Every finding on record at Dunbar Health & Rehab Center

Based on medical record review, staff and resident interviews, observations, review of a facility Self-Reported Incident (SRI), review of a video, and policy review, the facility failed to maintain an environment free from pests. This affected two (#60 and #19) of the three residents reviewed for the environment. The facility census was 58. Findings include: Review of the medical record for Resident #60 revealed an admission date of 05/20/25 and discharged on 05/27/25. Diagnoses included chronic respiratory failure with hypoxia, tracheostomy (trach), nontraumatic intracerebral hemorrhage, and diabetes mellitus. Review of a physician order for Resident #60 dated 05/22/25, revealed the resident was ordered to have trach checks and observations completed four times per day and as needed. Review of the discharge Minimum Data Set (MDS) assessment for Resident #60 dated 05/27/25, revealed Resident #60 was dependent for all activities of daily living (ADLs). Review of the facility SRI, dated 05/29/25, revealed the facility completed staff and resident interviews and observations. Review of a statement by Certified Nursing Assistant (CNA) #209 stated when she went to help another aide care for Resident #60, there were ants crawling on the resident. Review of the statement by CNA #222 stated on 05/25/25, Resident #60 had ants on her bed and her body. CNA #222 stated Resident #60 was washed up and repositioned. CNA #222 stated a personal blanket was noted on her bed covered with ants which was bagged and set aside for the family to pick up. Further review of staff statements revealed a statement dated 05/28/25 by the Administrator which stated she watched a video provided by Resident #60's husband which showed two to four ants on Residents #60's tracheostomy but none in the throat area. Review of the SRI revealed after observations and staff and resident interviews, the facility did not substantiate the allegation of neglect due to lack of evidence. Interview on 06/17/25 at 9:50 A.M. with Respiratory Nurse #208 revealed on 05/25/25 around 2:00 A.M. she observed about five ants on Resident #60's upper arm and on her bed but not on the resident's trach. Respiratory Nurse #208 stated she immediately notified the nurse and aide who gave Resident #60 a bed bath and changed her linens. Respiratory Nurse #208 stated she did not know where the ants came from and had not seen the ants in Resident #60's room before when providing trach care. Interview on 06/18/25 at 9:03 A.M. with Administrator and Director of Nursing (DON) via phone, revealed the DON stated she was notified by Resident #60's husband that Resident #60 was found to have ants on and around her tracheostomy on the afternoon of 05/25/25. The DON stated she contacted the housekeeping department to clean Resident #60's room, and she notified the Administrator. The Administrator and DON both confirmed they were not notified of the concerns about the ants found on Resident #60's by the facility staff when they were observed on 05/25/25 at 2:00 A.M. and were only notified of the concerns for ants by Resident #60's husband. The DON stated the facility staff provided personal care to Resident #60, changed her bed linens, and wiped down Resident #60's bed when the ants were observed on 05/25/25 at 2:00 A.M. The Administrator stated the facility received monthly pest control treatments and Resident #60's room was spot treated by the pest control company on 05/29/25. The Administrator stated she reviewed a video made by Resident #60's father which showed ants crawling around Resident #60's tracheostomy. The Administrator stated she completed an SRI after the hospital called on 05/29/25 related to neglect due to the ants found on Resident #60 per the family's video. Review of the medical record for Resident #19 revealed an admission date of 04/01/25. Diagnoses included atrial fibrillation and Parkinson's disease. Review of the admission MDS assessment for Resident #19 dated 04/08/25, revealed the resident had a Brief Interview for Mental Status (BIMS) of 12 out of 15, indicating the resident was cognitively intact. Interview on 06/16/25 at 11:25 A.M. with Resident #19, revealed there were gnats in her room at times. Observations of the facility on 06/16/25 and 06/17/25, revealed gnats to be flying around the facility and several noted on 300- Hall which is the ventilator unit. Interview on 06/17/25 at 9:25 A.M. with Licensed Practical Nurse (LPN) #201, revealed she sees a lot of gnats in the facility. Interview on 06/17/25 at 10:03 A.M. with Housekeeper #207, revealed she sees ants and gnats in the facility at times. Review of a video provided by the facility, which was not dated and time stamped, revealed Resident #60 lying in bed and two ants were noted to be crawling on Resident #60. One ant was observed to be crawling inside of Resident #60's trach mask and the other ant crawling on her trach ties. Review of the pest control company invoices, revealed documentation the facility received pest control treatments to the interior and exterior of the facility monthly and on 05/29/25. Review of the facility policy titled, Pest control, revised 08/12/18, stated if a pest situation was reported, the contractor would be notified and may be requested to make an unscheduled visit to address concerns. This deficiency represents non-compliance investigated under Complaint Number OH00166147.

Based on observation, staff interview, and record review, the facility failed to ensure the steam table was maintained in a clean and sanitary manner. This had the potential to affect 57 of 63 residents in the facility. The facility identified six residents (#167, #54, #62, #48, #49, and #43) who did not receive food from the kitchen. The facility census was 63. Findings include: Observation on 04/30/25 at 10:26 A.M. revealed the water wells of the steam table in the kitchen contained a yellowish-brown liquid with debris floating at the top and brown sediment around the bottom and edges of each well. Interview at the same time, [NAME] #735 verified the water wells of the steam table contained a yellowish-brown liquid and there was debris floating at the top of the liquid and brown sediment around the bottom and edges of each well. [NAME] #735 described the liquid as grimey and attributed the color to grease falling into the well when taking pans in and out of the steam table. [NAME] #735 stated she planned on cleaning the steam table wells the following day (05/01/25) and stated the steam table was cleaned weekly. Observations on 04/30/25 between 11:04 A.M. and 11:30 A.M. revealed [NAME] #735 serving food from the steam table for the lunch meal. Interview on 04/30/25 at 11:43 A.M., Dietary Manager (DM) #38 verified the steam table wells were in need of cleaning. DM #38 stated the last time the steam table wells were drained was 04/24/25 and stated the wells were drained and cleaned on a weekly basis. Interview on 05/01/25 at 12:12 P.M., Senior Registered Dietitian (SRD) #08 stated the expectation is for the steam table wells to be drained and cleaned daily and deep cleaned weekly. Review of the manual for the steam table, as provided by the facility, dated 10/27/08, revealed maintenance of the steam table included daily cleaning, consisting of draining or removing water from the well, utilizing a soft cloth or sponge with a mild detergent to clean the entire warmer assembly. Rinse completely with warm water and then dry. Utilize a plastic scouring pad and mild detergent to remove hardened food. Review of the [NAME] Daily Task schedule revealed the steam table was to be drained and cleaned at 6:45 P.M. daily.

Based on observation, staff interview, and record review, the facility failed to ensure portion sizes were served as planned. This had the potential to affect 57 of 63 residents in the facility. The facility identified six residents (#167, #54, #62, #48, #49, and #43) who did not receive food from the kitchen. The facility census was 63. Findings include: Review of the dietary spreadsheet for the lunch meal on 04/30/25 revealed the serving size for the rice was 1/2 cup, sliced carrots was 1/2 cup, and ground chicken was 3 ounces. Observation on 04/30/25 at 11:04 A.M. revealed [NAME] #735 making plates for the lunch meal. [NAME] #735 utilized a #12 scoop (1/3 cup) for the sliced carrots, a #20 scoop (1 5/8 ounces) for the ground chicken, and a #16 scoop (1/4 cup) for the rice. Observation on 04/30/25 at 11:12 A.M. revealed the first cart of trays was complete and left the kitchen to be delivered to the unit. Interview on 04/30/25 at 11:12 A.M., [NAME] #735 verified she was using a #12 scoop for the sliced carrots, a #20 scoop for the ground chicken, and a #16 scoop for the rice. [NAME] #735 continued on to plate food for the next cart of trays. [NAME] #735 stated she utilized the spreadsheets to determine the appropriate scoop size. Interview on 04/30/25 at 11:15 A.M., Dietary Manager (DM) #38 verified [NAME] #735 was utilizing the wrong size scoop for the sliced carrots, ground chicken, and rice.

Based on the review of Resident Council meeting minutes, resident interview, and staff interviews, the facility failed to document and follow up on resident concerns from the resident council meetings. This affected 10 out of 10 members of Resident council who regularly attended the meetings and had the potential to affect all residents residing at the facility. The facility census is 63. Findings include: Review of Resident Council meetings minutes from August 2024 to March 2025 revealed the facility did not follow up on concerns brought forward at the Resident Council meetings. Review of the meeting minutes revealed the resolutions from the last meeting concerns were left blank. The meeting concerns that had not been addressed included more outings, a higher activities budget, loud music in other residents' rooms, a pop up facility store, bed linen changes, call lights, and snacks for residents including fresh fruit. Interview on 04/30/25 at 3:14 P.M. with Resident Council President #12 verified that the previous meeting concerns had not been addressed and stated that they do not know when and if the facility will make a resolution to the council's concerns. Interview on 04/30/25 at 4:32 P.M. with Staff Member #655 verified the facility has not followed up with her or the residents on the concerns brought forward in Resident Council meetings. Interview on 05/01/25 at 9:26 A.M. with Administrator #72 verified the resolution sheets were not filled out, therefore the Resident Council committee members have not been provided a resolution to their concerns. This deficiency represents non-compliance investigated under Complaint Number OH00163645.

Based on medical record review, resident interview, family interview, review of the facility's self-reported incident (SRI), staff interview, and policy review, the facility failed to ensure a thorough investigation was conducted on abuse and misappropriation allegations. This affected three (#38, #117, and #12) of three residents reviewed for abuse and misappropriation. The facility census was 63. Findings include: 1. Review of the medical record of Resident #38 revealed an admission date of 03/17/23. Diagnoses included unspecified intracranial injury with loss of consciousness, quadriplegia, depression, dysphagia, anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident required setup/clean-up assistance with eating and was dependent on staff for all other activities of daily living. 2. Review of the medical record of Resident #117 revealed an admission date of 04/22/22. The resident discharged to another facility 03/21/25. Diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, type 2 diabetes mellitus, essential hypertension, cerebral infarction, schizoaffective disorder, vascular dementia, drug induced subacute dyskinesia, and anxiety disorder. Review of the annual MDS assessment dated [DATE] revealed the resident had intact cognition. The resident exhibited physical and verbal behaviors during the assessment period. The behaviors were identified as putting others at significant risk for physical injury, significantly intruding on the privacy or activity of others, and significantly disrupting care or living environment. The resident was independent with mobility. Review of the facility self reported incident (SRI) dated 02/26/25 revealed Residents #117 and #38 were in the dining room joking around when Resident #38 said something to Resident #117 that Resident #117 did not like. Resident #38 said he was joking, however, Resident #117 went up to Resident #38 and hit him in the face. The residents were immediately separated. Resident #117 stated she was joking and did not mean to hit Resident #38 as hard as she did. Neither resident had any injury. Review of the investigation revealed there was no information regarding who else was present at the time of the incident. There was no evidence of witness statements being obtained from staff or other residents, nor was there any evidence of other residents being assessed for any injury or psychosocial impact. Interview on 04/28/25 at 10:46 A.M., Resident #38 had no recollection of the event involving Resident #117 hitting him in the face. Interview on 05/01/25 at 11:40 A.M., the Administrator verified the investigation did not contain any information on who else was present at the time of the altercation, information about any events leading up to the altercation, witness statements regarding the altercation, nor assessment of other residents. The Administrator stated there were a lot of other residents present at the time of the altercation and stated she talked with the other residents but did not document these conversations. The Administrator stated she was unsure of if staff were present. The Administrator stated she did not do any further investigation on the incident as she felt the altercation was cut and dry, Review of the facility policy titled, Ohio Resident Abuse Policy, dated 07/11/24, revealed, as part of the investigation, residents, the accused, and all witnesses would be interviewed and written statements obtained. Witnesses include anyone who witnessed or heard the incident, came in close contact with the residents on the day of the incident (including residents, family members), and employees who worked closely with the victim the day of the incident. If there are no direct witnesses, then the interviews should be expanded to cover all employees on the unit or shift. 3. Review of the medical record for Resident #12 revealed the resident admitted to the facility on [DATE], diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus with hyperglycemia, hypertension, peripheral vascular disease, anemia, major depressive disorder, neuropathy, acquired absence of left leg above the knee, and generalized anxiety disorder. Review of the most recent MDS assessment for Resident #12 dated 03/25/25 revealed the resident was cognitively intact. During an interview with Resident #12 on 04/29/25 at 08:55 A.M., it was disclosed the resident had an iPad mini stolen from her room in February 2025, the incident was reported to the facility Administrator. Resident #12 stated she was offered $200.00 if she could provide proof of purchase from either the original receipt or a replacement receipt. Resident #12 reported being dissatisfied with the lack of investigation including the lack of a police report, for which she requested, and the financial reimbursement offer. Resident #12 reported she received the iPad mini for Christmas, a gift from her daughter, and at this time Resident #12 was unable to go out and purchase a replacement without receiving reimbursement in advance. Resident #12 further reported she was recently told by a night aide, there were two new aides working the night the iPad mini went missing and neither of them have returned to work since that night. Resident #12 did not disclose the name of the aide who shared the information. Interview on 04/29/25 at 2:45 P.M. with the Administrator revealed Resident #12 initially reported the iPad missing, then stolen and changed her story several times. Resident #12 never made it known to the facility she had an iPad, and while conducting staff interviews, no one could confirm or recall seeing Resident #12 with an iPad. Interview, via phone, on 05/01/25 at 12:27 P.M., with Resident #12's daughter confirmed she purchased a rose colored iPad mini from a cousin for $300.00 and gifted it to Resident #12 at Christmas. The daughter of Resident #12 verbalized how displeased she was the facilities investigation, claiming she had inquired if anything was seen on the facility cameras and was not provided a follow up from the facility. Further record review of the facility incident report revealed the theft occurred on 02/09/25 at 03:00 A.M. Documentation of investigation revealed Resident #12 reported she was sleeping when the iPad went missing. Staff were interviewed but the investigation report lacked any details of the dates or time of interview and the line of questioning. Review of an electronic message sent to Resident #12 by the Administrator dated 03/05/25 and timed 3:08 P.M., revealed the Administrator met with Resident #12 and let the resident know the facility would provide reimbursement around $200.00 for the iPad mini that went missing however a receipt would have to be provided for the reimbursement and that the reimbursement could take up to three months. The communication read that Resident #12 stated she understood. Follow up interview with the Administrator on 05/01/25 at 09:30 A.M., the Administrator verified the facility did not file a police report and the documentation of the incident investigation was lacking pertinent details. The Administrator verbalized she needs to document everything related to the investigation process with date and time stamps including conversations, and interviews. Review of the Ohio Resident Abuse Policy revealed the facility will contact the police for any allegation of misappropriation of resident property. Review of the Crime Reporting Policy reveals the facility is required to report any reasonable suspicion of a crime against any individual who is a resident or receiving care from the facility.

Based on medical record review, observations, staff interviews and policy review. The facility failed to provide nail care for one (#167) dependent resident of two sampled for activities of daily living. The facility census was 63. Findings include: Review of Resident #167's medical record revealed an admission date of 03/13/25. Diagnoses included respiratory failure with ventilator dependence, diabetes, and anxiety. Resident #167 required nutrition through a gastrostomy tube. The most recent Minimum Date Set (MDS ) dated 03/18/25 revealed the resident was totally dependent on staff for all care. Review of the residents activities of daily living plan of care dated 03/18/25 noted the resident is to get nail care weekly with his bath. During an observation of wound care on 04/30/25 at 9:30 A.M., Resident #167 was observed to have long fingernails that were growing downward into his finger tips. Interview with Licensed Practical Nurse (LPN #48 ) 04/30/25 at 9:35 A.M. verified the residents nails were too long. LPN #48 stated they would be taken care of. Review of the facility policy titled Morning Care/AM Care dated 01/11 stated the facility was to provide nail care daily. This deficiency represents non-compliance investigated under Complaint Number OH00163057.

Based on medical record review, hospital record review, staff interview, and policy review, the facility failed to ensure falls were thoroughly and timely investigated. This affected two (#46 and #66) of four residents reviewed for falls. The facility census was 63. Findings include: 1. Review of the medical record of Resident #46 revealed an admission date of 11/01/24. The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included chronic diastolic (congestive) heart failure, vascular dementia, left femur fracture, and age-related osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. Resident #46 was dependent on staff for transfers and toileting and required substantial/maximal assistance with bed mobility. Review of the Fall Risk Assessments dated 11/01/24 and 02/21/25 revealed Resident #46 was a high fall risk. Review of the care plan dated 04/28/25 revealed Resident #46 was at risk for falls related to cognitive deficit, muscle weakness, difficulty walking, pain, anxiety, and non-compliance with using call light for assistance. Interventions included a reacher, non-skid footwear when out of bed, keep familiar objects/commonly used items within reach, and keep bed in lowest position with brakes locked while the resident is in bed. Review of a progress note dated 02/09/25 revealed Licensed Practical Nurse (LPN) #85 was passing medications when she heard a resident call for help. The nurse immediately responded to the call and found Resident #46 lying on the floor on her side. When asked what happened, Resident #46 stated she was trying to get into her chair and further stated she knew she could not do it but tried anyway. The nurse and another staff member attempted to assist Resident #46 back to bed and Resident #46 began to scream in pain, stating she thought she had broken her hip and wanted to be sent to the hospital. The physician, Director of Nursing (DON) and family were notified and the resident was sent to the hospital for evaluation. Review of the hospital History and Physical (H&P) dated 02/09/25, revealed Resident #46 admitted to the hospital with a displaced intertrochanteric fracture of the left femur and a mechanical fall. Further review of the medical record revealed no evidence of a post-fall evaluation being completed for Resident #46's fall on 02/09/25. Review of the facility's fall investigation revealed a statement was obtained from LPN #85, which contained the same information as the progress note dated 02/09/25 and the resident had last been seen 25 minutes prior when LPN #85 gave Resident #46 her medications. The investigation also contained the hospital H&P and LPN #85's progress note, dated 02/09/25. There was no additional information regarding the fall, including interventions in place at the time of the fall and the events leading up to the fall. Interview on 04/30/25 at 2:40 P.M., the DON stated she did not have any additional information regarding the fall investigation for Resident #46. The DON confirmed there was not a thorough investigation completed following Resident #46's fall. The DON stated the immediate intervention was to send Resident #46 to the hospital and was found to have a hip fracture. The DON stated, when Resident #46 returned from the hospital, all previous interventions were resumed, no additional interventions were implemented, with the exception of educating Resident #46, which was not documented. The DON further confirmed Resident #46 had moderately impaired cognition would not likely be able to recall education provided. 2. Review of the medical record of Resident #46 revealed an admission date of 11/01/24. The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included chronic diastolic (congestive) heart failure, vascular dementia, left femur fracture, and age-related osteoporosis. Review of the quarterly MDS assessment dated [DATE] revealed Resident #66 had intact cognition. The resident was independent for eating, setup or cleanup for oral hygiene, supervision for showering and bathing, supervision for dressing, and setup for personal hygiene. The resident was occasionally incontinent of urinary & frequently incontinent of bowels. Review of the Fall Risk Assessments dated 1/22/25 revealed Resident #66 was moderate fall risk. Review of a progress note dated 02/10/25 revealed on 02/07/25 Resident #66 was sent to the hospital. A bed hold letter was provided once the immediate transfer was initiated. Review of event incident report dated on 02/07/25 revealed there was a unwitnessed fall and the investigation was not closed until 03/25/25. Review of the hospital Discharge summary dated [DATE], revealed Resident #66 was transferred to the hospital for a mechanical fall from his bed sustaining a facial injury, laceration to the left scalp, right arm and knee. Resident #66 was then admitted to the hospital for syncope versus fall with a scalp laceration and left knee abrasion. Resident #66 passed away on 02/07/25. Further review of the medical record revealed no evidence of a fall documented in the progress notes. Review of the facility's fall investigation revealed a statement was obtained from LPN #2005, which contained information that an unwitnessed fall occurred, and the resident was alert and oriented at the time staff responded. There was no additional information regarding the fall, including interventions in place at the time of the fall and the events leading up to the fall. Interview on 04/30/25 at 10:49 A.M. with Certified Nursing Assistant (CNA) #90., the CNA stated Resident #66 he was sitting on the edge of bed eating breakfast when she last saw him. The staff heard a cry of help and responded, in less than a minute, to find Resident #66 on the floor. CNA #90 stated that the same thing as what was contained in the witness statement, that Resident 66 was alert and talking to staff members. Interview on 04/30/25 at 11:10 A.M. with the DON, the DON stated she did not have any additional information regarding the fall investigation for Resident #66. The DON confirmed there was not a thorough investigation completed following Resident #66's fall. The DON stated the immediate intervention was to send Resident #66 to the hospital. The DON stated they do not have a timeline for when a fall investigation needs to be completed and can have as much time as they need to complete the investigation. Review of the facility policy titled, Fall Prevention and Management, dated 08/06/24, revealed all falls would be reviewed and investigated by an interdisciplinary team and any new interventions would be implemented, and the care plan updated as necessary. Such review should include the results of the new 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 further falls.

Based on medical record review, observation, staff interview and review of facility policy, the facility failed to ensure residents are observed taking medications and medications were not left with residents. This affected one (#31) of 21 residents observed in the sample. The census was 63. Findings include: 1. Review of Resident #31's medical record revealed an admission date of 02/03/20. Diagnoses listed included encephalopathy, malnutrition, psychotic disorder with hallucinations, major depression, and insomnia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had moderately impaired cognition. Observation on 05/01/25 at 9:40 A.M. revealed Resident #31 was in bed holding a medication cup that contained three pills. Resident #31's eyes were closed. Resident #31 could not be verbally aroused. During an interview on 05/01/25 at 9:43 A.M. Licensed Practical Nurse (LPN) #220 confirmed he had not observed Resident #31 consume the medications. LPN #220 identified the medications as two 2.5 milligram (mg) tablets of Olanzapine (antipsychotic) and one 10 mg tablet of Baclofen (muscle relaxant). LPN #220 verified residents should be observed taking medications. Further review of Resident #31's medical record revealed an order dated 04/24/25 for Olanzapine 5 mg twice day and an order dated 08/10/23 for 10 mg of Baclofen twice a day. Review of the facility policy titled, General Dose Preparation and Medication Administration dated revised 11/15/24 revealed staff should observe the resident's consumption of the medication(s) when administering medications.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure enhanced barrier precautions (EBP) were followed and also failed to ensure staff sanitized hands after providing care to a resident and delivering meal trays. This affected three Residents (#19, #54, and #55) observed during dining. The census was 63. Findings include: Review of Resident #54's medical record revealed an admission date of 09/30/24. Diagnoses listed included traumatic brain injury, anxiety, brain cancer, and obstructive sleep apnea. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #54 was severely cognitively impaired and had a feeding tube. Review of physician orders revealed an order dated 02/24/25 for Isolation/Transmission-Based Precautions: Enhanced Barrier Precautions (EBP). Observation on 04/29/25 at 7:42 A.M. revealed Certified Nurse Aide (CNA) #160 and CNA #760 repositioning Resident #54 in bed. Neither CNA #160 or CNA #760 were wearing gloves or gowns. CNA #160 then exited Resident #54's room and delivered a meal tray from a cart to Resident #55 who was across the hall from Resident #54. CNA #160 did not sanitize hands before exiting Resident #54's room or before obtaining Resident #55's meal tray. CNA #760 also exited Resident #54's room and delivered a meal tray from a cart to Resident #19 who was across the hall from Resident #54. CNA #760 did not sanitize hands before exiting Resident #54's room or before obtaining Resident #19's meal tray. During interviews on 04/29/25 at 7:46 A.M. CNA #160 and CNA #760 confirmed that they had not wore a gown or gloves when repositioning Resident #54. CNA #160 and CNA #760 also confirmed Resident #54 was on EBP and they had not sanitized their hands before exiting Resident #54's room and before delivering meal trays to Resident #19 and Resident #55. The Administrator was present during the interviews and confirmed the observations. Review of the facility's policy titled, Transmission-Based Precautions and Isolation Policy dated last revised 03/20/25 revealed EBP are intended to prevent transmission of multi-drug resistant organisms (MDROs) via contaminated hands and clothing of healthcare workers to high risk residents. EBP are indicated for high contact care activities for residents with chronic wounds and indwelling devices (such as central lines, urinary catheters, and tracheostomies) and for all those colonized or infected with a MDRO currently targeted by the Centers of Disease Control and Prevention (CDC). Other MDROs may be included at the discretion of the facility Infection Control Committee unless required by state guidance. Review of the facility's policy titled, Serving Meals dated revised December 2016 revealed staff would wash hands before delivering meals.

Based on review of the medical record, staff interviews, and policy review, the facility failed to adequately monitor weights and implement appropriate interventions in a timely manner. This affected one Resident (#64) of the three resident reviewed for significant weight changes. The facility census was 60. Findings include: Review of the closed medical record for Resident #64 revealed an admitted [DATE] with a discharge date of [DATE]. Diagnoses included epilepsy, major depressive disorder, anxiety disorder, and cerebral infarction. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #64 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 13. This resident was assessed to require setup with eating, dependent with toileting, substantial assistance with bathing and dressing, and partial assistance with transfers. Review of the care plan dated 01/14/25, revealed Resident #64 had increased nutrition/hydration risk related to seizures, cerebral infarction, and weight gain for three months. Interventions included monitor laboratory (lab) values per order, review preferences per routine and as needed (PRN), respect dietary choices, monitor weight per protocol, and monitor dietary intake. Review of the weight records for Resident #64 revealed the following dates and weights: a) On 06/07/24 a weight of 193.4 pounds (lbs.) was recorded. b) on 07/09/24 the resident was 193 lbs. c) On 08/06/24 the resident was 215.8 lbs. d) On 09/04/24 the resident was 242.4 lbs. e) On 10/21/24 the resident was 265.8 lbs. f) On 11/04/24 the resident was 267.4 lbs. g) On 12/2024, there was no weight recorded h) On 01/01/25 the resident was 283.6 lbs. Review of a progress note dated 09/11/24 at 5:09 P.M., revealed Resident #64 had a significant weight gain of 12.3 percent (%), which was 26.6 lbs. in one month, and 25.3 %, which was 49 lbs. in three months. Registered Dietician (RD) #50 requested a re-weight to ensure accuracy of the weight gain. Resident #64 consumed 76-100 % of meals and supplements. RD #50 discontinued ProStat (dietary supplement) due to no longer needed as wound had healed. Interview on 02/19/25 with RD #50 revealed on 09/11/24 she requested a re-weight on Resident #64. RD #50 verified she did not follow up the following week to ensure a re-weight was completed. RD #50 verified Resident #64 was not weighed again until 10/21/24, where she had a 23.4 lbs. increase. RD #50 stated she discontinued Resident #64's ProStat as it was no longer needed. RD #50 reported she had not requested weekly weights on Resident #64 to monitor weight gain more frequently. RD #50 revealed she spoke with Resident #64 regarding weight gain but could not provide documentation of the encounter. Review of the facility policy titled, Resident Weight Policy, dared 12/12/23 revealed weights would be obtained routinely in order to monitor nutritional health over time. Each resident's weight would be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk was identified, or as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00161977.

Based on review of the medical record and staff interviews, the facility failed to ensure medications were available and administered per physician orders. This affected one Resident (#65) of the three residents reviewed for medication administration. The facility census was 60. Findings include: Review of the medical record for Resident #65 revealed an admitted [DATE] with a discharge date of [DATE]. Diagnoses included congestive heart failure (CHF), cerebral infarction, and chronic obstructive pulmonary disease (COPD). Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #65 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require setup with eating, dependent with toileting and transfers, and substantial assistance with bathing and dressing. Review of the physician order dated 01/13/25, revealed Resident #65 was ordered Anbesol liquid (pain relief) 10 percent (%) to rinse mouth and spit out for thrush twice a day. Review of the medication administration record (MAR) dated January 2025, revealed Resident #65 did not receive Anbesol 10 % mouth wash from 01/13/25 through 01/20/25 due to unavailability. Interview on 02/19/25 at 11:14 A.M. with Pharmacy Representative #70, revealed the facility was responsible for obtaining the medication because it was considered an over the counter (OTC) prescription. Interview on 02/19/25 at 11:23 A.M. with Pharmacy Representative #71, revealed the facility was notified on 01/13/25 that Anbesol was on backorder and a substitution Nystatin could be ordered in replace of, which was reported to Licensed Practical Nurse (LPN) #22. Interview on 02/19/25 at 11:26 A.M. with Director of Nursing (DON), verified Resident #65 did not receive Anbesol mouth wash from 01/13/25 through 01/20/25. Interview on 02/19/25 at 11:40 A.M. with Nurse Practitioner (NP) #60, revealed she was never informed of Resident #65 medication's being on backorder. This deficiency represents non-compliance investigated under Complaint Number OH00162025.

Based on record review, observation, staff interview and review of manufacturer instructions, the facility failed to ensure staff primed an insulin pen prior to insulin administration resulting in a significant medication error. This affected one (#22) of six residents observed for medication administration. Facility census was 58. Findings include: Review of medical record for Resident #22 revealed admitted [DATE]. Diagnoses include diabetes mellitus type two, hypertension and peripheral vascular disease. Review of the physician orders for Resident #22 revealed an order to administer seven units of insulin Lispro subcutaneously with meals and a start date of 11/02/23. Observation on 03/05/24 at 12:18 P.M. of Registered Nurse (RN) #101 of medication administration for Resident #22 revealed she retrieved an insulin Lispro (fast acting) pen from the medicine cart, she removed the cap and cleansed the hub of the pen with an alcohol swab, she attached the needle and turned the dial if the pen to 7. The medication was given subcutaneously, along with her oral medication. RN #101 did not prime the insulin pen prior to administer Resident #22's insulin. Interview at 03/04/24 at 12:21 P.M. with RN #101 acknowledged she did not prime Resident #22's Lispro insulin needle prior to administration. Review of the manufactures instructions for insulin Lispro required the needle to be primed (removing the air from the needle) if this procedure was not done, too little or too much insulin could be administered. This deficiency represents non-compliance investigated under Complaint Number OH00151217.

Based on record reviews, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) manual, the facility failed to ensure residents comprehensive Minimum Data Set (MDS) assessments were completed timely. This affected four (#10, #16, #110, and #118) out of the four residents reviewed for comprehensive MDS assessments. The facility census was 66. Findings include: 1. Review of the medical record for Resident #10 revealed an admitted [DATE] with medical diagnoses of convulsions cerebral infarction, and psychotic disorder. Review of the medical record for Resident #10 revealed an admission MDS with assessment reference date (ARD) of 05/21/23 revealed the MDS had a completion date of 06/23/23. 2. Review of the medical record for Resident #16 revealed an admitted [DATE] with medical diagnoses of atherosclerosis heart disease (ASHD), visual loss both eyes, and chronic kidney disease (CKD) stage III. Review of the medical record for Resident #16 revealed an annual MDS with ARD of 06/26/23 revealed the MDS had a completion date of 07/15/23. 3. Review of the medical record for Resident #110 revealed an admitted [DATE] with medical diagnoses with chronic respiratory failure, cardiomyopathy, cerebral palsy, and paraplegia. Review of the medical record for Resident #110 revealed an annual MDS with ARD 05/08/23 revealed the MDS had a completion date of 06/11/23. 4. Review of the medical record for Resident #118 revealed an admitted [DATE] with medical diagnoses of orthostatic hypotension, chronic obstructive pulmonary disease (COPD), and diabetes mellitus. Review of the medical record for Resident #118 revealed an admission MDS with ARD 05/18/23 revealed the MDS had a completion date of 07/04/23. Interview on 08/22/23 at 9:15 A.M. with MDS Nurse #67 stated the facility utilizes the RAI manual guidelines as the facility's policy for MDS assessments and completion dates. MDS Nurse #67 confirmed the admission MDS assessments for Resident's #10 and #118 and the annual MDS assessments for Residents #10 and #16 were not completed timely. Review of the Chapter Two of the RAI manual (page 2-20 and 2-21) revealed comprehensive assessments included admission, annual, significant change in health status and significant correction assessments. The RAI manual stated the admission MDS assessment completion date must be no later than day 14 of the residents stay. The RAI manual revealed an annual MDS assessment must be completed no later than 14 days after the ARD. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record reviews, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) manual, the facility failed to ensure residents quarterly Minimum Data Set (MDS) assessments were completed timely. This affected five (#8, #18, #78, #108, and #124) residents out of the six residents reviewed for quarterly MDS assessments. The facility census was 66. Findings include: 1. Review of the medical record for Resident #8 revealed an admitted [DATE] with medical diagnoses of congestive heart failure (CHF), atrial fibrillation, anxiety, and obesity. Review of the medical record revealed a quarterly MDS assessment with Assessment Reference Date (ARD) of 05/20/23 revealed the MDS had a completion date of 07/09/23. 2. Review of the medical record for Resident #18 revealed an admitted [DATE] with medical diagnoses of end stage renal disease (ESRD), dementia, CHF, and anemia. Review of the medical record for Resident #18 revealed a quarterly MDS assessment with ARD of 07/17/23 revealed the MDS had a completion date of 08/04/23. 3. Review of the medical record for Resident #78 revealed an admitted [DATE] with medical diagnoses of diabetes mellitus (DM), CHF, cerebral infarction, and vascular dementia with behaviors. Review of the medical record for Resident #78 revealed a quarterly MDS assessment with ARD 07/06/23 revealed the MDS had a completion date of 07/24/23. 4. Review of the medical record for Resident #108 revealed an admitted [DATE] with medical diagnoses of chronic obstructive pulmonary disease (COPD), hypertension (HTN), dependence on ventilator, and tracheostomy. Review of the medical record for Resident #108 revealed a quarterly MDS assessment with ARD of 06/07/23 revealed the MDS had a completion date of 07/17/23. 5. Review of the medical record for Resident #124 revealed an admitted [DATE] with medical diagnoses of COPD, HTN, DM, ESRD, dependence on dialysis. Review of the medical record for Resident #124 revealed a quarterly MDS assessment with ARD 06/19/23 revealed the MDS had a completion date of 07/19/23. Interview on 08/22/23 at 9:15 A.M. with MDS Nurse #67 stated the facility utilizes the RAI manual guidelines as the facility's policy for MDS assessments and completion dates. MDS Nurse #67 confirmed the quarterly MDS assessments for Resident's #8, #18, #78, #108, and #124 were not completed timely. Review of Chapter Two of the RAI manual (page 2-33) revealed quarterly MDS completion dates must be no later than 14 days after the ARD (ARD + 14 calendar days). This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on closed record review, review of manufacturer's recommendations, staff and representative interview, the facility failed to ensure the battery was changed on an external defibrillator vest as ordered. This affected one (#100) of one resident reviewed for external defibrillator care. The facility census was 61. Findings included: Review of the closed medical record revealed Resident #100 was admitted to the facility on [DATE] and discharged on [DATE]. Resident #100 diagnoses included hyperlipidemia, peripheral vascular disease, type II diabetes with circulatory complications, chronic systolic (congestive) heart failure, hypothyroidism, end stage renal disease, bariatric surgery status, chronic venous hypertension (idiopathic) with ulcer and inflammation of the left lower extremity, cardiac arrest, generalized anxiety disorder, major depressive disorder, moderate protein-calorie malnutrition, atherosclerotic heart disease of the native coronary artery, gastro-esophageal reflux disease, anemia in chronic kidney disease, dysphagia, metabolic encephalopathy, acquired arteriovenous fistula, presence of a heart assistive device, and ischemic cardiomyopathy. Review of Resident #100's Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating she had moderate cognitive impairment. Resident #100 needed extensive assist of one staff for bed mobility, dressing, and personal hygiene. Resident #100 required extensive assist of two staff for transfer; did not walk; was totally dependent on one staff for locomotion, toilet use, and bathing; and was independent with setup help needed for eating. Review of the physician's orders revealed Resident #100 had an order dated 05/31/23 to change life vest battery every night shift. One battery was to be on charge at all times. Review of the Resident #100's Medication Administration Record (MAR) for June 2023 revealed the entry for changing the battery every night shift on 06/07/23 at 7:00 P.M., was coded 19 which meant other/see nurses notes. The note revealed she went out to the hospital for a fall on 06/07/23 at 7:12 P.M. Further review of the nursing notes revealed she returned on night shift at approximately 3:00 A.M. The record was silent regarding the battery being changed on that shift. Interview via telephone call was received from [NAME] Life Vest Representative #83, company technical support, on 08/02/23 at 3:21 P.M., revealed the information recorded by the company regarding Resident #100's battery level and when the battery was changed. [NAME] Life Vest Representative #83 stated the battery was changed on 06/06/23 at 8:23 P.M. (the battery read fully charged). The battery was not changed on 06/07/23 at 8:00 P.M., and showed the battery was completely depleted on 06/08/23 at 6:15 A.M. The report showed the battery was completely depleted until 06/08/23 at 1:44 P.M. [NAME] Life Vest Representative #83 said it may have enough charge to alarm but did not have enough charge to deliver a lifesaving shock leaving Resident #100 unprotected during that time. [NAME] Life Vest Representative #83 stated the batteries only held a charge for 24 hours. [NAME] Life Vest Representative #83 shared that tech support was available 24 hours each day if there were questions. Interview on 08/02/23 at 3:03 P.M., with the Director of Nurse (DON) stated Resident #100 went out to the hospital at the beginning of night shift 7:13 P.M. on 06/07/23 and returned approximately 3:00 A.M. on 06/08/23. The DON verified the Medication Administration Record (MAR) indicated see nursing note for the night shift battery change on 06/07/23. The other times were documented as being completed Review of the manufacturer's information pamphlet for the [NAME] Life Vest, dated 2003, revealed that every 24 hours, you need to change and recharge the batteries. This deficiency demonstrates non-compliance regarding Complaint Number OH00144523.

Based on record review, observation, interviews, and review of facility policy, the facility failed to perform appropriate infection control techniques during wound care. This affected one resident (#03) out of three residents reviewed for infection control. The facility census was 55. Findings Include: Review of medical record for Resident #03 revealed an admitted [DATE]. Diagnoses included tracheostomy, chronic pulmonary disease, and type two diabetes. Review of Minimum Data Set (MDS) assessment dated [DATE] for Resident #03, revealed the resident was severely cognitively impaired. Resident #03 required total dependence for activities of daily living (ADLs). Review of plan of care dated 06/19/23 for Resident #03, revealed the resident was at risk for skin impairment and had Pressure ulcers to left and right buttocks. Interventions included administer medications and treatments as ordered, assess and document per protocol, skin checks, Braden scale, and resident would be followed by wound physician. Review of the current physician orders dated 06/08/23 for Resident #03, revealed the resident was ordered to have left gluteal cleansed, a barrier cream with zinc applied every shift and as needed and no briefs until healed. Orders also revealed Resident #03 was ordered to have the right buttocks cleansed with normal saline, dried, calcium alginate (wound cream) applied and covered with abdominal, or foam dressing daily and as needed. Observation of wound care for Resident #03 on 07/11/23 from 1:24 P.M. with Registered Nurse (RN) #110 and State tested Nursing Assistant (STNA) #120, revealed RN #110 washed her hands and applied gloves before starting wound care. RN #110 sprayed wound cleaner on a four-by-four (4x4) gauze and cleaned the residents right buttocks. RN #110 changed her gloves, then completed the same procedure for the resident's left buttocks. RN #110 changed her gloves and applied calcium alginate in right buttocks and barrier cream with zinc to the left buttocks and applied an overlap dressing to cover the areas. RN #100 did not complete any hand hygiene while going from a dirty to a clean procedure. Interview on 07/11/23 at 1:55 P.M. with RN #110 verified she did not complete any hand hygiene before going from a dirty to clean procedure. Interview on 07/11/23 at 2:40 P.M. with Director of Nursing (DON), revealed her expectations were for staff to complete the appropriate hand hygiene when going between a dirty and clean wound care procedure. Review of facility policy titled Hand Hygiene and Handwashing Policy dated 09/2011, revealed to perform hand hygiene before and after having direct contact with residents, after removing gloves, before handling an invasive device for resident care, after contact with body fluids or excretion, mucous membranes, non-intact skin, and wound dressings. If moving from a contaminated body site to a clean body site during resident care. Review of facility policy titled Infection Control dated 05/11/2023 revealed it was our policy to maintain an organized, effective facility-wide program designed to systematically prevent, identify, and control and reduce the risk of acquiring and transmitting infections among employers, volunteers, and contract healthcare workers; to conduct surveillance of communicable disease and infectious outbreaks, and employee heath. This deficiency represents non-compliance investigated under Complaint Number OH00143963.

Based on medical record review, staff and resident interview, and policy review, the facility failed to timely report an alleged misappropriation of resident funds to the Administrator and the state agency. This affected one resident (#26) out of one reviewed for misappropriation. The facility census was 47. Findings include Review of the medical record for the Resident #26 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact. Resident #26 required extensive assistance of two staff for mobility. Interview on 08/29/22 at 11:22 A.M., with Resident #26 and State tested Nursing Assistant (STNA) #36 revealed she had a missing $50 bill that had been in a bank envelope on her bed. Resident #26 requested STNA #36 to provide an update on the status of finding the missing money. Resident #26 said the night housekeeper who changed her linens, took the money. STNA #36 informed Resident #26 the housekeeping manager and the laundry staff were updated and keeping an eye out in case the money turned up in laundry. Interview on 08/30/22 at 2:01 P.M., with STNA #36 revealed she informed the Housekeeping Staff #48 of the missing money the morning of 08/29/22. The STNA #36 revealed she had not informed the Administrator or Director of Nursing (DON) of the potential for misappropriation of the residents' money. Interview on 08/30/22 at 4:35 P.M. with Housekeeper #48 revealed she was informed of the missing money and revealed she had not found the money in the laundry on 08/29/22 and revealed she had not reported to the Administrator or the Director of Nursing. Interview on 08/30/22 at 5:05 P.M. with the DON revealed she had been informed of the missing money on 08/30/22 and denied any staff informing her of the possible misappropriation on 08/29/22 when it was reported by Resident #26. The DON revealed the social worker had started an investigation and confirmed they were trying to get in touch with resident's sister to confirm she brought in the money as Resident #26 had reported. The DON revealed if the resident's sister in fact brought in the money a self-reported incident (SRI) would be initiated. The DON verified a SRI had not been initiated. Interview on 08/31/22 at 9:40 A.M., with Social Services #92 revealed she was informed by Resident #26 on 08/30/22 around 1:00 P.M. and informed the Administrator about an hour later of the missing money. Social Services #92 revealed the money had not been found as of 08/31/22. She revealed the resident's sister verified she had brought Resident #26 fifty dollars and Social Services #92 revealed the SRI was initiated 08/30/22 in the evening. A follow-up interview on 09/01/22 at 4:00 P.M., with the DON and the Regional Clinical Manager #98 acknowledged the missing money from Resident #26 was not reported by their direct care staff or housekeeping manager on 08/29/22. Review of the facility policy titled Ohio Resident Abuse Policy, dated 07/14/22 revealed it was the facilities policy to investigate all allegations, suspicions and incidents of misappropriation of resident property. The policy revealed facility staff are to immediately report all allegations to the Administrator/Abuse Coordinator and an investigation will begin to notify the applicable local and state agencies. The policy revealed initial reports should be reported immediately to the Administrator, the DON and the state agency.

Based on medical record review, staff interview, review of the Self-Reported Incident (SRI), review of the facility investigation, and policy review, the facility failed to thoroughly investigate an alleged resident to resident abuse. This affected two residents (#18 and #33) out of three residents reviewed for abuse. The facility census was 47. Findings include 1. Review of the medical record for the Resident #18 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had cognitive impairment. The resident was independent with mobility requiring supervision and cueing due to cognition. Review of the progress note dated 08/17/22 revealed Resident #18 had a physical altercation on 08/16/22 with another resident where he struck her hand. 2. Review of the medical record for the Resident #33 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] revealed Resident #33 had cognitive impairment and required extensive assistance of one to two staff for mobility. Review of the progress note dated 08/17/22 revealed Resident #33 had a physical altercation with another resident on 08/16/22 where her hand was struck. Review of the Self-reported incident number 3 dated 08/17/22 revealed a physical altercation between Resident #18 and #33 occurred the previous day (08/16/22) when Resident #18 stuck Resident #33's hand. Staff responded immediately and separated the two residents and completed head to toe checks on both residents with no negative findings. The SRI investigation reported staff interviews were completed however, were not included in the investigation. No progress notes were written in either resident record detailing the incident or follow up steps and included only a head to toe assessment that flowed into a progress note until Social Services spoke with both residents the next day. Interview on 09/01/22 at 10:00 A.M. with the Director of Nursing (DON) and the Regional Clinical Director #98 revealed on 08/16/22 State tested Nursing Assistant (STNA) #12 reported to the DON that Resident #33 reported to her while the smokers were being directed into the building from the courtyard. Resident #18 took his hand and tapped Resident #33 on the hand to direct her to come into the building. The DON revealed all contact between residents are investigated and an SRI was submitted. At this time staff interview documentation was requested. Review of the staff interview dated 09/01/22 revealed only one staff was interviewed regarding the incident. A follow-up interview on 09/01/22 at 4:00 P.M., with the DON and Regional Clinical Director #98 acknowledged the facility did not have staff interviews as part of the investigation packet provided. Review of facility policy titled Ohio Resident Abuse Policy, dated 07/14/22, revealed the facility failed to implement the policy regarding the allegation. The policy revealed it was the facilities policy to investigate all allegations, suspicions and incidents of misappropriation of resident property. The policy revealed facility staff are to immediately report all allegations to the Administrator/Abuse Coordinator and an investigation will begin to notify the applicable local and state agencies. The investigation should be initiated and be finalized within five working days from the alleged occurrence. The investigation should include interviews of all involved residents and all witnesses including employees who had worked closely with the reported victim or perpetrator. If no direct witnesses than interviews should be expanded to all residents and all employees on the unit. Facility should obtain written statements from all witness of residents and staff and document evidence of the steps of investigation.

Based on medical record review, interview, and policy review, the facility failed to provide a written discharge notice to a resident and resident representative timely. This affected one resident (#38) of one reviewed for discharge. The facility census was 47. Findings include Review of the medical record for the Resident #38 revealed an admitted [DATE] and was hospitalized on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was not assessed for cognition. Review of the progress note dated 08/08/22 revealed Resident #38 had respirations of 54. The physician was contacted and decision made to transfer out to the hospital. Review of the progress note dated 08/31/22 revealed the social services #92 contacted Resident #38's representative via the telephone and did not want anything sent to her and wants her father to return when his hospital stay was completed. Interview on 08/31/22 at 10:18 A.M. with Social Services #92 revealed the facility had no evidence of the discharge notice being provided to the resident's family. Social Services #92 acknowledged the progress note written on 08/31/22 regarding discussion of the discharge notice. Review of facility policy titled Resident Discharge and Transfer Letter Policy, dated 10/05/17, revealed the letter would be given to resident and if applicable to the resident representative. The letter would be uploaded to the electronic medical record along with certified receipt.

Based on medical record review, interview, and policy review, the facility failed to ensure a bed hold notice was timely provided to a resident and resident representative upon discharge to the hospital. This affected one resident (#38) of one reviewed for discharge. The facility census was 47. Findings include Review of the medical record for the Resident #38 revealed an admitted [DATE] and was hospitalized on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was not assessed for cognition. Review of the progress note dated 08/08/22 revealed Resident #38 had respirations of 54. The physician was contacted and decision made to transfer out to the hospital. Review of the progress note dated 08/31/22 revealed the Social Services #92 contacted resident representative by the phone and did not want anything sent to her and wanted her father to return to the facility when his hospital stay was completed. Interview on 08/31/22 at 10:18 A.M., with Social Services #92 revealed facility had no evidence of the bed hold notification being provided to resident's family. Social Services #92 verified the progress note written on 08/31/22 was the first discussion of bed hold notices with Resident #38's family. Review of facility policy titled Bed Hold Letter Policy, dated 09/26/20, revealed a copy would be sent certified mail or with return receipt requested.

Based on review of a closed medical record, review of hospital records, review of the Emergency Medical Services (EMS) Incident Suppression Information Report, interviews with facility staff, the Funeral Home Director (FHD), and local Fire Department Captain (FDC), and review of the facility policy titled Change in Condition, the facility failed to ensure one resident (#01) was monitored and timely physician notification made for a significant change in condition. This resulted in Immediate Jeopardy and serious harm when Resident #01 experienced an elevated heart rate of 145 beats per minute (bpm) and respiratory distress requiring oxygen. Additional monitoring of Resident #01's vital signs was not completed, and the resident experienced a cardiac event and expired at the facility. The resident was a Full Code status and the medical record did not contain evidence Cardiopulmonary Resuscitation (CPR) was initiated. This affected one of 13 residents reviewed for a change in condition. Additionally, one resident (#48) was placed at risk for more than minimal harm that is not Immediate Jeopardy when the resident was not monitored for an elevated temperature. The facility census was 45. On [DATE] at 5:40 P.M., the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 8:00 P.M. when Licensed Practical Nurse (LPN) #24 obtained Resident #01's vital signs that included a pulse rate of 145 bpm, temperature of 99.4 degrees Fahrenheit (F), and respirations at 24 breaths per minute. LPN #24 did not monitor the resident's vital signs after the initial assessment and reporting to Nurse Practitioner (NP) #70 who had ordered to immediately (STAT) obtain a urine culture and sensitivity and Complete Blood Count (CBC) with differential. Resident #01's pulse oximetry rate declined to 81 percent on [DATE] at 10:02 A.M. NP #70 was not notified again of the significant change in Resident #01's vital signs until [DATE] at 2:54 P.M. On [DATE] at 11:49 A.M., Social Services (SS) #89 documented the resident passed away at 10:55 A.M. The Immediate Jeopardy was removed on [DATE] at 10:32 P.M. when the facility implemented the following corrective actions: · On [DATE], Regional Director of Clinical Service (RDCS) #42 educated the DON on the admission process, completing assessments, chart reviews, change of condition, clinical standup and follow-up tool. · On [DATE], RDCS #42 and the DON educated licensed nurses (four RNs and seven LPNs) on the admission process, completing assessments, chart reviews, change of condition, and documentation. · On [DATE] at 5:45 P.M., RDCS #42 educated the DON, LPNs #38 and #64 on how to review the progress notes to identify residents who had a change of condition. · On [DATE] from 6:00 P.M. to 7:15 P.M., RDCS #42, the DON, and LPNs #38 and #64 reviewed all residents progress notes for the past seven days, to identify any resident who had a noted change of condition. The facility identified six Residents (#03, #19, #23, #29, #37, and #40) with a recent change of condition. All six residents were receiving appropriate care and were added to the Change of Condition Audit form to ensure staff were providing monitoring. · On [DATE] at approximately 6:30 P.M., RDCS #42 created a Change of Condition Audit form. · On [DATE] from approximately 6:30 P.M. through 10:30 P.M., LPN #38 assessed all residents who were identified with a change of condition within the past seven days. The physician and family were notified of any abnormalities identified. The facility identified all six residents were being assessed for their identified change of condition; however, Resident's #19 and #40 were identified as requiring medication changes and blood work. · On [DATE] from 6:35 P.M. to 10:32 P.M. the DON, LPN #38, and LPN #64 educated licensed nursing staff (four RNs, 10 LPNs and 20 State tested Nurse Aides (STNA)) on identifying change of condition, monitoring and documenting each shift for 72 hours. Agency staff will be educated prior to working any shifts. · On [DATE] at approximately 7:00 P.M. through 10:30 P.M., Respiratory Therapist (RT) #50 assessed all residents on the vent unit for any changes, with no abnormalities noted. · On [DATE] at approximately 7:30 P.M. through 10:30 P.M., LPN #64 updated the communication board to ensure staff were aware to monitor vital signs of resident's who had a change of condition. · On [DATE] at 8:00 P.M., the LNHA educated the department heads and ancillary staff to include the DON, Dietary Supervisor, Admission Coordinator, Business Office Manager, Maintenance Director, nine dietary staff, seven housekeepers and six respiratory therapists on identifying change of condition and notification. · To monitor and maintain ongoing compliance, the DON and/or Designee will review progress notes during clinical meeting, five times a week, and review the documentation completed each shift for 72 hours. This monitoring will be completed five times a week for four weeks, and then monthly for two months. · Interviews were conducted on [DATE] from 6:20 P.M. to 6:45 P.M. with RNs #30 and #65 and LPNs #44 and #64. All four nurses verified receiving education on change of condition and their expectations to provide monitoring. Although the Immediate Jeopardy was removed on [DATE] at 10:32 P.M., the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Review of the closed medical record revealed Resident #01 was originally admitted to the facility on [DATE]. He was readmitted on [DATE] and expired at the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #01 had moderate cognitive impairment with inattention and disorganized thinking continuously present, and rejection of care behaviors noted one to three days during the lookback period. The resident required extensive one-person assistance with bed mobility, dressing, and personal hygiene. He was independent with eating, and transfer/walking/locomotion did not occur during the lookback period. Resident #01 was totally dependent with toileting with the use of an indwelling catheter. The resident had no noted shortness of breath and did not require the use of oxygen. He had surgical wounds and moisture associated skin damage present with surgical wound care and application of nonsurgical dressings and ointments noted. Review of the latest care plan with a revision date of [DATE] revealed the resident had a Foley catheter with the goal to show no signs/symptoms of urinary infection. Interventions included assess/record/report to the physician for signs/symptoms of urinary tract infection including but not limited to blood tinged urine, cloudiness, increased temperature and/or increased pulse. Further review of the care plan revealed the resident was at risk for pain related to wound and open areas, obesity and muscle weakness with the goal to continue to have pain controlled with interventions for vital signs as ordered and as needed and to contact the physician with any abnormalities. Review of the readmission progress note and readmission assessment dated [DATE] revealed Resident #01 was readmitted to the facility from a post-operative hospitalization stay. His vital signs were blood pressure ,[DATE], pulse 96, respirations 18, temperature of 96.5 degrees F, and oxygen saturation at 94% on room air. The resident was noted as alert and oriented. Review of a nursing progress note dated [DATE] at 8:19 P.M. revealed LPN #24 notified NP #70 that Resident #01 had a low-grade temperature of 99.4 degrees F with an elevated pulse, and the resident also had nausea and vomiting. The resident's vitals were documented as pulse of 145 bpm, blood pressure of ,[DATE], respirations at 24 breaths per minute and oxygen saturation of 95% on room air. The resident had a generalized complaint of not feeling well. NP #70 ordered to immediately (STAT) obtain a urine culture and sensitivity and Complete Blood Count (CBC) with differential. Review of a progress note dated [DATE] at 12:07 A.M. revealed Resident #01's oxygen saturation was 95% on room air. Review of the EMS Incident Suppression Information Report dated [DATE] at 8:33 A.M. revealed a call was made due to breathing concerns for Resident #01. Upon arrival to the facility, the team was met by a facility LPN (#38) that stated the resident was fine and was just trying to find out when he was leaving for a doctor's appointment that day. Resident #01 was without complaints and the call was canceled. Staff interviews confirmed that Resident #01 called EMS because he was not aware the facility staff could help him. Staff placed the resident on oxygen and notified NP #70 for orders. Review of a physician order dated [DATE] at 9:10 A.M. revealed an order for [REDACTED].M. revealed Resident #01 had an oxygen saturation level at 81% on room air. No other vital signs were documented. A physician order dated [DATE] at 4:53 P.M. revealed an order for [REDACTED]. Review of a nursing progress note dated [DATE] at 2:54 P.M. revealed LPN #38 notified NP #70 that Resident #01 had abnormal vital signs, shortness of breath, and altered urine output. Vital signs were pulse of 126 bpm, blood pressure of ,[DATE], respirations of 20 breaths per minute, temperature of 98.0 degrees F, and oxygen saturation of 97% per nasal cannula. Resident #01 was documented as sleepy, lethargic, with shortness of breath more than baseline, and urine output abnormal. At 3:20 P.M., LPN #38 documented Resident #01's Foley catheter was replaced with immediate urine flow visualized in the drainage tube and bag. Review of SS #89's progress note dated [DATE] at 11:49 A.M. revealed Resident #01 passed away at 10:55 A.M. The medical record contained no other documentation regarding the resident's vital signs, shortness of breath, urinary output, or Resident #01's death in the facility. Telephone interview conducted with LPN #27 on [DATE] at 2:08 P.M. revealed she was the nurse who cared for Resident #01 overnight on [DATE] to [DATE] from 7:00 P.M. to 7:00 A.M. LPN #27 stated she remembered Resident #01 wanted to go to the hospital. LPN #27 stated she called EMS and was informed Resident #01 had already called. LPN #27 stated she could not remember what the issue was but thought Resident #01 had an infection. LPN #27 stated EMS came and picked the resident up on [DATE] between 5:00 A.M. and 7:00 A.M. LPN #27 stated she did not remember if she checked the resident's vitals on her shift. She further stated if she had, she would have charted the vital signs in the medical record. LPN #27 stated prior to sending a resident out, she would notify the doctor or the NP for orders. She stated she must have called someone that morning for an order to send Resident #01 out. LPN #27 stated anytime a resident goes out she documents it in the medical record. She stated if there wasn't a note in the medical record, she must have forgot to do it. There was no evidence LPN #27 called EMS or that the resident was sent out on [DATE]. Interview conducted on [DATE] at 2:28 P.M. with FHD #49 revealed Resident #01's body was picked up from the facility on [DATE]. The cause of death on the death certificate was listed as unknown etiology: [MEDICAL CONDITION], urinary tract infection, and [MEDICAL CONDITION]. Interview conducted with LPN #38 on [DATE] at 3:21 P.M. and on [DATE] at 1:27 P.M. revealed she cared for Resident #01 on [DATE] during the first shift. LPN #38 stated early in the shift, Resident #01 called EMS because he was scared and complaining he couldn't breathe. Resident #01 didn't realize the facility staff could help him. LPN #38 stated Resident #01's oxygen saturation was in the 80's and his heart rate was running in the 140's so she started him on two liters (L) of oxygen per nasal cannula. After starting the oxygen, LPN #38 called NP #70 and she ordered a STAT chest x-ray. During the shift, Resident #01 was running a low-grade temperature around 99 degrees F so she medicated him with [MEDICATION NAME]. LPN #38 stated during the shift, Resident #01 had decreased urine output, so she changed his Foley catheter. She denied seeing any blood when she changed the Foley and Resident #01 did not have any complaints. LPN #38 stated after the resident was medicated with [MEDICATION NAME] and had his catheter changed, his heart rate was around 100. LPN #38 stated she called NP #70 three times that day, once in the morning after the resident called EMS and was complaining of shortness of breath, the second time to report the chest x-ray results and the resident's vitals, and the third time she called at the end of her shift to report changing the Foley catheter, the resident's pulse and that Resident #01 was feeling better. LPN #38 stated she normally documented vital signs and physician notification in the electronic health record and did not know why she didn't document the resident's changes that day. Interview conducted on [DATE] at 4:09 P.M. with NP #70 revealed she spoke with facility staff on [DATE] and [DATE]. NP #70 stated Resident #01 requested to go to the hospital. NP #70 stated she informed staff the resident could go to the hospital or she could order laboratory work for him. NP #70 stated she was informed the resident agreed to stay at the facility, so she ordered some laboratory work. NP #70 denied the facility staff reported Resident #01's pulse was in the 140's. NP #70 stated with a pulse in the 140's, and with the resident's history, she would have sent him to the hospital. NP #70 stated she remembered receiving a call on [DATE] and the staff reported issues with the Foley catheter not draining. NP #70 stated she might have told facility staff if they were unable to get the Foley catheter to drain then to send the resident to the hospital. NP #70 stated the staff only complained to her about the catheter not draining properly, and never mentioned he had a heart rate in excess of 140 bpm. NP #70 stated if there was an issue with his Foley catheter and his heart rate was 126, she would have expected once the staff were able to get the Foley catheter draining properly to continue to monitor him and his heart rate. NP #70 stated she was shocked when she was notified Resident #01 passed away. Interview conducted on [DATE] at 5:15 P.M. with STNA #31 verified she was one of the aides caring for Resident #01 the morning of [DATE]. STNA #31 stated the aide assigned to Resident #01 was out of the building on an appointment with another resident. STNA #31 stated she went into Resident #01's room in the morning to pick up his roommates breakfast tray and noticed Resident #01 was on oxygen. STNA #31 stated Resident #01 didn't look like himself. She made a comment to him about being on oxygen and he only commented, yeah. STNA #31 stated Resident #01 was usually very talkative. STNA #31 stated she went down the hall to give another resident a shower, and after she was finished, she felt she needed to go back and check on Resident #01. STNA #31 stated when she went back to Resident #01's room, his head was over to the side and he wasn't breathing right. She yelled down the hall for RN #22. STNA #31 stated RN #22 got the crash cart, took the residents vitals and began CPR. EMS arrived and took over CPR. They worked on him for quite a while and then pronounced him dead. Telephone interview on [DATE] at 2:06 A.M. with LPN #24, who cared for Resident #01 on [DATE] on the night shift, revealed she received report from the off going nurse that Resident #01 was not feeling well, had a temperature and had vomited. LPN #24 stated she notified NP #70 of the issues with Resident #01. LPN #24 stated she couldn't recall what Resident #01's vitals were but was sure she notified NP #70 of his vital signs. LPN #24 stated NP #70 ordered blood work and a urine test. LPN #24 stated Resident #01 remained the same during her shift. LPN #24 stated she did not monitor his vitals during her shift, but she did check his temperature because she medicated him with Tylenol. LPN #24 stated she gave report to the morning nurse and the resident had no other complaints throughout the night. Telephone interview conducted on [DATE] at 11:21 A.M. with STNA #41 revealed she cared for Resident #01 overnight [DATE] to [DATE] from 7:00 P.M. to 7:00 A.M. STNA #41 stated she worked with Resident #01 the night before he passed away. She stated he had oxygen on, which was not normal for him, and the resident complained he wasn't feeling well. STNA #41 stated she noticed Resident #01's urine bag looked like there was blood in the urine and she informed the nurse. STNA #41 stated blood in his urine was not normal for him. STNA #41 stated she was not sure if the nurse assessed the resident's vitals during the night. Interview conducted on [DATE] at 3:53 P.M. with RN #22 revealed she cared for Resident #01 on the morning of [DATE] and on [DATE]. She denied any concerns with Resident #01 on [DATE]. RN #22 stated she received report from LPN #27 the morning of [DATE] at approximately 7:00 A.M. and no concerns were passed on to her. RN #22 stated she had not assessed Resident #01 at the beginning of her shift. She stated at approximately 10:10 A.M., STNA #31 called out for help as Resident #01 did not look right. RN #22 stated Resident #01 looked at her in a daze and he did not respond to her. RN #22 stated she ran out of the room and called 911. She immediately went back into the room and administered oxygen because Resident #01 had shallow breathing. RN #22 stated Resident #01 then stopped breathing and she immediately started CPR until EMS arrived and took over. RN #22 stated she did not chart anything regarding the event because she had an asthma attack at the same time and she herself was sent to the hospital. RN #22 stated the DON did request for her to chart when she came back to the facility, but she forgot. Telephone interview on [DATE] at 10:14 A.M. with FDC #134 regarding the EMS call on [DATE] at 8:35 A.M., revealed there was a call made by Resident #01 from his personal cell phone with the complaint of breathing issues. When crews arrived at the scene, the nurse informed them the resident's vitals had just been checked and there were no issues. FDC #134 stated when EMS staff arrived the resident was asking questions about when his doctor's appointment was. Resident #01 was only observed by EMS and once the facility staff informed the resident of his appointment, there were no other complaints. FDC #134 stated the resident never refused to go to the hospital. 2. Review of the closed medical record of Resident #48 revealed he was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Review of a Patient Transfer Form dated [DATE] from the local hospital revealed Resident #48's vitals upon transfer to the facility included a temperature of 98.8 degrees F, pulse of 70 bpm, respiratory rate of 20 breaths per minute and blood pressure of ,[DATE]. Review of the Admission Evaluation dated [DATE] at 4:00 P.M. revealed Resident #48 was admitted to the facility for [MEDICAL CONDITION], status [REDACTED]. Review of the admission nursing progress note revealed the resident arrived at the facility and vital signs were within normal limits, with no signs and/or symptoms of infection noted. Review of Resident #48's care plan dated [DATE] revealed the resident had an infection, with the goal for the resident to remain free of complications related to the infection. Interventions included to monitor the resident for redness, swelling, increased pain, purulent discharge, and elevated temperature. Further review of the medical record revealed no monitoring of the resident's temperature from [DATE] at 4:00 P.M. until [DATE]. Review of the medical record revealed on [DATE] at 7:41 A.M. the resident was noted with a temperature of 105.4 degrees F temporal. Review of nursing progress notes dated [DATE] at 7:52 A.M. revealed LPN #66 documented Resident #48 had a continuous fever throughout the night. an order for [REDACTED].#48 was noted that morning with a temperature of 102.6 degrees F. He was given [MEDICATION NAME] ([MEDICATION NAME]) and cold wash cloths were put on his wrists and forehead. Review of the nurse's progress note dated [DATE] at 10:12 A.M. by RN #22 revealed the NP was called due to Resident #48 having a fever of 103.6 degrees F. The NP indicated to send the resident out, but to call and inform his physician first. The physician was notified at 8:22 A.M., EMS was called and the resident was sent to the local emergency room . The physician was documented as stating the resident's temperature was too high and the resident needed to be sent to the hospital now. Review of the Medication Administration Record [REDACTED].M., 11:00 A.M., 5:00 P.M., and 11:00 P.M. Further review of the MAR indicated [REDACTED].M. an order for [REDACTED].M., 1:00 P.M., 5:00 P.M. and 9:00 P.M. Per the times entered, the resident would go 12 hours without medication for fever. On the MAR indicated [REDACTED]. Telephone interview conducted on [DATE] at 6:50 P.M. with LPN #66 revealed she was the nurse caring for Resident #48 on night shift on [DATE]. LPN #66 stated she received report from the day shift nurse that Resident #48 had a temperature around 101 or 102 degrees F. LPN #66 stated she reported the fever to the NP but couldn't remember which NP she spoke to. LPN #66 stated she did not remember if she checked the resident's vitals when she called the NP, but she informed the NP that the resident had been running a fever all day. The NP ordered routine [MEDICATION NAME] to get the fever under control and a chest x-ray to see if his pneumonia was getting worse. LPN #66 stated the resident was already on routine Tylenol. LPN #66 stated the temperature was checked when providing the Tylenol and [MEDICATION NAME], and it stayed around 101 or 102 degrees F. LPN #66 stated that Nursing 101 was if it wasn't documented, it wasn't done. LPN #66 stated she did not know if the medication was effective because she only checked his temperature when she provided the medication. LPN #66 stated the next time Resident #48's temperature was checked was the next morning around shift change when the nursing student checked it. At that time, it was about 103 degrees F, and the nursing student asked if she could give him something for his fever. LPN #66 stated she told the nursing student to wait and see what the day shift nurse wanted to do, and she passed it on to the day shift nurse. Telephone interview on [DATE] at 2:38 P.M. with LPN #68 revealed she was the nurse caring for Resident #48 on [DATE] day shift. LPN #68 stated she worked for an agency and arrived at the facility between 11:00 A.M. and 12:00 P.M. that day. LPN #68 stated she was given report by the DON when she arrived. LPN #68 stated the DON informed her Resident #48 had ran a fever since admission. Resident #48 was on Intravenous (IV) antibiotics and the DON was hanging them when she arrived. LPN #68 stated there were nursing students assigned to Resident #48 and when they disconnected Resident #48's IV, they informed her the resident had a temperature. LPN #68 stated she was not sure what his temperature was but remembered it was over 100 degrees F. LPN #68 stated she did not recheck the temperature, she just provided his routine Tylenol. She stated she was busy with her other patients and had issues with another resident that took a lot of her time. LPN #68 stated she did recheck Resident #48's temperature to see if the Tylenol was effective. LPN #68 stated later that day around 5:00 P.M., Resident #48's mother requested she come and check his temperature because he was feeling warm. LPN #68 stated it was between 100 and 101.9 degrees F, she put a cool compress on the resident and medicated him with his routine Tylenol. LPN #68 stated she did recheck his temperature about an hour to an hour and fifteen minutes later and his temperature went up to 102.6 degrees F. She wet his cool compresses and the respiratory therapist and her both rechecked his temperature about ten minutes later and it was 101.9 degrees. LPN #68 stated she assumed the Tylenol was working. LPN #68 stated she did not call the physician to inform them of the temperatures because the facility had a note that indicated not to call the doctor unless it was an extreme emergency, the doctor will call and check in at 8:00 P.M. and other times throughout the day. LPN #68 stated she figured the doctor knew about the resident's temperature since the DON reported he had been running a fever since admission. LPN #68 stated she passed the information on to the night shift nurse to provide to the doctor when he called in at 8:00 P.M. Review of the facility policy titled Change in Condition dated ,[DATE] revealed the nurse will recognize and appropriately intervene in the event of a change in resident condition and the nurse will record information in the medical record relative to the changes. This deficiency substantiates Complaint Number OH 807

Based on observation, record review and staff interview, the facility failed to ensure residents with falls had care planned interventions to prevent further falls with injury. This affected three (Residents #104, #69, #87) of four sampled residents with falls. Resident #104, admitted for rehabilitation of a surgically repaired right hip fracture, had an avoidable fall and sustained another fracture of the right hip. The facility identified six of 103 residents with falls. Findings include: 1. Review of the facility recapitulation of stay form revealed Resident #104 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Prior medical history included renal failure with dialysis, [DIAGNOSES REDACTED], anemia, gout, arthritis, general deconditioning and frequent falls. Sensory and physical impairments were hard of hearing and intermittent confusion. The form titled Fall/Injury Assessment: Prevention and Management Plan of Care dated 07/07/10 revealed Resident #104 was at risk for falls related to pain, shuffled gait, leaning, tender joints, stiffness, unsteady, swollen joints, high blood sugar, low blood sugar, use of diuretic, use of narcotic pain medication and end stage renal disease. The risk assessment did not include the resident's preadmission falls and surgical repair of a hip fracture due to falling. The care plan goal was indicated as "will be free of a serious injury if a fall occurs". Interventions included: keep frequently used items within reach (call light); ambulate with one assist; transfer with one assist; low bed; lab test/x-ray evaluation; and matt to floor. Resident supervision needs was check marked: general; increased supervision; resident specific supervision (not described). Consults were listed: pharmacy regimen review and therapy consult. The resident's initial Minimum Data Set (MDS) assessment dated [DATE] identified he was admitted on [DATE] from an acute care hospital and had other [DIAGNOSES REDACTED]. The MDS further documented he fell in the last 30 days, had moderate pain less than daily, had a surgical wound with dressings, had special treatments and procedures (dialysis, intake and output, monitoring an acute medical condition, speech therapy, occupational therapy and physical therapy) and received antianxiety and antidepressant medications. The MDS further documented he required extensive assistance of one staff for bed mobility, transfers, ambulation and toileting (was occasionally incontinent of bladder). The MDS stated he was unsteady, had limited range of motion and partial loss of voluntary movement on one leg and his activities of daily living (ADL) function was deteriorated. The MDS described primary mode of locomotion was a wheelchair. The MDS Resident Assessment Protocol (RAP) for falls did not include the recent hip fracture with surgical repair from a fall, how that impacted his fall risk or precipitating factors for recent falls. Nursing notes dated 07/17/10 at 4:55 A.M. through 5:10 A.M. revealed the resident was unresponsive in bed and was transported to the hospital for evaluation of acute mental status changes. The emergency room (ER) record revealed the resident blood glucose level was 23. Nursing notes dated 07/19/10 revealed he returned to the facility by medic transportation at 5:15 P.M. "in stable condition." On 07/19/10, the physician ordered a walker with seat and touch down weight bearing only to the right leg. The Accident/Incident Report dated 07/19/10 at 9:15 P.M. revealed the resident's roommate called out and the Resident #104 was found lying on his left side with blood under his head. A 3/4 inch laceration was observed on the back of his head. The resident stated he was straightening up and lost his balance while ambulating in his room. The nurse documented the resident was transferring from wheelchair to bed, wore slippers, required assistance of one person when getting up and had pain medication 1-2 hours before the fall. An emergency room report dated 07/19/10 at 10:01 P.M. documented the resident arrived via medic "after a fall" and stated "his legs went out" and "he hit his head." The resident's [DIAGNOSES REDACTED]. On 07/20/10, the care plan was revised to include use of chair and bed alarms. The care plan was not revised to include potential for mental status changes, use of the walker, gripper socks or specific supervision requirements to prevent another fall. An Accident/Incident Report dated 07/31/10 at 8:35 A.M. revealed Resident #104 was found sitting on the floor next to the toilet. It stated the resident fell trying to transfer from the toilet to the wheelchair, did not use the call light, had on regular socks and slid off the toilet. The fall investigation did not state if the resident was left on the toilet by a nurse aide, if he had transferred himself to the toilet or if the wheelchair alarm required by the care plan were used and operational. The care plan was not revised regarding the resident's footwear, use of the call light or specific supervision requirements to prevent another fall. An Accident/Incident Report dated 08/17/10 at 6:30 P.M. revealed Resident #104 attempted to get out of bed by himself and slipped to the floor hitting his neck on the footboard. The report stated the resident had pain medication prior to the incident, required two person assistance when getting up, was trying to get to the toilet and wore slippers at the time of the fall. The report did not state if the bed alarm required by the care plan were used and operational to alert staff to his rising. The care plan was not revised regarding the resident's footwear. The 08/17/10 at 10:00 P.M. nursing note stated the resident remained on oral antibiotics and continued to have right arm edema and right arm arterial venous fistula. Review of the 09/09/10 significant change in status MDS assessment revealed Resident #104 had deteriorated cognitive function (moderate cognitive impairment requiring cues and supervision to make decisions) and his mental function varied over the course of the day. His mood also deteriorated and was not easily altered. The MDS revealed he had unsteady gait, daily moderate pain and continued to require extensive assistance of one staff with bed mobility, transfer and walking in his room and still had range of motion and voluntary movement of one leg. He deteriorated in continence, and now was frequently incontinent of bowel. He had new [DIAGNOSES REDACTED]. Medication included anxiolytics and antidepressants. Review of the care plan for fall prevention revealed no added interventions after the 09/09/10 MDS to ensure the resident's safety from repeated falls although he had cognitive and functional deterioration, required assistance for safe mobility, had new [DIAGNOSES REDACTED]. An Accident/Incident Report dated 09/12/10 at 7:00 A.M. stated Resident #104 was found on the floor in the room leading into the bathroom. He had swelling to the right forehead with bleeding and complained of pain in the right hip. The resident was confused and stated "I am trying to go to the bathroom." He was ambulating alone with his walker and required one person assistance. The report stated the resident was barefoot at the time of the fall and he was sent to the hospital ER by squad. The Incident and Accident Report and investigation did not include analysis of the fall including use and effectiveness of the bed alarm. Interview with the Director of Nursing (DON), Administrator, and Corporate Nurse at 7:40 P.M. affirmed the care plan was not analyzed and revised as needed, including lack of an intervention for footwear when the resident fell four times without proper footwear. They stated the resident was admitted to the hospital with [REDACTED]. The DON also affirmed the Accident/Incident Reports did not document use and proper function of care planned alarms on the bed and chair and did not know if the alarms were appropriate interventions to prevent the resident's falls. During telephone interview on 10/08/10 at 2:45 P.M., the MDS RN affirmed the assessment reference date (ARD) for the significant change in status MDS assessment was 09/09/10 and assessment data for the 09/09/10 MDS was gathered during the assessment period 09/03/10 - 09/09/10. MDS RN said she requested "corporate" to cancel that MDS. MDS RN stated when Resident #104 fell , fractured his hip and was discharged to the hospital on [DATE], she did not complete the RAP and update the care plan for him. MDS RN stated she had seven days after the ARD to complete the care plan and affirmed she had not done that. 2. Review of the Resident #69's nursing progress notes dated 09/01/10 at 6:00 P.M. revealed she was admitted from the hospital after right [PROCEDURE] due to cancer and was depressed "because she was dying." Physician orders [REDACTED]. The form titled Fall/Injury Assessment: Prevention and Management Plan of Care dated 09/01/10 documented she was at risk for falls due to acute infection, exhaustion, weakness and [DIAGNOSES REDACTED]. Intervention included: ambulate with one person assistance; general supervision; low bed; grab bar; and night light. Nursing notes dated 09/10/10 (no time) revealed Resident #69 was found on the floor lying on her right side. The Accident/Incident Report dated 09/10/10 at 10:30 P.M. revealed the resident stated she was coming from the rest room walking with a cane and had house slippers (no grip) on and she became weak. Immediate actions taken included: lowered bed to floor and instructed resident to use call bell for ambulation and transfer. Interview with the Director of Nursing and MDS Registered Nurse (RN) on 09/29/10 at 7:40 P.M. reviewed and affirmed the fall/injury risk assessment and care plan initiated 09/01/10. The assessment was a check list and did not analyze the resident's fall risk. The care plan stated "general supervision" was required, but did not describe supervision. After the resident fell and sustained a hip fracture, the care plan was updated on 09/24/10. No new interventions were put in place after the fall. The care plan did not include the use of grip footwear to prevent slipping. The pre-printed care plans for falls had a check list that included non-skid socks, but it was not checked as an intervention after the fall. The resident had a care planned intervention for the high low bed to be in the low position. The resident was observed on 09/29/10 at 4:13 P.M. in bed on her back. The bed was in the medium to high position. No fall mats were on the floor. The room was dark and quiet and no staff were present. At 4:40 P.M., the resident was observed in the same position. Licensed Practical Nurse (LPN) #122 walked to the resident's room and affirmed the resident's bed "could be lowered a lot." At 4:50 P.M., Resident #69 was observed again with the bed in the same high position. LPN #122 was interviewed regarding the resident's bed position. She stated that she asked the resident if she wanted her bed lowered and the resident stated, "no". LPN #122 affirmed she did not educate the resident regarding the reason the bed should be lowered. The bed position was not in accordance with the resident's care plan and put the resident at risk for a fall with further injury. Interview with the Director of Nursing, Administrator, and Corporate Nurse at 7:40 P.M. affirmed the care plan included a low bed and the resident at risk for a fall with injury when the bed was in the high position . The DON stated the nurse should have never left the room without lowering the bed or putting additional fall interventions in place. 3. Review of Resident #87's current physician orders [REDACTED]. The resident's MDS assessment dated [DATE] stated the resident had no falls, was extensively dependent on two staff members for bed mobility, totally dependent on two staff members for transfers, totally dependent on two staff members for ambulation, and extensively dependent on one staff member for toileting. The resident had severely impaired decision making ability. Interview with MDS RN #114 at 4:25 P.M. on 09/29/10 revealed the resident fell on [DATE] and the MDS was revised 09/24/10 to reflect the accurate status of the resident. Interview with the Director of Nursing and MDS RN on 09/29/10 at 7:40 P.M. revealed the resident's care plan also served as the fall assessment. Review of the care plan revealed it was initiated on 10/31/08 and reviewed on 08/31/10 upon a readmission to the facility. The 09/05/10 fall was noted. The Accident and Incident Report of 09/05/10 revealed the resident stated he woke up sliding off the bed. He was found on the floor. The resident's care plan had interventions to lock the bed wheels and have the bed in the low position. The care plan did not include interventions to prevent "sling off the bed." Resident #87 was observed on 09/29/10 at 4:10 P.M. The resident was in bed on his back. There were no interventions, including bolsters, pillows at his side, fall mats on the floor. The resident's bed was observed in high position. No staff were in the room at the time of the observation. At 4:15 P.M. the resident was observed in the same position. At 4:20 P.M. Licensed Practical Nurse #122 was asked to observe the resident. The LPN affirmed the bed was in the high position stating the bed should be low as the resident had just had a fall from the bed. This citation substantiated Complaint Control Number OH 390.