Every finding on record at Hawthorn Glen Nursing Center

Based observation, staff interview, record review, and facility policy review, the facility failed to ensure food was stored in a safe and sanitary manner. This had the potential to affect all residents. The facility census was 61.Findings include:Observation of the nourishment room on 07/30/25 starting at 3:08 P.M. revealed six packages of fruit, one container of cheese and a Styrofoam takeout container with unidentified food unlabeled and undated stored in the refrigerator. Interview with Director of Nursing (DON) #96 verified that the food was unlabeled and undated. Further observations in the bottom drawer of the fridge revealed two packages of raspberries, a package of cheese, and a package of bologna that were covered in a grey, fuzzy substance. The two packages of raspberries were dated 06/25. The cheese and bologna were undated. Interview with DON #96 verified the date of the raspberries and other items were undated. DON #96 also verified that the food was covered in a grey fuzzy substance. Further observations revealed five cartons of milk stored in the refrigerator door with an expiration date of 07/28/25. Interview with DON #96 verified that the milk was expired. Review of the facility policy titled, Dietary Policy and Procedure, dated 08/2021 revealed that food brought into the facility by visitors and family will be labeled with the name of the resident and the date. Dietary staff will monitor the dates and discard the food item after the third day.

Based on interviews and record review, the facility failed to timely initiate and complete Preadmission Screening and Resident Review, (PASRR). This affected four residents (Resident #57, # 74, 35 and #5) of six residents reviewed for preadmission screening. The facility total census was 61. Findings Include: 1.Record review of Resident #57 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #57 include hypertension, morbid obesity, diabetes, schizophrenia, depressive disorder and anxiety. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and required set up assistance with Activity of Daily Living skills. Review of PASRR documentation revealed no documenting of a PASRR screen prior to admission. A Level I PASRR was not completed and signed until 06/23/23. There was a Level II directed from the results of a 07/29 /25 PASRR submission due to a new diagnosis of schizoaffective and sexual behaviors on 02/22/22. 2. Record review of Resident #35 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #35 include cerebral atherosclerosis, chronic obstructive pulmonary disease, dementia, chronic kidney disease, hypertension, reflux, dysphagia, and abnormal weight loss. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had moderately impaired cognition and required moderate assistance with Activity of Daily Living skills. The resident received hospice services beginning on 12/01/24.Review of Resident #35 records revealed no PASRR hospice condition change submission and results. 3. Record Review of Resident #5 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident # 5 include dementia, and anxiety. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and required extensive assistance with Activity of Daily Living skills. The resident received hospice services starting on 10/26/24.Review of Resident #5 records revealed no PASRR hospice condition change submission and results. 4. Review of the medical record for Resident #74, revealed an admission date of 04/21/2018. Diagnoses included but were not limited to hemiplegia, type 2 diabetes, and dysphagia.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 0 which indicates resident has severe cognitive impairment. The resident was assessed to require to be dependent for eating, dependent on staff for toileting, dependent on staff for showering and bathing, dependent on staff for dressing, and personal hygiene. The resident received hospice services beginning on 08/12/24. Review of Resident #74 records revealed no PASRR hospice condition change submission and results. Interview on 07/31/25 at 11:40 A.M. The Social Service Designee, SSD#6 verified Resident #57 had no PASRR prior to admission, and was it first filed on 06/23/23. SSD #6 verified there were no hospice change of status PASRRs completed timely for Residents # 35, #5 and #74. SSD #6 stated she completed a new PASRR on 07/29/25 for Resident #57 due to a PASRR audit and Resident #57 had diagnosis changes, which had not been submitted timely. The SSD #6 verified there were many PASRRs which were incomplete and/or missing from the previous SSD. SSD #6 stated diagnosis changes, hospice status and other declines in condition should be submitted within couple days of the change. Newly admitted residents should have PASRRs completed prior to admission or within 30 days of admission.

Based on observation, staff interview, and policy review the facility failed to ensure medications were dated, labeled, and not expired. This had the potential to affect 36 (Resident #25, Resident #32, Resident #3, Resident #19, Resident #29, Resident #1, Resident #62, Resident #18, Resident #51, Resident #63, Resident #34, Resident #9, Resident #52, Resident #45, Resident #54, Resident #50, Resident #56, Resident #71, Resident #72, Resident #39, Resident #28, Resident #73, Resident #55, Resident #76, Resident #46, Resident #20, Resident #40, Resident #41, Resident #10, Resident #11, Resident #8, Resident #30, Resident #61, Resident #17, Resident #36, and Resident #63) residents. The facility also failed to ensure medications were disposed of properly. This had the potential to affect 24 (Resident #25, Resident #32, Resident #3, Resident #19, Resident #29, Resident #1, Resident #62, Resident #18, Resident #51, Resident #63, Resident #34, Resident #9, Resident #52, Resident #45, Resident #54, Resident #50, Resident #56, Resident #71, Resident #72, Resident #39, Resident #28, Resident #73, Resident #55, and Resident #76) residents. The facility census was 61.Findings include:Findings Include: Observation on [DATE] at 6:20 A.M of the medication cart revealed Resident #73 and Resident #1 had NovoLog insulin undated.Interview on [DATE] at 6:25 A.M with Registered Nurse (RN) #30 confirmed Resident #73 and Resident #1 NovoLog insulin was undated.Observation on [DATE] at 9:00 A.M of Medication Storage room [ROOM NUMBER] revealed 14 Intravenous (IV) tubing bags dated on 06/2024, covid vaccine vial dated on [DATE], Tuberculin vial dated on [DATE], and 8 flu vaccines dated on 06/2025.Interview on [DATE] at 9:02 A.M with the Director of Nursing (DON) confirmed there was 14 IV tubing bags dated on 06/2024, covid vaccine vial dated on [DATE], Tuberculin vial dated on [DATE], and 8 flu vaccines dated on 06/2025 in medication storage room [ROOM NUMBER].Observation on [DATE] at 9:03 A.M of the IV cart revealed one bag of lactated ringers & 5% dextrose (D5) dated on [DATE], one bag D5 and 0.9% Normal Saline (NS) dated on [DATE], one bag dated on D5 & 0.45 NS dated on [DATE], and two bags of D5 & 0.45 NS dated on [DATE].Interview on [DATE] at 9:10 A.M with the DON confirmed the IV cart contained one bag of lactated ringers & 5% dextrose (D5) dated on [DATE], one bag D5 and 0.9% Normal Saline (NS) dated on [DATE], one bag dated on D5 & 0.45 NS dated on [DATE], and two bags of D5 & 0.45 NS dated on [DATE].Observation on [DATE] at 9:11 A.M revealed the DON disposing the flu vaccine vials into the lidless trash can on the side of the medication cart.Interview on [DATE] at 9:15 A.M with LPN #30 confirmed that flu vaccine vials into the lidless trash can is an inappropriate place to dispose the flu vaccine vials.Observation on [DATE] at 9:17 A.M revealed LPN #30 removing the flu vaccines from the trashcan and disposing them correctly.Observation on [DATE] at 4:11 P.M of Medication Cart #3 had undated Lantus for Resident #46, Expired Lantus dated on [DATE] for Resident #46, and Undated Lantus for Resident #20.Interview on [DATE] at 4:15 P.M with RN #73 confirmed Medication Cart #3 had undated Lantus for Resident #46, Expired Lantus dated on [DATE] for Resident #46, and Undated Lantus for Resident #20.Review of facility policy titled Medication Administration dated on [DATE] revealed the expiration date should be checked, and an open date shall be placed on multi dose vials.

Based on interview, record review, and facility policy review, the facility failed to ensure resident funds were disbursed to the resident's estate within 30 days as required. This affected one (Resident #75) of six residents reviewed for funds. The facility census was 61.Findings include:Review of the medical record for Resident #75 revealed an admissions date of 06/21/24 with diagnoses including congestive heart failure, hypertension, and dementia. Resident #75 discharged from the facility on 04/30/25.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 was severely cognitively impaired.Review of a Resident Funds Authorization, for Resident #75 dated 08/03/24, revealed the authorization was signed by Resident 75's responsible party. The authorization was also signed by two witnesses.Review of a check dated 07/29/25, revealed a check was written to Resident #75's estate for $35.12.Review of the Resident Funds Statement, for Resident #75 revealed the resident had a balance of $35.12 on 07/29/25 when the account was closed.Interview on 07/31/25 at 8:30 A.M. with Administrator #50 verified Resident #75 was discharged to the hospital on [DATE] and Resident #75's funds were not conveyed to the estate until 07/29/25.Review of the facility policy titled, Management of Personal Funds dated 08/01/23, revealed the facility will reconcile and close all accounts within thirty days of discharge.

Based on resident interview, staff interview, and policy review the facility failed to ensure residents know their Resident Rights. This had the potential to affect 12 (Resident #20, Resident #23, Resident #13, Resident #55, Resident #42, Resident #14, Resident #60, Resident #57, Resident #39, Resident #63, Resident #5, and Resident #77) residents who attend the Resident Council meetings out of 61 residents. The facility census was 61.Findings include:Review of Resident Council Meeting monthly minutes from 08/24/24 to 07/25/25 revealed Resident Rights were not reviewed during Resident Council.Interview on 07/29/25 at 3:08 P.M with Resident #46, Resident #60, and Resident #13 confirmed Resident Rights were not reviewed during Resident Council and that they do not know where to find the resident rights.Interview on 07/29/25 at 3:30 P.M with Activities Director # 59 confirmed Resident Rights were not reviewed during resident council due to switching the resident council agenda forms.Review of policy titled Resident Council revealed the facility is designed to review resident rights.

Based on interview, record review and facility policy review, the facility failed to timely complete and submit a Self-Reported Incident (SRI) as required by the Ohio Department of Health, (ODH). This affected one resident (Resident #18) of five residents reviewed for SRI reporting. The facility total census was 61. Findings Include:Record review of Resident #18 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #18 include breast cancer, depressive disorder, and dysphagia. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and required moderate assistance for Activity of Daily Living skills.Review of the SRI reported on 04/11/25 to ODH, revealed the incident occurred on 04/11/25, and submitted as completed on 06/05/25. Review of the SRI investigation revealed the police were contacted on 06/05/25. Interview on 07/30/25 at 10:06 A.M., the Administrator and Director of Nursing, (DON) verified an occurrence, discovery date of 04/11/ 25, was reported as an SRI on 04/11/25. On 06/05/25, it was discovered by the DON that the completion date was not submitted to ODH. Additionally, the Administrator verified the police were contacted on 06/05/25, as there had been no police notification at the time of the investigation. The Administrator verified the final report should have been within five working days of the discovery of the incident. Review of the facility policy, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated October 2024, revealed the facility will submit an on SRI in accordance with ODH instruction. The investigation will be completed within five working days and submitted to the ODH no later than five working days after discovery of the incident.

Based on interview, record review , and facility policy review, the facility failed to thoroughly investigate a Self-Reported Incidents (SRI). This affected two residents (Residents #18 and #32) of five residents reviewed for SRI investigations. The facility total census was 61. Findings Include: 1. Record review of Resident #18 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #18 include breast cancer, depressive disorder, and dysphagia. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and required moderate assistance for Activity of Daily Living skills. Review of SRI dated 05/05/25 revealed the resident was found to have a bruise of unknown origin on her thumb. Review of staff investigations revealed no written staff statements of the incident. There were no resident interviews and non- verbal resident skin assessments. Review of SRI dated 06/29/25 revealed the resident alleged a staff person held down her hand. Review of staff investigations revealed no written staff statements of the incident. There were no resident interviews and non- verbal resident skin assessments. The investigation documentation included a staff education sign in sheet which was undated with no presenter and no topic listed.2. Record review of Resident #32 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #32 include metabolic encephalopathy, repeated falls. sepsis, Chronic Obstructive Pulmonary disease and hypertension. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and required extensive assistance for Activity of Daily Living skills.Review of SRI dated 05/20/25 revealed Resident #32 family representative reported an allegation of unknown origin bruises to the resident's torso. Review of the facility SRI investigation documents revealed there were no written staff and resident interviews. There were no nonverbal resident skin assessments. Interview on 07/31/25 at 1:30 P.M. the Administrator and Director of Nursing , (DON) verified the SRI investigations of Resident #18 dated 05/05/25 and 06/29/25, and Resident #32 SRI dated 05/20/25 did not show documented evidence of thoroughly investigated allegations of abuse. Review of the facility policy, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated October 2024, revealed the facility will interview the residents, and all witnesses, including anyone who may have come in close contact with the resident or the accused employee. If allegation is injury of unknow source, the investigation will involve interviewing staff on shift when injury is discovered and prior shifts. Interviews include interviews of other residents to determine if they have been affected.

Based on record review, staff interview, and policy review the facility failed to ensure care conferences were completed quarterly for Resident #43. The facility census was 61.Findings include:Review of the medical record for Resident #43 revealed an admissions date of 07/31/23 with diagnoses including dysphagia, chronic obstructive pulmonary disease, major depressive disorder, and seizures.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 is cognitively impaired.Review Resident #43's care conferences since admission revealed one was completed on 04/16/25.Interview on 07/31/25 at 11:26 A.M. with Director of Nursing (DON) # 96 verified that the only care conference completed for Resident #43 was on 04/16/25.Review of the facility policy titled Care Conferences, dated 01/2020 revealed care conferences will be scheduled as soon as possible after admission, routinely, and with a change in condition.This deficiency represents non-compliance investigated under Complaint Number 1388204.

Based on record review, staff interview, and policy review the facility failed to obtain an order for oxygen therapy. This affected two residents (Resident #25 and Resident #51) out of three reviewed for oxygen therapy. The facility census was 61.Findings Include:1. Review of the medical record for Resident #25, revealed an admission date of 06/27/25. Diagnoses included but were not limited to acute kidney failure, sleep apnea, and asthma.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated revealed a Brief Interview for Mental Status (BIMS) of 15 indicates intact cognition. The resident was assessed to be independent for eating, oral hygiene, toileting, shower/bath independent, partial/moderate assistance dressing, and supervision or touching assistance for personal hygiene.2. Review of the medical record for Resident #51, revealed an admission date of 04/24/25. Diagnoses included but were not limited to acute respiratory failure, chronic obstructive pulmonary disease, and sepsis.Review of the most recent Quarterly Minimum Data Set (MDS) 3.0 assessment dated 06/1725 revealed a Brief Interview for Mental Status (BIMS) of 15 which indicates intact cognition. The resident was assessed to require setup or cleanup assistance for eating, supervision or touching assistance for oral hygiene, dependent on staff for toileting, dependent on staff for showering/bathing, dependent on staff for dressing, and substantial/maximal assistance for personal hygiene.Observation on 07/29/25 at 1:25 P.M. revealed Resident #25 and Resident #51 to on 2 liters of oxygen via nasal cannula.Review of facility oxygen tubing list revealed Resident #25 and Resident #51 to be missing from the oxygen tubing list.Interview on 07/29/25 at 1:25 P.M. with Resident #25 confirmed she had oxygen since she was admitted to the facility on [DATE].Interview on 07/29/25 at 1:30 P.M. with Resident #51 confirmed she had oxygen since she was admitted to the facility on [DATE].Interview on 07/29/25 at 1:50 P.M. with the Director of Nursing (DON) confirmed the residents were receiving oxygen without an order. DON contacted the physician for Resident #51 and stated that she did not need to receive oxygen.Review of facility policy titled Oxygen Administration dated on April 2023 revealed oxygen is to be administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control.This deficiency represents non-compliance investigated under Complaint Number 1388206.

Based on record review, interview, and policy review the facility failed to provide behavioral health services to one (Resident #2) of three residents reviewed for behavior health. The facility census was 61.Findings include:Review of the medical record for Resident #2 revealed an admissions date of 11/10/21 with diagnoses including major depressive disorder, post-traumatic stress disorder, and anxiety disorder. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact. Review of Resident #2's orders revealed the resident has a physician order on 06/23/25 for a psychiatric evaluation and treatment. Review of Resident #2's medical record revealed the resident was receiving psychiatric services in 2024 for treatment of major depressive disorder and post-traumatic stress disorder. The last time Resident #2 received these services was on 05/07/24. Interview on 07/31/25 at 9:29 AM with Director of Nursing (DON) #96 verified that Resident #2 has current orders for psychiatric evaluation and treatment. DON #96 also verified that the last time Resident #2 received these services was on 05/07/24. Review of the facility policy titled, Behavioral Assessment, Intervention and Monitoring, dated December 2016, revealed that the facility will provide individualized care that supports the resident's physical, functional, and psychosocial needs.

Based on observation, interviews and record review , the facility failed to provide social services to maintain the resident's mental health after a traumatic incident. This affected three residents, (Residents # 18, #32 and #38) of five residents reviewed following a traumatic incident. The facility total census was 61. Findings Include: 1.Record review of Resident #18 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #18 include breast cancer, depressive disorder, and dysphagia. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and required moderate assistance for Activity of Daily Living skills. Review of Resident #18 State Reported Incident (SRI) dated 04/11/25 revealed the resident alleged a man came into her room and tried to remove her outer wear pants. He ran his hand down her leg. Review of Resident #18 SRI dated 06/29/25 revealed the resident alleged a staff person held down her hand. Review of social service notes of 4/11/25 through 07/28/25 revealed no social service documentation regarding counseling or providing follow-up psychosocial services for Resident #18 after the incident of 04/11/25 and 06/29/25. Interview on 07/30/25 at 12:56 P.M. Resident #18 stated she was very upset and fearful after the incidents. She stated she did not have a counselor or any staff visit her for counseling after the incidents. 2. Record review of Resident #32 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #32 include metabolic encephalopathy, repeated falls. sepsis, Chronic Obstructive Pulmonary disease and hypertension. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and required extensive assistance for Activity of Daily Living skills.Review of SRI dated 05/20/25 revealed Resident #32 family representative reported an allegation of unknown origin bruises to the resident's torso. Review of social service notes of 05/20/25 through 07/28/25 revealed no social service documentation regarding counseling or providing follow-up psychosocial services for Resident #32 after the incident of 05/20/25. Interview on 07/30/25 at 1:31 P.M. revealed the Resident #32 stated no staff had checked on her after the incident to see if she needed psychosocial support. 3. Record review of Resident #38 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #38 include end stage renal disease, depressive disorder, diabetes, anxiety disorders, mood disorder, morbid obesity, and embolism. The resident received out of facility dialysis treatment three times a week. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and required substantial assistance for Activity of Daily Living skills.Review of SRI dated 07/13/25 revealed Resident #38 reported an allegation of stolen gaming box device while he was admitted to the hospital from [DATE] through 07/13/25. The allegation was investigated and substantiated for missing gaming box. Review of social service notes of 07/20/25 through 07/28/25 revealed no social service documentation regarding counseling or assessment documentation for follow-up psychosocial services for Resident #38 after the incident of 07/13/25. Interview on 07/28/25 at 11:31 A.M revealed the Resident #38 stated no staff had checked on him after the incident to see if he needed psychosocial support. He stated he felt violated that someone came into his room and took his gaming box when he was at the hospital. He verified he was not visited by any staff or offered counseling services for his feelings following the gaming box theft. Interview on 07/31/25 at 11:40 A.M Social Service Designee, (SSD) # 6 verified after a traumatic occurrence, such as a allegation of abuse, the resident should be visited and assessed for need of psych service or counselor support. The SSD #6 verified there had been no psychosocial visits after alleged abuse occurrences of Residents # 18, #32 and #38. Review of the facility policy, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated October 2024, revealed the facility will notify the social service department after the incident so that appropriate interventions to care for the psychosocial needs of any involved residents are met.

Based on observation, staff interview, review of planned menu, substitution log, and policy review, the facility failed to follow the menu for residents ordered a puree diet. This affected five (Residents #8, 26, 43, and 55) of five residents ordered a puree diet. The facility also failed to have a dietician sign off on meal substitutions. This had the potential to affect all residents residing in the facility. The facility census was 61.Review of the puree menu for lunch on 07/30/25 revealed beef enchiladas, seasoned black beans, corn, Mexican street cornbread, snickerdoodle cookie, and coffee/tea.Observation on 07/30/25 at 11:13 A.M. revealed puree food being served was enchiladas, corn, black beans, and pie.Interview 07/30/25 at 11:17 A.M. with Dietary Director (DD) #101 verified that the residents with an order for a puree diet were being served enchiladas, corn, black beans, and pie. DD #101 verified that the Mexican street cornbread was not prepared for puree diets but was listed on the menu. DD #101 also verified that pie was substituted for the snickerdoodle cookie.Review of the substitution log on 07/31/25 revealed that eleven items had been substituted between 05/10/25 and 07/20/25. Further review revealed that a dietician had not signed off on the substitutions. Interview on 07/31/25 at 11:10 A.M. with Registered Dietician (RD) #150 verified that she had not signed off on the substitution log.Review of the facility policy titled Menu Planning, dated 2021 revealed that residents nutritional needs will be provided through nourishing well balance diets.This deficiency represents non-compliance investigated under Complaint Number 1388204.Review of the facility policy titled, Menu Substitutions, dated 2021, revealed the registered dietician will evaluate menu changes.

Based on observation, interviews and record review, the facility failed to provide a therapeutic diet as ordered by the physician. This affected one resident (Resident # 26) of one resident reviewed for therapeutic diets. The facility total census was 61. Findings Include: Record review of Resident #26 revealed the resident was admitted to the facility on [DATE]. The resident received hospices services. Diagnoses for Resident #26 include hypertension, dementia, obesity, and cancer antigen. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and was totally dependent on staff for dressing and hygiene, transfers and eating. The resident received a regular puree nectar thick liquids diet and nutritional supplement three times a day. Additionally, the resident had a physician order, the Resident may have thin liquids and pleasure food with staff supervision only. With the resident positioned upright, small sips from cup, without supervision. The Resident is to be on nectar thick liquids and puree diet. Reviews of Registered Dietitian nutritional assessment dated [DATE], revealed the Resident #26 diet included nectar thick liquids. Pleasure foods were ordered of thin liquids when supervised by staff. Observation 07/28/25 at 11:35 A.M. revealed Resident #26 family representative feeding the resident the lunch meal. The milk on the meal tray was in the closed milk carton. The Family representative opened the milk carton and gave the resident a drink of the milk through a straw. The resident had a slight cough. There were two other glasses of thicken juices on the meal tray. There was no staff assisting with feeding the resident the meal. Observation on 07/30/25 at 11:45 A.M revealed family representative feeding the Resident #26 lunch meal. The milk was in original carton on the meal tray. There was one glass of thickened juice on the meal tray. The resident had a slight cough when given the milk through a straw by the family representative. There was no staff assisting with feeding the resident the meal.Interview on 07/28/25 at 11:35 A.M. the Resident #26 family representative verified the milk in the carton was not thickened milk and could be sipped through a straw. The other liquids on the meal trays were thickened, at times needing a spoon. The family representative stated he fed the resident lunch and dinner meal on most days. The family representative verified the resident had a slight cough after drinking the thin milk. Interview on 07/30/25 at 11:40 A.M. Licensed Practical Nurse, (LPN) # 16 verified the milk in Resident #26 lunch tray was in the original carton and was not thicken. Fluids from the kitchen are thickened into serving glasses. Interview on 07/31/25 at 12:24 P.M. Registered Dietitian, (RD) #150 verified Resident #26 should have received nectar thickened milk, as ordered, unless thin milk was given and supervised by staff. Nectar thickened milk would not have been served in the original carton. Thickened milk would be served from the kitchen in a glass, purchased already thickened. Regular milk is considered thin and would need to thicken to be considered a nectar consistency. The RD #150 was unable to provide a facility policy regarding therapeutic diets and fluid consistencies.

Based on observations, record review, review of Emergency Medical Services (EMS) report, review of emergency room (ER) records, review of hospital records, staff interviews, review of personnel record, review of job descriptions, and review of facility policy, the facility failed to ensure residents were free from accidents while being transported by the facility's bus. This affected one (#25) of the three residents reviewed for accidents. The facility census was 64. Findings include: Review of the medical record for Resident # 25 revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on 10/25/24. Diagnoses included major depressive disorder, cerebral infarction (stroke), dementia, anxiety, chronic kidney disease, morbid obesity, congestive heart failure (CHF), essential primary hypertension, pneumonia, and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had impaired cognition and was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 04/27/24 for Resident #25, revealed the resident was at risk for falls due impaired cognition, vertigo and prior falls. Her interventions included assisting with toilet use, bariatric bed, Dycem to wheelchair, call light in reach, and monitor medications. The care plan revealed no documented evidence of being updated when the resident fell on [DATE] while being transported on the facility bus. Review of the cardiologist visit note dated 10/24/24 at 11:15 A.M. for Resident #25, revealed the resident was seen in the office for a follow-up and evaluation on her biventricular implantable cardioverter defibrillator (BiV ICD) (a small, battery-powered device that helps treat heart failure by improving heart function and preventing dangerous heart rhythms), nonrheumatic tricuspid valve regurgitation, primary hypertension and paroxysmal atrial fibrillation. The resident's vital signs were normal and the resident was scheduled for transesophageal echocardiogram on 11/15/24. follow up visit on 11/15/24 for a transesophageal echocardiogram (a non-invasive ultrasound procedure that allows a doctor to see the heart's structure and function) and was to follow-up with the heart failure clinic on 11/26/24. Review of a nurse's progress note dated 10/24/24 at 1:15 P.M. and recorded as a late entry on 10/25/24, for Resident #25, revealed the resident was being transported back to the facility from a medical appointment in the facility owned transport bus. Maintenance Supervisor (MS) #204 was driving bus and Certified Nurse Assistant (CNA) #202 accompanied the resident for the transport. During the return transport, MS #204 had to slam on the brakes to avoid hitting a car that pulled in front of them. This caused Resident #25 to fall from her wheelchair into the floor landing on her knees and then onto her stomach with her legs under her wheelchair. MS #204 immediately pulled over and CNA #202 checked the resident for any signs of trauma. MS #204 and CNA #202 assisted Resident #25 from the floor and back into her wheelchair. Upon return to the facility, the Director of Nursing (DON), two staff nurses, and two CNAs took Resident #25 to her room to assess her. Resident #25 stated a truck hit them, and she fell out of her chair. Resident #25 was assessed and there were no new skin injuries, no obvious swelling or trauma, range of motion (ROM) was within normal limits and blood pressure was 101/55 millimeters of mercury (mmHg), pulse 62 beats per minute, oxygen saturation was 84 percent (%) on two liters per minute (LPM) of oxygen. Review of the facility's investigation dated 10/24/24 at 1:15 P.M. for Resident #25 and authored by the DON, revealed the resident was being transported back to the facility from an appointment via the facility owned transport bus and being driven by MS #204 and CNA #202 was accompanying the resident. During the journey back to the facility, MS #204 had to slam on the brakes to avoid a car turning in front of them which caused the resident to fall from her wheelchair onto her knees and then onto her stomach with her legs under the wheelchair. Resident #25 stated a truck hit them and she fell out of her chair. MS #204 pulled over immediately and they checked on the resident for any signs of trauma and none were found. MS #204 and CNA #202 lifted the resident from the floor of bus, back into her wheelchair and drove back to the facility. Upon returning to the facility, the DON, two nurses and two CNAs took the resident to her room and put her in the bed to assess her. The assessment revealed there were no new skin injuries, no obvious swelling or trauma and range of motion was within normal limits. The resident's vital signs were as follows: blood pressure 101/55 mmHg, pulse 62 beats a minute, oxygen saturation of 84 % on two LPM of oxygen via nasal cannula The immediate intervention was to send Resident #25 to the hospital for an evaluation for possible injuries. The investigation revealed the resident's wheelchair was secured to the bus; however, the resident was not secured in the wheelchair with the vehicle's seat belt. Review of a nurse progress noted dated 10/24/24 at 2:00 P.M. and recorded as a late entry on 10/25/24 for Resident #25, revealed the resident had a brief period of unresponsiveness and staff performed a sternal rub which was effective. Blood pressure was 52/39 mm/Hg (very low), pulse was 61 beats per minute, temperature was 98.3 degrees Fahrenheit (F), and oxygen saturation was 62 % (very low) . A non-breather mask (a mask that delivers a high concentration of oxygen) was applied with five liters per minute (LPM) of oxygen and a breathing treatment was administered. The staff notified the nurse practitioner (NP) who ordered the resident to be sent to the emergency room (ER). The team called 911 and EMS arrived at 2:00 P.M. The head of bed was raised to 45 degrees and the crash cart was at bedside. Resident #25 was admitted to the hospital with a diagnosis of hypotension related to cardiovascular disease. Review of the EMS report dated 10/24/24, revealed EMS arrived at the facility at 2:02 P.M. for Resident #25 complaining of head pain related to injuries after a fall from her chair and shortness of breath. EMS found Resident #25 sitting up in her bed and appeared to be in respiratory distress with a nasal cannula in place. The staff reported the resident was being transported in the bus when she fell out of her wheelchair when the driver hit the brakes. The driver returned the resident to the nursing home and the staff got the resident back in bed when the resident became unresponsive. The staff reported the resident's oxygen saturation dropped to the 60's and the resident was hypotensive. EMS found the resident alert, oriented and stated she fell out of her wheelchair and hit her head and knee. The resident complained of pain at a six (pain scale from zero [no pain] to ten [extreme pain] on top of her head with a small hematoma noted to the top of head. The resident's blood pressure was 107/42 mmHg upon arrival and dropped to 86/57 mmHg during transport to the hospital. The resident was transported to the ER with no additional concerns. Review of the ER note dated 10/24/24 at 2:36 P.M., revealed Resident #25 arrived in the ER related to a motor vehicle accident (MVA) and shortness of breath. The resident was being transported back to her nursing facility in the facility van, when it suddenly slammed on its brakes and may or may not have hit another vehicle and the resident was thrown from the wheelchair in the van. The transporters got her back into her seat, but when she arrived back at the nursing facility she was unresponsive and did not have a pulse. Information was being relayed to the ER staff by the daughter of the resident who was not on scene. The resident arrived awake and answered questions but confused (baseline). An assessment revealed atraumatic without any gross deformity and no hematomas. The resident had no acute fractures or injuries after multiple radiographic images were completed. The resident initially arrived with a normal blood pressure but declined quickly and had to be upgraded to a trauma. The resident was admitted to the hospital for ascites, cardiogenic shock, acute on chronic respiratory failure with hypoxia and no evidence of traumatic abnormalities. The resident discharged back to the facility on [DATE] Review of the hospital's admission History and Physical dated 10/24/24 at 5:36 P.M., revealed Resident #25 was at her cardiologist's office earlier in the day when she was returning with medical transport, and they got in a motor vehicle accident and the resident was thrown from her wheelchair and hit the wall. The transporters put her back in the wheelchair and continued to her extended care facility (ECF) where the patient was found unresponsive and hypotensive. The resident remained hypotensive and unresponsive until a bilevel positive airway pressure (BIPAP) was placed and the resident woke up but remained hypotensive. A trauma workup was performed, and resident was fond to have no fractures, injuries or other causes for her sudden hypotension and cardiac which appeared to be cardiogenic shock. Resident #25 had a history of severe tricuspid regurgitation and having right sided heart failure and the resident was admitted to the intensive care unit. Resident #25 had a large volume overload with significant ascites. The resident had recent paracentesis at the end of September 2024 and would benefit from another procedure. The resident was at her cardiologist's officer earlier in the day and was noted to have significant volume overload but was not in any acute distress and unclear if the accident precipitated cardiogenic shock The resident was cleared by trauma and will be monitored closely as she denied any pain and unclear if thrown during the accident. Review of a witness statement dated 10/24/24 and authored by MS #204, revealed he was driving the bus on State Route 63 heading towards the facility when a car cut in front of the bus and then emergency braked for a traffic light that turned yellow and to avoid a collision with the vehicle, the bus came to abrupt stop. The resident slid out her wheelchair and onto the floor of the bus. The right leg was bent under her and the left was out front but bent at the knee. MS #204 put on the emergency hazard lights and helped the aide in getting the resident back into the wheelchair. MS #204 continued driving to the nursing home and made a report to the DON and the Administrator. Review of an updated witness statement by CNA #202 and narrated by the DON and Administrator, revealed MS #204 appeared to be driving too fast, when he had to stop hard for a red light, and when CNA #202 looked back, Resident #25 had fallen out her wheelchair. CNA #202 indicated the wheelchair was buckled in but the over-the-shoulder belt for the resident was never attached. The resident landed in front of her chair with her legs under the wheelchair and her head close to the seat in front of her and face down in the floor. CNA #202 and MS #204 helped the resident back into the wheelchair and we started talking about lunch. Resident #25 stated she was hungry and denied any pain. CNA #202 stated they did not hit another vehicle. CNA #202 noted she had the resident's daughter's phone number and was messaging her to ask how the resident was doing when she went to the hospital. Review of an Inter Disciplinary Team (IDT) note dated 10/28/24 at 11:24 A.M. and recorded as a late entry for Resident #25, revealed the IDT met to discuss the resident's fall. The resident was sent to the hospital to be evaluated. The hospital reported all scans were clear with no injuries or trauma. The resident was admitted for hypotension related to cardiovascular disease and was still out of the facility. All staff involved in facility transportation were re-educated and checked off for competency in bus safety policy and procedure. Review of a nurse's progress note dated 11/08/24 at 10:47 A.M. for Resident #25, revealed the resident returned to the facility by stretcher. The nurse went to the room and oriented the resident to the room and the family was present. The resident's oxygen concentrator was set up and applied to the resident, vitals were obtained and range of motion was normal for resident. Interview on 11/27/24 at 10:54 A.M. with the Director of Nursing (DON) revealed Resident #25 had an appointment on 10/24/24 with her cardiologist and was being transported in the facility bus by MS #204 and CNA #202. The DON stated she was in her office with CNA #203 when she heard the facility bus was out front and Resident #25 had a fall from her wheelchair while being transported. The DON stated MS #204 told her Resident #25 had a fall from her wheelchair onto the van floor. The DON stated Resident #25 required a Hoyer lift for all transfers and she questioned MS #204 and CNA #202 on how they got Resident #25 from the floor of the van and back into her wheelchair. The DON relayed the staff lifted the resident up by her arms and legs and placed her back in the wheelchair. The DON stated she would have expected for the resident to be properly assessed for any injuries prior to the staff putting the resident back in the chair and driving her back to the facility. The DON stated nursing and CNA staff got Resident #25 in her bed to be assessed when she went unresponsive. The DON stated the team called 911 and the resident was discharged to the hospital and remained in the hospital due to cardiac issues until she was readmitted on [DATE]. Interview with MS #204 on 11/27/24 at 11:15 A.M. revealed he transported Resident #25 to a medical appointment on the facility's bus along with CNA #202 on 10/24/24. MS #204 stated on the return trip, he had to stop suddenly, and Resident #25 fell out of her wheelchair. MS #204 stated he secured Resident #25's wheelchair to the bus; however, he didn't secure Resident #25 in the wheelchair. MS #204 stated Resident #25 slid from her wheelchair, and she landed in a praying position leaning on the seat in front of her. MS #204 stated CNA #202 asked the resident if she was hurt and when she reported she was not hurt, he and CNA #202 lifted the resident from the floor and placed her back in the wheelchair. MS #204 stated he continued on driving back to the facility. MS #204 when he got back to the facility, he was wheeling the resident inside when the DON was at the front desk, and he told her about the incident. MS #204 stated he was never been trained in how to secure a resident on the bus prior to this incident. Observation of the facility bus on 11/27/24 at 11:30 A.M. with MS #204, revealed Resident #25 was in a wheelchair and when he placed her in the bus, she was placed behind the last affixed row of seats on the driver's side of the bus. MS #204 demonstrated how he secured the resident's wheelchair to the bus by using four tie-down straps which hooked into the wheelchair and into anchors permanently affixed to the floor of the bus. MS #204 also demonstrated how he should have secured the resident to her wheelchair by using the shoulder and lap system designed for their bus. MS #204 stated he forgot to secure the seat-belt strap which went over the resident's shoulder and lap and secured into the tie-downs. MS #204 verified resident was not properly secured in her wheelchair when the incident occurred. Interview with CNA #202 on 11/27/24 at 1:30 P.M. revealed she was accompanying Resident # 25 while being transported to a medical appointment on 10/24/24. CNA #202 stated the bus suddenly stopped and when she looked back, the resident slid out of her wheelchair and her legs were under her and her cheek was against the seat in front of her. CNA #202 stated she had never accompanied a resident while being transported to an appointment and MS #204 was responsible for securing Resident #25 in the bus. CNA #202 verified Resident #25 was not properly secured in her wheelchair with a seat belt. CNA #202 stated she and MS #204 grabbed an arm and a leg of Resident #25 and placed her back into her wheelchair. CNA #202 stated she had told MS #204 to slow down while exiting the highway on the off ramp prior to the incident. CNA #202 stated she did not receive any prior training related to how to transport or secure a resident on the transport bus. Interview with the Administrator on 11/27/24 at 3:21 P.M., revealed he was not the Administrator when this incident happened. The Administrator stated he was reviewing files on the desk when he discovered the bus incident involving Resident #25. The Administrator stated he asked MS #204 to demonstrate exactly what happened when Resident #25 fell on the bus on 10/24/24. The Administrator stated he discovered Resident #25 was not properly secured in her wheelchair when the incident occurred. The Administrator verified MS #204 and CNA #202 placed the resident back in her wheelchair and drove the resident back to facility. The Administrator stated the staff made a judgement call. Review of the personnel file for MS #204 revealed a final written warning dated 11/14/24 for failure to obey safety rules. The personnel file revealed no documented evidence that MS #204 received any prior training related to transporting residents in the facility vehicles. Review of the job description dated and signed by MS #204 on 10/06/22 revealed no documentation related to transporting residents in the facility vehicles. Review of the personnel file for CNA #202 revealed a final written warning dated 11/14/24 for failure to obey safety rules. The personnel file revealed no documented evidence CNA #202 received any prior training related to transporting residents in the facility vehicles. Review of the job description dated and signed by CNA #202 on 08/23/24 revealed no documentation related to transporting residents in the facility vehicles. Review of the facility policy titled, Transportation, dated 08/02/24, confirmed it is the policy of the facility to arrange and ensure transportation is provided for doctors and specialist appointments if the resident does not have family, friend, or responsible party available for transport. Residents will be evaluated for cognitive impairment and the need to be escorted by staff to the appointment. Staff providing transpiration for residents will receive bus/van competency training. This deficiency represents non-compliance investigated under Complaint Number OH00160174.

Based on medical record review, staff interview, and policy review, the facility failed to ensure fall interventions were implemented to address the root cause of resident's falls. This affected one (#7) of three residents reviewed for falls. The census was 57. Findings included: Medical record review for Resident #7 revealed an admitted [DATE]. Diagnoses included stroke, aphasic, non-Alzheimer's dementia, hemiplegia, and seizure disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #7 was rarely or never understood. His functional status was a setup or clean-up assistance for eating, partial/moderate assistance for toileting and transfers, and the resident was independent for bed mobility. Review of the care plan updated 07/01/24 for Resident #7 revealed an intervention dated 05/23/23 to review information on past falls and attempt to determine the root cause of the falls. Review of an unwitnessed fall note on 07/25/24 at 5:46 A.M. revealed Resident #7 was attempting to self-toilet at the time of the fall. The note revealed the reason for the fall was evident. A new intervention was implemented to encourage the resident to change positions slowly. Review of an unwitnessed post fall note on 07/26/24 at 3:41 P.M. revealed Resident #7 was found in his room with feces around him on the floor and no non-skid socks on. The new intervention was to wear non-skid socks in the room and initiate neurological checks. Review of an unwitnessed fall note dated 07/31/24 at 7:00 A.M. revealed a fall occurred in the bathroom. Resident #7 was attempting to self-toilet in bare feet at time of the fall. The resident could not communicate what happened but pointed at the toilet. The resident was re-educated on the use of his call light for assistance, provided a non-skid sock, and staff transferred him to his recliner. Interview with the Assistant Director of Nursing (ADON) on 08/13/24 at 1:30 P.M. confirmed the fall interventions implemented for Resident #7's falls on 07/25/24, 07/26/24, and 0731/24 did not address the root cause of the resident's falls involving the resident attempting to self-toilet. Review of the policy titled, Falls Policy, dated 02/01/22, revealed it is the policy of the facility to identify residents at risk of falls and to implement a fall prevention approach to reduce the risk of falls and possible injury. This deficiency represents non-compliance investigated under Complaint Number OH00155954.

Based on medical record review, observation, and staff interview, the facility failed to ensure fall prevention interventions were in place. This affected one (#20) of three residents reviewed falls. The facility census was 60. Findings included: Medical record review for Resident #20 revealed an admitted [DATE]. Diagnoses include dementia with behaviors, atrial fibrillation, depression, hypotension, intraabdominal pelvis mass, elevated cancer antigens, Alzheimer's disease with early onset, hypertension, myocardial infarction, fibromyalgia, insomnia, retention of urine, restless and agitation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #20 revealed had severe cognitive impairment. Resident #20 required extensive assistance from two staff members for bed mobility, transfers, and toileting. Resident #20 was incontinent of bladder and bowel. Resident #20 had two or more falls without injury since the last MDS. Review of the plan of care for Resident #20 dated 04/16/21 with revisions on 05/19/23 revealed the resident is at risk of injury due to: behavior of putting self on the floor in room to sit related to poor cognition. Interventions include consider pain, discomfort, hunger, boredom, and personal needs that the resident is unable to communicate as possible causes of behavior, anticipate and meet needs to attempt to control behavior problems, encourage activities and socialization, provide calm reassurance, redirection or distractions and assess effectiveness and provide positive reinforcement for appropriate behavior. Reveal of the plan of care for Resident #20 dated 04/16/21 with revisions on 05/01/2023 revealed the resident is at risk for fall's and fall related injury. Interventions include assess fall potential on admit, quarterly, and change of condition, assist with and monitor positioning when in bed and chair, assure safe, proper body alignment, assist with toileting needs and incontinence care on routine rounds, resident request, bed put on lowest position, ensure dycem in chair at all times, scoop mattress at all times, involve resident and/or responsible party in treatment plan, update as needed regarding change in condition, keep call light within reach, encourage use, and answer calls promptly, keep fluids and frequently used items within easy reach, bed in lowest position while occupied, and proper footwear. Review of the fall risk assessment dated [DATE] revealed the resident was at high risk for falls. Review of the physician orders for Resident #20 revealed an order dated 11/28/23 for ensure dycem to chair at all times, and an order dated 03/05/22 for fall mats to side of bed for fall prevention. Observation on 05/22/23 at 2:45 P.M. of Resident #20 being transferred to bed with State tested Nursing Assistant (STNA) #66 and #38. Observation of Geri-recliner seat revealed no dycem was in place. Interview on 05/22/23 at 2:50 P.M. with STNA #66 and #38 verified dycem was not present as it should have been. Further stated they would have to find a piece of dycem and put it in her chair. Observation on 05/23/23 at 5:29 A.M. of Resident #20 resting in bed revealed no fall mat in place beside bed as ordered. Interview on 05/23/23 at 5:31 A.M. with Licensed Practical Nurse (LPN) #62 verified fall mat was not in place and should have been per Resident #20's physicians' order. Interview on 05/23/23 at 2:45 P.M. with Director of Nursing (DON) stated fall mat and dycem for Resident #20 are orders from the physician and included on the plan of care. Interventions should have been in place as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00142678.

Based on medical record review, observation and staff interview, the facility failed to provide a resident with appropriate urinary incontinent care. This affected one (#20) of three residents reviewed for urinary incontinence care. The facility census was 60. Findings include: Medical record review for Resident #20 revealed an admitted [DATE]. Diagnoses include dementia with behaviors, atrial fibrillation, depression, hypotension, intraabdominal pelvis mass, elevated cancer antigens, Alzheimer's disease with early onset, hypertension, myocardial infarction, fibromyalgia, insomnia, retention of urine, restless and agitation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #20 revealed the resident had severe cognitive impairment. Resident #20 required extensive assistance from two staff members for bed mobility, transfers, and toileting. Resident #20 was extensive assist for eating. Resident #20 was incontinent of bladder and bowel. Review of the plan of care dated 05/12/23 revealed the resident was incontinent of bladder due to dementia, behaviors, and Alzheimer's disease. Interventions include checking resident every two hours and as needed, observe for pattern of incontinence, provide pericare after incontinent episodes. Observation on 05/22/23 at 2:55 P.M. of Resident #20 revealed State tested Nursing Assistant (STNA) #66 gathered supplies for incontinent care and laid two washcloths on the bedside table without utilizing a barrier or cleaning the table off. STNA #66 and #38 assisted Resident #20 from Geri-chair into her bed without concerns. STNA #66 donned plastic gloves and removed Resident #20's outer clothing and then removed incontinent brief. STNA #38 assisted Resident #20 into position for perineal care. STNA #66 removed gloves and preformed hand hygiene, donning clean gloves. STNA #66 proceeded to pick up washcloths prepared prior to the Hoyer lift transfer (eleven minutes had passed) and cleansed residents perineal area. Resident #20 became agitated and began hitting and pinching both STNA's. STNA #66 completed perineal care using a different area of the washcloth for each swipe of the area, front to back. Resident #20 continued to be combative with staff. STNA #66 then tossed the washcloth into the trash bin next to the bed and picked up the second washcloth laying on the bedside table that was prepared prior to the transfer of Resident #20 into bed. STNA #66 wiped Resident #20' s perineal area using a clean area with each swipe. Resident #20's aggression and combativeness increased, swinging at both STNA's, grabbing and pinching arms. Perineal care was completed, and Resident #20 was redressed with incontinent brief and pants before leaving the room and disposing of the trash. Interview on 05/22/23 at 3:17 P.M. with STNA #66 verified she did not use a basin for Resident #20's incontinence care because the resident did not have one in her bathroom. Further verified she did not have a barrier on the bedside table or cleaned the area before placing supplies on the surface. STNA #66 verified she should have had a towel or plastic bag to contain washcloths. STNA #66 verified the washcloths were cool to the touch and stated she should have transferred the resident and then gathered the washcloths to ensure they were warm. Interview on 05/22/23 at 4:45 P.M. with the Director of Nursing (DON) verified STNA should have used basin to ensure warm water was used for perineal care and further verified the STNA should have used a barrier on the bedside table to maintain infection control practices. The DON stated it was the expectation that staff use a water basin at the bedside for perineal care to provide washcloths at appropriate and comfortable temperature; however, the facility does not have a policy regarding this expectation. This deficiency represents non-compliance investigated under Complaint Number OH00142678.

Based on medical record review, observation and staff interview, and policy review, the facility failed to ensure residents received timely assistance with toileting and incontinence care. This affected four (#43, #44, #45, and #54) of nine residents reviewed for toileting assistance. The census was 53. Findings include: 1. Review of the medical record for Resident #43 revealed an admitted [DATE]. Diagnoses included but were not limited to unspecified cerebral infarction, unspecified anxiety disorder, and unspecified dementia without behavioral disturbance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had severely impaired cognition. Resident #43 was always incontinent of bowel and bladder and required extensive two-person assistance with toileting. Review of a care plan dated 08/23/22 revealed Resident #43 had an activities of daily living (ADL) self-care deficit and required staff intervention to complete ADLs related to dementia and a simple pelvic fracture. Interventions included but were not limited to assisting with meal intake, assisting with toileting needs, incontinence care on routine rounds and as needed, and use two caregivers as needed to provide safe care. Review of a care plan revealed Resident #43 was incontinent of bowel and bladder related to dementia and decreased awareness of urge. Interventions included but were not limited to assisting with toileting needs and incontinence care on routine rounds and as needed, assist as needed with toileting hygiene, and assist with using incontinence undergarments to maintain social continence. 2. Review of the medical record revealed Resident #44 revealed an admitted [DATE] and had diagnoses that included but were not limited to unspecified dementia with behaviors, unspecified major depressive disorder, and hypothyroidism. Review of the MDS assessments dated 01/12/23 revealed Resident #44 had severely impaired cognition, was occasionally incontinent of bladder, was frequently incontinent of bowel, and required extensive one-person assistance with toileting. 3. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] and had diagnoses that included but were not limited to unspecified Alzheimer's disease, diabetes mellitus type II, and stage three chronic kidney disease. Review of the MDS assessment dated [DATE] revealed Resident #45 had severely impaired cognition, was always incontinence of bladder, was occasionally incontinent of bowel, and required extensive one-person assistance with toileting. 4. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] and had diagnoses that included but were not limited to unspecified dementia, mild protein-calorie malnutrition, and unspecified anxiety disorder. Review of the MDS assessment dated [DATE] revealed Resident #54 had severely impaired cognition, was occasionally incontinent of bowel and bladder, and required one-person supervision with toileting. Observation on 04/10/23 from 11:05 A.M. to 3:13 P.M., revealed State tested Nurse Aide (STNA) #128 did not provide toileting assistance, incontinence care, or check four (#43, #44, #45, and #54) of nine residents observed on the [NAME] Unit for incontinence and toileting assistance. Observation on 04/10/23 from 12:24 P.M. to 12:47 P.M., revealed STNA #128 laid Resident #44 down in bed without checking for incontinence or offering to toilet, but toileted Resident #55, assisted her to bed, and provided toileting and dressing assistance to Resident #39. Observation on 04/10/23 at 12:51 P.M., revealed the Director of Nursing (DON) entered the [NAME] Unit and propelled Resident #46 away for the unit door. Resident #46 stated to the DON he needed to go to the bathroom. At 12:55 P.M., Licensed Practical Nurse (LPN) #208 and STNA #128 propelled Resident #46 into the bathroom while the DON left the unit in search of a gait belt. At 12:57 P.M., the DON returned with a gait belt and left the room while LPN #208 and STNA #128 toileted Resident #46 who was incontinent of bowel and had stool stuck to his buttocks. LPN #208 left the bathroom to get towels and washcloths and returned at 1:03 P.M. to finish providing incontinence care. Observation on 04/10/23 from 2:16 P.M. to 2:44 P.M., revealed Resident Care Assistant (RCA) #130 supervised the [NAME] Unit while STNA #128 ambulated Resident #38 to the shower room on [NAME] Unit and provided a shower. During an interview on 04/10/23 at 2:44 P.M., RCA #130 verified she did not provide any toileting assistance or check any residents for incontinence while she supervised the unit from 2:16 P.M. to 2:44 P.M. because she was unlicensed. During an interview on 04/10/23 at 2:53 P.M., STNA #128 stated rounds to check residents for incontinence were to be completed every two hours. STNA #128 stated it took longer than two hours to complete a round with the residents sometimes because some of the residents fought staff. STNA #28 verified she had not checked for incontinence or offered toileting to Residents #43, #44, #45, and #54 since 11:00 A.M. Review of policy titled, Care of Incontinent Resident Policy and Procedure, revised 01/20, revealed all residents who were identified as being incontinent had incontinent care provided every two hours with a half-hour leeway to rounds.

Based on medical record review, observation, staff interview, and policy review, the facility failed to provide sufficient staffing to ensure residents received timely assistance with toileting, incontinence care, feeding assistance, and supervision with meals. This affected four (#43, #44, #45, and #54) of nine residents reviewed for toileting assistance and two (Residents #39 and #46) of nine residents reviewed for feeding assistance. The census was 53. Findings include: 1. Review of the medical record for Resident #43 revealed an admitted [DATE]. Diagnoses included but were not limited to unspecified cerebral infarction, unspecified anxiety disorder, and unspecified dementia without behavioral disturbance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had severely impaired cognition. Resident #43 was always incontinent of bowel and bladder and required extensive two-person assistance with toileting. Review of a care plan dated 08/23/22 revealed Resident #43 had an activities of daily living (ADL) self-care deficit and required staff intervention to complete ADLs related to dementia and a simple pelvic fracture. Interventions included but were not limited to assisting with meal intake, assisting with toileting needs, incontinence care on routine rounds and as needed, and use two caregivers as needed to provide safe care. Review of a care plan revealed Resident #43 was incontinent of bowel and bladder related to dementia and decreased awareness of urge. Interventions included but were not limited to assisting with toileting needs and incontinence care on routine rounds and as needed, assist as needed with toileting hygiene, and assist with using incontinence undergarments to maintain social continence. 2. Review of the medical record revealed Resident #44 revealed an admitted [DATE] and had diagnoses that included but were not limited to unspecified dementia with behaviors, unspecified major depressive disorder, and hypothyroidism. Review of the MDS assessments dated 01/12/23 revealed Resident #44 had severely impaired cognition, was occasionally incontinent of bladder, was frequently incontinent of bowel, and required extensive one-person assistance with toileting. 3. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] and had diagnoses that included but were not limited to unspecified Alzheimer's disease, diabetes mellitus type II, and stage three chronic kidney disease. Review of the MDS assessment dated [DATE] revealed Resident #45 had severely impaired cognition, was always incontinence of bladder, was occasionally incontinent of bowel, and required extensive one-person assistance with toileting. 4. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] and had diagnoses that included but were not limited to unspecified dementia, mild protein-calorie malnutrition, and unspecified anxiety disorder. Review of the MDS assessment dated [DATE] revealed Resident #54 had severely impaired cognition, was occasionally incontinent of bowel and bladder, and required one-person supervision with toileting. Observation on 04/10/23 from 11:05 A.M. to 3:13 P.M., revealed State tested Nurse Aide (STNA) #128 did not provide toileting assistance, incontinence care, or check four (#43, #44, #45, and #54) of nine residents observed on the [NAME] Unit for incontinence and toileting assistance. Observation on 04/10/23 from 12:24 P.M. to 12:47 P.M., revealed STNA #128 laid Resident #44 down in bed without checking for incontinence or offering to toilet, but toileted Resident #55, assisted her to bed, and provided toileting and dressing assistance to Resident #39. Observation on 04/10/23 at 12:51 P.M., revealed the Director of Nursing (DON) entered the [NAME] Unit and propelled Resident #46 away for the unit door. Resident #46 stated to the DON he needed to go to the bathroom. At 12:55 P.M., Licensed Practical Nurse (LPN) #208 and STNA #128 propelled Resident #46 into the bathroom while the DON left the unit in search of a gait belt. At 12:57 P.M., the DON returned with a gait belt and left the room while LPN #208 and STNA #128 toileted Resident #46 who was incontinent of bowel and had stool stuck to his buttocks. LPN #208 left the bathroom to get towels and washcloths and returned at 1:03 P.M. to finish providing incontinence care. During an interview on 04/10/23 at 2:05 P.M., STNA #128 stated she had completed incontinence rounds before 11:00 A.M. and had toileted all the residents except two (#44 and #54) who could toilet themselves. STNA #128 stated she usually completed a round after lunch, but she needed assistance with Resident #43 because she fought and would try to bite staff. Observation on 04/10/23 from 2:16 P.M. to 2:44 P.M., revealed Resident Care Assistant (RCA) #130 supervised the [NAME] Unit while STNA #128 ambulated Resident #38 to the shower room on [NAME] Unit and provided a shower. During an interview on 04/10/23 at 2:44 P.M., RCA #130 verified she did not provide any toileting assistance or check any residents for incontinence while she supervised the unit from 2:16 P.M. to 2:44 P.M. because she was unlicensed. During an interview on 04/10/23 at 2:53 P.M., STNA #128 stated rounds to check residents for incontinence were to be completed every two hours. STNA #128 stated it took longer than two hours to complete a round with the residents sometimes because some of the residents fought staff and one staff member could not do it all. STNA #28 verified she had not checked for incontinence or offered toileting to Residents #43, #44, #45, and #54 since 11:00 A.M. Review of policy titled, Care of Incontinent Resident Policy and Procedure, revised 01/20, revealed all residents who were identified as being incontinent had incontinent care provided every two hours with a half-hour leeway to rounds. 5. Review of the medical record revealed Resident #39 admitted to the facility on [DATE] and had diagnoses that included but were not limited to unspecified dementia, unspecified anxiety disorder, and unspecified bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had severely impaired cognition, required extensive two-person staff assistance with bed mobility, transfers, dressing, toileting, and personal hygiene, and required extensive one-person staff assistance with eating and locomotion. 6. Review of the medical record revealed Resident #46 admitted to the facility on [DATE] and had diagnoses that included but were not limited to non-traumatic brain dysfunction, unspecified Alzheimer's disease, and unspecified anxiety disorder. Review of the MDS assessment dated [DATE] revealed Resident #46 had severely impaired cognition, required extensive two-person assistance with bed mobility, transfers, dressing, toileting, locomotion, and personal hygiene, and required limited (staff provide guided maneuvering of limbs) one-person assistance with eating. Review of an undated list of residents who required feeding assistance provided by the facility revealed the facility identified Residents #54, #46, and #38 needed supervision and setup assistance. In addition to setup, Resident #37 needed cueing assistance, and Resident #55 needed feeding assistance. No other residents on the [NAME] Unit were identified on the list. During an interview on 04/10/2023 at 11:05 A.M., STNA #128 stated one (#46) resident on [NAME] Unit needed feeding assistance and two (#39 and #55) residents needed cueing assistance for eating. Observation on 04/10/2023 11:19 A.M. revealed State tested Nurse Aide (STNA) #128 set up trays for residents, directed Resident #55 to sit, and began feeding Resident #55 at 11:35 A.M. The lunch meal consisted of lasagna, steamed broccoli, a breadstick, and a dessert of diced peaches, ice cream, or both. Resident #39 began feeding herself diced peaches with her fingers, and Resident #46 began feeding himself broccoli with his fingers. Observation on 04/10/23 at 11:37 A.M. revealed Resident #39 had no food remaining on her plate or tray, and approximately half of the portions of broccoli, lasagna, and peaches were scattered across the resident's lap and floor surrounding her wheelchair. During an interview on 04/10/23 at 11:37 A.M., STNA #128 stated when she finished feeding Resident #55, she would go to the hallway to get Resident #38 out of bed and bring her to the dining room for lunch before assisting Residents #39 and #46 with eating. STNA #128 stated she often had to leave the residents unsupervised in the dining room to attend to other residents on the hall. Observation on 04/10/23 at 11:47 A.M., STNA #128 continued feeding Resident #55 while Resident #39 struggled to remove the lid of her water cup and Resident #46 fed himself a breadstick and attempted to eat ice cream. From 11:57 A.M. to 12:05 P.M., STNA #128 fed Resident #46 a few bites of lasagna, broccoli, and peaches. During an interview on 04/10/23 at 12:14 P.M., STNA #128 verified she provided set-up assistance only to Resident #39 and it appeared that half of her food ended up in her lap or on the floor. STNA #128 verified over 30 minutes had passed between the time she had set up Resident #46's meal tray and the time she sat down and provided feeding assistance to Resident #46. During an interview on 04/10/23 at 3:23 P.M. Licensed Practical Nurse (LPN) #208 stated the [NAME] Unit was always staffed with one nurse aide, and it was difficult to get staff coverage for breaks. LPN #208 stated incontinence and toileting rounds were to be completed every two hours. LPN #208 stated the nurse was responsible for supervising lunch, and verified she did not go back on the unit on 04/10/23 while residents were eating. LPN #208 verified she had not provided any assistance with toileting or incontinence checks while STNA #128 was off the unit. During an interview on 04/11/23 at 8:39 A.M., STNA #266 stated she worked alone on the [NAME] Unit up to four days per week. STNA #266 stated she did not feel it was safe for the residents or the caregiver to have only one aide on the unit and she had expressed these concerns to management, and the concerns were not addressed. STNA #266 stated there was no extra supervision provided during mealtimes, and stated she often had to leave residents unsupervised on the unit to get help with care. Observation on 04/11/23 from 11:27 A.M. to 12:03 P.M., STNA #266 was the only staff providing feeding assistance to residents for lunch on [NAME] Unit. Registered Nurse (RN) #164 was on the hall with the medication cart around the corner from the dining room and was unable to see residents eating while passing medications to residents in their rooms from 11:27 A.M. to 11:45 A.M. STNA #266 set up trays for Residents #37, #39, and #46 who were already seated at tables in the dining room. At 11:49 A.M., STNA#266 obtained gloves and sat down to assist Resident #46 to eat his fish sandwich. Resident #39 tore off pieces of the fish patty and bun and fed herself with her fingers. Resident #39 threw the top of the bun on the floor and attempted eating cake with her hands. At 11:57 A.M., Resident #39 pushed Resident #43's water cup off the table into Resident #43's lap. STNA#266 propelled Resident #39 away from the table and cleaned up the water while Resident #39 clapped repeatedly, grit her teeth, pulled at the miniature blinds, and shook Resident #37's table. STNA #266 offered Resident #39 a sip of water and Resident #39 refused. STNA #266 began cleaning tables and returning trays to meal cart. Resident #39 had consumed approximately half of her fish sandwich and potato chips, one fourth of her cake slice, and none of her soup and crackers or milk. The dining room floor was scattered with bits of cake, potato chips, and remnants of Resident #39's fish sandwich. At 12:02 P.M., STNA #266 redirected Resident #46 from attempting to eat his napkin and began to sit and feed Resident #46 cake. At 12:03 P.M., Resident #39 began pulling at the miniature blinds, continued manic clapping, wringing hands, taking deep breaths, and making repetitive statements. STNA #266 propelled Resident #39 in her wheelchair to the lounge area and finished clearing lunch trays from the dining room. Interview on 04/11/23 at a random time with RN #164 stated on some days staffing was not enough. RN #164 stated she went to the [NAME] Unit to administer medications at lunch time but did not stay to supervise residents during the meal. During an interview on 04/11/23 at 3:20 P.M. the Director of Nursing (DON) stated there was only one nurse aide staffed on the [NAME] Unit per shift since the acuity on the unit was not as high as it used to be. The DON verified there were a couple of unidentified residents that required two-staff assistance with care, and stated the nurse aide could use her cellular telephone to call for help. The DON verified there was no additional staff person assigned to supervise residents on the [NAME] Unit during lunch. This deficiency represents non-compliance investigated under Complaint Number OH00141362.

Based on medical record review, observation, and staff interview, the facility failed to ensure residents received timely and appropriate feeding assistance and supervision with meals. This affected two (Residents #39 and #46) of nine residents reviewed. The census was 53. Findings include: 1. Review of the medical record revealed Resident #39 admitted to the facility on [DATE] and had diagnoses that included but were not limited to unspecified dementia, unspecified anxiety disorder, and unspecified bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had severely impaired cognition, required extensive two-person staff assistance with bed mobility, transfers, dressing, toileting, and personal hygiene, and required extensive one-person staff assistance with eating and locomotion. 2. Review of the medical record revealed Resident #46 admitted to the facility on [DATE] and had diagnoses that included but were not limited to non-traumatic brain dysfunction, unspecified Alzheimer's disease, and unspecified anxiety disorder. Review of the MDS assessment dated [DATE] revealed Resident #46 had severely impaired cognition, required extensive two-person assistance with bed mobility, transfers, dressing, toileting, locomotion, and personal hygiene, and required limited (staff provide guided maneuvering of limbs) one-person assistance with eating. Review of an undated list of residents who required feeding assistance provided by the facility revealed the facility identified Residents #54, #46, and #38 needed supervision and setup assistance. In addition to setup, Resident #37 needed cueing assistance, and Resident #55 needed feeding assistance. No other residents on the [NAME] Unit were identified on the list. During an interview on 04/10/2023 at 11:05 A.M., STNA #128 stated one (#46) resident on [NAME] Unit needed feeding assistance and two (#39 and #55) residents needed cueing assistance for eating. Observation on 04/10/2023 11:19 A.M. revealed State tested Nurse Aide (STNA) #128 set up trays for residents, directed Resident #55 to sit, and began feeding Resident #55 at 11:35 A.M. The lunch meal consisted of lasagna, steamed broccoli, a breadstick, and a dessert of diced peaches, ice cream, or both. Resident #39 began feeding herself diced peaches with her fingers, and Resident #46 began feeding himself broccoli with his fingers. Observation on 04/10/23 at 11:37 A.M. revealed Resident #39 had no food remaining on her plate or tray, and approximately half of the portions of broccoli, lasagna, and peaches were scattered across the resident's lap and floor surrounding her wheelchair. During an interview on 04/10/23 at 11:37 A.M., STNA #128 stated when she finished feeding Resident #55, she would go to the hallway to get Resident #38 out of bed and bring her to the dining room for lunch before assisting Residents #39 and #46 with eating. STNA #128 stated she often had to leave the residents unsupervised in the dining room to attend to other residents on the hall. Observation on 04/10/23 at 11:47 A.M., STNA #128 continued feeding Resident #55 while Resident #39 struggled to remove the lid of her water cup and Resident #46 fed himself a breadstick and attempted to eat ice cream. From 11:57 A.M. to 12:05 P.M., STNA #128 fed Resident #46 a few bites of lasagna, broccoli, and peaches. During an interview on 04/10/23 at 12:14 P.M., STNA #128 verified she provided set-up assistance only to Resident #39 and it appeared that half of her food ended up in her lap or on the floor. STNA #128 verified over 30 minutes had passed between the time she had set up Resident #46's meal tray and the time she sat down and provided feeding assistance to Resident #46. During an interview on 04/11/23 at 8:39 A.M., STNA #266 stated she worked alone on the [NAME] Unit up to four days per week. STNA #266 stated she did not feel it was safe for the residents or the caregiver to have only one aide on the unit and she had expressed these concerns to management, and the concerns were not addressed. STNA #266 stated there was no extra supervision provided during mealtimes, and stated she often had to leave residents unsupervised on the unit to get help with care. Observation on 04/11/23 from 11:27 A.M. to 12:03 P.M., STNA #266 was the only staff providing feeding assistance to residents for lunch on [NAME] Unit. Registered Nurse (RN) #164 was on the hall with the medication cart around the corner from the dining room and was unable to see residents eating while passing medications to residents in their rooms from 11:27 A.M. to 11:45 A.M. STNA #266 set up trays for Residents #37, #39, and #46 who were already seated at tables in the dining room. At 11:49 A.M., STNA#266 obtained gloves and sat down to assist Resident #46 to eat his fish sandwich. Resident #39 tore off pieces of the fish patty and bun and fed herself with her fingers. Resident #39 threw the top of the bun on the floor and attempted eating cake with her hands. At 11:57 A.M., Resident #39 pushed Resident #43's water cup off the table into Resident #43's lap. STNA#266 propelled Resident #39 away from the table and cleaned up the water while Resident #39 clapped repeatedly, grit her teeth, pulled at the miniature blinds, and shook Resident #37's table. STNA #266 offered Resident #39 a sip of water and Resident #39 refused. STNA #266 began cleaning tables and returning trays to meal cart. Resident #39 had consumed approximately half of her fish sandwich and potato chips, one fourth of her cake slice, and none of her soup and crackers or milk. The dining room floor was scattered with bits of cake, potato chips, and remnants of Resident #39's fish sandwich. At 12:02 P.M., STNA #266 redirected Resident #46 from attempting to eat his napkin and began to sit and feed Resident #46 cake. At 12:03 P.M., Resident #39 began pulling at the miniature blinds, continued manic clapping, wringing hands, taking deep breaths, and making repetitive statements. STNA #266 propelled Resident #39 in her wheelchair to the lounge area and finished clearing lunch trays from the dining room. This deficiency represents non-compliance investigated under Complaint Number OH 00141362.

Based on medical record review, observations, staff interviews, and facility policy review, the faciliy failed to ensure three residents who were assessed at high risk for falls, had interventions in place to prevent falls. This affected three (Resident #100, #14, and #16) of three residents reviewed for falls and resulted in actual harm when Residents #100 and #14 fell , sustaining fractures, head injuries and subsequent hospitalization s. The facility census was 59. Findings include: 1. Review of Resident #100's medical record revealed an admission date of [DATE]. The resident was receiving hospice care at the time of admission. Medical [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed it was not completed. The MDS did not have the resident's Brief Interview for Mental Status (BIMS) available nor the activities of daily living or functioning available and was missing all sections exception Section A (identification information). Review of the fall risk evaluation dated 04/25/18 revealed Resident #100 had intermittent confusion, had no falls in the past three months, was ambulatory and incontinent, had adequate vision, balance problem while walking, decreased muscular coordination and required assistive devices. Further assessment review revealed Resident #100 had taken two or more medications that could cause lethargy or confusion and had no predisposing diseases. The residents fall score was a 13 indicating a high risk for falls. Further review of the medical record revealed there were no further evaluations completed. Review of Resident #100's medical record including all care plans revealed there was no care plan with interventions for prevention of falls. Review of hospice notes for Resident #100 revealed an admission to facility note dated 04/26/18 documenting the resident had a terminal [DIAGNOSES REDACTED]. Review of the facility incident log revealed Resident #100 had three falls while in the facility. Two falls on 04/29/18 were noted. One fall was at 5:50 A.M. and another at 7:14 P.M. The incident log documented both falls on 04/29/18 resulted in no apparent injuries. Resident #100 had a fall on 06/06/18 at 6:15 A.M. resulting in head trauma and a deep laceration. First aid was administered, and medical treatment sought which included hospitalization , x-rays and paramedic aid. It was unclear from the incident log or documentation in the medical record, if interventions were in place at the time of the falls and if any interventions were added after the above falls. Review of the resident progress note dated 04/29/18 at 7:26 P.M. revealed the resident was noted per staff to be sliding out of the wheelchair onto the floor in the common area. Staff were unable to reach the resident before the fall occurred. A head to toe assessment was completed with no injuries noted besides bruising from the earlier fall. Range of motion was within normal limits for this resident. The physician was notified and there were no new orders at that time. There was no indication of interventions in place at the time of the fall and if any interventions were added or changed after the falls. Review of Resident #100's progress note dated 06/06/18 at 6:24 A.M. revealed the room mate called out stating the resident had fallen. When staff entered the room, blood was coming from the residents head. A head to toe assessment was completed and a deep laceration to the right side of the forehead was noted. The family and physician was notified and a new order received to send the resident to the hospital for treatment. Review of Resident #100's hospice notes dated 06/06/18 revealed Licensed Practical Nurse (LPN) #20 called hospice to inform them Resident #100 had gotten up without assistance and fell hitting her head. The resident had an open laceration to the right forehead that was bleeding profusely. Resident #100 was sent to the local hospital for possible sutures. Continued review indicated the radiologist from the local hospital noted a [MEDICATION NAME] (T3) compression fracture and a 1.8-centimeter (cm) laceration which was sutured in the emergency room . A computerized topography (CT) of the head was noted to have shown an acute 0.5 cm thick left-sided subdural hematoma with mild mass effect and minimal midline shift. There was a hemorrhage in the posterior temporal lobe which may have represented a combination of hemorrhagic contusion and subarachnoid hemorrhage. Also noted was a tiny right frontal scalp hematoma with no acute fracture. The resident was transferred to another local hospital and was admitted . Review of the hospice note dated 06/08/18 revealed the family declined any neurological surgery interventions. Interview on 06/20/18 at 8:11 A.M. with Licensed Practical Nurse (LPN) #10 revealed Resident #100 fell before she arrived for her shift. LPN #10 stated Resident #100 was ambulatory, could get out of bed by herself and was one you had to watch to be sure she was not getting in and out of her chair. Interview on 06/20/18 at 8:24 A.M. with Hospice Registered Nurse (HRN) #500 stated Resident #100 had hospice care at home prior to being admitted to the facility. HRN #500 stated the resident was on the memory care unit, had a walker and could stand if the walker was in front of her but she would forget to use it. The resident had several falls at home. Interview on 06/25/18 at 11:24 A.M., with the DON verified the facility did not complete a fall risk assessment after each fall and had no individualized care plan in place as per the facility fall policy. The DON also verified there was no documented evidence of fall interventions in place at the time of the residents falls on 04/29 and 06/06/18. The DON verified Resident #100 sustained injuries after the fall on 06/06/18 requiring hospitalization . 2. Medical record review for Resident #14 revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the admission MDS revealed it was only partially completed but revealed a BIMS score of three which indicated severe cognitive impairment and under behaviors it was noted that wandering occurred daily. Review of the fall risk evaluation dated 04/21/18, 05/01/18 and 06/05/18 revealed the resident was assessed as a fall risk. There were no additional fall assessments completed. Review of Resident #14's medical record revealed the resident had seven falls since admission to the facility including on 04/22, 04/24, 05/02, 05/07, 05/10, 05/26, and 06/01/18. Review of the nurses' notes for Resident #14 revealed a note dated 04/22/18 which indicated family walked in and noted the resident was on the floor near the doorway. Upon entering the room, the resident was noted lying on the right side next to spouses' bed. The resident stated I want to go to bed. Spouse stated the resident was sitting on the bed and slid down slowly. The spouse stated she tried to tell him to stop but he wouldn't listen. There was no indication of interventions in place at the time of the fall. A new intervention documented in the nurses note included for the resident to wear hipsters as resident allowed. Review of the nurses' notes for Resident #14 revealed a note dated 04/24/18 which stated an STNA walked by the resident's room and noted the resident laying on the floor. The spouse was in the room and stated the resident went to lay his head down on the bed and slid on the floor real easy. There was no indication of interventions in place at the time of the fall and if any interventions were added or changed after the fall. Continued review of nurses' notes dated 05/02/18 revealed the resident was noted laying on the floor and the spouse stated the resident scooted to the edge of bed and scooted off the bed. There was no indication of interventions in place at the time of the fall and if any interventions were added or changed after the falls. Further review of nurses' notes revealed a note dated 05/07/18 which indicated an aide spotted the resident laying on the right side next to the roommate's bed. New intervention was for the resident to be in the memory care unit while awake as tolerated for fall prevention. There was no indication of interventions in place at the time of the fall. Further review of nurses' notes revealed on 05/10/18, the nurse answered the call light in resident's room and found the resident on the floor next to the roommate's bed. A new intervention included for the resident to be in the dining room for all meals. On 05/26/18, the resident was found on the floor at the end of the hallway on the memory care unit on his bottom. There was no indication of interventions in place at the time of the fall and if any interventions were added or changed after the fall on 05/26/18. Review of nurses' notes dated 06/01/18 revealed the resident was found on the floor when an STNA came out of another resident's room during rounding. The resident was found sitting on the floor in front of the chair he was placed in for the STNA to complete her rounds. The resident was rubbing his left lower leg and around his left hip area. Range of motion was very limited on the left side and the resident displayed signs and symptoms of pain and discomfort. Physician and Power of Attorney (POA) were notified of fall and increased pain and a STAT (at once) x-ray of the left hip and pelvis area was ordered. The resident was sent to the local hospital for evaluation and treatment. There was no indication of interventions in place at the time of the fall. Review of Resident #14's hospital documentation dated 06/05/18 revealed the resident presented to the emergency roiagnom on [DATE] after sustaining a mechanical fall at the nursing home. His injuries included a left [MEDICAL CONDITION] and a subacute subdural hematoma. The resident had a left hemiarthroplasty (surgery intervention for hip) on 06/02/18, and the repeat CT for the subacute subdural hematoma was stable. Additional nurses' note dated 06/06/18 revealed the resident returned from the hospital status [REDACTED]. Interview on 06/25/18 at 10:15 A.M.,., with Family Member (FM) #22 stated Resident #14 resident fell at home several times and explained the resident was very impulsive. FM #22 stated the resident had poor cognition, didn't remember things and didn't understand the consequences of his actions. FM #22 stated there were times he came to the facility and the resident was not wearing his hipsters. Interview on 06/25/18 at 11:24 A.M., with the DON verified the facility did not complete a fall risk assessment after each fall and had no individualized care plan in place as per the facility fall policy. The DON also verified there was no documented evidence of fall interventions in place at the time of the residents falls including the fall on 06/01/18 when Resident #14 sustained injuries requiring hospitalization . The DON also verified the facility incident report log was their only fall investigation. The DON verified the incident report was nurse driven and discussed in the weekly IDT meeting however, there were no formal or separate fall investigations. Interview on 06/25/18 at 12:12 P.M. with the Administrator verified the lack of MDS completion, fall care plans, fall assessments, inadequate documentation and inadequate fall investigations related to Resident #100's and #14's falls. 3. Review of Resident #16's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16's MDS dated [DATE] revealed the resident was assessed with [REDACTED]. Review of Resident #16's current fall risk care plan revealed interventions including to wear non-skid socks at all times when tennis shoes were not in place. Observations on 06/19/18 at 4:30 P.M. and 06/20/18 at 12:45 P.M. of Resident #16 revealed the resident was not wearing non-skid socks. Interview on 06/20/18 at 12:45 P.M. with Licensed Practical Nurse (LPN) #10 verified Resident #16 was not wearing non-skid socks as per the care plan. Review of the facility fall policy (dated (MONTH) (YEAR)) revealed the purpose of the policy was to ensure residents were as safe and injury free as possible and to ensure that residents are maintained at their highest level of function. The facility would complete a fall risk assessment upon admission, quarterly and with each fall. An individualized care plan would be completed, reviewed, and updated quarterly and as needed. Immediately after a fall, the nurse will review the plan of care and initiate or change interventions as necessary to prevent further falls. An incident report would be completed by the nurse on duty and turned into the DON who would then forward it to the falls committee. The appropriateness of the interventions would be monitored and assessed quarterly and as needed by the falls committee, and/or Interdisciplinary team (IDT) and/or nursing staff. This deficiency substantiates complaint number OH 438.