Every finding on record at Hillspring Health Care & Rehab

Based on medical record review, staff interview, wound nurse practitioner interview, policy review, and review of the National Pressure Injury Advisory Panel (NPIAP) guidelines, the facility failed timely identify a deep tissue injury (DTI) (a serious type of pressure injury where the soft tissue beneath the skin is damaged by prolonged pressure or friction) and timely refer to the wound nurse practitioner for a resident identified with a deep tissue injury. This affected one (Resident #03) out of four Residents (#03,#12, #63, #119) reviewed for pressure wounds. The facility census was 128.Findings include:Review of the medical record for Resident #03 revealed an admission date of 11/19/25. Diagnoses included peripheral vascular disease (PVD), edema, insomnia, anxiety disorder, and chronic kidney disease.Review of the Minimum Data Set (MDS) for Resident #03 dated 08/07/26 revealed the resident was cognitively impaired. Resident #35 was totally dependent on staff with all areas of activities of daily living (ADL). Further review of the MDS assessment revealed the resident was coded as being at risk for the development of pressure ulcers.Review of the report titled Nursing Admission/Evaluation/Assessment, dated 11/19/25 for Resident #03 revealed no skin issues.Review of the report titled Skin-Weekly Assessment, dated 11/28/25 revealed Resident #03 had a suspected deep tissue injury (DTI) on the left heel that measured 1.5 centimeters (cm) in length (l) by 2.0 cm in width (w) x 0.0 cm depth (d). The wound was identified as non-blanching brown discolorations. Resident #03 was to begin on weekly skin assessments. On 03/23/26, the left heel wound was identified as an unstageable wound and measured 1.5 cm (l) by 2.2 cm (w) by 0.1 cm (d) unstageable wound. On 04/27/26 the weekly skin assessment revealed 1.5 cm (l) by 2.0 cm (w) by 0.2 cm (d) left wound was measured as a stage III wound.Review of the report for Resident #03 titled Braden, dated 11/19/25 revealed Resident #03 was at a moderate risk to develop pressure wounds. Review of the most recent report titled Braden, dated 08/07/26 for Resident #03 revealed she was at a high risk for development of pressure wounds.Review of the progress notes for Resident #03 revealed nothing related to the identification of the wound on the left heel on 11/28/25.Review of the report titled Order Recap Report, for Resident #03 revealed an order with no start date to float heels as tolerated while in bed with an end date of 04/17/26. An order dated 11/19/25 apply skin prep to bilateral heels topically every day and night for wound for 14 days. An order for Prevalon boot to left foot every day and night shift ordered on 11/28/25 through 01/07/26. An order dated 12/12/25 for a powered air mattress. An order dated 01/21/26 for an Airmersus cushion to the wheelchair. An order for Prevalon boots to feet as tolerated, dated 01/07/26 through 04/28/26.Review of the Treatment Administration Record (TAR) for Resident #03 dated November 2025 revealed an order dated 11/19/25 for skin preparation wipes to bilateral heels every for preventative for fourteen days. A prevalon boot to left foot every day and night with a start date of 11/28/25. An order for powered air mattress every day and night shift with a start date 12/11/25. No order was identified on the TAR for November 2025 to float Resident #03's heels as a preventative intervention.Interview with the facility wound nurse (WN) #329 on 08/20/26 at 9:35 A.M., confirmed Resident #03 admitted to the facility on [DATE]. WN #329 confirmed the new admission skin assessment for Resident #03 revealed no skin issues upon admission. WN #329 confirmed she identified a deep tissue injury (DTI) on Resident #03's left heel while completing skin rounds on 11/28/25. WN #329 confirmed the DTI on Resident #03's left heel was identified as unstageable on 03/23/26 after the Wound Nurse Practitioner (WNP) #313 assessed Resident's left heel. WN #329 confirmed on 04/27/26 WNP #313 assessed Resident #329's heel and determined it was a stage III pressure wound. WN #329 confirmed she was unaware that the facility policy stated the facility should consider using the wound care consultant to assist with treatment plans when the following circumstances occur: Stage III, IV, and Unstageable pressure ulcers/DTI. WN #329 confirmed the facility has a standard order to float a residents heel to prevent a pressure ulcer, however the facility does not document the order or have staff sign off on the pressure injury prevention. WN#329 confirmed the facility does not have any documentation of decline in the appearance of the skin on Resident #03's left heel from the date of admission on [DATE] through the date of the Skin-Weekly Assessment, dated 11/28/25 that first identified Resident #03's left heel DTI.Interview with the Wound Nurse Practitioner (WNP) #315 on 08/20/26 at 12:16 P.M., confirmed she assessed Resident #03 on 02/16/26 and 03/03/26 and failed to assess Resident #03's wound on her left heel. WNP #315 revealed she assessed Resident #03's left heel on 03/23/26 and the left heel wound was identified as an unstageable wound and measured 1.5 cm (l) by 2.2 cm (w) by 0.1 cm (d) unstageable. On 04/27/26 the weekly skin assessment revealed the left heel wound measured 1.5 cm (l) by 2.0 cm (w) by 0.2 cm (d) and was a stage III wound. WNP #315 confirmed if proper preventative measures were in place prior to finding the deep tissue injury on Resident #03's heel were in place then the wound may have been avoidable. Interview with the Director of Nursing (DON) dated 08/20/26 at 3:11 P.M., confirmed the facility order to float heels as a pressure ulcer preventative was not identified on the TAR in November 2025 for Resident #03. The DON revealed this order was not signed off on by staff and the facility has no way of confirming if the order was initiated or followed. The DON confirmed the facility failed to have a start date listed for the order to float Resident #03's heels. The DON confirmed she was not aware of the facility policy that the facility should consider using the wound care consultant to assist with the treatment plan when the following circumstances occurr: there is a concern for healing with a skin issue, stage II pressure ulcer treatment has shown no improvement with treatment changes, Stage III, IV, and unstageable pressure ulcers/DTI.Review of the facility policy titled Skin Integrity-Skin Monitoring Process, dated 04/20/26 revealed the facility will use skin integrity team (SIT) to improve, maintain and monitor resident's skin integrity with the goal for residents not to develop pressure ulcers unless clinically unavoidable. Further review of the policy revealed the facility should consider using the wound care consultant to assist with the treatment plan with the following circumstances occur: there is a concern for healing with a skin issue, stage II pressure ulcer treatment has shown no improvement with treatment changes, Stage III, IV, and unstageable pressure ulcers/DTI.Review of the NPIAP guidelines, dated 2014, pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines, revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment.This deficiency represents non-compliance investigated under Complaint Number 3106719.

Based on interview, record review and policy review, the facility failed to ensure staff allowed a resident to have her personal cell phone. This affected one (Resident #2) of three residents reviewed for personal property. The facility census was 127.Findings include:Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included chronic diastolic heart failure, chronic kidney disease, stage three, dementia, anxiety disorder, history of falling, and mild cognitive impairment.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 had moderately impaired cognition, and required set up assistance from staff with eating and personal hygiene. Review of the progress note for Resident #2 dated 05/09/26 written by Registered Nurse (RN) #10 revealed the resident's cell phone was placed in A hall medication cart to avoid it getting misplaced due to resident confusion.Interview on 06/16/26 at 7:56 A.M. with RN #10 revealed RN #10 placed Resident #2's personal cell phone in the medication cart, because she was so confused. RN #10 does not recall if she had informed any other staff.Interview on 06/17/26 at 7:24 A.M. with Nurse Aide in Training (NAT) #20 confirmed the nurses removed Resident #2's personal cell phone from Resident #2's room for multiple days. Interview on 06/17/26 at 8:08 A.M. with Director of Social Services (SSD) #30 revealed SSD #30 was notified of Resident #2's missing cell phone and it was in the nursing medication cart for six days away from the resident. SSD #30 stated it was reported to the Administrator on 05/15/26.Interview on 06/17/26 at 8:26 A.M. with the Administrator confirmed on 05/15/26, she was made aware of the Resident #2's cell phone being put it the medication cart.Review of the policy titled Resident Rights Respect and Dignity Retain and Use of Personal Possessions, dated 10/2022, revealed the facility should not limit a resident's ability to retain or have a personal items in their room. This deficiency represents non-compliance investigated under Complaint Number 3015077.

Based on observation, interview, record review and policy review, the facility failed to ensure the resident's privacy was maintained during personal care. This affected one (Resident #43) of three residents reviewed for privacy. The facility census was 127.Findings include:Review of the medical record revealed Resident #43 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebrovascular disease, vascular dementia, anxiety disorder and major depressive disorder.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 was cognitively intact and dependent on staff for toileting. Interview and observation on 06/16/26 at 2:05 P.M. to 2:20 P.M. revealed Certified Nursing Assistants (CNA) #40 and CNA #50 provided peri care to Resident #43. Resident #43 was in a semi private room with a roommate, completing the peri care with no privacy curtains pulled on either side of Resident #43. There were no curtains drawn on the door (window from top of door to bottom of door) to the outside facing the street and parking lot and the window open to the outside street and parking lot with cars going by. Both CNA #40 and CNA #50 confirmed the privacy curtains should have been pulled and the window coverings for the door and window should have been closed. Interview on 06/17/26 at 8:43 A.M. with the Assistant Director of Nursing (ADON) #60 revealed CNAs should close privacy curtains and window coverings when providing personal care.Review of the facility's Resident Handbook with the Resident Rights dated 04/2026, revealed the resident right to privacy during medical examination or treatment and in the care of personal or bodily needs.This was an incidental finding discovered during the complaint investigation.

Based on medical record review, review of the facilities Self-Reported Incidents (SRI), staff interview, and policy review, the facility failed to ensure all allegations of physical abuse were reported to the State Survey Agency. This affected one (#2) of one resident reviewed for abuse. Findings include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included chronic diastolic heart failure, chronic kidney disease, stage three, dementia, anxiety disorder, history of falling, and mild cognitive impairment.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 had moderately impaired cognition, dependent on staff with bathing and required set up assistance from staff with eating and personal hygiene. Review of the progress notes dated 06/06/26 revealed Resident #2 exhibited behaviors. Resident #2 stated Certified Nursing Assistant (CNA) pushed her during care, resident appeared confused and provided inconsistent information when questioned further. There were no injuries, redness, bruising, or other signs of trauma were observed upon assessment. Interventions attempted, including nonpharmacological: reassurance, redirection, and resident's safety was maintained. Resident #2 calmed down. Review of the facilities SRIs from 06/06/26 to 06/16/26 revealed there were no allegations of physical abuse reported to the State Survey Agency involving Resident #2 being pushed by a CNA.Interview on 06/17/26 at 10:40 A.M. with the Administrator revealed the nurse who documented the progress note dated 06/06/26 regarding Resident #2 being pushed did not report this to anyone. The Administrator stated this should have been reported and confirmed the investigation started when they found this information out on 06/06/26. Review of the policy titled Abuse, Neglect, Misappropriation of Property, dated 09/2022 revealed ensure that all staff are aware that they need to report all incidents and allegations of abuse, neglect, mistreatment, exploitation and misappropriation of resident property.This was an incidental finding discovered during the complaint investigation.

Based on medical record reviews, staff and resident interviews, review of a facility medication error report, and facility policy review, the facility failed to administer medications as ordered. This affected one( #15) resident out of three residents reviewed for medications administration. The facility census was 117. Findings include: Review of the medical record for Resident #15 revealed an admission date of 04/10/25 with medical diagnoses of pulmonary hypertension, disorder of the autonomic nervous system, left hemiplegia, and atrial fibrillation. Review of the medical record for Resident #15 revealed an admission MDS assessment, dated 04/16/25, which indicated Resident #15 was cognitively intact and required partial/moderate staff assistance for eating, was dependent upon staff for toilet hygiene, and bathing, and required substantial/maximum assistance with bed mobility. Review of the medical record for Resident #15 revealed a communication form, dated 05/16/25 at 12:00 A.M., which stated Resident #15 was administered Meclizine (antihistamine) via percutaneous endoscopic gastrostomy (peg) tube in error around 10:30 P.M. The form stated Resident #15 had no adverse reaction, vital signs were taken, and Nurse Practitioner (NP) and family were notified of the medication error. Orders were given to monitor Resident #15. Review of the medical record for Resident #15 revealed no documentation to support an order for Meclizine. Review of the facility Medication Error Report, dated 05/16/25, stated on 05/15/25 Resident #15's roommate, Resident #16, had requested his Meclizine. The report stated the nurse administered the Meclizine to Resident #15 instead of Resident #16 and that Resident #15 did not have an order for Meclizine. The report stated the NP was notified and an order to monitor Resident #15 was given. Interview on 05/28/25 at 1:44 P.M. with Resident #15 confirmed he was given Resident #16's Meclizine by mistakes a few weeks ago. Resident #15 stated he had some dizziness afterwards but no residual effects from the medication administration error. Interview on 05/28/25 at 2:21 P.M. with Administrator confirmed Resident #15 was given the wrong medication on 05/15/25 and that staff education was provided. Administrator stated Resident #15 did not have a negative outcome from medication error. Review of facility policy titled Medication Administration, revised November 2024 stated the facility would ensure patients are given medication as per physician orders. The policy stated to ensure administration accuracy, the nurse/medication aide cross check the following reference points: a) physician's order b) medication administration record-label on drug container c) label on drug container- physician order. This deficiency represents non-compliance investigated under Complaint Number OH00165897.

Based on medical record review, resident and staff interview, and review of the facility policy, the facility failed to ensure the interdisciplinary team members attended care conferences and failed to ensure the resident was invited to care conferences. This affected one (Resident #49) of one resident reviewed for care conferences. The facility census was 111. Findings include: Review of Resident #49's medical record revealed an admitted on 01/14/20. Diagnoses included skin cancer, anxiety, chronic obstructive pulmonary disease, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was cognitively intact. Review of the care conference notes dated 08/09/24 revealed Social Service Designee (SSD) #388 was the only staff member in attendance. Resident #49 was documented as attending. The care conference notes dated 05/09/24 and 02/09/24 revealed Resident #49 or a representative/family member did not attend. SSD #388, Dietician #334, and Licensed Practical Nurse (LPN) #362 were documented as attending. Further review of Resident #49's medical record revealed no documentation of Resident #49 or representative/family member being notified of care conference dates. During an interview on 11/04/24 at 10:21 A.M., Resident #49 stated she had never had a care conference at the facility. During an interview on 11/06/24 at 10:40 A.M., SSD #388 confirmed he was the only staff member for a care conference with Resident #49 on 08/09/24. SSD #388 confirmed care team staff should be involved in resident care conferences. SSD #388 stated he informed residents of care conferences in person days before the care conference. SSD #388 stated representative/family members were invited through emails. SSD #388 was unable to provide any documentation informing Resident #49 of the care conferences on 02/09/24 and 05/09/24. Review of the facility's policy titled Care Conference dated revised August 2024 revealed the procedure during care conference is as follows, each discipline reviews the patients/responsible party problems, goals and interventions pertaining to their discipline. The interdisciplinary team discusses the progress of the patient in relation to the goals established. Patient/responsible party are part of the information exchange and decision making as to the patients care plan. Code status will be reviewed with the patient and/or the responsible party at each care conference. Those in attendance shall be documented in the attendance record in the note Social Services shall update the care conference schedule weekly to reflect significant changes and new admission reviews via the shared, facility specific calendar. If a team member cannot attend care conferences, she/he is responsible for finding a substitute to attend or providing notes prior to the conference to Social Services and/or documenting the care conference note.

Based on medical record review, observation, staff interview, review of medication manufacturer instructions, and review of facility policy, the facility failed to ensure a staff member primed (performed a safety test) when using an insulin pen-injector, resulting in a significant medication error. This affected one (Resident #34) of five residents observed for medication administration. The facility census was 111. Findings include: Review of Resident #34's medical record revealed an admitted [DATE]. Diagnoses included type one diabetes mellitus. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact and received insulin injections. Review of the physician orders revealed an order dated 10/27/24 for Lantus SoloStar Subcutaneous Solution Pen-injector 100 unit per milliliter (long-acting insulin) inject 38 units subcutaneously two times a day for diabetes mellitus. Observation on 11/06/24 at 8:42 A.M. revealed Registered Nurse (RN) #313 removed Resident #34's Lantus SoloStar Subcutaneous Solution Pen-injector from the medication cart and applied a new needle. RN #313 then entered Resident #34's room. RN #313 dialed 38 units on the Lantus SoloStar Subcutaneous Solution Pen-injector. RN #313 did not prime the Lantus SoloStar Subcutaneous Solution Pen-injector needle before dialing the dose. RN #313 then administered the insulin into Resident #34's right upper arm. During an interview on 11/06/24 at 8:48 A.M., RN #313 confirmed she did not prime Resident #34's Lantus SoloStar Subcutaneous Solution Pen-injector needle before administering the ordered dose. Review of the manufacturer instructions for the Lantus SoloStar Subcutaneous Solution Pen-injector revealed after attaching a needle to the pen, a safety test must be performed. A safety test was completed by: Dial a test dose of two units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test two more times. If there is still no insulin coming out, use a new needle and do the safety test again. Always perform the safety test before each injection. Never use the pen if no insulin comes out after using a second needle. Review of the facility's policy titled Administration of Insulin dated revised January 2023 revealed it is the policy of this facility to administer insulin to the resident in a safe, consistent manner, with the appropriate solution as prescribed per the physician. This deficiency represents non-compliance investigated under Complaint Number OH00159267.

Based on record review, staff interviews, review of Self-Reported Incidents (SRIs) and policy review, the facility failed to ensure allegations of abuse were reported to the State Agency. This affected one resident (#150) out of three residents reviewed for abuse. The facility census was 119. Findings included: Review of the medical record for Resident #150 revealed the resident was admitted to the facility on [DATE] and was discharged on [DATE]. Her diagnoses included, but not limited to, pathological fracture, protein-calorie malnutrition, history of falling, hypertension, anemia, legal blindness, personal history of diseases of the digestive system, personal history of venous thrombosis and embolism, age-related osteoporosis, and hearing loss. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #150, revealed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 15 indicating she was cognitively intact. Assessment indicated resident did not walk, was totally dependent of two staff for bathing, and required extensive assist for other activities of daily living (ADLs). Review of the nurse's progress note dated 01/30/23 at 2:56 P.M. for Resident #150, revealed the Assistant Director of Nursing (ADON) #36 and the Director of Nursing (DON) went into the resident's room to give the resident a bed bath and to discuss some claims the resident had made. The note indicated Resident #150 stated that she was hit in the mouth with a glove while in the dining room on Friday (01/27/23) during lunch time when her friend was visiting. The note indicated Resident #150 was never in the dining hall at any time during that day and had not been to the dining hall since she arrived due to refusals. The note also indicated Resident #150 stated while DON was giving her a bed bath, the DON put her finger in the resident's eye while cleaning her face. The note indicated two nurses were present at that time and the resident's eye was wiped with a wet cloth to remove build up. The resident stated that her eye was hard and now it was soft and she did not like it. The resident licked her finger and wiped her eye with it and education was given to the resident on the importance of not doing that. The progress note indicated the ADON and DON also had a talk with the resident regarding her screaming, yelling and the degrading manner in which she speaks to staff. The resident noted she could not help it. Resident #150 was informed that respect was a choice. Interview on 03/15/23 at 4:49 P.M. with the DON, verified Resident #150 made allegations of being stuck in the eye on 01/30/23 while she and the ADON provided care. The DON verified the facility did not create a SRI for the allegations due to her and the ADON being the ones accused of the allegations of sticking a finger in Resident #150's eye. Additionally, the DON verified Resident #150 made allegations of being hit in the mouth with a glove on 01/27/23 while the resident was in the dining room. The DON verified no SRI was created because they did not believe the resident was in the dining room. A phone interview on 03/16/23 at 1:06 P.M. with the Administrator, revealed the facility was aware Resident #150 made allegations of being hit in the mouth with a glove while the resident was in the dining room on 01/27/23. The Administrator stated the facility did not create an SRI for allegations due to resident not being in the dining room on that date. Additionally, the Administrator stated the facility had an outbreak of Coronavirus (COVID-19) and the facility was not using the dining room. The Administrator also verified the facility was aware Resident #150 made allegations of being stuck in the eye during care by the DON on 01/30/23. The Administrator verified the facility did not create an SRI for the allegations. Review of facility policy titled Abuse/Neglect/Misappropriation of Property, dated 09/22, revealed the facility did not implement the policy in regards to the allegation. The policy stated if a staff member is accused or suspected of Abuse, Neglect, Exploitation, Mistreatment of a resident. or Misappropriation of Resident Property, the facility should immediately remove that staff member from the facility and the work schedule pending the outcome of the investigation. It also indicated all incidents and allegations of Abuse, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property and all Injuries of Unknown Source must be reported immediately to the Administrator or designee. The Administrator or his/her designee will notify the State Survey Agency of all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property and Injuries of Unknown Source as soon as possible, but in no event later than twenty-four hours from the time the incident/allegation was made known to the staff member. Under the section entitled Investigation it stated Once the Administrator and the State Survey Agency are notified, an investigation of the allegation violation will be conducted. The investigation must be completed within five working days, unless there are special circumstances causing the investigation to continue beyond five working days.

Based on record review, staff interviews, and policy review, the facility failed to ensure allegations of abuse by a resident was thoroughly investigated. This affected one resident (#150) out of three residents reviewed for abuse. The facility census was 119. Findings included: Review of the medical record for Resident #150 revealed the resident was admitted to the facility on [DATE] and was discharged on [DATE]. Her diagnoses included, but not limited to, pathological fracture, protein-calorie malnutrition, history of falling, hypertension, anemia, legal blindness, personal history of diseases of the digestive system, personal history of venous thrombosis and embolism, age-related osteoporosis, and hearing loss. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #150, revealed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 15 indicating she was cognitively intact. Assessment indicated resident did not walk, was totally dependent of two staff for bathing, and required extensive assist for other activities of daily living (ADLs). Review of the nurse's progress note dated 01/30/23 at 2:56 P.M. for Resident #150, revealed the Assistant Director of Nursing (ADON) #36 and the Director of Nursing (DON) went into the resident's room to give the resident a bed bath and to discuss some claims the resident had made. The note indicated Resident #150 stated that she was hit in the mouth with a glove while in the dining room on Friday (01/27/23) during lunch time when her friend was visiting. The note indicated Resident #150 was never in the dining hall at any time during that day and had not been to the dining hall since she arrived due to refusals. The note also indicated Resident #150 stated while DON was giving her a bed bath, the DON put her finger in the resident's eye while cleaning her face. The note indicated two nurses were present at that time and the resident's eye was wiped with a wet cloth to remove build up. The resident stated that her eye was hard and now it was soft, and she did not like it. The resident licked her finger and wiped her eye with it and education was given to the resident on the importance of not doing that. The progress note indicated the ADON and the DON also had a talk with the resident regarding her screaming, yelling and the degrading manner in which she speaks to staff. The resident noted she could not help it. Resident #150 was informed that respect was a choice. Interview on 03/15/23 at 4:49 P.M. with the DON, verified Resident #150 made allegations of being stuck in the eye on 01/30/23 while her and the ADON provided care. DON verified there was no investigation completed because she and the ADON were the ones being accused of the allegations. Additionally, the DON verified Resident #150 made allegations of being hit in the mouth with a glove on 01/27/23 while the resident was in the dining room. The DON verified no investigation was completed because they did not believe the resident was in the dining room. A phone interview on 03/16/23 at 1:06 P.M. with the Administrator, revealed the facility was aware Resident #150 made allegations of being hit in the mouth with a glove while the resident was in the dining room on 01/27/23. Administrator stated the facility did not investigate the allegations due to resident not being in the dining room on that date. Additionally, the Administrator stated the facility had an outbreak of Coronavirus (COVID-19) and the facility was not using the dining room. The Administrator also verified the facility was aware Resident #150 made allegations of being stuck in the eye during care by the DON on 01/30/23. The Administrator verified the facility did not investigate the allegations. Review of facility policy titled Abuse/Neglect/Misappropriation of Property, dated 09/22, revealed the facility did not implement the policy in regards to the allegation. The policy stated if a staff member is accused or suspected of Abuse, Neglect, Exploitation, Mistreatment of a resident. or Misappropriation of Resident Property, the facility should immediately remove that staff member from the facility and the work schedule pending the outcome of the investigation. It also indicated all incidents and allegations of Abuse, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property and all Injuries of Unknown Source must be reported immediately to the Administrator or designee. The Administrator or his/her designee will notify the State Survey Agency of all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property and Injuries of Unknown Source as soon as possible, but in no event later than twenty-four hours from the time the incident/allegation was made known to the staff member. Under the section entitled Investigation it stated Once the Administrator and the State Survey Agency are notified, an investigation of the allegation violation will be conducted. The investigation must be completed within five working days, unless there are special circumstances causing the investigation to continue beyond five working days.

Based on observation, staff interview ,record review, and facilities policy review, the facility failed to ensure a resident's call light was accessible to the resident. This affected one resident (Resident #25) of twelve residents call lights observed on the hall. The facility census was 127. Findings included: Review of Resident #25's medical record revealed an admitted [DATE]. Admission diagnoses included Alzheimer's disease, dementia, peripheral vascular disease, depression, presence of cardiac pacemaker, and constipation. Review of Resident #25's Minimum Data Set (MDS) dated [DATE] revealed resident had impaired cognition. The MDS revealed the resident required total dependence with two-person assistance for bed mobility, and transfer. The resident required total dependence with one-person assist for dressing, and personal hygiene. The resident required extensive two-person assistance for toileting. The resident required supervision with set-up for eating. Review of Resident #25's plan of care dated 12/13/22 revealed the resident was dependent on staff for meeting the emotional, intellectual, physical, and social needs related to cognitive deficits. The care plan revealed the resident had a self-care deficit related to Alzheimer's disease, dementia, and advanced age. The plan of care included the intervention to keep the resident's call light within reach while the resident was in the room. Observation on 01/05/23 at 7:48 A.M. of Resident #25 revealed she was lying on her right side in bed with her eyes closed. The resident did not open her eyes upon greeting the resident. The resident's hair appeared to have been recently combed. The resident appeared to have been recently bathed. Observation revealed the resident's call light was under the bed. The call light cord was tangled with the bed frame at the head of the bed. Observation on 01/05/23 at 8:15 A.M. revealed staff brought Resident #25's breakfast tray into the resident's room. The staff sat the resident up in bed and opened the resident's tray. The staff peeled the resident's banana halfway down and handed the resident the banana. Further observation revealed the call light remained on the floor under the resident's bed. Observation on 01/05/23 at 8:44 A.M. revealed the environmental staff entered the room to provide housekeeping services. Observation following the environmental staff leaving the resident's room and revealed the Resident #25's call light remained on the floor under the bed. Observation on 01/05/23 at 9:27 A.M. of Resident #25's room revealed the nurse entered the room, called out the resident's roommate's name and left the room. Observation revealed the call light remained on the floor under the bed. Observation and interview on 01/05/23 at 9:45 A.M. revealed Dietary Staff (DS) #599 went into the resident's room to pick up the breakfast tray. DS #599 revealed the resident drank all her milk and eaten one or two bites of her banana. Further observation after the tray was removed revealed the resident's call light remained on the floor under the resident's bed. Interview and observation on 01/05/23 at 10:38 A.M. with Registered Nurse (RN) #170 in Resident #25's room revealed she was working as an aide. The RN #170 confirmed Resident #25's call light was on the floor under the bed and not accessible to the resident. The RN #25 untangled the call light and clipped the call light to the resident's pillow. Review of policy titled Call Lights last revised 08/2016 revealed all staff were able to answer call light and call lights were answered in a timely manner with courtesy. It was the responsibility of each charge nurse to ensure call lights were within residents' reach for patients capable of using them. This deficiency represents non-compliance under complaint number OH00138457.

Based on observation, interview, record review, and policy review the facility failed to provide adequate supervision in the dining room for residents who required feeding assistance. This affected one (Resident #110) of three residents sampled for feeding assistance. The census was 127. Findings include: Review of the medical record for the Resident #110, specified, revealed an admitted [DATE]. Diagnoses included but were not limited to cerebral atherosclerosis, unspecified dementia with behavioral disturbance, unspecified schizoaffective disorder, and unspecified dysphagia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition, had physical behaviors, did not reject care, and did not wander. Resident #110 was a two-person physical assist, required extensive assistance for bed mobility, transfers, dressing, toileting, personal hygiene, and eating, and total assistance for locomotion. Review of the care plan dated 12/26/22 revealed Resident #110 had an activities of daily living self-care performance deficit related to decreased mobility, gait/balance problems, weakness, cerebral atherosclerosis, impaired cognition, and dementia. Interventions included extensive one-staff assist with feeding, food in individual bowls, and regular soft diet with bite-sized pieces and slightly thickened liquids. Observation on 01/05/22 from 8:00 A.M. to 8:07 A.M. revealed Resident #110 sat in a tilt-and-space chair in the Healthcare-2 dining room unsupervised. Food in bowl in front of her contained crumbled bacon, scrambled eggs, and oatmeal. There were sliced bananas in her lap. Resident #110 was feeding herself the banana peel and mumbling to herself. During an interview on 01/05/22 at 8:07 A.M. State tested Nurse Aide #230 verified Resident #110 required feeding assistance and supervision for eating. The aide verified the resident had been left unsupervised and was feeding herself a banana peel. Review of policy titled Activities of Daily Living (ADL Care) dated 04/2022 revealed staff ensured residents who were unable to carry out activities of daily living were provide services to maintain good nutrition, grooming, and personal/oral hygiene. This deficiency represents non-compliance investigated under Complaint Number OH00138919.

Based on interview, observation, record review, and policy review, the facility failed to provide timely incontinence care for residents. This affected one (Resident #12) of three residents sampled for incontinence. The facility census was 127. Findings include: Review of the medical record for the Resident #12 revealed an admitted [DATE]. Diagnoses included but were not limited to fracture of unspecified neck of the tight femur with routine healing, cerebral infarction, chronic obstructive pulmonary disease, unspecified protein calorie malnutrition, unspecified dementia, and chronic kidney disease stage III. Review of the most recent Minimum Data Set (MDS) 3.0 assessment, initiated on 01/04/23 but not yet completed/submitted, revealed the resident had impaired cognition, had no behaviors, did not reject care, and did not wander. Resident #12 was a two-person physical assist, required extensive assistance for bed mobility, transfers, dressing, toileting, personal hygiene, and locomotion, and supervision for eating. Resident #12 was frequently incontinent of bowel and bladder. Resident #10 had no care plan for incontinence on the baseline care plan dated 01/04/23. Observation on 01/05/2023 at 5:48 A.M. State tested Nursing Assistants (STNA)'s #212 and #296 provided incontinence care to Resident #12 with no concerns noted. Observations made on 01/05/23 from 8:47 A.M. to 9:07 A.M. revealed at 8:47 A.M. Resident #12 activated her call light. At 8:53 A.M. Maintenance #380 entered the room and stated he needed to check the function of the overbed and bathroom lights. He did not acknowledge that Resident #2 call light was activated or offer to assist before leaving the room. At 9:05 A.M. STNA #230 entered the room and turned the call light off. At 9:07 A.M. Restorative STNA #227 and Physical Therapy Assistant #50 entered the room and assisted Resident #12 to toilet and dress while STNA #230 changed the bed linens. During an interview on 01/05/2023 at 9:12 A.M. STNA #230 stated she had not provided incontinence care to Resident #12 since she had started her shift. She had been busy with breakfast and was unaware Resident #12 had asked for assistance with incontinence care. During an interview on 01/05/2023 at 9:14 A.M. Restorative Aide #230 verified she had stopped in Resident #12's room earlier, time and told her she would be back to get her ready for therapy. She did not provide incontinence care before leaving the room. During an interview on 01/05/2023 at 9:16 A.M. Registered Nurse (RN) #231 verified Resident #12's husband told her Resident #12 needed incontinence care while breakfast trays were being passed, time not specified. RN #231 stated she told STNA #237 Resident #2 needed assistance with incontinence care. During an interview on 01/05/2023 at 9:25 A.M. STNA #237 stated she did not provide incontinence care to Resident #12. The STNA stated there was usually one staff member assigned to answer call lights on all three halls of the unit while other STNA's on the unit passed trays and fed residents. There was no additional staff that day to answer call lights. If a light was on, the aide would turn it off, continue to pass trays, and whatever the resident needed would be addressed after breakfast. The aide stated she completed two to three rounds per 12-hour shift. She began her shift at 7:00 A.M. and by the time she finished getting her shift report, it was time to pass breakfast trays. STNA #237 stated she did not start her first round of patient care, including incontinence rounds until after breakfast was completed. Review of policy titled Peri Care last revised 06/2021 revealed peri care was provided after each occurrence of bowel or bladder incontinence to promote good hygiene and prevent infection. Review of policy titled Activities of Daily Living (ADL Care) dated 04/2022 revealed staff ensured residents who were unable to carry out activities of daily living were provide services to maintain good nutrition, grooming, and personal/oral hygiene. This deficiency represents non-compliance investigated under Complaint Number OH00138919.

Based on observation, staff interview and record review the facility failed to ensure dietary assistive tableware was provided to a resident. This affected one resident (Resident #25) of three residents (#25, #110 and #12) reviewed for nutrition. The facility census was 127. Findings included: Review of Resident #25's medical record revealed an admitted [DATE]. Admission diagnoses included Alzheimer's disease, dementia, peripheral vascular disease, depression, presence of cardiac pacemaker, and constipation. Review of Resident #25's Minimum Data Set (MDS) dated [DATE] revealed resident had impaired cognition. The MDS revealed the resident required total dependence with two-person assistance for bed mobility, and transfer. The resident required total dependence with one-person assist for dressing, and personal hygiene. The resident required extensive two-person assistance for toileting. The resident required supervision with set-up for eating. Review of Resident #25's plan of care dated 12/13/22 revealed the resident was dependent on staff for meeting the emotional, intellectual, physical, and social needs related to cognitive deficits. The care plan revealed the resident had a self-care deficit related to Alzheimer's disease, dementia, and advanced age. Interventions related to nutrition included set-up for eating then supervision, and the resident required handled cups with a lid and a straw. The plan of care revealed the resident had right hand contracture's. The care plan revealed the resident had potential for dehydration and fluid deficit related to dementia, advanced age, and suboptimal intake. Additional interventions included to encourage resident to drink fluids. The plan of care revealed the resident had a nutritional risk of malnutrition. The goal for the resident was to have sufficient intake to relieve hunger and thirst. Interventions included to monitor signs of malnutrition including cachexia, muscle wasting, significant weight loss and report to the medical doctor. Interventions included to provide high calorie, high protein supplements, monitor intake and record intake every meal. Observation on 01/05/23 at 7:49 A.M. of Resident #25 revealed she was lying on her right side with her eyes closed. The resident did not open her eyes or respond when this surveyor greeted her and called her name. The resident's hair appeared to have been recently combed and appeared to have been recently bathed. Observation revealed the resident's call light was under the bed, tangled in the bedframe at the head of the bed. The room was clean and there were no pervasive odors in the room. Observation on 01/05/23 at 8:15 A.M. revealed the staff brought Resident #25's breakfast tray into the resident's room. The staff sat the resident up in bed and opened the resident's tray. The staff peeled the resident's banana halfway down and handed the resident the banana. The resident also had juice in a clear-no handle glass, carton of milk, cheerios, Danish, bacon and two hard boiled eggs. The lid for the juice remained and was not removed by the therapist. After the staff left, the resident attempted to remove the lid, however, was not successful due to her contracture and inability to grasp. Observation and interview on 01/05/23 at 9:45 A.M. revealed Dietary Staff (DS) #599 went into the resident's room to pick up the tray. DS #599 confirmed the resident drank all her milk and eaten one or two bites of her banana. The DS #599 was not observed encouraging the resident to eat more prior to removing the resident's tray. Interview and observation on 01/05/23 at 9:46 A.M. with Dietary Cook (DC) #503 confirmed Resident #25's meal ticket identified the resident was to have a handled cup with a lid and a straw. The DC #503 confirmed the juice cup on Resident #25's tray did not have a handle as required in the resident's plan of care. Review of policy titled Activities of Daily Living (ADL Care) dated 04/2022 revealed staff ensured residents who were unable to carry out activities of daily living were provide services to maintain good nutrition, grooming, and personal/oral hygiene. This deficiency represents non-compliance investigated under Complaint Number OH00138457.

Based on observation, staff interview, review of the facility's policy, and record review, the facility failed to accurately assess a resident on an anticoagulant for bruising. This affected one (#100) of four residents reviewed for skin integrity. The facility census was 110. Findings include: Medical record review revealed Resident #100 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #100's annual Minimum Data Set (MDS) assessment, dated 08/29/21, revealed the resident to be cognitively intact and the resident was on an anticoagulant. Review of Resident #100 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, dated 08/31/21, revealed Resident #100 was at risk for bleeding due to [MEDICATION(S)] ([MEDICATION(S)]) related to [CONDITION(S)]. Interventions included to monitor signs and symptoms of bleeding including bruising. Review of Resident #100's bleeding potential assessments dated 10/18/21, 10/19/21, 10/20/21 and 10/21/21 revealed Resident #100 had no bruising. Review of Resident #100's progress note, dated 10/21/21 at 10:13 A.M., revealed Resident #100 had a bruise to her left wrist, five small areas on her left hand, right wrist and forearm and three on her right first finger. Resident #100 stated she had bruising all the time and has old scars on both forearms and hands. Resident #100 stated she bumps into things periodically. Resident #100 was on [CONDITION(S)] and received [MEDICATION(S)] during [CONDITION(S)] treatments. Observation and interview with Resident #100 on 10/18/21 at 11:26 A.M. revealed Resident #100 had multiple scattered bruises on her right and left arms and a large bruise approximately two inches long by one inch wide on her left arm near her wrist. Resident #100 stated she was on a blood thinner and that she had multiple bruises including the bruise to her left arm. Interview with the Director of Nursing (DON) on 10/21/21 at 12:15 P.M. verified Resident #100 had bruising on her left harm. The DON also verified Resident #100's bruising was not identified on the bleeding potential assessments dated 10/18/21, 10/19/21, 10/20/21, and 10/21/21. The DON stated that Resident #100 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's skin monitoring process policy, dated January 2016, revealed there will be weekly head to toe skin assessments completed by the unit manager or charge nurse. The nurse assistant will report any new or abnormal skin conditions to the charge nurse.

Based observation, staff interview, review of the facility's policy, and record review, the facility failed to ensure residents receiving oxygen had physician orders for oxygen and oxygen tubing was changed according physician orders. This affected three residents (#10, #41, and #108) of 12 residents receiving oxygen therapy. Findings include: 1. Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan, dated 05/26/20, revealed Resident #10 had altered cardiopulmonary status related to shortness of breath or trouble when lying flat. I interventions included medications as ordered, assist with activities of daily living (ADLs) as needed, position resident to facilitate breathing and comfort, oxygen as ordered, and respiratory evaluation as needed. Review of the physician orders, dated 01/15/21, revealed Resident #10 had an order to change oxygen tubing every night shift on the 15th of every month for oxygen therapy. On 10/19/21, Resident #10 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Prior to 10/19/21, Resident #10 did not have any current orders for oxygen therapy. Observation on 10/18/21 at 10:12 A.M. revealed Resident #10 lay in bed with oxygen functioning and nasal cannula in place. Oxygen tubing was dated 09/16. Interview on 10/18/21 at 10:15 A.M. with Licensed Practical Nurse (LPN) #3 verified the label on Resident #10's oxygen tubing was dated 09/16 (no year). Interview on 10/19/21 at 1:19 P.M. with the Director of Nursing (DON) stated oxygen orders were listed under physician orders in the electronic medical record and verified Resident #10 had no current orders for oxygen therapy. 2. Review of Resident #41's record review revealed an admitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #41's care plans, dated 10/19/21, revealed the resident was receiving oxygen as ordered. Review of the physician orders, dated 10/19/21, revealed Resident #41 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no physician orders for administration of oxygen prior to 10/19/21 and there were no orders to replace the oxygen tubing. Observation and interview on 10/18/21 at 10:18 A.M. with Licensed Practical Nurse (LPN) #03 confirmed Resident #41 had unlabeled oxygen tubing. Interview on 10/21/21 at 11:14 A.M. with the Director of Nursing (DON) confirmed Resident #41 did not have an order regarding oxygen tubing. The DON verified Resident #41 did not have a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Review of Resident #108's record review revealed an admitted [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 08/31/21, revealed Resident #108 had impaired cognition. Review of the physician orders, dated 09/10/21, revealed Resident #108 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no physician order to change the oxygen tubing. Observation and interview on 10/18/21 at 10:15 A.M. with Registered Nurse (RN) #27 confirmed Resident #108 had oxygen tubing dated 09/16/21. RN #27 confirmed oxygen tubing was to be changed monthly and confirmed Resident #108 did not have any physician orders for the oxygen tubing to be changed monthly. Review of the facility's policy titled, Oxygen Administration, dated 03/2020, revealed the facility should obtain an order from the Physician for oxygen administration and replace the oxygen tubing every 30 days and as needed if it becomes soiled or if prongs become stiff.

Based on observation, staff, resident and family interviews, review of exterminator treatments and review of facility policy the facility failed to adequately maintain an effective pest control program to prevent flies in the facility. This affected five (#30, #40, #75, #85 and #95) of 122 total residents residing in the facility. Findings include: Interview on 09/30/19 at 12:30 P.M. with the daughter of Residents #30 and #40 (spouses) revealed the flies were bad. She revealed she had put up fly strips, but the facility said those were not allowed. The daughter stated her mother had a rectal tube and the room did have a strong odor at times. The daughter said her dad doesn't like the air conditioner, so she opens the window to get fresh air. The daughter thought the smell might be attracting the flies. Observation on 09/30/19 at 12:40 [NAME]M. of Resident #30 and Resident #40's room revealed two fly swatters sitting on the counter of the resident's room. The resident's window was cracked open and the screen was noted to have a dime-size hole. No flies were noted at that time. Interview with Licensed Practical Nurse (LPN) #160 on 09/30/19 at 12:45 P.M. revealed knowledge that some of the residents had complained about flies. LPN #160 stated she had worked at the facility for four years and had never seen flies until recently. LPN #160 stated Resident #30 had a daily bed bath and there was still has a faint odor that might be attracting the flies. Observation on 09/30/19 at 3:45 P.M. in Resident #75's room revealed a fly on her pillow. Resident 375 had a wash cloth in her hand. Interview at the time of the observation Resident #75 stated she used the wash cloth as a fly swatter. Resident #75 stated she had seen flies daily the last couple weeks. Resident #75 stated she had reported the flies to the nurses and the aides. Observation on 09/30/19 at 3:50 P.M. in Resident #95's room revealed a fly on her bed spread. Observation on 09/30/19 at 4:00 P.M. in Resident #85's room revealed a fly on the window. Interview at the time of the observation with Resident 85's son revealed having seen flies when visiting. Resident #85's son pointed out a fly on the window during the interview. Interview on 09/30/19 at 4:10 P.M. with Environmental Service Director #01 stated the facility did have routine treatments for spiders and ants however they had not treated for [REDACTED]. Review of the facility policy titled, Health Care Management dated 06/2015 revealed pest control is in operation in the facility. Pest control services are provided by the maintenance personnel or by contract. Care is taken to use the least toxic and least flammable, effective insecticides and rodenticides. This citation substantiates Master Complaint Number OH 269 and Complaint Number OH 130.

Based on observation, staff interview, medical record review and facility policy review, the facility failed to accurately administer medications. This affected one (Resident #63) of nine residents observed for medication administration. The facility identified 123 residents in the facility receiving medications. The facility census was 124. Findings include: Review of Resident #63's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 01/11/19, revealed the resident was cognitively intact. Review of Resident #63's plan of care, dated 01/11/19, revealed interventions related to [MEDICAL CONDITION] medications, paranoia, [MEDICAL CONDITIONS] and depression. The plan of care stated to administer medications as ordered and to monitor and document side effects and effectiveness. Review of Resident #63's physician order, dated 02/22/18, revealed [MEDICATION NAME] 300 mg., give two capsules by mouth three times a day related to [MEDICAL CONDITION]. Observation and interview of Resident #63 on 02/25/19 at 1:20 P.M. revealed Resident #63 walked up to Licensed Practical Nurse (LPN) #110. Resident #63 was holding in her hand a yellow capsule with SG 180 written on the capsule. Resident #63 stated she was not sure why she was taking this pill. Resident #63 stated the pill was not [MEDICATION NAME]. LPN #110 was observed to go into the resident's room and Resident #63 picked up her tissue box and pulled an additional five yellow capsules from the tissue box. The resident handed LPN #110 all six capsules. Interview on 02/25/19 at 1:30 P.M. with LPN #110 confirmed Resident #63 had six capsules in Resident #63's room in the tissue box. LPN #110 confirmed the all six capsules were [MEDICATION NAME] 300 milligram (mg.) capsules. LPN #110 confirmed Resident #63 had behaviors including paranoia. The LPN verified the pills should not have been left in her room. Review of facility policy, titled Administration Oral Medications, dated 06/2015, revealed the facility will ensure patients are given per the physician's orders [REDACTED].>

Based on clinical record review, observation, staff and resident interview, review of a fall investigation and policy review, the facility failed to ensure a resident was provided appropriate assistance during a transfer resulting in an avoidable fall. This resulted in actual harm when Resident #6 had reported feeling dizzy and was left sitting on the side of the bed, the resident fell forward and was subsequently sent to the hospital and received 47 sutures for a laceration to the right knee. This affected one (#6) of three residents reviewed for falls. The facility census was 131. Findings include: Clinical record review revealed Resident #6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 11/07/17, revealed the resident had intact cognition. The resident required extensive assistance of two staff for bed mobility, transfers and toileting. Review of the fall risk assessment dated [DATE] revealed the resident was at increased risk for falls. Review of the plan of care updated 11/07/17 revealed the resident was at risk for falls due to impaired mobility and impaired balance. Interventions included extensive assistance of one staff, (may adjust as needed), for bed mobility and toileting, monitor blood pressure with any complaint of dizziness. Review of physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED].M., on 11/14/17. Review of the nurses notes dated 11/14/17 time of occurrence 9:55 A.M., Resident #6 was observed on the floor next to her bed faced down, feet toward her bed and head toward the window, her hands were under her chest with elbows away from her body, small blood pool noted under right lower extremities (RLE), the RLE was on top of the legs of the bedside table. Resident #6 complained of 10 out of 10 pain to forehead, she was alert an oriented and moving about she was stabilized and instructed to remain as still as possible. A laceration was noted to the RLE which was cleansed, packed and pressure applied. Resident #6 was sent out by ambulance to the local emergency room . Blood pressure post fall was 105/65 millimeters of mercury (mm Hg). A later note on 11/14/17 at 3:45 P.M., revealed report was obtained from the local emergency room of Resident #6 would be transferred back with approximately 45 sutures to the RLE, a knee immobilizer in place for seven to eight weeks and non weight bearing. Review of the fall investigation dated 11/21/17 revealed it had documented State tested Nursing Assistant (STNA) #140 was answering the call light and she had gotten Resident #6 up, the resident said she was weak and so she sat her back on the side of the bed and went to the bathroom to obtain linens, the resident attempted to get up and fell at bedside. STNA #140 called for assistance. Further review of the fall investigation revealed Resident #6 was not asked what happened, there were no follow up questions asked pertaining to the written witness statements. Observation on 11/29/17 at 11:19 A.M., Registered Nurse (RN) #158 and Licensed Practical Nurse (LPN) #141 were completing the treatment to Resident #6, the resident had a large L shaped laceration with sutures intact to her right knee at this time. There was discoloration on both knees, there was discoloration to the right wrist and she had discoloration around her right eye and on her forehead at this time. Interview on 11/29/17 at 12:57 P.M., Certified Nurse Practitioner (CNP) #160 said she had ordered the [MEDICATION NAME] due to complaints of dizziness and she said she had meniere's (an inner ear disorder causes episodes of [MEDICAL CONDITION]), Resident #6 said she took it as needed at home and this was why she had ordered it as needed. Interview on 11/29/17 at 1:17 P.M., STNA #162 said if a resident had complaints of dizziness she would not have left them on the side of the bed alone. If she had to get supplies she would have placed the resident back into bed to ensure safety. Interview on 11/29/17 at 1:33 P.M., STNA #140 went to Resident #6's room to answer the call light, Resident #6 said she did not feel right and STNA #140 said sit right here and sat her on the side of the bed, she said she felt dizzy when she went to go stand and STNA #140 felt she was fine sitting there. She said she ran to her bathroom to get supplies and she heard a thud. She came out of the bathroom and Resident #6 was on the floor on her face and she ran and called for her nurse. Telephone interview on 11/29/17 at 1:53 P.M., RN #170 said she was called to the room by STNA #140, when she arrived Resident #6 was face down on the floor and she had complaints of pain to her head. She said she was on top of the legs of the bedside table, however the bedside table was not pulled over on her, she had a large laceration to her left knee/leg area. She said she had thought she had complained of dizziness earlier in the morning and she had given her something for it. She said they stabilized her, called for the emergency management system and made notifications. Interview on 11/29/17 at 2:04 P.M., Resident #6 said STNA #140 tried to get her up she said she told her she was too dizzy and she sat her on the bed and told her she would be fine. Resident #6 said she told her she was dizzy and would not be fine. The next thing she knew she was on the floor. She said she never got up on her own. Review of the policy titled Fall and Accident Management revised 05/2016 documented the facility will identify patients at risk for falls and other accidents. Interventions will be implemented and evaluated to reduce the risk of injuries, falls or other accidents. This policy provides guidance and does not establish a standard of care. This deficiency substantiates Complaint Number OH 673.

Based on record review, observation and staff interview, the facility failed to provide an environment free of hazards for six Residents (#55, #75, #98, #106, #126 and #246) identified by the facility as cognitively impaired and independent in locomotion. The facility census was 116. Findings include: On 06/17/15 at 11:00 A.M. during a tour of the facility, the dining room door to the Café dining area, on Health Care Two area of the facility, was open. Looking through the open door it was noted that both of the Dutch style doors (split so that top and bottom of door can be opened and closed independent of each other) were open leading into the serving kitchen area of the dining room. Upon closer observation of the serving kitchen area, the steam table in the Café dining/serving kitchen were noted to be turned on and emitting heat. No staff were observed in the Café dining or serving kitchen area. On 06/17/15 at 11:06 A.M., Registered Nurse ( RN) #83 verified the doors to the serving kitchen and dining room of the Café dining room were open, the steam table was turned on and no staff were present in this area. On 06/17/15 at 11:11 A.M., Chef #161 responded to the Café dining room area and was informed of the observed concern. The bottom door of the Dutch-style doors had been closed and the door leading into the dining room had been closed by RN #83. However, it was noted that the dining room door was not locked and was easily pushed open and while the lower door of the Dutch style door was locked, the door was easily opened by reaching over the half door and pushing down on the door handle. No staff were noted in the area. A temperature of the water in the steam table was obtained by Chef #161 and was found to be 199.5 degrees Fahrenheit. An interview conducted with Chef #161 on 06/17/15 at 11:11 A.M. revealed that a dietary aide assigned to each satellite kitchen comes up from dietary prior to meals and turns on the steam tables to ensure they achieve the required temperature for meal service. Chef #161 reported that the staff are to close the bottom door of the Dutch style door. On 06/17/15 between 11:13 A.M. and 11:15 A.M. a tour was conducted of the satellite kitchens/dining room areas of the two remaining satellite kitchens in the facility with Chef #161 present. The tour revealed in the Pub dining room/satellite kitchen, on Health Care Two area, the door to the dining room was closed, but not locked, so it easily pushed open. The top half of the Dutch-style doors leading to the satellite kitchen area was open and access to the steam table was easily gained by reaching over the lower door and pushing the door handle down. The steam table in the Pub satellite kitchen was turned on and a temperature reading of the water obtained by Chef #161 was 168 degrees Fahrenheit. No staff were observed in the kitchen or dining room area. A tour of the Health Care One dining room/ satellite kitchen area revealed the door leading into the dining room was open. The top half of the Dutch-style doors was open and access to the steam table area was easily gained by reaching over the lower door and pushing the door handle down. The steam table in Health Care One kitchen was on and a water temperature reading obtained by Chef #161 was 180 degrees Fahrenheit. No staff were observed in the area of the kitchen/dining room. On 06/17/15 at 5:00 P.M. the Director of Nursing provided a list of residents in the facility who were noted to be cognitively impaired but independent in locomotion. Residents #55, #75, #98, #106, #126 and #246. Residents #75, #98 and #106 were noted to be independent in ambulation while Residents #55, #126 and #246 were noted to be independent in propelling themselves in their wheelchairs. Resident #246 resided on Health Care Two area while all of the other five residents listed resided on the Health Care One area. On 06/18/15 at 12:18 P.M. Chef #161 reported that there were no policies or procedures governing the operation of the satellite kitchens or steam tables. Chef #161 reported it previously was the expectation that the staff close the bottom door of the two Dutch doors when staff were not in the kitchen area.

Based on interview, review of the facilities Bureau of Criminal Investigation Log, and review of the facilities policy for abuse, the facility failed to implement their abuse policy by failing to screen direct care employees prior to allowing them the work in the facility. This affected three new employees (#123, #91 and #67) of 13 employee records reviewed. This had the potential to affect all the residents in the facility. The facility census was 114. Findings include: The facility policy for abuse, revised on October 2014 states on page 3 that only properly screened employees, including criminal background checks, will be employed to provide care for the residents. The policy also states on page 4 that "BCI results must be returned, reviewed and determined appropriate by the Department Head and then the Administrator, before the person can be hired." 1. Staff #123 was hired as a full time State tested Nursing Assistant (STNA)on 10/24/14. Review of the facilities Bureau of Criminal Investigation(BCI)Log revealed STNA #123's background check was requested on 10/29/14 and returned forty days later on 12/8/14. 2. STNA #91 was hired on 10/17/14 as a part time employee. The BCI Log revealed STNA #91's criminal background check was sent out on 10/17/14 and returned forty seven days later on 12/03/14. 3.STNA #67 was hired as a full time employee on 10/21/14. The BCI log revealed STNA #67's criminal background check was requested on 10/21/14 and results returned forty eight days later on 12/08/14. On 12/09/14 at 4:47 P.M. the facility Administrator verified that STNA #123, STNA #91, and STNA #67 began working their assigned schedule without the required BCI results returned, starting with their date of hire. This is an incidental deficiency found during the investigation of Complaint Number OH 199.

Based on observation, record review and staff and resident interviews, the facility failed to provide necessary assistive devices to prevent an avoidable injury that resulted in a fracture. This affected one (#147) of three sampled residents. Findings include: Review of the medical record of Resident #147 revealed she was readmitted to the facility on [DATE] following a brief hospitalization . Review of the resident's mobility assessment/rehabilitation screening dated 12/16/09 revealed she had limited joint motion due to a fused left knee and required assistance of one with ambulation. Per the June 2010 physician orders [REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #147 had no short term or long term memory problems, was independent for daily decision making skills and had no behavioral symptoms. Further review of the assessment revealed the resident required limited assistance of one person for transfers and locomotion, she had limitations on one side with partial loss to her leg and her foot and her mode of locomotion was wheeling herself. Review of the resident's plan of treatment for [REDACTED].#147 was to be independent with wheelchair mobility from her room to dining room. Review of the resident's activity of daily living flow sheet dated 04/30/10 through 05/06/10 revealed her daily locomotion on the unit was limited assistance with one person physical assist. Therapy weekly progress notes dated 05/07/10 indicated progress summary as modified independence with 2 to 3 rest periods needed. Review of Medication Administration Record (MAR) for April 2010 revealed the resident had an order for [REDACTED]. Further review of the MAR revealed Resident #147 was medicated with Percocet 35 times during the month of April. Review of MAR for May 2010 revealed Resident #147 was medicated with Percocet 33 times. Nurse's notes dated 05/11/10 at 2:35 P.M. regarding locomotion on the unit stated the resident was directed and/or encouraged with some occasional physical assist to move about the unit without weight bearing assistance. The notes stated for locomotion off unit, the resident was directed and/or encouraged and occasionally given some physical assist to move off the unit with limited physical assistance, devices used and the resident propels her own wheelchair and is wheeled by others. Review of therapy weekly progress note dated 05/13/10 revealed the progress summary stated modified independence with rest brakes as needed. The notes further stated the resident's endurance continued to be an issue and she required frequent breaks during wheelchair mobility to and from her room to the dining room. According to a Statement form dated 05/14/10 at 9:30 A.M. by state tested nurse aide (STNA) #20, Resident #147 called STNA #20 to her table and stated she needed the nurse right away. STNA #20 stated the resident was hot, sweating, pale and upset so she immediately took her to the nurse in the hallway. In route to the nurse, Resident #147's left foot caught on the ground and her left knee, that was normally stiff, bent slightly. Resident #147 complained of left knee pain when she attempted to bear weight. STNA #20 informed the nurse of the resident's knee pain and an X-ray was ordered. Resident #147 was lying in her recliner with an ice pack on her left knee. STNA #20 made sure the resident had new foot pedals applied to prevent any further injury. Review of a facility Dialogue review dated 05/17/10 at 2:10 P.M., revealed it stated an employee tried to quickly get the resident to the nurse due to the resident's rapidly declining health condition during breakfast and resident's leg inadvertently got caught under own wheelchair while being transported out of dining room resulting in a femur fracture. Review of nurses notes dated 05/18/10 at 2:40 P.M. revealed on 05/14/10 at 8:00 A.M. the resident's left foot was caught on the floor, back under the seat of her wheelchair. The notes stated the resident was not "feeling well" and when a staff member wheeled the resident to nurse, her left foot caught on floor under seat of the wheelchair. The notes stated the resident's blood sugar was 47. Orange juice was given and the resident's blood sugar was retaken at 8:15 A.M. and was up to 72. The notes further stated the resident stated she felt better and she was in to eat breakfast. Her blood sugar was retaken at 9:00 A.M. and was 121. The resident was alert and oriented times 3, her knee was edematous, ice applied, her knee elevated and pain medication given per physician order. Review of the Mobilex Radiology Report revealed Resident #147 had a comminuted fracture of the distal femur with impaction. Review of MAR dated June 2010 revealed the resident had an order for [REDACTED]. Observation on 06/22/10 at 4:07 P.M., revealed staff transported the resident to her room in a wheelchair. The resident's left leg was elevated with a brace in place and the right leg was positioned on a foot pedal. On 06/24/10 at 9:46 A.M., Resident #147 was observed lying in bed asleep with a brace on her left leg. During interview on 06/24/10 at 10:40 A.M., Resident #147 stated her leg was fractured when a staff member wheeled her out of the dining room to see the nurse. She stated she was passing out from her blood sugar being too low and staff wheeled her to the nurse's station. The resident stated she was yelling at the staff that her leg was going to break then she heard a pop. She stated she did not remember who the staff member was that wheeled her out of the room to see the nurse. She stated the staff told her that her foot slipped off the foot rest that was attached to her wheelchair. The resident further stated she did not recall the staff member requesting help prior to wheeling her out of the room. The resident stated she always used the foot rests prior to her fracture. Resident #147 stated she was unable to have surgery on her left leg due to her heart condition. During interview on 06/24/10 at 12:36 P.M., STNA #118 she stated Resident #147 was able to bear weight prior to her fracture but was still assisted to the bathroom. She stated the resident had been able to use the wheelchair on her own prior to the fracture but only for short distances because she would get short of breath. She stated the resident used her hands as she propelled herself and she did not use her feet for mobility in the wheelchair. STNA #118 further stated Resident #147 used foot rests prior to her fracture and never refused to use them. During interview on 06/24/10 at 12:47 P.M., STNA #11 stated the resident was only able to propel herself with the use of her hands prior to her fracture. STNA #11 stated Resident #147 used foot rests on her wheelchair and never refused to use them. On 06/24/10 at 1:40 P.M. Resident #147 was observed lying in bed reading a book and wearing a brace on her left leg. During interview on 06/24/10 at 3:06 P.M., STNA #20 stated she was in the dining room to assist the residents on the morning of 05/14/10 when Resident #147 yelled her name. She stated the resident looked bad, she was pale and sweaty. STNA #20 stated she was aware of the resident's history of heart problems so she went to her nurse. She stated the nurse was busy at that time and stated to tell the resident she would be right there. STNA #20 stated she told Resident #147 the nurse was on her way and she walked out of the dining room and came back within 1 to 2 minutes. She stated Resident #147 again yelled her name and that the resident looked worse at that time. STNA #20 stated she made a judgement call and wheeled Resident #147 to the nurse. STNA #20 stated that but by the time she got the resident to the nurse's station she appeared to pass out, she dropped her legs and her left leg hit the ground and she made a noise like a whimper. She stated the resident's blood sugar was low and the registered nurse addressed the situation of her low blood sugar. STNA #20 stated she took the resident back to her room and put her in bed and called her daughter. She stated Resident #147 did not have foot pedals on her wheelchair at the time of the incident, because she would refuse the foot pedals and she was ambulatory prior to this. STNA #20 stated the resident's foot got in the way of the wheelchair due to her acute medical condition. STNA #20 stated she did not recall how many other nurses were on the unit that could have assisted Resident #147 and that she did not ask another nurse to assess Resident #147 prior to wheeling her to the nurse. During interview on 06/24/10 at 4:42 P.M., STNA #37 stated Resident #147 required assistance of one person prior to her fracture and was able to bear weight prior to the fracture but staff still had to assist her with transfers. She stated that prior to her fracture staff transported the resident to the dining room via a wheelchair with the use of foot pedals. She stated Resident #147 had never refused to use the foot pedals prior to injuring her leg and that the resident was able to transport herself for a short distance by using her hands to propel herself. She stated the resident would get tired and short of breath and then she would ask staff to wheel her down the rest of the way. During interview on 06/25/10 at 8:12 A.M., the Assistant Director of Nursing (ADON) #58 stated the resident was in the dining room demanding to see the nurse, she was pale and diaphoretic. She stated a staff member requested the nurse come to the dining room to see the resident but the nurse was busy and the aide took it upon herself to move Resident #147 from the dining room. ADON #58 stated that while transferring the resident in the wheelchair to see the nurse the resident's left leg got caught under the wheelchair. She stated the resident complained of pain so an x-ray was done which revealed she had sustained a fracture. Interview with Physical Therapist #127 on 06/25/10 at 8:32 A.M. revealed there is no formal evaluation done for the use of foot rests. She further stated if a resident requires the assist of staff to be transported while in a wheelchair they should have foot rests on. She further stated Resident #147 would not always wear the foot rests and liked to have them off while in the dining room.