This affected one resident (#50) of two reviewed for discharge. The facility census was 50. Findings include:Findings include: Review of the medical record of Resident #50 revealed an admission date of 08/20/25. Diagnoses include anoxic brain injury, dementia, delusional disorder, and diabetes mellitus type II. Review of the discharge Minimum Data Set assessment dated [DATE] revealed Resident #50 was cognitively impaired. Review of the Discharge summary dated [DATE] revealed only the social service section had been completed. Resident #50, nor his guardian, had been instructed on medications, and/or treatments. Interview on 07/30/26 at 12:20 P.M. with the Administrator revealed the facility was unable to produce a completed discharge summary with instructions on medications and/or treatments for Resident #50. Interview on 7/30/26 at 12:50 P.M. with Resident #50's Guardian revealed she had been given instructions, but no medications had been sent home with Resident #50 and medications had been called into a pharmacy, however that pharmacy was in another city hours away. Review of the policy titled, Transfer and Discharge (including AMA), dated 1/23/25 revealed the transfer or discharge will be provided to the resident and resident's representative in a language and manner they can understand. The notice will include a recap of the residents' stay that includes diagnoses, course of treatment or therapy, and pertinent lab, radiology, and consultation results, along with a reconciliation of all pre and post medications. This deficiency represents non-compliance investigated under Complaint Number 3047386.

Based on record review, staff interview and facility policy, the facility failed to ensure baseline care plan developed to represent a resident's current status. This affected one (Resident #45) out of fifteen residents reviewed for care plans. The facility census was 29. Findings include:Record review for Resident #45 revealed this resident was admitted to the facility on [DATE] with a diagnosis of dysphagia. Review of the baseline care plan dated 07/28/26 revealed the care plan only addressed activity needs and dietary needs. The baseline care plan was missing initial goals, physician orders, and therapy information. Interview on 07/28/26 at 1:32 P.M. with the Director of Nursing (DON) verified Resident #45's baseline care plan was not completed and was unaware of who completes the care plans due to changing companies. The facility does not have an in-house MDS nurse. Review of the facility policy, Baseline Care Plan, dated 06/01/24 revealed the baseline care plan will be developed within 48 hours of a resident's admission. Indued the minimum healthcare information necessary to properly care for a resident including initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services.

Based on resident interview, record review, review of the facility policy, and staff interview the facility failed to provide scheduled showers to residents. This affected two residents, Resident #8 and Resident #4, out of 7 residents reviewed for showers. The current census is 38. Findings include:1. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #8 include diabetes type two, depression, epilepsy, heart failure, traumatic brain injury, bipolar disorder, and spastic hemiplegia. Review of Resident #8's Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #8 had intact cognition and was dependent on staff for bathing. Review of Resident #8's care plan dated 02/25/26 revealed a focus for risk of activities of daily living deficits related to weakness. Interventions include the resident is dependent on staff for bathing and showers. Further review of the medical record revealed no evidence of the actual shower schedule or preference noted for Resident #8. Per the records there was no resident refusals of offered showers or re-attempts offered for showers after refusals. Review of Resident #8's showers sheets dating from 06/01/26 to 07/28/26 revealed the resident received 4 out of 18 showers.Interview on 07/27/26 at 2:00 P.M. with Resident #8 revealed the resident stated she has not been receiving her showers or bed baths per the schedule. Resident #8 stated she has asked nurses and aides repeatedly to get her schedule showers. Interview on 07/28/26 at 3:45 P.M. with the Director of Nursing, (DON) verified there was no evidence Resident #8 received more than the 8 showers per the shower sheets. DON verified as of 07/27/26 the resident had only received 4 out of 18 showers. The DON verified residents were supposed to receive two showers per week. 2. Record review for Resident #4 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #4 include orthopedic aftercare after surgical amputation, Escherichia coli, dementia, muscle weakness, and heart disease. Review of Resident #4's MDS comprehensive assessment dated [DATE] revealed the resident had impaired cognition and required staff assistance with bathing. Review of Resident #4's care plan dated 04/13/26 revealed a focus for activities of daily living self-performance deficit and need for assistance. Interventions include resident able to shower self with moderate assist from staff. Review of Resident #4's shower sheets dating from 06/01/26 to 07/27/26 revealed the resident received a bed bath on 06/16/26, a shower on 06/19/26, a shower on 06/23/26, a bed bath on 06/30/26, and a shower on 07/12/26 for total of 5 baths/showers out of 17 scheduled showers. Further review of the medical record revealed no evidence of the actual shower schedule or preference noted for Resident #4. Per the records there were no resident refusals of offered showers or re-attempted offered for showers after refusals. Interview on 07/28/26 at 3:45 P.M. with DON verified there was no evidence of refusals in the medical records for Resident #4. DON verified per the shower sheets Resident #4 received only 5 showers/baths out of 17 showers/baths to be given per protocols. The DON verified residents were supposed to receive two showers per week. Review of the facility policy titled, 'Resident Showers,' dated 07/01/25 revealed the facility will provide residents showers per request and per facility scheduled protocols.

Based on observation, staff interview, and policy review the facility failed to ensure appropriate care was provided to one resident (#7) of one reviewed receiving parenteral nutrition via a percutaneous endoscopic gastrostomy (PEG) tube. The facility census was 39. Findings include:Review of the medical record of Resident #7 revealed an admission date of 05/22/26. Diagnoses include systemic lupus erythematosus, neuropathy, and pyogenic arthritis. Review of the quarterly Minimum Data Set assessment, dated 06/03/26, revealed Resident #7 was cognitively intact. Observation on 07/27/26 at 11:00 A.M. revealed Certified Nursing Assistants (CNA) #116 and #119 assisting Resident #7 with repositioning in bed. A parenteral nutrition was instilling at 65 milliliters per hour via a percutaneous endoscopic gastrostomy (PEG) tube with a pump. CNA #116 lowered the head of the bed without alerting the nurse of the need to pause the feeding pump. CNA #116 then placed the bed in reverse Trendelenburg (head lower than the feet) to position Resident #7 higher in the bed. Interview immediately following the procedure, CNA #116 verified he had not alerted the nurse to pause the feeding pump and had placed Resident #7 in reverse Trendelenburg position. Interview on 7/28/26 at 11:00 A.M. with Director of Nursing revealed nurses are the only personnel permitted to pause and/or start tube feeding pumps and verified the pump should have been paused during the process.

Based on record review, resident interviews, staff interviews, review of facility scheduled medication pass times, and policy review the facility failed to administer medications as ordered. This affected three (Residents #2, #7 and #30) out of six residents reviewed for medication. The facility census was 39. Findings include: 1. Record review for Resident #2 revealed the resident admitted to the facility on [DATE]. Diagnoses for Resident #2 include sepsis, chronic obstructive pulmonary disease, end stage renal dialysis with dependence on dialysis, and anxiety. Review of Resident #2's Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition, receiving dialysis, and was receiving anti-anxiety medications. Review of the care plans for Resident #2 revealed the care plans dated 7/6/25 revealed a focus for complications relating to dialysis treatments and a focus for anxiety relating to alterations in activities due to dialysis appointments. Intervention includes administering medications per physician order. Review of Resident #2's physician orders revealed on 11/18/25 the resident was ordered to receive Alprazolam 0.25 milligrams (mg) 1 tablet by mouth one time a day every Tuesday, Thursday, and Saturday prior to dialysis. Review of Resident #2's Medication Administration Records (MAR) dated 06/2026 and 07/2026 revealed the resident did not receive the Alprazolam medication on 06/29/26, 06/30/26, 07/02/26, 07/04/26, and 07/07/26. Per the MARs Resident #2 was not administered the ordered Alprazolam medication 9 times out of 24 scheduled times. Review of the progress notes for Resident #2 dated from 06/01/26 to 07/09/26 revealed on 06/29/26 and 06/30/26 the nurses documented the Alprazolam was 'unavailable need new script'. Per the note dated 07/02/26 at 5:20 A.M. the Alprazolam 0.25 mg tablet medication was unavailable, unable to pull, pharmacy needs new script. Per the note dated 07/02/26 at 1:15 P.M. the nurse noted a refill request for Alprazolam was faxed to the physician and the nurse was waiting a response. Per the note dated 07/04/26 at 5:21 A.M. the Alprazolam medication was unavailable, unable to pull, pharmacy needs new script. On 07/07/26 at 3:55 A.M. the nurse documented the Alprazolam 'new script'. No other nurses' notes were noted in the records. Interview on 07/28/26 at 3:45 P.M. with the Director of Nursing, (DON) verified the missing Alprazolam medications noted in Resident #2's MARs and progress notes. DON verified there were missing administrations of the medications due to the pharmacy not supplying the ordered medications in a timely manner. 2. Record review of Resident #30 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #30 include alcoholic cirrhosis of the liver with ascites, bipolar disorder, depression, Wernicke's encephalopathy, and end stage renal disease. Further review of Resident #30's records revealed the resident was receiving hospice services. Review of Resident #30's MDS comprehensive assessment dated [DATE] revealed the resident had mildly impaired cognition and was receiving anti-anxiety medications. Review of Resident #30's care plans dated 09/16/25 revealed a focus for using anti-anxiety medications. Review of Resident #30's physician orders dated 12/13/25 revealed Resident #30 was ordered to receive Ativan 2 milligrams, (mg), two tablets for 4 mg dose six times a day for restlessness. Review of Resident #30's MARs dated 06/2026 revealed on 06/15/26 there was two missed doses at 6:00 P.M. and 8:00 P.M. on 06/20/26 there were three missed doses at 6:00 A.M., 2:00 P.M., and 6:00 P.M. on 06/23/26 there were two missed doses at 2:00 A.M. and 6:00 A.M. on 06/24/26 there was two missed doses at 2:00 A.M. and 2:00 P.M. on 06/27/26 there was one missed dose at 6:00 P.M., and there were two missed doses at 2:00 A.M. and 6:00 A.M on 06/30/26. Review of Resident #30's progress notes dated 06/15/26 at 7:22 P.M. noted the Ativan 4 mg dose had been administered by previous nurse at 6pm too soon to give. No other documentation was noted for 06/15/26. Per the note dated 06/20/26 at 5:24 A.M. and 1:11 P.M. the nurse documented the Ativan medications was 'unavailable'. Per the note dated 06/20/26 at 5:01 P.M. the nurse documented the Ativan medication was 'on order'. Per the notes dated 06/23/26 the notes stated 'See nurse note' no corresponding note was in the medical records. Per the notes dated 06/24/26 at 2:02 A.M., and 1:26 P.M. the nurses documented, 'medication unavailable'. Per the note dated 06/27/26 at 7:08 P.M. the nurse documented the Ativan was 'day shift meds'. Per the notes dated 06/30/26 at 1:42 A.M. and 3:17 A.M. the notes stated 'See nurse note' no corresponding note was in the medical records. Interview on 07/28/26 at 3:45 P.M. with the DON while reviewing the MAR and the corresponding notations in the medical record revealed per the DON, the protocol for a medication being found unavailable at the time of administration was to contact pharmacy and/or contact physician for a new script. The DON verified there was no documentation stating the nurses had followed the protocols and ordered the Ativan medication for Resident #30 when the supply ran out. 3. Review of the medical record of Resident #7 revealed an admission date of 05/22/26. Diagnoses include systemic lupus erythematosus, neuropathy, pyogenic arthritis, hypertension, gastro-esophageal reflux disease, atherosclerotic heart disease, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set assessment, dated 06/03/26, revealed Resident #7 was cognitively intact. Review of the MAR for Resident #7 for 07/26 revealed the following medications were scheduled to be administered at the A.M. hours: amlodipine 10 mg with parameters to hold if systolic blood pressure (SBP) was less than 90 milliliters of mercury (mm/hg), diastolic blood pressure (DBP) less than 60 mm/hg, or heart rate (HR) less than 60 beats per minute; aspirin 81 mg; clopidogrel 75 mg; doxycycline 25 mg/ml(milliliters) give 20 ml; lisinopril 2.5 mg; sertraline 25mg; tiotropium bromide-olodaterol inhalation 2 puffs; carvedilol 12.5 mg with parameters to hold if SBP less than 90, DBP less than 60, or HR less than 60; guaifenesin 600 mg; hydroxychloroquine 200mg; potassium chloride 40 milliequivalents/15 ml, give 10 ml; pregabalin 75 mg; topiramate 25 mg; and furosemide 40 mg. Interview on 07/27/26 at 11:00 A.M. with Resident #7 revealed he had not received any medications for the day. Review of the MAR for Resident #7 on 07/27/26 at 11:10 A.M. revealed no indication his morning medications had been administered at this time. Interview on 7/27/26 at 11:22 A.M. with Licensed Practical Nurse (LPN) #127 revealed she had not administered medications to Resident #7 as of this time because she was waiting to be able to administer his pain medication at the same time, which is available at 12:00 P.M. Review of the Medication Pass Times revealed morning med pass times were 7A-10A. Review of the policy titled, Medication Administration, dated 8/22/25 revealed the policy stated to administer within 60 minutes prior to or after scheduled time. This deficiency represents non-compliance investigated under Complaint Numbers 3072123 and 3064268.

Based on medical record review, staff interview, review of medscape, and review of the policy, the facility failed to ensure antibiotics were ordered for an appropriate diagnosis. This affected one resident (#7) of six reviewed for unnecessary medications. The facility census was 39. Findings include:Review of the medical record of Resident #7 revealed an admission date of 5/22/26. Diagnoses include systemic lupus erythematosus, neuropathy, and pyogenic arthritis. Review of the quarterly Minimum Data Set assessment, dated 6/3/26, revealed Resident #7 was cognitively intact. Review of the physician order dated 5/22/26 revealed an order for doxycycline Hyclate (a tetracycline) 100 milligram (mg) daily for prophylactic for right knee wound indefinitely. The order was amended on 6/9/26 to doxycycline monohydrate oral suspension, give 100 mg daily for preventative and amended again on 7/28/26 to indicate the reason for the medication was related to right lower extremity wound indefinitely. Review of the medical record revealed a wound culture had been obtained and resulted on 6/19/26 to reveal Methicillin resistant staphylococcus aureus. The organism was resistant to tetracycline, among others. Interview on 7/28/26 at 10:00 A.M. with the Director of Nursing (DON) revealed she was uncertain as to reason of antibiotic for Resident #7 and thought perhaps recurrent urinary tract infections. Interview on 7/28/26 at 2:00 P.M. with the DON revealed the diagnosis given for the antibiotic is right lower extremity wound. Interview on 7/29/26 with the DON revealed no additional information as to need of the prophylactic antibiotic has been identified. Review of the policy titled Antibiotic Stewardship Program dated 1/24/26 revealed any antibiotic ordered upon admission will the reviewed for appropriateness. Review of medication information from Medscape at https://reference.medscape.com/drug/vibramycin-doryx-doxycycline-342548#5 revealed Doxycycline is a antimicrobial used for treating certain infections. Prescribing doxycycline in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria.

Based on observation, staff interview, and facility policy, the facility failed to ensure accurate and completed crash cart audits. This affected eighteen (#10, #11, #12, #14, #18, #19, #20, #22, #23, #24, #25, #27, #28, #29, #30, #32, #42, and #43) out of thirty-five full code residents. The facility census was 35.Observation and interview of crash cart on 04/27/26 at 3:05 P.M. with the Director of Nursing (DON) revealed April 2026 daily audit documentation did not include verification of expiration dates. Review of the crash cart audit logs further showed an extension cord was in the cart on 04/13/26, 04/17/26 and 04/26/26: however, observation confirmed the extension cord was not present in the crash cart at the time of inspection. Additionally, the audit documentation indicated required items, including eye protection, saline, and clear plastic, were not present in the crash cart and documented they were in the crash cart. Verified at time of finding with the DON.The facility policy, undated, Emergency Crash Cart, revealed the emergency crash cart is checked every 24 hours and after every use. Equipment/supplies from the emergency crash cart are noted and replaced promptly.This deficiency represents non-compliance investigated under Complaint Number 2687380.

Based on medical record review, review of hospital documents, and resident and staff interview, the facility failed to prevent an avoidable fall. Actual harm occurred on 08/10/25 when Resident #33 was in the bathroom leaning on the sink. The sink broke loose from the wall, fell to the floor, and broke into pieces. Resident #33 subsequently fell on top of a sharp piece of the sink and sustained a five millimeter (mm) laceration which hemorrhaged blood and required hospitalization with sutures needed to close the wound. This affected one (Resident #33) of three residents reviewed for accidents. The census was 41. Findings include: Record review for Resident #33 revealed the resident was admitted to the facility on [DATE]. Diagnoses included hemiplegia, malnutrition, difficulty walking, and cerebral infarction. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #33 had mildly impaired cognition and required set-up only for daily hygiene. Review of Resident #33's care plans dated 06/10/25 revealed a focus for falls. Interventions include keeping the bedside table within reach, keeping the call light within reach, keeping the room free of clutter, and therapy as ordered. Review of Resident #33's weight records recorded on 08/02/25 revealed the resident weighed 115 pounds. Review of Resident #33's progress notes dated 08/10/25 at 7:30 P.M. revealed the nurse was alerted by staff and other residents that the resident had an unwitnessed fall. The nurse noted a trail of blood from the outer hallway to the bathroom and bedroom door. Resident #33 was found groaning in pain. There was a moderate amount of blood hemorrhaging from Resident #33's lower back side. The resident was assessed by the nurse, attempts to stop the bleeding were applied, and emergency medical services were contacted. The nurse documented Resident #33 said she was leaning against the sink momentarily to finish hygiene when the sink detached from the wall. She fell and the sink fell to the floor. Resident #33 said she landed on a sharp piece of the sink causing a laceration to the lower lumbar area. Resident #33 was transported to the hospital for evaluation and treatment, and the nurse contacted the maintenance director due to not being able to completely turn off the water flooding into the bathroom and hallway. Review of Resident #33's hospital documents, dated 08/10/25, revealed the resident was admitted to the hospital for treatment to a laceration obtained after a fall onto a sink at the nursing home. Resident #33 suffered a 5 mm laceration on her back and required six sutures for closure. The resident was treated for pain at the hospital and sent back to the facility on [DATE] with instructions on wound care. During an interview on 09/23/25 at 10:02 A.M., Resident #35 and Resident #16, both residents stated they did not see the actual fall Resident #33 sustained on 08/10/25 in the bathroom. Resident #35 and Resident #16 stated they heard Resident #33 fall and then cry out for help. Resident #16 stated she went to get staff help, and Resident #35 stated she activated her call light and went to see if she could help Resident #33. Both residents stated the staff responded quickly to help Resident #33 and emergency medical services took the resident quickly to the hospital. Resident #16 stated she and other residents reported their concerns with the broken sink to other staff including the maintenance department prior to 08/10/25. During an interview on 09/23/25 at 10:41 A.M., Corporate Maintenance Director (CMD) #1 verified the sink in the shower room was non-functional since 08/10/25 when the sink fell off the wall. During an interview on 09/23/25 at 1:12 P.M., Resident #33 stated the bathroom sink had been in disrepair since July 2025 but was totally broken after her fall in August 2025. Resident #33 did not provide any details regarding the fall at the time of the original interview but stated since the sink was still broken at the time of the survey and she was unable to do her daily hygiene regularly in her own bathroom. Resident #33 stated she was upset she had to walk down the hall to the other shower room on the other side of building in order to do simple tasks such as washing her face and brushing her teeth. During an interview on 09/23/25 at 5:00 P.M. Resident #33 stated she was showering and had her clothes on the sink. Resident #33 stated she was alone in the bathroom getting dressed after her shower when she felt she felt unstable. Resident #33 stated she leaned on the sink to steady herself and the sink then wobbled off the wall onto the ground causing her to fall on top of the sink and it cut her back. Resident #33 stated she was not using the water sink for hygiene at the time of the fall and stated the sink was wobbly prior to the day of her fall. Resident #33 stated she received sutures for the laceration and the staff acted quickly and got her to the hospital fast. Resident #33 stated she did have pain in her back from the laceration immediately after the fall; however, the resident stated she had no continued pain with the injury and the wound had since healed. During an interview on 09/23/25 at 4:22 P.M., Maintenance Director (MD) #116 stated on 08/10/25 the sink in the shared shower room adjacent to room [ROOM NUMBER] fell to the floor causing a break in the water lines. MD #116 stated the nurse was able to turn off the water to the sink, but MD #116 came to the facility the night of the incident and had to shut off water supply to the sink to prevent further flooding. MD #116 stated he was informed Resident #33 fell while she was using the sink. MD #116 stated the sink was old and only mounted to the wall by the studs and did not have any support legs. MD #116 stated he did not know the condition of the sink prior to 08/10/25 as he did not perform any routine maintenance checks on sinks in the facility. MD #116 stated he had conducted a sink audit on 08/11/25 and found three other wall mounted sinks in the facility similar to the sink in the shared shower room. MD #116 stated he could not recall any reports of the other sinks being in disrepair prior to the sink audit. MD #116 verified the new sink arrived at the facility on 09/10/25, was put in storage, and was currently being installed as of 09/23/25 during the survey. MD #116 stated the new sink would be installed with a support structure. During an interview on 09/23/25 at 5:30 P.M., the Administrator verified Resident #33 fell on [DATE] while she was using the sink in the resident's room which also was the shared shower room for the South unit. Resident #33 leaned her whole weight on the sink causing it to come loose from the wall and fall to the floor. The Administrator verified Resident #33 only weighed 115 pounds at the time of the fall. The Administrator stated, due to the age of the building, there was no way to determine the age of the wall mounted sink in the bathroom but stated she believed the sink to be in working order at the time of the fall. The Administrator denied Resident #33 suffered any pain from the injury and stated if the resident had not leaned on the sink, it would not have fallen causing her to fall to the ground. The Administrator verified there had been no witnesses to the fall and stated Resident #33 stated she was changing her clothes in the room when she grabbed the sink. The Administrator stated she believed the resident had to have applied greater force than 115 pounds in order for the sink to have come loose and fallen to the floor. The Administrator verified there were no routine maintenance checks on the sinks in the facility prior to the fall on 08/10/25.This deficiency represents an incidental finding discovered during the complaint investigation.

Based on observation, medical record review, resident and staff interview, and review of invoices and receipts, the facility failed to maintain a homelike environment for its residents. This affected four (#9, #16, #33, and #35) of 25 residents reviewed for physical environment. The census was 41. Findings include: 1. Record review for Resident #9 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, muscle weakness, and schizoaffective disorder.Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had impaired cognition and required assist from staff for bathing and daily hygiene needs.Review of Resident #9's care plans dated 08/19/25 revealed a focus for activity of daily living (ADLs) deficits. Interventions included staff to assist with all personal care.Observation on 09/23/25 at 10:00 A.M., during the initial tour, revealed Resident #9 was observed resting in her room. Resident #9 was unable to be interviewed due to her medical condition.2. Record review for Resident #16 revealed the resident was admitted to the facility on [DATE]. Diagnoses included encephalopathy, mood disorder, and chronic obstructive pulmonary disease.Review of the MDS comprehensive assessment dated [DATE] revealed Resident #16 had intact cognition and required only set-up assistance for daily hygiene. Observation on 09/23/25 at 10:00 A.M. revealed Resident #16 resided in the same room with Resident #9. Resident #16 was sitting on the side of her bed in the room. Interview on 09/23/25 at 10:02 A.M. with Resident #16 revealed since her admission to the facility in June 2025, the sink in her bathroom had been in disrepair. Resident #16 stated it disturbed her to have to walk to the other shower room down the hall in order to wash her face and brush her teeth. Resident #16 stated she was bothered by the fact she has to wait for all other residents, including the two (#12 and #30) residents residing in the room connected to the other shower room, to complete their care before her and her roommates could use the sink. Resident #16 stated she used the visitor bathrooms at times but those are also farther away from her room and during the evenings she would prefer to be able to use her own bathroom.3. Record review for Resident #35 revealed the resident was admitted to the facility on [DATE]. Diagnoses included acute kidney failure, diabetes type two, weakness, and malnutrition.Review of the MDS comprehensive assessment dated [DATE] revealed Resident #35 had intact cognition and required only set-up assistance for daily hygiene. Observation on 09/23/25 at 10:05 A.M. revealed Resident #35 was sitting on her bed in the same room as Resident #16 and Resident #9.Interview on 09/23/25 at 10:10 A.M. with Resident #35 revealed the resident stated the sink in her shared bathroom did not work properly when she admitted to the facility. Per Resident #35, the roommates and herself all reported the sink to the maintenance staff and were told the parts to fix the sink were being ordered. Resident #35 stated it was inconvenient to have to walk all the way down the hall to use some other resident's bathroom just to wash her hands. Resident #35 stated she reported her concerns with the bathroom issues to the staff with no resolution when she first admitted to the facility in July 2025. 4. Record review for Resident #33 revealed the resident was admitted to the facility on [DATE]. Diagnoses included hemiplegia, malnutrition, difficulty walking, and cerebral infarction. Review of the MDS comprehensive assessment dated [DATE] revealed Resident #33 had mildly impaired cognition and was a set-up only for daily hygiene. Interview on 09/23/25 at 10:15 A.M. with Resident #33 revealed she had fallen in the bathroom due to the sink being in disrepair in August 2025. Per Resident #33, the sink had been leaking in the past and was wobbly. Resident #33 stated she reported the sink to staff before in July 2025 and was told the sink was on back order and would be replaced but at the time of survey it still had not been fixed. Resident #33 stated it was inconvenient to walk all the way to the other shower room or visitor bathrooms to wash her hands or complete simple daily hygiene tasks. Observation on 09/23/25 at 10:40 A.M. of the shower room on the South unit revealed the room was accessible from the hallway and the room shared by Resident #9, Resident #16, Resident #33, and Resident #35. In the shower room there was a toilet and a shower with a shower curtain. Located next to the toilet there were water lines connected to a faucet and there was no porcelain basin connected to the wall. Interview on 09/23/25 at 1:35 P.M. with Certified Nurse Aide (CNA) #118 revealed the sink in the room shared by Resident #9, Resident #16, Resident #33, and Resident #35 on the South unit had been in disrepair for a long time. Per CNA #118 the staff and residents reported the need to repair the sink to the maintenance department and was told the sink was on a list of repairs and was ordered to be replaced. CNA #118 stated all personal care requiring a sink required the residents in the room to go to the other shared shower room or the visitor bathrooms. CNA #118 stated when staff care for Resident #9 the obtain water from the shower stall. Review of the undated list of projects in the facility for repairs revealed there were no repairs for any shower rooms or bathroom sink listed on the document. Review of the invoice dated 09/06/25 revealed a new porcelain sink basin had been ordered by the facility. Review of the receipt invoice dated 09/10/25 revealed the new porcelain sink basin had been received and shipped to the facility. Interview on 09/23/25 at 10:41 A.M. with the Corporate Maintenance Director (CMD) verified the sink in the shower room was non-functional since 08/10/25 when the sink fell off the wall. Per the CMD, the sink was being repaired and was on the scheduled list to be repaired soon. The CMD did not give any actual date for the completion of the repair. Interview on 09/23/25 at 11:25 A.M. with the Administrator revealed there was a list of projects to be completed. The Administrator verified the sink in the room shared by Resident #9, Resident #16, Resident #33, and Resident #35 had fallen off the wall on 08/10/25 and had been non-functional since. The Administrator verified there were no repairs to the shower rooms or bathrooms noted on the list of work-orders and projects to be completed. Per the Administrator all repairs were in progress but had no dates listed on the form provided. Interview on 09/23/25 at 4:22 P.M. with Maintenance Director (MD) #116 revealed on 08/10/25 the sink in the shared shower room adjacent to Resident #9, Resident #16, Resident #33, and Resident #35's room fell to the floor causing a break in the water lines. Per MD #116, the nurse was able to turn off the water to the sink, but MD #116 came to the facility the night of the incident and had to shut off water supply to the sink to prevent further flooding. MD #116 stated on 08/11/25 he reported to his supervisors and the Administrator on 08/11/25 the sink would need to be replaced, and a new basin would have to be ordered. MD #116 verified the projects list had no dates and no shower room or sink repairs noted on the list of work orders to be completed. MD #116 verified the new sink arrived at the facility on 09/10/25 and had been in storage until 09/23/25 when the surveyor observed the bathroom missing the sink and the he had been instructed to start the repair to replace the sink. This deficiency represents non-compliance investigated under Complaint Number OH00167414 (1261183).

Based on medical record review and staff interview, the facility failed to initiate a care plan related to anticoagulation medication use. This affected one (#24) of three residents reviewed for care plans. The census was 41. Findings include: Review of medical record for Resident #24 revealed admission date of 06/24/25. The resident was admitted with diagnoses including end stage renal disease, diabetes mellitus, hyperkalemia, dependence on renal dialysis, heart failure, and intellectual disabilities. Review of Resident #24's physician orders dated 01/17/25 for revealed orders for the anticoagulant warfarin sodium Tablet eight (8) milligram (mg) and one (1) mg; to give 0.5 tablet of 1 mg with 8 mg to equal 8.5 mg by mouth one time a day for treating and preventing blood clots. Review of Resident #24's care plan dated 07/20/25 revealed the plan was absent for anticoagulants. Interview with the Director of Nursing (DON) on 09/24/25 at 2:34 P.M. verified Resident #24 did not have a plan of care for anticoagulant medication use. This deficiency represents an incidental finding discovered during the complaint investigation.

Based on medical record reviews, staff, resident and resident representative interviews, review of Self-Reported Incidents (SRI's), and policy review, the facility failed to ensure a resident was free from sexual abuse. This affected one (#12) out of three residents reviewed for abuse. The facility census was 39. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 02/18/25 with medical diagnoses of cerebral infarction, dementia with other behavioral disturbance, psychotic disorder with delusions, and hypertension. Review of the medical record for Resident #12 revealed a quarterly Minimum Data Set (MDS) assessment, dated 05/20/25, which indicated Resident #12 had severely impaired cognition and required supervision with eating and toilet hygiene, substantial/maximum staff assistance for bathing, and partial/moderate staff assistance with bed mobility and transfers. Review of Resident #12's medical record revealed the resident resided on a secured/locked unit at the facility. Review of the medical record for Resident #12 a nurses' note, dated 05/17/25 at 5:48 P.M. which stated Resident #12 was observed with her curtain pulled in her room with another resident. The note stated Resident #12 was observed with her pants below her waist line and the other resident was seen touching her when this writer questioned Resident #12. Resident #12 stated he wasn't doing nothing but making her feel good. The note stated the residents were immediately separated and the nurse was notified. The note continued to stated a head to toe assessment was completed, and no injuries were noted. The note stated the family and physician were notified and Resident #12 declined to seek medical attention. 2. Review of the medical record for Resident #07 revealed an admission date of 07/27/22 with medical diagnoses of Intellectual Disabilities, diabetes mellitus, end stage renal disease, and depression. Review of the medical record revealed an annual MDS assessment, dated 04/24/25, which indicated Resident #07 was cognitively intact and was independent with eating and required supervision with showers, toilet hygiene, bed mobility, and transfers. Review of Resident #07's medical record revealed the resident resided on a secured/locked unit at the facility. Review of the medical record for Resident #07 revealed a nurses' note, dated 05/17/25 at 6:10 P.M., which stated Resident #07 was observed in another resident's room touching her while her pants were down. The note stated the writer questioned Resident #07 about what was going on and Resident #07 stated he was talking to the female resident about outside. The note stated Resident #07 was his own person and the Administrator was notified. Review of the facility SRI, dated 05/17/25, revealed the facility investigated a sexual abuse allegation against Resident #12 by Resident #07. The SRI revealed staff reported finding Resident #07 in Resident #12's room with his hand on her peri-area. The investigation included staff interviews, physical assessment for Resident #12, and notification to the Resident #12's family and the police department. Interview on 06/03/25 at 11:06 A.M. with Certified Nursing Assistant (CNA) #102 stated she walked into Resident #12's room and observed Resident #12 lying on her bed with her pants to her knees and Resident #07 sitting in his wheelchair next to her bed with his hand in her peri-area. CNA #102 stated she immediately separated the residents and notified the nurse. CNA #102 stated she asked Resident #12 what was going on and Resident #12 stated he was making her feel good. CNA #102 confirmed Resident #12 had impaired cognition and resided on a secured unit. Interview on 06/03/25 at 11:28 A.M. with Director of Nursing (DON) confirmed Resident #07 was found in Resident #12's room with his hand on her peri-area. DON confirmed the facility had not provided education to all staff on abuse or follow-up audits/monitoring of concerns for abuse. Interview on 06/03/25 at 11:44 A.M. with Licensed Practical Nurse (LPN) #105 stated he was notified by CNA #102 that Resident #07 was observed in Resident #12's room with her hand in her peri-area. LPN #105 confirmed CNA #102 immediately separated the residents and the Administrator was notified. LPN #105 stated a head to toe assessment was completed on Resident #12 with no apparent injuries. Interview on 06/03/25 at 11:55 A.M. with Resident #12's son stated he was not Resident #12's power of attorney (POA) but he was not aware of any allegation of abuse. Resident #12's son stated at times Resident #12 is alert and oriented but other times Resident #12 has no idea what was going on or where she was at. Interview on 06/03/25 at 1:05 P.M. with Resident #07 stated he and Resident #12 were friends and denied touching Resident #12 in her peri-area. Interview on 06/03/25 at 2:08 P.M. with Social Service Director (SSD) #110 stated Resident #12 had moderately impaired cognition and was able to answer some questions appropriately but stated she was not sure if Resident #12 was able to comprehend everything that was told to her. SSD #110 stated Resident #12 did not have the cognitive capacity to consent to a sexual encounter. Interview on 06/03/25 at 3:05 P.M. with Resident #12 revealed she was alert to person, place, and year. Resident #12 stated she recalled Resident #07 touching her in her peri-area but could not recall if she consented to allowing Resident #07 touch her. Interview on 06/03/25 at 3:15 P.M. with Administrator confirmed he initiated a SRI and completed an investigation into the sexual abuse allegation for Resident #12. Administrator stated after speaking with staff he did not feel there was a sexual assault by Resident #07 because he felt the sexual encounter was a mutual decision by Resident #12 and Resident #07. Administrator stated Resident #07 was put on 15-minute checks after the incident until the investigation was completed . Administrator stated at times Resident #12 will seek out Resident #07 and speak to him inappropriately. Administrator stated the police department were contacted but did not investigate the incident. Administrator confirmed the facility completed the investigation and did not substantiate the allegation of abuse. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriate of Resident Property, stated the residents have a right to be free from abuse, neglect, exploitation, and misappropriation of resident property. This included, but was not limited to, freedom from corporal punishment, involuntary seclusion, and any physician or chemical restraint that was not required to treat the resident's medical symptoms. The policy stated sexual abuse was non-consensual sexual contact of any type with a resident. The policy stated the facility would investigate all alleged violations involving Abuse, Neglect, Misappropriation of Resident Property, Exploitation or Mistreatment, including injuries of unknown source. The policy stated abuse included verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology, such as photographs and recording devices to demean or humiliate a resident. The policy continued to state if a resident was accused or suspected the facility would ensure other residents are protected as determined by the circumstances, which may include but are not limited to, increased supervision of the alleged perpetrator and/or other residents, room or staffing changes, and immediate transfer or discharge, if indicated. This deficiency represents non-compliance investigated under Complaint Number OH00166012 and OH00165956.

Based on review of a closed medical record, staff interview, policy review, Emergency Medical Services (EMS) run sheet, and review of staff statements, the facility failed to immediately start and continue Cardio-Pulmonary Resuscitation (CPR) until EMS were on scene for one resident (Resident #42) who was identified as a Full Code status and was found unresponsive without vital signs. This resulted in serious life-threatening harm and/or death when Resident #42 did not receive immediate and continuous CPR prior to EMS services arriving at the facility. This affected one (Resident #42) of three residents reviewed for code response. The facility identified 24 residents residing in the facility designated with Full Code status. The facility census was 40. On 05/07/25 at 2:30 P.M., the Administrator and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 05/04/25 at 7:45 A.M. when Resident #42 was found without vital signs Registered Nurse (RN) #164 failed to initiate CPR immediately and stopped CPR prior to the arrival of EMS. Resident #42 expired at the hospital. The Immediate Jeopardy was removed on 05/05/24, when the facility implemented the following corrective actions: • On 05/04/25 at approximately 7:45 A.M., Resident #42 was found without vital signs. • On 05/04/25, the DON completed education on the CPR policy for all licensed nursing staff. • On 05/04/25, the licensed nurse (RN #164) who did not perform continuous CPR on the full code status resident (#42) was removed from the facility and the agency notified of the situation and investigation. • On 05/04/25, the Administrator and DON reviewed the policies and procedures related to code status. There was no revision to the policy made. • On 05/04/25, a Root Cause Analysis was performed using a fishbone diagram for the incident. This was completed by the Regional Director of Operation (RDO) #700, Regional Director of Clinical Operation (RDCO) #200, and the DON. • On 05/04/25, disciplinary actions were taken by the facility on the licensed nurse (RN #164) who did not initiate continuous CPR on a full code resident by notifying the board of nursing of the situation through filing a complaint and notifying the staff agency of the situation and marking the nurse as a do not return (DNR) on the facility profile. • On 05/04/25, additional training by the DON or designee was completed on the facility's policy and procedure for initiating CPR. • On 05/04/25, the DON or designee audited all residents advanced directives to the physician's orders and care plan for accuracy and listing in Electronic Medical Records (EMR). Findings are to be reviewed at the monthly Quality Assessment and Assurance (QAA) committee meeting. • On 05/04/25, the DON or designee performed a Code Blue drill with licensed practical nursing staff. Code Blue drills will continue to be completed three times per week for a period of three weeks including off shifts. Findings will be reviewed at the monthly QAA meetings. • On 05/04/25, the DON or designee audited all licensed staff files to verify all licensed staff have an active CPR certification. • On 05/04/25, the crash cart was audited to ensure all items were stocked and functional. Audits will continue for four weeks three times per week. • On 05/04/25, the facility notified the staffing agency of the CPR policy and has it uploaded as a read and sign prior to any staff picking up a shift at the facility through the agency. • On 05/04/25, an ad hoc Quality Assurance Performance and Improvement (QAPI) meeting was conducted to review the plan of correction and abatement including education and audits. Although the Immediate Jeopardy was removed on 05/05/25, 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 is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #42 revealed an admission date of 03/20/25. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, bipolar disorder and acute respiratory failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident was independently ambulatory. Review of the physician's orders revealed the resident was a Full Code status indicating all resuscitative measures were to be done if she were to go into cardiac arrest. Review of the plan of care dated 03/27/25 revealed the resident chooses to be a full code. The goal is for CPR to be initiated in any event of arrest. Life sustaining measures will be implemented as needed to honor the resident's wishes. The interventions included the facility will implement CPR and life sustaining measures and the resident's advanced directives will be honored. Review of the nursing progress note dated 05/04/25 at 9:26 A.M. revealed at 8:00 A.M., upon the aide doing rounds, she found Resident #42 blue and unresponsive. Immediately the staff and this nurse, RN #164, ran to check the status of the resident. The resident had no pulse, and staff immediately began 30 compressions per 2 breaths continuously for 20 minutes. The resident remained unresponsive with no pulse. EMS arrived shortly after and began compressions. The DON was notified, and staff also made several attempts to contact the family. Review of Fire Department #1's EMS run report revealed they received the call on 05/04/25 at 8:05 A.M. and arrived at the facility at 8:11 A.M. The patient narrative of the incident was dispatched to location for a [AGE] year-old male, CPR in progress. Arrived on location to find patient on the floor, apneic, and pulseless. No CPR was being done upon arrival. EMS crew began CPR on this patient. Facility aides came into the room and were asked who initially started CPR. They advised the aides had begun CPR, followed by the nurse in charge of the patient's care. The nurse completed one cycle of CPR and made the statement, I am going to call this, and we are going to stop CPR. CPR was not being done on this patient for approximately five minutes prior to EMS arrival on scene. CPR was completed for two cycles and then placed on the LUCAS (automatic chest compression system) device for continuous CPR. Patient was lifted from the ground onto the cot and transported emergently to the hospital. Interview on 05/07/25 at 9:30 A.M. with Certified Nursing Assistant (CNA) #155 revealed the CNA worked on 05/04/25 from 6:00 A.M. to 6:00 P.M. The roommate of Resident #42 came out of the room and stated the resident is not eating and needed CNA #155 to go in and get him up to eat. Upon arrival to the room, the resident was unresponsive and lying on the right side. CNA #155 touched the resident's arm and face to get him to respond. The resident felt warm, so he was turned over onto his back and felt for a pulse. The resident was a bluish color and did not seem to be breathing. CNA #155 ran out of the room and told the agency nurse and other aides she needed help. The aides and nurse went to the room and got the other agency nurse. The nurse, RN #164, went to get the code status of the resident and Licensed Practical Nurse (LPN) #163 brought the crash cart. CNA#161 and CNA#155 lowered the resident to the floor because they did not have a back board on the crash cart. CNA #161 started compressions after knowing the resident was a full code status (unknown how long it was before CPR was initiated) and the agency nurse was doing breaths with a paper towel with a hole in it to cover the mouth due not having a mouthpiece for the Ambu bag. CNA#161 asked RN #164 to take over CPR and she did one round of compressions and stated, There is no pulse, stop CPR. LPN #163 stated she is just an LPN and RN #164 had authority over her. CNA #161 told RN #164, You cannot call a code you are not a doctor. RN #164 told her not to tell her how to do her job. It was about five to seven minutes before the EMS got on scene, and they were livid to find out that staff had stopped CPR. The EMS started CPR immediately upon arrival. Interview on 05/07/25 at 10:06 A.M. with RN #164 revealed she was notified around 7:30 A.M. to 8:00 A.M. Resident #42 was not responsive and went to the room. The resident was cyanotic and had no pulse. RN #164 left the room to check code status and found out the resident was a full code and yelled this down the hall to the nurse aides in the room. CNA #161 and LPN #163 took the crash cart to the room. The oxygen tank on the cart was empty and staff were unable to find any oxygen. A call was made to the DON and 911. RN #164 went to the room and took over CPR compressions. Then after one round, the resident did not have a pulse, was cyanotic and limp. Staff all just stopped doing the CPR, due to being in shock. RN #164 denied telling anyone to stop CPR. The facility made RN #164 write out a report and RN #164 had to leave the job around 11:19 A.M. When asked what they did wrong, the DON said, CPR should have continued until EMS arrived and not stopped. RN #164 agreed they should not have stopped CPR. Interview on 05/07/25 at 10:16 A.M. with CNA #161 revealed CNA #161 was in the hallway when CNA #162 was coming down the hallway saying something was wrong and Resident #42 was not breathing. CNA #161went to Resident #42's room at 7:50 A.M. and RN #164 came into the room and just looked at him and walked away to get the code status. LPN #163 brought down the crash cart and there was not a backboard on it, so staff placed the resident on the floor. At 8:00 A.M., code status was confirmed as full code and staff started CPR. The crash cart had an empty oxygen tank and the Ambu bag did not have a face mask, and no other face mask was found. LPN #163 had to use a paper towel with a hole in it to give breaths. RN #164 came back to the room and was asked to take over CPR. RN #164 was doing compressions as CNA #161went into the hallway to look for EMS. CNA #161 heard RN #164 say, I'm stopping compressions, he is already gone. CNA #162 said, You are not supposed to stop CPR. RN #164 said, Do not tell me how to do my job. When EMS showed up about five to seven minutes later, they asked, What happened, why was CPR stopped? When the DON showed up and had all the staff write up statements, the DON was notified of the crash cart being empty of essential items, and by the time staff left for the day, the crash cart was full of those items. Interview on 05/07/25 at 2:45 P.M. with the Administrator and DON both confirmed Resident #42 was a full code and RN #164 called the code due to the resident having passed away. The Administrator and DON verified RN #164 should not have stopped the CPR. The DON removed RN #164 from the building and placed her on a DNR (do not return) with the agency. The DON, the Administrator, and supervisory staff immediately began in-servicing the nurses on code status of residents as well as beginning an audit of all charts for code status. All of the nurses had been in-serviced regarding code status. The agency was updated on DNR policy and all nurses who picked up a shift will sign before working at the facility. Interview on 05/07/25 at 3:55 P.M. with CNA#162 revealed the food trays came to the hall and Resident #42's tray was delivered to his room. At that time, around 7:30 A.M., Resident #42 was still lying in bed, and the tray was set on the bedside tray table beside the bed. A little bit later (before 8:00 A.M.), CNA#155 yelled she needed help and CNA #162 ran down the hall to Resident #42's room. There was a bruise on the left side of the resident's face and CNA #155 said something was wrong. They both tried to wake up Resident #42 and he did not respond. The resident's pulse was taken and could not be found. CNA #155 stayed in the room as CNA #162 ran to the nurse, RN#164. The nurse was told the resident does not have a pulse and was not breathing. The nurse was just standing there and stated, I do not know the code status. CNA #161 had gone down to the room waiting for a code status, which took around five to seven minutes. She went to the locked hall and got the nurse who grabbed the crash cart and ran to the room while waiting for the code status, but no one was doing CPR. The nurse still did not have the code status and went down to show where it was on the EMR, and she yelled at the staff the resident was a full code. CNA#162 went to the room, and CNA#161 started CPR and LPN #163 looked for a face mask, not present in crash cart and ended up using a paper towel for giving breaths. RN #164 came to the room and watched them doing CPR, when CNA #161 asked to be switched out. RN #164 took over compressions and completed one round, then stopped. RN #164 told all of the staff to stop, and she was calling the code. CNA# 162 said, Once CPR is started, it should not be stopped until the squad gets here. RN #164 stated, He does not have a pulse; he is gone and do not continue CPR. RN #164 also stated, I am a RN and do not tell me what my job is. RN #164 was threatening all staff with write ups if they touched Resident #42 to do any more CPR. He was making gurgling sounds and CNA #162 wanted to continue CPR and didn't because she had no authority. The squad got there after about five to seven minutes and was upset that no one was doing CPR. It was explained RN #164 called the code and she was at the medication cart on the phone. The EMS wanted to know the name of the nurse and stated she cannot call a code and stop CPR. Review of the 911 call from Fire Chief #2, revealed the call came in on 05/04/25 at 8:06 A.M. for Resident #42 who was a full code. When asked are you doing CPR? RN #164 replied, Yes we are. When asked how long have you been doing CPR? RN #164 replied, For about three minutes. Review of the written statement from RN #164 revealed on 05/04/25 she arrived at the facility and shortly after getting report, around 8:00 A.M. the aide informed her that Resident #42 was not responding. Upon arrival to the room, the resident had no pulse, face blue and was not responding. Staff did CPR for 20 minutes. The ambulance was called and were notified. The ambulance arrived five minutes before CPR was stopped. Review of CNA #161's statement given on 05/04/25 revealed CNA#155 came running up the front hall and said she thinks something is wrong with a resident. CNAs #161 and #155 went down to Resident #42's room. The resident was on his right side and his face was purple. Then RN #164 came into the room and just looked at the resident. CNA #161 asked for the resident's code status and a crash cart. It took RN #164 seven to 10 minutes to get the code status. CNA #161 and #155 placed Resident #42 on the floor and started the code. LPN #163 came into the room and was looking through the crash cart looking for stuff. The oxygen tanks were empty. LPN #163 was doing the breaths and CNA #161 was doing compressions, which was started at 8:00 A.M. RN #164 came back to the room and was asked to do the compressions. RN #164 started doing compression and CNA #161 was leaving the room to check for the EMS. CNA #161 heard RN #164 stop the code and say he is already gone. Once the EMS showed up, CNA #161 went back to the unit. Review of the statement given by CNA #162 around 8:00 A.M., revealed CNA#155 came to get help because she found Resident #42 not breathing. Resident #42 was lying on his right side, and he had a bruise on the left side of his face. CNAs #155 and #162 immediately got the nurse. Upon getting the nurse, she was trying to find his code status (which took several minutes). CNAs #155 and #161 moved the resident off his bed to the floor. The nurse did not start compressions, CNA#161 started the CPR. CNA#162 went to get the other nurse, LPN #163, who grabbed the crash cart and proceeded to the room. When entering the room, CNA #161 was doing compressions. RN #164 stated she was calling the code. CNA #162 stated, You cannot cancel the code. CNA#162 went to get all the residents away from the door of his room. The squad arrived and wanted to know why CPR was stopped, and CNA #155 told them RN #164 had called the code. The EMS stated she was not allowed to do that, and they started life saving measures again immediately. The EMS stated they needed to report the nurse and wanted to know her name. Review of the statement on 05/04/25 from CNA#155 revealed at approximately 8:00 A.M., a resident came to her and told her his roommate (Resident #42) was not eating and requested that CNA #155 wake him up. When CNA #155 entered the room, Resident #42 was lying in his bed completely covered up with a blanket. The resident was on his right side and the left side of his face was bruised. CNA #155 called his name, shook his arm, tapped his cheek and got no response. CNA #155 ran down the hall and yelled for help. Two aides (CNA #161 and CNA #162) and the two nurses (RN #164 and LPN #163) came to help. CNAs #161 and #155 moved the resident to the floor and CNA #161 started CPR. LPN #163 came in and started doing breaths. RN #164 came to the room with the crash cart. CNA #161 requested for RN #164 to take over compressions. RN #164 did one round of compressions while LPN #163 was doing breaths. RN #164 then stated she was, Calling the code, told staff to stop CPR. From the time CPR was stopped until the EMS arrived was about five minutes. The EMS questioned why CPR was stopped and CNA #155 explained that RN #164 had, Called the code and told staff to stop. RN #164 was the highest authority in the building at the time. The EMS immediately started life saving measures again. The EMS stated that they were reporting RN #164 for stopping CPR. Review of the statement on 05/04/25 from LPN #163 revealed at 8:00 A.M., the nurse was doing morning medication pass when an aide called the nurse to run down to Resident #42's room. While running to the room, the resident was on the bed, the resident's face was purple, and he was unresponsive. While waiting for RN #164 to get the code status, LPN #163 ran to get the crash cart. After six minutes, RN#164 told staff Resident #42 was a full code. CNA #161 started doing 30 compressions and LPN #163 gave two breaths. LPN #163 heard the bones crack and while giving breaths, she heard gurgling sounds. The crash cart was not properly stocked, no backboard, and the oxygen tank was empty. While doing CPR for twenty minutes, RN #164 told CNA #161 that she is doing compressions now. RN #164 only did one set of compressions and after LPN #163 gave two breaths, RN#164 stopped the code and said, I'm calling it, he is gone. RN #164 stayed in the room and LPN #163 left the room because she was upset with what happened and waited for EMS to arrive. Review of the facility's policy, Cardiopulmonary Resuscitation (CPR), dated 04/28/25 revealed that it is the policy of the facility to adhere to residents' rights to formulate advanced directives. In accordance with these rights, this facility will implement guidelines regarding CPR. This deficiency represents non-compliance investigated under Master Complaint Number OH00165420 and Complaint Numbers OH00165380 and OH00165034.

Based on medical record review, staff interview, and review of the outside provider respiratory notes, the facility failed to ensure a Bilevel Positive Airway Pressure (BiPAP) was ordered after a resident returned from the hospital. This resulted in Actual Harm when Resident #34 was admitted to the hospital with an oxygen (O2) level of 38 percent (%) and was admitted to the hospital and placed on a ventilator. This affected one resident (#34) out of three residents reviewed for oxygen. The census was 40. Findings included: Review of the medical record for Resident #34 revealed an admission date of 03/11/25 and re-entry of 04/21/25. The resident was admitted with diagnoses including acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease (COPD), and anxiety. The resident was discharged on 05/04/25 to the hospital. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The resident was on intermittent O2 therapy and uses a non-invasive mechanical ventilator (BiPAP). Review of the plan of care dated 03/20/25 revealed the resident has potential for alteration in respiratory function related to COPD and respiratory failure. The interventions included for the resident to maintain O2 levels at or greater than 90%, Continuous Positive Airway Pressure (CPAP) or BiPAP therapy for Obstructive Sleep Apnea, resident will adhere to CPAP or BiPAP regimen, educate resident or representative on the importance of CPAP or BiPAP therapy, encourage resident's use of CPAP or BiPAP and to provide BiPAP at pressure of 12 centimeters (cm) of water (H2O) during inhalation (IPAP) and six cm H2O during exhalation (EPAP) (12/6 CM/H2O) pressure with heated humidification at bedtime (hs) 40% bled in. Review of the discharge orders from the hospital dated 04/07/25 revealed an order for BiPAP settings confirmed with attending is 12/6, humification and 40% O2 bled in, to use at night and during any naps. Review of the progress note dated 04/08/25 at 9:02 P.M. revealed the resident had new orders for CPAP given to the Director of Nursing (DON) so respiratory can be contacted. Review of the Advanced Respiratory Services document dated 04/22/25 revealed the recommendation was for four liters per minute of O2 continuous with BiPAP settings of 10/5 decreased in settings. The medication recommendations were made for clarification of BiPAP orders. The additional notes were that the resident states BiPAP is not blowing enough air pressure. The settings were decreased and educated the resident on the change. The respiratory therapist spoke with DON and the NP. Review of the current physician's orders revealed no orders for BiPAP. Review of the Medication Administration Record (MAR) for 04/25 and 05/24 revealed the resident had an order dated 03/13/25 with a discontinue date of 04/07/25 for BiPAP at 12/6 CM/H2O pressure with heated humidification at hs with 40% bled in. The MAR was absent from any order or documentation for BiPAP the months 04/25 and 05/25. Further review of Resident #42's medical record including the Treatment Administration Record (TAR) revealed there was no documentation of the BiPAP being implemented after the hospitalization on 04/07/25. Review of the progress notes dated 05/04/25 at 10:07 A.M. revealed the Certified Nurse Aide (CNA) called for help. The resident was in a wheelchair and was having difficulty breathing. She had just come from smoking, and she was not able to walk to her room and was placed in a wheelchair. She was taken to her room, and this DON placed her on O2 and O2 was at 38%. The resident was groggy but responded to voice commands. She was placed on supplemental O2, and she went up to 60% on six liters per minute (LPM) via nasal cannula (NC). This DON called 911 and Emergency Medical [NAME] (EMS) arrived, and she was assisted to the cart. She was able to follow commands and transfer to cart. Discussed with the EMS's her smoking and her noncompliance with fluid and salt intake. She was transferred to the care of EMS. Sent to hospital for evaluation. The physician was made aware of emergent transfer. Review of the hospital admission documentation dated 05/04/25 revealed the assessment plan as acute hypercapnic respiratory failure, the resident was intubated due to inability to protect airway. The resident's laboratory tests revealed arterial blood gas (ABG) the PH was 7.24 which indicated acidosis (normal 7.35 to 7.45), partial pressure of carbon dioxide indicates hypercapnia (PCO2) 91 (normal is 35 to 45 millimeters of mercury (mmHg), partial pressure of O2 indicating hyperoxia (PO2) 245 (normal is 75 to 100 mmHg) and bicarbonate (HCO3) 39 indicates metabolic alkalosis (normal is 22 to 26 milliequivalents per liter (meq/l)). Interview with DON on 05/07/25 at 3:25 P.M. stated that she felt Resident #42 had been using her BiPAP machine and the staff was putting it on her every night. The DON would not verify the absence of the order in the physician's orders or on the MAR and there were not any progress notes on the use of the BiPAP or refusals by the resident. When the DON was shown the progress note on 04/08/25 which stated resident had new BiPAP order which was given to DON, DON stated she had the respiratory therapist come out and give a note which was dated 04/22/25, which she said was the day the respiratory therapist came to see the resident. The therapist made a recommendation for the BiPAP setting and this did not get put into the physicians order. This was 14 days later after the progress note. Further interview on 05/14/25, when shown the document of the BiPAP document which was taken from the memory card of the machine, the DON verified the BiPAP was not on the night before the resident was taken to the hospital. Interview with the Assistant Director of Nursing (ADON) on 05/07/25 at 3:20 P.M. verified the absence of an order for the use of the BiPAP in physician's orders, the absence of documentation in the MAR and in the progress notes that the BiPAP was being used and or refusals by Resident #42. Interview with the Nurse Practitioner (NP) #175 on 05/07/25 at 3:25 P.M. verified there was not an order in the current physician's orders for the BiPAP settings for Resident #42. Interview on 05/08/25 at 4:50 P.M with the Administrator revealed there is a memory card in the BiPAP machine and they are going to download the information and send it. This will prove the staff were placing the BiPAP machine on at nighttime. Interview on 05/12/25 at 7:00 A.M. the Administrator verified the respiratory document, which was downloaded from the BIPAP machine, gave the dates of when the resident used the machine. Interview on 05/12/25 at 11:50 A.M. with Respiratory Supervisor #250 revealed the documentation shows the resident was being placed on the BiPAP machine at night. She verified there were six days where she did not have the BiPAP on which were 04/10/25, 04/13/25, 04/14/25 and resident went to the hospital on [DATE] until 04/20/25. The resident then did not have the BiPAP on 05/01/25 and 05/03/25 and left the facility to the hospital on [DATE]. Respiratory Supervisor #250 stated the resident was non-compliant with using the BIPAP but could not provide documentation of the resident refusals. Review of the documentation sent from Respiratory Supervisor #250 revealed Resident #42 was using the BiPAP at nighttime during the dates of 04/07/25 to 05/04/25 and did not have it on for the days of 04/10/25, 04/13/25, 04/15/25, 05/01/25 and 05/03/25. This documentation did not give any reason why the BIPAP was not applied on those missing days and after each time the resident missed two days, she was hospitalized with hypercapnia (a condition where there's an excessive amount of carbon dioxide (CO2) in the bloodstream).

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure the physician was notified of a change in condition when the resident had an elevated blood pressure. This affected one (Resident #34) of three reviewed for change in condition. The facility census was 40. Findings include: Review of closed medical record for Resident #42 revealed admission date of 03/20/25. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, bipolar disorder and acute respiratory failure. Review of the plan of care dated 03/27/25 revealed the resident had a plan for altered cardiovascular status related to atrial fibrillation with interventions which included monitor, document, and report to physician ant signs or symptoms of coronary artery disease. Review of the physician's orders revealed an order dated 03/26/25 and placed on hold on 05/04/25, for metoprolol succinate oral capsule extended release 24-hour sprinkle 25 milligrams (mg), to give one capsule by mouth one time a day for blood pressure (bp); hold if systolic bp is less than 90. Review of the Medication Administration Record (MAR) for 05/25 revealed an order for metoprolol succinate oral capsule extended release 24-hour sprinkle 25 milligrams (mg), to give one capsule by mouth one time a day for blood pressure (bp); hold if systolic bp is less than 90. On 05/03/25, the residents bp was documented as 167 systolic and 124 diastolic. The MAR was absent of any further documentation of the residents bp. Review of the vitals tab in the Electronic Medical Record (EMR) revealed Resident #42 blood pressure was 167 systolic and 124 diastolic. The vital tab was absent of any follow up documentation regarding bp. The progress notes for the dates of 05/03/25 and 05/04/25 were absent of documentation of increased bp, or notification to physician and any follow up bp taken. Interview on 05/07/25 at 11:25 A.M. with the Director of Nursing (DON) verified the resident's vital signs should have been documented in the vitals tab in the EMR. The DON verified the physician was not notified of the blood pressures. The staff will call the doctor if the concern needs immediate attention such as this high blood pressure of 167 systolic and 124 diastolic. Staff can use fax, but this is only for minor concerns. There are on-call doctors and if they do not get back to staff, staff can call the medical director. Review if the facility's policy titled, Change in Condition, dated 04/02/25 revealed the facility shall notify the resident, his or her medical practitioner, and representative of changes in the resident's medical conditions. The nurse supervisor or charge nurse will notify the residents medical practitioner or on-call medical practitioner when there has been a change in resident's condition. The nurse supervisor or charge nurse will record in the resident's medical record information relative to changes in the resident's medical condition or status. This deficiency represents non-compliance investigated under Complaint Number OH00165420.

Based on medical record review and staff interview, the facility failed to ensure a resident's care plan had goals and interventions in place for wound care. This affected one (Resident #45) of three residents reviewed for wound care. The facility census was 40. Findings include: Medical record review for Resident #45 revealed an admission date of 01/17/25. Diagnoses included asthma, Chronic Obstructive Pulmonary Disease (COPD), depression, obesity, cutaneous abscess of left lower limb, cutaneous abscess of right lower limb, abscess of bursa, anxiety, hyperlipidemia, essential primary hypertension, and anemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was cognitively intact. Review of the wound assessment dated [DATE] revealed Resident #45 had surgical incisions to the right and left hip with a wound vac applied to the left hip. Review of Resident #45's care plan revealed no goals or interventions in place for wounds or the use of a wound vac. Interview on 05/07/25 at 3:15 P.M. with the Director of Nursing (DON) verified Resident #45's care plan did not have goals or interventions in place for wounds or use of a wound vac. This deficiency represents non-compliance investigated under Complaint Number OH00165034.

Based on medical record review and staff interview, the facility failed to complete weekly wound assessments. This affected one (Resident #43) of three residents reviewed for wounds. Additionally, the facility failed to complete wound treatments as ordered. This affected one (Resident #12) of three residents reviewed for wound care. Lastly, the facility failed to ensure a resident made it to a scheduled outside doctor's appointment. This affected one (Resident #12) of three residents reviewed for appointments. The facility census was 40. Findings include: 1. Review of the medical record for Resident #43 revealed an admission date of 10/31/24. Diagnoses included cellulitis of left lower limb, non-pressure chronic ulcer of left foot, muscle weakness, type 2 diabetes, hyperlipidemia, essential primary hypertension, hypomagnesemia, Chronic Obstructive Pulmonary Disease (COPD), adult antisocial behavior, and depression. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #43 was cognitively intact. Review of the care plan with a date initiated of 11/07/24 revealed goals and interventions for wound management. Interventions included wound will be free of signs and symptoms of infection, administer antibiotic therapy as prescribed, encourage resident to elevate legs, and evaluate ulcer characteristics. Review of the weekly wound assessment dated [DATE] revealed Resident #43 had a diabetic ulcer to the left plantar foot measuring 2.0 centimeters (cm) by (x) 2.9 cm x 0.3 cm. Further review of wound assessments revealed no weekly wound assessments with measurements were completed for Resident #43 in March 2025. Review of the progress note dated 03/11/25 revealed podiatry saw Resident #43 outside the facility regarding his wound to foot, indicating the wound was still present in March 2025. Interview on 05/07/25 at 3:14 P.M. with the Director of Nursing (DON) verified there were no weekly wound assessments for Resident #43's wound in March 2025. 2. Review of Resident #12's medical record revealed an admission date of 01/22/25. Diagnoses included superficial frostbite of the right foot, left foot, right hand, and tissue necrosis of the left foot and left hand, homelessness, and cerebral vascular accident. The frostbite resulted in amputation of the right small finger and amputation of all digits on the left hand. Review of Resident #12's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident's cognition was intact. The resident had unhealed surgical wounds. Review of Resident #12's medical record revealed a physician's order dated 12/19/24 to cleanse the right hand with wound cleanser, apply betadine to wound bed of all affected areas, cover with abdominal pad, and wrap with rolled gauze daily and as needed for soiling/dislodgement. Review of Resident #12's medical record revealed a physician's order dated 12/19/24 to cleanse the left hip with wound cleanser, apply skin prep to peri-wound skin, apply calcium alginate to wound bed, and cover with border foam daily and as needed for soiling/dislodgement. Review of Resident #12's medical record revealed a physician's order dated 12/20/24 to cleanse the left foot with wound cleanser, apply betadine to wound bed of all affected areas, cover with abdominal pad, and wrap with rolled gauze daily and as needed for soiling/dislodgement. Review of Resident #12's medical record revealed a physician's order dated 12/20/24 to cleanse the left hand with wound cleanser, apply betadine to wound bed of all affected areas, cover with abdominal pad, and wrap with rolled gauze daily and as needed for soiling/dislodgement. Review of Resident #12's January 2025's Treatment Administration Record (TAR) revealed the resident's right hand, left foot, left hand, and left hip wound care was failed to be completed on 01/03/25 and 01/06/25. Review of Resident #12's medical record revealed a physician's order dated 02/05/25 to cleanse the left hand with wound cleanser, apply betadine to wound bed of all affected areas, cover with an abdominal pad, and wrap with rolled gauze daily and as needed. Review of Resident #12's TAR dated February 2025 revealed the left-hand dressing change failed to be completed on 02/05/25, 02/05/25, and 02/16/25. Review of Resident #12's medical record revealed a physician's order dated 02/06/25 for the left foot to cleanse the wound with wound cleanser, apply betadine-soaked gauze to wound and between toes, cover with a dry 4 x 4, and wrap with Kerlix daily and as needed for soiling/dislodgement every day shift for wound care initial and date dressing. Document wound appearance with every dressing change. Review of Resident #12's TAR dated February 2025 revealed the left foot wound care failed to be completed on 02/09/25 and 02/13/25. Review of Resident #12's medical record revealed a physician's order dated 02/13/25 revealed to cleanse the right foot with wound cleanser. Apply betadine-soaked gauze to the wound. Cover with an abdominal pad, wrap in Kerlix, and wrap with an elastic wrap daily and as needed for soiling/dislodgement. Review of Resident #12's medical record revealed a physician's order dated 02/13/25 revealed to cleanse the left foot with wound cleanser, apply betadine-soaked gauze to wound and between toes, cover with an abdominal pad or 4 x 4's and wrap with Kerlix daily and as needed for soiling/dislodgement every night shift for wound care. Initial and date dressing. Document wound appearance with every dressing change and as needed for soiling/dislodgement. Initial and date dressing. Document wound appearance with every dressing change. Review of Resident #12's medical record revealed physician orders dated 02/17/25 to cleanse the left hand with wound cleanser. Apply betadine to the wound bed of all affected areas, cover with an abdominal pad, and wrap with rolled gauze daily and as needed every night shift for wound care. Document wound appearance every dressing change and as need for soiling/dislodgement. Initial and date dressing. Document wound appearance with every dressing change. Review of Resident #12's medical record revealed a physician's order dated 02/17/25 to cleanse the right hand with wound cleanser. Apply skin prep to all affected areas. Leave open to air daily and as needed every night shift for wound care. Initial and date dressing. Document wound appearance with every dressing change and as needed for soiling/dislodgement. Initial and date dressing. Document wound appearance with every dressing change. Review of Resident #12's February 2025 TAR revealed the right hand wound care was failed to be completed on 02/05/25, 02/09/25, and 02/13/25, 02/18/25, and 02/19/25. Review of Resident #12's February 2025 TAR revealed the right foot wound care was failed to be completed on 02/14/35, 02/15/25, 02/16/25, 02/18/25, and 02/19/25. Review of Resident #12's March 2025 TAR revealed left foot treatment failed to be completed on 02/14/25, 02/14/25, 02/15/25, 02/18/25, and 02/19/25. Review of Resident #12's medical record revealed a physician's order dated 03/07/25 for left foot care. Cleanse with in house wound cleanser, pat dry, apply betadine-soaked gauze to surgical incision, cover with 4x4s, Kerlix, and elastic wrap. Change every night shift for wound care. Review of Resident #12's TAR dated March 2025 revealed the resident's left foot wound care failed to be completed on 03/09/25. Review of Resident #12's medical record revealed the record was absent of documentation regarding the missing wound care information. Interview with Resident #12 on 05/08/25 at 11:10 A.M. revealed his wound care failed to be completed timely, especially on the night shift. Interview with the Assistant Director of Nursing (ADON) on 02/13/25 at 9:22 A.M. verified Resident #12's wound care failed to be completed timely as physician ordered. Review of the facility policy titled, Wound Care, reviewed 04/28/25 revealed the purpose of the procedure is to provide guidelines for the care of wounds to promote healing. Verify that there was a physician's order for the procedure. Document that treatment was completed in the electronic medical record. If the resident refused the treatment and the reason(s) why. 3. Review of Resident #12's medical record revealed an admission date of 01/22/25. Diagnosis included superficial frostbite of the right foot, left foot, right hand, and tissue necrosis of the left foot and left hand, homelessness, and cerebral vascular accident. The frostbite resulted in amputation of the right small finger and amputation of all digits on the left hand. Review of Resident #12's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident's cognition was intact. The resident had unhealed surgical wounds. Review of Resident #12's most recent care plan revealed he was at risk for impaired skin integrity. Review of Resident #12's orthopaedic physician note dated 03/10/25 revealed the resident was seen for post status right small finger amputation and amputation of all digits on the left side. The physician ordered to see the resident in two weeks. An appointment was scheduled for 03/24/25. Interview with the Administrator on 05/08/25 at 10:32 A.M. revealed Resident #12 had missed the appointment on 03/24/25 because the resident called the orthopaedic office and canceled the appointment. Interview with Resident #12 on 05/08/25 at 1:12 P.M. denied canceling any appointments. He stated his wound healing was important. Telephone interview with Nurse #200 at the orthopaedic physician's office on 05/08/25 at 1:27 P.M. revealed Resident #12 was to see the physician on 03/24/25 and he failed to arrive to the appointment. She stated the patient did not call and cancel the appointment. Interview with staff revealed the facility had no policy regarding resident appointments. This represents non-comliance investigated under Complaint Number OH00165034.

Based on record review, staff interview, and facility policy review, the facility failed to ensure physician orders were followed during medication administration. This affected one resident (#12) of three reviewed for medication administration. The facility census was 40. . Findings included: Review of Resident #12's medical record revealed an admission date of 01/22/25. Diagnoses included superficial frostbite of the right foot, left foot, right hand, and tissue necrosis of the left foot and left hand, homelessness, and cerebral vascular accident. Review of Resident #12's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident's cognition was intact. The resident had a diagnosis of hypertension. Review of Resident #12's care plan revealed the resident had decreased cardiac output. The goal was to have a normal heart rate and rhythm. Interventions included to evaluate the blood pressure, heart rate, character, and rhythm. Review of Resident #12's medical record revealed a physician's order dated 03/05/25 for Metoprolol Tartrate (beta blocker) 50 milligrams (mg). Administer by mouth two times a day for hypertension. Hold for systolic blood pressure under 110 or a heart rate below 60. Review of Resident #12's Medication Administration Record dated May 2025 revealed on 05/01/25 the resident's blood pressure was 104/54 in the evening, and the Metoprolol Tartrate was administered. On 05/03/25 in the morning the resident's blood pressure was 100/71 and his medication was administered. On 05/05/25 in the morning the blood pressure was 100/70, on 05/06/25 in the evening the blood pressure was 109/74 and on 05/07/25 in the evening his blood pressure was 106/52 and the medication was administered each time. Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 05/12/25 at 9:25 A.M. verified Resident #12's Metoprolol Tartrate was administered beyond the perimeters directed by the physician. Review of Resident #12's medical record revealed he had no negative effects as a result of the medication administration. Review of the facility policy titled, Administering Medications, reviewed 04/28/25 revealed medications must be administered in accordance with the orders, including any required time frames. This deficiency represents non-compliance investigated under Complaint Number OH00165420.

Based on medical record review, staff interview, review of facility policy, and review of the Centers of Disease Control and Prevention (CDC) guidance, the facility failed to timely cohort COVID-19 positive residents. This affected four (Residents #39, #11, #29, and #34) of four residents reviewed for COVID-19 isolation. The facility census was 42. Findings include: 1. Review of the medical record revealed Resident #39 was admitted on [DATE]. Diagnoses included cerebral palsy, contracture of muscle multiple sites, hyperlipidemia, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment, dated 02/18/25, revealed the resident is rarely understood. Review of census data revealed Resident #39 has not experienced a room move since 03/14/25. Review of nursing progress notes, dated 04/11/25, revealed the resident tested positive for COVID-19. The resident was symptomatic and was sent to the emergency room for further evaluation due to risk factors for respiratory disease. Review of nursing progress notes, dated 04/11/25, revealed the resident returned from the hospital with a new prednisone order. Review of the medical record revealed Resident #11 was admitted on [DATE]. Diagnoses included Alzheimer's disease, dysphagia, cognitive communication deficit, major depressive disorder recurrent, unspecified dementia, hyperlipidemia, and pressure ulcer of the sacral region stage 3. Review of the MDS assessment, dated 03/06/25, revealed the resident is rarely understood. Review of census data revealed Resident #11 shared a room with Resident #39 since 03/14/25. Review of nursing progress notes, dated 04/13/25, revealed the resident tested positive for COVID-19. Interview on 04/17/25 at 8:41 A.M. with the Director of Nursing (DON) verified Resident #39 tested positive on 04/11/25, was sent to the hospital, and returned the facility the same day. The DON verified upon returning, Resident #39 was placed in a room with two negative residents (#11 and #19) and a room move was not made until 04/14/25. The DON verified Resident #11 tested positive for COVID-19 on 04/13/25. 2. Review of the medical record review revealed Resident #29 was admitted on [DATE]. Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease, type two diabetes mellitus with diabetic nephropathy, heart failure, unspecified dementia, acute kidney failure. Review of the MDS assessment, dated 03/24/24, revealed the resident is rarely understood Review of census data revealed resident has resided in the same room since 01/20/25. Review of nursing progress notes, dated 04/11/25, revealed the resident tested positive for COVID-19. The resident was not cooperative with isolation and refuses to wear a mask in the hallway. Resident #29 is angry about staying in his room. The physician and family were notified. Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnoses included primary generalized osteoarthritis, type two diabetes mellitus, heart failure, major depressive disorder recurrent, hyperlipidemia. Review of the MDS assessment, dated 03/03/25, revealed the resident was cognitively intact. Review of census data revealed Resident #34 shared a room with Resident #29 since 03/05/25. Review of nursing progress note, dated 04/15/25, revealed Resident #34 tested positive for COVID-19. Interview on 04/17/25 at 8:41 A.M. with the DON verified Resident #29 tested positive on 04/11/25 and roommate, Resident #34 was not moved from the room until 04/14/25 and tested positive for COVID-19 on 04/15/25. Review of policy, Responding to a Newly Identified SARS-CoV-2 infection Healthcare Personnel or Resident, reviewed September 2024, verified when performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. Review of CDC guidance titled, Testing and Management Considerations for Nursing Home Residents with Acute Respiratory Illness Symptoms when SARS-CoV-2 and Influenza Viruses are Co-circulating, dated 11/14/23, and located at https://www.cdc.gov/flu/hcp/testing-methods/nursing-homes.html verified residents confirmed to have SARS-CoV-2 infection should be placed in a single room, if available, or housed with other residents with only SARS-CoV-2 infection. If unable to move a resident, he or she should remain in the current room with measures in place to reduce transmission to roommates. This deficiency represents non-compliance investigated under Complaint Number OH00164725.

Based on review of facility submitted Self-Reported Incidents (SRIs), medical record review, staff interview, review of the facility investigation and review of facility policy, the facility failed to report an allegation of resident abuse to the Ohio Department of Health (ODH). This affected one (#03) of three residents reviewed for abuse. The facility census was 43. Findings include: Review of Resident #03's medical record revealed an admitted [DATE]. Diagnoses include dementia, depression, anxiety disorder, and psychotic disorder with delusions. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/21/25, revealed Resident #03 was cognitively impaired and required maximal staff assistance with activities of daily living (ADLs) and supervision with ambulation. Further review of Resident #03's medical record revealed no evidence of an incident involving potential abuse. Review of the facility submitted SRIs from 01/30/25 through 03/10/25 revealed no reported allegations of abuse involving Resident #03. Interview on 03/19/25 at 8:35 A.M. with the Administrator revealed on 03/03/25 ,Certified Nursing Assistant (CNA) #110 reported an allegation of abuse against Resident #03, perpetrated by Registered Nurse (RN) #112. CNA #110 did not witness the alleged abuse, but was informed about it by CNA #175. Former Director of Nursing (FDON) #200 was immediately notified and interviewed CNA #108, CNA #107, and RN #112. The Administrator stated Resident #03 had required a lot of attention from RN #112 that day. A CNA reported to RN #112 that another resident was having respiratory distress and needed RN #112. Reportedly, RN #112 rushed past Resident #03 and bumped shoulder to shoulder with the resident. Resident #03 did not stumble or fall during the incident. The Administrator stated CNA #110 apologized before the end of the shift and retracted the allegation. The Administrator confirmed the incident was not reported to the Ohio Department of Health as she felt the incident had been fully investigated and found the facility was not out of compliance. Review of the facility investigation, dated 03/03/25, confirmed the facility investigated the allegation of abuse, with no negative findings. Review of the facility policy titled, Abuse, Mistreatment, Exploitation, and Misappropriation of Resident Property, undated, revealed all allegations of abuse or serious bodily injury should be reported to ODH immediately, but no later than two hours after the allegation was made. All other allegations involving neglect, exploitation, mistreatment, misappropriation of resident property and injuries of unknown source should be reported immediately, but in no event later than 24 hours from the time the incident/allegation was made known to the staff member. Further review revealed once the Administrator and ODH were notified, an investigation of the allegation violation would be conducted. This was an incidental finding discovered during the complaint investigation.

Based on review of a closed medical record, review of hospital documentation, review of an emergency medical services (EMS) run detail report, review of a facsimile (fax) document, staff interviews, and review of facility policy, the facility failed to ensure a resident (#30) was provided appropriate and timely treatment, care, and services when the resident was assessed with changes in condition. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death when Resident #30 was ordered supplemental oxygen and a non-invasive ventilator (NIV) for use to aid the resident's respiratory status. Resident #30 was noted to refuse the NIV without notification to the physician and subsequently was assessed with low blood pressure and a low oxygen saturation rate on [DATE] which were not timely or appropriately reassessed, reported to the physician, or rechecked prior to providing medications to the resident. The lack of timely and appropriate care, services, and notification to the physician contributed to Resident #30's untimely death when she was found in her room with blue lips, removing her shirt and supplemental oxygen, was unable to answer questions, and her eyes were rolled in the back of her head. Resident #30 became unresponsive and absent of vital signs and was sent to the hospital where the resident was placed on a ventilator in the intensive care unit (ICU) and subsequently died . This affected one (#30) of three residents reviewed for appropriate care and services. The facility census was 30. On [DATE] at 3:19 P.M., the facility Administrator and Interim Director of Nursing (IDON) #600 were notified Immediate Jeopardy began on [DATE] at 6:42 A.M. when staff failed to provide Resident #30 with appropriate and timely treatment, care, and services after being assessed with a change in condition. Resident #30 was assessed as hypotensive (low blood pressure) on [DATE] at 6:42 A.M. and had low oxygen saturation levels at 2:42 P.M. with no recheck of the resident's blood pressure, no follow up assessments completed, no notification to the physician regarding the low oxygen saturation levels was made, and no recheck of the oxygen saturation level or respiratory assessment was completed. Resident #30 was then given antianxiety and narcotic pain medications at 4:15 P.M. and subsequently was found in her room with blue lips, removing her shirt and supplemental oxygen, was unable to answer questions, and her eyes were rolled in the back of her head. Resident #30 became unresponsive and absent of vital signs which required the facility staff to initiate cardiopulmonary resuscitation (CPR). Resident #30 was sent to the hospital via EMS where the resident was placed on a ventilator in the ICU and subsequently died on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 4:00 P.M., an interdisciplinary team (IDT) Quality Assessment and Assurance (QAA) meeting was held to discuss and develop a plan with Medical Director #800. The plan was reviewed through discussion with the Administrator, Regional Director of Operations (RDO) #700, IDON #600, and the [NAME] President Director of Clinical Services (VPDCS) #707. On [DATE] at 4:00 P.M., MD #800 was notified of the Immediate Jeopardy and review of the facility change in condition policy and plan for corrective action was reviewed with no changes made. On [DATE] at 4:00 P.M., the change in condition policy was reviewed by the Administrator and IDON #600 with no changes made. On [DATE] at 4:00 P.M., IDON #600 and Assistant Director of Nursing (ADON) #500 provided education to all Licensed Practical Nurses (LPNs) and Registered Nurses (RNs), including managers, on the facility change in condition policy and staff response to a change in condition. All nurses were educated by 9:50 P.M. with a plan for no nurses on leave and no agency nurses would be able to work without receiving the education. On [DATE] at 4:30 P.M., all resident medical records were reviewed by IDON #600 and ADON #500 to review vital signs, oxygen saturation, and the resident's physical condition. The focus of the medical review reviews was to determine if the resident was within their normal baseline and if not, notification to the physician would be made. On [DATE] at 7:00 P.M., all resident medical records were reviewed by IDON #600 and ADON #500 to review for change in condition. All identified changes in resident condition were notified to the physician. On [DATE], an audit tool was implemented to monitor resident charts relating to any change in condition, adverse effects, and specifically, assessments for changes in condition as it related to change in condition notification. IDON #600 and/or ADON #500 will review documentation of at least 20 percent (%) of the total resident census utilizing the audit tool to ensure notification of change was made and proper care and services were implemented. The audits will continue daily for two weeks, then three times a week for the third week, and then twice a week for the fourth week to ensure compliance. The audit tools will be presented in weekly QAA committee meetings for four weeks to determine the need to continue the plan, make any changes to the plan, or stop the audits if compliance has been achieved. On [DATE], two (#20 and #25) additional resident medical records were reviewed for appropriate care and services with a change in condition with no concerns identified. On [DATE], between 9:00 A.M. and 4:00 P.M., LPN #203, LPN #206, ADON #500, and IDON #600, verified they were educated on the facility's polices related to treatment of a change in condition, physician notification of a change in condition, and to document all assessments, including follow up assessments, of all abnormal vital signs. All staff members interviewed were knowledgeable about the education content and felt confident the information could be applied during their work tasks. Although the Immediate Jeopardy was removed on [DATE], 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 is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #30 revealed an admitted [DATE]. Diagnoses included bipolar disorder, respiratory failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus, fatigue, chronic pain syndrome, dependence on respirator, cocaine abuse, schizoaffective disorder, and non-compliance with medication regimen. The resident was discharged to the hospital on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #30 from [DATE] revealed the resident was assessed with modified independence in regard to decision-making. Resident #30 was assessed to utilize supplemental oxygen or NIV with no refusal of care assessed during the review period. Review of Resident #30's care plan for potential for alteration in respiratory function related to COPD, pneumonia, and sleep apnea, dated [DATE] and reviewed [DATE], revealed interventions which included to administer medications as ordered, administer supplemental oxygen and may use a portable oxygen tank, notify the physician of changes in respiratory status, and observe for signs or symptoms of dyspnea (shortness in breath). Review of Resident #30's care plan for chronic pain, dated [DATE] and reviewed [DATE], revealed interventions which included to administer analgesics per order, anticipate need for pain relief and respond immediately to complaints of pain, evaluate effectiveness of pain interventions, and identify and record side effects and impact on function. Review of the physician orders for Resident #30 revealed an order dated [DATE] for the narcotic pain medications Tramadol 50 milligrams (mg) to give two tablets by mouth four times a day and an ordered Percocet ,d+[DATE] mg to give one tablet by mouth four times a day for pain on [DATE]. Resident #30 was ordered the antianxiety medication Lorazepam one (1) mg to give one tablet by mouth once every 24 hours as needed on [DATE]. Resident #30 was ordered the blood pressure medication Metoprolol 50 mg to give one tablet by mouth daily with instructions to hold for systolic blood pressure less than 110 millimeters of mercury (mmHg) or heart rate less than 60 beats per minute on [DATE]. Resident #30 was ordered the antianxiety medication Clonazepam 1 mg by mouth three times daily. Resident #30 was ordered the combination drug for treatment of COPD Ipratropium 0.5 mg - albuterol three (3) mg (2.5 mg base) per milliliter (ml) to inhale 3 mls orally every four hours as needed for shortness of breath on [DATE]. Further review of Resident #30's physician orders revealed an order dated [DATE] that Resident #30 may use a portable oxygen concentrator with activity at two (2) liters via nasal cannula to maintain saturation greater than 90% every shift related to COPD. Resident #30 also had an order dated [DATE] for nursing to notify the physician if the resident's systolic blood pressure was less than 100 mmHg or greater than 175 mmHg, the diastolic blood pressure was less than 60 mmHg or greater than 100 mmHg, and heart rate was less than 50 beats per minute every day shift related to hypertension and every night shift for NIV with use completed nightly. The order contained specific settings for the NIV for nighttime use and as needed for naps and could be titrated for the resident's comfort every night. If abnormalities are noted, staff are to notify the physician and document notifications and abnormalities. Review of Resident #30's vital signs between [DATE] and [DATE] revealed the resident's vital signs were within normal limits except on [DATE] when the residents blood pressure was ,d+[DATE] mmHg. Review of the vital signs for Resident #30 revealed on [DATE] at 6:42 A.M. the resident had a blood pressure of ,d+[DATE] mmHg with a heart rate of 55 beats per minute. Further review of Resident #30's vital signs revealed Resident #30 had no other documented blood pressure obtained on [DATE]. Further review of Resident #30's vital signs record between [DATE] and [DATE] revealed the resident's oxygen saturation rates were obtained as ordered and were within normal limits except on [DATE] at 2:42 P.M. which revealed an 80% oxygen saturation rate with no further documentation of oxygen saturation rates obtained on [DATE]. It was also noted Resident #30's oxygen saturation rates obtained on [DATE], [DATE], and [DATE] were the only entries that indicated Resident #30 utilized the NIV at night as ordered. Review of Resident #30's nursing progress notes from [DATE] to [DATE] revealed multiple entries related to the resident not using her NIV as ordered and the nurses provided education to Resident #30. There was no documentation in the progress notes of the physician or nurse practitioner being notified of Resident #30 not wearing the NIV. Further review of the progress notes revealed on [DATE], Resident #30 was educated by a previous director of nursing that serious bodily injury, including death, was possible if poisonous gases reached a level in the resident's body at night if she did not wear her oxygen as ordered. Review of a nurse practitioner progress note dated [DATE] revealed Resident #30 was non-compliant with wearing oxygen, following a fluid restriction, and wearing compression stockings. The nurse practitioner documented the resident was compliant with wearing NIV at bedtime due to resident's chronic respiratory condition to reduce risk if resident developing significant adverse medical complications and frequent hospitalization s. Review of nursing progress notes between [DATE] and [DATE] revealed no significant issues with Resident #30's blood pressure or oxygen saturation rates, and no identification of any changes in condition. Review of a fax document sent to Medical Director #800 on [DATE] at 6:47 A.M. revealed LPN #207 sent a notification that Resident #30 had a blood pressure of ,d+[DATE] mmHg and a heart rate of 55 beats per minute. LPN #207 documented Resident #30 had her blood pressure medication held. Further review of a return fax document from Medical Director #800 revealed no instructions to the nurse for continued assessment, treatment, or care of Resident #30 following the low blood pressure reading. The only documentation from Medical Director #800 on the returned fax document was an illegible mark on the bottom right corner of the document. Review of Resident #30's [DATE] medication administration record (MAR) revealed on [DATE] the resident received an as needed breathing treatment of Ipratropium albuterol solution 3 mls inhaled for shortness of breath at 1:06 P.M. at which time the resident's oxygen saturation rate was 97%. At 2:07 P.M., Resident #30 received as needed Lorazepam for anxiety. Further review of the [DATE] MAR revealed Resident #30 received scheduled Tramadol 50 mg and Clonazepam 1 mg by mouth both at 3:00 P.M. as ordered. Resident #30 was also administered both Percocet ,d+[DATE] mg and Clonazepam 1 mg at 4:15 P.M. A review of nursing progress notes on [DATE] revealed a note entered at 1:06 P.M. which revealed Resident #30 received a breathing treatment due to the resident stating she could not breathe. Review of a progress note entered at 9:04 P.M. revealed Resident #30 was given Clonazepam 1 mg and Percocet ,d+[DATE] mg at 4:15 P.M. on [DATE]. State tested Nurse Aide (STNA) #124 entered the resident's room to answer the resident's call light. STNA#124 entered the room to find Resident #30 removing her shirt and oxygen tubing, and STNA #124 noticed Resident #30's lips were blue. STNA #124 asked Resident #30 what she needed but when the resident tried to respond, she was not able to talk and continued to remove her shirt and oxygen tubing. LPN #208 went to assess the situation and the nurse discovered Resident #30's eyes were rolled back in her head. Resident #30 was moved to the floor and staff began CPR. EMS were called while staff continued CPR until EMS arrival. Resident #30 was sent to a local hospital and at last report was on a ventilator and moved to the ICU. Further review of progress notes from [DATE] revealed no documented evidence of staff reassessing the resident's respiratory status, oxygen saturation levels, or notification to the physician regarding the resident's change in condition until Resident #30 left the facility via EMS. Review of an EMS run detail report dated [DATE] at 4:26 P.M. revealed dispatch was initiated for an unresponsive but breathing female (Resident #30). Upon response, dispatch was advised CPR was being initiated by nurses. EMS arrived on scene to find Resident #30 supine on the floor with CPR in progress. Resident #30 was unresponsive, apneic (not breathing), and had no pulse upon EMS arrival at the facility. Resident #30's skin was pale, dry, and cool to the touch. EMS continued CPR while the resident was transported to the hospital; however, the resident remained in asystole (no heart activity) throughout the transport. Resident #30's nurse advised that she came to check on the resident and noticed she was unresponsive and barely breathing. The nurse checked for a pulse, but no pulse was found. Review of hospital documentation revealed Resident #30 was examined on [DATE] with a chief complaint of pulseless electrical activity (PEA). Per the nursing facility, Resident #30 stated she was not feeling well, was given three different medications, then suddenly collapsed without a pulse. Resident #30 was transported to the hospital via EMS. A computed tomography scan of the resident's chest revealed there was not a pulmonary embolism but identified severe pneumonia bilaterally with infectious agents of extended-spectrum beta-lactamase (ESBL) and Methicillin-Resistant Staphylococcus Aureus (MRSA) which was highly suspicious for an aspiration event resulting in pneumonia, likely from the facility. Resident #30 was diagnosed were PEA, anoxic brain injury, sepsis with shock, acute chronic hypoxia hypercapnic respiratory failure with aspiration pneumonia, new onset of atrial flutter with rapid ventricular rate (RVR), acute kidney injury, renal failure, and subacute T6 mildly commuted fracture. Interview on [DATE] at 2:00 P.M. with ADON #500 revealed the residents, including Resident #30, who are supposed to wear their NIV at night are not compliant with using them. ADON #500 stated the facility staff educated the residents on the importance of using the devices but verified she had not notified the physician of the residents' non-compliance with the NIV. Interview on [DATE] at 10:11 A.M. with Medical Director #800 revealed he was not notified of Resident #30's low blood pressure or low oxygen level on [DATE]. MD #800 stated he did not receive any notifications about the resident until after she left the facility via EMS. MD #800 stated, after reviewing the events of [DATE], he would have probably had the nursing staff observe Resident #30. MD #800 stated he was not specifically notified of Resident #30's refusals to wear her NIV, but verified he knew the resident was non-compliant with her supplemental oxygen at times. MD #800 notified the surveyor that Resident #30 died on the morning of [DATE]. Interview on [DATE] at 11:44 A.M. with LPN #222 revealed she worked on [DATE] from 2:00 P.M. to 10:00 P.M. LPN #222 verified she received shift report from the nurse working the previous shift but did not receive information that Resident #30 had a low blood pressure. LPN #222 stated she was the staff member who found Resident #30 without her supplemental oxygen on and stated she put the oxygen back on the resident. LPN #222 stated Resident #30's oxygen saturation rate at that time was 80%, and verified she did not recheck the resident's oxygen levels after that. LPN #222 stated she just figured the resident's oxygen saturation rate would go up since she put the supplemental oxygen back on the resident. LPN #222 verified she would not have administered Resident #30 her narcotic pain medications and antianxiety medications on her shift if she had known the resident's blood pressure was so low earlier in the morning. LPN #222 explained the medications she gave Resident #30 would suppress her respiratory system. LPN #222 confirmed she gave Resident #30 Clonazepam 1 mg and Percocet ,d+[DATE] one tablet by mouth at 4:15 P.M. on [DATE] and Resident #30 took them without any issues. LPN #222 stated around 4:20 P.M., STNA #124 told her she was needed in Resident #30's room as she was found unresponsive. LPN #222 stated she and STNA #124 moved Resident #30 to the floor and initiated CPR until EMS arrived at the facility. Interview on [DATE] at 4:40 P.M. with LPN #224 revealed she faxed the doctor about Resident #30's low blood pressure on [DATE]. LPN #224 stated she had Resident #30 elevate her feet and stated she rechecked the resident's blood pressure but could not remember what the blood pressure was or if she documented it. LPN #224 stated she informed the oncoming nurse about Resident #30's low blood pressure because the physician had not faxed back yet. LPN #224 verified she did not update the physician about Resident #30's ongoing low blood pressure. Review of the facility policy titled, Change in Residents Condition, dated ,d+[DATE], revealed the facility shall notify the resident, his or her representative of changes in the residents medical or mental condition. The nurse supervisor or charge nurse will notify the residents attending physician or on call physician when there has been a change in the resident's condition.

Based on resident record reviews, staff interviews, and review of facility policy, the facility failed to conduct thorough root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury, resulting in actual harm when a resident experienced repeated falls resulting in fractures. This affected one resident (#30) of three residents reviewed for falls. The census was 30. Finding include: Review of the medical record for Resident #30 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, Alzheimer's disease, unsteadiness on feet, [CONDITION(S)], [CONDITION(S)], and cognitive communication deficit. Review of fall risk assessment dated [DATE], revealed Resident #30 was at moderate risk for falls. Review of admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #30 was severely cognitively impaired. The resident required extensive assistance of two people for bed mobility and toilet use and limited assistance of one person for transfers. The assessment revealed Resident #30 had a history of falls prior to admission. Review of care plan revised 01/13/22, revealed Resident #30 was at risk for falls and fall related injuries. Documentation revealed the resident did not realize physical limitations caused by a chronic medical condition and had a history of reoccurring falls. The resident had poor impulse control and poor muscle coordination due to weakness and a fractured right ankle, incontinence, and acute mental status changes which caused poor safety awareness. Interventions included, weight bearing to right foot with boot in place, check on safety during daily care rounds, check room while providing care, keep pathways free of clutter/obstacles, complete fall risk assessment per protocol, anticipate needs, position objects that are frequently used in proximity, encourage use of reacher, nonskid footwear, and mechanical lift for all transfers. Review of a document titled, Incident Audit Report, dated 01/04/22 at 11:42 P.M., revealed Resident #30 was sitting on the floor in his room with his back leaning against the recliner chair, no injury was noted. The resident reported toothpaste was dropped on the floor and he was attempting to pick it up. Resident #30 was assisted to the recliner and education was provided on the importance of using the call light and waiting for staff assistance. Further review revealed the resident was noncompliant with waiting for staff assistance due to cognition. The intervention was to continue to re-educate the resident for the importance of staff assistance. Continued review revealed the resident was alert and oriented to person and ambulatory with assistance. Fall factors were documented as confused, gait imbalance, impaired memory, incontinent, and weakness/fainted. The care plan was documented as reviewed. Review of a document titled, Incident Audit Report, dated 01/04/22 at 2:41 P.M., revealed Resident #30 was noted to be sitting on the bathroom floor with his back resting against the toilet. The resident complained of right ankle pain. Documentation revealed the resident was trying to go to the bathroom and the resident's ankle gave out. Resident #30 had swelling to his right ankle and was non-weight bearing. Two staff assisted Resident #30 to his wheelchair and the physician was called with orders received for Resident #30 to be sent to the hospital for evaluation and treatment. The resident was assessed as alert and oriented to self and ambulatory with assistance. Fall factors included gait imbalance, impaired memory, and ambulating without assistance. The resident was found to have a fracture of the right ankle. Actions included, non-weight bearing until seen by physician, mechanical lift for transfers, and therapy to work with resident cognitive barriers. Review of fall risk evaluation dated 01/04/22 at 2:47 P.M. revealed Resident #30 had a history of three or more falls in the past three months and was ambulatory/incontinent. The resident was assessed to have balance problems while standing, balance problems while walking, decreased muscular coordination, change in gait pattern when walking through doorway, and required use of assistive devices. The document included clinical suggestions such as rubber-soled shoes or nonskid slippers to be worn for ambulation, utilize toileting program, and utilize personal/pressure sensor alarms. None of the clinical suggestions were selected. The score for the assessment was 19, which indicated Resident #30 was at high risk for falls. Review of document titled, Incident Audit Report, dated 03/12/22 at 12:23 P.M., revealed Resident #30 was found on the bathroom floor. Documentation revealed the resident's bottom was on the floor and legs/feet were pointing south. The resident reported attempting to get on the toilet and slid off and onto the floor. The resident denied pain and denied hitting his head. Resident #30's family and physician were notified. Fall factors included impaired memory, incontinent, ambulating without assist, and improper footwear. Documentation revealed the interdisciplinary team (IDT) reviewed and agreed the resident was currently receiving therapy services, who would assess and make recommendations due to the poor cognition of Resident #30. Review of a fall risk evaluation dated 03/19/22 at 9:09 P.M. revealed Resident #30 had intermittent confusion. The resident had a history of one to two falls in past three months. The resident was noted to be chairbound and required restraints and assistance with elimination. The resident was assessed to have balance problems while standing, balance problems while walking, and required use of assistive devices. The document included clinical suggestions such as rubber-soled shoes or nonskid slippers to be worn for ambulation, utilize toileting program, and utilize personal/pressure sensor alarms. None of the clinical suggestions were selected. The score for the assessment was 15, which Resident #30 was at high risk for falls. Review of a document titled, Incident Audit Report, dated 04/12/22, revealed Resident #30 was sitting on the floor next to the bed. Resident #30 was noted to be incontinent of urine. The resident reported trying to get up to go to the bathroom. Documentation revealed the resident was alert and oriented to person and wheelchair bound. Fall factors included gait imbalance, impaired memory, incontinent, and ambulating without assistance. Further review revealed the IDT reviewed and agreed with physician order for an x-ray to Resident #30's right ankle. Resident #30 was documented as unteachable or redirectable to not ambulate without assistance. Review of radiology interpretation dated 04/13/22, revealed the impression was severe osteopenia, nondisplaced fracture through the bases of the second through fifth metatarsals, and soft tissue swelling. Acute fracture noted through the right distal fibula. Periosteal thickening in the proximal fibula may represent old injury. Review of a progress note dated 04/13/22 at 11:55 A.M. revealed the physician was made aware of the radiology results and a new order was received to send Resident #30 to the hospital for evaluation and treatment. Review of a progress note dated 04/13/22 at 8:55 P.M. revealed the resident returned to the facility from the hospital. The resident was non-weight bearing. A splint was noted on the right lower extremity and the splint was to remain in place until follow-up with the physician. Interview on 04/13/22 at 8:32 A.M. with Registered Nurse (RN) #105 revealed Resident #30 was not able to use the toilet or urinal. RN #105 revealed the resident was to be monitored for incontinence and provided care as needed. Interview on 04/13/22 at 11:20 A.M. with Therapy Staff (TS) #300 revealed Resident #30 received occupational and physical therapy. TS #300 reported the resident had a long-term goal for toileting. TS #300 revealed the resident required a mechanical lift for transfers and was currently a max assist of three staff for up to 15 seconds. TS #300 reported the resident was not safe to be on the toilet or a bedside commode related to poor trunk control, leaning, recall of less than a minute, and weakness. TS #300 reported therapy was working with the resident on trunk control and strengthening to reduce leaning. TS #300 revealed Resident #30 was able to self-propel in the wheelchair to his room and use the urinal. Interview on 04/13/22 at 4:25 P.M. with the Regional Nurse Consultant (RNC) revealed Resident #30 had a Brief Interview of Mental Status (BIMS) score of five, indicating Resident #30 was severely cognitively impaired. Resident #30 was not teachable, therefore the RNC felt the resident was not appropriate for a toileting program or scheduled toileting. The RNC verified the resident had three falls while attempting to take self to the toilet, two of which resulted in fractures. The RNC verified the intervention for the fall dated 01/04/22 at 11:42 was educating the resident to wait for staff assistance, the intervention for the fall dated 01/04/22 at 2:41 P.M. was hospital evaluation/treatment and mechanical lift for transfers, intervention for the fall dated 03/12/22 was therapy services, and the intervention for the fall dated 04/12/22 was x-ray of the right ankle. The RNC verified the interventions did not address toileting needs of Resident #30. Interview on 04/13/22 at 4:47 P.M. with the Director of Nursing (DON) revealed Resident #30 was not able to use a urinal because the resident was shaky and would spill the urine. Interview on 04/14/22 at 11:40 A.M. with the DON revealed the facility's incident audit report was their root cause investigation form. Interview on 04/14/22 at 1:21 P.M. with the DON revealed there was no policy for root cause analysis, they just followed the form. Review of undated facility policy titled, Falls Policy and Procedure, revealed, based upon assessment, the IDT would develop interventions based upon the resident risk factors and individual needs.