Every finding on record at Green Meadows Skilled Nursing and Rehab

Based on observations, record reviews and interviews, the facility failed to maintain sufficient levels of staff to meet the total care needs of all residents. This affected five residents (#109, #113, #114, and #184) of five residents reviewed for personal care services and had the potential to affect all 93 residents residing in the facility. The facility census was 93. Findings include: Observation and interview on 05/18/26 at 10:10 A.M. during the facility entry conference with Administrator and Licensed Practical Nurse (LPN) #213 revealed the facility Director of Nursing (DON) was on vacation this week and the facility did not currently have the assistant director of nursing (ADON) position filled. Continued observation during the survey from 05/18/26 through 05/21/26 revealed no DON and no ADON present at the facility. Review of the DON personnel file revealed she was hired as the previous ADON on 04/16/26. Further review revealed that on 05/03/26 she was transferred to the DON position.Interview on 05/19/26 at 10:36 A.M. with licensed practical nurse (LPN) #213 revealed she was the new infection preventionist nurse and started that position 13 days ago. LPN #213 reported she was the wound nurse prior and will continue that role in conjunction with the infection preventionist role. LPN #213 confirmed she just completed her certification for her role as infection preventionist the day before on 05/18/26 (date of entry of the survey). LPN #213 reported she had been receiving training from the corporate office.Interview on 05/19/26 at 10:40 A.M. with the minimum data set (MDS) coordinator, LPN #206 revealed she had been managing the infection control program for about one month until the position could be filled and that she did have a certification from previous employment at another facility. LPN #206 had been with the facility for less than one year and reported that the facility had three different DONs prior to the current DON in that time. The previous DON took a regional nursing position within the company, and the ADON had moved to the DON position. Review of the annual facility assessment updated 02/02/26 revealed the facility average daily census to be 87-100 residents residing in the facility. Further review of the facility assessment revealed a section titled Acuity: Special Treatments and Conditions based upon 08-06-24 Center for Medicare and Medicaid 672 form indicating the facility averaged 0-2 bedfast residents, 68-72 residents who are in their chair most or all of the time. There was no acuity section that indicated resident's level of dependance or function for personal care such as bathing and mobility for transferring. Further review of the facility assessment revealed the staffing plan, to include direct care staff based on resident acuity, preference, competencies of staff, and needs of residents. The average staffing pattern was 4-5 licensed nurses per shift depending on acuity and 2-4 certified nursing assistants (CNA)'s per unit per shift depending on resident acuity. Review of the facility provided resident information included a list of 37 residents requiring two person assisted mechanical lifts (residents who cannot safely transfer themselves or stand and pivot form bed to chair and are dependent to get out of bed or chair), 56 residents who were incontinent of urine or bowel and required being checked for incontinency and changed as required by staff every two hours, and a list of 13 residents who required feeding assistance for all meals (meaning supervision/queuing, or feeding). Review of both the licensed nursing and CNA schedules for the week of 05/18/26 through 05/22/26 revealed one (1) licensed nurse scheduled to each unit (4 total) each shift (6:00 A.M. to 6:00 P.M. and 6:00 P.M. to 6:00 A.M) and two (2) to three (3) CNA's per unit per shift (day 7:00 A.M. to 3:00 P.M., afternoon 3:00 P.M. to 11:00 P.M., and nights11:00 P.M. to 7:00 A.M.). More detailed review of the staffing schedule for the week of 05/18/26 to 05/22/26 revealed Unit A (long term residents) and Unit F (residents receiving skilled services) were scheduled with 1-2 CNA's on day shift, afternoons, and night shift. There was an additional transport aide scheduled daily from 6:00 A.M. to 4:30 P.M. to assist with dialysis and for resident transportation to and from appointments outside of the facility.Interview on 05/19/26 at 11:54 A.M. with LPN #210 revealed Unit E had seven residents who needed eating assistance (Resident #108, Resident #24, Resident #87, Resident #34, Resident #41, Resident #88, and occasionally Resident #65). During the observation of the afternoon meal, only four of the identified residents were present in the dining room. LPN #210 reported all the residents were normally up and in the dining room for meal assistance, however on this day the staff had all been really busy and ran out of time to get them up. Staff would have to assist Resident #41, Resident #34, and Resident #88 with eating in their room, and make sure the residents were all up for the dinner meal.Interview on 05/19/26 at 2:00 P.M. with CNA #192 revealed she has worked at facility since January 2026. CNA #186 reported that when the B Unit was scheduled with three CNA's, things go more smoothly and all residents were up and dressed by 10:30 A.M. If only two CNAs were working then it took longer due to some many mechanical lifts on the unit that required two persons to get them up, especially if one of the CNA's was an agency staff person and did not know where things were and did not know the residents. CNA #192 further reported there was always at least one agency CNA or Nurse working on the unit every shift. Interview on 05/19/26 at 2:38 P.M. with CNA #186 revealed she had worked at the facility since February 2023. CNA #186 confirmed she generally worked the B Unit but was pulled to the F Unit (skilled unit) for the day due to a report off of staff. CNA #186 reported there were a lot of residents requiring mechanical lift (for transfers) on the B Unit and if three CNAs were staffed residents were up and dressed for the day by 10:30 A.M. CNA #186 reported that if only two CNA were scheduled it was hard to get all the residents up in chairs and dressed for the noon meal especially if agency staff were working and did not know the residents. CNA #186 reported there were frequent call offs by the agency staff so everyday an aide was getting pulled to another unit to help.Interview on 05/20/26 at 12:50 P.M. with CNA #220 revealed he had worked at the facility for about one year and usually worked the A Unit. CNA #220 reported that it was difficult when only two CNAs were scheduled to work the unit because of the number of residents requiring mechanical lifts on the unit. CNA #220 reported the aides tried to get Resident #109 up and in chair for lunch like he liked but they don't always get to him in time. CNA #220 reported that the aides tried to make sure all the residents who wanted to eat in lunch in the dining room were dressed and up and taken down to the dining room by 11:00 A.M. and when only two aides were working it was difficult to get everyone done before lunch. Interview on 05/20/26 at 1:30 P.M. with the facility scheduler (SC) #323 revealed she was hired toward the end of November 2025. SC #323 reports the facility is trying to use less agency staff and agency staff sometimes are no call and no shows. SC #323 reported if a CNA reported off then they would pull a CNA from one of the units that has three assigned that day and then each unit would have at least two CNA for the shift. SC #323 reported that if the transportation aide was available between her duties she would help the units also. SC #323 verified that the facility utilized four different staffing agencies to cover both CNA and nursing needs.Interview on 05/20/26 at 2:10 P.M. with a family member of Resident #51 revealed concerns regarding the facility using agency staffing. She reported a few weeks before many of the routine staff had the flu, and most of the staffing was covered by agency staffers. During that time, her mother was not getting clean. She had the same socks on for the entire week. One Certified Nurse Aide (CNA) came into the room to deliver her lunch, and the smell of body odor was so bad it lingered in the room. She made sure to take all her trays out of the room herself, so the staff member did not return to the room. Review of the medical record for Resident #109 revealed admission to facility on 08/31/1992 with most recent reentry on 08/29/2013. The resident's diagnoses included stroke with hemiplegia, aphonia (difficulty speaking), heart failure, chronic lung disease, dysphagia (difficulty swallowing), major depression, bilateral retinopathy (affects vision to both eyes).Further review of the medical record for Resident #109 revealed his most recent quarterly minimum data set (MDS) assessment completed on 04/14/26 indicated a brief interview for mental status score of 15/15 indicating full cognition without deficit. The MDS 3.0 assessment further revealed that Resident #109 was dependent on staff for eating and oral hygiene, dependent on staff for bathing and dressing, and dependent on staff for transferring and mobility. Resident #109 required the use of a mechanical lift and two staff to transfer from bed to wheelchair and had both bowel and bladder incontinence.Observation on 05/19/26 at 12:45 P.M. of Resident #109 revealed he was lying in bed with his head elevated and no meal tray present. This was verified by licensed practical nurse (LPN) #217.Interview on 05/19/26 at 12:46 P.M. with LPN #217 revealed that Resident #109 had just ate his lunch and was fed by a nursing aide. LPN #217 further reported that Resident #109 preferred to get up in his wheelchair for meals, but the staff did not have time to get him up for lunch and were going to get him up in his wheelchair soon.Observation and interview on 05/20/26 at 12:52 P.M. with Resident #109 revealed he was dressed and groomed with no odor present and sitting up in his tilt wheelchair. The certified nurse aide (CNA) had just taken the tray from the room and Resident #109 was noted to have a clothing protector present. Resident #109 verified he liked to be up in his chair for lunch and dinner but sometimes ate his breakfast in bed. Resident #109 verified that the staff doesn't always get him up for lunch and when asked why he shrugged his shoulders.Review of the medical record for Resident #114 revealed admission to facility on 08/25/23 with most recent re-entry on 07/07/25. The resident had diagnoses including end stage renal disease, chronic respiratory failure, atrial fibrillation (irregular heartbeat), downs syndrome, morbid obesity, depression, mild intellectual disabilities, anemia (low blood count), kidney dialysis, and high blood pressure. Review of the medical record revealed Resident #114's BIMS score was15/15 revealing he was cognitively intact. Further review revealed Resident #114 was continent of urine and bowel. Resident #114 was dependent on staff for transferring from bed to wheelchair and dependent on staff to assist with bathing and dressing. Further review of the medical record for Resident #114 revealed a nursing progress note for wound evaluation dated 03/10/26 that the resident had a reddened, raised rash with fungal appearance to his bilateral buttocks that resolved with treatment on 04/07/26.Interview on 05/21/26 at 12:22 P.M. with Resident #114 revealed he was able to control his bowels and bladder and would put his call light on for the staff to help him get on the bed pan to urinate or move his bowels. Resident #114 further reported that he sometimes had to wait too long and that he would have accidents with his bowels/bladder in his bed. Resident #114 reported that his bottom was sore that day and the nurse told him that his bottom was red that morning. Resident #114 was unable to recall if the nurse put cream or ointment on his bottom. Interview on 05/21/26 at 12:30 P.M. with CNA #186 revealed that Resident #114 was not incontinent and would put his call light on for the bed pan if he needed to use the restroom. CNA #186 further reported that Resident #114 skin to his peri area was red and irritated this morning and she reported it to the nurse. CNA #186 further reported that she also had concerns with Resident #113 having a wet adult incontinence brief and bed this morning with skin irritation to buttocks that she reported to the nurse.Review of the medical record for Resident #113 revealed admission to facility on 05/30/24 with diagnoses including stroke, diabetes, dysarthria (difficulty finding words), anxiety, depression, impaired left eye, left side weakness from stroke, and high blood pressure.Further review of the medical record for Resident #113 revealed she required a two person transfer with a mechanical lift. Resident #113 was noted to be incontinent of urine and bowel and had a BIMS score of 11/15, indicating moderate cognitive impairment. Observation on 05/21/26 at 12:40 P.M. of incontinence care provided to Resident #113 revealed CNA #186 and CNA #192 gathered supplies and performed hand hygiene and put on clean gloves then transferred Resident #113 from her wheelchair to her bed using the mechanical lift. CNA #186 and #192 then removed Resident #113 pants and soiled adult brief and provided incontinence care using clean wash cloths with soap and water appropriately. Further observation noted that Resident #113 skin on her buttocks was red and irritated around her peri area and appeared to have moisture associated skin damage (MASD) to the area. LPN #223 was present and verified the area was red and irritated and applied Triad cream (a skin protectant cream) to the area after Resident #113 was clean and prior to placing a new incontinence brief.Interview on 05/21/26 at 12:45 P.M. with LPN # 223 revealed the skin protectant cream (Triad Cream) that was ordered for incontinent residents every shift and as need with incontinent episodes were kept locked at the nurses' station and could only be applied by the nursing staff. LPN #223 reports she was not always available when the CNAs were doing rounds to check and change residents and that if she was not available the cream was not applied. Interview with on 05/21/26 at 12:48 P.M. with CNA #186 revealed that the CNA must ask the nurse to use the skin protectant cream and it was not left at the bedside for the CNAs to use with check and changes. CNA #186 reported that LPN #223 was the best at trying to make sure to apply cream to the incontinent residents, but the agency nurses were not that good at getting to it.Review of the closed medical record for Resident #184 revealed admission to the facility on [DATE] for a planned short skilled stay for diagnoses including shingles, chronic lung disease, heart failure, high blood pressure, pain to right and left legs, and generalized weakness.Review of the medical record for Resident #184 revealed a comprehensive MDS assessment completed on 09/03/26 indicating a BIMS score of 15/15, cognitively intact. Further review of the MDS revealed Resident #184 required substantial/maximum assistance with toileting, dressing, and bathing/showering and required the use of a wheelchair for mobility.Review of the shower schedule for Resident #184 revealed she was to have assistance with showers on Monday and Thursday during the afternoon shift.Review of the facility self-reported incident (SRI) #265296 related to Resident #184 not receiving showers revealed Resident #184's daughter reported on 09/12/25 that the resident had not received a shower or bath since her admission to the facility and the daughter was not leaving the facility until her mother had a shower. The SRI revealed no documentation in the electronic medical record confirming that Resident #184 was provided with baths or showers from 08/29/25 through 09/11/25.Interview on 05/21/26 at 3:15 PM with the facility Administrator confirmed that the facility did not have evidence documented that Resident #184 had received baths or showers prior to the daughter's complaint on 09/12/26. This deficiency represents non-compliance investigated under Complaint Number #2742642, #2686119, and #2681301.

Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This had the potential to affect all 93 residents of the facility. The facility census was 93.Findings include:On 05/18/26 at 12:48 P.M., an observation of the Men's Restroom in the main lobby revealed a sign stating the restroom was temporarily out of order. The inside of the restroom revealed a hole in the ceiling over the toilet with honeycomb-like rusted metal exposed. On 05/18/26 at 12:50 P.M., an interview with the Administrator confirmed the restroom off the main lobby was closed because the roof had a leak and was causing the ceiling to fall down. The Administrator could not confirm when the restroom had been closed for public use. She reported it was a process to get the problem corrected and roofers were supposed to start repair of the roof of the entire facility in the coming week. On 05/18/26 at 1:08 P.M., an observation of the solarium of E Wing revealed 13 tiles with brown stains on them. On 05/18/26 at 1:08 P.M., an interview with Licensed Practical Nurse (LPN) #210 confirmed there were 13 ceiling tiles with brown stains in the E Wing Solarium. She reported the tiles would get replaced by maintenance, and then the roof would continue to leak and the staining would come back. On 05/18/26 at 3:29 P.M., an observation of the lobby area of the facility revealed multiple areas of ceiling tiles that were covered with a black, gray, or orange, mold-like substance, around hanging lights, and ceiling fans and scattered throughout the common areas of the facility. This was confirmed by the Maintenance Director at the time of the observation. On 05/18/26 at 3:40 P.M., interview with the Maintenance Director revealed the ceilings were probably not mold, just rust, and should not affect the residents' health conditions. He reported since he started at the facility, the ceiling had been leaking because the roof needed repaired, and he would just change the tiles when they got bad, since the roof had not been repaired. The metal tiles in the lobby would be taken down, cleaned or painted, then put back up. He reported the tiles were all stained and there was now a bucket under the tiles in the E-Wing solarium since the ceiling was leaking. On 05/18/26 at 4:00 P.M., an interview with Owner #400 revealed [named company] purchased the building two years ago. At the time of the purchase, the company was aware the roof needed repair. He indicated the repair had not been done because it took a lot of money, however roofers were coming the next day. On 05/19/26 from 9:10 A.M.to 9:22 A.M., a walk-through observation of F-Wing revealed the carpeting between room [ROOM NUMBER] and 112 as well as the carpeting outside of room [ROOM NUMBER] had multiple black stains. Observation of the shower room revealed a stained and dirty shower bed. The solarium of the F-Wing had three ceiling tiles with brown staining on them. Directly across from the nurses' station was the soiled linen and trash room. This room had a profound odor which emanated into the hallway of the resident care areas. This was confirmed by Housekeeper (HK) #150 during interview on 05/19/26 at 9:22 A.M. On 05/19/26 at 9:22 A.M., an interview with HK #150 revealed she did not know if the carpeting of F-Wing ever was cleaned. She did not think the facility had a carpet shampooer and did not know if anyone had come in to try to clean the carpets. She reported the soiled linen room had an odor which grosses me out. She thought the trash was taken out twice daily by the aides, however the smell never went away and it was not pleasant at all. She indicated any time someone opened the door, the smell would go into the hallway and linger. On 05/19/26 at 9:23 A.M., an interview with Resident #86 (room adjacent to the soiled linen room of F-Wing) revealed she occasionally would notice the smell from the soiled linen room but did not know what the facility could do about it. On 05/19/26 from 9:39 A.M. to 9:43 A.M., a walk-through observation of the A-Wing revealed a dirty, stained shower head in the shower room. The wall mounted shower was rusty. In front of the nurses' station, there were two ceiling tiles with brown stains on them. This was confirmed by LPN #217 during an interview on 05/19/26 at 9:44 A.M. On 05/19/26 at 9:44 A.M., an interview with LPN #217 revealed the ceiling tile staining had been there since she started at the facility a few years ago. She felt the issues in the shower were caused from hard water, however she personally would not want to shower in the shower room. On 05/19/26 from 9:55 A.M. to 10:10 A.M., a walk-through observation of the B-Wing revealed a rusted wall mounted shower in the shower room. There was a stained and dirty shower head and a dirty shower chair in the shower room. The hall in front of the nurses' station contained five ceiling tiles with brown stains. This was confirmed by the maintenance director at the time of the observations. On 05/20/26 at 1:55 P.M., an observation of the hallway on E-Wing between rooms [ROOM NUMBERS] revealed a black bucket with a yellow caution sign beside it. The ceiling was noted to be dripping from around the light fixture into the bucket. The space between the resident doorway and the bucket in the hall was small. This was confirmed by LPN #210 during an interview on 05/20/26 at 2:05 P.M. On 05/20/26 at 2:05 P.M., an interview with LPN #210 confirmed the black bucket with caution sign and leaking ceiling in the hallway between room [ROOM NUMBER] and 21. She reported the two residents in room [ROOM NUMBER] (Resident #32 and Resident #34) both required wheelchairs. Resident #32 would self-propel her wheelchair. The resident in room [ROOM NUMBER] (Resident #63) self-propelled his wheelchair. The LPN did not know if the placement of the bucket and signage in the hallway would affect the residents' ability to enter or exit their rooms. On 05/20/26 at 2:10 P.M., an interview with Resident #51 revealed she did not like to leave her room unless she had to. Left only to go to the shower room once a week. She indicated the shower never stops and it was very hot in the shower room. She said often there would be things piled up all over the room. She did not like to go to the solarium because everything was dirty and the room was just pitiful looking. On 05/20/26 at 2:25 P.M., an observation of the public hallway outside the entrance to the F-Wing revealed two brown trash cans and two yellow caution signs sitting on towels. There was noted water dripping from the ceiling. Resident #67 was observed running into the trash cans with her wheelchair as she attempted to leave the F-Wing. This observation was confirmed by Resident #67 at the time of the observation. On 05/20/26 at 2:25 P.M., an interview with Resident #67 revealed she was frustrated with the leaking roof. She stated it is about time they fixed this roof. It is terrible. People can't even get around this place without running into something. On 05/20/26 at 2:29 P.M., an observation of room [ROOM NUMBER] of the F-Wing revealed the ceiling was peeling and there was water leaking from the ceiling into a white bucket on the floor. This was confirmed at the time of the observation by Registered Nurse (RN) #309. On 05/20/26 at 2:29 P.M., an interview with RN #309 confirmed the ceiling of room [ROOM NUMBER] was peeling and there was water dripping from the ceiling into a bucket. She did not feel this was a problem because there was no resident currently residing in the room. On 05/20/26 from 2:30 P.M. to 2:38 P.M., an observation of the B-Wing hallway revealed outside room [ROOM NUMBER] there was a cracked ceiling light cover in a large X shape. Outside of room [ROOM NUMBER], the ceiling light cover had a linear crack from side to side. There was a ceiling tile in front of the nurses' station which had a large brown stain on it. These findings were confirmed at the time of the observations by Certified Nurse Aide (CNA) #404. On 05/21/26 at 11:15 A.M., an interview with Contractor #402 from [named company] revealed there had been delays in the roof being replaced. Delays included weather, scheduling and materials. The contract with the facility was originally presented on 12/20/25. The contract was signed on 03/26/26 and included repairing the roof of E and F wing and replacing the roof over the public areas that connected each wing and the roof over the multi-level portion of the building. It did not include any repairs or replacements of A-Wing, B-Wing, C-Wing, or D-Wing. The contractor provided a signed copy of the contract via electronic communication. This deficiency represents non-compliance investigated under Master Complaint 2748123 and Complaint Number 2742642.

Based on record review, observation of dining, interview, and review of facility policy, the facility failed to promote resident dignity and independence while dining, by standing over residents while assisting them to eat and not assisting the resident into a position to be able to feed themselves. This affected four residents (#24, #87,#92, and #65) of eleven residents observed for dining needs. The facility census was 93. Findings include:Review of the medical record for Resident #24, revealed an admission date of 04/11/23. Diagnoses included but were not limited to Alzheimer's Disease, dementia, gastroesophageal reflux, major depressive disorder, hyperlipidemia, type two diabetes, peripheral vascular disease, and anxiety disorder.Review of a quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #24, dated 03/19/26, revealed a Brief Interview for Mental Status (BIMS) of two on a 0-15 scale. A BIMS score of 0 to 7 points suggests severe cognitive impairment.The MDS indicated the resident required substantial/maximum assistance with eating, was dependent for toileting and required substantial/maximal assistance for bathing. She ambulated with touch assistance with no assistive devices. The resident was frequently incontinent of both bowel and bladder.Review of the care plan for Resident #24 revealed a focus of care for ADL self-care deficit, initiated on 10/27/22, and last updated 02/12/26. Interventions included offering assistance with meals if needed.Review of the medical record for Resident #87, revealed an admission date of 10/01/22. Diagnoses included but were not limited to cerebral infarction due to embolism of unspecified cerebral artery, unspecified dementia, vitamin B12 deficiency, other specified peripheral vascular disease, atherosclerotic heart disease of native coronary artery, major depressive disorder, gastroesophageal reflux disease, vascular dementia, mild, without behavioral disturbance, and presence of pacemaker.Review of a quarterly Minimum Data Set (MDS) version 3.0, dated 05/03/26, revealed a Brief Interview of Mental Status (BIMS) score of 0 on a 0-15 scale. A BIMS score of 0 would indicated severe cognitive impairment. The MDS further indicated the resident required partial to moderate assistance for all Activities of Daily living (ADLs) except she was dependent for toileting.Review of a care plan for Resident #87 revealed a focus of care for ADL (activities of daily living) assistance, initiated 10/27/22 and updated 02/12/26. Interventions included assisting with meals as needed.On 05/19/26 from 11:15 A.M. to 12:00 P.M., observation of the dining room of E-Wing revealed the following: At 11:15 A.M., Resident #65 was in the dining room and was at a table with Resident #64. Resident #64 received his tray at 11:15 A.M., and finished eating at 11:24 A.M. Resident #65 received his tray at 11:34 A.M. He was noted to not be eating. At 11:55 A.M., he was still not eating. LPN #213 arrived in the dining room at 11:57 A.M., and sat to assist Resident #65 with eating. This was confirmed by CNA #301 at the time of the observation.At 11:20 A.M., Resident #24 received her tray. No staff member was sitting with the resident assisting her with eating. Resident #87 was sitting at the same table with Resident #24 and being assisted with eating by an unknown Speech Therapist. Certified Nurse Aide (CNA) #236 walked past Resident #24, stopped and put some food in the resident's mouth and walked away to assist another resident. This was confirmed by CNA #301 at the time of the observation.At 11:25 A.M., Resident #92 was brought to the dining room. She was placed at the end of a table with one other resident who was already eating. Her wheelchair was sideways, facing away from the table. At 11:38 A.M., her tray was placed on the table, however there was no way for the resident to reach her food to feed herself. The resident required assistance to set up her tray and to position herself to be able to eat. This was confirmed by CNA #301 at the time of the observation.At 11:32 A.M., an observation revealed CNA #221 stood over Resident #24 and was assisting the resident with eating while talking with another resident at the table behind her. After several bites, licensed practical nurse (LPN) #210 advised CNA #221 to sit while assisting the resident. When CNA #221 sat to assist Resident #24, the Speech Therapist left the table and did not finish assisting Resident #87, leaving CNA #221 to assist both residents who required total assistance with eating. This was confirmed by CNA #301 at the time of the observation.At 11:50 A.M. on 05/19/26, an interview with CNA #301 confirmed Resident #24 and Resident #87 both required total assistance for eating. Resident #92 needed set-up assistance and occasional queuing to eat, and Resident #65 required assistance with feeding more than half the time, otherwise he would not eat. She confirmed observations which included: Staff assisting with eating for Resident #24 as they passed by her, then while they stood over her; Speech Therapist leaving the dining room in the middle of assisting Resident #87 with eating, leaving CNA #221 to assist both residents at the same time with eating; Resident #92 not being placed in a position to be able to reach her tray or feed herself; and Resident #65 sat for over 20 minutes with his tray in front of him and no one assisting or encouraging him to eat. On 05/19/26 at 11:59 A.M., an interview with Licensed Practical Nurse (LPN) #210 revealed staff members should be seated when assisting residents with eating. She further explained Resident #92 could feed herself, however the position she was in left her unable to reach her tray or her food. She also occasionally needed queuing to eat. Finally, Resident #64 needed assistance with set up of his food as well as assistance with eating or queuing to eat, otherwise he would not eat. She also reported all residents at a table should get their food at the same time, and should not have to wait with food in front of them for assistance.Review of an undated facility prepared document titled Residents that Need Fed revealed both Resident #24 and Resident #87 required feeding.Review of a facility policy titled Resident Rights, revised September 2022, revealed employees should always treat residents with kindness, respect and dignity. Rights included the right to a dignified existence.Review of an undated facility policy titled Activities of Daily Living (ADLS) revealed the residents would be provided with care, treatment and services to maintain or improve their ability to carry out ADLS. If the resident was unable to do so independently, they would receive services necessary to maintain good nutrition, grooming and personal and oral hygiene. In accordance with their plan of care, residents would receive assistance with hygiene, mobility, toileting, dining and communication.Review of an undated facility policy titled Dignity revealed each resident would be care for in a manner which promoted and enhanced their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. When assisting with care, residents were to be provided with a dignified dining experience. Standards of care which compromised dignity were prohibited. Staff were expected to promote dignity.This deficiency represents non-compliance investigated under Complaint Number 2742642.

Based on observation, interview and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior and to maintain a temperature between 71 degrees Fahrenheit (F) and 81 degrees F in the shower room of the E-Wing, which was the facility memory care unit. This affected all 26 of 26 residents residing on the facility's E-Wing. The facility census was 93. Findings include:On 05/18/26 at 1:08 P.M., an observation of the shower room of the E-Wing revealed a wall mounted shower with a handheld shower head which could not be shut off. Hot water was continually running. There was no thermometer in the room, however the room was very warm. The shower contained a wall-mounted shower, which had light green corrosion surrounding the bottom and had a built-in soap tray which was covered in the light green corrosion which would come off to touch. The heater and the floor drain of the shower were both rusted. The shower room was attached, without any doors, to the dirty laundry and trash room, and the odor of ammonia was strong throughout the room. This was confirmed by Licensed Practical Nurse (LPN) #210 at the time of the observation.On 05/18/26 at 1:08 P.M., an interview with LPN #210 confirmed the shower in the shower room could not be turned off, and there was light green corrosion on the wall mounted shower and soap dish, which residents would use during their showers. She confirmed the floor drain and the vent beside the shower were both rusted.LPN #210 further confirmed there was a strong odor coming from the dirty linen/trash room. During the observation, the LPN was notably perspiring and reported she would not feel clean if she had to shower in the E-Wing shower due to the heat and the odor. On 05/18/26 at 3:37 P.M., an observation of the Maintenance Director checking the temperature in the E-Wing Shower room revealed the temperature of the room was 82 degrees Fahrenheit (F). This was confirmed by the Maintenance Director at the time of the observation.On 05/18/26 at 3:40 P.M., interview with the Maintenance Director revealed he thought the temperature in the facility should be kept between 70 and 80 degrees Fahrenheit (F), and the temperature of the E-Wing shower room was 82 degrees F. He further revealed there were no ventilation or exhaust fans in any of the facility shower rooms, there were only transfer grills, which he believed contributed to the heat. He had been unable to get any parts to fix the shower, and had been asking for months to be able to fix it and update the shower room.On 05/19/26 at 10:10 A.M., an interview with LPN #210 revealed the only shower on the E-Wing was the shower room. There were no showers in the resident rooms. All residents of the unit had to use the shower room. The unit census was 26.On 05/19/26 at 10:24 A.M., an interview with Certified Nurse Aide (CNA) #248 revealed the E-Wing shower room was so hot I almost puke or pass out whenever she had to shower someone. It was hard to catch her breath in the room. Setting anything on the soap dish in the room would be unsanitary because of the green corrosion. Personally, I would not take a shower in there and I feel like I need to take a bleach shower when I leave that room. She confirmed all 26 residents used the shower room on E-Wing and there was nowhere else to safely take the residents of this unit to shower because they could not be taken off of the unit, and there were no other shower areas available on the E-Wing.On 05/20/26 at 2:10 P.M., an interview with Resident #51 revealed she did not like to leave her room unless she had to. Left only to go to the shower room once a week. She indicated the shower never stops and it was very hot in the shower room. She said often there would be things piled up all over the room. On 05/21/26 at 10:25 A.M., an interview with the Administrator revealed the shower on the E-Wing had been leaking for some time. The Maintenance Director had tried to order parts to fix it, however the company had discontinued the parts, since they were so old. She had a company come in on 05/19/26 and they were going to be able to order the parts. She was not sure how long they had been trying to get the parts, but she was aware it had been an issue for at least a few months.Review of facility TELS reports (TELS was a platform used by maintenance staff to document work orders) revealed the following work orders related to the shower room on the E-Wing:a) Work Order #6126, dated 01/29/26, reported E-Wing shower faucet would not turn. The maintenance response was It turned for me.b) Work Order #6188, dated 03/02/26, reported E-Wing shower dripping all weekend. Could not get the water to stop, and it was so hot there was mold growing up the wall. The maintenance response was Completed.c) Work Order #6191, dated 03/03/26, reported E-Wing shower water was luke warm. Maintenance response was adjusted water temperature.d) Work Order #6206, dated 03/09/26, reported E-Wing shower dripping. Maintenance response cancelled.e) Work Order #6223, dated 03/18/26, reported E-Wing shower needs floor drain cover. Maintenance response was completed.These work orders were confirmed by the Maintenance Director on 05/19/26 at 2:00 P.M.Review of an undated facility policy titled Dignity revealed residents would be cared for in a manner which promoted and enhanced their sense of well-being, level of satisfaction with life, and feelings of self worth and self esteem.This deficiency represents non-compliance investigated under Master Complaint Number 2748123 and Complaint Number 2742642.

Based on medical record review, policy review, resident observations, and staff and resident interviews, the facility failed to assist residents who were dependent on staff for their needs including timely incontinence care, getting up for meals timely, and bathing/showering as scheduled. This affected three residents (#109, #114, and #184) of three residents reviewed for provision of care. The facility identified 56 residents as needing assistance with incontinence care, bathing/showering, and required use of a mechanical lift to set up in chair for meals. The facility census was 93.Findings include:1.Review of the medical record for Resident #109 revealed admission to facility on 08/31/92 with most recent reentry on 08/29/13. The resident had diagnoses including stroke with hemiplegia, aphonia (difficulty speaking), heart failure, chronic lung disease, dysphagia (difficulty swallowing), major depression, bilateral retinopathy (affects vision to both eyes).Further review of the medical record for Resident #109 revealed his most recent quarterly minimum data set (MDS) assessment completed on 04/14/26 indicated a brief interview for mental status score of 15/15 indicating full cognition without deficit. The MDS 3.0 assessment further revealed that Resident #109 was dependent on staff for eating and oral hygiene, dependent on staff for bathing and dressing, and dependent on staff for transferring and mobility. Resident #109 required the use of a mechanical lift and two staff to transfer from bed to wheelchair and had both bowel and bladder incontinence.Observation on 05/19/26 at 12:45 P.M. of Resident #109 revealed he was lying in bed with his head elevated and no meal tray present. This was verified by licensed practical nurse (LPN) #217 at the time of the observation.Interview on 05/19/26 at 12:46 P.M. with LPN #217 revealed that Resident #109 had just eaten his lunch and was assisted by a nursing aide. LPN #217 further reported that Resident #109 preferred to get up in his wheelchair for meals, but the staff did not have time to get him up for lunch and are going to get him up in his wheelchair soon.Observation and interview on 05/20/26 at 12:52 P.M. with Resident #109 revealed he was dressed and groomed with no odor present and sitting up in his tilt wheelchair. The certified nurse aide (CNA) had just taken the tray from the room and Resident #109 was noted to have a clothing protector present. Resident #109 verified he likes to be up in his chair for lunch and dinner but sometimes eats his breakfast in bed. Resident #109 verified that the staff doesn't always get him up for lunch and when asked why he shrugged his shoulders.2.Review of the medical record for Resident #114 revealed admission to facility on 08/25/23 with most recent re-entry on 07/07/25. The resident had diagnoses including end stage renal disease, chronic respiratory failure, atrial fibrillation (irregular heartbeat), downs syndrome, morbid obesity, depression, mild intellectual disabilities, anemia (low blood count), kidney dialysis, and high blood pressure. Review of the medical record revealed Resident #114's BIMS score was 15/15 revealing he was cognitively intact. Further review revealed Resident #114 was continent of urine and bowel. Resident #114 was dependent on staff for transferring from bed to wheelchair and dependent on staff to assist with bathing and dressing. Interview on 05/21/26 at 12:22 P.M. with Resident #114 revealed he was able to control his bowels and bladder and would put his call light on for the staff to help him get on the bed pan to urinate or move his bowels. Resident #114 further reported that he sometimes had to wait too long and that he would have accidents with his bowels/bladder in his bed. Resident #114 reported that his bottom was sore that day and the nurse told him that his bottom was red that morning. Resident #114 was unable to recall if the nurse put cream or ointment on his bottom. Interview on 05/21/26 at 12:30 P.M. with CNA #186 revealed that Resident #114 was not incontinent and would put his call light on for the bed pan if he needed to use the restroom. CNA #186 further reported that Resident #114's skin to his peri area was red and irritated this morning and she reported it to the nurse.Further review of the medical record for Resident #114 revealed a nursing progress note for wound evaluation dated 03/10/26 identified the resident had a reddened, raised rash with fungal appearance to his bilateral buttocks that resolved with treatment on 04/07/26.3.Review of the closed medical record for Resident #184 revealed admission to the facility on [DATE] for a planned short skilled stay. The resident had diagnoses including shingles, chronic lung disease, heart failure, high blood pressure, pain to right and left legs, and generalized weakness.Review of the medical record for Resident #184 revealed a comprehensive MDS assessment completed on 09/03/26 indicating a BIMS score of 15/15, cognitively intact. Further review of the MDS revealed Resident #184 required substantial/maximum assistance with toileting, dressing, and bathing/showering and required the use of a wheelchair for mobility.Review of the shower schedule for Resident #184 revealed she was to have assistance with showers on Monday and Thursday during the afternoon shift.Review of the facility self-reported incident (SRI) #265296 related to Resident #184 not receiving showers revealed Resident #184's daughter reported on 09/12/25 that the resident had not received a shower or bath since her admission to the facility and the daughter was not leaving the facility until her mother had a shower. The SRI revealed no documentation in the electronic medical record confirming that Resident #184 was provided with baths or showers from 08/29/25 through 09/11/25.Interview on 05/21/26 at 2:30 PM with the facility Administrator confirmed that the facility did not have evidence documented that Resident #184 had received baths or showers prior to the daughter's complaint on 09/12/25. Review of the facility policy titled Activities of Daily Living, undated revealed appropriate care and services will be provided to residents who are unable to independently perform their own care including hygiene (bathing/dressing), mobility (transfers and walking), elimination (toileting), dining (meals/snacks, and communication methods in accordance with resident care plans. This deficiency represents non-compliance investigated under Complaint Numbers #2742642, #2686119, and #2681301.

Based on review of the medical record and facility policy, observations, and staff interview, the facility failed to ensure appropriate hand hygiene to stop the spread of infection. This affected one resident (#113) of two residents observed for incontinence care. The facility census was 93.Findings include: Review of the medical record for Resident #113 revealed admission to facility on 05/30/24 for diagnoses including stroke, diabetes, dysarthria (difficulty finding words), anxiety, depression, impaired left eye, left side weakness from stroke, and high blood pressure.Further review of the medical record for Resident #113 revealed an annual comprehensive minimum data set (MDS) 3.0 was completed on 05/14/26. The MDS revealed Resident #113 required a two person transfer with a mechanical lift. Resident #113 was noted to be incontinent of urine and bowel and had a BIMS score of 11/15, indicating moderate cognitive impairment. Observation on 05/21/26 at 12:40 P.M. of incontinence care provided to Resident #113 revealed certified nurse aides (CNA) #186 and CNA #192 gathered supplies and performed hand hygiene and put on clean gloves then transferred Resident #113 from her wheelchair to her bed using the mechanical lift. CNA #186 and #192 then removed Resident #113's pants and soiled adult incontinence brief and provided incontinence care using clean wash cloths with soap and water appropriately. Further observation noted that Resident #113's skin on her buttocks was red and irritated around her peri area and appeared to have moisture associated skin damage (MASD) to the area. Licensed Practical Nurse (LPN) #223 was present and verified the area was red and irritated and applied Triad cream (a skin protectant cream) to the area after Resident #113 was clean and prior to placing a new brief. Continued observation revealed CNA #192 did not remove her gloves after cleaning the resident and proceeded to touch Resident #113's items such as her call light, bed rails, and pulled her blankets up. Further observation revealed CNA #192 removed her gloves prior to leaving the room and did not perform hand hygiene before walking into the next room to remove a lunch tray from the other resident's room. Interview on 05/21/26 at 12:55 P.M. with CNA #192 revealed verification that she did not perform hand hygiene after removing gloves and prior to entering the next resident's room to pick up and remove lunch tray and place on meal cart.Review of the facility Hand Hygiene, policy dated 09/01/2022 revealed hand hygiene will be properly performed to assist in the spread of infection. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2681301.

Based on review of Quality Assurance (QA) committee meeting attendance sheets, policy review and interview, the facility failed to ensure a QA meeting was held the first quarter of 2024. This had the potential to affect all 89 residents. Findings include: Upon entrance with the Administrator and Director of Nursing (DON), sign in sheets for quality assurance meetings held in the year 2024 were requested. There were no attendance sheets provided for a meeting in the first quarter of 2024. Review of the Quality Assessment and Assurance policy (dated September 2021) revealed the committee shall meet at least quarterly to identify quality assessment and assurance issues, and to develop and implement or oversee implementation of, appropriate plans for identified quality deficiencies. On 02/10/25 at 2:40 P.M., the DON verified there was no documentation/attendance sheets which revealed a QA meeting was held the first quarter of 2024. On 02/10/25 at 3:13 P.M., the Administrator verified she had no evidence a QA meeting was held the first quarter of 2024. The records before she was employed were not available to her.

Based on record reviews, observations, interviews, facility policy review, and review of Centers for Disease Control (CDC) Guidelines, the facility failed to ensure a comprehensive infection control program was maintained to ensure the health and safety of all residents in the facility including timely notification of the local health department (LHD) regarding positive cases of Coronavirus (COVID-19), failed to have a procedure in place to address staff illness, failed to ensure a comprehensive water maintenance program was continuously implemented, failed to clean the rubber stopper of a multi-use insulin pen and failed to track and trend potential outbreak illness in the facility. This affected Resident #23, #35, #69, #71, #73, #186, #187 and #235 but had the potential to affect all 89 residents residing in the facility. Findings include: 1.Review of the medical record for Resident #235 revealed an admitted [DATE] with diagnoses including type II diabetes, end stage renal disease, cellulitis of right lower limb, dependence on renal dialysis, and hypertension (HTN), Review of the physician orders for January 2025 revealed an order for droplet precautions. Review of the minimal data system (MDS) quarterly assessment dated [DATE] revealed Resident #235 had intact cognition. Review of the progress note dated 01/25/25 11:42 .M. revealed Resident #235 tested positive for COVID on 01/26/25 per facility protocol. Review of the e-mail dated 02/04/25 from the DON to the LHD revealed the DON notified the health department of Resident #235 testing positive for COVID-19. Interview on 02/06/25 at 10:30 A.M. via phone with Registered Nurse (RN) #500 and RN #501 (from the LHD) revealed COVID cases are to be reported by the end of the next business day to the LHD. RN #500 and RN #501 confirmed they didn't receive notification of the COVID-19 case until 02/04/25 via email from the facility. Further interview revealed they received the email nine days after confirmation and the facility is a little behind in reporting to them. Interview on 02/10/25 at 8:54 A.M. with the Director of Nursing (DON) revealed the facility to report new COVID-19 cases as soon as possible to the health department. The DON confirmed the email dated 02/04/25 was the facility reporting the COVID-19 case to the LHD. The DON stated she called the LHD and reported the case to them but she was unable to provide evidence of the call made. 2.Interview on 02/06/25 at 9:30 A.M. with the Administrator revealed a management staff had been up all night vomiting and the Administrator was unsure if the staff person would be in Interview on 02/06/25 at 9:39 A.M. with the Administrator revealed she did not feel comfortable speaking regarding symptoms in which a staff member is to stay home. The Administrator reported if staff vomited all night she would encourage them to stay home for 24 hours. The Administrator verified there was no facility policy regarding staff illness. Interview on 02/06/25 at 10:30 A.M. via phone with RN #500 and RN #501 revealed best practice for sick staff is to stay home for at least 24 hours and free of symptoms. Both RN #500 and #501 stated the facility should follow their employee illness policy but this was the first time they had heard of a provider not having a policy or procedure regarding staff illness. Interview on 02/06/25 at 11:30 A.M. with Staffing Scheduler #440 revealed staff vomiting all night would not be permitted to work and would be sent home and would need to remain home for 48 hours before returning to work. Interview on 02/06/25 at 2:13 P.M. with the Assistant Director of Nursing (ADON) #336 revealed she would not permit a staff member to work if they vomited the night but the facility did not have an employee illness policy and procedure so the facility would follow the CDC guidelines which is 48 hours after symptoms are relieved. Review of the Center for Disease Control (CDC) guidelines for sick employees revealed all employees should stay home if they are sick until at least 24 hours, both are true: their symptoms are getting better overall, and they have not had a fever* (temperature of 100 degrees Fahrenheit or 37.8 degrees Celsius or higher) and are not using fever-reducing medication. There was no policy for staff illness. 3. Review of the facility water management program revealed the facility did not have water management logs for 2023. Interview on 02/10/25 at 8:54 A.M. with Maintenance Director #373 revealed he had no water management logs for the year 2023. Maintenance Director #373 reported they are to be done throughout the week, but he did not complete them in 2023. 35765 4. Observation of medication administration on 02/05/25 at 12:35 P.M. revealed Licensed Practical Nurse (LPN) #347 did not clean the rubber seal/needle access prior to placing the needle on the humolog KwikPen for Resident #35. On 02/05/25 at 12:40 P.M. an interview with LPN #347 verfied she had not cleaned the rubber seal/needle access prior to placing the needle on the humolog KwikPen for Resident #35. 22653 5. During the onsite survey, the following information was obtained: a.Review of Resident #187's medical record revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, chronic pain syndrome, heart disease, obstructive sleep apnea, and orthopedic aftercare. A nursing note dated 01/27/25 at 6:41 P.M. indicated the nurse received a call from Resident #187's daughter stating Resident #187 told her she had a cough and was coughing up yellow sputum. The nurse advised Resident #187's daughter that the resident did not present with a cough throughout the day as she had been there since 5:45 A.M. and Resident #187 had not complained of respiratory concerns. Resident #187's daughter became very argumentative and belligerent, demanding Resident #187 be sent to the emergency room for evaluation. The assistant director of nursing and certified nurse practitioner were notified of Resident #187's daughter's demands. A change in condition nursing note dated 01/27/25 at 6:55 P.M. indicated family was demanding Resident #187 be sent to the hospital. Resident #187's temperature was 97.7, respirations were 18, and blood pressure was 155/78. Oxygen saturation levels were 92% on room air. A nursing note dated 01/28/25 at 3:08 A.M. revealed Resident #187 returned from the hospital with a diagnosis of influenza A. On 02/03/25 at 10:49 A.M., Resident #187 was observed with isolation signs on her door. Certified Nursing Assistant (CNA) #367 reported Resident #187 was on isolation due to influenza A. b. On 02/03/25 at 10:48 A.M., Resident #186 was observed lying in bed with a basin at the foot of the bed. Resident #186 stated she was recovering from the flu and that was the first morning she had not vomited. Review of Resident #186's medical record revealed diagnoses including traumatic subdural hemorrhage, displaced fracture of the first cervical vertebra, multiple fractures of ribs on the right side, gastro-esophageal reflux disease, generalized anxiety disorder, fibromyalgia, and mild cognitive impairment. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #186 was cognitively intact. A nursing note dated 02/01/25 at 3:30 P.M. indicated Resident #186's family reported to the nurse that Resident #186 voiced her stomach was upset, then had an emesis. Resident #186 verified she had an emesis but denied headache, chest pain, and shortness of breath. Mylanta was administered and Resident #186 was encouraged to rest. A nursing note dated 02/01/25 at 5:08 P.M. indicated staff reported Resident #186 had another large emesis. Resident #186 reported an upset stomach and Resident #186 had another extra large emesis in front of the nurse which was yellow bile in color. Resident #186 also complained of a headache from all this throwing up. Resident #186 refused dinner and was encouraged to increase fluid intake. A nursing note dated 02/02/25 at 12:21 P.M. indicated Resident #186 refused both breakfast and lunch. Resident #186 had two additional emesis and complained of a queasy stomach. An electronic Medication Administration Record (eMAR) note dated 02/02/25 at 7:26 P.M. revealed senna-plus was held due to diarrhea. A nursing note dated 02/03/25 at 12:41 A.M. revealed a COVID test was negative. c. On 02/03/25 at 1:10 P.M., Resident #71 stated she was starting to feel a little better, stating she had been having flu symptoms. Review of Resident #71's medical record revealed diagnoses including cerebral infarction, type two diabetes mellitus, difficulty swallowing, migraine, and anxiety disorder. A quarterly MDS dated [DATE] revealed Resident #71 was cognitively intact. A nursing note dated 02/01/25 at 5:44 P.M. indicated Resident #71 had an emesis shortly after receiving her dinner tray. Resident #71 reported she opened her dinner tray and smelled it causing her stomach to become upset. Resident #71 had a large emesis and refused the rest of her dinner tray. Resident #71 requested to return to bed due to not feeling well. An eMAR note dated 02/01/25 at 8:53 A.M. indicated imodium was administered for loose stools. A nursing note dated 02/01/25 at 11:53 P.M. indicated Resident #71's temperature was 97.5. Resident #71 had a liquid emesis and three bowel movements of diarrhea. Imodium was administered on as necessary basis. An eMAR note dated 02/02/25 at 4:02 A.M. revealed the imodium had been ineffective. A nursing note dated 02/02/25 at 12:17 P.M. revealed Resident #71 had refused breakfast and lunch and had a small emesis. Resident #71 complained of an upset stomach. An eMAR note dated 02/02/25 at 7:42 P.M. indicated imodium was administered for loose stools. An eMAR note dated 02/03/25 at 2:49 A.M. indicated the imodium was effective. d. On 02/03/25 at 10:39 A.M., Resident #69 was observed in bed holding a basin in her hands. Upon hearing a knock on the door, Resident #69 stated not to enter because she had the flu. Review of Resident #69's medical record revealed diagnoses including heart failure, anxiety disorder, and depression. No documentation of flu-like or virus symptoms were recorded. A quarterly MDS dated [DATE] indicated Resident #69 was cognitively intact. On 02/03/25 At 10:44 A.M., the Director of Nursing (DON) stated Resident #69 did not have flu but was on hospice and it was routine for her to complain in the mornings then be fine the remainder of the day. e. On 02/03/25 at 10:55 A.M., Resident #73 stated she had the flu for two days. Review of Resident #73's medical record revealed diagnoses of cerebral infarction, hypertension, anxiety disorder, epilepsy, gastro-esophageal reflux disease and trouble swallowing. A quarterly MDS dated [DATE] revealed Resident #73 was cognitively intact. Review of progress notes on 02/02/25 indicated Resident #73 had diarrhea and vomiting requiring her to be changed eight times, complained of a headache and feeling sick to her stomach. The February 2025 MAR revealed imodium AD was administered on 02/03/25 at 3:14 A.M. for loose stools. f. On 02/03/25 at 10:51 A.M., Resident #23 was observed lying in bed with the head of her bed raised. Resident #23 stated she was vomiting that morning and felt chilled. Review of Resident #23's medical record revealed diagnoses including non-pressure chronic ulcer of the right foot, cerebral infarction, acute pulmonary edema, type two diabetes mellitus, chronic respiratory failure, chronic obstructive pulmonary disease, morbid obesity, asthma, heart disease and dependence on renal dialysis. A modification of a quarterly MDS dated [DATE] indicated Resident #23 was cognitively intact. Nursing notes on 02/03/24 revealed general complaints about not feeling well. Resident #23 was sent to the hospital from the wound care center on 02/04/25 and diagnosed with cellulitis. On 02/03/25 after resident interviews between 10:33 A.M. and 1:10 P.M. revealed multiple residents reported flu symptoms and were not noticed in isolation, the Director of Nursing (DON) was interviewed and stated the residents mentioned were a group of friends who talk and convince one another of ailments. The DON denied any of the residents had flu except Resident #187. On 02/23/25 at 10:57 A.M., Certified Nursing Assistant (CNA) #367 stated she had noticed an increase of residents with flu-like symptoms with abnormal vomiting and diarrhea and complaints of overall not feeling well. On 02/06/25 (time withheld to aid in maintaining confidentiality) a certified nursing assistant who requested anonymity stated she had noticed multiple residents on B hall had flu-like symptoms and it continued to spread. CNA #436 stated she did not believe the facility was testing symptomatic residents. On 02/06/25 at 11:00 A.M., the DON indicated although multiple residents had emesis, diarrhea and other symptoms from 01/27/25 to 02/02/25, Resident #71 had a history of nausea, vomiting and diarrhea. Resident #23 frequently complained of not feeling well and skipped appointments and treatment due to such so it was not a new onset illness. No explanation was provided as to the reason multiple residents had issues with similar symptoms within a day or two of one another other than the facility had an ill population. The DON stated she did not suspect an infectious outbreak because no residents had an elevated temperature. Lastly, the DON shared no tracking or increased precautions were needed.

Based on observations, interviews, record reviews, and facility policy, the facility failed to ensure the E wing (memory care unit) was homelike by having a basin on the hallway floor outside of Resident #55's room to collect water from a ceiling leak for an extended period of time and by having walls in disrepair in 9 resident's (#24, #35, #54, #62, #63, #76, #78, #335, and #336) rooms. This affected 10 residents (#24, #35, #54, #55, #62, #63, #76, #78, #335, and #336) out of 26 residents who resided on the E wing (memory care unit). Findings include: 1. Review of medical record for Resident #55 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease (COPD), unspecified dementia, malignant neoplasm of bladder (bladder cancer), benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (enlarged prostate), and major depressive disorder. The resident was at moderate risk of falling. Review of Resident #55's quarterly Material Data Set (MDS) assessment revealed the resident was severely impaired cognitively; exhibited inattention behavior, which was continuously present and did not fluctuate; rejected care daily; used a walker and could walk up to 150 feet with supervision or touch assistance from staff; and had no falls since prior assessment. Observation on 02/03/25 at 10:09 A.M. revealed a yellow square plastic basin sitting on the floor of the hallway with a wet floor sign sitting next to the basin, which was blocking part of Resident #55's doorway. The basin appeared to be collecting water from a ceiling leak. Interview on 02/03/25 at 12:32 P.M. with Responsible Party of Resident #55 revealed the last time she visited the resident about two weeks ago, there was a basin on the floor collecting water outside his room. Observation on 02/04/25 at 11:04 A.M. revealed the yellow plastic basin remained on the hallway floor with a caution wet floor sign observed sitting to the left of the sign right outside Resident #55's door. Interview on 02/04/25 at 2:17 P.M. with Certified Nursing Assistant (CNA) #433 revealed the drip pan had been there for months and having a basin collecting water from a ceiling leak was not homelike. Interview on 02/04/25 at 11:31 A.M. with Licensed Practical Nurse (LPN) #347 revealed the basin had been there for a couple months. Observation on 02/05/25 at 11:31 A.M. revealed the yellow basin and the wet floor sign had been removed from the hallway floor outside Resident #55's doorway. Interview at the time of observation with Resident #55 revealed he was unsure how long the yellow basin and wet floor sign had been outside his room. He stated at his home he wouldn't have had a bucket collecting water from a leak in the ceiling for a long time. Observations on 02/05/24 during an environmental tour from 1:35 P.M. to 1:47 P.M. with Maintenance Supervisor (MS) #373 and the Administrator revealed the yellow basin and wet floor sign had been removed from the hallway outside Resident #55's room. Interview at the time of observation with MS #373 confirmed the yellow basin and wet floor sign had been removed that morning since the ceiling was no longer leaking. He stated the roof above the hallway outside Resident #55's room had sprung a small leak, which he thought he had fixed but the leak continued. He stated he never called a roofer to come in and fix the leak and the leak had been going on and off for about a month or two. He confirmed having a basin collecting water from a leak in the ceiling for an extended period was not homelike. 2. Interview on 02/05/24 at 1:00 P.M. with family of Resident #336 revealed the gouges behind the bed and the condition of the wall was not homelike, and they wouldn't have had a wall like that at home. Environmental tour on 02/05/24 from 1:35 P.M. to 1:47 P.M. with Maintenance Supervisor #373 and Administrator revealed the following concerns on the E wing (the memory care unit): -On the right wall directly behind Resident #76's headboard was one circular softball sized black mark and 14 black linear marks varying in width from pencil thin to approximately one inch wide and approximately one to three inches long, and three linear gouge marks which caused the paint to be removed. -On the right wall directly behind Resident #35's headboard were 10 black pencil thin linear lines, approximately two feet long, and a large area, approximately two feet wide and one feet long, with many linear gouge marks, which caused areas of the paint to be removed. -On the left wall directly behind Resident #78's headboard and to the right of the headboard were 21 gouged areas varying from pencil thin to one half inch wide and one inch long, which caused areas of paint to be removed -On the right wall behind Resident #24's headboard and two feet on each side of the headboard was extensive damage to the wall with multiple gouged marks, which caused paint to be removed or peeled back, and multiple black linear marks. -On the left wall directly behind Resident #336's headboard were many gauge marks approximately one inch wide by four inches long, which caused areas of paint on the wall to be removed or peeled back -On the right wall to the right side of Resident #62's headboard were four circular quarter sized indentations in a line from the floor to halfway up the wall, and there was an abundance of linear gauge marks directly behind the headboard and behind the bedside table to the left of the headboard, which caused areas of the paint to be removed. -On the left wall directly behind and to the right of Resident #335's headboard was a large area with multiple gouged areas in the wall which had removed some of the paint. -On the right wall directly behind Resident #54's headboard were many gouged marks, which had caused the paint to be removed. -On the left wall directly behind Resident #63's headboard were many black linear marks and gouge marks in the wall which had removed or peeled back the paint. Interview on 02/05/24 with MS #373 during an environmental tour from 1:35 P.M. to 1:47 P.M. confirmed the areas of concern and stated maintenance didn't tour the facility for concerns and was only made aware of maintenance concerns through TELS (a platform used by maintenance staff for work orders). He stated he was responsible for many items in the facility, and it was hard to get everything done. Review of facility policy Resident Rights, revised September 2022, revealed a resident has a right to a dignified existence. This deficiency represents non-compliance investigated under Complaint Number OH00161856.

Based on review of employee files and staff interviews, the facility failed to consistently complete staff evaluations for two Certified Nursing Assistants (CNA). This was identified in two personnel files (CNA #367 and #370) out of five employee files reviewed and had the potential to affect all residents except the 26 residents (#12, #17, #18, #20, #24, #29, #30, #35, #42, #45, #48, #49, #53, #54, #55, #59, #61, #62, #63, #66 #76, #78, #79, #335, #336, #337) on the E wing where CNA #367 and #370 had not worked. Findings include: 1. An interview on 02/05/25 at 11:48 A.M. with CNA #367 revealed she was not receiving evaluations on a consistent basis. Review of CNA #367's employee file revealed a hire date of 11/09/22. There was no 90 day or yearly evaluation for 2023. There was a yearly evaluation dated 11/14/24. Interview on 02/10/25 at 9:05 A.M. and again at 10:42 A.M. with Human Resources (HR) /Personnel Manager #316 confirmed the only evaluation in Resident #367's employee file was dated 11/14/24, and she should have had a 90 day and a yearly evaluation in 2023. HR/Personnel #316 was not sure why the evaluations had been missed. 2. Reveiw of CNA #370 revealed a hire date of 10/07/24. There was no 90-day evaluation in her employee file. Interview on 02/10/25 at 10:42 A.M. with Human Resources (HR) /Personnel #316 confirmed a 90 evaluation had not been completed for CNA #370 and HR/Personnel #316 was not sure why it had been missed.

Based on review of the closed medical record, review of facility investigation, interview and review of the facility policy the facility failed to ensure Resident #82 was free from physical restraints. This affected one resident ( Resident #82) of three reviewed for accidents. Findings included: Review of the closed medical record revealed Resident #82 was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, respiratory failure, iron deficiency anemia, kidney disease, non-ST elevation myocardial infarction, diabetes, pulmonary edema, diabetic neuropathy, hypertension, glaucoma, hyperlipidemia, insomnia, and anxiety disorder. Review of the plan of care dated 11/21/24 with a revision dated of 02/06/25 revealed Resident #82 was at risk for falls related to incontinence, decreased strength and endurance, history of falls, need for activity of daily living assistance, poor balance, and unsteady gait. Interventions included bed alarm, bariatric bed, clear pathways, educate resident and family to call for assistance before transferring, environmental intervention, food and fluids within reach, bed in the lowest position, left chair remote in the pocket to discourage resident from adjusting (approved by the wife), call light within reach, maintain needed items within reach, mat ot the floor beside the bed when occupied, mattress to the open side of the bed, and bolsters to bed to define perimeters. Review of the Five-Day Medicare Minimum Data Set assessment dated [DATE] revealed Resident #82 had intact cognition. He required substantial/maximum assistance for turning and transfers. Physical Therapy Notes dated 01/17/25 revealed Resident #82 was a fall risk. He was legally blind and was weight bearing for only transfers due to bilateral heel ulcers and left toe gangrene. He actively participated with bed mobility. Review of the progress note dated 01/18/25 at 1:00 P.M. revealed staff was passing by the room of Resident #82 and his lift chair was in the high position. Resident #82 was sitting on the floor in front of the chair with the controller in his hand. His range of motion was within normal limits and he denied pain. The staff used a Hoyer lift to put him back to bed. His power of attorney was notified and requested he be sent to the emergency room for a mental status change. Review of the fall occurrence note dated 01/18/25 at 1:06 P.M. revealed Resident #82 was sitting on the floor in front of his lift chair with the recliner in the high position and the controller was in his right hand. The resident stated he did not know what he was doing. The new intervention was to place the lift chair remote in the pocket to discourage him from adjusting. Further review of the medical record revealed no documentation of a restraint assessment for taking the lift chair remote from Resident #82 for a fall intervention. On 02/10/25 at 11:40 A.M. an interview with the Director of Nursing revealed Resident #81's behaviors varied from day to day. She stated he had delusions and tremors on some days and would be able to have a conversation with him other days. She stated they tried several interventions with him, like bringing him out to the nurses station but he would get upset and want to go back to his room. She stated his wife could normally get him to calm down by talking to him but there were days he would not even talk to her. He stated he was able to move himself in the bed and he had therapy services the whole time he was at the facility. She stated he had a lift chair per the wife's request and they did not have any other recliners. She verified they took the remote away for him as an intervention due to he used it to position himself straight up and down in the recliner and he slid to the floor because he did not have the strength to keep himself in the recliner. She stated they would put the remote control in the side pocket on the side of the chair. She stated she did not believe it was a restraint but an interventions to keep him safe from falling out. She stated he was always in the recliner and hardly ever got into his bed. Review of the facility policy titled, Use of Restraints, dated 09/21 revealed restraints would not be used for the safety and well being of the residents and only after other alternatives had been tried unsuccessfully. Residents would only be used to treat the resident's medical conditions and never for disciple or staff convenience or for the preventions of falls. A physical restraint was defined as any manual method, physical, or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restraints normal access to one's body.

Based on review of a Self Reported Incident (SRI) with the facility's investigation, policy review, medical record review, and interview, the facility failed to ensure protection of a resident during an investigation of emotional/verbal abuse and the facility failed to ensure a thorough investigation was completed into allegations of verbal/emotional abuse. This affected one (Resident #188) of two residents reviewed for abuse. Findings include: Review of Resident #188's closed medical record revealed diagnoses including systemic lupus erythematosus (lupus that affects multiple organs and systems), osteomyelitis (infection of the bone) of the left ankle and foot, right sided weakness following a stroke, stage four kidney disease and heart disease. An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #188 was able to make himself understood, was able to understand others, was cognitively intact, and exhibited no behavioral symptoms. A nursing note dated 09/25/24 at 4:50 A.M. indicated a phlebotomist reported Resident #188 was aggressive with her when attempting to draw blood. The phlebotomist reported Resident #188 requested she use a butterfly needle and she explained he did not need a butterfly needle. Resident #188 yelled at the phlebotomist and used explicit language. The note indicated Registered Nurse (RN) #439 attempted to discuss the importance of lab tests and Resident #188 responded he did not need to have the laboratory tests done. Review of SRI #252856 revealed on 10/11/24 at approximately 7:00 A.M. a state survey agency surveyor reported Resident #188 alleged verbal abuse, telling the surveyor a nurse (later identified as RN #439) told him to stop being a cry baby. The report indicated the nurse was not in the facility at the time of the allegation. Registered Nurse (RN) #439 was contacted and immediately suspended pending investigation. Review of the facility's investigation revealed a typed statement signed by the Director of Nursing (DON) which indicated RN #439 was interviewed on 10/11/24 and stated on 09/25/24 Resident #188 could be heard yelling profanities down the hallway. Upon entering the room, Resident #188 was yelling at the phlebotomist to get out of his room and stating the phlebotomist was not going to touch him. Resident #188 proceeded to yell and be verbally aggressive with RN #439 when attempting to redirect and calm him. RN #439 stated she left the room after ensuring Resident #188 was safe. RN #439 denied calling Resident #188 a cry baby or speaking disrespectfully to him. Review of time punches and schedules revealed RN #439 worked night shift on 10/11/24, 10/12/24, and 10/13/24. Review of typed statements dated 10/16/24 indicated Certified Nursing Assistant (CNA) #356 and CNA #398 were interviewed because they worked the shift RN #439 identified during her interview. Both statements revealed they had not witnessed RN #439 call Resident #188 a cry baby or be verbally abusive to him. The final report of the facility's investigation was dated 10/16/24. On 02/06/25 at 3:28 P.M., RN #439 stated she was interviewed regarding anything unusual that occurred with Resident #188 and she reported Resident #188 refused to have his blood drawn for laboratory tests and he got belligerent with her. RN #439 stated she was also trying to obtain vital signs for dialysis. RN #439 stated she was encouraging Resident #188 to have the blood drawn and Resident #188 got upset and kicked her out of his room. A couple weeks later after Resident #188 filed a complaint was when management counseled her not to argue with residents and she was told not to interact with Resident #188. RN #439 stated she believed Resident #188 might have misinterpreted something that was said. RN #439 stated she reported the incident to the Director of Nursing (DON) right after the situation occurred. RN #439 denied she was suspended or missed any work but was counseled before her shift started. On 02/10/25 at 9:59 A.M., the Administrator stated after the allegation was reported on 10/11/24 the DON spoke to Resident #188 and he denied abuse although no statement was written regarding an interview being conducted. The Administrator verified RN #439 was permitted to work on 10/11/24, 10/12/24 and 10/13/24 while she waited for the certified nursing assistants to call back and provide witness statements. Review of the facility's Abuse Investigation and Reporting policy (dated September 2021) revealed the Administrator would suspend immediately any employee who had been accused of resident abuse, pending the outcome of the investigation. b. During the entrance conference held with the Administrator and Director of Nursing (DON) on 02/03/25 the facility's investigation into the allegation was requested. Review of the facility investigation information provided revealed a copy of the SRI, a copy of Resident #188's face sheet, a print out of nursing notes on 09/25/24 at 12:15 A. M, 12:34 A. M, and 4:50 A. M, a printed statement for an interview of RN #439 signed by the DON and 13 forms indicated residents were interviewed to ask if they knew who RN #439 was and if they had any issues with her. There was no documented interview of Resident #188 or other staff who could have potentially been a witness or the phlebotomist. On 02/05/25 at 1:55 P.M., the Administrator stated she had attempted to call Laboratory representative #503 so she could interview the phlebotomist but never got a response. The Administrator verified she had documented no attempts to contact the lab and could not provide any dates or times. On 02/05/25 at 2:07 P.M., a message was left for Laboratory Representative #503 requesting a return call. A return call was received at 3:26 P.M. Laboratory Representative #503 reported the phlebotomist who visited the facility to draw labs on 09/25/24 no longer worked for the lab but was a mandated reported and she was not aware of any reports of abuse against the facility. However, she would not get the reports directly. On 02/05/25 at 4:45 P.M. the DON was interviewed regarding the lack of interviews of any additional staff who may have been potential witness to abuse being interviewed. The DON stated she spoke with the Administrator who stated she needed time to search through other SRIs to determine if staff interviews might have been placed in the wrong folder. On 02/05/25 at 5:13 P.M., the DON provided undated papers she stated were sign in sheets for education done after the incident was reported and typed statements indicating Certified Nursing Assistants (CNAs) #356 and #398 were interviewed. Neither of the CNA interviews were signed. On 02/05/25 at 5:17 P.M., the Administrator stated she took CNA #356 and CNA #398's statements over the phone. The Administrator stated she generally spoke to staff and wrote their statements out for them because some staff did not write well. The Administrator verified the statements were not reviewed by staff or signed by them to verify accuracy. On 02/06/25 at 9:45 A.M., the Administrator verified there was no documentation of an interview with Resident #188 being conducted but stated she knew the DON had spoken to Resident #188. On 02/06/25 at 12:46 P.M., CNA #356 reported Resident #188 and RN #439 got into it at various times, one time regarding medication. Resident #188 could be very stern. CNA #356 denied anybody had ever questioned her about Resident #188 or RN #439. CNA #356 denied any knowledge of abuse. On 02/06/25 at 12:58 P.M., the DON stated after receiving the allegation of abuse, she went and spoke with Resident #188. When asked if he had problems with RN #439, Resident #188 responded no black person was going to draw his blood and RN #439 was telling him he just needed to let the phlebotomist draw his blood. On 02/10/25 at 9:07 A.M., the Administrator verified the lack of documentation of an interview with Resident #188 made it difficult to verify the incident occurred at the time of the phlebotomist blood draw or if it was an entirely separate incident in which a staff member called Resident #188 a cry baby. The Administrator verified she had not had staff review/sign their statements and did not interview any additional staff to determine if they had any additional information. Review of the facility's Abuse Investigation and Reporting policy (dated September 2021) indicated all reports of resident abuse or mistreatment should be promptly reported to local, state and federal agencies and thoroughly investigated by facility management. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source was reported, the Administrator would assign the investigation to an appropriate individual. The policy indicated the individual conducting the investigation would, at a minimum, interview any witness to the incident, interview the resident, and interview staff members on all shifts who had contact with the resident during the period of the alleged incident. Witness reports would be obtained in writing. Either the witness would write his/her statement and sign and date it, or the investigator might obtain a statement, read it back to the member and have him/her sign and date it. This deficiency represents non-compliance investigated under Complaint Number OH00161264.

Based on review of the medical record and interview with the staff the facility failed to ensure a Significant Change assessment was completed for Resident #2 after initiating hospice services. This affected one resident (Resident #2) of 26 residents reviewed for comprehensive assessments. Findings included: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, protein-calorie malnutrition, history of falling, kidney disease, vitamin D deficiency, hypothyroidism, hypertension, atherosclerotic heart disease, hyperlipidemia, osteoarthritis, hypotension, depression, anxiety disorder, heart failure, anemia, and edema. Review of the February 2025 physician's orders revealed Resident #2 had an order for hospice dated 01/12/25. Further review of the medical record revealed there was no evidence of a Significant Change Minimum Data Set assessment completed within 14-days of receiving hospice services for Resident #2. On 02/10/25 at 10:08 A.M. an interview with the Director of Nursing confirmed there was no significant change Minimum Data Set assessment completed within 14-day of hospice initiation for Resident #2.

Based on review of the medical record and interview with the staff the facility failed to ensure the comprehensive assessment accurately reflected a pressure ulcer for Resident #82 and correct hearing status and anti-anxiety medication use for Resident #44. This affected two residents ( Resident #44 and #82) of 26 residents reviewed for comprehensive assessments. Findings included: 1. Review of the medical record revealed Resident #82 was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, respiratory failure, iron deficiency anemia, kidney disease, non-ST elevation myocardial infarction, diabetes, pulmonary edema, diabetic neuropathy, hypertension, glaucoma, hyperlipidemia, insomnia, and anxiety disorder. Review of the wound evaluation note dated 11/21/24 at 2:14 P.M. revealed Resident # 82 was admitted with a Stage III pressure ulcer to the sacrum. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 did not have a pressure ulcer. Review of the Discharge Medicare MDS assessment dated [DATE] revealed Resident #82 did not have a pressure ulcer. On 02/06/25 at 3:20 P.M. an interview with the Director of Nursing confirmed the Admission Minimum Data Set (MDS) assessment dated [DATE] and the Discharge MDS assessment dated [DATE] were coded incorrectly indicating Resident #82 did not have a pressure ulcer despite having a pressure ulcer present on admission and discharge. 51514 2. Review of the medical record for Resident #44 revealed the resident was admitted to the facility on [DATE]. Medical diagnoses included recurrent major depressive disorder, anxiety disorder, mild neurocognitive disorder due to known physiological condition with behavioral disturbance, and end stage renal disease. Review of an audiology consult note dated 03/06/24 revealed Resident #44 was referred by the facility due to decreased hearing. The audiology note stated Resident #44's right ear had profound hearing loss and the left ear had moderately severe high frequency sensorineural hearing loss (a type of hearing loss that occurs due to inner ear damage or auditory nerve issues). Review of Resident #44's physician's orders identified orders for Ativan (lorazepam) 0.5 milligram (mg) one tablet by mouth in the morning every Monday, Wednesday, and Friday, for anxiety/agitation related to anxiety disorder (ordered 10/23/24). Review of Resident #44's medication administration record (MAR) revealed Ativan was administered on 12/18/24, 12/20/24, and 12/23/24, Review of the Minimum Data Set (MDS) 3.0 assessment, dated 12/23/24, indicated Resident #44 did not receive any anti-anxiety medication and hearing was assessed as adequate. Interview on 02/03/25 10:34 A.M. with Resident #44 stated they were having increased hearing difficulties. Interview on 02/06/25 at 3:22 P.M. with the Director of Nursing (DON) verified Resident #44's MDS assessment did not accurately reflect the resident taking an anti-anxiety medication or reflect the resident's hearing loss that was indicated on the audiology notes.

Based on record review and interview, the facility failed to develop a comprehensive care plan to include hearing loss and monitoring the correct dialysis access for Resident #44, constipation and diarrhea for Resident #71, and oxygen use for Resident #67. This affected three residents (#44, #67, and #71) of 26 resident records reviewed. The facility census was 89. Findings include: 1. Review of the medical record for Resident #67 revealed an admitted [DATE] with diagnoses including pulmonary embolism, heart failure, hypertension, and type two diabetes mellitus. Review of the physician's orders for February 2025 identified no orders for oxygen use or maintenance of oxygen equipment. Review of Resident #67's care plan, last reviewed 12/10/24, revealed there was no plan of care for oxygen use. On 02/03/25 at 11:04 A.M., observation of Resident #67 revealed he was receiving oxygen via nasal cannula. On 02/03/25 at 11:06 A.M., interview with Licensed Practical Nurse (LPN) #384 confirmed Resident #67 was receiving oxygen. On 02/04/25 at 10:46 A.M., observation of Resident #67 revealed he was receiving oxygen via nasal cannula. On 02/10/25 at 11:12 A.M., interview with the Director of Nursing (DON) confirmed there were no orders or care plan for oxygen use for Resident #67. 22653 2. Review of Resident #71's medical record revealed diagnoses including cerebral infarction, type two diabetes mellitus, depression, migraine, hypertension, hyperlipidemia, hypothyroidism, anxiety disorder, delusional disorder, osteoporosis, and constipation. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #71 was cognitively intact and able to make herself understood. Review of physician orders revealed the following medications for constipation and/or diarrhea were ordered: -miralax 17 grams every 24 hours as needed for constipation with a start date of 06/04/24. The January 2025 Medication Administration Record (MAR) revealed one dose was administered on 01/18/25. -milk of magnesia 30 milliliters every 24 hours as needed for constipation at bedtime if no bowel movement in three consecutive days with a start date of 09/27/24. The January 2025 MAR revealed one dose was administered on 01/14/25 which was ineffective. -bisacodyl laxative suppository 10 milligrams (mg) every 24 hours as needed for constipation at bedtime if no bowel movement after Milk of Magnesia was administered with a start date of 05/30/24 -mineral oil enema 118 milliliters (ml) every 24 hours as needed for constipation every day if no bowel movement after receiving a suppository. If no bowel movement within one hour of receiving the enema notify the physician. The start date was 05/30/24. - imodium A-D two tablets every six hours as needed for diarrhea with two caplets administered after the first loose stool, one caplet after each subsequent loose stool but no more than four caplets in 24 hours with a start date of 01/08/25. The January 2025 MAR revealed one dose was administered on 01/08/25. The February 2025 MAR revealed one dose was administered on 02/01/25 and on 02/02/25. No care plan was located regarding constipation. On 02/03/25 at 1:49 P.M., Resident #71 reported she had problems with constipation and sometimes went four to six days before she was able to have a bowel movement . Resident #71 stated this was not a new problem. While at home she used a little round pill. On 02/06/25 at 7:53 A.M., Certified Nursing Assistant (CNA) #436 stated Resident #71 required assistance to stand and pivot as she did not have use of one side of her body. Resident #71 also required assistance with toileting and was able to wipe herself. However, staff had to finish cleaning her. Resident #71 complained diarrhea at times and would ask for medicine to help her bowels move then Resident #71's daughter would request she be given medication for diarrhea. On 02/10/25 at 10:15 A.M., the Director of Nursing (DON) verified although Resident #71 had complaints of constipation and diarrhea, there was no care plan addressing gastrointestinal concerns (constipation and/or diarrhea). 51514 3. Review of Resident's #44 medical record revealed the resident was admitted to the facility on [DATE]. Medical diagnoses included recurrent major depressive disorder, anxiety disorder, mild neurocognitive disorder due to known physiological condition with behavioral disturbance, and end stage renal disease. Review of the audiology notes revealed Resident #44 had impacted (hard) ear wax removal from the right ear on 08/10/23, impacted ear wax removal from both ears on 10/16/23, profound hearing loss in the right ear on 03/26/24, and moderately severe high frequency sensorineural hearing loss (a type of hearing loss that occurs due to inner ear damage or auditory nerve issues) in the left ear on 03/26/24. Review of Resident #44's care plan, last reviewed on 01/09/25, revealed no focus areas, goals, or interventions for hearing loss or reversible hearing loss. Further review of the care plan revealed a goal for monitoring a dialysis catheter port for signs and symptoms of infection and there was no goal for monitoring the left upper arm fistula (a type of dialysis access which is a surgical joining of a vein and an artery). Review of the dialysis communication report dated 02/02/25 indicated Resident #44 had a left upper arm fistula that was the dialysis access site in use. Interview on 02/03/25 10:34 A.M. with Resident #44 stated they were having increased hearing difficulties. During the interview, the resident frequently was unable to hear questions and needed multiple questions repeated due to not being able to hear the questions. Interview on 02/05/25 at 3:21 P.M. with the Director of Nursing (DON) verified Resident #44's hearing impairment wasn't addressed in the comprehensive care plan. The DON confirmed Resident #44's care plan indicated the resident had a dialysis catheter and did not include monitoring the left upper arm fistula for signs and symptoms of infection. Interview on 02/06/25 at 3:29 P.M. with the DON verified Resident #44 had a left upper arm fistula and did not have a dialysis catheter. Interview on 02/10/25 at 10:44 A.M. with Assistant Director of Nursing #336 confirmed the audiology notes indicated Resident #44 had profound hearing loss and multiple procedures for impacted ear wax removal.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure Resident #55's doorway was free from potential fall hazards. This affected one (#55) resident of three residents reviewed for accidents. The facility census was 89. Findings include: Review of medical record for Resident #55 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease (COPD), unspecified dementia, malignant neoplasm of bladder (bladder cancer), benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (enlarged prostate), and major depressive disorder. The resident was at moderate risk of falling. Review of Resident #55's quarterly Material Data Set (MDS) assessment revealed the resident was severely impaired cognitively; exhibited inattention behavior, which was continuously present and did not fluctuate; rejected care daily; used a walker and could walk up to 150 feet with supervision or touch assistance from staff; and had no falls since prior assessment. Further review of Resident #55's medical record revealed a psychiatric note, dated 12/03/24, which indicated the resident was in his room most of the time, but he would come out to walk with his walker at times. Review of Resident #55's care plan, initiated on 06/20/23, revealed the resident was at risk for falls related to incontinence at times, COPD, BPH, depression, would forget to ring the call light, and had an unsteady gait with a goal to minimize risk for falls/minimize injuries related to falls through next review. Interventions included implement preventative fall interventions/devices. Observation on 02/03/25 at 10:09 A.M. revealed a yellow square plastic basin sitting on the floor of the hallway with a wet floor sign sitting next to the basin, which was blocking part of Resident #55's doorway. The basin appeared to be collecting water from a ceiling leak. Interview on 02/03/25 at 12:32 P.M. with Responsible Party of Resident #55 revealed the last time she visited the resident about two weeks ago, there was a basin on the floor collecting water outside his room. Observation on 02/04/25 at 11:04 A.M. revealed the yellow plastic basin remained on the hallway floor with a caution wet floor sign observed sitting to the left of the sign right outside Resident #55's door. Interview on 02/04/25 at 11:31 A.M. with Licensed Practical Nurse (LPN) #347 revealed the basin had been there for a couple months and confirmed Resident #55 would come out of his room with his rollator and the basin on the floor outside of Resident #55's room was a fall hazard, but no residents had tripped on it. Interview on 02/04/25 at 2:17 P.M. with Certified Nursing Assistant (CNA) #433 revealed the drip pan had been there for months. She stated Resident #55 used a rollator and would have to maneuver the rollator around the yellow basin to leave his room. Observation on 02/05/25 at 11:31 A.M. revealed the yellow basin and the wet floor sign had been removed from the hallway floor outside Resident #55's doorway. Interview at the time of observation with Resident #55 revealed he was unsure how long the yellow basin and wet floor sign had been outside his room. He stated he was able to leave his room by maneuvering his rollator around the sign and basin, which had been sitting on the hallway floor just outside his room. Observations on 02/05/24 during an environmental tour from 1:35 P.M. to 1:47 P.M. with Maintenance Supervisor (MS) #373 revealed the yellow basin and wet floor sign had been removed from the hallway outside Resident #55's room. Interview at the time of observation with MS #373 confirmed the yellow basin and wet floor sign had been removed that morning since the ceiling was no longer leaking. He stated the roof above the hallway outside Resident #55's room had sprung a small leak, which he thought he had fixed but the leak continued. He stated he never called a roofer to come in and fix the leak and stated the leak had been going on and off for about a month or two. Review of facility policy Falls, dated September 2021, revealed the staff would identify interventions to reduce the risk of falls. This deficiency represents non-compliance investigated under Complaint Number OH00161264.

Based on observation, interviews, record review, manufacturer's instructions, and facility policy review, the facility failed to ensure Resident #42 received nectar thick liquids as ordered. This affected one resident (#42); however, it had the potential to affect seven residents (#1, #30, #35, #42, #43, #50, #63) the facility identified as being on a thickened liquids. The facility census was 89. Findings include: Review of medical chart for Resident #42 revealed an admitted [DATE]. Diagnoses included altered mental status, oropharyngeal dysphagia (difficulty swallowing), dementia, schizophrenia (a mental health condition which may result in a mix of hallucinations, delusions, disorganized thinking and behavior), and legal blindness. Review of speech therapy evaluation and plan of treatment for Resident #42, signed 05/15/24, revealed the resident had been referred to speech therapy due to coughing/choking during oral intake, pneumonia, prolonged mastication with solids, and signs/symptoms of dysphagia. Clinical bedside assessment of swallowing revealed Resident #42 coughed one time on thin liquids and swallowing status was normal for mildly thick liquids. Review of care plan, created on 05/15/24, revealed Resident #42 was at altered nutritional status related to dementia and schizophrenia. Interventions included provide meals/snacks/fluids based on resident preferences and physician orders. Review of Resident #42's physician orders revealed an order dated 06/24/24 for regular diet, mechanical soft texture, nectar thick consistency diet. Review of speech therapy discharge summary for Resident #42, signed 06/28/24, revealed the resident had received speech therapy services from 05/15/24 to 06/28/24 and it was recommended the resident receive minced and moist diet consistency and slightly thick liquids (nectar thick). Review of Resident #42's quarterly Minimum Data Set (MDS) assessment, dated 11/15/24, revealed the resident was severely impaired cognitively, exhibited inattention and disorganized thinking behavior continuously which did not fluctuate, required supervision or touch assistance from staff for eating, and was on a mechanically altered diet. Review of Hormel Thick and Easy factory instructions printed on the canister revealed to achieve a mildly thick (nectar consistency) for eight ounces of coffee, two tablespoons and one and a half teaspoons of the product should be added to the liquid. Staff should then stir with a spoon or fork for approximately 15 to 30 seconds and allow one to four minutes for the beverage to reach desired thickness. Observation on 02/03/25 at 11:29 A.M. revealed the coffee on Resident #42's lunch's meal tray was not nectar thick consistency, it was too thin. Certified Nursing Assistant #368 confirmed she had added one and a half tablespoons of thickener to Resident #42's eight ounce mug of coffee and after reading the manufacturer's thickening chart on the canister, she confirmed she hadn't added enough thickening product to the coffee to achieve nectar consistency and then proceeded to add additional thickener to the coffee to achieve the appropriate nectar consistency. Interview on 02/04/25 at 10:21 A.M. with Speech Language Pathologist (SLP) #445 revealed the staff would need to follow the directions on the back of the Hormel Thick and Easy container for mildly thick liquids to achieve a nectar thick consistency. She indicated if the liquids were not thick enough for a resident requiring nectar thick liquids, the resident could develop potential signs and symptoms of pharyngeal dysphagia. Interview on 02/04/25 at 11:26 A.M. with Certified Nursing Assistant (CNA) #390 revealed she also had been adding one and a half tablespoons of the thickening powder to a mug of coffee to achieve nectar thick consistency. Interview on 02/04/25 at 4:44 P.M. with Licensed Practical Nurse (LPN) #347 revealed Resident #42 was on nectar thick liquids. Most of the nectar liquids came from the kitchen prethickened; however, the staff on the floor had to thicken the coffee. After reviewing the Hormel Thick and Easy thickener mixing chart on 02/06/25 at 11:46 A.M. with SLP #444, the speech therapist stated for an eight-ounce cup of coffee, two tablespoons and one and a half teaspoons of the thickener powder would be needed to achieve nectar consistency. She confirmed using one and a half tablespoons of thickener for eight ounces of coffee would achieve a liquid consistency too thin to be considered nectar thick. Review of facility policy Therapeutic Diets, dated 09/01/21, revealed mechanically altered diets, as well as diets modified for medical or nutritional needs, would be considered therapeutic diets, and the facility would ensure each resident received the diet as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00161651.

Based on observation, record review, and interview, the facility failed to ensure Resident #67 had physician's orders for oxygen use, oxygen tubing was dated at the time it was changed, and administration of oxygen was documented in the medical record at the time of each administration and Resident #2's oxygen cannula was stored properly. This affected two residents (#2 and #67) of three residents reviewed for respiratory care. The facility census was 89. Findings include: 1. Review of the medical record for Resident #67 revealed an admitted [DATE] with diagnoses including pulmonary embolism, heart failure, hypertension, and type two diabetes mellitus. Review of Resident #67's care plan, last reviewed 12/10/24, revealed there was no plan of care for oxygen use. Review of the physician's orders for February 2025 identified no orders for oxygen use or maintenance of oxygen equipment. Review of the medication administration record, vital signs, assessments, and progress notes for February 2025 revealed there was no documentation for the administration of oxygen via nasal cannula on 02/03/25 and 02/04/25. On 02/03/25 at 11:04 A.M., observation of Resident #67 revealed he was receiving oxygen via nasal cannula and the oxygen tubing was not dated. On 02/03/25 at 11:06 A.M., interview with Licensed Practical Nurse (LPN) #384 confirmed Resident #67 was receiving oxygen and there was no date on the oxygen tubing to indicate when it was changed. On 02/04/25 at 10:46 A.M., observation of Resident #67 revealed he was receiving oxygen via nasal cannula. On 02/10/25 at 11:12 A.M., interview with the Director of Nursing (DON) confirmed there were no orders or care plan for oxygen use for Resident #67. Review of the facility's policy for oxygen administration, dated 09/2021, revealed the need for oxygen would be determined by a physician's order. 35765 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, protein-calorie malnutrition, history of falling, kidney disease, vitamin D deficiency, hypothyroidism, hypertension, atherosclerotic heart disease, hyperlipidemia, osteoarthritis, hypotension, depression, anxiety disorder, heart failure, anemia, and edema. Observation on 02/03/35 at 10;20 A.M. revealed the portable oxygen tank nasal cannula was hanging on the back of the wheelchair for Resident #2 not in a protective bag. On 02/03/25 at 10:30 A.M. an interview with the Director of Nursing verified the portable oxygen tank nasal cannula was hanging on the back of the wheelchair for Resident #2 not in a protective bag.

Based on record review, review of the facility's dialysis contract, and interview, the facility failed to monitor vital signs and weights before and after dialysis for Residents #52 and #239, and failed to maintain adequate communication with the outside dialysis center for Resident #239. This affected two residents (#52 and #239) of three reviewed for dialysis. The facility census was 89. Findings include: 1. Review of the medical record for Resident #52 revealed an admitted [DATE] with diagnoses including end-stage renal disease, type two diabetes mellitus, dependence on renal dialysis, and heart failure. Review of the physician's orders for February 2025 identified orders for hemodialysis three times weekly on Monday, Wednesday and Friday at the in-facility dialysis center. Review of the dialysis communication reports for Resident #52 revealed pre-dialysis vital signs were not documented on 03/20/24, there was no dialysis communication form for 04/08/24, post-dialysis vital signs were not documented on 04/19/24, pre-dialysis weight and post-dialysis weight were not documented on 04/26/24, pre-dialysis vital signs were not documented on 06/10/24, pre-dialysis vital signs were not documented on 08/14/24, pre-dialysis vital signs were not documented on 08/28/24, pre-dialysis vital signs were not documented on 09/25/24, pre-dialysis vital signs were not documented on 10/28/24, and pre-dialysis vital signs were not documented on 12/24/24. Review of the vital signs recorded in the electronic health record revealed the following: - On 03/20/24, there was no documented oxygen saturation level, pulse, respiration rate, temperature, or weight. - On 04/08/24, there was no documented oxygen saturation level, pulse, respiration rate, temperature, weight, or pre-dialysis blood pressure. - On 04/19/24, there was no documented oxygen saturation level, pulse, respiration rate, temperature, or weight. - On 04/26/24, there was no documented weight. - On 06/10/24, there was no documented oxygen saturation level, pulse, respiration rate, temperature, weight, or blood pressure. - On 08/14/24, there was no documented oxygen saturation level, pulse, respiration rate, temperature, weight, or blood pressure. - On 08/28/24, there was no documented oxygen saturation level, pulse, respiration rate, temperature, weight, or blood pressure. - On 09/25/24, there was no documented oxygen saturation level, pulse, respiration rate, temperature, weight, or blood pressure. - On 10/28/24, there was no documented oxygen saturation level, pulse, respiration rate, temperature, weight, or blood pressure. - On 12/24/24, there was no documented oxygen saturation level, pulse, respiration rate, temperature, weight, or blood pressure. On 02/05/25 at 9:04 A.M., interview with the Director of Nursing (DON) verified vital signs were not documented on every dialysis day for Resident #52. Review of the facility's dialysis services and coordination agreement, dated 09/01/22, revealed facility staff were required to provide a dialysis communications form upon bringing residents to the dialysis center. Facility staff were required to list the resident's most recent vital signs, current weight, mental status, any change in condition since the previous dialysis treatment, and new medications. 2. Review of the medical record for Resident #239 revealed an admitted [DATE] with diagnoses including end-stage renal disease, type two diabetes mellitus, dependence on renal dialysis, and hypertension. Review of the physician's orders for February 2025 identified orders for dialysis every Tuesday, Thursday and Saturday and to obtain vital signs prior to and upon return from dialysis. Review of the dialysis communication forms revealed there was pre-dialysis weight or post-dialysis vitals recorded on 01/14/25, and there were no communication forms between the facility and the outside dialysis center on 01/18/25, 01/21/25, 01/23/25, 01/25/25, 01/28/25, and 01/30/25. Review of the vital signs recorded in the electronic health record revealed the following: - On 01/18/25, there was no documented pre-dialysis oxygen saturation level, pulse, respiration rate, temperature, weight, or blood pressure. - On 01/21/25, there was no documented pre-dialysis weight. - On 01/23/25, there was no documented pre-dialysis or post-dialysis weight. - On 01/25/25, there was no documented pre-dialysis or post-dialysis weight, and no documented post-dialysis oxygen saturation level, pulse, respiration rate, temperature, weight, or blood pressure. - On 01/28/25, there was no documented pre-dialysis oxygen saturation level, pulse, respiration rate, temperature, weight, or blood pressure, and no documented post-dialysis weight. - On 01/30/25, there was no documented pre-dialysis or post-dialysis blood pressure or weight, and there was no documented post-dialysis oxygen saturation level, pulse, respiration rate, or temperature. Review of the progress notes for January 2025 and February 2025 revealed two progress notes, dated 02/04/25 at 8:35 A.M. and 02/04/25 at 9:26 A.M., that the dialysis center was notified Resident #239 was being transferred to the hospital and would not be attending dialysis that date. There was no other documented communication between the facility and the dialysis center. On 02/05/25 at 3:55 P.M., interview with the Director of Nursing (DON) stated Resident #239's dialysis center did not always send the dialysis communication forms back to the facility. On 02/05/25 at 4:40 P.M., interview with the DON verified the facility did not have dialysis communication forms for Resident #239 for all dialysis days. On 02/06/25 at 9:56 A.M., interview with Dialysis Administrative Assistant #520 stated dialysis communication forms were not always sent with residents to dialysis and even if they were, they were not always completed by dialysis staff after each dialysis treatment.

Based on record review, interviews, and facility policy review, the facility failed to ensure narcotic pain medications were provided according to physician orders and non-pharmacologic pain relief interventions were encouraged prior to medication administration. This affected one resident (#14) of five residents reviewed for unnecessary medications. The facility census was 89. Findings include: Review of medical record for Resident #14 revealed an admitted [DATE]. Diagnoses included end stage renal disease (ESRD) with dependence on dialysis, muscle weakness, spondylolisthesis of thoracolumbar region( a condition where a vertebra slips out of alignment and presses on the vertebra below it which can put pressure on nerves around spine and cause back pain), osteoarthritis (a condition where the protective cartilage that cushions the end of bone wears down over time which can cause pain) of right knee, hydronephrosis with renal and ureteral calculous obstruction ( a condition where urine builds up in a kidney stone due to a blockage), generalized osteoarthritis, and chronic gout ( a form of arthritis characterized by sudden, severe attacks of pain, swelling, redness and tenderness in one or more joints). Review of care plan initiated on 10/23/22 revealed Resident #14 had a potential for pain related to end stage renal disease with dialysis status. Interventions included administering medications per physician orders. Review of Resident #14's modification of annual Minimum Data Set (MDS), dated [DATE], revealed the resident was cognitively intact, and during the assessment reference period had not received routine pain medications but had received non pharmacological interventions and as needed pain medications and had occasional pain level of five, which had affected her sleep and day to day activities. Review of Resident #14's physician orders revealed an order dated 12/24/24 for hydrocodone-acetaminophen tablet 5-325 milligram (mg), give one tablet every six hours as needed for a pain level between five and ten, with ten being the worst pain possible. Review of Resident #14's January 2025 Medication Administration Record (MAR) revealed the resident had received one tablet of hydrocodone-acetaminophen 5-325 mg for a pain level less than five on the following days : on 01/04/25 at 8:56 P.M. for a pain level of three, on 01/05/25 at 7:04 P.M. for a pain level of zero, on 01/06/25 at 8:33 P.M. for a pain level of three, on 01/08/25 at 4:37 A.M. for a pain level of three and again at 8:49 P.M. for a pain level of three, on 1/09/24 at 9:47 P.M. for a pain level of four, on 01/11/25 at 7:42 P.M. for a pain level of zero, on 01/12/25 at 7:38 P.M. for a pain level of zero, on 01/13/25 at 6:43 P.M. for a pain level of three, on 01/14/25 at 8:25 P.M. for a pain level of three, on 01/17/25 at 7:47 P.M. for a pain level of two, on 01/18/25 at 8:43 P.M. for a pain level of three, on 01/20/25 at 6:52 A.M. for a pain level of three and again at 8:39 P.M. for a pain level of three, and on 01/21/25 at 7:37 P.M. for a pain level of three. An interview on 02/10/25 at 8:15 A.M. with the Director of Nursing (DON) revealed Resident #14 was to receive one tablet hydrocodone-acetaminophen 5-325 mg when the resident was experiencing pain levels between five and ten scale. After reviewing the January 2025 MAR for Resident #14, the DON confirmed hydrocodone-acetaminophen 5-325 mg had been given to Resident #14 with pain levels less than five and stated she shouldn't have been given hydrocodone-acetaminophen 5-325 mg with pain levels less than five. The DON verified the nurse is to try non-pharmacologic interventions for pain and document those interventions tried in the progress notes or on the MAR. The DON confirmed there was no evidence to support the interventions were tried/offerred. Review of facility policy Pain Assessment and Management, dated September 2021, revealed pain management includes effectively recognizing the presence of pain, developing and implementing approaches to pain management, identifying and using specific strategies for different levels of pain. The nurses were to implement the medication regimen as ordered. Review of facility policy Administering Medications, undated, revealed medications must be administered in accordance with the orders. This deficiency represents non-compliance investigated under Complaint Number OH00161651.

Based on review of resident photographs, facility fall log review, resident medical record review, facility policy review and staff interview, the facility failed to appropriately identify and assess an acute change in Resident #98's condition (including altered mental status/and increased falls) to provide timely medical intervention/treatment for the resident. This affected one resident (#98) of three residents reviewed for falls. The facility census was 98. Actual harm occurred on 11/29/23 when Resident #98, who experienced an acute change in condition including three falls within an hour (between 8:00 A.M. and 9:00 A.M.), was not comprehensively assessed or provided timely medical evaluation/intervention. On 11/29/23 at approximately 2:42 P.M., following a fourth fall on this date, Resident #98 was transferred to the local emergency department for evaluation where she was assessed to have an elevated temperature of 103.1 degrees Fahrenheit (F) and was admitted for treatment of a urinary tract infection. The resident was hospitalized until 12/07/23. Findings include: Review of Resident #98's closed medical record revealed an admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease and hypertension. The resident was transferred to the hospital on 11/29/23 and did not return to the facility. Review of an Activity of Daily Living (ADL) self care performance deficit care plan dated 09/29/22 revealed the resident transferred with supervision assistance and used a walker for ambulation and transfer. Review of Resident #98's Minimum Data Set (MDS) 3.0 annual assessment with a reference date of 11/04/23 indicated the resident had an independent cognition level, used a walker for ambulation, required independent to limited staff assistance with mobility, was independent for transfers, was at risk for falls and had no falls since the previous assessment. Review of the resident's nursing progress notes revealed the first nursing progress note completed on 11/29/23 was an entry dated 11/29/23 at 9:45 A.M. as a late entry note. The note included the following: This nurse arrived on the unit at nurses request that resident be transferred to a psychiatric hospital for evaluation due to falls. Staff reported two unwitnessed falls this morning. The resident was noted to have purple discoloration to the right fourth knuckle and forearm and light purple scattered petechiae to her face. The note revealed the resident denied pain and had active range of motion/typical strength at that time. The note revealed the Psych 360 Nurse Practitioner would be in the facility tomorrow to evaluate the resident. Review of the facility fall and accident log for the last 30 days (11/12/23-12/12/23) revealed Resident #98 sustained four falls on 11/29/23. The resident, who had been assessed previously to have independent cognition, required limited assistance with transfers and no recent history of falls, sustained three falls within an hour (8:00 A.M., 8:30 A.M. and 8:50 A.M.) with noted increase in confusion during this time period. A fall investigation, completed on 12/01/23 by the Director of Nursing (DON) revealed on 11/29/23 at 8:00 A.M. Resident #98 experienced an unwitnessed fall in her bathroom. Staff indicated the resident was not using her rollator walker to assist with ambulation. Staff assisted the resident back to her bed with walker and reminded the resident to use the walker for ambulation. State tested Nurse Aide (STNA) reported bruising noted to resident's right hand knuckles, right arm and right side of face. There was no evidence of any additional comprehensive assessment being completed, including vital signs or changes in the resident medical/mental condition or status following this fall. Neither the physician or resident's family were notified of this fall. A fall investigation, completed on 12/01/23 by the DON revealed on 11/29/23 at 8:30 A.M. Resident #98 experienced an unwitnessed fall in her room near her doorway. Staff members were ambulating through the hallway picking up breakfast trays when the STNA observed the resident laying on her right side on the floor. Resident #98's oxygen concentrator was nearby and unplugged from the wall. [NAME] remained near the bed. STNA reports she notified nurse who assessed the resident. Resident assisted to bed in lowest position and oxygen reapplied. The investigation identified the root cause of fall was weakness, impaired gait, ambulating without assistance with lack of required oxygen therapy as a contributing factor. There was no evidence of any additional comprehensive assessment being completed, including vital signs or changes in the resident medical/mental condition or status following this fall or additional information related to the resident's weakness or impaired gait. Neither the physician or resident's family were notified of this fall. A fall investigation, completed on 12/01/23 by the DON revealed on 11/29/23 at 8:50 A.M. Resident #98 sustained an unwitnessed fall in her room at the bedside. The STNA ambulated past the resident's room and found her on the floor next to bed rolling back and forth. The STNA alerted the resident's nurse. The resident was unable to offer insight in cause of fall. STNA and nurse assisted resident into wheelchair with Dycem seating surface and anti-tippers then positioned resident in hallway next to nurse's station for supervision. The root cause analysis indicated the resident had poor safety awareness with increased confusion noted at this time. There was no evidence of any additional comprehensive assessment being completed, including vital signs or changes in the resident medical/mental condition or status following this fall or additional information related to the resident's increased confusion at that time. Neither the physician or resident's family were notified of this fall. Record review revealed no nursing progress notes were documented between the note on 11/29/23 at 9:45 A.M. and the note on 11/29/23 at 3:02 P.M. The nursing progress note, dated 11/29/23 at 3:02 P.M. revealed the resident was found on the floor in her bathroom by an STNA after she had taken in her breakfast tray. When asked what happened the resident stared blankly at staff. Ten minutes later the resident was observed by the STNA attempting to sit on the floor and roll around, back and forth in front of her bed. When asked what happened at that time she was breathing with pursed lips with a moan on exhale and wouldn't answer any of staff's questions. Physician notified but did not return call. The note revealed the DON was notified and had refused to let this nurse send resident out to emergency room for observation and follow-up, stating there is nothing wrong with the resident that she needs to be sent out for. The resident was brought to the hallway in a wheelchair to be monitored by floor nursing staff. The resident continued to try to stand up and ambulate without assistance or rollator walker. A short while later, during lunch, staff had found her with her left leg around the wheelchair break handle and she was laying in the seat of the wheelchair holding on to the backrest. Staff assisted the resident to stand and sit in the wheelchair. Resident refused her lunch tray. Just as shift had changed at roughly 2:42 P.M., when on-coming nurse turned onto the hallway, the resident stood without assistance and fell forward onto her face. She hit her face on the floor and had a very large lump with purple bruising. The resident's forehead also had some small red dots that resembled petechiae. The resident's left dorsal hand had a large purple bruise as well as her left forearm showed purple bruising. The physician was called with no response. The afternoon shift nurse assessed the resident. The note revealed DON notified and still refusing to send resident out but with persistence from this nurse DON than said to send her out and that she was done arguing with this nurse. 911 called. The nursing progress note also included the resident had shown some behaviors prior to these events. Regular floor staff noticed behaviors that had seemed to become worse over a short period of time that was observed after a medication dosage was decreased. Floor staff had asked that the resident's medication be reviewed and tailored to address her specific needs due to a decline in mood and behaviors starting. The DON and Assistant Director of Nursing (ADON) didn't think the resident would benefit from a review and nothing else had been said by them about it. The nursing progress note revealed the nurse completing the note asked multiple times this shift for one on one assistance and was denied by DON and ADON. Review of a facility fall investigation revealed Resident #98 sustained a fourth fall on 11/29/23 at 3:00 P.M. The fall investigation, completed by the DON on 12/01/23 revealed Resident #98 experienced a fall in the hallway that resulted in bruising to her face when she rose from her wheelchair to ambulate without assistance and fell forward striking her face on the floor. An STNA reported she heard a noise followed by the nurse calling for help and came out of a resident's room to observe the resident on the floor on her abdomen. The STNA assisted other staff to position the resident back in her wheelchair and immediately noted bruising over the resident's left eye and bleeding from her left wrist. The STNA then observed the nurse notify the DON and call 911 for transfer to the emergency room for evaluation. Root cause of fall was altered cognition related to acute illness and intervention was evaluation in emergency room . The nursing notes revealed no evidence of comprehensive resident assessment including assessment of vital signs, cognition and overall status after each of the the first three falls (11/29/23 at 8:00 A.M., 8:30 A.M., and 8:50 A.M.). After the fourth fall (11/29/23 at 3:00 P.M.), Resident #98 was assessed for injury with blood pressure, heart rate and respiration rate assessed with pulse of 121 beats per minute, respirations of 24 breaths per minute and blood pressure of 129/91 mmHg (millimeters of mercury). There was no evidence the vital sign assessment included obtaining the resident's body temperature. The last temperature recorded for the resident was on 11/26/23 at 9:55 A.M. with temperature of 97.4 F. A nursing note on 11/29/23 at 9:20 P.M. indicated Resident #98 was still at the hospital and had (an elevated) temperature of 103.1 degrees F. An additional nursing note on 11/29/23 at 11:50 P.M., indicated Resident #98 was admitted to the hospital with admission diagnoses that included altered mental status, urinary tract infection and status post fall. Review of photographs, taken of Resident #98 on 11/29/23 at the hospital, provided by the resident's representative revealed numerous bruises to the resident's bilateral eyes, forehead, right elbow, left elbow and forearm and right hand. All bruises were red to purple in color and new in appearance. Review of hospital emergency room evaluation and admission records revealed Resident #98 was admitted to the hospital from 11/29/23 to 12/07/23 with admission diagnoses that included mechanical falls, urinary tract infection, concussion and extracranial scalp hematoma. Hospital stay was complicated with respiratory failure and urinary retention. Admission history and physical identified bruising and swelling around both eyes. Urinalysis identified a large amount of bacteria growth in the resident's urine. Temperature was assessed as being 103.1 degrees F. The resident did not return to the facility following this hospitalization . On 12/12/23 at 11:55 A.M. interview with the Director of Nursing revealed on 11/29/23 nursing staff failed to completely assess Resident #98 following falls including assessment with vital signs and temperature. The DON further verified Resident #98 was admitted to the hospital with a UTI and altered mental status which was a probable cause of the falls on 11/29/23. The surveyor requested to review the facility's post fall assessment policy. On 12/19/23 at 10:30 A.M. the DON reported no post fall assessment policy was found. Review of the facility undated policy Change in Resident's Condition or Status revealed the nurse would notify the resident's attending physician or physician on call when there has been a(an) accident or incident involving the resident. The nurse would record in the resident's medical record information relative to changes in the resident medical/mental condition or status. This deficiency represents non-compliance investigated under Complaint Number OH00148864.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on observation, medical record review, review of a facility investigation, interviews with facility staff, Family Member #200, Physician #300, and review of the facility policy on elopement, the facility failed to provide adequate supervision to prevent Resident #1, who had moderately impaired cognition and a diagnosis of [CONDITION(S)], from leaving the facility unsupervised. This resulted in Immediate Jeopardy on 10/10/22 between 12:00 A.M. and 2:00 A.M. when Resident #1 was able to enter the key code to unlock the door at the main facility entrance, due to the code being taped to the code box and exit the facility unsupervised. The potential for serious life-threatening harm and injury occurred when the resident was missing for up to two hours during the night, ultimately being found by a passerby lying by a main road in front of the facility approximately 525 feet from the facility entrance with an abrasion to her knee. This affected one resident (#1) of three residents reviewed for accident hazards/elopement. The facility identified 14 current residents, Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14 who were at risk for elopement. The facility census was 98 On 10/18/22 at 3:30 P.M., the Administrator, Interim Director of Nursing (DON), and Assistant Director of Nursing were notified Immediate Jeopardy began on 10/10/22 at approximately 12:00 A.M. when staff last observed Resident #1 in the facility. Between 12:00 A.M. and 2:00 A.M. the resident was able to exit the facility unsupervised, after entering the key code to the main entrance that was posted on the door. Facility staff were unaware Resident #1 was missing from 12:00 A.M. until 2:00 A.M. at which time a passerby noticed the resident on the ground by the road (a road with a 45 mile per hour speed limit). The resident was returned to the facility and assessed to have abrasions (top layer of skin removed) to her right knee. The past noncompliance immediate jeopardy began on 10/10/22. The immediate jeopardy was removed and the deficient practice corrected on 10/11/22 after the facility implemented a systemic plan that included the following actions: On 10/10/22, around 2:00 A.M. Registered Nurse (RN) #211, who was leaving the facility at the end of the shift was alerted by a passerby who entered the building to inform her a resident (subsequently identified as Resident #1) was outside the facility on the ground with her walker next to her. Interview with the resident revealed she walked to the front door, read the sign on the door which contained the door code, entered the code, and exited through the front door. The resident informed staff she was going to see her uncle and then her mom. The resident reported she was walking down the hill with her walker and her walker started to go faster than her and she fell . On 10/10/22 at approximately 2:00 A.M., Resident #1 was returned to the facility and assessed to have an abrasion to her right knee. On 10/10/22 at 2:00 A.M. Resident #1 was placed on every 15 minutes checks until she was moved to the facility secured care/locked unit at 3:15 A.M. at which time every 15-minute checks continued for 72 hours. On 10/10/22 at 2:10 A.M. the Administrator was notified of the elopement incident by Licensed Practical Nurse (LPN) #215. On 10/10/22 at 2:30 A.M. the Interim Director of Nursing was notified of the incident by the Administrator. On 10/10/22 at 2:30 A.M. RN #210 initiated a headcount on all residents in the facility to ensure all residents were accounted for, all residents were present in the facility at that time. On 10/10/22 at 3:12 A.M. Physician #300 was notified of the incident involving Resident #1. On 10/10/22 at 3:53 A.M. Resident #1's son and daughter were notified of the elopement incident. On 10/10/22 at 8:15 A.M. the Administrator removed the key code sign with the door code from the facility door. On 10/10/22 at 10:35 A.M. RN #216 initiated a facility wide audit to ensure all residents had updated elopement assessments. On 10/10/22 at 12:29 P.M., RN #216 completed an elopement assessment for Resident #1 which indicated the resident was a high risk for elopement and her care plan was updated. On 10/10/22 at 2:19 P.M., RN #216 completed the secured unit assessment for Resident #1, the resident's daughter and the physician were notified and all in agreement for the resident to remain on the secured unit due to her high risk for elopement. The resident's care plan updated. On 10/10/22 at 6:00 P.M. RN #216 audited the care plans and Kardex information for all residents at risk for elopement to ensure appropriate interventions were in place. On 10/10/22 at 6:23 P.M. Resident #1 was assessed by Psychiatric Nurse Practitioner #219 . On 10/10/22 at 6:32 P.M. the Administrator educated all facility staff related to not displaying and not sharing the secure codes with residents or family members. On 10/10/22 at 6:39 P.M. the Administrator trained all staff on the facility Elopement Best Practice. On 10/10/22 at 8:13 P.M. the Administrator completed an audit on all doors equipped with secure codes to ensure the code to exit was not displayed at the door. On 10/11/22 at 9:10 A.M. audits were initiated by the Administrator/designee to be completed three times a week for four weeks on all doors equipped with sensor alarms to ensure their function and placement. Any negative findings would be addressed immediately by the administrator and reported to the Quality Assurance (QA) committee for tracking and trending. On 10/11/22 from 9:15 A.M. to 10:00 A.M. Maintenance Director #350, Housekeeping Manager, the Corporate Nurse and Administrator checked all doors equipped with secure codes to ensure proper functioning and to ensure they were loud enough for all staff to hear. On 10/11/22 at 10:30 A.M. Maintenance Director #350/RN #196 conducted staff elopement drills on all shifts. On 10/11/22, at 11:00 A.M. RN #216 added Resident #1 to the elopement book. On 10/11/22 at 11:00 A.M. RN #216 updated the facility elopement folder to ensure all residents at risk for elopement had their picture and face sheet in the elopement folder. On 10/11/22 at 2:30 P.M. Maintenance Director #350 checked all exterior doors armed with magnetic (mag) locks to ensure they functioned per manufactures guidelines. On 10/11/22 at 4:30 P.M. Maintenance Director #350 changed the code on all doors equipped with secure codes. On 10/11/22 at 8:15 P.M. the Ombudsman was in the facility and was notified of the incident and facility plan of action by the Administrator. On 10/18/22 at 10:10 A.M. during the onsite investigation, observation of the facility exit doors revealed there were no sticker(s) attached with the door code to unlock the door(s). On 10/19/22 from 4:20 P.M. to 4:50 P.M. interviews with LPN #193, LPN #191, LPN #192, LPN #187, STNA 209, STNA #190, STNA # 189, STNA #188, and STNA #186 revealed all staff were knowledgeable of the facility elopement policy and voiced they had received education regarding the door code not being posted on the keypad to unlock the doors. Findings Include: Review of the medical record for Resident #1 revealed an admitted [DATE] with diagnoses including cerebral infarction, [CONDITION(S)], pacemaker, [CONDITION(S)], depressive disorder, [CONDITION(S)], anxiety, dementia, [CONDITION(S)] and COVID-19. Review of the plan of care, dated 04/11/22 revealed Resident #1 had impaired cognitive function/dementia or impaired thought process related to a dementia diagnosis. Interventions included to administer medications as ordered, cue, reorient and supervise as needed, monitor, document, report any changes in cognitive function and review medications for possible causes of cognitive deficit. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/13/22 revealed Resident #1 had moderately impaired cognition. The assessment noted the resident did not have any behaviors of wandering and required limited assistance from one staff member for ambulation. Record review revealed the resident did not have any type of wandering or elopement plan of care implemented on admission due to being assessed to be at low risk for elopement. Review of a nursing note, dated 10/10/22 at 3:12 A.M. revealed Resident #1 was brought into the facility in a wheelchair by two nurses (RN #210 and RN #212) to the facility secured unit. The resident's vital signs were within normal limits, and she was assessed to be alert and oriented to self. The resident's skin was warm, dry, and pink in color. Every 15-minute checks were initiated, and two staff members assisted the resident into bed. The resident was noted to have an abrasion to her right knee and the area was cleansed with normal saline and [MEDICATION(S)] and [MEDICATION(S)] was applied. The area was wrapped with Kerlix. The note indicated the physician was aware and the resident was resting quietly in bed with no distress. Review of a late entry nursing note dated 10/10/22 at 3:53 A.M. and authored by RN #210 revealed at 2:00 A.M. the nurse (RN #210), noted Resident #1 was not in her room and was outside. The nurse went outside and observed Resident #1 was sitting on the side of the road. A wheelchair was brought outside and the resident was assisted into the wheelchair. The resident was assessed and had full range of motion to all her extremities, she was alert and oriented to person and place. She was brought back into the facility and placed on the secured unit. The resident was made comfortable in bed. A head-to-toe assessment was completed, and the resident was noted to have an abrasion to her right knee. The physician, the resident's daughter and son were notified. Staffing on the unit where Resident #1 resided revealed there was one nurse, RN #210 and one State tested Nurse Aide (STNA), Agency STNA #199 assigned to care for the 22 residents on the unit on 10/10/22 at the time of the incident involving Resident #1. Review of the local weather hourly weather report revealed the temperature on 10/10/22 between 12:00 A.M. to 2:00 A.M. was 48 to 49 degrees Fahrenheit (F). Review of Psychiatric Certified Nurse Practitioner (CNP) #219's progress note, dated 10/10/22 (no time noted) revealed staff reported Resident #1 had a Brief Interview for Mental Status score of 10 (out of 15), had increased periods of confusion and poor safety awareness. The CNP assessment revealed the resident reported she slept okay, appetite was good, denied feeling depressed or anxious. She reported she lived alone, had decreased memory, and was forgetting things. She was alert and oriented to person and place with a few gaps. She had no [CONDITION(S)] or hypermania, no delusions or paranoia and no audiovisual hallucinations. The resident's mood was pleasant, affect congruent with mood, no acute distress, her decisions, and awareness were impaired and her memory was impaired. The facility provided an investigation of the incident. The investigation, was completed by the Administrator and included interviews with the following staff who were involved with the incident. The investigation did not include a root cause as to why/how the incident occurred or information related to the circumstances surrounding the incident. a. On 10/10/22 (no time noted) Social Service #217 interviewed Resident #1. Resident #1 indicated she had walked to the front door, read the sign (code) on the door, entered the code to the door and the door opened. The resident stated she was going to see her uncle and then her mom (staff indicated this was the name she called her daughter). The resident indicated she was outside with her walker and she started to go down a little hill when her walker started going faster and faster then she fell . b. On 10/11/22 at 8:21 P.M. interview with RN #210 revealed she had seen Resident #1 in her room several times during the evening of 10/09/22 into 10/10/22. She stated both her and Agency STNA #199 were busy answering lights when Resident #1 was last seen. She stated she was sitting at the A wing nursing station charting on the COVID residents and speaking to another resident, who was seated at the nurse's station adjacent to her. She stated she was short in stature and could not readily see above the nursing station's desk ledge. She stated Agency STNA #199 saw Resident #1 go to her room (time not noted) and the resident had been wearing a black top, long pants, and foot coverings, but she was not sure if the foot coverings were shoes or socks. Agency STNA #199 then reported to her Resident #1 was out in the front area but was later seen in the vicinity of her room. Another nurse, Licensed Practical Nurse #197, heard an alarm sounding (time not noted) and called to her to remind her to check her unit. She stated she checked (no time noted) and Resident #1 was observed in her room. RN #210 indicated around 2:00 A.M., a man driving down the road came into the building, encountered RN #211, who was leaving her shift, and notified her there was someone by the road. At this juncture, RN #211 summoned the F unit nurse, Agency Nurse #198, who went out to assist. She stated she had been paged to check her rooms again and Resident #1 was missing from her room. The RN indicated she then brought out a wheelchair to assist Resident #1 back into the building. She stated Resident #1 remarked upon re-entry she wanted to go home. She indicated Resident #1 never came out of her room at night and did not appear to be upset about anything. She stated Resident #1 did not inform her how she got out of the building, and she had not asked her. She stated she was unsure of the timeline as she did not look at the clock. c. On 10/12/22 at 6:00 P.M. interview with RN #211 revealed she was getting ready to leave when a man came into the building and stated there was someone on the ground out by the road. She stated she went to get RN #212 because she did not know the man who had come into the building. She stated they both went outside, and the man was standing by the side of the road with the lights of his car on and Resident #1 was sitting down on the side of the road edge with her walker facing west. She stated the resident's walker was not tipped over. She stated she was wearing pants and sweatshirt. She stated she yelled at RN #210 to go get a wheelchair. She stated Resident #1 indicated she just walked out the front door and was going to a barbeque. d. On 10/12/22 (no time noted) an interview with RN #112 revealed at 2:00 A.M. RN #211 came down to her unit and stated when she was leaving a man flagged her down and stated there was a lady laying the road in front of the building. She stated she told another nurse to do a head count while she went outside to investigate. She stated as she approached the road by the building's mailbox a car was stopped with his headlights facing a lady laying in the road with her walker. The gentleman drove away at that time. She stated she asked the lady what her name was and she told her it was (Resident #1). She stated she asked her if she was injured, the resident replied no, she was just trying to get home and asked her if she would give her a ride. She stated she called the facility from her cell phone for further assistance then called the Assistant Director of Nursing and notified him of the situation per policy. The resident was then assisted inside and assessed for any injuries. e. On 10/12/22 (no time noted) an interview with LPN #197 revealed at 12:15 A.M. the front door alarm kept going off and normally A unit staff checked the door alarm. She indicated she called over to the A unit and asked if all residents were okay and RN #210 indicated to her all the residents were there. She stated she had not heard the alarm again the rest of the night. On 10/18/22 at 9:10 A.M. interview with Family Member #200 revealed she received a call on 10/10/22 at 2:37 A.M. from RN #210 stating her mother (Resident #1) had somehow gotten out of the building, had made it to the road and a passerby came to the facility and told staff the resident was out by the road. Family Member #200 revealed staff brought the resident back to the facility. She stated when she got to the facility (on 10/10/22 around 9:30 A.M.), her mother told her she left because she had wanted to go home. Family Member #200 reported Resident #1 told her she had gone out the front door by entering the code displayed at the key code box at the door. She stated she even told her what the code was. She stated her mother told her the walker got caught in the gravel and she fell . She stated she told her she had seen a car coming up the road and waved her arms to get the car to stop. Family Member #200 revealed her mother asked the man who stopped to take her home, but he said he would get someone from the nursing home to help her. Family Member #200 revealed her mother was afraid of the dark, so it was so unusual for her to go outside in the dark. She stated her mother's cognition came and went, but she seemed good at that time. On 10/18/22 at 1:10 P.M. interview with Physician #300 revealed Resident #1 should not be allowed outside by herself due to her poor safety awareness and her need to ambulate with a walker. Physician #300 also indicated Resident #1 had dementia. The physician indicated he had been surprised when facility staff called him to tell him the resident had gotten out of the building because (to his knowledge), she had never had that type of behavior before. On 10/18/22 at 3:20 P.M. interview with the Administrator revealed the code for the key pad to unlock the main entrance doors had always been posted on the door for anyone to access. During the interview, the Administrator verified Resident #1 was able to leave the facility unsupervised and without staff knowledge on 10/10/22 between 12:00 A.M. and 2:00 A.M. after putting the posted code in the keypad to unlock the door. On 10/18/22 at 3:40 P.M. interview with Receptionist #400 revealed she had worked at the facility for two years and the door code had always been taped to the keypad. She stated she did not remove the code from the door at any time, it stayed up all the time. On 10/19/22 at 8:30 A.M. interview with STNA #207 revealed the code to the front door code had been posted all the time (prior to the incident with Resident #1) and had never been taken down. The code had been removed following the incident with Resident #1. On 10/19/22 at 7:50 A.M. observation of the posted speed limit sign revealed the posted speed limit for the road Resident #1 was found lying next to was 45 miles per hour. On 10/19/22 at 7:55 A.M. observation of the distance from the front door to the mailbox (the location where Resident #1 was found) was noted to be approximately 525 feet. On 10/19/22 at 8:33 A.M. interview with Licensed Practical Nurse (LPN) #208 revealed the code to the front door keypad had been posted all the time and was never taken down. She stated the code had been taken down after the incident with Resident #1. On 10/19/22 at 8:36 A.M. interview with STNA #209 revealed the code to the front door key pad had been posted all the time and was never taken down. She indicated the code had recently been taken down and the code changed. On 10/19/22 at 1:30 P.M. interview with RN #210 regarding the elopement incident with Resident #1 on 10/10/22 revealed she was not sure of the time she had last seen Resident #1 because she had not looked at the clock. She stated she was sitting at the desk when she saw the resident in the hallway with her walker. She stated she thought that was around 12:00-12:30 A.M. She stated around 2:00 A.M. another nurse called her to tell her Resident #1 was outside and a man driving past had found her by the road. She stated they brought the resident inside and she took her back to her room to do an assessment. RN #210 revealed she had no idea what the resident had been wearing at the time because she was more worried about if the resident was okay. RN #210 indicated she got Resident #1 settled into bed and then called the physician and the resident's daughter and son around 2:30 A.M. She stated usually Resident #1 never left her room. During the interview, RN #210 verified the code to unlock the door was posted on the key pad at the door. On 10/19/22 at 1:44 P.M. an attempt was made to contact RN #211. A message was left with no return call. A second attempt to reach RN #211 was made at 1:55 P.M. No voicemail message could be left at this time. On 10/19/22 at 1:50 P.M. an attempt was made to contact Agency STNA #199. A message was left with no return call. Review of the facility undated policy titled, Elopement revealed the policy was to reduce the risk of elopement and timely report and investigate all incidents of elopement. The procedure revealed all residents at a greater risk of elopement would have their pictures and identifying information in a designated notebook. The notebooks were kept at the nurse's station and the front desk. The remainder of the policy detailed what staff were to do in the event of an actual missing resident. This deficiency represents non-compliance investigated under Complaint Number OH 681.

Based on interview, observation and record review the facility failed to ensure Resident #50 received the proper staff assistance for turning in bed as care planned. This resulted in actual harm when Resident #50 was turned in bed by only one staff member, fell out of the bed and sustained an acute proximal right humerus fracture. In addition the facility did not ensure fall interventions were in place for Resident #71 and failed to ensure the memory impaired unit was adequately secured. This affected two of five residents reviewed for falls and 17 of 20 residents residing on the secured memory care unit. Findings include: 1. Resident #50 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #50 received Hospice services. Resident #50's quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident's cognition was intact. Resident #50's annual MDS dated [DATE] revealed Resident #50 required the extensive assistance of two staff for bed mobility, which included turning and repositioning. Review of Resident #50's current comprehensive care plan related to Activities of Daily Living (ADL) dated 04/26/13 revealed the resident required two staff assistance for bed mobility. Review of Resident #50's Hospice Aide Care Plan Report from 09/16/16 to 11/14/16 revealed the resident required two staff assistance with bed mobility when turning and positioning. Interview with Resident #50 at 1:37 P.M. on 06/13/17 revealed there was an incident in November, 2016 with a Hospice aide, resulting in her falling to the floor and suffering a broken arm and pain in her right shoulder. Review of a fall report dated 10/31/16 revealed at 7:25 P.M., Licensed Practical Nurse (LPN) #100 was called into the resident's room by Hospice State tested Nursing Assistant (STNA) #101 who said she had lowered Resident #50 to the floor upon giving her a bed bath. When LPN #100 entered the room, Resident #50 was observed on her left side on the floor, with her face halfway buried in a pillow, and her right arm up beside her head. The side rails were not up on the bed. Resident #50 claimed she was lying on her left side with Hospice STNA #101 standing in front of her and the side rail was down. Hospice STNA #101 attempted to pull the sheets out from under her. Resident #50 said while Hospice STNA #101 was pulling the sheets out form under her torso, she fell out of the bed towards Hospice STNA #101. Resident #50 said Hospice STNA #101 moved out of the way and she fell to the floor on her left arm. Upon an immediate assessment, Resident #50 had an abrasion to the left shin and a scabbed area on her left breast re-opened. Resident #50 was sent the the emergency room for evaluation. Upon return from the hospital, x-ray reports revealed Resident #50 suffered an acute proximal right humerus fracture (a break in the upper arm bone that connects the elbow and shoulder). Treatment involved the use of a sling to her left arm to limit mobility. Review of Hospice STNA #101's witness statement confirmed on 10/31/16 she gave Resident #50 a bed bath and changed her linens. Hospice STNA #101 stated she grabbed a hold of the bed pads to assist in rolling Resident #50 to her left side when Resident #50's feet slipped out of the right side of bed, resulting in her having to lower Resident #50 to the floor. Interview on 06/13/17 at 2:00 P.M. with the Director of Nursing (DON) confirmed Resident #50 required two staff assistance for bed mobility at the time of the fall on 10/31/16. The DON verified Hospice STNA #101 did not read Resident #50's care plan prior to providing care, resulting in her turning the resident in bed by herself with the side rail down resulting in a fall with fracture. 2. Resident #71 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of a fall risk assessment dated [DATE] revealed Resident #71 was at a risk for falls due to medications, diagnoses, age, mobility, impaired balance, assistance required with elimination, cognitive and behavioral changes in the past 90 days, and increased falls in the past 90 days. Review of a fall investigation dated 04/20/17 revealed Resident #71 turned off her chair alarm and was found on the floor next to her recliner. The resident sustained [REDACTED]. A motion sensor alarm and alarming floor mat were implemented to attempt to prevent further falls. Review of a fall investigation dated 05/20/17 revealed staff responded to an alarm sounding and found Resident #71 on the floor in front of her recliner. Resident #71 sustained a laceration to her forehead and right hand. Each laceration required sutures/stitches. The investigation revealed Resident #71 attempted to get out of the recliner and slipped and fell . The alarming floor mat was discontinued and a pressure sensitive alarm to the recliner was implemented. Review of a fall investigation dated 06/03/17 at 6:50 P.M. revealed a nurse was passing the room and observed Resident #71 on the floor with her back against the recliner chair. The pressure sensor chair alarm was not sounding. However, the alarm functioned when pressure was applied. The cord was intact. Resident #71 revealed she may have turned it off. The resident's daughter was notified and revealed she had seen Resident #71 grabbing at the alarm box. Review of a physician order [REDACTED]. The order required the clip alarm be in place when Resident #71 was in her wheelchair and recliner. Resident #71 was observed on 06/12/17 at 2:54 P.M. Resident #71 was asleep in her recliner with her legs elevated. A clip alarm was not observed attached to the resident or within the surrounding area of the recliner. The resident's wheelchair was at the foot of the bed and the clip alarm was observed attached to the wheelchair. This observation was verified at 3:02 P.M. by STNA #25. STNA #25 verified the clip alarm was required when Resident #71 was in the recliner and the alarm was not in place. STNA #25 verified the clip alarm remained attached to the resident's wheelchair. 3. An entrance tour of the facility's memory impaired secured unit was completed on 06/12/17 at 9:30 A.M. Entry to the unit was directly from the circular common hallway. A push button to the right of the double doors unlocked the doors and provided access. Entering the unit revealed a T-shaped long hallway with resident rooms on each side of the long and short hallways. Residents were observed walking or propelling their wheelchairs to breakfast in the unit dining room. Exiting the unit was through the same double doors. A keypad code was required for exit. Approximately five feet to the right of the the exit door within the secured unit, a small common lounge was observed. The lounge contained a couch, two lounge chairs and a television. Three closed doors were observed inside the lounge. Two of three doors were locked. The third door was unlocked. Upon opening the third door, entry to a hallway revealed two storage rooms and an office. At the end of the hallway was an unlocked door that entered directly into the circular common area of the facility. The main exit from the facility was within the common circular area. The main entrance/exit door was secured with a keypad code to exit. The code was posted on the keypad and unlocked the door. The observation was verified on 06/12/17 at 9:41 A.M. by Licensed Practical Nurse (LPN) #27. LPN #27 revealed the lounge doors were to be secured at all times in order to prevent any of the memory impaired residents from exiting the facility unattended. The facility identified 17 of 21 residents on the secured unit were independently mobile.

Based on observation, medical record review, and staff interview, the facility failed to implement interventions to prevent falls, determine the reason for non-compliance of fall interventions and/or plan new interventions when the plan of care related to falls was not effective. This affected three (Residents #1, #82, and #86) of four residents reviewed for accidents. Harm occurred to Resident #82 on 12/25/14 after the facility failed to implement a restorative ambulation program, identify reasons for non-compliance with fall interventions, and revise interventions prior to Resident #82 falling and sustaining a fractured nose. Findings include: 1. Review of Resident #82's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Hospital discharge information indicated Resident #82 was at high risk for falls. Resident #82 was assessed upon admission and determined to be at risk for falls. Risk factors included a change in cognitive status over the previous 90 days, behaviors, and need for assistance with ambulation. An immediate care plan revealed interventions including instructing Resident #82 on safety measures and assessing her footwear for proper fit and non-skid soles. Physical therapy evaluated Resident #82 on 07/23/14 and determined she could benefit from services. A nursing note dated 07/27/2014 at 10:55 P.M. revealed a State tested nursing assistant (STNA) notified the nurse Resident #82 was found sitting on her buttocks on the floor in her room with no shoes or socks on. Resident #82 sustained no injuries. The nursing note indicated Resident #82 was educated regarding proper foot wear when walking and staff was to provide several pair of non-skid footwear. On 07/28/14, an order was written for gripper socks at all times except during hygiene. A physical therapy (PT) discharge summary dated 09/08/14 revealed at the time of discharge from PT Resident #82 was able to maintain standing balance without support against minimal resistance. The discharge summary indicated in order to facilitate Resident #82 maintaining her level of performance and in order to prevent decline, development of and instruction in the following restorative nursing programs had been completed with the interdisciplinary team: ambulation and ROM (active). There was no documentation of a restorative ambulation program being implemented. A nursing note dated 11/10/2014 at 6:58 A.M. indicated Resident #82 was observed on the floor in front of her bathroom door sitting on her buttocks. The note indicated there were no apparent injuries. Resident #82 did not have any shoes or grippers on. A nursing note dated 11/10/2014 at 3:10 P.M. revealed at 8:00 A.M. a discoloration was observed on Resident #82's left lateral thigh from her previous fall. The discoloration measured 8 centimeters (cm) x 13.5 cm. A fall investigation dated 11/10/14 revealed Resident #82 was oriented to person and place but not to situation or time. The investigation indicated Resident #82 had impaired memory. On 11/10/14, an order was written to assist Resident #82 to the bathroom upon rising. The order was discontinued 11/11/14 with an order to encourage/remind the resident to wear non-skid foot wear for safety although the treatment administration records revealed non-compliance with the use of the non-skid footwear. No new interventions were implemented and there was no indication the facility attempted to identify the reason for the previous non-compliance. A nursing note on 11/12/2014 at 7:43 P.M. indicated the discolored area on the left lateral thigh was purple in color, measuring 13 cm x 14 cm. Resident #82 was encouraged to wear gripper socks. On 12/02/14, an order was written to discontinue the gripper socks. No documentation was found to indicate the facility investigated the reason for Resident #82's non-compliance. A nursing note on 12/21/2014 at 7:10 A.M. indicated the nurse heard Resident #82 calling for help. Resident #82 was observed on the floor in front of the recliner on her knees. Resident #82 stated she slipped on water and the floor was wet in front of the chair. No injuries were noted. A fall investigation dated 12/23/14 for the fall on 12/21/14 revealed the wet spot may have been urine and a bowel and bladder tracker was initiated for determination of changes and/or patterning. On 12/24/14, an order was received for physical therapy. A nursing note dated 12/25/14 at 4:05 P.M. revealed at 10:40 A.M., Resident #82 was heard calling for help. Resident #82 was observed on her knees and hands at the doorway of her room. Resident #82's nose was bleeding and there was an open area on top of her nose measuring 0.2 cm x 0.1 cm x 0.1 cm. There was a trail of blood on the floor from the the doorway to the side of the bed. The call light was not on. Resident #82 had no footwear on. Resident #82 described, "I was sitting up before I started walking. I fell forward and caught my fall with my forehead and nose. The only pain I have is in my forehead." The area on Resident #82's forehead above her nose was swollen and measured 5.5 cm x 8.0 cm x 3.0 cm. Her nose was swollen and bruising. Resident #82 was sent to the emergency room . Resident #82 returned to the facility the same day with a [DIAGNOSES REDACTED]. A fall investigation dated 12/25/14 revealed Resident #82 was confused with a recent change in cognition, had gait imbalance and impaired memory. Resident #82 had improper footwear. Resident #82 was barefoot and her bed sat a a level where she had to scoot to the edge of the bed and lean forward to touch the ground. On 12/26/14, interventions added to the plan of care included wearing non-skid footwear, monitoring medications for side effects and effectiveness, and ensuring the bed was low enough for her feet to touch the floor. A nursing note dated 12/26/14 at 3:15 A.M. revealed Resident #82 complained of back pain. All interventions were ineffective and Tylenol was administered at 1:00 A.M. Resident #82 reported it did not help relieve the pain. The nurse documented he would continue to monitor Resident #82. Medication administration records revealed Resident #82 also received pain medication on 12/27/14 at 8:00 A.M. but did not reveal why the medication was administered. Prior to the fall, the last dose of Tylenol administered was on 11/19/14. On 01/13/15 at 2:35 P.M., the director of nursing (DON) was interviewed. A request was made for documentation regarding the ambulation restorative program recommended by physical therapy when Resident #82 was discharged on [DATE]. On 01/13/15 at 3:03 P.M., STNA #15 was interviewed and stated Resident #82 had required more assistance since her fall on 12/25/14. STNA #15 reported Resident #82 was forgetful and did not recall to ask for assistance. On 01/14/15 at 12:30 P.M., the DON was interviewed and was asked if there had been an evaluation to determine why Resident #82 frequently refused to wear non-skid footwear. The DON stated it was not until she was investigating Resident #82's fall that occurred on 12/25/14 that staff reported Resident #82 had to scoot way forward on the edge of the bed in order for her feet to touch the floor. At 4:30 P.M., the DON stated she was unable to find any documentation indicating staff evaluated the reason for Resident #82's non-compliance with the use of non-skid footwear. The DON also stated Resident #82 had not been started on a restorative ambulation program when PT was discontinued on 09/08/14. The DON indicated PT had placed Resident #82 back onto their caseload on 12/24/14. The DON stated after speaking to Resident #82 she learned the reason for the non-compliance with the non-skid footwear was that the footwear provided was too warm. The DON stated after speaking to Resident #82 about the risk of continued falls, she agreed to try non-skid footwear again and the facility would try to find some that were not as warm. On 01/15/15 at 10:02 A.M., Physical therapy assistant (PTA) #16 was interviewed and stated when residents were discharged from therapy and if the therapist thought a resident would benefit from restorative services, they recommended restorative programs. It was then up to nursing to develop and implement the program. PTA #16 provided a form labeled Restorative Rehabilitation Program Recommendations for Resident #82 with a therapy discontinuation date of 09/08/14. Recommendations included an ambulation program with the resident ambulating 250 feet with stand by assistance. PTA #16 revealed Resident #82's status had declined between her discharge on 09/08/14 and her re-evaluation on 12/24/14. However, she could not identify the reason for the decline. 2. Review of Resident #1's medical record revealed [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE] revealed Resident #1 was at risk for falls and had been observed on the floor that same day. The plan of care revealed interventions to encourage Resident #1 to wear gripper socks when up and for Resident #1 to wear proper and non-slip footwear. On 01/13/15 at 1:38 P.M., 2:57 P.M., 3:00 P.M., and , Resident #1 was observed sitting in a Broda chair in the lounge area at the front of B wing. Resident #1 was not wearing gripper socks or footwear with non-skid surfaces. On 01/13/15 at 3:03 P.M., STNA #15 verified Resident #1 was not wearing socks or shoes with non-skid surfaces though she was sitting in the Broda chair. STNA #15 stated Resident #1 only wore grippy socks in bed. On 01/14/15 at 1:20 P.M., Resident #1 was observed sitting in a Broda chair and was wearing socks without non-skid surfaces. On 1/14/15 at 1:30 P.M., STNA #17 verified Resident #1 was not wearing footwear with non-skid surfaces. STNA #17 stated she did not routinely work with Resident #1 and was unaware there was a care plan intervention for Resident #1 to wear non-slip footwear. On 01/14/15 at 4:15 P.M., the DON verified Resident #1's care plan interventions for fall prevention included use of non-skid footwear. 3. Review of Resident #86's medical record revealed [DIAGNOSES REDACTED]. oneself and ones surroundings). A fall risk assessment dated [DATE] revealed Resident #86 was at risk for falls. A plan of care initiated 12/17/14 included an intervention for the use of anti-tippers to the front of the wheelchair. On 01/14/15 at 10:43 A.M., Resident #86 was observed lying in bed. The wheelchair sitting at her bedside did not have anti-tippers. At 11:25 A.M., an unidentified nursing assistant propelled Resident #86 to the dining area for lunch. Licensed practical nurse (LPN) #18 was present. On 01/14/15 at 11:28 A.M., LPN #18 was interviewed. When asked about the anti-tippers not being observed on Resident #86's wheelchair, LPN #18 stated she would have to research if Resident #86 was supposed to have anti-tippers then pointed out Resident #86 had "things" on the wheels, pointing to anti-roll bars. LPN #18 stated the device prevented Resident #86's wheelchair from rolling forward or back. At 11:40 A.M., LPN #18 attempted to demonstrate how the anti-roll bars worked but the wheelchair rolled freely forward and back. LPN #18 stated that was not how the device was supposed to work. On 01/14/15 at 3:12 P.M., Resident #86 was observed sitting in her room alone gliding the wheelchair back and forth with her feet. No anti-tippers had been applied to the wheelchair. On 01/14/15 at 4:19 P.M., the DON verified Resident #86 had a fall intervention on her plan of care for anti-tippers to the front of the wheelchair. This deficiency substantiates Complaint Number OH 443.