Every finding on record at Diplomat Healthcare

Based on closed record review, review of hospital medical records, review of a local in-progress police report, policy review and interview, the facility failed to adequately and accurately identify and record a decline in a wound for Resident #150. This affected one resident (#150) of three residents reviewed for wounds and skin impairments. The facility census was 108. Actual Harm occurred on 10/21/25 when Resident #150 was admitted to the hospital with altered mental status, a urinary tract infection, dehydration, and malnutrition and assessed to have an unstageable pressure ulcer (a full-thickness wound where the depth of the damage cannot be determined because the wound bed is obscured by dead tissue) to the coccyx (tailbone area) that measured seven centimeters (cm) in length by eight cm in width. Resident #150's coccyx's wound was noted to have a foul odor and a moderate amount of serosanguineous drainage with 60% of the wound bed noted to have brown and black eschar (dead tissue) and the remainder was a mixture of yellow slough and red and moist wound bed. Resident #150's family declined surgical debridement and Resident #150 was admitted to palliative care. Resident #150 was hospitalized until 10/24/25, at which time he transferred to a local residential hospice facility where he later passed away on 11/02/25. Findings include:Review of Resident #150's closed medical records revealed an admission date 09/04/19 with diagnoses including Parkinsons, dementia, muscle weakness and need for personal care assistance. Resident #150 was transferred to a local hospital on [DATE] and did not return to the facility. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #150 had no cognition score due to being rarely/never understood. Resident #150 was noted to be dependent on staff for toileting, bathing, and bed mobility tasks. Review of a Braden Scale (tool used to predict a patient's risk for developing pressure ulcers) dated 10/10/25 revealed Resident #150 scored a 15 indicating he was at mild risk for developing pressure ulcers. Review of the care plan revised on 10/14/25 revealed Resident #150 was at risk for activities of daily living (ADL) decline. The care plan noted Resident #150 was dependent on staff for toileting, bathing, and bed mobility and was incontinent of bowel and bladder. Resident #150 was additionally noted to be at risk for pressure ulcer development. Listed interventions included to provide incontinence care as needed, utilize barrier cream after incontinence episodes, utilize a pressure reducing mattress, complete weekly skin evaluations, keep skin as dry and clean as possible, avoid friction to the skin, and report any signs of skin breakdown. Review of a wound progress note authored by Wound Nurse Practitioner (WNP) #450 dated 10/16/25 revealed Resident #150 was seen for moisture-associated skin dermatitis (MASD, inflammation of the skin caused by prolonged exposure to moisture) to the sacrum and bilateral buttocks. The MASD was described as partial thickness and measured six centimeters (cm) in length by six cm in width with 0.2 cm depth. The wound bed was recorded to be 70% pink and 30% epithelial with moderate serous (clear) drainage. The wound status was determined to be unchanged but referenced the resident was having large, soft stools, and noted excoriations to the right buttock. The treatment orders included to cleanse the area with normal saline, apply calcium alginate (absorbent wound dressing used for moderate to heavy drainage), and cover with a clean dry dressing daily and as needed, and to continue the current treatment for one week. There were no additional or new orders/interventions to address the large, soft stools referenced in the progress note or to ensure the resident's skin was not subjected to prolonged moisture related to the resident's incontinence. Review of a head-to-toe assessment dated [DATE] authored by Licensed Practical Nurse (LPN) #376 revealed Resident #150 had moisture-associated skin damage (MASD) to his buttocks. Review of Resident #150's progress notes revealed a note dated 10/21/25 at 11:33 A.M. authored by Licensed Practical Nurse/Assistant Director of Nursing (LPN/ADON) #341 reflected Resident #150's Power of Attorney (POA) was called regarding a change in condition. The note further referenced an unnamed Nurse Practitioner (NP) provided an order to send Resident #150 to a local emergency room for evaluation. A follow up note timed 2:16 P.M. authored by LPN #376 revealed Resident #150 had been noted to have a continual decline in cognition, was unable to answer questions or communicate needs. Resident #150 was not swallowing food, medications, and pocketing was noted. The note referenced a call was placed to an unnamed NP who ordered the resident be sent out to a local emergency room for evaluation. Review of hospital records dated 10/21/25 revealed Resident #150 was transferred to a local emergency department for evaluation. The record stated the facility noted Resident #150 had mental status changes since the night of 10/19/25 (however, the resident's medical record from the facility did not include documentation of these mental status changes) and the resident had been less responsive than normal. Emergency Medical Services (EMS) reported the resident was usually alert and oriented to person, place and time but was now non-verbal. Resident #150 was noted to have critically elevated sodium levels and was admitted into the intensive care unit (ICU) with hypernatremia, an acute urinary tract infection, and altered mental status. Resident #150 was noted to have a decubitus sacral wound that was noted to have been present on admission. Review of the hospital initial wound assessment dated [DATE] revealed Resident #150 was seen for an initial assessment. The note indicated an old dressing was removed. Resident #150's wound was cleansed and gently mechanically debrided with saline and gauze. The note stated the coccyx wound was an unstageable pressure ulcer measuring seven cm in length by eight cm in width, with no depth recorded. The wound was noted to have a found odor when the dressing was removed, with a moderate amount of serosanguineous drainage with 60% of the wound with brown to black eschar (dead, blackened tissue that forms over a wound), with the remainder a mixture of yellow slough (another type of dead tissue that is often stringy and moist and can delay healing and increase infection risk) and red moist wound bed. The peri-wound (skin surrounding the wound) was macerated (where the surrounding skin has softened and broken down due to prolonged exposure to moisture, such as from wound drainage, sweat, and/or incontinence). The note referenced a surgical consult for debridement was recommended. Review of a hospital progress note dated 10/23/25 revealed Resident #150's family members were present at bedside after flying in from out of state. Resident #150 was noted to have an overall deconditioned state, and palliative care was consulted for a goals of care discussion with the resident's family. The family expressed frustration at Resident #150's prior facility, noting discrepancies between information provided and the patient's current, critical condition. After discussion with hospital providers the family members opted to proceed with hospice care. The note referenced a hospice consult was placed and communicated to the hospice liaison and case manager. A follow up note dated 10/23/25 revealed Resident #150's code status had been changed to Do Not Resuscitate Comfort Care. The family members present indicated they did not wish for Resident #150 to receive cardiopulmonary resuscitation (CPR) or intubation, but rather complete comfort care while still treating his wound and urinary tract infection. Review of a local police report dated 10/26/25 revealed an allegation of patient abuse and neglect had occurred at the facility. The report indicated an investigation was pending and listed the facility as an involved party. Review of the supplemental report narrative revealed an officer met with a local attorney at the local police department on 10/26/25 to discuss possible abuse of a patient at the facility. The attorney indicated the patient involved was Resident #150. The narrative included information that upon arrival to the local hospital on [DATE], Resident #150 was noted to be extremely malnourished and had a severely necrotic wound on his coccyx that was going to need surgery. An additional supplement to the report noted that on 11/03/25, an officer spoke with a representative from the local regional forensic science lab after obtaining information that Resident #150 passed away on 11/02/25. The report noted that an autopsy was pending on Resident #150, and that detective follow up would be needed. The report indicated the investigation was on-going. Telephone interview on 11/10/25 at 3:30 P.M. with Resident #150's POA revealed she had filed a complaint with the local ombudsman and the local police department related to neglect of Resident #150 that included her not being made aware of Resident #150's wound and the severity of the wound upon the resident's arrival to the hospital on [DATE]. The POA reported on 10/21/25 at 10:32 A.M., she had received a voicemail message from LPN/ADON #341 that Resident #150 had a change in condition. The POA stated she had immediately returned the call to the facility and had been informed Resident #150 was out of sorts and was going to be sent to the hospital for evaluation and treatment. The POA stated she had spoken with the physician at the hospital and had been told Resident #150 had a severe wound to his buttocks that would require surgical intervention, but that Resident #150's wound was severely infected, and the resident may not survive the surgery. The POA stated due to Resident #150's condition upon arrival to the hospital, the physician had stated Resident #150 may not survive for more than a week, and after discussion, she and the family had made the decision to place Resident #150 into hospice for comfort care. A follow up interview with Resident #150's POA on 11/12/25 at 9:32 A.M. revealed Resident #150 had passed away on 11/02/25 and an autopsy had been performed with the results pending. Telephone interview on 11/12/25 at 2:29 P.M. with WNP #450 revealed she had evaluated and treated Resident #150 on 10/16/25 for Moisture Associated Dermatitis to his buttocks and had given orders to cleanse the area with normal saline, apply calcium alginate and cover with a clean dry dressing daily and as needed. WNP #450 stated she had not been made aware of any concerns related to a decline in Resident #150's wound. Interview on 11/12/25 at 2:55 P.M. with LPN/ADON #341 revealed she was the facility's wound nurse; however, she had not had any official training or certification. LPN/ADON #341 stated she had performed wound rounds with WNP #450 every Thursday and had seen Resident #150 on 10/16/25 at which time he was noted to have had MASD to his buttocks and stated his skin alterations were not considered a pressure ulcer. LPN/ADON #341 stated WNP #450 had ordered for the calcium alginate and a foam dressing to be applied to the wound daily and as needed. LPN/ADON #341 stated Resident #150 had been sent to the hospital on [DATE] due to a change in condition that included difficulty swallowing. LPN/ADON #341 stated she had attempted to contact Resident #150's POA, however she had only left a voicemail message. LPN/ADON #341 stated she had then called to arrange for transport to the hospital and had not sent Resident #150 via emergency services. LPN/ADON #341 stated she had obtained a copy of Resident #150's hospital paperwork a few days later and noted Resident #150 had been admitted with a pressure ulcer that may have required surgery. LPN/ADON #341 denied being made aware of any concerns related to Resident #150 having a pressure ulcer prior to his hospital admission. Interview on 11/13/25 at 8:06 A.M. with LPN #376 revealed she cared for Resident #150 on 10/21/25. She recalled Resident #150 was not responding normally and he had not been swallowing or drinking. LPN #376 stated she had informed LPN/ADON #341 and contacted the facility's nurse practitioner who had advised to send Resident #150 to the hospital for evaluation. LPN #376 stated she had assisted with Resident #150's incontinence care prior to his transport to the hospital and she was shocked when she had seen Resident #150's wound. LPN #376 stated she had seen Resident #150's wound approximately a week prior but on the morning of 10/21/25, the resident's coccyx wound was much larger, deeper, had black areas, and a foul odor. LPN #376 stated she had informed LPN/ADON #341 about the wound via text message the morning of 10/21/25. LPN #376 provided a copy of the text message for review. Review of text messages on 10/21/25 at 9:16 A.M. sent from LPN #376 to LPN/ADON #341 stated Are we charting the unstageable wound on Resident #150's bottom. And moving forward I'm charting everything I see to protect by license as well as my residents. LPN #376 received a response from LPN/ADON #341 which stated Its documented as MASD. WNP is trying everything to not change it to pressure. LPN #376's response to LPN/ADON #341 was You and I know what his wound really is. A follow-up interview on 11/13/25 at 9:56 A.M. with LPN #376 revealed she had been told by LPN/ADON #341 to not document Resident #150's wound as a pressure ulcer and to continue to document the wound as MASD. LPN #376 confirmed she had documented Resident #150's head-to-toe assessment on 10/21/25 and had documented Resident #150's wound as MASD. She stated she should not have documented the wound that way as she knew the area to Resident #150's coccyx was an open pressure ulcer. Interview on 11/17/25 at 8:25 A.M. with Certified Nursing Assistant (CNA) #366 revealed she had cared for Resident #150 on 10/20/25 and 10/21/25. CNA #366 stated she had observed Resident #150's wound on 10/20/25 and the wound to his buttock was a large, open wound that was necrotic and had a foul odor. CNA #366 reported on the morning of 10/21/25, she had cared for Resident #150 and he seemed off. CNA #366 stated she had informed LPN #376 and had then assisted with Resident #150's incontinence care and had also observed Resident #150's wound. Interview on 11/17/25 at 9:16 A.M. with the Director of Nursing (DON) and Regional Registered Nurse #451 revealed they had interviewed LPN #376 on 11/13/25 and had obtained a statement. Review of LPN #376's statement dated 11/13/25 revealed on 10/21/25, Resident #150 had a wound and was not acting as himself. The statement included on 10/17/25, the wound was stable and on 10/20/25, LPN #376 had noted a decline in the area, and she had last seen Resident #150's wound approximately a week prior. The statement further included when LPN #376 was asked why she had documented Resident #150's wound as MASD on his head-to-toe assessment, LPN #376 responded I probably shouldn't have, but that was what everyone else was calling it. RRN #451 stated she had attempted to obtain more specific information regarding a description of Resident #150's wound from LPN #376, however LPN #376 had been difficult during the interview and had not provided any additional information. Interview on 11/18/25 at 1:45 P.M. with DON and RRN #451 revealed they had obtained a questionnaire from LPN #376 regarding Resident #150's condition prior to hospitalization. Review of LPN #376's questionnaire with the DON and RRN #451 revealed Resident #150's sacral wound had significantly declined and LPN/ADON #341 had been informed. Review of the policy Skin and Wound Care Best Practices last reviewed 09/17/25, revealed the purpose of the policy was to provide evidence based preventative skin care and wound treatment to prevent unavoidable skin complications. The policy referenced the licensed nurse will complete a Weekly Skin Check. The interdisciplinary team will review residents with pressure injuries/wounds during the resident review meeting. Review of the policy Change in condition last reviewed on 06/02/25 revealed the physician and responsible party will be notified when there has been a significant change in the resident's physical condition. This deficiency represents non-compliance investigated under Complaint Numbers 2657376 and 2656169.

Based on observation, interview and record review The facility failed to ensure medication consumption was monitored to ensure medications were safely swallowed. This affected one resident (#28) of four residents observed and reviewed for medication administration. The facility census was 108. Findings include: Review of Resident #28's medical records revealed an admission date of 06/05/15. Diagnoses included stroke with left sided weakness, muscle weakness dysphagia (difficulty swallowing) and dementia.Review of Resident #28's physician's orders revealed an order dated 05/12/23 that medications may be crushed unless contraindicated. Resident #28 additionally had an order dated 06/16/25 for acetaminophen (an over-the-counter mild pain reliever) 650 milligrams (mg) every six hours as needed for pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had no recorded cognition score due to the resident was rarely/never understood. Observation of wound care on 11/10/25 at 11:47 A.M. with Licensed Practical Nurse (LPN) #402, LPN/Assistant Director of Nursing (LPN/ADON) #341 and Regional Registered Nurse (RRN) #452 for Resident #28 revealed Resident #28 was expressing non-verbal complaints of pain that including withdrawing his leg and foot when his right leg was touched. At the time of observation, RRN #452 had informed LPN #402 to administer pain medication as ordered. LPN #402 had exited Resident #28's room and had returned with a cup of crushed medications mixed with applesauce that LPN #402 had indicated was the resident's as-needed acetaminophen. LPN #402 administered the crushed medication to Resident #28 and exited his room. RRN #452 had remained in the room and asked if Resident #28 had swallowed his crushed medication and RRN #452 confirmed Resident #28 had not swallowed them. RRN #452 proceeded to manually massage Resident #28's throat in order to stimulate his swallowing. RRN #452 stated LPN #402 should have stayed present to ensure medications had been swallowed prior to exiting the room. This deficiency represents non-compliance investigated under Complaint Number 2657376.

Based on observation, interview, record review, and facility policy review, the facility failed to inform a resident's physician of ongoing medication refusals and failed to ensure resident representative were notified of changes. This affected three residents (#62, #103 and #106) of six residents reviewed for notification of change in condition. The facility census was 108.Findings include: 1.Review of Resident #62's medical records revealed an admission date of 11/07/17. Diagnoses included bipolar, psychosis and schizoaffective disorders Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 had intact cognition. Review of current physician orders for November 2025 revealed Resident #62 was ordered Risperdal (an antipsychotic) 25 milligrams/2 milliliter injection on Wednesday every two weeks. Review of Resident #62's Medication Administration Record (MAR) from October 2025 and November 2025 revealed Resident #62 had refused biweekly Risperdal injections on 10/01/25, 10/15/25, 10/29/25, and 11/12/25. Review of Resident #62's progress notes from October and November 2025 revealed no documentation related to Resident #62's medication refusals or the physician being notified of refusals. Interview on 11/18/25 at 12:20 P.M. with Licensed Practical Nurse (LPN) #402 revealed Resident #62 had been ordered Risperdal injections every two weeks. LPN #402 stated the medications were documented as being refused, however no one had told the family or the physician. Observation at time of interview revealed four boxes of single injection Risperdal with Resident #62's name on them. Interview on 11/18/25 at 1:45 P.M. with Director of Nursing (DON) confirmed if a medication had been refused the physician and resident representative should be notified. Review of Resident #62's medical records with DON at time of interview confirmed no documentation related to medication refusals had been recorded. 2. Review of Resident #103's medical records revealed an admission date of 01/11/23. Diagnoses included cognitive impairments, dementia and anxiety. Review of the MDS assessment dated [DATE] revealed Resident #103 had impaired cognition. Review of Resident #103's physician orders revealed on 10/07/25 Resident #103 was ordered Benadryl (an over the counter medication used to treat allergy symptoms and skin rash) every four hours as needed and hydrocortisone cream (a topical corticosteroid used to relieve redness, itching, and swelling from skin irritation). On 10/21/25 and 10/30/25, Resident #103 was ordered Permethin (synthetic insecticide used to treat parasitic infections including scabies). Review of Resident #103's progress notes revealed a note dated 10/07/25 which referenced Resident #103 had redness to right and left extremities. The hospice nurse was notified and orders for Benadryl and hydrocortisone cream were received. The progress note did not include resident representative notification of the new orders. Review of a note dated 10/22/25 authored by LPN #420 revealed there was a new treatment for a skin rash. The note did not include that the resident's representative had been notified of the new orders. There was no progress notes referencing the 10/30/25 order for Permethin. Interview on 11/18/25 at 1:45 P.M. with the DON confirmed there was no evidence Resident #103's representative had been notified of the new orders. The DON reported medication changes should be discussed with the resident's representative. 3. Review of Resident #106's medical records revealed an admission date of 10/04/24. Diagnoses included dementia, Huntington's disease and restlessness. Review of the MDS assessment dated [DATE] revealed Resident #106 had no cognition score due to being rarely/never understood. Review of progress note dated 10/13/25 authored by LPN #360 revealed a new order for prednisone (steroid) for seven days for inflammation. Progress note did not include resident representative notification. Interview on 11/18/25 at 1:45 P.M. with the DON confirmed there was no evidence Resident #106's representative had been notified of the new orders. The DON reported medication changes should be discussed with the resident's representative. Review of facility policy titled Resident Change in Condition Policy reviewed 06/02/25 revealed physician/family/responsible party will be notified when there has been a need to alter a resident's medical treatment. This deficiency represents non-compliance investigated under Complaint Number 2656169.

Based on resident interview, medical record review, staff interview, and facility policy review, the facility failed to ensure routine care plan conferences were conducted. This affected two residents (#150 and #73) of five residents reviewed for care plan conferences. The census was 108.Findings include:1.Record review of Resident #150 revealed an admission date of 09/04/19 with diagnosis that include Parkinson's disease, schizophrenia, bipolar disorder, hypothyroidism, dementia, and muscle weakness. Review of Resident #150's Brief Interview for Mental Status (BIMS) score completed on 08/12/25 revealed a score of 0 due to resident being unable to complete assessment questions, indicating severely impaired cognition. Review of Resident #150 care plan history from 07/01/23 through 11/12/25 revealed the resident's care plan was updated on 5/23/25, 08/19/25, 09/19/25, and 10/14/25.Interview on 11/13/24 at 11:54 A.M. with Resident #150 Power of Attorney (POA) revealed she attended a care conference in March 2025 with a previous Director of Social Services but had not had one since March 2025. Resident #150's POA reported she had left messages with the new Director of Social Services but had not heard back.2. Record review of Resident #73 revealed an admission date of 07/10/25 with diagnosis that include: dementia, muscle weakness, essential hypertension, impulse disorder and insufficient sleep syndrome. Review of Resident #73's BIMS score completed on 10/15/25 revealed a score of 00 due to resident being unable to complete assessment questions, indicating severely impaired cognition. Resident #73's spouse was listed as his emergency contact and responsible party.Review of Resident #73's record revealed an admission care conference was held on 07/22/25 with Resident #73's spouse and other facility staff. Resident #73's care plan was updated on 10/22/25 but the record did not include any additional care conferences had been held.Interview on 11/13/25 at 10:07 A.M. with Director of Social Services (DSS) #421 revealed care plan meetings are held upon admission, quarterly, and whenever there is a significant change in condition. Care conferences are held with the resident, their family members, guardians, nurses, and certified nursing assistants. DSS #421 confirmed a care conference had not been held for Resident #150 and his daughter was not in attendance. Director of Social Services #421 reported she was behind on scheduling and conducting resident care conferences. DDS #421 was not aware of any missed calls from Resident #150 daughter. DDS #421 revealed Resident #73's spouse was not involved in his care conferences and that she was just the emergency contact. Review of the facility's Comprehensive Care Planning Policy dated 03/20/25 revealed the comprehensive care plan will be prepared by an interdisciplinary team that includes but is not limited to: To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representatives is determined not to be practicable for the development of the resident's care plan.This deficiency represents non-compliance investigated under Complaint Number 2656169.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health. This affected one resident (#150) and had the potential to affect all residents residing in the facility. The facility census was 108.Findings include: 1. Review of Resident #150's closed medical records revealed an admission date 09/04/19 with diagnoses including Parkinson's, dementia, muscle weakness and need for personal care assistance. Resident #150 was transferred to a local hospital on [DATE] and did not return to the facility. Review of the Medical Nutritional Therapy Observation dated 08/19/25 completed by Registered Dietitian (RD) #408 revealed that Resident #150's nutrition risk included dementia and potential for decreased awareness of hunger and thirst. RD #408 estimated Resident #150's fluid needs as 2040-2380 milliliters per day and that his current diet orders provided 1440 ml of fluid.Review of Resident #150 fluid intake revealed Resident #150 consumed 960 ml of fluids on 10/18/25 and 10/19/25 and consumed 650 ml of fluids on 10/20/25. Record review of Resident #150 hospital records dated 10/21/25 through 10/23/25 revealed resident was admitted to the hospital on [DATE] with sodium levels of 167 millimoles per liter (mmol/L). Resident was admitted for diagnosis that included change in mental status, acute urinary tract infection and acute hypernatremia (a condition of abnormally high sodium levels in the blood, often caused by dehydration from insufficient water intake, excessive sweating, vomiting, or diarrhea).Interview on 11/17/25 at 9:16 P.M. with the Director of Nursing (DON) and Regional Registered Nurse (RRN) #451 reviewed Resident #150's hospital laboratory results and the facility's fluid intake documentation. The DON and RRN #451 confirmed Resident #150 had decreased fluid intake on 10/18/25, 10/19/25, and 10/20/25 which could have contributed to the resident's dehydration identified at the hospital on [DATE]. 2. Observation on 11/10/25 at 4:53 P.M. revealed multiple residents were seated in the dining room. Two residents had small medication water cups but no styrofoam water cups. Continued observation at 5:01 P.M. revealed staff began to pass beverages for dinner that included milk, juice, and coffee. Interview on 11/10/25 at 5:11 P.M. with Certified Nursing Assistant (CNA) #380 revealed styrofoam cups were used to provide residents with water and were passed out to residents earlier in the day. CNA #380 guessed that styrofoam cups were probably in the resident ' s rooms.Observation on 11/17/25 at 11:44 A.M. of dining room C in the memory care unit revealed 14-15 residents were eating lunch, with only 2 residents with drinks. Continued observation at 11:46 A.M. of dining room A reveled Resident #84 and Resident #81 did not have anything to drink. Interview on 11/17/25 at 11:46 A.M. with CNA #397 confirmed Resident #84 and Resident #81 had no drinks provided to them. CNA #397 proceeded to provide the two residents with drinks after surveyor intervention. CNA #397 passed out drinks to dining room C residents at 11:51 A.M. She revealed lunch was passed out between 11:30 A.M. through 11:40 A.M. and she was not sure why residents were not provided with drinks. Observation and interviews on 11/17/25 at 11:54 A.M. revealed Resident #79 and Resident #92 had empty juice cups. Both residents reported they were still thirsty. Resident #92 said she had a water cup in the room but Resident #79 was unsure if he had a water cup.Interview on 11/17/25 at 11:56 A.M. with CNA #397 confirmed Resident #79 and Resident #92 had empty juice cups and were still thirsty. CNA #397 refilled resident ' s cups after surveyor intervention.Interview on 11/18/25 at 4:44 P.M. with the Administrator and Assistant Director of Nursing (ADON) #356 revealed the plastic cups served at meals are 8 ounce cups of water. The facility does water passes at 10:00 A.M., 2:00 P.M. and HS (hour of sleep, bed time) with styrofoam cups. The Administrator was unsure why water was not being passed out during meal times. ADON #356 stated staff should be documenting intakes based on how much water they have consumed and not just how much water a resident is provided. Observation on 11/18/25 at 5:00 P.M. of the secured unit with the DON and ADON #356 revealed the dinner beverage cart was present on the unit stocked with juice, lemonade, coffee, and milk. Observation of approximately 20 residents in dining room A revealed only 2 residents had water provided to them. Continued observation in dining room C revealed approximately 8 residents observed, all who did not have water provided to them. Review of the Resident Council meeting dated 09/09/25 and 10/07/25 revealed both meetings had complaints about water not being passed out. Review of in-servicing completed on 09/10/25 and 10/02/25 with staff revealed all staff had been re-educated that all staff were responsible for providing water to residents.Review of facility's Hydration Policy dated 06/22/20 revealed residents will be offered/administered sufficient fluid intake to maintain hydration. A variety of fluids will be offered to residents, depending on preference and nutritional/diagnosis considerations.This deficiency represents non-compliance investigated under Complaint Numbers 2657376, 2656169, and 2597119.

Based on record review, interview, and facility policy review, the facility failed to ensure laboratory results were timely obtained and results timely reported to the provider to allow for timely treatment of a urinary tract infection (UTI). This affected one resident (#12) of three residents reviewed for UTIs. The facility census was 108. Findings include: Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, major depressive disorder, hyperlipidemia, anxiety, hypertension and malignant neoplasm of large intestine.Continued record review revealed on 09/02/25, Resident #12 was seen by the nurse practitioner for UTI symptoms and ordered Urinalysis with Culture and Sensitivity (UA C&S). UA C&S orders were not placed until 09/04/25. On 09/04/25 a urine sample was collected and the sample was sent to the lab for testing. The urinalysis showed the resident's urine was turbid in color and tested positive for nitrite, leukocytes, epithelial, white blood cells, and bacteria. The facility received the urine culture results on 09/07/25 that indicated the resident had Escherichia coli extended-spectrum beta-lactamase (ESBL, an enzyme produced by certain bacteria that makes them resistant to many common antibiotics) in the urine. Further record review revealed on 09/10/25, Assistant Director of Nursing (ADON) #356 reported final UA C&S result to the nurse practitioner and received an order for Nitrofurantoin monohyd (an antibiotic) capsule 100 milligram (mg) twice daily for 7 days. Review of Resident #12's Medical Administration Record (MAR) for September 2025 revealed the ordered Nitrofurantoin monohyd was started on 09/10/25. Resident #12 completed the medication on 09/17/25. Interview on 11/17/25 at 3:23 P.M. with the Director of Nursing (DON) revealed she would check to see what the delay in reporting the urine culture was. The DON further stated the nurses are expected to report any abnormal laboratory results as soon as possible to the physician or ordering provider.Interview on 11/17/25 at 3:26 P.M. with ADON #356 revealed she reported the results of the urine culture to the nurse practitioner on 09/10/25 when she noticed the lab result had not been reported to the nurse practitioner. She was unsure what the reason for the delay in reporting the result was. Review of the facility policy Resident Change in Condition dated 06/27/24 revealed the Physician/Provider and Resident/Family/Responsible Party will be notified when there has been a need to alter the resident's medical treatment, including a change in provider orders.This deficiency represents non-compliance investigated under Complaint Number 2657376 and 2614362.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure adequate incontinence care was provided to Resident #28. This affected one resident (#28) of three residents reviewed for incontinence care. The facility census was 108. Findings include:Review of Resident #28's medical record revealed an admission date of 06/05/15. Diagnoses included stroke with left sided weakness, muscle weakness, and dementia. Review of Resident #28's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had no recorded cognition score due to resident was rarely/never understood. Resident #28 was incontinent of bowel and bladder and was dependent on staff for toileting. Review of the care plan updated 11/04/25 revealed Resident #28 was incontinent of bowel and bladder. Interventions included to assist with incontinence care as needed. Resident #28 was noted to be at risk for skin breakdown and had listed interventions to apply a skin barrier ointment after incontinence episodes. Review of Resident #28's current physician orders for November 2025 revealed an order to cleanse buttocks with soap and water and apply thick zinc barrier (barrier ointment used to form a protective barrier on the skin to shield the skin from irritants and moisture) every shift and as needed. Observation of incontinence care on 11/10/25 at 11:39 A.M. for Resident #28 with Certified Nursing Assistant (CNA) #385 revealed a large amount of dried stool to the crease of Resident #28's buttocks. Resident #28 was observed to have two bath blankets and a fitted sheet underneath him, which had large amounts of dried urine and other identifiable debris. There was an odor of urine coming from Resident #28's bed and bed linens. Interview with CNA #385 at time of observation revealed she had provided Resident #28 with incontinence care approximately one hour prior. CNA #385 reported Resident #28 had a reddened area to his buttocks and coccyx (tailbone) area at times and stated he required barrier cream to be applied after incontinence care. Observation of incontinence care at the time of interview revealed no evidence of barrier cream residue on Resident #28. CNA #385 confirmed the presence of the dried stool and confirmed she had not applied barrier cream to Resident #28 after she last provided incontinence care. CNA #385 confirmed she had not seen the soiled linens when she had previously provided incontinence care one hour prior. Review of facility policy titled Perineal Care Incontinence Care Procedure reviewed 10/30/25 revealed to turn patient on his/her side and wash the rectal area, working outward to include the buttocks. The policy additionally stated to apply a moisture barrier if care planned. This deficiency represents non-compliance investigated under Complaint Numbers 2656169, 2614362 and 2597119.

Based on interview, record review, facility fall investigation, emergency medical services (EMS) run report, and facility policy review, the facility failed to ensure an accurate and thorough fall investigation was completed. This affected one resident (#150) of three residents reviewed for falls. The facility census was 108.Findings include: Review of Resident #150's closed medical records revealed an admission date 09/04/19 with diagnoses including Parkinson's, dementia, muscle weakness and need for personal care assistance. Resident #150 was transferred to a local hospital on [DATE] and did not return to the facility.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #150 had no cognition score due to being rarely/never understood. Resident #150 was noted to be dependent on staff for toileting, bathing, and bed mobility tasks. Review of the care plan revised on 08/12/25 revealed Resident #150 was at risk for activities of daily living (ADL) decline. Interventions included two staff assistance with personal hygiene, bed mobility, transfers and toileting. Resident #150 was at risk for falls and interventions included keeping the bed in the lowest position with brakes locked.Review of a progress note dated 10/02/25 timed 4:06 A.M. authored by Licensed Practical Nurse (LPN) #414 revealed she had been alerted Resident #150 had fall. Upon assessment Resident #150 was observed to have had a small one inch laceration to his forehead and another small laceration on his right knee. Resident #150's heart rate was 130 beats per minute (elevated, normal range is 60-100) and oxygen saturation was 65% (low, normal range is 92-100%). On call physician was notified and Resident #150 was sent to the hospital.Review of the facility fall investigation dated 10/02/25 revealed a statement authored by Certified Nursing Assistant (CNA) #336 that stated Resident #150 was last observed at approximately 2:20 A.M. and at approximately 3:00 A.M,. Resident #150 was observed on the floor by the right side of his bed. CNA #336 had immediately notified the nurse. Review of Post Fall Huddle authored by LPN #414 revealed date of fall at 10/02/25 at 3:00 A.M. with Resident #150 last being toileted at 2:20 A.M. Review of an EMS report dated 10/01/25 revealed a call for EMS services was received at 11:44 P.M. The report noted EMS personnel arrived on scene at 11:52 P.M. The EMS narrative included a call was received for a patient who had fallen and upon EMS arrival at the facility, an unnamed nurse had met EMS personnel at the elevator and stated Resident #150 was found next to his bed two hours prior to EMS arrival. The report noted it was assumed Resident #150 had fallen. The unnamed nurse stated they had helped Resident #150 back into bed and had contacted EMS for abnormal vital signs and reported Resident #150 had a small laceration to his forehead which the nurse stated was from a prior fall. The report noted the resident was transported to a local hospital and EMS departed the scene on 10/02/25 at 12:03 A.M. Review of hospital paperwork dated 10/02/25 timed 4:30 A.M. revealed EMS had arrived to facility for a chief complaint of a fall and abnormal vital signs and EMS stated Resident #150 had a fall two hours prior. Staff had assisted Resident #150 back into bed and he had went back to sleep and staff had taken his vital signs that morning and Resident #150 was tachycardic (elevated heart rate) and hypoxic (low oxygen saturation).Telephone interview on 11/17/25 at 12:43 P.M. with Resident #150's Power of Attorney (POA) revealed she had received a call on 10/02/25 at approximately 3:45 A.M. that stated Resident #150 had fallen and was being sent to the emergency department. The POA further stated she had obtained a copy of the EMS report that stated a call was place on 10/01/25 before midnight. Interview on 11/17/25 at 3:36 P.M. with the Director of Nursing (DON) and Regional Registered Nurse (RRN) #431 confirmed fall investigation had included Resident #150 had a fall on 10/02/25 at approximately 3:00 A.M. Review of EMS run report confirmed a call was placed on 10/01/25 at 11:44 P.M. The DON and RRN #431 reported they were unable to provide an explanation of the discrepancies in time frames for when Resident #150 fell and when EMS was summoned to the facility in response to Resident #150's fall. Review of the facility policy Fall Prevention and Management Policy dated 07/07/25 revealed falls will be reviewed by an interdisciplinary team. Such reviews should include results of fall risk assessment, discussion with resident and/or any witnessing parties as to potential causal factors, review of the environment where the fall occurred, and discussion as to any new interventions which may help to prevent future falls. This deficiency represents non-compliance investigated under Complaint Number 2656169.

Based on observation, record review, review of hospice notes, review of a facility self-reported incident, review of hospital records, facility policy review and interview, the facility failed to provide adequate, necessary and timely treatment for Resident #67, a resident with cognitive impairment who was dependent on staff for activities of daily living, following an acute change in condition. The facility also failed to thoroughly investigate the change in condition to determine the circumstances surrounding the change. Actual Harm occurred beginning on 11/21/24 when Licensed Practical Nurse (LPN) #279 observed Resident #67's normally contracted left arm to be flaccid with increased pain noted. There was no evidence a hospice-ordered x-ray examination was completed on 11/21/24. Resident #67 had not been re-assessed or his change in condition addressed until 11/26/24 (five days later) when a visiting hospice nurse identified the resident had continued pain and bruising to the left arm and inquired about the delay in obtaining the ordered x-ray examination. An x-ray completed on 11/26/24 identified a left humerus fracture. The resident was transported to the hospital for additional evaluation and treatment. This affected one Resident (#67) of three residents reviewed for changes in condition. The facility census was 101. Findings include: Review of the medical record for Resident #67 revealed an admitted [DATE] with diagnoses including senile degeneration of the brain, dementia with agitation, reduced mobility, age related osteoporosis, and muscle wasting and atrophy. Resident #67 was on hospice services for senile degeneration of the brain. Review of a physician's order dated 04/18/24 revealed Resident #67 had an order for Oxycodone (treats moderate to severe pain) 10 milligram (mg) every four hours as needed (PRN) for pain. The resident also had a physician's order dated 06/10/24 for Acetaminophen 325 mg two tablets every six hours PRN and Acetaminophen 650 mg suppository one time per day PRN (not exceed three grams of Acetaminophen in a 24-hour period from all sources). A physician's order dated 09/20/24 revealed Resident #67 had order for Morphine (treats severe pain) 10 mg PRN every two hours for pain. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was rarely understood or able to understand and was unable to participate in cognitive assessment. Resident #67 had unclear speech, short and long-term memory problems, and severely impaired decision making. Resident #67 was dependent on staff for toileting hygiene, bed mobility, dressing, and transfers. Resident #67 was noted to have functional limitations in range of motion to all four of his extremities. Record review revealed a physician's order dated 10/17/24 for Oxycodone 10 mg every six hours for pain. Review of a Certified Nurse Practitioner (CNP) progress note dated 11/11/24 revealed Resident #67 was at baseline for mentation and known to yell out intermittently. Review of a Hospice Client Episode Coordination Note dated 11/20/24 revealed Hospice Registered Nurse (RN) #403 visited Resident #67. Hospice RN #403 noted Resident #67 leaned in bed to the right side. Hospice RN #403 noted having to reposition Resident #67 several times. Hospice RN #403 reported Resident #67 was yelling out during the visit. It was noted Resident #67 had a healing laceration to right forehead from a fall approximately three weeks prior. The note revealed Resident #67's upper and lower extremities were stiff and contracted with pain during movement. Review of a nursing progress note dated 11/21/24 at 7:39 A.M. by Licensed Practical Nurse (LPN) #279 revealed during incontinence care at approximately 12:30 A.M., a caregiver observed Resident #67's left upper arm to be very flaccid (soft and hanging loosely or limply). There was no redness or bruising noted at this time. Resident #67 vocalized pain and had a noted grimace. LPN #279 notified the nighttime supervisor and was advised to notify the hospice provider of Resident #67's current condition (this was noted to be an acute change in condition (from contracted and stiff to flaccid). LPN #279 called hospice and received an order to treat the resident for pain and monitor the resident's condition. It was noted a hospice nurse would come in to see Resident #67 in the morning. LPN #279 medicated Resident #67 with as needed pain medications and medications were noted to be effective. The note included LPN #279 noted Resident #67's arm had no bruising or redness at the end of her shift. LPN #279 indicated Resident #67's condition was shared with the oncoming nurse. Review of a Hospice Coordination Note Report dated 11/21/24 revealed Licensed Practical Nurse (LPN) #279 called hospice on call service on 11/21/24 at 12:15 A.M. and reported Resident #67's left upper arm appeared displaced. LPN #279 indicated Resident #67 was normally very contracted but tonight the arm flopped open. There was no reported bruising or swelling. LPN #279 reported Resident #67 often yelled out and she was unable to determine if in pain. The on-call Hospice LPN #404 was notified. The Hospice Coordination Note Report dated 11/21/24 authored by Hospice LPN #404 revealed LPN #279 reported Resident #67's left arm was limp and loose, the resident had facial grimacing and yelling out when touched. LPN #279 indicated Resident #67's baseline was tense and contracted arms. LPN #279 indicated she believed Resident #67's left arm/shoulder was dislocated and reported no fall or trauma. Hospice physician contacted and gave order for left shoulder and upper arm x-ray. It was noted Resident #67's wife was not notified due to late hour. The Hospice Coordination note dated 11/21/24 revealed LPN #279 called hospice on call service on 11/21/24 at 5:25 A.M. and reported as needed pain medication was effective for Resident #67. The Hospice Coordination Note dated 11/21/24 revealed Hospice LPN #402 visited Resident #67 as follow-up to on-call report. Resident #67 was found in bed leaning towards the right side. Resident #67 did not wake to verbal or touch stimuli. Resident #67 was noted to be pale and open mouth breathing with snoring. Hospice LPN #402 observed Resident #67's left arm was lying along his left side with palm at waist/hip area. Hospice LPN #402 noted Resident #67's baseline was bilateral upper and lower extremity contractures. Resident #67's arms would normally be bent at elbows and tightly pressed across chest. Hospice LPN #402 discussed findings with LPN #224. LPN #224 indicated she was unaware of the change in condition or order for x-ray. Hospice LPN #402 returned to room and talked with Certified Nursing Assistant (CNA) #263. CNA #263 reported she had heard about Resident #67's arm becoming loose and asked if care could still be provided. Hospice LPN #402 instructed to be gentle and limit movement to left side. Hospice LPN #402 attempted to call Resident #67's wife but was unable to reach her. Hospice LPN #402 noted being unable to locate LPN #224 upon departure and left a written note encouraging comfort for Resident #67 and to notify hospice when x-ray results were obtained. Review of the Medication Administration Record (MAR) for November 2024 revealed Resident #67 received PRN Morphine on 11/20/24 at 5:47 P.M., 11/21/24 at 1:01 P.M., 11/22/24 at 12:48 P.M. and 7:10 P.M., 11/23/24 at 6:38 P.M., 11/24/24 at 11:23 A.M. and 7:26 P.M., and 11/25/24 at 10:11 P.M. Pain was noted to range from a rating of six to 10 on a zero to 10 scale (zero being no pain and 10 being the worst possible pain). Resident #67 received routine Oxycodone. There was no administration of PRN Acetaminophen. Resident #67 received PRN Ativan on 11/20/24 at 5:47 P.M., 11/23/23 at 6:38 P.M., and 11/24/24 at 7:25 P.M. for behavior issues including yelling, moaning, and combativeness with care. Resident #67 received PRN Oxycodone on 11/21/24 at 12:23 A.M. Further review of the resident's electronic and paper medical records for Resident #67 revealed there was no evidence of follow up monitoring/assessment/treatment by facility staff to Resident #67's arm becoming flaccid from 11/21/24 until 11/26/24. The Hospice Coordination Note dated 11/26/24 at 8:50 A.M. revealed Hospice LPN #402 visited Resident #67. Hospice LPN #402 observed Resident #67's left arm to be yellow and swollen from the shoulder to past the elbow. Resident #67 grimaced in pain when touched and was yelling out with a distressed facial appearance. Hospice LPN #402 discussed with LPN #261 and found an x-ray had not been completed. Hospice LPN #402 wrote an order for x-ray to left arm with two views. Review of the nursing progress note dated 11/26/24 at 3:05 P.M. by Assistant Director of Nursing (ADON) #223 revealed Resident #67's hospice nurse was in to visit Resident #67. Hospice nurse believed Resident #67 was in pain to left upper extremity and ordered an x-ray to be completed. Resident #67's wife was updated at this time. Review of the physician's order dated 11/26/24 revealed Resident #67 to have an immediate (STAT) x-ray of left arm for swelling and bruising. Results should be reported to hospice. The Hospice Coordination Note dated 11/26/24 revealed Hospice Licensed Social Worker (LSW) #400 visited Resident #67 on 11/25/24 at 4:20 P.M. Hospice LSW #400 noted Resident #67 making a yelling noise during visit. Hospice LSW #400 contacted Resident #67's wife. Resident #67's wife reported his arm used to be contracted but now it was loose and hanging down. Resident #67's wife reported an x-ray was supposed to be done last week; however, she had not gotten any results. The Hospice Coordination Note dated 11/26/24 revealed LPN #211 called hospice on-call service on 11/26/24 at 7:37 P.M. and reported Resident #67 had a severely fractured left arm after a fall. Resident #67 had been medicated with Oxycodone 10 mg but was still yelling in pain. Review of Radiology Report dated 11/26/24 at 8:01 P.M. revealed Resident #67 had two-view x-ray examination to left humerus. X-ray examination report revealed a 32.5 degree angulated mid humerus fracture with soft tissue swelling. Review of a facility Self-Reported Incident (SRI), tracking number 254520 revealed the facility reported an injury of unknown source for Resident #67 to the State agency on 11/26/24 at 9:49 P.M. Review of Focused Head to Toe Observation form dated 11/26/24 at 10:15 P.M. revealed Resident #67 had a left humerus fracture. Resident #67 was aphasic but responded to intense pain stimuli. The resident was noted to have bilateral upper and lower extremity contractures. There was noted bruising to the left upper extremity. Resident #67 was unable to verbalize pain; however, non-verbal pain symptoms were noted as behaviors, facial expressions, and non-verbal vocal sounds. Review of an Event Report dated 11/26/24 dated 10:33 P.M revealed Resident #67 had an injury of unknown origin. Resident #67 was in pain and an x-ray of his left arm showed a left humerus fracture. Resident #67 was unable to provide a description of the event. Resident #67 was yelling out when moved for care. Review of a nursing progress note dated 11/26/24 at 11:51 P.M. by LPN #211 revealed x-ray results had returned and revealed Resident #67 had an angulated mid humerus fracture to his left arm. LPN #211 notified the resident's hospice provider, wife, and nurse practitioner. The nurse practitioner gave an order to send Resident #67 to hospital in the morning so as not to upset Resident #67 late at night. Resident #67 was given pain medication and was noted to be resting comfortably. Review of Nursing Home to Hospital Transfer Form dated 11/26/24 revealed Resident #67 was transferred to hospital for left humerus fracture. The nurse was unable to assess the resident's pain level. Resident #67 required further evaluation of the left humerus fracture and was on comfort care. Resident #67 was alert but disoriented and unable to follow simple instructions. The Hospice Coordination Note dated 11/26/24 at 12:00 A.M. authored by Hospice LPN #401 revealed the hospice on-call service was notified by LPN #211 of Resident #67's x-ray results. It was noted Resident #67 had a fracture of left arm with increased pain and anxiety. LPN #211 indicated a fall had happened over a month ago and there had been multiple delays in obtaining the x-ray. It was noted LPN #211 implied the x-ray was not obtained as hospice had declined it however there was an order received from hospice physician for an x-ray. The Hospice physician requested the actual results report be sent for review. LPN #211 indicated she was going to send Resident #67 to the emergency room in the morning per the facility Nurse Practitioner. The hospice physician agreed after reviewing the x-ray results. Review of the nursing progress note dated 11/27/24 at 6:51 A.M. by LPN #211 revealed there was an issue with transport for Resident #67 to the hospital. Transport was re-scheduled for between 8:00 A.M. and 8:30 A.M. Review of nursing progress note dated 11/27/24 at 8:45 A.M. by LPN #222 revealed Resident #67 was transported to hospital via transport services. Review of interdisciplinary team (IDT) progress note dated 11/27/24 at 11:51 A.M. revealed Resident #67 was reviewed for a left humeral fracture as an injury of unknown origin. Resident #67 had an order for non-weight bearing status and was sent to emergency room for further evaluation. Review of hospital Final Report for x-ray of left humerus and left forearm dated 11/27/24 at 10:25 A.M. revealed an acute fracture of the proximal humeral shaft, acute fracture along the posterior margin of the humeral head, and posterior supervisor dislocation of the humeral head in relation to the glenoid fossa. There was soft tissue swelling along the upper arm and shoulder. The hospital record included Resident #67 was found on the floor at the nursing home. Resident #67 arrived at hospital in makeshift splint with contractures and known left humerus fracture. Resident #67 was unresponsive. The Hospice Coordination Note dated 11/27/24 authored by Hospice RN #403 revealed Resident #67 remained at hospital as of 4:00 P.M. Orthopedic physician indicated Resident #67's arm would not have surgical interventions or casting. Resident #67's arm would be placed in sling. Review of Resident #67's hospital Emergency Department Discharge Instructions dated 11/27/24 revealed an order to keep the sling in place, give Morphine every two hours as needed for pain, and continue hospice care. The Hospice Coordination Note dated 11/27/24 at 6:12 P.M. revealed Hospice LPN #401 visited Resident #67 who was yelling and anxious, speech nonsensical, and unable to make needs known. Resident #67 had returned to the facility at approximately 6:00 P.M. from the hospital with left arm in a sling. Assessment of Resident #67's arm revealed his left arm was immobile, flaccid, and slightly swollen near shoulder. Resident #67 flinched when touched. Review of nursing progress note dated 11/27/24 at 6:36 P.M. by LPN #222 revealed Resident #67 returned from the hospital. Resident #67 wore a sling to the left arm related to the humeral fracture. Resident #67 returned with orders for continued pain control. Review of the Weekly Observation Assessment form dated 11/28/24 revealed Resident #67 had bruising to left upper arm. Telephone interview on 12/03/24 at 2:00 P.M. with LPN #211 revealed when she arrived for work on 11/26/24 there were x-ray results for Resident #67. LPN #211 indicated was unaware of what had happened to Resident #67's arm. She reported being told by the Certified Nursing Assistants (CNAs) when they moved the resident's arm, it seemed like it hurt Resident #67. LPN #211 noted Resident #67 did have a fall at the beginning of November 2024. LPN #211 indicated there had not been any other incidents to her knowledge since last fall on 11/01/24. LPN #211 noted Resident #67 could be difficult to care for due to contractures making it hard to turn and reposition him. Telephone interview on 12/03/24 at 2:38 P.M. with LPN #279 revealed on 11/21/24, CNA #296 came to her and reported something was wrong with Resident #67's arm. LPN #279 stated she observed the arm in the way it was written in her progress note as very flaccid. LPN #279 stated Resident #67's arm was usually contracted. LPN #279 stated there was no bruising or redness. LPN #279 noted no reported trauma or falls to suggest injury. LPN #279 stated she did not remember any other information about the situation. Telephone interview on 12/03/24 at 3:05 P.M. with Hospice LPN #402 revealed on 11/21/24 the hospice on-call service was notified of a change in Resident #67's arm and an x-ray was ordered. Hospice LPN #402 indicated she did a follow up visit on 11/21/24 and noted Resident #67's left arm to be laying at his left side. Hospice LPN #402 indicated she spoke to the nurse on duty and was told she knew nothing about an x-ray for Resident #67 and she was too busy at the time to look further into it. Hospice LPN #402 stated she returned on 11/26/24 and noted Resident #67's arm had swollen and was yellow. Hospice LPN #402 stated there was knot/lump at his shoulder. Hospice LPN #402 stated she again asked about x-ray results and was told it was never ordered by hospice. Hospice LPN #402 stated this was not true and an x-ray had been ordered on 11/21/24 through on-call service. Interview on 12/03/24 at 3:38 P.M. with the Director of Nursing (DON) revealed the facility SRI investigation for injury of unknown origin revealed no additional trauma or incidents for Resident #67. The DON indicated Resident #67's fall on 11/01/24 could have contributed to the humeral fracture found on 11/26/24. The DON confirmed she had been notified on 11/21/24 when Resident #67's arm was found flaccid. The DON indicated she was told by facility nurses that hospice had only wanted to monitor and keep the resident comfortable in regard to pain. The DON indicated she was unaware of an order for x-ray on 11/21/24. The DON indicated Resident #67 was frequently on the facility pain monitoring report prior to the incident and did not notice any changes or new patterns on report. Telephone interview on 12/03/24 at 4:50 P.M. with CNA #296 revealed on 11/21/24 at approximately 12:00 P.M. she had gone into Resident #67's room to provide incontinence care. CNA #296 noted Resident #67 was making his normal noises when she entered the room. CNA #296 stated she attempted to remove Resident #67's t-shirt and he screamed. CNA #296 stated this startled her but Resident #67 had stopped screaming so she continued with care. CNA #296 indicated she took the shirt off him without additional screaming and provided incontinence care. CNA #296 stated she then tried to put a gown on him and grabbed his left arm by the elbow. CNA #296 stated Resident #67's left arm was like a noodle at this time so she set it down on the bed covered Resident #67 and went to get the nurse. CNA #296 did not report any trauma or incidents involving Resident #67 during care or her shift. CNA #296 denied any rough care for Resident #67. Observation on 12/09/24 at 11:56 A.M. revealed Resident #67 lying in bed, positioned on his back. His eyes were open and he was heard making groaning noises repeatedly. The resident did not look at the surveyor or answer any questions when asked. Telephone interview on 12/09/24 at 1:52 P.M. with RN #294 revealed on 11/21/24 she was the nighttime supervisor. RN #294 indicated LPN #279 had asked her to come and assess Resident #67. RN #294 indicated she did not note any bruising, redness, or swelling to Resident #67's arm. RN #294 stated she was told Resident #67 was having pain in his left arm, so she did not move his arm to check to see if it was limp. RN #294 stated she informed LPN #279 to call hospice and keep the resident comfortable. RN #294 returned to her floor and told LPN #279 to update her with any changes. RN #294 stated she was not made aware of any x-ray orders for Resident #67. Interview on 12/10/24 11:41 A.M. with LPN #224 revealed on 11/21/24 Hospice LPN #402 had asked her about an x-ray. LPN #224 stated she had not worked and did not know what had happened. LPN #224 stated she did not get a report from LPN #279 on the situation with Resident #67 at the start of her shift. LPN #224 stated an CNA had told her about Resident #67's arm. LPN #224 stated with being on the first floor during day shift a lot of people come to the nursing station so if an order was not written down or charted it would likely get lost in the shuffle. Review of facility policy Resident Change in Condition Policy dated 06/27/24 revealed a licensed nurse would recognize and intervene in the event of a change in resident condition. If the attending physician does not respond in a timely manner, then the Medical Director could be contacted for guidance and orders. The nurse would record information related to the change in condition and subsequent events and notifications in the health record. Changes in condition would be included on reports and communicated during morning meetings. This deficiency represents non-compliance investigated under Complaint Number OH00160241. This deficiency is a recite from the annual survey dated 10/10/24.

Based on observation and staff interview, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all residents who received meals from the kitchen with the exception of one resident, Resident #63 who received nothing by mouth. The facility census was 101. Findings include: Observation on 12/10/24 at 11:33 A.M. of the kitchen area revealed the trash can in the kitchen had a swivel lid and the trash was overflowing above the lid. Food and Nutrition Aide #229 confirmed the overflowing uncovered trash can in the kitchen. Observation and interview with Dietary Manager (DM) #221 of kitchen on 12/10/24 at 11:35 A.M. revealed a tall cart across from the tray line with pudding, silverware, cups, and cereal stored on the shelves of the cart. Each of the multiple shelves, top and bottom, including the four legs had a thick scummy build up covered in thick dust particles. The kitchen floor was dirty and had multiple sticky area throughout the kitchen. Under the coffee pot was a large coffee spill on the floor. DM #221 confirmed each shelf, top and bottom (including the legs of the shelving units) that stored the clean cooking and serving items was covered with a thick, scummy substance with thick dust like particles, the kitchen floor was dirty and had sticky areas throughout the floor, the large coffee spill. DM #221 confirmed the items stored on the shelves were used for cooking food and serving the food and drinks to the residents. This was an incidental finding discovered during the course of the complaint investigation.

Based on staff interview, review of facility self-reported incident (SRI) investigation, review of facility policy, hospice record review, and medical record review, the facility failed to thoroughly investigate a resident's injury of unknown origin. This affected one (Resident #67) of seven residents reviewed for abuse. The facility census was 101. Findings include: Review of the medical record for Resident #67 revealed an admitted [DATE]. Diagnoses included senile degeneration of the brain and dementia with agitation. Resident #67 was on hospice services for senile degeneration of the brain. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was rarely understood and was unable to participate in cognitive assessment. Resident #67 was dependent on staff for toileting hygiene, bed mobility, dressing, and transfers. Review of the nursing progress note dated 11/21/24 at 7:39 A.M. revealed during incontinence care at approximately 12:30 A.M., a caregiver observed Resident #67's left upper arm to be very flaccid (soft and hanging loosely or limply). There was no redness or bruising noted at this time. Resident #67 vocalized pain and had a noted grimace. Review of the Hospice Coordination Note Report dated 11/21/24 revealed Licensed Practical Nurse (LPN) #279 called hospice on call service on 11/21/24 at 12:15 A.M. and reported Resident #67's left upper arm appeared displaced. LPN #279 indicated Resident #67 was normally very contracted but tonight the arm flopped open. There was no reported bruising or swelling. LPN #279 reported Resident #67 often yelled out and she was unable to determine if in pain. The on-call Hospice LPN #404 was notified. The Hospice Coordination Note Report dated 11/21/24 authored by Hospice LPN #404 revealed LPN #279 reported Resident #67's left arm was limp and loose, had facial grimacing, and yelling out when touched. LPN #279 indicated Resident #67's baseline was tense and contracted arms. LPN #279 indicated she believed Resident #67's left arm/shoulder was dislocated and reported no fall or trauma. Hospice physician contacted and gave order for left shoulder and upper arm x-ray. Review of the nursing progress note dated 11/26/24 at 3:05 P.M. by Assistant Director of Nursing (ADON) #223 revealed Resident #67's hospice nurse was in to visit Resident #67. Hospice nurse believed Resident #67 was in pain to left upper extremity and ordered an x-ray to be completed. Review of physician's order dated 11/26/24 revealed Resident #67 to have an immediate (STAT) x-ray of left arm for swelling and bruising. Review of the Radiology Report dated 11/26/24 at 8:01 P.M. revealed Resident #67 had two view x-rays to left humerus. X-ray results were 32.5 degree angulated mid humerus fracture with soft tissue swelling. Review of the SRI control number 254520 revealed the facility reported an injury of unknown source for Resident #67 to the State Survey Agency on 11/26/24. Review of the facility's SRI investigation started on 11/26/24 revealed there was no evidence of hospice records located in the investigation. There was no evidence the progress note LPN #279 authored on 11/21/24 where Resident #67's left arm was found flaccid from a normally contracted position was addressed in the investigation. There was no evidence of witness interviews completed related to the findings on 11/21/24. Interview on 12/10/24 at 10:47 A.M. with the Director of Nursing (DON) confirmed the facility did not complete a thorough investigation into Resident #67's injury of unknown origin. The DON confirmed the information from 11/21/24 was omitted, there were no hospice notes included in the facilities investigation, and there were no witness statements obtained related to Resident #67's change in condition on 11/21/24. Review of the facility policy titled Ohio Resident Abuse Policy dated 07/11/24 revealed an investigation of an abuse allegation which by definition included injury of unknown origin would be completed within five working days from the alleged occurrence. The investigation would include interviewing all witnesses, obtaining statements from each witness, and obtaining all medical reports and statements. Evidence of the investigation should be documented. All evidence should be analyzed to make a determination of the probable source of the injury of unknown origin. This deficiency represents non-compliance investigated under Complaint Number OH00160241.

Based on family and staff interview, medical record review, and facility policy review, the facility failed to timely notify Resident #67's representative of a change in condition. This affected one (Resident #67) of three residents reviewed for change in condition. The facility census was 101. Findings include: Review of the medical record for Resident #67 revealed an admitted [DATE] and diagnoses included senile degeneration of the brain and dementia with agitation. Resident #67 was on hospice services for senile degeneration of the brain. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was rarely understood or understands and was unable to participate in cognitive assessment. Review of the nursing progress note dated 11/21/24 at 7:39 A.M. revealed during incontinence care at approximately 12:30 A.M., a caregiver observed Resident #67's left upper arm to be very flaccid (soft and hanging loosely or limply). There was no redness or bruising noted at this time. Resident #67 vocalized pain and had a noted grimace. LPN #279 notified the nighttime supervisor and was advised to notify hospice of current condition. LPN #279 called hospice and was given order to treat for pain and monitor condition. There was no evidence Resident #67's representative was notified of the change in condition on 11/21/24 by the facility staff. Review of the Hospice Coordination Note Report dated 11/21/24 revealed Licensed Practical Nurse (LPN) #279 called hospice on call service on 11/21/24 at 12:15 A.M. and reported Resident #67's left upper arm appeared displaced. LPN #279 indicated Resident #67 was normally very contracted but tonight the arm flopped open. There was no reported bruising or swelling. LPN #279 reported Resident #67 often yelled out and she was unable to determine if in pain. The on-call Hospice LPN #404 was notified. The Hospice Coordination Note Report dated 11/21/24 authored by Hospice LPN #404 revealed LPN #279 reported Resident #67's left arm was limp and loose, had facial grimacing, and yelling out when touched. LPN #279 indicated Resident #67's baseline was tense and contracted arms. LPN #279 indicated she believed Resident #67's left arm/shoulder was dislocated and reported no fall or trauma. Hospice physician contacted and gave order for left shoulder and upper arm x-ray. It was noted Resident #67's wife was not notified due to late hour. The Hospice Coordination Note dated 11/21/24 revealed Hospice LPN #402 visited Resident #67 as follow up to on-call report. Hospice LPN #402 observed Resident #67's left arm was lying along his left side with palm at waist/hip area. Hospice LPN #402 attempted to call Resident #67's wife but was unable to reach her. Hospice LPN #402 reached Resident #67's wife at 5:30 P.M. Resident #67's wife was unaware of what had happened to Resident #67's arm. Resident #67's wife was noted to be upset and planned to visit the facility the next morning. Review of the nursing progress note dated 11/26/24 at 3:05 P.M. by Assistant Director of Nursing (ADON) #223 revealed Resident #67's hospice nurse was in to visit Resident #67. Hospice nurse believed Resident #67 was in pain to left upper extremity and ordered an x-ray to be completed. Resident #67's wife was updated at this time. Review of the physician's order dated 11/26/24 revealed Resident #67 to have an immediate (STAT) x-ray of left arm for swelling and bruising. Results should be reported to hospice. Review of the Radiology Report dated 11/26/24 revealed Resident #67 had two view x-ray to left humerus. X-ray results were an angulated mid humerus fracture with soft tissue swelling. Telephone interview on 12/03/24 at 4:21 P.M. with Resident #67's wife via phone confirmed she had not been notified of the change Resident #67's arm on 11/21/24. Resident #67's wife indicated she was not notified of the change by the facility until 11/26/24 when the x-ray was ordered. Interview on 12/10/24 at 4:58 P.M. with Director of Nursing (DON) confirmed there was no evidence in the medical record to suggest Resident #67's wife/responsible party was notified on 11/21/24 when a change in condition was identified for Resident #67. Review of the facility policy titled Resident Change in Condition dated 06/27/24 revealed when a resident has a change in condition, the family/responsible party would be notified as soon as the resident was stable. Family/Responsible Party would be notified when there was an injury, incident, or need to change the medical treatment. This deficiency represents non-compliance investigated under Complaint Number OH00160241.

Based on observation, family, resident, and staff interview, record review and review of the facility policy, the facility failed to ensure a clean environment free of consistent foul odors for the residents. This affected two (Residents #5 and #39) of three resident reviewed for incontinence care. The facility census was 101. Findings include: 1. Record review for Resident #5 revealed an admitted [DATE]. Diagnoses included bipolar type schizoaffective disorder and dementia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was moderately cognitively impaired. Resident #5 was dependent on staff for toileting hygiene and for personal hygiene. Resident #5 was always incontinent of bowel and bladder. Observation and interview on 12/09/24 at 11:44 A.M. revealed Resident #5 was lying on the mattress on the floor. Resident #5's room had a foul odor of urine. Resident #5's family member was visiting and verified the odor. Resident #5 did not respond appropriately to questions. Observation and interview on 12/09/24 at 11:59 A.M. with Certified Nursing Assistant (CNA) #282 stated she recently changed Resident #5's brief. Observation with CNA #282 revealed Resident #5's brief he was wearing was dry. Observation revealed a saturated brief behind Resident #5's entrance door. CNA #282 verified the brief was saturated with urine lying on the floor. CNA #282 stated the soiled brief was from the previous shift. CNA #282 verified the strong foul urine odor in the room and stated, It [the soiled brief] was that way since start of my shift. CNA #282 stated she started her shift at 6:30 A.M. 2. Record review for Resident #39 revealed an admitted [DATE]. Diagnoses included encounter for orthopedic aftercare following surgical amputation, acquired absence of right leg above knee, and generalized muscle weakness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact. Resident #39 had no behaviors, and was frequently incontinent of bowel, required partial/moderate assistance from staff with chair/bed transfers and with toilet transfer. Interview and observation on 12/10/24 at 8:20 A.M. with CNA #290 verified as approached Resident #39's room, a foul stool odor was lingering from Resident #39's room into the hall. After entering Resident #39's room, observation revealed a soiled brief with stool inside the trash can against the wall. The liner of the trash can had visible stool. On the floor near the trash can, there was a smear of stool with stool particles. CNA #290 stated she started her shift at 6:30 A.M. and Resident #290's room was like that a lot when she came in for her shift. CNA #290 stated the night shift does not do their job. CNA #290 stated Resident #39 could not have changed himself and put the brief there. Resident #39 stated he had a bowel movement during the night, the night shift CNA changed him during the night, and left the soiled brief in his room. Resident #39 stated the odor bothered him. Interview on 12/10/24 at 12:20 P.M. with the Director of Nursing (DON) stated soiled briefs should be disposed of and removed from residents room at the time the care was provided. Any spills should also be cleaned at that time. Review of the facility policy titled General/Routine Environmental Cleaning and Disinfection Policy revised 06/28/24 revealed household surfaces should be cleaned on a regular basis, when spills occur, and when surfaces are visibly soiled (floors, tabletops, resident care areas, etc). This was an incidental finding during the course of the complaint investigation.

Based on staff interview, review of the facilities Self-Reported Incidents (SRI) and investigations, review of policy, and medical record review, the facility failed to timely report an injury of unknown origin to the State Survey Agency and failed to complete self-report incident investigations within five days of the required timeline. This affected two (Residents #67 and #78) of seven residents reviewed for abuse. The facility census was 101. Findings include: 1. Review of the medical record for Resident #67 revealed an admitted [DATE]. Diagnoses included senile degeneration of the brain and dementia with agitation. Resident #67 was on hospice services for senile degeneration of the brain. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was rarely understood and was unable to participate in cognitive assessment. Resident #67 was dependent on staff for toileting hygiene, bed mobility, dressing, and transfers. Review of the nursing progress note dated 11/21/24 at 7:39 A.M. revealed during incontinence care at approximately 12:30 A.M., a caregiver observed Resident #67's left upper arm to be very flaccid (soft and hanging loosely or limply). There was no redness or bruising noted at this time. Resident #67 vocalized pain and had a noted grimace. Licensed Practical Nurse (LPN) #279 notified the nighttime supervisor and was advised to notify hospice of current condition. LPN #279 called hospice and was given order to treat for pain and monitor condition. Further review of the facilities' electronic and paper medical records for Resident #67 revealed there was no evidence of follow-up to Resident #67's arm becoming flaccid from 11/21/24 until 11/26/24. There was no evidence of any falls or accidents recorded for Resident #67. Resident #67's last fall was on 11/01/24. Review of the Hospice Coordination Note Report dated 11/21/24 revealed LPN #279 called hospice on call service on 11/21/24 at 12:15 A.M. and reported Resident #67's left upper arm appeared displaced. LPN #279 indicated Resident #67 was normally very contracted but tonight the arm flopped open. There was no reported bruising or swelling. LPN #279 reported Resident #67 often yelled out and she was unable to determine if in pain. The on-call Hospice LPN #404 was notified. The Hospice Coordination Note Report dated 11/21/24 authored by Hospice LPN #404 revealed LPN #279 reported Resident #67's left arm was limp and loose, had facial grimacing, and yelling out when touched. LPN #279 indicated Resident #67's baseline was tense and contracted arms. LPN #279 indicated she believed Resident #67's left arm/shoulder was dislocated and reported no fall or trauma. Review of the nursing progress note dated 11/26/24 at 3:05 P.M. by Assistant Director of Nursing (ADON) #223 revealed Resident #67's hospice nurse was in to visit Resident #67. Hospice nurse believed Resident #67 was in pain to left upper extremity and ordered an x-ray to be completed. Review of physician's order dated 11/26/24 revealed Resident #67 to have an immediate (STAT) x-ray of left arm for swelling and bruising. Review of the Radiology Report dated 11/26/24 at 8:01 P.M. revealed Resident #67 had two view x-rays to left humerus. X-ray results were 32.5 degree angulated mid humerus fracture with soft tissue swelling. Review of the SRI control number 254520 revealed the facility reported an injury of unknown source for Resident #67 to the State Survey Agency on 11/26/24 at 9:49 P.M. The facility's SRI investigation started on 11/26/24 revealed there was no evidence the progress note LPN #279 authored on 11/21/24 where Resident #67's left arm was found flaccid from a normally contracted position was addressed as an injury of unknown origin in the investigation. Review of the interdisciplinary team (IDT) progress note dated 11/27/24 at 11:51 A.M. revealed Resident #67 was reviewed for left humeral fracture as an injury of unknown origin. Interview on 12/10/24 at 10:47 A.M. with the Director of Nursing (DON) confirmed the self-reported incident for injury of unknown origin for Resident #67's left arm was not opened until 11/26/24 when x-ray results showed a humeral fracture. DON confirmed the SRI was not opened on 11/21/24 when Resident #67 first showed signs of an unexplained change in condition. 2. Review of the medical record for Resident #78 revealed an admitted [DATE] and diagnoses including Alzheimer's disease, dementia with behavioral disturbance, and impulse disorder. Resident #78 was scored 0.0 on Brief Interview for Mental Status (BIMS) assessment indicating severe cognitive impairment. Review of self-reported incident (SRI) investigation dated 10/14/24 revealed Resident #78 was involved in a verbal altercation with a visitor. There were no sustained injuries or psychosocial outcomes. Review of SRIs submitted to the Ohio Department of Health's Enhanced Information Dissemination Collection System (EIDC) (a database used for facilities to report required incidents of abuse, neglect, injuries of unknown origin, and misappropriation) revealed SRI #252959 was initiated on 10/14/24 and completed on 10/22/24. This was beyond five working days of the initial incident. Interview on 12/10/24 at 2:14 P.M. with Assistant Administrator #264 revealed submission of SRI #252959 had been an oversight due to a busy schedule. Assistant Administrator #264 confirmed SRI #252959 was initiated on 10/14/24 and completed on 10/22/24. Review of the facility policy titled Ohio Resident Abuse Policy dated 07/11/24 revealed an investigation of an abuse allegation which by definition included injury of unknown origin would be completed within five working days from the alleged occurrence. All allegations of abuse or injuries of unknown origin must be reported immediately to the Administrator, Director of Nursing, and applicable State Agency. The investigation must be completed within five working days from the alleged occurrence. This deficiency represents non-compliance investigated under Complaint Number OH00160241.

Based on observations, staff interviews, record review, and review of the facility policy, the facility failed to ensure physician orders were implemented to promote healing of a resident's wound to his foot. This affected one (Resident #67) of three residents reviewed for wounds. The facility census was 101. Findings include: Review of the medical record for Resident #67 revealed an admitted [DATE]. Diagnoses included senile degeneration of the brain, dementia with agitation, generalized muscle weakness, and muscle wasting and atrophy. Review of the annual Minimum Data Set (MDS) assessment, dated 10/14/24, revealed Resident #67 had unclear speech, was rarely/never understood or understands, and was moderately cognitively impaired. Resident #67 was dependent on staff for lower body dressing, putting on /taking off footwear, personal hygiene, and bed mobility. Review of the wound care progress note for Resident #67 dated 10/17/24 completed by Wound Care Certified Nurse Practitioner (CNP) #303 revealed Resident #67 was being seen for follow up wound care services. The lower extremities included no tenderness, no edema, mild stiffness, and grossly normal alignment. The wound location was left medial bunion and it was a skin tear. The depth was full thickness that measured 2.4 centimeters (cm) in length by 2.5 cm in width by 0.2 cm in depth. The wound base had 50% granulation, 10% slough, and 40% hyper-granulation. The wound status was improved/healing. Apply Prevalon boots (a cushioned bottom that floats the heel off the surface of the mattress, helping to reduce pressure). The individualized treatment plan included education was provided to nursing staff. Educated on the importance of offloading importance to promote wound healing. Review of Resident #67's physician orders dated 11/21/24 revealed a treatment to cleanse skin tear to the left bunion area with normal saline, pat dry, apply calcium alginate to wound bed, cover with small super absorbent pad, wrap with ABD and kerlix daily and as needed. The physician orders for the month of December 2024 identified orders for heel lift boots at all times as tolerated. Additional orders dated 12/03/24 included a bariatric bed with an air mattress for safety and repositioning. Review of the plan of care dated 12/05/24 revealed Resident #67 had a skin tear to the left medial bunion. The goal included the resident's skin tear will heal without complications. Interventions included recording location, size, width, depth color, surrounding skin, presence/absence of drainage, pain, and signs of healing. Observation and interview on 12/09/24 at 11:56 A.M. revealed Resident #67 was lying in bed on a low air loss mattress. The left outer foot was lying directly on the mattress. The low air loss mattress was beeping and the light on the device connected to the mattress revealed low pressure. The mattress appeared partially/mostly deflated. Resident #67 had his eyes open, and he was making groaning noises. Certified Nursing Assistant (CNA) #282 stated Resident #67 groaned all the time. CNA #282 stated the bed malfunctioned, and the beeping noise the bed made occurred all the time. CNA #282 stated she would shut the beeping noise off and it would just start again after a few minutes. CNA #282 stated she worked last Friday (three days prior) and the bed noise was doing it then. CNA #282 confirmed the bed was partially deflated. Observation and interview on 12/09/24 at 12:09 P.M. with Registered Nurse (RN) #247 confirmed Resident #67's mattress read low pressure. RN #247 stated she will have to call the hospice provider who provided the mattress. RN #247 stated she first noticed the malfunctioned mattress the day before and confirmed she had not notified the hospice provider yet. Observation with RN #247 confirmed Resident #67's bottom was touching the frame of the bed. There was air pushed to the top and bottom of the mattress (not fully inflated) but none in the center. Resident #67's left outer ankle wound had a dressing covering the wound and the area laying directly on the mattress. There was no pressure relieving heel boot on Resident #67's left foot. Interview on 12/09/24 at 4:13 P.M. with Licensed Practical Nurse (LPN) #230 stated the company that provided Resident #67's bed came out to look at it and said it was unfixable. The bed company will bring another mattress tomorrow. Observation of wound care and interview on 12/09/24 at 4:35 P.M. with Assistant Director of Nursing (ADON) #223 and #238 revealed Resident #67 was lying on his back. The low air loss mattress was beeping. ADON #223 stated the company was coming tomorrow (12/10/24) to fix the mattress, they came today but it was unfixable. ADON #223 verified there was air pushed to the top and bottom of the mattress (not fully inflated) but the center of the mattress was fully deflated. ADON #223 verified Resident #67 did not have the ordered heel boot on his left foot, the left leg was contracted and the wound (covered with a dressing) on the left foot was lying directly on the mattress. ADON #223 stated sometimes the facility was washing the pressure relieving heel boot. Observation and interview on 12/10/24 at 7:59 A.M. with CNA #282 verified Resident #67 did not have a heel boot on his left foot. CNA #282 stated the heel boot must be dirty or something. CAN #282 stated she started her shift at 6:30 A.M., and the heel boot was not on the left foot when she started her shift. Interview on 12/10/24 at 12:10 P.M. with Assistant Director of Nursing (ADON) #223 stated Resident #67's wound to the left bunion started as a callus over his bunion. The callus fell off on 06/06/24, then it was opened so they considered it a skin tear. Interview on 12/10/24 at 10:17 A.M. with the Director of Nursing (DON) stated if a specialized boot was ordered for a resident and was not available, the staff should have went to the therapy department to see if they had another one. Review of the facility policy titled Skin and Wound Care Best Practices, revised 11/05/24 included pressure injuries and wounds will be treated with evidence-based interventions as ordered by the provider. This deficiency represents non-compliance investigated under Complaint Number OH00160241.

Based on staff interview and medical record review, the facility failed to ensure a resident received appropriate assistance during incontinence care to prevent accidents. This affected one (Resident #67) of three residents reviewed for accidents. The facility census was 101. Findings include: Review of the medical record for Resident #67 revealed an admitted [DATE] and diagnoses including senile degeneration of the brain, dementia with agitation, and muscle wasting and atrophy. Resident #67 was on hospice services for senile degeneration of the brain. Review of the plan of care initiated 06/06/23 revealed Resident #67 had the potential for falls. Interventions included two staff members for incontinence care and repositioning (added 11/01/24), get resident up in chair when restless, perimeter mattress, occupational therapy evaluation, observe frequently, and place in a supervised area when out of bed. Review of the Fall Risk assessment dated [DATE] revealed Resident #67 was at high risk for falls. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was rarely understood or understands and was unable to participate in cognitive assessment. Resident #67 had unclear speech, short- and long-term memory problems, and severely impaired decision making. Resident #67 was dependent on staff for toileting hygiene and bed mobility. Review of the Occupational Therapy Discharge Summary dated 11/01/24 revealed Resident #67 required one to two staff maximal assistance for sitting balance and total dependence on staff for activities of daily living. Review of Post Fall Huddle Form dated 11/01/24 revealed at approximately 11:15 A.M., Resident #67 was being changed by Certified Nursing Assistant (CNA) #282 and Resident #67 slipped out of her hand and rolled over onto the floor. Resident #67 first hit head then rolled onto left side. Resident #67 was unable to report what had happened. Interventions included two staff assistance and wedge pillow while turning as Resident #67 moved a lot. Review of the undated witness statement from CNA #282 revealed on 11/01/24, she provided care to Resident #67. CNA #282 stated she turned Resident #67 towards her in bed and his feet/legs began to go off the bed. CNA #282 stated she had tried to stop Resident #67 from falling but was unable. Resident #67 slid out of bed and CNA #282 got the nurse to assess. Review of the Event Report dated 11/01/24 revealed Resident #67 had a witnessed fall in his room. Resident #67 fell from the bed. Resident #67 had generalized pain of nine out of 10. Resident #67 had skin tear on head with bruising and a bump. The nurse provided direct pressure to the skin tear then applied steri strips (an adhesive strip used on minor wounds). Post fall monitoring was initiated, physician notified, and resident representative notified. Interview on 12/03/24 at 1:30 P.M. with CNA #282 confirmed Resident #67 had fallen from the bed while she was completing incontinence care. CNA #282 stated while she was completing incontinence care she had turned Resident #67 towards her in bed. CNA #282 indicated Resident #67's feet started to come out of bed and he slid out of bed. CNA #282 indicated she had tried to use her body to stop Resident #67 from falling but was unsuccessful and had to lower him to the floor. CNA #282 indicated Resident #67 had a bump on his forehead. CNA #282 stated since the incident, they have started using two people for Resident #67 during care. CNA #282 stated Resident #67 was totally dependent on staff for activities of daily living and had contracted arms and legs. CNA #282 stated when Resident #67 was turned in bed due to stiffness/contractures, his whole body drops down as one. Interview on 12/03/24 at 1:44 P.M. with Registered Nurse (RN) #247 stated she had been notified on 11/01/24 Resident #67 had a fall. RN #247 stated the CNA turned Resident #67 during incontinence care and Resident #67 fell to the floor. RN #247 stated there was a skin tear on Resident #67's forehead and she applied steri strips. This deficiency represents non-compliance investigated under Complaint Number OH00160241.

Based on observation, record review and interview, the facility failed to ensure Resident #11, who was cognitively impaired, dependent on staff for incontinence care/management and had moisture associated dermatitis (MASD) was provided necessary incontinence care to promote optimal skin integrity and prevent additional complications from the MASD. This affected one resident (#11) of three residents reviewed for incontinence care. The facility census was 101. Findings include: Record review for Resident #11 revealed an admitted [DATE] with diagnoses including cerebral infarction due to occlusion or stenosis of left middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following cerebral infarction, dementia, and muscle weakness. Review of the care plan for Resident #11 dated 06/06/23 revealed Resident #11 experienced bladder incontinence related to hemiplegia /hemiparesis following cerebral infarction. Interventions included to provide incontinence care after each incontinent episode. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was moderately cognitively impaired. The assessment revealed Resident #11 required substantial/maximum assistance from staff with toileting and was always incontinent of bowel and bladder. Review of a Wound Management note revealed on 11/11/24, Resident #11 was noted to have moisture associated skin damage (MASD) to the gluteal fold and bilateral buttocks, measuring 17 centimeters (cm) in length by 14.5 cm. wide. On 12/05/24, Resident #11's MASD measured 17 cm by 14 cm and the status was stable and comments included Resident #11 continued to refuse incontinence care as frequently as needed. On 12/10/24 at 8:17 A.M. Resident #11 was observed sitting up in bed. Resident #11 was covered up with a white blanket. The left side of the blanket and a portion of the sheet viewed was observed to be saturated with a yellow substance (that appeared to be urine). The resident's room also had a strong foul urine odor. An attempt to interview Resident #11 at the time of the observation revealed the resident did not respond to questions. On 12/10/24 at 8:20 A.M., interview with Certified Nursing Assistant (CNA) #290 revealed she started her shift on this date at 6:30 A.M. and was assigned to care for Resident #11. At the time of the interview, the CNA revealed she had not yet been in to provide incontinence care to Resident #11 (since her shift began). In addition, the CNA also voiced concerns that night shift staff did not do their job (eluding to the provision of incontinence care for Resident #11). During the interview, the CNA did not provide any information or evidence that the resident had refused incontinence care on this date, but did indicate the resident would not allow all CNAs to work with her and stated the resident did require a lot of staff time because she was so particular. CNA #290 went on to provide information for how to best work with Resident #11, an gave an example of giving her juices. An observation of Resident #11 with CNA #290 verified the left side of Resident #11's blanket was visibly soiled (due to incontinence). CNA #290 removed Resident #11's blanket, and Resident #11 had a soiled brief on. Observation revealed the sheet, and pad surrounding Resident #11's lower back, buttocks, and upper thighs were saturated with urine. The left side of the blanket was saturated with urine. Resident #11 and the room she resided in had a strong foul odor of urine. CNA #290 confirmed Resident #11 always allowed her to do care for her, she just didn't like people she didn't know. In addition, CNA #290 revealed Resident #11's bottom was sore and sometimes bled (related to incontinence). Interview on 12/10/24 at 10:17 A.M. with the Director of Nursing (DON) revealed residents were to be checked and changed every two hours and as needed. Interview on 12/10/24 at 3:52 P.M. with Assistant Director of Nursing (ADON) #223 revealed sometimes Resident #11 only wanted certain staff to change her, there were three CNAs she would regularly allow. The ADON revealed it was her expectation that staff always approached the resident for care and then were to notify the nurse if the resident refused. ADON #223 stated she told Resident #11 she needed to allow the staff to change her at least once a shift but some nurses were afraid to just tell her she needed changed when she refused. ADON #223 confirmed Resident #11 continued to have MASD to her bilateral buttocks (due to incontinence). ADON #223 confirmed effective/individualized interventions were not in place for offering Resident #223 snacks or juice to allow staff to change her when she refused. The facility did not provide any evidence Resident #11 had refused incontinence care on 12/10/24 between 6:30 A.M. and 8:20 A.M. or information as to when the resident had last been provided incontinence care by night shift staff prior to 6:30 A.M. on this date. This deficiency represents non-compliance investigated under Complaint Number OH00159770.

Based on record review and interview, the facility failed to ensure appropriate assessments and resident care was completed for Resident #203's groin condyloma (genital warts). This finding affected one (Resident #203) of three residents reviewed for wound care. Findings include: Review of Resident #203's Solid Tumor Service History and Physical Exam form dated 08/28/24 at 2:25 P.M. indicated the resident endorses that about two weeks ago he had his port placed and developed generalized weakness, decreased appetite, fatigue and widespread blisters. During this time, the resident also noted that he began having oozing and bloody drainage from his penile condyloma. He stated that the condyloma initially was small and first noted approximately [AGE] years ago but had since increased in size. The resident previously saw dermatology for the widespread blisters and was given prednisone. The blisters were improving but present. The exam performed indicated a large verrucous (wart-like growth) mass surrounding the penis with site of leakage covered with a partially saturated dressing. Review of Resident #203's Urology Consult Note dated 08/28/24 at 4:43 P.M. revealed on evaluation, the resident was afebrile, and the resident's vital signs were within normal limits. Imaging reviewed and showed a 15.5 cm left renal mass concerning for malignancy, as well as an 18 cm penile and pubic condyloma mass extending down into the scrotum. The exam revealed a large condyloma over the penis, obscuring any sort of penile shaft or meatus, unable to see the urethral opening. Areas of purulence, around area of condyloma where the resident stated urine comes out. The resident would need a discussion regarding the renal mass and the penile condyloma with urologic oncology. An outpatient appointment was scheduled for 09/04/24. The physical exam showed a massive foul-smelling fungating (term used to describe skin lesion that occurs when a cancer breaks through the skin's surface) condyloma mass overlying the suprapubic region and entirely encompassing the penis. Unable to visualize the penile shaft, glans or urethral meatus with areas of purulence within. Review of Resident #203's hospital Solid Tumor Service Progress Note dated 08/30/24 at 7:55 A.M. revealed a wound culture of the condyloma was ordered with Zosyn antibiotic ordered. If the culture was negative, consider stop taking the Zosyn antibiotic. No acute intervention for the condyloma or renal mass and to follow up as an outpatient. Review of Resident #203's closed medical record revealed the resident was admitted on [DATE] with diagnoses including condyloma latum (groin area), muscle weakness and malignant neoplasm of the esophagus. Resident #203 was discharged on [DATE]. Review of Resident #203's progress note dated 08/31/24 at 7:01 P.M. authored by Licensed Practical Nurse (LPN) #543 revealed the resident had a urology appointment on 09/04/24 at 10:00 A.M. The resident's personal belongings were listed in the matrix. A focused head to toe assessment was performed and the resident was noted to have a patch over the implanted chemotherapy port to the right side of the chest. Ace bandages were on the resident's bilateral lower extremities to decrease edema caused by lymphedema and a large verrucous mass surrounded the penis with site of leakage covered with a dressing. The medications were verified by the nurse practitioner. Review of Resident #203's medical record did not reveal evidence of an comprehensive assessment of the resident's groin area which appeared to have drainage or wound care orders to address the drainage in the groin area while the resident was admitted at the facility. Interview on 10/08/24 at 2:08 P.M. with LPN Assistant Director of Nursing (ADON) #593 stated she did not have time to assess Resident #203 for wounds as she only worked on 09/03/24 while the resident resided in the facility. LPN ADON #593 was unaware if the resident had any wounds. Interview on 10/09/24 at 10:23 A.M. with LPN #543 stated she admitted Resident #203 and noticed the dressing on the resident's groin/penis area. She stated the resident was leaking clear looking fluid underneath of the condyloma mass and she placed dry dressings to absorb the drainage. LPN #543 stated she forgot to mention the drainage to the physician to obtain physician orders for a dressing. Review of the Skin and Wound Care Best Practices revised 09/19/24 revealed the purpose of the policy was to provide evidence based preventative skin care and wound treatment to prevent unavoidable skin complications. This deficiency represents non-compliance investigated under Complaint Number OH00157620.

Based on medical record review, facility policy review, and interview, the facility failed to ensure resident-to-resident physical altercations were reported the State Agency as required. This affected ten Residents (#28, #30, #39, #48, #57, #58, #69, #77, #85, and #357) of 39 residents who reside on the secured memory care unit. The facility census was 99. Findings include: 1. Review of the medical record for Resident #30 revealed an admitted [DATE] and diagnoses including Alzheimer's disease, dementia with behavioral disturbance, major depressive disorder, delusional disorders, and wandering. Review of the Medicare Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #30 had Brief Interview for Mental Status (BIMS) score of 99 indicating Resident #30 was unable to complete the assessment. Resident #30 had memory problems, severely impaired decision making, inattention, and disorganized thinking. Review of Resident #30's progress note dated [DATE] at 7:32 P.M. revealed Resident #30 was walking down hallway trying to hold the hand of Resident #357. Resident #30 was redirected several times by staff however continued to try to hold Resident #357's hand. Resident #357 grabbed Resident #30 by the neck and threw her against the wall. Resident #30 had a small bruise on left side of her head and her eye appeared a little droopy. Resident #30 was assessed by the nurse with no pain noted and neurological checks were initiated. The local police and responsible party were notified of the altercation. Review of the closed medical record for Resident #357 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses including dementia with behavioral disturbance, traumatic brain injury, delusional disorders and hallucinations. Resident #357 had not yet had a MDS admission assessment completed. Review of the Focused Head to Toe Observation assessment dated [DATE] revealed Resident #357 had cognitive and memory loss, was oriented to person, and had a medical diagnosis of traumatic brain injury. Review of Resident #357's progress note dated [DATE] at 8:32 P.M. revealed several residents including Resident #357 and Resident #30 were walking in the hallways. Resident #30 was being intrusive and touching Resident #357's arm. Staff were approaching to separate the two residents when Resident #357 grabbed Resident #30 by the neck and slammed her into the wall causing her to hit her head. Resident #357 had to be physically pried off Resident #30. Hospice services for Resident #357 were in the facility and gave order for Ativan as needed. The nurse practitioner, director of nursing, and Resident #357's wife were notified. Resident #357 was sent to the hospital for behavioral/psych evaluation. Review of self-reported incidents (SRIs) submitted to the Ohio Department of Health's Enhanced Information Dissemination Collection System (EIDC) (a database used for facilities to report required instances of abuse, neglect, injuries of unknown origin, and misappropriation) revealed there was no evidence the resident-to-resident physical altercation on [DATE] was reported. 2. Review of the medical record for Resident #39 revealed an admitted [DATE] and diagnoses including paranoid schizophrenia, anxiety disorder, personality disorder, delirium, bipolar disorder, psychotic disorder with delusions, mood disorder, and age-related cognitive decline. Review of the Medicare MDS Quarterly assessment dated [DATE] revealed Resident #39 had a BIMS score of 15 indicating intact cognition. Review of Resident #39's progress note dated [DATE] at 12:18 P.M. revealed Resident #39 was found on the floor next to her bed and her nose was bleeding. Resident #39 reported Resident #58 had come into her room knocked her to the ground, hit her twice in the nose with a closed fist, and choked her. Three staff had to physically remove Resident #58 from Resident #39's room. Resident #58 was yelling and crying Resident #39 had stolen his money. Resident #39 and Resident #58 were kept separated. Resident #39's nurse practitioner and guardian were notified. Review of the closed medical record for Resident #58 revealed an admitted [DATE]. Diagnoses including dementia with agitation and delirium. Resident #58 expired on [DATE] of unrelated medical conditions on hospice services. Review of the Medicare MDS Quarterly assessment dated [DATE] revealed Resident #58 had BIMS score of 05 indicating severe cognitive impairment. Review of Resident #58's progress note dated [DATE] at 11:25 A.M. revealed staff heard yelling and found Resident #58 in Resident #39's room fixated on money. Staff removed Resident #58 from the room. Resident #58 indicated he punched Resident #39 because she had his money. Resident #58's psych physician was notified and gave new order to send to hospital for behaviors. Review of SRIs submitted to the Ohio Department of Health's EIDC database revealed there was no evidence the resident-to-resident physical altercation on [DATE] was reported. 3. Review of the medical record for Resident #28 revealed an admitted [DATE] and diagnoses including Alzheimer's disease, dementia with behavioral disturbance and agitation, major depressive disorder, schizoaffective disorder, psychotic disorder, anxiety disorder, and altered mental status. Review of the Medicare MDS Annual assessment dated [DATE] revealed Resident #28 had a BIMS score of 99 indicating Resident #28 was unable to complete the assessment. Resident #28 had memory problems, severely impaired decision making, and disorganized thinking. Review of Resident #28's progress note dated [DATE] at 1:58 A.M. revealed Resident #28 was at the nursing station yelling. Resident #69 was sitting a chair nearby, stood up, and struck Resident #28 in the mouth with a closed fist. Resident #28 had a small cut on left upper corner of her lip with no bleeding noted. Resident #28 and Resident #69 were separated. Resident #28's responsible party and hospice were notified of the incident. Review of the medical record for Resident #69 revealed an admitted [DATE] and diagnoses including dementia with behavioral disturbance, alcohol-induced mood disorder, residual schizophrenia, and major depressive disorder. Review of the Medicare MDS Quarterly assessment dated [DATE] revealed Resident #69 had a BIMS score of 99 indicating Resident #69 was unable to complete the assessment. Resident #69 had memory problems and severely impaired decision making. Review of Resident #69's progress note dated [DATE] at 2:29 A.M. revealed Resident #28 was in front of Resident #69 yelling and Resident #69 struck Resident #28 in the mouth. It was noted Resident #28 got into his face and Resident #69 stood up from a chair, struck Resident #28 with a closed fist, and sat back down. Resident #69's physician was notified. Review of SRIs submitted to the Ohio Department of Health's EIDC database revealed there was no evidence the resident-to-resident physical altercation on [DATE] was reported. 4. Review of the medical record for Resident #57 revealed an admitted [DATE] and diagnoses including dementia with agitation and behavioral disturbance, restlessness and agitation, impulse disorder, delusional disorders, hallucinations, post traumatic stress disorder, psychosis, and traumatic brain injury. Review of the Medicare MDS Quarterly assessment dated [DATE] revealed Resident #57 had a BIMS score of five indicating severe cognitive impairment. Review of Resident #57's progress note dated [DATE] at 10:44 P.M. revealed Resident #57 was standing in the hallway shouting at Resident #85. Resident #57 swung his fist at Resident #85 and missed. Resident #85 swung his fist and hit Resident #57 on the left side of his face. Resident #57 sustained an abrasion to his face. Resident #57 did not allow the nurse to provide first aide. Resident #57's family and the nurse practitioner were notified of the incident. Review of the medical record for Resident #85 revealed an admitted [DATE] and diagnoses including dementia, anxiety disorder, bipolar disorder, and major depressive disorder. Review of the Medicare MDS Annual assessment dated [DATE] revealed Resident #85 had a BIMS score of 13 indicating intact cognition. Review of Resident #85's progress note dated [DATE] at 10:18 P.M. revealed Resident #57 was standing in the hallway shouting at Resident #85. Resident #57 swung with his fist at Resident #85 and missed. Resident #85 swung with his fist and hit Resident #57 on the left side of his face. Resident #85's family and nurse practitioner were notified with no new orders. Review of SRIs submitted to the Ohio Department of Health's EIDC database revealed there was no evidence the resident-to-resident physical altercation on [DATE] was reported. 5. Review of the medical record for Resident #48 revealed an admitted [DATE] and diagnoses including vascular dementia with behavioral disturbance, psychosis, schizoaffective disorder, hallucinations, panic disorder, anxiety disorder, delusional disorder, and major depressive disorder. Review of the Medicare MDS Quarterly assessment dated [DATE] revealed Resident #48 had a BIMS score of 99 indicating Resident #48 was unable to complete the assessment. Resident #48 had severely impaired decision-making, inattention, disorganized thinking, and memory problems. Review of Resident #48's progress note dated [DATE] at 7:26 P.M. revealed Resident #48 was having increased behaviors and anxiety. The nurse was giving Resident #77 medication and Resident #48 approached while screaming. Resident #77 picked up Resident #48 and threw her to the floor. Resident #48 and Resident #77 were separated. Resident #48 had no signs or symptoms of pain and no noted injuries. The local police and responsible party were notified. Review of the medical record for Resident #77 revealed an admitted [DATE] and diagnoses including dementia with behavioral disturbance and impulse disorder. Review of the Medicare MDS Annual assessment dated [DATE] revealed Resident #77 had a BIMS score of 99 indicating Resident #77 was unable to complete the assessment. Resident #77 had memory problems and severely impaired decision-making. Review of Resident #77's progress note dated [DATE] at 6:01 P.M. revealed while Resident #77 was at the cart medication waiting for his medications, Resident #48 approached the area screaming. Resident #77 picked up Resident #48 and threw her to the ground. Resident #48 and Resident #77 were separated and placed on one-on-one supervision. Resident #77 was sent to hospital for geriatric psych evaluation. The local police, physician, and responsible party for Resident #77 were notified. Review of SRIs submitted to the Ohio Department of Health's EIDC database revealed there was no evidence the resident-to-resident physical altercation on [DATE] was reported. Interview on [DATE] at 4:44 P.M. with Director of Nursing (DON) and Assistant Director of Nursing (ADON) #593 confirmed incidents on [DATE], [DATE], [DATE], [DATE], and [DATE] were not reported via the EIDC database. DON indicated she had just been promoted from ADON to DON. DON indicated the former DON made the decisions on what was reportable. DON indicated herself and ADON #593 investigated situations of potential abuse immediately and reported findings to the former DON. DON indicated she believed the resident-to-resident altercations on [DATE], [DATE], [DATE], [DATE], and [DATE] were not reported as there were no major injuries. Review of the facility policy Ohio Resident Abuse Policy revised on [DATE] revealed all allegations of abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property would be reported to the Administrator/Abuse Coordinator. Physical abuse was defined as hitting, slapping, pinching, or kicking. Investigation would begin immediately and applicable local and state agencies would be notified. It was noted All abuse allegations would be reported to the State Agency, an investigation would be completed, and a final report would be submitted within five working days.

Based on record review and interview, the facility failed to ensure individualized cared planned interventions were in place to prevent resident behaviors resulting in resident to resident altercations on the secured memory care unit (SCMU). This affected nine Residents (#28, #30, #39, #48, #57, #58, #69, #77, and #85) of ten residents reviewed for behavioral health services. The facility census was 99. Findings include: 1. Review of the medical record for Resident #28 revealed an admitted [DATE] and diagnoses including Alzheimer's disease, dementia with behavioral disturbance and agitation, major depressive disorder, schizoaffective disorder, psychotic disorder, anxiety disorder, and altered mental status. Review of the Medicare MDS Annual assessment dated [DATE] revealed Resident #28 had a BIMS score of 99 indicating Resident #28 was unable to complete the assessment. Resident #28 had memory problems, severely impaired decision making, and disorganized thinking. There were no behaviors noted. Review of Resident #28's care plan interventions related to behavioral symptoms revealed to allow distance in seating areas, assess whether behaviors endanger the resident or others, intervene as necessary, avoid overstimulation, avoid power struggle with resident, offer reassurance if resident was having delusions or hallucinations, ignore verbal abuse, maintain a calm environment and approach to resident, praise appropriate resident behaviors, provide daily schedule resembling prior lifestyle, provide consistency, and refocus when resident becomes verbally abusive. Although the care plan identified numerous interventions it lacked Resident #28's individualized stressors, the resident's response to these stressors and specific interventions to address them. Review of Resident #28's progress note dated 08/13/24 at 1:58 A.M. revealed Resident #28 was involved in a physical altercation with Resident #69. Resident #28 was at the nursing station yelling. Resident #69 was sitting a chair nearby, stood up, and struck Resident #28 in the mouth with a closed fist. Resident #28 had a small cut on left upper corner of her lip. Review of Resident-to-Resident Risk Tool dated 08/13/24 revealed the root cause of the physical altercation between Resident #28 and Resident #69 was noise on the unit. Review of the Quality Assessment and Performance Improvement (QAPI) dated 08/13/24 revealed both residents resided on secured unit, have diagnoses of dementia, and both residents have behaviors due to noise on unit. Resident #28's care plan was updated to include verbal behaviors; however, it was not specific to what triggered verbal behaviors. Interview on 10/10/24 at 12:47 P.M. with MDS #545 and MDS #603 confirmed Resident #28's care plan did not include individualized interventions to manage and modify resident behaviors to prevent resident to resident altercations. Interview on 10/10/24 at 1:13 P.M. with Director of Nursing (DON) and Regional Nurse #805 reported they were aware of the lack of individualization in resident care plans and had been slowly working on improving them. 2. Review of the medical record for Resident #30 revealed an admitted [DATE] and diagnoses including Alzheimer's disease, dementia with behavioral disturbance, major depressive disorder, delusional disorders, and wandering. Review of the Medicare MDS Quarterly assessment dated [DATE] revealed Resident #30 had BIMS score of 99 indicating Resident #30 was unable to complete the assessment. Resident #30 had memory problems, severely impaired decision making, inattention, and disorganized thinking. There were no noted behaviors. Review of Resident #30's care plan interventions related to behavioral symptoms revealed assess whether behaviors endanger resident or others, intervene as necessary, avoid over stimulation, maintain a calm environment and approach, and allow resident to express feelings. Although the care plan identified numerous interventions it lacked Resident #30's individualized stressors, the resident's response to these stressors and specific interventions to address them. Review of the progress note dated 06/26/24 at 7:30 P.M. revealed Resident #30 was involved in a physical altercation with Resident #357. Resident #30 and Resident #357 were walking in the hallway. Resident #30 was attempting to hold Resident #357's hand. Resident #357 grabbed Resident #30 by the neck and threw her against the wall. Resident #30 sustained bruising to left side of her head and her eye had appeared droopy following the altercation. Review of Resident-to-Resident Risk Tool dated 06/26/24 revealed the root cause of the physical altercation between Resident #30 and Resident #357 was history of aggressive behaviors. Review of the Quality Assessment and Performance Improvement (QAPI) dated 06/27/24 revealed both residents had dementia with behavioral disturbances, both residents ambulate on the unit throughout the day and reside on secured unit related to elopement risk. Staff were educated on abuse and potential triggers/de-escalation related to behaviors; however, there was no evidence of what specific triggers Resident #30 had. Interview on 10/10/24 at 12:47 P.M. with MDS #545 and MDS #603 confirmed Resident #30's care plan did not include individualized interventions to manage and modify resident behaviors to prevent resident to resident altercations. Interview on 10/10/24 at 1:13 P.M. with DON and Regional Nurse #805 reported they were aware of the lack of individualization in resident care plans and had been slowly working on improving them. 3. Review of the medical record for Resident #39 revealed an admitted [DATE] and diagnoses including paranoid schizophrenia, anxiety disorder, personality disorder, delirium, bipolar disorder, psychotic disorder with delusions, mood disorder, and age-related cognitive decline. Review of the Medicare MDS Quarterly assessment dated [DATE] revealed Resident #39 had a BIMS score of 15 indicating intact cognition. There were no noted behaviors and Resident #39 had no or minimal depressive symptoms. Review of Resident #39's care plan interventions related to behavioral symptoms revealed to allow resident to verbalize feelings, assess whether behaviors endanger resident or others, intervene as necessary, monitor behavior in response to medications. Although the care plan identified numerous interventions it lacked Resident #39's individualized stressors, the resident's response to these stressors and specific interventions to address them. Review of Resident #39's progress note dated 07/17/24 at 12:18 P.M. revealed Resident #39 was involved in a physical altercation with Resident #58. Resident #39 was found on the floor next to her bed and her nose was bleeding. Resident #39 reported Resident #58 had come into her room knocked her to the ground, hit her twice in the nose with a closed fist, and choked her. Three staff had to physically remove Resident #58 from Resident #39's room. Review of Resident-to-Resident Risk Tool dated 07/17/24 revealed the root cause of the physical altercation between Resident #39 and Resident #58 was unprovoked physical aggression. Interview on 10/10/24 at 12:47 P.M. with MDS #545 and MDS #603 confirmed Resident #39's care plan did not include individualized interventions to manage and modify resident behaviors to prevent resident to resident altercations. Interview on 10/10/24 at 1:13 P.M. with DON and Regional Nurse #805 reported they were aware of the lack of individualization in resident care plans and had been slowly working on improving them. 4. Review of the medical record for Resident #48 revealed an admitted [DATE] and diagnoses including vascular dementia with behavioral disturbance, psychosis, schizoaffective disorder, hallucinations, panic disorder, anxiety disorder, delusional disorder, and major depressive disorder. Review of the Medicare MDS Quarterly assessment dated [DATE] revealed Resident #48 had a BIMS score of 99 indicating Resident #48 was unable to complete the assessment. Resident #48 had severely impaired decision-making, inattention, disorganized thinking, and memory problems. There were no noted behaviors and Resident #48 had no or minimal depressive symptoms. Review of Resident #48's care plan interventions related to behavioral symptoms revealed to allow resident to have control over situations, begin with short concise interactions with resident and increase the interactions as suspicion decreases, maintain calm environment and approach, assess whether behaviors are a danger to resident or others, intervene as necessary, monitor resident mood and response to medications, if resident becomes disruptive provide comfort measures for basic needs, encourage to verbalize feelings, and provide support and reassurance in new situations. Although the care plan identified numerous interventions it lacked Resident #48's individualized stressors, the resident's response to these stressors and specific interventions to address them. Review of the progress note dated 08/30/24 at 7:26 P.M. revealed Resident #48 was involved in a physical altercation with Resident #77. Resident #48 was having increased behaviors and anxiety. The nurse was giving Resident #77 his medications and Resident #48 approached while screaming. Resident #77 picked up Resident #48 and threw her to the floor. Resident #48 had no signs or symptoms of pain and no noted injuries. Review of Resident-to-Resident Risk Tool dated 08/30/24 revealed the root cause of the physical altercation between Resident #48 and Resident #77 was physical aggression related to yelling. Staff were educated on abuse and potential triggers/de-escalation related to behaviors; however, there was no evidence of what specific triggers Resident #48 had. Interview on 10/10/24 at 12:47 P.M. with MDS #545 and MDS #603 confirmed Resident #48's care plan did not include individualized interventions to manage and modify resident behaviors to prevent resident to resident altercations. Interview on 10/10/24 at 1:13 P.M. with DON and Regional Nurse #805 reported they were aware of the lack of individualization in resident care plans and had been slowly working on improving them. 5. Review of the medical record for Resident #57 revealed an admitted [DATE] and diagnoses including dementia with agitation and behavioral disturbance, restlessness and agitation, impulse disorder, delusional disorders, hallucinations, post-traumatic stress disorder, psychosis, and traumatic brain injury. Review of the Medicare MDS Quarterly assessment dated [DATE] revealed Resident #57 had a BIMS score of five indicating severe cognitive impairment. There were no noted behaviors and Resident #57 had no or minimal depressive symptoms. Review of Resident #57's care plan interventions related to behavioral symptoms revealed to assess whether behaviors endangers resident or others, intervene as necessary, avoid over stimulation, avoid power struggle with resident, convey acceptance towards resident, explore with resident effective versus ineffective coping mechanisms, offer reassurance for delusions and hallucinations, maintain a calm environment and approach, obtain a psych consult, praise resident when behaviors are appropriate, provide daily schedule resembling prior lifestyle, refocus conversation when becomes verbally abusive, provide one on one sessions as necessary, provide consistent staff as often as possible, remove from group activities when behaviors are unacceptable, and when resident becomes physically abusive keep distance with others. Although the care plan identified numerous interventions it lacked Resident #57's individualized stressors, what the resident's prior lifestyle entailed, the resident's response to these stressors and specific interventions to address them. Review of the progress note dated 08/29/24 at 10:44 P.M. revealed Resident #57 was involved in a physical altercation with Resident #85. Resident #57 was standing in the hallway shouting at Resident #85. Resident #57 swung his fist at Resident #85 and missed. Resident #85 swung his fist and hit Resident #57 on the left side of his face. Resident #57 sustained an abrasion to his face. Review of Resident-to-Resident Risk Tool dated 08/30/24 revealed the root cause of the physical altercation between Resident #57 and Resident #85 was physical aggression related to yelling. Review of the Quality Assessment and Performance Improvement (QAPI) dated 08/30/24 revealed both residents have diagnoses of dementia, both have history of verbal aggression towards others, and both residents have psychological disorders with psychotropic medications. Resident #85's care plan was updated to include physical aggression and Resident #57's care plan was updated to include verbal and physical aggression. Staff were educated on abuse and potential triggers/de-escalation related to behaviors; however, there was no evidence of what specific triggers Resident #57 had. Interview on 10/10/24 at 12:47 P.M. with MDS #545 and MDS #603 confirmed Resident #57's care plan did not include individualized interventions to manage and modify resident behaviors to prevent resident to resident altercations. Interview on 10/10/24 at 1:13 P.M. with DON and Regional Nurse #805 reported they were aware of the lack of individualization in resident care plans and had been slowly working on improving them. 6. Review of the closed medical record for Resident #58 revealed an admitted [DATE] and a discharge date of [DATE] with diagnoses including dementia with agitation and delirium. Review of the Medicare MDS Quarterly assessment dated [DATE] revealed Resident #58 had BIMS score of 05 indicating severe cognitive impairment. There were no noted behaviors. Review of Resident #58's care plan interventions related to behavioral symptoms revealed maintain calm environment and approach, assess whether behavior endangers resident or others, intervene as necessary, maintain slow approach with resident, encourage resident to verbalize feelings, and avoid use of restraints. Although the care plan identified numerous interventions it lacked Resident #58's individualized stressors, the resident's response to these stressors and specific interventions to address them. Review of the progress note dated 07/17/24 at 11:25 A.M. revealed Resident #58 was involved in a physical altercation with Resident #39. Staff heard yelling and found Resident #58 in Resident #39's room fixated on money. Staff removed Resident #58 from the room. Resident #58 indicated he punched Resident #39 because she had his money. Resident #58 was transferred to the hospital for evaluation following the altercation. Review of Resident-to-Resident Risk Tool dated 07/17/24 revealed the root cause of the physical altercation between Resident #39 and Resident #58 was unprovoked physical aggression. Staff were educated on abuse and potential triggers/de-escalation related to behaviors; however, there was no evidence of what specific triggers Resident #58 had. Interview on 10/10/24 at 12:47 P.M. with MDS #545 and MDS #603 confirmed Resident #58's care plan did not include individualized interventions to manage and modify resident behaviors to prevent resident to resident altercations. Interview on 10/10/24 at 1:13 P.M. with DON and Regional Nurse #805 reported they were aware of the lack of individualization in resident care plans and had been slowly working on improving them. 7. Review of the medical record for Resident #69 revealed an admitted [DATE] and diagnoses including dementia with behavioral disturbance, alcohol-induced mood disorder, residual schizophrenia, and major depressive disorder. Review of the Medicare MDS Quarterly assessment dated [DATE] revealed Resident #69 had a BIMS score of 99 indicating Resident #69 was unable to complete the assessment. Resident #69 had memory problems and severely impaired decision making. There were no noted behaviors and Resident #69 had no or minimal depressive symptoms. Review of Resident #69's care plan interventions related to behavioral symptoms revealed to assess whether behaviors or mood was danger to the resident or others, intervene as necessary, attempt non-pharmacological interventions, allow resident to express feelings, encourage family to visit, encourage point system to help with managing behaviors, provide emotional support as needed, and referral to psych as needed. Although the care plan identified numerous interventions it lacked Resident #69's individualized stressors, the resident's response to these stressors and specific interventions to address them. Review of Resident #69's progress note dated 08/13/24 at 2:29 A.M. revealed Resident #69 was involved in a physical altercation with Resident #28. Resident #28 was in front of Resident #69 yelling, Resident #69 stood up from a chair, struck Resident #28 in the mouth with a closed fist, and sat back down. Review of Resident-to-Resident Risk Tool dated 08/13/24 revealed the root cause of the physical altercation between Resident #28 and Resident #69 was noise on the unit. Review of the Quality Assessment and Performance Improvement (QAPI) dated 08/13/24 revealed both residents resided on secured unit, have diagnoses of dementia, and both residents have behaviors due to noise on unit. Resident #69's care plan was updated to include verbal behaviors. Staff were educated on abuse and potential triggers/de-escalation related to behaviors; however, there was no evidence of what specific triggers Resident #69 had. Interview on 10/10/24 at 12:47 P.M. with MDS #545 and MDS #603 confirmed Resident #69's care plan did not include individualized interventions to manage and modify resident behaviors to prevent resident to resident altercations. Interview on 10/10/24 at 1:13 P.M. with DON and Regional Nurse #805 reported they were aware of the lack of individualization in resident care plans and had been slowly working on improving them. 8. Review of the medical record for Resident #77 revealed an admitted [DATE] and diagnoses including dementia with behavioral disturbance and impulse disorder. Review of the Medicare MDS Annual assessment dated [DATE] revealed Resident #77 had a BIMS score of 99 indicating Resident #77 was unable to complete the assessment. Resident #77 had memory problems and severely impaired decision-making. There were no noted behaviors. Review of Resident #77's care plan interventions related to behavioral symptoms revealed to administer medications, allow distance in seating areas, allow resident to discuss anger, assess whether behavior endangers resident or others, intervene as necessary, avoid over-stimulation, avoid power struggle with resident, offer reassurance with delusions and hallucinations, provide a calm environment and approach, obtain a psych consult, offer one step directions for tasks, praise when behaviors are appropriate, provide consistent staff as much as possible, remove to calm place when behaviors are not acceptable, provide daily schedule resembling prior lifestyle, keep distance when resident becomes physically abusive, reduce stressors, and involve family in identifying activities that reduce behaviors. Although the care plan identified numerous interventions it lacked Resident #77's individualized stressors, what the resident's prior lifestyle schedule was, the resident's response to these stressors and specific interventions to address them. Review of the progress note dated 08/30/24 at 6:01 P.M. revealed Resident #77 was involved in a physical altercation with Resident #48. Resident #77 was at the medication cart waiting for his medications and Resident #48 approached the area screaming. Resident #77 picked up Resident #48 and threw her to the ground. Resident #77 was transferred to the hospital for geriatric psych evaluation. Review of Resident-to-Resident Risk Tool dated 08/30/24 revealed the root cause of the physical altercation between Resident #48 and Resident #77 was physical aggression related to yelling. Staff were educated on abuse and potential triggers/de-escalation related to behaviors; however, there was no evidence of what specific triggers Resident #77 had. Interview on 10/10/24 at 12:47 P.M. with MDS #545 and MDS #603 confirmed Resident #77's care plan did not include individualized interventions to manage and modify resident behaviors to prevent resident to resident altercations. Interview on 10/10/24 at 1:13 P.M. with DON and Regional Nurse #805 reported they were aware of the lack of individualization in resident care plans and had been slowly working on improving them. 9. Review of the medical record for Resident #85 revealed an admitted [DATE] and diagnoses including dementia, anxiety disorder, bipolar disorder, and major depressive disorder. Review of the Medicare MDS Annual assessment dated [DATE] revealed Resident #85 had a BIMS score of 13 indicating intact cognition. There were no noted behaviors and Resident #85 had no or minimal depressive symptoms. Review of Resident #85's care plan interventions related to behavioral symptoms revealed to administer medications, monitor effectiveness, assess whether behaviors endanger resident or others, intervene as necessary, avoid over stimulation, avoid power struggle with resident, maintain a calm environment and approach, convey acceptance towards resident, obtain a psych consult, offer one step directions for tasks, praise resident behaviors as appropriate, provide consistent staff as much as possible, remove resident when behaviors not acceptable, provide daily schedule resembling prior lifestyle, keep distance when resident becomes physically abusive, refocus conversation when resident becomes verbally abusive. Although the care plan identified numerous interventions it lacked Resident #85's individualized stressors, what the resident's prior lifestyle schedule was, the resident's response to these stressors and specific interventions to address them. Review of the progress note dated 08/29/24 at 10:18 P.M. revealed Resident #85 was involved in a physical altercation with Resident #57. Resident #57 was standing in the hallway shouting at Resident #85. Resident #57 swung with his fist at Resident #85 and missed. Resident #85 swung with his fist and hit Resident #57 on the left side of his face. Review of Resident-to-Resident Risk Tool dated 08/30/24 revealed the root cause of the physical altercation between Resident #57 and Resident #85 was physical aggression related to yelling. Review of the Quality Assessment and Performance Improvement (QAPI) dated 08/30/24 revealed both residents have diagnoses of dementia, both have history of verbal aggression towards others, and both residents have psychological disorders with psychotropic medications. Staff were educated on abuse and potential triggers/de-escalation related to behaviors; however, there was no evidence of what specific triggers Resident #85 had. Interview on 10/10/24 at 12:47 P.M. with MDS #545 and MDS #603 confirmed Resident #57's care plans did not include individualized interventions to manage and modify resident behaviors to prevent resident to resident altercations. Interview on 10/10/24 at 1:13 P.M. with DON and Regional Nurse #805 reported they were aware of the lack of individualization in resident care plans and had been slowly working on improving them.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, facility Self-Reported Incident (SRI) review, facility policy and procedure review, and interview, the facility failed to ensure Resident #40 was free from resident-to-resident physical abuse. Actual harm occurred on 07/27/23 when Resident #45 pushed Resident #40 to the floor after Resident #40 wandered into his room causing Resident #40 to fall to the floor and suffer a hip fracture that required surgical intervention at a local hospital. This affected one resident (Resident #40) of three residents reviewed for abuse. Findings include: Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, major depressive disorder, and chronic kidney disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was severely cognitively impaired and independently mobile. Review of the care plan dated 08/22/22 revealed Resident #40 wanders throughout the day and has a short attention span. Resident #45 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, major depressive disorder, and anxiety disorder. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #45 was cognitively intact and required supervision for completing his activities of daily living. Review of a facility SRI) tracking number #237522 dated 07/28/23 revealed Resident #40 was observed on the floor in another resident's room (Resident #45's room) at 8:00 P.M. on 07/27/23. Resident #40 was observed laying on his left side. Upon assessment, Resident #40 was grimacing and expressed pain in his left hip. Local emergency services were contacted, and Resident #40 was transported to a local emergency room for evaluation. Upon evaluation in the emergency room , Resident #40 was admitted to the hospital with a hip fracture. At the time of the incident, residents in the room were asked what happened and did not respond to staff at the time of the incident. Follow-up interviews/investigation on 07/28/23 revealed, when residents were re-interviewed, Resident #45 admitted he pushed Resident #40 onto the floor. Resident #45's roommate (Resident #150) was also interviewed and revealed that he witnessed Resident #45 push Resident #40 to the floor. Per multiple staff interviews on 07/28/23, Resident #40 was engaging in typical baseline behaviors (continuous wandering) in the time leading up the incident. Per baseline Resident #40 was easily re-directable by staff when wandering behaviors became intrusive to others. At 8:00 P.M., staff observed Resident #40 at the nurse's station. Between 8:00 P.M. and 8:30 P.M., Resident #40 was observed by multiple staff ambulating in the hallway eating a snack and standing at the nurse's station. Between 8:15 P.M. and 8:30 P.M, Licensed Practical Nurse (LPN) #900 was finishing her medication pass on Resident #40's unit. LPN #900 observed the door closed in Resident #45's and thought she heard Resident #40 talking. LPN #900 proceeded to the door and knocked and opened it and observed Resident #40 on the floor. Upon assessment and consultation with Resident #40 primary care physician, an order was obtained to send Resident #40 to a local hospital for evaluation. Interview with the Administrator on 08/12/23 at 10:15 A.M. verified the events of the SRI. Review of the facility policy entitled Ohio Abuse Policy, dated 10/03/22, revealed This Facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. The deficient practice was corrected on 07/28/23 when the facility implemented the following corrective actions: The facility conducted head to toe assessment on the residents involved in the altercation. The injured resident (Resident #40) was sent to the hospital for evaluation on 7 /27/23. Residents #40 and #45's attending physicians were notified of the altercation and any injuries identified. No new orders received. The facilities consulting psychiatrist was notified of the altercation and scheduled follow-up visit. The responsible parties for the residents involved in the altercation were informed. The facility notified the local police department of the incident. The facility submitted an initial SRI to the Ohio Department of Health on 7/28/23. To identify other potential like residents, on 7/28/23 residents that were unable to be interviewed, had a head-to-toe skin observation completed for potential signs of abuse. No negative findings were noted. To prevent this from recurring, on 07/28/23 the facility completed an audit of residents who were intrusive wanderers, and residents who were territorial of their room. No other residents who were territorial with their room were noted or they had interventions in place, i.e. stop signs. The Director of Nursing/ Designee educated facility all staff on its abuse policy and re-directive and behavioral techniques related to intrusive wanderers and residents who were territorial of their room on 07 /28/23. A quality assurance and performance improvement meeting was completed on 07/28/23 to address the issue and develop procedures to prevent other similar reoccurrences. To monitor and maintain ongoing compliance the facility will conduct five resident head-to-toe observations weekly for four weeks then monthly for two months to ensure there are no identified cases of potential abuse. Audit results will be submitted to the Quality Assurance and Performance Improvement (QAPI) committee for further review and recommendation. This deficiency represents noncompliance investigated under Self-Reported Incident, Control Number OH00145207.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on record review, observation, review of a facility Self-Reported Incident (SRI), review of the facility investigation, and review of facility policy and procedures, the facility failed to ensure Resident #105 was free from physical abuse by Resident #106, who had known physical behaviors towards others. Actual Harm occurred on 09/11/21 when Resident #106 struck Resident #105 causing Resident #105 to sustain a bloody lip and caused Resident #105 to fall to the floor. Both residents were cognitively impaired. Resident #105 required supervision for walking and eating and required supervision of one staff with physical assist for bed mobility and transferring. Residents #105 and #106 were both sent to the hospital for further evaluation; Resident #105 was admitted to the hospital. This affected one Resident (#105) of three residents reviewed for abuse. Findings include: Review of the medical record for Resident #105 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/04/21, revealed Resident #105 had moderately impaired cognition. The resident required supervision of one staff with physical assistance for bed mobility and transferring. She required supervision for eating and walking. Review of behavior and mood revealed the resident did not hallucinate or have delusions. She exhibited no physical behavioral symptoms directed toward others. She did not resist care and does not wander. She did not receive antipsychotics the last seven days. Review of the plan of care, dated 07/04/21 revealed Resident #105 had actual falls and potential for falls related to impaired cognition and safety awareness due to diagnoses. Interventions included administer medications as ordered, monitor for effectiveness and side effects, notify the physician/ Nurse Practioner (NP) of any changes as needed, assess risk for falls upon admission, quarterly and as needed, and assist with mobility as needed and encourage her to use handrails or assistive devices properly. Review of the medical record for Resident #106 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS, dated [DATE], revealed Resident #106 had severely impaired cognition. The resident required supervision of one staff for physical assist for personal hygiene and toilet use and locomotion off the unit. He required supervision for transfers, walking and eating. Review of behaviors he had physical symptoms directed at others including hitting, kicking, and pushing. He did not resist care and does not wander. Review of the plan of care, dated 07/05/21, revealed Resident #106 had behaviors problems as evidenced by striking out at other residents. Interventions included to administer medications as ordered, intervene as necessary to protect others, remove from the area, monitor for effectiveness, notify the physician/ NP of changes as needed, and assess quarterly and as needed. Review of a facility Self-Reported Incident (SRI) dated 09/11/21 timed 3:07 P.M. revealed the facility investigated an injury sustained to Resident #105 by Resident #106. On 09/11/21 between 2:38-2:39 P.M. State tested Nurse Aide (STNA) #217 was talking with Resident #106 at the nurse's station and then she went to the restroom. Resident #106 had no agitation or signs of anxiety. At approximately 2:40 P.M. STNA #208 last observed Resident #106 in the dining room watching TV. STNA #208 saw Resident #105 as she was walking to go into the dining room. At approximately 2:45 P.M. STNA #217 observed Resident #106 standing by the elevator and she asked him what the noise was. STNA #208 heard Resident #106 yelling that he hit someone, and staff ran to the dining room. Resident #105 was observed lying on the floor. Nurses went to Resident #105 to assess her while an unidentified STNA walked Resident #106 to his room and kept him on one-on-one. The police were notified. Approximately 2:46 P.M. Resident #105's POA was notified as well as the physician. The physician for Resident #106 was also called and gave orders for him to be sent to the hospital for a psych evaluation and his guardian was notified. Between 2:49 P.M. to 2:50 P.M. Resident #105 became unresponsive and 911 (Emergency Medical Services/EMS) was called. At 3:00 P.M. Resident #105 left the facility with EMS. The POA was notified, and the physician was updated. At 3:15 P.M. Resident #106's guardian was notified. At 3:30 P.M. Resident #106 departed the facility and went to the hospital for evaluation. From 3:30 P.M. through 9:00 P.M. all third-floor residents had a skin check with no problems identified. There were no interviewable residents on the third floor. All staff were educated regarding the abuse policy, behaviors, and monitoring of common areas. Like residents with behavior care plans were reviewed by the Director of Nursing (DON) and both unit managers for appropriate interventions. An ad hoc QAPI and root cause analysis was completed. At 9:37 P.M. Resident #106 returned to the facility and was placed one on one supervision. The nurse spoke with the psychologist and obtained new orders. His guardian was updated. Review of the incident/accident log for 07/01/21 through 09/30/21 revealed no patterns or trends. Interviews on 09/29/21 from 10:16 A.M. through 1:30 P.M. and on 10/04/21 from 11:32 A.M. through 11:37 A.M. with Registered Nurse (RN) #214, Licensed Practical Nurses (LPNs) #209, #211, #213, and STNAs #202, #203, #204, #205 and #208, #212, #217 and #218 revealed Resident #106 punched Resident #105 in the face causing a bloody lip and caused Resident #105 to fall to the floor. Interview on 09/29/21 at 11:25 A.M. with the Administrator and the Director of Nursing (DON) verified Resident #106 punched Resident #105 in the face causing a bloody lip and caused Resident #105 to fall to the floor. Review of the written statement from LPN #211 revealed she did not witness Resident #105 or #106 prior to the incident. She overheard Resident #106 state, yea, I punched her. She stated that she and a few other staff members went to investigate. Upon arriving in the dining room, Resident #105 was being assessed by another nurse. Resident #105 was observed lying on her side with blood coming from her mouth. Resident #106 was asked to walk with her to his room and he agreed. Staff were assigned one-on-one with him at that time. LPN #211 returned to assist the other nurse. Resident #105 was assisted into a chair. She was alert and oriented to her baseline. While the other nurse continued investigation and collecting statements and she stayed with Resident #105, Resident #105 began vomiting and becoming hard to arouse although continuing breathing. EMS was called. Resident #105's blood pressure and pulse oximetry (p. ox.) were unable to be obtained and two liters of oxygen were placed. The resident's pulse ox. was 98% and pulse was 154. While awaiting the arrival of EMS, Resident #105 became very tense and was tightly clenching her fist. She was still difficult to arouse. EMS arrived and transported her to the hospital. Review of the written statement from STNA #208 revealed he last observed Resident #105 walking to go into the dining room and Resident #106 was in the dining room watching TV. He heard Resident #106 yelling that he hit someone. STNA #208 ran into the dining room and saw blood from Resident #105. He asked Resident #106 what happened, and he said he hit her because she kept telling him to stay out of her room. Review of the written statement from STNA #217 revealed before the incident she was standing at the nurse's station talking with Resident #106 and left to go to the restroom. When she was leaving the restroom, Resident #106 was no longer at the nurse's station. STNA #217 heard something hit the floor. She leaned over the nurse's station counter and saw Resident #106 standing by the elevator across from the dining room. She asked him about the noise. Resident #106 stated, I knocked her the (expletive) out! That's what happened. STNA #217 ran around the nurse's station desk to the dining room and saw Resident #105 lying on the floor with blood around her face. STNA #217 called out to the nurses and STNA #212 and LPN #211 came running. The nurses proceeded to assist Resident #105 by getting her in a chair, checking her vitals, cleaning her up and to see where the blood was coming from. STNA #212 was asking Resident #105 questions but she was not responding. EMS was called, arrived, and transported Resident #105 to the hospital. Resident #106 continued to be monitored until EMS came to transport him to the hospital. Review of the written statement from STNA #203 revealed she was on C-hall charting when Resident #105 walked past her with no walker. STNA #203 asked her to wait while she went and got her walker. Resident #105 stated she would wait in the dining room while STNA #203 got her walker. STNA #203 finished charting and went to A-hallway to care for another resident. As she passed the nurse's station, she heard yelling to call 911. STNA #203 indicated that STNA #208 and #212 were assisting Resident #105 who was vomiting and appeared unresponsive. STNA #203 indicated she went to get towels from the linen closet. Review of the physician's orders for Resident #106, effective 09/11/21 revealed [MEDICATION(S)] solution five milligrams per milliliter (mg/ml) inject two mg intramuscularly every six hours as needed for agitation related diffuse traumatic brain injury (TBI) with loss of consciousness of unspecified duration, subsequent encounter until 09/26/21 (14 days). [MEDICATION(S)] tablet two mg by mouth every six hours as needed for agitation related to diffuse traumatic brain injury with loss of consciousness of unspecified duration, subsequent encounter until 09/26/21 (14 days). [MEDICATION(S)] tablet one and a half mg by mouth two times a day for TBI. Review of the head-to-toe evaluation dated 09/11/21 at 2:46 P.M. revealed Resident #106 became agitated at Resident #105 as she was repeating, do not go in my room. Resident #106 punched her causing her to fall to the floor. Staff immediately responded to the yelling and noise and found Resident #105 on the floor bleeding. Resident #106 was asked what happened and he said, she told me not to in her room, so I knocked her the (expletive) out. The two residents were immediately separated. Resident #106 was escorted to his room. Emergency care was given to the resident on the floor. She was bleeding from the right side of her lip and had lump beginning on her left temporal area. After getting Resident #105 up, washed, and stable, she began vomiting approximately five minutes later and became unresponsive. 911 was called and she was immediately sent to the hospital. Staff remained with her until EMS arrived and took over. Review of a nursing note on 9/11/21 at 4:48 P.M. revealed Resident #105 was involved in an incident. She became unresponsive with vomitus coming out of her mouth and nose. 911 was called and she was taken to the hospital per order from the NP. The responsible party was made aware. Review of the facility policy titled, Ohio resident abuse policy, dated 07/14/20, revealed that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. It is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, Involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown source. The Administrator/Abuse Coordinator immediately begin an investigation and notify the applicable local and state agencies. As a result of the incident, the facility implemented the following corrective actions to correct the deficient practice by 09/20/21: -On 09/11/21, Resident #106 was removed from the area. A head to toe assessment was completed. Resident #106's physician and guardian were notified. The resident was transferred to the hospital. Upon return from the hospital, the resident was placed on 1:1 supervision and the physician adjusted medications. The resident discharged from the facility on 09/20/21. -On 09/11/21, Resident #105 was transferred to the hospital for treatment. -On 09/11/21, the facility initiated a Self-Reported Incident (SRI). -On 09/11/21, the facility reported the incident to local police. -On 09/11/21, all residents residing on the same floor as Resident #106 had skin checks completed by the interdisciplinary team to ensure there were no other indications of abuse. None of the residents on the unit were interviewable. -On 09/11/21, like residents with a history of physical aggression had care plans reviewed by the interdisciplinary team to ensure appropriate interventions were in place. -On 09/11/21, all staff were educated on the facility's Abuse policy and resident supervision by the Director of Nursing. -On 09/11/21, an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to discuss the incident and define appropriate corrective actions. A Root Cause Analysis was also completed. -On 09/15/21, nursing staff were educated on Resident #106's triggering behaviors. -Beginning 09/20/21, to monitor ongoing compliance, the facility completed weekly audits to identify unreported incidents of abuse. The audits will continue for three residents weekly for four weeks, then monthly for two months. This deficiency substantiated complaint OH 000, OH 141 and OH 184

Based on record review and interview the facility failed to notify the court appointed guardian of Resident #141's discharge to the community. This affected one of three residents reviewed for discharge from the facility. This failure resulted in actual harm when the guardian was unable to locate the resident and filed a missing person's report. When located, Resident #141 was disoriented and confused and required transportation to local hospital for evaluation where she was admitted and remained at the time of the survey. The facility census was 113. Findings Include: Review of Resident #141's closed medical record revealed Resident #141 had [DIAGNOSES REDACTED]. Review of an admission note dated 07/02/20 revealed the resident had been admitted from another long-term care facility for [MEDICAL CONDITION] following a cerebral infarction (lack of blood flow to the brain which may result in stroke). The admission assessment also indicated the resident was alert and oriented to self, had confusion and was pleasant. Review of Resident #141's face sheet (document that gives a resident's information at a quick glance and includes contact details) revealed the grandmother was listed as the contact, no other contacts were listed. Further review of the medical record which was provided by the Medical Records Director did not reveal evidence of a court appointed guardian. Review of a progress note dated 07/13/20 authored by the Assistant Director of Nursing (ADON) revealed Resident #141's grandmother was contacted regarding a pneumonia vaccine. Review of progress note dated 08/14/20 authored by the Director of Nursing (DON) revealed the resident was to be discharged home with family. Review of progress note dated 08/17/20 authored by Registered Nurse (RN) #404 revealed the resident was discharged home with family and the resident friend (no name listed) had picked the resident up at 1:15 P.M. Review of an Admission and Discharge list revealed Resident #141 was admitted on [DATE] and discharged home without home health services on 08/17/20. Review of a police report dated 10/15/20 at 2:18 P.M. revealed Resident #141 had been reported missing by the court appointed guardian, had an active arrest warrant, history of drug overdoses, lacked the ability to make decisions for herself, and was in need of 24/7 medical care. The report further detailed Resident #141 was admitted to the nursing home on 07/02/20 for treatment of [REDACTED]. The resident was to remain at a healthcare facility for the remainder of her life due to her conditions. Resident #141 was signed out of the facility at the end of August 2020 or early September 2020 by an unknown person. The guardian stated she was not aware of the situation until 10/15/20 when she completed a wellness check. At the time of the wellness check the guardian was not aware of the resident's whereabouts and initiated a missing person's report. The guardian stated she informed local police of the resident's possible whereabouts at the grandmother's home, and on inspection of the home, police determined she was not at the residence. Police were able to speak with the resident's grandmother and obtain permission to search the residence; however, during the course of interview with the grandmother it was believed the grandmother lacked the mental capacity to officially obtain the proper consent to search the home. On 10/16/20 local police attempted to contact the resident by telephone with no answer and a message was left. Police contacted the nursing home and spoke with the DON which revealed the resident was admitted on [DATE] and was discharged on [DATE] to her grandmother's care. The DON stated she would forward the admission information which included the resident's contact information. The police stated they had spoken with the guardian who stated she had the admission paperwork that was received and electronically signed for by the facility indicating there was a legal guardian in place for Resident #141. The police attempted to locate Resident #141 at the last known address obtained from the resident's arrest on 09/18/20. Upon arrival at the last known address, police indicated the side door was ajar and after announcing themselves they entered and discovered no one was at the residence. Police then made contact with the courts and obtained verbal consent to detain and transport the resident to the hospital for medical clearance and to notify the guardian when she was located. On 10/13/20 the guardian informed police she had been made aware Adult Protective Services (APS) were at the grandmother's residence for a separate matter and discovered Resident #141 was there and became concerned for Resident #141's wellbeing. On 10/16/20, at the time of discovery Resident #141 said she was out of her medications. Police had obtained a written court order to detain and admit Resident #141 to the local hospital for evaluation. On 10/19/20 at 10:50 A.M. interview with the DON revealed Resident #141 had been a resident at the facility. The DON was unsure of the exact dates however she stated the resident was there for a brief time, approximately one month. The DON denied being aware Resident #141 had a court appointed guardian upon admission, she stated she was aware the resident resided with her grandmother prior to entering the facility. The DON said the resident was placed in the facility because she had suffered a stroke. The grandmother was listed on the paperwork as being the resident's guardian and any concerns related to the resident's care had been discussed with the grandmother. The DON stated she was unaware of the exact discharge date however she stated the resident was discharged to her grandmother's home sometime in August of 2020. The DON said she was not aware the resident had a court appointed guardian until 10/16/20 when the facility received a phone call from a detective due to a missing person's report had been filed. DON denied being aware the resident had been considered missing. An interview on 10/19/20 at 10:29 A.M. with Resident #141's court appointed guardian revealed she was appointed guardian on 06/16/20. She stated she had contacted the facility in regard to admitting Resident #141 to their facility because the facility had a locked unit to prevent elopement. The guardian explained Resident #141 had a history of [REDACTED]. She stated she had admitted the resident to the facility in July of 2020; however, due to covid restrictions she was not able to visit the resident after her admission. She stated she had made calls to the facility to check on the resident. In August of 2020 she had called the facility in an attempt to speak with the resident and upon answering the phone a staff member transferred the guardian to the resident's room, but the transferred call was not answered. She further stated she called the resident on her cell phone and the resident answered but did not indicate she was no longer at the facility. The guardian called the facility again in September of 2020 and again her phone call was transferred and was not answered. The guardian attempted to call the resident's cell phone, but the number had been disconnected. In October of 2020 the guardian called the facility to make arrangements for a care plan meeting with the Licensed Social Worker (LSW) and she was not able to reach the LSW; however, at the time of this phone call (she was unable to state exact date) she was made aware by the receptionist the resident had been discharged home on[DATE]. At the time of the phone call she requested to speak with the Administrator, but the administrator was not available, and she left a message asking for a return call which was never received. The guardian made another attempt to contact the administrator, which was again unsuccessful, but she did speak with the LSW. The LSW informed her the resident had been discharged to her grandmother's home on 08/17/20. She stated once she was made aware the resident was no longer at the facility she contacted the court to inform of the resident's discharge and on 10/16/20 she filed a missing person's report and was notified by the police on 10/18/20 the resident had been located and was transferred to a local hospital for evaluation. On 10/19/20 at 10:50 A.M. a follow up interview with the DON and Administrator revealed neither were aware the resident had been missing. However, they confirmed they were notified on 10/16/20 a missing person's report had been filed for the resident. On 10/19/20 at 11:35 interview with LSW #300 revealed she had not been aware Resident #141 had a court appointed guardian, she stated the admission information had a grandmother listed and made no mention of the resident having a guardian. She indicated she had been in contact with the resident's grandmother and the grandmother was agreeable Resident #141 could be discharged to her home. LSW #300 further stated she had informed the grandmother she would be discharged to her home on 08/17/20 and the resident did not require any at home health services. On 10/20/20 at 10:46 A.M. a phone interview with the court appointed guardian revealed she had documentation the facility received the signed Admission Agreement for Resident #141 which indicated the guardian as Resident #141's resident representative. The document had been electronically signed on 07/07/20 by Assistant Admissions Director (AAD) #301. The guardian said Resident #141 was given a court appointed guardian due to her frequent drug abuse and being declared mentally incompetent. She further stated the resident's grandmother was not able to care for herself and was not able to care for the resident. On 10/20/20 at 2:25 P.M. a phone interview was conducted with the Administrator and DON regarding the electronically signed documents, they stated AAD #301 was no longer employed with the facility, she had left her position approximately two weeks prior. The DON and Administrator denied being aware AAD #301 had electronically signed an Admission Agreement which indicated Resident #141 had a court appointed guardian. They stated the only documents they were aware of were in the resident's closed chart and Resident #141's grandmother was the only known contact. On 10/22/20 at 2:41 P.M. a telephone interview with the detective from the local police department confirmed a missing person's report had been filed on 10/15/20 by Resident #141's court appointed guardian. He said on arrival to the home of Resident #141's grandmother (10/16/20) the home did not appear to have any safety concerns; however, medical personnel on site stated Resident #141 was disoriented and could not answer questions appropriately. He stated medical personnel was informed by Resident #141 she was out of her medications, but it was not known which medications or the duration of when they were out. He stated the resident was transported to a local hospital for evaluation. This deficiency substantiates Complaint Number OH 537.