Every finding on record at Health Center at the Renaissance

Based on medical record review, hospital record review and interview, the facility failed to develop and implement a comprehensive and individualized fall prevention program/fall interventions to decrease Resident #2's risk of falls including falls with injury. This affected one resident (#2) of one resident reviewed for falls. The facility census was 82.Actual Harm occurred on 12/09/24 when Resident #2, who was at risk for falls and had a history of falls, sustained a left hip fracture without evidence the facility had implemented individualized and effective interventions to prevent the fall with fracture. The resident had sustained falls on 11/29/24 and 12/08/24 with the only intervention listed post fall was to remind the resident to call for assistance. Actual Harm continued on 02/10/25 when Resident #2, who remained at risk for falls and continued to sustain falls, was assessed to have a right hip fracture as a result of a fall when Certified Nursing Assistant (CNA) #899 failed to maintain hands-on contact assistance during a resident transfer which resulted in the fall. Resident #2 had severe pain and decreased range of motion to the right hip, was transported to the hospital and subsequently diagnosed with a closed fracture of the right hip (superior and inferior pubic rami). Findings include:Review of the medical record for Resident #2 revealed an admission date of 11/22/24 and diagnoses including diabetes mellitus, abnormalities of gait and mobility, osteopenia, osteoarthritis, anemia, lymphedema, repeated falls, and generalized muscle weakness. Review of the hospital paperwork for admission dated 11/19/24 revealed Resident #2 had previously fallen at home and sustained a nondisplaced periprosthetic fracture of the femoral component and a chronic subdural hematoma . Review of the Fall Risk Evaluation dated 11/22/24 revealed Resident #2 was at risk for falls.Review of the care plan initiated 11/23/24 revealed Resident #2 was at risk for falls. Initial interventions included for staff assistance with ambulation and transfers, and to utilize therapy recommendations Review of a Brief Interview for Mental Status (BIMS) score dated 11/29/24 revealed a score of 13 (out of 15) indicating Resident #2 had intact cognition. Review of a fall investigation report dated 11/29/24 revealed Resident #2 had an unwitnessed fall in the bedroom due to an attempted self-transfer but had no injury. Staff intervention included educating Resident #2 to call for assistance. Review of a fall investigation report dated 12/08/24 revealed Resident #2 had an unwitnessed fall in the bedroom due to an attempted self-transfer but had no injury. Staff intervention was educating Resident #2 to call for assistance (the same intervention initiated after the unwitnessed fall on 11/29/24). Review of a fall investigation report dated 12/09/24 revealed Resident #2 had an unwitnessed fall in the doorway into the hall, and the resident was unable to report what happened. Blood was observed on multiple areas of both legs and was then transferred to the hospital. A staff intervention following the incident was to bring Resident #2 into the common area for increased supervision.Review of hospital paperwork dated 12/09/24 revealed Resident #2 had fallen and complained of left hip pain. Resident #2's left leg was shortened and externally rotated. There was a left hip (peri trochanteric femur) fracture. No surgical interventions were taken. Review of admission summary note dated 12/13/24 revealed Resident #2 returned from the hospital with a left hip fracture and was non-weight bearing to the left side. Review of the Fall Risk Evaluation dated 12/13/24 revealed Resident #2 was at risk for falls. Review of the daily note dated 01/07/25 revealed Resident #2 was transferring unassisted and required education on waiting for assistance. Review of an order note dated 01/10/25 revealed Resident #2 received new therapy orders for transfers to graduate from a mechanical lift to transfer with a slide board.Review of the Medicare Minimum Data Set (MDS) five-day assessment dated [DATE] revealed Resident #2 had a (BIMS) score of 12 (out of 15) which indicated the resident had moderate cognitive impairment. The assessment revealed the resident required partial/moderate (staff) assistance for transfers and was independent for bed mobility and wheelchair use. Review of the physician's orders dated 02/10/25 revealed Resident #2 required one staff assistance with transfers, bilateral enabler bars for turning and repositioning, and weight bearing as tolerated. Review of a fall investigation report dated 02/10/25 revealed Resident #2 had a witnessed fall while being assisted by CNA #899 to transfer from the chair scale to the wheelchair. During the transfer while Resident #2 was standing, CNA #899 swapped the two chairs while not holding on to the resident. Resident #2 lost balance and fell backwards, then complained of pain to the right hip and had decreased range of motion. The resident was sent to the hospital. Following the incident, CNA #899 received education on safe transfers and was reminded of Resident #2 requiring hands-on assistance for standing and transfers. Review of the incident note dated 02/10/25 revealed Resident #2 was yelling out in pain and complained of severe pain to the right hip. Review of hospital paperwork dated 02/10/25 revealed Resident #2 had fallen and complained of right hip and shoulder (scapula) pain. Resident #2 had transferred from a chair scale to a wheelchair, then fell onto the buttocks. Resident #2 sustained a closed fracture of the right hip (superior and inferior pubic rami). Review of a fall investigation report dated 02/16/25 revealed Resident #2 had an unwitnessed fall out of bed. Record review revealed no information as to what interventions were in place at the time of the fall and/or why they were ineffective. At the time of the fall, Resident #2 was bleeding from the nose and mouth. The resident was transferred to the hospital. Review of corresponding hospital paperwork revealed Resident #2 had fallen and complained of right hip pain. There were no new fractures noted; however, the right hip fracture of the right pubic rami remained from the previous fall. Staff intervention following the incident included a body pillow to the open side of the resident's bed. Review of an Inservice Record Sheet dated 02/26/25 revealed CNA #899 was educated by Former Director of Therapy #716 on transfers. It was noted CNA #899's hands should always be on the resident during transfers, CNA #899 should call for assistance if needing to move away from a standing resident, and the resident should be seated if unable to physically assist. Review of the Fall Risk Evaluation dated 03/01/25 revealed Resident #2 was at risk for falls. Review of the behavior note dated 03/05/25 revealed Resident #2 had transferred unassisted from the wheelchair to the bed. Staff re-educated Resident #2 to call for assistance. There was no evidence of any additional/individualized and/or effective interventions initiated at this time to decrease the resident's risk of falls. Review of a fall investigation report dated 03/11/25 revealed Resident #2 had an unwitnessed fall in the bathroom due to self-transferring onto the toilet. Staff intervention was to encourage Resident #2 to call for assistance. There was no evidence of any additional/individualized and/or effective interventions initiated at this time to decrease the resident's risk of falls. Review of daily note dated 03/14/25 revealed Resident #2 was transferring unassisted throughout the shift. The resident was educated several times. There was no evidence of any additional/individualized and/or effective interventions initiated at this time to decrease the resident's risk of falls.Review of daily note dated 04/08/25 revealed Resident #2 was transferring unassisted throughout the shift. The resident was re-educated multiple times on call light use. There was no evidence of any additional/individualized and/or effective interventions initiated at this time to decrease the resident's risk of falls. Review of the Fall Risk Evaluation dated 06/07/25 revealed Resident #2 was at risk for falls. Review of a fall investigation report dated 07/29/25 revealed Resident #2 had an unwitnessed fall in the room due to self-transferring. There were no injuries. Staff interventions were to educate Resident #2 to call for help and wear non-skid socks.Review of the Fall Risk Evaluation dated 08/05/25 revealed Resident #2 was at risk for falls. Review of a fall investigation report dated 08/13/25 revealed Resident #2 had an unwitnessed fall in the room due to self-transferring. There were no injuries. Staff intervention as to educate Resident #2 to call for assistance. There was no evidence of any additional/individualized and/or effective interventions initiated at this time to decrease the resident's risk of falls.Review of a fall investigation report dated 08/26/25 revealed Resident #2 had an unwitnessed fall in the room. Resident #2 had fallen asleep in the wheelchair and then slid out. There were no injuries. Staff intervention was to encourage sitting in the recliner or bed to watch television. Review of daily note dated 09/03/25 revealed Resident #2 was observed by activities staff sitting on the floor of the room. Resident #2 voiced fixing something on the bed. There was no evidence of any additional/individualized and/or effective interventions initiated at this time to decrease the resident's risk of falls. Review of the plan of care revised 09/04/25 revealed Resident #2 was at risk for falls related to impaired mobility, non-compliance with recommendations, poor safety awareness, and impulsiveness. Interventions included enabler bar to bed, administer medications as ordered, assess for pain every shift, keep call light within reach and encourage use of call light, Dycem (non-slip surface) to the recliner chair, encourage to be in common area when out of bed, encourage participation, anti-roll backs to the wheelchair, keep items within reach, one staff assistance for transfers, monitor labs as ordered, therapy evaluation and treatment as needed, and ensure wearing appropriate footwear.Review of a fall investigation report dated 09/11/25 revealed Resident #2 had an unwitnessed fall in the bathroom due to self-transferring and not locking the wheelchair brakes. There were no injuries. Staff interventions were to apply anti-roll backs to the wheelchair and educate on locking the wheelchair brakes. Review of plan of care note, first dated 09/12/25 revealed Resident #2 was non-compliant with transfer assistance, and the resident had a long history of forgetfulness. Interventions included for staff to administer medications as ordered, approach and speak in a calm manner, assess for physical factors that may foster behavior, consult psychiatric services, divert attention from stimulus, monitor for changes, provide education, redirect resident as needed, use distraction, and help the resident to understand why the behavior was inappropriate. This care plan note did not address the resident's non-compliance as it pertained to fall risk/safety needs. On 09/24/25 at 10:35 A.M. Resident #2 was observed sitting in his wheelchair in his room. The resident was not noted to be in a common area at this time. An attempted interview with the resident at the time of the observation revealed the resident was unable to recall having any falls.Interview on 09/24/25 at 1:44 P.M. with CNA #899 revealed being the primary caregiver for Resident #2 who required one staff assistance for transfers. CNA #899 indicated on 02/10/25 she obtained Resident #2's weight using the scale chair. CNA #899 then stood the resident up from the wheelchair and went to get the wheelchair. CNA #899 described moving the scale chair and while attempting to move the wheelchair behind Resident #2, the resident fell straight backwards onto the buttocks. CNA #899 stated Registered Nurse (RN) #952 came to help and while trying to move the resident, he grabbed his leg and stated a belief it was broken. CNA #899 indicated emergency medical services (EMS) were called and got Resident #2 off the floor. Interview on 09/24/25 at 3:41 P.M. with RN #952 revealed being the assigned nurse for Resident #2 on 02/10/25. RN #952 stated CNA #899 was getting Resident #2's weight. CNA #899 had stood up Resident #2 and then went to get the wheelchair. RN #952 stated CNA #899 trusted Resident #2 too much and should have kept hands on Resident #2. RN #952 confirmed she educated CNA #899 on transfers following the incident. RN #952 stated Resident #2 complained of pain, was sent to hospital, and ended up with a fracture.Interview on 09/25/25 at 7:48 A.M. with Director of Nursing (DON) revealed Resident #2 was impulsive, non-compliant and did not slow down enough to allow time for safety. The DON indicated Resident #2 was often educated following falls and was encouraged to use the call light (however, these interventions were noted to be ineffective). The DON indicated she believed education was an adequate intervention for Resident #2 to prevent falls as the resident was resistive to changes in care and it maintained his independence without restricting him. The DON confirmed Resident #2 sustained a fracture following the fall which occurred on 02/10/25 while being assisted by CNA #899 to transfer when the CNA failed to ensure adequate hands-on assistance was being provided to the resident. Interview on 09/25/25 at 9:45 A.M. with Physical Therapy Assistant (PTA) #989 and Occupational Therapist (OT) #991 revealed Resident #2 required one staff assistance for transfers with contact guard assist (CGA) at the time of the fall on 02/10/25. It was noted Resident #2 was inconsistent with recommendations to call for assistance and had a history of poor follow-through. Review of the facility policy, Falls Policy, dated August 2024 revealed all residents would receive adequate supervision, assistance, and devices to aide in prevention of falls. This deficiency represents non-compliance investigated under Complaint Number 1374286 (OH00161744).

Based on resident record review, staff interviews, review of Self-Reported Incidents (SRIs), and review of facility concern logs, a soft file investigation and facility policy review, the facility failed to ensure Residents #33 and #48 were free from verbal and physical abuse. This affected two residents (#33 and #48) of two residents reviewed for abuse. The facility census was 82.Findings include:1. Review of the medical record for Resident #33 revealed an admission date of 08/23/20 and diagnoses including dementia, hypertension, and major depressive disorder.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 had short- and long-term cognition impairment, was severely impaired regarding tasks of daily life, had a history of physical and verbally aggressive behaviors, was resistant to care, and was dependent on staff for toileting, lower body dressing and mobility.Review of the care plan last updated on 08/22/25 revealed Resident #33 had a diagnosis of dementia with a history of behaviors during care that included kicking, grabbing, pushing, pinching, scratching, spitting, biting, abusive language, threatening behaviors and attempts to grab and hit staff members. Interventions included staff were to anticipate Resident #33's needs, approach in a calm and friendly manner, and/or stop care and reapproach later. Resident #33 was also resistive to allowing staff to provide care with interventions including to leave and return five to ten minutes later and try again. The resident had an electronic monitoring device in the room in accordance with the provisions of Esther's Law.Review of the progress note dated 03/06/25 at 12:10 P.M. revealed Resident #33 was combative with hygiene care and with routine medication.Review of the progress note dated 03/22/25 at 4:34 A.M. revealed Resident #33 was combative during care and punched an unknown nurse in the mouth and lips.Review of the progress note dated 03/30/25 at 9:39 P.M. revealed Resident #33 moved away an unknown nurse's hand during medication administration.Review of the SRI tracking system located within the Ohio Department of Health (ODH) for certification and licensing website revealed an SRI dated 03/24/25 of an allegation of alleged abuse. Resident #33's son contacted the facility and complained of staff being too rough during care, which resulted in Registered Nurse (RN) #717 being immediately suspended pending investigation. Resident #33's son provided video footage, reviewed by the Administrator, which revealed RN #717 assisting Certified Nurse Aide (CNA) #720 with Resident #33's incontinence care. Resident #33 was then observed punching RN #717 in the face. RN #717 was heard stating You will NOT do that as she then grabbed Resident #33's hands and held them while rolling Resident #33 over to continue with incontinence care. RN #717 revealed she and CNA #720 struggled to provide care for Resident #33, so she held Resident #33's hands as a result.Further review of the SRI revealed Resident #33's son informed the Administrator of another incident regarding CNA #720 while providing care to Resident #33 and as she turned Resident #33, she hit the resident's head on the enabler bar. CNA #720 did not stop providing care and did not report the incident to the nurse on duty which resulted in CNA #720's termination. The Administrator stated CNA #720's haste in providing care resulted in Resident #33 hitting her head.Review of the progress notes in Resident #33's medical record revealed no progress note related to the alleged incident.Review of the mandatory training for all staff revealed the facility educated staff on sensitivity and dementia care dated 06/16/25, 07/14/25, and 08/11/25. Subsequently implemented approximately three months after the alleged incident, which occurred in March 2025.Review of the facility document titled New Hire Orientation dated 09/25/25 revealed the staff were educated on abuse policy and protocols and dementia care related to trauma, behaviors, and substance.Review of the staff education revealed staff were educated on trauma-informed care 02/01/25, challenging behaviors for dementia residents 03/02/25, and abuse, neglect, and exploitation 09/01/25.Review of the personnel file for RN #717 revealed a hire date of 08/06/21 and education received for the abuse, neglect and misappropriation policy on 08/06/21 and 08/09/21.Review of the job termination notice dated 03/25/25 revealed RN #717 was terminated after the incident on 03/23/25 because of violating the facility's conduct and behavior policy. Review of the termination notice revealed RN #717 was observed on video footage reacting firmly and abruptly to Resident #33, who struck her during care. Review of the notice revealed RN #717 actions were loud, reactive, and lacked the calm, professional demeanor expected of quality resident care. RN #717, rather than deescalating the situation was observed on video raising her voice and holding Resident #33 hands in a manner to prevent striking, but it did not align with best practices for dealing with combative behaviors.An interview with RN #717 and CNA #720 was attempted throughout the survey period. However, attempts were unsuccessful as their employment was terminated with the facility and numbers provided were no longer in working order.Interview on 09/25/25 at 8:30 A.M. with the Administrator and the Director of Nursing (DON) revealed Resident #33's son forwarded a video from Resident 33's room camera which showed RN #717 and CNA #720 providing care in bed. RN #717 was struck in the face by Resident #33 and as a result, RN #717 grabbed Resident #33's hands and stated, You will not do that and finished helping CNA #720 provide care. Resident #33's family felt RN #717's behavior was rough and scolding. The Administrator and DON confirmed and verified the above findings at the time of the interview.Interview on 09/25/25 at 9:32 A.M. with [NAME] President of Council (VPC) #730 revealed RN #717 was terminated due to not meeting the standards of the facility related to their conduct and behavior policy. VPC #730 confirmed and verified the above findings at the time of the interview.2. Review of the medical record for Resident #48 revealed an admission date of 03/03/25 with diagnoses including Alzheimer's disease, hypertension, osteoarthritis of the left knee, and right artificial hip joint.Review of the MDS assessment dated [DATE] revealed Resident #48 had a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment and the resident was dependent on staff for toileting, lower body dressing and hygiene.Review of the physician orders dated 03/03/25 revealed an order to assist Resident #48 with turning and repositioning during routine rounds and as needed.Review of the progress note dated 03/04/25 at 4:44 P.M. revealed Resident #48 was admitted to the facility after a fall which resulted in a right hip fracture with repair.Review of the concern log for March 2025 revealed Resident #48's son contacted the Administrator on 03/24/25 to express concerns regarding the conduct of an agency aide, CNA #718, who was assigned to Resident #48. Out of abundance of caution, CNA #718 was immediately removed from duty pending a full investigation, and after a thorough review of the incident, it was determined CNA #718 would not return to the facility.Review of the facility folder titled Soft File for Resident #48 dated 03/23/25 revealed an incident timeline and analysis. Review of the timeline revealed on 03/23/25 at 8:36 P.M., the Administrator missed a call from an unknown number and at 8:37 P.M. Resident #48's son sent a text message to the Administrator requesting a callback regarding the situation. The Administrator returned the call at 8:38 P.M. and was informed the aide on duty (CNA #718) was unprofessional during care as observed via the room camera. Resident #48's son stated CNA #718 mocked Resident #48 and sent a video clip to the Administrator. At 8:46 P.M. Assistant Director of Nursing (ADON) #862 notified the Director of Nursing (DON) and the Administrator that she had also received a call to report Resident #48's family was upset. ADON #862 revealed Resident #48's family alleged CNA #718 was rough while turning Resident #48 during care and mocked him. ADON #862 confirmed Licensed Practical Nurse (LPN) #894 was present at the time of care being provided.At 8:52 P.M. the Administrator instructed ADON #862 to send CNA #718 home.At 9:12 P.M. the Administrator contacted Resident #48's son and daughter and informed them CNA #718 was sent home due to the family's concern and for failing to uphold the professionalism expected at the facility. As a result, the facility initiated a Do-Not-Return (DNR) order for CNA #718.Further review of the soft file revealed the provided video of the alleged incident was reviewed by the Administrator and DON which showed CNA #718 assisted Resident #48 with changing clothes and transferred him to bed using a Hoyer lift with the assistance of LPN #894. As Resident #48 was transferred, he made moaning noises, in which CNA #718 paused and asked if she was doing something wrong or if Resident #48 was in pain. CNA #718 was then heard mimicking the noise Resident #48 made. As CNA #718 walked toward the bathroom, she then repeated the mimicked noise from Resident #48's indication of pain.Interview on 09/24/25 at 3:21 P.M. with LPN #894 was attempted via phone. However, contact was unsuccessful as the number was disconnected.Interview on 09/24/25 at 4:12 P.M. with the Administrator revealed Resident #48's son contacted her on a weekend in March of the current year regarding an agency aide's (CNA #718) conduct, in which she had a soft file pertaining to the incident.Interview on 09/25/25 at 8:01 A.M. with the Administrator and the DON revealed Resident #48 had a fall prior to being admitted to the facility, and the family wanted a camera installed in the room. Resident #48's son reported CNA #718 was unprofessional and mocked the resident and sent a video clip of the incident in question. The Administrator revealed prior to reviewing the video clip, CNA #718 was sent home, and subsequently, after watching the video clip, CNA #718 was placed on the DNR list. The video clip revealed Resident #48 was in process of being transferred into bed by CNA #718 and LPN #894 via Hoyer lift when Resident #48 made a moaning noise indicating pain. CNA #718 asked Resident #48 if she was doing something wrong and mimicked the noise made by Resident #48. Once Resident #48 was in bed, CNA #718 walked towards the bathroom while mimicking Resident #48's moaning noise.Review of additional video clips with the Administrator and DON present, revealed CNA #718 provided incontinence care to Resident #48 while in bed. The resident was heard yelling out in pain and CNA #718 stated, You have to help me and stop resisting. CNA #718 was then observed with both hands placed on Resident #48's right hip and pushed him onto his left side as he yelled out in pain. LPN #894 then entered the resident's room and asked him to verify and confirm his name. CNA #718 continued to attempt to turn Resident #48 on his left side while he yelled out in pain. LPN #894 then placed both hands on Resident #48's right side to hold him in place on his left side, while CNA #718 continued to provide care. LPN #894 was heard asking Resident #48 if he was in pain and then stated, I just gave you Tylenol. CNA #718 was then heard telling Resident #48 to turn towards her. Resident #48 was observed not to be moving towards CNA #718, when CNA #718 was then observed placing both hands on Resident #48 left side of his body and pulling him all the way over onto his right side and holding him in place. Resident #48 continued to yell out in pain while CNA #718 asked What's the matter? After completing Resident #48 care, CNA #718 was then seen pushing Resident #48 bed using her upper legs against the wall.Interview on 09/25/25 at 8:01 A.M. with the Administrator revealed there was no longer a video to be reviewed regarding the Hoyer transfer due to receiving a new phone and the incident of alleged abuse was not reported to the State Survey Agency. The Administrator also revealed CNA #718 and LPN #894 no longer were employed by the facility. The Administrator confirmed and verified the above findings at the time of the interview.Review of the mandatory training for all staff revealed the facility educated staff on sensitivity care on 06/16/25, 07/14/25, and 08/11/25 approximately three months after the incident.Review of the facility document titled New Hire Orientation dated 09/25/25 revealed the staff were educated on abuse policy and protocols.Review of the staff education revealed staff were educated on abuse, neglect, and exploitation on 09/01/25.Review of the facility document titled Abuse, Neglect, Misappropriation, and Exploitation Policy revised 11/28/16, revealed the facility had a policy in place that all residents had a right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including but not limited to, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Further review of the policy revealed alleged violations would be reported to the State Survey Agency. Review of the document revealed the facility did not implement the policy in regard to the allegation.This deficiency represents noncompliance investigated under Complaint Number 1374287 (OH00164161).

Based on resident record review, staff interviews, review of Self-Reported Incidents (SRIs), review of facility soft file investigation, and facility policy review, the facility failed to report an incident of alleged abuse to the State Agency. This affected one (Resident #48) of two residents reviewed for abuse. The facility census was 82.Findings include:Review of the medical record for Resident #48 revealed an admission date of 03/03/25 with diagnoses including Alzheimer's disease, hypertension, osteoarthritis of the left knee, and right artificial hip joint. Review of the MDS assessment dated [DATE] revealed Resident #48 had a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment and the resident was dependent on staff for toileting, lower body dressing and hygiene. Review of the physician orders dated 03/03/25 revealed an order to assist Resident #48 with turning and repositioning during routine rounds and as needed. Review of the progress note dated 03/04/25 at 4:44 P.M. revealed Resident #48 was admitted to the facility after a fall which resulted in a right hip fracture with repair. Review of the concern log for March 2025 revealed Resident #48's son contacted the Administrator on 03/24/25 to express concerns regarding the conduct of an agency aide, CNA #718, who was assigned to Resident #48. Out of abundance of caution, CNA #718 was immediately removed from duty pending a full investigation, and after a thorough review of the incident, it was determined CNA #718 would not return to the facility. Review of the facility folder titled Soft File for Resident #48 dated 03/23/25 revealed an incident timeline and analysis. Review of the timeline revealed on 03/23/25 at 8:36 P.M., the Administrator missed a call from an unknown number and at 8:37 P.M. Resident #48's son sent a text message to the Administrator requesting a callback regarding the situation. The Administrator returned the call at 8:38 P.M. and was informed the aide on duty (CNA #718) was unprofessional during care as observed via the room camera. Resident #48's son stated CNA #718 mocked Resident #48 and sent a video clip to the Administrator. At 8:46 P.M. Assistant Director of Nursing (ADON) #862 notified the Director of Nursing (DON) and the Administrator that she had also received a call to report Resident #48's family was upset. ADON #862 revealed Resident #48's family alleged CNA #718 was rough while turning Resident #48 during care and mocked him. ADON #862 confirmed Licensed Practical Nurse (LPN) #894 was present at the time of care being provided. At 8:52 P.M. the Administrator instructed ADON #862 to send CNA #718 home. At 9:12 P.M. the Administrator contacted Resident #48's son and daughter and informed them CNA #718 was sent home due to the family's concern and for failing to uphold the professionalism expected at the facility. As a result, the facility initiated a Do-Not-Return (DNR) order for CNA #718. Further review of the soft file revealed the provided video of the alleged incident was reviewed by the Administrator and DON which showed CNA #718 assisted Resident #48 with changing clothes and transferred him to bed using a Hoyer lift with the assistance of LPN #894. As Resident #48 was transferred, he made moaning noises, in which CNA #718 paused and asked if she was doing something wrong or if Resident #48 was in pain. CNA #718 was then heard mimicking the noise Resident #48 made. As CNA #718 walked toward the bathroom, she then repeated the mimicked noise from Resident #48's indication of pain. Interview on 09/24/25 at 3:21 P.M. with LPN #894 was attempted via phone. However, contact was unsuccessful as the number was disconnected. Interview on 09/24/25 at 4:12 P.M. with the Administrator revealed Resident #48's son contacted her on a weekend in March of the current year regarding an agency aide's (CNA #718) conduct, in which she had a soft file pertaining to the incident. Interview on 09/25/25 at 8:01 A.M. with the Administrator and the DON revealed Resident #48 had a fall prior to being admitted to the facility, and the family wanted a camera installed in the room. Resident #48's son reported CNA #718 was unprofessional and mocked the resident and sent a video clip of the incident in question. The Administrator revealed prior to reviewing the video clip, CNA #718 was sent home, and subsequently, after watching the video clip, CNA #718 was placed on the DNR list. The video clip revealed Resident #48 was in process of being transferred into bed by CNA #718 and LPN #894 via Hoyer lift when Resident #48 made a moaning noise indicating pain. CNA #718 asked Resident #48 if she was doing something wrong and mimicked the noise made by Resident #48. Once Resident #48 was in bed, CNA #718 walked towards the bathroom while mimicking Resident #48's moaning noise. Review of additional video clips with the Administrator and DON present, revealed CNA #718 provided incontinence care to Resident #48 while in bed. The resident was heard yelling out in pain and CNA #718 stated, You have to help me and stop resisting. CNA #718 was then observed with both hands placed on Resident #48's right hip and pushed him onto his left side as he yelled out in pain. LPN #894 then entered the resident's room and asked him to verify and confirm his name. CNA #718 continued to attempt to turn Resident #48 on his left side while he yelled out in pain. LPN #894 then placed both hands on Resident #48's right side to hold him in place on his left side, while CNA #718 continued to provide care. LPN #894 was heard asking Resident #48 if he was in pain and then stated, I just gave you Tylenol. CNA #718 was then heard telling Resident #48 to turn towards her. Resident #48 was observed not to be moving towards CNA #718, when CNA #718 was then observed placing both hands on Resident #48 left side of his body and pulling him all the way over onto his right side and holding him in place. Resident #48 continued to yell out in pain while CNA #718 asked What's the matter? After completing Resident #48 care, CNA #718 was then seen pushing Resident #48 bed using her upper legs against the wall. Review of the SRI tracking system located within the Ohio Department of Health (ODH) for certification and licensing website revealed no incidents regarding Resident #48. Interview on 09/25/25 at 8:01 A.M. with the Administrator revealed the incident of alleged abuse was not reported to the State Survey Agency. The Administrator confirmed and verified the above findings at the time of the interview. Review of the facility document titled Abuse, Neglect, Misappropriation, and Exploitation Policy revised 11/28/16, revealed the facility had a policy in place that all residents had a right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including but not limited to, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Further review of the policy revealed alleged violations would be reported to the State Survey Agency. Review of the document revealed the facility did not implement the policy in regard to the allegation. This deficiency represents noncompliance investigated under Complaint Number 1374287 (OH00164161).

Based on record review, observations, staff interviews, and facility policy review, the facility failed to provide accommodation for a dependent resident's needs. This affected one (Resident #38) of three residents reviewed for nutrition. The facility census was 82. Findings include:Review of the medical record for Resident #38 revealed an admission date of 01/30/22 with diagnoses including dementia, major depressive disorder, and carpal tunnel syndrome of the right upper limb. Resident #38 received hospice care services. Review of the physician order dated 07/06/23 revealed an order for Resident #38 to reside in the memory support unit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had severe cognitive impairment and required assistance from staff for activities of daily living (ADL). Review of the care plan dated 08/18/25 revealed Resident #38 had an altered nutritional status related to dementia with a contributing history of decreased meal acceptance and weight loss. Interventions included limiting weight loss, providing set-up for meals, cutting up meats, reminders to complete meals, and beverages in a Kennedy cup (a spill-proof cup designed for people with difficulty drinking). Review of the progress note dated 08/18/25 at 9:39 A.M. revealed Resident #38 had a regular diet that required cut up meats, a Kennedy cup and reminders and cueing for meal completion. Resident #38 required use of a Kennedy cup for ease in self-feeding due to history of prior beverage spilling with oversight and encouragement while dining in the memory care unit dining room. Review of the physician order effective September 2025 revealed an order for a regular diet, regular texture, and regular consistency. Review of the hospice note dated 09/04/25 at 5:21 P.M. revealed Resident #38 was a setup for meals, required more prompting with meals and was observed to frequently play in food. Review of the Interdisciplinary Team (IDT) Care Conference assessment dated [DATE] revealed Resident #38 had severely impaired cognition, had a history of weight loss and malnutrition, required meats to be cut up, a Kennedy cup, and meals in the memory care unit for oversight and self-fed. Review of the hospice note dated 09/24/25 at 3:23 P.M. revealed Resident #38 required hand feeding during meals upon visit. Observation on 09/24/25 at 8:39 A.M. revealed Resident #38 was seated alone at a table in the memory care unit dining room with a Kennedy cup in her right hand and a fork in her left hand. The resident took a bite of her breakfast meal frequently nodding off. At the time, Certified Nurse Assistants (CNAs) #820 and #849 were observed seated at an adjacent table assisting four other unknown residents. Observation on 09/24/25 at 8:43 A.M. revealed the Director of Nursing (DON) talking to Resident #38 inquiring if Resident #38 wanted some coffee with cream. The DON was then observed requesting Resident #38 be given a cup of coffee. Resident #38 was then given a cup of hot coffee in a Styrofoam cup without a lid with steam visibly seen coming from the top of the cup. Observation and interview on 09/24/25 at 8:45 A.M., revealed CNA #820 sat in a chair next to Resident #38's left hand side and handed Resident #38 the cup of coffee. Resident #38 was then observed grabbing the cup of coffee, visibly shaking the cup, struggling to lift it and bring it to her mouth almost spilling the hot liquid. CNA #820 was then observed grabbing the cup of coffee and stated, Oh it's still hot, you almost spilled it. CNA #820 revealed she was unaware if all Resident #38's drinks were to be in a Kennedy cup and stated the resident fell asleep all the time, so she required assistance with meals including reminders and cueing. CNA #820 confirmed and verified Resident #38 was seated at the table alone with no staff assisting or providing reminders and cueing during the consumption of her meal. Interview on 09/24/25 at 10:40 A.M. with Registered Nurse (RN) #868 revealed Resident #38 required assistance during meals with encouragement and cues. Interview on 09/24/25 at 10:58 A.M. with Registered Dietician (RD) #976 revealed Resident #38 utilized a Kennedy cup due to spilling liquids all over herself and tablemates and required oversight having had recent episodes of mixing or playing with her food. RD #976 confirmed and verified Resident #38 was a good eater with staff oversight and keeping an eye on her. Review of the facility document titled Activities of Daily Living undated, revealed the facility had a policy in place to ensure the care and services provided was person-centered, and honored and supported each resident's preferences, choices, values and beliefs. Review of the policy revealed the facility would provide the necessary care and services to ensure a resident's abilities in activities of daily living would not diminish including but not limited to, dining and/or eating, setting up meals and assisting with meals. Review of the document revealed the facility did not implement the policy.

Based on record review, observation, interview and facility policy review, the facility failed to ensure medications were given according to physician's orders, creating a medication error rate of 16.0 percent (%). This affected two residents (#29 and #32) of three residents observed for medication administration. The facility census was 82. Findings include:1. Review of the medical record for Resident #29 revealed an admission date of 09/08/25 and diagnoses including metabolic encephalopathy, ventricular tachycardia, and stage four chronic kidney disease. A physician's order dated 09/18/25 was for 12.5 milligrams (mg) of spironolactone (a diuretic) to be given daily, with no other current orders for this medication. Another physician's order dated 09/08/25 was for a senna-docusate 8.6-50 mg (laxative and stool softener) combination medication to be given twice daily, and no current order for any senna-only pills to be given. Observation of a medication administration procedure for Resident #29 on 09/24/25 at 8:29 A.M. by Registered Nurse (RN) #868 revealed the nurse drew out two doses of spironolactone from different containers, each being a 25 mg pill split in half for a dose of 12.5 mg each. Both half-pills were placed in a medication cup along with the resident's other pills. Additionally, the nurse drew out and administered one senna (a stool softener) 8.6 mg pill and did not draw or administer any senna-docusate combination pills. Interview with RN #868 on 09/24/25 at 8:49 A.M. verified the nurse was ready to administer the spironolactone at which time the surveyor intervened to identify the two spironolactone doses in Resident #29's cup. RN #868 then looked at the resident record, confirmed the resident was to receive only one 12.5 mg pill of spironolactone, and discarded the other spironolactone pill. Interview with RN #868 on 09/24/25 at 10:05 A.M. confirmed Resident #29 was administered the incorrect type of senna medication and had to be stopped before administering two doses of spironolactone to the resident. 2. Review of the medical record for Resident #32 revealed an admission date of 09/10/25 and diagnoses including hypertension, repeated falls, and fracture of right femur. A physician's order dated 09/10/25 was for a 500 mg chewable calcium carbonate tablet (medication for heartburn and indigestion) daily in the morning, and no active orders for a calcium-vitamin D combination tablet. Another physician's order dated 09/10/25 was for a senna-docusate 8.6-50 mg combination medication to be given twice daily, and no current order for any senna-only pills to be given. Observation of a medication administration procedure for Resident #32 on 09/24/25 at 9:09 A.M. by Licensed Practical Nurse (LPN) #893 revealed the nurse drew out and administered one senna 8.6 mg pill and did not draw or administer any senna-docusate combination pills. The nurse also drew and administered one combination oyster shell calcium 500 mg and vitamin D 5 microgram (mcg) pill and did not give any other calcium supplement. Interview with LPN #893 on 09/25/25 at 10:10 A.M. confirmed the above findings. The above findings identified four errors out of 25 observed medication administration opportunities, creating a total medication error rate of 16.0%. Review of the facility's undated medication administration policy revealed medications were administered according to orders, and staff were to verify the right medication and dosage before giving the medication.

Based on record review, review of the Self-Reported Incident (SRI) and interviews, the facility did not ensure all residents were protected from misappropriation of resident funds by staff. This affected one resident of four residents reviewed for resident rights. The facility census was 74. Findings included: Record review for Resident #535 revealed an admission date of 05/22/23 with diagnoses including anxiety disorder, hypertension, constipation, anorexia, major depressive disorder. Record review of the facility Minimum Data Set ( MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status ( BIMS) score of 11 indicating moderate cognitive impairment. Record review of the SRI dated 10/03/23 and the facility investigation revealed agency State Tested Nurse Assistant (STNA) # 176 took a check from Resident #535 and wrote it out for $4000. On 10/03/23 the family of Resident #535 alerted the facility that a check allegedly signed by Resident #535 had been electronically presented for payment to the bank. The check for $4,000 dollars was made out to STNA #176. STNA #176 was employed as an agency state tested nurse aid and had worked on Resident #535's unit on 09/30/23. The allegation of misappropriation was substantiated by the facility. Review of the investigation report from the Abuse, Neglect and Misappropriation investigator from the Ohio Deptartment of Health revealed the staff person (STNA #176) admitted to taking the check and writing it out for $40000 so she could by a car and pay for her outstanding warrants of approximately $1,000. Interview with the Executive Director (ED) #177 on 12/21/23 at 1:45 PM verified the agency STNA #176 did take a check from Resident #535 and attempt to cash it at the bank for $4000.00. ED #177 stated the money was reimbursed to the resident. This deficieny resulted from incidental findings during the investigation of Complaint Number OH00149086.

Based on record review, review of the Self-Reported Incident (SRI) and interviews, the facility did not ensure all residents were protected from misappropriation of resident funds by staff. This affected one resident of four residents reviewed for resident rights. The facility census was 74. Findings included: Record review for Resident #535 revealed an admitted [DATE] with diagnoses including anxiety disorder, hypertension, constipation, anorexia, major depressive disorder. Record review of the facility Minimum Data Set ( MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status ( BIMS) score of 11 indicating moderate cognitive impairment. Record review of the SRI dated 10/03/23 and the facility investigation revealed agency State tested Nurse Assistant (STNA) # 176 took a check from Resident #535 and wrote it out for $4000. On 10/03/23 the family of Resident #535 alerted the facility that a check allegedly signed by Resident #535 had been electronically presented for payment to the bank. The check for $4,000 dollars was made out to STNA #176. STNA #176 was employed as an agency state tested nurse aid and had worked on Resident #535's unit on 09/30/23. The allegation of misappropriation was substantiated by the facility. Review of the investigation report from the Abuse, Neglect and Misappropriation investigator from the Ohio Deptartment of Health revealed the staff person (STNA #176) admitted to taking the check and writing it out for $40000 so she could by a car and pay for her outstanding warrants of approximately $1,000. Interview with the Executive Director (ED) #177 on 12/21/23 at 1:45 PM verified the agency STNA #176 did take a check from Resident #535 and attempt to cash it at the bank for $4000.00. ED #177 stated the money was reimbursed to the resident. This deficieny resulted from incidental findings during the investigation of Complaint Number OH00149086.

Based on record review and interviews the facility failed to provide two staff to assist, as required for the Sit to Stand Mechanical Lift transfer for Resident #3 who slipped off the bed and was lowered to the floor. This affected one resident, Resident #3, out of a total of seven residents who required the use of the Sit to Stand Mechanical Lift for transfers. The facility census was 85. The findings include: 1. Resident #3 was admitted to the facility on [DATE] with a diagnosis of [CONDITION(S)] disease, dementia, [CONDITION(S)], diabetes mellitus with complications, [CONDITION(S)], [CONDITION(S)], history of [CONDITION(S)] (TIA), peripheral vascular disease, hypertensive retinopathy, and hypertension. Resident #3 went on hospice services on 05/19/21 due to continual, unavoidable decline. 2. The care plan, dated 04/27/21 revealed Resident #3 was at high risk for falls and required a two person assist to transfer using the Sit to Stand Mechanical Lift. 3. Review of the incident report dated 05/11/21 revealed the State tested Nurse Aide (STNA) #7 set Resident #3 up for a transfer using the Sit to Stand Mechanical Lift without another staff member present to assist. By the time the other staff member arrived, Resident #3 had slipped off the bed but did not fall to the floor. Resident #3 was assisted back to bed. 4. According to the facility policy for using the Sit to Stand Mechanical Lift, all Sit to Stand Mechanical Lifts require two staff. 5. Interview with the Administrator, Director of Nursing (DON), and Licensed Practical Nurse (LPN) #140, confirmed that all Sit to Stand Mechanical Lifts require two staff. The verified that STNA #7 was the only staff assisting. This deficiency substantiates Complaint Number OH 616.

Based on observation, record review and interview the facility failed to ensure a variety of foods were offered for Resident #51 and Resident #85 and failed to ensure Resident #2, Resident #65 and Resident #80, who were ordered a pureed diet received the proper serving size of soup. This affected two residents (#51 and #85) of four residents reviewed for food concerns based on the menu and three residents (#2, #65 and #80) of three residents reviewed for pureed diets. Findings include: On 03/10/20 observation of both the lunch and dinner meals revealed beef and barley soup was served for both meals. Interview with Dietary Managers #201 and #202 on 03/10/20 at 5:45 P.M. regarding observations of beef barley soup having been served on 03/10/20 for both lunch and dinner meals, and concerns residents (#51 and #85) had stated in regard to the lack of variety of meals served were discussed. Dietary Manager #201 stated, The same meals are not served back to back and denied beef and barley soup had been served at lunch and dinner on 03/10/20. Review of the menu spreadsheet on 03/10/20 with Dietary Managers #201 and #202 at 5:47 P.M. confirmed the menu had beef and barley soup listed for both meals. Dietary Manager #201 stated this was a typo. Observation of Dietary Aide #205 serving lunch on 03/10/20 at 11:37 A.M. revealed the beef and barley soup was served to residents on the second floor with a six ounce ladle, and a three ounce serving was served to residents on the second floor prescribed pureed diets. Interview with Dietary Aide #205 at 11:47 A.M. confirmed the size of the soup ladle was six ounces and the size of the spoon used for the pureed portions of soup was three ounces. Interview with Dietary Aide #200 on 03/10/20 at 11:49 A.M. revealed the Dietary Aides serve the foods to residents without referring to the dietary cards and go by memory. Interview on 03/10/20 with Dietary Manager #201 confirmed residents on the second floor who received pureed diets, (Resident #2, Resident #65 and Resident #80), should have received six ounce servings of soup for lunch and that staff should have known not to serve only three ounces, as they all had been trained. Review of the facility record, Diet Type Report dated 03/09/20, revealed there were 44 of 45 residents on the second floor who had meals served by the facility and three of the 45 residents, (Resident #2, Resident #65 and Resident #80) were prescribed pureed diets. Record review of the facility documents titled, Diet Spreadsheets Fall and Winter, revealed the portion size for residents prescribed either a regular or pureed diet was a six ounce ladle of soup.

Based on observation, record review and interview the facility failed to ensure a sanitary food preparation area was maintained during tray/serving line of meals to prevent potential contamination and/or food borne illness. This had the potential to affect 44 residents (#1, #2, #4, #5, #7, #9, #12, #13, #14, #18, #20, #22, #24, #27, #28, #29, #31, #35, #37, #48, #49, #51, #52, #58, #61, #64, #65, #66, #68, #73, #74, #77, #79, #80, #81, #84, #88, #90, #91, #93, #293, #294, #295 and #296) of 45 residents who take foods by mouth, reside on the second floor and receive their meals from the pantry. Findings include: Interview with Dietary Manager #201 on 03/09/20 at 10:00 A.M. revealed all dietary staff had been trained in safe food serving. Observation of the second floor food tray/serving line 03/10/20 at 11:28 A.M. revealed Dietary Aide #200 was observed to put a used paper towel, alcohol wipe and wrapper onto the serving area and those items fell upon the heavily traveled pantry floor. Dietary Aide #200 picked the items up off of the floor with bare hands and placed them back onto the serving area in front of the hot foods before the items were discarded in the trash. The food prep/serving area was not cleaned afterward. Dietary Aide #206 set the soup ladle onto the uncleaned serving area, placed the soup ladle into the soup and then served the residents. The facility identified 44 residents, Resident #1, #2, #4, #5, #7, #9, #12, #13, #14, #18, #20, #22, #24, #27, #28, #29, #31, #35, #37, #48, #49, #51, #52, #58, #61, #64, #65, #66, #68, #73, #74, #77, #79, #80, #81, #84, #88, #90, #91, #93, #293, #294, #295 and #296 who take foods by mouth, reside on the second floor and receive their meals from the pantry. Review of the policy titled Dietary Infection Control, dated 03/11/20; Food Handling, dated 03/11/20, revealed it was the policy of the facility that all local, state and federal standards and regulations were followed in order to assure a safe and sanitary dietary department. The Infection Control policy indicated, all employees would be in good health, would have clean personal habits and would handle all foods safely. The food handling policy revealed all food items were prepared to conserve maximum nutritive value, develop and enhance flavor and to be free of injurious organisms and substances.

Based on record review and interview the facility failed to ensure proper bed hold notices were provided as required upon resident transfers to the hospital. This affected two residents (#3 and #66) and had the potential to affect all 87 residents residing in the facility. Finding include: 1. Record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment, dated 02/17/20 revealed the resident had intact cognition and needed extensive assistance from staff for bed mobility, transfers and toileting. Review of nurses' progress note, dated 12/24/19 revealed resident was sent to the emergency room for increased temperature and lethargy. There was no evidence the resident's representative was provided the facility written bed hold policy notice at the time of transfer. Interview on 03/12/20 at 2:22 P.M. with Licensed Social Worker (LSW) #203 verified the facility could not provide evidence a written bed hold notice was provided to Resident #3's representative upon the resident's transfer to the hospital. 2. Record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS 3.0 assessment, dated 11/28/19 revealed the resident had impaired cognition and required extensive assistance from staff for bed mobility and toileting. Review of the nurses' progress note dated 02/02/20 revealed Resident #66 was sent 911 to the emergency room (ER) for respiratory distress. A note dated 01/24/20 revealed Resident #66 was sent 911 to ER for nausea, vomiting and respiratory distress. There was no evidence the resident's representative was provided the facility written bed hold policy notice at the time of either transfer. Interview on 03/12/20 at 2:22 P.M. with Licensed Social Worker (LSW) #203 verified the facility could not provide evidence a written bed hold notice was provided to Resident #66's representative upon the resident's transfer to the hospital.

Based on record review, policy review, and interview, the facility failed to prevent misappropriation of resident medications. This affected one (Resident #78) of four residents reviewed for concerns during the survey. Findings include: Review of self-reported incident (SRI) # 8 revealed that on 08/16/19 the facility was informed staff members gave drugs from a medication cart to one of their children. The facility investigation revealed Registered Nurse (RN) #602 gave one pill of [MEDICATION NAME] (an anti-nausea medication) from her medication cart to State-tested Nursing Aide (STNA) #601 to give to STNA #601's son, who she had brought to the building. This was verified by the investigation's interview with RN #602. The facility investigation revealed one unaccounted tablet of [MEDICATION NAME] missing from a medication card prescribed for Resident #78. The investigation revealed no evidence Resident #78 missed any medications, and both her and staff denied that she needed any [MEDICATION NAME] during her stay. Based on their investigation, the facility substantiated the allegation of misappropriation and terminated both employees. The surveyor confirmed the above findings in an interview with the Administrator on 01/02/20 at 11:04 [NAME]M. Record review of Resident #78 revealed she was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of her Medication Administration Record [REDACTED]. Review of her progress notes revealed no evidence of her having any nausea, vomiting, or other symptoms appropriate for management with [MEDICATION NAME] from (MONTH) 2019 onwards, and no other evidence of missing medications. Review of the facility's abuse, neglect, and misappropriation policy dated 11/28/16 revealed all residents had a right to be free from misappropriation as defined by state law. All such allegations were to be reported and investigated. This deficiency is cited as an incidental finding to Complaint Number OH 960.

Based on observation and staff interview, the facility failed to maintain registered nurse (RN) coverage in the facility at least eight consecutive hours a day seven days a week as required. This had the potential to affect all 91 facility residents. Findings include: Review of the POS [REDACTED]. The facilities Director of Nursing and Administrator verified the above findings in an interview on 01/30/19 at 7:57 A.M.

Based on record review and interview the facility failed to provide the appropriate liability notices to Resident #23, #55, #95, #116 and #135. This affected five residents (Residents #23, #55, #95, #116 and #135) of seven residents reviewed for liability notices. Findings include: Review of Resident #23's medical record revealed the resident was admitted to facility on 02/09/16 with skilled therapy services scheduled to end on 03/21/16. Resident #23 remained in the building and received a Notice of Medicare Non-Coverage (Center for Medicare Services {CMS} form ) but did not receive the Skilled Nursing Facility Advance Beneficiary Notice (CMS form ) as required. Review of Resident #55's medical record revealed the resident was admitted to the facility on [DATE] with skilled therapy services scheduled to end on 01/22/16. Resident #55 remained in the facility and received a Notice of Medicare Non-Coverage (CMS form ) but did not receive the Skilled Nursing Facility Advance Beneficiary Notice (CMS form ) as required. Review of Resident #95's medical record revealed the resident was admitted to the facility on [DATE] with skilled therapy services scheduled to end on 04/07/16. Resident #95 remained in the facility and received a Notice of Medicare Non-Coverage (CMS form ) but did not receive the Skilled Nursing Facility Advance Beneficiary Notice (CMS form ) as required. Review of Resident #116's medical record revealed the resident was admitted to the facility on [DATE] with skilled therapy services scheduled to end on 02/19/16. Resident #116 remained in the facility and received a Notice of Medicare Non-Coverage (CMS form ) but did not receive the Skilled Nursing Facility Advance Beneficiary Notice (CMS form ) as required. Review of Resident #135's medical record revealed the resident was admitted to the facility on [DATE] services with physical therapy and occupational therapy services scheduled to end on 08/15/16. Resident #135 remained in the facility and received a Notice of Medicare Non-Coverage (CMS form ) but did not receive the Skilled Nursing Facility Advance Beneficiary Notice (CMS form ) as required. Interview on 08/16/16 with Licensed Social Worker (LSW) #231 revealed Resident #23, #55, #95, #116 and #135 received skilled services with Medicare insurance and remained in the facility. LSW #231 confirmed all five residents did not receive the appropriate liability notices as noted above.

Based on record review and interview the facility failed to ensure weights were obtained for Resident #133 to monitor for weight loss according to physician orders. This affected one resident (Resident #133) out four residents reviewed for nutrition. Finding Include: Record review revealed Resident #133 was admitted to the facility on [DATE]. On 04/17/16 he was sent to the emergency department and then admitted for [MEDICAL CONDITION] and metabolic [MEDICAL CONDITION]. He returned to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/04/16 revealed the resident had severe cognitive impairment. He was not experiencing any depression and he had no potential indicators of [MEDICAL CONDITION]. His functional assessment for this date revealed he required extensive assistance of one person for all activities of daily living except for eating. For eating he just needed supervision. Resident #133 was being followed by the dietician due to weight loss. The resident upon admission weighed 185 pounds and by August 2 of 2016 he weighed 159 pounds. He was receiving supplement including health shakes three times a day and Prostat twice a day. When his weight loss started at the end of May the physician ordered weekly weights for 4 weeks. Review of his weight log showed that he did not have his weight taken as ordered. This order was written on 05/24/16 and review of the weight log showed that he did not receive a weight for the week of June 6th or for the week of June 20th, 2016. Interview with the director of nursing (DON) held on 08/17/16 at 2:00 P.M. verified that the weights were not done according to the physician's orders [REDACTED].

Based on record review and interview, the facility failed to ensure Resident #19's fall care plan was updated to accurately reflect current physician orders. This affected one resident (Resident #19) of four residents reviewed for falls. Findings include: Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #19's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited intact cognition. Review of Resident #19's physician orders [REDACTED]. Review of Resident #19's Fall Care Plan revealed an intervention dated 05/25/16 for a Dycem to the resident's recliner. Interview on 08/18/16 at 10:31 A.M. with Licensed Practical Nurse (LPN) #230 confirmed Resident #19's fall care plan was not updated timely and did not accurately reflect the resident's physician orders [REDACTED].

Based on observation, record review and interview, the facility failed to ensure appropriate supervision was provided for Resident #19 when transferring and toileting the resident. The facility also failed to ensure fall interventions were implemented as planned for Resident #19 and Resident #75. This affected two residents (Residents #19 and #75) of four residents reviewed for falls. Findings include: 1. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #19's fall risk assessment dated [DATE] indicated the resident was at risk for falls. Review of Resident #19's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited intact cognition. Review of Resident #19's MDS 3.0 assessment dated [DATE] indicated the resident required extensive two person assist for transfers and extensive two person assist for toilet use. Review of Resident #19's physician orders [REDACTED]. Observation on 08/17/16 at 11:55 A.M. revealed Resident #19 was in his wheelchair in the hallway. A Dycem was not on Resident #19's wheelchair. Interview on 08/17/16 at 11.58 A.M. with State tested Nursing Assistant (STNA) #227 revealed a Dycem was not on Resident #19's wheelchair. Interview on 08/17/16 at 12:03 P.M. with Licensed Practical Nurse #228 confirmed Resident #19 did not have a Dycem placed on his wheelchair and the resident was in the hallway self-propelling in the wheelchair. 2. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #19's Fall Risk assessment dated [DATE] indicated the resident was at risk for falls. Review of Resident #19's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited intact cognition. Review of Resident #19's MDS 3.0 assessment dated [DATE] indicated the resident required extensive two person assist for transfers and extensive two person assist for toilet use. Review of Resident #19's fall care plan revealed an intervention dated 05/25/16 which indicated the resident may need the assistance of two staff members with transfers because the resident sometimes pushed back when transferring, making it difficult for just one person. Review of Resident #19's Nurse Aide Kardex indicated Resident #19 required a two person extensive assist with transfers with the use of a gait belt (safety device used for transfers). The resident would resist transfers and push back at times. Review of Resident #19's medical record revealed a progress note dated 06/12/16 at 10:38 P.M. indicating at approximately 7:10 P.M. the State tested Nursing Assistant (STNA) was assisting Resident #19 to the toilet and the resident changed direction mid turn and grabbed the other rail of the toilet riser. The toilet riser tipped and the resident fell to the floor and landed on his buttocks. Resident #19 obtained a superficial abrasion to his back from the shelf under the counter. Review of Resident #19's medical record revealed a progress note dated 07/01/16 at 12:01 P.M. indicating Resident #19 was noted to be sitting on the floor directly in front of his wheelchair. Resident #19's legs were bent up against the wheelchair foot rests and a gait belt was on the resident but loose. The STNA indicated Resident #19's legs buckled when the aide told the resident to sit down and the locked wheelchair moved. No injuries were noted. Interview on 08/18/16 at 10:03 A.M. with STNA #229 confirmed Resident #19 was transferred to his wheelchair after morning care on 08/18/16 with a one person assist and a gait belt. STNA #229 was unaware Resident #19 was a two person assist for transfers and toileting. Interview on 08/18/2016 at 10:06 A.M. with the Director of Nursing (DON) revealed she was aware Resident #19 required a two person assist with transfers and toileting and confirmed the staff did not provide the appropriate assistance with transfers and toileting the resident. The DON indicated staff education was to be provided. Also, the DON revealed the nursing assistants from Resident #19's falls on 06/12/16 and 07/01/16 were not interviewed to determine why the resident was transferred with a one person assist. The DON indicated a complete and accurate investigation including interviews of the care staff related to Resident #19's falls on 06/12/16 and 07/01/16 was not performed and the investigative notes were shredded and not available. Review of the facility Post Fall Procedure dated 06/2015 indicated the nurse would complete a fall investigation form and obtain interview statements from any staff. 3. Record review revealed Resident #75 was admitted to the facility on [DATE]. She was discharged home and then returned on 09/14/15. Record review revealed the resident was disoriented and had anxiety with inability to redirect away from unsafe and disruptive behaviors. Her admitting [DIAGNOSES REDACTED]. Review of the MDS 3.0 assessment, dated 05/22/16 revealed the resident had severe cognitive impairment. She was experiencing minimal depression and had no potential indicators of psychosis. Her functional assessment for this date showed that the resident needed extensive assistance of two people for bed mobility, transfers, locomotion off the units, and toilet use. She needed extensive assistance of one person for, locomotion on the unit, and personal hygiene. Resident #75 was totally dependent on staff for locomotion off the unit with a one person assist. Review of her care plan for falls revealed the resident was to be wearing her glasses everyday while awake. Observation of Resident #75 on 08/16/16 revealed she was involved in activities in the common area. The resident did not have her glasses on. At this time the resident was attempting to paint ornaments. A second observation of this resident on 08/18/16 at 8:45 A.M. revealed the resident being assisted into her wheelchair by STNA #40. When the resident was being wheeled out of the room the STNA was asked if the resident had normal vision or if she wore glasses. The STNA stated she really did not know since she was a float and rarely worked on this unit. The resident was then positioned in the dining room for breakfast. Interview with the lead STNA, STNA #41 on 08/18/16 at 8:50 A.M. in the dining room, verified the resident did not have her glasses on.

Based on observation, record review and interview, the facility failed to implement interventions as indicated in the physician order. This affected one (Resident #85) of three residents reviewed for pressure ulcers. The facility census was 87. Findings include: Review of Resident #85's medical record revealed the resident was admitted to the facility on [DATE] and dicharged home on 03/24/16 with [DIAGNOSES REDACTED]. Review of Resident #85's admission nurse progress note dated 02/12/16 at 10:46 P.M. indicated the resident had a reddened buttock and a open area to the lower crack of the buttock measuring 0.5 centimeters (cm) by 0.5 cm by 0.5 cm. Review of Resident #85's physician orders [REDACTED]. Review of Resident #85's Treatment Administration Record (TAR) from 02/12/16 to 03/24/16 revealed the order dated 02/12/16 for a duoderm to the right buttock to be changed every Wednesday was not placed on the TAR and was not implemented by the facility staff. Interview on 04/08/16 at 10:55 A.M. with Licensed Practical Nurse (LPN) #8 indicated Resident #85's TARS and physician orders [REDACTED].#8 confirmed the order for the duoderm was not placed on the TAR and was not implemented by facility staff. This deficiency substantiates Complaint Number OH 389.

Based on record review and interview, the facility failed to provide sufficient staffing levels to assure resident receive appropriate care and treatment. This affected one (Resident #74) of 18 residents reviewed for shower completion and had the potential to affect 76 residents in the facility. Findings include: 1. Interview on 06/29/15 during the initial tour between 8:35 A.M. and 10:00 A.M. with Registered Nurse (RN) #20, Licensed Practical Nurse (LPN) #21, LPN #27 and RN #28 revealed there should be four State tested Nurse Aides (STNAs) on each floor or a total of eight STNAs for each shift. If staffing was short resident care suffered. Showers were missed, and other care was rushed. Review of the nursing staffing schedule for the 2:00 P.M. to 10:00 P.M. evening shift dated 06/15/15 revealed five STNAs for the entire shift and one additional STNA for the last two hours of the shift for the second and third floor. Review of the staffing schedule for the 2:00 P.M. to 10:00 P.M. shift dated 06/18/15 revealed four STNAs scheduled for the entire shift, one additional STNA scheduled for the first four hours of the shift and a second STNA scheduled for the last three hours of the shift for the second and the third floors. Review of the staffing schedule for the 2:00 P.M. to 10:00 P.M. shift dated 06/20/15 revealed three STNAs scheduled for the entire shift for the second and the third floors. Review of the staffing schedule for the 2:00 P.M. to 10:00 P.M. shift dated 06/21/15 revealed four STNAs for the entire shift for the second and the third floors. 2. Interview on 06/29/15 between 9:42 A.M. and 9:46 A.M. with Residents #7 and #42 revealed residents sometimes wait as long as 30 minutes for their call light to be answered and there wasn't enough staff to provide care in an unhurried manner. Review of Resident Council Meeting Minutes dated 03/04/15 revealed a resident felt there was a staffing shortage of State tested Nurse Aides (STNAs). The Meeting Minutes dated 03/27/15 revealed a concern with call lights being answered in a timely manner and the Meeting Minutes 05/29/15 revealed an issue with call light response time. 3. Interview on 06/29/15 at 2:35 P.M. with Resident #74 's spouse revealed the resident did not receive a shower on 06/15/15 and 06/25/15. The spouse said that both days there were only two STNAs working on the evening shift. Review of the shower sheets used to document shower delivery and skin integrity revealed Resident #74 had no shower sheets dated 06/15/15, 06/18/15 or 06/25/15. Interview with the Director of Nursing (DON) on 06/29/15 at 4:40 P.M. verified the staffing schedules dated 06/15/15, 06/18/15, 06/20/15 and 06/21/15 for the 2:00 P.M. to 10:00 P.M. shift were not fully staffed with STNAs. The DON verified there were no shower sheets for Resident #74 on 06/15/15, 06/18/15 and 06/25/15. This deficiency substantiates Complaint Number OH 510.

Based on observation, interview, and record review, the facility failed to ensure Resident #56, who fell at the facility and fractured his elbow, had his elbow elevated according to the physicians order. These concerns affected one of 37 residents reviewed. Findings include: 1. Review of a physican order dated 05/26/15 for Resident #56 revealed to keep left hand elevated above the heart at all times with two to three pillows. Review of the treatment administration record (TAR) for June 2015 revealed the TAR for the order was not signed off for 06/02/15, 06/03/15 or 06/04/15. Review of the State tested Nurse Aide (STNA) assignment sheet and care plan revealed there was no evidence the order was implemented. On 06/03/15 at 10:22 A.M., Resident #56 was observed in the common area in the wheelchair with the left arm in a cast and the cast was laying on the resident's lap. On 06/03/15 at 11:00 A.M. STNA #51 verified the resident's cast was resting on his lap and not elevated as ordered. STNA #51 verified she was not aware the resident's arm was to be elevated. On 06/03/15 at 11:10 A.M., interview with STNA #52 verified the resident's left arm was not elevated and was laying on his lap. STNA #52 verified she was not aware the resident had an order to elevate his left arm. On 06/04/15 at 8:30 A.M., the resident was observed in bed with his arm not elevated. On 06/04/15 at 2:15 P.M., the resident was observed in the wheelchair with his cast resting on his lap. On 06/04/15 at 2:20 P.M., interview with Licensed Practical Nurse (LPN) #60 verified the resident's cast was resting on the resident's lap. LPN #60 was not aware the resident had an order to elevate his arm. LPN #60 and the surveyor observed the resident's left arm and there was bruising at the top of the cast throughout the underarm and the resident's hand was very swollen.

Based on observation, interview and record review, the facility failed to ensure a resident's fall interventions were implemented. This resulted in Actual Harm to Resident #56 who fell and sustained a fractured elbow. This affected one (Resident #56) of three residents reviewed for falls. Findings include: Review of the medical record revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, required limited assistance of one person for bed mobility, extensive assistance of one person for toileting, balance was not steady and the resident had limitations in function range of motion on both sides. Review of a typed summary, not dated or signed, provided by the restorative nurse, Licensed Practical Nurse (LPN) #70, revealed the resident sustained [REDACTED]. There was no documented evidence in the medical record the resident sustained [REDACTED]. Review of the falls communication board dated 04/13/15 revealed frequent checks, redirect out of the room, monitor for unassisted ambulation each shift was to sign off and the form was incomplete. Review of the physicians order dated 04/14/15 revealed toilet riser and grip strips to bathroom floor. Review of the falls care plan, initially developed on 05/15/15, revealed to ensure the call light was within reach, bed in low position and locked, one assist with transfers due to poor balance, grip strips to the bathroom floor and ensure the walker was within reach and in good repair. Resident was non ambulatory at times. The care plan was updated 05/27/15 to included resident needed increased assist with activities of daily living and transfers because of his recent cast on the left arm and ensure resident was in the nursing area when out of bed. The care plan was updated 06/02/15 to include dycem to the seat of the recliner and wheelchair and assist resident to common areas into comfort chair. Review of the nursing notes dated 05/25/15 at 2:37 P.M., revealed the resident was found on the floor in the doorway of his room laying on the left side, and yelling out at any movement stating, my shoulder hurts. Blood noted to left arm. The resident was sent to the hospital for evaluation. There was no documented evidence if any interventions were in place. Review of a typed summary, not dated or signed, provided by LPN #70 revealed the resident had poor balance prior to the fall and was attempting to stand and walk unassisted during the night. There was no evidence the staff put any interventions in place prior to or after the fall. Review of the falls communication board dated 05/25/15 revealed assist with ambulation due to cast from fractured elbow and encourage out of room. The sheet was not signed off as implemented by staff. Review of the nursing notes dated 05/30/15 at 5:30 P.M., revealed the resident was found sitting on his buttocks on the floor near the recliner. The resident stated he attempted to toilet himself and slid out of the chair. Review of a typed summary, not dated or signed, provided by LPN #70 revealed it reiterated the above nursing note and indicated to add a dycem to the recliner and wheelchair. Review of the falls communication board dated 05/30/15 revealed assist to common areas in comfort chair, and dycem to chair. The sheet was not signed off as implemented by staff. Review of the physicians order dated 05/30/15 revealed dycem to wheelchair. On 06/03/15 at 10:15 A.M., the resident's room was observed to be carpeted, bed was against the wall, no dycem was on the recliner chair and no grip strips were on the bathroom floor. On 06/03/15 at 10:22 A.M., the resident was observed in an activity in the wheelchair. The resident kept repeating to the activities person, I can't stay awake, I am tired. The resident was not wearing his glasses. After the activity at 10:30 A.M., all other residents and staff left the area and the resident attempted to move the wheelchair and was unsuccessful until staff returned at 10:55 A.M. On 06/03/15 at 11:00 A.M., interview with State tested Nurse Aide (STNA) #51 revealed Resident #56 had recent falls and the intervention was a dycem in the seat of the wheelchair. When questioned about how she monitored the resident she did not indicate to keep the resident near the nursing station or to have frequent checks on the resident. STNA #51 stood the resident up from the wheelchair and there was a dycem on top of the removable cushion but not between the cushion and the plastic seat of the wheelchair. STNA #51 went to the resident's room and verified there were no grip strips on the bathroom floor. On 06/03/15 at 11:05 A.M., interview with Resident #56 verified he fell and broke his elbow when he was standing at the sink. He stated he just fell and did not remember what happened. On 06/03/15 at 11:10 A.M., interview with STNA #52, who was the resident's STNA that day, verified she knew all the residents very well. She did not indicate Resident #56 was to have frequent checks or be kept out of his room. On 06/03/15 at 3:50 P.M., interview with LPN #70 and the Director of Nursing (DON) verified there was no falls care plan prior to 05/15/15 despite Resident #56 sustaining a fall on 04/13/15. The DON verified there was no documented evidence of the 04/13/15 fall in the medical record. The DON verified there were no post fall assessments completed after any of the resident's falls on 04/13/15, 05/25/15 and 05/30/15. The DON verified all fall documentation was in the computer system. The DON verified a quality assurance summary was conducted but not part of the medical record and it was not able to be provided to the surveyor. LPN #70 verified there were no grip strips on the resident's bathroom floor because the resident's room was changed on 04/22/15 and no one applied them to the new room. The DON verified the resident was ambulatory at times but needed assistance from the staff for safety and the staff tried to redirect him but because of his behaviors and dementia to was unsuccessful. The DON verified he was non ambulatory after the 05/25/15 fall when the resident fractured his left elbow. The DON verified there was no documented evidence the staff had more frequent monitoring of the resident because there was no federal regulation for this. LPN #70 verified the above typed summaries provided to the surveyor were just developed for the surveyor. There were no witness statements or other documentation available to ensure any of the interventions were in place at the time of the falls including the call light, the grip strips to the bathroom floor, the walker within reach, frequent monitoring, or keeping the resident in the common area. There was no documented evidence of the resident's location prior to the falls to determine the most appropriate interventions and there was no re-assessment after the falls to ensure the interventions were in place. On 06/04/15 at 8:30 A.M., the resident was observed in bed with the call light out of reach and the wheelchair positioned up next to the bed turned toward the resident. On 06/04/15 at 12:10 P.M., interview with the DON and the Administrator verified all the above concerns and that they had no additional documentation to provide the surveyor.

Based on interview and record review, the facility failed to ensure a resident who was diagnosed with [REDACTED]. Actual Harm occurred when Resident #75, who had a history of [REDACTED]. Emergency transport was called and the resident was transported to the hospital and admitted with [DIAGNOSES REDACTED]. This affected one (Resident #75) of two residents reviewed for dehydration. The facility also failed to monitor the fluid intake of a resident on fluid restriction. This affected one (Resident #12) of five residents reviewed for weight loss since admission. Findings include: 1. Review of the closed medical record of Resident #75 revealed the annual history and physical summary dated [DATE] and signed by the physician revealed Resident #75 did not have a [DIAGNOSES REDACTED]. Review of the sodium level dated [DATE] revealed high at 152 (normal range 135 to 145 milliquivelants per liter). Review of the physician orders [REDACTED]. Review of the [DATE] Medication Administration Record [REDACTED]. Review of the sodium level on [DATE] was high at 149, on [DATE] was 145, and on [DATE] was high at 149. There were no further sodium levels until [DATE]. Review of Resident #75's nutrition assessments dated [DATE] and [DATE] revealed no mention of history of high sodium levels or interventions to monitor for the increased sodium levels. Review of the nursing notes from [DATE] through [DATE] revealed there was no mention of Resident #75's fluid restriction, fluid intake or sodium levels. Review of the monthly signed physicians order for [DATE] revealed to initiate 240 ml of oral fluids with meals and in between meals. Review of the [DATE] Medication Administration Record [REDACTED]. Review of the nurse practitioner's order dated [DATE] at 6:00 P.M., revealed to obtain an influenza swab, monitor vitals every eight hours for 48 hours, and obtain chest x-ray and chemistry panel. Review of the nursing notes dated [DATE] at 1:34 A.M., revealed the day shift nurse had reported the resident was not feeling well and orders were written for chest x-ray and blood work. Review of sodium level dated [DATE] revealed a critically high value of 160. Review of the telephone physician's orders [REDACTED]. Review of the telephone physician's orders [REDACTED]. Review of the telephone order dated [DATE] revealed give one more liter of 0.45 NS at 75 cc an hour tonight. Review of the sodium level dated [DATE] revealed a high level at 158. Review of the telephone order dated [DATE] revealed to discontinue the IV fluids and encourage oral fluids with meals. Review of the [DATE] sodium level revealed a high level at 155. There were no further sodium levels obtained until [DATE] when the sodium level was critically high at 175. Review of the nursing notes between [DATE] and [DATE] revealed there was no evidence or monitoring or assessing for dehydration. Review of the physicians order dated [DATE] revealed initiated hydration protocol for two weeks. Review of the [DATE] nutrition assessment revealed the electrolytes reflected fluid volume depletion. The resident was at risk for fluid volume depletion and additional fluids were being encouraged with the hydration protocol to provide additional 240 ml of fluid four times a day between meals. Review of the physicians' progress note dated [DATE] revealed there was no mention of sodium levels of the resident having recent critically high sodium levels. Review of the telephone order dated [DATE] revealed hydration protocol 240 ml between meals and at night. Review of the nurse practitioner note dated [DATE] revealed the resident's oral mucosa appeared dry, and will begin hydration protocol. No sodium level was obtained. Review of the physician's progress note dated [DATE] revealed no mention of [MEDICAL CONDITION] or sodium levels. Review of the physician's progress note dated [DATE] revealed no mention of [MEDICAL CONDITION] or sodium levels. Review of the nursing notes between [DATE] and [DATE] did not indicate any monitoring for hydration status. Review of the telephone physician's orders [REDACTED]. Review of the sodium level dated [DATE] revealed a critically high level at 174. Review of the telephone physician's orders [REDACTED].#75 sent to the hospital. Resident #75 was admitted to the hospital, returned to the facility on [DATE], and expired on [DATE]. On [DATE] at 11:30 A.M., interview with Assistant Director of Nursing (ADON) #1 verified there was no documented nursing notes besides what was in the computer and no further assessments of sodium levels were available. On [DATE] at 8:30 A.M., interview with the DON verified there was no further documentation available and verified the above documentation. 2. Review of the medical record revealed Resident #12 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nursing notes dated [DATE] revealed the resident was admitted from the hospital with a [MEDICAL CONDITION] and had an indwelling urinary catheter. Review of the [DATE] nutrition assessment, written by Registered Dietician (RD) #30, revealed the resident was known to the RD from a previous admission. The resident had [MEDICAL CONDITION] (swelling). The assessment indicated health shakes three times a day with all meals would be initiated in an effort to increase intake. Review of the [DATE] nutrition assessment revealed Resident #12 was discharged to the hospital on [DATE] with fluid loss noted. Review of the nutrition assessment dated [DATE] revealed the resident's daughters took shifts to assist with most meals, and the facility would initiate chocolate health shakes three times a day with meals and add four ounces of 2Cal HN supplement twice a day at medication pass. Review of the physician's orders [REDACTED]. Review of the clarification order dated [DATE] revealed a breakdown of 1080 ml for dietary and 420 ml for nursing (240 ml 1st shift and 180 ml 2nd shift). Review of an undated State-tested Nurse Aide (STNA) assignment sheet, revealed the resident was on a fluid restriction of 360 ml each meal and report intake to the nurse. On [DATE] at 11:30 A.M., interview with ADON #1 revealed she thought the nurse documented hydration on the Medication Administration Record [REDACTED]. She was responsible for monitoring the input in care tracker. She said if the residents don't consume 100%, she monitored to see how their intake was. The ADON could not verify any guidelines for monitoring for dehydration or any documentation of her monitoring the resident's fluid restriction. On [DATE] at 2:00 P.M., interview with RD #30 verified the resident had alot of [MEDICAL CONDITION] from [MEDICAL CONDITIONS]. RD #30 verified the team asked the physician if the fluid restriction could be discontinued because of the resident's increased oral intake but the physician insisted he wanted to continue the fluid restriction because of the [MEDICAL CONDITION] and the resident's fluid overload. On [DATE] at 8:45 A.M., interview with Dietary Aide #32 verified Resident #12's meal ticket did not indicate a fluid restriction but refered to the list on the board which indicated the resident was on a fluid restriction. The breakfast meal ticket indicated 120 ml of orange juice, a large health shake 240 ml and another 120 ml drink. Dietary Aide #32 verified the limit for breakfast was to be 360 ml but the ticket would provide 480 ml. On [DATE] at 9:30 A.M., the resident was observed in her room eating breakfast and had drank all her liquids. A 600 ml water pitcher was full at her bedside. The resident did not know she was suppose to watch how much fluids she drank. On [DATE] at 9:35 A.M., interview with STNA #50 verified the resident drank all her liquids on her breakfast tray and verified she did not know the resident was on a fluid restriction. STNA #50 verified she filled the resident's 600 ml water pitcher up with water daily on day shift and did not document the intake from the water pitcher. On [DATE] at 9:38 A.M., interview with Licensed Practical Nurse (LPN) #60 verified she did not monitor the STNA's care tracker records or calculate the total daily fluid intake. On [DATE] at 12:10 P.M., interview with the DON and Administrator verified there was no documented evidence of monitoring Resident #12's fluid intake to ensure the resident did not receive over the 1500 ml restriction daily. The STNAs entered fluids in the care tracker and the nurses documented on the paper MAR but no one monitored or calculated the total intake. On [DATE] at 1:15 P.M., interview with Resident #12's daughter verified the resident was not on a fluid restriction and said they were trying to push fluids because of the resident's urinary tract infection. The daughter verified no one asked her how much fluids the resident took in and verified someone in the family was present during most meals.

Based on record review and interview, the facility failed to ensure staff transferred Resident #84 according to her plan of care. After an improper transfer Resident #84 was diagnosed with [REDACTED]. This affected one of five sampled residents. Facility census was 89. Findings include: Review of Resident #84's medical record revealed [DIAGNOSES REDACTED]. A comprehensive assessment dated [DATE] revealed Resident #84 required extensive assistance with two plus persons for transferring. A fall care plan dated 10/26/11 revealed Resident #84 needed the assistance of two persons for transferring. Nurse's notes dated 01/12/13 at 6:30 P.M. revealed when attempting to get Resident #84 out of bed, she was uncooperative and thrashing her legs about the bed. A nurse's note dated 01/12/13 at 6:50 P.M. revealed the nurse assessed Resident #84 and found her leg was swollen and had a bump. A nurse's note dated 01/12/13 at 7:00 P.M. revealed Resident #84 had a 10 centimeter (cm) x 8 cm swollen area below the right knee. Nurse's notes dated 01/12/13 at 10:00 P.M. revealed the area was "now bruising." Review of an x-ray report dated 01/13/13 revealed right proximal tibia and fibular fractures and soft tissue swelling. Review of State tested Nurse Aide (STNA) #2's interview statement dated 01/13/13 revealed on 01/12/13 at 6:30 P.M., after STNA #2 had transferred Resident #84 into a chair, Resident #84 said her leg felt like it was broke. STNA #2 observed a knot and swelling to the right lower leg. STNA #2 took Resident #84 to the nurse and reported the resident's complaint and the observation of the knot and swelling. Review of Licensed Practical Nurse (LPN) #4's interview statement dated 01/14/13 revealed STNA #2 reported Resident #84 was very uncooperative with getting out of bed. STNA #2 said that once she got Resident #84 into the wheelchair she noticed a bump on her leg and the resident said her leg was hurting. The nurse indicated there was a big bump but it was not red or bruised and there was no broken skin. The bump was hard to touch and painful to the resident while palpating. Observation and interview of Resident #84 on 01/31/13 at 12:20 P.M. revealed a long leg cast on the right leg. The cast was covering the right leg from the toes to the upper thigh just below the groin. Resident #84 was unable to say how her leg was injured or why the cast had been applied. Interview with LPN #5 and the director of nursing on 01/31/13 at 3:50 P.M. confirmed Resident #84's plan of care indicated she was a two person transfer. The DON also confirmed that on 01/12/13 at 6:30 P.M. Resident #84 was transferred with one staff. Immediately after the transfer Resident #84 was noted to have a knot, swelling and pain to the right lower leg. An x-ray completed on 01/13/13 revealed right tibia and fibular fractures. This deficiency was an incidental finding during the complaint investigation for #OH 701.