Every finding on record at Hickory Ridge Nursing & Rehabilitation Center

Based on observations, interviews and facility policy review, the facility failed to ensure clean food service areas. This had the potential to affect all residents who received meals from the kitchen. The facility did not identify any residents who received nothing by mouth. The facility census was 141.Findings include:Observation of the kitchen area on 01/05/26 between 8:14 A.M. and 8:35 A.M. with Dietary Manager (DM) #378 revealed the following that was verified at the time of discovery:- There were mold and dried liquid droplets on four out of four racks in reach-in #1.- There were mold and dried liquid droplets on five out of six racks in reach-in #1.- The shelf underneath the steam table had food residue, food crumbs and pieces of parchment paper.- The back splash of the mixer had dried batter on it.- In the dish area, the final rinse of the dish machine registered 169 degrees Fahrenheit (F). Dietary Aide (DA) #447 put a rack of plate lids that were not stacked appropriately to be washed on top of a rack of plastic bowls. DM #378 stated that racks should not be put on top of each other. Review of the facility policy titled, Infection Control- Dietary/Food Handling, dated 10/18/01, revealed the guidelines for the date preparation, handling and storage of perishable food and proper environmental cleaning. It also stated that the dish machine should have a final rinse of 180 degrees F and dishes should not be stacked one top of another.

Based on record review, observation, interview and facility policy review, the facility failed to honor preferences. This affected six residents (#9, #17, #71, #105, #106, and #129) out of six residents for beverage preferences. This had the potential to affect 141 residents who received meals from the facility. No residents were identified as receiving nothing by mouth (NPO). The facility census was 141.Findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 12/19/25. Diagnoses included fracture of the upper end of right tibia, muscle weakness, and osteoarthritis.Review of the care plan dated 11/20/25 for Resident #17 revealed there was a potential for alteration in nutrition due to diagnoses. Interventions included but not limited to providing diet as ordered and honoring preferences.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 had intact cognition and required supervision for eating and partial assistance for other activities of daily living. Review of the physician's orders for January 2026 revealed that Resident #17 was ordered a regular diet with regular texture and thin liquids with double entrees all meals, eggs, grits, and meat related to at risk for malnutrition. Review of Resident 17's breakfast dietary ticket revealed that he was to receive eight ounces of orange juice.Interview on 01/05/26 at 2:17 P.M. with Resident #17 revealed that the portions sizes were not correct, especially at breakfastObservation on 01/06/26 at 8:06 A.M. of Resident #17's breakfast tray revealed that he did not receive orange juice for breakfast. This was verified at time of observation with Certified Nursing Assistant (CNA) #350.2. Review of the medical record for Resident #9 revealed an admission date of 08/26/20 with a readmit date of 02/01/24. Diagnoses included anxiety disorder, schizoaffective disorder, and osteoarthritis.Review of the care plan dated 09/01/20 with a most recent revision date of 11/11/25 for Resident #9 revealed there was a potential for alteration in nutrition due to diagnoses. Interventions included but not limited to providing diet as ordered and honoring preferences.Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #9 had intact cognition and was dependent on staff for eating.Review of the physician's orders for January 2026 revealed Resident #9 was ordered a regular diet with pureed texture and thin liquids. Review of Resident 9's breakfast dietary ticket revealed that she was supposed to get orange juice and coffee.Observation on 01/06/26 at 8:13 A.M. of Resident #9's breakfast tray revealed that she did not receive orange juice or coffee. This was verified at time of observation with CNA #350.3. Review of the medical record for Resident #71 revealed an admission date of 03/30/16 and a readmission date of 09/23/16. Diagnoses included anorexia, vascular dementia, and major depressive disorder.Review of the care plan dated 04/03/16 with the most recent revision date of 10/31/25 for Resident #71 revealed there was a potential for alteration in nutrition due to diagnoses. Interventions included but not limited to providing diet as ordered, honoring preferences, and nutrient dense foods offered at meals.Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #71 had severely impaired cognition and required supervision for eating and substantial assistance activities of daily living. Review of the physician's orders for January 2026 revealed that Resident #71 was ordered a regular diet with regular texture and thin liquids diet with fortified cereal and fortified eggs at breakfast.Review of Resident 71's breakfast dietary ticket revealed that he was supposed to get orange juice.Observation on 01/06/25 at 8:14 A.M. revealed that Resident #71 did not get orange juice for breakfast. This was verified by CNA # 502 at time of observation.4. Review of the medical record for Resident #129 revealed an admission date of 08/06/19. Diagnoses included multiple sclerosis, chronic obstructive pulmonary disease and schizophrenia disorder.Review of the care plan dated 08/08/19 with the most recent revision date of 11/15/25 for Resident #129 revealed there was a potential for alteration in nutrition due to diagnoses. Interventions included but not limited to providing diet as ordered and honoring preferences.Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #129 had intact cognition and required supervision for eating and dependent on staff or other activities of daily living. Review of Resident #129's breakfast dietary ticket revealed that he was supposed to receive eight ounces of orange juice.Observation on 01/06/26 at 8:17 A.M. revealed that Resident #129 did not receive orange juice. This was verified by Licensed Social Worker (LSW) #372 at the time of the observation.5. Review of the medical record for Resident #105 revealed an admission date of 08/23/24. Diagnoses included metabolic encephalopathy, diabetes mellitus, and unspecified severe protein-calorie malnutrition. Review of the care plan dated 08/26/24 with the most recent revision date of 11/01/25 for Resident #105 revealed there was a potential for alteration in nutrition due to diagnoses. Interventions included but not limited to providing diet as ordered, honoring preferences, and nutrient dense foods offered at meals.Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #105 had slightly impaired cognition and required supervision for eating and was dependent on staff for activities of daily living. Review of Resident 105's breakfast dietary ticket revealed that he was supposed to get four ounces of orange juice.Observation on 01/06/25 at 8:22A.M. revealed that Resident #105 did not get orange juice for breakfast. This was verified by LSW #372 at the time of the observation.6. Review of the medical record for Resident #106 revealed an admission date of 05/17/17. Diagnoses included chronic atrial fibrillation, chronic obstructive pulmonary disease and nicotine dependence.Review of the care plan dated 05/25/17 with the most recent revision date of 09/09/25 for Resident #106 revealed there was a potential for alteration in nutrition due to diagnoses. Interventions included but not limited to providing diet as ordered and honoring preferences.Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #106 had intact cognition and required supervision for activities of daily living. Review of Resident 106's breakfast dietary ticket revealed that he was supposed to receive four ounces of orange juice.Observation on 01/06/26 at 8:28 A.M. revealed that Resident #106 did not receive orange juice. This was verified by Corporate Dietary Manager #500 at time of observation.Interview on 01/06/26 at 9:03 A.M. with Dietary Manager (DM) #378 revealed that there were two new employees on the tray line being trained and when they ran out of orange juice, they did not put another type of juice on the tray.Interview on 01/06/26 at 9:03 A.M. with Registered Diet Technician (DTR) #340 revealed that the average fluid amount per resident, who was not on a fluid restriction, was 1440 milliliters (ml) and the juice served at breakfast is equal to approximately 60 ml for four ounces.Review of the spreadsheet for breakfast on 01/06/26 revealed that residents were supposed to get four ounces of juice for breakfast. Review of the facility policy titled, Food First Program, dated 10/18, revealed that when managing the nutritional status of the resident, it is vital to obtain their preferences. Honoring their food and beverage preferences and incorporating them into the resident's diet is an effective intervention.This deficiency represents non-compliance investigated under Complaint Number 2628778.

Based on observation, interview, and facility policy review, the facility failed to ensure staff utilized appropriate hand hygiene during medication administration. This affected four residents (#27, #68, #105, and #116) out of eight residents observed for medication administration. The facility census was 141.Findings include:Observation on 01/08/26 from 8:23 A.M. to 8:39 A.M. of medication administration with Licensed Practical Nurse (LPN) #388 revealed the following: on 8:23 A.M. LPN #388 dispensed and administered medications to Resident #19 and did not complete hand hygiene after; LPN #388 then immediately dispensed and administered medications to Resident #27 and did not complete hand hygiene after; and then LPN #388 immediately dispensed and administered medication to Resident #105.An interview on 01/08/26 at 8:43 A.M. with LPN #388 verified the above findings. Observation on 01/08/26 from 8:45 A.M. to 9:11 A.M. of medication administration with LPN #435 revealed the following: LPN #435 dispensed and administered medications to Resident #137 and did not complete hand hygiene after; LPN #435 then immediately dispensed and administered a nutritional supplement to Resident #116 and did not complete hand hygiene after; and then LPN #435 then immediately dispensed and administered medications to Resident #68.An interview on 01/08/26 at 9:18 A.M. with LPN #435 verified the above findings. A review of the facility policy titled Medication Administration-General Guidelines for Medication Administration, dated 06/21/17, revealed medications were to be administered consistent with accepted standards of practice and hands were to be cleansed as appropriate.A review of the facility policy titled Hand Hygiene, dated 11/28/17, revealed hand hygiene was to be performed to prevent the spread of infection, staff were to perform hand hygiene when indicated, and hand hygiene was to be performed before and after resident contact.

Based on medical record reviews, observations, interviews, personnel file review, and employee handbook review, the facility failed to ensure resident respect and dignity was maintained when Certified Nursing Assistants (CNA) acted in an unprofessional manner while working in the facility. This affected two residents (Resident #01 and #85) out of eight residents reviewed for abuse. The facility census was 141.Findings include:Review of the medical record for Resident #85 revealed admission date of 08/25/22 with diagnoses including, but not limited to, unspecified dementia, alcohol dependence with alcohol-induced dementia, vascular dementia, anxiety, depression, insomnia, encephalopathy, and unspecified psychosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #85 had a Brief Interview Mental Status (BIMS) score of 09 indicating impaired cognition. The assessment indicated he could adequately hear, had clear speech, understood others, and had no behaviors noted. Review of Resident #85's care plan dated 09/26/22 for mood/behaviors revealed Resident #85 can refuse care at times and repetitively ask the same questions requiring assistance and cuing to perform activities of daily living (ADL). Review of the medical record for Resident #01 revealed admission date on 03/10/22 with diagnoses including, but not limited to, unspecified mood disorder, anxiety, post-traumatic stress disorder, and depression. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. The assessment indicated he could adequately hear, had clear speech, understood others, and had no behaviors noted. Review of Self-Reported Incident (SRI) #269286 from the facility on 01/01/26 revealed CNA #413 made inappropriate comments to Resident #85. The staff member was suspended but had no previous disciplinary actions. A head-to-toe assessment was completed with no negative findings. Resident #85 denied any physical contact with CNA #413. His guardian and doctor were notified of the incident. Interviews conducted with residents with BIMS of 09 or greater completed with no additional concerns identified. Assessments of residents with BIMS of less than 09 completed with no significant findings. Interviews with staff revealed no concerns. The staff was re-educated on the abuse policy. Review of the witness statement from CNA #413 on 01/01/26 revealed Resident #85 was extremely agitated most of the day. CNA #413 denied making any other derogatory statements to Resident #85 or any other residents. This statement was taken by the Administrator and originally had CNA #413 ' s first name with an incorrect last name. Review of the witness statement taken by the Administrator on 01/01/26 from Resident #01 (Resident #85 ' s roommate) for SRI #269286 revealed he had not heard any inappropriate statements and was only aware of the situation because Resident #85 had told him. Review of a hand-written witness statement by Licensed Practical Nurse (LPN) #392, dated 01/01/26, revealed she was sitting in the conference room having lunch and heard a loud commotion coming from the smoking area. LPN #392 went to investigate and saw CNA #413 standing in the doorway passing out cigarettes and screaming profanities. It was unclear who CNA #413 was yelling at. She stated the situation then settled down. LPN #392 did not hear her making specific threats toward any patients, only cursing. Review of a typed witness statement by LPN #392, dated 01/01/26, revealed she was sitting in the conference room with several staff having lunch when there was a commotion coming from the smoking area. Resident #85 was agitated yelling out. LPN #392 did not hear CNA #413 making any specific threats toward any residents. Review of a witness statement by LPN #386, dated 01/01/26, observed CNA #413 cursing and yelling near the common lounge area. CNA #413 was sent home by the supervisor for her behavior. Interview on 01/08/26 at 9:28 A.M. with Resident #85 revealed CNA #413 was very inappropriate and always mean to people. He stated during the smoke break on 01/01/26, CNA #413 stated to him that he had a very small dick and her husband ' s was bigger. Resident #85 stated she was swearing at him. Resident #85 indicated his roommate (Resident #01) overheard the statements made because he was right next to him during the smoke break. He stated there were no other staff present. Interview on 01/08/26 at 9:30 AM with Resident #01 revealed CNA #413 made inappropriate comments to Resident #85 including the size of his penis and was using profanities at him. Resident #01 indicated the comments were made at smoking break and no other staff were present. Interview on 01/08/26 at 9:39 A.M. with the Director of Nursing (DON) revealed CNA #413 was no longer employed by the facility but she was unsure why she was terminated. Interview on 01/08/26 at 10:14 A.M. with the DON revealed CNA #413 was terminated due to her lack of professionalism. Previously CNA #413 had disciplinary action for professionalism so she was terminated due to this being her second offense. Interview on 01/08/26 at 1:46 P.M. with the Human Resources (HR) Director #370 indicated the DON was given the witness statements related to CNA #413 ' s termination. Observation and interview on 01/08/26 at 1:49 P.M. of the HR Director #370 speaking with the DON revealed the HR Director #370 revealed she had given the witness statements to the DON by placing them in her mailbox the previous day. The DON indicated the witness statements were given to Regional Director #503. Interview on 01/08/26 at 2:26 P.M. with CNA #348 revealed on 01/01/26 there was a commotion at the smoking door. She stated she had observed CNA #413 and two residents arguing. CNA #348 was unsure why CNA #413 was not sent home immediately after, but she did not leave the facility until 3:00 P.M. CNA #348 indicated the facility was short-staffed that day. CNA #348 indicated CNA #413 had been observed treating residents without respect and dignity in the past. Interview on 01/12/26 at 10:54 A.M. with the Administrator revealed when Resident #01 was interviewed the verbiage used was Resident #85 told Resident #01 about the situation. The Administrator stated it was a he said, she said situation. She stated she had never asked Resident #01 if he was present during the incident between Resident #85 and CNA #413. The Administrator indicated Resident #01 was cognitively intact. Interview on 01/12/26 at 10:54 A.M. with the Administrator verified it was documented on the SRI that CNA #413 had no previous disciplinary actions. After review with her with CNA #413 ' s employee file, she verified CNA #413 had a previous disciplinary action in her employee file dated 05/02/25 for arguing with another employee at the nurse ' s station and yelling on the floor. The Administrator indicated the reason it was documented on the SRI that way was due to CNA #413 not having disciplinary actions toward residents or their care. The Administrator revealed CNA #413 was not terminated due to the SRI allegation but due to her unprofessional behavior and profanities she was yelling at the smoking area. Interview on 01/12/26 at 11:14 A.M. with Regional Director #503 revealed CNA #413 was having a bad day, acting inappropriately, and was sent home early on 01/01/26. She stated that CNA #413 was displaying behaviors that the company would not tolerate so she was terminated. Regional Director #503 denied CNA #413 making any derogatory comments to Resident #85 but did admit to using profanities while on duty. Interview on 01/12/26 at 2:40 P.M. with LPN #384 revealed she was the charge nurse that weekend. LPN #384 revealed she was in the conference room eating and heard CNA #413 using profanities. She indicated there were residents out in the smoking area as it was smoke break. She stated she cannot remember which residents were in the smoking area, but it was multiple residents and were the normal smokers. LPN #384 revealed she could not hear who CNA #413 was specifically cursing at but when they arrived at the smoking door, CNA #413 calmed down. Interview on 01/12/26 at 2:44 P.M with LPN #386 revealed he was present in the facility on 01/01/25. LPN #386 indicated he was eating in the conference room when he heard a commotion from the smoking area. He stated CNA #413 was cursing but had calmed down when he got to the door. CNA #413 stated Mother [expletive] stated he was going to hit me. LPN #386 revealed Resident #85 had never made false accusations about staff. Interview on 01/14/26 at 9:30 A.M. with LPN #392 who was working in the facility on 01/01/26. She stated she was in the conference room near the 400-hall eating lunch and heard a loud noise that sounded like chaos and voices. She stated CNA #413 was in the doorway handing out cigarettes to residents and using profanities at someone in the smoking area. She was unsure who CNA #413 was speaking too. LPN #392 verified there were no residents having behaviors or noted to be agitated. She was unsure what residents were in the smoking area but stated it was the usual smokers. LPN #392 revealed she wrote a handwritten statement and was told by management it had been misplaced so she was asked to email another statement on 01/02/26. LPN #392 did not remember seeing Resident #85 in the smoking area during the incident and verified that her typed statement was inaccurate. Review of the emailed witness statement dated 01/06/26 from LPN #392 to LPN #339 revealed on 01/01/26 LPN #392 was sitting in the conference room with several other staff having lunch when there was a loud commotion from the smoking area. LPN #392 followed the nursing supervisor to check on the situation. CNA #413 was standing in the doorway, passing out cigarettes, and screaming profanities. LPN #392 was unsure who CNA #413 was screaming the profanities too. LPN #392 did not hear any specific threats toward any patients, only cursing. Review of the employee file for CNA #413 revealed she had a hire date of 12/09/24. CNA #413 had received her job description on hire which included for her to follow all resident rights and adhere to all facility policy and procedures. On 05/02/25 there was a disciplinary action form stating CNA #413 was arguing with the appearance of aggressive behavior or use of inappropriate, abusive or foul language towards or in the presence of a resident, employee or visitor. This was a final written warning. CNA #413 refused to sign the disciplinary action form. On 01/01/26 there was a disciplinary action form stating CNA #413 had been arguing with the appearance of aggressive behavior and use of foul language towards or in the presence of resident, employee or visitor. The CNA #413 was notified by phone of the termination by the Director of Nursing (DON) and HR Director #370. Review of the employee handbook, revised 06/15/23, revealed the facility has established certain rules, regulations and standards guiding employee behavior and conduct. Employees were expected to project a mature, professional and courteous attitude toward residents, visitors, and co-workers. The level of discipline given would be dependent upon the seriousness of the offense or performance concern. Class 2 work rule violations were considered serious. If they did not result in immediate termination, they would result in a final written warning for the first occurrence. Arguing, the appearance of aggressive behavior, or use of inappropriate abusive or foul language towards or in the presence of a resident, employee, or visitor is an example of class 2 work rule violations. This deficiency represents noncompliance investigated under Complaint Number 2645564.

Based on interview, medical record review, personnel file review, and policy review, the facility failed to implement their abuse protocol when an allegation of verbal abuse was reported to staff. This affected one resident (Resident #80) of seven residents reviewed for abuse. The facility census was 141. Findings Include: Resident #80 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, high blood pressure, atrial fibrillation, dementia without behavioral disturbance, anxiety disorder, high risk heterosexual behavior, major depressive disorder, and liver cell carcinoma. Review of the comprehensive Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #80 was cognitively intact and exhibited no behaviors. Review of the nursing notes revealed an Interdisciplinary Team (IDT) note dated 12/19/25 at 12:28 P.M. revealed Licensed Practical Nurse (LPN) #505 reviewed Resident #80's behaviors in the last 90 days included cursing at others, destructive behavior, public sexual act, delusions and grabbing. The resident last saw the Psychiatric Nurse Practitioner (PNP) #506 on 12/10/25. Review of PNP #506's evaluation dated 12/10/25 revealed Resident #80 was observed touching himself inappropriately during the interview, with audible rustling of his Depends noted and calling female staff derogatory names. The resident also had a recent episode of agitation with nursing staff who he felt were calling him names (pissy-ass), leading to cursing and behavioral issues. Review of the facility's Self Reported Incidents (SRI) to the state agency revealed no allegations of verbal abuse for Resident #80 dated 12/10/25 or 12/11/25. Interview with Resident #80 on 01/05/26 at 10:18 A.M. revealed he is scared of the aides as they call him abusive names. The resident said he told the nurse but they brush it off. The red head aide is mean to him and tells him everyone is going to die here. Interview with LPN #397 on 01/05/25 at 11:04 A.M. revealed Resident #80 was very sexually inappropriate with female staff. LPN #397 confirmed the resident does have a problem with the aides. LPN #397 said if you put your foot down and tell him his behavior is inappropriate the resident will agree and apologize. LPN #397 identified Certified Nurse Aide (CNA) #350 as the aide Resident #80 complained about. LPN #397 said she did not think CNA #350 would be verbally abusive towards him but she has heard CNA making comments but not about anyone specifically. LPN #397 said management is aware as far as she knows. Interview with the Administrator and the Director of Nursing (DON) on 01/13/26 at 11:15 A.M. revealed neither one was aware of the allegation of verbal abuse Resident #80 informed PNP #506 about on 12/10/25. The Administrator asked if the facility should file an SRI since they were just made aware of the concern and was advised to follow their policy regarding allegations of abuse. The Administrator confirmed PNP #506 had not advised them of her visit with Resident #80 and his allegation of verbal abuse. The Administrator said she believes PNP #506 emails the facility with a summary of her visits. The DON said the nurse practitioner notes do not show up on the daily summary of care report they receive for each day. Interview with Resident #80 on 01/13/26 at 1:30 P.M. revealed the red haired aide was nasty to him and called him names, tells him he stinks and that he is going to die here. The resident said he just saw her today as she was working. The resident said he will not talk to the aide anymore as she does not talk respectfully to him. Resident #80 said the nurses know about his concerns but was unaware if the Director of Nursing or the Administrator knew. Interview was conducted with the Administrator and the Regional Administrator (RA) #503 on 01/13/26 at 2:00 P.M. and they were informed of Resident #80's comments and the description of the aide involved had red hair and, according to Resident #80, was working today. The Administrator said they will file an SRI with the state agency, interview Resident #80, and suspend the aide pending an investigation if they are able to identify the person. The Administrator said the resident is known for his behaviors and this may be attention seeking behavior. The Administrator said she spoke with PNP #506 and educated her on the need to advise the facility when concerns are made by a resident. Interview with the Administrator and the DON on 01/13/25 at 3:30 P.M. revealed they had identified the aide Resident #80 had made his allegation of abuse against and identified her as CNA #350 and she was suspended pending investigation. Review of CNA #350's personnel file revealed a background check had been completed, her license was in good standing with the Nurse Aide Registry, reference checks were completed, and had received no disciplinary actions since she was hired in 2024. Review of the facility's SRIs revealed the facility filed an SRI on 01/13/26 regarding Resident #80's allegation of verbal abuse and had begun their investigation of the incident reported on 12/10/25. Review of the facility's Abuse, Neglect, Exploitation & Misappropriation of Resident Property policy, implemented on 11/21/16, revealed the facility will investigate all alleged allegations of abuse, neglect, and misappropriation. Staff are trained to report all allegations of abuse to administration upon hire and annually thereafter. The facility policy is to protect the resident from further abuse. All allegations will be reported to the state agency within two to twenty-four hours and complete the investigation within five days.

Based on medical record review, observations, interviews, and facility policy reviews, the facility failed to ensure a thorough investigation was completed for verbal abuse during a self-reported incident (SRI) investigation. This affected one (Resident #85) out of eight residents reviewed for abuse. The facility census was 141.Findings Include:Review of the medical record for Resident #85 revealed an admission date on 08/25/22 with diagnoses including, but not limited to, unspecified dementia, alcohol dependence with alcohol-induced dementia, vascular dementia, anxiety, depression, insomnia, encephalopathy, and unspecified psychosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #85 had a Brief Interview Mental Status (BIMS) score of 09 indicating impaired cognition.Review of SRI #269286 from the facility on 01/01/26 revealed Certified Nursing Assistant (CNA) #413 made inappropriate comments to Resident #85. The staff member was suspended but had no previous disciplinary actions. A head-to-toe assessment, pain assessment, and skin assessment was completed on 01/01/26 with no negative findings. Resident #85 denied any physical contact with CNA #413. His guardian and doctor were notified of the incident. Interviews conducted with residents with BIMS of 09 or greater completed with no additional concerns identified. Assessments of residents with BIMS of less than 09 completed with no significant findings. Interviews with staff revealed no concerns. Social services followed up and Resident #85 was at baseline for mood and behaviors. The staff was re-educated on the abuse policy. CNA #413 had no previous disciplinary actions and a valid CNA license. The facility unsubstantiated the abuse allegation. The discovery date of the allegation was 01/01/26 and the SRI was completed on 01/04/26.Review of the witness statement from CNA #413 on 01/01/26 revealed Resident #85 was extremely agitated most of the day. CNA #413 denied making any other derogatory statements to Resident #85 or any other residents. This statement was taken by the Administrator and originally had CNA #413's last name incorrect.Review of the witness statement taken by the Administrator on 01/01/26 from Resident #01 (Resident #85's roommate) for SRI #269286 revealed that he had not heard any inappropriate statements and was only aware of the situation because Resident #85 had told him.Review of a hand-written witness statement by Licensed Practical Nurse (LPN) #392, dated 01/01/26, revealed she was sitting in the conference room having lunch and heard a loud commotion coming from the smoking area. LPN #392 went to investigate and saw CNA #413 standing in the doorway passing out cigarettes and screaming profanities. It was unclear who CNA #413 was yelling at. She stated the situation then settled down. LPN #392 did not hear her making specific threats toward any patients, only cursing.Review of a typed witness statement by LPN #392, dated 01/01/26, revealed she was sitting in the conference room with several staff having lunch when there was a commotion coming from the smoking area. Resident #85 was agitated yelling out. LPN #392 did not hear CNA #413 making any specific threats toward any residents.Review of a witness statement by LPN #386, dated 01/01/26, observed CNA #413 cursing and yelling near the common lounge area. CNA #413 was sent home by the supervisor for her behavior. Review of the emailed witness statement from 01/06/26 from LPN #392 to LPN #339 revealed on 01/01/26 she was sitting in the conference room with several other staff members having lunch. She stated there was a loud commotion coming from the smoking area. LPN #392 followed the nursing supervisor to check on the situation. CNA #413 was standing in the doorway, passing out cigarettes, and screaming profanities. LPN #392 was unsure who CNA #413 was yelling at and then the situation calmed down. LPN #392 did not hear specific threats toward any patients, only cursing.Interview on 01/08/26 at 9:28 A.M. with Resident #85 revealed CNA #413 was very inappropriate and always mean to people. He stated during the smoke break on 01/01/26, CNA #413 stated to him that he had a very small dick and her husband's was bigger. Resident #85 stated she was swearing at him. Resident #85 indicated his roommate (Resident #01) overheard the statements made because he was right next to him during the smoke break. He stated there were no other staff present.Interview on 01/08/26 at 9:30 AM with Resident #01 revealed CNA #413 made inappropriate comments to Resident #85 including the size of his penis and was using profanities at him. Resident #01 indicated the comments were made at smoking break and no other staff were present.Interview on 01/08/26 at 1:46 P.M. with the Human Resources (HR) Director #370 revealed CNA #413's last name on her employee file was correct and not the SRI.Interview on 01/08/26 at 2:26 P.M. with CNA #348 revealed on 01/01/26 there was a commotion at the smoking door. She stated she had observed CNA #413 and two residents arguing. CNA #348 was unsure why CNA #413 was not sent home immediately after, but she did not leave the facility until 3:00 P.M. CNA #348 indicated the facility was short-staffed that day. CNA #348 indicated CNA #413 had been observed treating residents without respect and dignity in the pastInterview on 01/12/26 at 10:54 A.M. with the Administrator revealed CNA #413's last name was not correct on the SRI. It was documented on the SRI that CNA #413 had no previous disciplinary actions however she had a previous disciplinary action in her employee file. The Administrator indicated the reason it was documented on the SRI that way was due to CNA #413 not having disciplinary actions toward residents or their care. CNA #413 was not added as the perpetrator to the SRI due to an oversight. The Administrator indicated being unaware of Resident #85's roommate being present during the incident. When the roommate was interviewed the verbiage used was what Resident #85 told him. The Administrator stated it was a he said, she said situation and the roommate was not asked if he was present during the incident. Resident #85's roommate was cognitively intact. The Administrator indicated not being aware of the allegation made until approximately 8:00 P.M. on 01/01/26.Interview on 01/14/26 at 9:30 A.M. with LPN #392 revealed she worked at the facility on 01/01/26. She stated she was in the conference room near the 400 hall eating lunch and heard a loud noise that sounded like chaos and voices. She stated CNA #413 was in the doorway handing out cigarettes to residents and using profanities at someone in the smoking area. She was unsure who CNA #413 was speaking too. LPN #392 verified there were no residents having behaviors or noted to be agitated. She was unsure what residents were in the smoking area but stated it was the usual smokers. LPN #392 revealed she wrote a handwritten statement and was told by management it had been misplaced so she was asked to email another statement on 01/02/26. LPN #392 did not remember seeing Resident #85 in the smoking area during the incident and verified that her typed statement was inaccurate.Review of the employee file for CNA #413 revealed she had a hire date of 12/09/24. CNA #413 had received her job description on hire which included for her to follow all resident rights and adhere to all facility policy and procedures. On 05/02/25 there was a disciplinary action form stating CNA #413 was arguing with the appearance of aggressive behavior or use of inappropriate, abusive or foul language towards or in the presence of a resident, employee or visitor. This was a final written warning. CNA #413 refused to sign the disciplinary action form. On 01/01/26 there was a disciplinary action form stating CNA #413 had been arguing with the appearance of aggressive behavior and use of foul language towards or in the presence of resident, employee or visitor. The CNA #413 was notified by phone of the termination by the Director of Nursing (DON) and HR Director #370.Review of the employee handbook, revised 06/15/23, revealed the facility has established certain rules, regulations and standards guiding employee behavior and conduct. Employees were expected to project a mature, professional and courteous attitude toward residents, visitors, and co-workers. The level of discipline given would be dependent upon the seriousness of the offense or performance concern. Class 2 work rule violations were considered serious. If they did not result in immediate termination, they would result in a final written warning for the first occurrence. Arguing, the appearance of aggressive behavior, or use of inappropriate abusive or foul language towards or in the presence of a resident, employee, or visitor is an example of class 2 work rule violations. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 11/21/16, revealed the facility was to have evidence that all alleged violations of abuse are thoroughly investigated and to report the results of all investigations to the State Survey Agency within five working days of the incident.This deficiency represents noncompliance investigated under Complaint Number 2615601.

Based on observation, interview, and record review the facility failed to ensure safe smoking interventions were in place for Resident #106 and failed to ensure fall interventions were implemented at all times for Resident #16 and Resident #25. This affected three residents (Resident #16, Resident #25, and Resident #106) out of eight residents reviewed for accidents. The facility census was 141.1.Review of the medical record for Resident #106 revealed an admission date of 05/17/17. Diagnoses included but not limited to chronic atrial fibrillation, chronic obstructive pulmonary disease and nicotine dependence. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #106 had intact cognition and required supervision for activities of daily living. Review of the physician's orders for January 2026 revealed that Resident #106 was ordered to wear a fire-retardant apron when smoking for safety. Review of the care plan dated 08/26/21 with a revision date of 9/21/22 for Resident #106 revealed that a smoking apron must be worn when smoking. Observation on 01/05/2026 at 1:37 P.M. revealed Resident #106 was observed smoking in designated area. Resident #106 had a cigarette burn hole on his left pant leg and was not wearing a smoking apron. This was verified by Certified Nursing Assistant (CNA) #502 at time of observation. Observation on 01/05/26 at 1:39 P.M. revealed Resident #106 was propelling himself to the door with the cigarette hanging from his mouth. CNA #502 approached resident politely and took the cigarette from his mouth. CNA #502 stated that she told a nurse a while back but couldn't remember which one that he needed a smoking apron. Interview on 01/08/26 at 8:03 A.M. with Director of Nursing (DON) verified that Resident #106's physician's order and care plan stated that Resident #106 should wear a smoking apron. Review of the facility policy dated 11/23/11 with a most recent revision date of 10/21/22 revealed that the facility provides a safe and healthy environment for residents including safety as related to smoking. 2. Review of the medical record for Resident #25 revealed they were admitted to the facility on [DATE] with diagnoses that included stroke, dementia, epilepsy, unsteadiness on feet, chronic kidney disease, and weakness. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 used corrective lenses, was cognitively intact, required supervision or touching assistance for transfers, and had two or more falls since admission. Review of the physician orders revealed an order dated 09/10/25 for a pressure alarm to the wheelchair and for placement and function to be checked every shift. Review of the progress notes revealed on 09/08/25 Resident #25 had fallen when transferring from their wheelchair to the bedside commode and on 12/16/25 they had fallen out of their recliner while trying to pick up an item up from the floor. Review of the care plan revealed Resident #25 was at risk for falls due to weakness, impaired balance, and impaired cognition and the goal was to minimize risk factors related to falls with interventions that included a chair alarm. An observation on 01/08/26 at 9:26 A.M. revealed Resident #25 was in their wheelchair self-propelling in the room, and then the resident was visualized self-transferring from their wheelchair to the bedside commode. On observation of the transfer an alarm pressure pad and alarm speaker were visualized on the wheelchair. When Resident #25 transferred out of the wheelchair to the bedside commode the alarm did not sound. An interview on 01/08/26 at 9:28 A.M. with Licensed Practical Nurse (LPN) #383 revealed the wheelchair alarm should have sounded when Resident #25 transferred out of the wheelchair. LPN #383 checked the function of the wheelchair alarm and verified it was not disconnected; it was not turned off; it did not function correctly and should have sounded when the resident transferred out of the wheelchair. When LPN #383 assisted Resident #25 from the bedside commode to the wheelchair it was noted the left wheel lock for the wheelchair was broken and did not lock the wheel. LPN #383 verified the wheel lock did not function correctly. Review of the facility policy titled Fall Management, dated 10/17/16 revealed the facility would reduce the risk of falls and reoccurrence of falls by care plan development, implementation of interventions, and ongoing monitoring. 3. Review of the medical record for Resident #16 revealed they were admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, Parkinson's, dementia, repeated falls, weakness, unsteadiness on feet, and history of falling. Review of the physician orders revealed an order dated 12/11/25 for a call don't fall sign in the room. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #16 was cognitively intact, required supervision or touching assistance for transferring and ambulating, and had a history of falls prior to admission. Review of the fall risk assessment dated [DATE] revealed Resident #16 was at risk for falls due to three or more falls in the last 90 days, displayed cognition behaviors, ambulated with problems, and was unsteady transferring. Review of the care plan dated 12/12/25 revealed Resident #16 was at risk for falls related to Alzheimer's disease, Parkinson's, generalized weakness, dementia, and history of falling the goal was to minimize fall risk factors; interventions included analyze previous falls to determine pattern or trends, call don't fall sign to room, and to ensure the call light is within reach. Review of the fall investigation dated 11/08/25 revealed Resident #16 fell in their room while independently ambulating. It was noted that the call light was not in reach and a new intervention of a call don't fall sign was implemented. An observation on 01/07/25 at 10:56 A.M. revealed Resident #16 was sitting in their recliner near on the left side of the room nearest to the hallway. On observation it was noted the call light was clipped to the room divider curtain outside of Resident #16's reach and the absence of a call don't fall sign in the room. An interview on 01/07/26 at 11:05 A.M. with LPN# 384 revealed interventions for a resident that is at risk for falls could include a call don't fall sign, assistive devices in reach, and a call light in reach. LPN# 384 verified the absence of a call don't fall sign and that the call light was out of reach for Resident #16. An interview on 01/07/26 at 12:00 P.M. with the Director of Nursing (DON) revealed the facility doesn't not have a call light policy. A review of the Treatment Administration Record (TAR) from 01/01/26 to 01/07/26 revealed documentation that a call don't fall sign was in Resident #16's room. Review of the facility policy titled Fall Management, dated 10/17/16 revealed the facility would reduce the risk of falls and reoccurrence of falls by care plan development, implementation of interventions, and ongoing monitoring. This deficiency represents noncompliance investigated under Complaint Numbers 2645564 and 2637112.

Based on observation, interview, and record review, the facility failed to ensure proper diets were followed. This affected three residents (Residents #17, #71, and #106) out of five residents for nutrition. The facility census was 141.1. Review of the medical record for Resident #17 revealed an admission date of 12/19/25. Diagnoses included but not limited to fracture of the upper end of right tibia, muscle weakness, and osteoarthritis. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 had intact cognition and required supervision for eating and partial assistance for other activities of daily living. Review of the physician's orders for January 2026 revealed that Resident #17 was ordered a regular diet with regular texture and thin liquids diet with double entrees all meals, eggs grits and meat related to at risk for malnutrition. Review of the care plan dated 11/20/25 for Resident #17 revealed there was a potential for alteration in nutrition due to diagnoses. Interventions included but not limited to provide diet as ordered and honor preferences. Review of Resident 17's breakfast diet ticket revealed that he was on a regular diet with double meat/entree with sausage at breakfast. Interview on 01/05/26 at 2:17 P.M. with Resident #17 revealed that the portions sizes are not correct especially at breakfast. Observation on 01/06/26 at 8:06 A.M. of Resident #17's breakfast tray revealed that he did not receive double portions and no meat for breakfast. This was verified at time of observation with Certified Nursing Assistant (CNA) #350. Interview on 01/08/26 at 8:03 A.M. with Director of Nursing (DON) verified that Resident #17's physician orders for a regular diet with regular texture and thin liquids diet with double entrees all meals, eggs grits and meat related to at risk for malnutrition. 2. Review of the medical record for Resident #71 revealed an admission date of 03/30/16 and a readmission date of 09/23/16. Diagnoses included but not limited to anorexia, vascular dementia, and major depressive disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #71 had severely impaired cognition and required supervision for eating and substantial assistance activities of daily living. Review of the physician's orders for January 2026 revealed that Resident #71 was ordered a regular diet with regular texture and thin liquids diet with fortified cereal and fortified eggs at breakfast. Review of the care plan dated 04/03/16 with the most recent revision date of 10/31/25 for Resident #71 revealed there was a potential for alteration in nutrition due to diagnoses. Interventions included but not limited to provide diet as ordered, honor preferences, and nutrient dense foods offered at meals. Review of Resident 71's breakfast diet ticket revealed that he was on a regular diet with fortified cereal and fortified eggs. Observation on 01/06/25 at 8:14 A.M. revealed that Resident #71 did not get his fortified cereal for breakfast. This was verified by CNA # 502 at time of observation. Interview on 01/08/26 at 8:03 A.M. with DON verified that Resident 71's physician orders for a regular diet with regular texture and thin liquids diet with fortified cereal and fortified eggs at breakfast. 3. Review of the medical record for Resident #106 revealed an admission date of 05/17/17. Diagnoses included but not limited to chronic atrial fibrillation, chronic obstructive pulmonary disease and nicotine dependence. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #106 had intact cognition and required supervision for activities of daily living. Review of the physician's orders for January 2026 revealed that Resident #106 was ordered to a no added salt, mechanical soft texture and thin liquids diet with fortified cereal and fortified eggs at breakfast. Review of the care plan dated 05/25/17 with the most recent revision date of 09/09/25 for Resident #106 revealed there was a potential for alteration in nutrition due to diagnoses. Interventions included but not limited to provide diet as ordered and honor preferences. Review of Resident 106's breakfast diet ticket revealed that he was on a no added salt mechanical soft diet with fortified cereal and fortified eggs. Observation on 01/06/26 at 8:28 A.M. revealed that Resident #106 did not receive his fortified cereal. This was verified by Corporate Dietary Manager #500 at time of observation. Interview on 01/06/25 at 9:03 A.M. with Dietary Manager (DM) #378 revealed that there were two new employees on the trayline being trained and must have missed the fortified cereals. Interview on 01/08/26 at 8:03 A.M. with Director of Nursing (DON) verified that the Resident #106's physician orders for a regular diet with regular texture and thin liquids diet with fortified cereal and fortified eggs at breakfast. Review of the facility policy dated 10/18 titled, Food First Program, revealed that when managing the nutritional status of the resident, it is vital to obtain their preferences. Honoring their food and beverage preferences and incorporating them into the resident's diet is an effective intervention. This deficiency represents non-compliance investigated under Complaint Number 2674639.

Based on record review, observations and interviews, the facility failed to ensure respiratory equipment was maintained in a sanitary manner and oxygen orders were individualized to meet resident specific needs to reduce the risk of complications from variations in oxygen treatment. This affected two (Residents #127 and #136) of two residents reviewed for respiratory care with the potential to affect 20 residents who utilized oxygen. The facility census was 141.Findings include:1. Review of the medical record for Resident #127 revealed an admission date of 09/25/23 with diagnoses including dementia, chronic obstructive pulmonary disease (COPD) and protein-calorie malnutrition.Review of the care plan dated 09/28/23 for Resident #127 revealed she had respiratory deficiencies or abnormalities of pulmonary function related to COPD, allergic rhinitis and emphysema. She also had shortness of breath on exertion. Interventions included for staff to monitor lung sounds as ordered, monitor oxygen saturation as ordered, administer oxygen as ordered, respiratory assessments as ordered and to update the physician with any abnormal or new findings for possible evaluation or further treatment as ordered.Review of the care plan dated 02/27/25 for Resident #127 revealed she required oxygen related to COPD. The goal was to keep her oxygen level at the desired level as set per the physician. Staff were to administer oxygen as ordered, monitor oxygen saturation as ordered and observe for signs and symptoms of shortness of breath.Review of the physician's orders for Resident #127 revealed she had an orders related to respiratory function as follows:-Respiratory Therapy: Respiratory system observation, monitoring, and data collection of current respiratory deficiencies or abnormalities of pulmonary function: COPD, asthma, every day and night shit. Update the physician as needed based upon findings dated 04/17/25. Staff were to document the lung sounds, minutes assessed, temperature and oxygen saturation. -Check oxygen saturation every shift while on oxygen dated 04/28/25. -Change oxygen tubing/cannula/mask weekly every night shift on Sunday dated 05/04/25.-Vital signs weekly every day shift on Friday for monitor dated 11/21/25. Staff were to document the blood pressure, temperature, heart rate, respiratory rate and oxygen saturation.-Oxygen 0 to 5 liters per nasal cannula to maintain saturation of 90 percent (%) every shift dated 11/26/25. Staff were to document the liters of oxygen and oxygen saturation.Review of the Treatment Administration Record (TAR) for December 2025 revealed staff had documented Resident #127 received 8 liters of oxygen on nightshift on 12/10/25 and the oxygen liters were documented as not applicable on 12/28/25 on dayshift. Observation on 01/05/25 at 2:26 P.M. of Resident #136 revealed she was wearing the oxygen via a nasal cannula at 2 liters. The oxygen tubing had a whitish residue on the outside of the tubing. Resident #136 stated staff did not change the tubing very often.Interview on 01/05/26 at 2:29 P.M. with Licensed Practical Nurse (LPN) #397 verified Resident #136's oxygen tubing was not dated. She stated when she would change oxygen tubing and nasal cannulas she placed a date at the connector end that connected to the oxygen concentrator. She stated it was the facility's policy but there were staff who did not date it when changing the tubing.Observation on 01/07/26 at 9:09 A.M. of Resident #127 revealed she was on 3 liters of oxygen. The oxygen tubing was not dated to show the staff had changed the tubing or cannula per the weekly order. Interview on 01/07/26 at 9:11 A.M. with LPN #385 verified the oxygen tubing was not dated for Resident #127 and confirmed the whitish residue on the tubing. She stated she was educated on 01/06/26 nursing staff were not dating the oxygen tubing per their policy. LPN #385 stated she always dated the oxygen tubing and had ensured all of her oxygen tubing was dated on her unit on 01/06/26, however, LPN #339 had come to the unit and replaced all of the residents oxygen tubing to ensure none of the tubing was dated.Interview on 01/07/26 at 10:04 A.M. with the Director of Nursing (DON) revealed she was unsure why the oxygen orders for residents were noted to be between 0 to 5 liters and not an individualized order. She stated the facility policy did not state staff had to date the oxygen tubing when changing it as there was a physician order the nursing staff were signing off on.Interview on 01/07/26 at 12:00 P.M. with the DON revealed it was the facility's policy to place orders for all residents for oxygen at 0 to 5 liters to allow nursing judgement to titrate the oxygen and increase and decrease it as needed. She stated Medical Director (MD) #508 provided the orders. She stated Resident #127's TAR for 12/10/25 and 12/28/25 were probably errors in documentation.Interview on 01/07/26 at 2:35 P.M. was attempted with MD #508. There was no answer when he was called and voicemail message was left. There was no return contact made.Interview on 01/07/26 at 2:37 P.M. was attempted with Nurse Practitioner (NP) #507. There was no answer when she was called and voicemail message was left. There was no return contact made.Interview on 01/12/26 at 2:30 P.M. with LPN #388 stated she knew what oxygen liter each resident was on from the physician's orders. She stated the physician's order stated the exact liter of oxygen and she followed the order.Interview on 01/12/26 at 2:40 P.M. with LPN #384 verified the oxygen orders were in the electronic medical records. She stated nursing staff normally set the oxygen liters at 2 to 3 liters for each resident.Review of the facility policy titled, Respiratory Equipment Cleaning/Disinfection, revised on 07/30/24, revealed the facility would maintain respiratory equipment in a manner that prevents the spread of disease and infections. Staff were to change tubing weekly or as needed. Review of the facility policy titled, Oxygen Administration, revised on 07/30/24, revealed oxygen was to be administered to residents who needed it, consistent with professional standards of practice, comprehensive person-centered care plans and the residents' goals and preferences. Oxygen was to be administered under orders of a physician. Oxygen tubing and mask/cannula may be changed weekly and as needed if it became soiled or contaminated. The physician would be notified as needed for changes or complications associated with the use of oxygen.2. Review of the medical record for Resident #136 revealed an admission date of 07/02/23 with diagnoses including chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypercapnia (a buildup of too much of carbon dioxide in the blood), acute and chronic respiratory failure with hypoxia (low oxygen) and congestive heart failure.Review of the care plan dated 07/20/23 for Resident #136 revealed she had respiratory deficiencies or abnormalities of pulmonary function related to COPD, chronic respiratory failure and shortness of breath. Interventions included for staff to monitor lung sounds as ordered, monitor oxygen saturation as ordered, administer oxygen as ordered, respiratory assessments as ordered and to update the physician with any abnormal or new findings for possible evaluation or further treatment as ordered.Review of the care plan dated 07/20/23 for Resident #136 revealed she required oxygen related to COPD and chronic respiratory failure. The goal was to keep her oxygen level at the desired level as set per the physician. Staff were to administer oxygen as ordered, monitor oxygen saturation as ordered and observe for signs and symptoms of shortness of breath.Review of the physician's orders for Resident #136 revealed she had an orders related to respiratory function as follows:-Respiratory Therapy: Respiratory system observation, monitoring, and data collection of current respiratory deficiencies or abnormalities of pulmonary function: COPD, asthma, every day and night shit. Update the physician as needed based upon findings dated 07/28/25. Staff were to document the lung sounds, minutes assessed, temperature and oxygen saturation. -Check oxygen saturation every shift while on oxygen dated 07/28/25. -Change oxygen tubing/cannula/mask weekly every night shift on Tuesday dated 07/29/25.-Weekly vital signs on night shift on Thursday dated 11/06/25. Staff were to document the blood pressure, temperature, heart rate, respiratory rate and oxygen saturation.-Oxygen 0 to 5 liters per nasal cannula to maintain saturation of 90 percent (%) every shift dated 11/26/25. Staff were to document the liters of oxygen and oxygen saturation.Review of the Treatment Administration Record (TAR) for January 2026 revealed staff had documented they changed Resident #136's oxygen tubing on 01/06/26. Observation on 01/05/25 at 2:26 P.M. of Resident #136 revealed she was wearing the oxygen via a nasal cannula at 2 liters. The oxygen tubing had a whitish residue on the outside of the tubing. Resident #136 stated staff did not change the tubing very often.Interview on 01/05/26 at 2:29 P.M. with Licensed Practical Nurse (LPN) #397 verified Resident #136's oxygen tubing was not dated and had a whitish residue on the tubing. She stated when she would change oxygen tubing and nasal cannulas she placed a date at the connector end that connected to the oxygen concentrator. She stated it was the facility's policy but there were staff who did not date it when changing the tubing.Observation on 01/07/26 at 9:09 A.M. of Resident #127 revealed she was on 3 liters of oxygen. The oxygen tubing was not dated to show the staff had changed the tubing or cannula per the weekly order. Interview on 01/07/26 at 9:11 A.M. with LPN #385 verified the oxygen tubing was not dated for Resident #127. She stated she was educated on 01/06/26 nursing staff were not dating the oxygen tubing per their policy. LPN #385 stated she always dated the oxygen tubing and had ensured all of her oxygen tubing was dated on her unit on 01/06/26, however, LPN #339 had come to the unit and replaced all of the residents oxygen tubing to ensure none of the tubing was dated.Interview on 01/07/26 at 10:04 A.M. with the Director of Nursing (DON) revealed she was unsure why the oxygen orders for residents were noted to be between 0 to 5 liters and not an individualized order. She stated the facility policy did not state staff had to date the oxygen tubing when changing it as there was a physician order the nursing staff were signing off on.Interview on 01/07/26 at 12:00 P.M. with the DON revealed it was the facility's policy to place orders for all residents for oxygen at 0 to 5 liters to allow nursing judgement to titrate the oxygen and increase and decrease it as needed. She stated Medical Director (MD) #508 provided the orders. Interview on 01/07/26 at 2:35 P.M. was attempted with MD #508. There was no answer when he was called and voicemail message was left. There was no return contact made.Interview on 01/07/26 at 2:37 P.M. was attempted with Nurse Practitioner (NP) #507. There was no answer when she was called and voicemail message was left. There was no return contact made.Interview on 01/12/26 at 2:30 P.M. with LPN #388 stated she knew what oxygen liter each resident was on from the physician's orders. She stated the physician's order stated the exact liter of oxygen and she followed the order.Interview on 01/12/26 at 2:40 P.M. with LPN #384 verified the oxygen orders were in the electronic medical records. She stated nursing staff normally set the oxygen liters at 2 to 3 liters for each resident.Review of the facility policy titled, Respiratory Equipment Cleaning/Disinfection, revised on 07/30/24, revealed the facility would maintain respiratory equipment in a manner that prevents the spread of disease and infections. Staff were to change tubing weekly or as needed. Review of the facility policy titled, Oxygen Administration, revised on 07/30/24, revealed oxygen was to be administered to residents who needed it, consistent with professional standards of practice, comprehensive person-centered care plans and the residents' goals and preferences. Oxygen was to be administered under orders of a physician. Oxygen tubing and mask/cannula may be changed weekly and as needed if it became soiled or contaminated. The physician would be notified as needed for changes or complications associated with the use of oxygen.

Based on staff interviews, medical record review, and facility policy review, the facility failed to ensure a resident who required dialysis received ongoing assessments of condition before and after dialysis treatments. This affected one Resident (#14) of one resident identified as receiving dialysis. The facility census was 141.Review of the medical record for Resident #14 revealed an admission date of 06/19/19 and diagnoses including end stage renal disease (ESRD), diabetes mellitus, dependence on renal dialysis, morbid obesity, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF).Review of the plan of care dated 05/13/20 revealed Resident #14 received dialysis treatments three times per week for ESRD. It was noted Resident #14 frequently refused to go to dialysis treatments. Interventions included assist with transfer needs when going to dialysis, auscultate lung sounds as ordered, monitor for edema, check for new orders upon return from dialysis, send lunch with resident to dialysis, maintain communication with dialysis staff and physician, monitor labs, monitor shunt site for bleeding and signs/symptoms (s/s) of infection, monitor bruit and thrill, replace dressing as needed, and provide education regarding consequences of refusing dialysis.Review of physician's order dated 11/01/22 revealed order to check left arm arteriovenous (AV) fistula for bruit and thrill every shift.Review of physician's order dated 04/20/24 revealed Resident #14 had dialysis every Tuesday, Thursday, and Saturday at a location outside the facility. Resident #14's appointment time was 11:00 A.M.Review of Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #14 had a brief interview for mental status (BIMS) score of 15 indicating intact cognition. Resident #14 had no refusal behaviors noted on the assessment. Resident #14 received dialysis treatments.Further review of the medical record revealed no evidence of pre-treatment or post-treatment assessments related to dialysis treatments for Resident #14 were completed by the facility.Review of the dialysis center's communication forms from October 2025 to January 2026 revealed the center provided Resident #14's pre-treatment and post-treatment weights, blood pressure, temperature, and status/condition. The center also provided a list of medications administered while in center.Interview on 01/08/26 at 2:22 P.M. with Licensed Practical Nurse (LPN) #435 revealed she was Resident #14's regularly assigned nurse. LPN #435 stated Resident #14 had a binder he took with him to dialysis. LPN #435 stated she filled out a form with vitals and any s/s of pain or sickness. LPN #435 was unable to produce Resident #14's binder as he was at dialysis. LPN #435 was also unable to provide a sample of the form they filled out.Interview on 01/12/26 at 4:22 P.M. with Director of Nursing (DON) revealed she was unable to locate any assessments filled out by the facility pre and post treatment for Resident #14. DON confirmed the communication forms provided were completed by the dialysis center.Review of facility policy Dialysis Management dated 10/11/18 revealed the facility would assess monitor for complications, and provide adequate intervention in the management of those receiving dialysis based on physician orders and plan of care.This deficiency represents noncompliance investigated under Master Complaint Number 2712681.

Based on observation, interview, and record review the facility failed to ensure behavioral health interventions were implemented for Resident #45 with PICA (a mental health condition where a person eats things that aren't food). This affected one resident (Resident #45) out of three residents reviewed for behaviors. The facility census was 141. Findings include: Review of the medical record for Resident #45 revealed they were admitted to the facility on [DATE] with diagnoses that included diabetes mellitus type two, dementia with behavioral disturbance, hearing loss, anxiety disorder, peripheral vascular disease, and chronic kidney disease. Review of the physician orders from 12/01/25 to 01/07/26 revealed the absence of any orders to monitor Resident #45 for gastrointestinal (GI) symptoms related to PICA or to monitor Resident #45's physical environment for broken or damaged items that could be ingested. Review of the progress notes revealed the following: on 11/21/25 Resident #45 was documented as having [NAME] like behavior by Nurse Practitioner (NP) #507; on 12/28/25 Resident #45 was documented as having [NAME] like behavior by NP #507; on 12/29/25 at 6:12 P.M. Resident #45 was documented as eating the plastic rim off the bedside table and the resident was educated and redirected by nursing staff; on 12/29/25 at 6:13 P.M. Resident #45 spit out the plastic that was in his mouth and the request for a new tray table was initiated by nursing staff; and on 01/06/26 Resident #45 was seen by NP #506 due to [NAME] behaviors, [NAME] behaviors were likely related to progressive dementia, and nursing staff confirmed Resident #45 had been eating non-food items over the past year such as plaster from the wall and pulling items from their recliner. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #45 was moderately cognitively impaired, they did not have a change in behaviors, and they required supervision or touching assistance for activities of daily living. Review of the care plan revealed the following: Resident #45 has altered health maintenance related to mental status and disease process, the goal was to avoid injury, no interventions to monitor GI symptoms or monitor the physical environment for damaged items were noted; Resident #45 experienced alteration in mood or behavior as evidenced by picking at wall paper, wall lining, bedside tables and attempted to chew or eat furniture, the wall, and bedside table material. The goal was to display appropriate affect for the situation with an intervention for the bedside table to be removed except for meals, there was no intervention to monitor GI symptoms or the physical environment for damaged items that could be ingested; Resident #45 has altered cognitive function and has impaired decision making abilities the goal was for Resident #45 to make decisions on a consistent basis despite cognitive impairment with assistance as needed, there were no interventions to monitor for GI symptoms or monitor the physical environment for damaged items. An observation on 01/12/26 at 2:38 P.M. revealed Resident #45 was on their right side and was picking at the bed linen and mattress. Resident #45 was noted to be spitting phlegm on the hard plastic wall protector and then using their finger to move it around on the wall protector. An interview on 01/12/26 at 2:43 P.M. with Licensed Practical Nurse (LPN) #386 revealed they had witnessed Resident #45 picking at the wall, eating materials from the wall, and that the resident still attempts to pick at the wall. LPN #38 verified Resident #45 did not have orders or interventions to monitor GI symptoms or to monitor the physical environment for damaged items. An interview on 01/14/26 at 12:30 P.M. with the Administrator revealed the facility doesn't have a behavior management policy, the facility follows the regulations.

Based on record review and interview, the facility failed to ensure Resident #135's medical record was complete and accurate to reflect secured unit placement. This affected one resident (Resident #135) of three residents reviewed for medical records related to behavioral health services.Findings include:Review of the medical record for Resident #135 revealed they were admitted to the facility on [DATE] with diagnoses that included epilepsy, bipolar disorder, suicidal ideation, impulsiveness, anxiety, and need for assistance with personal care. Review of the current physician orders revealed the absence of an order for Resident #135 to reside in a secured unit. On 12/03/24 the order for placement on a secured unit was discontinued.Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #135 was cognitively intact, exhibited delusions, exhibited verbal behaviors, and required supervision or touching assistance for activities of daily living. An interview on 01/13/26 at 10:12 A.M. with LPN #382 revealed a resident required a physician's order to reside in a secured unit. An interview on 01/12/26 at 12:08 P.M. with the Director of Nursing (DON) revealed the facility did not have a secured unit policy.An interview on 01/13/26 at 12:50 P.M. with LPN #383 revealed residents needed a physician's order to reside in a secured unit. LPN #383 verified Resident #135 did not have a current order to reside in a secured unit.

Based on observation, record review, interview, policy and procedure review, and review of the Centers for Disease Control (CDC) guidance, the facility failed to ensure staff performed appropriate hand hygiene and ensure all staff implemented enhanced barrier precautions. This affected two of three residents reviewed for incontinence care (Residents #65 and #8) and one of 20 residents who ate their meals and resided on the 100 hall (Resident #58). These failures also had the potential to affect all 20 residents currently residing on the 100 hall (Residents #8 #17, #25, #37, #58, #65, #71, #74, #75, #78, #94, #95, #105, #109, #117, #135, #137, #139, #143 and #146). The facility census was 147. Findings include: 1. Clinical record review revealed Resident #65 was admitted on [DATE] with diagnoses including liver cancer, chronic bronchitis, aphasia, high blood pressure, heart failure, intermittent explosive disorder, dementia, anxiety, viral hepatitis, hyperlipidemia, ventral hernia, and intestinal obstruction. Review of Resident #65's plan of care initiated on 08/02/25 indicated Resident #65 was at risk for infection related to chronic disease including viral hepatitis with liver cell carcinoma. The goal of the plan of care was for Resident #65 to remain free from signs and symptoms of infection. Further review of Resident #65's care plan initiated on 08/02/25 indicated Resident #65 had an alteration in elimination with frequent bowel and bladder incontinence. Intervention on the plan of care included to provide incontinence care as needed. An observation of Certified Nursing Assistant (CNA) #150 and Assistant Director of Nursing (ADON) #151 on 01/28/25 at 11:00 A.M. perform Resident #65's incontinence care revealed a failure to perform hand hygiene to prevent cross contamination of germs. ADON #151 did not perform hand hygiene prior to assisting Resident #65 with incontinence care. ADON #151 donned a pair of gloves and removed the urine soaked bed linen by assisting Resident #65 with turning side-to-side. ADON #151 placed the soiled linens in a plastic bag and removed her gloves and did not perform hand hygiene. ADON #151 then donned another pair of gloves and proceeded to assist CNA #150 with obtaining clean linens needed for the incontinence care changing her gloves a third time during the process and donning another pair of gloves without performing hand hygiene. CNA #150 proceeded to don two pairs of gloves and cleaned Resident #65's perineal area with soap was water and cleaned the urine and feces from Resident #65's skin. CNA #150 completed cleaning Resident #65's perineal area of feces and urine and removed one of the two pairs of gloves and proceeded to assist Resident #65 with donning a clean incontinence brief. CNA #150 changed her gloves and did not perform hand hygiene. CNA #150 then obtained clothing from Resident #65's closet and assisted him with donning the clothing and transferring him to his wheelchair using a sit-to-stand mechanical lift. CNA #150 then removed the soiled linen from Resident #65's room, exited the room and placed the soiled linen in the shower room and did not wash her hands and proceeded to gather clean linens and placed the linens in Resident #65's room. An interview with CNA #150 on 01/28/25 at 11:30 A.M. verified the above findings and confirmed she should have performed hand hygiene between glove changes and before she obtained the clean linens from the shower room. An interview with ADON #151 on 01/28/25 at 11:45 A.M. verified she had failed to perform hand hygiene between glove changes while assisting with Resident #65's incontinence care. 2. Clinical record review revealed Resident #8 was admitted on [DATE] and readmitted on [DATE] with diagnoses including end stage prostate/colon/bone/skin cancer, diabetes mellitus, severe malnutrition, severe adjustment disorder with anxiety, anemia, bradycardia, venous thrombosis, and schwannomatosis (a rare genetic disorder characterized by the formation of multiple benign tumors called schwannomas on the nerve). Review of Resident #8's plan of care initiated on 01/14/25 indicated Resident #8 was at risk for infection related to cancer, chronic disease, implanted vascular access device to right chest, and pressure wound. The goal of the plan of care was for Resident #8 to remain free of signs and symptoms of infection. Interventions included to follow enhanced barrier precautions (EBP) as needed and to assess for signs and symptoms of infection and report to physician; redness, swelling, increased pain, purulent drainage, elevated temperature, change in color of secretions, cough, congestion, abnormal lung sounds, diarrhea, and/or vomiting. Further review of Resident #8's plan of care initiated on 01/14/25 indicated Resident #8 had a alteration in elimination with frequent episodes of bowel and bladder incontinence. Interventions on the plan of care indicated to monitor signs and symptoms of urinary tract infection including elevated temperature dysuria, flank pain, hematuria, and foul smelling urine and report to the physician and to provide incontinence care as needed. Review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 had frequent bowel and bladder incontinence. An observation on 01/28/25 at 10:46 A.M. of CNA #150 checking Resident #8 for incontinence revealed CNA #150 failed to wear appropriate personal protective equipment (PPE) . CNA #150 entered Resident #8's room and donned a pair of gloves and proceeded to assist Resident #8 with rolling side-to-side. CNA #150 then opened Resident #8's incontinence brief to ensure the incontinence brief was dry. CNA #150 then secured the incontinence brief and assisted Resident #8 with repositioning for comfort. Outside of Resident #8's room a cart with three drawers containing PPE was present with a sign located above Resident #8's name plate outside of his room. The sign indicated enhanced barrier precautions (EBP) should be implemented when providing care for Resident #8. CNA #150 verified the signage was present outside of Resident #8's room and verified she had failed to wear the additional PPE including a gown. ADON #151 was present during the observation and also confirmed Resident #8 had EBP in place due to the presence of a wound and verified CNA #150 should have implemented the EBP when checking Resident #8 for incontinence. 3. Clinical record review revealed Resident #58 was admitted on [DATE] with diagnoses including anemia, high blood pressure, peripheral vascular disease, hyperlipidemia, arthritis, dementia, malnutrition, anxiety, depression, schizophrenia, and asthma. Review of Resident #58's MDS assessment dated [DATE] indicated Resident #58 needed assistance with meals. Clinical record review revealed Resident #8 was admitted on [DATE] and readmitted on [DATE] with diagnoses including end stage prostate/colon/bone/skin cancer, diabetes mellitus, severe malnutrition, severe adjustment disorder with anxiety, anemia, bradycardia, venous thrombosis, and schwannomatosis (a rare genetic disorder characterized by the formation of multiple benign tumors called schwannomas on the nerves). Review of Resident #8's MDS assessment dated [DATE] indicated Resident #8 needed assistance with meals. An observation of the breakfast meal tray service on 01/28/25 at 8:12 A.M. revealed CNA #150 was delivering trays to the residents on the 100 hallway. CNA #150 opened the food cart and obtained a meal tray for Resident #8 and delivered the tray. CNA #150 assisted with repositioning Resident #8 in bed and setting-up the food items on the meal tray. Resident #8 refused his meal. CNA #150 exited Resident #8's room, did not perform hand hygiene and returned Resident #8's meal tray to the meal cart. CNA #150 proceeded to obtain Resident #58's meal tray and delivered the meal to Resident #58. CNA #150 assisted with the set-up of Resident #58's meal tray and exited the room and obtained a packet of honey, opened the packet and emptied the packet of honey on Resident #58's cereal. CNA #150 exited Resident #58's room and was stopped and asked to perform hand hygiene. Interview on 01/28/25 at 8:40 A.M. with CNA #150 verified the above observations and confirmed she did not perform hand hygiene between delivery of the meal trays between Resident #8 and Resident #58. CNA #150 stated she was not aware she was supposed to perform hand hygiene between delivery of the meal tray to each resident. Review of the facility policy titled Hand Hygiene revised 11/23/16 indicated hand hygiene would be properly performed to assist in the prevention of spreading infections. Staff would perform hand hygiene when indicated, using proper technique. Alcohol-based hand sanitizers were the most effective products for reducing the number of germs on the hands of healthcare providers. Alcohol-based hand sanitizers were the preferred method for cleaning hands in most clinical situations. During routine resident care, use of alcohol-based hand sanitizers was acceptable: a. Before touching a resident, b. Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, c. Before moving from work on a soiled body site to a clean body site on the same resident (when hands are not visibly dirty), d. After touching a resident or the resident's immediate environment, e. After contact with blood, body fluids or contaminated surfaces, f. Immediately after glove removal, g. When there was a single case of Clostridium difficile or Norovirus or during non-outbreak times in the facility, h. All other situations not listed under bullet seven (7.) of this policy. Hands were washed with soap and water: a. Whenever they were visibly dirty, b. Before eating, c. After using the restroom, d. After caring for a person with known or suspected infectious diarrhea, and, e. After caring for a resident with known or suspected Clostridium (C.) difficile or Norovirus infection during an outbreak, or if infection rates of C.difficile infection (CDI) are high. Review of the facility policy titled Infection Prevention and Control Program (IPCP) indicated it was a policy of the facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Item number three indicated: Hand Hygiene Protocol a. All staff shall perform hand hygiene their when coming on duty, between resident contacts, after handling contaminated objects, after PPE removal, before/after eating, before/after toileting, and before going off duty. b. Staff shall perform hand hygiene before and after performing resident care procedures and per our facility's established hand hygiene procedure. Review of the CDC enhanced barrier precautions information dated 10/20/24 indicated during high contact resident care task including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, during device care or use, and during wound care enhanced barrier precautions should be implemented. Enhanced barrier precautions included the use of a gown and gloves during high contact resident care tasks. Review of the census provided by the facility revealed Residents #8 #17, #25, #37, #58, #65, #71, #74, #75, #78, #94, #95, #105, #109, #117, #135, #137, #139, #143 and #146 resided on the 100 unit. This deficiency represents non-compliance investigated under Complaint Number OH00161669.

Based on record review and staff interview the facility failed to ensure Resident #65's care plan clearly reflected interventions to be used for safe transfer. This affected one (#65) out of three residents reviewed for falls. The facility census was 147. Findings include: Clinical record review revealed Resident #65 was admitted on [DATE] with diagnoses including liver cancer, chronic bronchitis, aphasia, high blood pressure, heart failure, intermittent explosive disorder, dementia, anxiety, viral hepatitis, hyperlipidemia, ventral hernia, and intestinal obstruction. Review of Resident #65's plan of care initiated on 08/15/24 indicated Resident #65 was at risk for falls related to a diagnosis of impaired cognition, dementia, anxiety, pain, use of psychotropic medications, and medical conditions including unsteadiness on feet, abnormalities of gait and mobility, abnormal posture, dizziness and giddiness. Interventions on the plan of care included to ensure environment was free of clutter and maintain a clear pathway. On 11/18/24 an additional intervention was added to use a Hoyer lift for transfers (Hoyer is a brand name that includes many different types of lifts including manual lifts, power lifts, stand up lifts, overhead lifts, bath lifts, and pool lifts). The care plan was not specific to whether a mechanical lift, power lift, overhead lift or stand up lift should be utilized. Review of Resident #65's fall risk assessment dated [DATE] indicated Resident #65 had a high risk for falls. Review of Resident #65's health status note dated 11/18/24 indicated Resident #65 was assessed for safety in use of sit-to-stand mechanical lift. Resident #65 was assessed and participated in a transfer from a bed to a chair, demonstrating upright stance with feet in proper placement on base of lift, bilateral knees supported by leg support, sling secured in place around waist with use of blue loops on hooks. Resident #65 demonstrated safe hand placement on lift, and assisted to maintain upright stance during transfer. An interview on 01/28/25 at 3:20 P.M. with the Administrator and Regional Clinical Director confirmed the plan of care was revised on 11/18/24 for the use of a Hoyer lift for transfers instead of a sit-to-stand lift. Regional Clinical Director verified the health assessment indicated Resident #65 could safely transfer with the use of a sit-to-stand lift.

Based on observation, record review, interview, and review of the nursing assistant job description, the facility failed to ensure Resident #17 was consistently assisted with shaving his facial hair on a daily basis. This affected one (#17) out of three residents reviewed who were dependent of staff for assistance with their activity of daily living (ADL) needs. The facility census was 147. Findings include: Clinical record review revealed Resident #17 was admitted on [DATE] with diagnoses including multiple sclerosis, cerebral infarction (stroke), depression, transient ischemic attack (TIA), heart failure and dementia. Review of Resident #17's Minimum Data Set (MDS) assessment dated [DATE] indicated he had mild cognitive impairment. Review of Resident #17's plan of care initiated on 11/08/24 revealed Resident #17 could require assistance with ADLs and could be at risk of developing complications associated with decreased ADL self-performance. Fluctuations and/or decline expected due to progressive neurological disease (multiple sclerosis). Interventions on the plan of care indicated Resident #17 needed assistance with bathing, grooming including nails, shaving and hair grooming. An observation and interview with Resident #17 on 01/27/25 at 12:05 P.M. revealed Resident #17 had thick unshaven facial hair. Resident #17 stated he hated the facial hair and wanted assistance with shaving but the facility did not provide an electric razor or assist him routinely with shaving his facial hair. Resident #17 stated he had a diagnosis of multiple sclerosis and needed assistance with grooming. An interview with Certified Nursing Assistant (CNA) #153 on 01/27/25 at 12:50 P.M. revealed Resident #17 preferred an electric razor for shaving his facial hair but the facility only had disposable razors available to shave the residents' facial hair. CNA #153 stated Resident #17's facial hair was too coarse to shave with a disposable razor. Resident #17 informed CNA #153 he would like to have his facial hair shaved every day and she offered and provided Resident #17 the disposable razors to shave his facial hair. An observation and interview with Resident #17 on 01/28/25 at 9:20 A.M. revealed he had unshaved facial hair. Resident #17 stated he needed assistance with shaving his facial hair and a couple of days ago an aide (unnamed) had assisted him with shaving his facial hair. Resident #17 stated he was not provided the disposable razors to shave his facial hair and had not been assisted with shaving for the last few days. An interview with CNA #154 on 01/27/25 at 9:55 A.M. revealed she had assisted Resident #17 with shaving his facial hair two days ago. CNA #154 stated she was aware Resident #17 needed assistance with shaving his facial hair but did not have time to assist Resident #17 with shaving on a daily basis. Review of the Nursing Assistant Job description revealed the nursing assistant was responsible for providing direct care to residents, assisting the clinical team in providing activities of daily living for the residents and worked under the supervision of a licensed nurse. The nursing assistant worked in accordance with facility policies and procedures and reported resident needs and concerns to a licensed nurse. The nursing assistant was responsible for assisting all responsible residents with activities of daily living (ADLs), including but not limited to feeding, bathing, dressing, transferring, ambulation, locomotion, personal hygiene, and toileting. This deficiency represents non-compliance investigated under Complaint Number OH00161220.

Based on record review, resident and staff interviews, and policy and procedure review, the facility failed to ensure the safe transfer of Resident #65 resulting in a fall and failed to maintain Resident #137's care planned interventions to prevent falls. This affected two (#65 and #137) of three residents reviewed for falls. The facility census was 147. Findings include: 1. Clinical record review revealed Resident #65 was admitted on [DATE] with diagnoses including liver cancer, chronic bronchitis, aphasia, high blood pressure, heart failure, intermittent explosive disorder, dementia, anxiety, viral hepatitis, hyperlipidemia, ventral hernia, and intestinal obstruction. Review of Resident #65's plan of care initiated on 08/15/24 indicated Resident #65 was at risk for falls related to a diagnosis of impaired cognition, dementia, anxiety, pain, use of psychotropic medications, and medical conditions including unsteadiness on feet, abnormalities of gait and mobility, abnormal posture, dizziness and giddiness. Interventions on the plan of care included to use a mechanical lift for transfers, ensure environment was free of clutter and maintain a clear pathway. Review of a fall investigation dated 11/17/24 revealed contributing factors of the fall included Resident #65's legs gave out. Certified Nursing Assistant (CNA) #152's witness statement revealed while attempting to transfer Resident #65 using a sit-to-stand lift, the lift tilted to one side and Resident #65 fell . Review of Resident #65's fall risk assessment dated [DATE] indicated Resident #65 had a high risk for falls. An interview with Resident #65 on 01/27/25 at 11:45 A.M. indicated he had a fall when an aide was assisting him out of bed using a sit-to-stand lift. Resident #65 stated while using the lift to transfer him back to bed the lift tilted and he fell on his buttocks on the floor. Resident #65 stated he had no injury except his bottom was sore for a few days. An interview with CNA #152 on 01/28/25 at 11:17 A.M. revealed CNA #152 was assisting Resident #65 to bed on 11/17/24 using the sit to stand lift. Resident #65 started to slide down due to weakness, the sit-to-stand lift tilted and he fell to the floor on his buttocks. CNA #152 stated the front wheel of the sit-to-stand lift was caught on a washcloth that was located under the bed which contributed to the lift tilting to the side. CNA #152 stated he was educated to have two staff assist when using the sit-to-stand lift to transfer a resident. Review of CNA #152's education document dated 11/18/24 indicated the Director of Nursing conducted the training. The training included ensuring the mechanical lift was working correctly and ensuring proper sweep of the floor to ensure it was free of clutter. The education indicated a washcloth was under the bed and caught on the wheel of the sit-to-stand lift causing the lift to tilt to one side. An interview on 01/28/25 at 3:20 P.M. with Administrator and Regional Clinical Director verified the above findings. 2. Clinical record review revealed Resident #137 was admitted on [DATE] with diagnoses including diabetes mellitus, pulmonary disease, cerebral vascular disease, heart failure with a cardiac defibrillator implanted device, high blood pressure, atherosclerotic disease, peripheral vascular disease, cataracts with visual disturbances, thrombocytopenia, carpal tunnel syndrome of upper limbs, osteoarthritis, and breast cancer. Resident #137 had medical conditions including low back pain, unsteadiness on feet, muscle weakness, and abnormal gait, mobility and need for assistance with personal care. Review of Resident #137's plan of care initiated 12/05/23 indicated a risk of falls related to acute/unstable medical condition, stroke, debilitation, weakness, disease process, impaired balance, pain, history of falls, poor coordination, unsteady gait, and visual deficit. Interventions on the plan of care included to keep the bed in the lowest position, Call, don't fall sign, Dycem (non slip mat) to wheelchair, encourage and remind to ask for assistance, encourage resident to wear non-skid socks at all times when not wearing shoes, encourage resident to ask for assistance to get items out of closet, encourage resident to not do activity of daily living tasks while sitting on rollator, ensure call light is within reach, ensure environment is free of clutter, have commonly used articles within easy reach, maintain a clear pathway, new shoes provided to resident, non-skid strips next to bed, provide rest periods and resident to wear proper and non slip footwear. An observation of Resident #137's room on 01/27/28 at 2:00 P.M. and on 01/28/25 at 8:30 A.M. revealed there was no Dycem on Resident #137's wheelchair and there were no non-skid strips located on the floor beside Resident #137's bed. On 01/28/25 at 9:15 A.M. Certified Nursing Assistant (CNA) #150 verified there was no Dycem on Resident #137's wheelchair and there were no non-skid strips located on the floor beside Resident #137's bed. CNA #150 also verified Resident #137's plan of care to prevent falls had interventions including to place a Dycem to the wheelchair and non-skid strips should have been placed on the floor beside Resident #137's bed. An interview with Assistant Director of Nursing (ADON) #151 on 01/28/25 at 2:45 P.M. verified she was informed of the missing Dycem and non-skid strips in Resident #137's room to prevent falls and verified Resident #137's plan of care included these interventions. Review of the facility policy titled Fall Management dated 10/17/16 indicated each resident would be assessed throughout the course of treatment for different parameters such as: cognition, safety awareness, fall history, mobility, medications, or predisposing health conditions that could contribute to fall risk. An interdisciplinary plan of care would be developed, implemented, reviewed and updated as necessary to reflect each resident's current safety needs and fall reduction interventions. The interdisciplinary team would attempt to balance safety needs, resident rights, and quality of life issues that would positively impact each resident's individual situation and reduce the risk of occurrence. Residents who experienced a fall would receive prompt medical attention. Immediate needs would be quickly assessed and responded to. A plan would be identified and implemented as necessary to protect the resident and/or others from recurrence. This deficiency represents non-compliance investigated under Complaint Number OH00161220.

Based on record review, interview, and review of the American Nurses Association (ANA) guidelines for accuracy of documentation, the facility failed to ensure staff accurately documented the presence of interventions to prevent a fall. This affected one of three residents reviewed for falls (Resident #137). The facility census was 147. Findings include: Clinical record review revealed Resident #137 was admitted on [DATE] with diagnoses including diabetes mellitus, pulmonary disease, cerebral vascular disease, heart failure with a cardiac defibrillator implanted device, high blood pressure, atherosclerotic disease, peripheral vascular disease, cataracts with visual disturbances, thrombocytopenia, carpal tunnel syndrome of upper limbs, osteoarthritis, and breast cancer. Resident #137 had medical conditions including low back pain, unsteadiness on feet, muscle weakness, and abnormal gait, mobility and need for assistance with personal care. Review of Resident #137's plan of care initiated 12/05/2023 indicated a risk of falls related to acute/unstable medical condition, stroke, debilitation, weakness, disease process, impaired balance, pain, history of falls, poor coordination, unsteady gait, and visual deficit. Interventions on the plan of care included to keep the bed in the lowest position, Call, don't fall sign, Dycem (non skid mat) to wheelchair, encourage and remind to ask for assistance, encourage Resident #137 to wear non-skid socks at all times when not wearing shoes, encourage resident to ask for assistance to get items out of closet, encourage resident to not do activity of daily living tasks while sitting on rollator, ensure call light was within reach, ensure environment was free of clutter, have commonly used articles within easy reach, maintain a clear pathway, new shoes provided to resident, non-skid strips next to bed, provide rest periods and resident was to wear proper and non slip footwear. An observation of Resident #137's room on 01/27/28 at 2:00 P.M. and on 01/28/25 at 8:30 A.M. revealed there was no Dycem on Resident #137's wheelchair and there were no non-skid strips located on the floor beside Resident #137's bed. Review of Resident #137's treatment administration record (TAR) dated 01/01/25 to 01/27/25 indicated documentation the Dycem was present on Resident #137's wheelchair and the non-skid strips were present on the floor. During an interview on 01/28/25 at 9:15 A.M., Certified Nursing Assistant (CNA) #150 verified there was no Dycem on Resident #137's wheelchair and there were no non-skid strips located on the floor beside Resident #137's bed. An interview with Assistant Director of Nursing (ADON) #151 on 01/28/25 at 2:45 P.M. verified the documentation on Resident #137's TAR indicated the care planned interventions of Dycem to wheelchair and non-skid strips were in place from 01/01/25 to 01/27/25. Review of the American Nurses Association (ANA) guidelines for accuracy of documentation dated 2010 indicated clear, accurate, and accessible documentation was an essential element of safe, quality, evidence-based nursing practice. Accurate nursing documentation significantly influenced the quality of patient care. It not only provided a clear picture of the patient's medical history but also served as a vital tool of communication among healthcare professionals. When filled accurately and systematically, it could also protect nurses legally if there was a complaint or lawsuit related to patient care. This deficiency represents non-compliance investigated under Complaint Number OH00161120.

Based on medical record review, observation, and interview the facility failed to provide oral care in a timely manner. This affected one (Resident #1) of three residents reviewed for activities of daily living. The census was 139. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE]. Diagnoses included schizoaffective disorder, type two diabetes, morbid obesity, unspecified dementia. Resident #1 required assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/26/24, revealed Resident #1 had intact cognition and was dependent for bed mobility, transfers, and oral care. Review of the Plan of care dated 01/19/20 revealed Resident #1 had impaired dentition and was at risk for oral problems related to broken, loose teeth with interventions including to provide oral care at least daily and/or more frequently as needed. Review of the oral care task sheet for Resident #1 dated 05/20/24 through 06/17/24 revealed on 05/22/24, 05/24/24, 05/25/24, 05/26/24, 05/27/24, 05/30/24, 06/03/24, 06/03/24, 06/06/24, 06/08/24, and 06/13/24 there was no documentation oral care was completed. Interview on 06/17/24 at 8:41 A.M. with Resident #1 revealed he did not receive oral care daily and he had not received oral care this morning. Observation of Resident #1 revealed his teeth were not clean and he was not shaved. Interview on 06/17/24 at 8:59 A.M. with State tested Nurse Assistant (STNA) #204 revealed he did not complete Resident #1's oral care because third shift staff were responsible for providing oral care. Record review and interview on 06/17/24 at 11:13 A.M. with Assistant Director of Nursing (ADON) #208 and ADON #210 verified oral care was not documented as completed for Resident #1 on 05/22/24, 05/24/24, 05/25/24, 05/26/24, 05/27/24, 05/30/24, 06/03/24, 06/03/24, 06/06/24, 06/08/24, and 06/13/24. There was documentation that oral care was provided on 06/17/24 at 9:32 A.M. A follow up interview on 06/17/24 at 11:18 A.M. with STNA #204 verified that he had not completed oral care for Resident #1 on 06/17/24. Observation of Resident #1's oral cavity on 06/17/24 at 11:23 A.M. with ADON #208 and ADON #210 verified Resident #1 had caked on food debris between his teeth. Both ADON #208 and #210 indicated oral care had not been completed. This deficiency represents non-compliance investigated under Complaint Number OH00154437.

Based on record review and interviews, the facility failed to timely report an allegation of sexual abuse involving Resident #94 and Resident #44 to the state agency. This affected two residents (Resident #64 and #94) of three reviewed for abuse. The facility census was 145. Findings included: Review of the medical record revealed Resident #94 was admitted to the facility on [DATE]. Diagnoses included diabetes, inflammatory spondylopathy, chronic obstructive pulmonary disease, nutritional marasmus, heart failure, neurogenic bowel, schizophrenia, anxiety disorder, hypertension, neuromuscular dysfunction of the bladder, COVID-19, and paraplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 had moderately impaired cognition with no behaviors. He required extensive assistance from one staff member for bed mobility, transfers, dressing toilet use and personal hygiene. Further review revealed he was incontinent of bowel and bladder. Review of the medical record revealed Resident #64 was admitted to the facility 02/16/18. Diagnoses included dementia, paranoid schizophrenia, epilepsy, anxiety disorder, alcohol abuse, nicotine dependence, COVID-19, left leg amputation, major depressive disorder, severe protein-calorie malnutrition, adult failure to thrive, vitamin D deficiency, and constipation. Review of the quarterly MDS assessment dated [DATE] revealed Resident #64 had intact cognition and he had no behaviors. Review of the incident note dated 07/16/23 at 5:43 A.M. revealed Resident #64 was noted to be sexually inappropriate with his roommate (Resident #94). They were separated and Resident #94 was moved to a new room on the 100 Hall. Resident #94 was interviewed by the nursing supervisor and stated he was fine, not hurt and was okay with moving to a new room. Review of the social service note dated 07/16/23 at 9:42 A.M. revealed the Licensed Social Worker (LSW) interviewed Resident #64 and he denied any sexual behavior between him and his previous roommate. His last documented Brief Interview for Mental Status score was 15. Review of a signed witness statement dated 07/16/23 written by State tested Nursing Assistant (STNA) #200 at 4:45 A.M. indicating she noticed the door of room [ROOM NUMBER] was shut so she went into the room to check on the residents. The resident in bed two (Resident #94) was in bed naked and the resident in bed one (Resident #64) was digging in the rectum of Resident #94. Resident #64 been in the bed with Resident #94. She indicated there was bowel movement (BM) all over the bed. The linens were on the floor with BM on them. Review of the signed witness statement dated 07/16/23 by Licensed Practical Nurse (LPN) # 210 revealed at approximately 4:50 A.M. the charge nurse and STNA notified LPN #210 that Resident #94 and Resident #64 were being sexually inappropriate. Both residents denied anything sexual occurred between them. On 07/20/23 at 3:15 P.M. an interview with Resident #94 revealed he was confused, he stated he was practicing his praying, and was going on about his brother not coming to see him. He stated he did not think he was sexual assaulted. On 07/20/23 at 4:15 P.M. an interview with the Interim Administrator verified they had not reported the incident to the Ohio Department of Health on 07/16/23 because they did not feel it was sexual abuse. She stated they believe Resident #94 had asked Resident #64 to help him. She stated they had been roommates for years with no problems. On 07/20/23 at 4:17 P.M. an interview with the Director of Nursing (DON) revealed the niece of Resident #94 came into the facility on [DATE] around 11:00 P.M. with the Akron police alleging there was sexual abuse against her uncle by Resident #64. She stated the niece demanded Resident #94 go to the hospital to be checked out. She stated Resident #94 did not want to go to the hospital but finally went after the niece persisted. She stated the hospital would not give them any paperwork because the resident was his own responsible party. She stated at that point she started the investigation and filed the Self-Reported Incident. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 11/21/16, revealed it was the facility policy to investigate all alleged violations of abuse, neglect, exploitation, mistreatment of the resident or misappropriation of resident property including injuries of unknown source. Additionally, the facility should immediately report all such allegation to the Administrator and the Ohio Department of Health . This deficiency represents non-compliance investigated under Complaint Number OH00144686.

Based on interviews with residents, interview with dietary staff, review of a test tray, and review of the facility policy the facility failed to ensure foods were palatable and served at appropriate temperatures. This had the potential to affect 127 residents who received food from the kitchen. The facility identified one resident (#117) as receiving nothing by mouth. The facility census was 128. Findings include: On 01/09/23 at 10:35 A.M., interview with Resident #87 stated the food did not taste good. On 01/09/23 at 10:43 A.M., interview with Resident #77 stated the food was cold and did not taste good. On 01/09/23 at 10:50 A.M., interview with Resident #63 stated the food was cold. On 01/11/23 from 12:36 P.M. to 12:51 P.M., review of a test tray with Certified Dietary Manager (CDM) #700 revealed the meal included meatloaf, mashed potatoes, and corn. The test tray was started on the tray line at 12:36 P.M., had a hot plate warmer under the plate, was covered with a dome lid, loaded onto a closed cart at 12:37 P.M., the cart was delivered to the 400-hall at 12:38 P.M., and the test tray was delivered to the 400-hall nurse's station at 12:51 P.M. CDM #700 used the facility thermometer to measure the temperature of the food items on the test tray. The meatloaf was 111 degrees Fahrenheit (F) and felt cold while eating. The mashed potatoes were 114 degrees F, felt cold while eating and lacked flavor. The corn was 95 degrees F and felt cold while eating. At the time of the test tray review, CDM #700 verified all food items were cold and the mashed potatoes were bland. Review of the facility policy titled Infection Control - Dietary/Food Handling, dated March 2016, revealed hot food items should be at a palatable temperature at the point of service.

Based on clinical record review, staff interviews, review of the facility's abuse investigative reports and self-reported incidents, and review of the facility's policy on abuse protocol the facility failed to ensure that Resident #121 was free from physical abuse. This resulted in Immediate Jeopardy for one resident, Resident #121, of 26 residents reviewed for abuse on the 600 unit, a secured unit for residents with behaviors. The facility census was 170. On 08/23/12 at 2:40 P.M., the Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were notified Immediate Jeopardy began on 07/24/12 at 11:45 P.M., when Licensed Practical Nurse (LPN) #4 slapped Resident #121 in the face, hit her repeatedly on the arms, restrained her, sprayed water into her face from the shower nozzle, and threatened her that the same treatment would continue if she refused care. Two State tested Nursing Assistants, (STNA) # 3 and #5, witnessed the abuse but failed to intervene or report the abuse immediately. Resident #121 sustained bruising to her face, mid back, right forearm and right lower leg. The Immediate Jeopardy was removed on 08/06/12, when the facility implemented the following corrective actions: ? LPN #4 and STNAs #3 and #5 were terminated on 08/06/12. ? On 07/31/12 through 08/06/12 the administrator, DON and ADON in serviced all 78 direct care staff, 3 Registered Nurses (RNs), 28 LPNs and 47 STNAs, on the facility ' s policy titled Abuse, Neglect, Misappropriation of Resident property, resident behaviors and the Resident ' s Bill of Rights. ? On 08/23 & 24/12 interviews with direct care staff on the 600 unit, STNAs #16, #18, and #19, and LPN# 21 verified they were knowledgeable of the facility ' s policy and procedures on abuse. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Scope and Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) due to the facility ' s failure to complete a thorough investigation. No other residents were evaluated to determine possible incidents of abuse or potential for abuse. Findings include: Resident #121 was readmitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The minimum data assessment dated [DATE] revealed that Resident #121 was usually able to make her needs known and was able to understand others. She was severely impaired, displayed behaviors of inattention, and had disorganized thinking. She was usually depressed, short-tempered and easily annoyed. She displayed physical behaviors such as hitting, kicking, pushing, scratching and grabbing. She was verbally abusive and displayed behavioral symptoms not directed towards others such as hitting or scratching herself, making disruptive sounds and throwing items one to three days a week. She was dependent on two staff members for bathing. Resident #121's care plans indicated Resident #121 had short and long term memory deficits and impaired decision making skills. She was easily distracted, had altered perceptions and periods of restlessness and her mental function varied. The interventions included to repeat the direction and to give the resident two choices when presenting decisions. The care plan for verbal, physical aggressiveness and socially inappropriate periods indicated Resident #121 had periods of hitting, scratching, biting, kicking, yelling, crying, throwing things, flailing hands, punching the staff and crying. The interventions included to not invade the resident's personal space and to leave the resident and re-approach later if the interventions were unsuccessful. Staff should approach the resident from the front, using a low, non-confrontational tone. The care plan for resisting care, delusional behaviors and paranoia indicated that Resident #121 was combative and agitated at times. The interventions included to not invade the resident's personal space and to leave the resident and re-approach later if the interventions were unsuccessful. Staff should approach the resident from the front, using a low, non-confrontational tone. Resident #121 was ordered an antidepressant ([MEDICATION NAME]), a [MEDICAL CONDITION] drug, ([MEDICATION NAME]), a scheduled antianxiety medication ([MEDICATION NAME]), an anticonvulsant medication, and as needed (PRN) anti-anxiety medication ([MEDICATION NAME]) twice a day for agitation. Resident #121 did not receive her PRN anti-anxiety for agitation any time during July, 2012. The July, 2012 behavior intervention log revealed that on 07/28/12 Resident #121 displayed behaviors of yelling and was combative. There were no inventions documented regarding the behaviors. The social service designee (SSD) documented that she talked with Resident #121 regarding the incident of 07/24/12. Resident #121 stated that " staff members were in her room, messing with her stuff and were physical with her. Resident #121 indicated she felt safe and stated " I know a lot of people love me " . The DON documented on 07/25/12 at 2:45 P.M. that she was contacted by the ADON regarding an allegation of physical and verbal abuse towards Resident #121 by LPN #4. A head to toe assessment was completed by the nursing supervisor. Resident #121 had a 1.0 centimeter (cm) by a 1.5 cm bruise on her right forearm, a 2.5 cm by 3.0 cm area of petechiae, and a 1.0 cm by 1.0 cm reddish purple bruise on her mid-back. Her left lower lip had a 0.5 cm by 1.5 cm purple and swollen area, her left cheek was swollen under her left eye and she had a 2.0 by 3.0 cm bruise to her right lower leg. Resident #121 was interviewed by the DON and consistently stated that LPN #4 pulled and grabbed her by her hair. A report was filed with the police department and a police investigation was in process. The facility initiated a " Quick Response " form that identified the sister was notified of the incident; however there was no evidence as to a date or time of this notification on this form. The nurse ' s notes were void of information regarding notification of physician or family. The nurse ' s notes dated 07/25/12 at 2:45 A.M. reflected a member of the local police department was in the building completing a report. There was a progress note in the medical record from the physician dated 07/25/12 (no time) which reflected knowledge of the incident. STNAs #3 and #5 and LPN #4 were terminated on 08/06/12 and were unavailable for interview. Registered nurse (RN) #8, who initiated the investigation, was out of town and unavailable for interview. The facility ' s Self- Reported incident form and an in-house abuse investigation dated 07/25/12 were reviewed. The investigation documented that on 07/24/12 around 8:00 P.M., Resident #121 was upset and threw a can of pop on the floor. Resident #121 was placed in bed at that time in attempts to calm her down. Between 07/24/12 at 11:30 P.M. and 07/25/12 at 12:00 P.M., STNA #3 approached the resident to give her a shower. At this time Resident #121 threw a can of pop at STNA#3 and told the staff to " leave her alone " . LPN #4 intervened and insisted that Resident #121 take a shower. LPN #4 grabbed Resident #121 ' s wrists and forcefully placed her into the shower chair. Resident #121 remained upset and was combative. LPN #4 attempted to quiet Resident #121 by spraying water in her face and cursing at her. LPN #4 and STNA #3 and #5 placed Resident #121 in bed following the shower. Resident #121 became quiet following the spray of water in her face per STNA #3 and STNA #5 ' s statements. STNA #3 and #5 reported the incident to LPN #6 at approximately 1:30 A.M. on 07/24/12. LPN #6 then reported the incident to Registered Nurse (RN) #8. RN #8 assessed Resident #121. The assessment revealed that Resident #121 had scattered petechiae and bruising to her right forearm. Her lower lip was slightly swollen and discolored. This occurred when LPN #4 held Resident #121 by the wrists, crossing the resident ' s arms across her chest, and held her down on the bed. LPN #4 corroborated the information. She stated it was an attempt to gain an adequate hold on the resident to place her in the shower chair. LPN #4, STNA #3 and STNA #5 were suspended by RN #8 for failure to report the incident. X-rays were obtained for Resident #121 ' s wrists, arms and shoulder. The x-rays were all negative. The facility interviewed LPN #4, STNA #3 and STNA#5. Interviews conducted during the investigation revealed that the allegation of abuse was substantiated and LPN #4 was terminated. STNA #3 and STNA #5 were terminated for failure to intervene to stop the abuse and for failure to immediately report the abuse. An interview with LPN #4, during the facility's investigation revealed that from 07/24/12 to 07/25/12, Resident #121 was agitated and grumbling most of the night. LPN#4 indicated that Resident #121 was swinging her arms. LPN#4 demonstrated how she restrained Resident #121's arms at her wrists and then crossed them over her chest to hold the resident and" keep her from hitting and swinging". LPN #4 revealed that she held Resident #121 ' s knees and arms while in the shower. The resident was combative and sliding from the chair. STNA #5 ' s statement dated 07/24/12 revealed that LPN #4 and STNA #3 entered Resident #121 ' s room. LPN #4 told Resident #121 that she " was getting a shower " . Resident #121then swatted at the nurse. LPN #4 began hitting Resident #121 on the hands and did not stop hitting Resident #121. LPN #4 grabbed her wrist, crossed them over her chest and lay on top of Resident #121. LPN #4 grabbed Resident #121 ' s wrists and " snatched " her out of bed, picked her up and put her in the shower chair. Resident #121 was screaming, crying, and flipping around in the shower chair when she was taken into the shower room. LPN #4 then slapped Resident #121 " upside the right side of her head " and grabbed the shower nozzle spraying Resident #121 in the face. LPN #4 stated " Oh look, she is going to fake that she fainted. " LPN #4 continued to yell and curse at Resident #121. Resident #121 was not yelling or combative at this time. The shower was completed and Resident #121 was returned to her room. LPN #4 stated to Resident #121, " if slapping you up your head to get you to shut the Fu-- up, I will do it every time. " After providing a shower for another resident, STNA #5 reported the incident to LPN #6. STNA #3's initial statement from 07/24/12 indicated that Resident #121 was being prepared for her shower, when she became combative and violent, swinging her arms and swearing. STNA #3 indicated the resident was fighting the entire time. The STNA stated " we tried to hold her so she would not fall. LPN #4 tried to calm her down. I was totally focused on what I was doing, as far as her care was concerned, and as to what I considered a difficult situation at the time, At no time did I see LPN #4 strike Resident #121, other than to grab her when she was out of control." A second statement from STNA #3 was obtained on 07/25/12;she revealed that Resident #121 was combative, cursing and swinging her arms. The statement indicated that STNA #5 approached Resident #121 about a shower when Resident #121 stated " leave me alone, get out of here " . LPN #4 held her by her wrists to keep her from swinging her arms, and said " it ' s your shower night; you need to get in the shower. " LPN #4 held Resident #121 down against the bed by her wrists. During the shower, LPN #4 used a very loud tone towards Resident #121 and used inappropriate words, calling her both a [***] and a devil. On 08/01/12, STNA #3 spoke with Human Resource Director #23 and stated that she did not witness anything done by LPN #4. STNA also #3 stated " what was I supposed to do tackle LPN #4? " RN #8 assessed Resident #121 at the time of the abuse allegation. Resident #121 voiced the same allegations as expressed by STNA #3 and STNA #5. RN #8 identified scant petechiae and a small bruise on her right forearm. Her left lower lip was slightly swollen and discolored. LPN #4 was suspended pending the outcome of the investigation. The staff were interviewed; the police, the family and the physician were notified of the incident. The outcome of the investigation concluded that LPN #4 and that STNA #3 and STNA #5, who witnessed the event were terminated. Interviews with the DON and the ADON on 08/23/12 at 11:30 A.M. confirmed that LPN #4 physically and verbally abused Resident #121. The DON and the ADON revealed that the two STNA ' s were removed from the 600 unit and were placed on other units. STNA #3 left the faciity on [DATE] at 2:44 A.M. due to the incident. STNA#5 worked on another unit during the night shifts on 07/24/12 and 07/25/12. LPN #4 was sent home at 2:00 A.M. on 07/25/12 pending an investigation. The DON and the ADON verified that STNA #3 and STNA #5 did not stop the abuse or report the abuse immediately. They also verified that STNA #5 was permitted to work on another unit. The facility did not interview any other staff members who could have had knowledge or information pertinent to this incident. The facility did not interview any other residents on the 600 unit. The Abuse Prevention Policy dated 10/18/01 revealed that all potential new employees were screened for a history of abuse, neglect, or mistreatment of [REDACTED]. The facility would provide an orientation for all new employees and volunteers. The orientation would include nursing expectation which covered the responsibility to promote the health, safety, and welfare of residents; how to treat residents and proper procedure for reporting concerns. The staff was trained when and how to report witnessed, alleged, or suspected abuse. The staff was trained that if abuse was witnessed by a staff member the staff member will first and foremost take whatever action was needed to protect the resident. During and after the investigation the residents were protected from harm through supervision by staff. If the alleged abuser was an employee, the employee will be removed from the facility and suspended pending the results of the facility's investigation. The policy of this facility indicated that reports of abuse are promptly and thoroughly investigated. When an incident or suspected incident of abuse is reported, the administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation may consist of a review of the completed incident report, interviews with person(s) reporting the incident. Interviews with any witness to the incident, interview with the Resident if possible, review of the medical record, interview with staff members having contact with the resident during the period/shift of the alleged incident. Interview with the Resident ' s roommate, family members, and visitors and a review of all circumstances surrounding the incident This deficiency substantiates Complaint Number OH 756.

Based on clinical record review, staff interviews, review of the facility's abuse investigative reports and self-reported incidents, and review of the facility's policy on abuse protocol the facility failed by continuing to employ individuals who have been found guilty of abuse, neglect or mistreatment of [REDACTED].#121, of 26 residents reviewed for abuse on the 600 unit, a secured unit for residents with behaviors. The facility census was 170. On 08/23/12 at 2:40 P.M., the Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were notified Immediate Jeopardy began on 07/24/12 at 11:45 P.M., when Licensed Practical Nurse (LPN) #4 slapped Resident #121 in the face, hit her repeatedly on the arms, restrained her, sprayed water into her face from the shower nozzle, and threatened her that the same treatment would continue if she refused care. Two State tested Nursing Assistants, (STNA) #3 and #5, witnessed the abuse but failed to intervene or report the abuse immediately. Resident #121 sustained bruising to her face, mid back, right forearm and right lower leg. The Immediate Jeopardy was removed on 08/06/12, when the facility implemented the following corrective actions: ? LPN #4 and STNAs #3 and #5 were terminated on 08/06/12. ? On 07/31/12 through 08/06/12 the administrator, DON and ADON in serviced all 78 direct care staff, 3 Registered Nurses (RNs), 28 LPNs and 47 STNAs, on the facility ' s policy titled Abuse, Neglect, Misappropriation of Resident property, resident behaviors and the Resident ' s Bill of Rights. ? On 08/23 & 24/12 interviews with direct care staff on the 600 unit, STNAs #16, #18, and #19, and LPN# 21 verified they were knowledgeable of the facility ' s policy and procedures on abuse. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Scope and Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) due to the facility ' s failure to complete a thorough investigation. No other residents were evaluated to determine possible incidents of abuse or potential for abuse. Findings include: Resident #121 was readmitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The minimum data assessment dated [DATE] revealed that Resident #121 was usually able to make her needs known and was able to understand others. She was severely impaired, displayed behaviors of inattention, and had disorganized thinking. She was usually depressed, short-tempered and easily annoyed. She displayed physical behaviors such as hitting, kicking, pushing, scratching and grabbing. She was verbally abusive and displayed behavioral symptoms not directed towards others such as hitting or scratching herself, making disruptive sounds and throwing items one to three days a week. She was dependent on two staff members for bathing. Resident #121's care plans indicated Resident #121 had short and long term memory deficits and impaired decision making skills. She was easily distracted, had altered perceptions and periods of restlessness and her mental function varied. The interventions included to repeat the direction and to give the resident two choices when presenting decisions. The care plan for verbal, physical aggressiveness and socially inappropriate periods indicated Resident #121 had periods of hitting, scratching, biting, kicking, yelling, crying, throwing things, flailing hands, punching the staff and crying. The interventions included to not invade the resident's personal space and to leave the resident and re-approach later if the interventions were unsuccessful. Staff should approach the resident from the front, using a low, non-confrontational tone. The care plan for resisting care, delusional behaviors and paranoia indicated that Resident #121 was combative and agitated at times. The interventions included to not invade the resident's personal space and to leave the resident and re-approach later if the interventions were unsuccessful. Staff should approach the resident from the front, using a low, non-confrontational tone. Resident #121 was ordered an antidepressant ([MEDICATION NAME]), a [MEDICAL CONDITION] drug, ([MEDICATION NAME]), a scheduled antianxiety medication ([MEDICATION NAME]), an anticonvulsant medication, and as needed (PRN) anti-anxiety medication ([MEDICATION NAME]) twice a day for agitation. Resident #121 did not receive her PRN anti-anxiety for agitation any time during July, 2012. The July, 2012 behavior intervention log revealed that on 07/28/12 Resident #121displayed behaviors of yelling and was combative. There were no inventions documented regarding the behaviors. The social service designee (SSD), documented that she talked with Resident #121 regarding the incident of 07/24/12. Resident #121 stated that " staff members were in her room, messing with her stuff and were physical with her " . Resident #121 indicated she felt safe and stated " I know a lot of people love me " . The DON documented on 07/25/12 at 2:45 P.M. that she was contacted by the ADON regarding an allegation of physical and verbal abuse towards Resident #121 by LPN #4. A head to toe assessment was completed by the nursing supervisor. Resident #121 had a 1.0 centimeter (cm) by a 1.5 cm bruise on her right forearm, a 2.5 cm by 3.0 cm area of petechiae, and a 1.0 cm by 1.0 cm reddish purple bruise on her mid-back. Her left lower lip had a 0.5 cm by 1.5 cm purple and swollen area, her left cheek was swollen under her left eye and she had a 2.0 by 3.0 cm bruise to her right lower leg. Resident #121 was interviewed by the DON and consistently stated that LPN #4 pulled and grabbed her by her hair. A report was filed with the police department and a police investigation was in process. The facility initiated a " Quick Response " form that identified the sister was notified of the incident; however there was no evidence as to a date or time of this notification on this form. The nurses ' notes were void of information regarding notification of physician or family. The nurse ' s notes dated 07/25/12 at 2:45 A.M. reflected a member of the local police department was in the building completing a report. There was a progress note in the medical record from the physician dated 07/25/12 (no time) which reflected knowledge of the incident. STNAs #3 and #5 and LPN #4 were terminated on 08/06/12 and were unavailable for interview. Registered nurse (RN) #8, who initiated the investigation, was out of town and unavailable for interview. The facility ' s Self- Reported incident form and an in-house abuse investigation dated 07/25/12 were reviewed. The investigation documented that on 07/24/12 around 8:00 P.M., Resident #121 was upset and threw a can of pop on the floor. Resident #121 was placed in bed at that time in attempts to calm her down. Between 07/24/12 at 11:30 P.M. and 07/25/12 at 12:00 P.M., STNA #3 approached the resident to give her a shower. At this time Resident #121 threw a can of pop at STNA#3 and told the staff to " leave her alone " . LPN #4 intervened and insisted that Resident #121 take a shower. LPN #4 grabbed Resident #121 ' s wrists and forcefully placed her into the shower chair. Resident #121 remained upset and was combative. LPN #4 attempted to quiet Resident #121 by spraying water in her face and cursing at her. LPN #4 and STNA #3 and #5 placed Resident #121 in bed following the shower. Resident #121 became quiet following the spray of water in her face per STNA #3 and STNA #5 ' s statements. STNA #3 and #5 reported the incident to LPN #6 at approximately 1:30 A.M. on 07/24/12. LPN #6 then reported the incident to Registered Nurse (RN) #8. RN #8 assessed Resident #121. The assessment revealed that Resident #121 had scattered petechiae and bruising to her right forearm. Her lower lip was slightly swollen and discolored. This occurred when LPN #4 held Resident #121 by the wrists, crossing the resident ' s arms across her chest, and held her down on the bed. LPN #4 corroborated the information. She stated it was an attempt to gain an adequate hold on the resident to place her in the shower chair. LPN #4, STNA #3 and STNA #5 were suspended by RN #8 for failure to report the incident. X-rays were obtained for Resident #121 ' s wrists, arms and shoulder. The x-rays were all negative. The facility interviewed LPN #4, STNA #3 and STNA#5. Interviews conducted during the investigation revealed that the allegation of abuse was substantiated and LPN #4 was terminated. STNA #3 and STNA #5 were terminated for failure to intervene to stop the abuse and for failure to immediately report the abuse. An interview with LPN #4, during the facility ' s investigation revealed that from 07/24/12 to 07/25/12, Resident #121 was agitated and grumbling most of the night. LPN#4 indicated that Resident #121 was swinging her arms. LPN#4 demonstrated how she restrained Resident #121 ' s arms at her wrists and then crossed them over her chest to hold the resident and " keep her from hitting and swinging " . LPN #4 revealed that she held Resident #121 ' s knees and arms while in the shower. The resident was combative and sliding from the chair. STNA #5 ' s statement dated 07/24/12 revealed that LPN #4 and STNA #3 entered Resident #121 ' s room. LPN #4 told Resident #121 that she " was getting a shower " . Resident #121then swatted at the nurse. LPN #4 began hitting Resident #121 on the hands and did not stop hitting Resident #121. " LPN #4 grabbed her wrist, crossed them over her chest and lay on top of Resident #121. LPN #4 grabbed Resident #121 ' s wrists and " snatched " her out of bed, picked her up and put her in the shower chair " . Resident #121 was screaming, crying, and flipping around in the shower chair when she was taken into the shower room. LPN #4 then slapped Resident #121 " upside the right side of her head " and grabbed the shower nozzle spraying Resident #121 in the face. LPN #4 stated " Oh look, she is going to fake that she fainted. " LPN #4 continued to yell and curse at Resident #121. Resident #121 was not yelling or combative at this time. The shower was completed and Resident #121 was returned to her room. LPN #4 stated to Resident #121, " if slapping you up your head to get you to shut the fu-- up, I will do it every time. " After providing a shower for another resident, STNA #5 reported the incident to LPN #6. STNA #3 ' s initial statement from 07/24/12 indicated that Resident #121 was being prepared for her shower, when she became combative and violent, swinging her arms and swearing. STNA #3 indicated the resident was fighting the entire time. The STNA stated " we tried to hold her so she would not fall. LPN #4 tried to calm her down. I was totally focused on what I was doing, as far as her care was concerned, and as to what I considered a difficult situation at the time, At no time did I see LPN #4 strike Resident #121, other than to grab her when she was out of control. " A second statement from STNA #3 was obtained on 07/25/12; she revealed that Resident #121 was combative, cursing and swinging her arms. The statement indicated that STNA #5 approached Resident #121 about a shower when Resident #121 stated " leave me along, get out of here " . LPN #4 held her by her wrists to keep her from swinging her arms, and said " it ' s your shower night, you need to get in the shower. " LPN #4 held Resident #121 down against the bed by her wrists. During the shower, LPN #4 used a very loud tone towards Resident #121 and used inappropriate words, calling her both a [***] and a devil. On 08/01/12, STNA #3 spoke with Human Resource Director #23 and stated that she did not witness anything done by LPN #4. STNA also #3 stated " what was I supposed to do tackle LPN #4? " RN #8 assessed Resident #121 at the time of the abuse allegation. Resident #121 voiced the same allegations as expressed by STNA #3 and STNA #5. RN #8 identified scant petechiae and a small bruise on her right forearm. Her left lower lip was slightly swollen and discolored. LPN #4 was suspended pending the outcome of the investigation. The staff was interviewed and the police, the family and the physician were notified of the incident. The outcome of the investigation concluded that LPN #4 and that STNA #3 and STNA #5, who witnessed the event were terminated. Interviews with the DON and the ADON on 08/23/12 at 11:30 A.M. confirmed that LPN #4 physically and verbally abused Resident #121. The DON and the ADON revealed that the two STNA ' s were removed from the 600 unit and were placed on other units. STNA #3 left the faciity on [DATE] at 2:44 A.M. due to the incident. STNA#5 worked on another unit during the night shifts on 07/24/12 and 07/25/12. LPN #4 was sent home at 2:00 A.M. on 07/25/12 pending an investigation. The DON and the ADON verified that STNA #3 and STNA #5 did not stop the abuse or report the abuse immediately. They also verified that STNA #5 was permitted to work on another unit. The facility did not interview any other staff members who could have had knowledge or information pertinent to this incident. The facility did not interview any other residents on the 600 unit. The Abuse Prevention Policy dated 10/18/01 revealed that all potential new employees were screened for a history of abuse, neglect, or mistreatment of [REDACTED]. The facility would provide an orientation for all new employees and volunteers. The orientation would include nursing expectation which covered the responsibility to promote the health, safety, and welfare of residents; how to treat residents and proper procedure for reporting concerns. The staff was trained when and how to report witnessed, alleged, or suspected abuse. The staff was trained that if abuse was witnessed by a staff member the staff member will first and foremost take whatever action was needed to protect the resident. During and after the investigation the residents were protected from harm through supervision by staff. If the alleged abuser was an employee, the employee will be removed from the facility and suspended pending the results of the facility's investigation. The policy of this facility indicated that reports of abuse are promptly and thoroughly investigated. When an incident or suspected incident of abuse is reported, the administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation may consist of a review of the completed incident report, interviews with person(s) reporting the incident. Interviews with any witness to the incident, interview with the Resident if possible, review of the medical record, interview with staff members having contact with the resident during the period/shift of the alleged incident. Interview with the Resident ' s roommate, family members, and visitors and a review of all circumstances surrounding the incident This deficiency is a recite from the complaint investigation completed on 07/02/12. This deficiency substantiates Complaint Number OH 756.

Based on interview and and record review, the facility failed to ensure an allegation of abuse was immediately reported to the administrator for one Resident (#133). The facility census was 168. Findings include: Review of Resident #133's clinical record revealed she had [DIAGNOSES REDACTED]. Review of her MDS 3.0 dated 11/30/11 documented she had moderately impaired cognition. She had unclear speech and sometimes understood communication. Review of the resident's medication orders revealed she was receiving [MEDICATION NAME] (a blood thinner). Review of nurses notes dated 05/27/12 at 7:13 A.M. documented during resident care the footrest of the resident's wheelchair bumped into the resident's left thigh resulting in a bruise. The bruise was described as purple in color and measured 4.0 centimeters (cm) by 7.5 cm by 0.0 cm. No other bruising was noted. The note dated 05/27/12 at 23:07 (11:07 P.M.) documented the nurse notified the guardian and the resident's doctor of the bruise. Interview with Resident #147 on 06/28/12 at 11:00 A.M. indicated she had reported to staff that she thought she heard a staff member hitting Resident #133 a few weeks ago. The resident indicated she could not remember who she reported it to. Interview with State tested Nurse Aide (STNA) #3 on 06/28/12 indicated she heard a lot of noise and that the resident was yelling out in the morning. She went into the room and the residents were agitated. She indicated STNA #6 told her the footrest had bumped the Resident #133's thigh when she was attempting to put it on the wheelchair. STNA #3 indicated she was not in the room at the time of the incident. She also indicated Resident #133 had pushed the footrest toward her when she came to assist causing the footrest to hit STNA #6's leg. Interview with Licensed Practical Nurse (LPN) #2 on 06/28/12 at 3:30 P.M. indicated she was told the footrest hit the resident in the leg. She was not present in the room at the time. Interview with STNA #1 on 06/28/12 at 4:00 P.M. with the director of nursing present indicated that a few weeks ago she had observed the bruise on Resident #133's leg. She indicated Resident #133 had told her a staff member punched her in the leg. She indicated she had told the nurse about the bruise and she was told of the leg rest incident. On 06/28/12 the facility made an Immediate (24 ) hour report and began an investigation. On 07/02/12 review of STNA #1's statement indicated the resident told her a STNA punched her in the thigh and she asked the nurse what happened. The statement did not indicate she immediately reported the allegation of a STNA punching the resident to the nurse. This was an incidental finding at the time of the Complaint Investigation.