Every finding on record at Kingston Health Center of Sylvania

Based on resident interview, review of a test tray, and staff interview, the facility failed to ensure resident meals were palatable and served at an appropriate temperature. This had the potential to affect all 122 residents in the facility.Findings include:Interview on 01/05/26 at 9:53 A.M. with Resident #112 revealed the vegetables were overcooked and the portions seemed to be getting smaller. Interview on 01/05/26 at 10:22 A.M. with Resident #36 revealed the food was visually unappealing, was not seasoned, and was cold. Interview on 01/05/26 at 10:55 A.M. with Resident #77 revealed the food was cold and bland. Interview on 01/05/26 at 12:00 P.M. with Resident #20 revealed the food was always cold and did not taste good. Interview on 01/05/26 at 2:48 P.M. with Resident #83 revealed she did not like the food and the food was often cold. Interview on 01/06/26 at 9:14 A.M. with Resident #130 revealed Resident #130 often asked for meal substitutes because the main meal was always cold and unseasoned. Interview on 01/07/06 at approximately 9:30 A.M. with [NAME] #727 revealed the beef brisket needed to be cooked to at least 165 degrees Fahrenheit (F) before serving. Observation on 01/07/06 at 11:02 A.M. revealed [NAME] #729 taking the temperature of beef brisket upon removal from the steamer oven. Continued observation and concurrent interview revealed the meat temperature was 51 degrees F. [NAME] #729 stated the meat would need to reach appropriate temperature before service began at 11:30 A.M. Interview on 01/07/06 at 11:37 A.M. with [NAME] #729 stated she already began serving meal trays. [NAME] #729 stated the beef brisket reached a temperature of 202 degrees F when she removed it from the oven. Observation on 01/07/06 at 11:40 A.M. revealed Interim Dietary Manager (IDM) #708 checking the temperature of the beef brisket. Continued observation and concurrent interview with IDM #708 revealed the beef brisket temperature was 160 degrees F. Interview on 01/07/06 at 11:40 A.M. with [NAME] #729 regarding the discrepancy of the beef brisket temperature from 202 degrees F to 160 degrees F revealed [NAME] #729 stated the gravy she mixed into the beef brisket must have cooled down the meat temperature. Observations on 01/07/06 beginning at 11:59 A.M. revealed [NAME] #729 plated a test tray. The test tray left the kitchen at 12:02 P.M. and had to be carried individually by Dietary Aide #721 as staff did not load it on the cart. The meal tray arrived on the floor at 12:04 P.M. but was on a tray too large for the cart. The tray was set on a counter in the hall. At 12:05 P.M. Dietary Aide #721 brought a tray from the kitchen and put the test tray on the new tray and loaded it into the cart. IDM #708 joined the surveyor on the floor at 12:06 P.M. The first meal tray was passed by staff at 12:08 P.M. The final meal tray was passed by staff at 12:23 P.M. At 12:23 P.M. the test tray was removed from the cart and taken the dining room. Review of the test tray on 01/07/06 beginning at 12:23 P.M. revealed IDM #708 used a thermometer to determine the beef brisket temperature was 125 degrees F. Concurrent sampling of the test tray by the Surveyor and IDM #708 revealed the beef brisket was warm, but not hot, and was bland and not very flavorful. Further review revealed the mixed vegetables were cool and very bland and seemed to only be seasoned with black pepper. No concern was identified with the baked sweet potato, which was palatably warm, a creamy texture, and flavorful without any additional seasonings. Interview on 01/07/06 at 12:35 P.M. with Resident #77 stated she had not begun to eat her meal as staff was providing personal care assistance, but stated the lid and plate felt warm, and further stated that's a first. Follow-up interview on 01/07/26 at approximately 12:45 P.M. with Resident #77 revealed concerns regarding the taste and temperature of her lunch. Resident #77 stated that the taste of today's lunch food was inferior and less than lukewarm. The resident also stated that six to seven of her meals between lunch and supper per week consist of chicken noodle soup as an alternative because she was not happy with what was typically served. Interview on 01/07/06 at approximately 12:50 P.M. with Resident #20 revealed she had not yet received her meal tray and was actively working with therapy. Interview on 01/07/06 at 2:26 P.M. with Resident #20 revealed she attempted to eat the beef brisket but found it too chewy and without flavor. Resident #20 requested a substitute and received a hamburger instead of the beef brisket. Resident #20 stated she was able to make the mixed vegetables palatable by adding seasonings and butter.

Based on medical record review, observation, review of the legionella weekly fixture exercise logs for the year of 2025, staff interview, and policy review, the facility failed to ensure documentation for legionella prevention was accurate. This had the potential to affect all residents. Furthermore, the facility failed to ensure medications were accurately transcribed and the medical record was accurate regarding the receipt of medications for Resident #20. This affected one resident (#20) of four residents reviewed for accurate medical records. The facility census was 122.Findings include: 1. Review of the Legionella weekly fixture exercise log for the year of 2025 revealed the documents for July, August, and September had been copied and used again for the months of October, November, and December. Interview on 01/07/26 at 12:52 A.M. with Regional Nurse/Registered Nurse #800 verified the Legionella documents were photocopied. Interview on 01/07/26 at 2:50 P.M. with Maintenance Assistant (MA) #689 verified he had made copies of the forms because he does not like to write and it would take more time. The facility did not have a policy regarding accurate documentation. 2. Review of Resident #20's medical record revealed an admission date of 12/22/25. Diagnoses included acute kidney failure, cellulitis of the right lower limb, hypertensive heart disease, congestive heart failure, metabolic syndrome, chronic obstructive pulmonary disease, type two diabetes mellitus, and gastroesophageal reflux disease. Review of Resident #20's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #20 had intact cognition. Review of Resident #20's physician orders revealed an order on 12/22/25 for Cozaar oral tablet 25 milligram (mg) with instructions to give one tablet by mouth one time a day for hypertension. Review of Resident #20's Medication Administration Record (MAR) for the months of December 2025 and January 2026 revealed an order for Cozaar oral tablet 25 mg with instructions to give one mg by mouth one time a day for hypertension. Interview on 01/06/26 at 11:43 A.M. with Licensed Practical Nurse (LPN) #684 verified there was a discrepancy between the physician's orders and the MAR for the Cozaar ordered for Resident #20, and the order should have been verified prior to administering the medication. Review of the facility policy with an approval date of August 2022 titled Documentation of Medication Administration revealed all medications administered by a nurse or Certified Medication Aide should be documented on the MAR. 3. Interview on 01/06/26 at 10:55 A.M. with Resident #20 revealed she had not received her morning medications yet, including a water pill for swelling in both lower legs. Resident #20 stated she went to therapy right after breakfast. Review of the January 2026 MAR for Resident #20, on 01/06/26 at 10:57 A.M. revealed Resident #20's morning medications were marked off with a check mark, indicating the medications were dispensed and administered, including Bumetanide (a diuretic) tablet 2 mg ordered for congestive heart failure/lymphedema. Interview on 01/06/26 at 11:22 A.M. with Licensed Practical Nurse (LPN) #684 confirmed she pulled Resident #20's medications from the medication cart, charted in the electronic medical record to indicate the medications were administered, then realized Resident #20 was not in her room and was unable to administer the medications. LPN #684 confirmed the charting indicated Resident #20 had received her medications; however, LPN #684 showed the cup of Resident #20's medications remained in the medication cart awaiting administration. Review of the policy, Medication Administration, approved 04/2024, revealed the individual administering the medication must initial in the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

Based on medical record review, observation, staff interview, resident interview, and review of facility policy the facility failed to ensure the proper use of personal protective equipment (PPE) during care of residents on isolation and in enhanced barrier precautions (EBP). This affected six residents (#15, #9, #94, #119, #82, and #72) of eight residents reviewed for infection control practices. The facility census was 122. Findings include: 1. Observation on 01/05/26 at 10:22 A.M. found Certified Nursing Assistant (CNA) #655 entered room [ROOM NUMBER] occupied by Resident #15. CNA #655 wore standard glasses, donned a gown, gloves, and an N-95 mask prior to entering the room. A sign was posted on the door indicating Resident #15 was on droplet precautions. The posting listed the required Personal Protective Equipment (PPE) when entering the room was gloves, gown, goggles, and an N-95 mask. CNA #655 did not apply goggles or any other eye protection over her standard glasses. CNA #655 did not disinfect her glasses after exiting the room. Interview on 01/05/26 at 10:26 A.M. with CNA #655 verified Resident #15 was on droplet isolation due to having COVID-19. CNA #655 also verified she had not applied goggles prior entering Resident #15's room. CNA #655 reported wearing standard glasses was sufficient eye protection when providing care for residents on droplet precautions. 2. Observation on 01/05/26 at 10:54 A.M. found CNA #655 entered room [ROOM NUMBER] occupied by Resident #82. CNA #655 again wore standard glasses, donned a gown, gloves, and an N-95 mask prior to entering the room. A sign was posted on the door indicating Resident #82 was on droplet precautions and required PPE when entering the room was gloves, gown, goggles, and an N-95 mask. CNA #655 did not disinfect her glasses after exiting the room. 3. Observation on 01/05/26 at 10:58 A.M. found CNA #655 entered room [ROOM NUMBER] occupied by Resident #9. CNA #655 again wore standard glasses, donned a gown, gloves, and an N-95 mask prior to entering the room. CNA #499 also entered room [ROOM NUMBER] and donned goggles, gown, gloves and an N-95. A sign was posted on the door indicating Resident #9 was on droplet precautions and required PPE when entering the room was gloves, gown, goggles, and an N-95 mask. Coinciding interview with CNA #655 verified Resident #82 and Resident #9 were on droplet isolation due to COVID-19. No goggle or eyeglass disinfection was observed. 4. Observation on 01/05/26 at 11:47 A.M. found CNA #647 entered room [ROOM NUMBER] to assist with resident care for Resident #94 and #119. Signs were posted indicating Resident #94 and #119 were on droplet precautions and required PPE when entering the room were gloves, gown, goggles, and an N-95 mask. CNA #647 was observed entering the room with a surgical mask only and her standard eyeglasses. CNA #647 donned a gown and gloves but not an N-95 mask or goggles. Interview on 01/05/26 at 11:51 A.M. with CNA #647 verified she had entered room [ROOM NUMBER], a room with COVID positive residents, with a surgical mask and her standard eyeglasses. CNA #647 stated her eyes nose and mouth were covered and an N-95 was advised for COVID rooms but not required. 5. Observation on 01/05/26 at 11:57 A.M. found CNA #647 entered into room [ROOM NUMBER] occupied by Resident #82 to respond to a call light. CNA #647 continued to wear a surgical mask and her standard eyeglasses only when entering a droplet isolation/COVID room. 6. Observation on 01/05/26 at 12:02 P.M. found the Administrator in Training (AIT) #739 assisting with meal delivery. AIT #739 was observed changing into an N-95 mask from a surgical mask, donning a gown, gloves and goggles prior to entering room [ROOM NUMBER], occupied by Resident #9. Interview on 01/05/26 with AIT #739 verified Resident #9 in room [ROOM NUMBER] was on droplet isolation and to enter required an N-95, gown, gloves, and eye covering being either goggles or a face shield. AIT #739 reported shoe coverings were available but optional. Goggles were disinfected and hand hygiene was completed following removal of all PPE before exiting the room. 7. Observation on 01/05/26 at 12:12 P.M. found CNA #647 exited out of room [ROOM NUMBER] and changed her surgical mask. CNA #647 had not worn an N-95 when providing care to Resident #82. CNA #647 also at no time disinfected her standard eyeglasses after exiting droplet isolation rooms and no goggles were worn. Interview on 01/05/26 at 3:44 P.M. with Resident #9 in room [ROOM NUMBER] found him to be alert and aware. Resident #9 verified staff were not always wearing the necessary PPE when helping him with care. 8. Observation on 01/07/26 at 12:15 P.M. revealed CNA #647, wearing standard glasses, donning a gown, gloves, and an N-95 mask and entering a COVID isolation room occupied by Resident #9 to provide a meal tray. CNA #647 did not don goggles prior to entering the room and passing a meal tray. Interview on 01/07/26 at 12:16 P.M. with the Administrator and CNA #647 confirmed she was not wearing goggles before passing the meal tray. 10. Review of the medical record for Resident #72 revealed an admission date of 1/24/25. Diagnoses included dementia, depression, Alzheimer's disease, and long term use of anticoagulants. Review of the quarterly MDS assessment, dated 11/17/25, revealed Resident #72 had intact cognition (BIMS 13), used a walker and wheelchair for mobility and was dependent for personal hygiene. Review of Resident #72's care plan initiated on 01/27/25 and last revised on 12/04/25 revealed Resident #72 required EBP related to a urinary catheter and wounds. Interventions included staff to wear appropriate PPE as indicated when providing patient care, and to educate resident and caregiver on EBP precautions and appropriate PPE. Review of Resident #72's physician orders dated 12/05/25 revealed an order for enhanced barrier precautions every shift for wounds. Observation on 01/07/26 at 8:47 A.M. of Resident #72's wound measurements revealed Licensed Practical Nurse (LPN) Unit Supervisor #570, Registered Nurse (RN) Unit Supervisor #566, and Nurse Practitioner (NP) #850 to be present in the room for the wound measurement. All three staff present were wearing gloves and a surgical face mask but did not have on a gown. Interview on 01/07/26 at 8:52 A.M. with NP #850, LPN #570, and RN #566 verified all three staff members were not wearing the appropriate PPE for EBP when caring for Resident #72. Review of the facility policy with an approval date of July 2024 titled Enhanced Barrier Precautions revealed EBPs require the use of gown and gloves for high contact resident care activities such as dressing, changing briefs, assisting with toileting, and wound care.

Based on medical record review, staff interview, and review of the psychotropic consent forms, the facility failed to ensure residents and/or their representatives were informed of and consented to the use of psychotropic medications prior to administration. This affected five residents (#113, #3, #5, #4 and #49) of five residents reviewed for unnecessary medications. The facility census was 122. Findings include:1. Review of Resident #113's medical record revealed an admission date of 09/21/25 and a discharge date of 01/08/26. Diagnoses included adjustment disorder, Parkinson's disease, type II diabetes, dementia with mood disorder, immunodeficiency due to medications (cancer medications), major depressive disorder, and general anxiety disorder. Review of Resident #113's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating Resident #113 was moderately cognitively impaired. Resident #113 required maximal assistance with toilet use, bathing, and dressing. Resident #113 displayed no behaviors at the time of the review. Review of Resident #113's care plan revised 12/30/25 revealed supports and interventions for chronic confusion related to dementia, risk for adverse effects from psychotropic medication use, short term stay for rehabilitation therapy, depression, anxiety, altered sensory perception, self-care deficit, pain, and COVID-19. Review of Resident #113's physician orders revealed an order dated 09/21/25 for Duloxetine HCl (hydrochloride) (anti-depressant) delayed release sprinkles 60 milligrams (mg) in the morning for mood. Further review of Resident #113's physician orders found an order dated 09/21/25 for Olanzapine (antipsychotic) 7.5 mg at bedtime for symptoms of anxiety and major depression related to diagnosis of Parkinson's disease. Review of Resident #113's Psychotropic Medication informed Consent dated 09/21/25 revealed Resident #113 Olanzapine 7.5 milligrams (mg) nightly was listed for consent. The consent form was not signed by Resident #113 or his representative. Registered Nurse (RN) #581 was the only signature on the form. Further review of Resident #113's Psychotropic Medication Informed Consent forms revealed there was no consent form signed for the use of Resident #113's Duloxetine HCl 60 mg in the morning for mood. Interview on 01/12/26 at 12:47 P.M. with Regional Nurse Registered Nurse #800 verified Resident #113's Olanzapine 7.5 mg consent was not signed by Resident #113 or his representative and there was not a consent completed for Resident #113's Duloxetine HCl sprinkles 60 mg. Interview on 01/12/26 at 12:58 P.M. with Registered Nurse #581, who had signed Resident #113's psychotropic medication consent form, verified consent from Resident #113 or his representative had not been acquired for his psychotropic medications. 2. Review of the medical record for Resident #3 revealed an admission date of 12/01/25 with diagnoses of left femur fracture, hypertensive heart disease and chronic kidney disease, dementia, heart failure, Alzheimer's disease, hyperparathyroidism, osteoporosis, and dependence on supplemental oxygen. Resident #3 discharged home on [DATE]. Review of the comprehensive admission MDS assessment, dated 12/08/25, revealed Resident #3 had impaired cognition and received antipsychotics, and antianxiety and antidepressant medications. Review of the physician order initiated 12/01/25 and discontinued 01/05/26 revealed Resident #3 received Trazodone HCl (an antianxiety medication) oral tablet 50 mg once daily by mouth at bedtime for sleep. Review of the physician order initiated 12/01/25 revealed Resident #3 received buspirone HCl (an antidepressant) oral tablet 5 mg once, one tablet three times daily for anxiety. Review of the physician order initiated 12/01/25 and discontinued 12/03/25 revealed Resident #3 received Quetiapine Fumarate (an antipsychotic) 50 mg twice daily for anxiety. Review of the physician order initiated 12/03/25 revealed Resident #3 received Quetiapine Fumarate oral tablet 50 mg once daily at bedtime for anxiety. Review of the physician order initiated 12/03/25 revealed Resident #3 received Quetiapine Fumarate oral tablet 25 mg once daily for anxiety. Review of the physician order initiated 01/05/26 revealed Resident #3 received trazodone HCl oral tablet 50 mg, 1.5 tablets by mouth at bedtime for sleep. Review of the document Psychotropic Medication Informed Consent, dated 12/01/25, revealed a recommendation for Resident #3 to receive Seroquel (Quetiapine Fumarate) 50 mg twice daily. Further review of the form revealed no diagnoses were listed and no indications for use were included on the form. Additionally, the form did not include trazodone HCl or buspirone HCL, two additional psychotropic medications prescribed to, and received by, Resident #3. Review of the Medication Administration Record (MAR) for December 2025 and January 2026 revealed Resident #3 received the three psychotropic medications as ordered. Interview on 01/08/2026 at 11:31 A.M. with Unit Supervisor #568, and concurrent review of Resident #3's Psychotropic Medication Informed Consent, confirmed no indications for the use of Seroquel were listed, and the form did not include trazodone HCl or buspirone HCl. Interview on 01/08/26 at 3:51 P.M. with Regional Registered Nurse #800 confirmed all psychotropic medications should be listed on the consent form. 3. Review of Resident #5's medical record revealed an initial admission date of 11/17/25 and a re-admission date of 12/06/25. Diagnoses included unspecified mental disorder due to known physiological condition, unspecified lack of expected normal physiological condition, type two diabetes mellitus, gout, and hypertensive chronic kidney disease. Review of Resident #5's Medicare five-day MDS assessment dated [DATE] revealed a BIMS score of 01 which indicated Resident #5 had severely impaired cognition. Review of Resident #5's care plan that was initiated on 11/18/25 revealed Resident #5 had an alteration in cognitive status related to short and long-term memory loss with interventions that included monitoring for changes in cognitive patterns and to notify the physician of changes and to provide verbal reminders and cues to assist Resident #5 in orientation. Review of Resident #5's face sheet revealed Resident #5 had two resident representatives and was not his own responsible party. Review of Resident #5's psychotropic medication informed consent signed on 12/07/25 revealed Resident #5 was admitted to the facility taking Seroquel (antipsychotic) 25 mg daily in the morning and 12.5 mg daily at bedtime by mouth. Furthermore, Resident #5 had electronically signed the psychotropic medication informed consent form. Interview on 01/12/26 at 10:24 A.M. with Regional Nurse/Registered Nurse #800 verified Resident #5 signed the psychotropic medication informed consent and should not have signed the form as one of his resident representatives should have. 4. Review of Resident #4's medical record revealed the resident was admitted [DATE] and had diagnoses that included, but were not limited to, severe bipolar disorder without psychotic features, depression, and insomnia. Review of Resident #4's quarterly MDS assessment, dated 11/08/25, revealed the resident was cognitively intact. The assessment indicated the resident received antipsychotic medication on a routine basis. Review of Resident #4's physician orders revealed they included orders for Quetiapine (antipsychotic) 25 mg for bipolar disorder (ordered 11/02/25), Aripiprazole (antipsychotic) 25 mg at bedtime for bipolar disorder (ordered 11/02/25), Sertraline (antidepressant) 50 mg daily for depression (originally ordered 11/18/25 at 25 mg daily), Ramelteon (Melatonin receptor agonist) 8 mg at bedtime for insomnia (ordered 11/02/25), and trazodone (antidepressant) 50 mg at bedtime for insomnia (ordered 11/02/25). Review of Resident #4's MAR for November and December 2025 and January 2026 (through 01/08/25), confirmed the aforementioned medications were administered as ordered. Review of Resident #4's comprehensive care plan further revealed the resident was at risk for depression and mood fluctuations, for which an intervention was listed to administer medications as ordered. The care plan identified a risk for adverse effects of the antipsychotic and antidepressant medication with interventions to monitor for such. Review of progress notes from Resident #4's psychiatric evaluation on 12/18/25, revealed the medications and potential side effects were discussed with the resident, and nursing staff were to obtain written consent from the resident. Further review of Resident #4's record revealed it contained a form titled, Psychotropic Medication Informed Consent, that was electronically signed by Resident #4 on 10/21/25. The form listed the prescribed medications as Ability (Aripiprazole), 15 mg daily for bipolar schizophrenia. No other medications were included on the form. Resident #4's record included a second copy of the consent form that was signed by Resident #4 on 11/02/25. The form was blank other than Resident #4's signature and date, and no medications or potential side effects were listed. Interview on 01/08/26 at 3:50 P.M. with Regional Registered Nurse #800, confirmed the facility had not obtained consent for Resident #4's psychotropic medications. 5. Review of Resident #49's medical record revealed an admission date of 10/05/25. Diagnoses included amputation, osteomyelitis of the right ankle and foot, type II diabetes mellitus, and depression. Review of Resident #49's MDS dated [DATE] revealed the resident had an intact cognition. Antidepressant medication was administered daily. Review of Resident #49's medical record revealed a physician's order dated 10/05/25 for Fluoxetine (antidepressant) HCI 20 milligrams (mg) to be taken by mouth one time a day. Review of Resident #49's Psychotropic Medication Informed Consent form dated 10/05/25 revealed the resident was failed to be educated regarding Fluoxetine. The medication information, consent, resident/resident representative information was left blank, but a staff nurse had signed the form on 10/05/25 at 3:27 P.M. Interview with Resident #49 on 01/12/26 at 10:44 A.M. revealed he did not recall signing the consent form. Interview with Corporate Nurse #800 on 10/12/26 at 8:22 A.M. verified that Resident #49's Psychotropic Medication Informed Consent form was failed to be completed prior to administering the antidepressant medication. Review of the form titled Psychotropic Medication Informed Consent revealed each resident's medication is managed and monitored to improve their quality of life, functional capacity, promote or maintain their highest practicable mental, physical and psychosocial well-being. In some instances, this will include the use of psychotropic medication. Psychotropic medication intervention would only be initiated after nonpharmacological interventions were attempted and found to be ineffective.

Based on observation, medical record review, staff interview, and policy review, the facility failed to administer medications per physician orders. This affected three residents (#5, #20, and #125) of four residents reviewed for medication administration. The medication error rate was 21.43 percent with six errors for the 28 medication opportunities. The facility census was 122.Findings include: 1. Review of Resident #5's medical record revealed an admission date of 12/06/25. Diagnoses included hypertensive chronic kidney disease stage 3B, anxiety, non-ischemic myocardial injury, gout, and type II diabetes mellitus. Review of Resident #5's Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 01 which indicated Resident #5 had severely impaired cognition. Review of Resident #5's physician orders revealed an order initiated on 12/23/25 for a Depakote oral tablet delayed release 125 milligrams (mg) with instructions to give one tablet by mouth two times a day for agitation. Observation on 01/07/26 at 10:39 A.M. of Licensed Practical Nurse (LPN) #685 preparing medications for Resident #5 revealed LPN #685 did not prepare the Depakote. Concurrent interview with LPN #685 verified she was omitting the medication due to an inability to crush the pill. LPN #685 stated Resident #5 took his pills through his feeding tube. Review of Resident #5's Medication Administration Record (MAR) for the month of January revealed LPN #685 marked a 9 which indicates other and to see the nurses notes. Review of Resident #5's nurses notes revealed LPN #685 did not enter a nurses note regarding the omission of the Depakote. 2. Review of Resident #20' s medical record revealed an admission date of 12/22/25. Diagnoses included acute kidney failure, cellulitis of the right lower limb, hypertensive heart disease, congestive heart failure, metabolic syndrome, chronic obstructive pulmonary disease, type II diabetes mellitus, and gastroesophageal reflux disease. Review of Resident #20's admission MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated Resident #20 had intact cognition. Review of Resident #20's physician orders revealed an order to give Bumetanide two mg with instructions to give one two mg tablet by mouth one time day for congestive heart failure/lymphedema. Further review of the physician orders revealed an order for Janumet oral tablet 50-500 mg with instructions to give one tablet by mouth two times a day for diabetes mellitus. Interview on 01/06/26 at 10:55 A.M. with Resident #20 revealed she had not received her morning medications yet, including Bumetanide used for swelling. Resident #20 stated she went to therapy right after breakfast. Observation of medication administration on 01/06/26 at 11:37 A.M. completed by LPN #684 revealed that the medications were administered at 11:43 A.M LPN #684 also verified she was not giving the Janumet due to the medication being unavailable as the previous nurse did not re-order the medication in time. 3. Review of the medical record for Resident #125 revealed the resident was originally admitted [DATE] and had diagnoses that included schizoaffective disorder; depressive type, adjustment disorder with mixed anxiety and depressed mood, adjustment insomnia, generalized anxiety disorder, and psychotic disorder with hallucinations. Review of Resident #125's quarterly MDS assessment, dated 10/22/25, revealed the resident had intact cognition. The assessment indicated the resident received antipsychotics on a routine basis. Review of Resident #125's physician orders revealed they included multiple medication orders, including one dated 05/26/25 for Aripiprazole (antipsychotic) 20 mg tablet, give one tablet once daily, and Aripiprazole 5 mg tablet, give one tablet once daily (to equal a total dose of 25 mg once daily) for schizoaffective disorder. The record also included an order dated 08/20/25 for Risperdal 1 mg tablet, give one tablet twice daily for schizoaffective disorder. Observation on 01/07/26 at 8:30 A.M. revealed that during the preparation of Resident #125's morning medications, LPN #685 was unable to locate the Aripiprazole 20 mg tablets and the Risperdal 1 mg tablets. During this observation, LPN #685 stated those medications could not be administered since they were unavailable. The nurse prepared and administered the Aripiprazole 5 mg tablet and confirmed that without the 20 mg tablet, Resident #125 received 5 mg of Aripiprazole instead of the ordered 25 mg dose. Subsequent review of Resident #125's medical record confirmed LPN #685 documented the Aripiprazole 20 mg tablet and Risperdal 1 mg tablet were not administered because they were unavailable. Interview on 01/12/26 at 9:35 A.M. with Regional Registered Nurse #800 further confirmed LPN #685 did not administer the Aripiprazole 20 mg tablet on the morning of 01/07/26, resulting in a dosage error since the order was for Aripiprazole 25 mg. The nurse further confirmed LPN #685 did not administer the Risperdal 1 mg tablet as ordered on the morning of 01/07/26. Interview on 01/12/26 at 10:36 A.M. with Registered Nurse Unit Supervisor #568, confirmed the facility's automated dispensing cabinet in the main storage room contained a supply of Aripiprazole for Resident #125. The nurse confirmed the full dose of the medication could have been administered on the morning of 01/07/26, had the administering nurse accessed it from the dispensing unit. Review of a policy titled, Administering Medications, dated April 2024, confirmed medications shall be administered in a safe manner, as prescribed.

Based on observation, staff interview, review of the medical record, and review of the menu spreadsheet, the facility failed to ensure residents on a pureed diet received adequate protein portions. This affected all five residents (#5, #21, #72, #80, and #124) on a pureed diet. Additionally, the facility failed to ensure residents on a pureed diet received all menu items on their meal tray. This affected one (#80) of one resident observed for menu items. Further, the facility failed to ensure residents received double portions as ordered. This affected one (#77) of three residents reviewed for nutrition. The facility census was 122.Findings include:1. Observations on 01/07/26 beginning at 11:37 A.M. revealed [NAME] #729 and [NAME] #727 plating meals for the noon meal, including trays for residents on a pureed diet. Interview and observation on 01/07/26 at 11:59 A.M. with [NAME] #727 confirmed a blue handled serving scoop was used to plate pureed beef brisket. Follow-up observation on 01/07/26 at 12:45 P.M. revealed the kitchen had completed serving noon meals, and all serving utensils remained in the serving containers, including the blue scoop in the pureed beef brisket. Interview on 01/07/26 at 12:45 P.M. with [NAME] #731, and concurrent review of the menu spreadsheet for the noon meal served 01/07/26, revealed residents on a pureed diet should receive a #6 scoop size portion of pureed beef brisket. [NAME] #731 stated the blue scoop used to serve pureed beef brisket was a two-ounce portion. [NAME] #731 further stated a #6 scoop provided a five-and 1/3 ounce portion of protein. [NAME] #731 confirmed residents on a pureed diet received less than half of the serving size identified on the menu spreadsheet. 2. Record review for Resident #80 revealed an admission date of 11/27/25 with diagnoses of dysphagia and dementia. Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 12/04/25, revealed Resident #80 had impaired cognition and was able to eat with setup or clean-up assistance. Review of the physician order initiated 11/30/25, and revised 12/29/25, revealed Resident #80 received a regular diet with blenderized (pureed) texture and thin liquids. Observation on 01/07/26 at 11:55 A.M. revealed [NAME] #729 plating a pureed meal tray. No pureed bread was observed to be plated with the meal. Interview on 01/07/26 at 12:00 P.M. with [NAME] #729 revealed she served the pureed bread under the protein portion on the plate. Observation on 01/07/26 at 12:13 P.M. of Resident #80's meal plate, and concurrent interview with Interim Dietary Manager #708, confirmed no evidence of a bread serving was under the pureed meat on Resident #80's plate. Review of the menu spreadsheet for the noon meal on 01/07/26 revealed residents on a pureed diet should receive a pureed bread serving. 3. Review of Resident #77's medical record revealed an admission date of 11/07/26. Diagnoses included diabetes mellitus type two, cardiomegaly, and morbid obesity. Review of Resident #77's 5-day admission MDS dated [DATE] revealed her cognition was intact. Review of Resident #77's most recent care plan revealed having choices were important to her. The resident was at risk for impaired skin integrity related to diabetes mellitus, morbid obesity, and impaired circulation. Interventions included to give treatments as ordered. Review of Resident #77's medical order revealed a physician's order dated 11/10/25 for no concentrated sweets diet, regular texture, and thin consistency related to type II diabetes mellitus with diabetic polyneuropathy. Review of Resident #77's dietary note dated 12/15/25 revealed the resident had a high body mass index (BMI.) Previously the resident was ordered a liquid protein drink, but did not like the flavor. A new recommendation was made to begin double protein meals. Interview with Resident #77 on 01/07/26 at 10:57 A.M. revealed she was to receive double protein meals, but failed to receive the proper diet. Observation of Resident #77's meal tray on 01/07/26 at 1:08 P.M. revealed the resident ' s meal contained two sweet potatoes, two dinner rolls, approximately one cup of shredded meat, mixed vegetables, cranberry juice, a cookie, and small container of brown sugar. Review of the portion size spreadsheet dated 01/07/26 revealed the single portion serving of meat was eight ounces, so Resident #77 should have received 16 ounces of meat. Interview with Dietary Manager #708 on 01/08/26 at 7:50 A.M. revealed Resident #77 was to receive double protein at lunch and dinner. Review of the resident's meal ticket revealed it read double protein, Dietary Manger #708 verified the resident had been receiving double portions instead of double protein. Interview with Dietician #686 on 01/12/26 at 1:24 P.M. revealed she ordered double protein meals for lunches and dinners for Resident #77 on 12/15/25. Dietician #686 verified the dietary manager placed the order in the dietary computer program and the resident's meal tickets were printed properly as double protein. When explained to the dietician what the resident had received for her meal, she stated the staff are providing double portions instead of double protein. In addition, she verified that the order in the medical record read regular texture, thin consistency and no concentrated sweets and failed to be updated as double protein. Review of the facility policy titled Diet Orders, dated August 2018 revealed diets will be offered as ordered by the physician. The dietetics professional will be notified of any special diets not listed on the menu, so that they can be written.

Based on staff interview and policy review, the facility failed to ensure nurses dispensed and administered medications within appropriate standards of practice. This affected 12 residents (#16, #34, #35, #36, #46, #62, #70, #72, #85, #111, #125, and #126). The facility census was 122.Findings include:Interview on 01/06/26 at 11:22 A.M. with Licensed Practical Nurse (LPN) #684 revealed she was an agency nurse and arrived late for the shift on 01/06/26. LPN #684 stated she completed a medication pass in coordination with Medication Aide - Certified (MA-C) #653. LPN #684 stated she pulled the medications from the cart, charted the medications were administered, and handed the medications to MA-C #653 to administer to residents.Interview on 01/06/26 at 11:29 A.M. with MA-C #653 confirmed she assisted LPN #684 with a medication pass. Follow-up interview on 01/06/25 at 1:07 P.M. with MA-C #653 revealed she worked with LPN #684 during the morning medication pass on 01/06/26. MA-C #653 stated they were working together because LPN #684 arrived late for her shift. MA-C #653 stated LPN #684 pulled the medications from the cart and MA-C #653 administered the medications to the residents. MA-C #653 stated this occurred for 12 residents (#16, #34, #35, #36, #46, #62, #70, #72, #85, #111, #125, and #126). Interview on 01/07/26 at 9:30 A.M. with Regional Registered Nurse (RN) #800 revealed it was not a nursing standard of practice for a nurse to pull medications from the cart and another staff to administer the medications.Review of the policy, Medication Administration, approved 04/2024, revealed the individual administering the medication must initial in the resident's MAR (Medication Administration Record) on the appropriate line after giving each medication and before administering the next ones.

Based on observation, record review, staff interview, and policy review, the facility failed to ensure pressure-reducing devices were in place. This affected two (#28 and #123) of six residents reviewed for skin breakdown. The facility census was 122.Findings include:1. Review of the medical record for Resident #28 revealed an admission date of 12/22/25 with diagnoses of atrial fibrillation, dementia, and Raynaud syndrome. Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 12/29/25, revealed Resident #28 had impaired cognition and required substantial/maximal assistance for bed mobility. Further review revealed Resident #28 was at risk for developing pressure injuries.Review of the current care plan, initiated 12/22/25, revealed Resident #28 was at risk for impaired skin integrity, Interventions, initiated 12/23/25, revealed staff should off-load Resident #28's heels while in bed. Review of the physician order dated 12/23/25 revealed Resident #28 was to wear heel lift boots to both lower extremities when in bed. Observation on 01/05/26 at 2:07 P.M. revealed Resident #28 lying in bed. A pair of offloading boots were sitting on the shelf opposite her bed.Interview on 01/05/26 at 2:15 P.M. with Certified Nursing Assistant (CNA) #628 confirmed Resident #28 was not wearing the offloading boots. CNA #628 stated he believed the boots were used when Resident #28 was in bed for the night, and did not offer to place them on Resident #28's feet when he laid her in bed for a nap. Concurrent review of the electronic medical record (EMR) for Resident #28 revealed CNA #628 confirmed Resident #28 had an order to wear heel lift boots when in bed. 2. Review of the medical record for Resident #123 revealed an admission date of 04/12/15 with diagnoses of anxiety, chronic respiratory therapy, depression, embolism and thrombosis. Resident #123 was under the care of hospice. Review of the quarterly MDS assessment, dated 11/13/25, revealed Resident #123 had impaired cognition, was dependent on staff for bed mobility, and was at risk for developing pressure ulcers. No pressure ulcers were identified at the time of the assessment. Review of the physician order dated 10/06/25 revealed Resident #123 should have heel lift boots on as tolerated while in bed for skin integrity. Review of the physician order dated 10/06/25 revealed Resident #123 should offload heels when in bed if resident tolerates or will allow. Review of the current care plan, revised 01/06/26, revealed Resident #123 was at risk for impaired skin integrity related to total dependence for care. Interventions include off-loading heel boots as tolerated. Observation on 01/05/2026 at 2:28 P.M. and concurrent interview with Unit Supervisor (US) #566 revealed Resident #123 lying in bed. Offloading boots were observed on a shelf in the room. US #566 confirmed Resident #123 was not wearing offloading boots. Continued interview, with concurrent review of the EMR, revealed US #566 confirmed Resident #123 had a physician order to wear heel lift boots, as tolerated, while in bed for skin integrity. US #566 proceeded to ask Resident #123 if US #566 could place offloading boots on her heels and Resident #123 was agreeable.Review of the policy Wound and Skin Management Protocol, approved 09/2024, revealed the facility would implement preventative interventions (to protect skin integrity) immediately upon admission.

Based on record review, staff interview, resident review, and policy review, the facility failed to ensure nursing staff assessed wounds accurately. This affected Resident #123 and had the potential to affect 31 residents (#1, #6, #12, #15, #20, #27, #33, #36, #38, #49, #51, #57, #59, #68, #72, #87, #89, #95, #97, #99, #103, #104, #112, #120, #123, #124, #127, #129, #137, #140, and #141) identified with wounds. Additionally, the facility failed to ensure a resident did not receive food in preparation for a scheduled medical test. This affected one (#4) of one resident reviewed for medical testing. The facility census was 122. Findings include: 1. Review of the medical record for Resident #123 revealed an admission date of 04/12/15 with diagnoses of anxiety, chronic respiratory therapy, depression, embolism and thrombosis. Resident #123 was under the care of hospice. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/13/25, revealed Resident #123 had impaired cognition, was dependent on staff for bed mobility, and was at risk for developing pressure ulcers. No pressure ulcers were identified at the time of the assessment. Review of Resident #123's weekly skin assessments, titled Non-Pressure Injury Review, dated 11/19/25, revealed a right buttock wound, described as end of life skin failure measured 8 centimeters (cm) long by 5 cm wide by 2 cm deep. Review of the Non-Pressure Injury Review, dated 11/25/25, revealed Resident #123's right buttock wound measurement stated 10 cm by 6 cm by 0.1 cm (total area). Review of the Non-Pressure Injury Review, dated 12/09/25, revealed Resident #123's right buttock wound, measured 9 cm by 5.2 cm. Review of the Non-Pressure Injury Review, dated 12/16/25, revealed Resident #123's right buttock wound measured 8 cm by 5 cm. Review of the Non-Pressure Injury Review, dated 12/23/25, revealed Resident #123's right buttock wound measured 8 cm by 5 cm by less than 0.1 cm. No assessment was completed 12/30/25. Review of the Non-Pressure Injury Reviews, dated 01/06/26, revealed Resident #123's right buttock wound measured 1.4 cm by 4 cm by 0.1 cm. Interview on 01/07/26 at 10:07 A.M. with Unit Supervisor (US) #566 confirmed she remeasured a wound on Resident #72, another resident diagnosed with an end of life skin failure, after an agency floor nurse measured it incorrectly. Interviews on 01/08/26 at 2:17 P.M. and 3:26 P.M. with Unit Supervisor/Wound Nurse (USWN) #570 revealed she completed the assessment and measurement of Resident #123's wound on 01/06/26. USWN #570 stated Resident #123 was under the care of hospice, and her wound was not considered a pressure ulcer; therefore, facility floor nurses were assigned the task of measuring and assessing her wound. USWN #570 stated she was assigned the task of doing weekly rounds with the Wound Provider on Tuesdays for residents with pressure ulcers. Continued interview regarding the discrepancy in measurements between 12/23/25 and 01/06/26, USWN #570 stated the nurses conducting the assessments may have measured the whole darkened area; whereas the wound measurements should only reflect the open area of the wound. Additionally, USWN #570 stated the floor nurses may have not oriented their measurements correctly to the head-to-toe of the resident; suggesting the measurements taken on 12/23/25 of 8 cm by 5 cm by 0.1 cm may more likely have been 5 cm by 8 cm by 0.1 cm. Additionally, USWN #570 stated she found discrepancies in the way nurses were measuring wounds since she began the position as wound nurse approximately three months previously. Review of the policy, Wound and Skin Management, approved 09/2024, revealed Charge/Staff Nurse to complete Non-Pressure Skin Condition Record every week; and staff education on skin and wound practice guidelines with pressure injuries and wound/skin conditions upon orientation and annually at a minimum. 2. Review of Resident #4's medical record revealed the resident was admitted [DATE] and had diagnoses that included type II diabetes mellitus and dysphagia (difficulty swallowing). Review of Resident #4's quarterly MDS assessment, dated 11/08/25, revealed the resident was cognitively intact. Review of Resident #4's comprehensive care plan revealed it identified a potential for an altered nutrition and/or hydration status, due in part, to the diagnosis of dysphagia. Review of Resident #4's physician orders revealed they included an order for a National Dysphagia Diet (NDD); Level 3 (to include moist, soft foods) with nectar-thick liquids. The record further included an order for an Esophagogastroduodenoscopy (EGD). This test, which uses a flexible scope to examine the esophagus, stomach, and small intestine, was scheduled to be performed 01/08/26 at an area hospital. Included with this order, dated 01/07/26, was an order for the resident to have nothing by mouth after midnight, in preparation for the EGD. Review of a nurse's progress note dated 01/08/26, revealed Resident #4 was provided with a breakfast tray on this date, and the resident ate the meal. The progress note stated the nurse notified the outpatient survey center which canceled the procedure and rescheduled it for 01/30/26. Interview on 01/12/26 at 9:25 A.M. with Regional Registered Nurse #800 confirmed Resident #4 was provided a breakfast meal on the morning of 01/08/26, thereby necessitating the EGD to be rescheduled. The nurse stated the kitchen is typically made aware of such orders and will hold the breakfast meal, which did not happen in this case. The nurse further confirmed Resident #4's EGD was rescheduled for 01/30/26 (22 days later).

Based on observation, record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure dependent residents received adequate activities of daily living care. This affected one Resident (#77) for toenail care and one Resident #72 for fingernail care. This had the ability to affect all residents. The facility census was 122.Findings include: 1. Review of Resident #77's medical record revealed an admission date of 11/07/26. Diagnoses included osteoarthritis, type II diabetes mellitus, and a history of lower leg cellulitis. Review of Resident #77's 5-day admission Minimum Data Set (MDS) dated [DATE] revealed the resident had an intake cognition. The resident required substantial assistance with rolling left and right and lying to sitting. Review of Resident #77's most recent care plan revealed the resident required assistance with activities of daily living related to weakness, low hemoglobin, and osteoarthritis in bilateral knees. Staff assistance was required for dressing and grooming. Review of Resident #77's medical record revealed a physician's order dated 11/07/25 revealed the resident may have dental, podiatry, optometry, or psychiatry consult as needed. Review of a social service progress note dated 12/22/25 revealed a referral was sent to podiatry. Observation on 01/07/25 at 9:10 A.M. of Resident #77's toenails revealed the right great toenail was extremely thick and long. The nail was grown approximately one inch past the top of her toe and curled inward. The second toe on the left foot was viewed the same. All other toenails were longer than the resident wished and thick. Interview with Resident #77 on 01/07/26 at 9:10 A.M. revealed she had asked to see the podiatrist on admission but had not. The resident revealed due to having the diagnosis of diabetes mellitus the staff refused to trim her toenails. Interview with Certified Nursing Assistant (CNA) #620 on 01/08/26 at 7:38 A.M. verified Resident #77's toes nails were very long, thick, and flaky and in need of seeing the podiatrist. CNA #620 stated staff do not trim resident toenails if they have a diabetic diagnosis. Interview with Licensed Social Worker (LSW) #557 on 01/12/26 at 9:24 A.M. verified the she was unaware that Resident #77 had asked to see podiatry on admission, was not informed by nursing that the resident was in need, and but the referral was placed. The resident was on the podiatrist list for the next visit. 2. Review of the medical record for Resident #72 revealed an admission date of 1/24/25 with diagnoses of dementia, depression, Alzheimer's disease, and long-term use of anticoagulants. Review of the quarterly MDS assessment, dated 11/17/25, revealed Resident #72 had intact cognition and was dependent for personal hygiene. Review of the comprehensive care plan, initiated 01/27/25, and revised 01/12/26, revealed Resident #72 required assistance with activities of daily life due to fluctuating cognition and end of life hospice care. Interventions included encouraging Resident #72 to complete activities of daily life as independently as possible. Interview on 01/07/26 at 4:14 P.M. with CNA #642, and concurrent observation of Resident #72's fingernails, revealed Resident #72's fingernails were very long, extending well beyond her fingertips, were painted red, and had debris under most of them. CNA #642 stated Resident #72 was unable to feed herself. CNA #642 further stated when she tried to clean Resident #72's nails in the past, Resident #72, who had difficulty expressing herself, acted like the cleaning hurt. Interview on 01/12/26 at 9:25 A.M with CNA #651, and concurrent observation of Resident #72's fingernails, revealed Resident #72's fingernails were long, extending well beyond her fingertips, and the sides of the fingernail at the edge of the fingertip were curving and pressing into the skin at the sides of the fingertips. This was observed and confirmed on her left hand for the ring finger, middle finger, and pointer finger; and on her right hand for the ring finger, middle finger, and thumb. CNA #651 confirmed there was debris under the fingernails, but also stated it appeared the skin was bunched up under the fingernails. Further observation revealed no broken skin or open wounds on Resident #72's fingers. Review of the facility policy titled Care of Fingernails/Toenails dated May 2023 revealed the purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care includes regular cleaning and regular trimming. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

Based on record review, resident interview, staff interview, and policy review the facility failed to inform a resident of an impending room change. This affected one resident (#77) who was unexpectedly moved to a new room. This had the ability to affect all residents. The facility census was 122. Findings include:Review of medical record revealed Resident #77 was admitted on [DATE]. Diagnoses included osteoarthritis, diabetes mellitus, hepatomegaly, splenomegaly, and cardiomegaly.Review of Resident #77's 5-day admission Minimum Data Set (MDS) dated [DATE] revealed the resident's cognition was intact.Review of Resident #77's most recent care plan revealed that while in the facility choices were important to her.Review of Resident #77's progress note dated 01/02/26 at 11:15 A.M. revealed the resident was moved to room [ROOM NUMBER]-A with a report, medications, and chart were given to the nurse assigned.Interview with Resident #77 on 01/05/26 at 10:36 A.M. revealed she was moved from her room on the second floor without a choice to the room on the first floor on 01/02/26 without proper notification. The resident denied the move was COVID related. Interview with Licensed Social Worker (LSW) #557 on 01/12/26 at 9:24 A.M. verified that the resident's chart was absent of documentation regarding notification of a room move on 01/02/26. LSW #557 revealed all residents and families were normally notified prior to a room move.Review of the facility policy titled Room Change Policy dated November 2000 revealed following the decision of a room move the social worker or designee will follow up with the appropriate parties as needed including the resident and the resident representative to ensure that they are in agreement with the plan.

Based on medical record review, and staff interview, the facility failed to monitor the use of psychotropic medications to confirm they were necessary. This affected one resident (Resident #4) of five residents reviewed for unnecessary medications. The census was 122.Findings include:Review of Resident #4's medical record revealed the resident was admitted [DATE] and had diagnosis that included insomnia. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/08/25, revealed the resident was cognitively intact. The assessment indicated Resident #4 had reported trouble falling asleep, staying asleep, or sleeping too much, on 12 to 14 days of the two-week assessment period.Review of Resident #4's physician orders revealed they included an order for trazodone hydrochloride (an antidepressant) 50 milligrams (mg) daily at bedtime, and an order for Ramelteon (a Melatonin receptor agonist) 8 mg daily at bedtime. Both orders were dated 11/02/25 and both orders specified the medications were ordered to treat insomnia. Review of Resident #4's Medication Administration Records (MAR) for 11/01/25 through 01/12/26, confirmed the trazodone and Ramelteon were administered at bedtime every night as ordered. Review of Resident #4's comprehensive care plan revealed it included neither the diagnosis of insomnia, nor any goals or interventions, including but not limited to, the routine administration of the two medications ordered specifically for insomnia, and/or monitoring of the resident's sleep patterns to support the use of those two medications.Further review of Resident #4's medical record, including nurse and Certified Nursing Assistant (CNA) documentation, further confirmed the facility was not monitoring the resident's sleep patterns.Interview on 01/12/26 at 9:35 A.M. with Regional Registered Nurse #800 confirmed Resident #4's record did not include documented monitoring of the resident's sleep patterns, to support the use of the two routine psychotropic medications administered to Resident #4 for insomnia.

Based on medical record review, staff interview, and review of policy for care planning, the facility failed to develop a care plan for a diagnosis of insomnia. This affected one resident (Resident #4) of 23 residents reviewed for care planning. The census was 122.Findings include:Review of Resident #4's medical record revealed the resident was admitted [DATE] and had diagnosis that included insomnia. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/08/25, revealed the resident was cognitively intact. The assessment indicated Resident #4 had reported trouble falling asleep, staying asleep, or sleeping too much, on 12 to 14 days of the two-week assessment period.Review of Resident #4's physician orders revealed they included an order for trazodone hydrochloride (an antidepressant) 50 milligrams (mg) daily at bedtime, and an order for Ramelteon (a Melatonin receptor agonist) 8 mg daily at bedtime. Both orders were dated 11/02/25 and both orders specified the medications were ordered to treat insomnia. Review of Resident #4's Medication Administration Records (MAR) for 11/01/25 through 01/12/26, confirmed the trazodone and Ramelteon were administered at bedtime every night as ordered. Review of Resident #4's comprehensive care plan revealed it included neither the diagnosis of insomnia, nor any goals or interventions, including but not limited to, the routine administration of the two medications ordered specifically for insomnia.Interview on 01/12/26 at 9:35 A.M. with Regional Registered Nurse #800 confirmed Resident #4's comprehensive care plan did not include the diagnosed insomnia, nor a goal(s) or interventions for such, despite the facility administering trazodone and Ramelteon routinely to Resident #4.Review of a policy titled, Care Planning - Interdisciplinary Team, dated December 2021, confirmed a comprehensive care plan shall be developed within seven days of the comprehensive assessment.

Based on observation, medical record review, staff interview, resident interview, and policy review, the facility failed to ensure tube feedings were administered per the physician's orders and per professional nursing standards of practice. This affected one (#5) of one resident review for tube feeding. The facility census was 122.Findings include: Review of Resident #5's medical record revealed an admission date of 12/06/25. Diagnoses included hypertensive chronic kidney disease stage 3B, anxiety, non-ischemic myocardial injury, gout, and type two diabetes mellitus.Review of Resident #5's Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 01 which indicated Resident #5 had severely impaired cognition. Furthermore, Resident #5 was dependent for eating and all mobility.Review of Resident #5's care plan with a date initiated of 12/06/25 revealed Resident #5 required a tube feeding to maintain adequate nutrition and hydration with interventions that included to check the residual every shift and as needed, tube feeding formula/rate as ordered, and to elevate the head of the bed over 30 degrees.Observation on 01/07/26 at 10:45 A.M. of Licensed Practical Nurse (LPN) #685 administering medications via the gastrostomy (stomach feeding) tube (g-tube) revealed LPN #685 verified placement of the tube by pushing 10 milliliters (ml) of air into the tube and listening for the air with a stethoscope. LPN #685 then began to administer the crushed Tylenol dissolved in water by sucking the Tylenol from the medication cup with a syringe, placing the syringe into the g-tube, unclamping the g-tube, and pushing the Tylenol into the tube. After pushing the Tylenol, LPN #685 stated I know to check for gastric residual volume (GRV), just pretend I did that. Without removing the syringe from the residents g-tube, LPN #685 then pulled the plunger out of the syringe. Resident #5 was repeatedly stating he was sensitive. LPN #685 re-assured Resident #5 that tube feedings should not hurt. LPN #685 then began to administer the crushed Metoprolol dissolved in water by sucking the Metoprolol from the medication cup with a syringe, placing the syringe into the g-tube, unclamping the g-tube, and pushing the Metoprolol into the tube.Interview on 01/07/26 at 10:57 A.M. with LPN #685 verified she had only given Resident #5 medications through his g-tube and had not given him any bolus feedings that shift.Interview on 01/07/26 at 11:17 A.M. with Resident #5 revealed he was very hungry. Resident #5 stated no one had fed him breakfast this morning.Interview on 01/07/26 at 11:20 A.M. with LPN #685 verified Resident #5's breakfast tray was on his overbed stand and the food was untouched by Resident #5.Interview on 01/07/26 at 11:21 A.M. LPN #685 stated she was not aware Resident #5 received bolus tube feeding but now was aware and she was preparing to administer the feeding. LPN #685 stated she would mark the scheduled 08:00 A.M. tube feeding as omitted due to time restraints and administer the tube feed now. LPN #685 verified she was running behind and the patient load is too much. She stated she normally does not push medications or anything with the plunger when administering through a g-tube. LPN #685 stated she usually would check residual but she was rushed by the patient assignment. LPN #685 stated she would not normally pull back the plunger when the syringe is in the tube. LPN #685 stated she would put the syringe in the tube and pour the medications in. Review of the facility policy with an approval date of March 4th, 2025 titled Enteral Tube Feeding via Continuous Pump revealed to check the GRV. If stomach content cannot be aspirated, pull back slightly on the tube to reposition. If the tube is still not patent, withhold medication and notify the physician.

Based on record review, staff interview and policy review, the facility failed to ensure medications were administered per physician orders. This affected one (#3) of seven residents reviewed for medication administration. The facility census was 122.Findings include:Review of the medical record for Resident #3 revealed an admission date of 12/01/25 with diagnoses of hypertensive heart disease and chronic kidney disease, dementia, and heart failure. Resident #3 discharged home on [DATE].Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 12/08/25, revealed Resident #3 had impaired cognition and received antipsychotics, and antianxiety and antidepressant medications. Review of the physician order initiated 12/01/25 and discontinued upon discharge on [DATE], revealed Resident #3 received Lisinopril (a blood pressure lowering medication) oral tablet 40 milligrams (mg), one tablet daily for hypertension; hold for SBP (systolic blood pressure) less than 100 millimeters of Mercy (mmHg).Review of Resident #3's blood pressure on 12/22/25 revealed it was 90/62 mmHg. Review of Resident #3's blood pressure on 01/05/26 revealed it was 94/52 mmHg, on 01/06/26 it was 99/70 mmHg, and on 01/08/26 it was 91/57 mmHg.Review of Resident #3's Medication Administration Record (MAR) for December 2025 revealed she received Lisinopril on 12/22/25.Review of Resident #3's MAR for January 2026 revealed she received Lisinopril on 01/05/26, 01/06/26, and 01/08/26.Interview on 01/08/26 at 3:50 P.M. with Regional Registered Nurse (RRN) #800 confirmed Resident #3 received Lisinopril when Resident #3's SBP was less than 100 on four occasions, 12/22/25, 01/05/26, 01/06/26, and 01/08/26. Review of the policy, Administering Medications, approved 04/2024, revealed medications must be administered in accordance with the orders.

Based on observation, medical record review, staff interview, and review of policy for medication storage, the facility failed to label insulin injector pens with open dates. This affected three residents (Residents #5, #20, and #148). The facility identified 22 residents with current orders for insulin injections. Further, the facility failed to properly store medications during the medication administration process. This affected one resident (Resident #20) of four residents observed during medication administration. The census was 122.Findings include: 1. Review of Resident #5's medical record revealed an admission date of 12/06/25 with diagnoses that included type II diabetes mellitus. Review of Resident #5's physician orders revealed they included an order for insulin Glargine (Lantus) solution via pen injector, inject 35 units every 12 hours for diabetes. Observation on 01/12/26 at 10:47 A.M. of the C-2 Hall medication cart, revealed it contained an insulin Glargine pen injector for Resident #5, with approximately 70 units of insulin remaining. The pen injector was not marked with an open date. Review of manufacturer instructions at www.lantus.com confirmed the insulin Glargine pen injector should be discarded within 28 days after opening, if it is not refrigerated. 2. Review of Resident #20's medical record revealed an admission date of 12/22/25 with diagnoses that included type II diabetes mellitus. Review of Resident #20's physician orders revealed they included an order for insulin Lispro (Humalog) solution via pen injector per sliding scale for diabetes. Observation on 01/12/26 at 10:47 A.M. of the C-2 Hall medication cart, revealed it contained an insulin Lispro pen injector for Resident #20, with approximately 230 units of insulin remaining. The pen injector was not marked with an open date. Review of manufacturer instructions at www.pi.lilly.com confirmed the insulin Lispro pen injector should be discarded within 28 days after opening, if it is not refrigerated. 3. Review of Resident #148's medical record revealed a most recent admission date of 01/02/26 with diagnoses than included type II diabetes mellitus. Review of Resident #148's physician orders revealed they included an order for insulin aspart (Novolog) solution via pen injector, inject 3 units before meals along with an additional dosage based on a sliding scale for diabetes. Observation on 01/12/26 at 10:47 A.M. of the C-2 Hall medication cart, revealed it contained an insulin aspart pen injector for Resident #148, with approximately 75 units of insulin remaining. The pen injector was not marked with an 'open' date. Review of manufacturer instructions at www.novolog.com confirmed the insulin aspart pen injector should be discarded within 28 days after opening, if it is not refrigerated. Interview on 01/12/26 during these observations with Registered Nurse #577 confirmed the aforementioned insulin pen injectors were not marked with 'open' dates. Review of a policy titled, Storage of Medications, dated 01/07/24, confirmed nursing staff shall not use outdated or deteriorated drugs or biologicals. 4. Review of the medical record for Resident #20 revealed an admission date of 12/22/25 with diagnoses of cellulitis of right lower limb, hypertensive heart disease, congestive heart failure, metabolic syndrome, chronic obstructive pulmonary disease, and type II diabetes mellitus. Review of the comprehensive admission MDS assessment, dated 12/29/25, revealed Resident #20 had intact cognition. Interview on 01/06/26 at 10:55 A.M. with Resident #20 revealed she had not received her morning medications yet, including a water pill for swelling in both lower legs. Resident #20 stated she went to therapy right after breakfast. Review of the January 2026 MAR for Resident #20, on 01/06/26 at 10:57 A.M. revealed Resident #20's morning medications were marked off with a check mark, indicating the medications were dispensed and administered, including Bumetanide (a diuretic) tablet 2 mg ordered for congestive heart failure/lymphedema. Interview on 01/06/26 at 11:22 A.M. with Licensed Practical Nurse (LPN) #684 revealed she was an agency nurse and completed the morning medication pass with the assistance of Medication Aide Certified (MA-C) #653. LPN #684 could not verify whether she dispensed and administered Resident #20's morning medications until she spoke with MA-C #653. Continued interview on 01/06/26 at approximately 11:26 A.M. with LPN #684, after LPN #684 spoke with MA-C #653, confirmed LPN #684 pulled Resident #20's medications, then realized Resident #20 was not in her room and was unable to administer the medications. LPN #684 confirmed the charting indicated Resident #20 had received her medications; however, LPN #684 showed the cup of Resident #20's medications remained in the top drawer of the medication cart awaiting administration. LPN #684 confirmed seven medications were in an unlabeled medication cup. Review of the policy, Storage of Medications, approved 01/07/24, revealed drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure Do Not Resuscitate (DNR) orders were signed in the medical record. This affected one (#50) of 24 residents reviewed for advanced directives. The facility census was 122.Findings include:Review of Resident #50's medical record revealed an admission date of [DATE]. Diagnoses included traumatic subarachnoid hemorrhage without loss of consciousness, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), dementia, and depression. Review of Resident #50's Medicare five-day Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 05 which indicated Resident #50 had severely impaired cognition.Review of Resident #50's physician orders revealed an order for code status; Do Not Resuscitate - Comfort Care Arrest (DNR-CCA) that was initiated on [DATE].Review of Resident #50's care plan dated [DATE] revealed Resident #50 and her family had chosen a DNR-CCA order with interventions that included in the event of cardiac or respiratory arrest, do not initiate Cardiopulmonary Resuscitation (CPR) and obtain the appropriate DNR order.Observation on [DATE] at 2:50 P.M. revealed Resident #50's DNR-CCA form was not signed by the physician/Nurse Practitioner (NP).Interview on [DATE] at 2:25 P.M. with NP #501 revealed it was the responsibility of the NP to sign the DNR orders for the residents they saw. NP #501 verified there was no signature on Resident #50's DNR form and the pen marks at the bottom of the form were not her signature. NP #501 stated she had now signed the form, and it was placed back into the chart.Review of the facility policy with an approval date of [DATE] titled Advanced Directives revealed a DNR Order is a directive issued by a physician which states that a resident should not receive CPR.

Based on observation, medical record review, resident interview, and staff interview, the facility failed to ensure a toilet raiser was provided for resident #130. This affected one (#130) of one resident reviewed for accommodation of needs. The facility census was 122. Findings include:Review of Resident #130's medical record revealed an admission date of 11/25/25. Diagnoses included hypertensive heart disease, acute pulmonary edema, unspecified atrial fibrillation, anxiety, depression, a non-pressure chronic ulcer of other part of right foot with fat layer exposed and a non-pressure chronic ulcer of the left thigh limited to breakdown of skin. Review of Resident #130's admission/Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #130 had intact cognition. Furthermore, Resident #130 was dependent for toileting hygiene and lower body dressing, required substantial or maximal assistance for sitting to standing, and required substantial or maximal assistance for toilet transfers which included the ability to get on and off a toilet or commode.Review of Resident #130's care plan initiated on 11/26/25 and last revised on 12/09/25 revealed Resident #130 required activities of daily living (ADL) assistance due to weakness related to heart failure with interventions that included the use of assistive devices to improve mobility and ADL independence as indicated and to encourage Resident #130 to complete ADL's as independently as possible within limitations of illness/acute process.Review of the Occupational Therapy (OT) evaluation and plan of treatment for Resident #130 revealed a new goal with a baseline date of 11/26/25 that stated Resident #130 will safely perform toileting tasks using a raised toilet seat/three in one commode and grab bars while maintaining respiration rate with a target date of 12/09/25. Further review revealed Resident #130 reported her prior living setting was a private residence where she utilized a raised toilet seat with grab bars.Review of the OT therapy progress report for Resident #130 revealed the goal to safely perform toileting tasks using a raised toilet/three in one commode and grab bars with modified independence while maintaining respiratory rate. The baseline-initiated goal date was 11/26/25, a previous initiated goal date of 12/15/25, and a current initiated goal date of 12/30/25.Interview on 01/06/26 at 9:21 A.M. with Resident #130 revealed she has asked multiple nurses, nurse aides, and physical and occupational therapists for a toilet raiser and no one would get one for her. Resident #130 could not recall any specific staff members she had asked for a toilet raiser but stated she had made it known to many people she needed one as she had always used one when she lived independently.Observation on 01/06/26 at 9:23 A.M. of Resident #130's bathroom revealed there was no toilet raiser present in the bathroom.Observation on 01/07/26 at 3:27 P.M. of Resident #130's bathroom revealed a toilet raiser was present on the toilet.Interview on 01/08/26 at 9:46 A.M. with the Director of Rehabilitation - Physical Therapy (DOR-PT) #552 revealed Resident #130 had a lot of room changes recently, possibly due to the COVID-19 outbreak in the facility. On 12/29/25, Resident #130 moved from room [ROOM NUMBER] to 237. On 01/01/26, Resident #130 moved from room [ROOM NUMBER] to 255. On 01/02/26, Resident #130 moved from room [ROOM NUMBER] to 127. DOR-PT #552 stated when Resident #130 lived upstairs, she had been in a room with another resident who had a toilet raiser and she used that one. DOR-PT #552 stated if the facility were to provide the raiser, it would be entered into the physician's orders by the physical therapist who initiated it. DOR-PT #552 stated a toilet raiser would not be an order from the physician; it is more-so something used to assist with toileting. DOR-PT #552 verified a toilet raiser would be considered an assistive device that may promote independence.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of facility submitted Self-Reported Incidents (SRI), review of personnel records, and review of the facility policy, the facility failed to ensure residents were free from staff-to-resident abuse. This affected one (#108) of three residents reviewed for abuse. The facility census was 117.Findings include:Review of the medical record revealed Resident #108 was admitted on [DATE]. Diagnoses included unspecified dementia moderate with other behavioral disturbances, chronic kidney disease stage two, anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, and dysphagia oropharyngeal phase.Review of the Minimum Data Set (MDS) assessment, dated 08/19/25, revealed the resident was severely cognitively impaired and required substantial assistance with chair to bed transfers. Review of nursing progress note, dated 09/23/25 at 7:15 A.M. revealed a bruise was noted under Resident #108's left eye. Another nurse asked what happened to her eye and the resident stated someone hit me in the eye. The bruise was noted to be 0.5 centimeters (cm) x 1.5 cm red and blue. The resident reported a lady hit her in the eye last night but could not provide any additional details. Review of nursing progress note, dated 09/23/25 at 7:18 A.M. revealed a head-to-toe assessment was completed and noted a bruise to the left wrist measuring 4 cm x 3 cm. Review of physician progress noted, dated 09/23/25, revealed Resident #108 was clinically stable and found to have two areas of ecchymosis this morning with one located under her left eye and another on her left wrist. No indication of fractures and the resident denies pain. Review of Weekly Skin Observation, dated 09/23/25, revealed new skin impairment was identified on Resident #108's left wrist measuring 4 cm x 3 cm described as red and blue and a bruise under the left eye measuring 0.5 cm x 1.5 cm. Review of Non-Pressure Injury Review, dated 09/23/25, revealed a wound was located below the left eye measuring 0.5 cm x 1.5 cm and left wrist out aspect 4 cm x 3 cm. Review of physician orders, dated 09/23/25, revealed new orders to monitor the bruise under the left eye every shift until healed and monitor the bruise to the left wrist every shift until healed. Interview on 10/09/25 at 11:20 A.M. with Licensed Practical Nurse (LPN) #276 verified she had observed Resident #108 on 09/23/25 and noted a bruise under her left eye that had not been there the day before. Interview on 10/09/25 at 11:27 A.M. with LPN #277 verified working with Resident #108 the following day and completed the skin assessments. LPN #277 stated Resident #108 appeared to be at baseline. Interview on 10/09/25 at 2:19 P.M. with Certified Nursing Assistant (CNA) #275 verified she had worked on 09/22/25 from 2:00 P.M. to 10:00 P.M. and provided care to Resident #108 with CNA #300. CNA #275 stated she is new to healthcare and it was her third day in orientation. CNA #275 stated while providing care to Resident #108, CNA #300 was being aggressive. It was reported CNA #300 was attempting to assist the resident in transferring to bed and the resident was grabbing CNA #300's wrists. In return, CNA #300 grabbed onto Resident #108's wrists. CNA #275 stated CNA #300 threw Resident #108 on the bed and when doing so the bed bounced a little. CNA #275 assisted by taking Resident #108's feet and gently placed them on the bed. CNA #275 stated she does not know when the bruising could have occurred especially to the face as she never saw any contact with the resident's face. Review of Self-Reported Incident (SRI) #265552, dated 09/23/25, revealed an allegation of physical abuse of Resident #108 with the perpetrator identified as CNA #300. Resident #108 was found to have a bruise under her left eye and a bruise on her wrist. Once identified, Resident #108 received a head-to-toe assessment. CNA #300 was identified as the caretaker who provided care to Resident #108 and CNA #300 was suspended pending investigation. Resident #108 indicated she was hit in the eye but could not recall who did it. A CNA who was working with CNA #300 stated she thought the aide was being aggressive in that she had grabbed the resident's arms and the resident said ow. Resident #108's roommate indicated the nurse was rough with the resident. Neither witness observed Resident #108 being struck in the face or indicated that it appeared the aide intended to hurt Resident #108. It was reported the resident was combative during care and the resident was agitated and aggressive when she was put to bed. The allegation was unsubstantiated due to inconclusive evidence. As a result of the investigation, the facility dismissed CNA #300 from employment. The police were notified and the family opted not to press charges. Review of witness statement, dated 09/23/25, with CNA #275 verified she had assisted CNA #300 get Resident #108 to bed. CNA #275 stated CNA #300 was aggressive stating she picked the resident up and threw her into bed. CNA #275 lifted the resident's legs into bed. CNA #275 states at one point CNA #300 had grabbed the resident's arms and the resident said ow. Review of the personnel file revealed CNA #300 had been hired on 08/15/15. Review of corrective action form dated 09/24/25 revealed CNA #300 was terminated due to violent behavior or use of force towards residents. On the evening shift of 09/22/25 a serious incident occurred involving an employee toward a resident. Following a thorough investigation, it was confirmed the employee engaged in behavior that violated multiple facility work rules, including harassment in the form of verbal or physical mistreatment, actions that placed a resident at risk of harm, and conduct that demeaned the resident's dignity and showed a lack of courtesy and respect. The incident was reported by the resident involved and corroborated by multiple witnesses. The outcome of this behavior included physical bruising and identifying marks on the resident, which is deeply concerning and unacceptable. This conduct is in direct conflict with the facility's commitment to providing compassionate, respectful, and safe care to all residents. Review of policy, Abuse and Neglect- Staff Treatment of Residents, dated 03/03/20, verified residents have the right to be free from abuse, neglect, and exploitation. Every employee has a responsibility to report immediately any and all known instances of abuse, neglect or misappropriation of property, which may be self-inflicted or caused by employees, other residents, or visitors. The deficiency was corrected on 10/06/25 when the facility implemented the following corrective actions: On 09/23/25, Resident #108 was assessed for injuries and psychosocial wellbeing. On 09/23/25, Resident #97 was assessed for injuries and psychosocial wellbeing. On 09/23/25, all staff were educated on the abuse policy and reporting allegations of abuse timely. On 09/23/25, CNA #300 was suspended pending investigation. On 09/23/25, CNA #275 received one on one education on reporting timely. On 09/23/25, all residents were interviewed to ensure they felt safe and there were no further concerns of abuse. On 09/23/25, head to toe assessments were completed on memory impaired residents who were unable to answer questions. On 09/25/25, AD-HOC Quality Assurance meeting conducted. The Director of Nursing or designee will interview five residents weekly for four weeks and then five residents monthly for two months to ensure residents feel safe and there are no concerns of allegations of abuse in the facility. All audits will be taken to Quality Assurance (QA). The DON is responsible for ongoing compliance. This deficiency represents non-compliance investigated under Complaint Number 2630679.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of a facility submitted Self-Reported Incident (SRI), and review of facility policy, the facility failed to ensure staff timely reported allegations of abuse. This affected one (#108) of three residents reviewed for abuse. The facility census was 117.Findings include:Review of the medical record revealed Resident #108 was admitted on [DATE]. Diagnoses included unspecified dementia moderate with other behavioral disturbances, chronic kidney disease stage two, anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, and dysphagia oropharyngeal phase.Review of the Minimum Data Set (MDS) assessment, dated 08/19/25, revealed the resident was severely cognitively impaired and required substantial assistance with chair to bed transfers. Review of a nursing progress note dated 09/23/25 at 7:15 A.M. revealed a bruise was noted under Resident #108's left eye. Another nurse asked what happened to her eye and the resident stated, someone hit me in the eye. The bruise was noted to be 0.5 centimeters (cm) x 1.5 cm red and blue. The resident reported a lady hit her in the eye last night but could not provide any additional details. Review of Non-Pressure Injury Review, dated 09/23/25, revealed a wound was located below the left eye measuring 0.5 cm x 1.5 cm and left wrist out aspect 4 cm x 3 cm. Review of the facility submitted SRI, dated 09/23/25, revealed an allegation of physical abuse of Resident #108 with the perpetrator identified as CNA #300. Resident #108 was found to have a bruise under her left eye and a bruise on her wrist. Once identified, Resident #108 received a head-to-toe assessment. CNA #300 was identified as the caretaker who provided care to Resident #108 and CNA #300 was suspended pending investigation. Resident #108 indicated she was hit in the eye but could not recall who did it. A CNA who was working with CNA #300 stated she thought the aide was being aggressive in that she had grabbed the resident's arms and the resident said ow. Resident #108's roommate indicated the nurse was rough with the resident. Neither witness observed Resident #108 being struck in the face or indicated that it appeared the aide intended to hurt Resident #108. It was reported the resident was combative during care and the resident was agitated and aggressive when she was put to bed. The allegation was unsubstantiated due to inconclusive evidence. As a result of the investigation, the facility dismissed CNA #300 from employment. The police were notified, and the family opted not to press charges. Interview on 10/09/25 at 2:19 P.M. with Certified Nursing Assistant (CNA) #275 verified she had worked on 09/22/25 from 2:00 P.M. to 10:00 P.M. and provided care to Resident #108 with CNA #300. CNA #275 stated she was new to healthcare and it was her third day in orientation. CNA #275 stated while providing care to Resident #108, CNA #300 was being aggressive. CNA #300 was attempting to assist the resident in transferring to bed, and the resident was grabbing CNA #300's wrists. In return, CNA #300 grabbed onto Resident #108's wrists. CNA #275 stated CNA #300 threw Resident #108 on the bed and when doing so the bed bounced a little. CNA #275 assisted by taking Resident #108's feet and gently placed them on the bed. CNA #275 stated she did not know when the bruising could have occurred, especially to the face, as she never saw any contact with the resident's face. CNA #275 verified not reporting the incident immediately, stating she was new and did not know who to tell. Review of policy, Abuse and Neglect- Staff Treatment of Residents, dated 03/03/20, verified residents have the right to be free from abuse, neglect, and exploitation. Every employee has a responsibility to report immediately any and all known instances of abuse, neglect or misappropriation of property, which may be self-inflicted or caused by employees, other residents, or visitors. The deficiency was corrected on 10/06/25 when the facility implemented the following corrective actions: On 09/23/25, LPN #277 assessed Resident #108 for injuries and psychosocial wellbeing. On 09/23/25, the DON or designee initiated re-educated for all facility staff on the abuse policy and reporting of allegations of abuse timely. Evidence was received to verify education was completed on 09/30/25. On 09/23/25, CNA #300 was suspended pending investigation and terminated on 09/24/25. On 09/23/25, the DON provided CNA #275 one-on-one education on timely reporting of potential abuse allegations or concerns. On 09/23/25, the DON or designee interviewed all interviewable residents to ensure they felt safe and there were no further concerns of abuse. On 09/23/25, the DON or designee completed head-to-toe assessments on all residents who were not interviewable. No concerns were identified. On 09/25/25, an AD-HOC Quality Assurance and Performance Improvement (QAPI) committee meeting was held to review the incident and the corrective action implemented. Beginning on 10/01/25, the DON or designee will interview five residents weekly for four weeks and then five residents monthly for two months to ensure residents feel safe and there were no abuse concerns. All audits will be reviewed by QAPI to ensure on-going compliance. The DON is responsible for ongoing compliance. Evidence was received to verify audits were completed on 10/01/25 and 10/06/25, with no concerns identified.This deficiency represents non-compliance investigated under Complaint Number 2630679.

THIS DEFICIENCY REPRESENTS AN EXAMPLE OF PAST NON-COMPLIANCE. Based on medical record review, staff interview, review of facility policy, review of facility investigation documentation, and review of facility corrective action documentation, the facility failed to ensure staff utilized a mechanical lift safely during transfer of Resident #1. Actual harm occurred when two state tested nurse aides lifted Resident #1 with a mechanical lift from a wheelchair and one lift sling strap became dislodged causing Resident #1 to fall to the floor. As a result of the fall Resident #1 sustained subdural hematoma and required hospitalization . This affected one (#1) of three residents reviewed for mechanical lift transfers in a facility census of 112. Findings include: Review of the medical record revealed Resident #1 admitted to the facility on [DATE]. Diagnoses included dementia, acute respiratory distress, type II diabetes mellitus, peripheral vascular disease, major depression, vitamin D deficiency, hypertension, anemia, spinal stenosis, heart failure, urinary incontinence, anxiety disorder, right hand contracture, and dysphagia. The resident no longer resides at the facility. Review of the Minimum Data Set assessment, dated 07/06/23, Resident #1 was assessed with severely impaired cognition, dependent on staff for activities of daily living, required two plus staff for transfer and bed mobility, and utilized a wheelchair for mobility. Review of the plan of care dated 01/10/17 revealed Resident #1 needed assistance with activities of daily living due to diagnoses of dementia, osteoarthritis, diabetes mellitus and spinal stenosis. Interventions initiated on 06/09/17 included the use of a mechanical full lift with two assist for transfers and and an intervention dated 12/14/17 identified to use two assist for care. Review of nursing progress notes on 07/30/23 at 12:30 P.M. revealed Resident #1 was being lifted back to bed using a mechanical (Hoyer). The nurse (Licensed Practical Nurse (LPN) #300) heard a thunk at the nurses station and was about to go down to see what happened when state tested nurse aide (STNA) #200 came out of the resident's door and yelled for help. LPN #300 went to assess situation and found Resident #1 was laying on the floor on her stomach and face forward. Resident #1 had a goose egg on the right side of her head. Vital signs included a blood pressure of 169/101, pulse of 84, and respirations of 18. A pain review noted Resident #1 with verbal/non-verbal signs/symptoms revealing the resident was in pain to the head. Resident #1 rated her pain as a six on a scale of zero to ten. Faces pain scale revealed Hurts even more. Emergency Medical Services (EMS/911) was called. Resident #1 was unable to describe what happened, just stating Get me off the floor. At 12:38 P.M. EMS arrived and at 12:50 P.M. Resident #1 was transported to the hospital. On 07/30/23 at 4:50 P.M. LPN #300 documented Resident #1 was being admitted to the hospital with the diagnosis subdural hematoma. Review of a witness statement on 07/30/23 by STNA #200 revealed STNA #200 and STNA #201 entered Resident #1's room and brought in the Hoyer lift. The STNAs pushed the lift up to the resident and hooked the black sling (pad) loops on top and the green loops on the bottom with the sling legs criss crossed. They then raised the resident all the way up until the lift stopped. STNA #201 was holding onto the Hoyer as STNA #200 pulled the resident's chair out of the was to allow STNA #201 to push the resident over to her bed. As soon as the chair was moved back, the Hoyer pad came loose and dropped the resident. STNA #201 went to get a nurse while STNA #200 stayed with the resident. STNA #200 stated the Hoyer pad was observed with no obvious rips or tears. Review of a witness statement on 07/30/23 by STNA #201 revealed STNA #200 and STNA #201 were getting Resident #1 from her chair to bed. They hooked the resident to the Hoyer pad, which had no rips,and crossed the pad between her legs and supported her. The STNAs hooked the black loops on top and green loops on the bottom. Resident #1 was stable going up and did not move the Hoyer. Then as she was lifted up all the way, STNA #200 moved the chair back. Resident #1 was not touching on the chair any longer and the top of the Hoyer pad came loose and Resident #1 fell . The STNAs immediately got the nurse and STNA #201 stayed with Resident #1 as nurse came to assess and Emergency Medical Technicians came. Review of LPN #300's statement dated 07/30/23 noted LPN #300 to respond to Resident #1's room after STNA #201 yelled for her. Resident #1 was observed laying on the floor. Resident #1 mumbled something and Registered Nurse (RN) #400 also arrived in the room. LPN #300 called 911. RN #400 had assessed Resident #1 for injuries and measured her scalp wound with no open areas discovered. Resident #1 still had a wig on and EMS removed the wig to see goose egg which RN #400 had measured. Review of of RN #400's witness statement on 07/31/23 revealed the STNAs called out for a nurse. LPN #300 and RN #400 responded to Resident #1's room. RN #400 looked into the room and the mechanical (Hoyer) lift was there with three of four straps (loops) in place. Resident #1 was on the floor on her stomach. Resident #1 was turned onto her right side. RN #400 assessed the resident with Resident #1 stating the only pain was to her head. Upon looking under the resident's wig a 9.5 centimeter (cm) by 9.0 cm raised area was discovered. EMS arrived, assessed the resident, and transported her to the hospital. Interview on 09/07/23 at 2:12 P.M. via telephone with STNA #201 revealed on 07/30/23 she was transferring Resident #1 using the mechanical lift with assistance from STNA #200. Resident #1 was propelled in a tilt style wheelchair into her room. The mechanical lift sling was already in place under the resident. STNA#201 placed the lift over the resident from the direction of the resident's feet and was utilizing the controls. STNA #201 opened the legs of the lift to place the lift mechanism over the resident. STNA #200 hooked the sling to the lift with the black loops on the lift hooks which extended behind the residents shoulders. STNA #201 took the lower sling straps and placed the black loops to the lift hooks by criss crossing the sling under the residents thighs and hooking the left side to the right hook and right loop to the left hook. STNA #201 lifted the resident using the electronic control to the highest point. STNA #200 then pulled the chair out from under the resident. At that time the left or right upper loop disconnected from the lift and Resident #1 fell to the floor. STNA #201 pushed the lift to the side and called for help. STNA #200 went to the door and also called for help. RN #400 and LPN #300 responded and initiated an assessment of the resident, followed by calling 911. STNA #201 was unable to verbalize how the resident fell from the lift or verify all lift sling loops were in place. Review of the facility policy titled Mechanical Lift Transfer Policy, revised August 2023, revealed attaching the sling to lift. Attach the loops nearest the residents shoulders, to the hanger bar hooks of the lift nearest each shoulder using the same length and color of loop strap on each side. Take the sling leg lying over the left leg, cross it over and attach it on the hook of the hanger bar located on the right side of the resident. Next take the sling leg lying over the right leg, cross it over and attach it on the hook of the hanger bar located on the left side of the resident using the same length and color of loop strap on each sling leg. Make a final check of all four loop attachment points to ensure each loop is sufficiently attached to the respective hook hanger bars. Resident is now ready to be lifted. Interview on 09/11/23 at 7:15 A.M. the Director of Nursing (DON) confirmed Resident #1 sustained a subdural hematoma due to falling from a Hoyer lift. STNA #200 and STNA #201 did not ensure the Hoyer lift sling remained in place with all sling straps affixed to the lift throughout the transfer. As a result of the incident the facility implemented corrective action to prevent further mechanical lift related occupancies. As a result of the deficient practice, the facility has implemented corrective action, which was completed as of 08/30/23, as follows: On 07/30/23 the DON, Administrator, and Quality Assurance Nurse were notified of the incident. The lift and sling was pulled from service by RN #400. On 07/30/23 starting at the next shift change, a review of safe transfer practice was initiated by RN #400 for current shift nursing staff and oncoming shift nursing staff. Staff Development Registered Nurse (SDRN) continued education with oncoming shifts. The education to all nursing staff was completed on 08/08/23. On 07/31/23 SDRN and designee completed mechanical lift transfer education and return demonstration competency check off for all nursing and therapy staff. On 07/31/23 the Interdisciplinary Team (IDT) fall and risk review was completed for Resident #1. On 07/31/23 the mechanical lift slings were inspected and found to be free of rips, tears, or fraying by Central Supply Manager, State tested Nurse Aide (STNA) #209. Maintenance Manager #1 inspected all lifts for proper function and found no lifts not working properly. On 07/31/23 Quality Assurance (QA) Audits were established. On 08/08/23 fall information was introduced to monthly QA meetings, reviewed the incident and equipment reviewed the education of nursing and therapy staff regarding safe transfers with the mechanical lift. The facility continued random demonstration competencies with staff by SDRN and designee. Random total lift audits by the nurse management staff continued on 08/09/23 twice, 08/11/23 twice, 08/21/23 twice, 08/24/23 twice, and 08/30/23 once. On 09/06/23 at 9:05 A.M. observation of Resident #5 during a mechanical lift transfer by STNA #210 and LPN #315 noted appropriate and safe transfer provided in accordance with facility policy. On 09/11/23 interview with STNA #205, STNA #206, LPN #301, and RN #401 confirmed education on 07/30/23 of the mechanical lift. This deficiency represents an episode of non-compliance investigated under Complaint Number OH00145861.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a self-reported incident (SRI), observation, staff and resident interview, review of a personnel file, policy review and review of a wheelchair manual, the facility failed to ensure Resident #63 was appropriately assisted during a wheelchair transport resulting in an avoidable fall. This resulted in Actual Harm when Housekeeper #1 failed to maintain physical contact with Resident #63's wheelchair and/or lock the wheelchair brakes while moving the resident outside of the facility and the resident's wheelchair began moving down an inclined surface resulting in Resident #63 falling from the wheelchair and fracturing her right tibia (lower leg). This affected one (Resident #63) of three residents reviewed for accidents. The census was 109. Findings include: Review of Resident #63's medical record revealed the resident was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) for Resident #63, dated 11/17/17, revealed moderate cognitive impairment. The MDS further revealed the resident required extensive two-person physical assistance with bed mobility, transfers, and locomotion off the unit, and extensive one-person physical assistance with locomotion on the unit. The MDS confirmed Resident #63 required use of a wheelchair. Further review of the medical record for Resident #63 revealed that on 11/02/17, the resident overturned in her wheelchair and was transported by emergency services for evaluation at a local emergency department. Radiological testing confirmed a [MEDICAL CONDITION] end of the right tibia (lower leg), and ruled out injuries to the head, neck, chest, and pelvis. Additionally, the resident sustained [REDACTED]. The resident returned to the facility with a knee immobilizer in place and an order for [REDACTED]. Review of the plan of care for Resident #63 revealed that prior to the incident on 11/02/17, the plan included a risk for falls and a self-care deficit with activities of daily living. Review of the facility SRI revealed that on 11/02/17, Housekeeper #1, pushed Resident #63 outdoors in a wheelchair that subsequently overturned. The report documented Housekeeper #1 pushed the wheelchair forward to allow the door to close, and the chair rolled down a sloped gradient before tipping off the sidewalk and onto the adjacent driveway. The report further documented the resident was transported to a local emergency center, and the facility provided education to all staff that only direct care staff may propel residents in wheelchairs. Investigation by the facility unsubstantiated neglect. Interview on 12/06/17 at 9:30 A.M. with Resident #63 revealed the resident was alert but mildly confused. Resident #63 confirmed her leg was fractured after her wheelchair overturned recently, but was unable to answer specific questions about the sequence of events. Resident #63 confirmed ongoing use of the immobilizer and denied unmanaged pain. Observation of Resident #63 during the interview revealed the resident was sitting in a wheelchair with her right leg elevated and an immobilizer properly applied to the leg. Interview on 12/06/17 at 10:22 A.M. with the Director of Nursing (DON), confirmed the events stated in the SRI. The DON reported that prior to the incident, the facility did not have a policy specific to which staff may or may not, propel residents in wheelchairs. Interview on 12/06/17 at 10:32 A.M. with Dietary Aide #1 revealed that on 11/02/17, the employee opened an exterior door near the kitchen to take out the garbage, and observed Resident #63 laying on the driveway intertwined in an overturned wheelchair while Housekeeper #1 stood beside the resident. Dietary Aide #1 stated she immediately ran inside to get a nurse while another Dietary Aide remained with the resident. Interview on 12/06/17 at 10:37 A.M. with Dietary Aide #2 revealed that on 11/02/17, the employee was with Dietary Aide #1 when both opened the exterior door to take out the garbage. Dietary Aide #2 confirmed Resident #63 was laying on the pavement intertwined in an overturned wheelchair with Housekeeper #1 standing beside her. Dietary Aide #2 stated she stayed with Resident #63 to minimize movement and/or further injury while Dietary Aide #1 ran inside to get a nurse. Observation was made on 12/06/17 at 10:40 A.M. of the site of the accident, while accompanied by Dietary Aide #1 and Dietary Aide #2. The exterior door identified by the two aides was observed to open to a sidewalk that ran alongside the building. The edge of the sidewalk was observed to be approximately four feet from the door and had a drop to a driveway, of approximately seven inches. Both aides confirmed Resident #63 was observed laying on the driveway beyond the sidewalk at the time of the accident. Attempts to interview Housekeeper #1 on 12/06/17 were unsuccessful after attempts were made to reach the former employee by phone at 11:10 A.M. and 12:50 P.M. Interview on 12/06/17 at 12:03 P.M. with the Administrator, further confirmed on 11/02/17 Housekeeper #1 assisted Resident #63 out the doors to go outside per the residents' request. The Administrator confirmed Housekeeper #1 let go of Resident #63's wheelchair to close the doors and the staff did not lock the wheelchair locks/brakes. The Administrator confirmed Resident #63's wheelchair began going down the inclined walk way. The Administrator confirmed Resident #63 fell out of her wheelchair and fractured her right tibia. The Administrator further reported that immediately following the incident, management detected an odor indicative of impairment on Housekeeper #1. The Administrator stated Housekeeper #1 was immediately suspended, transported for drug and alcohol testing, and subsequently terminated when testing confirmed the presence of alcohol. Interview on 12/06/17 at 4:20 P.M. via telephone with Licensed Practical Nurse (LPN) #30, revealed that on 11/02/17, Housekeeper #1 asked her for permission to take Resident #63 outside after the resident requested to go see ducks by the pond. LPN #30 stated she secured the foot pedals to the resident's wheelchair and explained to Housekeeper #1 that the foot pedals must be in place when the chair is mobilized. LPN #30 stated she then gave Housekeeper #1 permission to push the resident outside in the wheelchair. Review of the personnel file for Housekeeper #1 confirmed the employee was terminated 11/02/17 after drug and alcohol testing confirmed [MEDICAL CONDITION] while on duty at the time of the accident. Further review of the drug and alcohol test report from an independent testing center, dated 11/02/17, further confirmed Housekeeper #1 tested positive for [MEDICAL CONDITION]. Review of the job description for the Housekeeper position, revealed it did not include job duties related to assisting residents with wheelchair mobility. Review of a policy titled, Patient/Resident Transfer Policy, dated November 2017, revealed the policy did not include guidelines or a protocol regarding which staff may or may not propel a resident in a wheelchair and/or push a resident in a wheelchair from the building, to the outdoors. Review of an addendum to the policy, dated 11/16/17, revealed the policy for Patient/Resident Transfers, was revised to specify that residents unable to independently propel a wheelchair, shall require assistance from designated personnel only, when requesting to go outdoors. The policy stated such designated personnel shall include trained team members such as nurses, State tested Nurse Aides (STNA), therapists, activities staff, or a resident's responsible party. Review of a policy titled Drug-Free Work Place, dated February 2014, revealed the facility requires all employees be free from drug or alcohol impairment. The policy further stated an alcohol and drug test will be required anytime an employee has a workplace injury that requires offsite treatment, or anytime an employee's behavior, demeanor or appearance gives reasonable evidence of impairment or substance abuse. Review of the manual for wheelchair safety for an Invacare manual wheelchair, identified by the DON as the type involved in the incident, revealed locking the brakes will prevent the wheelchair from moving. The manual further instructed NEVER to leave an unoccupied wheelchair on an incline and that serious injury may occur in the event of a fall from a wheelchair. As a result of the incident, the facility implemented the following corrective actions to correct the deficient practice by 12/01/17: · Housekeeper #1 was terminated on 11/02/17. · On 11/02/17, Resident #62's was sent to the emergency room for evaluation and treatment. Resident #63's plan of care was revised 11/02/17 to specify that only trained personnel may assist with, or propel the resident in the wheelchair. · Physician order [REDACTED].#63 that only trained personnel may assist with, or propel the resident in the wheelchair. · Policy revision to Patient/Resident Transfers, effective 11/16/17, to specify that only designated care staff may assist residents with wheelchair mobility when the resident has requested to go outdoors. · On 11/03/17, the DON implemented all staff in-service training on the revised wheelchair safety policy and on the drug-free workplace policy. The training was completed on 11/06/17. · On 11/02/17, the Administrator and DON implemented daily ongoing monitoring to ensure compliance with policy revision for wheelchair safety. As of 12/01/17 there had been no further incidents or concerns identified. · On 12/06/17, two (#54 and #79) residents were sampled and no further concerns were identified. This deficiency substantiates Complaint Number OH 809.

Based on medical record review, hospital record review, policy review and staff interview, the facility failed to ensure a resident received the correct medications which resulted in a significant medication error. This resulted in actual harm when a Medication Administration Student (MAS) administered Former Resident #2's medications to Resident #121 who developed a low blood pressure and was subsequently hospitalized . This affected one (#1) of three residents reviewed for medication administration. The facility census was 119. Findings include: Review of Resident #121's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimal Data Set (MDS) assessment revealed Resident #121 had a mild cognitive deficit with a Brief Intellectual Mental Score (BIMS) of 12/15. Review of Resident #121's physician orders revealed the following medication orders [REDACTED]. Review of Medication Administration Student (MAS) #1's Statement dated 06/14/17 revealed she had prepared oral and inhalation medications for Former Resident #2. Preparation included pills and an inhaler. MAS #1 revealed she entered Former Resident (FR) #2's room and a resident was in the room being assessed by activities. MAS #1 asked resident if she was FR #2 and Resident #121 said Yes. Activities Staff (AS) #500 confirmed the identity. MAS #1 then administered the medication to the resident who was actually Resident #121. Review of AS #500's statement dated 06/14/17 revealed she was in the room of FR #2 with the name of FR #2 on the door and they thought Resident #121 was her. AS #500 stated she did a full assessment thinking it was in fact that person. MAS #1 came into the room and asked Resident #121 if she was FR #2 and the resident said yes. AS #500 also verified the resident and MAS #1 gave resident the medications. A few minutes later someone brought the real FR #2 back in the room and that was when AS #500 realized the mistake had been made. Review of Registered Nurse (RN) #300's statement dated 06/14/17 revealed MAC #1 entered FR #2's room and found Resident #121 in the room being assessed by activities. MAC #1 asked Resident #121 if she was FR #2 and Resident #121 said yes and Activity Staff #500 confirmed as well. MAC #1 then administered the medication to Resident #121. The mistake was discovered a few minutes later when FR #2 returned to the room. Resident #121 was evaluated and blood pressure was found to have decreased from 124/80 millimeters of mercury (mmHg) to 90/58 mmHg. Certified Nurse Practitioner (CNP) #120 was in the building and immediately evaluated the medications Resident #121 received. Resident #121's blood pressure was found to have decreased to 80/50 mmHg. CNP #120 requested that Resident #121 be transferred to the emergency room for evaluation. Resident #121 was transported to a local emergency room by emergency squad. Review of the local emergency medical services Patient Care Report dated 06/14/17 revealed the paramedics arrived to find Resident #121 awake but lethargic lying in bed. Resident #121 was in rehabilitation from a fall that resulted in a fractured vertebra in her lumbar spine. Resident #121 also complained of sub sternal chest pain. Resident #121 was treated with intravenous (IV) fluids and evaluated with a 12-lead electrocardiogram. Review of the local hospital report dated 06/14/17 revealed Resident #121 was a nursing home resident that was administered another resident's medications at about 9:00 A.M. The patient was an [AGE] year-old female who was admitted for [MEDICAL CONDITION] and status [REDACTED].#121 was accidentally given the wrong medications. She was given her normal dose of antihypertensive medications earlier in the morning along with her neighbor's antihypertensive medications which included an additional dose of [MEDICATION NAME] and Imdur. Resident #121 did have a history of multiple falls and had a brace on for compression fracture. She was pleasantly confused with history of [MEDICAL CONDITION] and dementia. She denied any chest pain or shortness of breath at that time. Resident #121 was admitted to the hospital on telemetry and intravenous fluids. Resident #121 remained stable and was released back to the facility the following day. Interview with the Director of Nursing (DON) on 06/27/17 at 10:40 A.M. verified in the morning on 06/12/17, MAC student #1 was with the instructor and prepared the medications for FR #2 but Resident #121 was in the wrong room which resulted in the medication error. Resident #121 confirmed that she was FR #2 so the aide/student administered the medications to her. Investigation revealed that a dietary staff member had placed Resident #121 into the wrong room. Resident #121 was confused which was why she verified identity to the student/instructor. The CNP assessed and reviewed the medications given and wanted to monitor Resident #121 in the facility and administer IV fluids. The nursing staff was unable to get IV access and since Resident #121's blood pressure was dropping it was decided to transport to the hospital. Resident #121 was admitted for observation and returned to the facility on [DATE]. Interview with Resident #121's family member via telephone on 06/27/17 at 9:13 A.M. revealed Resident #121 was transported to a local hospital on [DATE] after receiving another resident's medications. The family member confirmed Resident #121 was administered IV fluids and was observed in the hospital for 24 hours and released without any complications. Review of the facility policy titled Administering Medications dated August 2016 revealed the individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include checking an identification band if present, checking photograph attached to the medical record, ask resident to state their name or if necessary verifying resident identification with other facility personnel. This deficiency substantiates Complaint Number OH 995.

Based on medical record review, review of the Nursing Drug Handbook and staff interview, it was determined the facility failed to administer anti-[MEDICAL CONDITION] medication to two residents as ordered by the physician. This resulted in actual harm when Resident #1 had a [MEDICAL CONDITION] and sustained a left femur fracture during the [MEDICAL CONDITION] activity. This affected two (#1 and #3) of three residents who receive anti-[MEDICAL CONDITION] medication. The facility census was 127. Findings include: 1. Review of the medical record for Resident #1 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the minimum data set (MDS) assessment dated [DATE], identified the resident with no cognitive impairment, usually understood and usually missed some part/intent of a message but comprehended most of the conversation. He used an electric wheelchair to propel himself in the facility due to his non-ambulatory status and required extensive assistance with two person physical assistance for bed mobility and transfers. His sitting/standing balance was not steady and was only able to stabilize with human assistance. He was not assessed for walking or turning around as those activities did not occur during the assessment period. He had impairment in range of motion on one side of his lower extremity and upper extremity. Review of the plan of care for safety developed on 11/09/07 revealed the resident required the use of a lap tray to his wheelchair because he was unaware of his safety needs due to a subarachnoid hemorrhage, leaning, fall and was at risk for complications related to the use of a restraint such as impaired mobility. The falls plan of care which was developed on 10/12/07 revealed he was at risk for falls due to his cognitive impairment, [MEDICAL CONDITION], diabetes, [MEDICAL CONDITION], restlessness at times and use of psychoactive medications. Interventions included a custom wheelchair with padded seat and back, foot pedals and a lap tray, medications as ordered and assess for pain and/or infection. A plan of care was developed on 12/11/08 for risk of injury related to [MEDICAL CONDITION] disorder secondary to a subarachnoid hemorrhage. Interventions included to obtain labs as ordered and notify the physician of any abnormal results, monitor for [MEDICAL CONDITION] activity and allow freedom of movement while maintaining safety during the [MEDICAL CONDITION] occurrence, administer anti-[MEDICAL CONDITION] medication as ordered and report all [MEDICAL CONDITION] to the physician. Review of the monthly physician's orders [REDACTED].M. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR for June 2011 revealed the [MEDICATION NAME] was not administered on 06/01/11 and 06/02/11. Interview with the Director of Nursing on 06/28/11 at 2:23 P.M. verified there was no documentation the [MEDICATION NAME] was administered as ordered. Review of the nurse's notes dated 06/03/11 at 9:30 A.M. revealed the nurse was notified that Resident #1 was "not acting right in the dining room". The resident was noted to be twitching his head to the left and had bilateral hand and arm spasms. The resident was removed from the dining room. Certified Nurse Practitioner (CNP) #1 was notified and completed an evaluation of the resident. She ordered a one time dose of an anti-[MEDICAL CONDITION] medication ([MEDICATION NAME]) 500 mg and Tylenol which was administered to Resident #1 for leg pain. He was assisted into bed and monitored. On 06/03/11 at 12:30 P.M., the resident continued to complain of left groin pain. Interview with Licensed Practical Nurse (LPN) #7 on 06/28/11 at 11:34 A.M., revealed Resident #1 was eating breakfast in the dining room. Between 9:00 A.M. and 9:30 A.M. on 06/03/11, State tested Nurse Aide (STNA) #11 came to her and stated the resident was "acting funny". She went to the dining room and observed the resident in his wheelchair with a full lap tray "flailing his arms a little bit". Interview with STNA #11 on 06/28/11 at 12:49 P.M., stated that at approximately 9:00 A.M. on 06/03/11, she was in the dining room feeding another resident. Other staff were transporting residents out of the dining room. Out of the corner of her eye she saw Resident #1 in his wheelchair with the full lap tray in place to have "what appeared to be a [MEDICAL CONDITION]." The resident's entire body was jerking and his arms were flailing. His whole body was moving so she went to get the nurse. She informed the nurse what she saw. Resident #1 was removed from the dining room and taken to the nurse's station. Review of the physician's progress note dated 06/03/11 revealed Resident #1 was seen by CNP #1 a second time regarding complaints of pain. The resident's chief complaint was left groin pain that was worse with movement. Her exam noted the resident was in bed, complained of pain with palpation to the groin area and had no pain over the pelvis and greater trochanter area. There was no documentation CNP #1 assessed the range of motion of his leg or any other assessment of his leg. She documented her assessment finding as left groin pain that was probably a strain. She ordered bedrest, an anti-anxiety medication ([MEDICATION NAME]), an anti-spasmodic medication ([MEDICATION NAME]) and an anti-[MEDICAL CONDITION] medication. Further review of the nurse's notes on 06/03/11 at 1:30 P.M. revealed Resident #1 continued to remain in bed. At 2:30 P.M., the resident was administered another [MEDICATION NAME] and other routine medications. On 06/04/11, a late entry note for 06/03/11 at 9:30 A.M. was documented and revealed the resident continued to wiggle and squirm in his wheelchair following the [MEDICAL CONDITION] type activity. The nurse asked the resident if he had any pain and he replied "yes, I think I pulled a muscle in my leg" and continued to wiggle. CNP #1 and family were notified of the continued complaints of pain. On 06/04/11 at 8:30 A.M., Resident #1 continued to complain of pain to his left groin area. He rated the pain while lying in bed at an eight on a scale of zero to ten (zero equaled no pain). CNP #1 was notified and ordered an x-ray of his leg. Review of the left hip x-ray results conducted on 06/04/11 revealed an acute complete femoral neck fracture without displacement. Review of the nurse's notes dated 06/04/11 at 12:20 P.M. revealed CNP #1 was notified of the x-ray results and ordered the resident to be transported to the hospital for evaluation and treatment. Review of the hospital's admission history and physical dated 06/04/11 revealed the resident had surgery on 06/05/11 for open reduction and internal fixation (ORIF) of the left femoral neck fracture. Interview with the Director of Nursing (DON) on 06/29/11 between 8:53 A.M. and 9:10 A.M. revealed that as a result of the investigation, she concluded Resident #1 was not administered his anti-[MEDICAL CONDITION] medication from 05/30/11 through 06/02/11. She stated Registered Nurse (RN) #8 re-ordered the resident's medication on 05/29/11; however, there was no follow-up regarding the [MEDICATION NAME]. The DON indicated she was not made aware of Resident #1's missed medication until 06/06/11, four days after the resident experienced [MEDICAL CONDITION] activity. Review of the Nursing Drug Handbook-26th Edition revealed a nursing consideration warning that [MEDICAL CONDITION] can occur if the drug is stopped abruptly. 2. Review of the medical record for Resident #3 revealed she was admitted to the facility on [DATE] at 6:40 P.M. with [DIAGNOSES REDACTED]. Review of the admission physician's orders [REDACTED]. Review of the MAR for May and June 2011 revealed the scheduled times for the [MEDICATION NAME] were 8:00 A.M., 2:00 P.M. and 8:00 P.M. There was no documentation the 8:00 P.M. dose was administered as ordered on [DATE], 05/29/11, 05/30/11, 05/31/11 and 06/23/11. Interview with the DON on 06/28/11 at 2:23 P.M., verified there was no documentation the [MEDICATION NAME] was administered to Resident #3. Review of facility policy entitled, "Identifying and Managing Medication Errors and Adverse Consequences" revised April 2007, revealed the staff and practitioner shall try to prevent medication errors and adverse consequences, and shall strive to identify and manage them appropriately when they occur. The staff and practitioner shall strive to minimize adverse consequences by: following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication. The staff shall report clinically significant adverse medication consequences and medication errors with adverse clinical consequences to the resident's Attending Physician immediately. "This deficiency substantiates Master Complaint Number OH 377 and Control Number OH 228."