Every finding on record at Kenwood Terrace Healthcare Center

Based on medical record review, staff interview, observations and policy review, the facility failed to investigate the allegation of missing dentures. This affected one Resident (#35) of three reviewed for dental appliances. The facility census was 87. Findings include:Review of the medical record for Resident #35 revealed an admission on [DATE] with diagnoses including hypertension, hemiplegia and hemiparesis following a subdural hemorrhage affecting the right side, type two diabetes mellitus and congestive obstructive pulmonary disease. Review of the physician's orders for Resident #35 revealed an order dated 09/22/23 for the resident to receive dental services. Review of the care plan for Resident #35 dated 11/06/23 and updated on 03/27/25 revealed resident was at risk for altered nutritional states related to dysphagia (difficulty swallowing), need for pureed diet, hospice care, and was edentulous with dentures. Interventions included the following: ensure dentures were utilized for meals, monitor meal intake, provide assistance with meals as needed. Review of the dental progress note for Resident #35 dated 06/24/24 revealed the resident had upper and lower dentures in place. Review of the facility personal effects inventory for Resident #35 undated revealed dentures were included on the form in the listing of the resident's possessions. Review of the progress notes for Resident #35 dated 01/01/25 to 07/29/25 revealed the notes did not include documentation of missing dentures. Review of the hospice progress note for Resident #35 dated 01/04/25 at 12:50 P.M. revealed the resident representative reported to facility Nurse #94 the resident's lower denture was missing. Review of the hospice progress note for Resident #35 dated 02/03/25 at 10:47 A.M. revealed the resident's lower denture was not in her mouth and the denture was lost. Review of the dental progress note for Resident #35 dated 03/11/25 revealed the resident had a dental exam with no concerns. The upper denture was in place, but the lower denture was not in place at the time of the visit. Review of the facility grievance log dated 05/01/25 to 07/28/25 revealed there was no documentation regarding missing dentures.Review of the Minimum Data Set (MDS) assessment for Resident #35 dated 05/09/25 revealed the resident had impaired cognition, required extensive assistance with activities of daily living (ADLs), and was edentulous.Review of the nutritional assessment for Resident #35 dated 06/27/25 revealed the assessment did not include documentation regarding the resident's missing lower denture. Review of the facility grievance log dated 05/01/25 to 07/28/25 was silent for any documentation of missing dentures. Observation on 07/29/25 at 2:50 P.M. of Resident #35 revealed the resident's lower denture was not in place. Interview on 07/29/25 at 2:51 P.M. of Resident #35 confirmed her lower denture had been missing for approximately eight months. Resident #35 reported the facility staff and hospice staff were notified the denture was missing and she had not heard of any plans for replacement of the lower denture. Interview on 07/29/25 at 1:28 P.M. with Mobile Dentist Office Staff (MDOS) #109 confirmed the dental progress note for Resident #35 dated 03/11/25 indicated the resident did not have her lower denture on the day of the exam. MDOS #109 confirmed there were had been prior authorization submitted for denture replacement for Resident #35 and the dental notes did not include documentation of the resident's lower denture being reported as missing. Interview on 07/29/25 at 1:47 P.M. with Certified Nursing Assistant (CNA) #47 confirmed Resident #35's lower denture had been missing for a long time, and she denied any knowledge of plans for replacement. CNA #47 stated she was unsure of who she notified regarding Resident #35's missing lower denture as it was months ago. Interview on 07/29/25 at 2:11 P.M. with Registered Nurse (RN) #91 confirmed Resident #35's lower denture had been missing for an undetermined amount of time, and RN #91 denied knowledge of plans for replacement. Interview on 07/30/25 at 12:27 P.M. with Hospice Executive Director ([NAME]) #113 confirmed Resident #35 had stated the missing denture was reported to the facility by hospice staff. [NAME] #113 confirmed hospice staff documented in Resident #35's progress notes the missing denture was reported to the hospice case manager on 01/04/25. Interview on 07/30/25 at 3:19 P.M. with the Administrator confirmed the facility management was never notified of Resident #35's missing denture. Review of the facility policy titled Dental Services undated revealed the facility would promptly (within three days) refer residents with lost or damaged dentures for dental services. This deficiency represents noncompliance investigated under Complaint 2572145.

Based on medical record review, hospice documentation, staff interview, hospice staff interview, review of the contract between the hospice provider and the facility, and review of the facility policy, the facility failed to ensure collaboration between the hospice provider and the facility was documented in the medical record. Additionally, the facility failed to retain copies of hospice provider progress notes at the facility. This affected two (Residents #35 and #7) of three residents reviewed for hospice services. The facility census was 87 residents. Findings include:1.Review of the medical record for Resident #35 revealed an admission date of 09/22/23 with diagnoses including hypertension, hemiplegia and hemiparesis following a subdural hemorrhage affecting the right side, type two diabetes mellitus and congestive obstructive pulmonary disease. Review of the facility plan of care for Resident #35 dated 09/28/23 and revised on 07/25/25 revealed resident had an activities of daily living (ADL) self-care performance deficit related to cognitive and functional deficits and disease progression. Interventions included the following: provide set up assistance for eating, maximal assist for oral hygiene, resident is dependent for toileting, bathing, dressing, and personal hygiene. The facility plan of care did not include specified tasks each provider would complete. Review of the facility plan of care for Resident #35 dated 11/15/23 and revised on 01/27/25 revealed the resident received hospice services related to vascular disease. Interventions included the following: adjust level of ADL assistance to compensate for residents changing ability, encourage participation, administer medications as ordered, report abnormal findings, assure the resident and resident representative are involved in the development of goals and treatment plan, pain evaluation, expression of feelings, invite hospice staff to care conferences, offer emotional support. Review of the physician's orders for Resident #35 revealed an order dated 01/03/25 to admit the resident to hospice services.Review of the hospice plan of care for Resident #35 dated 03/03/25 revealed the nurse would visit one to two times a week and the home health aide (HHA) would visit one to two times a week. Review of the home health aide (HHA) care plan with a start of care for Resident #35 dated 03/04/25 through 05/02/25 revealed the HHA would provide the following services with every visit one to two times per week: turning and repositing in bed, assistance with feeding, bathing, shampoo, skin care, apply moisturizer, perineal care apply barrier, cream to intact skin, oral care, offer fluids, provide conversation. There was no updated HHA care plan in place during the survey. Review of the Minimum Data Set (MDS) assessment for Resident #35 dated 05/09/25 revealed the resident had impaired cognition, required extensive assistance with activities of daily living (ADLs), and received hospice services. Review of the hospice binder for Resident #35 revealed it did not include documentation of hospice visits, assessments completed, HHA visits and care provided.2. Review of the medical record for Resident #7 revealed an admission date of 12/24/21 with diagnoses including extrapyramidal and movement disorders, type two diabetes, hypertension, and adult failure to thrive.Review of the MDS assessment for Resident #7 dated 05/16/25 revealed the resident had impaired cognition, was coded as dependent on staff for ADLs, and received hospice care during the assessment period. Review of the physician's orders for Resident #7 revealed an order dated 05/26/25 to admit to hospice services. Review of the care plan for Resident #7 dated 06/23/25 revealed the resident received hospice services for cerebrovascular disease. Interventions included the following: decrease pain, adjust ADL assistance to compensate for changing abilities, medications as ordered, pastoral care as needed, coordinate care with hospice agency, invite hospice staff to care conference, offer nonpharmacological interventions as needed. Review of the hospice binder for Resident #7 revealed it did not include documentation of hospice visits, assessments completed, HHA visits and care provided. Interview on 07/28/25 at 4:25 P.M. with Hospice Registered Nurse (HRN) #112 confirmed the hospice agency receptionist was supposed to print hospice notes so the field staff could put them in the facility binder. HRN #112 verified the agency receptionist had stopped printing the hospice notes for the field staff since December 2024. Interview on 07/29/25 at 10:34 A.M. with the Social Service Director (SSD) confirmed she was the point of contact for the facility in regards to the hospice patients. The SSD stated hospice and facility staff met monthly but do not document or address the plan of care specifically. The SSD verified she did not develop or update the hospice plan of care for the facility. The SSD stated the facility had all participants sign a signature sheet when care conferences occurred but denied any conversations related to the plan of care specifically addressing services each provider would perform and when the care would be scheduled. Interview on 07/29/25 at 1:47 P.M. with Certified Nurse Assistant (CNA) #47 confirmed she was not aware of any care scheduled for Resident #35 or Resident #7 to be completed by hospice staff. CNA #47 stated she provided Resident #35 a bed bath every day that she was assigned to the resident per the resident representative request. CNA #47 stated hospice staff usually arrive after the bed bath was provided by the facility staff. CNA #47 denied any knowledge of hospice documentation for care provided for Resident #35 or Resident #7 or a schedule for days they would be providing care. Interview on 07/29/25 at 2:41 P.M. with Registered Nurse (RN) #91 assigned to both Resident #35 and Resident #7 verified there was no documentation of hospice visits in the residents' medical records when the hospice CNA or nurse visited. RN #91 stated the hospice nurse would share the vital signs obtained during the visit but did not know the location of hospice documents detailing the visit. Interview on 07/30/25 at 10:58 A.M. with the Director of Nursing (DON) confirmed the facility did not have documentation of hospice visits and care provided for Residents #7 and #35. Interview on 07/30/25 at 11:34 A.M. with Hospice Executive Director ([NAME]) #113 confirmed the hospice documentation for Residents #35 and #7 were emailed to the facility DON on 07/30/25 as it was reported the facility did not have any progress notes in the hospice binders for the residents. Interview on 07/30/25 at 4:59 P.M. with MDS Nurse #33 confirmed she had not collaborated with hospice staff for the development of the care plans for Residents #35 and #7 and the care plans did not include the specific tasks each provider would be performing for Resident #35 and Resident #7. Review of the hospice agency contract with the facility dated 2025 revealed the hospice and the facility should develop and maintain a written plan of care. The plan of care should identify which provider was responsible for performing the respective functions that had been agreed upon and included in the resident care plan. The care plan should be reviewed and updated every fifteen days or sooner when there were changes in the hospice residents' condition. The hospice and the facility should communicate with each other regularly and each party was responsible for documenting such communication in each resident's clinical record to ensure the needs of the hospice care were met. Review of the facility policy titled Coordination of Care for Hospice Services undated revealed the facility and hospice service would develop a coordinated clinical plan of care that was specific for each resident receiving hospice services within the facility. This deficiency represents noncompliance investigated under Complaint 2572145.

Based on observation, interviews, and review of facility water temperatures, the facility failed to maintain a comfortable hot water supply to ensure a comfortable environment. This affected four (#33, #34, #43 and #52) out of four residents review for hot water temperatures and had the potential to affect 59 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58 and #59) residents residing on the 100, 200, 300, 400, 500 and part of the 600 hallway. The facility census was 79. Findings include: Observation of random hot water faucet temperatures on 06/20/25 at 9:30 A.M. revealed the following temperatures: empty resident room [ROOM NUMBER] was 95 degrees F (F), empty resident room [ROOM NUMBER] was 97 degrees F, Resident #33 and #34's room was 99 degrees F, Resident #43's room was 102 degrees F, Resident #52's room was 102 degrees F and empty resident room [ROOM NUMBER] was 98 degrees F. All hot water temperatures were taken and verified by the Administrator at the time of the observation. Interview with the Administrator and Director of Nursing (DON) on 06/20/25 at 10:00 A.M. revealed the facility had a problem with hot water temperatures that had affected 59 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58 and #59) who resided on the the 100, 200, 300, 400, 500, and part of the 600 hall up to room [ROOM NUMBER]. Both stated they were having trouble with the mixing valves and a company had been out on 06/13/25 per the invoice. The Administrator and DON stated there have been resident complaints in the past and not recent. The Administrator and DON confirmed the expectation is that hot water temperatures would be maintained between 105-120 degrees F to ensure they are comfortable and the Administrator verified the affected rooms were not at the appropriate temperature range of 105-120 degrees Fahrenheit per regulations. The Administrator also verified the facility has no record of the water temperature logs for May and June 2025. Review of water temperature logs on 06/20/25 at 10:45 A.M. revealed random water temperature monitoring had not been completed by the maintenance department for the months of May 2025 and June 2025. This deficiency represents non-compliance investigated under Complaint Number OH00166126.

Based on closed medical record review, observations, mechanical lift users manual, and interviews, the facility failed to properly maintain and inspect mechanical lifts to prevent injuries for residents being transported. This affected one resident (Resident #46) out of four reviewed that required the use of mechanical lifts. The facility census was 78. Findings include: Review of the closed medical record for Resident #46 revealed an admission date of 05/16/24. Diagnoses included cardiomegaly, congestive heart failure, dysphagia, morbid obesity, hypertension, atrial fibrillation, gout, peripheral vascular disease, osteoarthritis, muscle weakness, chronic venous ulcers, low back pain, and cervical stenosis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/14/25, revealed the resident had intact cognition. The resident was dependent on staff for bed mobility, transfers, ambulation. Review of physician orders revealed this resident was to be a two-person mechanical lift for all transfers, bathing, and incontinence. Review of the nurses notes dated 04/30/25 at 5:01 P.M. revealed this resident was being transferred by a mechanical lift by two staff when the lift tilted to the right, and the sling bar swung and struck the resident on the forehead. The resident was noted with moderate swelling to his forehead above the nose. The resident voiced no complaints at the time, with all neurological checks being completed with no adverse findings. Review of the nurses notes dated 04/30/25 through 05/10/25 revealed no concerns, complaints, or adverse effects noted from the incident that occurred on 04/30/25. There were no concerns with the ability to properly feed himself. This resident was still able to operate his wheelchair on a daily basis to have lunch with his wife on another hall while he was a resident. Review of progress note dated 05/10/25 revealed Resident #46 had complaints of numbness to bilateral hands and felt like his kidneys were shutting down as this has happened in the past and he knew what it felt like. Review of hospital note dated 05/10/25 revealed Resident #46 was admitted with cervical stenosis, multilevel Degenerative Joint Disease, and central cord syndrome (spinal cord injury). Interview with the Director of Nursing and the Administrator on 05/21/25 at 1:45 P.M. revealed the specific lift that was used on 04/30/25 was an Invacare Reliant 450/600 electric panel lift. Both stated after the incident, it was placed out of service until an inspection had taken place by the Maintenance Director. Both stated that upon inspection, it was determined that a mechanical strut had broken on the lift, which caused the floor legs to fold back in and tilt the lift during the incident. Interviews with Certified Nursing Assistants #585 and #590 on 05/21/25 at 2:10 P.M. revealed Resident #46 was being transferred to his wheelchair on 04/30/25 when the lift suddenly tilted forward and to the right, pinning one of them under it. Both stated that the sling bar had swung back and struck the resident on the forehead. The resident did not complain of anything at the time, only checking to see if they were both alright. No complaints of hand numbness or tingling following this incident. Review of the Invacare Reliant 450/600 battery power mechanical lift Users Manual on 05/21/25 at 11:00 A.M. revealed on page 13, all mechanical parts must be inspected at least every six months to determine any extent of wear and tear. If any metal contacts or parts are visibly worn, it must be replaced immediately before use. Interview with Physician #998 on 05/21/25 at 4:45 P.M. verified he had performed surgery on Resident #46 on 05/14/25. He verified this resident had chronic cervical stenosis, and the accident may have had an impact however, he would have needed surgery eventually regardless. Review of mechanical lift inspections could not be provided by the facility as none had been completed for each lift in service. Interview with Certified Nurse Practitioner #999 on 05/22/25 at 11:05 A.M. revealed she had seen Resident #46 via Telehealth appointment after he had requested to go to the hospital. She verified the resident had stated complaints for flank pain and kidney pain as he knows what that feels like. She then provided staff an order to send the resident to the emergency room per request. Interview with the Administrator and Director of Nursing on 05/22/25 at 12:00 P.M. verified they could not provide any evidence that the mechanical lifts had been properly inspected and routine maintenance was completed. This deficiency represents non-compliance under Complaint Number OH00165705.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure food was stored in a safe manner and failed to ensure kitchen equipment was kept in a clean and sanitary manner. This had the potential to affect all 82 residents residing in the facility. The facility census was 82. Findings include: Observation on 02/10/25 at 6:45 P.M. of the facility kitchen revealed the walk-in refrigerator contained marinara sauce and two whipped toppings without expiration dates. The freezer had opened cauliflower without an expiration date. Observation of the pantry revealed open raisin bran, toasted oats, marshmallows, and cornbread without an expiration date. On the spice shelf above the preparation station was a container of oregano with an expiration date of 09/28/23. Observation of the kitchen dry storage area on 02/10/25 at 6:50 P.M. revealed cans of mandarin oranges and pumpkin that were severely dented and placed on the shelf indicated for facility use. Further observation at 7:01 P.M. revealed a large amount of debris with a strong odor in the microwave. Interview on 02/10/25 with Executive Chef (EC) #10 between 6:45 P.M. and 7:01 P.M. confirmed the aforementioned food items were not properly dated, verified the dented cans in dry storage, and confirmed the appearance of the microwave. EC #10 stated dented cans were supposed to go on the bottom shelf to be sent back and not on the shelves to be used and stated the microwave was supposed to be cleaned once a shift. Review of the facility policy titled, Food Preparation-Food Storage, dated 08/20/18, revealed all food should be stored in a sealed container and should be labeled and dated.

Based on medical record review, staff interview, review of a facility policy, the facility failed to a physician was notified promptly of a critical laboratory value. This affected one (#16) of three residents reviewed for change in condition. The facility census was 82. Findings include: Review of Resident #16's medical record revealed an admitted [DATE] with diagnoses of diabetes mellitus type II with diabetic polyneuropathy, chronic obstructive pulmonary disease (acute) with lower respiratory infection, and muscle weakness (generalized). Review of the admission Minimum Data Set (MDS) assessment, dated 11/04/2024, revealed Resident #16 had moderate impairment in cognition. Review of a Telehealth notification note dated 07/15/24 (6:00 P.M.) revealed Resident #16 felt lightheaded and dizzy after going out to smoke. The resident's vital signs and blood sugar were checked at that time. Orders were placed to obtain a complete blood count (CBC) and comprehensive metabolic panel (CMP) laboratory work. The laboratory work was completed on 07/16/24 at 7:46 A.M. and results were reported on 07/16/24 at 6:22 P.M. Review of Resident #16's laboratory results revealed the resident had a critically low blood sugar level. Review of the progress note date 07/17/24 at 12:21 P.M. revealed the Medical Director was notified of Resident #16's critical laboratory results from 07/16/24. A new order was received for the resident to have fasting blood sugar checked every morning at 6:00 A.M. and at bedtime. Further review of Resident #16's medical record revealed no evidence of a physician being notified of the critically low blood sugar level on 07/26/24 at 6:22 P.M. until the Medical Director was notified on 07/24/24 at 12:21 P.M. Interview with the Director of Nursing (DON) on 02/12/25 at 3:15 P.M. verified there was no documentation of a physician being promptly notified of Resident #16's critical laboratory value on 07/16/24. Review of the undated facility policy titled, Critical Laboratory Value Management, revealed when critical values are obtained in any method, the nurse will place a call to the ordering physician and will document the time, the number called, and to whom a message was given. The resident/representative will also be contacted for changes in condition, if applicable.

Based on medical record review, resident and staff interviews, and policy review, the facility failed to ensure care conferences were held as required for residents and their representatives. This affected two (#12 and #38) of three residents reviewed for care conferences. The facility census was 82. Findings include: 1. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses of end stage renal disease (ESRD) with dependence on hemodialysis, diabetes mellitus type II, cerebrovascular accident (CVA) with left (dominate) side hemiplegia/hemiparesis, congestive heart failure (CHF), and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had no cognitive impairment and was frequently incontinent of bowel and bladder. The resident required set up assistance for eating, maximal assistance for oral hygiene and bed mobility, and was dependent for personal hygiene, toileting, bathing, dressing and transfers. Review of the documentation provided by the Regional Director of Clinical Operations #3030 revealed Resident #12 or her representative were offered care conferences in the third quarter (July, August, and September) and attended on 08/23/24. There was no documented evidence that a care conference was offered or completed with the resident/representative for the second quarter (April, May or June) or fourth quarter (October, November or December) of 2024. Interview on 02/13/25 at 8:30 A.M. with Resident #12 revealed no knowledge of the facility discussing her care with her at any time. Interview on 02/13/25 at 9:55 A.M. with RDCO #3030 verified the facility had no documentation that a care conference was conducted with Resident #12 or her representative during the second quarter (April, May, or June) and fourth quarter (October, November, or December) of 2024. 2. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), hypertensive heart and chronic kidney disease, atrial fibrillation, diabetes mellitus type II, obstructive and reflux uropathy, and metabolic encephalopathy. Review of the annual MDS assessment dated [DATE] revealed Resident #38 had moderate cognitive impairment, had an indwelling urinary catheter, and was always incontinent of bowel. The resident was dependent for eating, oral and personal hygiene, toileting, bathing, dressing, bed mobility, and transfers. Review of the documentation provided by the RDCO #3030 revealed Resident #38 or his representative were offered care conferences in the third (July, August, and September) and fourth (October, November, and December) quarters of 2024 and attended on 09/18/24 and 12/18/24. There was no documented evidence that a care conference was offered or completed with the resident or the resident's representative for the first quarter (January, February, or March) and second quarter (March, April, or May) of 2024. Interview on 02/13/25 at 9:55 A.M. with RDCO #3030 verified the facility had no documentation that a care conference was conducted with Resident #38 or his representative during the first quarter (January, February, or March) and second quarter (April, May, or June) of 2024. Review of the undated policy titled, Plan of Care Overview, revealed residents/representatives will be informed of their Plan of Care (POC) in the most understandable manner possible. Residents/representatives will be offered opportunities to voice their view. The facility will review care plans quarterly and/or with significant changes in care and will support the residents right to participate in treatment and care planning. Care plan documents will be maintained in electronic form or paper form and attendees will sign and date care plan meeting agendas/documents.

Based on medical record review and staff interviews, the facility failed to ensure residents were administered antipsychotic medications for appropriate indications. This affected two (#84 and #241) of the five residents reviewed for unnecessary medications. The facility census was 82. Findings include: 1. Record review for Resident #241 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included end stage renal disease, gout, and anemia. There were no diagnoses with indications for use of an antipsychotic medication in the medical record. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/06/24, revealed Resident #241 was assessed to have intact cognition. Review of the active physicians order dated 01/27/25 revealed Resident #241 was to be administered 25 milligrams (mg) of Seroquel (an antipsychotic medication) once a day in the mornings. There were no indication for the use of the medication present. Interview with Divisional Director of Clinical Operations (DDCO) #850 on 02/13/25 at 10:49 A.M. confirmed Resident #241 received Seroquel without adequate indications for use. 49771 2. Review of the medical record revealed Resident #84 was admitted to the facility on [DATE] with diagnoses of Alzheimer's dementia, cerebrovascular accident (CVA) with right (dominant) side hemiplegia/hemiparesis, and diabetes mellitus type II. Review of the MDS admission assessment dated [DATE] revealed Resident #84 had severe cognitive impairment and was frequently incontinent of bowel and bladder. Review of physician orders revealed an order dated 11/30/24 for Resident #84 to be administered the antipsychotic olanzapine five (5) mg with instructions to give one tablet by mouth at bedtime for insomnia. Review of the medication administration record (MAR) for December 2024, January 2025, and February 2025 revealed Resident #84 was administered olanzapine 5 mg as ordered. Interview on 02/13/25 at 12:15 P.M. with the Director of Nursing verified Resident #84 did not have an appropriate diagnosis indicated for use of olanzapine.

Based on medical record review and staff interview, the facility failed to complete discharge Minimum Data Set (MDS) assessments in a timely manner. This affected two (#63 and #82) of three residents reviewed for resident assessments. The facility census was 82. Findings include: 1. Review of Resident #63's medical record revealed the resident was admitted to the facility on [DATE] and discharged to home on 10/09/24. Diagnoses included chronic obstructive pulmonary disease, urinary tract infections, malignant neoplasm of the larynx, pulmonary insufficiency, acute kidney failure, protein-calorie malnutrition, gastronomy, adult failure to thrive, dysphagia, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had intact cognition with no behavior symptoms. Review of the medical record revealed Resident #63 discharged from the facility on 10/09/24 to home with proper discharge. Further review revealed a discharge MDS assessment was not completed and was overdue. 2. Review of Resident #82's medical record revealed the resident was admitted to the facility on [DATE] and discharged to home on 10/23/24. Diagnoses included spinal fusion, bacteremia, thyroid disorder, sleep apnea, dysphagia, hypoxemia, gastronomy, muscle weakness, gastro-esophageal reflux disease, and cognitive communication deficit. Review of the quarterly MDS assessment dated [DATE] revealed Resident #82 had intact cognition with no behavior symptoms. Review of the medical record revealed Resident #82 discharged from the facility on 10/23/24 to home with proper discharge. Further review revealed a discharge MDS assessment was not completed and was overdue. Interview with MDS Nurse #495 on 02/12/25 at 11:30 A.M. verified discharge MDS assessments were not completed timely for Resident #63 and Resident #82.

Based on medical record review and resident and staff interview, the facility failed to promote and honor a resident's choice for bathing. This affected one (#21) of two residents reviewed for activities of daily living (ADLs). The facility census was 82. Findings include: Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis, thrombocytopenia purpura, chronic kidney disease stage II, hypertension, chronic pain syndrome, osteoarthritis, diverticulosis, gastro-esophageal reflux, vascular dementia, hyperlipidemia, and visual disturbance. Review of Resident #21's admission Minimum Data Set (MDS) assessment dated [DATE] and the annual MDS assessment dated [DATE] revealed the choice of bathing options was very important to the resident. Review of the most recent MDS assessment dated [DATE] revealed Resident #21 was cognitively intact. Review of Resident #21's shower sheets for December 2024, January 2025, and February 2025 revealed the resident received only four showers between 12/-6/24 and February 2025. Further review revealed the resident received bed baths 13 times in that same time period, and three shower sheets dated 01/03/25, 01/20/25, and 01/17/25 were not completed and did not identify what type of bathing was provided. Review of a social services note dated 01/02/25 at 12:28 P.M. revealed Social Worker (SW) #125 and the Executive Director (ED) met with Resident #21 to discuss the shower schedule and any other concerns SW #125 and the ED encouraged the resident to use the appropriate pathways if she did not feel she was getting the care she needed which started by letting the nursing staff know and then calling the front desk to get in contact with the Director of Nursing (DON), the ED or social worker at the time of need so Resident #21 was ensured to get the care requested. Interview with Resident #21 on 02/10/25 at 8:37 P.M. revealed she has not received regular baths or showers. Resident #21 revealed she wanted to consistently receive showers two times weekly. Resident #21 revealed staff gave her bed baths despite her requests for showers. Follow up interview with Resident #21 on 02/12/25 at 10:37 A.M. confirmed she rarely received showers and was mostly given bed baths. Resident #21 stated her bathing days are on Tuesday and Saturday and verified she preferred getting showers over bed baths because she does not feel they get her clean enough. Interview with Certified Nurse Aide (CNA) #532 on 02/12/25 at 9:18 A.M. confirmed Resident #21 received showers on occasion but mostly received bed baths. This deficiency represents non-compliance investigated under Complaint Number OH00161944.

Based on observation, resident and staff interview, and medical record review, the facility failed to ensure residents were provided with prompt and appropriate dental services upon the discovery of a resident with missing dentures. This affected one (#62) of six residents reviewed for personal property. The facility census was 82. Findings include: Review of Resident #62's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizoaffective bipolar disorder, depression, dysphagia, extrapyramidal and movement disorder, cognitive communication disorder, difficult ambulation, muscle weakness, dementia, gastro-esophageal reflux disease, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 had minimal cognitive impairments with no behavior symptoms. Review of Resident #62's medical record contained no item inventory list upon admission to determine if the resident had full set of dentures upon arrival to the facility. Review of dental notes revealed Resident #62 was last seen by a dental provider on 10/22/24 as a follow up. Further review revealed the dental assessments provided no proposed treatment for missing lower dentures. Review of dietary progress notes documented on 12/20/24 at 1:54 P.M. revealed Resident #62 reported occasional difficulty chewing tough or hard foods due to long-term absence of bottom dentures. Further review of Resident #62's medical record revealed no document evidence of the facility arranging for dental services at least as far back as 12/20/24 when it was revealed in the dietary progress notes the resident reported absence of bottom dentures to staff. Interview and observation with Resident #62 on 02/10/25 at 7:49 P.M. revealed the resident had missing bottom dentures and was only wearing top dentures. The resident did not know what happened to the bottom dentures and could not rule out someone taking them. Follow up interview and observation of Resident #62 on 02/13/25 at 10:39 A.M. revealed she was admitted to the facility with both upper and lower dentures and could not remember when the dentures went missing but staff were unable to find them. Resident #62 further denied pain or weight loss as a result of the missing dentures. Observation of Resident #62 at that time revealed the resident did not have bottom dentures. Interview with Regional Director of Clinical Services #3030 on 02/13/25 at 9:45 A.M. verified the facility could not provide any further documentation in regards to Resident #62 having missing dentures or arranging for dental services once staff were informed the dentures were missing.

Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure medications were stored in appropriate containers in the medication cart. This had the potential to affect three (Residents #59, #61, and #62) of three residents prescribed iron on the 500-Hall. The facility census was 87. Findings include: Review of the medical record revealed Resident #59 had physician orders for ferrous sulfate 325 milligrams (mg) by mouth twice daily with meals for anemia. Review of the medical record revealed Resident #61 had physician orders for ferrous sulfate 325 mg by mouth in the morning with breakfast for anemia. Review of the medical record revealed Resident #62 had physician orders for ferrous sulfate 325 mg by mouth once daily with breakfast for anemia. Observation on 11/18/2024 at 10:17 A.M. revealed the 500-Hall medication cart had an unlabeled plastic medication cup containing multiple green round tablets. During an interview on 11/18/24 at 10:17 A.M., Licensed Practical Nurse (LPN) #162 verified the cup full of green pills she identified as iron were not labeled and were not appropriately stored in the medication cart. Review of the policy titled Storage of Medications dated 08/2020 revealed medications and biologicals were stored safely, securely, and properly according to manufacturer recommendations. This was an incidental finding discovered during the course of the complaint investigation.

Based on observation, staff interview, and policy review, the facility failed to ensure staff prepared food in a sanitary manner. This affected one (Resident #3) of one resident reviewed during tray line service. The facility census was 87. Findings include: Observation on 11/18/24 at 12:32 P.M. revealed Dietary Manager #142 touched two hamburger buns with bare hands during lunch meal preparation. During an interview on 11/18/24 at 12:55 P.M., Dietary Manager #142 verified she had used her bare hands to open hamburger buns while preparing Resident #3's lunch tray. Dietary Manager #142 acknowledged she was not supposed to touch food with her bare hands. Review of the policy titled Food Preparation dated 09/2017 revealed all staff used serving utensils appropriately to prevent cross contamination. This was an incidental finding discovered during the course of the complaint investigation.

Based on observations, interviews, medical record review, and policy review, the facility failed to implement appropriate infection prevention procedures during medication administration. This affected two (Residents #63 and #79) of five residents reviewed for medication administration. The facility census was 87. Findings include: 1. Review of the medical record revealed Resident #79 was admitted to the facility on [DATE]. Diagnoses included major depressive disorder and mixed hyperlipidemia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #79 had physician's orders for routine morning medications including Amlodipine (treats high blood pressure) 10 milligrams (mg) by mouth once daily and Galantamine (treats dementia) eight mg by mouth once daily. Observation of medication administration on 11/18/24 at 9:36 A.M. revealed while preparing medications for administration, Registered Nurse (RN) #136 popped Resident #79's Amlodipine from the pill card into her bare hand before dropping the pill into the medication cup and picked up Galantamine eight mg with her bare hand and placed it in the medication cup after the pill had dropped onto the top of the medication cart. During an interview on 11/18/24 at 9:48 A.M., RN #136 confirmed she had touched Resident #79's Amlodipine and Galantamine medications with her bare hands. 2. Review of the medical record revealed Resident #63 was admitted to the facility on [DATE]. Diagnoses included chronic diastolic congestive heart failure, major depressive disorder, generalized anxiety disorder, and stage III chronic kidney disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had severely impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #63 had physician orders for routine morning medications including Namenda (treats Alzheimer's disease) 10 milligrams (mg) by mouth once daily, Zoloft (antidepressant) 100 mg by mouth once daily, Acetaminophen (treats minor pain and aches) 325 mg by mouth three times daily, and Cyanocobalamin (vitamin) 1,000 micrograms (mcg) by mouth once daily. Observation of medication administration on 11/18/24 at 9:59 A.M. revealed while preparing medications for administration, Registered Nurse (RN) #228 popped Resident #63's Namenda 10 mg and Zoloft 100 mg medications from the pill card into her bare hand before dropping the pills into the mediation cup and used bare fingers to fish out Acetaminophen 325 mg and Cyanocobalamin 1,000 mcg pills from house stock bottles. During an interview on 11/18/24 at 10:05 A.M., RN #228 confirmed while preparing Resident #63's morning medications, she had touched multiple medications with her bare hands and stated she did not normally do that. Review of the undated policy titled Medication Administration revealed licensed medical professionals do not touch medication during administration and discard dropped medications. This was an incidental finding discovered during the course of the complaint investigation.

Based on resident and staff interview, observation, record review, and policy review, the facility failed to develop comprehensive care plans for pain management to include indwelling medical devices. This affected one (Resident #69) of ten residents reviewed for care plans. The facility census was 87. Findings include: Review of the medical record revealed Resident #69 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, chronic kidney disease, obesity, and non-pressure chronic ulcer of the let hell and mid-foot. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #69 was cognitively intact, had no behaviors, did not reject care, and did not wander. Review of the hospitals' After Visit Summary dated 05/21/24 revealed Resident #69 had a Past Surgical History including thoracic laminectomy with paddle lead and rechargeable battery in left hip performed 03/14/22. Review of the care plan dated 05/09/24 revealed Resident #69 had complaints of acute and chronic pain and was at risk for pain. Interventions included administering nonpharmacological interventions for pain, complete pain assessments routinely and as needed, and follow physician orders for complaints of pain. There were no information and instructions on how to care for an implanted spinal cord stimulator Observation on 11/19/24 at 1:02 P.M. revealed Resident #69 had a spinal cord adapter with a blue cord and paddle visible in his room among personal items stored on top of a nightstand located adjacent to the wall in the right corner of the room. During an interview on 11/19/24 at 1:02 P.M., Resident #69 stated he had three separate back surgeries and had an implanted spinal cord stimulator which he recharged with an adapter himself. Due to back pain, he was unable to tolerate lying in bed and was advised by his surgeon to sleep in his recliner chair. Resident #69 stated he had told nursing staff he was unable to tolerate being in the bed and preferred to sleep in the recliner chair. During an interview on 11/19/24 at 3:17 P.M., the Director of Nursing (DON) stated if a resident had a spinal cord stimulator on admission, the facility would contact the provider for instructions on how to care for it. The device would be included in a care plan for implantable devices or pain management. The DON verified Resident #69's care plan did not include information about an implanted spinal cord stimulator. During an interview on 11/19/24 at 3:50 P.M., Licensed Practical Nurse #168 stated she completed the care plans for every resident after admission. LPN #168 stated she reviewed hospital documents provided on admission or researched recent hospital stays if she had access to determine resident care needs. LPN #168 stated she interviewed residents upon admission for mental status and to address mental health needs. LPN #168 verified Resident #168 was not care-planned for a spinal cord stimulator because she was unaware that Resident #168 had it. Review of the undated policy titled Plan of Care Overview revealed the facility provided a resident-centered care plan to meet the psychosocial, physical , and emotional needs and concerns of residents. This deficiency represents noncompliance investigated under Complaint Number OH00159893.

Based on record review, interview, and policy review, the facility failed to notify residents of Medicaid account balances. This affected three residents (#28, #29 and #61) out of three residents reviewed for notification of Medicaid account balances. The facility census was 94. Findings include: 1. Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses of schizoaffective disorder, alcohol use, unspecified psychosis, diabetes mellitus type II and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #28 had intact cognition. Review of the Resident Fund Management Service (RFMS) Trial Balance report dated 10/03/24 revealed Resident #28 had a balance of $27,554.84. The current Supplemental Security Income (SSI) resource limit is $2,000.00. Interview on 10/03/24 at 2:20 P.M. with Resident #28 revealed he had not received a notification letter from the facility of being within $200 of the Social Security Income limit. 2. Review of the medical record revealed Resident #29 was admitted on [DATE] with diagnoses of combined systolic and diastolic congestive heart failure, unspecified dementia and hypertension. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #29 had intact cognition. Review of the Resident Fund Management Service (RFMS) Trial Balance report dated 10/03/24 revealed Resident #29 had a balance of $6,942.67. The current Supplemental Security Income (SSI) resource limit is $2,000.00. Interview on 10/03/24 at 2:30 P.M. with Resident #29 revealed he had not received a notification letter from the facility of being within $200 of the Social Security Income limit. 3. Review of the medical record revealed Resident #61 was admitted on [DATE] with diagnoses of schizoaffective disorder, malignant neoplasm of bladder and depression. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #61 had intact cognition. Review of the Resident Fund Management Service (RFMS) Trial Balance report dated 10/03/24 revealed Resident #61 had a balance of $16,775.66. The current Supplemental Security Income (SSI) resource limit is $2,000.00. Interview on 10/03/24 at 3:58 P.M. with Resident #61 revealed he had not received a notification letter from the facility of being within $200 of the Social Security Income limit. Interview on 10/03/24 at 2:55 P.M. with Business Office Manager (BOM) #1200 confirmed Residents #28, #29 and #61 were over the Supplemental Security Income (SSI) resource limit of $2,000 which could negatively impact their Medicaid eligibility, and that the facility did not make written or verbal notification to them when they were within $200 of being at the Supplemental Security Income (SSI) resource limit. As of 10/03/24, Resident #28's current RFMS balance was $27,554.84, Resident #29's current RFMS balance was $6,942.67 and Resident #61 was $16,775.66. Review of the Resident Trust Fund policy revised 10/19/17 revealed monthly, the facility shall issue a notification letter to any Medicaid resident with a trust fund balance within $200 of the Social Security Income (SSI) limit. This deficiency represents non-compliance investigated under Complaint Number OH00158460.

Based on record review, interview and policy review, the facility failed to properly investigate grievances and provide a summary of the findings to the resident or resident representative. This affected two residents (#55 and #8601) out of three residents reviewed for grievances. The facility census was 94. Findings include: 1. Review of the medical record revealed Resident #55 was admitted on [DATE] with diagnoses of schizoaffective disorder, depression, anxiety, diabetes mellitus type II, morbid obesity, chronic obstructive pulmonary disease and tracheostomy. Review of the Minimum Data Set (MDS) significant change assessment dated [DATE] revealed Resident #55 had moderate cognitive impairment and was always incontinent of bowel and bladder. The resident required set- up assistance with eating and oral hygiene, maximal assistance with bed mobility and was dependent for toileting, bathing, dressing, personal hygiene and transfers. Review of grievances/concerns revealed a concern was initiated on 09/30/24 by Resident #55's family member for care concerns attributed to State tested Nurse Aide (STNA) #501 to Resident #55 on 09/28/24. Review of the staffing sheet for 09/28/24 revealed LPN #410 and STNA #501 had been assigned to Resident #55. Review of Resident #55's progress notes after this alleged incident did not reveal any behavioral changes in Resident #55. Interview on 10/07/24 at 9:22 A.M. with Resident #55's family member revealed on 09/28/24 Resident #55 allegedly heard STNA #501 telling LPN #410 You have to do something about her (Resident #55's) diarrhea. Phone interview on 10/07/24 at 9:22 A.M. with Resident #55's family member confirmed there is a camera with audio capability in Resident #55's room that is monitored by another family member. Allegedly, on 09/28/24, a STNA identified by the family member as STNA #501, was overheard by Resident #55 telling the nurse You need to do something about all of this diarrhea. The family member of Resident #55 confirmed a grievance/concern was filed with the facility on 09/30/24 and revealed there has been no communication from the facility regarding the investigation, findings and resolution of this concern. 2. Review of the medical record revealed Resident #8601 was admitted on [DATE] with diagnoses of right femur neck fracture, chronic obstructive pulmonary disease and depression. The resident discharged home with home health services on 09/21/24. Review of the Minimum Data Set (MDS) Medicare five-day assessment dated [DATE] revealed Resident #8601 had moderate cognitive impairment and was frequently incontinent of bowel and bladder. The resident required set up assistance for eating, moderate assistance for oral hygiene, maximal assistance for bed mobility and was dependent for toileting, bathing, dressing, personal hygiene and transfers. Review of grievances/concerns revealed a concern was initiated on 09/10/24 by Resident #8601's family member regarding care provided by STNA #500 to Resident #8601 on 09/09/24. Review of the staffing sheet for 09/09/24 revealed STNA #500 had been assigned to Resident #8601. Review of Resident #8601's progress notes after this alleged incident did not reveal any behavioral changes in Resident #8601. Phone interview on 10/07/24 at 9:06 A.M. with Resident #8601's family member revealed according to Resident #8601 an aide told her she should have used the restroom before she got in bed. The family member of Resident #8601 confirmed a concern was initiated on 09/10/24 and the family member requested a copy of the report and was told by the Administrator these go only to the State. The family member of Resident #8601 stated the results of the investigation were never provided. Interview on 10/07/24 at 1:18 P.M. with the Executive Director confirmed the facility failed, upon receiving a grievance/concern,to investigate the concern, complete a comprehensive written concern decision, inform the resident or the individual of the concern resolution and provide a written concern decision upon request. Review of the Resident Grievances policy and standard procedures reviewed 02/20/24 revealed upon receipt of an oral, written or anonymous grievance by a resident or another individual involved in resident care, the Grievance Official will take immediate action to prevent further violations of any resident right while the alleged violation is being investigated; will complete a timely investigation of the resident's grievance; will complete a written grievance decision that includes the date the grievance was received, a summary statement of the grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action and the date the decision was issued. The Grievance Official will meet with the resident and inform the resident of the results of the investigation and how the resident's grievance was resolved or will be resolved. A copy of the written grievance decision will be provided to the resident or the individual reporting the grievance, upon request. This deficiency represents non-compliance investigated under Complaint Number OH00158349.

Based on medical record review, observations, interviews and policy review, the facility failed to ensure medications were securely stored. This affected three (#56, #24 and #54) residents of three reviewed for medication storage. The facility census was 86. Findings include: Medical record review for Resident #56 revealed an admitted [DATE] with diagnoses including but not limited to schizoaffective disorder, major depression, personality and behavioral disorder due to known physiological condition. Review of the quarterly MDS dated [DATE] revealed an intact cognition. Resident #56 requires supervision for eating, toileting, bed mobility and transfers. Review of the plan of care for Resident #56 dated 12/08/22 revealed resident uses psychotropic medication for diagnoses of schizophrenia. Interventions include aims testing, pharmacy consults, monitoring of adverse side effects, and consistent daily routines when possible. Review of the active physician orders for Resident #56 for July 2024 revealed an order dated 03/22/24 for Fluticasone Propionate (corticosteriod) 50 micrograms (mcg) suspension one spray in each nostril for allergies. Observation on 07/02/24 at 2:57 P.M. of unsecured pharmacy labeled Fluticasone Propionate in Resident #56 room sitting on his dresser. Interview on 07/02/24 at 2:59 P.M. with Licensed Practical Nurse (LPN) #301 verified the observation of the bottle of Fluticasone Propionate in Resident #56 room, stating that it should not have been left in the room. 2. Medical record review for Resident #24 revealed an admission on 12/17/22 with diagnoses including but not limited to hemiplegia, affecting left dominate side, hemiplegia and hemiparesis following a cerebral infarction, diabetes type two, acute kidney failure and bipolar disorder, wernicke's encephalopathy and anxiety. Review of the quarterly MDS assessment for Resident #24 dated 05/03/24 revealed resident had intact cognition. Resident #24 was independent with eating. Resident #24 required supervision for bed mobility, transfers and toileting. Review of the plan of care for Resident #24 revealed resident has history of Cerebral Vascular Accident (CVA) left side weakness limited range of motion in left hand with complaint of pain and hemiplegia. Interventions included administer medications as ordered, observe for adverse side effects and effectiveness. Review of the physician orders for the Month of July 2024 for Resident #24 did not include orders for Gabapentin (anticonvulsant) or Hydroxyzine (antihistamine). Observation on 07/02/24 at 1:57 P.M. of three medication bottles (one Gabapentin bottle and two Hydroxyzine bottles) all with medication capsules/tablets visible sitting on the dresser in Resident #24's room with prescriptions dated 03/28/24. Interview on 07/02/24 at 1:57 P.M. with Resident #24 stated his psychologist prescribes the medication for him (Gabapentin 600 milligrams and Hydroxyzine (antihistamines) daily and he keeps them in his room so he can take them when he needs them. Interview on 07/02/24 at 2:04 P.M. with the Director of Nursing (DON) verified Resident #24 should not have any prescription medications in his room and did not have any order in the medical record for the prescribed medication. 3. Review of the medical record for Resident #54 revealed an admission on 05/16/24 with diagnoses including but not limited to disorders of the vein, non pressure chronic ulcer of right ankle with unspecified severity. Review of the comprehensive MDS dated [DATE] for Resident #54 revealed an intact cognition. Resident #54 required set up assistance for eating, supervision for bed mobility and toileting. Resident #54 required moderate assistance for transfers. Resident #54 was coded with five venous ulcers. Review of the plan of care dated 05/16/24 for Resident #54 revealed resident had impaired skin integrity and at risk for pressure ulcer development related to weakness, fatigue, venous insufficiency, obesity and lymphoid. Resident #54 has current skin impairments on the left inner foot, left heel, right lower leg, right great toe and right ankle. Interventions include administer treatments as ordered by medical provider, complete skin at risk assessment as ordered, weekly skin checks and encourage resident to turn and reposition or assist as needed as resident allows Review of the active physicians order for Resident #54 revealed an order dated 06/18/24 for left inner foot, cleanse with normal saline, apply betadine to base of wound, secure with rolled gauze and ace bandage change daily. Observation on 07/02/24 at 3:30 P.M. of Resident #54's in room sink revealed a large bottle of betadine unsecured with a warning label to notify poison control if ingested. Interview on 07/02/24 at 3:42 P.M. with Registered Nurse (RN) #302 verified the bottle should have not been left in the residents room. Review of the facility policy titled Storage of Medications, dated 09/2018 stated medications and biologicals are stored safety, securely and properly. Additionally stated medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications.

Based on record review, observation, and staff interviews, the facility failed to accommodate resident food preferences. This affected one (#30) out of three residents reviewed for food preferences. The census was 89. Findings include: Review of the medical record for Resident #30 revealed he was admitted to the facility on [DATE]. Diagnoses included mild persistent asthma with acute exacerbation, congestive heart failure, hypertension, chronic viral hepatitis c, acute respiratory failure with hypoxia, gout, type two diabetes mellitus with other specified complication, hypokalemia, vitamin d deficiency, hypertensive urgency, chronic pain syndrome, major depressive disorder, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/20/24, revealed Resident #30 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require setup assistance for eating and oral hygiene, and moderate assistance for toileting, bathing, dressing, personal hygiene, bed mobility, and transfer. Review of the facility assessment titled Diet History/Food Preferences, dated 01/29/24, revealed Resident #30 disliked peas. Observation on 03/06/24 at 12:26 P.M. of Resident #30's lunch revealed he was served meatloaf, cheesy potatoes, and peas. Interview on 03/06/24 at 12:29 P.M. with Registered Nurse (RN) #206 confirmed Resident #30 was served peas. Interview on 03/06/24 at 5:00 P.M. with the Director of Nursing (DON) confirmed the dietary assessment indicated Resident #30 disliked peas. This deficiency represents non-compliance investigated under Complaint Number OH00151191.

Based on medical record review, staff and resident interview, and policy review, the facility failed to ensure physician orders were followed correctly. This affected one (#17) out of three residents reviewed for medications. The facility census was 100. Findings included: Review of the medical record for Resident #17 revealed an admitted [DATE]. Diagnoses included cerebrovascular attack (CVA/stroke) with hemiplegia affecting left dominant side, renal insufficiency, and non-Alzheimer's dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #17, revealed the resident was cognitively intact. Her functional status was impairment of her upper and lower extremities, and she was independent for activities of daily living (ADLs). Review of the physician's orders dated 10/13/23 for Resident #17 revealed the resident ordered to have Metro Vaginal Gel one tube applied intravaginally at bedtime for bacterial vaginitis times six days. Review of the Medication Administration Records (MARs) dated 10/13/23, 10/14/23, and 10/15/23 which had a number 9' indicating to see the nurse's progress notes. Review of the nurse's progress notes for Resident #17 revealed no documented evidence resident received her Metro Vaginal Gel on 10/13/23, 10/14/23 and 10/15/23. Interview with Resident #17 on 12/06/23 at 9:11 A.M., revealed the Metro Vaginal Gel was not administered to her as ordered for the six days. Interview with the Director of Nursing (DON) on 12/06/23 at 3:30 P.M., confirmed the staff were late in giving Metro Vaginal Gel to Resident #17 and verified it was not given as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00147673.

Based on medical record review, review of hospital records, review of a facility Self-Reported Incident (SRI), review of staff time card punches, observations, review of the facility abuse policy, and interviews with staff, residents, and a police detective, the facility failed to implement their abuse policy when one State tested Nurse Aide (STNA) neglected to report that he had dropped a resident during an improper transfer, and one additional STNA who was aware the resident had been dropped also neglected to report the incident. This resulted in Immediate Jeopardy and serious life-threatening injuries when Resident #40 experienced increased pain and suffering due to the delayed identification of the extent of the injuries sustained by the resident during the improper transfer. Resident #40 was then transferred to the emergency room of a local hospital where she was found to have acute fractures to both the left and right distal femurs, and remote right pubic rami fractures. This resulted in Immediate Jeopardy for one (#40) of five residents reviewed for abuse and neglect. Additionally, the facility failed to ensure one (#55) out of five residents reviewed were free from verbal abuse by a staff member that was not Immediate Jeopardy. The facility census was 78. On 04/04/19 at 2:37 P.M., the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Corporate Director of Nursing (CDON) #150 were notified Immediate Jeopardy began on 03/21/19 at approximately 7:15 P.M., when STNA #123 dropped Resident #40 during an improper transfer and then neglected to report he had dropped the resident. The resident complained of increased pain to both knees on 03/21/19, 03/22/19, and 03/23/19 without notification of the resident's physician until 03/24/19. Resident #40 was then transferred to the emergency roiagnom on [DATE] where she was found to have acute fractures to both the left and right distal femurs, and remote right pubic rami fractures and subsequently required hospitalization . The Immediate Jeopardy was removed on 03/26/19 when the facility suspended STNA #123 and #127 and interviewed and/or assessed all residents on STNA #123's assignment (300 Hall) to ascertain if any improper transfer occurred or injury had been sustained as a result of care delivered by the nurse aide, or any other staff person, and the facility implemented the following corrective actions: · On 03/24/19, the DON notified the Medical Director to discuss the resident's current medical condition. · On 03/24/19, the facility initiated an investigation into the root cause of Resident #40's injuries by interviewing nursing staff and obtaining written statements. The facility continued interviewing all nursing staff who had contact with Resident #40 prior to 03/24/19 to ascertain the source of the injuries. · On 03/25/19, the DON and Doctor of Physical Therapy (DPT) #203 began in-servicing STNA's on abuse, transfers, incident reporting, and cooperating with an investigation. The in-services were completed on 03/25/19. · On 03/25/19, the DON and DPT #203 began audits of transfers that included return demonstration from nursing staff. The audits have been completed daily Monday through Friday and will be continued daily Monday through Friday for three weeks, then weekly for three weeks, and then monthly for three months. · On 03/25/19, the Clinical Reimbursement Specialist, Registered Nurse (RN) #247 audited all resident's comprehensive care plans for transfer status. · On 03/26/19, the DON and CDON #150 audited all resident care cards (Kardex) and care plans to ensure the proper transfer status was reflected on the care plan. · On 03/26/19, licensed nurses were in-serviced by the DON regarding notification of the physician with all resident accidents, incidents, and changes in condition. The in-services were completed on 03/26/19. · On 03/26/19, the CDON #150 met with the Medical Director and reviewed the status of the facility's investigation into Resident #40's injuries and the plan of action. A facility SRI was submitted to the state survey agency on 03/26/19 identifying Resident #40's femur fractures as injuries of unknown origin. · On 03/26/18 a detective from the County Sherriff's office (Detective #163) arrived at the facility and initiated an investigation into the source or Resident #40's injuries. The Sherriff's office was contacted by the resident's family. · On 03/28/19, the LNHA and the DON initiated audits related to abuse/neglect. The audits have been completed daily Monday through Friday and will continue daily Monday through Friday for three weeks, then weekly for three weeks, then monthly for three months. · On 04/02/19, STNA #123 and STNA#127 were terminated from the facility at the conclusion of Detective #163's investigation. · On 04/03/19 and 04/04/19, STNAs #08, #73, #83, #84, #51, #69, #74, and #58 were interviewed to ascertain if they had received in-service education regarding the facility's abuse policy, abuse/neglect reporting procedures and incident reporting, safe transferring of residents, reviewing care cards (Kardex) and if they had been observed performing transfers. All staff interviewed reported they had been educated regarding the aforementioned topics and had been observed by either the DON or DPT #203 while they were transferring residents. · On 04/04/19, STNAs #73, #84, #83, #69, and #51 were observed transferring residents from one surface to another and competently performed the transfers consistent with the respective resident's written plan of care. · On 04/04/19, Licensed Practical Nurses (LPN) #99, #109, #94, #93, #96, and #97 were interviewed to ascertain if they had received in-service education and training on notification of change in resident's condition, incident reporting, abuse/neglect reporting procedures and incident reporting. All nurses interviewed communicated they had received in-service education regarding the aforementioned topics and were able to verbalize what was learned. · During the survey, three (#07, #70 and #10) additional residents were reviewed for abuse and neglect. No concerns were identified. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE], and recently readmitted from the hospital on [DATE]. [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had good memory and recall as the resident had a 15 out of 15 on the Brief Interview for Mental Status (BIMS). Further review of the MDS revealed the resident required physical assistance of two staff persons for bed mobility, transferring, and toilet use. Resident #40 did not walk and was assessed as having no fall since the prior assessment. The resident received routine opioid medication daily. Review of the Resident #40's current comprehensive plan of care revealed a care plan dated 10/11/16 indicating the resident was at high risk for falls related to balance deficits, cognitive deficits, deconditioning and fall history. The fall care plan documented staff have been educated on appropriate transfer techniques following instructions on Kardex for transfer status. Further review of a care plan titled Activities of Daily Living (ADL) self-care deficit which fluctuates related to deconditioning/muscle weakness, fatigue dated 10/11/16 revealed Resident #40 requires extensive to dependent assistance of two staff members for toileting and transfers via a mechanical (Hoyer) lift and two staff members as tolerated. Further review of a Kardex with a print date of 03/27/19 revealed Resident #40 required extensive to dependent assistance of two staff members for transfers. Review of Resident #40's physician's orders [REDACTED]. In addition, the resident had orders to received [MEDICATION NAME] 500 mg every eight hours as needed for pain. Review of Resident #40's nursing progress notes revealed on 03/22/19 at 4:33 P.M., LPN #93 documented the resident was administered 50 mg of [MEDICATION NAME] for complaints of bilateral lower extremity pain. LPN #93 documented there was no injury noted. The resident denied falling or injury with impact to her bilateral lower extremities; the resident had a shower during the evening on 03/21/19. LPN #93 noted repositioning was ineffective, passive range of motion was refused and fluids increase was ineffective. LPN #93 further documented arthritis was a chronic issue for the resident, that the resident's left knee was enlarged slightly more than the resident's other knee with no bruising noted. The resident had no complaints of pain upon palpation, no redness, or warmth to the extremity. On 03/22/19 at 11:42 P.M., LPN #113 documented she administered 500 mg of [MEDICATION NAME] to the resident for complaints of pain to her bilateral lower extremities, not relieved by rest or repositioning. On 03/23/19 at 3:53 P.M., LPN #99 documented she administered 50 mg of [MEDICATION NAME], as needed, to the resident for pain as Resident #40 was crying, stating she was having pain in her knees. On 03/24/19 at 11:13 A.M., LPN #99 documented she auscultated Resident #40's lung sounds due to the resident experiencing shortness of breath and weakness and rhonchi (abnormal lung sound) was noted to the right lower lobe of the lung. Resident #40 also complained of severe knee pain to bilateral knees. Resident #40's knees were swollen. Resident #40's color was slightly yellow. Resident #40 was very weak and can be incoherent at times. Resident #40 was afebrile, and vital signs were within normal limits. LPN #99 further documented she called Resident #40's physician to ask for STAT (immediate) x-rays and laboratory tests. The on-call physician ordered a chest x-ray and x-rays to both the resident's knees. Resident #40's family member was also notified. On 03/24/19 at 11:34 A.M., LPN #99 documented Resident #40 stated she fell to the floor in her room a few days ago and hit her knees. Resident #40 complained of severe knee pain to both knees and her knees are swollen. When this nurse started shift yesterday (on 03/23/19), the night shift nurse stated Resident #40 was in bed all day Friday 03/22/19 due to knee pain. The night shift nurse also stated Resident #40 had bilateral knee pain on Friday, 03/22/19 shift. Resident #40 complained of knee pain yesterday (on 03/23/19) as well. It is to be noted the resident has a [DIAGNOSES REDACTED]. Review of Resident #40's (MONTH) 2019 Medication Administration Record [REDACTED]. The resident's pain was rated by nurses, either by verbalization by the resident or signs/symptoms of pain on a scale of one through 10, with 10 being the worst pain imaginable. On 03/21/19 at 8:00 A.M., the resident's pain was rated at zero, on 03/21/18 at 10:04 P.M. the resident's pain was rated as a four, on 03/22/19 at 4:33 P.M. the resident's pain was rated at eight, on 03/22/19 at 9:42 P.M. the resident's pain was rated at seven, on 03/23/19 at 8:00 A.M. the resident's pain was rated at seven, on 03/23/19 at 3:53 P.M. the resident's pain was rated at six, on 03/23/19 at 7:25 P.M. the resident's pain was rated at six, on 03/24/19 at 8:00 A.M. the resident's pain was rated at six, and on 03/24/19 at 12:43 P.M. the resident's pain was rated at eight. Review of Resident #40's nursing progress notes, and MAR, failed to reveal any documentation Resident #40's physician was notified of the increased complaints of pain, and continued complaints of pain, until 03/24/19 at 11:34 A.M. Further review of the nursing progress notes revealed on 03/24/19 at 7:19 P.M., LPN #99 documented the x-ray results of Resident #40's knees revealed the resident had acute distal femur fractures. The physician was notified, and an order was received to send the resident to the hospital. The resident was picked up on 03/24/19 at approximately 5:00 P.M. and taken to a local hospital for evaluation. The resident was then admitted to the hospital. Review of hospital records dated 03/24/19 revealed Resident #40 had a fall at the skilled nursing facility. Further review revealed the hospital obtained x-rays of both lower extremities and Resident #40 was found to have an acute [MEDICAL CONDITION] femur, right pubic rami fractures, and an acute [MEDICAL CONDITION] distal femur with subluxation and angulation. Resident #40 was subsequently hospitalized for [REDACTED]. Resident #40 remained hospitalized until 03/29/19. Review of a facility SRI dated 03/26/19 revealed Resident #40 was found to have bilateral femur fractures on 03/24/19. The SRI, completed by the DON and Licensed Nursing Home Administrator (LNHA), indicated Resident #40 had bilateral femur fractures confirmed through an x-ray. Resident #40 stated she had fallen; however, the facility was unable to confirm a fall through the initial investigation and is now considering this an SRI related to an injury of unknown origin. The SRI further documented the police were notified and on 03/28/19 the facility was notified by a police detective that they did an interview with STNA #123 and he admitted to dropping the resident on 03/21/19 during transfer to the shower chair before the shower occurred. STNA #123 acknowledged that the resident had pain during his shift Friday 03/22/19. He also denies telling LPN #107 about the incident as he had previously stated. Resident #40 received continued routine and as needed medications from Thursday, 03/21/19 at 10:00 P.M. through Sunday, 03/24/19. The facility has concluded STNA #123 will be terminated due to failure to report an incident, failure to cooperate with a facility investigation and negligence. Additionally, the facility has concluded that STNA #127 will be terminated due to failure to cooperate with a facility investigation, failure to report an incident and negligence. Both employees (STNAs #123 and #127) remain suspended as of 03/29/19 and will be terminated once the police detective notifies the facility that they have completed their interviews. LPN #107 remains suspended as of 03/29/19 pending her being questioned by the police detective. The SRI was substantiated. An interview was conducted with the LNHA, the DON, and CDON #150 on 04/03/19 at 3:14 P.M. regarding the SRI and their investigation into Resident #40's injuries. The DON reported through the investigation it was determined STNA #123 dropped Resident #40 while transferring her from her bed to a shower chair for an evening shower on 03/21/19, sometime between 7:00 P.M. and 7:15 P.M. at the start of his shift. The DON reported STNA #123 transferred Resident #40 by himself; however, the DON stated Resident #40 required two staff for safe transferring. The DON reported STNA #123 did not report to any staff member or nurse that he had dropped the resident, with the exception of STNA #127 who was getting ready to leave her day shift on 03/21/19. Both STNA #123 and STNA #127 failed to report Resident #40 was dropped during the transfer. CDON #150 communicated that both STNA #123 and STNA #127 were interviewed more than once by the facility and denied any knowledge of Resident #40 falling or being dropped. She stated STNA #123 admitted to dropping Resident #40 to a detective from the county Sherriff's office (Detective #163) during an interview on 03/28/19. CDON #150 shared that finally during STNA #127's third interview, the nurse aide admitted that she was told by STNA #123 on 03/21/19 that he dropped the resident during a transfer. Both STNA #123 and #127 were suspended by the facility on 03/26/19, due to inconsistencies during their second interview regarding Resident #40 and how her injuries may have occurred, and with what was observed on facility cameras the night of the incident. CDON #150 stated both STNA #123 and #127 were being terminated as Detective #163 had concluded his investigation. The facility provided all documentation of the investigation into Resident #40's leg fractures including interviews and statements from nursing staff who worked with the resident from 03/21/19 through 03/24/19. Review of time card punches for STNA #123 revealed the nurse aide continued to care for Resident #40 throughout the night shift (7:00 P.M. through 7:00 A.M.) on 03/21/19 into 03/22/19, and during the night shift on 03/22/19 into 03/23/19, without reporting to nurses or administrative staff that he had dropped the resident. Review of time card punches for STNA #127 revealed the nurse aide continued to work with the resident during the day shift (7:00 A.M. through 7:00 P.M.) on 03/22/19 without reporting to nurses or administrative staff of her knowledge that Resident #40 had been dropped by STNA #123. Resident #40 was observed, and interviewed on 04/02/19 at 6:26 P.M. The resident was resting in bed. During the observation, Resident #40 was observed with braces/splints to the lower extremities. Resident #40 was asked if she could tell this surveyor about how her legs were broken. Resident #40 stated first that she was not sure how her legs were broke, then stated she was getting out of bed and was under the impression that someone gave me a push. Resident #40 then stated her injuries occurred because there were supposed to be two people helping her and I had only one helping. Resident #40 stated the incident happened at night; however, could not recall what staff person was assisting her when it happened, or specifically if it was a man or woman. Resident #40 stated she has not been out of bed since her legs were broken, and that the pain medicine was helping and denied being in pain at that time. An interview was conducted with Detective #163 on 04/04/19 at 9:36 A.M. regarding the investigation into the source of Resident #40's injuries. He reported he could not disclose all the details of the investigation/interviews as the case was still ongoing. Detective #163 was able to share he interviewed STNA #123 on 03/28/19 and the nurse aide admitted to dropping the resident, and at first stated he had told a nurse, then admitted to the detective that he did not tell a nurse. Detective #163 reported STNA #123 admitted to him that the resident was experiencing pain when he worked with her that night on 03/21/19, and during the next night shift on 03/22/19. Detective #163 also reported he interviewed STNA #127 who also stated the resident was experiencing significant pain when she provided incontinence care on 03/22/19 and told the nurse the resident was having knee pain, but affirmed she did not communicate to the nurse that she knew why the resident was having increased pain. An interview with LPN #99 was conducted on 04/04/19 at 10:04 A.M. regarding Resident #40's leg fractures and to ascertain why the resident's physician was not notified regarding the residents increased complaints of pain, and reports of falling/being dropped prior to 03/24/19. LPN #99 stated STNA #69 reported to her on Saturday, 03/22/19, the resident was having knee pain. LPN #99 shared she physically assessed Resident #40's knees/legs. LPN #99 reported Resident #40's entire legs were not swollen or out of alignment. She reported the resident was alert with confusion at times and didn't really rate her pain using a numerical scale, but she assessed the resident's pain based on observations of the resident, and her verbal expressions of pain. LPN #99 stated on Saturday, 03/22/19, the resident asked to call her daughter, so she dialed the number for her and she spoke with her daughter. She communicated Resident #40's daughter then called her and stated to LPN #99 the resident was reporting that she had been dropped on her knees, and then said that she knew her mother could be confused, and LPN #99 told the daughter she did not have any reports of the resident having fallen, been dropped, or having any injuries. When asked why she did not report to Administrative staff that Resident #40 was saying she had been dropped, LPN #99 stated she did not think it was necessary to report as the claim came from the daughter who did not believe that it had occurred. LPN #99 was then queried as to when the determination was made to contact Resident #40's physician and notify administrative staff regarding the resident's report of being dropped. She stated on Sunday, 03/24/19, STNA #69 called her to come talk with Resident #40 during breakfast so the resident could tell her what she had told STNA#69. LPN #99 stated the resident told STNA #69 and herself that she had been dropped but was confused about when it happened stating something like the day before, the day before yesterday. She communicated the resident reported she thought it was a man who dropped her but was not certain. LPN #99 stated the resident did appear to have swelling in both knees at that time. She reported she called the DON after the resident told her she had been dropped and also called the resident's physician. LPN #99 reported the physician ordered x-rays of both legs on 03/24/19, both legs were positive for fracture, and the resident was then sent out to the hospital for evaluation. An interview was conducted with Receptionist #21 on 04/04/19 at 10:48 A.M. regarding Resident #40's injuries. Receptionist #21 reported she was familiar with the resident and spoke with her daily when she was up. Receptionist #21 stated Resident #40 was not out to the dining area, or reception area, all day on Friday, 03/22/19 or Saturday morning, 03/23/19. She presumed she was in bed. Receptionist #21 reported Resident #40's daughter was in and wanted the resident to get up, and she did come out in the afternoon before the scheduled entertainment arrived. Receptionist #21 communicated that was when Resident #40 told her that her legs were absolutely killing her. Receptionist #21 stated she gently rolled up her pants, as they were loose fitting, and observed the resident's knees were huge and swollen. Receptionist #21 stated she asked the resident how her knees got like that and the resident was not able to exactly state how it happened, but her exact words were that she was dropped. Receptionist #21 stated the resident did state to her it was a male aide, that he did not mean to hurt her, and was confused as to when it exactly happened. Receptionist #21 stated she thought for sure Resident #40's daughter would have known about it, and would have been notified. Receptionist #21 communicated she reported what Resident #40 said to her to the nurse who was caring for her that day, and described LPN #99. She stated she also told the Administrator on the following Monday. The facility policy and procedure titled Reporting Abuse to Facility Management and revised on 08/16/16 was reviewed. The review revealed the policy statement specified it was the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etcetera to immediately report any incident or suspected incident of neglect or resident abuse including injuries of unknown source and theft and/or misappropriation of resident property to facility management. Additionally, the facility policy and procedure titled Reporting/Investigation Resident Accidents/Incidents and revised 08/16/16 revealed the policy statement specified that all accidents/incidents involving residents must be immediately reported to the Administrator and the DON. In addition, all person's witnessing an accident or incident involving a resident must immediately report such information to their department supervisor. 2. Review of the medical record for Resident #55 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated on 02/20/19 revealed the resident had minimal cognitive impairments and required extensive assistance of two with her care. Review of a SRI dated on 03/15/19 revealed Resident #55 reported to the Director of Nursing (DON) STNA #120 pulled her by her arm and leg when turning her. Resident # 55 noted bruises on her arms. Resident #55 also revealed STNA #120 yelled at her. The facility substantiated the SRI. Review of a statement in the facility investigation provided by LPN #121 noted Resident #55 told the LPN she would have bruises in the morning on 03/14/19 due to the way STNA #120 turned her and was rough and called her names. Review of the written statement by Registered Nurse (RN) #115 revealed on the morning of 03/15/19 at 8:00 A.M. Resident #55 reported STNA #120 was yelling at her and was rough leaving bruises on her arms. Resident #55 told RN #115 she was awake and shaking in her bed the rest of the night afraid STNA #120 would return. Observations of Resident #55 on 04/01/19 at 3:00 P.M. revealed the resident was in her room sitting in her wheel chair. The resident was alert and oriented and agreed to the interview. Resident #55 noted she had small yellow bruises on her right arm. Interview with Resident #55 on 04/01/19 at 3:00 P.M. revealed on the night of 03/14/19 STNA #120, pulled her by her arm and leg yanking the resident over to her side. STNA #120 then began to verbally abuse the resident. Resident #55 noted the STNA called her fat and told her she was ugly. The resident stated it made her feel so degraded and worthless. Resident #55 said she was trying very hard to lose some weight and had been feeling good about her progress. Resident #55 was tearful during the interview. The resident said for the rest of the night she lay awake shaking and would not put her call light on until the next morning when she was sure STNA #120 was gone. The resident said she was relieved STNA #120 would not be back. Interview on 04/04/19 at 10:00 A.M. with the Director of Nursing (DON) revealed LPN #121 did not report the allegation of abuse the night of 03/14/19. The DON was not informed of the allegation until the morning of 03/15/19. The DON also confirmed the SRI involving STNA #120 abusing Resident #55 was substantiated. Review of the Abuse Policy dated on 08/16/19 revealed the facility does not condone abuse by any one of any kind. Any individual observing an incident of abuse must immediately report to a member of the management immediately. Abuse is defined as willful infliction of injury, unreasonable confinement , intimidation, punishment, resulting in physical harm, pain, or mental anguish. This deficiency substantiates Master Complaint Number OH 564 and Complaint Number OH 353.

Based on medical record review, review of hospital documentation, review of a facility Self-Reported Incident (SRI), review of facility investigations, review of written statements, observations, staff, resident, detective and ambulette personnel interviews and policy review, the facility failed to provide adequate supervision and/or assistance for each resident to ensure their safety. This resulted in actual harm to two residents (#40, #29) who both sustained multiple fractures when being transferred. Resident #40 sustained bilateral distal femur fractures when transferred from bed to a shower chair without appropriate assistance and Resident #29 sustained multiple rib fractures while being transferred off an ambulette without adequate supervision at the entrance to the facility. This affected two (#40 and #29) out of five residents were reviewed for accidents. The facility census was 78. Findings include: 1. Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE], and recently readmitted from the hospital on [DATE]. [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had good memory and recall as the resident had a 15 out of 15 on the Brief Interview for Mental Status (BIMS). Further review of the MDS revealed the resident required physical assistance of two staff persons for bed mobility, transferring, and toilet use. Resident #40 did not walk and was assessed as having no fall since the prior assessment. The resident received routine opioid medication daily. Review of the Resident #40's current comprehensive plan of care revealed a care plan dated 10/11/16 indicating the resident was at high risk for falls related to balance deficits, cognitive deficits, deconditioning and fall history. The fall care plan documented staff have been educated on appropriate transfer techniques following instructions on Kardex for transfer status. Further review of a care plan titled Activities of Daily Living (ADL) self-care deficit which fluctuates related to deconditioning/muscle weakness, fatigue dated 10/11/16 revealed Resident #40 requires extensive to dependent assistance of two staff members for toileting and transfers via a mechanical (Hoyer) lift and two staff members as tolerated. Further review of a Kardex with a print date of 03/27/19 revealed Resident #40 required extensive to dependent assistance of two staff members for transfers. Review of Resident #40's physician's orders [REDACTED]. In addition, the resident had orders to received [MEDICATION NAME] 500 mg every eight hours as needed for pain. Review of Resident #40's nursing progress notes revealed on 03/22/19 at 4:33 P.M., Licensed Practical Nurse (LPN) #93 documented the resident was administered 50 mg of [MEDICATION NAME] for complaints of bilateral lower extremity pain. LPN #93 documented there was no injury noted. The resident denied falling or injury with impact to her bilateral lower extremities; the resident had a shower during the evening on 03/21/19. LPN #93 noted repositioning was ineffective, passive range of motion was refused and fluids increase was ineffective. LPN #93 further documented arthritis was a chronic issue for the resident, that the resident's left knee was enlarged slightly more than the resident's other knee with no bruising noted. The resident had no complaints of pain upon palpation, no redness, or warmth to the extremity. On 03/22/19 at 11:42 P.M., LPN #113 documented she administered 500 mg of [MEDICATION NAME] to the resident for complaints of pain to her bilateral lower extremities, not relieved by rest or repositioning. On 03/23/19 at 3:53 P.M., LPN #99 documented she administered 50 mg of [MEDICATION NAME], as needed, to the resident for pain as Resident #40 was crying, stating she was having pain in her knees. On 03/24/19 at 11:13 A.M., LPN #99 documented she auscultated Resident #40's lung sounds due to the resident experiencing shortness of breath and weakness and rhonchi (abnormal lung sound) was noted to the right lower lobe of the lung. Resident #40 also complained of severe knee pain to bilateral knees. Resident #40's knees were swollen. Resident #40's color was slightly yellow. Resident #40 was very weak and can be incoherent at times. Resident #40 was afebrile, and vital signs were within normal limits. LPN #99 further documented she called Resident #40's physician to ask for STAT (immediate) x-rays and laboratory tests. The on-call physician ordered a chest x-ray and x-rays to both the resident's knees. Resident #40's family member was also notified. On 03/24/19 at 11:34 A.M., LPN #99 documented Resident #40 stated she fell to the floor in her room a few days ago and hit her knees. Resident #40 complained of severe knee pain to both knees and her knees are swollen. When this nurse started shift yesterday (on 03/23/19), the night shift nurse stated Resident #40 was in bed all day Friday 03/22/19 due to knee pain. The night shift nurse also stated Resident #40 had bilateral knee pain on Friday, 03/22/19 shift. Resident #40 complained of knee pain yesterday (on 03/23/19) as well. It is to be noted the resident has a [DIAGNOSES REDACTED]. Review of Resident #40's (MONTH) 2019 Medication Administration Record [REDACTED]. The resident's pain was rated by nurses, either by verbalization by the resident or signs/symptoms of pain on a scale of one through 10, with 10 being the worst pain imaginable. On 03/21/19 at 8:00 A.M., the resident's pain was rated at zero, on 03/21/18 at 10:04 P.M. the resident's pain was rated as a four, on 03/22/19 at 4:33 P.M. the resident's pain was rated at eight, on 03/22/19 at 9:42 P.M. the resident's pain was rated at seven, on 03/23/19 at 8:00 A.M. the resident's pain was rated at seven, on 03/23/19 at 3:53 P.M. the resident's pain was rated at six, on 03/23/19 at 7:25 P.M. the resident's pain was rated at six, on 03/24/19 at 8:00 A.M. the resident's pain was rated at six, and on 03/24/19 at 12:43 P.M. the resident's pain was rated at eight. Review of Resident #40's nursing progress notes, and MAR, failed to reveal any documentation Resident #40's physician was notified of the increased complaints of pain, and continued complaints of pain, until 03/24/19 at 11:34 A.M. Further review of the nursing progress notes revealed on 03/24/19 at 7:19 P.M., LPN #99 documented the x-ray results of Resident #40's knees revealed the resident had acute distal femur fractures. The physician was notified, and an order was received to send the resident to the hospital. The resident was picked up on 03/24/19 at approximately 5:00 P.M. and taken to a local hospital for evaluation. The resident was then admitted to the hospital. Review of hospital records dated 03/24/19 revealed Resident #40 had a fall at the skilled nursing facility. Further review revealed the hospital obtained x-rays of both lower extremities and Resident #40 was found to have an acute [MEDICAL CONDITION] femur, right pubic rami fractures, and an acute [MEDICAL CONDITION] distal femur with subluxation and angulation. Resident #40 was subsequently hospitalized for [REDACTED]. Resident #40 remained hospitalized until 03/29/19. Review of a facility SRI dated 03/26/19 revealed Resident #40 was found to have bilateral femur fractures on 03/24/19. The SRI, completed by the DON and Licensed Nursing Home Administrator (LNHA), indicated Resident #40 had bilateral femur fractures confirmed through an x-ray. Resident #40 stated she had fallen; however, the facility was unable to confirm a fall through the initial investigation and is now considering this an SRI related to an injury of unknown origin. The SRI further documented the police were notified and on 03/28/19 the facility was notified by a police detective that they did an interview with STNA #123 and he admitted to dropping the resident on 03/21/19 during transfer to the shower chair before the shower occurred. STNA #123 acknowledged that the resident had pain during his shift Friday 03/22/19. He also denies telling LPN #107 about the incident as he had previously stated. Resident #40 received continued routine and as needed medications from Thursday, 03/21/19 at 10:00 P.M. through Sunday, 03/24/19. The facility has concluded STNA #123 will be terminated due to failure to report an incident, failure to cooperate with a facility investigation and negligence. Additionally, the facility has concluded that STNA #127 will be terminated due to failure to cooperate with a facility investigation, failure to report an incident and negligence. Both employees (STNAs #123 and #127) remain suspended as of 03/29/19 and will be terminated once the police detective notifies the facility that they have completed their interviews. LPN #107 remains suspended as of 03/29/19 pending her being questioned by the police detective. The SRI was substantiated. An interview was conducted with the LNHA, the DON, and CDON #150 on 04/03/19 at 3:14 P.M. regarding the SRI and their investigation into Resident #40's injuries. The DON reported through the investigation it was determined STNA #123 dropped Resident #40 while transferring her from her bed to a shower chair for an evening shower on 03/21/19, sometime between 7:00 P.M. and 7:15 P.M. at the start of his shift. The DON reported STNA #123 transferred Resident #40 by himself; however, the DON stated Resident #40 required two staff for safe transferring. The DON reported STNA #123 did not report to any staff member or nurse that he had dropped the resident, with the exception of STNA #127 who was getting ready to leave her day shift on 03/21/19. Both STNA #123 and STNA #127 failed to report Resident #40 was dropped during the transfer. CDON #150 communicated that both STNA #123 and STNA #127 were interviewed more than once by the facility and denied any knowledge of Resident #40 falling or being dropped. She stated STNA #123 admitted to dropping Resident #40 to a detective from the county Sheriff's office (Detective #163) during an interview on 03/28/19. CDON #150 shared that finally during STNA #127's third interview, the nurse aide admitted that she was told by STNA #123 on 03/21/19 that he dropped the resident during a transfer. Both STNA #123 and #127 were suspended by the facility on 03/26/19, due to inconsistencies during their second interview regarding Resident #40 and how her injuries may have occurred, and with what was observed on facility cameras the night of the incident. CDON #150 stated both STNA #123 and #127 were being terminated as Detective #163 had concluded his investigation. The facility provided all documentation of the investigation into Resident #40's leg fractures including interviews and statements from nursing staff who worked with the resident from 03/21/19 through 03/24/19. Resident #40 was observed, and interviewed on 04/02/19 at 6:26 P.M. The resident was resting in bed. During the observation, Resident #40 was observed with braces/splints to the lower extremities. Resident #40 was asked if she could tell this surveyor about how her legs were broken. Resident #40 stated first that she was not sure how her legs were broke, then stated she was getting out of bed and was under the impression that someone gave me a push. Resident #40 then stated her injuries occurred because there were supposed to be two people helping her and I had only one helping. Resident #40 stated the incident happened at night; however, could not recall what staff person was assisting her when it happened, or specifically if it was a man or woman. Resident #40 stated she has not been out of bed since her legs were broken, and that the pain medicine was helping and denied being in pain at that time. An interview was conducted with Detective #163 on 04/04/19 at 9:36 A.M. regarding the investigation into the source of Resident #40's injuries. He reported he could not disclose all the details of the investigation/interviews as the case was still ongoing. Detective #163 was able to share he interviewed STNA #123 on 03/28/19 and the nurse aide admitted to dropping the resident, and at first stated he had told a nurse, then admitted to the detective that he did not tell a nurse. Detective #163 reported STNA #123 admitted to him that the resident was experiencing pain when he worked with her that night on 03/21/19, and during the next night shift on 03/22/19. Detective #163 also reported he interviewed STNA #127 who also stated the resident was experiencing significant pain when she provided incontinence care on 03/22/19 and told the nurse the resident was having knee pain, but affirmed she did not communicate to the nurse that she knew why the resident was having increased pain. An interview with LPN #99 was conducted on 04/04/19 at 10:04 A.M. regarding Resident #40's leg fractures and to ascertain why the resident's physician was not notified regarding the residents increased complaints of pain, and reports of falling/being dropped prior to 03/24/19. LPN #99 stated STNA #69 reported to her on Saturday, 03/22/19, the resident was having knee pain. LPN #99 shared she physically assessed Resident #40's knees/legs. LPN #99 reported Resident #40's entire legs were not swollen or out of alignment. She reported the resident was alert with confusion at times and didn't really rate her pain using a numerical scale, but she assessed the resident's pain based on observations of the resident, and her verbal expressions of pain. LPN #99 stated on Saturday, 03/22/19, the resident asked to call her daughter, so she dialed the number for her and she spoke with her daughter. She communicated Resident #40's daughter then called her and stated to LPN #99 the resident was reporting that she had been dropped on her knees, and then said that she knew her mother could be confused, and LPN #99 told the daughter she did not have any reports of the resident having fallen, been dropped, or having any injuries. When asked why she did not report to Administrative staff that Resident #40 was saying she had been dropped, LPN #99 stated she did not think it was necessary to report as the claim came from the daughter who did not believe that it had occurred. LPN #99 was then queried as to when the determination was made to contact Resident #40's physician and notify administrative staff regarding the resident's report of being dropped. She stated on Sunday, 03/24/19, STNA #69 called her to come talk with Resident #40 during breakfast so the resident could tell her what she had told STNA#69. LPN #99 stated the resident told STNA #69 and herself that she had been dropped but was confused about when it happened stating something like the day before, the day before yesterday. She communicated the resident reported she thought it was a man who dropped her but was not certain. LPN #99 stated the resident did appear to have swelling in both knees at that time. She reported she called the DON after the resident told her she had been dropped and also called the resident's physician. LPN #99 reported the physician ordered x-rays of both legs on 03/24/19, both legs were positive for fracture, and the resident was then sent out to the hospital for evaluation. An interview was conducted with Receptionist #21 on 04/04/19 at 10:48 A.M. regarding Resident #40's injuries. Receptionist #21 reported she was familiar with the resident and spoke with her daily when she was up. Receptionist #21 stated Resident #40 was not out to the dining area, or reception area, all day on Friday, 03/22/19 or Saturday morning, 03/23/19. She presumed she was in bed. Receptionist #21 reported Resident #40's daughter was in and wanted the resident to get up, and she did come out in the afternoon before the scheduled entertainment arrived. Receptionist #21 communicated that was when Resident #40 told her that her legs were absolutely killing her. Receptionist #21 stated she gently rolled up her pants, as they were loose fitting, and observed the resident's knees were huge and swollen. Receptionist #21 stated she asked the resident how her knees got like that and the resident was not able to exactly state how it happened, but her exact words were that she was dropped. Receptionist #21 stated the resident did state to her it was a male aide, that he did not mean to hurt her, and was confused as to when it exactly happened. Receptionist #21 stated she thought for sure Resident #40's daughter would have known about it, and would have been notified. Receptionist #21 communicated she reported what Resident #40 said to her to the nurse who was caring for her that day, and described LPN #99. She stated she also told the Administrator on the following Monday. The facility policy titled Safe Lifting and Movement of Residents was reviewed. The policy statement included the following language: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. The policy interpretation and implementation section specified that nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. 2. Review of the record for Resident #29 revealed she was initially admitted to the facility on [DATE] with a re-admission on 06/15/18. [DIAGNOSES REDACTED]. Review of the MDS for Resident #29 revealed her Brief Interview of Mental Status score was seven indicating severe cognitive impairment, she was independent with eating and required extensive assistance with Activities of Daily Living (ADL's), bed mobility and transfers with a two-person assist required for transfers. Review of the progress notes for Resident #29 revealed LPN #98 documented a note on 12/20/18 that she received a call from the front desk receptionist to come outside and assist Resident #29. The nurse went to the front entrance and noted Resident #29 lying on her back on the ramp of the ambulance. The ambulance driver and Resident #29's daughter stated the wheelchair flipped back in the truck and the resident slid backwards and fell out of the truck onto the ramp with the resident hitting her head. Resident #29 was complaining of head, arm, and left foot pain. The Supervisor and Director of Nursing were notified and nine-one-one (911) was called. An ambulance transferred the resident to the hospital emergency room . The doctor was made aware. An additional note this same date documented Resident #29 was admitted to the hospital with [REDACTED]. Review of the hospital records for the incident date of 12/20/18 for Resident #29 revealed the resident had pain in her head and chest after a fall and was found to have fractured ribs. She was admitted for observation. A Computed Tomography (CT) scan of her head was negative, and X-rays showed fractures of the anterolateral 5th and 6th rib on the left side. The primary encounter [DIAGNOSES REDACTED]. Review of a progress note dated 01/30/19 revealed Resident #29 was receiving Physical Therapy and Occupational Therapy for rib fractures and muscle weakness after a fall with transport services. Review of the Fall with Major Injury Investigation Form dated 12/20/18 at 4:30 P.M. revealed Resident #29 fell in the parking lot and the Nurse Practitioner #293 was notified. The incident was described as Resident #29 tipping out of her wheelchair and out of the ambulance and was noted to be lying on her back behind the ambulance. The incident happened in the parking lot of the facility when she was coming back from an appointment. Employees of the facility were called to the area after the incident. The lift on the ambulance was not working properly and the driver called the company to get it fixed. The driver had unhooked both residents in the van and then the lift didn't work for Resident #29. Resident #29 was admitted to the hospital with [REDACTED]. Further review of the statement by the ambulette driver revealed she forgot to raise the lift after removing another person who was in the path of Resident #29 causing Resident #29 to fall back out of the van onto the ramp and the ground. During an interview with the Director of Nursing (DON) and Corporate Registered Nurse #150 on 04/04/19 at 9:08 A.M., revealed on 12/20/18 Resident #29 was returning to the facility from a doctor's appointment with her daughter following in her car. The receptionist contacted nursing to assist the resident and two nurses (LPN #92 and RN #350) and the DON responded. The DON stated the resident was on the ground on her back in her wheelchair when staff went out to assist. He reported they covered her to keep her warm and called 911. The DON stated they did not move the resident as they were concerned she had a back or head injury based on the way she was laying on the ground on her back. The DON stated 911 was called, Resident #29 was transported to the hospital and it was determined she had several broken ribs. The DON reported the ambulette driver wrote a statement and had not returned to the facility since. He stated the ambulette company did not provide them with their internal investigation. During an interview with Registered Nurse (RN) #155 on 04/04/19 at 10:18 A.M., revealed he responded when Resident #29 was injured on 12/20/18. He reported he was called out by the receptionist and found Resident #29 behind the van in her wheelchair on her back laying on the van lift that was on the ground. He reported her vitals were taken but she was not moved due to the possibility of injury. He reported 911 was immediately called and the resident was transported to the hospital. He stated Resident #29 was complaining of pain in her side. He reported he did not witness her fall, but it was his understanding the van driver was trying to get the resident out of the van and as the lift was already down, Resident #29 kept going out of the van onto the ground. During an interview with Receptionist #21 on 04/04/19 at 10:41 A.M. she stated on 12/20/18 she witnessed the van driver standing on the ground by the van with the lift down. She reported the driver was backing Resident #29's wheelchair toward the back of the van when the chair flipped off the end and landed on the lift that was laying on the ground. She stated she immediately called for nursing assistance for the resident. During an interview with Resident #29's daughter on 04/04/19 at 12:11 P.M., she stated she observed the fall. She reported the van driver was on the ground, the gate was down and the lever that holds a wheelchair in place until it can be placed on the lift was not down so Resident #29's wheelchair rolled out backward onto the lift that was on the ground before the van driver could get the lift back up. She reported the van driver had already gotten another resident out of the van which is why the lift was down. Resident #29's daughter stated her mother complained of pain in her head and ended up with fractured ribs. She reported 911 was called and Resident #29 was sent to the hospital and a CT scan and x-rays were completed to ensure there were no head or back injuries. She stated the nursing home staff came out immediately, assessed her vitals, but did not move her. She stated they offered comfort in the form of a blanket for the cold and a sheet cover to keep her out of the rain and reassured her until the squad came. During an interview with Resident #29 on 04/04/19 at 1:20 P.M. she stated someone was supposed to be helping her get out of the van and they did it wrong and she fell . She stated her head hurt when she fell , and she had broken ribs from the fall. During an interview with the Corporate Registered Nurse #150 on 04/04/19 at 4:30 P.M., she stated the facility did not have a contract in place with the ambulette service. During an interview with the Director of the Ambulette Company #295 on 04/05/19 at 2:35 P.M., revealed the driver of the ambulette who was involved in the incident on 12/20/18 had put in her resignation on 12/12/18 with her last date of service as 12/20/18. She stated as it was the drivers last day, she returned to their facility, completed a statement and left. She reported a more formal investigation was not able to be completed due to the driver no longer working for them or being available. She stated the information she received was the driver had two people on the van, forgot to put the lift back up after removing the first person, and the resident fell out of the truck onto the ground. This deficiency substantiates Master Complaint Number OH 564.