Every finding on record at Crown Pointe Care Center

Based on record review and interviews, the facility failed to ensure incontinent care was provided at least once every shift. This affected five (Resident #1, #2, #3, #4, and #17) out of nine residents reviewed for incontinence care. The facility census was 78.Findings include: 1. Review of the medical record revealed Resident #1 was admitted on [DATE] with diagnoses that included acute and chronic respiratory failure, cerebral infarction, hemiplegia and hemiparesis, aphasia, anxiety disorder, and benign prostatic hyperplasia. Review of Resident #1's care plan dated 05/08/24 revealed Resident #1 had alteration in elimination and required assistance with toileting. Interventions included to provide incontinence care as needed. Review of Resident #1's bowel and bladder assessment dated [DATE] revealed Resident #1 was always incontinent of bowel and bladder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had severe cognitive impairment and was dependent on staff for toileting. The MDS revealed Resident #1 was frequently incontinent of bowel and bladder. Review of the bowel and bladder elimination documentation by Certified Nursing Assistants (CNA) revealed Resident #1 had incontinent care provided one out of two shifts on 01/25/26, 01/30/26, 02/02/26, 02/05/26, 02/07/26, 02/08/26, 02/09/26, 02/12/26, 02/13/26, 02/16/26, and 02/17/26. Resident #1 did not have incontinent care provided on 01/29/26 and 02/11/26. 2. Review of the medical record revealed Resident #2 was admitted on [DATE] with diagnoses that included Parkinson's disease, multi-system degeneration of the autonomic nervous system, chronic kidney disease, dementia, and benign prostatic hyperplasia. Review of Resident #2's care plan dated 08/05/25 revealed Resident #2 had alteration in elimination and was completely incontinent of bowel and bladder. Interventions included to provide incontinence care as needed. Review of the quarterly MDS dated [DATE] revealed Resident #2 had severe cognitive impairment and was dependent on staff for toileting. The MDS revealed Resident #2 was frequently incontinent of bowel and bladder.Review of Resident #2's bowel and bladder assessment dated [DATE] revealed Resident #2 was always incontinent of bowel and bladder. Review of the bowel and bladder elimination documentation by CNA's revealed Resident #2 had incontinent care provided one out of two shifts on 01/25/26, 01/29/26, 02/02/26, 02/05/26, 02/7/26, 02/08/26, 02/09/26, 02/13/26, 02/16/26, and 02/17/26. Resident #2 did not have incontinent care provided on 02/11/26.3. Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses that included Type II Diabetes, dementia, and hypertension.Review of Resident #3's care plan dated 04/27/21 revealed Resident #3 had alteration in elimination and was dependent on staff for incontinence care. Interventions included to provide incontinence care as needed.Review of Resident #3's bowel and bladder assessment dated [DATE] revealed Resident #3 was always incontinent of bowel and bladder.Review of the quarterly MDS dated [DATE] revealed Resident #3 had moderate cognitive impairment and required substantial/maximal assistance with toileting. Resident #3 was occasionally incontinent of bowel and bladder. Review of the bowel and bladder elimination documentation by CNA's revealed Resident #3 had incontinent care provided one out of two shifts on 01/23/26, 01/24/26, 01/25/26 01/29/26, 01/31/26, 02/06/26, 02/07/26, 02/08/26, 02/11/26, 02/12/26, 02/13/26, 02/17/26. Resident #3 did not have incontinent care provided on 02/05/26. 4. Review of the medical record revealed Resident #4 was admitted on [DATE] with diagnoses that included dementia, osteoarthritis, and chronic pain syndrome. Review of Resident #4's care plan dated 02/05/24 revealed Resident #4 may require assistance with care. Interventions included Resident #4 required assistance with toileting. Review of Resident #4's bowel and bladder assessment dated [DATE] revealed Resident #4 was frequently incontinent of bowel and bladder. Review of the annual MDS dated [DATE] revealed Resident #4 had moderate cognitive impairment and required partial/moderate assistance with toileting. The MDS also revealed Resident #4 was frequently incontinent of bowel and bladder.Review of the bowel and bladder elimination documentation by CNA's revealed Resident #4 had incontinent care provided one out of two shifts on 02/07/26, 02/08/26, 02/11/26, 02/12/26, and 02/13/26. 5. Review of the medical record revealed Resident #17 was admitted on [DATE] with diagnoses that included Type II Diabetes, acute kidney failure and anorexia.Review of Resident #17's care plan dated 04/15/24 revealed Resident #17 had alteration in elimination and was frequently incontinent of bowel and bladder. Interventions included to provide incontinence care as needed.Review of the quarterly MDS dated [DATE] revealed Resident #17 was cognitively intact and was dependent on staff for toileting. The MDS revealed Resident #17 was frequently incontinent of bowel and bladder. Review of Resident #17's bowel and bladder assessment dated [DATE] revealed Resident #17 was always incontinent of bowel and bladder. Review of the bowel and bladder elimination documentation by CNA's revealed Resident #17 did not have incontinent care provided on 01/26/26 and 02/19/26. Resident #17 had incontinent care provided one shift on 01/26/26, 01/28/26, 01/30/26, 02/01/26, 02/05/26, 02/09/26, and 02/15/26. During an interview on 01/20/26 at 8:12 A.M. a Resident that requested to be anonymous stated that there was not enough staff. The resident stated staff did not check residents frequently for incontinence. The resident stated she complained once and the staff refused to provide any care and incontinence care was not provided for 17 hours.During an interview with the Director of Nursing (DON) on 02/20/26 at 1:47 P.M. the DON verified the CNA documentation revealed incontinent care was not being provided every shift for Resident #1, #2, #3, #4, and #17. The DON stated staff were being educated about charting, but The DON could not verify that incontinent care had been provided. During an interview with Resident #4's family on 01/20/26 at 2:16 P.M. the family stated they found Resident #4 frequently incontinent and had asked that Resident #4 be checked and changed every two hours, but it was not being done. This deficiency represents non-compliance investigated under Complaint Number 2717356.

Based on observation, staff interview, and facility policy review, the facility failed to ensure staff wore hair nets in the kitchen as required. This had the potential to affect 88 residents in the facility. The facility identified one resident (#03) who did not receive food from the kitchen. The facility census was 89. 1. Observation on 07/23/25 at 7:20 A.M. revealed [NAME] #168 assisting [NAME] #119 with obtaining food temperatures on the steam table. [NAME] #168 was observed with braids which extended approximately 18 inches down her back and was not wearing a hair net. Observation on 07/23/25 at 7:36 A.M., [NAME] #168 was observed briefly leaving the kitchen and returned, wearing a hair net, however her braids still remained hanging outside of the hairnet. [NAME] #168 was then observed tending to food items on the facility stove.Interview on 07/23/25 at the time of the observation., [NAME] #168 verified she had not been wearing a hairnet until she left the kitchen and returned wearing the hair net, which still did not contain all of her hair. 2. Observation on 07/23/25 at 7:47 A.M., Maintenance Director (MD) #213 entered the kitchen without a hair net, walked past the stove and food preparation area, and checked the thermostat above the food preparation area. MD #213 was observed with short hair, approximately one inch in length, and no hair restraint. Interview at the time of the observation, MD #213 verified he was not wearing a hair net upon entering the kitchen and verified he should have applied a hair net prior to entering the kitchen. Review of the facility policy titled, Infection Control-Dietary/Food Handling, dated 02/2016, revealed hair nets or caps must be worn to effectively keep hair from contacting exposed food, clean equipment, utensils, and linens. This deficiency represents non-compliance investigated under Complaint Number 1327653.

Based on medical record review, resident interview, and staff interview, the facility failed to timely provide a physical therapy evaluation. This affected one (#04) of two residents reviewed for abuse. The facility census was 89. Findings include:Review of the medical record of Resident #04 revealed an admission date of 01/30/23. Diagnoses included metabolic encephalopathy, parkinsonism, schizoaffective disorder, bipolar disorder, and hypertension. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was assessed as exhibiting delusions, verbal behavioral symptoms directed towards others during the assessment period. The resident utilized a walker and wheelchair for mobility. The resident required setup/clean-up assistance with eating, partial/moderate assistance for dressing, substantial/maximal assistance for toileting, bed mobility, and transfers, and was dependent for bathing. Review of a self-reported incident (SRI) dated 05/27/25 revealed Resident #04 was involved in an altercation with Resident #48 when Resident #04 was observed running his power scooter into Resident #48's left foot and walker. Resident #04 stated he ran his power scooter into Resident #48 because Resident #48 would not get out of his way. The residents were assessed for injuries and had no negative findings. Resident #04 was moved to a manual wheelchair and was to be reassessed by therapy for the ability to safely use the power scooter. Resident #04 acknowledged understanding and was aware therapy would work with him on the scooter. Review of a social services progress note dated 05/28/25 revealed the resident was being assessed for the use of his electric scooter. At that time, the resident was not authorized to use the scooter. Review of a nursing progress note dated 07/02/25 revealed the nurse talked with therapy and re-educated the resident on proper use of walker and wheelchair. The nurse made a therapy referral to follow-up on the resident's non-compliance. Review of physician orders dated 07/02/25 revealed an order for a Physical Therapy (PT) screen and/or evaluation or treatment for proper transfer/use of adaptive equipment due to non-compliance. Review of therapy documentation revealed Resident #04 was last seen by PT 01/08/25-02/03/25 and Occupational Therapy (OT) 01/03/25-01/31/25. Further review of the medical record revealed no evidence of Resident #04 being assessed by therapy since the incident which occurred on 05/27/25. Observations on 07/24/25 at 4:00 P.M. and 07/28/25 at 10:20 A.M., revealed Resident #04's scooter was parked in the hallway outside of Resident #04's room. Interview on 07/28/25 at 10:20 A.M., the resident stated he had not been able to use his electric scooter in several months. The resident verified his scooter was sitting in the hallway and stated he had not been assessed for its use since it was taken away months prior. Interviews on 07/28/25 at 10:26 A.M. and 11:25 A.M., Director of Rehabilitation (DOR) #162 stated she did not have any evidence of evaluating Resident #04 for the use of his electric scooter following the 05/27/25 incident. DOR #162 verified Resident #04 had an order for a PT evaluation on 07/02/25 and there was no evaluation completed until the morning of 07/28/25. DOR #162 stated she looked at the resident following the order on 07/02/25, however made the determination to wait until the resident's mental status became more stable, as he was having issues with complying with his medication regimen. DOR #162 stated there was no documentation regarding the need to wait to complete the evaluation. DOR #162 stated the expectation, following receiving an order for a therapy evaluation or screen, is to have it completed and documented within a few days but no more than a week.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure a resident's responsible party was notified of a new order for a therapy evaluation. This affected one (#97) of one residents reviewed for a change in condition. The facility census was 89. Review of the medical record of Resident #97 revealed an admission date of 10/15/21. The resident discharged from the facility on 07/15/25. Diagnoses included chronic obstructive pulmonary disease, morbid obesity, hemiplegia and hemiparesis following cerebral infarction affecting left-non-dominant side, hyperlipidemia, atrial fibrillation, depression, dementia, anxiety, legal blindness, mood disorder, insomnia, and dysphagia. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. Review of the medical record revealed an order dated 04/15/25 for the resident to have a physical therapy and occupational therapy evaluation and treatment. The order was signed by Licensed Practical Nurse (LPN) #177. The area on the order for family notification was blank. Further review of the medical record revealed no evidence of Resident #97's responsible party being notified of the new order for therapy evaluation and treatment. Interview on 07/24/25 at 1:17 P.M., LPN #177 verified she was the nurse who signed the order for Resident #97 to receive evaluation and treatments from therapy. LPN #177 stated she assumed she notified Resident #97's responsible party of the new order, however verified there was no documented evidence in the medical record of the responsible party being notified of the new order. Review of the facility policy, dated 04/2013, revealed the unit supervisor or charge nurse will notify the guardian/interested family member of any significant changes in a resident's clinical condition or status, including ADL [activities of daily living] physical functioning and document said notification. This deficiency represents non-compliance investigated under Complaint Number 1327655.

Based on medical record review and staff interview, the facility failed to ensure entry and discharge Minimum Data Set (MDS) assessments were completed in a timely manner. This affected two (#37 and #40) of three residents reviewed for resident assessment. The facility census was 89.Findings Include:1. Review of the medical record of Resident #37 revealed an admission date of 12/24/24. The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses included amyotrophic lateral sclerosis and dementia. Review of the Medicare 5-day MDS assessment dated [DATE] revealed the resident had severely impaired cognition. Further review of completed MDS assessments revealed the resident's discharge MDS assessment dated [DATE] was not completed until 02/10/25. The resident's entry MDS assessment dated [DATE] was not completed until 02/10/25. Interview on 07/24/25 at 1:13 P.M., Licensed Practical Nurse (LPN) #144 verified Resident #37's discharge MDS assessment dated [DATE] and entry MDS assessment dated [DATE] were not completed within the required time frames. 2. Review of the medical record of Resident #40 revealed an admission date of 05/27/25. The resident discharged from the facility on 05/31/25. Diagnoses included dementia and cerebral infarction. Review of the admission MDS assessment dated [DATE] revealed the resident had severely impaired cognition. Further review of the medical record revealed there was no discharge MDS completed following the resident's discharge. Interview on 07/24/25 at 1:13 P.M., LPN #144 verified Resident #40 did not have a discharge MDS completed following his discharge on [DATE].

Based on observation and staff interview, the facility failed to ensure residents had access to their call lights. This affected two (#01 and #28) of two residents reviewed for access to call lights. The facility census was 89. 1. Review of the medical record of Resident #28 revealed an admission date of 06/01/19. Diagnoses included acute and chronic respiratory failure with hypoxia, cerebral infarction, hemiplegia and hemiparesis following cerebrovascular disease, aphasia, hypothyroidism, anxiety, depression. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required supervision with eating, substantial/maximal assistance with toileting, bed mobility, and was dependent on staff for bathing and transfers. Review of the care plan dated 06/13/19 revealed the resident was at risk for falls due to a history of cerebrovascular accident, debilitation, weakness, impaired balance, unsteady gait, and use of psychotropic medications. Interventions included to ensure call light is within reach. Observation on 07/21/25 at 10:00 A.M. revealed Resident #28 was lying in bed sleeping. His call light was observed out of reach, resting on the floor mat beside his bed. Interview on 07/21/25 at 10:01 A.M., Registered Nurse (RN) #179 verified Resident #28's call light was not in reach and further verified Resident #28 was capable of using his call light. 2. Review of the medical record for Resident #1 revealed an admission date of 10/15/24. Diagnoses included cerebral infarction, hemiplegia and hemiparesis affecting left non-dominant side, hypertensive chronic kidney disease, chronic obstructive pulmonary disease, schizoaffective disorder, bipolar disorder, obstructive sleep apnea, and malignant neoplasm of uterus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of 7 and dependent for toileting and oral hygiene, and moderate to maximal assist with dressing and personal hygiene. Care plan dated 05/11/25 revealed a focus of assistance with activities of daily living with a risk of developing complications associated with decreased ADL self-performance. Interventions include transferring, toileting, grooming, bathe with total care and Hoyer lift with two person assist. Care plan revealed a focus of risk for falls with interventions: encourage and remind to ask for assistance and have commonly used articles within easy reach. Observation on 07/21/25 at 10:56 A.M. revealed Resident #1's call light laying on left side of the bed. Nurse #123 confirmed Resident #1 was capable of using call light. Observation on 07/23/25 at 2:11 P.M. revealed Resident #1's call light was at the bottom left side of her bed out of resident reach. Interview on 07/23/25 at 2:13 P.M. with Staff Nurse #123 confirmed the call light was located at the bottom left side of her bed out of reach for resident.

Based on observations, interviews , medical record review and facility policy review, the facility failed to ensure fall interventions were in place for one, (Resident #76) of one reviewed for falls. The facility census was 89. Review of the medical record for Resident #76 revealed an admission date of 06/08/23. The record revealed the resident had severe cognitive deficits. Resident #76's diagnoses included dementia, chronic obstructive pulmonary disease, heart disease, anemia, depression, and chronic kidney disease. The resident was documented to require one-to-two-person assistance with activities of daily living and ambulation, and the resident had a history of falls.Review of Resident #76's nurse progress notes revealed on 05/29/25 the nurse was called by certified nursing assistant (CNA) at 12:40 P.M. to report he had seen Resident #76 on the floor in bedroom. The nurse went in immediately and found the resident lying on the floor in front of the closet in the bedroom. When the staff asked Resident #76 what happened, the resident told the nurse he fell. Resident #76 was assisted by the nurse and CNA into a wheelchair. A head to toe assessment was completed, and a hematoma was seen on the back of Resident #76's head. Ice was applied and as needed Tylenol (analgesic) was offered. Family, assistant director of nursing (ADON) and the physician were notified. Vitals were documented as stable and neurological checks were documented as in place. Resident had no nausea or vomiting observed at the time.Review of a fall investigation report dated 05/29/25 at 12:45 P.M. revealed Resident #76 was found in his room on the floor in front of his closet. He was alert and orientated to himself and reported he had fallen. A head-to-toe assessment revealed Resident #76 had a hematoma to the back of his head. Neurological checks were established. All parties were notified. The new fall precaution for Resident #76 was to have a safety alarm on while he was in a chair and or in bed. Staff to verify placement every shift.Review of Resident #76's plan of care last updated 6/11/25 revealed the resident had the following fall interventions: physical therapy, occupational therapy, non-skid strips in the bathroom, in front of closet and in front of bathroom entry, and bilateral assist bars to enhance bed mobility. On 07/24/25 Observation of Resident #76 on 07/24/25 at 11:24 A.M. revealed the resident was sitting in the lounge area in a wheelchair without a safety alarm in place. After surveyor intervention CNA #120 verified there was no safety alarm and clipped it on the Resident #76 shirt and wheelchair. On 07/24/25 at 11:37 A.M. observation and interview with Licensed Practical Nurse (LPN) #184 confirmed there is only one alarm for Resident #76, when he is in his bed, he is to have the alarm clipped to the mattress and himself and staff are to check the alarm every shift. Review of facility policy titled Alarms-person monitoring policy, dated 07/15/2003, revealed it is the Licensed Profession Nurse to ensure the residents personal monitoring alarms are in place and ordered.Review of facility policy titled Fall Management, dated 10/17/16 revealed Residents who experience a fall will receive prompt medical attention. Immediate needs will be quickly assessed and responded to. The interdisciplinary team will determine the need for development of additional facility-wide or resident specific interventions, staff, resident and/or family education and training, or other follow up measures that may be needed to reduce the risk of recurrence.

Based on observation , interview and facility policy review the facility failed to follow proper infection control policies when an outbreak of a contagious skin infection occurred in the facility. This affected two residents (#46 and #87) out of 13 residents who resided in the three hundred unit. The facility also failed to follow appropriate infection control practices by not performing proper hand hygiene after performing catheter care for one resident (#6) . The census was 89. 1.Review of the medical record for Resident #87 revealed an admission date of 04/23/24 with a brief interview of mental status (BIMS) score of 99 indicating severe cognitive deficits. Diagnoses included cerebral infarction, malignant neoplasm, paroxysmal atrial fibrillation, anxiety, hyperlipidemia , dementia, gastro esophageal reflux disease (GERD) and hypertension. The resident was independent with ambulation and wanders throughout the facility. Review of Resident #87's physician orders revealed a rash appeared on his body around 12/27/24 on his upper chest, back, bilateral forearms, abdomen and left side. The rash was treated with multiple medications until it was diagnosed as scabies (an infestation of the human skin by an itch mite) on 01/23/25. The scabies treatment started on 01/24/25 . Resident #87 was placed in contact isolation from 01/27/25 to 02/08/25 . Review of the Dermatologist progress note on 1/23/25 revealed the resident was diagnosed with scabies. Assessment and Plan included scabies located on his trunk, extremities, umbilicus and genitals: Patient informed of etiology and contagious nature of condition. Treatment options discussed. Start Ivermectin 3 milligrams (mg) tablets take five tablets on day 0, repeat in one week. Risk/ benefit/Side Effect (R/B/SE) and proper use of medication disc. Start TAC 0.1% ointment two times a day to itchy areas. R/B/SE and proper use of medication disc. Return to office in four weeks for rash follow up. Family was present and verbalized understanding and agreed with plan. Review of Resident #87's nurses progress notes from 01/20/25 to 01/31/25 revealed on 01/23/25 he was observed walking throughout the facility with no pants on . After several minutes the resident allowed staff to put his pants on. There was no indication staff were notified to follow contact isolation when treating Resident #87 at this time.Review of the Infection Control Surveillance Log from 01/01/25 to 03/31/25 revealed Resident #87 was not listed on the log for the scabies diagnosis.On 07/24/25 at 9:49 A.M. an interview with the Assistant Director of Nursing (ADON) #177 confirmed only one resident in the facility was diagnosed and treated for scabies. She could not confirm the facility completed skin sweeps on residents in Unit 300 or in the facility when Resident #87 was diagnosed with scabies.On 07/24/25 at 3:30 P.M. an interview with a Former Employee #510 confirmed there were two residents diagnosed with scabies. The Former Employee stated there was no staff education regarding scabies or infectious skin conditions. Resident #87 was allowed to wander throughout the facility going into the dining room for meals, lounge area and congregate with fellow residents and staff, while being on contact isolation. On 07/28/25 at 8:38 A.M. an interview with Licensed Practical Nurse # 184 confirmed Resident #87 would not stay in his room when he had scabies. The nurse verified the resident continued to walk throughout the facility while being treated for scabies. 2. Review of the medical record of Resident #46 revealed an admission date of 01/28/22 with a BIMS score of 15 indicating the resident was cognitively intact. Diagnoses included chronic obstructive pulmonary disease, cerebral infarction, schizoaffective disorder, depression, and anxiety. Resident #46 used a walker for mobility and required one person to assist with activities of daily living. Review of Resident #46's nurses progress notes from 01/20/25 to 01/29/25 revealed the nurses reported to Nurse Practitioner (NP) #500 Resident #46 was complaining of itching all over her body. NP #500 visited Resident #46 on 01/24/25 and determined she had crusted scabies since she did not respond to prednisone taper through 01/23/25. Review of Resident #46's physician orders for 01/01/25 to 01/31/25 revealed she started treatment for scabies on 01/24/25 and was in contact isolation until 02/08/25. Review of the Infection Control Surveillance Log from 01/01/25 to 03/31/25 revealed Resident #46 was not listed on the log for the scabies diagnosis. The infection log had no indication of any residents in the facility being diagnosed and treated for scabies. With surveyor intervention , the Regional Clinical Director #400 submitted additional surveillance log for 01/01/25 to 01/31/25 indicating one resident was treated for scabies.On 07/24/25 at 9:49 A.M. an interview with the Assistant Director of Nursing (ADON) #177 confirmed only one resident in the facility was diagnosed and treated for scabies. She could not confirm the facility completed skin sweeps on the residents in Unit 300 or in the facility when scabies was identified in the facility. On 07/24/25 at 2:00 P.M. the interview with the Regional Clinical Director #400 confirmed the facility had one resident who was diagnosed and treated for scabies. Regional Clinical Director #400 confirmed the facility had no documentation indicating the local health department was notified of a scabies outbreak at the facility or documentation indicating if all residents in the facility or residents on Unit 300 had a skin sweeps completed to check for scabies after Resident #87 was diagnosed with scabies. On 07/24/25 at 2:25 P.M. interview with Laundry Representative #109 confirmed he recalls washing contaminated linen in January for two residents who were diagnosed with scabies. He denied being educated about scabies or being questioned if he had any rashes. On 07/28/25 at 8:33 A.M. an interview with Resident #47 revealed she was treated for scabies; it was awful and finally it went away. On 07/28/25 at 8:49 A.M. interview with the City of Columbus Health Department Representative #600 confirmed there was no documentation of the facility providing notification to their office of having two residents diagnosed with scabies. Representative #600 stated it is required to report to the local health department when two or more residents in a long-term care facility are diagnosed with scabies. Representative #600 stated then information is sent to the facility with instructions to treat and the health department follows the outbreak for six weeks.Review of the City of Columbus Health Department resource titled: Michigan Department of Community Health Scabies Prevention and Control Manual dated 2005 provided to the surveyor by Representative #600 as the information that would have been issued to the facility had the outbreak of scabies been reported to the local health department. The resource revealed the need for standard precautions stating gowns and gloves should be worn by all facility personnel who have direct contact with suspected or confirmed scabies patients, until completion of treatment, or until scabies has been ruled out. Restrict both patient and roommate(s) to their room for duration of therapy. Do not restrict patient to his/her room if the entire unit is undergoing treatment, but do restrict movement within the nursing unit. Post signs to alert health care workers, visitors, and volunteers of precautions being observed. Any specific isolation precautions beyond standard precautions should be discontinued after treatment has been completedReview of facility policy titled Scabies, dated 07/2018, revealed Staff will implement based on the CDC recommendations to prevent, eradicate, and contain Sarcoptes scabiei (Scabies). The facility should take a systemic approach, including detection and treatment of affected residents. Appropriate transmission-based precautions and infection control practices should be used. Measures to control scabies depend on factors such as how many cases are diagnosed or suspected, how long infested persons have been at the facility while undiagnosed and /or unsuccessfully treated. The local health department may be consulted for any outbreak that may have community implications, including possible spread by patients or staff to other institutions. Control measures for an outbreak involving one or more confirmed crusted scabies may include additional measures for detection , diagnosis, infection control, and treatment measures dependent on community factors . A facility information program may be implemented to instruct all management, medical, nursing, and support staff about scabies, the scabies mite, and how scabies is and is not spread.3. Review of the medical record for Resident #6 revealed a readmission date of 01/13/25. Diagnoses included Diabetes Mellitus type 2, neuromuscular dysfunction of the bladder, benign prostatic hyperplasia with lower urinary tract symptoms, history of urinary tract infections (UTI), extended spectrum beta lactamase (ESBL) resistance, dysphagia, and atherosclerotic heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact with a Brief Interview for Mental Status (BIMS) of 13. Resident #6 had no impairment with functional limitation of range of motion, utilized a walker and wheelchair for mobility, and required moderate assistance with toileting and showering. Resident #6 was frequently incontinent of bowel.Review of the plan of care dated 06/11/25 revealed a risk for infection with a goal that resident will remain free of signs and symptoms of infection with interventions for foley catheter care and monitor for signs and symptoms of urinary tract infection (UTI): foul smelling urine, cloudy urine, sediment, and decreased output.Review of physician orders for 01/14/25 for Resident #6 revealed orders for enhanced barrier precautions due to foley catheter and to perform catheter care every shift.Observation of catheter care on 7/23/25 at 10:03 A.M. revealed certified nurse aide (CNA) #158 did not remove her soiled gloves and perform hand hygiene after she provided catheter care to Resident #6. CNA #158 assisted resident with dressing, straightened his linens, assisted him to his wheelchair, and placed his call light back on the bed with soiled gloves.Interview with Assistant Director of Nursing (ADON) #177 confirmed CNA #158 should have removed soiled gloves and performed hand hygiene before assisting Resident #6 with dressing, transferring, and handling linen and call light.Facility policy dated October 18, 2001, titled Catheter Care/Urinary stated Remove gloves and discard into designated container. Wash and dry your hands thoroughly. Reposition the bed covers. Make resident comfortable. Place call light within easy reach of resident.This deficiency represents non-compliance investigated under Complaint Number 1327647.

Based on medical record review and staff interview, the facility failed to ensure admission comprehensive Minimum Data Set (MDS) assessments were completed within the required timeframes. This affected two (#03 and #37) of three residents reviewed for resident assessment. The facility census was 89. 1. Review of the medical record of Resident #37 revealed an admission date of 12/24/24. The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses included amyotrophic lateral sclerosis and dementia. Review of the medicare 5-day MDS assessment dated [DATE] revealed the resident had severely impaired cognition. Further review of completed MDS assessments revealed the resident's admission MDS assessment dated [DATE] was not completed until 01/10/25. The resident's discharge MDS assessment dated [DATE] was not completed until 02/10/25. The resident's entry MDS assessment dated [DATE] was not completed until 02/10/25. Interview on 07/24/25 at 1:13 P.M., Licensed Practical Nurse (LPN) #144 verified Resident #37's admission MDS assessment was not completed within 14 days of the resident's admission. 2. Review of the medical record of Resident #03 revealed an admission date of 06/23/25. Diagnoses included chronic obstructive pulmonary disease (COPD) and severe protein-calorie malnutrition. Review of the admission MDS assessment dated [DATE] revealed the resident had moderately impaired cognition. The assessment was not completed until 07/09/25. Interview on 07/24/25 at 1:06 P.M., LPN #144 verified Resident #03's admission MDS assessment was not completed within 14 days of the resident's admission.

Based on observation and staff interview, the facility failed to ensure State Agency survey results were maintained, updated, and available for viewing. This had the potential to affect all 89 residents in the facility. Findings include:Observation on 07/24/25 at 2:45 P.M. revealed the survey results binder, located at the front of the building, next to the Administrator's office, revealed the most recent survey results were dated 04/20/24.Review of Enhanced Information Dissemination Collection (EIDC) revealed the facility had surveys completed on 07/31/24 and 10/10/24. Interview on 07/24/25 at 2:48 P.M., the Administrator verified survey results dated 07/31/24 and 10/10/24 were not contained in the survey results binder. The Administrator verified survey results should be placed in the survey results binder following each survey.

Based on staff interview, record review, review of the facility's Self-Reported Incidents and investigations, and policy review, the facility failed to thoroughly investigate and obtain statements from staff for an injury of unknown origin for Resident #50 and Resident #101. This affected two (Resident #50 and #101) of three residents reviewed for abuse. The facility census was 85. Findings include: 1. Record review of Resident #50 revealed an admitted [DATE] with diagnoses including aphasia, disorder of bone density and structure, generalized osteoarthritis, Alzheimer's disease, osteoarthritis, presence of right artificial hip, and age related osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 was rarely or never understood and does not use and mobility devices. Review of the progress note dated 09/27/24 at 8:32 A.M. revealed Resident #50 was experiencing pain in lower extremities. Nurse Practitioner notified and ordered bilateral x-rays of hips and pelvis. The progress note dated 09/27/24 at 4:00 P.M. revealed the x-ray results revealed a right femoral neck fracture. Resident #50 to be sent to the emergency room for evaluation. Review of a facility self-reported incident (SRI) control number 252375 dated 09/27/24 revealed Resident #50 was found to have a fracture of the femoral neck. All steps immediately taken to ensure the resident was protected which included additional staff interviews, resident interviews, and comprehensive investigation to follow. The facilities investigation revealed the facility did not have statements from the staff. There was no documented interviews with staff asking if they had seen anything out of the ordinary with Resident #50. The facility had a basic SRI Investigation form that was evidence of training. The form was signed by trained employees that asks have you witnessed any staff, resident, or visitor be abusive toward any resident. Have you ever committed abuse, neglect or mistreated a resident? Do you know who to report to? The bottom of the paper stated I acknowledge that my answers are accurate and I understand the inservice provided to me. There was no evidence of a statement from Licensed Practical Nurse (LPN) #12 or State tested Nursing Assistant (STNA) #14, who were the staff working when they identified fracture, was obtained by the facility. A statement dated 10/01/24 and signed by the Director of Nursing (DON) stated she designated the Assistant Director of Nursing #11 to interview all nurses and STNA on duty the night of 09/26/24 to the morning of 09/27/24. Per all nursing staff and STNA, nothing unusual or out of the ordinary occurred during the shift. Interview with the Administrator on 10/10/24 at 10:40 A.M. verified the facility did not have any further information on the SRI investigation including staff interviews/statements. Interview with Assistant Director of Nursing #11 on 10/10/24 at 11:20 A.M. stated she just called the staff and interviewed the staff by telephone but she did not have any documented interviews. Interview with LPN #12 on 10/10/24 at 11:37 A.M. stated Resident #50 would not get out of bed on 09/27/24. LPN #12 stated normally she could walk by herself unassisted sometimes, but usually needed help. LPN #12 stated she was not asked to write a statement about the incident. Interview with STNA #14 on 10/10/24 at 11:49 A.M. stated the morning of 09/27/24, Resident #50 yelled in pain when she put her sock on. STNA #14 went and got the nurse on duty. She thought the nurse told her to write a statement but she was unsure if she wrote a statement or not. 2. Record review of Resident #101 revealed an admitted [DATE] and he passed away in the facility on 09/03/24. Diagnoses included dementia without behaviors, traumatic subdural hemorrhage without loss of consciousness, and age related osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 was severely cognitively impaired and used a wheelchair to aid in mobility. Review of the progress note dated 08/15/24 at 5:40 P.M. revealed Resident #101 had pain in his right leg starting at right foot radiating up the leg. Slight warmth to the touch minimal swelling. The progress note dated 08/16/24 at 4:56 A.M. revealed right hip two view x-ray stat was ordered. The progress note dated 08/16/24 at 10:47 A.M. revealed Resident #101 was sent to the hospital due to a fracture of the right hip. Review of the facility's self-reported incident (SRI) control number 250845 dated 08/16/24 revealed an injury of unknown origin was reported to the State Survey Agency. On 08/16/24, Resident #101 was found to have a right hip fracture. The facility's investigation did not include staff statements or staff interviews asking if they had seen anything out of the ordinary for Resident #101 except for one. The Director of Nursing (DON)'s statement stated the Nurse Practitioner said it was possible the hip was just dislocated itself since it was replaced [AGE] years prior. The facility had a basic SRI Investigation form that was evidence of training. The DON stated she spoke with each STNA that worked the night of 08/15/24 into the morning of 08/16/24. Each STNA stated there was nothing out of the ordinary with this resident. There was no documented interview with any of the staff in the investigation. The form was signed by trained employees that asked have you witnessed any staff, resident, or visitor be abusive toward any resident. Have you ever committed abuse, neglect or mistreated a resident? Do you know who to report to? The bottom of the paper stated I acknowledge that my answers are accurate and I understand the inservice provided to me. The facility's SRI investigation revealed there was no evidence of a statement from Licensed Practical Nurse (LPN) #12 or State tested Nursing Assistant (STNA) #14. Interview with the Administrator on 10/10/24 at 10:40 A.M. verified the facility did not have any further information on the SRI investigation including staff interviews/statements. Interview with LPN #12 on 10/10/24 at 11:37 A.M. revealed Resident #101 could not get up safely out of bed and she was not interviewed about his dislocated femur. LPN #12 stated she was not asked to write a statement about the incident. Interview with STNA #14 on 10/10/24 at 11:49 A.M. revealed she was not asked to write a statement about Resident #101's dislocated femur. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Resident Property Policy dated 11/21/16 revealed in response to abuse, neglect, exploitation, or mistreatment, the facility must have evidence that alleged violations are thoroughly investigated. This deficiency represents non-compliance investigated under Complaint Number OH00158297.

Based on review of monthly infection control surveillance logs, staff interview, and facility policy review, the facility failed to to maintain a complete and accurate tracking system for all infections. This had the potential to affect all 86 residents residing in the facility. The census was 86. Findings Include: Review of the facility infection control monthly surveillance log on 03/13/24 revealed the facility failed to document the results of cultures for residents with suspected or actual infections from May 2023 through February 2024. On 03/13/24 at 10:20 A.M., interview with the Director of Nursing (DON) and the Regional Nurse #200 verified the infection control log was not tracking the bacteria being treated for community acquired and facility acquired infections. Review of the facility policy titled, Infection Surveillance, last revised 11/28/17, revealed data to be used in the surveillance activities may include but are not limited to 24-hour shift reports, laboratory (lab) reports, antibiograms obtained from lab, antibiotic use reports from pharmacy, and documentation of signs and symptoms in clinical record.

Based on medical record review, review of investigations, staff interview, and policy review, the facility failed to thoroughly investigate an injury of unknown origin. This affected one (#6) of one resident reviewed for skin conditions. The facility census was 86. Findings include: Review of the medical record for Resident #6 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, depression, gastro-esophageal reflux disease, and senile degeneration of the brain. Review of Resident #6's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. Review of Resident #6's progress notes dated 10/01/23 through 10/19/23 revealed no concerns related to a fall or injury. Review of Resident #6's progress note dated 10/21/23 at 12:16 P.M. revealed Resident #6 was noted to have edema to the left elbow. Hospice was updated and they advised the facility to monitor for changes. Review of Resident #6's incident investigation dated 10/21/23 and completed on 10/24/23 revealed Resident #6 had swelling to the left elbow. Licensed Practical Nurse (LPN) #105 and State tested Nurse Aide (STNA) #145 were interviewed regarding Resident #6's condition. No additional staff members, residents, or family members were interviewed. The summary of the incident indicated the nurse noted edema to Resident #6's left elbow. The resident was noted to be combative with care that morning. The resident was frequently combative with care. She would swing her arms and attempt to hit the staff. Resident #6 frequently yelled out. The hospice provider, Resident #6's guardian, and physician were notified. A head-to-toe assessment was completed, and no other areas were noted. Resident #6 was swinging at the nurse during the assessment. An x-radiation (x-ray) image was ordered and a possible distal humeral fracture was noted. An orthopedic referral was given, the guardian was not interested in the referral. There was no pain or discomfort noted. Review of Resident #6's progress note dated 10/22/23 at 12:00 P.M. revealed Resident #6's guardian was updated on the edema to the elbow. Review of Resident #6's physician order dated 10/24/23 revealed an order for an x-ray, two views, to the left swollen elbow and arm. Review of Resident #6's progress notes dated 10/24/23 revealed an order was placed for an x-ray to the left arm. The x-ray results were received with a finding of massive soft tissue swelling of the elbow noted with a possible distal humeral fracture. A new order for an orthopedic appointment was given. Review of Resident #6's x-ray results dated 10/24/23 revealed two radiographs of the left elbow were completed. Massive edema of the elbow, distal arm, and forearm were noted. There was a possible supracondylar fracture of the humerus, but it was unclear, and additional imaging was recommended. Review of Resident #6's progress note dated 10/26/23 revealed the resident's guardian was not interested in an orthopedic referral. Review of Resident #6's physician progress note dated 10/30/23 revealed Resident #6 had edema to her left arm by an unknown source. An x-ray was completed with a possible distal humerus fracture. Hospice would not complete a full work up with orthopedics. Interview on 03/11/24 at 3:10 P.M. with STNA #145 revealed Resident #6 required total care with most activities of daily living. STNA #145 verified Resident #6 could get combative, but reported if the resident was somewhat combative they would get a second staff member, and if she remained combative, they would leave her and come back later. STNA #145 could not recall the events that lead to Resident #6 injuring her arm. Interview on 03/12/24 at 1:55 P.M. with the Director of Nursing (DON) stated Resident #6's guardian and hospice did not want to follow up after the x-ray. The DON verified only two staff were interviewed and witness statements were not collected. The DON additionally verified the investigation was not thorough. Review of the policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 11/21/16, revealed an injury was classified as an injury of unknown source when both of the following conditions are met including the source of the injury was not observed or could not be explained by the resident and the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed, or the incidence of injuries over time. In response to allegations the facility must ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property are reported to the administrator or designee of the facility and to other officials including the State Survey Agency. This must be reported immediately, but not later than two hours after the allegation is made if the events involve abuse or result in serious bodily injury. It should be reported no later than 24 hours if the events do not involve abuse and do not result in serious bodily injury. The facility needs to provide evidence that all alleged violations are thoroughly investigated and report the results to the administrator and State Survey Agency within five working days of the incident.

Based on observation, medical record review, and staff interview, the facility failed to ensure adequate fluids were available and provided throughout the day to promote hydration. This affected one (#6) of seven residents reviewed for nutrition. The facility census was 86. Findings Include: Review of the medical record for Resident #6 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, depression, gastro-esophageal reflux disease, and senile degeneration of the brain. Review of Resident #6's nutrition assessment dated [DATE] revealed the resident required 2190 milliliters (ml) of fluid a day. Review of Resident #6's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was rarely or never understood. The resident was on a mechanically altered and therapeutic diet. Review of Resident #6's fluid intake from 02/12/24 to 03/10/24 revealed fluid intake was only documented on six days. Fluid intake included 120 ml on 02/12/24, 360 ml on 02/13/24, 240 ml on 02/23/24, 240 ml on 02/24/24, 240 ml on 03/01/24, and 80 ml on 03/07/24. Review of Resident #6's plan of care dated 03/07/24 revealed the resident had the potential for alteration in nutrition and hydration related to diagnoses, overweight status, requiring a mechanically altered diet, pressure wounds, and hospice status. Interventions included adaptive equipment as ordered, hospice services, medications as ordered, monitoring the consistency of diet served, providing assistance with meals as necessary, providing supplement as ordered, weighing as ordered, and providing foods and fluids the resident could tolerate and enjoy. Review of Resident #6's physician order dated 03/10/24 revealed an order for regular diet, with a pureed texture, and fluids were to be regular consistency. Observation on 03/10/24 at 10:33 A.M., 11:40 A.M., and 1:49 P.M. revealed Resident #6 was in bed with a large cup of water on the nightstand; however, the nightstand was at the end of the bed next to the resident's feet. Observation on 03/11/24 at 7:58 A.M., 8:59 A.M., 9:30 A.M., 10:16 A.M., 10:49 A.M., 11:40 A.M., and 4:40 P.M., revealed Resident #6 was in bed with a large cup of water on the nightstand; however, the nightstand was at the end of the bed next to her feet. Observation on 03/12/24 at 7:53 A.M. revealed Resident #6 was in her chair in her room. There was water located several feet away from the resident. Observation on 03/12/24 at 9:47 A.M., 10:16 A.M., and 11:03 A.M. revealed Resident #6 was in her chair at a table in the common area and there was no water at the table. Observation on 03/12/24 at 3:09 P.M. revealed Resident #6 was in her bed, there was no water observed in her room. Interview on 03/12/24 at 3:09 P.M. with State tested Nurse Aide (STNA) #156 verified there was no water available to Resident #6. STNA #156 reported Resident #6 had just been laid down for a nap, so she did not bring her water. STNA #156 verified water should not be placed on the nightstand as Resident #6 could not reach it there. STNA #156 reported she usually brought water for Resident #6 to drink on her own, and when she did this, she put the bedside table by the head of the bed. Observation on 03/12/24 at 4:40 P.M. revealed Resident #6 remained in bed and there was no water observed in her room. Observation on 03/13/24 at 9:11 A.M. revealed Resident #6 was in her chair at a table in the common area and there was no water at the table. Interview on 03/13/24 at 9:25 A.M. with Dietary Technician (DT) #201 revealed residents were to receive 1440 mls of fluids on meal trays and she expected them to have water pitchers at bedside in between meals. DT #201 verified Resident #6 required more fluids than what came from the kitchen. DT #201 additionally reported Resident #6 could eat and drink on her own, but her assistance needs could vary at times. Interview on 03/13/24 at 9:47 A.M. with the Administrator revealed they did not have a hydration policy. The Administrator stated he expected staff to replenish the residents' water in the morning. Alert and oriented residents could call for more water as needed and residents who were not physically able to drink on their own should be offered fluids every two hours. 43064

Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to administer supplemental oxygen as ordered. This affected one (#339) of one residents reviewed for oxygen administration. The facility census was 86. Findings include: Review of the medical record revealed Resident #339 was admitted to the facility on [DATE] with diagnoses including emphysema, chronic obstructive pulmonary disease, and fracture of lumbosacral spine and pelvis. Review of the care plan dated 03/08/24 revealed Resident #339 had a history of respiratory deficiencies and staff interventions include administering oxygen as ordered. Review of current physician orders for Resident #339 revealed an order for continuous oxygen at three liters per nasal cannula with a start date of 03/08/24. Observation on 03/11/24 at 1:34 P.M., on 03/12/24 at 9:36 A.M., and on 03/12/24 at 11:41 A.M. revealed Resident #339 was observed wearing supplemental oxygen set at 4.5 liters via nasal cannula. Interview on 03/12/24 at 11:41 A.M. with Licensed Practical Nurse (LPN) #110 confirmed Resident #336 had an order to receive three liters of oxygen, and confirmed the resident was receiving 4.5 liters of oxygen at the time of the interview. Interview on 03/12/24 at 3:45 P.M. with the Director of Nursing (DON) confirmed Resident #339 had an order for three liters of oxygen nasal cannula. Review of the oxygen administration policy dated 04/17/23 revealed oxygen is administered under orders of a physician and the physician will be notified as needed for changes.

Based on medical record review and staff interview, the facility failed to ensure dialysis services were completed thoroughly including obtaining resident weights before and after dialysis services. This affected one (#8) of one residents reviewed for dialysis. The census was 86. Findings Include: Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, type II diabetes, unspecified hemorrhoids, lack of coordination, weakness, dysphagia, end stage renal disease, atrial fibrillation, and dependence on renal dialysis. Review of Resident #8's Minimum Data Set (MDS) assessment, dated 01/11/24, revealed the resident was cognitively intact. Review of Resident #8's current physician orders revealed the resident had scheduled dialysis services three days a week, on Mondays, Wednesdays, and Fridays. Review of Resident #8 dialysis notes, dated 12/01/23 to 03/11/24, revealed there were no documented pre- or post- weights documented for Resident #8 on 12/22/23, 01/10/24, 01/12/24, 01/15/24, 01/17/24, 01/19/24, 01/22/24, 01/24/24, 01/26/24, 01/29/24, 01/31/24, 02/02/24, 02/05/24, 02/07/24, 02/09/24, 02/12/24, 02/19/24, 02/21/24, 02/23/24, 02/26/24, 02/28/24, 03/04/24, 03/08/24, and 03/11/24. Further review revealed no documentation of a pre-weight on 02/16/24, and no documentation of a post-weight on 12/01/23, 12/11/23, 12/15/23, 12/18/23, and 02/12/24. Review of Resident #8's weights obtained by the facility dated between 12/01/23 and 03/11/24 revealed no weights to support a pre- or post-weight completed on the days the resident had dialysis and the weights were not documented. Interview with the Director of Nursing (DON) on 03/13/24 at 9:12 A.M. confirmed the facility had difficulty getting completed dialysis documentation back from the dialysis center. The DON confirmed she would contact them to see what documentation they could provide. Interview with DON and Regional Nurse #200 on 03/13/24 at 9:36 A.M. confirmed there were no pre- and post-weights on Resident #8's dialysis communication forms from the date with missing weights. Interview with Dietary Technician (DT) #201 on 03/13/24 at 10:45 A.M. confirmed the dialysis center was not obtaining weights as they should be each day Resident #8 received dialysis. DT #201 confirmed the new process for weights with residents who go to dialysis would be the facility staff will take a pre- and post-weight to confirmed it was being completed, even if the dialysis center started documenting the weights on the medical records.

Based on medical record review, review of investigations, review of self-reported incidents, staff interview, and review of a facility policy, the facility failed to timely report an injury of unknown origin to the State Survey Agency. This affected one (#6) of one residents reviewed for skin conditions. The facility census was 86. Findings include: Review of the medical record for Resident #6 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, depression, gastroesophageal reflux disease, and senile degeneration of the brain. Review of Resident #6's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. Review of Resident #6's progress notes dated 10/01/23 through 10/19/23 revealed no concerns related to a fall or injury. Review of Resident #6's progress note dated 10/21/23 at 12:16 P.M. revealed Resident #6 was noted to have edema to the left elbow. Hospice was updated and they advised the facility to monitor for changes. Review of Resident #6's incident investigation dated 10/21/23 and completed on 10/24/23 revealed Resident #6 had swelling to the left elbow. Licensed Practical Nurse (LPN) #105 and State tested Nurse Aide (STNA) #145 were interviewed. No additional staff, residents, or family members were interviewed. The summary of the incident indicated the nurse noted edema to Resident #6's left elbow. The resident was noted to be combative with care that morning. The resident was frequently combative with care. She would swing her arms and attempt to hit the staff. Resident #6 frequently yelled out. Hospice, guardian, and physician were all noted. A head-to-toe assessment was completed and no other areas were noted. Resident #6 was swinging at the nurse during the assessment. An x-ray was ordered for a possible distal humeral fracture. An orthopedic referral was given, but the resident's guardian was not interested in the referral. No pain or discomfort noted. Review of Resident #6's progress note dated 10/22/23 at 12:00 P.M. revealed Resident #6's guardian was updated on the edema to the elbow. Review of Resident #6's physician order dated 10/24/23 revealed an order for an x-ray, two views, to the left swollen elbow and arm. Review of Resident #6's progress notes dated 10/24/23 revealed an order was placed for an x-ray to the left arm. The x-ray results were received and showed massive soft tissue swelling of the elbow was noted with a possible distal humeral fracture. A new order for an orthopedic appointment was created. Review of Resident #6's x-ray dated 10/24/23 revealed two radiographs of the left elbow were completed. Massive edema of the elbow, distal arm, and forearm were noted. There was a possible supracondylar fracture of the humerus but it was unclear. Additional imaging was recommended. Review of Resident #6's progress note dated 10/26/23 revealed the resident's guardian was not interested in an orthopedic referral. Review of Resident #6's physician progress note dated 10/30/23 revealed Resident #6 had edema to her left arm by an unknown source. An x-ray was completed with a possible distal humerus fracture. Hospice would not complete a full work up with orthopedics. Review of the facility's self-reported incidents (SRIs) from 10/21/23 to 03/10/24 revealed there were no SRIs reported to the State Survey Agency involving Resident #6. Interview on 03/11/24 at 1:20 P.M. with Regional Nurse #200 verified Resident #6's injury was not reported as an SRI. Interview on 03/12/24 at 1:55 P.M. with the Director of Nursing (DON) verified an SRI was not submitted to the State Survey Agency regarding Resident #6's injury of unknown origin and should have. Review of the policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 11/21/16, revealed an injury was classified as an injury of unknown source when both of the following conditions are met including the source of the injury was not observed or could not be explained by the resident and the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed, or the incidence of injuries over time. In response to allegations the facility must ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property are reported to the administrator or designee of the facility and to other officials including the State Survey Agency. This must be reported immediately, but not later than two hours after the allegation is made if the events involve abuse or result in serious bodily injury. It should be reported no later than 24 hours if the events do not involve abuse and do not result in serious bodily injury. The facility needs to provide evidence that all alleged violations are thoroughly investigated and report the results to the administrator and State Survey Agency within five working days of the incident.

Based on medical record review, staff interview, review of activity calendars, and policy review, the facility failed to ensure activities were offered to residents throughout the week based on assessment, care plan, and resident preference to promote resident well-being. This affected two (#6 and #55) of two residents reviewed for activities. The facility census was 86. Findings include: 1. Review of the medical record for Resident #6 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, depression, gastro-esophageal reflux disease, and senile degeneration of the brain. Review of Resident #6's activity assessment dated [DATE] revealed she preferred activities in a one-on-one setting. Resident #6's preferred activities included watching television and listening to music or the radio. The assessment did not indicate what type of music or television she preferred. Review of Resident #6's comprehensive Minimum Data Set (MDS) 3.0 dated 10/18/23 revealed the resident was rarely or never understood. According to her family, it was somewhat important to listen to music Resident #6 liked, to be around animals, go outside when the weather was good, participate in religious services, and do favorite activities. Review of Resident #6's quarterly MDS 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. Review of Resident #6's plan of care dated 01/30/24 revealed she was withdrawn from large group activity settings. She was to be offered one-on-one engagement and sensory stimulating activities as tolerated. Interventions included offering small group or one-on-one engagement as the resident may become agitated in large groups. It was additionally noted that Resident #6 spent most of the day in bed but would request to be out of bed around dinner time. The resident was to be offered sensory stimulating activities in her room. Review of the activities calendar for February 2024 revealed activities were mostly scheduled from 9:30 A.M. to 3:00 P.M. One activity was scheduled at 7:30 P.M. on 02/11/24, and it was the only activity after 3:00 P.M. Review of Resident #6's activities documentation for February 2024 revealed for the weekend of 02/03/24 and 02/04/24 and the weekend of 02/10/24 and 02/11/24 only one activity was offered (a manicure) and it was refused. For the weekend of 02/17/24 and 02/18/24 one activity was offered (a manicure) and it was accepted. For the weekend of 02/24/24 and 02/25/24 there were no weekend activities offered. Review of the activities calendar for March 2024 revealed activities were scheduled from 9:00 A.M. to 3:00 P.M. There were no activities scheduled after 3:00 P.M. Review of Resident #6's activities documentation from 03/01/24 to 03/09/24 revealed for the weekend of 03/02/24 and 03/03/24 all activities were marked with an 'X'. On 03/09/24 no activities were offered. 2. Review of the medical record for Resident #55 revealed an admitted [DATE] with diagnoses including type two diabetes mellitus, respiratory disorders, insomnia, hyperlipidemia, and generalized osteoarthritis. Review of Resident #55's plan of care dated 09/24/21 revealed the resident had been more withdrawn recently related to family not visiting her very often. The resident needed encouragement to attend activities so she could have interactions with others. Interventions included encouraging and assisting the resident to go outdoors, inviting and encouraging her to attend special events, offering assistance getting to activities, offering supplies for leisure activities, and respecting her choice for what she does and does not want to do. Review of Resident #55's activity assessment dated [DATE] revealed Resident #55 preferred small group activities and one-on-one activities. She preferred chair exercises, cooking and baking, family-oriented activities, television and movies, and music and radios. The assessment did not indicate what type of music or television the resident preferred. Resident #55 spent a lot of time in common areas listening to the television and enjoying occasional visitors. Review of Resident #55's comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #55 was rarely or never understood. An interview for activities with the resident was conducted and revealed it was somewhat important to listen to music she liked and somewhat important to go outside when the weather was nice. Review of the activities calendar for February 2024 revealed activities were mostly scheduled from 9:30 A.M. to 3:00 P.M. One activity was scheduled at 7:30 P.M. on 02/11/24, it was the only activity after 3:00 P.M. Review of Resident #55's activities for February 2024 revealed there were no activities provided on four (02/03/24, 02/10/24, 02/17/24, and 02/24/24) of four Saturdays in the month. Review of the activities calendar for March 2024 revealed activities were scheduled from 9:00 A.M. to 3:00 P.M. There were no activities scheduled after 3:00 P.M. Review of Resident #55's activities from 03/01/24 to 03/09/24 revealed for the weekend of 03/02/24 and 03/03/24 all activities were marked as 'X.' Resident #55 had no activities listed on Saturday 03/09/24. Interview on 03/13/24 at 10:20 A.M. and 12:30 P.M. with Activities Director (AD) #122 revealed activities personnel included her and one assistant and they worked until 4:00 P.M. and 4:30 P.M. AD #122 reported the activities assistant came in every other weekend and she would come in at times to assist with getting residents to the in-facility church services. AD #122 verified Resident #6 and Resident #55 did not have many activities listed for the weekend. AD #122 revealed weekend activities for the cognitively impaired residents included church services. AD #122 verified the only activities assessment in Resident #6's medical record was from 01/28/23, which was over a year ago. She believed there were additional assessments, but she was unable to produce them. AD #122 verified 3:00 P.M. was the last scheduled activity and the activity usually went until 4:00 P.M. AD #122 reported sometimes in the evenings nursing staff would turn on the radio in common areas or put on a comedy show. AD #122 additionally reported the 'X' on the activity documentation for Resident #6 and Resident #55 meant the usually accepted or preferred activities were not offered or on the calendar that day. Review of the policy titled, Program Planning and Scheduling, dated March 2007, revealed the activities calendar was to include some evening and weekend activities and were to be geared to all groups residing in the facility.

Based on observation, staff interview, and policy review, the facility failed to ensure fall interventions were in place and resident transfers were performed in a manner to prevent falls. This affected two (#12 and #50) of seven residents reviewed for falls. The census was 86. Findings include: 1. Review of the medical record for Resident #50 revealed an admitted [DATE] with diagnoses including type two diabetes mellitus, Parkinsonism, anxiety disorder, major depressive disorder, and combined systolic and diastolic heart failure. Review of Resident #50's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 had severely impaired cognition. Review of Resident #50's plan of care dated 05/11/23 revealed the resident was at risk for falls due to debilitation, weakness, disease process, and use of psychotropic medications. Interventions included encouraging and reminding the resident to ask for assistance, ensuring the call light was within reach, keeping commonly used articles within easy reach, providing a mat to the floor for safety when the resident was in bed, and added 11/29/23, state tested nurse aides (STNAs) were reeducated on proper use of the sit-to-stand lift. Review of Resident #50's progress note dated 11/26/23 revealed an assessment was completed and Resident #50 was transferred to bed with a two-person assistance. No injuries were noted; however, the resident complained of lower back pain and an x-ray was ordered. Review of Resident #50's progress note dated 11/27/23 revealed the x-ray was negative for fracture. Review of Resident #50's interdisciplinary team (IDT) fall review dated 11/30/23 revealed on 11/26/23 at 8:30 A.M. the STNA was transferring Resident #50 to the wheelchair via the sit-to-stand lift. The resident slid to the floor with assistance of the STNA. The STNA notified the nurse and an assessment was completed. There were no visible injuries noted and no complaints of pain. The resident was assisted to the wheelchair via two staff members. The STNA was reeducated on the use of the sit to stand lift, and the intervention was to make Resident #50 a two-person assistance with transfers. Interview on 03/11/24 at 1:20 P.M. with Regional Nurse #200 verified Resident #50's progress notes did not indicate what led to the fall on 11/26/23. Interview on 03/12/24 at 1:55 P.M. with the Director of Nursing (DON) revealed staff were reeducated on the sit-to-stand lift. The DON stated, based on what she saw from the STNA who assisted Resident #50, the STNA did not have the strap on the sit-to-stand lift appropriately for the lift. 32654 2. Review of the medical record for Resident #12 revealed an initial admitted [DATE] with the diagnoses including anemia, asthma, hypertension, gastro-esophageal reflux disease, traumatic brain injury and thrombocytopenia. Review of the plan of care dated 06/28/22 revealed Resident #12 was at risk for falls related to impaired balance, history of traumatic brain injury, and had been frequently putting self on the floor. Interventions included to provide two staff assist from the wheelchair to the bed at night for safety, encourage and remind to ask for assistance, ensure the call light was within reach, have commonly used items within easy reach, new sturdy rubber soled shoes were purchased for safety, no pillow to the back of wheelchair for safety, non-skid strips to the left side of bed, non-skid strips to the floor in front of the window for safety, alarm to the bathroom door to alert staff when resident was trying to toilet without assistance, wear proper non-slip footwear, therapy referral as needed, and Velcro to bedside table and bottom of basket to keep frequently used items within close reach and verbal reminders. Review of the fall risk evaluation dated 10/30/23 revealed a score of 9.5 indicating Resident #12 was at risk for falls. Review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident had two or more falls since the prior assessment with no injuries. Review of Resident #12's physician orders identified no orders related to fall interventions. On 03/12/24 at 9:45 A.M., observation of Resident #12's fall interventions revealed no non-skid strips in front of the resident's bed, the tab alarm to the resident's bathroom door was not activated to sound to alert staff of the resident's self attempts with toileting, and the resident's basket with Velcro was not in place. On 03/12/24 at 9:49 A.M., interview with Registered Nurse (RN) #164 verified Resident #12 had no non-skid strips in place in front of his bed, tab alarm was not activated to alert staff, and the resident had no basket on his bedside table with Velcro on the bottom per the fall risk care plan. Review of the facility's policy titled, Fall Management, dated 10/17/16, revealed understanding the significance of mobility, movement and the ingrained nature of walking, it is our intention to promote programs geared to improving mobility, stamina and reduce the risk of falls through a comprehensive interdisciplinary process of assessment, care plan development and implementation with ongoing monitoring and review. An interdisciplinary plan of care will be developed, implemented, reviewed and updated as necessary to reflect each resident's current safety needs and fall reduction interventions.

Based on observation, medical record review, and staff interviews, the facility failed to ensure adequate nail care was provided for dependent residents. This affected two (#22 and #42) of seven residents reviewed for activities of daily living. The facility census was 86. Findings Include: 1. Review of the medical record for Resident #22 revealed an initial admitted [DATE] with the latest readmitted [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, cerebrovascular accident (CVA) with right sided hemiplegia, aphasia, hypothyroidism, hypertension, gastro-esophageal reflux disease, anemia, and anxiety disorder. Review of the plan of care dated 06/02/19 revealed Resident #22 required assistance with activities of daily living (ADLs) and may be at risk for developing complications associated with decreased ADL self-performance and indicated the resident used an electric wheelchair. Interventions included the resident wore incontinence briefs, required assistance with bathing, dressing, grooming (nails/shave/hair), supervision with bed mobility, preferred showers, had bilateral assist bars, wore glasses, and had lower partial dentures to be removed at bedtime. Review of Resident #22's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the resident's quarterly clinical care assessment dated [DATE] revealed the resident required substantial/maximal assistance with personal hygiene. On 03/10/24 at 11:08 A.M., observation of Resident #22's finger nails revealed they were long, dirty, and jagged with a brown substance under the nails. On 03/11/24 at 10:46 A.M., observation of Resident #22' finger nails revealed they remained long, dirty, and jagged with a brown substance under the nails. On 03/12/24 at 11:41 A.M., interview with Registered Nurse (RN) #164 verified Resident #22's finger nails were long, jagged, and dirty with a brown substance under them. 2. Review of the medical record for Resident #42 revealed an initial admitted [DATE] with diagnoses including senile degeneration of the brain, diabetes mellitus, obstructive sleep apnea, chronic kidney disease, anemia, hyperlipidemia, atrial fibrillation, hypertension, and altered mental status. Review of the plan of care dated 01/13/24 revealed Resident #42 may require assistance with ADLs and may be at risk of developing complications associated with decreased ADL self-performance. Interventions include Resident #42 was blind in both eyes and kept the right eye closed, the resident was dependent on staff for transfers, toileting, grooming, was incontinent of both bowel and bladder, was non-ambulatory, and required assistance with bathing. Review of the significant change MDS assessment dated [DATE] revealed Resident #42 had a severe cognitive deficit. On 03/10/24 at 10:50 A.M., observation of Resident #42's finger nails revealed they were long, jagged, and dirty with a brown substance under the nails. On 03/11/24 at 12:55 P.M., observation of the resident revealed his finger nails remained long, jagged, and dirty with a brown substance under the nail. On 03/11/24 at 1:15 P.M., interview with the Director of Nursing (DON) verified Resident #42's nails were long, jagged, and dirty with a brown substance under the nails.

Based on medical record review, review of the facility's investigation, staff interview, review of the coroner's report, and review of the facility's policies, the facility failed to provide a resident with adequate supervision to prevent an avoidable fall and conduct a thorough root cause analysis of the circumstances surrounding the fall to prevent the same action, situations, and/or practices from occurring in the future. This resulted in Actual Harm to Resident #86 when State tested Nursing Aide (STNA) #130 stepped away from Resident #86 to obtain a blanket, leaving the resident alone in the shower chair when Resident #86 stoop up and subsequently fell , sustaining an acute intertrochanteric hip fracture requiring surgical repair. This affected one (Resident #86) of three residents reviewed for falls. The facility census was 81. Findings include: Review of Resident #86's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, type II diabetes mellitus, anxiety, and a history of transient ischemic attack (TIA). Review of the Fall Risk assessment dated [DATE] revealed Resident #86 was not at risk for falls. The assessment stated Resident #86 did not have a fall in the last 90 days. Review of the physical therapy (PT) note dated [DATE] revealed Resident #86 was a standby assist (SBA) with transfer from sit to stand. The goal was for an elderly mobility scale (a score between 14 and 20 suggests that the older resident has good mobility overall and they should be able to handle most activities of daily living (ADL) on their own) to be ,d+[DATE] to demonstrate the decreased risk for falls. The current score was eight (The elderly resident will have to depend on someone for help with ADL.) on [DATE]. Resident #86's mobility on the unit was without an assistive device with SBA. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 was severely cognitively impaired. Resident #86 required limited assistance one-person physical assist for transfers and was one-persona physical assistance with bathing. FSR #86 had no durable medical equipment for mobility. Review of the care plan dated [DATE] revealed Resident #86 was at risk for falls related to dementia, osteoporosis, impaired cognition, debilitation, and weakness. The goal was to minimize potential risk factors to rule out falls. Interventions included to ensure the call light was within reach, ensure the environment was free of clutter, and have commonly used articles within easy reach. Review of the progress note dated [DATE] at 11:47 A.M. revealed Registered Nurse (RN) #220 was called to the bathroom and found Resident #86 on the floor, lying flat on his back. State tested Nursing Aide (STNA) #130 stated she was giving Resident #86 a shower and left Resident #6 sitting on the shower chair to go get a blanket (located in the shower room). STNA #130 came back and found Resident #86 on the floor. Resident #86 was put in a sitting position on the floor, and neurological checks were initiated, and vital signs were checked. Resident #86 was unable to bare weight on his left leg and complained of pain when touched or moved. No visible signs of any bruising or swelling currently. The nurse practitioner was notified, and x-rays were ordered. Family member and nurse management was aware. On [DATE] at 8:46 P.M., the x-ray results showed an acute intertrochanteric (IT) hip fracture. The physician was notified, and the physician ordered Resident #86 to be sent to the hospital for evaluation. Review of the facility's fall investigation dated [DATE] revealed Resident #86 had a fall in the shower room. STNA #130 stated Resident #86 was given a shower in the shower chair. STNA took eight to 10 steps to the linen cart to obtain a blanket for Resident #86. STNA then took eight to 10 steps back to the resident. Resident #86 was lying on the floor. The new intervention was to place a blanket on the shower chair to ensure Resident #86 does not slide out of it. Review of STNA #130's witness statement dated revealed Resident #86 was not left alone in the shower room prior to his fall. STNA #130 took a few steps away from Resident #86 to obtain a blanket and by the time she turned around to get back to Resident #86, he was on the floor. STNA #130 then left the shower room to obtain a nurse for assistance with Resident #86's fall. STNA #130 stated Resident #86 was not talking at the time of the fall and not exhibiting any behaviors. Review of the hospital documentation dated [DATE] revealed Resident #86 was seen at emergency room for a left femur fracture. The hospital diagnosis was closed left IT hip fracture with left hip intramedullary nail. The history of present illness (HPI) said Resident #86 was ambulatory with a cane and the resident stated he fell while in shower being assisted by staff. Review of the progress note dated [DATE] revealed Resident #86 returned from the hospital status post-surgery for the left femur fracture. Resident #86 did not have any other falls at the facility from [DATE] to [DATE]. Review of the progress note dated [DATE] revealed Resident #86 was hypoxic and had shortness of breath and emergency [DATE] services were called. Resident #86 was sent to the emergency room (ER) and died in theER on [DATE]. Review of the coroner's report revealed the immediate cause of Resident #86's death was complications of blunt impact to trunk and extremities with left femur fracture because of a fall. Other significant conditions were hypertension, diabetes mellitus, and dementia. The manner of death was accident. Observation of the shower room on [DATE] at 3:40 P.M. revealed there was a linen closet and linen cart in the shower room. Two call lights were in the shower room and were functioning. The shower chair was plastic and had a bar at the feet so a resident's feet could rest on the bar. All four wheels of the shower chair had working brakes. Interview on [DATE] at 4:04 P.M. with STNA #130 stated she gave Resident #86 a shower in a shower chair on [DATE]. STNA #130 stated she walked a few steps away from Resident #86 to obtain a blanket from the linen cart. Resident #86 stood up from his shower chair and fell on to the shower room floor. Interview on [DATE] at 7:57 A.M. with RN #220 stated STNA #130 came out of the shower room after Resident #86 had fallen. RN #220 stated Resident #86 was on his back on the floor. RN #220 stated Resident #86 did not complain of pain at that time, but his left leg would not move upon assessing. RN #220 stated she notified the physician right away, received an order for an x-ray, and sent Resident #86 to the hospital after the results were received. Interview on [DATE] at 9:45 A.M. with the Director of Nursing (DON) stated even if STNA #130 was standing next to Resident #86, he could have still fallen. The DON stated STNA #130 turned around to grab a bath blanket off the linen cart. The DON stated STNA #130 never left the shower room when Resident #86 was on the shower chair. The DON stated the STNAs at the facility were to grab supplies for the residents before a shower was performed. Subsequent interview on [DATE] at 10:30 A.M. with STNA #130 stated she did lock all four wheels to the shower chair before transferring him to and bathing him in the shower. STNA #130 stated Resident #86 had never fallen before and could understand small commands to assist in care. STNA #130 stated she grabbed the bath blanket to assist with water on the floor. STNA #130 stated she was so nervous that Resident #86 had fallen on the floor, she forgot to use the call light, and rushed to the nurse on the hall to get help. Review of the facility policy titled Fall Management, dated [DATE], revealed a fall risk evaluation was completed on admission, after a significant change, quarterly, and as necessary. After a fall resident was assessed, prompt medical attention provided, emergency services contacted, when necessary, notify responsible party and physician, nurse gathers and records much pertinent data of fall, care plan was updated, and new fall intervention are communicated. Review of the facility's bathing/shower policy, last revised ,d+[DATE], revealed the purpose was to provide cleanliness and comfort, stimulate circulation, and observe condition of resident. The supplies to obtain included a bath blanket, if necessary. The procedure included to assemble supplies in shower room, except the chair and bath blanket. This deficiency represents non-compliance investigated under Complaint Number OH00144046.

Based on observation, review of the clinical record and staff interview the facility failed to implement the plan of care for behaviors and to prevent neglectful care that resulted in a fall which caused harm to a resident. The resident required hospitalization and staples to two lacerations to her head. This affected one of three residents (Resident #58) reviewed for abuse. The facility census was 82. Findings include: Observation on 10/09/13 at 09:30 A.M. revealed Resident #58 was sitting in the dining room eating breakfast independently. The resident was dressed and groomed appropriately. Review of the clinical record for Resident #58 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Plan of Care dated 07/30/13 and revised on 09/16/13 revealed the resident resisted care at times and would refuse showers or to allow staff to assist with hygiene or change her clothes. The goal was the resident would be clean, dry, odor free and appropriately dressed. Interventions included approach calmly, if resident resists care, approach and try again at a later time. Review of the fall progress note dated 09/17/2013 at 08:30 A.M. titled Health Status Note Text: Resident (#58) found on the floor in room by STNA (State tested Nursing Assistant) with blood coming from her head. Resident was unable to describe details of the fall. Pressure applied to head until bleeding stopped. Two open lacerations noted to the back of the head, one on the left and one on the right posterior. Wounds cleansed with normal saline and ice applied. Daughter and Nurse Practitioner made aware. Daughter transported resident to emergency department per her request where five staples were placed. Resident returned to facility at 12:00 P.M. A Self-Reported incident dated 9/17/13 revealed STNA #6 was giving peri-care to Resident #58 and Resident #58 became combative and scratched STNA #6. STNA #6 reacted to Resident #58 being combative and Resident #58 fell back. STNA had visible scratches to her arm. STNA #6 was removed from the facility. Resident #58's daughter arrived at the facility. STNA #7 reported an allegation of abuse to the Human Resources Staff, reporting STNA #6 pushed resident #58 down to the floor and the resident struck her head on a table after the STNA was scratched on the arm while giving care to the resident. The allegation of abuse was unsubstantiated by the facility. The Self-Reported incident did not include information the resident fell to the floor and hit her head sustaining two lacerations necessitating a hospital visit with five staples to her head. Review of the incident report completed by Licensed Practical Nurse #8 on 09/17/13 at 9:58 A.M. revealed Resident #58 was found on the floor in room by STNA with blood coming from her head. When this nurse arrived to room resident was sitting on the bed holding a washcloth to her head. Resident unable to describe details of fall. The incident report stated there were no injuries observed post fall and the section resident taken to hospital, was marked no. The resident did go to the hospital and received five staples to her [MEDICAL CONDITION]. Review of the investigation statements by staff revealed: A statement obtained from STNA #6 stated the resident grabbed her arm while she was making the bed, resident scratched her (STNA) and she pulled away and then she (Resident #58) lost her balance. LPN #8's statement dated 0/17/13 at 8:30 A.M., she was passing medications when STNA #6 stated Resident #58 had blood coming from her head. STNA was asked what had happened and she stated, " I don ' t know, she ' s in her room. " Resident was sitting in her bed and had blood pouring from the back of her head. Two fresh lacerations to the posterior head present. Blood was also seen in the middle of the floor. Resident was unable to provide details of the fall. This nurse also wrote the statement above in the clinical record which read, progress note dated 09/17/2013 at 08:30 A.M. titled Health Status Note Text: Resident found on the floor in room by STNA (State tested Nursing Assistant) with blood coming from her head. A statement from STNA #7 revealed she was in a resident ' s room assisting with patient care. STNA #6 was training her to dress the resident. STNA #6 went to clean the resident (peri-care). The resident scratched STNA #6 and that's when STNA #6 reacted and pushed the resident down. The resident fell and bumped her head on the table. Interview on 10/09/13 at 11:00 A.M. with the Director of Nursing and Administrator revealed they had completed an in-service with staff on abuse and terminated the employee because she did not walk away when the resident became combative and return later to complete care as she should have according to the resident ' s plan of care and facility protocol. The protocol if a resident is agitated or becomes combative is to make sure the resident is safe and come back and try to complete the care later. The Administrator stated she interviewed the roommate and the resident but both residents are confused and provided no useful information. She stated STNA #7 was uncomfortable with the situation and reported the incident to Human Resources staff #11 and they notified Minimum Data Set Nurse #12 as the Administrator was on route to work. STNA #6 was asked to leave the facility after the allegation was made. The administrator stated they did not believe it was abuse but the employee was reacting to being scratched on the arm. Interview with LPN #8, at 3:40 P.M., revealed STNA#6 came to her while she was passing medications in the dining room, probably about 9-9:30 A.M. and stated the resident had blood on her head. She went back to look at resident and the resident was sitting on the side of the bed. She stated she never seen her on the floor and doesn't know how she got up from the floor. Interview via telephone on 10/10/13 at 3:55 P.M. with STNA #7 stated she witnessed the incident. She stated she was training with STNA #6 that day and went into the room, STNA #6 was telling her (Resident #58) it was time to get up for breakfast and the resident was irritated with her, she (STNA) was kind of rough with peri-care. Resident #58 scratched STNA#6. STNA#6 grabbed her (Resident #58) and pushed her to the floor. Resident #58 hit her head on a table and blood went pouring onto the floor. STNA #7 grabbed wash clothes and towels and STNA#6 left of the room and stated she was going to tell the nurse. When nurse came in, she asked the resident, do you remember what happened, she said " yes they done this to me " , the nurse repeated the question twice and the resident response was the same. The nurse was LPN#8. STNA#7 was asked when LPN#8 came in the room, where the resident was and she stated she was sitting on the bed. She stated the nurse came immediately and she (STNA #7) then went up and reported what she saw to Human Resources. She stated she was interviewed by the administrator on that day and there were no other witnesses to the incident. Review of STNA #6 personnel file revealed her employment was terminated for a violation of a class I offense on page 32 of the employee handbook revised 07/12, #19, Violation of health and safety and or fire rules, regulations and policies, this includes neglectful or unsafe behavior and careless acts or misconduct that caused or had the potential to cause harm or injury to a resident, visitor, coworker or self. A class I rule violation are considered very serious and will result in a suspension and/or termination for the first occurrence. These violations may include any action that causes disruption to the work environment, damage to facility property or are considered to be illegal, unethical or immoral acts. This deficiency substantiates Complaint Number OH 266.