Every finding on record at Judson Park

Based on observation, interview, record review, and facility policy review, the facility failed to ensure infection control protocols were maintained during medication administration for Resident #3 and during wound care for Resident #22. Additionally, the facility failed to ensure appropriate personal protective equipment was available and utilized for four residents (#1, #4, #26, and #45) who required enhanced barrier precautions. The facility identified seven residents who required enhanced barrier precautions. This affected six residents (#1, #3, #4, #22, #26, and #45) of seven residents reviewed for infection control. The facility census was 22. Findings include: 1. Record review revealed Resident #3 was admitted to the facility 04/15/24. Diagnoses included type one diabetes mellitus (DM1) with hyperglycemia, long-term (current) use of insulin and hypertensive heart disease with heart failure. Review of Resident #3's physician orders revealed an order dated 03/31/26 for Insulin Lispro (a short-acting injectable medication used to lower blood sugar levels) 10 units scheduled before breakfast. Resident #3 also had an additional order for sliding scale insulin which specified for an additional four units of insulin to be administered based on a blood sugar level between 201 and 250. Resident #3 had an additional order dated 03/10/26 for Lantus (a long-acting injectable medication used to lower blood sugar levels) 38 units once daily in the morning. Review of the care plan dated 06/20/26 revealed Resident #03 had diabetes mellitus. Interventions included administering diabetes medication as ordered by doctor and to monitor/document for side effects and effectiveness. Observation on 07/22/26 at 8:55 A.M. with Agency Licensed Practical Nurse (LPN) #841 revealed she checked Resident #3's blood sugar and obtained a result of 219. Agency LPN #841 prepared to administer Resident #3's insulin Lispro and Lantus via two insulin pens. During observation, Agency LPN #841 failed to cleanse the hub of the pen with an alcohol swab prior to placing a new single-use needle on each pen. Agency LPN #841 proceeded to draw up the resident's ordered doses, 14 units of insulin Lispro and 38 units of Lantus and administered both injections to Resident #3. An interview on 07/22/26 immediately following the observation with Agency LPN #841 verified she did not cleanse the hub of the insulin pens prior to attaching a new single-use needle. Review of the instructions for use of Insulin Lispro and Lantus dated 07/2023 revealed the instructions called for the nurse to wipe the rubber seal with an alcohol swab prior to attaching a new needle. 2. Record review revealed Resident #22 was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus, moderate dementia with agitation, and hypertensive heart disease with heart failure. Review of Resident #22's care plan dated 05/06/26 revealed Resident #22 had the potential for pressure ulcer development related to decreased mobility and diabetes mellitus. Interventions included administering treatments as ordered and monitoring for effectiveness. Review of Resident #22's physician orders revealed an order dated 07/20/26 for wound care of the left lateral foot: cleanse the area with quarter-strength (0.0125%) Dakin's solution, pat dry, and apply silver alginate. Cover with an abdominal (ABD) pad (absorbent dressing) and kerlix (gauze) wrap and change daily and as needed. Observation on 07/23/26 at 10:16 A.M. of the left foot dressing change for Resident #22 revealed Agency LPN #840 and Minimum Data Set (MDS) Registered Nurse (RN) #817 prepared to provide wound care to Resident #22's left lower leg. LPN #840 gathered her equipment, put on a gown and gloves, and prepared Resident #22's bedside table with the wound care supplies. Agency LPN #840 proceeded to open the packages of the ABD pad, kerlix, and gauze pads, touching the material inside each package. LPN #840 removed the green pressure relief ankle foot orthosis (PRAFO) boot off of Resident #22's left lower leg and placed it aside. LPN #840 then began to remove the resident's old dressing, cut the tape securing the dressing with scissors that were not sanitized. The old dressing was adhered to the wound so LPN #840 squirted 1/4 strength Dakin's solution on the soiled dressing multiple times to loosen the dressing before it was removed and discarded in the trash. LPN #840 then proceeded to cleanse the resident's wound with Dakin's. She used the same scissors she previously used to cut the old dressing to cut a piece of the silver alginate dressing to the size of the wound. LPN #840 covered the silver alginate with the ABD pad and secured the dressing with Kerlix and tape. She re-applied Resident #22's PRAFO boot. Throughout the procedure of removing the old dressing, cleansing the wound, and applying the new dressing, LPN #840 did not change her gloves or perform hand hygiene. An interview on 07/23/26 at 10:35 A.M. with LPN #840 and MDS RN #817 verified infection control procedures were not maintained during Resident #22's wound care. Review of the facility policy, Infection Control Program dated 01/2012 revealed all staff will be instructed upon hire and annually on Standard Precautions/Universal Precautions and all staff will follow these precautions to prevent the spread of infection from body fluid exposure with the use of personal protective equipment. Review of the facility policy, Infection Control and Prevention dated 07/20/26 revealed the standard precautions include the following five procedures: hand washing, use of personal protective equipment, correct handling and disposal of waste, appropriate cleaning of client care equipment and hygienic environmental control. Standard precautions apply whenever you may come in contact with the following four bodily substances: blood (including dried blood), all body substances, secretions and excretions (excluding sweat), regardless of whether or not they contain visible blood, non-intact kin and mucous membranes. Handwashing is the single most effective way to reduce the number of microorganisms on the surface of the skin. It should always be performed: before and after contact with a client, before and after eating, after using the toilet, before and after using gloves, after contact with used equipment and immediately following contact with bodily fluids. 3. Record review for Resident #4 revealed resident was admitted on [DATE] with diagnosis that included Parkinson's disease, gout, pneumonia, dementia, vitamin b12, protein-calorie malnutrition, anemia, essential hypertension and dysphagia. Resident #4's record indicated Resident #4 had a percutaneous endoscopic gastrostomy (PEG) tube and received medications and enteral feed via the PEG tube. Observation on 07/21/26 at 4:26 P.M. of Resident #4 room revealed he had a sign outside his room for Enhanced Barrier Precautions (EBP). Continued observation revealed Certified Nursing Assistant (CNA) #834 going into Resident #4 room to provide care. CNA #834 put on gloves but no gown and assisted the resident's private aide with using a Hoyer (mechanical) lift to assist the resident back to bed. Once the resident was transferred into the bed, CNA #834 and his private aide provided incontinence care. Interview immediately following the observation with CNA #834 outside of Resident #4's room revealed she had been working at the facility for just over 90 days and was not sure where the gowns were. She confirmed she did not wear a gown while providing care to Resident #4. 4. Record review for Resident #26 revealed an admission date of 08/09/25 with diagnoses that included major depressive disorder, stage four pressure ulcer of the sacral region, Parkinson's disease, urinary tract infection, and essential hypertension. Observation on 07/21/26 at 4:47 P.M. of Resident #26 room revealed she had a sign outside her room for Enhanced Barrier Precautions (EBP). Observation of CNA #834 answering Resident #26 call light and resident asked to reposition her bed. CNA #834 put on gloves but no gown and repositioned resident in her bed. Interview with CNA #834 confirmed she did not wear a gown again while providing care. CNA #834 revealed she asked LPN #803 where the gowns were and LPN #803 called the supervisor to get Personal Protective Equipment (PPE) for residents on precautions. Observation in Resident #26 room revealed there was no PPE outside of the room and only gloves were in the resident's bathroom. 5. Record review for Resident #1 revealed the resident was admitted on [DATE] with diagnosis that included Parkinson's disease, retention of urine and acute kidney injury. Review of Resident #1's active orders revealed the resident had a foley (indwelling) catheter. Observation and interview on 07/21/26 at 4:52 P.M. with CNA #834 in Resident #1 room revealed resident was on EBP and did not have any PPE in his room. 6. Record review for Resident #45 revealed the resident was admitted on [DATE] with diagnosis that included history of stroke, essential hypertension, and dysphagia. Review of Resident #45's active orders revealed the resident had a percutaneous endoscopic gastrostomy (PEG) tube through which the resident received medication administration and enteral feedings. Observation and interview on 07/21/26 at 4:54 P.M. with LPN #803 in Resident #45 room revealed the resident was on EBP. There was no PPE outside of the room, but there were gloves in the resident's bathroom and an open packet of gowns sitting on the resident's bathroom sink counter. An interview with LPN #803 at the time of observation confirmed leaving gowns on the resident's bathroom sink was not a proper infection control practice. Observation on 07/21/26 at 4:58 P.M. revealed MDS RN #817 placed a plastic drawers containing PPE outside of residents' rooms who were on precautions. Review of the facility policy Infection Control and Prevention dated 07/20/26 revealed gowns and gloves are to be utilized for the following high-contact resident care activities to prevent the spread of multi-drug resistant organisms. These precautions are implemented for any resident for the device care or use: central line, urinary catheter, feeding tube, tracheostomy and wound care for any skin opening requiring a dressing. Signage will be displayed to inform providers and associates regarding the precautions. The policy further stated gowns and clothes such as overalls will reduce the possibility of contact with hazardous or contaminated substances. Fabric or paper gowns will be worn to protect self from an infectious client or worn to protect the client from possible exposure to microorganisms. This deficiency represents non-compliance investigated under Complaint Number 2996268.

Based on record review, interview, and policy review, the facility failed to ensure adequate supervision and individualized care planned interventions to prevent/reduce risk of falls and injury. This affected one resident (#27) of three residents reviewed who were at risk for falls. Actual harm occurred on 09/02/24 when Resident #27, who was identified as a high risk for falls, was found on the floor, unable to move her left leg and in severe pain. Resident #27 was sent to the hospital for evaluation and treatment where she was diagnosed with a fractured hip. Prior to the incident, Resident #27's scheduled sitter did not show up and the family nor the contacted company that provided the sitter were notified so arrangements for a replacement could be made. In addition, there was no evidence facility fall interventions were in place at the time of the resident's fall. While unsupervised in her room, Resident #27 got up from a wheelchair and walked out to the corridor where she fell . Findings include: Review of medical record for Resident #27 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included restlessness and agitation, chronic kidney disease, Alzheimer's disease, and delirium due to known physiological condition. Review of the facility Fall Risk assessment dated [DATE] revealed Resident #27 was disoriented to person, place, and time daily. Resident #27 was bed bound and required use of assistive devices including wheelchair, walker, furniture, and or cane. Resident #27 scored a 17 on the assessment indicating a high risk for falls. Review of the paper initial/interim plan of care dated 08/27/24 revealed Resident #27 was at risk for falls. Interventions included keep call light signal within reach, keep bed in lowest position and locked and ensure proper footwear, non-skid with proper soles. Review of the plan of care located in the electronic medical record dated 08/27/24 revealed Resident #27 was at risk for falls. The care plan did not include any interventions to prevent falls or to protect the resident from injury. Review of a nurse progress note dated 08/26/24 timed 10:40 P.M. revealed Resident #27 did not walk; a walking goal was not clinically indicated. Review of a nurse progress note dated 08/27/24 timed 12:07 A.M. revealed Resident #27 was always disoriented to person, place, and time. Review of a nurse progress note dated 08/28/24 timed 3:08 P.M. revealed Resident #27 had a fall on 08/27/24. The progress note indicated that a fall mat and alarm were in place. The progress note provided no information regarding the time, place or specifics of the fall. Further review of the medical record revealed no evidence of a post fall assessment, monitoring, or a fall investigation related to the 08/27/24 fall. Review of an activity participation progress note dated 08/29/24 timed 2:53 P.M. revealed Resident #27 indicated she was bed bound and could not walk. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/02/24, revealed Resident #27 had impaired cognition. Behaviors identified on the MDS assessment included verbal and physical aggressiveness toward staff. Review of nurse progress note dated 09/02/24 timed 8:30 P.M. revealed Resident #27's son, who was at the facility after a fall requested that staff contact emergency services due to Resident #27's increased pain levels and long wait time for x-rays. Review of the nurse progress note dated 09/02/24 timed 8:45 P.M. revealed emergency services arrived at the facility. There was no information regarding the fall, injury, pain, or assessment of the resident. Review of nurse progress note dated 09/03/24 timed 1:57 A.M. revealed Resident #27 was admitted to the hospital with a left femur fracture. Review of the facility's undated and untimed fall incident report revealed on 09/02/24 Resident #27 was found on the floor in the hallway. Resident #27 complained of severe pain in left hip. Resident #27 was unable to straighten left leg due to severe pain. Predisposing physiological factors included gait imbalance and impaired memory. Resident #27 was ambulating without assistance. The family and physician were notified on 09/02/24 at 7:32 P.M. Interview on 09/29/24 at 8:35 A.M. with Registered Nurse (RN) #103 revealed she was not sure if Resident #27 had any alarms in place during her stay at the facility. RN #103 stated typically residents at risk for falls had bed and chair alarms, staff kept the bed at its lowest level and beds were placed with one side against the wall if possible. Interview on 09/30/24 at 10:52 A.M. with Resident #27's physician revealed she received a call from staff notifying her Resident #27 had a fall. The physician stated that Resident #27 had no rotation in her leg, could put weight on the leg and did not want to go the hospital. Follow up interview on 09/29/24 at 11:15 A.M. with RN #103 revealed she found Resident #27 on the floor in the hallway just outside the resident's room around 7:00 P.M. RN #103 assessed Resident #27 who indicated her left hip was hurting and she could not move the leg. RN #103 stated it took three staff members to transfer Resident #27 from the floor to her wheelchair and then to her bed. RN #103 contacted the physician who ordered x-rays. RN #103 said a sitter the family hired to stay with Resident #27 was not working at the time of the fall. RN #103 did not know why the sitter was not working or why staff did not contact the family to report the scheduled sitter did not show for the assigned shift. RN #103 did not recall an alarm sounding when she found Resident #27 on the floor. RN #103 did not send Resident #27 to the hospital immediately because the physician wanted x-rays prior to sending the resident to the hospital. Resident #27 could not bear weight on the left leg. Resident #27 was sent to the hospital upon the son's request. Interview on 09/30/24 at 12:12 P.M. with the Director of Nursing (DON) and Resident Care Coordinator (RCC) #106 confirmed there were no progress notes regarding Resident #27's falls on 08/27/24 and 09/02/24. They indicated the facility had not completed a fall investigation related to the 08/27/24 fall to determine the root cause which could have potentially prevent another fall. They verified the electronic plan of care dated 08/27/24 indicated Resident #27 was at risk for falls but did not include interventions to prevent falls or protect the resident from injury if a fall occurred. RCC #106 stated Resident #27 had an alarm on her wheelchair and bed and a fall mat next to the bed but verified there was no documentation to support they were implemented. RCC #106 indicated a sitter for Resident #27 had been at the facility (on 09/02/24) and then left. The DON and RCC #106 did not know why the sitter left the facility or why the family was not informed of the sitter leaving. Upon the sitter leaving Resident #27's supervision by facility staff was not increased. Interview on 09/30/14 at 2:25 P.M. with agency State tested Nurse Assistant (STNA) #107 revealed she worked 2:30 P.M. to 11:00 P.M. on 09/02/24 the day Resident #27 fell . STNA #107 stated Resident #27 had no sitter while STNA #107 was working which was the 2:00 P.M. to 11:00 P.M. shift. STNA #107 stated when the family arrived after being notified of the fall they asked where the sitter was. STNA #107 stated Resident #27 had a bed alarm only, there was no alarm on the wheelchair. STNA #107 explained a sitter for another resident observed Resident #27 stand up from wheelchair and walk into the hallway by herself. Resident #27 was in excruciating pain and screamed out every time staff tried to move her. The physician wrote an order for x-rays which did not happen because of the long wait time. The family requested for staff to send Resident #27 to the hospital. Resident #27 left for the hospital at approximately 8:30 P.M. Interview on 09/30/24 at 3:54 P.M. with Unit Supervisor (US) #108 revealed she was informed of Resident #27's fall at 7:00 P.M. The x-ray technician did not arrive at the facility until after Resident #27 left the facility. Resident #27 left the facility around 8:30 P.M. Interview on 09/30/24 at 4:10 P.M. with the DON revealed Resident #27 should have had an alarm on her wheelchair. Interview on 10/01/24 at 11:23 A.M. with the director of the company responsible for providing sitters for residents at the facility revealed the sitter for Resident #27 flat out lied to the company indicating she/he was at the facility providing services for Resident #27 at the time of the fall. The director stated if the facility would have contacted the company when the sitter did not show the sitter would have been replaced. The director stated it was an unfortunate situation. Review of the facility's visitor/contractor sign in log revealed the sitter assigned to work with Resident #27 did not sign into the facility on [DATE]. Review of the facility Falls Policy, dated 2020 indicated all residents would be assessed for fall risk. Interventions would be incorporated into the plan of care utilizing the Fall Assessment Follow-up Tool as guidance for interventions. This deficiency represents non-compliance investigated under Complaint Number OH00157559.

Based on record review and interview the facility failed to provide written information to the resident or resident representative regarding the facility bed hold policy upon discharge to hospital. This affected one (Resident #27) of three residents reviewed who required a bed hold notice. Findings include: Review of medical record for Resident #27 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included restlessness and agitation, chronic kidney disease, Alzheimer's disease, and delirium due to known physiological condition. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/02/24, revealed Resident #27 had impaired cognition. Review of the nurse progress note dated 09/02/24 timed at 8:30 P.M. revealed Resident #27's son, who was at the facility after a fall, requested staff to contact emergency services because of Resident #27's increased pain levels and long wait time for x-rays. At 8:45 P.M. emergency services arrived at the facility to transport Resident #27 to the hospital. Review of the nurse progress note dated 09/03/24 timed at 1:57 A.M. revealed Resident #27 was admitted to the hospital with a left femur fracture. Interview on 09/30/24 at 11:20 A.M., with Admission Director (AD) #105 revealed each resident who was discharged to the hospital from the facility received a packet which included information regarding bed holds Review of a packet which AD #105 indicated each resident received upon discharge confirmed the packet included the required bed hold notice information. AD #105 could not confirm that Resident #27 or the resident's representative received a packet which would have included the bed hold information. Interview with Resident #27's son on 10/07/24 at 9:46 A.M. revealed he did not receive a bed hold notice or discharge packet when his mother discharged emergently to the hospital after a fall on 09/02/24. However, on 09/03/24 he contacted the facility and requested a bed hold based on the information he read in admission agreement which was signed by himself and the facility representative. Resident #27's son said he wanted to ensure his mother had a place to go upon her discharge from the hospital. His mother's payer source was Medicare. This deficiency represents non-compliance investigated under Complaint Number OH00157559.

Based on record review, policy review, and interview the facility failed to allow a resident to return to the facility after discharge to hospital for a change in condition. This affected one (Resident #27) of three residents reviewed who had been transferred to the hospital. Findings include: Review of medical record for Resident #27 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included restlessness and agitation, chronic kidney disease, Alzheimer's disease, and delirium due to known physiological condition. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/02/24, revealed Resident #27 had impaired cognition. Review of the nurse progress note dated 09/02/24 timed at 8:30 P.M. revealed Resident #27's son, who was at the facility after a fall requested staff to contact emergency services because of Resident #27's increased pain levels and long wait time for x-rays. At 8:45 P.M. emergency services arrived at the facility to transport Resident #27 to the hospital. Review of the nurse progress note dated 09/03/24 timed at 1:57 A.M. revealed Resident #27 was admitted to the hospital with a left femur fracture. Interview on 09/30/24 at 11:20 A.M., with Admission Director (AD) #105 revealed Resident #27 was not readmitted to the facility because the census was 30 (capacity 36) and the facility held/reserved beds for any potential admission from their sister facilities. AD #105 contacted her supervisor who directed her to refuse the readmission. AD #105 stated the facility policy did not reflect the procedure for reserving beds because the procedure/process was internal. AD #105 said the family of Resident #27 contacted the facility within 24 hours to request a bed-hold. Interview with Resident #27's son on 10/07/24 at 9:46 A.M. revealed he did not receive a bed hold notice when his mother discharged emergently to the hospital after a fall on 09/02/24. However, on 09/03/24 he contacted the facility and requested a bed hold based on the information regarding bed holds located in the signed admission agreement. The complainant wanted to ensure his mother had a place to go upon her discharge from the hospital. He was told they could not hold a bed for his mother. His mother's payer source was Medicare Advantage. Resident #27 was discharged from the hospital on 09/15/24 and admitted to another area nursing home. Review of the facility Bed Hold and Return to Facility Policy and Procedure, dated 2016 revealed the following. 1. Medicare as the primary payer source- unlimited days with payment of daily room rate. 2. Medicaid as primary payer source- 30 days. 3. Private pay as the primary payer source- unlimited days with payment of daily room rate. Facility will readmit or allow the opportunity for return to facility when: 1. Residents to return to facility after hospitalization or therapeutic leave if their needs were met by the facility. 2. The resident required the services provided by the facility. 3. If the resident was eligible for Medicare or Medicaid skilled nursing facility services. This deficiency represents non-compliance investigated under Complaint Number OH00157559.

Based on record review and interview the facility failed to ensure the medical record contained an accurate representation of the resident's actual experience. This affected one (Resident #27) of three residents reviewed for falls. Findings include: Review of medical record for Resident #27 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included restlessness and agitation, chronic kidney disease, Alzheimer's disease, and delirium due to known physiological condition. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/02/24, revealed Resident #27 had impaired cognition. Behaviors identified on the MDS included verbal and physical aggressiveness toward staff. Review of the plan of care dated 08/27/24 revealed Resident #27 was at risk for falls. Review of a nurse progress note dated 08/28/24 timed 3:08 P.M. revealed Resident #27 had a fall on 08/27/24. The progress note indicated that a fall mat and alarm were in place. The progress note provided no information regarding the time, place or specifics of the fall. Further review of the medical record revealed no evidence of a post fall assessment, monitoring, or a fall investigation related to the 08/27/24 fall. Review of nurse progress note dated 09/02/24 timed 8:30 P.M. revealed Resident #27's son, who was at the facility after a fall requested that staff contact emergency services due to Resident #27's increased pain levels and long wait time for x-rays. Review of the nurse progress note dated 09/02/24 timed 8:45 P.M. revealed emergency services arrived at the facility. There was no information regarding the fall, injury, pain, or assessment of the resident. Review of nurse progress note dated 09/03/24 timed 1:57 A.M. revealed Resident #27 was admitted to the hospital with a left femur fracture. Interview on 09/30/24 at 10:52 A.M. with Resident #27's physician revealed she received a call from staff notifying her Resident #27 had a fall. The physician stated that Resident #27 had no rotation in her leg, could put weight on the leg and did not want to go the hospital. Interview on 09/29/24 at 11:15 A.M. with Registered Nurse (RN) #103 revealed she found Resident #27 on the floor in the hallway just outside the resident's room around 7:00 P.M. RN #103 assessed Resident #27 who indicated her left hip was hurting and she could not move the leg. RN #103 stated it took three staff members to transfer Resident #27 from the floor to her wheelchair and then to her bed. RN #103 contacted the physician who ordered x-rays. Resident #27 could not bear weight on the left leg. Resident #27 was sent to the hospital upon the son's request. Interview on 09/30/24 at 12:12 P.M. with the Director of Nursing (DON) and Resident Care Coordinator (RCC) #106 confirmed there were no progress notes regarding Resident #27's falls on 08/27/24 and 09/02/24. This deficiency represents non-compliance investigated under Complaint Number OH00157559.

Based on closed medical record review, staff interview, review of emergency medical services report, review of hospital records, review of facility policy, and review of manufacturer's guidelines, the facility failed to ensure resident safety during a Hoyer lift transfer. Actual harm occurred on 02/21/24 when Resident #30, who was cognitively impaired, at risk for falls and dependent on staff for transfers using a mechanical (Hoyer) lift, fell from the Hoyer lift during a staff assisted transfer resulting in hospitalization with injuries including a right frontal bone fracture extending into superior orbit, bilateral maxillary bone fractures, and bilateral inferior orbital wall fractures with involvement of right nasal lacrimal duct. This affected one resident (#30) of three reviewed for safe transfers. The facility census was 24. Findings include: Review of the closed medical record for Resident #30 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included vascular Parkinsonism, mild cognitive impairment, vascular dementia, congestive heart failure, and chronic peripheral venous insufficiency. Review of the admission nursing assessment for Resident #30 dated 02/08/24 revealed the resident arrived at the facility by stretcher and was disoriented, confused, and required verbal cues. Resident #30 was on hospice care, had contractures and impaired range of motion to the bilateral lower extremities. Review of the restorative nursing screener for Resident #30 dated 02/08/24 revealed the resident was dependent on staff for transfers to and from a bed to a chair or wheelchair and used a manual wheelchair for mobility. Review of fall risk evaluation for Resident #30 dated 02/09/24 revealed the resident was at risk for falls and was bed bound. Review of the Minimum Data Set (MDS) assessment for Resident #30 dated 02/21/24 revealed the resident was dependent on staff for transfers to and from a bed to a chair or wheelchair. Review of an incident note for Resident #30 dated 02/21/24 timed at 9:46 A.M. revealed the resident was being lifted in a Hoyer lift when he slipped out and landed on his right side. The staff called 911 and the resident was transported to the hospital per emergency medical services (EMS.) Review of a witnessed fall incident report for Resident #30 dated 02/21/24 timed at 9:58 A.M. revealed the resident had fallen out of Hoyer lift during transfer. Resident #30 had observed injuries including an abrasion to top of the scalp, unspecified injury to back of head, skin tear to right antecubital space, and an unspecified injury to right upper arm. Resident #30 was stuporous (responsive only to vigorous stimulation) following the incident. Review of an EMS report for Resident #30 dated 02/21/24 revealed EMS arrived at the facility at 9:14 A.M. and the resident arrived at hospital at 9:32 A.M. Resident #30 was found lying supine on floor of his room, and facility staff reported the resident had fallen out of Hoyer lift while being transferred. The resident had an abrasion with bleeding to the forehead and right forearm and deformity of right upper arm and right elbow. Resident #30 was confused and unable to answer questions or recall what had happened. Review of the health status note for Resident #30 dated 02/21/24 revealed the resident was admitted to hospital. Review of the hospital record for Resident #30 dated 02/21/24 revealed the resident was transported to the hospital after sustaining a fall from a Hoyer lift at the facility in which he was dropped by the facility nursing staff. Upon arrival at the hospital Resident #30 complained of right arm pain and right sided frontal head pain. Resident #30 sustained injuries including the following: right frontal bone fracture extending into superior orbit, bilateral maxillary bone fractures, bilateral inferior orbital wall fractures with involvement of right nasal lacrimal duct, superficial skin tears of right side of the forehead, a large superficial skin tear of the right forearm. Review of the incident statement for Resident #30 dated 02/22/24 per State tested Nursing Assistant (STNA) #803 revealed she was not the assigned caregiver for Resident #30 on 02/21/24 but she did assist STNA #804 with a transfer. Review of the statement revealed Resident #30 went forward out of Hoyer pad during the transfer, and STNA #803 notified Licensed Practical Nurse (LPN) #802. Review of the incident statement for Resident #30 dated 02/22/24 per STNA #804 revealed she was the assigned caregiver for Resident #30 on 02/21/24. Review of the statement revealed Resident #30 was being lifted into his Broda chair per the Hoyer lift when he fell out. Further review of the statement revealed Resident #30 rolled out of the Hoyer lift and onto the floor because he was contracted, and Resident Care Manager (RCM) #800 and LPN #802 were notified. Interview on 03/06/24 at 10:00 A.M. with LPN #802 confirmed on 02/21/24 STNA #803 notified her Resident #30 had fallen out of the Hoyer lift, and she and RCM #800 found the resident in his room lying on his right side bleeding profusely. Initially, LPN #802 was unable to confirm where the blood was coming from, but after further assessment she determined he was bleeding from his nose. LPN #802 asked RCM #800 to call 911. The resident had bruising on his right arm from shoulder to elbow, bruising on right knee, a skin tear on his right arm, and his right eye was swollen shut. LPN #802 confirmed there were no mechanical issues with the Hoyer lift or the Hoyer pad nor were there any environmental hazards present in the room at the time of the fall. Interview on 03/06/24 at 10:44 A.M. with STNA #803 confirmed on 02/21/24 she had assisted STNA #804 with a Hoyer lift transfer of Resident #30 from his bed to a Broda chair. STNA #803 indicated she was controlling the Hoyer lift and STNA #804 was guiding. STNA #803 indicated when she began to lower Resident #30 down into the chair, he fell forward out of the Hoyer sling, and she was unsure how or why the resident fell forward. STNA #803 confirmed after resident fell , she ran for help while STNA #804 stayed with the resident. STNA #803 confirmed there were no mechanical issues with the Hoyer lift or Hoyer sling nor were there any environmental hazards present in the room at the time of fall. Interview on 03/06/24 at 11:06 A.M. with STNA #804 confirmed on 02/21/24 she requested assistance from STNA #803 to transfer Resident #30 out of bed. STNA #804 confirmed she prepared Resident #30 on the Hoyer pad and brought in the Hoyer lift. STNA #804 confirmed Resident #30 had contractures of his legs and he resembled a ball. STNA #804 confirmed STNA #803 helped her hook up the straps to the Hoyer lift, and she was guiding while STNA #803 was operating the lift. STNA #804 confirmed she was unsure why Resident #30 fell out of the Hoyer sling. STNA #804 confirmed as soon as STNA #803 turned the Hoyer from over the bed Resident #30 fell forward. STNA #804 reported she stayed with Resident #30 while STNA #803 went to get help. STNA #804 confirmed Resident #30 was bleeding after the fall and she supported his head. STNA #804 confirmed there were no mechanical issues with the Hoyer lift or Hoyer sling nor were there any environmental hazards present in the room at the time of fall. Interview on 03/06/24 at 12:22 P.M. with the [NAME] President (VP) of Health Services revealed the facility conducted an investigation regarding Resident #30's fall on 02/21/24. The VP of Health Services indicated the Hoyer lift used for the transfer for Resident #30 was checked (following the incident) with no equipment failure identified. The VP of Health Services revealed the facility was unsure if the size of the Hoyer lift sling was appropriate for the resident, and the facility had concluded the root cause of Resident #30's fall from Hoyer lift was user error. Interview on 03/06/24 at 12:42 P.M. with RCM #800 confirmed LPN #802 called her to Resident #30's room on 02/21/24 because STNA #803 and STNA #804 reported the resident had fallen during a Hoyer lift transfer. RCM #800 indicated she went to call 911 while LPN #802 assessed Resident #30. RCM #800 confirmed Resident #30 had a large bulge on right arm, a laceration to his elbow, and was bleeding from an unknown source. RCM #800 confirmed she waited on floor with Resident #30 until EMS arrived. Interview on 03/06/24 at 2:22 P.M. with the Director of Nursing (DON) confirmed the facility conducted an investigation regarding Resident #30's fall from the Hoyer lift on 02/21/24. The DON confirmed Resident #30 had contractures which caused him to be top heavy while being transported in a Hoyer sling. The DON confirmed she interviewed STNA #803 who confirmed Resident #30 was leaning forward in Hoyer sling during the transfer due to contractures. The DON questioned STNA #804 if she maintained hands on contact with Resident #30 while he was being transferred, and STNA #804 revealed she did not have hands on the resident but stated she was standing by while the resident was lifted in Hoyer lift. Interview with the DON confirmed the root cause of Resident #30's fall from the Hoyer lift was staff failed to recognize Resident #30 was top heavy due to contractures and failed to maintain hands on contact with the resident during the transfer. Review of facility policy titled Hoyer Lift Transfer dated 03/10/14 revealed one staff member should control the lift while the second staff member should oversee the positioning of the resident for safe transfer. When raising a resident, the staff member overseeing positioning must have their hands on the resident. Review of manufacturer's guidelines for the Hoyer lift dated 2011 revealed two assistants were recommended for all lifting, preparation, and transferring of residents. This deficiency represents non-compliance investigated under Complaint Number OH00151335.

Based on observation, record review and interview, the facility failed to ensure Resident #181, #184 and #186 had accurate advance directive orders and documentation in place for staff to accurately identify code status. This affected three Residents (#181, #184 and #186) out of five residents reviewed for advanced directives. The facility census was 25. Findings include: 1 Review of Resident #181's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of aftercare following joint replacement surgery, spinal stenosis lumbar, sleep apnea, osteoarthritis, Parkinson's disease, malignant neoplasm of prostate, myocardial infarction, and atrial fibrillation. Review of the physician's orders for Resident #181 revealed there were no orders to identify code status in the electronic medical record (EMR) or in the hard medical chart. Review of the facility document titled DNR Order Form, dated [DATE] and having Resident #181's name on it, revealed a physician signature, a large line drawn across the form and through the date and the word full written in large letters next to the words DNR comfort care. There was no patient nor authorized representative's signature on the form. Interview on [DATE] at 2:05 P.M. with Director of Nursing (DON) #301 confirmed there was no code status in the orders and in the hard medical chart was a DNR CC form was not completed to accurately identified code status and was not signed by Resident #181 or their authorized representative. DON #301 revealed the code status was supposed to be in the orders and in the hard medical chart. Interview on [DATE] at 2:07 P.M. Registered Nurse (RN) #304 confirmed there was no code status in the orders and in the hard medical chart was a DNR CC form not properly completed. RN #304 revealed the code status was supposed to be in the orders and in the hard medical chart. Interview on [DATE] at 3:36 P.M. with [NAME] President of Health Services (VPHS) #300 confirmed there was no code status in the orders and in the hard medical chart was a DNR CC form not properly completed. VPHS #300 revealed the code status was supposed to be in the orders and in the hard medical chart. 2 Review of Resident #184's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of Cellulitis of right lower limb, edema, hypertension, acute kidney failure with tubular necrosis, and obstructive sleep apnea. Review of the physician's orders for Resident #184 revealed there was no order for code status in the electronic medical record (EMR) or in the hard medical chart. Review of the facility document titled DNR Order Form, dated [DATE] and having Resident #184's name on it, revealed a physician signature, a large line drawn across the form and through the date and the word full written in large letters next to the words DNR comfort care. There was no patient nor authorized representative's signature on the form. Interview on [DATE] at 2:05 P.M. with the DON confirmed there was no code status in the orders and in the hard medical chart was a DNR CC form not properly completed, crossed out, and on top written Full. The DON revealed the code status was supposed to be in the orders and in the hard medical chart. Interview on [DATE] at 2:07 P.M. RN #304 confirmed there was no code status in the orders and in the hard medical chart was a DNR CC for not completed correctly, crossed out, and on top written Full. RN #304 revealed the code status was supposed to be in the orders and in the hard medical chart. Interview on [DATE] at 3:36 P.M. with VPHS #300 confirmed there was no code status in the orders and in the hard medical chart was a DNR CC for not completed correctly, crossed out, and on top written Full. VPHS #300 revealed the code status was supposed to be in the orders and in the hard medical chart. 3 Review of Resident #186's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, acute kidney failure with tubular necrosis, alcohol dependence, and epilepsy. Review of the physician's orders for Resident #186 revealed there was no order for code status in the electronic medical record (EMR) or in the hard medical chart. Review of the facility document titled DNR Order Form, dated [DATE] and having Resident #186's name on it, revealed a physician signature. There was no patient nor authorized representative's signature on the form. The form did not specify what the resident's code status was in the event of cardiac or respiratory arrest. Interview on [DATE] at 2:05 P.M. with the DON confirmed there was no code status in the orders and in the hard medical chart was a DNR CC for not completed. DON revealed the code status is supposed to be in the orders and in the hard medical chart correctly. Interview on [DATE] at 2:07 P.M. RN #304 confirmed there was no code status in the orders and in the hard medical chart was a DNR CC form not completed. RN #304 revealed the code status is supposed to be in the orders and in the hard medical chart correctly. Interview on [DATE] at 3:36 P.M. with VPHS #300 confirmed there was no code status in the orders and in the hard medical chart was a DNR CC form not completed. VPHS #300 revealed the code status was supposed to be in the orders and in the hard medical chart correctly. Review of facility policy, Advance Directives/CPR, revised ,d+[DATE], revealed every resident had a right to make an informed decision about their advance directives, physicians would write orders for the advance directives and copies of the advanced directives would be kept in the resident's medical record.

Based on observation, record review, policy review and interview, the facility failed to ensure influenza vaccinations were offered to Resident #17, #185 and #186 at least annually. This affected three residents (Resident #17, #185, and #186) of five residents reviewed for vaccines. The faciliy census was 25. Findings include: 1 Review of Resident #17's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of normal pressure hydrocephalus, presence of cerebrospinal fluid drainage device, dementia, and benign prostatic hyperplasia with lower urinary tract symptoms. Review of Quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was moderately impaired for decision making and required extensive assistance of two plus for bed mobility, transfers, toileting, and was extensive assistance of one for hygiene, and dressing. Review of Resident #17's immunization records revealed he had an influenza vaccine on 10/20/21 and there was no evidence the facility offered an influenza vaccine for 2022. 2. Review of Resident #185's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, atrial fibrillation, depression, and mild cognitive impairment. Review of Admission MDS 3.0 assessment dated [DATE] revealed the resident was moderately impaired for decision making and required extensive assistance of one for bed mobility, dressing, toileting, limited assistance of one for transfers, hygiene, and eating supervision with set up help. Review of Resident #185's immunization records revealed he had an influenza vaccine on 11/19/19 prior to his admission on 01/03/23 and there was no evidence the facility offered an influenza vaccine upon admission. 3 Review of Resident #186's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, acute kidney failure with tubular necrosis, alcohol dependence, epilepsy, and unspecified dementia. Review of Resident #186's immunization records revealed she had an influenza vaccine on 09/20/17 prior to her admission on 01/04/23 and there was no evidence the facility offered an influenza vaccine upon her admission to the facility. Interview on 01/18/23 at 3:36 P.M. with VPHS #300 verified staff were not offering vaccinations screening accurately upon admission and yearly as required. VPHS #300 was unable to provide any documentation the influenza vaccine was offered to Resident #185 and #186 upon admission nor Resident #17 at least annually. VPHS #300 reported this was an issue at the facility. Review of facility policy, Influenza and Pneumococcal Immunization Program, revised 10/2018, revealed the nurse admitting the resident was responsible for completing Influenza/Pneumococcal Immunization Resident Assessment form to determine which residents needed vaccines and annual flu vaccination education would be provided to the resident or their representative. The flu vaccination would be offered to all residents able to get the vaccine.

Based on observation, record review, and interview, the facility failed to ensure call lights were functioning and that needed repairs received timely intervention. This affected one of one residents (Resident #2) reviewed for environmental concerns. The facility census was 25. Findings include: Record review of Resident #2 revealed she was admitted to the facility 08/09/06 and had diagnoses including multiple sclerosis, dysphagia, wheelchair dependence, neuromuscular bladder dysfunction, and unspecified dementia. Her last Minimum Data Set 3.0 assessment on 10/29/22 revealed she had moderate cognitive impairment, was incontinent of bowel and bladder, and required extensive or total staff assistance for bed mobility, transfers, locomotion, hygiene, and toileting. Interview with Resident #2 on 01/17/23 at 10:21 A.M. revealed her call light had been broken for weeks. She shouted for help when she needed assistance and denied any negative effects from this. Observation at the time of the above interview revealed Resident #2's call light cord connected to a plastic box which appeared to be hanging loose from the wall. Pushing the call light button revealed no light or sound went on above the door, in the hall, or at the nursing station to notify staff the call light was used. The resident had no handbell or other alternate means of ringing for assistance. On entry to the room, the door was closed and the television was turned up to a loud volume. Interview with Licensed Practical Nurse (LPN) #501 on 01/17/23 at 10:31 A.M. confirmed the above findings. She said she would call maintenance to address the concern. Observation of Resident #2's room on 01/17/23 at 11:24 A.M. and 1:39 P.M. revealed the call light attachment box was now firmly connected to the wall. However, testing it again revealed there was still no noise or light visible from the alarm lights above the doorway, in the hall, or at the nursing station, and she still did not have any substitute means of summoning assistance. Interview with LPN #501 on 01/17/23 at 1:39 P.M. confirmed the above findings. Observation of Resident #2's room on 01/18/23 at 9:48 A.M. revealed the call light to still not be functional, and she still had no alternate means of ringing for assistance. Interview with State tested Nursing Aide (STNA) #502 on 01/18/23 at 9:50 A.M. confirmed the above findings. She said the call lights were silent, but were supposed to activate the lights above the doors and in central hallways positions so staff could see someone needed help. They were also supposed to activate STNA pagers. Observation at the time of the above interview revealed Resident #2's call light did not activate STNA #502's pager. Interview with Registered Nurse #503 on 01/18/23 at 9:55 A.M. revealed LPN #501 contacted maintenance regarding the broken call light, who said they would need to send out a service call. She confirmed the facility should have provided the resident a substitute means of calling for help until the problem was addressed. Following surveyor intervention, the facility provided Resident #2 with a handbell on 01/18/23 at 10:00 A.M.

Based on record review, staff interview, and policy review the facility failed to ensure Resident #32 was free from verbal abuse and humiliation. This affected one (Former Resident #32) of three residents reviewed for abuse. The facility census was 31. Findings include: Review of the closed medical record for Resident #32 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #32 was discharged to his personal residence on 06/14/22. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 05/26/22, revealed the resident had intact cognition and required extensive assistance of one staff person for bed mobility, transfers, ambulation. Review of self-reported incident (SRI) tracking number # 4 and investigation revealed on 05/31/22 Resident #32's wife reported via email that her husband (Resident #32) was scolded, shamed, and humiliated after pushing his call button at 3:00 A.M. on 05/30/22. She stated he needed to go to the bathroom urgently and when he did not get a response to the call button after five minutes, he attempted to get up unassisted. At that point Resident #32's wife described Resident #32 as having a disaster and he soiled himself and the floor. She then stated he was forced to sit naked on the toilet while his assigned aide, State tested Nursing Assistant (STNA) #900, cleaned him up in the bathroom, scolding him the entire time. An investigation was initiated and STNA #900 was suspended pending the outcome of the investigation. The investigation did not substantiate abuse, but the investigation produced consistent statements and stories that STNA #900 scolded Resident #32 and was verbally inappropriate toward him after his incontinence episode and made him sit on the toilet while she cleaned up his incontinence episode. Interview with the Administrator and Chief Executive Officer on 06/16/22 at 9:33 A.M. verified the events of the SRI. Review of the policy titled Abuse, Neglect and Misappropriation of Resident Property, dated 05/04/22, revealed no owner, licensee, Administrator, licensed nurse, employee or volunteer of the nursing home or assisted living facility shall physically, mentally or emotionally abuse, mistreat or neglect a resident. This deficiency substantiates Complaint Number OH 222.

Based on record review, interview and policy review, the facility did not ensure two residents (Residents #20 and #137) of five residents reviewed for unnecessary medications had as needed [MEDICAL CONDITION] medications addressed for necessity and a duration. The facility identified three additional residents who received as needed [MEDICAL CONDITION] medications, Residents #3, #4, and #8. Findings include: 1. Review of the medical record for Resident #20 revealed an admission on 02/05/20. [DIAGNOSES REDACTED]. The medical record reflected on 02/05/20 the physician had placed an initial order for [MEDICATION NAME], an antianxiety medication, 0.5 milligram (mg) every two hours as needed for anxiety or restlessness. No stop date was indicated or stated on the order. An interview was completed on 03/03/20 at 4:50 P.M. with the Registered Nurse (RN) #502 and verified the lack of evidence of a 14-day re-evaluation for the use of the anti-anxiety medication. Upon entrance to the facility on [DATE] at 7:30 A.M. no information was provided to evidence the 14-day reevaluation requirement. A note was left at the surveyor's desk to indicate the medication was discontinued. No evidence of the 14-day requirement was presented. An interview on 03/04/20 at 3:05 P.M. was conducted with the Administrator and these findings were verified. Review of the document titled, [MEDICAL CONDITION] Medications, last revision 01/2019, was completed, and this policy stated under bullet point #8, The physician or advanced practice nurse provides documentation in the clinical record to support the need for medications. If as needed medications are used, the documentation should be reviewed every 14 days and the rationale documented in the clinical record. 2. Resident #137 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #137's March 2020 physician orders revealed an order for [REDACTED]. Review of Resident #137's medical record revealed Resident #137 had been seen by the physician on 02/06/20 who documented the order of the as needed antianxiety medication and on 02/05/20 and 02/19/20 by the nurse practitioner who documented in the 02/19/20 note to continue as needed medications, not currently using at this time. None of the three visit notes specifically documented Resident #137's receipt of the as needed antipsychotic medication or a duration for the as needed antianxiety medication. Resident #137's medical record did reveal the pharmacy had reviewed the physician orders on 02/14/20 and only identified a need for a [DIAGNOSES REDACTED].#137's antidepressant medication. Review of Resident #137's Medication Administration Record [REDACTED]. Interview with RN #502 on 03/03/20 at 4:50 P.M. verified the presence of the antianxiety and antipsychotic medication orders without stop dates and physician justification. Review of the facility policy titled, [MEDICAL CONDITION] Medications, revised January 2019, stated the physician or advanced practice nurse provides documentation in the clinical record to support the need for medications and if as needed medications are used, the documentation should be reviewed every 14 days and the rationale documented in the clinical record.

Based on observations, interview and record review, the facility failed to ensure medication was administered and secure for one resident (Resident #131) of 33 residents observed during the annual survey. The facility identified nine residents (Residents #1, #11, #13, #14, #15, #127, #129, #135 and #139) who were independently mobile with or without an assistive device. Findings include: Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #131's medical record revealed a Brief Interview for Mental Status (BIMS) was completed on 02/28/20 where Resident #131 scored a 14 which demonstrated no cognitive impairment. Observation of Resident #131's bedside table on 03/02/20 at 9:55 A.M. revealed a breakfast tray which the resident was still eating off of, numerous toiletry items including tissues, a mirror, and brush, and a small plastic cup with five pills. During Resident #131's interview on 03/02/20 at 9:55 A.M., Resident #131 stated the facility staff leave her medications for her to take after she finishes her breakfast. Staff interview with Registered Nurse (RN) #500 on 03/02/20 at 10:02 A.M. verified the cup of medications at Resident #131's bedside and stated the medications should not have been left, and RN #500 then took the medications from Resident #131's room. On 03/02/20 at 10:05 A.M., RN #501 verified she had left the medications and identified the medications as Losartan (used to treat high blood pressure), [MEDICATION NAME] (antidiarrheal), [MEDICATION NAME] (used to treat high blood pressure), Tylenol (pain medication), and [MEDICATION NAME] (asthma medication).

Based on interview, review of self reported incident (SRI) reports, and review of the facility investigation, the facility failed to thoroughly investigate an allegation of abuse. This affected two (Residents #33 and #35) of two residents reviewed in one SRI report. Findings include: Review of an SRI report revealed on 10/26/17 Resident #33 reported that Resident #35 touched her leg, pointing to her thigh. The resident later reported Resident #35 touched her vagina. Review of the facility's investigation included the Director of Nursing (DON)'s interviews of Licensed Practical Nurse #102 who reported the allegation, Resident #33, and Resident #33's family and statements from Social Worker (SW) #113 and the facility Vice President. There were no statements or interviews with the State tested Nurse Aides (STNA's) scheduled to work 10/26/17 on the 500 floor (STNA's #107, #114, and #115) or other staff who may have been on the unit. In an interview on 11/15/17 at 9:35 A.M., the DON verified the facility investigation did not include any witness statements or interviews from the STNA's working the 500 floor on 10/26/17.

Based on interview, review of a facility Self Reported Incident (SRI) report, review of the facility's investigation, and review of the facility's abuse policy, the facility failed to implement their policy when an allegation was not thoroughly investigated. This affected two (Residents #33 and #35) of two residents reviewed in an SRI report regarding abuse. Findings include: Review of an SRI report revealed on 10/26/17 Resident #33 reported that Resident #35 touched her leg, pointing to her thigh. The resident later reported Resident #35 touched her vagina. Review of the facility's investigation included the Director of Nursing's (DON's) interviews of Licensed Practical Nurse #102 who reported the allegation, Resident #33, and Resident #33's family and statements from Social Worker #113 and the facility Vice President. There were no statements or interviews with the State tested Nurse Aides (STNA's) scheduled to work 10/26/17 on the 500 floor (STNA's #107, #114, and #115) or other staff who may have been on the unit. In an interview on 11/15/17 at 9:35 A.M., the DON verified the facility investigation did not include any witness statements or interviews from the STNA's working on the 500 floor on 10/26/17. Review of the facility's Abuse, Neglect, and Misappropriation of Resident Property (revised January 2016) revealed reports of abuse should be promptly and thoroughly investigated. The investigation of abuse should include who was involved, residents' statements, involved staff and witness statements.

Based on observation, review of the facility policy and interview, the facility failed to maintain a sanitary environment in the service level laundry facilities. This had the potential to affect all 88 residents currently residing in the facility. Findings include: Observation on 06/25/15 at 11:12 A.M. of the service level laundry room revealed an clear plastic bag located on the floor in the doorway of the laundry room with six soiled resident clothing protectors observed on the floor near the untied plastic bag. An interview with Environmental Services #3 immediately following the observation verified the resident clothing protectors were not in the plastic bag and the plastic bag was on the floor and not in the nearby laundry cart. Review of the facility Laundry Handling policy dated 2009 stated all linens when stored or transported must be in covered containers or contained in a bag.

Based on observation and interview, the facility failed to ensure call lights were functioning. This affected one (Resident #122) of 35 resident call lights tested . The facility census was 88. Findings include: Observation on 06/23/15 at 11:13 AM revealed Resident#122 on the floor wrapped in bed linens. The call light was attached to the linens and totally extended. The resident was asleep. The bed was in the lowest position. The surveyor pushed the call light button to call for help. The call light clicked but did not function. At this time, state tested nursing assistant (STNA) #8 was called to the room and verified the call light did not work. An additional observation of the resident's call light at 11:30 A.M. with registered nurse (RN) #4 revealed Resident #122's call light still did not work. RN #4 verified the call light was still not functioning.

Based on observation, review of the laundry policy and interview, the facility failed to ensure a clean and sanitary equipment in the laundry room. This had the potential to affect all 34 residents residing on the Bruening Health Center Fifth Floor. The facility census was 88. Findings include: Observations on 06/25/15 at 11:05 A.M. revealed a fan located in the Bruening Health Center Fifth Floor laundry room in front of the washers. The fan had all four fan blades and the outer metal casing covered in dust and the fan was blowing on resident clothing that was folded and laying on top of the washing machine. Interview with Environmental Services #3 immediately following the observation verified the fan was not maintained in a sanitary condition and the dust covered fan was blowing on resident clothing. Review of the facility Laundry Handling policy dated 2009 revealed it was the policy of the facility that proper infection control and universal precaution techniques would be practiced to ensure the safety of residents, staff and others.

Based on interview and record review, the facility failed to maintain accurately documented clinical records. This affected one resident (Resident #115) of three residents reviewed for clinical records. The facility census was 112. Findings include: Resident #115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of standing physician orders [REDACTED]. The blood sugar needed rechecked 15 minutes after the intervention and document the results. If no improvement, the nurse may give [MEDICATION NAME] (a form of sugar) 1 milligram intramuscular (IM) and notify the Medical Doctor (MD) soon as possible if [DIAGNOSES REDACTED] is not resolved by intervention. Review of nurses notes dated 02/22/14 at 7:07 A.M. revealed Licensed Practical Nurse (LPN) #204 went to Resident #115's room at 5:55 A.M. to administer medication and noticed the resident was unresponsive and flaccid. Resident #115 was assessed and her blood sugar was 34. The supervisor was paged and the nurse obtained [MEDICATION NAME] to inject intramuscular (IM) at 6:00 A.M. The resident's vital signs were: blood pressure of 181/72, 72 pulse and 99 percent pulse oxygen level with oxygen by nasal cannula. The resident's doctor was paged, he returned the call and gave an order to discontinue the previous [MEDICATION NAME] (insulin) order and begin [MEDICATION NAME] 6 units at bedtime. The nurses started an intravenous line (IV), and the resident started coming around. The resident pulled away when her arms were touched, however she did not open her eyes. Review of nurse progress notes and the blood sugar log revealed a lack of documentation regarding the resident's blood sugar 15 minutes after the [MEDICATION NAME] was given. Review of the nurse progress notes revealed there was a lack of documentation regarding interventions provided by the RN supervisor. Review of nurse progress note dated 02/22/14 at 8:08 A.M. revealed at 7:00 A.M. the resident was unresponsive to verbal or tactile stimulation. Blood pressure 178/70, pulse oxygen 100 percent, temp 97.1 degrees Fahrenheit, respirations 17 and blood sugar was 135. The doctor was paged and ordered the resident to be sent out to hospital via 911 EMS at 7:56 A.M. The resident's family was notified. Review of Resident #115's Medication Administration Record documented the nurse administered [MEDICATION NAME] 10 units insulin subcutaneous at 7:00 A.M. on 2/22/14. The other medications were documented as not administered (NA). Interview with LPN #204 on 04/02/14 at 4:00 P.M. indicated that morning Resident #115 looked odd and LPN #204 tried to wake her up. Resident #115 did not respond. LPN #204 indicated she set medications on the resident's nightstand (pills and insulin) and went back to the medication cart to get the glucometer and check the resident's blood sugar. The resident's blood sugar was low, at 34. She went to get assistance. Another nurse went to get the [MEDICATION NAME] medication. LPN #204 indicated she gave the [MEDICATION NAME]. LPN #204 verified she marked the insulin as "given" on the Medication Administration Record (MAR) but did not give the insulin. She indicated once the medication was documented on the MAR, the documentation could not be changed. The nurse stated she did not document a note to indicate the insulin was marked in error and was not administered. Interview with the Director of Nursing on 04/02/14 at 5:00 P.M. indicated once the electronic medical record is marked, the documentation cannot be changed. She indicated an additional note is required to provide accurate documentation. This deficiency was an incidental finding from the complaint survey. The deficiency is also an example of continued noncompliance from the complaint investigation completed on 02/19/14.

Based on interview and medical record review, the facility failed to ensure documentation in the medical record was complete and accurate for three (Resident #8, Resident #9 and Resident #10) of twelve residents whose records were reviewed. Findings include: 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was dependent on the extensive assistance of one or two staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Review of nursing progress notes dated 01/21/14 at 3:34 A.M. revealed Resident #8's family was notified that bruises were found on the resident's right arm and leg. There was no documentation regarding the size, shape, color or exact location of the bruises. This was confirmed with the director of nursing (DON) during an interview on 02/19/14 at 10:50 A.M. Review of the Self Reported Incident (SRI) report revealed that bruises were discovered on Resident #8's right hand and right arm on 01/21/14. The facility initiated an investigation of the injuries of unknown origin and determined that the bruises likely were caused by a combination of the resident's medications and by her habit of repositioning her right arm by lifting it with her left hand and "dropping" it into place. Review of the SRI report with Administrator #1 and Administrator #2 on 02/19/14 at 12:10 P.M. did not reveal evidence of a description of Resident #8's bruises, only the general location of the bruises. This was confirmed by LNHA #1 at the time of the interview. 2. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility SRI report revealed an investigation of an injury of unknown origin was initiated on 09/29/13 when Resident #10 was found to have a fractured right hip. The facility concluded that Resident #10 sustained a right [MEDICAL CONDITION] when State tested Nurse Aide (STNA) #32 positioned the resident too close to the edge of her bed and then was not able to reposition her. Resident #10 fell out of bed when STNA#32 left her bedside and went to the doorway to call for help. Resident #10 was assisted back to bed by mechanical lift. On 09/29/13, Resident #10 complained of pain to her right leg. An x-ray confirmed Resident #10 sustained a right [MEDICAL CONDITION]. Review of nursing progress notes for Resident #10 from 09/27/13 through 09/29/13 did not reveal any evidence that Resident #10 had fallen from her bed. A nursing progress note dated 09/27/13 at 11:00 P.M. indicated Resident #10 was status [REDACTED]." On 09/28/13 at 7:35 A.M., "post-incident" charting continued. On 09/28/13 at 11:30 P.M., Resident #10 was status [REDACTED]." There was no documentation in Resident #10's medical record regarding the circumstances surrounding her fall on 09/27/13. When interviewed on 02/19/14 at 1:30 P.M., the DON stated that an Interdisciplinary Team (IDT) progress note written on 10/14/13 at 2:22 P.M. served as documentation of Resident #10's fall on 09/27/13. The IDT progress note read as follows: IDT review of incident on 9-27. Resident found on floor. Low bed and mattress implemented. 3. Resident #5 was admitted to the facility on [DATE]. On 01/25/14, her physician ordered the narcotic pain medication [MEDICATION NAME]-acetominophen 5-325 milligrams (mg) one tablet by mouth every four hours as needed for mild pain. Review of January 2014 Medication Administration Record [REDACTED]. Review of the Controlled Drug Receipt/Proof-of-use/Disposition Form dated 12/13/13 revealed Resident #5 was administered [MEDICATION NAME]/APAP 5-500 mg on 01/25/14 at 9:00 P.M. On 02/19/14 at 1:45 P.M., the DON confirmed the documentation in Resident #5's January 2014 MAR indicated [REDACTED]. The above findings substantiate Complaint Number OH 548.

Based on observation, record review and interview the facility failed to maintain appropriate assessed interventions to prevent falls for two residents with recent falls and injuries (Resident #38 and #48) out of six residents reviewed for falls in a facility census of 126. Findings include: 1. Resident #38 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident to be moderately impaired in cognition for decision making, to be able to recall only staff by names and/or by faces and to have both short and long term memory impairment. The MDS revealed the resident to require an extensive assistance by one staff member for bed mobility and by two staff members for transferring and toileting. A plan of care for the resident at risk for falls due to history of falls dated 08/21/09 revealed multiple interventions including a bed alarm, a chair alarm, bed in low position, perimeter mattress, mattress on floor next to be, keep in area of activity on unit, and a seatbelt in wheel chair, all listed interventions with start dates of 08/21/09. All devices were applied to the resident soon after her admission. A body pillow to the resident's left side was added on 07/28/10 and two mattresses on the floor next to the bed was added on 03/28/12. Observation of Resident #38 on 08/20/12 at 9:15 A.M. the resident was lying in her bed, on an air mattress with STNA #200 combing the resident's hair. He then uncovered a plate of breakfast food (scrambled eggs and pureed French toast) and left the room and the resident to heat up the meal. No alarm device was noted on the resident's bed and no mattress was observed on the floor next to the resident's bed. The fall mattress was noted lying sideways up against the wall by the entrance door of the resident's room. At 9:20 A.M., STNA #200 returned to the resident's room with the heated plate of food. He verified there was no alarm device on the resident's bed and verified that no fall mattress was on the floor next to the resident's bed. He stated the resident does not have an alarm to her bed. She only has one on her wheel chair. Progress notes dated 02/26/12 at 4:00 P.M. revealed that a state tested nursing assistant (STNA) placed the resident on the toilet and "left room to get cream for the resident's buttocks." Upon return to the room the resident was found halfway standing and leaning to the left. The STNA grabbed the resident and placed her back in a wheel chair. The resident complained of pain to her bilateral legs with movement. The physician was called and x-rays were ordered. The x-ray results confirmed a non-displaced fracture through the femoral neck which may be incomplete involving the inferior cortex. There is no dislocation or mal-alignment. The bones are osteopathic. Following the fracture event a significant change MDS was completed for the resident on 03/17/12. The MDS revealed the resident's cognition to be unchanged but the resident was now required a total assistance by two staff members for bed mobility and toileting and that any transferring or locomotion on or off of the unit did not occur. During review of the facility investigation for the fractured hip, the summary verified that the resident was left unattended in the bathroom on a toilet. The investigation also revealed that the family member was advised of the x-ray results and did not want the resident sent to the hospital or any aggressive interventions. During interview with the director of nursing (DON) and fifth floor nurse manager, Registered Nurse (RN) #205 on 08/21/12 at 8:30 A.M. the DON indicated that they do not feel the resident had a fall. RN #205 verified that the incident was "not witnessed" and that a STNA left the resident unattended in the bathroom. Both verified they were aware of the observation the surveyor had of the resident on 08/20/12 with no bed alarm and no mattress on the floor next to the bed. 2. Resident #48 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. An annual MDS 3.0 assessment dated [DATE] revealed the resident to be moderately impaired in cognition for decision making and to require an extensive assistance by one staff member for bed mobility, transferring, dressing, eating and toileting and to require a moderate assistance by one staff member for locomotion on and off of the unit. A significant change MDS assessment dated [DATE] was noted following the right femoral fracture in April 2012. The MDS revealed the resident to now require an extensive assistance by two staff members for bed mobility, transferring and toileting. Physician orders [REDACTED]. Nursing progress notes dated 06/06/12 at 10:30 P.M. revealed the resident was found on the floor in her room. The resident complained of right hip pain. The physician was notified and the resident was sent to the hospital emergency room with a fractured right hip. The resident returned to the facility on [DATE] with staples intact to her right hip following a surgical hip repair. Review of the facility investigation summary for the fall on 06/06/12 revealed a STNA statement that indicated "I heard a thump first, then an alarm." A revised plan of care for Resident #48 being at risk for falls dated 06/28/12, revealed multiple interventions including a bed alarm, chair alarm, keep bed in low position, keep call light in reach, keep in area of activity on unit and a self-releasing seat belt device. During observation of Resident #48 on 08/20/12 at 10:05 A.M. the resident was sitting up in her wheel chair alone in her room. The resident was extremely confused, babbling over and over "where do I go, how can I get rid of this (tapping on her wheel chair arm). A self releasing seatbelt was noted on the resident. One alarm box was observed on the resident's bed and two alarm boxes were observed on the resident's wheel chair. The resident was confused, alone in her room and not being kept in a common area of activity on the unit as indicated on the resident's plan of care. None of the three alarm boxes were lit up and appeared to be not working. At 10:10 A.M. a STNA #210 entered the resident's room with the surveyor. After requested by the surveyor, the STNA unfastened the resident ' s seat belt and stood the resident up in front of her wheel chair. No alarm sounded. STNA #210 reconnected one of the alarm boxes and one of the alarms began to weakly and quietly sound. The second alarm box on the wheel chair was opened and found to have no batteries in the alarm box. STNA #210 then attempted to sound the alarm on the resident's bed. The alarm again did not sound. The box was found to be cracked and mangled along the side of the alarm. STNA #210 stated "I am going to get these both replaced right now, someone should have checked them." This citation substantiates Complaint Master Control Number OH 886 and Number OH 678.