Every finding on record at Hamilton Respiratory and Nursing Center

Based on medical record review, staff interview, and review of the facility policy, the facility failed to timely complete quarterly Minimum Data Set (MDS) assessments. This affected four (Residents #2, #11, #26, #39) of 18 residents sampled. The facility census was 75 residents.Findings include: 1.Review of the medical record for Resident #26 revealed an admission date of 09/04/24 with diagnoses including mood disorder and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #15 dated 03/12/26 revealed the MDS was not completed until 04/15/26. Interview on 04/16/26 at 1:45 P.M. with MDS Nurse #284 verified Resident #26's quarterly MDS dated [DATE] was not completed within the required timeframe. 2.Review of the medical record for Resident #39 revealed an admission date of 10/29/23 with diagnoses including Alzheimer's disease, depression, and congestive heart failure. Review of the quarterly MDS assessment for Resident #39 dated 03/19/26 revealed the MDS was not completed and should have been submitted by 04/02/26. Interview on 04/16/26 at 1:47 P.M. with MDS Nurse #284 verified Resident #39's quarterly MDS dated [DATE] was not completed within the required timeframe. 3. Review of the medical record for Resident #2 revealed an admission date of 02/28/23 with diagnoses including type two diabetes mellitus, major depressive disorder, and anxiety disorder. Review of the quarterly MDS assessment for Resident #2 dated 03/09/26 revealed the MDS was not completed until 04/09/26. Interview on 04/16/26 at 1:39 P.M. with MDS Nurse #284 verified Resident #2's quarterly MDS dated [DATE] was not completed within the required timeframe. 4.Review of the medical record for Resident #11 revealed an admission date of 07/10/23 with diagnoses including borderline personality disorder, bipolar disorder, and type one diabetes mellitus. Review of the quarterly MDS assessment for Resident #11 dated 12/28/25 revealed the MDS was not completed until 01/19/26. Interview on 04/16/26 at 1:43 P.M. with MDS Nurse #284 verified Resident #11's quarterly MDS was not completed within the required timeframe. Review of the facility policy titled MDS 3.0 Completion revised on 04/16/26 revealed residents were assessed using a comprehensive assessment process to identify care needs and to develop an interdisciplinary care plan. A quarterly assessment should be completed using an assessment reference date no later than 92 days from the most recent prior quarterly or comprehensive assessment.

Based on medical record review and staff interview, the facility failed to ensure written authorization to manage resident funds. This affected one (Resident #55) of five residents reviewed for resident funds. The facility census was 75 residents.Findings include: Review of the funds record for Resident #55 revealed there was no authorization by the resident or his representative. Interview on 04/16/26 at 3:12 P.M. with Business Office Coordinator (BOC) #237 confirmed the facility was managing Resident #55's funds, but the facility had not obtained written authorization to manage funds for the resident from the resident nor from the resident's representative. Review of the facility policy titled Resident Funds revised December 2009 revealed the facility would inform residents of the procedures for managing funds and residents were not obligated to deposit their funds with the facility.

Based on record review and staff interview the facility failed to timely disburse funds following resident death. This affected one (Resident #94) of five residents reviewed for resident funds. The facility census was 75 residents.Findings include: Review of the funds record for Resident #94 revealed the resident expired in July of 2025 and his funds had not yet been disbursed to the resident's representative. Interview on [DATE] at 3:12 P.M. with Business Office Coordinator (BOC) #237 confirmed Resident #94 expired in [DATE] and the facility had not yet disbursed the funds remaining in the resident's account to the resident's family.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure care conferences were completed quarterly. This affected two (Residents #8 and #11) of 18 sampled residents. The facility census was 75 residents. Findings include: 1.Review of the medical record for Resident #8 revealed an admission date of 12/31/25 with diagnoses including end stage renal disease (ESRD), hypertension, and anemia. Review of the Minimum Data Set (MDS) assessment for Resident #8 dated 01/07/26 revealed the resident had intact cognition. Review of the medical record for Resident #8 revealed there was no documentation of care conferences being completed for the resident. Interview on 04/16/26 at 2:31 P.M. with Social Services Director (SSD) #297 verified the facility had not held a care conference with Resident #8. 2.Review of the medical record for Resident #11 revealed an admission date of 07/10/23 with diagnoses including borderline personality disorder, bipolar disorder, and type one diabetes mellitus. Review of the MDS assessment for Resident #11 dated 12/28/25 revealed the resident had intact cognition. Review of the medical record for Resident #11 for the last 12 months revealed care conferences were completed on 07/18/25 and 09/25/25. No other care conferences had been completed. Interview on 04/16/26 at 2:27 P.M. with SSD #297 verified care conferences were to be completed quarterly, and Resident #11 had only received two in the last year. Review of the facility policy titled Care Planning-Resident Participation revised 05/25/25 revealed the facility supported the resident's right to be informed of, and participate in, his or her care planning and treatment. The facility would honor requests for care plan meetings and acknowledge requests for revisions to the person-centered plan of care.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to implement timely interventions to monitor for and prevent unplanned weight loss. This affected one (Resident #2) of three residents reviewed for nutrition. The facility census was 75 residents. Findings include:Review of the medical record for Resident #2 revealed an admission date of 02/28/23 with diagnoses including type twp diabetes mellitus, major depressive disorder, and chronic pancreatitis. Review of the weight record for Resident #2 dated 09/05/25 revealed the resident weighed 190.8 pounds (lbs.) Review of the weight record for Resident #2 dated 10/16/25 revealed the resident weighed 176 lbs. which was a 7.76 percent (%) weight loss in under 30 days. Review of the nutritional progress note for Resident #2 dated 10/16/25 at 3:42 P.M. revealed the dietitian recommended the staff to obtain a re-weight of the resident to rule out discrepancies with the scales. Review of the weight record for Resident #2 dated 10/16/25 revealed there was no re-weight recorded. Review of the weight record for Resident #2 dated 11/14/25 revealed the resident weighed 163 lbs. which was a 7.39 % weight loss in 30 days. Review of the weight record for Resident #2 dated 12/03/25 revealed the resident weighed 161 lbs. Review of the weight record for Resident #2 dated 01/06/26 revealed the resident weighed 150 lbs. which was a 6.83% weight loss in 30 days. Review of the weight record for Resident #2 dated 01/15/26 revealed the resident weighed 146 lbs. Review of the physician's order for Resident #2 dated 01/15/26 revealed an order to obtain weekly weights for four weeks. Review of the weight record for Resident #2 dated 01/22/26 revealed the resident weighed 145 lbs. Review of the weight record for Resident #2 dated 01/29/26 revealed there was no weekly weight obtained. Review of the weight record for Resident #2 dated 02/25/26 revealed the resident weighed 133 lbs. which was an 8.28% weight loss in 30 days. Review of the nutritional progress note for Resident #2 dated 02/27/26 at 7:21 P.M. revealed the dietitian recommended the resident be started on appetite stimulant due to weight loss. Review of the nutritional progress note dated 03/05/26 at 10:18 P.M. revealed the dietitian requested a reweight for the resident due to unplanned weight loss. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 03/09/26 revealed the resident had moderate cognitive impairment and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #2 dated 03/16/26 revealed and order for the appetite stimulant Remeron 7.5 milligrams (mg) at bedtime. Review of the weight record for Resident #2 dated 04/08/26 revealed the resident weighed 125 lbs. Review of the nutritional progress note for Resident #2 dated 04/15/26 at 2:52 P.M. revealed the dietitian made the following recommendations: increase house supplement to three times a day, obtain a re-weight, obtain weekly weights for four weeks. Interview on 04/16/26 at 10:27 A.M. with Dietary Tech (DT) #341 confirmed Resident #2 had a significant weight loss from 09/05/25 to 04/08/26. DT #341 stated reweights were requested for Resident #2 on 10/16/25, 03/05/26 and on 04/15/26, but the facility had not obtained the reweights. DT #241 confirmed on 01/15/26 there was an order for weekly weights for four weeks, but the facility obtained only one weight for Resident #2 from 01/15/26 to 02/25/26. DT #314 confirmed the dietitian made a recommendation on 02/27/26 to start an appetite stimulant for Resident #2, but it was not started until 03/16/26. Review of the facility policy titled Weight Monitoring revised 11/06/25 revealed all residents would have weights obtained, documented, and reviewed routinely. Significant weight changes would be promptly addressed with appropriate interventions and physician notification.

Based on review of the medical record, observation, staff interview, and review of the facility policy, the facility failed to ensure staff completed hand hygiene during catheter care and failed to ensure enhanced barrier precautions (EBP) were implemented for a dialysis resident. This affected two (Resident #8 and #13) of 18 residents sampled. The facility census was 75 residents. Findings include: 1.Review of the medical record for Resident #8 revealed an admission date of 12/31/25 with diagnoses included end stage renal disease (ESRD), hypertension, and anemia. Review of the Minimum Data Set (MDS) assessment for Resident #8 dated 01/07/26 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the care plan for Resident #8 dated 01/20/26 revealed the resident received hemodialysis three times weekly. Observation on 04/15/26 at 11:11 A.M. revealed Resident #8 did not have an enhanced barrier precautions (EBP) sign or personal protective equipment (PPE) available for patient care. Interview on 04/15/26 at 11:13 A.M. with the Director of Nursing (DON) verified Resident #8 was supposed to be on EBP related to dialysis chest port. Review of the facility policy titled Enhanced Barrier Precautions revised 07/01/25 revealed the facility implemented EBP for the prevention of transmission of multidrug-resistant organisms (MDROs). An order would be obtained for residents with wounds or orders for indwelling medical devices including hemodialysis catheters. 2.Review of the medical record for Resident #13 revealed an admission date of 12/02/25 with diagnoses including gram-negative sepsis, type two diabetes mellitus, and hemiplegia and hemiparesis affecting right side. Review of the (MDS) assessment for Resident #13 dated 02/04/26 revealed the resident had severe cognitive impairment and required assistance with toileting and had a urinary catheter. Review of the physician's orders for Resident #13 revealed an order dated 04/13/26 for catheter care every shift. Observation on 04/15/26 at 11:20 A.M. of catheter care for Resident #13 per Certified Nursing Assistant (CNA) #260 revealed the aide did not remove soiled gloves after providing catheter care and then touched the resident's clean sheets and oxygen tubing with her gloved hands. Interview on 04/15/26 at 11:32 A.M. with CNA #260 verified she did not change her gloves during or after catheter care. Review of the facility policy titled Basic Principles of Prevention dated 2025 revealed hand hygiene was a general term that applied to handwashing and alcohol-based hand rub. It had been deemed the number one practice for breaking the chain of infection. The hand hygiene procedures to be followed by staff involved in direct resident contact should be written, communicated, and enforced.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure staff provided the appropriate level of resident supervision during mechanical lift transfers. This affected one (Resident #31) of three residents reviewed for falls. The facility census was 76 residents. Findings include: Review of the medical record for Resident #31 revealed an admission date of 08/06/25 with diagnoses including cerebral infarction, chronic obstructive pulmonary disease (COPD), and respiratory failure. Review of the Minimum Data Set (MDS) assessment for Resident #31 dated 11/13/25 revealed the resident was dependent on staff to transfer between surfaces.Review of the nurse progress note for Resident #31 dated 12/03/25 at 6:00 P.M. revealing the resident slid out of a mechanical lift (Hoyer) during transfer. Staff assessed Resident #31 and the resident was transferred to the emergency room for evaluation.Review of a hospital note for Resident #31 dated 12/03/25 revealed the resident was evaluated in the emergency department for a fall from a mechanical lift and returned to the facility on [DATE]. Interview on 02/23/26 at 10:10 AM with the Director of Nursing (DON) confirmed on 12/03/25 Resident #31 slid from the Hoyer lift during a transfer. The DON confirmed Certified Nurse Assistant (CNA) #111 and family member of Resident #31 performed the transfer at the time of the incident. The DON confirmed the facility's policy required two trained staff members for all mechanical lift transfers and stated her expectation was that at least two trained staff members always operated mechanical lifts.Interview on 02/23/26 at 10:50 AM with CNA #111 confirmed she performed a transfer from chair to bed for Resident #31 on 12/03/25 utilizing a Hoyer lift. CNA #111 stated the resident's family member offered to assist with the transfer, but the aide stated she told the family member she would find another staff member. CNA #111 stated when Resident #31's family member insisted on helping with the transfer, the aide and the family member completed the transfer. CNA #111 stated Resident #31 was in a chair, and she attempted to reposition the Hoyer pad below the resident's knees prior to initiating the lift. CNA #111 stated she began lifting the resident with the mechanical lift when the resident started screaming and jiggling. CNA #111 stated she lowered the mechanical lift and the resident slid down onto the floor. CNA #111 confirmed Resident #31 has required a Hoyer lift since admission and is always a two-person assist for transfers with trained staff.Review of the facility policy titled Mechanical Lift dated 07/15/25 revealed during transfers staff are to use the required number of trained staff and follow manufacturer instructions. This deficiency represents noncompliance investigated under Complaint Number 2722681 and Complaint Number 2701173 and Complaint Number 2701465.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected two (Residents #65 and #66) of four residents reviewed for medication administration. The facility census was 76 residents. Findings include: Review of the medical record for Resident #65 revealed an admission date of 04/02/19 with diagnoses including seizure disorder, disorganized schizophrenia, and anxiety. Review of the Minimum Data Set (MDS) assessment for Resident #65 dated 11/02/25 revealed the resident had severe cognitive impairment.Review of the medication error report for Resident #65 dated 11/14/25 revealed on 11/14/25 at approximately 8:30 P.M. Licensed Practical Nurse (LPN)#188 administered Ativan one milligram (mg), Metformin 500 mg, and Remeron 7.5 mg to Resident #65. Resident #65 did not have orders for these medications. Review of the medical record for Resident #66 revealed an admission date of 07/18/25 with diagnoses including dementia, diabetes mellitus type two, and schizoaffective disorder. Review of the MDS assessment for Resident #66 dated 10/30/25 revealed the resident had severe cognitive impairment. Review of medication error report for Resident #66 dated 11/14/25 revealed on 11/14/25 at approximately 8:30 P.M. LPN #188 administered Lithium 750 mg, Lamictal 150 mg, Clozapine 300 mg, atorvastatin 20 mg, and Risperdal one mg to Resident #66. Resident #65 did not have orders for these medications.Review of the progress note for Resident #66 dated 11/14/25 revealed that following the medication administration on 11/14/25 at 11:00 P.M. Resident #66 was found unresponsive. and was transferred via emergency medical services to the hospital for evaluation. Hospital documentation revealed the resident was admitted with a diagnosis of complicated urinary tract infection.Review of the facility's medication error investigation revealed LPN #188 administered medications prescribed for Resident #66 to Resident #65 and medications prescribed for Resident #65 to Resident #66. The medication error investigation report further revealed that LPN #188 was orienting with Registered Nurse (RN) #151.Interview on 02/19/26 at 3:11 P.M. with RN #151 confirmed she was orienting LPN #188 on 11/14/25. RN #151 stated she instructed LPN #188 to administer medications as part of his orientation and informed him she was available if he needed assistance or had questions. RN #151 stated she remained on the unit and was accessible, but she did not enter the room with LPN #188 during the medication administration that resulted in the error. RN #151 stated LPN #188 notified her of the medication error after they observed Resident #66's change in conditionInterview on 02/23/26 at 10:03 A.M. with the Director of Nursing (DON) confirmed LPN #188 was in orientation during the incident on 11/14/25 and that he entered the resident's room for medication administration by himself The DON further confirmed LPN #188 stated he confused the residents residing in the shared room and administered the medications incorrectly.Review of the facility policy titled Medication Administration dated 06/17/25 revealed medications are to be administered in accordance with professional standards of practice and that staff must ensure the six rights of medication administration are followed, including right resident, right medication, right dose, right route, right time, and right documentation. The policy requires staff to compare the medication source with the Medication Administration Record (MAR) to verify the correct resident prior to administration.This deficiency represents noncompliance investigated under Complaint Number 2722681 and Complaint Number 2701173.

Based on closed medical record review, review of facility-initiated discharge notices, review of the discharge appeal hearing decision, staff interview, guardian interview, Hospital Social Worker (HSW) interview and review of facility policy, the facility failed to ensure an appropriate resident discharge. This affected one resident (#8601) of three residents reviewed for discharge. The facility census was 61. Findings include: Review of Resident #8601's medical record revealed an admitted [DATE]. Diagnoses included Huntington's disease, Alzheimer's disease with early onset, severe protein-calorie malnutrition and repeated falls. Further review revealed Resident #8601 was discharged on [DATE]. Review of physician orders from orders from 08/01/24 to 09/19/24 revealed no discharge order for Resident #8601. Further review revealed a physician order, dated 08/28/24, to send Resident #8601 to the Emergency Department (ED) for further psychological evaluation, one time only, for further evaluation and treatment of physical aggression. Review of the facility-initiated discharge notice, dated 08/23/24, revealed a 30-day discharge notice was issued to Resident #8601 and the resident's guardian. The effective date of the discharge was identified as 09/21/24 and reasons for discharge included noncompliance with care, combativeness and posing a safety risk to himself and others. Further review revealed appropriate notification of the discharge was made to the Ombudsman and state agencies. Review of a progress note dated 08/28/24 revealed Resident #8601 was sent to the ED for further psychological evaluation per physician order. The psychological services provider completed an application for emergency admission (pink slip) and Resident #8601 was transported to the ED by Emergency Medical Services (EMS) with law enforcement escort. Further review of a progress note dated 08/28/24 revealed the hospital notified the facility Resident #8601 was ready to return. The Director of Nursing (DON) informed the ED nurse the facility would not accept the resident back. Review of a progress note dated 09/03/24 revealed the hospital notified the facility that Resident #8601 was ready to return. The facility made Resident #8601 and the resident's guardian aware the resident would not be accepted back to the facility. Review of the discharge appeal hearing examiners decision and order, dated 09/05/24, revealed Resident #8601's guardian requested an emergency appeal of the resident's discharge and indicated the resident was in the hospital and the facility refused to accept him back. The document stated the facility did not attend the hearing. Further review of the appeal decision revealed the facility was not authorized to discharge Resident #8601 and was ordered to readmit the resident. A copy of the decision was sent via electronic mail (e-mail) to the Administrator on 09/06/24. Review of the facility-initiated emergency discharge notice, dated 09/12/24, revealed the notice was issued to Resident #8601 and his guardian. The discharge notice indicated the effective date of the discharge was 09/12/24 and the reasons for discharge included the safety of the individuals in the home was endangered, the resident's urgent medical needs necessitated a more immediate transfer or discharge and the welfare and needs of the resident could not be met at the facility. The notice did not include any specific information related to the discharge reasons indicated. Further review of Resident #8601's medical record revealed no specific documentation from the physician indicating what needs the facility could not meet for the resident to result in an emergency discharge. Interview on 09/16/24 at 2:50 P.M. with the Administrator, Social Worker (SW) #106 and Hospital Liaison (HL) #175 confirmed the hospital wanted to send Resident #8601 back to the facility on [DATE], but the facility refused readmission pending a neurological evaluation. As of 09/16/24, Resident #8601 remained in the hospital. A telephone interview on 09/17/24 at 2:09 P.M. with HSW #1001 and HSW #1002 confirmed on 08/28/24, the hospital attempted to return Resident #8601 to the facility following an ED evaluation; however, the facility refused to unlock the coded door to allow access and the resident was transported back to the hospital. On 09/12/24, after receiving the discharge appeal ruling from 09/05/24, the hospital attempted to have Resident #8601 readmitted to the facility, but the facility again refused readmission and the resident was transported back to the hospital. HSW #1002 stated the facilities identified on the facility-initiated discharge notices as the discharge location for Resident #8601 had never accepted the resident for admission. HSW #1001 and HSW #1002 denied the facility had any proactive conversations with them related to Resident #8601 not being accepted back to the facility. A telephone interview on 09/18/24 at 1:26 P.M. with Resident #8601's guardian revealed she was aware the facility was seeking alternative placement for the resident. However, the guardian stated she was unaware the facility was going to refuse to readmit the resident from the hospital. Resident #8601's guardian stated she learned from HSW #1001 that the facility would not allow the resident to return. The guardian stated there were several back and forth conversations with the facility from 08/28/24 through 09/05/24 related to Resident #8601 returning, with the facility stating they were not taking him back, they did not have to take him back and they would not let him in. The guardian stated the communications came from the Administrator, DON and SW #106. The guardian stated she received the same response from the facility on 09/12/24 when the hospital again attempted to discharge the resident back to the facility and he was refused readmission. The guardian stated even after the discharge appeal hearing on 09/05/24, which ordered the facility to readmit Resident #8601, the facility refused the resident's readmission. A telephone interview on 09/19/24 at 9:10 A.M. with Licensed Practical Nurse (LPN) #425 revealed the psychological services Nurse Practitioner (NP) did not assess Resident #8601 before completing the pink-slip to send Resident #8601 to the hospital. LPN #425 stated the NP completed the pink slip and sent it to the facility via e-mail. At the time Resident #8601 was sent to the hospital, LPN #425 stated she was unaware the facility would not readmit the resident. During a meeting on 08/29/24, Regional Director of Operations (RDO) #500 decided Resident #8601 was being discharged immediately and would not return to the facility. A telephone interview on 09/20/24 at 2:12 P.M. with the Administrator confirmed on 08/28/24 at 8:34 P.M., text messages were exchanged between her, the DON, Registered Nurse (RN) #306, LPN #425 and HL #175 indicating Resident #8601 would not be readmitted to the facility. The Administrator confirmed RDO #500 made the decision not to readmit Resident #8601 and this decision was communicated to all department heads during the morning meeting on 08/29/24. Resident #8601 did not return to the facility, even after the discharge appeal hearing officer ordered the facility to readmit the resident. Review of the facility policy titled Transfer and Discharge, revised 03/26/24, revealed the transfer and discharge process must provide sufficient preparation and orientation of residents to ensure a safe and orderly transfer or discharge from the facility. Further review revealed the facility may not transfer or discharge a resident while an appeal is pending unless the failure to discharge or transfer would endanger the resident or other individuals in the facility. In cases where the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility, the documentation made by the resident's physician must include the specific resident needs the facility could not meet, the facility efforts to meet those needs and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the facility. If a resident's clinical or behavioral status (or condition) endangers the health or safety of individuals in the facility, documentation regarding the reason for the transfer or discharge must be provided by a physician, not necessarily the attending physician. This deficiency represents noncompliance investigated under Master Complaint Number OH00157356.

Based on closed medical record review, review of facility-initiated discharge notices, staff interviews and review of facility policy, the facility failed to ensure discharge notices were accurately completed. This affected one resident (#8601) of three residents reviewed for discharge. The facility census was 61. Findings include: Review of Resident #8601's medical record revealed an admitted [DATE]. Diagnoses included Huntington's disease, Alzheimer's disease with early onset, severe protein-calorie malnutrition and repeated falls. The resident was transferred to the hospital on 08/28/24. Review of the facility initiated 30-day discharge notice, dated 08/23/24, revealed a discharge notice was issued to Resident #8601 and his guardian. Appropriate notification was made to the Ombudsman and required state agencies. Further review of the discharge notice revealed the discharge was effective 09/21/24 and a specified nursing facility was identified as the discharge location for Resident #8601. Review of a progress note dated 08/19/24 revealed the facility identified as the discharge location for Resident #8601 denied the resident admission (four days prior to the facility identifying it as the discharge location for the resident). Review of the facility-initiated emergency discharge notice, dated 09/12/24, revealed an immediate discharge notice was issued to Resident #8601 and his guardian. Appropriate notification was made to the Ombudsman and required state agencies. The effective date of the discharge was 09/12/24 and a specified nursing facility was identified as the discharge location for Resident #8601. Interview on 09/16/24 at 2:50 P.M. with the Administrator and Social Worker (SW) #106 confirmed the facility had knowledge prior to issuing the 30-day discharge notice on 08/23/24 that the facility identified as the discharge location for Resident #8601 had already denied the resident admission. An updated discharge notice indicating Resident #8601 would not be discharged to the identified facility was not issued. A telephone interview on 09/20/24 at 10:54 A.M. with the Administrator verified the facility identified on the emergency discharge notice dated 09/12/24 as the discharge location for Resident #8601 had not accepted the resident for admission. An updated discharge notice indicating Resident #8601 would not be discharged to the identified facility was not issued. A follow-up telephone interview on 09/20/24 at 2:12 P.M. with the Administrator confirmed Resident #8601 was transferred to the hospital on 08/28/24, the facility did not readmit the resident and no alternative placement had been identified for the resident. Review of the facility policy titled Transfer and Discharge, revised 03/26/24, revealed the contents of the discharge notice must include the specific location to which the resident is being transferred or discharged (if a change in destination indicates that the original basis for discharge has changed, a new notice is required).

Based on closed medical record review, review of facility-initiated discharge notices, review of the discharge appeal hearing decision, staff interview, guardian interview and Hospital Social Worker (HSW) interview, the facility failed to ensure a resident was readmitted to the facility upon discharge from the hospital. This affected one resident (#8601) of three residents reviewed for discharge. The facility census was 61. Findings include: Review of Resident #8601's medical record revealed an admitted [DATE]. Diagnoses included Huntington's disease, Alzheimer's disease with early onset, severe protein-calorie malnutrition and repeated falls. Further review revealed Resident #8601 was transferred to the hospital and discharged on [DATE]. Review of physician orders from orders from 08/01/24 to 09/19/24 revealed no discharge order for Resident #8601. Further review revealed a physician order, dated 08/28/24, to send Resident #8601 to the Emergency Department (ED) for further psychological evaluation, one time only, for further evaluation and treatment of physical aggression. Review of the facility-initiated discharge notice, dated 08/23/24, revealed a 30-day discharge notice was issued to Resident #8601 and the resident's guardian. The effective date of the discharge was identified as 09/21/24 and reasons for discharge included noncompliance with care, combativeness and posing a safety risk to himself and others. Further review revealed appropriate notification of the discharge was made to the Ombudsman and state agencies. Review of a progress note dated 08/28/24 revealed Resident #8601 was sent to the ED for further psychological evaluation per physician order. The psychological services provider completed an application for emergency admission (pink slip) and Resident #8601 was transported to the ED by Emergency Medical Services (EMS) with law enforcement escort. Further review of a progress note dated 08/28/24 revealed the hospital notified the facility Resident #8601 was ready to return. The Director of Nursing (DON) informed the ED nurse the facility would not accept the resident back. Review of a progress note dated 09/03/24 revealed the hospital notified the facility that Resident #8601 was ready to return. The facility made Resident #8601 and the resident's guardian aware the resident would not be accepted back to the facility. Review of the discharge appeal hearing examiners decision and order, dated 09/05/24, revealed Resident #8601's guardian requested an emergency appeal of the resident's discharge and indicated the resident was in the hospital and the facility refused to accept him back. The document stated the facility did not attend the hearing. Further review of the appeal decision revealed the facility was not authorized to discharge Resident #8601 and was ordered to readmit the resident. A copy of the decision was sent via electronic mail (e-mail) to the Administrator on 09/06/24. Review of the facility-initiated emergency discharge notice, dated 09/12/24, revealed the notice was issued to Resident #8601 and his guardian. The discharge notice indicated the effective date of the discharge was 09/12/24 and the reasons for discharge included the safety of the individuals in the home was endangered, the resident's urgent medical needs necessitated a more immediate transfer or discharge and the welfare and needs of the resident could not be met at the facility. The notice did not include any specific information related to the discharge reasons indicated. Interview on 09/16/24 at 2:50 P.M. with the Administrator, Social Worker (SW) #106 and Hospital Liaison (HL) #175 confirmed the hospital wanted to send Resident #8601 back to the facility on [DATE], but the facility refused readmission pending a neurological evaluation. As of 09/16/24, Resident #8601 remained in the hospital and had not been permitted to return to the facility. A telephone interview on 09/17/24 at 2:09 P.M. with HSW #1001 and HSW #1002 confirmed on 08/28/24, the hospital attempted to discharge Resident #8601 back to the facility following an ED evaluation; however, the facility refused to unlock the coded door to allow access, and the resident was transported back to the hospital. On 09/12/24, after receiving the discharge appeal ruling from 09/05/24, the hospital attempted to have Resident #8601 readmitted to the facility, but the facility again refused readmission, and the resident was transported back to the hospital. HSW #1001 and HSW #1002 denied the facility had any proactive conversations with them related to Resident #8601 not being accepted back to the facility. A telephone interview on 09/18/24 at 1:26 P.M. with Resident #8601's guardian revealed she was aware the facility was seeking alternative placement for the resident. However, the guardian stated she was unaware the facility was going to refuse to readmit the resident from the hospital. Resident #8601's guardian stated she learned from HSW #1001 that the facility would not allow the resident to return. The guardian stated there were several back-and-forth conversations with the facility from 08/28/24 through 09/05/24 related to Resident #8601 returning, with the facility stating they were not taking him back, they did not have to take him back and they would not let him in. The guardian stated the communications came from the Administrator, DON and SW #106. The guardian stated she received the same response from the facility on 09/12/24 when the hospital again attempted to discharge the resident back to the facility, and he was refused readmission. The guardian stated even after the discharge appeal hearing on 09/05/24, which ordered the facility to readmit Resident #8601, the facility refused the resident's readmission from the hospital. A telephone interview on 09/19/24 at 9:10 A.M. with Licensed Practical Nurse (LPN) #425 revealed at the time Resident #8601 was sent to the hospital on 08/28/24, she was unaware the facility would not readmit the resident. During a meeting on 08/29/24, Regional Director of Operations (RDO) #500 decided Resident #8601 was being discharged immediately and would not return to the facility. A telephone interview on 09/20/24 at 2:12 P.M. with the Administrator confirmed on 08/28/24 at 8:34 P.M., text messages were exchanged between her, the DON, Registered Nurse (RN) #306, LPN #425 and HL #175 indicating Resident #8601 would not be readmitted to the facility. The Administrator confirmed RDO #500 made the decision not to readmit Resident #8601 and this decision was communicated to all department heads during the morning meeting on 08/29/24. Resident #8601 did not return to the facility, even after the discharge appeal hearing officer ordered the facility to readmit the resident from the hospital. This deficiency represents noncompliance investigated under Master Complaint Number OH00157356.

Based on medical record review, staff interview, and policy review, the facility failed to notify the physician as ordered. This affected one (#28) resident of three reviewed for change in condition. The facility census was 73. Findings include: Medical record review for Resident #28 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia with anxiety, chronic obstructive pulmonary disease, severe protein calorie malnutrition, heart failure, and depression. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #28 revealed the resident was assessed with an intact cognition. Resident #28 required supervision for bed mobility, transfers, toileting and eating. Resident #28 weight was documented as 186 pounds. Review of the plan of care for Resident #28 dated 11/03/23 revealed the resident was at risk for malnutrition and dehydration related to chronic disease, advanced age, and potential for weight and intake decline related to disease progression. Interventions include to administer medication as ordered, provide diet as ordered and obtain weight at a minimum of monthly. Report significant changes of five percent or more in a month to the physician and the dietician. Review of the physician orders for Resident #28 revealed an order dated 12/12/23 for weekly weights every Tuesday, and to notify the physician if weight gain was greater than five pounds for congestive heart failure. Review of the electronic health record for Resident #28 revealed the resident weighed 186 pounds (lbs.) on 11/02/23, 190.4 lbs. on 11/29/23, 189.3 lbs. on 12/05/23, 190.2 pounds on 01/02/24 at 4:13 A.M., and 206.6 lbs. on 01/02/24 at 2:51 P.M. Review of the progress notes and medical record for Resident #28 dated 01/01/24 through 01/18/24 was silent for any physician notification of a weight gain greater than five pounds after 01/02/24. Interview on 01/11/23 at 11:30 A.M. with Licensed Practical Nurse (LPN) #1 verified Resident #28's medical record did not contain any documentation that the physician was notified of the significant weight gain and should have been. Interview on 01/11/23 at 3:30 P.M. with Director of Nursing (DON) #17 verified Resident #28's medical record did not contain any documentation that the physician was notified of the significant weight gain and should have been. Request for policy related to the collection or weights or physician orders was requested during the survey and not provided for review. Review of the facility policy titled, Notification of Change, dated 12/12/22, revealed the facility must inform the guest/resident, consult with the guest's/residents physician when there is a change in status. This deficiency represents non-compliance investigated under Complaint Number OH00149058.

Based on medical record review and staff interview, the facility failed to follow physicians orders for obtaining weights. This affected one (#28) resident of three reviewed for weight monitoring. The facility census was 73. Findings include: Medical record review for Resident #28 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia with anxiety, chronic obstructive pulmonary disease, severe protein calorie malnutrition, heart failure, and depression. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #28 revealed the resident was assessed with an intact cognition. Resident #28 required supervision for bed mobility, transfers, toileting and eating. Resident #28 weight was documented as 186 pounds. Review of the plan of care for Resident #28 dated 11/03/23 revealed the resident was at risk for malnutrition and dehydration related to chronic disease, advanced age, and potential for weight and intake decline related to disease progression. Interventions include to administer medication as ordered, provide diet as ordered and obtain weight at a minimum of monthly. Report significant changes of five percent or more in a month to the physician and the dietician. Review of the physician orders for Resident #28 revealed an order for a mechanical soft diet dated 01/17/24, and order dated 12/13/23 for the diuretic Lasix oral tablet 20 milligram (mg) to give one tablet by mouth two times a day for edema and hold for systolic blood pressure less than 100 millimeters of mercury (mmHg), an order dated 12/12/23 for weekly weights every Tuesday and to notify the physician for weight gain greater than five pounds for congestive heart failure, and an ordered dated 12/05/23 to apply compression stockings or ACE wraps to the resident's bilateral lower extremities daily and remove at bedtime once daily for edema. Review of the electronic health record for Resident #28 revealed the resident weighed 186 pounds (lbs.) on 11/02/23, 190.4 lbs. on 11/29/23, 189.3 lbs. on 12/05/23, 190.2 pounds on 01/02/24 at 4:13 A.M., and 206.6 lbs. on 01/02/24 at 2:51 P.M. Review of the medical record and nursing progress notes for Resident #28 dated 01/01/24 through 01/18/24 was silent for any additional weights obtained during this time frame. Interview on 01/11/23 at 11:30 A.M. with Licensed Practical Nurse (LPN) #1 verified Resident #28's medical record did not contain weekly weights and it should have after it was ordered on 12/12/23. Interview on 01/11/23 at 3:30 P.M. with Director of Nursing (DON) #17 verified weekly weights were not obtained for Resident #28 per the physician order dated 12/12/23. Request for policy related to the collection or weights or physician orders was requested during the survey and not provided for review. This deficiency represents non-compliance investigated under Complaint Number OH00149058.

Based on medical record review, staff and hospital staff interviews and policy review, the facility failed to provide a timely discharge notice to a resident. This affected one (#75) of three residents reviewed for discharge. The facility census was 72. Findings include Medical record review for Resident #75 revealed an admitted [DATE]. Diagnoses include schizoaffective disorder, cerebral infarction, expressive language disorder, aphasia, hemiplegia and hemiparesis of right dominant side, seizures, depression, anxiety, migraine, mood affective disorder, hallucinations, behavioral disorders, and insomnia. Review of the discharge not anticipated Minimum Data Set (MDS) assessment dated [DATE] for Resident #75 revealed the resident was severely impaired cognition. Resident #75 was coded with physical, verbal, and behavioral symptoms directed at self and others, rejection of care, and wandering during the assessment period. Resident #75 was supervised for bed mobility, transfers, eating and toileting. Review of the plan of care for Resident #75 revealed the resident has a psychosocial well-being problem actual or potential related to schizoaffective diagnosis, with anxiety, insomnia, depression, traumatic brain injury, mood disorder and behavioral disorders including hallucinations. Interventions include allow the resident time to answer questions and to verbalize feelings perceptions, and fears as needed (PRN). Consult with pastoral care, social services, psych services, when conflict arises, and remove resident to a calm safe environment. Review of the progress notes for Resident #75 dated 04/30/23 at 2:16 P.M. revealed the resident refused to come back into building after smoke break, aide redirected Resident #75 multiple times, with continued refusals to reenter the facility. Resident #75 proceeded to punch staff in shoulder. Resident #75 refused to come in building, proceeded to the exit gate started pulling on gate, resident turned around started to be more combative by hitting, kicking, and punching staff. Staff called for help via cell phone, resident took cell phone and hit it against the gate. Resident #75 forcefully pushed gate and broke gate. Nurses came to intervene, and 911 called. Resident #75 was sent to hospital for evaluation. Review of the progress note for Resident #75 dated 04/30/23 at 3:40 P.M. revealed emergency room nurse from hospital called facility and advised Resident #75 was diagnosed with a urinary tract infection (UTI) and are sending resident back to the facility. Review of the progress note for 04/30/23 at 6:50 P.M. revealed in-house psychologist sent over pink slip referral for Resident #75 to be transferred to psychiatric facility. Spoke with emergency room (ER) nurse at hospital and advised they are going to transport her back to facility at this time with an order of antibiotics for UTI. Resident #75 will be on one-on-one (1-on-1) until we get confirmation from psychiatric facility. Administrator and all parties are notified. Review of the Ohio Department of Mental Health and Addiction Services application for emergency admitted d 04/30/23 for Resident #75 revealed the resident has become increasingly agitated and aggressive. Resident #75 currently represents a substantial risk of harm to others based on her violet behavior today. Resident #75 physically attacked multiple staff members including punching and hitting. Staff are now concerned for their safety and for the residents in the facility. Resident #75 destroyed facility property. Redirection and medication have been ineffective, and her current needs outweigh what the facility is able to provide. Please admit for stabilization. Further review of Resident #75's medical record revealed there was a discharge notice issued to the resident on 05/17/23. Review of the facility transfer notice to the Ombudsmen dated 05/01/23 revealed Resident #75 was sent to the hospital on 04/30/23. Interview with facility Social Worker Designee (SWD) #9 on 05/24/23 at 1:58 P.M. stated Resident #75 was sent to hospital and then diagnosed back to the facility with a UTI. SSD #9 stated Resident #75 was being returned to the facility and the resident was in route when she started biting/attacking the emergency medical technician (EMT) and was taken to a different hospital. SWD #9 stated she received a request for her PASARR from a place at another facility and they have accepted her. SWD #9 stated she was told by management to start looking for alternate placement as the facility was not going to accept her back due to her behavior. Interview on 05/24/23 at 2:49 with the Administrator verified she advised the hospital social worker that the facility would not be accepting Resident #75 return to the facility due to aggressive behaviors and did not provide a discharge notice until 05/17/23. Administrator stated she was unable to recall when she advised the hospital that she would not be able to take Resident #75 back, but it was before the discharge notice was sent. The Administrator further stated she was not aware of the requirement to send a discharge notice to the resident or representative until alerted by another Administrator. Interview on 05/26/23 at 2:19 P.M. with Hospital Licensed Social Worker (LSW) #502 stated the hospital attempted to discharge Resident #75 back to the nursing facility on 05/09/23 and was advised by the Nursing Home Administrator the facility would not be accepting her back at this time due to her behaviors. Review of facility policy titled Transfer and Discharge, dated 02/28/23, revealed when a facility-initiated transfer is made the facility will issue a notice in writing at least 30 days prior to the transfer. This deficiency represents non-compliance investigated under Complaint Number OH00142720.

Based on observation, staff and resident interview and policy review, the facility failed to ensure substitutions were available for each resident who would like a different choice of foods during meal service. This had the potential to affect all residents who receive meals from the kitchen. The facility census was 70. Findings include: Interview on 05/07/23 at 2:44 P.M., Resident #02 said they were not provided menus or substitutions for the meals served. Interview on 05/08/23 at 9:02 A.M., Resident #10 said they were not provided menus or substitutions for the meals served. Interview on 05/09/23 at 8:01 A.M., Resident #20 said they were not provided menus or substitutions for the meals served. Interview on 05/10/23 at 9:50 A.M., Resident #28 said they were not provided menus or substitutions for the meals served. Interview on 05/08/23 at 1:39 P.M., and on 05/09/23 at 11:02 A.M., with dietary staff #39 and #67 stated the menus were not offered to residents and substitutions were not offered unless brought up by the residents' and the substitutions were not always available due to food available at the facility. Interview on 05/09/23 at 8:28 A.M., State tested Nursing Assistant (STNA) #53 said the residents' get what they get because they often have no substitutions available. Observation of the facility kitchen on 05/08/23 at 1:39 P.M., and on 05/09/23 at 11:02 A.M., revealed the facility had no substitution options for meals and no substitution logs available to review. This was verified by the Kitchen Manager #55 and the Cook #39. Review of a policy titled Meal Service, dated 11/19/21 revealed residents are interviewed for preferences upon admission and as needed on what they like to eat, where they like to eat, guest are assisted as needed to the dining room and with meal set up and feeding if needed. This deficiency represents noncompliance in Complaint Number OH00140119.

Based on observation, medical record review, staff and resident interview and policy review the facility failed to ensure residents had access to menus and substitutions were available. This affected eight residents (#02, #10, #20, #28, 26, #36, #59 and #69) out of eight residents reviewed for menus and substitutions. The facility also failed to ensure double portions were served for one resident (#59) of one resident reviewed for double portions for meals. The facility census was 70. 1. Medical record review for Resident #26 revealed an admitted [DATE]. Medical diagnoses included traumatic brain dysfunction, peripheral vascular disease, renal insufficiency, and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was cognitively intact. He was independent for bed mobility, transfers, toilet use and eating. Interview and observation with Resident #26 on 05/07/23 at 3:39 P.M. revealed he didn't receive a menu and wasn't able to get a substitution if he didn't like his meal. There was not a menu in his room. 2. Medical record review for Resident #36 revealed an admission of 06/21/22. Medical diagnoses included cancer, anxiety and depression. Review of the quarterly MDS dated [DATE] revealed Resident #36 was cognitively intact. The resident required supervision for bed mobility, transfers and toilet use. She was independent for eating. Interview and observation on 05/07/23 at 4:00 P.M. Resident #36 revealed was unable to get a menu and could not receive a substitution either. There was not a menu located in her room. 3. Medical record review for Resident #59 revealed an admitted [DATE]. Medical diagnoses included post traumatic stress disorder (PTSD), and diabetes. Review of the quarterly MDS dated [DATE] revealed Resident #59 was moderately cognitively impaired. His functional status was independent for bed mobility, transfers, toilet use and eating. Interview and observation with Resident #59 on 05/08/23 at 7:43 A.M., revealed he said he could not get a menu, he has requested double portions and doesn't receive them, and he wasn't able to choose what he wanted to eat. There was not a menu located in his room. Interview with State tested Nursing Aide (STNA) #26 on 05/09/23 at 7:47 A.M., verified there was not a menu or substitution menu posted on the unit's for Resident's #26, #36 and #59 and there wasn't any in the resident's rooms either. She stated the staff had been passing out the menus, but she couldn't find any. She stated the staff have to walk to the kitchen to find out what the substitution was to let the resident's know what it would be. Observation of a menu ticket and breakfast tray for Resident #59 on 05/09/23 at 7:58 A.M. revealed he was supposed to receive double portions for his meals. On his breakfast tray he had two waffles, and four slices of bacon like all the other residents' had on their trays. Interview with STNA #26 on 05/09/23 at 8:00 A.M., confirmed Resident #59's meal ticket said double portions and he had not received a double portion on his breakfast tray. Interview with STNA #53 on 05/09/23 at 8:28 A.M. revealed the residents' get what they get because the facility often doesn't have substitutions. Interview with the Dietary Aide (DA) #67 on 05/09/23 at 12:00 P.M. revealed the substitutions were not known to the residents until the kitchen can figure out what they had available and the new kitchen manager started yesterday. 47058 4. Observation on 05/07/23 through 05/10/23 revealed no menus were available for residents' use to know what the planned meals for the day or what substitutions were available. Interview on 05/07/23 at 2:44 P.M., Resident #02 said they were not provided menus or substitutions for the meals served. Interview on 05/08/23 at 9:02 A.M., Resident #10 said they were not provided menus or substitutions for the meals served. Interview on 05/09/23 at 8:01 A.M., Resident #20 said they were not provided menus or substitutions for the meals served. Interview on 05/10/23 at 9:50 A.M., Resident #28 said they were not provided menus or substitutions for the meals served. Interview on 05/08/23 at 1:39 P.M., and on 05/09/23 at 11:02 A.M., with dietary staff #39 and #67 stated the menus were not offered to residents and substitutions were not offered unless brought up by the residents' and the substitutions were not always available due to food available at the facility. Review of the policy titled Meal Service, dated 11/19/21 revealed the residents are to be interviewed for preferences upon admission and as needed on what they like to eat, where they like to eat, guest are assisted as needed to the dining room and with meal set up and feeding if needed. Clothing protectors as needed, no mention of menus or food preference in policy. This deficiency represents noncompliance in Complaint Number OH00140119.

Based on observation, interview, medical record review, review of an invoice and policy review, the facility failed to ensure residents were treated with dignity and respect. This affected two residents (#05 and #59) of 24 residents sampled for dignified care. The facility census was 70. Findings Include: 1. Review of the medical record for the Resident #05 revealed an admitted [DATE]. Diagnoses included acute osteomyelitis. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #05 had intact cognition, had no behaviors, did not reject care, and did not wander. Resident #05 required supervision assistance for activities of daily living (ADL) care. Review of an invoice dated 05/03/23 revealed [NAME] Plumbing and Sewer provided plumbing services to the facility for concerns with water pressure. During an interview on 05/07/23 at 10:54 A.M., Resident #05 stated last week, unsure of exact date, a plumber walked into her room without her permission to look at something in the bathroom, disregarding her pleas for him not to enter as she was unclothed and in the process of dressing after a shower. During an interview on 05/10/2023 at 9:03 A.M., Maintenance #59 confirmed an outside vendor was in the building last week, unsure of the exact date, working on issues with water pressure in resident rooms on the 500-Hall. Maintenance #59 verified he knocked on Resident #05's door, Resident #05 stated she was not completely dressed, asked staff to wait, and the vendor continued to the walk across the room to the resident's bathroom. Maintenance #59 stated he waited until Resident #05 gave permission to enter the room, went into the bathroom, and educated the plumber, about Residents' rights to dignity and not entering a room without a resident's permission. 34291 2. Medical record review for Resident #59 revealed an admitted [DATE]. Medical diagnoses included post traumatic stress disorder (PTSD) and diabetes. Review of the quarterly MDS dated [DATE] revealed Resident #59 was moderately cognitively impaired. His functional status was independent for bed mobility, transfers, toilet use and eating. Observation on 05/07/23 at 12:29 P.M. revealed State tested Nursing Aide (STNA) #63 revealed she knocked on the resident's door and came into the room without the resident saying she could come into the room. Interview with STNA #63 on 05/07/23 at 12:30 P.M. confirmed she should have waited for the resident to acknowledge and say she could enter the room before entering. Review of the policy titled Guest/resident Dignity and Personal Privacy, dated 05/01/22 revealed the facility would provide care for guests/residents in a manner that respects and enhances each guest's/ resident's dignity, individuality, and right to personal privacy. Each guest's/resident's right to personal privacy includes the confidentiality of his or her personal and clinical affairs. Dignity means that when interacting with guests/residents, staff would carry out activities that assist the guest/resident in maintaining and enhancing his or her self-esteem and self-worth. This deficiency represents non-compliance investigated under Complaint Number OH00140119.

Based on staff and resident interview, observation, and record review, the facility failed to ensure resident rooms were equipped to maintain complete privacy. This affected one resident (#05) of 24 residents screened for privacy. The facility census was 70. Findings include: Review of the medical record for the Resident #05 revealed an admitted [DATE]. Diagnoses included acute osteomyelitis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #05 had intact cognition, had no behaviors, did not reject care, and did not wander. Resident #05 required supervision assistance for activities of daily living. During an interview on 05/07/2023 at 10:57 A.M. Resident #05 stated her room di not allow her to maintain privacy because her privacy curtain was broken and did not provide privacy all the way around her living area. During an observation and interview on 05/10/2023 at 9:42 A.M. Housekeeper #85 verified the privacy curtain in Resident #05's room was missing a panel and could not provide complete wall-to-wall privacy. Review of the policy titled Guest/resident Dignity and Personal Privacy, dated 05/01/22 revealed staff pulled the privacy curtain to provide privacy during care.

Based on medical record review, staff and resident interview, observation, review of the activity calender, and policy review, the facility failed to ensure activities of resident interests were provided on the weekends. This affected two residents (#26 and #36) of four residents reviewed for activities. The census was 70. Findings included: 1. Medical record review for Resident #26 revealed an admitted [DATE]. Diagnoses included traumatic brain dysfunction, peripheral vascular disease, renal insufficiency, and dementia. Review of the activity evaluation dated 01/04/23 for Resident #26 revealed it was very important to keep up with the news, go outside for fresh air, and have books and magazines. The assessment documented it was somewhat important to listen to music, to do his favorite activities, and do activities with groups of people. Review of the activity progress notes from 02/08/23 to 05/07/23 revealed there wasn't any refusals for activities. Review of activity documentation from 04/08/23 to 05/08/23 revealed there wasn't anything marked for the weekends. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was cognitively intact. He was independent for bed mobility, transfers, toilet use and eating. Review of the care plan dated 04/20/23 for Resident #26 revealed he liked to attend daily scheduled activities. Review of the activity calendar dated 05/07/23 revealed daily chronicle, word search, coloring page, bible study on three halls, leisure cart, and left right center game conducted on three halls. Further review revealed on 05/14/23, 05/21/23 and 05/28/23 revealed the same schedule. Interview with Resident #26 on 05/07/23 at 3:37 P.M. revealed there wasn't enough activities on the weekends and sometimes there wasn't any at all. 2. Medical record review for Resident #36 revealed an admission of 06/21/22. Diagnoses included cancer, anxiety and depression. Review of the activity evaluation dated 06/22/22 for Resident #36 revealed it was very important to have books and magazines, listen to music, be with animals, groups of people, and do favorite activities. Review of the activity progress notes from 02/08/23 to 05/07/23 revealed there wasn't any refusals for activities. Review of the quarterly MDS dated [DATE] revealed Resident #36 was cognitively intact. The resident required supervision for bed mobility, transfers and toilet use and could eat independently. Review of the documentation from 04/08/23 to 05/08/23 revealed there wasn't anything marked for the weekends. Review of the care plan dated 04/13/23 for Resident #36 revealed she liked to attend daily activities as scheduled, and to invite and encourage her to attend scheduled activities of interest. Observations on 05/07/23 at 10:00 A.M. through 4:00 P.M. at random times revealed there wasn't anyone participating in activities. Interview with Activity Aide (AA) #73 on 05/07/23 at 2:25 P.M. revealed she was the only aide for activities on this day. She stated she passed out chronicles, and had the bible study, but only two people attended bible study. She stated she didn't take the leisure cart around to the residents, because it was games no one wanted to play. She stated she invited resident's to play left right center but only got a couple of people to play. She stated there wasn't much to do on Sunday it was the slowest day of the week for activities. She stated there wasn't enough budget on the weekends to play the games like they did during the week. She further revealed it was the same schedule on Sundays every week. Interview with Resident #36 on 05/07/23 at 3:58 P.M. revealed there wasn't much to do on the weekends regarding activities and it was boring. Review of the policy titled Activity Program, 08/03/21 revealed he facility would provide an ongoing activity/recreation program based on the individual guest/resident comprehensive evaluation, care plan, and stated preferences. The activity/recreation program supports guests/residents in their choice of activities and includes group, individual, and independent activities which empowers, maintains, and supports all guests/residents in the facility. Recreational activities are designed to encourage both independence and interaction in the community.

Based on observation, medical record review, and resident and staff interview, the facility failed to ensure residents received timely medical treatment. This affected one resident (#15) of two residents reviewed for bowel and bladder. The facility census was 70. Findings included: Medical record review for Resident #15 revealed an admitted [DATE]. Diagnoses included coronary artery disease, heart failure, hypertension, diabetes and renal insufficiency. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #15 was cognitively intact. She was independent for bed mobility, transfers, eating and toilet use. She was always continent of bowel and bladder. Review of the physician orders dated 02/13//23 revealed to give Imodium two milligram (mg) one tablet every six hours as needed for diarrhea. Review of the Medication Administration Record (MAR) for Imodium, revealed from 05/01/23 through 05/08/23 the resident had not been given Imodium for diarrhea. Interview with Resident #15 on 05/07/23 at 11:46 A.M., revealed she doesn't get any medications for her diarrhea. Interview and observation on 05/09/23 at 8:27 A.M., Resident #36 revealed her roommate, Resident #15 asked for something for diarrhea about an hour ago and had not received anything yet. At the time of the interview Licensed Practical Nurse (LPN) #74 was observed on the opposite hall of the resident passing medications. A follow-up interview with Resident #15 on 05/09/23 at 10:16 A.M., revealed she had diarrhea since early this morning. LPN #74 told her she had no Imodium on her medication cart, but would be back later to give her the medication. Interview with the LPN #74 on 05/09/24 at 10:24 A.M., revealed Resident #15 reported she had diarrhea earlier but had no Imodium on her medication cart and there was none on another cart as well. She stated she would have to go all the way over to another building in the basement to get the Imodium and she had time to do that now.

Based on medical record review, observation, resident and staff interviews, review of hospital record, review of facility self-reported incident (SRI), and review of Abuse Prohibition, Investigation, and Reporting policy, the facility failed to ensure a resident was free from abuse when a cognitively impaired resident wandered into another residents room. Resident #13 placed his hands on Resident #05 in an attempt to remove him from his room. This resulted in actual harm when Resident #05 fell and sustained facial contusion, periorbital hematoma of the left eye, lip laceration, dental contusion, and left and right wrist sprains. This affected one Resident (#05) of three reviewed for abuse. The facility census was 77. Findings include: Medical record review revealed Resident #05 was originally admitted to the facility on [DATE] with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The resident was [AGE] years old, Review of quarterly minimum data set ((MDS) dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident required extensive assistance with bed mobility, transfers, toileting, personal hygiene and only required supervision for locomotion without any mobility devices. Review of quarterly secured unit evaluation dated 09/25/19 revealed continued placement was recommended by the interdisciplinary team (IDT) as moving Resident #05 off the unit would exacerbate confusion and behaviors. Behaviors included wandering, refusal of care, and exit seeking. Review of nursing progress note dated 10/20/19 at 9:30 P.M. revealed Resident #05 was found on the floor in Resident #13s doorway. Resident #05 was bleeding from the left side of the face, had a laceration to the left side of the lip with swelling and an open abrasion above the left eyebrow. Nine-one-one (911) was called, management was notified, and Resident #05 was transported to the hospital. Review of nursing progress note dated 10/21/19 at 12:45 [NAME]M. revealed report was received from the hospital. Resident #05 was being returned to the facility. X-rays, lab work, and electrocardiogram (EKG) revealed no abnormalities. Resident #05s left eye was now swollen completely shut with an open abrasion above the left eyebrow. The laceration to the left side of the lip was sealed with dermabond, an adhesive wound closure device. Review of nursing progress note dated 10/21/19 at 1:23 P.M. revealed the IDT met and reviewed the incident involving Resident #05. Resident #05 was found on the floor with an open laceration above the left eyebrow. Resident #05 was unable to provide any explanation about what happened but was noted with untied shoes on his feet. Immediate intervention included the resident was sent to the emergency room for further evaluation. Upon return to the facility, staff were to verify Resident #05 had appropriate footwear including tied shoes, when out of bed. Both the physician and family were notified. Review of emergency room [DIAGNOSES REDACTED].#05s final [DIAGNOSES REDACTED]. Review of physician order [REDACTED]. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with diagnose including osteo[DIAGNOSES REDACTED] of vertebra [MEDICATION NAME] region, heart failure, and substance abuse including opioid dependence. Resident #13 was [AGE] years old Review of admission MDS dated [DATE] revealed intact cognitive skills for daily decision making and supervision was required with all activities of daily living except extensive assistance was required with dressing. A wheelchair was utilized for mobility. Review of secured unit evaluation pre-admission screening dated 10/10/19 revealed Resident #13 had a history of [REDACTED]. Resident #13 previously left the facility against medical advise (AMA). Increased supervision was required related to history of drug abuse, leaving AMA, and to monitor visitors closely. Resident #13 was in agreement to reside on a secured unit. Review of facility SRI dated 10/20/19 revealed staff heard a commotion coming from Resident #13s room. Upon entering, staff observed Resident #05 on the floor with an abrasion to the head. Staff immediately contacted management as the assumption was a physical altercation had occurred between Residents #05 and #13. The SRI was initiated and the director of nursing (DON) was contacted to investigate. Upon further investigation, it was determined no physical contact had occurred and staff had not witnessed any physical contact. Resident #13 reported Resident #05 entered his room and upon leaving lost his balance and fell which caused the commotion staff overheard. The abrasion to Resident #05 was a result of a fall, not physical contact. Resident #13 did not show any signs of agitation or aggression per staff when interviewed immediately after the incident. Resident #05 was unable to answer questions appropriately due to [DIAGNOSES REDACTED]. Observation during a facility tour on 11/05/19 at 9:41 [NAME]M. revealed Resident #05 was asleep in a chair in the common area of the secured unit, directly in front of the nursing station. Black bruising was observed to both eyes. Observation on 11/05/19 at 11:31 [NAME]M. revealed Resident #05 returned to the secure unit from lunch and was wandering throughout the halls independently without any assistive devices. Interview with the resident revealed a confused mental status and inability to answer questions accurately or provide any meaningful information. Resident #05 had black bruises to both eyes, down the left jawline to the neck. Interview on 11/05/19 at 2:21 P.M. with Resident #13 reported one altercation at the facility, with Resident #05, on sweetest day weekend. Resident #13 reported Resident #05 had made inappropriate sexual comments to his girlfriend in the past. On sweetest day, Resident #13s girlfriend was visiting and needed to use the bathroom so they went to Resident #13s room. The girlfriend was in the bathroom and Resident #13 was seated on the bed, looking through his phone, when he heard the bathroom door knob rattle as the bathroom door was locked. When Resident #13 looked up, he observed Resident #05 attempting to enter the bathroom, on the girlfriend. Resident #13 reported Resident #05 wandered into other residents rooms and acted like he didn't know what he was doing but its wasn't okay for Resident #05 to follow females into the bathroom. Resident #13 insisted Resident #05 knew his girlfriend was in the bathroom and intentionally was attempting to go in after her. Resident #13 reported he had to stand up for his girlfriend, yelled at Resident #05 whom was about to bolt but then stopped. Resident #13 reported he knew he wasn't supposed to put his hands on Resident #05 but he jumped up, put his hands on Resident #05s shoulders, and was escorting him out his room when Resident #05 stopped. Resident #13 reported he wasn't sure how fast he was moving as his [MEDICATION NAME] was pumping, but when Resident #05 stopped just prior to exiting the room, Resident #13 kept moving with his hands on Resident #05s shoulders, pushing him, and Resident #05 fell flat onto his face into the hall. Resident #13 reported in the report it stated he was standing over Resident #05, hitting him, but Resident #13 denied hitting Resident #05, and reported he had spent half his life in prison, was institutionalized, and Resident #05 was lucky that was all that happened. Interview on 11/05/19 at 5:15 P.M. with the Administrator reported the investigation into the incident involving Resident #05s fall revealed the only witness was Resident #13. Interview on 11/05/19 at 5:45 P.M. with registered nurse (RN) #50 reported on 10/20/19, he was at the medication cart, when he heard yelling and a commotion coming from the direction of Resident #13s room. The state tested nursing assistant (STNA) assigned to the unit was down the opposite hall providing care in a residents room. RN #50 responded along with the STNA and upon nearing Resident #13s room, Resident #05 was observed falling out of the room, hitting his head on the floor. RN #50 reported Resident #13s doorway obscured the view and staff were unable to see what caused the fall. The only witness to the event was Resident #13 whom was more focused about Resident #05 being in his room and reported he assisted the resident out of his room. RN #50 reported Resident #05 was known to wander around the unit independently, would occasionally enter other residents room, but was easily verbally redirected. RN #50 reported the incident happened so quickly, staff were unaware Resident #05 had wandered into Resident #13s room and therefore didn't have time to redirect Resident #05. Interview on 11/06/19 at 10:39 [NAME]M. with the DON reported she completed the investigation into the incident which occurred on 10/20/19 and it was determined Resident #05 fell due to not having proper footwear in place. Resident #13 was interviewed and reported Resident #05 fell after being asked to leave his room. Resident #05 paced the hallways at times but usually didn't enter other residents rooms. Females were not permitted on the unit as it was a secure male unit. Resident #13 let his girlfriend on the unit to use his bathroom and Resident #05 may have followed them to the room as females were not allowed on the unit. Interview on 11/06/19 at 10:59 [NAME]M. with RN #59 reported she was at the facility at the time of Resident #05s fall. Upon arrival to the unit, Resident #05s body was in the hall on the floor with feet remaining in Resident #13s room. Resident #05 had a large abrasion and laceration above the left eyebrow which was bleeding. RN #59 reported at the time of the incident, the STNA was in a room on another hall and the nurse was near the nursing station. Both staff members heard arguing, responded, and observed Resident #05 on the floor in the hall. RN #59 reported upon her arrival to the unit, the nurse was assessing Resident #05 and Resident #13 was outside smoking. Upon interviewing Resident #13, RN #59 reported Resident #13 was visiting with his girlfriend who needed to use the bathroom. Resident #13 had brought his girlfriend onto the secure male unit, which was against the rules, to his room to use the bathroom. Resident #05 followed them into the room. Resident #13 asked Resident #05 to leave, Resident #05 turned around to leave and fell . Resident #13 reported Resident #05 took one step and fell but from where he landed in the hall, he had to have taken more than one step. RN #59 reported she assessed Resident #13 and there weren't any marks on his hands. Staff heard the two residents arguing but couldn't make out what was being said. Resident #13 reported he was yelling at Resident #05 to get out of his room. Resident #13 was upset about Resident #05 being in his room and reported Resident #05 knew better. Resident #13 kept saying Resident #05 wouldn't get out of his room and was mumbling while attempting to enter the bathroom. Review of Abuse, Prohibition, Investigation, and Reporting policy revised (MONTH) 2019 revealed it is the policy of the facility to prohibit mistreatment, neglect, and abuse of residents and/or misappropriation of resident property or resources. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and/or psychological well-being. Physical abuse includes, but is not limited to, hitting, slapping, pinching, biting, kicking, etc. It also includes controlling behavior through corporal punishment. Willful is defined as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. This deficiency substantiates Complaint Number OH 935.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to the survey. Based on clinical record review, staff interviews, interview with Fairfield Township Fire Department personnel, review of Licensed Practical Nurse (LPN) #58's personnel file, and review of the facility's policy titled Cardio-Pulmonary Resuscitation for Adults, the facility failed to provide necessary care and service when nursing staff did not implement cardiopulmonary resuscitation (CPR) for Resident #61. This resulted in Immediate Jeopardy for one (Resident #61) of 5 sampled residents. The facility identified 46 residents with "Full Code Measures" advanced directives for CPR. On [DATE] at 2:20 P.M., the Administrator and the Director of Nursing were notified Immediate Jeopardy began on [DATE] at 1:25 A.M. when facility staff found Resident #61 unresponsive, not breathing and without vital signs. LPN #58 did not initiate CPR although the resident had a physician's orders [REDACTED]. The Immediate Jeopardy was removed and the deficient practice was corrected on [DATE] when the facility implemented the following actions: - LPN #58 was not allowed to return to work after the incident on [DATE] and was terminated on [DATE]. - On [DATE], [DATE] and [DATE], all licensed nurses were in-serviced regarding the location of residents' code status in their medical record and on the facility's existing CPR policy. -On [DATE], the facility started an on-going program to monitor all new admissions to ensure proper code status is prominently displayed in the medical record and on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. - On [DATE], five nurses were interviewed and correctly stated the location of the residents' CPR advance directive information in the medical records and what their responsibility was when a resident required CPR. Findings include: Review of the closed medical record of Resident #61 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Nurse's notes dated [DATE] at 6:38 A.M., by LPN #58, stated at approximately 1:25 A.M., State tested Nurse Aide (STNA) #30 alerted her that while doing rounds, she observed Resident #61 to be non-responsive. The notes stated STNA #30 expressed "I think he is dead." The notes stated upon entering the room, LPN #58 observed Resident #61 non-responsive and began assessing the resident's vital signs. According to the nurse's notes, LPN #58 was unable to obtain the resident's blood pressure, pulse, or to detect respirations. The nurse's notes revealed LPN #58 went from the 500 unit to the 100 unit and asked the 100 unit nurse (Registered Nurse #55) to assess the resident. LPN #58 further documented Registered Nurse (RN) #55 asked her what the resident's code status was. LPN #58 documented she went to the nurse's station to view the resident's chart and found no code status on file. The nurse's notes stated LPN #58 notified the Director of Nursing (DON) and Administrator. The nurse's notes further stated 911 was called at 1:37 A.M. and the squad arrived at 1:42 A.M. The nurse's notes stated the emergency medical technicians (EMTs) determined Resident #61 was not viable and did not attempt CPR. There was no documentation in resident's medical record that CPR was ever initiated. During telephone interview on [DATE] at 11:35 A.M., STNA #30 stated she last provided incontinence care and repositioned Resident #61 on [DATE] at 12:40 A.M. or 12:45 A.M. STNA #30 stated she was walking past Resident #61's room at 1:20 A.M. or 1:25 A.M. and stopped and looked in because it did not appear as if the resident was breathing. STNA #30 stated she went in the room and rubbed the resident's chest and did not feel any breathing so she immediately alerted LPN #58 who was at the nurse's station three doors down from Resident #61's room. STNA #30 stated LPN #58 immediately went into Resident #61's room and started assessing the resident. STNA #30 stated she went into another resident's room to provide care to a sick resident. STNA #30 stated she walked past Resident #61's room approximately 10 to 15 minutes later and noted that both LPN #58 and RN #55 were in the room. She stated approximately 3 minutes later the emergency squad arrived. STNA #30 stated she did not see either nurse initiate CPR. During interview on [DATE] at 12:15 P.M., RN #55 stated on [DATE] she was seated in the 100 unit nurse's station when LPN #58 approached her and asked her if she had a few minutes. She stated she did not remember the exact time this occurred but it was sometime around 1:30 A.M. RN #55 stated LPN #58 asked her to bring her stethoscope and to come to the 500 nurse's station. RN #55 stated LPN #58 did not indicate it was an emergency and did not seem hurried so she told LPN #58 she would come as soon as she finished charting. RN #55 stated approximately three to five minutes later she went to the 500 unit and LPN #58 asked her to check Resident #61's vital signs. She stated she assessed the resident's vital signs and found no pulse, blood pressure and no respirations. She stated the resident was completely pale. RN #55 stated she was new to the facility and had never worked on the 500 unit where Resident #61 resided so she was not familiar with the resident. She stated she asked LPN #58 what the resident's code status was and LPN #58 told her the resident's code status was do not resuscitate (DNR). RN #55 stated she returned to the 100 unit assuming LPN #58 was going to take care of the situation. RN #55 reported she did not call 911 at that time and she did not believe LPN #58 called 911. Interview on [DATE] at 9:00 A.M. with the Administrator and the Director of Nursing (DON) revealed LPN #58 called both of them at home on [DATE] between 1:30 A.M. and 1:35 A.M. The DON stated LPN #58 reported to her that she could not find the resident's code status on his medical record and that she thought for sure the resident's code status was DNR. The DON stated she told LPN #58 if she could not find the code status to call 911 and begin CPR. The Administrator stated the facility investigated the incident and found the resident's code status was clearly documented as a "full code" on the physician's orders [REDACTED]. Attempts to contact LPN #58 on [DATE] were unsuccessful. Review of LPN #58's personnel file revealed she last worked at the facility during the 7:00 P.M. to 7:00 A.M. shift on [DATE] to [DATE]. According to the "Disciplinary Action Form" dated [DATE], LPN #58 failed to initiate CPR on resident with a full code status. According to the form, LPN #58's employment at the facility was terminated on [DATE] due to violation of facility's health and safety rules, jeopardizing the health and safety of a resident, careless acts causing harm, failure to comply with standards of nursing procedures, and failing to comply with the facility's CPR policy. Telephone interview on [DATE] at 10:45 A.M. with Fire Chief (FC) #97 from the Fairfield Township Fire Department, revealed the 911 call came into the fire department at 1:37 A.M. and the emergency squad arrived to the facility at 1:42 A.M. FC #97 stated upon arrival Resident #61 was without vital signs, his pupils were fixed, and he had rigidity in his back and arms. He stated the electrocardiogram (EKG) machine was hooked up to the resident and showed no heart beat (asystole). FC #97 stated Resident #61 was pale in color and that the facility staff were not sure of his code status when the EMTs arrived. He stated the coroner was called and the resident's body was released at 2:05 A.M. He stated the EMTs left the facility at 2:25 A.M. Review of the facility's policy entitled "Cardio-Pulmonary Resuscitation (CPR) for Adults" with a revision date of [DATE], revealed CPR should be started immediately if the resident is a full code and has no pulse, no respirations or no normal respirations, and is unresponsive. This certification deficiency substantiates Complaint Control Number OH 199.