Every finding on record at Hillsboro Health and Rehab LLC

Based on observation, staff interviews and record reviews, the facility failed to ensure food was stored, prepared and served in a safe and sanitary manner to prevent foodborne illness. This affected all 76 residents who received foods from the kitchen. The facility total census was 76.Findings include:Observations during the kitchen tour on 05/26/26 at 8:17 A.M., revealed there were two ceiling vents directly above the food preparation areas and stove which had a visible buildup of gray colored debris. There were three stacks of unopened boxes of food stored directly on the floor of the freezer. There was an open thickener container with no open date. There was no thermometer inside the milk cooler.Review of the dishwasher temperature and sanitation log on 05/26/26 at 8:30 A.M. for May 2026 with Dietary Manager #500 (DM), revealed no record of the sanitation testing results for the dishwasher. DM #500 stated the facility changed from a high temperature style dishwasher, which did not require sanitization testing, to a low dishwasher style, which required sanitation testing, sometime in May 2026. DM #500 verified the dishwasher logs from 05/01/26 through 05/27/26, had no recordings of the dishwasher sanitation testing completed. DM #500 verified the low temperature dishwasher sanitation must be monitored and recorded during the dishwasher cycles after each meal to ensure the proper level of sanitation is reached by the dishwasher.Observation of the 400-unit resident refrigerator on 05/28/26 at 9:00 A.M. with Licensed Practical Nurse (LPN ) #408, revealed a sign on the outside of the refrigerator stating all items must have a date, name of resident and name of item. There were three containers of food identified as staff foods in the refrigerator. There were six open-food items, identified as residents' foods, with no open dates.During an interview on 05/28/26 at 9:00 A.M., LPN #408 verified the resident refrigerator should be for the storage of resident food items only and the open foods should have an open date. Observation on 05/28/26 at 9:15 A.M. with the Director of Nursing, (DON) revealed the resident designated refrigerator on the 200-unit had an area of approximately four inches by two inches area on the bottom shelf of dried red debris. The freezer had approximately one inch built up of ice around top and sides of freezer. Interview at the same time, the DON verified that the bottom shelf needed to be cleaned and the freezer needed to be defrosted. The DON stated the night shift aides are to maintain the cleanliness of the resident refrigerators.Review of facility policy titled, Sanitation, dated 2008, revealed the low temperature dishwasher must have a final rinse of 50 parts per million, (PP) for at least 10m seconds.Review of facility policy titled, Food Storage , dated 2008, revealed the foods shall be received and stored in a manner that complies with safe food handling.Review of facility policy titled, Safety of Foods Brought by Visitors, dated 2008, revealed staff will ensure food is in a labeled container with resident's name and discarded three days from date received.

Based on observation, staff interviews and record reviews, the facility failed to provide and serve foods as planned by the Registered Dietitian (RD). This affected four Residents ( #1, #2, #57, and #4) of the four residents reviewed. The facility total census was 76. 1) Record review of Resident #1 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #1 included diabetes, chronic obstructive pulmonary disease, morbid obesity, and respiratory failure. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE], revealed Resident #1 had intact cognition and required set up assistance for meal and unable to ambulate. Review of the physician order for Resident #1 dated 03/31/26, revealed the resident was ordered a consistent carbohydrate large portion diet.Review of Resident #1's breakfast ticket on 05/27/26 at 8:06 A.M., revealed the resident was to receive a consistent carbohydrate regular portion diet.Observation on 05/27/26 at 8:10 A.M. with Dietary Manger (DM) #500 revealed Resident #1 received two servings of egg and two servings of biscuit with sausage gravy and two servings of egg. Observation on 05/28/26 at 8:00 A.M. with DM #500 revealed Resident #1 received no syrup or butter with his meal of waffles.During an interview on 05/27/26 at 8:15 A.M., DM #500 verified Resident #1 should not have received two servings of biscuit with sausage gravy and two servings of egg on consistent carbohydrate regular or on a large portion diet. DM #500 verified there was no specified definition of the measurement of description of what a large portion consisted of on the meal spreadsheet or in a policy. DM #500 stated the cook was to follow the food portions listed on the residents' meal ticket and the therapeutic diet meal spreadsheet. During an interview on 05/28/26 at 8:05 A.M., DM #500 verified Resident #1 received no syrup or butter with his meal of waffles and should have received diet syrup and butter with his meal of waffles, as listed on his meal ticket and the therapeutic diet meal spreadsheet. 2) Record review of Resident #2 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #2 included chronic obstructive pulmonary disease (COPD), anxiety disorder, kidney failure, cerebral vascular accident, heart failure, and diabetes. Review of the physician order for Resident #2 dated 04/13/26, revealed the resident was ordered to receive a consistent carbohydrate large portion diet.Review of the MDS comprehensive assessment dated [DATE], revealed Resident #2 had intact cognition and required assistance with Activities of Daily Living (ADL). Review of Resident #2 's breakfast meal ticket dated 05/027/26 at 8:08 A.M., revealed the resident was to receive one biscuit with sausage gravy and one egg. Observation on 05/27/26 at 8:05 A.M. with DM #500, revealed Resident #2 received two servings of egg and two servings of biscuit with sausage gravy and two servings of egg. The resident received regular syrup with his meal of waffles as listed on his meal ticket and the therapeutic diet meal spreadsheet. During an interview on 05/27/26 at 8:15 A.M., DM #500 verified Resident #2 should not have received two servings of biscuit with sausage gravy and two servings of egg on consistent carbohydrate regular or on a large portion diet. DM #500 verified there was no specified definition of the measurement of description of what a large portion consisted of on the meal spreadsheet or in a policy. The cook was to follow the food portions listed on the residents' meal ticket and the therapeutic diet meal spreadsheet.Observation on 05/28/26 at 8:05 A.M. with DM #500, revealed Resident #2 received regular syrup with his meal of waffles. Interview at the same time, DM #500 Verified Resident #2 received regular syrup with his meal of waffles and should have received diet syrup on with his meal of waffles, as listed on his meal ticket and the therapeutic diet meal spreadsheet 3) Record review of Resident #57 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #57 included dementia, chronic obstructive pulmonary disease, hypertensive heart disease, diabetes, and chronic kidney disease. Review of the physician order for Resident #57 dated 05/09/23, revealed the resident was ordered to receive a no added salt diet and house supplement three times a day .Review of the MDS comprehensive assessment dated [DATE], revealed Resident #57 had severely impaired cognition and required assistance with Activities of Daily Living, (ADL) skills. Review of the Resident #57's meal ticket on 05/27/26 at 8:35 A.M., revealed the resident was to receive a 2-gram sodium no added salt diet. The breakfast meal ticket indicated the resident was to receive a low sodium fried egg sandwich. Review of the recipe for low sodium fried egg sandwich on 05/27/27 following reviewing the meal ticket, the sandwich was to consist of one large fried pasteurized egg between two slices of white toasted bread. Observation on 05/27/26 at 8:35 A.M. with DM #500, revealed Resident #57 received a sliced biscuit with scrambled eggs in between the slices of biscuit. During an interview on 05/27/26 at 9:35 A.M., DM #500 and [NAME] #501 verified Resident #57 received a sliced biscuit with scrambled eggs in between the slices of biscuit and should have received a fried egg sandwich . The sandwich should have consisted of one large fried pasteurized egg between two slices of white toasted bread. [NAME] #501 revealed there were no pasteurized eggs available, and she was unaware of the Resident #57 diet required a fried egg sandwich. 4) Review of Resident #4 medical record revealed an admission date of 11/12/24 with diagnoses including dementia, diabetes mellitus type two, unspecified psychosis, osteoporosis, hypertension and hypothyroidism.Review of the physician order for Resident #4 dated 09/25/25, revealed the resident was ordered to receive a no added salt and consistent controlled carbohydrate diet.Review of the Quarterly MDS dated [DATE] revealed Resident #4 had cognitive impairments and is dependent on staff for set-up/clean up assistance with eating, oral hygiene, and upper and lower body dressing including footwear. She requires partial to moderate assistance with showering and bathing. Review of Resident #4's meal ticket on 05/27/26 at 7:35 A.M., revealed the resident was to receive a 2-gram sodium no added salt diet. The breakfast meal ticket revealed the resident was to receive a low sodium fried egg sandwich.Observation on 05/27/26 at 7:35 A.M. revealed Resident #4 received a biscuit and gravy. There was no substitute or preference written the tray ticket for biscuit and gravy. During an interview on 05/27/26 at 7:35 A.M., [NAME] #501 verified Resident #4's meal ticket stated a fried egg sandwich was to be served as listed on the meal ticker for the 2-gram sodium diet and on the diet meal spreadsheet. [NAME] #501 verified the resident received biscuit and gravy and there was no documentation the resident had requested biscuits and gravy instead of the fried egg sandwich. During an interview on 05/27/26 at 1:12 P.M. the RD, #900 revealed the 2-gram sodium diet is the same as the no added salt diet on the therapeutic diet meal spreadsheet. RD #900 verified the foods served should be the foods listed on the meal ticket and as listed on the therapeutic diet spreadsheet. RD #900 did not have a definition of the large portion. Review of facility policy titled, Therapeutic Diets , dated 2008, revealed the food service manager will use a tray identification system to ensure that each resident receives his or her diet as ordered. Residents will not receive extra portions that are not part of the diet. There was no definition of large portion measurement provided.

Based on observation, staff interview, and record review the facility failed to ensure infection control standards were implemented. This affected four residents (Resident #80, Resident #13, Resident #62, and Resident #51) out of five residents reviewed for infection control. The facility census was 76.Findings Include: 1) Record review for Resident #80 revealed this resident was admitted to the facility on [DATE]. Diagnoses included acute posthemorrhagic anemia, dementia, and cerebrovascular disease.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 had severe cognitive impairment evidenced by a Brief Interview for Mental Status (BIMS) score of 01. This resident was assessed to require to be dependent on staff for all activities of daily living (ADL). Record review for Resident #13 revealed this resident was admitted to the facility on [DATE]. Diagnoses included acute parkinsonism, depression, and dementia. Review of the MDS assessment dated [DATE], revealed Resident #13 had severe cognitive impairment. The resident was dependent on staff for all ADL. Record review for Resident #62 revealed this resident was admitted to the facility on [DATE]. Diagnoses included acute chronic kidney disease, stage 2, chronic kidney disease, and major depressive disorder.Review of the MDS assessment dated [DATE], revealed Resident #62 had severe cognitive impairment evidenced by a BIMS score of 03. This resident was assessed to require maximal assistance for ADL. Record review for Resident #51 revealed the resident was admitted to the facility on [DATE]. Diagnoses included acute muscle weakness, dysphagia oropharyngeal phase, and displaced intertrochanteric fracture of left femur.Review of the MDS assessment dated [DATE], revealed Resident #51 had intact cognition evidenced by a BIMS score of 15. This resident was dependent for all ADL. Resident is always incontinent of bladder and bowel. Observation of the medication administration on 05/27/26 at 7:50 A.M to 8:30 A.M. revealed Registered Nurse (RN) #402 administered medications to Resident #80, Resident #13, and Resident #62 without any hand hygiene. RN #402 was observed to go help another staff member and then prepared and administered Resident #80's medications without using hand hygiene. RN #402 was observed using their bare hands to place Resident #62's medication in their medication cup.During an interview on 05/27/26 at 8:35 A.M, RN #402 confirmed there was no hand hygiene used between administering medications to Resident #80, Resident #13, and Resident #62. RN #402 verified using bare hands to place Resident #62's medication in their medication cup. 2.) Observation of incontinence care on 05/28/26 at 11:48 P.M. completed by Certified Nursing Assistant (CNA) #210 and Nurse Supervisor (NS) #410 revealed CNA #210 did not change gloves after incontinence care and used the same gloves to apply a clean brief to Resident #51. CNA #210 did not change gloves from the beginning to the end of care. During an interview on 5/28/26 at 12:15 P.M., NS #410 confirmed CNA #210 did not change gloves from the beginning to the end of care. Review of the facility policy, Administering Medications dated on December 2009 revealed staff shall follow infection control procedures when administering medications.Review of the facility policy, Perineal Care dated on December 2011 revealed staff must discard gloves, use hand hygiene, and apply clean gloves prior to putting a clean brief on a resident.

Based on observation, staff interview, and record review the facility failed to ensure medications were labeled properly. This affected two residents (Resident #39 and Resident #4) out of five residents reviewed. The facility also failed to ensure immunizations were stored properly. This had the potential to affect all residents. The facility census is 76.Findings include:Record review for Resident #39 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes, hypothyroidism, and unspecified fracture of the lower right leg.Review of the physician order for Resident 39 dated 05/04/26, revealed the resident was ordered to receive Fiasp (ultra-fast acting insulin aspart) FlexTouch subcutaneous solution pen-injector and Trulicity (diabetes) subcutaneous injection. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #39 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 14. This resident was assessed to require to be dependent on staff for all activities of daily living (ADL).Record review for Resident #4 revealed the resident was admitted to the facility on [DATE]. Diagnoses included type 2 diabetes mellitus with hyperglycemia, gastro-esophageal reflux disease without esophagitis, and hypertension.Review of the physician order for Resident #4's dated 10/01/25, revealed the resident was ordered to receive Lantus (long-acting insulin injection) Solostar subcutaneous solution pen-injector. Review of the MDS assessment for Resident #4 dated 04/08/26 revealed the resident had moderate cognition evidenced by a BIMS score of 8. This resident was assessed to require moderate assistance for activities of daily living (ADLs). Observation of the 400-hall medication room on 05/26/26 at 4:06 P.M. with the Director of Nursing (DON), revealed there was one vial of tuberculin in the medication refrigerator with an open date for 02/11/26. Interview with the DON at the same time verified the findings. Observation of the 100-hall medication cart on 05/26/26 at 4:32 P.M. with the DON revealed one Fiasp FlexTouch solution pen-injector and one Trulicity solution auto injector for Resident #39. Both were open with no open date and no expiration date. The DON verified the findings at the time of the observation. Observation of the 200-hall medication cart on 05/26/26 at 4:34 P.M. with the DON, revealed one Lantus Solostar solution pen-injector for Resident #4. The Lantus pen was opened with no open date or expiration date. The DON verified the findings at the time of the observation. Review of the facility policy titled, Administering Medications revealed when opening a multi-dose container, the date shall be recorded on the container.

Based on observation, staff interview, and review of facility documentation, the facility failed to maintain comfortable water temperatures. This affected one (#10) out of the five residents reviewed for environment but had the potential to affect all 22 residents on the 100-hallway. The facility census was 76.Findings include:Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses include type II diabetes mellitus, generalized muscle weakness, adjustment disorder with anxiety, and essential hypertension.Review of Minimum Data Set (MDS) dated [DATE], revealed Resident #10 was cognitively intact. During an interview on 05/26/26 at 10:17 A.M., Resident #10 stated she has not had hot water in her bathroom since February. Resident #10 stated she receives a tub of warm water in the morning and evening to wash with but would like to be able to use the hot water in her bathroom. During an interview with Resident #10, the hot water was turned on and left running for five minutes and did not get warm. During an interview on 05/26/2026 at 2:20 P.M., Maintenance Director #308 confirmed that the residents of the 100-hallway have not had hot water in their rooms since March 2026. Maintenance Director #308 stated two hot water heaters on 100-hallway were replaced in March but did not fix the problem. Maintenance Director #308 stated after the water heaters were replaced, they discovered a water line was busted which needed to be fixed in order for the hot water to be functional on the 100-hallway. Maintenance Director #308 stated he had submitted the bid for the repair to corporate office on/around April 2026, but it has not yet been approved. Observation of the water temperatures for the 100-hallway on 05/26/26 at 3:40 P.M. and taken by Maintenance Director #308, revealed that seven of the nine bathrooms on the 100 hallways had hot water temperatures in the 63 - 67 degree Fahrenheit range.

Based on closed medical record review, observations, interviews with facility staff and a facility resident, interview with Medical Director #275, interviews with Resident Representatives, interviews with Homeless Shelter employees, interviews with insurance employees, and interview with Ombudsman #250, the facility failed to provide a safe discharge to an appropriate location for Resident #79. On 12/08/25 Resident #79, who had resided in the facility for more than 22 years, was discharged to a homeless shelter with no income and had limited skills, knowledge, and resources required to provide for himself. In addition, the homeless shelter did not have staff with medical knowledge or training and had experienced recent funding cuts which resulted in no programs available to assist the resident in obtaining housing. The homeless shelter only provided food and housing for a maximum of 90 days. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or negative health outcomes on 12/08/25 when Resident #79, who had diagnoses including type one diabetes mellitus, celiac disease, hypokalemia, degenerative disease of the nervous system, and long-term use of insulin was discharged to the homeless shelter without sufficient notice, preparation, skills, or knowledge to provide care for himself and to obtain income and housing before the 90 day stay at the homeless shelter expired. This affected one (Resident #79) of four residents reviewed for discharge. The facility census was 74. On 12/15/25 at 4:07 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 12/08/25 when Resident #79 was discharged to a homeless shelter with limited diabetic supplies, insufficient skills and knowledge to provide adequate care for himself, and less than 90 days to obtain income and housing before the stay at the homeless shelter expired. Information obtained during the investigation revealed concerns identified by the local Ombudsman as well as homeless shelter staff related to the homeless shelter not being an adequate or appropriate and safe discharge location for Resident #79. The immediate Jeopardy was removed on 12/19/25, when the facility implemented the following corrective actions: -On 12/15/25, the Administrator immediately reviewed the last 30 days of discharges to ensure safe discharges occurred. No other areas of concern were noted. Follow up contact was made to Resident #83, # 84, #85, #86, #87, and #88 who were discharged in the last 30 days. No concerns regarding discharge and no additional needs were identified by each resident. -On 12/15/25, the Administrator immediately reviewed the pending discharges for Resident #16 and Resident #26 to ensure safe discharges plans with no other areas of concern noted. -Social Services Director #180 and/or designee will notify the Ombudsman of the date the discharge notice is given. -On 12/15/25, an in-service regarding the discharge process was completed by the Administrator with Social Services Director #180 that addressed the following: 1. Except as specified below, a resident, and/or his or her representative will be given thirty (30)-day advance notice of an impending transfer or discharge from our facility: a. The transfer is necessary for the residents' welfare and the residents' needs cannot be met in the facility. b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the residents no longer need the services provided by the facility. c. The safety of individuals in the facility is endangered due to clinical or behavioral status of the residents. d. The health of individuals in the facility would otherwise be endangered. e. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. f. An immediate transfer or discharge is required by the residents' urgent medical needs. g. The resident is transferred for other than medical reasons. h. The resident has not resided in the facility for thirty (30) days; and/or i. The facility ceases operating. 2. The resident, and/or representative will be provided with the following information: The facility will send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. a. The reason for the transfer or discharge. b. The effective date of the transfer or discharge. c. The location to which the resident is being transferred or discharged . d. The name, address, and telephone number of the state long-term care ombudsman. e. The name, address, and telephone number of each individual or agency responsible and the name, address, and telephone number of the state department agency that has been designated to handle appeals of transfers and discharge notices. 3. The facility will not transfer or discharge the resident while an appeal for discharge is pending, unless the failure to discharge or transfer will endanger the health or safety of the resident or other individuals in the facility. -On 12/15/25, a Quality Assurance and Performance Improvement (QAPI) meeting with the Administrator, Director of Nursing, Medical Director #275 and SSD #180 was held to review the discharge policy and procedure. No changes were made to the discharge policy and procedure at this time. -On 12/17/25, the Facility Administrator was in-serviced by [NAME] President of Operations #375 regarding the discharge process, required notifications, required notices, and preparation and orientation for discharge. -On 12/17/25, a full Intradisciplinary Team (IDT) meeting was held which included the Administrator, DON, SSD #180, Business Office Manager (BOM) #152, Assistant Director of Nursing (ADON) #166, and Activity Director #128 regarding the discharge process, required notifications, required notices, and preparation and orientation for discharge that addressed the following: 1. Except as specified below, a resident, and/or his or her representative will be given thirty (30)-day advance notice of an impending transfer or discharge from our facility: a. The transfer is necessary for the residents' welfare and the residents' needs cannot be met in the facility. b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the residents no longer need the services provided by the facility. c. The safety of individuals in the facility is endangered due to clinical or behavioral status of the residents. d. The health of individuals in the facility would otherwise be endangered. e. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. f. An immediate transfer or discharge is required by the residents' urgent medical needs. g. The resident is transferred for other than medical reasons. h. The resident has not resided in the facility for thirty (30) days; and/or i. The facility ceases operating. 2. The resident, and/or representative will be provided with the following information: The facility will send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. a. The reason for the transfer or discharge. b. The effective date of the transfer or discharge. c. The location to which the resident is being transferred or discharged . d. The name, address, and telephone number of the state long-term care ombudsman. e. The name, address, and telephone number of each individual or agency responsible and the name, address, and telephone number of the state department agency that has been designated to handle appeals of transfers and discharge notices. 3. The facility will not transfer or discharge the resident while an appeal for discharge is pending, unless the failure to discharge or transfer will endanger the health or safety of the resident or other individuals in the facility. -On 12/19/25, A full house education was done by the Administrator and DON regarding the discharge process, required notifications, required notices, and preparation and orientation for discharge. -Pending discharges will be discussed in the Stand-up Meeting daily Monday-Friday on business days, discharges pending for the weekends or holidays will be covered in the meeting Monday-Friday by Friday, with the IDT to ensure safe discharge plans and teaching or other needs. The IDT includes the following: Administrator, DON, ADON #166, BOM #152, SSD #180, and Activity Director #128. In the absence of one of these team members the other team members will act on their behalf. -The Administrator, DON, or SSD #180 will notify Medical Director #275 of any pending discharge plans daily Monday-Friday on business days, discharges pending for the weekends or holidays will be covered in the meeting Monday-Friday by Friday. -Pending discharge plans will be reviewed by the Administrator and/or designee and Director of Nursing and/or designee in Stand-up Meeting at least 3 times weekly for 6 weeks to ensure safe discharge plans have been made. Although the Immediate Jeopardy was removed on 12/19/25, the deficiency remains at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Closed record review for Resident #79 revealed the resident was admitted to the facility in 05/2003 and had diagnoses which included type one diabetes mellitus, celiac disease, hypokalemia, degenerative disease of the nervous system, and long-term use of insulin. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/13/25, revealed the resident was cognitively intact. Review of the care plan, initiated on 06/05/19 and cancelled on 12/09/25, revealed Resident #79 was at risk for impaired visual function related to history of cataracts, history of glaucoma, and diabetes mellitus with history of diabetic retinopathy and cataracts. Interventions included refer to ophthalmologist/optometrist as needed. Review of the care plan, initiated on 10/26/25 and cancelled on 12/09/25, revealed Resident #79 had a functional ability deficit and required assistance with self-care/mobility related to celiac disease, diabetes mellitus type one retinopathy, hypomagnesemia, Vitamin D deficiency, hypokalemia, and anemia. Interventions included staff to assist with completion of Activities of Daily Living (ADLs) daily. Review of the care plan, initiated on 06/05/19 and cancelled on 12/09/25, revealed Resident #79 was at risk for fluctuation in blood sugar levels related to diabetes mellitus. Required daily insulin, hypoglycemic unaware, and non-compliance with diabetic diet. Able to draw up own insulin into syringe. Had a history of requiring supervision to draw insulin up into syringe to assure correct dose is drawn up and required teaching to alternate sites of insulin injections. Required oversight with diabetic regimen due to history of non-compliance and knowledge deficits. Chooses to perform his own accu-checks at times. Prefers nursing staff to administer his insulin to him at times. Requires supervision with insulin regimen. Interventions included observe for signs and symptoms of hyperglycemia and hypoglycemia, provide supervision when performing own accu-checks and educate as needed when not performing accu-checks per facility standards, supervise when drawing up own insulin into syringe to ensure correct dose of insulin is drawn up into syringe, and supervise when giving own insulin injections and ensure that guest is performing insulin injection correctly and is alternating sites of injections. Review of the care plan, initiated on 03/06/20 and cancelled on 12/09/25, revealed Resident #79 required 24-hour care/Long Term Care (LTC) placement at this time. Resident has verbalized acceptance of plans to remain in the facility. Interventions included assessing discharge plans on admission and review quarterly. Review of all additional care plans for Resident #79 revealed no care plans for discharge planning/discharge were in place at the time the resident was discharged on 12/08/25. Review of the physician's orders, revised on 09/28/25 and ending on 12/10/25, revealed resident may draw up his own insulin and may keep glucometer at bedside to monitor blood sugars. No physician orders to self-administer insulin or other medications were present. Review of the Optometry Order Form, dated 06/30/25, revealed an order to refer to local Optometrist for neovascularization of disc, left eye (a process that can occur in our body when new blood vessels grow which may leak and cause vision loss). No additional optometry appointments or visit notes were available for review. Review of the neurocognitive assessment and testing results, dated 07/09/25, revealed Resident #79 had resided at the facility for the previous 22 years due to a long history of medical problems. The resident had a high school education and had never worked or had a job due to medical problems and had been generally supported by his parents most of his life. The resident is single and lives with a roommate at the extended care nursing facility. Both parents are deceased . He does have friends at the facility. The results of the current evaluation on Resident #79 reveal him to be a gentleman whose innate intellectual levels of function were judged to be generally within the average range. His academic levels are well within the normal range as well. He does seem to do better somewhat with nonverbal processing of information than verbal processing of information; however, his visual memory appears to be somewhat less than his verbal memory. His comprehension of ordinary affairs as well as adaptive functioning as indicated by the individual at his care facility would indicate that he has some difficulty with executive functioning and general socialization and interaction with others. While no significant psychopathology was indicated he does appear to be somewhat immature for his age and past traumatic issues were indicated and guardedness. I believe that Resident #79 has developed what appears to be some learned helplessness in terms of doing things. Clearly, intellectually he functions within the average range. Memory functions are somewhat variable, but his adaptive skills are below expectations. Review of the facility CHMI -Social Service-Re-eval - V3 assessment, dated 07/15/25, revealed Resident #79 was a long-term guest with no plans for discharge. Resident #79 has been a long-term guest for the last 22 years. Review of the facility Care Plan Conference Summary V2, dated 08/21/25, revealed topics discussed included discharge potential. The Interdisciplinary Team (IDT) held a care conference with resident to discuss plan of care. Resident is a long-term resident with no plans for discharge. Resident is happy with the care at the facility. Review of the facility CHMI-Social Service - Re-eval - V3 assessment, dated 09/07/25, revealed the resident was a long-term guest with no plans for discharge. Review of the physician progress note, dated 09/15/25, revealed Resident #79 was seen for follow-up of his diabetes mellitus, celiac disease with associated deficiencies, allergic rhinitis, and anemia. The resident is now using a continuous glucose monitor. Resident notes last sensor only lasted 14 days. Told him that the typical lifespan of them is 14 days and they have to be changed every two weeks. He voiced understanding of this. Assessment/plan: Diabetes Mellitus type 1. The resident is on 35 units of Lantus (a long-acting insulin) and 5 units of Novolog (a fast-acting insulin) three times a day. I am going to go ahead and modify the Novolog to six units three times a day. Small changes in insulin have resulted in large changes in blood sugar. Continue his sliding scale (insulin administration based on blood sugar results). Review of the facility Care Plan Conference Summary V2, dated 11/18/25, revealed topics discussed included discharge potential and insurance/financials. Care plan reviewed, code status discussed, no change indicated at this time. Review of the facility progress notes, dated 07/10/25 through 12/07/25, revealed no evidence of discharge planning, notice of intent to discharge, or need for discharge from the facility for Resident #79. No evidence of diabetic teaching was documented. No evidence of attempts to obtain income or alternative housing was documented. Review of the facility progress note, dated 12/08/25 and timed 2:09 P.M., revealed Resident #79 was discharged to the community with meds per Medical Director #275. Review of the facility Discharge Plan of Care, dated 12/08/25, revealed Resident #79 was being discharged to a homeless shelter/housing program. Social support in community/family assistance were listed as a Pastor and a friend. A follow-up appointment had been scheduled with a physician on 12/10/25 at 9:00 A.M. Nutritional needs included a carbohydrate-controlled diet. Discharge medication orders included a FreeStyle Libre 3 Reader Device (Continuous Glucose System Receiver), FreeStyle Libre 3 Sensor Miscellaneous (Continuous Glucose System Sensor), Novolog Injection Solution 100 unit/milliliter (ml), Glucose 15 Gel 40 percent, Glucagon (rDNA) Kit 1 milligram (mg), Lantus Subcutaneous Solution 100 unit/ml, Ferrous Sulfate 325 mg, MagOx 400 Oral tablet, Calcium-D Tablet 600-400 mg-unit, potassium cl ER 20 milliequivalent (mEq), Tylenol tablet 325 mg, loratadine 10 mg tablet, daily vite tablet, Vitamin C oral tablet, and Vitamin D3 oral tablet 1.25 mg. The number of medications sent with the resident had not been filled in. Review of the physician progress note, dated 12/08/25, revealed Resident #79 was seen for discharge. The resident had been residing at the facility for 22 years. At the time of his admission, he was found to be homeless, living at the local rest stop with out-of-control diabetes, weighing about 90 pounds, and suffering from severe protein-calorie malnutrition. The resident also has celiac disease with associated multiple deficiencies. He is unfortunately somewhat non-compliant with his gluten-free diet. The resident's third-party payor had unfortunately dictated they will not cover his care at this service and other alternatives including assisted living have apparently not been covered either by the insurance company and they are forcing a discharge. We have had multiple conversations with them about the residents' unique set of circumstances including his diabetes with very brittle control and his hypoglycemia unawareness where unfortunately the first symptom of hypoglycemia is typically unconsciousness. He is going to the homeless shelter where he will be supervised initially at least. He has primary care follow-up scheduled with a community physician. The resident himself feels well today but is somewhat overwhelmed with the discharge process as he has quite a lot of belongings which have been accumulated in the 22 years here in the facility. He is up and ambulatory. He has been able to check his sugars here using a Libre 3 device and has been taught to manage his sliding scale. Assessment/plan - diabetes mellitus with labile control. History of Diabetic Ketoacidosis 22 years ago but never since. Will be discharging to a homeless shelter as noted above. Has a new book for his sliding scale. Will be seeing a primary care provider in the community in two days' time and I will speak with that provider personally and give him a history. Social - as noted above, social situation is tenuous but unfortunately insurance has given us no other choice in this matter. Will try to arrange for follow-up as we can obtain, but I do believe the resident will likely be at risk for rehospitalization. This has been relayed to the third-party payor. Electronically signed by Medical Director #275 on 12/08/25 at 9:35 P.M. Interview on 12/11/25 at 9:30 A.M. with SSD #180 confirmed the employee had just started the position of Social Service Director three weeks ago. SSD #180 stated she had been employed as a Certified Nursing Assistant (CNA) in the facility prior to taking the position as SSD and was receiving education and training from the Administrator. Interview on 12/11/25 at 10:45 A.M. with Licensed Practical Nurse (LPN) #179 confirmed the employee had worked in the facility on 12/07/25 and was not aware of an upcoming discharge date or location for Resident #79. LPN #179 stated Resident #79 seemed autistic and had been left at a truck stop 22 years prior weighing around 90 pounds. LPN #179 stated she had not worked in the facility on 12/08/25 but confirmed Resident #79 was discharged to a homeless shelter on that day. Interview on 12/11/25 at 11:10 A.M. with Business Office Manager (BOM) #152 confirmed the facility changed ownership in 07/2025. BOM #152 confirmed they were sent a request for records by Resident #79's insurance company in 10/2025 and had not been getting paid for the residents stay in the facility for quite some time. BOM #152 confirmed the records were sent as requested and a denial notice was received. BOM #152 confirmed the facility was unable to find alternate placement for Resident #79 other than the homeless shelter. Interview on 12/11/25 at 11:28 A.M. with the Director of Nursing (DON) confirmed the employee had worked at the facility for six years and a new company had taken over in 07/2025. The DON confirmed Resident #79 was discharged to a homeless shelter located in the same county as the facility on 12/08/25. The DON confirmed the resident did not have a Guardian or Power of Attorney (POA) and was his own responsible person. The DON confirmed there had been discussion during a recent care conference about the resident being discharged but she was unsure where the process was at following the care conference. The DON confirmed the day after the care conference the facility received a call from the quality control department from the insurance company stating a complaint had been voiced by Resident #79's case manager regarding the facility not assisting with the discharge process. The DON confirmed she was not aware when leaving the facility on Friday 12/05/25 the resident would be discharged on Monday 12/08/25. Observation inside Homeless Shelter #500 on 12/11/25 at 1:30 P.M. revealed Resident #79 was sitting at a table in the common area watching television. Interview with the resident at the time of the observation confirmed facility staff had entered his room on the morning of 12/08/25 and told him to pack up his belongings. The resident denied knowledge he was being taken to the homeless shelter. Interview on 12/11/25 at 1:33 P.M. with Homeless Shelter House Manager (HSHM) #305 confirmed the homeless shelter was only permitted to allow people to stay for a maximum of 90 days. HSHM #305 confirmed people staying at the shelter were only permitted to have a small tote full of personal items and toiletries due to limited space. HSHM #305 confirmed Resident #79 came to the shelter with medications but without needles to inject his insulin. HSHM #305 confirmed facility staff brought needles to Resident #79 a couple days later. HSHM #305 confirmed the facility had told the shelter staff Resident #79 needed to come stay there or he would be out on the street. Interview on 12/11/25 at 1:59 P.M. with the Administrator and SSD #180 confirmed Resident #79's stay at the facility was denied payment by his insurance due to him not requiring the level of care provided by the facility. They confirmed the facility had not been getting paid for his stay since 03/2022. They confirmed he did not qualify for group homes due to not having the correct diagnoses in place. They confirmed referrals had been sent to other Skilled Nursing Facilities all with denials. They confirmed Homeless Shelter #500 was discovered by SSD #180 and the shelter had community readiness programs in place. They confirmed on 12/08/25 Resident #79 was discharged to Homeless Shelter #500. They confirmed no discharge notice had been provided to Resident #79 as he was agreeable to go. They confirmed no discharge notice had been made to the Ombudsman as of the present date and time. Interview on 12/11/25 at 2:35 P.M. with Resident #74 confirmed he was the roommate of Resident #79 prior to the resident being discharged . Resident #74 confirmed an employee who had just gotten promoted came in and told Resident #79 they had found him a place to go and made it sound like an assisted living apartment where he could cook for himself and have his own place. Resident #74 confirmed Resident #79 got some of his clothes and stuff and they took him away. Resident #74 stated I found out the next day Resident #79 was dropped off at some homeless shelter. I can't believe they would do someone dirty like that. Telephone interview on 12/11/25 at 2:59 P.M. with Resident Representative #509 confirmed she was a former employee of the facility and a friend of Resident #79. Resident Representative #509 confirmed that a current employee of the facility had messaged her and informed her Resident #79 was sent to live at the homeless shelter. Resident Representative #509 confirmed she was told Resident #79 had not been informed he was being discharged . Telephone interview on 12/15/25 at 9:14 A.M. with Resident Representative #400 confirmed she had been employed at the facility until around 08/2025 and was friends with Resident #79 as she had worked at the facility for 16 years. Resident Representative #400 confirmed Resident #79 was testing his own blood sugar, but nurses were administering his insulin. Resident Representative #400 confirmed Resident #79 was managing his own insulin at the homeless shelter but did not have the cognitive ability to make judgements regarding changing dosages based on his insulin levels. Resident Representative #400 confirmed she had to purchase insulin pen needles and insulin syringes for Resident #79 on 12/13/25 as the facility had not provided him with enough. Resident Representative #400 confirmed the facility had made a follow-up appointment for Resident #79 with a doctor to take place on 12/10/25 but did not arrange for transportation and the resident missed the appointment. Resident Representative #400 confirmed the resident called and messaged her frequently and had never mentioned being discharged until 12/08/25. Resident Representative #400 confirmed Resident #79 did not have a Driver's License, State Identification card, copy of his Social Security card, copy of his Birth Certificate, or income to assist himself in obtaining a job, income, or housing. Telephone interview on 12/15/25 at 9:30 A.M. with Insurance Employee #410 confirmed the employee was unaware Resident #79 had been discharged by the facility to a homeless shelter. Insurance Employee #410 confirmed Resident #79's insurance had stopped paying for the residents stay at the facility a couple years prior due to the resident not requiring the level of care provided at the facility. Insurance Employee #410 confirmed facility staff had told the insurance company they would just keep the resident there and deal with it. Interview on 12/15/25 at 1:50 P.M. with Medical Director #275 confirmed he had known Resident #79 since the resident was first admitted to the facility. Medical Director #275 confirmed Resident #79 had fallen through the cracks. Medical Director #275 confirmed Resident #79 had no Developmental Disability (DD) diagnosis but was likely autistic. Medical Director #275 confirmed he was aware of the need for the resident to be discharged from the facility at some point but the discharge to the homeless shelter was sudden and he was notified only about an hour before the discharge. Medical Director #275 confirmed Resident #79 was not safe to use syringes due to impaired vision and insulin pens with needles were better to administer his insulin as he had some diabetic retinopathy. Telephone interview on 12/15/25 at 2:31 P.M. with Insurance Company Case Worker #425 confirmed she had spoken with a social service employee at the facility about the goal of discharge for Resident #79 as the residents' stay was not being covered due to not meeting the criteria for placement at a Skilled Nursing Facility. Insurance Company Case Worker #425 confirmed she had talked with facility staff about the need to assist with finding some sort of income so Resident #79 could get alternate placement. Insurance Company Case Worker #425 confirmed the previous facility staff/social worker had stated Resident #79 could just remain in the facility and they would work towards getting income. Insurance Company Case Worker #425 confirmed she was not notified until 12/10/25 that Resident #79 had been discharged to a homeless shelter on 12/08/25. Telephone interview on 12/16/25 at 9:05 A.M. with Resident Representative #450 confirmed she had been the previous social worker at the facility and was employed there until 09/12/25. Resident Representative #450 confirmed she had worked at the facility for just short of nine years and there had been no plans for Resident #79 to be discharged as of her ending employment with the facility on 09/12/25. Resident Representative #450 confirmed Resident #79 was immature mentally. Resident Representative #450 confirmed there was no discharge planning documentation as of her leaving employment on 09/12/25 due to the facility agreeing to allow the resident to remain there. Resident Representative #450 confirmed Resident #79 had reached out to her stating he just wanted to go home. Interview on 12/16/25 at 10:12 A.M. with the Administrator and DON confirmed the Executive Director of Homeless Shelter #500 had posted a list on Facebook of all the services the shelter offered. They confirmed they did not assist with setting up transportation to the follow-up appointment for Resident #79 as the Executive Director of Homeless Shelter #500 had stated he would assist in doing so. They confirmed there was no documentation of self-administration of insulin or other medications in the resident's medical record since 12/04/24. They confirmed there was no additional documentation of discharge planning or diabetic teaching in the resident's medical record since 07/2025. Telephone interview on 12/16/25 at 10:40 A.M. with Executive Director #360 (Homeless Shelter #500 employee) confirmed he had told staff at the facility this would not be a good program for Resident #79 as the resident did not have any recent work skills or references, had no income, and had no life skills. Executive Director #360 confirmed he told the facility as a last resort they would be happy to help. Executive Director #360 confirmed after 90 days the resident would be discharged out of the homeless shelter and there were no good housing options for him. Executive Director #360 confirmed medical care and treatment were not provided by himself or House Manager #305 and they were the only two employees of the shelter. Executive Director #360 confirmed Resident #79 seemed to have the mentality of a child and appeared to be agoraphobic (fearing or avoiding places or situations which might cause panic) as he almost always remained in his dorm on his bed. Interview on 12/16/25 at 11:51 A.M. with Ombudsman #250 during her visit to the facility revealed a complaint regarding an inappropriate discharge had been called into the Ombudsman's office for Resident #79. Ombudsman #250 confirmed she had visited Resident #79 at Homeless Shelter #500 and he had stated he was unaware of discharge plans prior to 12/08/25 and wanted to return to the facility. Ombudsman #250 confirmed she had not been notified by the facility of the plan to discharge the resident before or after his discharge. Ombudsman #250 confirmed she was filing an appeal regarding the resident's inappropriate discharge. Interview with LPN #179 on 12/16/25 at 2:31 P.M. confirmed Resident #79 was able to draw up his own insulin but had problems with his eyesight and did not do well with insulin vials and insulin syringes. Telephone interview on 12/16/25 at 3:52 P.M. with Insurance Employee #472 confirmed neurocognitive testing had been completed for Resident #79 prior to his discharge which showed the resident had developed learned helplessness while residing in the facility. Insurance Employee [TRUNCATED]

Based on closed record review and staff interviews, the facility failed to provide notice of discharge timely and appropriately. This affected one resident (#79) out of the four residents reviewed for discharge. The facility census was 74.Findings include:Closed record review for Resident #79 revealed the resident was admitted to the facility in 05/2003 and had diagnoses which included type one diabetes mellitus, celiac disease, hypokalemia, degenerative disease of the nervous system, and long-term use of insulin.Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/13/25, revealed the resident was cognitively intact.Further record review for Resident #79 revealed no discharge notice had been provided to the resident or Ombudsman prior to the resident being discharged from the facility on 12/08/25.Interview on 12/11/25 at 1:59 P.M. with the Administrator and Social Service Director #180 confirmed no discharge notice had been provided to Resident #79 as he was agreeable to go. They confirmed no discharge notice had been made to the Ombudsman as of the present date and time.This deficiency represents non-compliance identified during the investigation of Complaint 2690578 and 2688635.

Based on record review and staff interview the facility failed to utilize the services of a registered nurse (RN) for at least eight hours a day, seven days a week as required. This had the potential to affect all 74 residents residing at the facility. The facility census was 74.Findings Include:Review of facility staff records titled Daily Staffing dated 08/06/2025 through 08/13/2025, revealed that no RN was was staffed at the facility on 08/08/2025, 08/09/2025, 08/10/2025 and 08/13/2025.Interview with Director of Nursing and Administrator on 08/13/2025 confirmed that no RN was scheduled or worked on those days. This deficiency represents non-compliance investigated under Master Complaint Number 258139 Complaint Number 2574281.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observations, record reviews, and interviews, the facility failed to ensure residents were transferred in a manner to prevent major injury. This affected one resident (#24) out of the three residents reviewed for accidents. The facility census was 86. Actual harm occurred on 10/05/23 at approximately 1:00 P.M. when Resident #24 sustained a fracture of the right distal tibia during a staff assisted transfer from the resident's room to the shower room in a shower chair which did not have leg and foot support. Findings include: Record review for Resident #24 revealed an admitted [DATE] and diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right side, spastic hemiplegia affecting the right side, anxiety disorder, dementia, unspecified visual loss, age-related nuclear cataract, and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/13/23, revealed Resident #24 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 03. Resident #24 was assessed to require extensive assistance from two staff members for bed mobility, extensive assistance from one staff member for transfers and toileting and was dependent on one staff member for locomotion on the unit. Resident #24 was assessed to utilize a wheelchair for mobility. Review of the care plan, most recently revised on 05/23/22, revealed Resident #24 had an Activities of Daily Living (ADL) Self Care Performance Deficit and required assistance with ADLs and mobility related to weakness, lack of coordination, impaired mobility, and hemiplegia. Interventions included resident was unable to ambulate and required a wheelchair for locomotion, resident needed to be pushed (extensive assistance of one) but could assist with propelling own wheelchair at times. Review of the late entry nurses progress note, dated 10/05/23 and timed 2:00 P.M., revealed the writer was notified that while Resident #24 was in shower chair being transported to her room Resident #24's right foot became caught under the shower chair. The physician was notified, and new orders were obtained for a two view x-ray of the right foot. Review of the facility incident report, dated 10/05/23, revealed on 10/05/23 around 1:00 P.M. State tested Nursing Assistant (STNA) #200 and another STNA transferred Resident #24 from the bed onto shower chair. Resident #24 crossed her right foot over her left foot due to weakness of the right leg. STNA #200 then proceeded to push Resident #24 from her room to the shower room in the shower chair. While pushing Resident #24 down the hallway, the resident's right foot came off the left foot and got stuck under the shower chair. STNA #200 stopped pushing the shower chair, then pulled the chair back to get the resident's right foot out from under the shower chair. STNA #200 reported that when she asked the resident if she was in pain the resident pointed to her right foot. Review of the physician's visit note, dated 10/05/23, revealed Resident #24 was seen on 10/05/23 for evaluation of the right ankle. The resident apparently twisted the ankle and notes pain in the right ankle. There was swelling of the right ankle compared with the left ankle and the resident had pain with inversion and eversion of the ankle. The documented assessment/plan included right ankle swelling, could be related to previous stroke but also consider possibility of fracture. Will obtain two view x-ray. Review of the radiology report, dated 10/07/23, revealed an acute medial malleolar fracture and possible distal fibular fracture of the right ankle. Observation on 10/27/23 at 10:32 A.M. revealed Resident #24 was lying in bed and had an orthopedic boot in place to the right lower leg, ankle, and foot. Resident #24 was interviewed at the time of the observation regarding the incident on 10/05/23 and stated They hurt me before becoming tearful and falling back asleep. Interview with STNA #200 on 10/27/23 at 11:15 A.M. revealed on 10/05/23 she had transferred Resident #24 from the bed to the shower chair in the resident's room. STNA #200 then assisted Resident #24 to place her right leg over her left leg, as the resident had right sided weakness and had to use her left leg to support the right leg during transfers in the shower chair. STNA #200 further stated while she was pushing Resident #24 down the hallway in the shower chair, the resident's right shoe came off and the resident's right leg fell and became stuck under the shower chair. Resident #24 exclaimed Ow! and STNA #200 immediately stopped, backed up the shower chair, and got the resident's right foot out from under the chair and placed it back on Resident #24's left leg until they reached the shower room. The deficient practice was corrected on 10/13/23 when the facility implemented the following corrective actions: On 10/05/23 the medical director was notified of the incident and assessed the resident. On 10/06/23 all facility shower chairs were taken out of service until staff education was completed. On 10/06/23 the Director of Nursing (DON)/designee educated all nursing staff regarding not using shower chairs for transport and monitoring foot placement during transport. On 10/13/23 an audit was conducted of all residents residing in the facility to determine if the residents utilized a wheelchair and/or footrests for mobility. Audits of residents being transported to the shower using appropriate seating devices and monitoring of resident foot placement were conducted on 10/09/23, 10/16/23, and 10/23/23 by the DON/designee with no discrepancies noted. Quality Assurace and Performance Improvement (QAPI) will review the audits during monthly meeting to ensure corrective action effective and no ongoing safety problems related to transfers. This deficiency represents non-compliance identified during the investigation of Complaint OH00147291.

Based on observation, review of open and closed medical records, staff interviews, review of a death certificate, review of water sample testing reports, review of weekly water temperature and chlorine level logs, review of water sample testing kit manufacturer's instructions, review of the facility's water management plan, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to ensure the water system was accurately tested for chlorine levels and maintained in a safe manner which resulted in elevated levels of Legionella bacteria in the facility's water system and exposure to the residents. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death when one resident (#100) was found to have altered mental status and abnormal vital signs on [DATE], was sent to the emergency room (ER) for evaluation, tested positive for Legionella pneumonia in the hospital on [DATE], and subsequently died on [DATE]. The facility's failure to have an effective water management program in place to monitor control measures to prevent the growth of potential Legionella in the water system placed all 78 residents at potential risk for Legionella bacteria exposure. Additionally, the facility failed to ensure staff members wore appropriate personal protective equipment (PPE) while in the rooms of three (#06, #22, #51) residents who had tested positive for COVID-19 infection, in accordance with CDC recommendations, to prevent further transmission of COVID-19 to residents who were not infected with the virus. This affected three (#06, #22, #51) of eight residents reviewed during the survey for implementation of appropriate infection prevention and control practices. The census was 78. On [DATE] at 5:05 P.M., the Administrator, Director of Nursing (DON), Maintenance Director #122, Regional Clinical Consultant Coordinator (RCCC) #555, Regional Clinical Consultant #444, and Contracted Corporate Employee #333 were notified that Immediate Jeopardy began on [DATE] when the facility was notified by the hospital Resident #100 tested positive for Legionella Pneumonia. Review of Resident #100's change in condition evaluation dated [DATE] revealed the resident was documented to have altered mental status, abnormal vital signs, elevated white blood count, pneumonia, and jaundice. The physician was documented as being notified on [DATE] at 2:33 P.M. and the resident was transferred to the hospital for evaluation. Review of the Resident #100's death certificate dated [DATE] revealed the resident died on [DATE] at 10:50 A.M. with an immediate cause of death as drug induced liver injury due to Legionella pneumonia, chronic obstructive pulmonary disorder, and liver cirrhosis. Review of the Legionella bacteria test result report dated [DATE], and finalized on [DATE], revealed 30 out of the 33 water samples taken from the facility on [DATE] tested positive for the presence of Legionella pneumophilia, serogroup one. Resident #100 had resided in one of the identified positive Legionella rooms. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], Resident #100 was transferred to the hospital. On [DATE], upon notification of the positive urine antigen test regarding Resident #100, all facility residents were reviewed by the DON/designee to ensure no additional residents were exhibiting symptoms consistent with Legionella infection. Medical Director #500, the Local County Health Department (LCHD), and the corporate office were notified by the DON of Resident #100's positive diagnostic test results for Legionella Pneumonia. On [DATE], the facility contracted with Industrial Water Management (IWM) to assist in testing and remediation if any Legionella bacteria was discovered. On [DATE], a meeting was held with IWM, the Ohio Department of Health (ODH), and the LCHD where the water system process flow and schematics were reviewed, and target areas were identified on the 100 and 200 hallways where Legionella bacteria could potentially grow. On [DATE], biologic Point of Use ([NAME]) filters were installed on all water outlets (showers, sinks, and beauty shop hair sink) by IWM contractors. These filters were rated for 90-day efficacy from the date of installment. On [DATE], the Administrator directed tap water to be restricted from use for drinking and cooking, and bottled water was to be used for hydration and cooking for residents and staff. The ice and juice machines were also instructed to be taken out of use. On [DATE], the facility continued daily review by the DON/designee of all resident clinical changes in condition to ensure appropriate follow-up with the physician. Since [DATE], all facility residents positive for pneumonia were tested for Legionnaire's disease (pneumonia caused by Legionella bacteria) and all tested negative. On [DATE], Dietary Manager #237 disposed of all ice in the ice machine and thoroughly disinfected the ice machine. On [DATE], the DON/designee provided in-services to all staff, residents, and residents responsible parties regarding the water management program, Legionella screening symptoms, facility remediation measures, and the plan for continued water management. On [DATE], the installation of the in-line ice filter was completed by Maintenance Director #122 using the connection kit supplied with the in-line filter provided by IWM. The ice machine was then put back into service. On [DATE], the installation of an in-line filter for the juice machine was completed by Maintenance Director #122 at which time the juice machine was put back into service. On [DATE], the facility established a water management program team to include the Administrator, Maintenance Director #122, Regional Maintenance Director #222, the DON, Health Division Risk Officer #790 from IWM, and the Environmental Consultant #898 from IWM. On [DATE], a monochloramine remediation process was completed with 2.0 to 3.0 parts per million (PPM) of monochloramine introduced paired with a contact time of 21 days. A daily flushing regime was completed following this process to ensure introduction and reintroduction of the disinfecting agent on all pipework throughout the remediation event. On [DATE], Maintenance Director #122 and all maintenance staff, Infection Control Preventionist (ICP) #200, and the Administrator were educated on the water management program policy with a focus on controls, documentation, and validation by Corporate Infection Preventionist #932. This education was provided again on [DATE]. On [DATE], IWM Employee #777 reported it would be necessary to suspend the plumbing project at the facility related to Legionella bacteria due to positive COVID-19 virus in the facility. IWM's policy indicated the company did not risk their employees' exposure to the virus. IWM Employee #777 stated the monochloramine treatment would be extended in the facility, if needed. Upon IWM resumption of the plumbing project, the dead legs would be removed or reactivated with the installation of a valve allowing for water flow so that it could be routinely flushed. On [DATE], chlorine levels of the facility water were tested and retested in the facility. IWM Employee #777 verified with facility management and ODH surveyors the current filters applied to all faucets provided adequate protection against Legionella bacteria. A retest of the facility water system will be scheduled 72 hours post-remediation. A sample set will be collected at that time, repeating the exact sample set as initially tested . Two weeks following that test, a third test will be completed. Both post-remediation water sample testing results will be submitted to the LCHD and the ODH for review. The investigation will not conclude until there is an agreement by the local and state health departments. The Administrator/designee will complete random audits weekly for eight weeks, then monthly for four months, to ensure the facility water management program is implemented and effective, controls/tasks are completed and documented, and resident review for symptoms of Legionella infection are completed during the morning clinical meeting with appropriate follow-up with the physician. Additional education and monitoring will be initiated for any identified concerns. Corrective actions will be completed as needed with additional audits to ensure corrective action was effective. Interview on [DATE] at 10:35 A.M. with Maintenance Director #122, at 2:32 P.M. with Maintenance Assistant #232, and at 2:41 P.M. with Maintenance Employee #180 all verified they were educated about water management procedures and Legionella bacteria testing. All staff members interviewed were knowledgeable regarding the content of the education. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of the closed medical record for Resident #100 revealed the resident was admitted to the facility on [DATE], discharged on [DATE], readmitted on [DATE], transferred to the hospital on [DATE], and discharged on [DATE]. This resident had diagnoses including chronic obstructive pulmonary disease, dependence on supplemental oxygen, hypertension, and heart failure. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 was assessed with intact cognition as evidence by a Brief Interview for Mental Status (BIMS) assessment score of 13. The resident was assessed to require supervision with bed mobility, transfers, toileting, and eating. Review of Resident #100's change in condition evaluation dated [DATE] revealed the resident was documented to have altered mental status, abnormal vital signs, elevated white blood count, pneumonia, and jaundice. The physician was documented as being notified on [DATE] at 2:33 P.M. and the resident was transferred to the hospital for evaluation. Review of the Resident #100's death certificate dated [DATE] revealed the resident died on [DATE] at 10:50 A.M. with an immediate cause of death as drug induced liver injury due to Legionella pneumonia, chronic obstructive pulmonary disorder, and liver cirrhosis. During an interview on [DATE] at 2:35 P.M. with the Administrator confirmed Resident #100 was diagnosed with Legionella Pneumonia and verified this diagnosis was a contributing factor to the resident's death on the death certificate. Review of the facility water temperature log as part of the facility's Legionella bacteria prevention plan revealed water was tested weekly from four random resident rooms to measure temperature and chlorine levels. Review of the weekly logs dated [DATE] through [DATE] revealed no measurements of chlorine levels present in the water. Further review of the weekly logs dated [DATE] through [DATE] revealed all chlorine level results were documented as being 0.5 PPM or higher. Review of the Legionella bacteria test result report dated [DATE], and finalized on [DATE], revealed 30 out of the 33 water samples taken from the facility on [DATE] tested positive for the presence of Legionella pneumophilia, serogroup one. Observation on [DATE] at 9:35 A.M. revealed there were specialized water filters in place on all the facility faucets and shower heads. Interview with Maintenance Director #122 on [DATE] at 3:20 P.M. revealed the facility conducted testing for Legionella bacteria annually in January and obtained water temperatures and chlorine levels in water samples weekly. Maintenance Director #122 verified there was no evidence Legionella bacteria testing was completed on facility water samples in January of 2023 as the previous maintenance director was thought to have disposed of all maintenance records prior to being walked out of the facility at the end of [DATE]. Observation on [DATE] at 1:45 P.M. revealed Maintenance Assistant #232 obtained a water sample from the bathroom sink in the conference room and tested the water sample using the WaterWorks 5-WAY Water Check testing strip. Maintenance Assistant #232 then held the testing strip bottle vertically with the cap upward and attempted to read the results by holding the testing strip vertically against the vertical bottle where the results reference was located, when he should have been reading the results horizontally due to the orientation of the bottle. Further observation revealed the testing strip had an indicator that contained five blocks per strip to test for free chlorine, total chlorine, potential of hydrogen (pH), total alkaline, and total hardness. Each block per strip was specific to each of the testing methods. The strip must be aligned across all five testing blocks for each one of the testing components with the color chart results printed on the testing strip bottle to obtain a proper reading. Interview at the time of the observation with Maintenance Assistant #232 verified he attempted to read the results in the wrong direction which would result in inaccurate readings. Maintenance Assistant #232 verified he was performing the weekly sampling of chlorine levels present in the facility water supply and may have documented inaccurate results due to reading chlorine results incorrectly. Observation on [DATE] at 3:44 P.M. revealed Maintenance Director #122 obtained a water sample from the bathroom sink in the conference room and tested the water sample using the WaterWorks 5-WAY Water Check testing strip. Maintenance Director #122 then attempted to read the results by holding the testing strip bottle vertically with the cap upward and read the results by holding the testing strip vertically against the vertical bottle where the results reference was located, when he should have been reading the results horizontally due to the orientation of the bottle. At the time of the observation, Maintenance Director #122 verified he was reading the results in the wrong direction which would result in inaccurate readings. Review of the undated WaterWorks 5-Way Water Check manufacturer's instructions revealed dip one test strip into a [NAME] sample for five seconds with a constant, gentle back and forth motion, remove the strip and shake once briskly to remove excess water, wait 25 seconds and then match pH, total alkalinity, free chlorine, total chlorine, and total hardness, in that order, to the color chart. Complete color matching within 30 seconds. Review of the facility policy titled, Water Management Plan, dated [DATE], revealed seven key activities were routinely performed in a Legionella water management program including deciding where control measures should be applied and how to monitor them and establish ways to intervene when control limits are not met. Control measures may include visible inspections, use of disinfectant, and temperature (that may require mixing valves to prevent scalding). Monitoring such control includes testing protocols for control measures, acceptable ranges, and documenting the results of testing. Review of the CDC website at, https://www.cdc.gov/legionella/wmp/healthcare-facilities/water-mgmt-validation.html, revealed according to the CDC/Healthcare Infection Control Practices Advisory Committee (HICPAC), healthcare facilities have two options for confirming that their water management program is working as intended including performing environmental sampling for Legionella and performing active clinical surveillance for infections due to Legionella. 2) Review of Resident #22's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, hypertension, constipation, depression, anxiety, diabetes mellitus type II, and COVID-19. Review of the most recent MDS assessment completed on [DATE] revealed Resident #22 was assessed with severe cognitive impairment. Review of Resident #22's physician orders revealed the resident was on isolation precautions (contact and droplet) since [DATE] when the resident tested positive for COVID-19. Observation of Resident #22 on [DATE] at 9:15 A.M. revealed the resident was lying in bed with no roommate noted. There was an isolation cart located outside of the room at the door and was stocked with N-95 face masks, gowns, face shields, and gloves for staff and visitors to put on prior to entry of the room. There was a sign posted on the door which indicated the resident was on isolation precautions. Observation of State tested Nurse Aide (STNA) #175 on [DATE] at 9:17 A.M. revealed this staff member entered Resident #22's room without wearing proper PPE as STNA #175 did not put on an N-95 face mask, gown, gloves, or a face shield prior to entering the room. Interview on [DATE] at 9:22 A.M. with Licensed Practical Nurse (LPN) #135 verified STNA #175 was in Resident #22's room while on isolation precautions without wearing proper PPE. 3) Review of the medical record for Resident #51 revealed an admitted [DATE]. Diagnoses included cerebral atherosclerosis, dementia, dysphagia, metabolic disorder, and COVID-19. Review of the MDS assessment dated [DATE] revealed Resident #51 was rarely or never understood and required extensive assistance of two staff members for transfers and mobility. Review of the nursing progress notes dated [DATE] at 1:15 A.M. revealed Resident #51 was tested for COVID-19 after signs of a non-productive cough, and the test result was positive for COVID-19. Resident #51 was started on the COVID-19 treatment medication Paxlovid. Review of physician orders dated [DATE] revealed Resident #51 was started on contact and droplet isolation for a COVID-19 positive test result. Observation and interview on [DATE] at 10:40 A.M. to 11:00 A.M. revealed Maintenance Employee #170 was observed in Resident #51's room wearing a surgical mask. Resident #51's door had a sign posted indicating the resident was in droplet and contact isolation. Interview with Maintenance Employee #170 at the time of the observation stated he was packing up a closet full of belongings from a previous resident, and confirmed he should be wearing an N-95 face mask due to Resident #51's COVID-19 isolation status. 4) Review of the medical record for Resident #06 revealed an admitted [DATE]. Diagnoses included dementia, asthma, cerebral infarct, pain syndrome, and COVID-19. Review of the MDS assessment dated [DATE] revealed Resident #06 was cognitively impaired and was totally dependent for transfers. Review of the nursing progress notes dated [DATE] revealed Resident #06 tested positive for COVID-19. Review of physician orders dated [DATE] revealed Resident #06 was started on contact and droplet isolation for a COVID-19 positive test result. Observation on [DATE] at 12:06 P.M. revealed STNA #252 and STNA #253 were passing out lunch trays to residents on the hall. Further observation revealed STNA #252 entered Resident #06's room wearing a surgical mask. Interview with STNA #252, on [DATE] at the time of the observation, confirmed Resident #06 was COVID-19 positive and N-95 face masks were to be worn when in COVID-19 isolation areas. STNA #252 stated the reason she did not wear proper PPE while in Resident #06's room was due to the facility not having enough PPE carts. Review of the CDC website at, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, last updated [DATE], revealed healthcare professionals (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a National Institute for Occupational Safety and Health (NIOSH) Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). This deficiency represents non-compliance investigated under Master Complaint Number OH00146830, Complaint Number OH00146579, and Complaint Number OH00146062. 42728 44070

Based on medical record review and staff interview, the facility failed to provide evidence that pre-admission screening and resident review (PASARR) assessments were completed and failed to follow up on PASARR level II determinations. This affected two (#24 and #32) of two resident reviewed for PASARR assessments. The census was 78. Findings include: 1. Review of the medical record for Resident #24 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis, chronic obstructive pulmonary disease, dementia, anxiety, bipolar disorder, depression, and psychotic disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was cognitively impaired and required extensive assistance of one to two staff members for transfers and mobility. Review of the medical record found no evidence of Resident #24 having any PASARR assessment completed. 2. Review of the medical record for Resident #32 revealed an admitted [DATE]. Diagnoses included paranoid schizophrenia, anxiety, and depression. Review of the MDS assessment dated [DATE] revealed Resident #32 had moderate cognitive impairment and required extensive assistance of one to two staff members for transfers and mobility. Review of the Agency on Aging Pre-Admission Screening (PAS) determination letter dated 10/19/18 revealed Resident #32 required level II services for further evaluation. Review of the medical record revealed no evidence Resident #32 had any PASARR assessment completed. Interviews on 09/27/23 from 4:15 P.M. to 4:45 P.M. with Social Services (SS) #115 revealed medical records staff should get a copy of the PASARR assessments and will inform her if changes are needed. SS #115 verified the facility did not have a copy of PASARR assessments for Resident #24 or Resident #32. SS #115 revealed they were able to get an older copy of the PASARR assessment for Resident #24, and confirmed it did not contain any mental health diagnoses and also was marked no when asking if Resident #24 had a diagnosis of dementia. Interview on 09/28/23 4:07 P.M. with SS #115 revealed Resident #32 previously was at another facility, and a request was made to get a copy of the PASARR assessment from that other facility. SS #115 verified she was unable to locate any copy of the PASARR assessment in facility records. SS #115 confirmed facility did not have any evidence of level II services being followed up for Resident #32.

Based on observation, medical record review, staff and resident interviews, review of meal tickets, and review of a facility policy, the facility failed to ensure resident food preferences were honored. This affected two (#6 and #18) of two residents reviewed for food preferences. The census was 78. Findings include: 1. Review of the medical record for Resident #6 revealed an admitted [DATE]. Diagnoses included dementia, asthma, cerebral infarct, pain syndrome, and COVID-19. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively impaired and was totally dependent for transfers. Review of the plan of care dated 08/10/23 revealed Resident #6 was at nutritional and/or dehydration risk with interventions to provide diet preferences and substitutes as ordered. Review of Resident #6's meal ticket dated 09/26/23 revealed the resident dislike of cheese. Observation on 09/26/23 from 4:50 P.M. to 5:00 P.M. revealed Resident #6 had No cheese printed on her meal ticket and was given cheese on her burger. Observation and interview on 09/26/23 at 5:22 P.M. with Licensed Practical Nurse (LPN) #187 confirmed Resident #6 received a burger with cheese. LPN #187 verified the meal ticket on Resident #6's meal tray did not match what was delivered. 2. Review of the medical record for Resident #18 revealed an admitted [DATE]. Diagnoses included chronic kidney disease stage four, dementia, heart failure, and vascular disease. Review of the MDS assessment dated [DATE] revealed Resident #18 was cognitively intact, and required extensive assistance of two staff members for mobility and transfers. Review of the plan of care dated 08/11/23 revealed Resident #18 was at nutritional and/or dehydration risk with interventions to provide diet preferences and substitutes as ordered. Review of Resident #18's meal ticket dated 09/26/23 revealed the resident disliked raw vegetables with a note of them being difficult to chew. Observation on 09/26/23 from 4:50 P.M. to 5:00 P.M. revealed Resident #18 had No raw veggies due to chewing difficulties on her ticket, and was given the raw vegetable toppings of lettuce and tomato for the burger. Observation and interview on 09/26/23 at 5:18 P.M. with State tested Nurse Aide (STNA) #214 confirmed Resident #18 received raw vegetables (lettuce and tomato) for her burger. Interview on 09/26/23 at 5:25 P.M. with Dietary Manager (DM) #237 confirmed resident preferences should be honored. DM #237 revealed she interpreted the statement for no raw vegetables on Resident #18's meal ticket to mean no hard raw vegetables such as carrots. Interview on 09/26/23 at 6:00 P.M. with Resident #18 revealed she had difficulty chewing raw vegetables, and confirmed her meal ticket requested no raw vegetables. Review of the undated facility policy titled, Food preference assessment, revealed each resident can make note of preferences in several categories including cereal, starches, bread, fruits, vegetables, and meats.

Based on medical record review staff interview, and review of Food and Drug Administration (FDA) medication information, the facility failed to provide an appropriate diagnosis for the use of psychotropic medications. This affected one (#22) of five residents reviewed for unnecessary medications. The census was 78. Findings include: Record review of Resident #22 revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, urinary tract infection, hypertension, depression, anxiety, diabetes mellitus type II, anemia, and insomnia. Review of the most recent Minimum Data Set (MDS) assessment completed 09/12/23 revealed Resident #22 was assessed with severe cognitive impairment. Review of current physician orders revealed Resident #22 received the anticonvulsant and mood stabilizer Depakote Sprinkles 125 milligrams (mg), one capsule by mouth every eight hours related to unspecified dementia, the antipsychotic medication Seroquel 25 mg, one tablet by mouth daily related to unspecified dementia, Seroquel 25 mg two tablets by mouth daily at bedtime related to unspecified dementia, and Seroquel 25mg, one-half tablet by mouth once daily related to unspecified dementia. Review of the FDA Black Box Warning for Seroquel revealed elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk for death. Seroquel was not approved for the treatment of patients with dementia-related psychosis. Interview with the Director of Nursing and the Administrator on 09/29/23 at 09:34 A.M. verified Resident #22 received Depakote and Seroquel, and confirmed unspecified dementia was not an acceptable diagnosis for the use of Seroquel and Depakote.

Based on observation, staff and resident interview, medical record review, and review of a facility policy, the facility failed to ensure residents received hearing supports and devices in a timely manner. This affected one (#2) of one residents reviewed for hearing ancillary services. The census was 78. Findings include: Review of the medical record for the Resident #2 revealed a re-admitted [DATE]. Diagnoses included diabetes mellitus type II, chronic obstructive pulmonary disease, heart failure, vascular dementia, schizophrenia unspecified. Review of an audiology evaluation dated 10/14/22 revealed Resident #2 was seen for a hearing test on 07/11/22 in which bilateral hearing loss was found. The resident voiced interest in hearing aides at that time. Further review of the report revealed facility staff agreed hearing aides were appropriate for the resident and bilateral earmold impressions were completed. The hearing test found severe to profound mixed hearing loss in the right ear and a moderately severe sensorineural hearing loss in the left ear. The plan included the resident's desire to proceed with amplification. The resident reported she previously was evaluated, and told she was getting hearing aides and impressions were taken at this time. The audiology providers gave facility the order for two hearing aides with a plan for follow up for hearing aide fitting. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact, required extensive assistance of two staff members for transfers and mobility, and assessed Resident #2 with moderate difficulty with hearing with no hear aides or appliances. Review of the plan of care dated 08/22/23 revealed Resident #2 had a hearing impairment with no care plan interventions to assess for hearing aides or order hearing aides as requested. Review of current physician orders revealed no current or past orders for Resident #2's hearing aides. Interview and observation on 09/25/23 at 10:20 A.M. with Resident #2 revealed she had difficulty hearing. Observation at that time revealed Resident #2 did not have hearing aides in her ears. Resident #2 revealed she was waiting on hearing aides, and was told by the audiologist it would take about five weeks for them to be delivered. Resident #2 voiced concern as she had been waiting several months, but could not remember exactly how long. Interview on 09/27/23 at 4:15 P.M. with Social Services (SS) #115 revealed she was not aware Resident #2 was waiting on hearing aides. SS #115 confirmed Resident #2's audiology visit dated 10/14/22 revealed hearing aides were ordered by the ancillary service provider. Interview on 09/27/23 at 4:45 P.M. with Social Services (SS) #115 revealed she never received the hearing aide order information, they were not signed by the facility physician, and the hearing aides not subsequently ordered for Resident #2. SS #115 revealed the ancillary services typically would provide this information to nursing and they were supposed to then provide it to her for follow up. SS #115 confirmed she never received the information. SS #115 revealed she got a new form, and would be providing it to the physician for their signature to get the hearing aides ordered for Resident #2. Review of facility policy titled, Social Services Referral to Outside Providers, dated 09/26/23, revealed a report from the provider visit should be maintained in the resident's medical record and service providers recommendations were to be integrated into the resident's care plan if adopted. Recommendations shall be communicated to direct staff and follow up visits and services shall be scheduled as needed. If/when new inventory appliance were received a inventory list shall be updated.

Based on record review, personal funds review, and staff interview, and review of a facility policy, the facility failed to return and complete final accounting of resident funds in a timely manner after a resident death. This affected one (#281) of one residents reviewed for discharged resident funds. The census was 78. Findings include: Review of the medical record for Resident #281 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included cerebral atherosclerosis, dementia, embolism, cerebrovascular disease, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #281 was assessed with cognitive impairment and required extensive assistance of two staff members for transfers and mobility. Review of the resident funds authorization form dated [DATE] revealed Resident #281 opened a resident fund account at the facility. Review of the resident fund statement dated [DATE] revealed Resident #281's account was closed on this date. Review of the undated Ohio Department of Medicaid Personal Needs Allowance Account Remittance Notice revealed Resident #281 died on [DATE]. The notice included information on timeliness and expectations for return of resident monies. For residents without estate and when monies are to be returned to the State of Ohio, funds are to be returned no later than 90 days after the date of death . Review of the copy of the return check dated [DATE] revealed a check was made out to the Ohio Treasury Department and Ohio Attorney General Office in the amount of $1,854.56. Interview on [DATE] at 3:06 P.M. with Business Office Manager (BOM) #160 and Corporate Business Office Manager (CBOM) #251 confirmed Resident #281 died on [DATE], and the funds were not returned until [DATE]. BOM #160 revealed she was waiting on family to reach out about funeral arrangements, and revealed she thought she had three to six months to return funds to resident, family, or State of Ohio. Review of facility policy titled, Resident Trust, dated [DATE], revealed residents discharging from the facility, or who expire while in the facility shall have account balances closed in five business days and a full accounting is provided. To ensure timely closure, business office will provide Administrator the balance report every Monday, Wednesday, and Friday for discharged residents.

Based on medical record review, staff interview, and policy review, the facility failed to complete a thorough investigation following an allegation of misappropriation of medication. This affected three (Residents #1, #10, and #15) of three residents reviewed for medication misappropriation. The census was 94. Findings include: 1. Resident #1 was admitted to the facility on [DATE]. Her diagnoses were cerebral infarction, hemiplegia and hemiparesis, hypertension, type II diabetes, anxiety disorder, venous insufficiency, pressure ulcer to left heel, hypokalemia, hypo-osmolality and hyponatremia, neuromuscular dysfunction of bladder, restless leg syndrome, hypothyroidism, peripheral vascular disease, atherosclerotic heart disease, hyperlipidemia, anemia, chronic kidney disease, heart failure, Bell's palsy, and osteoarthritis. Review of her Minimum Data Set (MDS) assessment dated [DATE], revealed she had a severe cognitive impairment. Review of Resident #1's physician orders revealed she had an order for Oxycodone HCl, five milligrams (mg) every four hours as needed for pain and an order for two tablets (tab) every four hours as needed for pain (the resident could have one to two tabs for pain per request or nursing judgment of pain level). Review of the facility and pharmacy delivery documentation dated [DATE] revealed Licensed Practical Nurse (LPN) #101 signed and accepted 60 tablets of Oxycodone HCl five mg for Resident #1. Review of Resident #1's Controlled Drug Record dated [DATE] to [DATE], revealed the form was designated for her order of Oxycodone HCl five mg tabs. The form had a pre-printed total of 60 tabs, but it was altered by an ink pen to state only 30 tabs were to be documented on the form. There was no other form or document to support the other 30 tabs, accepted by LPN #101 on [DATE], were administered, destroyed, sent back to the pharmacy, or not received when the pharmacy delivered it; there was concern the medications were misappropriated. 2. Resident #10 was admitted to the facility on [DATE]. Her diagnoses were COPD, hypertension, congestive heart failure, hypothyroidism, anxiety disorder, major depressive disorder, other chronic pain, and rheumatoid arthritis. Review of her MDS assessment dated [DATE], revealed she was cognitively intact. Review of Resident #10's physician orders revealed she had an order for Oxycodone-Acetaminophen 7XXX,d+[DATE] mg every six hours as needed for pain. Review of Resident #10's Controlled Drug Record dated [DATE], revealed 150 tabs were delivered and to be administered to Resident #10; this was confirmed by the nurse signing the form, accepting 150 tabs. On the first page of the controlled drug record, there were 11 tabs administered, which left 139 tabs of the 150. On the first page of the controlled drug record, there was also an arrow,pointed to the right, drawn below the last entry/administration of the Oxycodone-Acetaminophen, indicating there was a second page. On the second page of the same medication's controlled drug record, revealed the pre-printed number of tabs accepted by the facility was changed with an ink pen from 150 tabs to 90 tabs. The second form started documenting the administration of the medication at tab number 90. This indicated there were 49 tablets unaccounted for. 3. Resident #15 was admitted to the facility on [DATE]. Her diagnoses were chronic kidney disease (stage 4), congestive heart failure, type II diabetes, major depressive disorder, peripheral vascular disease, hypertension. hyperlipidemia, insomnia, difficulty walking, muscle weakness, anemia, personal history of transient ischemic attack, hypocalcemia, chronic pain syndrome, hypokalemia, pressure ulcer to right heel and left heel, enterocolitis, generalized edema, bipolar disorder, anxiety disorder, atherosclerotic heart disease, and dementia. Review of her MDS assessment dated [DATE], revealed she was cognitively intact. Review of Resident #15's physician orders revealed an order for Hydrocodone-Acetaminophen 7XXX,d+[DATE] mg one tab every six hours as needed for pain. Review of Resident #15's Controlled Drug Record dated [DATE], revealed the pre-printed number of tabs accepted by the facility was changed on the form with an ink pen from 118 tabs to 88 tabs, which would equal one, 30 tab bubble pack card of medication. Review of the facility Controlled Substance Inventory Count Sheet for the 100 hallway, starting date of [DATE], revealed on [DATE] at the 6:00 P.M. during nursing shift change, the outgoing nurse documented there were 30 medication containers/cards in the controlled substance lock box. LPN #101 documented, as the on-coming nurse, there were 29 containers/cards in the controlled substance lock box. There was no documented justification for the one unaccounted for card/container. Interview on [DATE] at approximately 2:20 P.M. the Director of Nursing (DON) reported he completed an investigation pertaining to the allegation of medication misappropriation, which included staff and resident interviews. However, the DON verified he did not document the investigation or staff interviews stating he, Probably should have. Therefore, there was no evidence a thorough investigation, including staff interviews to determine discrepancies with controlled medication, was completed. The facility provided no documented evidence a thorough investigation, including staff interviews, was completed regarding the allegation of misappropriation of medications. Review of the facility's Controlled Substances policy dated [DATE], revealed it is the policy of the facility to store and/or destroy all discontinued or expired controlled substances, in accordance with legal and regulatory requirements. Any discrepancies will be reported to the DON. If the DON is not available, the administrator will be informed of the error. The DON and/or administrator will initiate an investigation regarding the discrepancy as soon as the error is identified by the administrator and/or the DON. The facility will follow guidelines for reporting the the board of nursing if appropriate. Review of facility's Abuse Prohibition Policy dated [DATE], revealed allegations of resident misappropriation of property shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies. This deficiency represents non-compliance investigated under Complaint Number OH00139957.

Based on medical record review, staff interview, and policy review, the facility failed to report an allegation of medication misappropriation to the State Agency (SA) in a timely manner. This affected three (Residents #1, #10, and #15) of three six residents reviewed for medication misappropriation. The census was 94. Findings include: 1. Resident #1 was admitted to the facility on [DATE]. Her diagnoses were cerebral infarction, hemiplegia and hemiparesis, hypertension, type II diabetes, anxiety disorder, venous insufficiency, pressure ulcer to left heel, hypokalemia, hypo-osmolality and hyponatremia, neuromuscular dysfunction of bladder, restless leg syndrome, hypothyroidism, peripheral vascular disease, atherosclerotic heart disease, hyperlipidemia, anemia, chronic kidney disease, heart failure, Bell's palsy, and osteoarthritis. Review of her Minimum Data Set (MDS) assessment dated [DATE], revealed she had a severe cognitive impairment. Review of Resident #1's physician orders revealed she had an order for Oxycodone HCl, five milligrams (mg) every four hours as needed for pain and an order for two tablets (tab) every four hours as needed for pain (the resident could have one to two tabs for pain per request or nursing judgment of pain level). Review of the facility and pharmacy delivery documentation dated [DATE] revealed Licensed Practical Nurse (LPN) #101 signed and accepted 60 tablets of Oxycodone HCl five mg for Resident #1. Review of Resident #1's Controlled Drug Record dated [DATE] to [DATE], revealed the form was designated for her order of Oxycodone HCl five mg tabs. The form had a pre-printed total of 60 tabs, but it was altered by an ink pen to state only 30 tabs were to be documented on the form. There was no other form or document to support the other 30 tabs, accepted by LPN #101 on [DATE], were administered, destroyed, sent back to the pharmacy, or not received when the pharmacy delivered it; there was concern the medications were misappropriated. 2. Resident #10 was admitted to the facility on [DATE]. Her diagnoses were COPD, hypertension, congestive heart failure, hypothyroidism, anxiety disorder, major depressive disorder, other chronic pain, and rheumatoid arthritis. Review of her MDS assessment dated [DATE], revealed she was cognitively intact. Review of Resident #10's physician orders revealed she had an order for Oxycodone-Acetaminophen 7XXX,d+[DATE] mg every six hours as needed for pain. Review of Resident #10's Controlled Drug Record dated [DATE], revealed 150 tabs were delivered and to be administered to Resident #10; this was confirmed by the nurse signing the form, accepting 150 tabs. On the first page of the controlled drug record, there were 11 tabs administered, which left 139 tabs of the 150. On the first page of the controlled drug record, there was also an arrow,pointed to the right, drawn below the last entry/administration of the Oxycodone-Acetaminophen, indicating there was a second page. On the second page of the same medication's controlled drug record, revealed the pre-printed number of tabs accepted by the facility was changed with an ink pen from 150 tabs to 90 tabs. The second form started documenting the administration of the medication at tab number 90. This indicated there were 49 tablets unaccounted for. 3. Resident #15 was admitted to the facility on [DATE]. Her diagnoses were chronic kidney disease (stage 4), congestive heart failure, type II diabetes, major depressive disorder, peripheral vascular disease, hypertension. hyperlipidemia, insomnia, difficulty walking, muscle weakness, anemia, personal history of transient ischemic attack, hypocalcemia, chronic pain syndrome, hypokalemia, pressure ulcer to right heel and left heel, enterocolitis, generalized edema, bipolar disorder, anxiety disorder, atherosclerotic heart disease, and dementia. Review of her MDS assessment dated [DATE], revealed she was cognitively intact. Review of Resident #15's physician orders revealed an order for Hydrocodone-Acetaminophen 7XXX,d+[DATE] mg one tab every six hours as needed for pain. Review of Resident #15's Controlled Drug Record dated [DATE], revealed the pre-printed number of tabs accepted by the facility was changed on the form with an ink pen from 118 tabs to 88 tabs, which would equal one, 30 tab bubble pack card of medication. Review of the facility Controlled Substance Inventory Count Sheet for the 100 hallway, starting date of [DATE], revealed on [DATE] at the 6:00 P.M. during nursing shift change, the outgoing nurse documented there were 30 medication containers/cards in the controlled substance lock box. LPN #101 documented, as the on-coming nurse, there were 29 containers/cards in the controlled substance lock box. There was no documented justification for the one unaccounted for card/container. Review of the facility's Self-Reported Incidents (SRI) to the SA revealed an allegation of misappropriation for the above three residents, against LPN #101, was not reported on the day it was discovered, which was [DATE]. It was not reported to the SA until [DATE] (10 days later). Interview with Director of Nursing (DON) and Administrator on [DATE] at approximately 1:42 P.M. and 1:57 P.M. confirmed they did not report the allegation of misappropriation until [DATE]. They confirmed it should have been reported within two hours after suspicion/discovery on [DATE]. Review of the facility's Controlled Substances policy dated [DATE], revealed it is the policy of the facility to store and/or destroy all discontinued or expired controlled substances, in accordance with legal and regulatory requirements. When a controlled substance is delivered from the pharmacy, the nurse will open the controlled substance bag and confirm the resident name, name and strength of the medication, and quantity of medication; sign the pharmacy log that the controlled substance was received; complete the section of the controlled substance proof of use sheet that included amount received, date received, and nurse signature; put the medication in the medication cart controlled substance lock box, and file the controlled substance proof of use form in the appropriate binder. Add this medication to the full/partial count sheet in the binder. If the nurse discovers any of the following, the nurse will not accept the medication from the driver, and will write refused on the shipping slip; and contact the pharmacy regarding the concern: medication received does not reflect the medication order, including inaccurate dose, the count is not accurate, or liquids are delivered in a bottle that is not calibrated. The nurse will re-order the medication if it is refused and request that the medication be delivered ASAP or drop shipped. All controlled substances will be stored in the medication cart, The medication cart and controlled substance drawer will always be locked when not within view of the nurse who's responsible for the cart. The licensed nurse verifies the quantity of medication remaining, inserts quantity onto the proof of use sheet, and the DON/designee signs witness to the quantity of medication being accepted. Any discrepancies will be reported to the DON. If the DON is not available, the administrator will be informed of the error. The DON and/or administrator will initiate an investigation regarding the discrepancy as soon as the error is identified by the administrator and/or the DON. The facility will follow guidelines for reporting the board of nursing if appropriate. Review of facility Abuse Prohibition Policy, dated [DATE], revealed allegations of resident misappropriation of property shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies. This deficiency represents non-compliance investigated under Complaint Number OH00139957.

Based on state/federal economic stimulus and Medicaid guidelines, resident financial record review, staff interview, and facility policy review, the facility failed to ensure the resident's financial accounts were maintained within the appropriate limits. This affected twelve residents (Residents #28, #35, #40, #43, #50, #59, #64, #68, #71, #74, #75 and #79) of thirty-eight resident financial records reviewed. The facility census was 86. Findings include: Review of the current state Medicaid resident trust guidelines revealed each resident that utilizes Medicaid insurance may not keep more than $2,000 in a trust account. Also, the same guidelines confirmed that the COVID-19 stimulus checks (three total) do not count as monthly income; so it would not affect a resident's medical coverage. But, a resident who utilizes Medicaid insurance, and received stimulus payment(s), they have 12 months to spend that money from the time they receive it. Review of the federal COVID-19 stimulus documentation revealed three different economic impact payments made to eligible persons. The following were the dates and payment amounts for individuals: $1,200 in April 2020, $600 in December 2020/January 2021, and $1,400 in March 2021. With these guidelines, a resident who received all three stimulus payments would only be permitted to have the following amounts in their trust account: from April 2020 to December 2020/January 2021, $3,200; from December 2020/January 2021 to March 2021, $3,800; and from March 2021 to April 2021, $5,200. Starting in April 2021, residents were only permitted to have $4,000. Starting in December 2021/January 2022, residents were only permitted to have $3,400. Then, in April 2022, residents would have to be back down to the permitted $2,000. 1. Review of Resident #28's financial records revealed she utilized Medicaid as her insurance source. According to her current account statement, the resident had $3,910.14 available in her trust account effective 06/06/22. This was over the maximum allotment of $2,000.00. The resident and/or representative was provided with a spend-down notification on 03/21/22, with no other action taken. 2. Review of Resident #35's financial records revealed she utilized Medicaid as her insurance source. According to her current account statement, the resident had $4,344.61 available in her trust account effective 06/06/22. This was over the maximum allotment of $2,000.00. The resident and/or representative was provided with a spend-down notification on 03/21/22, with no other action taken. 3. Review of Resident #40's financial records revealed she utilized Medicaid as her insurance source. According to her current account statement, the resident had $4,800.05 available in her trust account effective 06/06/22. This was over the maximum allotment of $2,000.00. The resident and/or representative was provided with a spend-down notification on 03/21/22, with no other action taken. 4. Review of Resident #43's financial records revealed she utilized Medicaid as her insurance source. According to her current account statement, the resident had $3,663.18 available in her trust account effective 06/06/22. This was over the maximum allotment of $2,000.00. The resident and/or representative was provided with a spend-down notification on 03/21/22, with no other action taken. 5. Review of Resident #50's financial records revealed she utilized Medicaid as her insurance source. According to her current account statement, the resident had $5,309.03 available in her trust account effective 06/06/22. This was over the maximum allotment of $2,000.00. The resident and/or representative was provided with a spend-down notification on 03/21/22, with no other action taken. 6. Review of Resident #59's financial records revealed she utilized Medicaid as her insurance source. According to her current account statement, the resident had $5,967.09 available in her trust account effective 06/06/22. This was over the maximum allotment of $2,000.00. The resident and/or representative was provided with a spend-down notification on 03/21/22, with no other action taken. 7. Review of Resident #64's financial records revealed he utilized Medicaid as his insurance source. According to his current account statement, the resident had $5,925.79 available in his trust account effective 06/06/22. This was over the maximum allotment of $2,000.00. The resident and/or representative was provided with a spend-down notification on 03/21/22, with no other action taken. 8. Review of Resident #68's financial records revealed she utilized Medicaid as her insurance source. According to her current account statement, the resident had $3,528.97 available in her trust account effective 06/06/22. This was over the maximum allotment of $2,000.00. The resident and/or representative was provided with a spend-down notification on 03/21/22, with no other action taken. 9. Review of Resident #71's financial records revealed she utilized Medicaid as her insurance source. According to her current account statement, the resident had $5,257.38 available in her trust account effective 06/06/22. This was over the maximum allotment of $2,000.00. The resident and/or representative was provided with a spend-down notification on 03/21/22, with no other action taken. 10. Review of Resident #74's financial records revealed she utilized Medicaid as her insurance source. According to her current account statement, the resident had $6,098.77 available in her trust account effective 06/06/22. This was over the maximum allotment of $2,000.00. The resident and/or representative was provided with a spend-down notification on 03/21/22, with no other action taken. 11. Review of Resident #75 financial records revealed she utilized Medicaid as her insurance source. According to her current account statement, the resident had $9,210.38 available in her trust account effective 06/06/22. This was over the maximum allotment of $2,000.00. The resident and/or representative was provided with a spend-down notification on 03/21/22, with no other action taken. 12. Review of Resident #79's financial records revealed she utilized Medicaid as her insurance source. According to her current account statement, the resident had $4,437.51 available in her trust account effective 06/06/22. This was over the maximum allotment of $2,000.00. The resident and/or representative was provided with a spend-down notification on 03/21/22, with no other action taken. Interview with Business Office Manager (BOM) #204 on 06/07/22 at 12:05 P.M. verified Residents #28, #35, #40, #43, #50, #59, #64, #68, #71, #74, #75 and #79 have a balance over the allowable $2,000 limit for Medicaid Personal Trust Accounts. BOM #204 stated all twelve residents were issued a spend-down notification on 03/21/22. BOM #204 verified the facility has taken no other actions since then in attempt to decrease these fund accounts. Review of the facility's policy titled Resident Trust Fund Management, dated October 2019, revealed the facility will maintain the management of resident trust fund accounts in each campus to ensure compliance with state and federal guidelines. The campus will notify resident in writing who receives Medicaid benefits when the balance of the account was $200 less than the maximum amount allowed to be eligible for Medicaid. Review of the facility's undated policy titled Medicaid Fund Surplus revealed the definition of a surplus of funds was when there was an amount of cash over the resource limit for an active Medicaid recipient. Having a surplus at the time of Medicaid application or recertification can cause eligibility to be denied. To ensure the funds are appropriately spent down below the resource limit, follow the below process: funds should be spent on the needs of the resident. Clothes, toiletries, electronics, etc. Or a pre-paid burial plan.

Based on observations, staff interview, and record review, the facility failed to ensure pressure relieving devices to prevent new or worsening pressure ulcers were in place as ordered by the physician. This affected one (Resident #11) of five residents reviewed for pressure ulcers. This facility identified nine residents residing in the facility who had pressure ulcers. The facility census was 86. Findings include: Record review for Resident #11 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change Minimum Data Set (MDS) assessment, dated 03/09/22, revealed Resident #11 had severely impaired cognition. Resident #11 required extensive assistance from one staff member for bed mobility and transfers. Resident #11 had one unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) which was present upon admission to the facility. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's Treatment Administration Record (TAR), dated 06/01/22 through 06/07/22, revealed documentation that heel protectors were on as ordered on day and night shift. Review of the TAR, dated 06/08/22, revealed documentation heel protectors were on as ordered on day shift. Review of the progress notes, dated 01/01/22 through 06/07/22, revealed no documentation of refusal to wear heel protectors by Resident #11. Observation on 06/06/22 at 10:18 A.M. revealed Resident #11 was sitting up in the wheelchair beside the bed in the resident's room. No heel protectors were observed to be worn by Resident #11 on either foot. Observations on 06/06/22 at 2:35 P.M., on 06/07/22 at 11:15 A.M., on 06/07/22 at 3:06 P.M., and on 06/08/22 at 10:05 A.M. revealed Resident #11 was sitting up in the wheelchair beside the bed in the resident's room. No heel protectors were observed to be worn by Resident #11 on either foot. Observation and interview with Licensed Practical Nurse (LPN) #217 on 06/08/22 at 10:10 A.M. verified Resident #11 did not have heel protectors on either foot and there were no heel protectors visible in the resident's room. This deficiency substantiates Master Complaint Number OH 840, and Complaint Numbers OH 931, and OH 415.

Based on medical record review and staff interview, the facility failed to update a resident's Pre-Admission Screening and Resident Review (PASARR) when a significant change occurred or was discovered. This affected two (Resident #4 and #33) of two residents reviewed for PASARR. The facility census was 86. Findings include: 1. Review of Resident #4's medical record revealed Resident #4 was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of his Minimum Data Set (MDS) 3.0 assessment, dated 05/22/22, revealed Resident #4 had a mild cognitive impairment. Review of Resident #4's PASARR screening document, dated 09/13/17, revealed under section C, Medical Diagnosis, it indicated Resident #4 did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #4's face sheet and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Social Services Staff (SSS) #242 on 06/08/22 at 8:27 A.M. confirmed Resident #4's PASARR was not accurate and up to date. SSS #242 confirmed when there was a significant change in a resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of Resident #33's medical record revealed Resident #33 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of her MDS 3.0 assessment, dated 04/06/22, revealed Resident #33 had a severe cognitive impairment. Review of Resident #33's PASARR screening document, dated 02/16/22, revealed under section C, Medical Diagnosis, it indicated Resident #33 did not have any mental health diagnoses. Review of Resident #33's face sheet and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #33 PASARR screening document, dated 06/08/22, revealed under section C, Medical Diagnosis, it indicated Resident #33 only had mood disorder. Interview with Social Services Staff (SSS) #242 on 06/08/22 at 8:27 A.M. confirmed Resident #33's PASARR was not accurate and up to date. SSS #242 confirmed when there was a significant change in a resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed she updated Resident #33's PASARR this morning (06/08/22) due to seeing the mistakes that were on it. SSS #242 also confirmed that even with the update completed on 06/08/22, it still did not indicate all Resident #33's mental health diagnoses. SSS #242 stated would redo the PASARR again.

Based on medical record review, review of fall investigations, review of facility fall management program guidelines and staff interviews, the facility failed to provide adequate supervision to prevent falls. This resulted in actual harm for one (#92) confused, dependent resident with a history of falls, when she was left unsupervised in a wheel chair in her room. The resident fell forward from the wheel chair and sustained multiple facial fractures and a thoracic compression fracture, was hospitalized , and subsequently intubated due to extensive facial swelling. This affected one (#92) of three residents reviewed of 79 identified as being at risk for falls. The facility census was 92. Findings Include: Review of Resident #92's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #92 was discharged to the hospital on [DATE] for evaluation and treatment. Review of Resident #92's fall risk assessment dated [DATE] revealed the resident had intermittent confusion, needed assistance with elimination, was legally blind, had three or more predisposing diseases, took three or four of the listed medications in the past seven days, had balance problems while standing, walking, a decrease in muscular coordination, and required assistive devices for mobility. The total fall risk assessment score was 23. A fall risk assessment score greater than 10 represented a high risk for falls. A post fall investigation report dated 02/01/14 at 2:14 P.M., documented Resident #92 was found in her room sitting on the floor in front of her wheel chair with the alarm sounding. Resident #92 was not injured. New interventions were to use floor mats by the bed and to put the resident to bed after lunch. Review of the physician telephone order sheet dated 04/01/14 revealed an order to discontinue Resident #92's alarms. Review of Resident #92's physician's orders [REDACTED]. A fall risk assessment form dated 04/02/14 revealed Resident #92 had intermittent confusion, one or more falls in the past three months, needed assistance with elimination, was legally blind, had three or more predisposing diseases, took three or four of the listed medications in the past seven days, had balance problems while standing, walking, a new balance problem while sitting, and required assistive devices for mobility. The total fall risk assessment score was 33, up from 23 the previous quarter. A fall risk assessment score greater than 10 represented a high risk for falls. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #92 was severely cognitively impaired, had moderate hearing difficulty, was rarely or never understood, would sometimes understand, had disorganized thinking, needed extensive two person assistance with transfers, ambulation and toileting and had a history of [REDACTED]. Resident #92's at risk for falls plan of care dated 04/23/14 revealed interventions which included to offer to assist the resident to bed after breakfast, to monitor for fatigue and/or unsteadiness, encourage rest periods and to provide extensive assistance with transfers. A post fall investigation report dated 04/25/14 at 9:45 A.M., revealed Resident #92 was found in her room lying face down on the floor in front of her wheel chair with no alarm in use. The resident was documented as being up in a wheel chair awaiting a shower. Review of the facility's investigation included staff interviews which revealed State tested Nursing Aide (STNA) #55 had returned Resident #92 to her room after breakfast, toileted the resident and left the resident in her wheel chair in her room. STNA #50 and #55 provided care for the roommate and then left the room. Review of Resident #92's nurse's note dated 04/25/14 at 9:45 A.M. revealed Registered Nurse (RN) #37 heard someone yell down the hallway "I need some help in here." RN #37 ran to the resident's room and the STNA yelled out "I need a nurse in here." Upon arriving to the room, the resident was observed lying in a prone position in front of the wheel chair with blood under the resident's face. RN #37 told someone to call the doctor and grab the crash cart. RN #37 told someone else to call 911 while grabbing towels and washcloths from a cart outside the resident's room. The resident was still in sight of the nurse. It was documented the resident was turned to the right side with assistance from RN #37 and two STNA's to assess where the blood was coming from. The resident was documented as alert, talking and asking for help. Blood was noted coming from the resident's nose; pressure and ice were applied to the nose and the resident's mouth was suctioned by RN #37. The resident was documented as still responsive, range of motion was within normal limits and oxygen saturation was 95 percent on room air. The emergency squad arrived, the resident was moved from the floor to the stretcher, her nose was packed and the resident left by squad to the hospital for evaluation and treatment. Review of Resident #92's local emergency room report dated 04/25/14 revealed the resident, who was on Coumadin, fell face forward out of her wheelchair, landed on her face at the nursing home and was bleeding from her nose on arrival. The report also documented the resident had a facial fracture, was unstable, and was requiring surgical intervention. The resident was being transferred to another hospital for evaluation of her significant severe facial fractures. Review of Resident #92's transfer hospital emergency trauma history and physical report dated 04/25/14 revealed the resident was admitted with [DIAGNOSES REDACTED]. Documentation revealed the resident presents status [REDACTED]. The Computed Tomography (CT) scan (uses x-ray to make detailed pictures of structures inside the body) showed left orbital (around the eye) fractures and a T9 compression fracture. There was a concern for respiratory compromise due to extensive facial swelling. It was documented the resident was intubated in the emergency department and was admitted to the intensive care unit. On 05/13/14 at 4:18 P.M., an interview with RN #37 revealed she heard the shower aide say "I need some help in here." Resident #92 was lying face down on the floor with her hands down. The resident had been in her room waiting for a shower. On 05/14/14 at 8:50 A.M., an interview with RN #30 revealed Resident #92 called to the nurse as the nurse passed the room. Resident #92 told the nurse that she was tired and wanted to lie down. RN #30 stated she told the resident the aide was coming to give her a shower and then she would be put in bed. The nurse left the room and went on to finish her work. The interview revealed RN #30 heard a call for help, went to the room of Resident #92 and multiple staff were in the room already. The resident was on the floor face down with her arms down and bleeding from the head somewhere. Interview on 05/14/14 at 10:45 A.M. with STNA #55 verified she had taken Resident #92 to the bathroom after breakfast and left her in her wheel chair in her room. STNA #55 was in the room a while longer providing care to the roommate. When the STNA left the room, Resident #92 was still waiting for a shower. STNA #55 went to care for another resident and saw people in Resident #92's room. STNA #55 was unable to identify the length of time Resident #92 was in the room unattended. At 10:59 A.M., interview with Housekeeper #40 revealed, just prior to the fall, Housekeeper #40 walked down the hall and observed Resident #92 dozing in her wheel chair in her room. At 11:30 A.M., an interview with STNA #57 revealed resident showers were not completed in a particular order. All residents with appointments and dialysis would get showers first and then the rest of the residents were showered as scheduled for the day. STNA #57 stated on 04/25/14 she was taking another resident back to their room and passed Resident #92's room. STNA #57 stated she heard a sound and saw Resident #92 lying face down on the floor with a pool of blood around her head and her arms were down and the STNA called for help. A review of the facility Fall Prevention Program policy dated October 2010 revealed guests who were at risk for falls would have a green identifier tag placed on the assistive device (walker, wheel chair) as appropriate. If a guest was determined not to be at risk for falling, the green identifier tag would be removed and a clear tag would be placed on the wheel chair or walker as appropriate. Each guest would be evaluated for risk factors quarterly. The facility policy did not address resident directed approaches including specific interventions such as frequency of supervision based on individual resident assessed needs and identified risk factors to prevent accidents. This deficiency substantiates Complaint Number OH 493.