Every finding on record at King David Post Acute Nursing & Rehabilitation LLC

Based on observation and interview, the facility failed to maintain a safe physical environment by using unapproved electric coiled space heaters for heating. This had the potential to affect an unidentified number of residents residing on eight resident units who utilized the exit corridors, dining areas and nurses' workstations. The facility census was 267.Findings include:Observation on 01/20/26 from 5:15 P.M. until 7:15 P.M. during a tour of the facility with Maintenance Director (MD) #501 and Nursing Supervisor (NS) #500 revealed a total of 18 unapproved coiled portable electric space heaters located within eight of the facility's resident units in the exit corridors, nurses' workstations and dining areas. Interview at the time of the observation with MD #501 and NS #500 verified the electric coiled space heaters were placed throughout the facility due to the building heating system not maintaining required temperatures of 71 degrees to 81 degrees Fahrenheit.This deficiency represents non-compliance investigated under Complaint Number 2725672 and Complaint Number 2721209.

Based on observation, interview, record review, drug package insert review, prescribing information review and review of the facility policy, the facility did not ensure residents were administered medications free of medication error rate of five percent or less. This affected two (Residents #171 and #173) out of six residents observed for medication administration. The facility census was 243.Findings include:Observation on 12/03/25 from 8:11 A.M. to 11:03 A.M. and 12/04/25 at 10:56 A.M. of medication administration completed by Licensed Practical Nurses (LPN)s #606, #611, #612, #614, and #615 revealed there were two medication errors out of 25 opportunities resulting in an eight percent medication error rate. 1. Review of the medical record for Resident #173 revealed an admission date of 07/15/21 with diagnoses including dysphagia, hypokalemia (low potassium), dementia, and atherosclerotic heart disease.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #173 had cognitive impairment as she was rarely or never understood. Review of the December 2025 physician orders revealed Resident #173 had an order dated 06/04/25 for potassium chloride extended release (ER) 20 milliequivalent (mEq) give one tablet by mouth in the morning for hypokalemia. The order revealed the medication was not to be crushed, and it was to be dissolved in 30 milliliters (ml) of water. Observation on 12/03/25 at 8:18 A.M. revealed LPN #611 placed Resident #173's morning medications in a cup including her potassium chloride ER 20 mEq and crushed the medications. LPN #611 then poured the crushed medications including the potassium chloride ER into a supplement drink. She proceeded to administer Resident #173's medication in the supplement drink. Interview on 12/03/25 at 8:32 A.M. with LPN #611 verified she crushed Resident #173's potassium chloride ER 20 mEq. She verified that the physician order revealed the following instructions: do not crush the potassium chloride and to dissolve in 30 ml of water to administer. Interview on 12/03/25 at 9:08 A.M. with Onsite Facility Pharmacist #613 verified potassium chloride ER was not to be crushed and revealed crushing the medication could result in releasing the medication faster than recommended as it was ER. 2. Review of the medical record for Resident #171 revealed an admission date of 05/08/23 with diagnoses including dementia and fractured right femur. Review of the quarterly MDS assessment dated [DATE] revealed Resident #171 had cognitive impairment as she was rarely or never understood. Review of December 2025 physician orders revealed Resident #171 had an order dated 09/05/25 to receive calcium carbonate- vitamin D 500 milligram (mg) - 5 microgram (mcg) tablet give two tablets by mouth two times a day. Observation on 12/03/25 at 8:34 A.M. revealed LPN #612 prepared Resident #171's morning medications including calcium carbonate- vitamin D 500 mg - 5 mcg one tablet, crushed the medications and administered Resident #171 the medications including one tablet of carbonate- vitamin D 500 mg - 5 mcg in applesauce. LPN #612 then proceeded to document the administration of the medications including the calcium carbonate- vitamin D.Interview on 12/03/25 at 8:41 A.M. with LPN #612 verified she had only administered one tablet of calcium carbonate- vitamin D 500 mg - 5 mcg to Resident #171. She verified Resident #171's physician order was to administer two tablets. Review of the facility policy dated 09/14/25 and unlabeled revealed the purpose of the policy was to provide guidance for medication administration in a safe manner as prescribed. The policy revealed prior to crushing medications staff would verify that the medication could be crushed. The policy revealed staff administering medications would check the label three times and verify the right resident, right medication, right dose, right time, right route, and right documentation. Review of Drugs.com dated 11/20/25 revealed the package insert and prescribing information for Potassium Chloride ER tablets were to be taken with meals and a glass of water or liquid. Potassium Chloride ER tablets were to be swallowed without crushing, chewing or sucking. This deficiency represents non-compliance investigated under Master Complaint Number 2679829 and Complaint Number 2679645.

Based on closed record review, review of emergency medical services (EMS) run report, review of a facility incident report, staff interviews, and facility policy review, the facility to ensure cardiopulmonary resuscitation (CPR) was initiated immediately and performed appropriately following Resident #271, a resident with a Full code status (indication for healthcare providers to perform all possible life saving measures in the event of a cardiac or respiratory arrest) was found unresponsive. This affected one resident (#271) of three residents reviewed for advance directives. The facility identified 178 residents who had an advance directive of a full code. The facility census was 270.Findings include:Review of the closed medical record for Resident #271 revealed an admission date of 09/25/25 and a date of death of [DATE]. Diagnoses included but were not limited to unspecified convulsion, traumatic subdural hemorrhage without loss of consciousness, end stage renal disease, dependence upon renal dialysis, adult failure to thrive, metabolic encephalopathy, dementia without behaviors, severe sepsis without septic shock, pneumonitis due to inhalation of food and vomit. Resident code status was noted to be full code.Review of the five-day Minimum Data Set (MDS) 3.0 assessment for Resident #271 dated 09/26/25 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severely impaired cognition. Resident #271 was noted to be dependent on staff for eating, dressing, bathing, and toileting. Resident #271 required maximum assistance from staff for chair transfers and to move from sitting to lying position. Review of a physician visit note dated 09/27/25 at 12:26 P.M. revealed Resident #271 was a [AGE] year-old frail, elderly male resident. The note listed Resident #271's condition as guarded due to multiple medical conditions.Review of a nursing progress note dated 09/27/25 at 8:50 P.M. revealed Registered Nurse (RN) #514 notified Unit Manager #516 that Resident #271 was unresponsive. Unit Manager #516 and another nurse immediately went to the unit and noted Resident #271 without a pulse, respiration, or blood pressure. Resident #271 was noted to be cool to the touch. Chest compressions were started immediately, and nine-one-one (911) was called. Following the arrival of emergency medical services (EMS), the resident was pronounced deceased at 9:10 P.M.Review of a local Fire Department run report dated 09/27/25 at 8:55 P.M. revealed dispatch was notified EMS was needed and EMS personnel arrived on site at the facility at 9:02 P.M. for a non-responsive and non-breathing male. The report noted facility staff were noted to be performing ineffective CPR. Facility staff members reported Resident #271 had last been seen at approximately 8:30 P.M. but was not seen moving or talking. Upon seeing Resident #271 and the CPR that was being performed, the report noted apparent rigidity had set in. Resident #271 was checked for signs of life and was noted to be cold in his limbs and chest. Resident #271's mouth was noted to be stiff and unable to move. His right eye was partially open btu extremely cloudy and fixed. Resident #271's tongue was visible and cyanotic. Resident #271 had rigidity in his fingers, toes, neck, and back. A pillow was removed from behind Resident #271's head and the resident's head did not move from its position. A four-lead electrocardiogram (ECG) was taken and asystole (absence of heart rhythm which is incompatible with life). Resident #271's time of death was pronounced by EMS after collaboration with an outside emergency physician at 9:10 P.M. Review of Certified Nursing Assistant (CNA) #510's witness statement dated 09/30/25 stated about 8:10 P.M. she and CNA #509 proceeded to take Resident #271, who appeared to be sleeping, from the dining room to his room. Once they got Resident #271 into his room, they noticed his fingertips were blue, he was cold to touch and felt slightly hard. Following checking vitals, CNAs #509 and #510 ran to find RN #514. Upon RN #514 returning to the room with them, RN #514 started crying and panicking and stated, I don't do well with dead people. CNA #510 asked RN #514 if Resident #271 was a full code and RN #514 left the room to go check. About two minutes later, RN #514 returned and screamed put him in bed, we gotta do chest compressions. RN #514 asked CNAs #509 and #510 if they knew CPR and they said no. CNAs #509 and #510 put Resident #271 in bed and CNA #517 called EMS. RN #514 called RN #515 and screamed come over here and do chest compressions. CNA #510 stated Resident #271 did not have anything hard under his back. When RN #515 arrived, chest compressions were initiated until EMS arrived.Review of the witness statement from RN #515 dated 09/28/25 revealed while working on another unit, Unit Manager #516 received a phone call stating a code was called on the Fairmont unit. RN #515 and Unit Manager #516 rushed to Resident #271's room and found Resident #271 not breathing, without spontaneous movement of the chest, no audible sounds upon auscultation, no circulation, and eyes were fixed and dilated with no reaction to light. There was also no response to painful stimuli such as pressure applied to the supraorbital nerve. Code status was verified and RN #515 initiated CPR while paramedics were being called. Resident #271 was pronounced dead at 9:12 P.M.Review of the undated witness statement for Licensed Practical Nurse (LPN) #508 revealed Resident #271 refused medications three times when offered earlier in the day. Resident #271 only took two bites of lunch and refused to eat dinner on 09/27/25. LPN #508 stated Resident #271 was last seen in the dining room at the end of shift.Review of the 09/28/25 witness statement written by LPN #519 revealed she checked Resident #271 between 6:00 P.M. and 6:30 P.M. and the resident was noted to have his eyes open.Interview on 10/08/25 at 11:42 A.M. with LPN #508 revealed she worked the day shift of 09/27/25 and attempted to feed Resident #271 lunch and he only took a couple bites. Between 3:00 and 3:30 P.M., she rounded and noticed Resident #271 was sitting on the side of his bed and assisted the aide to change him. LPN #508 later attempted to feed Resident #271dinner but he refused. LPN #508 stated they kept Resident #271 near the nurses' station for safety, and she and the other nurse had commented on the color of his eyes just prior to leaving her shift around 6:30 P.M. LPN #508 stated she did not notice any concerns for Resident prior to leaving her shift at approximately 8:30 P.M.Interview on 10/08/25 at 11:57 A.M. with CNA #509 revealed he worked on 09/27/25 from 7:00 A.M. till almost 10:00 P.M. Around 7:30 P.M., CNA #509 left the unit with CNA #510 to get approval to work overtime on the unit. CNA #509 stated they came back around 8:00 P.M. and were both working on the hall Resident #271 resided on. Around 8:10 P.M., they proceeded to take Resident #271, who was in the dining room and appeared to be sleeping, to his room for bed. Once they got Resident #271 into his room, they realized he was unresponsive. Both CNAs #509 and #510 checked for a pulse. CNA #510 stated they noticed Resident #271's fingers were blue. CNAs #509 and #510 left the room to look for RN #514. Within two minutes they returned to Resident #271's room with RN #514. RN #514 told them to get vitals. CNA #509 stated RN #514 was nervous and stated she did not do well with dead people. CNA #510 told RN #514 to go check Resident #271's code status and she came back with the crash cart within several minutes. CNAs #509 and #510 proceeded to lay Resident #271 down in bed and RN #514 proceeded to call Unit Manager #516 and it was on speaker phone. Shortly thereafter, Unit Manager #516 and RN #515 came to Resident #271's room. RN #515 started to do chest compressions and less than five minutes after, EMS showed up.Interview on 10/08/25 at 12:23 P.M. with CNA #510 revealed around 8:00 P.M., CNA #509 and CNA #510 came back to the Fairmont unit to help cover a call off. Around 8:10 P.M., CNAs #509 and #510 approached Resident #271 in the dining room and told him they were going to get him ready for bed and proceeded to roll his wheelchair back to his room. As they were wheeling Resident #271, they noticed his legs were straight and he appeared unresponsive. CNA #509 checked his wrist and found no pulse. CNA #510 checked his neck and found no pulse and stated his neck was cool and appeared to be slightly hard. CNA #510 stated Resident #271's fingertips appeared to be blue. CNAs #509 and #510 left to find RN #514 and returned to the room with her in less than a minute. RN #514 told CNAs #509 and #510 to get the vitals machine and check his vitals. RN #514 left the room and returned shortly thereafter. She appeared nervous, scared, and stated she did not do well with dead people. CNA #510 asked RN #514 if Resident #271 was a full code and RN #514 left to go check and brought back the crash cart less than a minute or so later. CNAs #509 and #510 laid Resident #271 down in bed and RN #514 called Unit Manager #516. RN #514 asked CNAs #509 and #510 if they were CPR certified and neither of them were currently certified. CNA #510 stated RN #514 did not do chest compressions. When RN #515 arrived, chest compressions were initiated. Another (unnamed) CNA called EMS and was on speaker while RN #514 was explaining the situation. Unit Manager #516 arrived and switched off CPR with RN #514. CNA #510 left to go meet EMS in the lobby and then brought them back to Resident #271's room.Phone interview on 10/08/25 at 4:35 P.M. with RN #514 revealed she saw Resident #271 at the beginning of her shift shortly after 7:00 P.M. from a distance in the dining room but did not approach him as he appeared to be sleeping. CNAs #509 and #510 came to get her around 8:45-8:50 P.M. and stated Resident #271 was unresponsive. When RN #514 arrived at Resident #271's room she noticed he appeared to be sleeping, was noted to be unresponsive, had no pulse and was cyanotic (bluish in color), and had some skin mottling. RN #514 notified Unit Manager #516. RN #514 left the room to go get the crash cart. RN #514 confirmed she did not initiate CPR prior to RN #514 and Unit Manager #516 arriving at the room. RN #514 called 911 and they told her they were already enroute. RN #515 and Unit Manager #516 took turns doing chest compressions until EMS arrived and pronounced Resident #271 deceased at 9:10 P.M.Interview on 10/09/25 at 6:18 A.M. with RN #515 revealed during his night shift on 09/27/25, Unit Manager #516 was on his unit when she received a call from RN #514 stating Resident #271 was unresponsive. RN #515 and Unit Manager #516 both went to Resident #271's room. Unit Manager #516 arrived first and when RN #515 arrived, the crash cart was in the room, and they were setting up the bed for CPR. RN #515 noted Resident #271 was cool but not cold, his body was stiff, and fingertips were cyanotic. RN #515 asked RN #514 why CPR had not been started and RN #514 stated she had to go get the crash cart first. RN #515 stated they arrived at Resident #271's room within three to five minutes after the call was received since it is a big building. RN #515 started CPR immediately after arriving to Resident #271's room and continued until EMS arrived less than 10 minutes later. Interview on 10/09/25 at 6:41 A.M. with Unit Manager #516 revealed she was the Unit Manager the night of 09/27/25. The Fairmont unit was short a nurse and she was assisting to cover. Unit Manager #516 stated she needed to check all the units to make sure staff were covered and arrived at the unit around 8:30 P.M. to count meds with LPN #508 prior to her leaving. Following counting meds, she spoke with RN #514, CNA #509, CNA #510 and another aide about covering since she may need to step off the unit to handle concerns on other units. Around 8:45 P.M., Unit Manager #516 was on the unit RN #515 was working on and received a phone call from RN #514 stating Resident #271 was unresponsive. Unit Manager #516 and RN #515 both responded to assist within two minutes. Unit Manager #516 stated upon arrival, Resident #271 was noted to be unresponsive, with no pulse or respirations. Resident #271 was cool to the touch and pupils were fixed and CPR had not been started yet. Unit Manager #516 stated she looked up Resident #271's code status and yelled he was a full code to RN #515, who then started CPR. RN #515 and Unit Manager #516 continued compressions until EMS arrived about six minutes later. Unit Manager #516 confirmed when she arrived the crash cart was in the hall outside the room and was unsure why RN #514 had not started CPR. Unit Manager #516 stated typically the protocol would be to check code status, yell for help, and start CPR.Phone interview on 10/09/25 at 11:58 A.M. with CNA #517 revealed around 8:45 P.M., CNAs #509 and #510 told her they thought Resident #271 was deceased and CNA #517 went to Resident #271's room with RN #514 and found Resident #271 unresponsive. RN #514 asked CNAs #509, #510, and #517 if they were CPR certified, and they told her no. CNA #517 stated RN #514 appeared to panic and did not know what to do. RN #514 then called RN #515. RN #514 did not initiate CPR and acted scared of a dead body. When RN #515 arrived a few minutes later, RN #515 initiated CPR.Phone interview on 10/14/25 at 8:11 A.M. with LPN #519 revealed she had discussed the pretty eye color of Resident #271 with LPN #508 and had observed Resident #271 alert in the dining room between 6:00 P.M. and 6:30 P.M.Phone interview on 10/14/25 at 8:40 A.M. with CNA #525 revealed she had last seen Resident #271 alert in the dining room around 7:00 P.M.A follow-up phone interview on 10/14/25 at 9:03 A.M. with CNA #510 revealed she worked from 7:00 A.M. to 3:00 P.M. on Fairmont and was called to another unit until 7:30 P.M. At 7:30 P.M., she went down to see if she could get overtime to assist on the Fairmont unit since there was a staff call off. Around 8:00 P.M., CNA #510 was given permission to help on Fairmont, and she proceeded to go to the unit shortly after 8:00 P.M. and sometime later found Resident #271 unresponsive.Interview on 10/14/25 at 9:08 A.M. with the Regional Clinical Director #499 revealed if a resident is found unresponsive, staff should immediately initiate CPR following confirmation of a full code status.Follow up phone interview on 10/14/25 at 10:09 A.M. with RN #515 confirmed when he arrived at Resident #271's room on 09/27/25, Resident #271 was lying in his bed and there was no board or hard surface underneath him. Resident #271's fingers appeared to be blue, and RN #514 had not initiated CPR. When RN #515 asked why she had not started CPR, RN #514 stated she had gone to get the crash cart and then called Unit Manager #516. RN #515 initiated CPR and continued till EMS arrived.Review of the facility employee Cardiopulmonary Resuscitation (CPR) report printed on 10/09/25 revealed RN # 515's CPR license expired as of 08/01/25.Observation on 10/14/25 at 10:45 A.M. of the cardiopulmonary resuscitation Basic Life Support (CPR BLS) card for RN #515 revealed it was renewed on 10/09/25. Interview at the time of observation with the Assistant Director of Nursing (ADON) confirmed RN #515's CPR certification was expired on 09/27/25 when CPR was performed on Resident #271.Phone interview on 10/15/25 at 7:30 A.M. with Paramedic #520 revealed when he arrived on the scene on 09/27/25, one staff member was doing CPR, and two other staff members were in the room but not assisting. No one was managing Resident #271's airway, no bag or AED were present. The staff member providing compressions was not doing them at the correct rate and a backboard was not present under Resident #271. Paramedic #520 stated he did not recall seeing the crash cart and upon seeing the ineffective CPR being performed, he promptly asked them to stop. Paramedic #520 assessed Resident #271 and found no signs of life and that rigor mortis (stiffening of the joints and muscles of a body which sets in a few hours after death) had set in. Paramedic #520 stated when the staff member was performing CPR, Resident #271's body was stiff and bent in the middle, and his head was off the pillow when staff was performing compressions. Upon stopping compressions, Resident #271's head remained in the raised position and did not fall back onto the pillow. Paramedic #520 stated staff kept saying they had last seen the resident at 8:30 P.M., but the condition observed upon entrance at the scene did not reflect proof of life at 8:30 P.M. Paramedic #520 reported Resident #271 appeared to have been deceased for at least 2-3 hours prior to EMS arrival. Paramedic #520 stated upon arriving on scene, staff did not provide additional information about Resident #271 and appeared to not know how to appropriately handle the emergent situation.Review of the 01/03/25 reviewed facility policy called; Cardiopulmonary Resuscitation (CPR) Policy- Ohio Long Term revealed CPR (basic life support) includes chest compressions, ventilations and use of AED (as applicable) to restore circulation/respiration. The facility shall initiate CPR when a resident is found in cardiac arrest) absence of respirations or pulse), unless a valid advance directive or DNR order is present. If a resident is discovered unresponsive or without respirations/pulse, immediate action must be taken: call a 'Code Blue', certified staff should begin CPR (compressions, ventilations) and/or use AED per training once it is safe to do so until arrival of EMS.This deficiency represents non-compliance investigated under Complaint Number 2635740.

Based on observation, test tray and interviews, the facility failed to ensure meals were served at a safe and palatable temperature. This had the potential to affect all residents who received meals from the facility except for six residents (#1, #2, #101, #212, #240, and #261) identified by the facility as having orders for nothing by mouth (NPO). The facility census was 259. Findings include:Interview on 09/08/25 at 11:17 A.M. Resident #58 stated there was no good help in the kitchen. The food in the kitchen is strictly kosher, and she is not getting enough food. She stated sometimes the food is cold because there were not enough staff. By the time she gets her food, it's cold. She also stated the food comes from the kitchen late and it's not good. Interview on 09/08/25 at 12:28 P.M. Resident #192 stated the food is bad, and she cannot eat it. Interview on 09/08/25 at 3:54 P.M. Resident #272 stated the food is gross, cold, and not cooked properly. Interview on 09/09/25 at 8:29 A.M. Resident #54 stated the food was okay, but not seasoned. Interview on 09/11/25 at 8:32 A.M. with Certified Nursing Assistant (CNA) #708 stated she hears a lot of residents complain about the food. They say they get small amounts of food and have to pay for food at the cafe. Interview on 09/11/25 t 8:34 A.M. with Licensed Practical Nurse (LPN) #693 stated she hears a lot of food complaints from the residents. They have to go to the cafe and buy food because they do not like the food or they receive a small amount and are still hungry. Observation on 09/11/25 at 11:20 A.M. revealed the Interim Certified Dietary Manager (CDM) #508 was taking food temperatures for lunch from the steam table in the kitchen. The eggplant cheese lasagna was 174 degrees Fahrenheit (F), the eggplant cheese lasagna with no tomato sauce was 151 degrees F, the veggie patty was 137 degrees F, the Italian green beans were 162 degrees F, and the puree Italian green beans were 134 degrees F. The veggie patties were pulled from the tray line and heated to 160 degrees F. The pureed green beans were pulled from the line and heated to 170 degrees F. Meals were plated and placed on the meal cart to be taken to the unit. No thermal plate liners were used. On 09/11/25 at 11:41 A.M. a test tray was placed on the meal cart. At 11:47 A.M. the meal cart arrived at the Fairmount Pavilion, and the trays were immediately passed to the residents. At 11:58 A.M. all residents had been served their lunch. At 11:59 A.M. the food on the test tray was tasted by the surveyor and CDM #509, with Interim CDM #508 taking the temperatures. The eggplant cheese lasagna was 138 degrees F, the eggplant cheese lasagna with no tomato sauce was 123 degrees F, and the green beans were 121 degrees F. Interview with Interim CDM #508 verified the food temperatures of the eggplant lasagna with no tomato sauce, and the green beans were not at an acceptable service temperature for palatability at the time of the test tray. This deficiency represents non-compliance investigated under Complaint Number 2591287, 2562355, 1383326 (OH00163396) and 1383324 (OH00163342).

Based on record review, interview, observation and review of facility policy, the facility failed to ensure medical records were accurate and/or legible. This affected two residents (#8 and #91) out of 44 resident records reviewed for accuracy and/or identifiable information. The facility census was 259. Findings include: 1. Review of the medical record for Resident #91 revealed an admission date of 05/15/25 with diagnoses including dysphagia, moderate protein-calorie malnutrition, adult failure to thrive, and dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #91 had impaired cognition and was dependent on staff for eating. She held food in her mouth and cheeks and received nutrition through parenteral feedings (a medical treatment that provides essential nutrients directly into the bloodstream through an intravenous (IV) line). Review of the After Visit Summary revealed Resident #91 was hospitalized from [DATE] to 09/02/25 as she was admitted to the hospital due to her [NAME] catheter (central venous catheter used to deliver medications, fluids, and nutritional supplements) malfunctioned and she needed the catheter replaced. She was discharged back to the facility on total parenteral nutrition (TPN). Review of September 2025 physician orders revealed Resident #91 had an order for TPN due to malnutrition. The TPN was to start at 8:00 P.M. at 68 milliliters (ml) for one hour, then increase the rate to 136 ml per hour for 10 hours and then decrease the rate to 68 ml per hour until 8:00 A.M. Review of September 2025 Medication Administration Record (MAR) revealed Resident #91's MAR for her TPN at 8:00 P.M. was not signed as administered on 09/06/25, 09/09/25 and 09/10/25. Interview on 09/09/25 at 8:55 A.M. with Resident #91's son revealed he felt his mother missed doses of TPN. Interview on 09/15/25 at 8:52 A.M. with Dietitian #951 verified the MAR for Resident #91's TPN on 09/06/25, 09/09/25 and 09/10/25 was blank. She verified she had no documented evidence that Resident #91's TPN was administered on 09/06/25, 09/09/25 and 09/10/25. Review of an email dated 09/15/25 at 12:12 P.M. from Registered Nurse (RN) Supervisor #763 to Regional Nurse #672 revealed she hung Resident #91's TPN on 09/10/25 and made sure it was running but did not sign it off. Review of an email dated 09/15/25 at 3:30 P.M. from RN Supervisor #614 to Regional Nurse #672 revealed during her shifts on 09/06/25 and 09/09/25 she hung and monitored Resident #91's TPN. Interview on 09/15/25 at 3:34 P.M. with the Director of Nursing (DON) verified the MAR for Resident #91's TPN on 09/06/25, 09/09/25 and 09/10/25 was blank. She revealed the TPN was administered according to the emails by the nurse that was responsible for hanging the TPN but verified they had not documented on the MAR that they were administered. Interview on 09/16/25 at 9:16 A.M. with RN Supervisor #763 verified on 09/10/25 she hung Resident #91's TPN as ordered but forgot to document on the MAR that she administered it. Review of the facility policy labeled, Total Parental Nutrition (TPN) Administration Policy, dated February 2014, revealed all orders, lab monitoring and TPN administration must be documented in the electric medical record. 2. Review of the medical record for Resident #8 revealed an admission date of 03/12/25 with diagnoses including diabetes, hemiplegia following cerebral infarction affecting right dominant side, major depression, hypertension, and depression. Review of the care plan dated 03/24/25 revealed Resident #8 had a self-care performance deficit related to hemiplegia following cerebral infarction. Interventions included providing a sponge bath when a full bath or shower could not be tolerated, and he was totally dependent on one staff to provide a bath and/or shower as necessary. There was nothing in the care plan regarding Resident #8 refusing showers and/or personal hygiene. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #8 had impaired cognition with no behaviors identified. He had impairment on one side of his upper and lower extremities. He was dependent on staff for activities of daily living (ADL) including dressing, personal hygiene, transfers and showers. Review of the nursing notes from 07/01/25 to 09/11/25 revealed no documented evidence that Resident #8 had refused a shower and/or personal hygiene. Review of the electronic monitoring task bar for bathing from 08/18/25 to 09/16/25 revealed no documentation Resident #8 had received a shower and/or bath. The task bar revealed he was scheduled to have a shower every Monday and Thursday on night shift. Review of the Skin Monitoring: Comprehensive CAN (certified nursing assistant) Shower Review sheets revealed Resident #8 received a shower or bath on 09/01/25, 09/04/25, 09/08/25, and 09/11/25. The shower sheets dated 09/01/25, 09/04/25, 09/08/25 and 09/11/25 had the same signature located on the sheet, but the signature was illegible to determine who the staff was that had given Resident #8 a shower and/or bath. Interview and observation on 09/08/25 at 11:14 A.M. with Resident #8 revealed he was in bed and his hair appeared greasy with white specks throughout. Resident #8 revealed he was supposed to get a shower twice a week on Monday and Thursday, and he had not had a shower in the last two weeks. He preferred a shower twice a week but when he asked for a shower, they would never give him one. Observation on 09/10/25 at 8:47 A.M. revealed Resident #8 was lying in bed, and his hair continued to appear unkept and greasy. Interview on 09/10/25 at 12:20 P.M. with Resident #8 revealed he still had not received a shower, and staff had never offered a shower. Interview and observation on 09/11/25 at 7:48 A.M. revealed Resident #8 was lying in bed and his hair continued to be unkept and greasy. Resident #8 revealed he had not received a shower. Interview on 09/11/25 at 10:50 A.M. with CNA #674 verified Resident #8's hair was unkept and greasy. She revealed he was scheduled as an evening shift shower every Monday and Thursday. She did not feel he received the showers as scheduled as he often appeared with body odor and/or greasy hair. Resident #8 had also stated that he had not received a shower on his shower days, and he wanted a shower. She had often passed it on to the aides that came in that he needed and wanted a shower but often the next day she would come in and he still had not received the shower. Interview on 09/15/25 at 1:58 P.M. with the DON revealed she was unable to identify who had given Resident #8 a shower on 09/01/25, 09/04/25, 09/08/25 and 09/11/25 as the signature on the shower sheets was illegible and they had contacted the staff on duty for that day and were unable to determine who provided the shower. They were still working on to determine who had. Attempted to contact the following staff that had worked on the identified days (09/01/25, 09/04/25, 09/08/25 and 09/11/25): CNA 779, CNA #977, and CNA #943 on 09/16/25 from 11:00 A.M. to 1:05 P.M. but there was no answer, and no return call was received. Interview with staff that had worked the identified days (09/01/25, 09/04/25, 09/08/25 and 09/11/25) on 09/16/25 from 11:03 A.M. to 1:02 P.M. with CNA #637, CNA #790, and CNA #827 revealed they did not give Resident #8 a shower and/ or bath and had not witnessed him receive one. Interview on 09/16/25 at 10:00 A.M. with the Administrator and DON revealed they were unable to determine the staff that had signed off on the shower sheet for 09/01/25, 09/04/25, 09/08/25 and 09/11/25 as the signature was illegible. They had contacted the staff on duty and were unable to determine who provided Resident #8 the shower and/or bath for these days. The DON revealed she did not have a policy regarding ensuring medical records had identifiable, legible, and accurate information. Review of facility policy labeled, Resident Bath/ Showering/ Scheduling, dated 09/09/22, revealed residents would be bathed or showered according to their preference in order to maintain hygiene and skin condition. The policy revealed when the bath or shower was completed, the staff would document on the shower sheet and/or electronic record. If the bath or shower could not be given or the resident refused, the nursing assistant would report to the charge nurse.

Based on record review, interview, self-reported incident (SRI) review and facility policy review, the facility failed to ensure incidents of resident-to-resident incident physical abuse were thoroughly investigated. This affected four (Residents #106, #259, #275 and #286) of eight residents reviewed for abuse and had the potential to affect all residents. The facility census was 259. Findings include:1. Review of the medical record for Resident #106 revealed an admission date of 07/03/25. Diagnoses included encephalopathy (a disturbance in brain function that causes changes in mental state, behavior, and cognitive abilities), muscle weakness, kidney failure, communication deficit and dementia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #106 was severely cognitively impaired. He required partial to moderate assistance for eating, personal and oral hygiene and substantial to maximum assistance for toileting, showering and dressing. Review of the care plan dated 07/03/25 revealed Resident #106 required a locked unit due to wandering. Interventions included assessing reasons for restlessness, assisting with activities of daily living (ADL) and giving cues and reminders as necessary. 2. Review of the medical record for Resident #259 revealed an admission date of 09/27/24. Diagnoses included muscle weakness, artificial hip joints, dementia, depression and glaucoma. Review of the quarterly MDS assessment dated [DATE] revealed Resident #259 was severely cognitively impaired. He required set-up help for eating, partial to moderate assistance for oral hygiene, and substantial to maximum assistance for toileting, personal hygiene and showering. 3. Review of the medical record for Resident #275 revealed an admission date of 11/12/24. Diagnoses included muscle weakness, dementia, communication deficit and bladder cancer. Review of the quarterly MDS assessment dated [DATE] revealed Resident #275 was severely cognitively impaired. He was independent in eating, oral hygiene, toileting, dressing and personal hygiene and required supervision for showering. Review of the care plan dated 06/20/25 revealed Resident #275 had the potential to be physically aggressive towards others. Interventions included physical and verbal cues to relieve anxiety, giving choices and intervening before agitation escalated. 4. Review of the medical record for Resident #286 revealed an admission date of 10/07/24. Diagnoses included Alzheimer's disease, psychosis, muscle weakness, kidney disease and pulmonary embolism. Review of the quarterly MDS assessment dated [DATE] revealed Resident #286 was severely cognitively impaired. She required supervision for eating and substantial or maximum assistance for oral hygiene, toileting, showering, dressing and personal hygiene. Review of the care plan dated 06/06/25 revealed Resident #286 required a locked unit due to wandering. Interventions included assessing reasons for restlessness, dementia education and providing for needs. Review of the nursing progress note dated 03/05/25 and timed 2:46 P.M. revealed Resident #286 was walking in the hall with a bloody mouth. She did not state what happened. Review of investigation and SRI tracking number 257919 dated 03/05/25 revealed Resident #286 was observed walking in the hall with a bloody mouth. Resident #286 could not explain what happened. Resident #286 was separated from Resident #259, who reported he punched Resident #286 because she went into his room. Education was provided regarding the importance of not hitting people and calling for assistance. Both residents were assessed for injuries, and none were noted. (Resident #286 had a bloody nose).The Administrator, DON and physician were notified. There was no evidence of vital signs were assessed for either resident, no assessment for range of motion and no evidence of the incident in either resident's medical record. The incident was not witnessed by staff. Review of the nursing progress note dated 03/06/25 at 10:52 P.M. revealed Resident #275 was found in the hallway with his knee on another residents' neck, stating he would hurt him. The residents were separated and physicians and families notified. (There was no SRI or investigation for this incident). Review of investigation and SRI tracking number 263699 created on 08/06/25 at 10:44 A.M. revealed on 08/04/25 Residents #106 and #275 were involved in a physical altercation. Resident #275 said Resident #106 wandered into his room, so he hit him. Resident #275 was placed on one-to-one supervision, and Resident #106 was moved to a different unit. Head-to-toe assessments were completed, and Resident #106 was found to have a bump on his head and a bruise on his upper and lower lip. Resident #275 sustained a cut to his finger and complained of finger pain. An x-ray of Resident #275's right hand was obtained at the request of the physician and showed an acute fracture of the fifth digit. There was no evidence of vital signs for either resident, no assessment for range of motion and no evidence of the incident in either resident's medical record. The incident was not witnessed by staff, and the facility did not determine the root cause of the incident. Interview on 09/15/25 at 2:18 P.M. with the Director of Nursing (DON) revealed the facility considered all resident-to-resident incidents worthy of an investigation to rule out abuse. She confirmed that an SRI and investigation were not completed for the incident involving Resident #275 on 03/06/25. She also confirmed the investigations for SRI tracking numbers 257919 and 263699 were not comprehensive since they did not include a full resident assessment or root cause analysis. Interview on 09/16/25 at 12:50 P.M. with Licensed Practical Nurse (LPN) #704 revealed she did not recall the incident on 03/06/25 with Resident #275, but for an incident of this nature she would have notified the unit manager, the DON and the Administrator, as well obtained vital signs for both residents and assessed them for pain and injuries. Review of the facility policy titled Ohio Resident Abuse Policy dated 07/11/24 revealed the facility would investigate all allegations, incidents or suspicions of abuse, neglect, involuntary seclusion, exploitation of residents, misappropriation or injuries of unknown origin. If a resident is injured, staff would immediately report the incident to their supervisor, perform an assessment to include range of motion, vital signs a full body assessment for signs and symptoms of injury. The facility would document the results of the assessment in the nurses' notes, notification to the physician and responsible party and treatment provided.

Based on record review, observation, interview and review of the facility policy, the facility failed to ensure residents dependent on staff for activities of daily living (ADL) received assistance for feeding and showers as ordered, recommended per therapy and/or per preference. This affected two residents (#8 and #195) out of four residents reviewed for resident's dependent on ADL care on the [NAME] unit. This had the potential to affect four residents (#91, #107, #185, and #195) that required feeding assistance, and all 31 residents (#8, #33, #45, #61, #89, #91, #93, #102, #104, #107, #143, #146, #155, #181, #185, #187, #192, #194, #195, #198, #199, #200, #203, #213, #229, #231, #233, #249, #252, #267, and #292) that the facility identified requiring assistance with showers on the [NAME] unit. The facility census was 259. Findings include: 1. Review of the medical record for Resident #195 revealed an admission date of 02/01/10 with diagnoses including hemiplegia affecting the right dominant side, dysphagia, diabetes, and gastro-esophageal reflux disease (GERD). Review of the care plan dated 02/14/20 revealed Resident #195 had a self-care performance deficit. Interventions included assistance of one staff with eating. Review of the care plan dated 02/14/20 revealed Resident #195 required assistance with ADL including cues and assistance with feeding as needed to assist in choking prevention. Interventions included cueing the resident and/or assisting with feeding and reminding the resident to slow down when feeding self. Review of the undated Assignment B report sheet revealed Resident #195 was not to have coffee, was on a soft diet with honey thick liquids, no cold cereal, encourage oral fluids, and head of bed up at 45 degrees at all times. Review of the nursing notes dated 06/11/25 at 8:47 A.M. and authored by Registered Nurse (RN) #958 revealed Resident #195 choked on scrambled eggs. Nurses and Certified Nursing Assistants (CNAs) were able to dislodge the food, as Resident #195 was lowered to the floor. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #195 had intact cognition and had impairment of one of her upper extremities. She required set up and clean up assistance with eating. She was on a mechanically altered diet. Review of the Speech Therapy Updated Therapy Plan dated 08/22/25 and completed by Speech Therapist (ST) #712 revealed Resident #195 had dysphagia and hemiplegia of her right dominant side. She had a choking incident on 06/11/25 and required cues to reduce rate and alternate liquids and solids. She had precautions in place that included instructing the resident to double swallow, no hot liquids and soft texture diet. Review of the September 2025 physician orders revealed Resident #195 had an order for mechanical soft, diabetic diet with nectar thickened liquids and an order dated 06/12/25 for Resident #195 to be fed by staff, including to sit with the resident, and remind the resident to slow down and chew her food thoroughly before attempting to swallow every shift. Observation on 09/10/25 at 8:15 A.M. revealed Resident #195 was eating breakfast in the dining room with her tray in front of her. She was eating scrambled eggs, banana, and hot cereal independently. She appeared to place large bites into her mouth utilizing a foam handled spoon and taking another bite before fully swallowing the previous bite. She had an occasional cough while eating and drinking. CNA #506 was observed in the dining room with her back to Resident #195 feeding Resident #185 and was not reminding Resident #195 to slow down and chew her food thoroughly before attempting to swallow. Interview on 09/10/25 at 8:30 A.M. with CNA #506 revealed she was told that Resident #195 ate by herself and did not require any assistance, including feeding, monitoring, cueing, reminding the resident to slow down, and/or to chew her food thoroughly before attempting to swallow. She was not aware of any previous choking incidents and was not aware of any feeding interventions. Observation on 09/10/25 at 12:25 P.M. revealed Resident #195 received her tray from CNA #656 in the dining room. He uncovered her tray which included an enchilada, diced carrots, rice and pears and then went back to pass other trays. Resident #195 picked up the enchilada and began to take a bite, chewed once and then took another bite. Resident #195 continued to take multiple bites at a fast pace without fully chewing and swallowing the food. After completing the enchilada, she picked up her spoon with foam handle and began scooping a heaping spoonful of rice and carrots placing it in her mouth. Before she completely chewed and swallowed, she consumed another heaping spoonful. She continued to repeat the process until she completed the rice and carrots. She then took the fruit cup lifted the cup to her mouth and took one large gulp of juice and fruit (pears) and before fully chewing and swallowing she repeated and took a second gulp (emptying the fruit cup) in the two gulps. During the process, Resident #195 coughed intermittently, and no staff intervened attempting to feed, remind Resident #195 to slow down and chew her food thoroughly before attempting to swallow or take another bite. Interview on 09/10/25 at 12:30 P.M. with CNA #656, after Resident #195 completed eating her enchilada, revealed he was just assigned to pass the trays as he usually did not work on the [NAME] unit. He verified he gave Resident #195 her tray and was not aware if she needed fed, cued or reminded to slow down and chew her food thoroughly before attempting to swallow or take another bite during her meal. CNA #656 walked away and proceeded to continue to pass trays as Resident #195 continued to eat independently. Interview on 09/10/25 at 12:25 P.M. with ST #698 revealed Resident #195 was on and off the speech case load over the years due to dysphagia. She was currently on a maintenance program where ST checked in on her status every two weeks. She had a history of coughing on her food, eating at a fast pace, and taking a bite before chewing fully and swallowing the previous bite. She had a choking incident in the past, and staff were to remind her to double swallow, take small bites, alternate liquids and food, and slow down her rate of eating. Staff should be monitoring as she eats because Resident #195 had cognitive impairment and needed continuous reminders. She did not have any documented evidence that staff were trained on the dining interventions and stated the unit manager for the unit usually completed the education. Interview on 09/10/25 at 1:07 P.M. with RN Unit Manager #726 verified Resident #195 had a physician order that included she was to be fed by staff and required staff to sit with the resident, remind her to slow down and chew food thoroughly before attempting to swallow. She verified Resident #195 had a previous choking incident and needed monitored during meals as she ate with a fast pace as well as took bites of food without properly chewing and swallowing the previous bites. She revealed staff on the floor received a report sheet at the beginning of the shift that was detailed regarding the care needs of each resident and Resident #195's dining needs and interventions were on that report sheet. RN/ Unit Manager #726 went up to CNA #656 and requested the report sheet he had for Resident #195. CNA #656 revealed he had only grabbed Assignment A report sheet and not Assignment B which had Resident #195 on it. He verified again to RN/ Unit Manager #726 he was unaware Resident #195 had any specific dining interventions. RN/ Unit Manager #72 then located Assignment B report sheet in the nursing office and verified the report sheet identified that Resident #195 was not to have coffee, was on a soft honey thick liquid diet, no cold cereal, encourage oral fluids, and head of bed up at 45 degrees. She verified the report sheet was incorrect as Resident #195 was not on honey thick liquids instead she was on nectar and verified there was nothing on the report sheet regarding dining interventions including that she was to be fed by staff, staff were to sit with the resident, and remind her to slow down and chew food thoroughly before attempting to swallow as ordered. She verified she had no other education or training that staff would be aware of the dining interventions. Interview on 09/15/25 at 1:58 P.M. with the Director of Nursing (DON) verified Resident #195 had a physician order to be fed by staff, staff was to sit with Resident #195, remind her to slow down and chew her food thoroughly before attempting to swallow as she had a previous choking incident. She revealed there was no policy regarding feeding and/or dining interventions. 2. Review of the medical record for Resident #8 revealed an admission date of 03/12/25 with diagnoses including diabetes, hemiplegia following cerebral infarction affecting the right dominant side, major depression, hypertension, and depression. Review of the care plan dated 03/24/25 revealed Resident #8 had a self-care performance deficit related to hemiplegia following cerebral infarction. Interventions included providing a sponge bath when a full bath or shower cannot be tolerated, and he was totally dependent on one staff to provide a bath and/or shower as necessary. There was no documented evidence in the care plan stating Resident #8 refused showers and/or personal hygiene. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #8 had impaired cognition with no behaviors identified. He had impairment on one side of his upper and lower extremities. He was dependent on staff for ADL including dressing, personal hygiene, transfers and showers. Review of the nursing notes from 07/01/25 to 09/11/25 revealed no documented evidence that Resident #8 refused a shower and/or personal hygiene. Review of the Skin Monitoring: Comprehensive CNA Shower Review sheets revealed Resident #8 received showers 07/14/25, 07/17/25, 07/28/25, 07/31/25, 08/04/25, 08/07/25, 08/08/25, 08/11/25, 08/14/25, 08/18/25, 09/01/25, 09/04/25, and 09/08/25, 09/11/25. There were no shower sheets from 07/17/25 to 07/28/25 indicating Resident #8 had gone ten days without a bath and/or shower. There also was no shower sheet from 08/18/25 to 09/01/25 indicating Resident #8 had gone 12 days without a bath and/or shower. The shower sheets dated 09/01/25, 09/04/25, 09/08/25 and 09/11/25 had the same signature located on the sheet but it was illegible to determine who the staff was that had given Resident #8 a shower and/or bath. Review of the monitoring task bar in the electronic medical record for bathing dated from 08/18/25 to 09/16/25 revealed no documented evidence Resident #8 had received a shower and/or bath. The task bar revealed he was scheduled to have a shower every Monday and Thursday on night shift. Interview and observation on 09/08/25 at 11:14 A.M. with Resident #8 revealed he was in bed, and his hair appeared greasy with white specks throughout. Resident #8 revealed he was supposed to get a shower twice a week on Monday and Thursday, and he had not had a shower in the last two weeks. He preferred a shower twice a week, but when he asked for a shower, they would never give him one. Observation on 09/10/25 at 8:47 A.M. revealed Resident #8 was lying in bed and his hair continued to appear unkept and greasy. Interview on 09/10/25 at 12:20 P.M. with Resident #8 revealed he still had not received a shower. He stated, staff had never offered a shower. Interview and observation on 09/11/25 at 7:48 A.M. revealed Resident #8 was lying in bed, and his hair continued to be unkept and greasy. Resident #8 stated he had not received a shower. Interview on 09/11/25 at 10:50 A.M. with CNA #674 verified Resident #8's hair was unkept and greasy. She revealed he was scheduled as an evening shift shower every Monday and Thursday. She did not feel he received the showers as scheduled as he often appeared with body odor and/or his hair was greasy. She revealed Resident #8 had also stated that he had not received a shower on his shower days, and he wanted a shower. She had often passed it on to the aides that came in that he needed and wanted a shower but often the next day she would come in and he still had not received the shower. Interview on 09/15/25 at 1:58 P.M. with the DON verified there were no shower sheets from 07/17/25 to 07/28/25 indicating Resident #8 had gone ten days without a bath and/or shower. There were also no shower sheet from 08/18/25 to 09/01/25 indicating Resident #8 had gone 12 days without a bath and/or shower. She was unable to identify who had given him a shower on 09/01/25, 09/04/25, 09/08/25 and 09/11/25 as the signature on the shower sheets was illegible and that they had contacted the staff on duty for that day and were unable to determine who provided the shower. She revealed they were still working on determining who had. Interview on 09/16/25 at 10:00 A.M. with the Administrator and DON revealed they were unable to determine which staff member signed off on the shower sheet for 09/01/25, 09/04/25, 09/08/25 and 09/11/25 as it is illegible and they contacted the staff on duty and were unable to determine who had provided Resident #8 the shower and/or bath for these days. Review of the facility policy labeled, Resident Bath/ Showering/ Scheduling, dated 09/09/22, revealed residents would be bathed or showered according to their preference in order to maintain hygiene and skin condition. Each resident would be scheduled to receive bathing a minimum of two times per week unless they prefer less frequently. When the bath or shower was completed, the staff would document on the shower sheet and/or the electronic record. If the bath or shower could not be given or the resident refused, the nursing assistant would report to the charge nurse. The charge nurse would speak with the resident to determine alternative arrangements and document the refusal in the medical record. This deficiency represents non-compliance investigated under Complaint Numbers 2601023, 2562355, 1383330 (OH00166217), 1383336 (OH00165819), and 1383342 (OH00163342).

Based on record review, observation and interview, the facility failed to ensure Resident #201 was offered activities to meet her preferences. This affected one resident (#201) of three residents reviewed for activities. The facility census was 259. Findings include:Review of the medical record for Resident #201 revealed an admission date of 07/19/23. Diagnoses included Alzheimer's disease, congestive heart failure, glaucoma, kidney disease and anxiety. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #201 was severely cognitively impaired. She required setup help for eating, and supervision for oral hygiene, toileting dressing, showering and hygiene. It was very important to her to have books, newspapers and magazines to read, listen to music that she liked, be around animals, keep up with the news, do things with groups of people, get fresh air outside and participate in religious services or practices. Review of the care plan dated 07/25/25 revealed Resident #201 would benefit from activities such as walking groups, discussions, keeping up with the news, ice cream socials, religious services and being outdoors. Interventions included assisting her with the television (TV) as needed, encouraging her to attend scheduled outdoor programming and religious activities, attending scheduled activities during the week such as music and special events and accepting room visits from life enrichment staff. Review of the activity calendar for July, August and September 2025 revealed no activities listed for the locked dementia unit where Resident #201 resided. Review of the activity participation note dated 08/26/25 revealed resident #201 enjoyed being social with others and liked to participate in activities such as music, art and games. Interview on 09/08/25 at 1:43 P.M. with Resident #201's granddaughter/guardian revealed the resident was often alone in her room when she came to visit. She would encourage her grandmother to leave her room while she was there, which the resident did willingly. Observation on 09/10/25 at 12:50 P.M. revealed Resident #201 was sitting at the end of the hallway holding a toy doll, she was pleasant and alert. She was not involved in actives. Observation on 09/11/25 at 1:53 P.M. revealed Resident #201 was sitting by herself at the end of the hallway. She was not involved in activities. Observations of the locked dementia unit on 09/08/25, 09/09/25, 09/10/25, 09/11/25, 09/15/25 and 09/16/25 revealed no formal activities on the locked dementia unit. Review of the document titled Record of One-on-One Activities dated 08/04/25 through 09/12/25 revealed Resident #201 participated in music therapy six times and received a visit from activity staff eight times. She was described as chatty, talking, singing and dancing at various intervals throughout the events. Interview on 09/16/25 at 1:18 P.M. with Activity Director #845 revealed activities such as hand massages, music, walking and activity carts were available for residents on the locked unit where Resident #201 resided. She revealed Resident #201 participated in approximately one group activity in the past few weeks and did not normally attend group activities. She confirmed activity staff did not remind residents on the unit when a group activity was taking place or encourage participation. She also confirmed there were multiple activities that occurred outside of the locked unit; however, staff availability did not always afford the option for residents on the locked dementia unit where Resident #201 resided to attend those events. She acknowledged Resident #201 had an interest in activities such as music, animals, keeping up with the news, being with groups of people and other social events but could provide no additional evidence that those activities had been provided to or offered to Resident #201. She confirmed the activity calendar for July, August and September 2025 did not identify specific activities that would occur on the locked dementia unit where Resident #201 resided. This deficiency represents noncompliance investigated under Complaint Number 1383336 (OH00165819).

Based on record review and interview, the facility failed to ensure a change in condition was thoroughly addressed and vital signs were obtained as ordered. This affected two residents (#93 and #278) of three residents reviewed for change in condition. The facility census was 259. Findings include:1. Review of the medical record for Resident #278 revealed an admission date of [DATE] and expired on [DATE] (. Diagnoses included malnutrition, diabetes, spinal stenosis, high cholesterol and dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #278 was severely cognitively impaired. She required setup help for eating, substantial or maximum assistance for oral care and was dependent on staff for toileting, showering and personal hygiene. Review of the physician's orders for [DATE] revealed an order for a Do Not Resuscitate Comfort Care Only Arrest (DNRCCA) (order that allows patients to receive all standard medical treatments, including resuscitation, until a cardiac or respiratory arrest occurs). Review of the nursing progress note dated [DATE] at 5:17 P.M. revealed Licensed Practical Nurse (LPN) #865 was notified by an unidentified certified nursing assistant (CNA) that Resident #278 was vomiting. LPN #865 assessed the resident who had yellow feces all over her with no smell. The nurse practitioner (NP) was notified and gave orders for a KUB (x-ray of the kidneys, ureter and bladder), chest X-ray and CBC (complete blood count), BMP (basic metabolic panel) and MA (magnesium level), STAT (immediately). Review of the nursing progress note dated [DATE] at 7:28 P.M. revealed a stool sample was needed to rule out Clostridioides difficile (C, Diff) (a bacterium that can cause severe diarrhea and other gastrointestinal problems). Her temperature was reported as 97.8 degrees Fahrenheit (F). Review of the KUB and chest x-ray results dated [DATE] at 8:22 P.M. revealed no obstructive bowel gas pattern and no acute abnormalities. Interview on [DATE] at 9:24 A.M. with LPN #981 confirmed the CBC, BMP, MA and stool sample order for Resident #278 was never obtained. She confirmed Resident #278 was identified as having a change in condition, which was not fully addressed. Interview on [DATE] at 9:51 A.M. with LPN #865 revealed she identified a change in condition for Resident #278 and notified the NP who ordered a KUB, chest X-ray and STAT labs. She assessed the color of Resident #278's vomit, and took her blood pressure and temperature, but confirmed they were not documented in the resident's medical record. She could not verify a formal assessment had been documented. Interview on [DATE] at 10:30 A.M. with LPN #644 revealed Resident #278 had been declining for a while prior to her change in condition. She was consuming Boost (nutritional supplement) as ordered and taking an appropriate amount of fluids. Interview on [DATE] at 10:36 A.M. with LPN #984 revealed Resident #278 appeared to be at baseline in the days prior to her expiring. She could not recall if any additional labs are treatments were ordered or in place for her. Interview one [DATE] at 10:40 A.M with LPN #798 revealed Resident #278 was at baseline in the days prior to her expiring. She could not confirm her stool sample had been completed but stated it would have been documented if it had been done. She revealed Resident #278 had loose stools when she called the physician, and he ordered the labs and KUB. Interview on [DATE] at 10:44 A.M. with LPN #663 revealed she observed no vomiting or diarrhea for Resident #278 in the days prior to her expiring. She revealed she was at baseline. On [DATE] at 10:50 A.M. a phone call made to Resident #278's NP #507 that was not returned. Interview on [DATE] at 11:08 A.M. with LPN #679 revealed she spoke with the physician and Resident #278's family. She revealed that residents' son was on-site when she expired. Resident #278 was last seen at approximately 2:00 P.M. and was doing well. She had no knowledge of Resident #278 not feeling well. Review of the facility policy titled “Resident Change in Condition Policy,” dated [DATE], revealed the nurse would address any emergent situation and gather information such as current vital signs including blood pressure, temperature, pulse, respirations and pulse ox and provide the information to the physician. Information related to the change in condition and subsequent events and notifications would be documented in the residents' medical record. 2. Review of the medical record for Resident #93 revealed an admission date of [DATE] with diagnoses including congestive heart failure (CHF), hypertension, acute kidney failure, acute and chronic respiratory failure with hypoxia, and history of myocardial infarction. Review of the [DATE] physician orders revealed Resident #93 had an order dated [DATE] for vital signs vitals every four hours (four times a day) for CHF. Review of the Treatment Administration Record (TAR) for [DATE] and [DATE] revealed Resident #93 was to have vitals every four hours (four times a day) for CHF. The TAR revealed the nurse signed off at 9:00 A.M., 1:00 P.M., 5:00 P.M. and 9:00 P.M. that vitals were obtained but there were no specific vital signs documented as ordered on the TAR. Review of the “Pulse Summary” in the electronic monitoring system from [DATE] to [DATE] revealed Resident #93's pulse rates: [DATE] at 9:38 A.M. his pulse rate was 60 beats per minute, [DATE] at 9:19 A.M. his pulse rate was 59 beats per minute, [DATE] at 12:45 P.M. his pulse rate was 63 beats per minute, [DATE] at 5:14 P.M. his pulse rate was 62 beats per minute, [DATE] at 10:05 A.M. his pulse rate was 62 beats per minute, [DATE] at 3:34 A.M. his pulse rate was 69 beats per minute, and on [DATE] at 10:12 A.M. his pulse rate was 78 beats per minute. (There was no documented evidence that his pulse was assessed as ordered). Review of the “Respiration Summary” in the electronic monitoring system from [DATE] to [DATE] revealed Resident #93's respiratory rates: [DATE] at 9:38 A.M. his respirations were 18 per minute, [DATE] at 9:19 A.M. his respirations were 17 per minute, [DATE] at 12:45 P.M. his respirations were 17 per minute, [DATE] at 5:14 P.M. his respirations were 16 per minute, [DATE] at 10:05 A.M. at his respirations were 16 per minute, [DATE] at 3:34 A.M. his respirations were 18 per minute, [DATE] at 10:12 A.M. his respirations were 18 per minute, and [DATE] at 11:06 P.M. his respirations were 18 per minute. (There was no documented evidence that his respirations were assessed as ordered). Review of the “Temperature Summary” in the electronic monitoring system from [DATE] to [DATE] revealed Resident #93's temperature: [DATE] at 9:38 A.M. his temperature was 97.7 degrees Fahrenheit (F), [DATE] at 9:19 A.M. his temperature was 98.4 degrees F, [DATE] at 12:45 P.M. his temperature was 97.5 degrees F, [DATE] at 5:14 P.M. his temperature was 98.2 degrees F, [DATE] at 10:05 A.M. his temperature was 98.2 degrees F, [DATE] at 3:34 A.M. his temperature was 96 degrees F, [DATE] at 10:12 A.M. his temperature was 98 degrees F and [DATE] at 11:06 P.M. his temperature was 98.7 degrees F. (There was no documented evidence that his temperature was assessed as ordered). Review of the “Blood Pressure Summary” in the electronic monitoring system from [DATE] to [DATE] revealed Resident #93's blood pressure was obtained: [DATE] at 12:09 A.M., 9:38 A.M. and 10:54 P.M., [DATE] at 11:49 A.M., [DATE] at 9:14 P.M., [DATE] at 9:19 A.M.,12:45 P.M., 5:14 P.M., 8:47 P.M., [DATE] at 9:17 A.M., 8:56 P.M., [DATE] at 10:05 A.M., [DATE] at 1:12 P.M., 9:37 P.M., [DATE] at 8:00 A.M., 10:42 A.M., [DATE] at 1:12 P.M., 10:08 P.M., [DATE] at 9:40 A.M., 10:46 P.M., [DATE] at 9:13 A.M., 1:30 P.M., 8:34 P.M., [DATE] at 8:14 A.M., 10:14 P.M., [DATE] at 3:34 A.M., 8:15 A.M., 3:19 P.M, 9:49 P.M., [DATE] at 8:03 A.M. 8:42 P.M., [DATE] at 10:02 A.M., [DATE] at 8:06 A.M., 11:49 P.M., [DATE] at 8:33 A.M., 3:06 P.M., 8:35 P.M., [DATE] at 5:06 A.M., 1:06 P.M., 11:31 P.M., [DATE] at 3:27 P.M., 10:57 P.M., [DATE] at 8:37 A.M., 11:43 P.M., [DATE] at 10:37 A.M., 10:49 P.M., [DATE] at 8:06 A.M. 1:17 P.M., [DATE] at 8:09 A.M., 1:05 P.M., 10:17 P.M., [DATE] at 8:04 A.M., 1:07 P.M., 10:08 P.M., [DATE] at 8:11 A.M., 1:01 P.M., 10:03 P.M., [DATE] at 10:56 A.M., [DATE] at 8:35 A.M., 1:14 P.M., [DATE] at 12:00 A.M., 1:35 P.M., [DATE] at 9:54 A.M., [DATE] at 8:01 A.M., 1:07 P.M., 10:43 P.M., [DATE] at 8:02 A.M., 1:42 P.M., 10:58 P.M., [DATE] at 8:04 A.M., 1:03 P.M., 10:34 P.M., [DATE] at 8:04 A.M., 10:58 P.M., [DATE] at 9:37 A.M., 1:08 P.M., 10:36 P.M., 11:31 P.M., [DATE] at 8:09 A.M. 1:09 P.M., [DATE] at 8:02 A.M., 1:33 P.M., [DATE] at 8:42 A.M., 1:11 P.M. 8:35 P.M., [DATE] at 8:49 A.M., 1:16 P.M., 11:12 P.M., [DATE] at 8:02 A.M., 1:00 P.M., 11:27 P.M. and [DATE] at 9:00 A.M. His blood pressure varied during this time frame as his blood pressure ranged from 103/61 to 200/108. There was no blood pressure documented on [DATE], and [DATE]. (There was no documented evidence that his blood pressure was assessed as ordered). Interview on [DATE] at 1:58 P.M. with the Director of Nursing (DON) verified Resident #93 had an order dated [DATE] that read the following: vitals every four hours (four times a day) for CHF. She verified that the nurse was just initialing on the TAR and that there was no documented evidence that vital signs were obtained as ordered. She verified vital signs including blood pressure, pulses, respirations, and temperatures were not assessed as ordered. She revealed she did not have a policy in regard to obtaining vital signs and the documentation of. This deficiency represents non-compliance investigated under Complaint Numbers 2601023.

Based on record review, observation, interview and facility policy review, the facility failed to ensure fall interventions were in place and falls were thoroughly investigated. This affected one resident (Resident #259) of three reviewed for falls and orders. The facility census was 259. Findings include:Review of the medical record for Resident #259 revealed an admission date of 09/27/24. Diagnoses included muscle weakness, artificial hip joints, dementia, depression and glaucoma. Review of the care plan initiated 10/09/24 revealed Resident #259 was at risk for falls. Interventions included anticipating the resident's needs, anticipating safety needs and potential hazards, assessing proper footwear and suggesting change if needed, ensuring the resident's call light is within reach and encouraging the resident to use it to call for assistance. A new intervention was added on 11/11/24 to lay the resident down after meals. Review of the care plan dated 10/16/24 revealed Resident #259 had an actual fall. Interventions included providing one-on-one activities that promote exercise and strength where possible, provide one-on-one activities if bedbound, physical therapy (PT) consult for strength and mobility, ensuring the call light was within reach, encouraging the resident to use the call light for any transfers, ensuring the resident has non-skid socks or proper shoes for transfers, and encouraging the resident to go to the dining room for dinner. New interventions were added lay the resident down after lunch (11/10/24), pain medication regimen (11/19/24), keep the bathroom light on at night as tolerated by the resident (11/25/24), bed in low position (12/09/25), and a bolster mattress (03/22/25). Review of the fall risk assessment dated [DATE] revealed Resident #259 was at risk for falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #259 had severe cognitive impairment and required partial to moderate assistance for lower body dressing, hygiene, sit-to-stand, chair/bed-to-chair transfers and toilet transfers. The resident required substantial to maximum assistance for toileting hygiene and showers. Resident #259 was occasionally incontinent of bowel and bladder. Review of the fall investigation dated 07/24/25 at 1:20 P.M. revealed Resident #259 was oriented to himself and sustained an abrasion to his left hip. Witness statements were obtained by staff, and the nurse practitioner (NP), family and nursing supervisor were notified. A toileting program was implemented as an immediate intervention. There was no evidence that the residents' vital signs were assessed, or a full body assessment was completed. In addition, there was no mention of whether appropriate footwear was in place at the time of the fall. Review of the progress note dated 07/24/25 at 3:28 P.M. revealed Resident #259 was found on the floor in his room. (This is the progress note for the fall investigation above). He was lying on his right side, he denied hitting his head. He stated he was on his way to the bathroom and complained of left hip pain. The NP was notified and ordered bilateral STAT (immediate) hip x-rays. Resident #259's guardian and sister were notified; the resident was given Tylenol (analgesic) for pain and neurological checks were initiated. The x-ray revealed a left femur fracture, and Resident #295 was sent to the local emergency department (ED). Review of the fall investigation dated 08/02/25 at 10:30 A.M. revealed Resident #259 was oriented to himself and sustained no injuries. Witness statements were obtained by staff, and the nurse supervisor, family and physician were notified. The resident's vital signs were obtained, and his blood pressure was 131/62, heart rate 79, temperature 98 degrees Fahrenheit (F), respirations 18 and pulse ox 96%. He reported his back pain at a six on a one to 10 scale with 10 being the worst. He was described as confused and incontinent at the time; the physician ordered an x-ray of the back and left hip. There was no documented evidence of the bolster mattress being in place, the call light being in reach, when the resident was last toileted, nonskid socks being in use or the bed being in the lowest position. Review of the progress note dated 08/02/25 at 1:41 P.M. (this is the progress note for the fall investigation above) revealed Resident #259 was found on the floor in his room between his bed and bedside table. His head was at the foot of his bed, and his feet were at the top of the bed. Resident #259 was lying on his back with his wheelchair behind him facing the window. The resident was wrapped in his sheets and complained of back pain. No injuries were noted, his vital signs were blood pressure 131/62 heart rate 98 temperature 96 degrees F, respirations 18. The resident was placed back into bed, and his family and the supervisor were notified. Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #259 was severely cognitively impaired and required set-up help for eating, partial to moderate assistance for oral hygiene, chair/bed-to-chair transfers, and toilet transfers. He required substantial to maximum assistance for toileting, personal hygiene and showering. He was frequently incontinent of bowel and bladder. Observation on 09/11/25 at 7:20 A.M. revealed Resident #259 was lying asleep in his bed. A fall mat was noted to be folded up at the head of Resident #259's bed. There was no bolster mattress on Resident #259's bed. Interview at the time of the observation with Certified Nurse Aide (CNA) #854 confirmed Resident #259 never had a bolster mattress to his bed, and there was not one in place at that time. He also confirmed the fall mat should have been spread out on the side of Resident #259's bed, and it had been implemented as an intervention as a result of the fall on 07/24/25. (The fall mat was not noted on the fall investigation or on the care plan). Interview on 09/15/25 at 2:16 P.M. with the Director of Nursing (DON) confirmed the fall investigations for Resident #259 did not have all the necessary information to consider the investigations complete and thorough. Review of the facility policy titled Fall Prevention and Management Policy, dated 12/09/19, revealed residents would be assessed for falls on admission, quarterly and as needed. If risks were identified, preventative measures would be put in place and care planned, and all falls would be reviewed and investigated. Individualized interventions would be implemented and added to the care plan accordingly. This deficiency represents noncompliance investigated under Complaint Number 1383335 (OH00166244).

Based on record review, observation, interview and review of facility policy, the facility failed to ensure oxygen tubing was dated when changed and proper signage on the entrance to a resident's rooms indicating oxygen was in use. This affected two residents (#45 and #93) out of two residents reviewed for respiratory needs. This had the potential to affect 16 additional residents (#2, #13, #27, #60, #79, #85, #101, #105, #122, #170, #177, #185, #193, #231, #242, and #272) identified by the facility as using oxygen. The facility census was 259. Findings include:1. Review of the medical record for Resident #93 revealed an admission date of 11/27/23 with diagnoses including acute and chronic respiratory failure with hypoxia (low level of oxygen in body tissues), hypertension, and congestive heart failure (CHF). There was nothing in the medical record to indicate when Resident #93's oxygen tubing was changed. Review of the physician order dated 07/25/25 revealed Resident #93 had an order for oxygen at two liters per nasal cannula (a flexible tube with prongs that fit into the nostrils to deliver oxygen) as needed for hypoxia and oxygen saturation level below 92 percent. There were no orders regarding the frequency of when the oxygen tubing was to be changed. Review of the care plan dated 07/28/25 revealed Resident #93 tested positive for COVID-19. Interventions included administering medications as ordered, monitoring for presence of symptoms including shortness of breath, and reporting worsening signs and symptoms of infection or lack of improvement from treatment. There was nothing in the care plan regarding oxygen use. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #93 had intact cognition, and he was not identified as using oxygen. Observation on 09/08/25 at 11:40 A.M. revealed Resident #93 had a green e-cylinder (a cylinder with oxygen) in a holder sitting by his wall in his room with a nasal cannula hanging on top of the cylinder. The nasal cannula tubing was undated. There was no signage on the outside of the room indicating Resident #93 was on oxygen. Interview on 09/08/25 at 11:40 A.M. with Resident #93 revealed he wears oxygen when needed, but that it had been a while. He was unsure when the last time the nasal cannula tubing was changed. Interview on 09/08/25 at 11:44 A.M. with Registered Nurse (RN) #913 and Licensed Practical Nurse (LPN) #859 verified there was no date on Resident #93's nasal cannula tubing and no signage on the outside of his room indicating Resident #93 had oxygen. 2. Review of the medical record for Resident #45 revealed an admission date of 10/24/23 with diagnoses including muscle weakness, hypertension, and chronic kidney disease. There was nothing in the medical record to indicate when Resident #93's oxygen tubing was changed. Review of the care plan dated 07/28/25 revealed Resident #45 tested positive for COVID-19. Interventions included administering medications as ordered, monitoring for presence of symptoms including shortness of breath, and reporting worsening signs and symptoms of infection or lack of improvement from treatment. There was nothing in the care plan regarding oxygen use. Review of the quarterly MDS 30 assessment dated [DATE] revealed Resident #45 had intact cognition and used oxygen. Review of the September 2025 physician's orders revealed Resident #45 had an order dated 07/28/25 for continuous oxygen at two liters per nasal canula, check placement, and record oxygen saturation every shift. There was no order to change her oxygen tubing. Observation on 09/08/25 at 11:35 A.M. revealed Resident #45 was lying in bed and had a green oxygen cylinder in her bathroom as well as an oxygen concentrator (a device that extracts oxygen from the surrounding air to deliver an oxygen-enriched gas stream to a patient) next to her bed. The oxygen concentrator had a nasal cannula connected that was not dated as to when it was last changed. There was no signage on the outside of the room indicating Resident #45 was on oxygen. Interview on 09/08/25 at 11:44 A.M. with RN #913 and LPN #859 verified there was no date on Resident #45's nasal cannula tubing and no signage on the outside of her room indicating Resident #45 had oxygen. Interview on 09/15/25 at 1:58 P.M. with the Director of Nursing (DON) verified any rooms that contain oxygen should have signage upon entrance indicating oxygen was in use for safety. She also verified all oxygen tubing should be changed once a week, and the nurse should label the tubing when they changed it and/or there should be an order on the treatment administration record (TAR) as to frequency, and the nurse should document the oxygen tubing changes. She verified Residents #45 and #93 did not have orders on their TAR indicating when their oxygen tubing was changed and/or anything in their medical record regarding when their tubing was changed last. Review of the undated facility policy labeled, Oxygen Storage and Handling Practices revealed the purpose of the policy was to ensure safe storage, handling and accessibility of oxygen cylinders and concentrators. There was nothing in the policy regarding ensuring proper signage was present indicating oxygen was in use and/ or there was nothing in the policy regarding labeling of oxygen tubing when it was changed.

Based on record review, interview, self-reported incident (SRI) review and facility policy review, the facility failed to ensure Resident #286 was free from physical abuse by Residents #259 and #201 and failed to ensure Resident #106 was free from physical abuse by Resident #275. This affected two (Residents #286 and #106) of eight residents reviewed for abuse and had the potential to affect all residents. The facility census was 259. Findings include:1. Review of the medical record for Resident #106 revealed an admission date of 07/03/25. Diagnoses included encephalopathy (a disturbance in brain function that causes changes in mental state, behavior, and cognitive abilities), muscle weakness, kidney failure, communication deficit and dementia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #106 was severely cognitively impaired. He required partial to moderate assistance for eating, personal and oral hygiene and substantial to maximum assistance for toileting, showering and dressing. Review of the care plan dated 07/03/25 revealed Resident #106 required a locked unit due to wandering. Interventions included assessing reasons for restlessness, assisting with activities of daily living (ADL) and giving cues and reminders as necessary. 2. Review of the medical record for Resident #259 revealed an admission date of 09/27/24. Diagnoses included muscle weakness, artificial hip joints, dementia, depression and glaucoma. Review of the quarterly MDS assessment dated [DATE] revealed Resident #259 was severely cognitively impaired. He required set-up help for eating, partial to moderate assistance for oral hygiene, and substantial to maximum assistance for toileting, personal hygiene and showering. 3. Review of the medical record for Resident #275 revealed an admission date of 11/12/24. Diagnoses included muscle weakness, dementia, communication deficit and bladder cancer. Review of the quarterly MDS assessment dated [DATE] revealed Resident #275 was severely cognitively impaired. He was independent in eating, oral hygiene, toileting, dressing and personal hygiene and required supervision for showering. Review of the care plan dated 06/20/25 revealed Resident #275 had the potential to be physically aggressive towards others. Interventions included physical and verbal cues to relieve anxiety, giving choices and intervening before agitation escalated. 4. Review of the medical record for Resident #286 revealed an admission date of 10/07/24. Diagnoses included Alzheimer's disease, psychosis, muscle weakness, kidney disease and pulmonary embolism. Review of the quarterly MDS assessment dated [DATE] revealed Resident #286 was severely cognitively impaired. She required supervision for eating and substantial or maximum assistance for oral hygiene, toileting, showering, dressing and personal hygiene. Review of the care plan dated 06/06/25 revealed Resident #286 required a locked unit due to wandering. Interventions included assessing reasons for restlessness, dementia education and providing for needs. 5. Review of the medical record for Resident #201 revealed an admission date of 07/19/23 with a diagnosis including late onset Alzheimer's disease. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #201 had severe cognitive impairment. She had wandering behaviors four to six days of the seven-day assessment reference period. She required set-up and clean-up assistance with eating and was independent with ambulation. Review of the nursing progress note dated 03/05/25 and timed 2:46 P.M. revealed Resident #286 was walking in the hall with a bloody mouth. She did not state what happened. Review of investigation and SRI tracking number 257919 dated 03/05/25 revealed Resident #286 was observed walking in the hall with a bloody mouth. Resident #286 could not explain what happened. Resident #286 was separated from Resident #259, who reported he punched Resident #286 because she went into his room. Education was provided regarding the importance of not hitting people and calling for assistance. Both residents were assessed for injuries, and none were noted. (Resident #286 had a bloody mouth). The Administrator, DON and physician were notified. The facility SRI conclusion stated the investigation does not currently verify an abusive event occurred. The investigation is inconclusive but resident-to-resident abuse is suspected. (Despite the diagnosis of dementia, this shows willful intent as Resident #259 explained why he punched resident #286 in the mouth). Review of SRI tracking number 261279 created on 06/05/25 at 4:44 P.M. revealed Resident #286 was pushed by Resident #201 in the dining room of the locked unit of Beachwood. Resident #286 hit her head on the floor and was sent to the emergency room (ER) for evaluation as a precaution. A hematoma was noted to her head. Staff members were present in the dining room but were unable to get to the residents fast enough. The narrative of the incident included Resident #201 carries around baby dolls to comfort her. Resident #286 came up to her in the dining room and started touching the baby dolls, and Resident #201 got upset and pushed Resident #286 backwards to get away from her and her baby doll. The facility unsubstantiated the Sri stating there was no willful intent by Resident #201. (Despite the diagnosis of late-stage Alzheimer's, this shows willful intent of Resident #201 pushing Resident #286 to get her away from her baby doll). Review of the nursing progress note dated 06/05/25 at 5:46 P.M. revealed Resident #286's son was notified of an altercation involving his mother and another resident (Resident #201). Resident #286 was being transferred to the hospital at the request of the physician. Review of the nursing progress note dated 06/06/25 at 2:00 A.M. revealed Resident #286 returned from the hospital with a large hematoma to the left side of the head. She was treated for a closed head injury. Review of investigation and SRI tracking number 263699 dated 08/06/25 revealed on 08/04/25 Residents #106 and #275 were involved in a physical altercation. Resident #275 said Resident #106 wandered into his room, so he hit him. Resident #275 was placed on one-to-one supervision, and Resident #106 was moved to a different unit. Head-to-toe assessments were completed, and Resident #106 was found to have a bump on his head and a bruise on his upper and lower lip. Resident #275 sustained a cut to his finger and complained of finger pain. An x-ray of Resident #275's right hand was obtained at the request of the physician and showed an acute fracture of the fifth digit. The facility conclusion stated the facility is unable to substantiate any wrongdoing of staff at this time. All staff were re-educated on resident-to-resident altercations as a preventative measure. Residents BIMS (Brief Interview for Mental Status) scores suggest they lack the mental capacity to intentionally induce harm on another. (Despite the diagnosis of dementia, this shows willful intent as Resident #275 explained why he hit Resident #106). Interview on 09/15/25 at 2:18 P.M. with the Director of Nursing (DON) verified the information in the above incidents. Review of the facility policy, Ohio Resident Abuse Policy, revised 07/11/24 revealed physical abuse was the willful act of hitting, slapping, punching or kicking of a resident. Willful meant the individual acted deliberately and not whether the individual intended to inflict injury.

Based on record review, interview, self-reported incident (SRI) review and facility policy review, the facility failed to ensure allegations of resident-to-resident physical abuse were reported to the State Agency within two hours as required. This affected four (Residents #106, #259, #275 and #286) of eight reviewed for abuse and had the potential to affect all residents. The facility census was 259. Findings include:1. Review of the medical record for Resident #106 revealed an admission date of 07/03/25. Diagnoses included encephalopathy (a disturbance in brain function that causes changes in mental state, behavior, and cognitive abilities), muscle weakness, kidney failure, communication deficit and dementia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #106 was severely cognitively impaired. He required partial to moderate assistance for eating, personal and oral hygiene and substantial to maximum assistance for toileting, showering and dressing. Review of the care plan dated 07/03/25 revealed Resident #106 required a locked unit due to wandering. Interventions included assessing reasons for restlessness, assisting with activities of daily living (ADL) and giving cues and reminders as necessary. 2. Review of the medical record for Resident #259 revealed an admission date of 09/27/24. Diagnoses included muscle weakness, artificial hip joints, dementia, depression and glaucoma. Review of the quarterly MDS assessment dated [DATE] revealed Resident #259 was severely cognitively impaired. He required set-up help for eating, partial to moderate assistance for oral hygiene, and substantial to maximum assistance for toileting, personal hygiene and showering. 3. Review of the medical record for Resident #275 revealed an admission date of 11/12/24. Diagnoses included muscle weakness, dementia, communication deficit and bladder cancer. Review of the quarterly MDS assessment dated [DATE] revealed Resident #275 was severely cognitively impaired. He was independent in eating, oral hygiene, toileting, dressing and personal hygiene and required supervision for showering. Review of the care plan dated 06/20/25 revealed Resident #275 had the potential to be physically aggressive towards others. Interventions included physical and verbal cues to relieve anxiety, giving choices and intervening before agitation escalated. 4. Review of the medical record for Resident #286 revealed an admission date of 10/07/24. Diagnoses included Alzheimer's disease, psychosis, muscle weakness, kidney disease and pulmonary embolism. Review of the quarterly MDS assessment dated [DATE] revealed Resident #286 was severely cognitively impaired. She required supervision for eating and substantial or maximum assistance for oral hygiene, toileting, showering, dressing and personal hygiene. Review of the care plan dated 06/06/25 revealed Resident #286 required a locked unit due to wandering. Interventions included assessing reasons for restlessness, dementia education and providing for needs. Review of the nursing progress note dated 03/05/25 and timed 2:46 P.M. revealed Resident #286 was walking in the hall with a bloody mouth. She did not state what happened. Review of the abuse investigation and SRI tracking number 257919 dated 03/05/25 and timed 9:18 P.M. revealed on 03/05/25 at 11:00 A.M. Resident #286 was observed walking in the hall with a bloody mouth. Resident #286 could not explain what happened. Resident #286 was separated from Resident #259, who reported he punched Resident #286 because she went into his room. Education was provided regarding the importance of not hitting people and calling for assistance. Both residents were assessed for injuries, and none were noted. The Administrator, Director of Nursing (DON) and physician were notified. Review of the nursing progress note dated 03/06/25 at 10:52 P.M. revealed Resident #275 was found in the hallway with his knee on another residents' neck, stating he would hurt him. The residents were separated and physicians and families notified. (There was no SRI or investigation for this incident). Review of the abuse investigation and SRI tracking number 263699 dated 08/06/25 and timed 10:10 A.M. revealed on 08/04/25 Assistant Director of Nursing (ADON) #981 reported to the Administrator, Residents #106 and #275 were involved in a physical altercation. Resident #275 said Resident #106 wandered into his room, so he hit him. Resident #275 was placed on one-to-one supervision, and Resident #106 was moved to a different unit. Head to toe assessments were completed and Resident #106 was found to have a bump on his head and a bruise on his upper and lower lip. Resident #275 sustained a cut to his finger and complained of finger pain. An x-ray of Resident #275's right hand was obtained at the request of the physician and showed an acute fracture of the fifth digit. Review of the nursing progress note dated 08/06/25 at 3:06 P.M. revealed Resident #275's daughter was notified of an incident that involved Resident #275. Interview on 09/15/25 at 2:18 P.M. with the DON revealed all SRI's involving potential resident abuse should be reported to the state within two hours. She confirmed SRI tracking number 257919 and SRI tracking number 263699 were not reported to the State Agency within the required time frame and the incident with Resident #275 on 03/06/25 was not reported to the State Agency at all. Review of the facility policy titled Ohio Resident Abuse Policy, dated 07/11/24, revealed all allegations of abuse, neglect, involuntary seclusion, exploitation of residents, misappropriation or injuries of unknown origin would be reported immediately to the Administrator. If the event involved an allegation of abuse or serious bodily injury, the incident would be reported to the State Department of Health no later than two hours after the allegation was made.

Based on record review, interviews and facility policy review, the facility failed to adequately provide trauma-informed care to Residents #8 and #74. This affected two residents (#8 and #74) out of two residents reviewed for trauma-informed care. This had the potential to affect four residents (#8, #74, #81, and #157) identified by the facility with a diagnosis of post-traumatic stress disorder (PTSD). The facility census was 259. Findings include:1. Review of the medical record for Resident #8 revealed an admission date of 03/12/25 with diagnoses including PTSD (on admission), diabetes, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and major depression. Review of the Social Service Initial Evaluation dated 03/14/25 and completed Social Service Designee (SSD) #844 revealed on Resident #8's evaluation under trauma informed care, it asked if the resident reported or if the medical record reflected any history of trauma, and it stated it was unable to be determined. The evaluation also asked if Resident #8 experienced trauma and/or had any triggers, but the areas were blank. Review of the comprehensive care plan dated 03/18/25 revealed Resident #8 did not have a care plan that included the diagnosis of PTSD, triggers, and/or interventions regarding trauma-informed care. Review of the Psychiatric Initial assessment dated [DATE] and completed by Psychiatric Nurse Practitioner (NP) #505 revealed staff referred Resident #8 to her due signs of depression, withdrawal, agitation and trauma/stressor related disorder. The note revealed Resident #8 would be non-verbal with staff and family without reason, history of behaviors, and he had trauma from war. The note revealed Resident #8 had current symptoms of sad moods, loss of interest, fatigue, decreased concentration and appetite change. The assessment revealed he scored four out of five on the Primary Care PTSD Screen for DSM-5 (PC-PTSD) assessment as he chose not to answer the last question. The assessment revealed he had positive trauma history and reported current emotional symptoms indicating probable PTSD. Review of Social Service Initial Evaluation dated 06/12/25 completed by SSD #844 revealed Resident #8 did not have a history of trauma/PTSD, did not have disturbing memories, thoughts or images of stressful experiences from the past, and under the area of triggers, it was blank. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 had impaired cognition. He was identified to have PTSD. Review of the Psychiatric Subsequent assessment dated [DATE] and completed by Psychiatric NP #505 revealed Resident #8 was evaluated for depression, withdrawal, agitation and trauma/stressor related disorder. The note revealed Resident #8 would go non-verbal with staff and family without reason, history of behaviors, and he had trauma from war. The report revealed that staff reported history of sad moods, loss of interest, fatigue, agitation, and decreased concentration. Interview on 09/10/25 at 12:20 P.M. with Resident #8 revealed he was abused at a previous facility as he stated, a big heavy-set guy punched me hard multiple times in the chest. I got beat up so I just always felt it would happen again. He also revealed he served in the military for many years including in a war. He did not want to share any further details. Interview on 09/11/25 at 9:28 A.M. with Director of Social Service #812 revealed she had worked at the facility since 07/28/25, and Resident #8 was admitted prior to her working at the facility. She verified Resident #8 had a diagnosis of PTSD on admission. She verified per the psychiatric notes; Psychiatric NP #505 had identified Resident #8 as having PTSD that was triggered by war as he had served in the military. She verified the social service assessments dated 03/14/25 and 06/12/25 revealed under the trauma informed care, it was answered unable to be determined if he had previous trauma, and there was no further assessment assessing his PTSD and/or his triggers. She revealed she was unsure why the assessment did not identify his PTSD and/or triggers. She revealed if a resident had PTSD, social service was to assess and develop a care plan identifying the PTSD, triggers and possible interventions. She verified Resident #8 did not have a care plan regarding PTSD, triggers and/or interventions. Review of the facility policy labeled, Post-Traumatic Stress Disorder (PTSD), dated February 2018, revealed the purpose of the policy was to provide trauma- informed care and services to residents with PTSD. The policy revealed residents would be screened for PTSD history and symptoms during admission and routine assessments. Individualized care plans would include known triggers and calming interventions. The policy revealed all PTSD related care, interventions, and episodes would be documented in the medical record. 2. Review of the medical record revealed Resident #74, was admitted to the facility on [DATE] with diagnoses including generalized osteoarthritis, generalized weakness, history of substance abuse, schizophrenia and post-traumatic stress disorder (PTSD). Review of the MDS 3.0 assessment dated [DATE] revealed Resident #74 required substantial to maximal assistance with showering and personal hygiene and was dependent for toileting. A Brief Interview for Mental Status (BIMS) score of nine out of 15, revealed the resident was cognitively impaired. Review of the Social Service Initial Evaluation dated 07/23/25 and completed SSD #844 revealed on Resident #74's evaluation under trauma informed care it was asked if the resident reported or if the medical record reflected any history of trauma, and it stated no. The evaluation also asked if Resident #74 experienced trauma and/or had any triggers, but the areas were blank. The assessment also asked if Resident #74 had been followed with psychiatry at the facility and had a psychiatric follow up been scheduled or completed; the answer was no to both questions. When reviewed on 09/11/25, the care plan completed on 08/06/25 revealed there was no care planning for the Resident #74's PTSD diagnosis. The care plan was revised on 09/15/25 to add a care plan for PTSD and interventions, after the facility had been advised of the lack of care planning for residents with PTSD. Resident #74 was admitted to the facility with the PTSD diagnosis on 04/16/25, and the care plan for PTSD was absent until 09/15/25. Interview on 09/16/25 1:07 P.M. MDS Coordinator #921 confirmed the new PTSD care plan was added on 09/15/25. Review of the facility policy labeled, Post-Traumatic Stress Disorder (PTSD), dated February 2018, revealed the purpose of the policy was to provide trauma- informed care and services to residents with PTSD. The policy revealed residents would be screened for PTSD history and symptoms during admission and routine assessments. Individualized care plans would include known triggers and calming interventions. The policy revealed all PTSD related care, interventions, and episodes would be documented in the medical record.

Based on record review, observation, interview and facility policy review, the facility failed to ensure the call light was within reach for Resident #173. This affected one resident (#173) of 15 residents on the 200-hall of the Beachwood unit and had the potential to affect all 259 residents residing in the facility. Findings include:Review of the medical record for Resident #173 revealed an admission date of 12/11/24. Diagnoses included dementia, arthritis of the knee, depression, diabetes and high cholesterol. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #173 was severely cognitively impaired. She was independent with eating, required partial to moderate assistance for oral hygiene, dressing, showering and personal hygiene and substantial to maximum assistance for toileting. Observation 09/09/25 at 7:45 A.M. revealed Resident #173 was lying in bed asleep. Her call light was hanging over the partition next to the bed, out of reach. Interview on 09/09/25 at 7:47 A.M. with Licensed Practical Nurse (LPN) #808 confirmed the call light in Resident #173's room was not within reach and should be accessible to her. She verified Resident #173 was capable of using the call light. Review of the facility policy titled Call Light Policy dated December 2023 revealed call lights would be within the reach of the resident in order to aide in requesting assistance and a timely response.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview and record review the facility failed to ensure Resident #7 was provided with reliable transportation to and from dialysis. This affected one resident (#7) of two residents reviewed for transportation. The facility census was 295. Findings include:Review of the medical record for Resident #7 revealed an admission date of 12/27/24. Diagnoses included fracture of the left fibula, acute pain due to trauma, diabetes with diabetic neuropathy, and dependence on renal dialysis. Review of physician order dated 12/28/24 revealed Resident #7 received dialysis on Tuesday, Thursday, and Saturday. The resident must be in the lobby at 9:00 A.M. for pick-up. Review of the admission Minimum Data Set (MDS) 3.0 assessment for Resident #7 dated 01/08/25 revealed the resident was cognitively intact. Resident #7 used a walker and a wheelchair. Transfers were not attempted due to medical condition. Review of the plan of care dated 01/23/25 revealed Resident #7 was at risk for potential complications of dialysis related to end stage renal disease (ESRD) and received dialysis at CDC Fresenius on Tuesday, Thursday, and Saturday. The plan of care specified King [NAME] provided transportation. Review of the nursing progress note dated 02/25/25 at 1:32 P.M. Resident #7 missed the scheduled dialysis chair time related to transportation. The resident stated she did not have transportation. This nurse informed dialysis, and dialysis was rescheduled for Wednesday, 02/26/25 at 1:00 P.M. The resident was aware, and the physician ordered a cardiac assessment. Vital signs were obtained, and the resident was asymptomatic at this time. Review of nursing progress note dated 03/03/25 at 11:40 A.M. revealed the nurse received a phone call from the hospital informing the facility nurse of Resident #7's upcoming appointment on 03/07/25 at 8:00 A.M. related to dialysis catheter port replacement. The hospital nurse inquired about transportation. The facility nurse informed her that Resident #7 was responsible for providing transportation. The facility nurse reiterated to Resident #7 that she was responsible for setting up transportation. Resident #7 was provided with second copy of transportation companies. Review of the Pre/Post Dialysis Evaluations noted Resident #7 was transported to and from dialysis via a private car on 03/08/25, 03/11/25, 03/20/25, 03/22/25, 03/29/25, 04/03/25, 04/08/25, and 04/12/25. Interview on 9/10/25 at 9:20 A.M. with Resident #7 revealed when the Resident first arrived at the facility, she missed dialysis two or three times because she had no one to take her. The facility to the resident she had to find her own transportation. For Para transport, she had to wait for the application to go through and she didn't have money for Uber. The resident stated she was still in a wheelchair, and Uber and Lift were not supposed to have to get out of their car to assist. Later, the facility started taking the resident to her dialysis appointments. The Unit Manager usually arranged the transportation with the transportation office. The transportation department and transporters were very good and treated her well. Interview on 09/16/25 at 2:20 P.M. with Regional Nurse Director #672 revealed she had been at the facility about five months. She stated she didn't know what the transportation set up was previously but knew the facility had used some different transportation companies and there had been concerns with consistent transportation for residents. The facility has been working on correcting transportation issues. The facility had implemented several major changes in how they did resident transportation in May 2025 and felt the issue was corrected. Review of the Transportation Policy dated 09/11/24 revealed the facility will arrange transportation to and from medically necessary appointments and assist with arranging transportation to and from social events. Procedure: Facility will ensure residents receive facility transportation to medically necessary appointments with in-house transportation. The deficient practice was corrected on 05/13/25 when the facility implemented the following corrective actions: By 05/01/25, all facility staff and residents were educated by Regional Nurse Director #672 using in-services and signs hanging on the units of the facility providing transportation to outside medical appointments when necessary either by the facility or insurance related transport. On 05/01/25, all unit managers were educated by Regional Nurse Director #672 on the process of ensuring residents' appointments and transportation needs were given to the transportation scheduler. On 05/13/25, Regional Nurse Director #672 and Previous Administrator #510 met with all the facilities and created the workflow schedule of the drivers to understand schedule availability. On 05/13/25, Previous Administrator #510 educated the transportation coordinators to work together on the scheduling of appointments. On 05/13/25, Regional Nurse Director #672 educated the drivers and transportation coordinators that the dialysis residents were assigned to a specific driver and kept on their schedule to help with continuity. On 05/13/25, the transportation policy was reviewed by the interdisciplinary team including the unit managers and Regional Nurse Director #672. No changes to the policy were needed. Beginning 05/13/25, audits were conducted by Regional Nurse Director #672 or designee weekly for four weeks then monthly for two months. Results of the audits and any negative findings were forwarded to the QAPI (Quality Assurance and Performance Improvement) committee. On 05/22/25, Activities Coordinator #845 reminded all residents in the monthly Resident Council meeting of the facility providing transportation to outside medical appointments when necessary either by facility or insurance related transport. This deficiency represents non-compliance investigated under Complaint Number 1383325 (OH00163377).

Based on closed record review, and interview, the facility failed to ensure Resident #284 was permitted to return to the facility after being transferred to the emergency room due to an acute change in condition. This affected one resident (#284) of one resident reviewed for hospitalization . The facility census was 283. Findings include: Review of the closed medical record for Resident #284 revealed an admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), peripheral vascular disease, amputation, and atherosclerotic heart disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #284 was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #284 was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 02/04/22 revealed Resident #284 was expected to remain in the facility for long-term care placement. Review of the physician's orders dated November 2024 through February 2025 revealed Resident #284 had no discharge orders in place. Review of a progress note dated 11/22/24 at 11:20 A.M. but entered approximately three days later on 11/25/24 at 1:43 P.M., revealed Social Service Designee (SSD) #677 informed Resident #284's daughter via phone of the need to reschedule a care conference that was scheduled for 11/25/24 at 10:30 A.M. During the phone conversation, Resident #284's daughter requested the Director of Nursing (DON), and Assistant Director of Nursing (ADON) not attend the care conference and further inquired if the Administrator would be present, stating that if the Administrator was present, she would not be able to attend the care conference as she had been informed by her lawyer that the Administrator was not to have contact with herself or Resident #284. Review of the progress note dated 11/26/24 at 2:00 P.M., but entered approximately 15 days later on 12/11/24, revealed SSD #677 presented Resident #284 with a 30-day discharge notice and a copy of the notice was mailed to Resident #284's son. Resident #284 was informed he had a right to file an appeal if he did not agree with the discharge. Resident #284 requested to file an appeal and Resident #284's son filed the appeal. A hearing was scheduled to take place on 12/13/24 at 4:00 P.M. Review of the 30-day discharge notice dated 11/26/24 revealed Resident #284 received a discharge notice to take effect on 12/26/24 due to the welfare and needs of Resident #284 no longer being able to be met by the facility. Further review of the notice verified Resident #284 signed acknowledging the receipt of the notice and Resident #824's son was mailed a copy of the notice. Review of Resident #284's medical record failed to contain documentation of the specific needs that could no longer be met by the facility. Review of the progress note dated 01/17/25 at 10:56 A.M. revealed it was documented that Resident #284 became lethargic and unresponsive while attempting to shower. After vital signs were taken, Resident #284 was placed back in bed and aroused slowly. Orders were received to transfer Resident #284 to the hospital for evaluation. Review of the progress note dated 01/17/25 at 11:33 A.M. revealed Resident #284's daughter was notified of the resident's transport to the acute hospital. Review of the Nursing Home to Hospital Transfer Form assessment dated [DATE] revealed Resident #284 was emergently transferred to the acute hospital due to loss of consciousness (syncope) with a plan to return to the facility. Review of the assessment revealed Resident #284 was a chronic long-term care resident at the time of the transfer to the hospital. Review of the progress notes dated 01/17/25 through 02/26/25 revealed Resident #284 had not returned to the facility. Interview on 02/24/25 at 10:42 A.M. with SSD #677 verified Resident #284 received a 30-day discharge notice on 11/26/24 and Resident #284, his daughter, and son, requested an appeal. SSD #677 revealed Resident #284 won the appeal process and was granted permission to remain in the facility for long-term care. SSD #677 then verified Resident #284 was transferred to the hospital due to a fainting episode and was expected to return to the facility. However, SSD #677 verified Resident #284 had not returned to the facility and was not sure why as the SSD revealed residents who transferred to the hospital were expected to return to the facility after medically cleared Interview on 02/24/25 at 10:55 A.M. with the DON verified Resident #284 was sent out to the hospital on 01/17/25 and had not returned to the facility. The DON and was uncertain whether the resident remained in the hospital and was not sure when or if the resident would return to the facility. The DON verified Resident #284 received a 30-day discharge notice in November 2024, but could not recall for what reasons. The DON revealed the Administrator was responsible for all decisions regarding Resident #284, including the 30-day discharge notice being given in November 2024 and the decision to not allow Resident #284 to return to the facility on [DATE] (when he returned to the building). In a follow-up interview with the DON, she denied knowledge of Resident #284 returning to the facility on [DATE] after being medically cleared at the hospital, but denied entry into the building. The DON was unable to answer if Resident #284 was provided 30-day discharge notice when denied re-entry on 01/17/25. Interview on 02/24/25 at 11:06 A.M. with Admissions Director (AD) #679 revealed she was responsible for all facility admissions, including the re-admission of residents returning to the facility after a hospitalization . AD #679 revealed that once the hospital informed her that Resident #284 was ready to return to the facility on [DATE], she sent the call to the Administrator as directed by the Administrator. AD #679 stated she was informed by the Administrator that Resident #284 would not return to the facility due to the facility not being able to manage Resident #284's care. On 02/24/25 at 12:00 P.M. an attempted interview with the Administrator regarding Resident #284 revealed he vaguely remembered Resident #284 and would have to return to complete the interview once he reviewed his notes in regard to the resident. A follow-up interview on 02/24/25 at 4:40 P.M. with the Administrator revealed Resident #284 did not return to the facility after evaluation for the syncopal episode on 01/17/25, due to the facility being unable to meet the resident's needs. The Administrator was unsure why the facility could no longer meet Resident #284 needs, stating he asked nursing about the resident returning and was told the facility could not meet Resident #284's care needs. The Administrator acknowledged Resident #284 had been a resident since 2022 and confirmed Resident #284 transferred to the hospital on 01/17/25 but had not been permitted to return as of this date. In a follow up interview, the Administrator denied knowledge of Resident #284 attempting to return (on 01/17/25) to the facility and being denied entry and was unable to verify if a 30-day notice had been provided to Resident #284 on or after 01/17/25. Interview on 02/25/25 at 9:21 A.M. with Licensed Practical Nurse (LPN) #714 revealed Resident #284 was appropriate to be long-term care in the facility. LPN #714 revealed Resident #284 did not display any behaviors, required some assistance from staff, and did not have any complaints regarding care. LPN #714 had expected Resident #284 to return after his hospitalization (on 01/17/25). Interview on 02/25/25 at 9:24 A.M. with Certified Nursing Assistant (CNA) #500 revealed Resident #284 was appropriate to be a resident in the facility. CNA #500 revealed Resident #284 did not require any more care than any other resident residing in the facility. CNA #500 revealed Resident #284 required some assistance for toileting and could maneuver by himself. CNA #284 revealed Resident #284 was also very cognitively aware. Interview on 02/25/25 at 9:58 A.M. with LPN #794 revealed Resident #284 was a total care for ADLs and required some assistance from staff for other needs, like having water set-up in his room. LPN #794 stated Resident #284, whether totally dependent or not, was an appropriate resident for the facility, as there were other residents residing in the facility who required more hands-on care. Interviews with Resident #284's family throughout the survey process revealed the family had placed a camera in Resident #284's room and when there were care concerns, lack of staff response to the call light or when medications were not administered timely the daughter would call and talk with nurse. The daughter of Resident #284 stated on 01/17/25 she was notified by the facility of Resident #284 having a syncopal episode while in the shower and that Resident #284 was being transported to the hospital per private ambulance. The daughter questioned why by private ambulance and not emergency services and was not provided with an answer. Additionally, the daughter requested Resident #284 not be sent to the hospital the facility had identified he was being transported to. The daughter stated she again inquired why the resident was not going to a hospital closer to the facility, as there were two, due to the emergency situation and again was not provided an answer. The daughter stated she received a call form the hospital around 3:30 P.M. on 01/17/25 informing her Resident #284 had been medically cleared and was being returned to the facility per private ambulance. The family met Resident #284 and the ambulance at the facility. The daughter stated both Resident #284 and the family were denied entry into facility and were told they were not welcome back as the family was too much trouble. The daughter stated the family requested to obtain Resident #284's dentures and phone from his room and again were denied access. Police were called and with a police escort one family member was able to obtain Resident #284's dentures and phone from the resident's room. The daughter continued, since Resident #284 was not able to return to facility he had to be transported to another hospital, which was full and unable to accept Resident #284 as he did not have an emergency condition, so he was then sent to another hospital where he remained until 01/24/25. The daughter stated family was unable to care for Resident #284 at home and needed to find safe alternate placement. An interview during the survey process with the hospital Care Transition Manager (CTM) where the resident was ultimately admitted on [DATE] revealed Resident #284 was admitted on [DATE] and discharged on [DATE]. The CTM stated the hospital had no choice but to keep Resident #284 as the resident did not have a safe place to discharge to (when the nursing home refused to allow him to return). The CTM stated upon arrival to the emergency department on 01/17/25, Resident #284 shared he had been at another hospital earlier in the day due to an altered level of consciousness, after a work-up he was discharged and upon returning to the facility where has lived since 2022, was denied entry. The CTM stated they called the facility and was told Resident #284 could not return, with no other explanation provided. In a conference call on 01/20/25 at 4:30 P.M. with the facility Administrator, the CTM stated she could not get confirmation as to why Resident #284 was not permitted to return to the facility and further could not get confirmation of Resident #284 being provided with the required 30-day notice. The CTM stated the Administrator had a 'canned' dissertation about Resident #284's family. The CTM stated after three attempts of explaining the requirement of the 30-day notice and informing the Administrator that Resident #284's return could not be refused, she stated she gave up because the Administrator only provided a repeat of the canned dissertation and never answered her question, if a 30-day discharge notice had been provided. The CTM stated she assumed no notice had not been provided, at which time the CTM stated hospital staff started to send referrals to other facilities, with a total of 22 referrals sent. The CTM stated finding placement for Resident #284 was a challenge as they received several denials due to the referring facilities reaching out to the facility Resident #284 had resided and being told horrible things about the resident's family. The CTM stated the resident was accepted by a facility within a close proximity from the original facility on 01/24/25 at 1:14 P.M. and was discharged . A request was made to review any policy and procedures related to discharge; however, as of 02/27/25 at the completion of the survey, no policy had been provided to review. During the complaint survey, the DON had indicated the facility was willing to take the cite over dealing with the resident's family. The DON had stated, We already figured we were getting that cite. This deficiency represents non-compliance investigated under Complaint Numbers OH00161872, OH00161814, OH00161818, and OH00161828.

Based on observation, interview, record review, review of the label directions on the cleaning wipes and review of the facility policy, the facility failed to ensure proper cleaning of a blood glucose meter while checking resident blood sugar levels. This affected two residents (Resident #127 and #271) and had the potential to affect an additional 28 residents (Resident #5, #31, #36, #46, #49, #51, #58, #61, #81, #85, #92, #116, #124, #145, #148, #152, #163, #186, #195, #230, #242, #245, #254, #261, #272, #273, #275, and #276) who received blood glucose level checks via a glucometer. The facility census was 277. Findings include: 1. Record review for Resident #127 revealed an admitted [DATE]. Diagnosis included type two diabetes mellitus with diabetic chronic kidney disease. Review of the physician orders for Resident #127 revealed an order dated 11/15/24 for Humalog solution 100 units/milliliter (ml) (Insulin Lispro) Inject as per sliding scale before meals for diabetes. Observation on 01/14/25 at 8:44 A.M. of a blood sugar assessment via glucometer revealed Licensed Practical Nurse (LPN) #557 removed the glucometer from the top right hand drawer (lying on the bottom of the drawer uncovered) of the medication cart. Inside the drawer was insulin vial, alcohol wipes, and lancets. LPN #557 did not clean the glucometer. Observation revealed LPN #557 entered Resident #127's room and assessed Resident #127's blood sugar via glucometer. LPN #557 then sat the glucometer directly on Resident #127's nightstand while conversing with Resident #127. LPN #557 then returned to the medication cart and put the glucometer directly back in the top right hand drawer without cleaning the glucometer. 2. Record review for Resident #271 revealed an admitted [DATE]. Diagnosis included type two diabetes mellitus and need for assistants with personal care. Review of the physician orders for Resident #271 revealed an order dated 11/29/24 for Humalog solution 100 units/milliliter (ml) (Insulin Lispro) Inject as per sliding scale subcutaneously before meals for diabetes. Observation on 01/14/25 at 9:01 A.M. of blood sugar assessment via glucometer revealed LPN #557 removed the glucometer (the same glucometer used for Resident #127) from the top right hand drawer of the medication cart. LPN #557 then opened an alcohol wipe and wiped the front of the glucometer only with an alcohol wipe for approximately three to five seconds. LPN #557 then placed the glucometer in a small green basket located on the medication cart, entered Resident #271's room and assessed Resident #271's blood sugar via glucometer. LPN #557 then returned the basket with the glucometer in it to the medication cart, took an alcohol wipe, and cleaned the glucometer front and back with the alcohol wipe for approximately three to five seconds. LPN #557 then placed the glucometer back in the basket then back in the top right-hand drawer of the medication cart. the Interview on 01/14/25 at 9:15 A.M. with LPN #557 confirmed she did not clean the glucometer before or after use for Resident #127 then used an alcohol wipe only to clean the glucometer prior to and after assessing Resident #271's blood sugar via glucometer. LPN #557 confirmed each medication cart had one glucometer to share with the residents receiving medications from that cart. Interview on 01/14/25 at 1:47 P.M. with Director of Nursing (DON) and Assistant Director of Nursing (ADON) #744 revealed per DON glucometer's were to be cleaned between residents. The facility used Super Sani cloth wipes. Per ADON #744 the nurses were to wipe the entire glucometer with the wipe then allow two minutes wet time then do not reuse until completely dry. Review of the label directions on the container of the Super Sani cloth wipes for cleaning hard surfaces including glucometer's on the container of the Super Sani cloth wipes with ADON #744 revealed to thoroughly wet surface. Allow the surface to remain wet two minutes, let air dry. Interview 01/15/24 at 3:40 P.M. with ADON #744 revealed LPN #557 worked all areas of the facility. Review of the facility policy titled, Blood Sampling - Capillary (Finger Sticks) undated revealed the purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employees. Always ensure the blood glucose meters intended for reuse are cleaned and disinfected between resident uses with approved germicidal disinfectant and let dry between uses.

Based on interview, record review, and review of the facility policy, the facility failed to ensure Resident #138's physician and responsible party was notified of a change in condition. This affected one resident (Resident #138) of three residents reviewed for a change in condition. The facility census was 277. Findings include: Record review for Resident #138 revealed an admitted [DATE]. Diagnosis included need for assistants with personal care, stress incontinence, and morbid severe obesity. Observation on 01/13/25 at 11:26 A.M. of incontinent care for Resident #138 provided by Certified Nursing Assistant (CNA) #748 revealed Resident #138 had an open area to the right anterior/medial thigh. The open area was actively bleeding a small amount serosanguinous drainage. No treatment was observed to the area. CNA #748 revealed she worked on Saturday, 01/11/25, and the same open area was there then. CNA #748 wiped off the wound during incontinent care while Resident #138 revealed the area was painful. Observation on 01/13/25 between 11:48 A.M. and 12:29 P.M. of the wound on Resident #138's right anterior/medial thigh with Licensed Practical Nurse (LPN) #790 confirmed the wound was open and bleeding. LPN #790 revealed she was Resident #138's primary care nurse and revealed she was unaware of the wound to that area. LPN #790 confirmed Resident #138 did not have a treatment order for the specified wound. Record review on 01/15/25 at 4:28 P.M. for Resident #138 (of the physician orders, Medication Administration Record (MAR), Treatment Administration Record (TAR) progress notes and Assessments), with Assistant Director of Nursing (ADON) #744, (DON present), confirmed there was no documentation of the open area on the anterior/medial thigh, no treatment, or physician/family notification of the open area on Resident #138's anterior thigh after the area was found on 01/11/25 through 01/13/25 at 11:26 A.M. (during the observation of incontinent care with the surveyor) . DON and ADON #744 confirmed Wound Care Nurse #377 was notified of the open area to the anterior thigh on 01/11/25 but the physician or family was not notified, and no treatment was initiated prior to the surveyor observation on 01/13/25 at 11:26 A.M. Phone interview on 01/15/25 at 4:50 P.M. with Wound Care Nurse #377 confirmed she was made aware of the open area to Resident #138's thigh on Saturday, 01/11/25 by the floor Supervisor. Wound Care Nurse #377 revealed the open area was due to moisture. Review of the facility policy titled, Change in Resident's Condition or Status revised February 2021 revealed the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and or status. The nurse will record in the residents medical record information related to changes in the resident's medical/mental condition or status. This deficiency represents non-compliance investigated under Complaint Number OH00161351.

Based on observation, interview, record review, and review of the facility policy, the facility failed to timely assess and provide wound care for Resident #138. This affected one resident (Resident #138) of three residents reviewed for incontinence care. The facility census was 277. Findings include: Record review for Resident #138 revealed an admitted [DATE]. Diagnosis included need for assistants with personal care, stress incontinence, and morbid severe obesity. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #138 was cognitively intact. Resident #138 used a wheelchair for mobility, required partial/moderate assistants for toileting hygiene, and dependent for personal hygiene. Resident #138 was frequently incontinent of bowel and bladder. Resident #138 was at risk for pressure ulcers/injuries. Record review of the care plan dated 06/10/24 revealed Resident #138 had potential for impaired skin integrity. Interventions included to provide skin care per facility guidelines. Review of the Weekly Skin Check completed 01/08/25 by Registered Nurse (RN) #717 revealed Resident #138's skin was intact. Record review of the progress notes and assessments for Resident #138 from 01/07/24 through 01/13/24 at 12:00 P.M. revealed no documentation of open areas to Resident #138 anterior thigh. Review of the physician orders for Resident #138 revealed no order for a treatment to Resident #138's open area to the anterior/medial right thigh. Observation on 01/13/25 at 11:26 A.M. of incontinent care for Resident #138 provided by Certified Nursing Assistant (CNA) #748 revealed Resident #138 had an open area to the right anterior/medial thigh. The open area was actively bleeding a small amount serosanguinous drainage. No treatment was observed to the area. CNA #748 revealed she worked on Saturday, 01/11/25, and the same open area was there then. CNA #748 wiped off the wound during incontinent care while Resident #138 revealed the area was painful. Observation on 01/13/25 between 11:48 A.M. and 12:29 P.M. with Licensed Practical Nurse (LPN) #790 of the wound on Resident #138's right anterior/medial thigh confirmed the wound was open and bleeding. LPN #790 revealed she was Resident #138's primary care nurse and revealed she was unaware of the wound to that area. LPN #790 confirmed Resident #138 did not have a treatment order for the specified wound. Observation revealed LPN #790 measured the wound and LPN #790 revealed the wound measured 1.7 centimeters (cm) in length by 0.5 cm in width by 0.5 cm in depth. Record review on 01/15/25 at 4:28 P.M. for Resident #138 (of the physician orders, Medication Administration Record (MAR), Treatment Administration Record (TAR) progress notes and Assessments), with Assistant Director of Nursing (ADON) #744, (DON present), confirmed there was no documentation of the open area on the anterior/medial thigh, no treatment, or physician/family notification of the open area on Resident #138's anterior thigh after the area was found on 01/11/25 through 01/13/25 at 11:26 A.M. (during the observation of incontinent care with the surveyor). DON and ADON #744 confirmed Wound Care Nurse #377 was notified of the open area to the anterior thigh on 01/11/25 but the physician or family was not notified, and no treatment was initiated prior to the surveyor observation on 01/13/25 at 11:26 A.M. DON confirmed a treatment should have been initiated on 01/11/25 after the wound was found to be open. Phone interview on 01/15/25 at 4:50 P.M. with Wound Care Nurse #377 confirmed she was made aware of the open area to Resident #138's thigh on Saturday, 01/11/25 by the floor Supervisor. Wound Care Nurse #377 revealed the open area was due to moisture. Review of the facility policy tilted, Wound Care, revised October 2010, revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. Documentation of the wound included type of wound care given, the date and time the wound care was given, the position in which the resident was placed, the name of the individual performing wound care, any change in the resident's condition, all assessment data (wound bed color, size, drainage, etc.) obtained when inspecting the wound, how the resident tolerated the procedure, any complaints or problems made by the resident related to the procedure, if the resident refused the treatment and the reason why, and the signature and title of the person recording the data. Reporting requirements included notify the supervisor if the resident refused wound care and report other information in accordance with facility policy and professional standards of practice. Review of the facility policy titled, Change in Resident's Condition or Status revised February 2021 revealed the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and or status. The nurse will record in the residents medical record information related to changes in the resident's medical/mental condition or status. This deficiency represents non-compliance investigated under Complaint Number OH00161351.

Based on closed medical record review, review of a facility fall investigation, hospice staff interview, review of a hospice electronic mail (e-mail) correspondence, staff interview and review of facility policy, the facility failed to ensure physician ordered fall interventions were implemented and further failed to accurately report assessment findings and timely notify the attending physician and resident representative following a fall. Actual harm occurred on 09/15/24 at 11:00 P.M. when Resident #280, who was assessed to be at high risk for falls, sustained a fall from bed onto the floor without a physician ordered fall mat in place sustaining a fractured right clavicle (collarbone) and fracture at the sixth and seventh ribs. At the time of the fall, nursing staff assessed the resident and identified Resident #280 had limited range of motion (ROM) to her upper extremities and pain. The facility failed to accurately report Resident #280's injuries to the hospice provider, and did not immediately notify the attending physician, which delayed evaluation and treatment for approximately 10 hours. This affected one resident (#280) of three residents reviewed for falls. The facility census was 276. Findings Include: Review of Resident #280's medical record revealed an admitted [DATE]. Diagnoses included hypertension, heart failure, vertigo, anxiety, syncope, seizures and depression. Further review revealed the resident was discharged on [DATE] at 5:17 P.M. to an in-patient hospice facility. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 06/19/24, revealed Resident #280 was cognitively intact, had impairment on one side of the lower extremities and used a wheelchair. Resident #280 required partial to moderate (staff) assistance with rolling right to left and substantial (staff) assistance with lying to sitting, sit to stand and toilet transfer. Resident #280 had no falls indicated on the MDS. Review of the fall risk assessment dated [DATE] revealed Resident #280 was assessed to be at high risk for falls. Review of the plan of care, dated 07/08/24, revealed Resident #280 was at risk for falls related to deconditioning and gait balance problems. Interventions included to ensure the resident's call light was within reach and encourage use, educate resident and family on safety reminders, ensure the resident was wearing appropriate footwear when ambulating or mobilizing in the wheelchair and encourage resident to participate in activities that promote exercise and physical activity for strengthening and improved mobility. The plan of care did not identity a mat to the floor or side bed rails. Review of a physician order dated 08/20/24 revealed, while in bed, ensure there is a mat next to the bed. Review of the September 2024 physician orders revealed Resident #280 required two-person assistance for transfers. Additional review revealed the following orders: on 09/16/24 at 2:45 P.M. an x-ray of the right shoulder due to a fall with pain, 09/16/24 at 11:00 P.M. ice pack to right shoulder four times daily for 20 minutes, 09/17/24 at 6:00 P.M. air mattress with bolsters and 09/18/24 at 6:00 A.M. apply lidocaine patch to right clavicle and ribs daily. Review of an undated facility fall investigation revealed on 09/15/24 at 11:00 P.M., Resident #280 was calling for help and the nurse found the resident lying face down on the floor. Resident #280's head was turned towards the door, with her right arm positioned under her chest. The resident's lower extremities were tangled in the bedding, slightly elevated on the bed. The resident's bed rail was in the up position. Resident #280 stated she was attempting to turn and then rolled off the bed. Initial nursing assessment, while the resident remained on the floor, revealed the resident complained of pain to the right arm with no signs of deformity. A head-to-toe assessment was completed once the resident was put back in bed. Pain was noted to the right arm (rated) on a scale of three out of ten (with ten being the most severe pain). Resident #280 had limited range of motion to the bilateral upper extremities. The investigation indicated there were injuries to the top of the scalp and right upper arm. The investigation indicated the side rail was up but did not indicate the fall mat was in place at the time of the fall. It was noted Resident #280 had clutter in the bed and was too close to the right rail. The supervisor and hospice were notified. Further review revealed family was notified on 09/16/24 at 12:30 P.M. and the attending physician was notified on 09/17/24 at 7:15 A.M. Review of a nursing progress note dated 09/16/24 at 1:15 A.M. revealed an assessment was completed and Resident #280 had complaints of right arm pain with no signs of deformity. The resident denied neck pain on palpation. Resident #280 denied shortness of breath. Lungs were equal and clear bilaterally and abdomen was soft and non-tender. Resident #280 had limited ROM to upper and lower extremities, which was normal. Resident placed back in bed. Supervisor and hospice notified. The progress note did not indicate the assessment was completed as a result of Resident #280 falling from bed, nor did it include any additional details related to the fall. Review of a hospice e-mail correspondence dated 09/16/24 at 1:34 A.M. revealed the hospice on-call nurse communicated to the hospice team that she received a call from the facility reporting Resident #280 was turning in bed and had a fall. The fall was unwitnessed and there were no apparent injuries. The facility nurse was advised to continue neurological checks and report any concerns to hospice. Review of a hospice summary visit, dated 09/16/24, revealed Hospice Nurse Practitioner (HNP) #949 assessed Resident #280 with the chief complaint being a mechanical fall with injury to the right shoulder. Resident #280 was unable to move her right arm and complained of severe pain. The assessment indicated the resident's right shoulder had limited range of motion, was ecchymosis (bruising), swollen and tender with minimal touch. The note further stated the attending physician's nurse practitioner (NP), and the resident's daughter were notified. Review of the radiology imaging report dated 09/16/24 at 5:28 P.M. revealed Resident #280 had a fracture of the right clavicle and a fracture at the sixth and seventh ribs. Review of a late entry progress note, dated 09/19/24, revealed Resident #280 had one to two falls in the past three months. Interview on 09/24/24 at 1:04 P.M. with Resident #280's daughter revealed she initially learned of the resident's fall the morning of 09/16/24, when hospice staff left her a voice mail indicating they ordered an x-ray due to her injuries. Resident #280's daughter stated the facility did not notify her of the fall until 09/16/24 at approximately 10:00 P.M., even though the fall had occurred the night prior. Resident #280's daughter confirmed the resident sustained a right clavicle fracture and fracture at the sixth and seventh ribs. The resident's daughter stated Resident #280 subsequently discharged from the facility on 09/19/24 to the hospice's inpatient facility. Interview on 09/25/24 at 11:00 A.M. with Hospice Case Manager (HCM) #498 revealed the facility nurse reported Resident #280's fall on the night it occurred to the on-call hospice nurse. HCM #498 stated the facility nurse indicated there were no apparent injuries at the time of the notification. The on-call hospice nurse sent out an email to the hospice team notifying them of a fall with no injuries and to follow up within 24 hours. HCM #498 stated if the facility nurse would have notified them of Resident #280's pain and/or injury, a hospice physician would have been notified at that time of the call for further orders. HCM #498 stated HNP #949 was unaware of the injury until she visited the resident the next day, 09/16/24, at approximately 10:00 A.M. HCM #498 stated an x-ray was ordered and an air mattress with bolsters was implemented. Interview on 09/25/24 at 2:59 P.M. with State tested Nursing Assistant (STNA) #931 revealed she was assigned to provide care for Resident #280 on the night of her fall. STNA #931 stated she checked on the resident around 10:00 P.M. and the resident was sleeping. STNA #931 stated the nurse found the resident on the floor around midnight. STNA #931 stated she went to the resident's room and saw her on the floor, with her face positioned toward the door, her abdomen on the floor and her hips were turned to the side. STNA #931 stated Resident #280 had bruising to her right arm. STNA #931 verified there was no fall mat in place and further stated she was unaware of the fall mat intervention and there was no mat in the resident's room. Interview on 09/25/24 at 5:15 P.M. with STNA #829 revealed on the night Resident #280 fell , he went into the room and found the resident lying on the floor on her stomach. STNA #829 stated the resident's hips and torso were sideways and her right arm was bent at the elbow behind her hips. STNA #829 stated the resident's lower extremities were tangled in the bedding. STNA #829 stated when Resident #280 lifted her right arm, she had pain and there was bruising to her chest on the right side. STNA #829 verified there was no fall mat in Resident #280's room. Interview on 09/26/24 at 9:12 A.M. with HNP #949 revealed she received notification that Resident #280 had a fall with no injuries. HNP #949 stated she did not typically follow-up on a fall with no injuries, but stated she happened to in this case. HNP #949 stated she visited Resident #280 the morning of 09/16/24 and was surprised to see the resident had pain, bruising and swelling of the right shoulder. HNP #949 ordered an x-ray of the right shoulder and a sling. HNP #949 stated she notified the family of the fall and discussed treatment options. Interview on 09/26/24 at 1:50 PM with Registered Nurse (RN) #930 revealed she was off at the time of the resident's fall and could not verify if all fall interventions, including the fall mat, were in place. RN #930 stated the interventions in place would have been filled out on the fall investigation by the nurse on duty. Interview on 09/26/24 at 2:45 P.M. with the Director of Nursing (DON) revealed she could not verify if Resident #280's fall mat was in place at the time of the fall and stated she would have to investigate to determine that. The DON declined to review the fall investigation with the surveyor and stated the information was documented in the investigation. The DON stated it was her opinion the physician and family were notified timely. Review of the facility policy titled Change in a Resident's Condition or Status, revised February 2021, revealed the facility promptly notified the resident, his or attending physician and the resident representative of change in the resident's medical/mental condition. Except in medical emergencies, notification would be made within twenty-four hours of a change occurring in the resident's condition. Review of the facility policy titled Falls and Fall Risk, Managing, revised March 2018, revealed in conjunction with the attending physician, staff would identify and implement relevant interventions to minimize serious consequences of falling. This deficiency represents noncompliance investigated under Master Complaint Number OH00158189 and Complaint Number OH00158027. This deficiency is an example of continued noncompliance from the survey completed 09/12/24.

Based on interview, closed record review and policy review, the facility failed to ensure adequate interventions and ordered treatments were implemented to identify a facility acquired pressure ulcer in an early stage and prevent the deterioration of a pressure ulcer. Actual Harm occurred on 10/01/21 when Resident #1 who required two-staff assist with bed mobility and was totally dependent of two-staff assistance with transfers was found to have an unstageable pressure ulcer (a wound caused by pressure that had full thickness tissue loss in which the base of the ulcer was covered by slough (nonviable dead tissue that is white or yellow in appearance) to the bilateral buttocks/coccyx area. Wound Physician (WP) #609 wrote a new treatment order on 10/01/21. The facility failed to transcribe the order until 10/04/21 and failed to complete the treatment as ordered until 10/05/21. This affected one (Resident #1) of three (Resident's #1, #2, and #3) reviewed for pressure ulcers. The facility identified three current residents (Resident's #2, #3 and #6) with facility acquired pressure ulcers. The facility census was 305. Findings include: Review of the closed medical record for Resident #1 revealed an admitted [DATE] and discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 02/24/21 revealed Resident #1 had the potential for impairment to skin integrity related to fragile skin. Interventions included bilateral heel protectors, bi-weekly skin checks, identify and document potential causative factors, keep skin clean and dry, and use caution during transfers. Review of the quarterly Braden Scale for Predicting Pressure Sore Risk dated 08/08/21 revealed Resident #1 was at moderate risk for developing pressure ulcers as he was slightly limited with sensory perception, chairfast, occasionally moist, completely immobile, had inadequate nutrition, and had a potential problem with friction and shear. Review of the care plan dated 08/08/21 revealed Resident #1 had moisture associated skin damage (MASD) noted to bilateral buttocks. Interventions included educate on the importance of keeping the skin clean and moisturized and encourage frequent offloading. Review of the facility form labeled Bi-Weekly Skin Check- V3, dated 09/23/21, and completed by Registered Nurse (RN) #605 revealed Resident #1's skin was intact. Review of the facility form labeled Bi-Weekly Skin Check- V3, dated 09/27/21, and completed by RN #605 revealed Resident #1 had shearing to the right and left buttocks. RN #605 described the area as an open lesion other than ulcers, rashes, or cut. There were no documented measurements or any other description of the area. Review of the facility form labeled Bi-Weekly Skin Check- V3, dated 09/28/21, and completed by RN #605 revealed Resident #1 had shearing to the left and right buttocks. RN #605 revealed the area was MASD, and Resident #1 had a pressure reducing device to the chair. There were no documented measurements or any other description of the area. There was a new order for Critic-aid paste (topical ointment used as barrier for skin) three times a day and obtain a wound consult. Review of the quarterly Braden Scale for Predicting Pressure Sore Risk dated 10/01/21 and completed by RN #611 revealed Resident #1 remained at moderate risk for developing pressure ulcers. Review of WP #609's progress note dated 10/01/21 revealed Resident #1 had an unstageable pressure wound to the bilateral buttocks/coccyx area measuring 8.3 centimeters (cm) in length by 7.0 cm in width, and the depth was unable to be determined. WP #609 revealed Resident #1 had poor mobility and was incontinent. WP #609 revealed Resident #1 had developed MASD recently but with his poor compliance with offloading, the area had deepened into a full thickness pressure wound. WP #609 revealed the wound base was composed of 40 percent granulated tissue, five percent slough, 30 percent eschar, and 25 percent intervening healthy skin. WP #609 revealed the wound was large, moist, and clearly had full involvement. WP #609 revealed the wound had moderate serous drainage, was macerated, and displayed no signs of infection. WP #609 ordered a treatment to pack wound with alginate silver, cover with an ABD pad, apply [MEDICATION(S)] and change daily. WP #609 revealed he was going to follow-up in one week. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 had intact cognition. Resident #1 required extensive assistance of two staff with bed mobility, extensive assist of one staff with toileting, and total dependence of two staff with transfers. Resident #1 was unable to ambulate, was frequently incontinent of urine, and always was incontinent of bowel. Resident #1 had one unstageable pressure ulcer which was not present on admission. Resident #1 had pressure reducing devices to the chair and bed and had a turning and repositioning schedule. Review of the October 2021 physician orders for Resident #1 revealed orders dated 10/04/21 for an air mattress to the bed, bilateral heel protectors when in bed, bi-weekly skin checks, check and change every two hours due to incontinence, cushion to wheelchair, turn and reposition resident every two hours, lay down every day in bed at 2:00 P.M. per resident request, apply Critic-aid clear ointment (skin protective barrier) to buttocks/coccyx area three times a day, and apply calcium alginate silver pad (highly absorbent dressing) to the bilateral buttocks topically, cover with an abdominal (ABD) pad and [MEDICATION(S)] (waterproof barrier) and change once daily. Review of the Treatment Administration Record (TAR) revealed Resident #1 had a physician order dated 10/04/21 to apply calcium alginate-sliver pad to the bilateral buttocks topically, cover with an ABD pad and [MEDICATION(S)] once a day. The treatment was initialed as completed on 10/05/21. There was no documented evidence Resident #1 had the treatment completed from 10/01/21 to 10/04/21 as ordered per WP #609's progress note dated 10/01/21. Review of the facility form labeled Bi-Weekly Skin Check- V3, dated 10/08/21, completed by RN #610 revealed Resident #1 had a pressure ulcer to the coccyx/ bilateral buttocks area measuring 10.9 cm in length by 11.6 cm in width, and the depth was unable to be determined. RN #610 revealed Resident #1's wound had worsened. Review of WP #609's progress note dated 10/08/21 revealed he evaluated Resident #1's unstageable pressure wound to the bilateral buttocks/coccyx area. The wound measured 10.9 cm in length by 11.6 cm in width, and the depth continued to be undetermined. WP #609 revealed Resident #1's wound base was composed of 30 percent granulation tissue, 20 percent slough, 30 percent eschar, and 20 percent intervening healthy skin. WP #609 revealed Resident #1's measurements were larger in size, and the wound bed remained with multiple areas of eschar, granulation tissue, moist slough, and intervening skin. WP #609 revealed the surrounding skin remained moist, irritated, and the wound had moderate serous drainage with no signs of infection. WP #609 revealed the peri-wound was macerated, and the overall condition of the wound had declined. WP #609 revealed Resident #1 was poorly compliant with offloading, had poor nutritional intake, was incontinent, had poor overall medical condition making the deterioration and presence of the wound unavoidable. WP #609 recommended to continue to pack the wound with alginate silver, cover with an ABD pad and [MEDICATION(S)] daily, consider applying [MEDICATION(S)] to the surrounding skin, air mattress, and offloading. WP #609 revealed he would follow up in one week. Review of the care plan dated 10/08/21 revealed Resident #1 had an unstageable pressure ulcer to coccyx region. Interventions included administer treatments as ordered, monitor nutritional status, and weekly treatment documentation including measurements. Review of the nursing note dated 10/08/21 at 8:55 P.M. and authored by RN #612 revealed Resident #1 was sent to the hospital due to abnormal vital signs. An observation of the wound was unable to be completed as the resident was in the hospital at the time of the investigation. Interview on 11/19/21 at 11:44 A.M. with RN #605 revealed Resident #1 often refused to offload as he liked to lay on his back and at times refused to have a pillow applied to assist in turning. RN #605 revealed on 09/27/21 and 09/28/21 per Bi-Weekly Skin Check- V3 Resident #1 was found to have shearing to his bilateral buttock area. RN #605 described Resident #1's area as removal of the top layer of skin, but the area contained no slough or eschar. She revealed she notified Resident #1's Primary Care Physician #900 and he ordered Critic-aid topically to be applied three times a day and a wound consult. Interview on 11/19/21 at 1:27 P.M. with WP #609 revealed he evaluated Resident #1's bilateral buttocks/coccyx pressure wound, and it was unstageable. He revealed the wound measured 8.3 cm in length by 7.0 cm in width, and the depth was unable to be determined. WP #609 revealed he had ordered to pack the wound with calcium alginate silver, cover with ABD pad and [MEDICATION(S)] and change daily. WP #609 revealed he ordered the treatment to begin 10/01/21, and he had verbally given the order to the nurse but could not remember who he had given the order to. WP #609 revealed he could not say why the order was not transcribed until 10/04/21 and why the order had not been initiated until 10/05/21 as he had ordered it on 10/01/21. WP #609 revealed he consulted on 10/08/21, and Resident #1's wound to the bilateral buttocks/coccyx area had declined as it was larger in size and the wound bed contained more slough. WP #609 revealed the wound continued to be an unstageable and measured 10.9 cm in length by 11.6 cm in width, and the depth was unable to be determined. WP #609 revealed he had no knowledge regarding Resident #1's wound after he was sent to the hospital. Interview on 11/19/21 at 1:33 P.M. with the Director of Nursing (DON) verified WP #609 ordered a treatment to Resident 1's unstageable pressure ulcer to the bilateral buttocks/coccyx area per his progress note dated 10/01/21. The DON verified the order was not transcribed until 10/04/21, and the treatment was not initiated as completed as ordered until 10/05/21. The DON verified Resident #1's wound had declined from 10/01/21 to 10/08/21 as it had increased in size as well as contained more slough per WP #609's progress notes. The DON also verified Resident #1's Bi-Weekly Skin Check- V3 dated 09/28/21 and completed by RN #605 revealed Resident #1 had shearing to the left and right buttock area that was described as MASD, but the next documentation of the area was WP #609's progress note dated 10/01/21 stating Resident #1 had an unstageable pressure wound to the bilateral buttocks/coccyx area. Review of the facility policy titled Wounds and Pressure Ulcers revealed the purpose of this procedure was to provide guidelines for the care of wound to promote wound healing. The policy did not include transcribing of treatment orders timely after a resident was seen by a physician. This deficiency substantiates Complaint Number OH 242 and is an example of continued noncompliance from the survey completed on 10/28/21.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure appropriate care and services were provided for one resident (Resident #44) to prevent a pressure ulcer to the coccyx and buttock, and prevent pressure injuries to the right and left heels. Actual Harm occurred when care planned interventions were not implemented, physician orders were not followed, and a pressure ulcer to Resident #44's coccyx and buttock, and pressure injuries to the right and left heels were not treated or documented before they were identified as unstageable pressure ulcer/injuries. This affected one resident (Resident #44) out of three residents reviewed for pressure injury. Findings include: Review of Resident #44's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #44's After Visit Summary from the local hospital for an admission 08/20/21 through 08/29/21 revealed Resident #44 was not discharged with any pressure ulcers, injury. Review of Resident #44's physician orders dated 08/29/21 revealed the following: 1. a cushion to chair. 2. encourage turning and repositioning every two hours and as needed. 3. encourage resident to off-load heels while in bed. 4. Chamosyn (moisture barrier) ointment 0.45-20 percent, apply topically to buttocks every morning and bedtime for treatment. 5. apply Vitamin A&D ointment topically to heels every morning and at bedtime. Review of Resident #44's physician orders on 08/30/21 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #44's care plan, dated 08/31/21, revealed Resident #44 had the potential for impairment to skin integrity related to fragile skin, bowel and bladder incontinence, poor intake, refusal of food and fluids, malnutrition diagnosis, impaired cognition, and weight loss. The care plan indicated Resident #44 would be free from injury through the review date. Interventions included charge nurse to complete bi-weekly skin assessments on shower days, Mondays and Thursdays, cushion to chair, follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #44's progress notes from 08/29/21 through 09/27/21 did not reveal documentation Resident #44 refused to be turned and repositioned or to have her heels off- loaded while in bed. Review of Resident #44's Minimum Data Set (MDS) 3.0 assessment, dated 09/05/21, revealed Resident #44 had severe cognitive impairment and required extensive assistance of two staff for bed mobility, transfers, and toilet use. The MDS assessment revealed Resident #44 did not have a pressure ulcer injury. Review of Resident #44's Braden Scale For Predicting Pressure Sore Risk, dated 09/05/21 and 09/13/21, revealed the resident was at risk for developing a pressure sore. Review of Resident #44's Braden Scale For Predicting Pressure Sore Risk, dated 09/14/21, revealed the resident was at moderate risk for developing a pressure sore. Resident #44 responded to verbal commands, but could not always communicate discomfort or the need to be turned. Resident #44's skin was occasionally moist requiring extra linen changes approximately once per day. Resident #44's ability to walk was severely limited or non-existent, could not bear own weight and must be assisted into chair or wheelchair. Resident #44 made occasional slight changes in body or extremity position but unable to make frequent or significant changes independently, never eats a complete meal, moved feebly or required minimal assistance, during a move skin probably slid to some extent against sheets, chair or other devices, and occasionally slid down in chair or bed. Review of Resident #44's Bi-Weekly Skin Check form, dated 09/14/21, revealed the resident did not have a pressure ulcer, injury. The form revealed Resident #44 was at risk for developing a pressure ulcer injury, resident's skin was intact, and there were no changes from the previous assessment. Review of Resident #44's Bi-Weekly Skin Check forms revealed a form was not filled out for 09/16/21 (Thursday), and was not completed until 09/20/21. Review of Resident #44's Bi-Weekly Skin Check form dated, 09/20/21 revealed the resident had a suspected Deep Tissue Injury to the coccyx and buttock. No measurements of the injury were included in the documentation. Review of Resident #44's progress notes from 08/29/21 through 09/20/21 did not reveal documentation of any redness, open areas, or concern regarding the coccyx and buttock. Review of Resident #44's progress notes dated 09/20/21 at 2:57 P.M. written by Unit Coordinator (UC) #800, revealed an area of skin concern to bilateral buttocks and coccyx was noted, treatment initiated, and a skin consult was sent. No measurements of the bilateral buttocks and coccyx skin injury were documented in the note. Review of Resident #44's progress notes from 09/20/21 through 09/23/21 did not reveal any documentation of the skin injury on the coccyx and buttock including measurements and appearance. Review of Resident #44's Bi-Weekly Skin Check, dated 09/24/21, revealed documentation of an unstageable pressure ulcer to bilateral buttocks and coccyx. Measurements were length 11.4 centimeters (cm), width 7.3 cm, and depth not measured. Review of Resident #44's Wound Care physician note on 09/24/21 written by Medical Doctor (MD) #801 revealed 09/24/21 was the initial evaluation of an unstageable pressure ulcer to the bilateral buttock and coccyx which was present on admission. Measurements were length 11.4 cm, width 7.3 cm, and depth unable to be determined. The wound base was 30 percent granulation tissue, 10 percent slough, and 60 percent intervening healthy skin. Several open areas with intervening healthy skin were noted. MD #801 wrote to consider using Critic Paste (moisture barrier), apply widely and thickly, and to follow up in one week. Review of Resident #44's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #804). Review of Resident #44's progress notes dated 09/27/21 written by UC #800 revealed an area of concern was noted to Resident #44's bilateral heels and was evaluated per MD #804, treatment was initiated, with new orders for heel lift boots and a skin consult. Review of Resident #44's Bi-Weekly Skin Check form dated 09/27/21 revealed suspected Deep Tissue Injury to the right and left heels. There were no wound measurements recorded and no documentation of appearance of the right and left heel wounds. Review of Resident #44's physician orders dated 09/27/21 revealed orders to document on wounds to bilateral heels with each dressing change every shift, but there were no orders related to treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #44's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #44's progress notes from 09/27/21 through 10/01/21 revealed no documentation of resident's right and left heel wounds, including measurement and appearance of the wounds. Review of Resident #44's Wound Care Note on 10/01/21 written by MD #801 revealed an unstageable pressure ulcer to the bilateral buttock area on the coccyx measuring length 9.0 cm, width 6.1 cm, and depth unable to be determined. Evaluation of a second wound revealed an unstageable pressure injury of the right heel and measurements were length 0.9 cm, width 1.6 cm, depth unable to be determined, 100 percent eschar. An initial evaluation of a third wound revealed an unstageable pressure injury of the left heel and measurements were a length of 1.8 cm, width of 2.9 cm, unable to determine depth, 100 percent eschar. Review of Resident #44's Wound Care physician note addendum on 10/27/21 revealed MD #801 wrote he made an error and incorrectly documented resident's coccyx and heel wounds were present on admission. MD #801 further wrote the pressure ulcer's seemed to develop in house likely due to resident's poor mobility, poor compliance with off-loading, confusion and incontinence. Observation on 10/26/21 at 1:40 P.M. of Resident #44 sitting in a wheelchair in the common area. Resident #44 was not sitting on a pressure relieving cushion. Observation on 10/26/21 at 2:30 P.M. of Resident #44's wheelchair revealed there was no pressure reducing cushion in the chair. UM #803 confirmed the cushion was not on the chair, and did not know why it was not there. Observation revealed a pressure relieving cushion laying in the seat of another wheelchair without a leg rest in Resident #44's bathroom. UM #803 stated the staff must have forgotten to move the cushion to the other wheelchair. Observation on 10/26/21 at 2:18 P.M. of Resident #44's dressing changes of the coccyx and bilateral heels with Licensed Practical Nurse (LPN) #802 and Registered Nurse/Unit Manager (RN/UM) #803 revealed Resident #44's left heel was dark brown/black in the center and light pink around the edges. Measurements were a length of 3.5 cm, width 2.0 cm and depth unable to be determined. Resident #44's right heel had a small dark reddish brown center and light red around the edges. Measurements were a length of 1.5 cm, width 0.5 cm, and depth was unable to be determined. Observation of the coccyx revealed a small open area which had a dark reddish black center and was dark reddish purple around the edges. Observation of the left buttock revealed a quarter size open area with wound base a reddish pink color and the edges were dark reddish purple. The dressing for all three wounds were applied per physician orders. Interview on 10/26/21 at 2:57 P.M. with State tested Nurse Aid (STNA) #811 revealed Resident #44 could be challenging to take care of, she had to talk her into letting her give her care. STNA #811 stated Resident #44 did not refuse to be turned and repositioned, or to elevate her heels but sometimes STNA #811 was too busy to turn her every two hours and assist with elevating her heels. Interview on 10/26/21 at 3:05 P.M. with STNA #812 revealed she could reposition Resident #44 without a problem, and assist her to elevate her heels off the bed but sometimes she was too busy to make sure it was done every two hours. Interview on 10/26/21 at 4:11 P.M. with UC #800 revealed on 09/20/21 Resident #44's coccyx was red and excoriated. UC #800 stated she thought it was a Deep Tissue Injury because the coccyx was dark purple and did not blanche, but wanted the physician to confirm the findings. UC #800 confirmed 09/20/21 was the first day the pressure injury was noted on Resident #44's coccyx, and confirmed measurements and a description of the wound was not completed until 09/24/21. UC #800 stated a week later Resident #44's son found bilateral heel wounds he was concerned about, MD #804 was notified and evaluated Resident #44's heel wounds and a referral was sent to have the wound physician evaluate and treat the heels. UC #800 confirmed 09/27/21 was the first day Resident #44's heel injuries were noted and measurements and a description of the wound was not completed until 10/01/21. UC #800 confirmed the pressure ulcers were first identified when they were unstageable pressure ulcers. Interview on 10/27/21 at 8:21 A.M. with MD #801 revealed he read his notes, they were confusing, and he thinks he might have made a mistake when he documented Resident #44 was admitted to the facility with pressure ulcers to her coccyx and heels. MD #801 stated he may have assumed Resident #44 was admitted with pressure ulcers to her heels and coccyx and it might be inaccurate. Interview on 10/27/21 at 8:33 A.M. of Family Member (FM) #805 revealed Resident #44 did not have any pressure injuries or ulcers when she was admitted to the facility. FM #805 stated Resident #44 developed a small ulcer on her heels the last week of September, the ulcers were not evaluated right away, FM #805's brother came to the facility from out of state so he could make sure the wounds would be managed. Interview on 10/27/21 at 9:03 A.M. of FM #806 revealed Resident #44 was a diabetic, he was worried about the open ulcers on her heels, and insisted the nurse call the physician to have the wounds evaluated. FM #806 could not remember the date Resident #44's heel ulcers were found, but knew it was toward the end of September. Interview on 10/27/21 at 11:09 A.M. with the Director of Nursing (DON) confirmed Resident #44 was not admitted to the facility with any pressure ulcers, injuries. The DON stated MD #801's documentation was incorrect, and the pressure ulcers were acquired in-house. Interview on 10/27/21 at 2:57 P.M. with Registered Nurse (RN) #807 revealed Resident #44 could be combative when care was provided. RN #807 stated when she applied cream to Resident #44's bottom she noticed the skin was red, and was blanchable. RN #807 stated she did not remember charting anything about the red area on Resident #44's bottom in the medical record. RN #807 stated she filled out the Bi-Weekly Skin Check forms on Resident #44's shower days if she was working. RN #807 stated she did not notice Resident #44's heels were red or had open areas on them, her son brought it to her attention and she called the physician. MD #804 evaluated Resident #44's heels shortly after she called him and Resident #44's heels were wrapped. Interview on 10/27/21 at 3:14 P.M. with STNA #808 revealed Resident #44 could be combative when care was provided, but it was all in the way she was approached, and she did not have any problems providing care for her. STNA #808 stated she noticed Resident #44 had redness on her bottom and reported it to RN #807. STNA #808 stated she did not remember seeing redness on Resident #44's heels. Observation on 10/27/21 at 3:16 P.M. of Resident #44 revealed she was laying on a floor mat by the side of the bed and did not have heel lift boots on her feet. Registered Nurse (RN) #809 confirmed Resident #44 was laying on the mat without heel lift boots and stated she was recently assisted to lay down in bed and she would find someone to help her back to bed and put her heel lift boots on. Interviews on 10/27/21 between 3:39 P.M. and 3:42 P.M. with Registered Nurses (RNs) #809 and #810 revealed the STNAs were responsible for turning and repositioning the residents every two hours, and off-loading heels, and the nurses were responsible to make sure it was done. RNs #809 and #810 said for sure it did not happen every two hours when staffing was low and the STNAs and nurses were too busy to do it every two hours. Interview on 10/28/21 at 7:55 A.M. with RN #813 revealed when she applied Chamosyn ointment (moisture barrier) to Resident #44's bottom she noticed it was slightly red, no open areas, and did not remember if the area blanched. RN #813 stated she did not remember if she documented the redness or notified the physician. RN #813 stated she did not notice redness on Resident #44's heels when she applied A&D ointment. RN #813 stated Resident #44 was immobile, incontinent and needed turned and repositioned every two hours. Review of the facility policy titled, Wounds and Pressure Ulcers, dated, 01/30/21 included the purpose of the procedure was to provide guidelines for care of wounds to promote healing. Nurses were expected to verify physician orders prior to completing wound care. Information recorded in the medical record included type of wound care, assessment data including wound bed color, size, drainage, and to notify supervisor if resident refused care. This deficiency substantiates Complaint Number OH 639.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of the facility's Coronavirus (COVID-19) policy, review of the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-20-14-NH (revised 3/13/20), review of the World Health Organization (WHO) hand hygiene brochure, and review of the Centers for Disease Control and Prevention (CDC) guidelines, observations, interviews, and record review the facility failed to implement appropriate infection control practices by not ensuring appropriate use of personal protective equipment (PPE) for residents on COVID-19 quarantine precautions, and proper hand hygiene. This resulted in Immediate Jeopardy on 10/13/20 when the facility failed to ensure staff members donned appropriate PPE when entering residents' rooms on quarantine and droplet precautions, permitted residents on droplet and quarantine precautions to be in common areas of the facility, and failed to ensure surgical masks/KN95/N95 respirators and hand hygiene were consistently implemented to prevent the spread of Covid-19 infections. The lack of effective infection control practices placed all residents in the facility at risk for serious life-threatening harm, complications and/or death related to the facility's failed practice of infection control. The facility census was 291. The administrator was notified on 10/15/20 at 5:07 P.M. that an Immediate Jeopardy began on 10/13/20 when the facility failed to implement appropriate and recommended infection control practices by not following the CDC guidelines when State tested Nurse Aide (STNA) #82 did not don a KN95 or N95 respirator, an isolation gown, and gloves when entering Resident #1's quarantine room on droplet precautions. STNAs #87, #88 and Housekeeper #90 did not don isolation gowns, gloves and did not use hand sanitizer/wash hands when entering Residents #6 and #8 rooms, who were quarantined as new admissions. Observations were made of Residents #9, quarantined due to new admission, and Resident #10, quarantined without a documented [DIAGNOSES REDACTED]. Physical therapy was provided to Resident #3, on droplet precautions for pneumonia, and Resident #9 who was on quarantine due to new admission, in the common areas of the facility. In addition, the facility failed to ensure surgical masks/KN95/N95 respirators and hand hygiene were consistently implemented to potentially prevent the spread of Covid-19 infections. The facility identified eight residents in the facility were COVID-19 positive. The Immediate Jeopardy was removed on 10/17/20 when the facility implemented the following correction actions: · 10/13/20 at approximately 7:00 P.M. a contracted STNA was immediately educated by Assistant Director of Nursing (ADON) #84 and provided with facility specific PPE, the contracted STNA applied the designated appropriate PPE. · 10/13/20 at approximately 7:30 P.M. following the notification to the administrator that one contracted STNA was wearing a cloth face mask, the Assistant Director of Nursing (ADON) #84 and Nursing Supervisor #100 made rounds on every patient care area to ensure all staff were compliant with current mask and eye protection. All staff were noted to be compliant. · 10/13/20 at 7:35 P.M. entrance screening desk staff were verbally educated/reminded by the ADON #84 to offer everyone entering the facility facemasks upon entering the facility, also offering eye protection for any individual who provides direct care or will be in a patient care area. · 10/13/20 at 7:40 P.M. additional supplies of masks and eye protection were provided at the entrance screening desk and will be maintained at the desk for staff to provide to staff and visitors as needed. Staff were instructed by the ADON to notify management if additional PPE is needed. · 10/13/20 at approximately 8:00 P.M. the facility DON and ADON #84 implemented a plan for all residents in the facility to have twice daily COVID screenings completed by nursing staff with no adverse effects or outcomes noted and will continue to be monitored closely. Review of room entry logs revealed the STNA #82 entered room [ROOM NUMBER] and #117. · All staff who interact with patients or residents in resident care areas, or enter resident rooms, including nursing, therapy, housekeeping, engineering, social services, life enrichment, medical staff, will be educated 10-16-20 on the topics identified below. Staff who are not educated on 10-16-20 will be educated upon return to work and prior to working any shifts. Education will be completed by department supervisor/designee. · Hand Hygiene - Power Point & looping CDC Hand Hygiene and sparkling surfaces · Facility Personal Protective equipment - eye protection and masking · Nursing Specific- Discontinuation of transmission-based precautions and removal of signage from resident rooms · On 10/17/20 at 8:30 a.m., the DON or designee will begin conducting daily observations of staff to ensure the correct PPE is being utilized by staff, residents on isolation or quarantine precautions are properly identified with correct signage on the door, and residents who have a COVID-19 [DIAGNOSES REDACTED]. The audits will be done daily on varying shifts for at least 4 weeks. Although the Immediate Jeopardy was removed on 10/17/20, 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 was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the Department of Health and Human Services, Centers for Medicare and Medicaid (CMS) Memo QSO 20-20-ALL dated 03/03/20 revealed CMS is committed to taking critical steps to ensure America's healthcare facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (Covid-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of infection control priorities during this time of crisis, and providers may perform a voluntary self-assessment of their ability to meet these priorities. The Quality, Safety and Oversite Group (QSO) Memo included additional instructions to nursing homes. We are disseminating the Infection Control survey developed by CMS and Centers for Disease Control (CDC) so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of Covid-19. We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable diseases or infections should be reported (42 CFR 483.80 (a) (2) (i) and (ii). Observation and interview on 10/13/20 at 6:55 P.M. in a quarantine unit with Registered Nurse (RN) #80 revealed RN #80 had a surgical mask across her face covering her mouth, with a KN95 respirator across her nose. When asked about the different masks RN #80 stated she was allergic to the KN95 respirator and wore a surgical mask under it, but the KN95 would not stay in place and usually would ride up and only cover her nose. During the interview RN #80 reached up with her hand and adjusted her KN95 respirator three to four times without using hand sanitizer/washing hands. RN #80 confirmed she did not use hand hygiene before or after touching her KN95 respirator. Review of the medical record for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/21/20 revealed the resident had severe cognitive impairment. Observation on 10/13/20 at 7:23 P.M. in a quarantine unit revealed STNA #82 wearing a dark cloth face mask covering her nose and mouth. STNA #82 entered Resident #1's room and did not don gloves, an N95 or KN95 respirator, or an isolation gown. Resident #1's door had a blue paper with large bold letters stating STOP, see nurse before entering. There was a cart with PPE by the door to the room. Interview on 10/13/20 at 7:29 P.M. with STNA #82 confirmed she was not wearing an N95 or KN95 respirator and did not don an isolation gown or gloves before entering Resident #1's room. STNA #82 stated she left her N95 respirator in her car, and the facility scheduler, who gave out the KN95 respirators had left for the day. STNA #82 further stated she did not ask a nurse if they could give her a N95 or KN95 respirator. When asked about the blue paper on the door with the words STOP, see a nurse, STNA #82 stated she saw the sign, was not sure what it meant and did not ask a nurse. STNA #82 also stated she was assigned to different to units in the facility depending on the need for the day. Review of the electronic record for Resident #1 revealed a physician order, dated 10/13/20, indicating droplet precautions for pneumonia until 10/18/20. Observation was made on 10/13/20 at 8:11 P.M. with ADON #84 in a quarantine unit of many boxes of isolation gowns stacked against the wall. ADON #84 stated there were so many residents on droplet, quarantine and transmission precautions it was hard to keep the carts stocked. Staff members knew the isolation gowns were in this location if they were needed. Interview on 10/13/20 at 8:50 P.M. with Infection Preventionist (IP) #83 confirmed staff wore face shields/goggles if giving direct care to the residents. Observation and interview on 10/13/20 at 9:35 P.M. in a quarantine unit of STNA #85 with a KN95 respirator pulled off her face and hanging around her neck, sitting on an upholstered chair in the common area with her right leg over the arm of the chair. STNA #85 was sitting approximately six inches from Resident #4 who was in a Broda (padded wheelchair) chair. STNA #85 confirmed her KN95 respirator was not on her face, scratched her nose with her right hand, pulled the KN95 respirator onto her face covering her mouth and nose, scratched her face over the KN95 respirator, then reached over and touched Resident #4 on the arm. STNA #85 confirmed she did not use hand hygiene before touching Resident #4. STNA #85 further stated this was not her assigned unit, and she was asked to leave her area to come and sit with Resident #4 while the STNA for the unit was assisting other residents. Observation and interview on 10/14/20 at 11:32 A.M. in a quarantine unit with STNA #86 of Resident #5's room revealed a yellow sign on the door and a plastic PPE cart to the side of the entrance to the room. STNA #86 stated she understood the yellow sign meant the resident was on quarantine precautions and if she entered the resident ' s room, she should don PPE. STNA #86 further stated she felt like the facility left it up to the staff whether to don PPE because as you could see the cart did not have any isolation gowns, gloves, masks or face shields/goggles in the drawers. Observation of the cart revealed no isolation gowns, no gloves, no masks, or face shields/goggles and two booties in the bottom drawer. STNA #86 stated if she entered the room of a resident on quarantine precautions but was not giving direct care to the resident, she did not don PPE. Observation on 10/14/20 at 11:49 A.M. of STNA #87 and STNA #88 as they entered Resident #6's room and closed the door revealed Resident #6 had a yellow sign (quarantine) on the door indicating Resident #6 should stay in his room and anyone entering the room should don an isolation gown, gloves, an N95 or KN95 respirator and use hand sanitizer or wash hands. A plastic PPE cart to the side of the entrance to the room. STNA #87 and STNA #88 did not don an isolation gown, or gloves or use hand sanitizer before entering the room. Interview on 10/14/20 at 11:53 A.M. with STNA #87 and STNA #88 after they exited Resident #6's room confirmed they did not don an isolation gown, gloves, or use hand sanitizer/wash hands before entering Resident #6's room. STNA #87 stated she only donned an isolation gown and gloves if she was providing direct care for the resident. STNA #87 further stated Resident #6 was trying to have a bowel movement and they helped position him. STNA #87 also stated she worked in different units in the facility depending on the need for the day. Interview on 10/14/20 at 12:01 P.M. with Registered Nurse/Nurse Manager (RN/NM) #89 revealed she was the nurse manager for two quarantined units. RN/NM #89 stated yellow signs were for residents on quarantine precautions due to an appointment out of the facility, or an admission from the hospital. Residents on quarantine precautions had therapy and activities in their room. RN/NM #89 stated residents on quarantine precautions could be in the common area if kept at a social distance from other residents. Staff entering rooms of residents on quarantine precautions should don isolation gowns and gloves, but there were not enough PPE carts for all the residents on precautions, so the carts were placed at intervals in the hallway to provide access to all the rooms. RN/NM #89 stated staff were given one KN95 respirator per week, and it could be replaced as needed if it became soiled. Review of the medical record for Resident #3 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 3.0 assessment, dated 10/05/20, revealed the resident had moderate cognitive impairment. Observation and interview on 10/14/20 at 12:27 P.M. of Resident #3's room in a quarantine unit revealed a blue droplet precaution sign on the open door indicating Resident #3 should stay in her room, and anyone entering the room should use hand sanitizer or wash their hands, don gloves, an isolation gown, and an N95 or KN95 respirator. A plastic PPE cart to the side of the doorway and Resident #3 sitting in a chair in her room. Resident #3 stated she had pneumonia and had returned from therapy. Resident #3 pulled a blue surgical mask out of her pants pocket and stated she wore the mask when she went to exercise. Review of Resident #3's electronic record revealed a physician phone order on 10/14/20 at 10:41 A.M. for droplet precautions related to pneumonia. Review of Resident #3's Physical Therapy Treatment Encounter Notes revealed on 10/14/20 at 12:31 P.M. therapy had been provided by Physical Therapy Assistant (PTA) #98. Interview on 10/15/20 at 3:17 P.M. with PTA #98 revealed she had provided physical therapy to Resident #3 on 10/14/20. Therapy was provided in the large gym downstairs, in the quarantine unit hallway, and in the resident room. Observation and interview on 10/14/20 at 12:37 P.M. of Resident #8's room revealed a yellow quarantine sign indicating Resident #8 should stay in her room and anyone entering Resident #8 ' s room should don an isolation gown, gloves, an N95 or KN95 respirator and use hand sanitizer or wash their hands. Isolation gowns in a bin attached to the wall. Observation of Housekeeper #90 revealed she entered Resident #8's room without donning an isolation gown or gloves or using hand hygiene. Housekeeper #90 confirmed there was a yellow quarantine sign on the door, isolation gowns in a bin on the wall and she did not don an isolation gown or gloves or use hand sanitizer /hand washing before entering the room. Housekeeper #90 stated she would don an isolation gown when she started cleaning. Interview on 10/14/20 at 1:43 P.M. with IP #83 revealed blue signs on the resident doors were for droplet precautions, one side of the blue sign said STOP see Nurse before entering and the other side of the sign had instructions for anyone entering the residents room for PPE, equipment and hand hygiene. IP #83 further stated yellow signs were for quarantine precautions, one side had STOP see Nurse before entering and the second side was plain yellow with no writing on it. IP #83 stated it did not matter what side of the sign was showing, staff knew what the colors meant and it was human error if the signs were not all showing the same information when asked why some of the resident doors had the side of the sign stating to STOP see a Nurse before entering and some of the resident doors had the instructions for hand hygiene, PPE, and equipment for anyone entering the room on them. IP #83 further stated staff should wear eye protection, N95 or KN95 respirators, gloves, and isolation gowns when entering the resident room on droplet and quarantine precautions. IP #83 stated residents on droplet and quarantine precautions were encouraged to stay in their room but were not forced to because they had the right to leave their room. IP #83 also stated if the residents chose to leave their room, they were encouraged to wear a mask but were not forced to. If residents chose not to wear a mask social distancing was encouraged. Interview on 10/14/20 at 2:08 P.M. with the DON revealed residents on droplet and quarantine precautions should stay in their room. The DON stated residents on quarantine precautions included residents admitted from the hospitals, were a high-risk population and staff should wear eye protection, KN95 or N95 respirators, isolation gowns, and gloves. Staff members were given one KN95 or N95 respirator per week and it was replaced if it became soiled. The DON stated KN95/N95 respirators were taken home after their shift by staff members. The DON further stated it was not acceptable for staff to wear cloth masks in resident areas. Staff were not expected to change their KN95 or N95 mask after caring for resident on droplet or quarantine precautions unless it became soiled. Phone interview on 10/14/20 at 4:20 P.M. with IP #83 revealed her contact at the local health department was Health Department Official (HDO) #92. IP #83 further stated HDO #92 did not provide guidance on N95 or KN95 respirators or PPE. Phone interview on 10/15/20 at 12:00 P.M. with HDO #92 revealed she was the facility contact from the health department since mid-July 2020. HDO #92 stated she had not given guidance on N95 or KN95 respirators or PPE to the facility. Phone interview on 10/15/20 at 1:45 P.M. with Medical Director (MD) #93 revealed the facility followed CDC guidelines for residents on droplet and quarantine precautions. The resident doors had blue or yellow signs with the protocol to follow for anyone entering the room, and there were carts in front of the rooms with PPE supplies in them. The resident doors were closed at all times and the residents were not allowed out of their room. MD #93 further stated if the resident needed therapy it was done in the room, and activities were also done in the resident room. Residents on droplet and quarantine precautions were not allowed in the common areas. Residents on droplet and quarantine precautions were to be kept in their room for 14 days. MD #93 stated if a resident was a high fall risk and on droplet or quarantine precautions they were kept in their room, and on a very rare occasion if they must be out for safety reasons the resident must have a mask on if they were in the common areas. Observation was made on 10/15/20 at 2:03 P.M. of Resident #9's room in a quarantine unit with a yellow quarantine sign on the door and Resident #9 was not in the room. Observation was made on 10/15/20 at 2:05 P.M. of Resident #9 wearing a blue surgical mask sitting in a wheelchair in the common area with PTA #94 sitting approximately three to six inches from the resident working with her. Interview on 10/15/20 at 2:10 P.M. with PTA #94 stated this was the first day she worked with the resident and confirmed she administered therapy to Resident #9 in the common area. Interview on 10/15/20 at 2:15 P.M. with RN #95 confirmed Resident #9 was on quarantine precautions and was in the common area. RN #95 stated Resident #9 had a fall in the past, became confused in her room, and staff kept an eye on her in the common area. Observation on 10/15/20 at 2:38 P.M. revealed Resident #9 in the common area not wearing a mask. Observation on 10/15/20 at 3:38 P.M. revealed Resident #9 in the common area not wearing a mask. Interview on 10/15/20 at 3:39 P.M. with RN #96 confirmed Resident #9 was in the common area without a face mask. RN #96 stated Resident #9 took her mask off and we try to keep her distanced from other residents. Observation on 10/15/20 at 3:50 P.M. in the quarantine unit revealed Resident #10 sitting by a table in the common area without a face mask. Resident #11 was also sitting by a table approximately 15 feet from Resident #10 in the common area. Further observation revealed Resident #10 had a yellow quarantine sign on her door indicating Resident #10 should stay in her room and anyone entering the room should don an N95 or KN95 respirator, isolation gown and gloves and use hand sanitizer or wash their hands. Interview on 10/15/20 at 3:59 P.M. with RN #97 confirmed Resident #10 was on quarantine precautions and sitting in the common area without a mask. RN #97 stated she would not leave a mask on her face, and she was in the common area because we could keep a better eye on her out here. Review of the facility policy titled Menorah Park Covid-19 Preparedness Information, dated 10/01/20, stated Respiratory illness is defined as the common cold, influenza, and influenza-like illnesses, pneumonia, lower respiratory tract infections, and now Covid-19. Review of the facility policy titled, Memorandum-COVID Exposure, dated, May 29,2020, updated, 09/2/20, Protocol for respiratory infection isolation stated the patient is immediately placed in his/her room with the door shut and cannot leave their room (this includes bathing) for the duration of the respiratory illness. Review of the facility policy, titled Menorah Park Coronavirus Plan, undated, stated the facility will monitor CDC for guidance of COVID-19. The policy also stated Infection control precautions for probable and suspect cases of COVID-19 the resident will immediately be placed in a single occupancy private room with the door closed in the Nursing Home. Review of the facility policy, titled Patient masking and Social Distancing, updated 09/02/20, stated for Nursing Home residents Nursing Staff will be responsible for the following: A cloth mask is applied to the resident prior to exit from his/her room by self or nursing staff, and is re-applied as needed, if at any time the mask is removed by the resident while in a common area. A surgical mask will be used, if the cloth mask is not available. Review of CDC Coronavirus Disease 2019 (COVID 19), Using PPE, updated August 19,2020 states don't touch or adjust your face mask without cleaning your hands before and after and don't wear your face mask around your neck. Review of the CDC, Coronavirus Disease 2019 (Covid-19), Interim Infection Prevention and Control recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Infection Control Guidance, updated July 15, 2020 stated Healthcare Personnel (HCP) should wear a face mask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. Further review stated HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or face mask if respirator not available), and gown, gloves and eye protection. HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection. If [DIAGNOSES REDACTED]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis). · They should also: Wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. · HCP should remove their respirator or facemask, perform hand hygiene, and put on their cloth face covering when leaving the facility at the end of their shift. · Place a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection in a single-person room with the door closed. The patient should have a dedicated bathroom. Review of CMS policy memo QSO-20-14-NH revised 3/13/20 titled, Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes, revealed facilities were to Increase the availability and accessibility of alcohol-based hand rubs, and to reinforce strong hand-hygiene practices. Review of the Centers for Disease Control and Prevention (CDC) training titled, Hand Hygiene in Nursing Homes, dated 02/25/19 revealed hand hygiene was an element of standard precautions. It was an important Infection Prevention Control (IPC) practice for breaking the chain of infection. Hand hygiene protects both residents and staff. Hand hygiene was a simple and effective method for preventing the spread of pathogens by direct and indirect contact. The hands of staff members may become transiently contaminated with pathogens after touching a resident or surfaces in their environment. Staff members can transfer those pathogens to themselves and they can also transfer those pathogens to other residents or surfaces. Performing hand hygiene removes pathogens and protects both staff and residents. Since staff cannot tell whether their hands have been contaminated with a pathogen, hand hygiene should be consistently performed. Review of the World Health Organization (WHO) Hand Hygiene brochure titled Hand Hygiene: Why, How, and When?, revised August 2009, revealed hands are the main pathways of germ transmission during health care and hand hygiene is therefore the most important measure to avoid the transmission of harmful germs and prevent health care-associated infections. The brochure further revealed hand hygiene is indicated after touching any object or furniture when leaving the patient surroundings to protect the health-care environment against germ spread.

Based on record review and interview the facility failed to ensure the correct medications were administered to the correct resident. Actual Harm occurred when a registered nurse (RN) administered eight medications to the wrong resident, Resident #10. Resident #10's blood pressure subsequently dropped very low requiring transfer and admission to the hospital. This affected one resident (Resident #10) of three residents reviewed for medication administration. The facility census was 346. Findings include: Record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #10 was assessed to be alert and oriented to person, place and time and required extensive assistance for most activities of daily living. Review of the nurse's notes dated 08/16/16 at 11:21 A.M. revealed Resident #10 was given aspirin, [MEDICATION NAME] (blood pressure medication), Apixaban (blood thinner), Oyst-Cal-D (calcium supplement), [MEDICATION NAME] (blood pressure), Losartan (cholesterol), Vitamin D 3 and [MEDICATION NAME] (antidepressant). The note indicated the physician and family were notified. Review of the nurse's notes dated 08/16/16 at 12:01 P.M. revealed Resident #10 went to the hospital at 11:57 A.M. for [MEDICAL CONDITION] (low blood pressure) and was alert and oriented. Review of the nurse's notes dated 08/16/16 at 12:19 P.M. revealed staff entered the room to find Resident #10 complaining of not feeling well and stating help me while sitting in wheelchair. She was assisted back to bed with two staff, her vital signs were the following: blood pressure low at 71/41, heart rate elevated at 90, respirations 20, oxygen saturation 98% on 2 liters of oxygen and temperature was 99 degrees. The physician was contacted and Resident #10 was ordered to be sent to the emergency room for evaluation and treatment. Resident #10 was admitted to the hospital and as of 08/22/16 and had not returned to the facility. A review of the physician orders [REDACTED]. On 08/22/16 at 12:00 P.M., an interview was conducted with the Assistant Director of Nursing (ADON) verifying that Resident #10 received the wrong eight medications on 08/16/16. She stated Registered Nurse (RN) #90, who administered the wrong medications to Resident #10, was in the last days of orientation and was being followed by a preceptor, RN #100. She said RN #100 observed RN #90 coming out of Resident #10's room after prepping medications for a different resident, Resident #20. RN #90 then verified that Resident #10 received the wrong medications, the medications that were ordered for Resident #20. The ADON indicated the Director of Nursing (DON) was informed immediately, went in and assessed Resident #10 with no abnormal findings or complaints at first. The physician was notified along with the in-house pharmacist and a thorough review of Resident #10's medications was completed to see what needed to be held or administered. Resident #10's family was also notified that she received the wrong medications. The ADON stated that after an hour or so, Resident #10 complained that she did not feel well and her blood pressure had dropped. The physician was notified and Resident #10 was sent to the hospital emergency room for further evaluation and treatment. She has not returned to the facility. The ADON stated Resident #10 was admitted to the hospital for [MEDICAL CONDITION] (low blood pressure). The ADON stated that RN #90 was suspended pending facility investigation of the medication error and the DON completed the follow up. Review of the undated facility policy titled, Menorah Park Center for Senior Living Nursing Department Medication Administration, reveals staff are to follow guidelines. Guidelines included staff to address each resident by name, administer medications by appropriate methods, administer medications by proper technique for identification, administration and documentation. On 08/22/16 at 12:25 P.M., an interview was conducted with the DON verifying that Resident #10 received the wrong medications on 08/16/16. She stated that RN #90 was observed walking out of Resident #10's room after administering the medications that were prepared for Resident #20. The DON stated that Resident #10 had here name on her door, and still had her name band identification from the hospital that she transferred to the facility from. She went on to state that all RN's are aware and taught in nursing school how to correctly identify a resident prior to administering medications and was not sure why RN #90 had not done so. The DON stated that RN #90 was terminated on 08/18/16 after the incident for failing to administer the correct medications to the correct resident. She went on to state that Resident #10 was already declining in health and a hospice consult had been initiated prior to her receiving the wrong medications, that the facility monitored her closely after the error and she was properly assessed and then sent to the hospital when her blood pressure dropped to be evaluated and treated there. Resident #10 had not returned to the facility. This deficiency substantiates Complaint Number OH 342.