Every finding on record at Liberty Health Care Center Inc

Based on observation, interview, record review, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were maintained for chronic wound ulcers. This affected one resident (Resident #273) out of three residents reviewed for wound care. The facility census was 95.Findings include:Record review of Resident #273 revealed an admission date of 03/31/26 with diagnoses of cerebral infarction (stroke), Alzheimer's disease, peripheral vascular disease, type two diabetes, and muscle wasting and weakness.Review of Resident #273's care plan revised 05/22/26 revealed goals and interventions for person-centered care included EBP related to the resident's chronic wound.Review of Resident #273's wound assessment dated [DATE] revealed a chronic one-centimeter left heel pressure ulcer which required daily dressing changes, and it was not a new area. Review of provider orders initiated on 06/04/26 revealed EBP every shift while Resident #273 had an indwelling medical device or chronic wound.Observation on 06/04/26 at 11:15 A.M. of left heel wound dressing change for Resident #273 revealed Licensed Practical Nurse (LPN) #614 did not wear a gown when in contact with and providing wound care for Resident #273 per EBP.Interview with Director of Nursing (DON) and Infection Control Nurse (ICN) #587 on 06/04/26 at 2:49 P.M. verified EBP should have been maintained per order, and LPN #614 should have worn a gown while performing the dressing change to Resident #273's chronic left heel wound. Review of facility policy labeled, Enhanced Barrier Precautions (EBP), revised 11/2024, revealed EBP were used in conjunction with standard precautions and expanded the use of personal protective equipment (PPE) with the donning of a gown and gloves during high contact resident care activities. Indications for EBP were indicated for chronic wounds such as pressure ulcers, diabetic foot ulcers, venous stasis ulcers, arterial ulcers, and unhealed surgical wounds. This deficiency represents non-compliance investigated under Complaint Number 3007806.

Based on record review, review of the facility's self-reported incident (SRI) investigation, and interview, the facility failed to maintain complete and accurate records of transactions for resident funds accounts. This affected nine residents (#16, #45, #49, #59, #63, #68, #124, #125, #126) out of 15 residents reviewed for resident funds. The facility census was 101.Findings include:1. Review of the medical record for Resident #16 revealed an admission date of [DATE] with diagnoses including unspecified head injury, hyperlipidemia, type two diabetes mellitus, and major depressive disorder.Review of the resident trust transaction history for Resident #16 revealed there were cash withdrawals of $15.00 on [DATE], $6.00 on [DATE], and $6.00 on [DATE] with no receipts available for these transactions.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had no cognitive impairment.2. Review of the medical record for Resident #45 revealed an admission date of [DATE] with diagnoses including Parkinson's disease, type two diabetes mellitus, anxiety disorder, and major depressive disorder.Review of the quarterly MDS assessment dated [DATE] revealed Resident #45 had no cognitive impairment.Review of the resident trust transaction history for Resident #45 revealed there was a cash withdrawal of $10.00 on [DATE] with no receipt available for this transaction.3. Review of the medical record for Resident #49 revealed an admission date of [DATE] with diagnoses including Multiple Sclerosis, type two diabetes mellitus, depression, and hypertension.Review of the resident trust transaction history for Resident #49 revealed there was a cash withdrawal of $30.00 on [DATE] with no receipt available for this transaction.Review of the annual MDS assessment dated [DATE] revealed Resident #49 had no cognitive impairment.4. Review of the medical record for Resident #59 revealed an admission date of [DATE] with diagnoses including hypothyroidism, hyperlipidemia, bipolar disorder, dementia, mild cognitive impairment, and major depressive disorder.Review of the resident trust transaction history for Resident #59 revealed there were cash withdrawals of $5.00 on [DATE], $5.00 on [DATE], and $5.00 on [DATE] with no receipts available for these transactions.Review of the quarterly MDS assessment dated [DATE] revealed Resident #59 had no cognitive impairment.5. Review of the medical record for Resident #63 revealed an admission date of [DATE] with diagnoses including anxiety disorder, major depressive disorder, hypothyroidism, hypertension, and cerebral infarction.Review of the resident trust transaction history for Resident #63 revealed there were cash withdrawals of $360.00 on [DATE], $20.00 on [DATE], and $90.00 on [DATE] with no receipts available for these transactions.Review of the quarterly MDS assessment dated [DATE] revealed Resident #63 had no cognitive impairment.6. Review of the medical record for Resident #68 revealed an admission date of [DATE] with diagnoses including anxiety disorder, major depressive disorder, hyperlipidemia, and hypertension.Review of the resident trust transaction history for Resident #68 revealed there was a cash withdrawal of $10.00 on [DATE] with no receipt available for this transaction.Review of the annual MDS assessment dated [DATE] revealed Resident #68 had no cognitive impairment.7. Review of the closed medical record for Resident #124 revealed an admission date of [DATE] with diagnoses including Parkinson's disease, dementia with agitation, hypertension, type two diabetes mellitus, and Alzheimer's disease. Resident #124 expired on [DATE].Review of the resident trust transaction history for Resident #124 revealed there was a cash withdrawal of $100.00 on [DATE] with no receipt available for this transaction.Review of the quarterly MDS assessment dated [DATE] revealed Resident #124 had severe cognitive impairment.8. Review of the closed medical record for Resident #125 revealed an admission date of [DATE] with diagnoses including major depressive disorder, dementia with anxiety, amnesia, and anxiety disorder. Resident #125 discharged on [DATE].Review of the resident trust transaction history for Resident #125 revealed there was a cash withdrawal of $140.00 on [DATE] with no receipt available for this transaction.Review of the discharge MDS assessment dated [DATE] revealed Resident #125 had severe cognitive impairment.9. Review of the closed medical record for Resident #126 revealed an admission date of [DATE] with diagnoses including major depressive disorder, type two diabetes mellitus, hyperlipidemia, and cerebral infarction. Resident #126 discharged on [DATE].Review of the resident trust transaction history for Resident #126 revealed there were cash withdrawals of $10.00 on [DATE] and $10.00 on [DATE] with no receipts available for these transactions.Review of the discharge MDS assessment dated [DATE] revealed Resident #126 had no cognitive impairment.Review of the facility's investigation of SRI tracking number 271333, opened on [DATE], revealed nine residents (#16, #45, #49, #59, #63, #68, #124, #125, #126) had cash withdrawals from their accounts, which were managed by the facility, with no receipt available for those withdrawals totaling $822.00. The Administrator interviewed the alleged perpetrator during their investigation of the incident, and the alleged perpetrator stated she knew there would be errors claiming health issues were to blame for the errors. During their investigation, the facility was unable to locate any receipts confirming those withdrawals occurred. There was no evidence to support misappropriation; however, the lack of receipts for documented withdrawals demonstrated a lack of a complete and accurate accounting of resident funds managed by the facility.On [DATE] at 11:53 A.M., an interview with the Administrator stated they investigated the incident for misappropriation and could not prove that the funds were misappropriated. The Administrator confirmed their investigation identified there were 16 cash withdrawals from resident accounts with no receipts documented for those transactions. She stated when a former employee identified as the alleged perpetrator was questioned, that employee claimed there were possibly bookkeeping mistakes due to underlying health issues, and she denied taking any money from resident accounts. The Administrator stated they replaced the funds in question out of good faith despite not being able to prove the funds were misappropriated.

Based on record review, resident interview, staff interview, and review of the facility policy, the facility failed to provide showers as scheduled and per resident preferences for residents who required assistance with bathing. This affected five residents (#55, #81, #87, #90, and #98) out of five reviewed for bathing. The facility census was 101. Findings include:1. Review of the medical record for Resident #81 revealed an admission date of 03/22/16 with diagnoses including major depressive disorder, hypertension, Barrett's esophagus, atrial flutter, muscle weakness, congestive heart failure, chronic kidney disease, hypothyroidism, and peripheral vascular disease. Review of the care plan dated 10/03/19 revealed Resident #81 would receive a person-centered care plan based on physician orders and resident choices. Interventions included assistance of one staff for bathing and sit to stand lift for transfers. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #81 had no cognitive impairment. The assessment indicated Resident #81 was dependent on staff for showering/bathing and dependent on staff for transfers. Review of the shower schedules revealed Resident #81 was scheduled for showers on Wednesdays and Saturdays. Review of the shower documentation from 09/01/25 through 03/01/26 revealed Resident #81 received 21 showers and two bed baths out of 50 scheduled shower days with six refusals documented on 09/01/25, 11/08/25, 11/12/25, 11/26/25, 12/03/25, and 01/10/26. Review of the progress note dated 02/19/26 at 12:27 P.M. revealed Resident #81's daughter requested a care plan meeting with the Administrator and Director of Nursing (DON). Review of the progress note dated 02/27/26 at 11:23 A.M. revealed the Administrator met with Resident #81's daughter for a care plan meeting, which included discussions about the shower schedules. On 03/04/26 at 10:01 A.M., an interview with Certified Nursing Assistant (CNA) #599 stated all showers were documented electronically on tablets and if it was blank, then no shower was provided. On 03/04/26 at 3:04 P.M., an interview with Licensed Practical Nurse (LPN) #515 confirmed showers were only documented electronically, and documentation was an issue. LPN #515 verified the shower documentation and that multiple days were documented as not applicable, including scheduled shower days for Resident #81. LPN #515 stated if it was not documented then it was not done. On 03/04/26 at 4:55 P.M., an interview with Corporate Quality Assurance (QA) Registered Nurse (RN) #499 confirmed shower documentation had been an ongoing concern at the facility. Review of the facility's policy titled Bath (Shower), dated 02/2026, revealed the frequency of baths and showers were based on resident preference as noted on the care plan. 2. Review of the medical record for Resident #87 revealed an admission date of 01/06/24 with diagnoses including vertigo, anxiety disorder, muscle wasting and atrophy, major depressive disorder, hemiplegia and hemiparesis following cerebral infarction, muscle weakness, and limitations of activities due to disability. Review of the annual MDS assessment, dated 01/09/26, revealed Resident #87 had no cognitive impairment. The assessment did not indicate what kind of assistance was required for showering/bathing, and the question was answered not applicable. Review of the care plan dated 01/06/24 revealed Resident #87 would receive a person-centered care plan based on physician orders and resident choices. Interventions included assistance from two staff for bathing and a mechanical lift for transfers. Review of the shower schedules revealed Resident #87 was scheduled for showers on Wednesdays and Saturdays. Review of the shower documentation from 09/01/25 through 03/01/26 revealed Resident #87 received eight showers and 11 bed baths out of 52 scheduled shower days with only one refusal documented on 11/08/25. On 03/02/26 at 3:35 P.M., an interview with Resident #87 stated she did not receive showers as often as she would like. On 03/04/26 at 10:01 A.M., an interview with CNA #599 stated all showers were documented electronically on tablets and if it was blank, then no shower was provided. On 03/04/26 at 3:04 P.M., an interview with LPN #515 confirmed showers were only documented electronically, and documentation was an issue. LPN #515 verified the shower documentation. LPN #515 stated if it was not documented then it was not done. On 03/04/26 at 4:55 P.M., an interview with Corporate QA RN #499 confirmed shower documentation had been an ongoing concern at the facility. Review of the facility's policy titled Bath (Shower), dated 02/2026, revealed the frequency of baths and showers were based on resident preference as noted on the care plan. 3. Review of the medical record for Resident #90 revealed an admission date of 01/14/26 with diagnoses including Alzheimer's disease, dementia with psychotic disturbance, adjustment disorder with anxiety, muscle weakness, and repeated falls. Review of the care plan dated 01/14/26 revealed Resident #90 would receive a person-centered care plan based on physician orders and resident choices. Interventions included assistance from one staff for bathing and transfers. Review of the admission MDS assessment dated [DATE] revealed Resident #90 had no cognitive impairment. The assessment indicated Resident #90 required substantial or maximal assistance for showering/bathing. Review of the physician's orders for Resident #90 identified orders for transfer assistance of one staff effective 01/28/26. Review of the shower schedules revealed Resident #90 was scheduled to receive showers on Tuesdays and Fridays. Review of shower documentation since admission for Resident #90 revealed nine showers were provided out of 13 scheduled shower days with no documented refusals. On 03/02/26 at 10:44 A.M., an interview with Resident #90 stated she did not get showers as scheduled. On 03/04/26 at 10:01 A.M., an interview with CNA #599 stated all showers were documented electronically on tablets and if it was blank, then no shower was provided. On 03/04/26 at 3:04 P.M., an interview with LPN #515 confirmed showers were only documented electronically, and documentation was an issue. LPN #515 verified the shower documentation. LPN #515 stated if it was not documented then it was not done. On 03/04/26 at 4:55 P.M., an interview with Corporate QA RN #499 confirmed shower documentation had been an ongoing concern at the facility. Review of the facility's policy titled Bath (Shower), dated 02/2026, revealed the frequency of baths and showers were based on resident preference as noted on the care plan. 4. Record review for Resident #98 revealed an admission date of 11/28/25 with diagnoses including periprosthetic fracture around an internal prosthetic left knee. Review of the care plan dated 11/28/25 indicated Resident #98 required two staff assistance with showers, and he was to receive showers twice weekly. Review of the MDS assessment dated [DATE] revealed Resident #98 was moderately cognitively impaired. Review of the facility's shower documentation indicated Resident #98's preferred shower Mondays and Thursdays. Interview on 03/02/26 at 10:47 A.M. revealed Resident #98 stated he was not receiving showers, and he had only received one in the past month. Review of the facility's shower documentation from 11/28/25 through 03/01/26 revealed there were 26 scheduled shower days within a 93-day period. Documentation showed the resident received only nine showers/bed baths, with one documented refusal. Interview with LPN #515 on 03/02/26 at 8:05 A.M. revealed residents should receive their showers according to their care plan and preferred schedule unless refused which should be documented. LPN #515 stated staff received an in-service on 02/13/26 regarding shower documentation. LPN #515 confirmed Resident #98 was scheduled to receive showers on Mondays and Thursdays and acknowledged the documentation did not show Resident #98 received showers as scheduled or documentation of refusals. Record review revealed staff received an in-service on shower documentation on 02/13/26. Review of the shower documentation after the in-service training revealed Resident #98 had four scheduled shower opportunities with only one shower provided, and no documentation of refusal for the remaining missed showers. Review of the facility's policy titled Bath (Shower), dated 02/2026, revealed the frequency of baths and showers were based on resident preference as noted on the care plan. 5. Resident #55 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, gastroesophageal disease (GERD), generalized anxiety, aphasia, dysphagia, stroke, bone disorders, bradycardia, and obesity. Her cognition was severely impaired. Review of Resident #55's medical record revealed she was ordered showers on Mondays, Wednesdays, and Fridays. Family wanted notified if the resident refused. Progress notes on 02/15/26 and 02/21/26 revealed Resident #55 often refuses personal care, to include showers, incontinent care, and getting out of bed in the morning. Review of CNA documentation for showers revealed from 09/01/25 through 03/01/26, Resident #55 was scheduled for 79 showers. She received 46 showers and refused three showers, or 58.2 percent (%). In-service related to resident showers on 02/13/26 was completed by all nursing staff. After that, Resident #55 has had six scheduled showers and received four. Interview on 03/02/26 at 11:53 A.M. with Resident #55's daughter revealed the resident had not been receiving all her showers for several months. On 03/03/26 at 8:05 A.M., the Nurse Aide Supervisor, LPN #515 verified documentation did not indicate Resident #55 received her showers in accordance with her physician order. Review of the facility's policy titled Bath (Shower), dated 02/2026, revealed the frequency of baths and showers were based on resident preference as noted on the care plan. This deficiency represents non-compliance investigated under Master Complaint Number 2724622 and Complaint Number 2715174.

Based on record review, observation and interview, the facility failed to ensure Resident #45 was treated with dignity and respect by failing to provide appropriate clothing and coverings to maintain privacy and dignity. This affected one resident (#45) out of two residents investigated for dignity. In addition, the facility failed to ensure the call light was within reach for Resident #45. This affected one resident (#45) out of eight residents investigated for call lights. The facility census was 101.Findings include:1. Record reviewed for Resident #45 revealed an admission date of 06/29/25 with diagnoses including Parkinson's disease, muscle wasting and atrophy, muscle weakness, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #45 was cognitively intact. The resident required substantial/maximal assistance for upper and lower body dressing. Observation on 03/02/26 at 2:56 P.M. revealed Resident #45 lying in bed with the door to the room open, the curtain open with no blanket or sheet for the resident to cover himself. Resident #45 was wearing a t-shirt and incontinence brief. Interview with Resident #45 on 03/02/26 at the time of the observation confirmed he was not comfortable lying in his bed uncovered and exposed and would like to be covered up. Interview on 03/02/26 at 3:02 P.M. with Personal Care Aide (PCA) # 541 verified Resident #45 could be seen from the hallway, was not covered, had no blanket or sheet available, and the resident was wearing only an incontinence brief and t-shirt. PCA #541 verified Resident #45 should have been covered. 2. Record reviewed for Resident #45 revealed an admission date of 06/29/25 with diagnoses including Parkinson's disease, muscle wasting and atrophy, muscle weakness, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #45 was cognitively intact and required substantial/maximal assistance for upper and lower body dressing. Review of the care plan revealed staff was to ensure call light is in reach (07/07/25).Observation on 03/02/26 at 2:56 P.M. revealed Resident #45 lying in bed with call light not in reach. The resident confirmed due to limitations of hands and arms he was unable to reach call light placed over his right shoulder.Interview on 03/02/26 at 3:02 P.M. with Personal Care Aide #541 (PCA) confirmed Resident #45 was not able to reach his call light.Observation on 03/03/26 at 11:54 A.M. revealed Resident #45's call light was not in reach. The call light was placed on the bed near the resident's right shoulder. He stated PCA #575 had just finished personal care, and he was not able to reach his call light.Interview on 03/03/26 at 11:56 A.M. with PCA #575 confirmed she completed Resident #45's personal care and did not ensure his call light was within reach before leaving the room. Interview on 03/03/26 at 12:15 P.M. with Physical Therapist #407 revealed due to Resident #45's primary diagnosis of Parkinson's disease, the resident's ability to move his arms and hands depended of the day; some days Resident #45 was able to use his arms and hands more than normal but was limited on an ongoing basis.Phone interview on 03/04/26 at 1:04 P.M. with Resident #45's uncle revealed on numerous occasions he observed the call light was not within reach for the resident upon arrival for visits.This deficiency represents non-compliance investigated under Master Complaint Number 2724622 and Complaint Number 2715174.

Based on observation, medical record review, policy review and interview, the facility failed to identify and monitor bruises for one (Resident #76) of 42 residents observed for non-pressure related skin concerns and failed to implement bowel protocol and physician orders for Resident #85 and failed to change Resident #105's peripherally inserted central catheter (PICC) line dressing changed weekly as ordered by the physician. This affected two residents (#76 and 3105) of five residents reviewed for medication use. The facility census was 101. Findings include:1. On 03/02/26 at 10:53 A.M., ecchymotic (bruised) areas were observed on Resident #76's left upper arm and right wrist. Resident #76 was unable to provide any information related to the bruises. Review of Resident #76's medical record revealed diagnoses including displaced fracture of the base of the neck of the right femur (thigh bone), presence of a right artificial hip joint, repeated falls, and dementia. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #76 was severely cognitively impaired. No documentation was able to be located related to the bruises. On 03/03/26 at 2:05 P.M., Licensed Practical Nurse (LPN) #560 stated she was unaware of the bruises, and there was no documentation in the medical record regarding the bruises. During observations of Resident #76 with LPN #560 at that time, it was verified Resident #76 had bruises on the left upper extremity, right upper extremity, and right wrist. Review of a nursing note dated 03/03/26 at 2:33 P.M. indicated Resident #76 was noted to have small bruises to bilateral upper arms and the right wrist. The right upper arm bruise measured 2.5 centimeters (cm) by 1.5 cm in diameter. All bruises were dark and purple. Resident #76's daughter was notified and indicated she was already aware of the bruises stating she figured Resident #76 must have bumped them on the side rail. The physician was notified of the incident. Review of a nursing note dated 03/04/26 at 9:51 A.M. indicated the bruising was reassessed with a registered nurse (RN). Resident #76's son-in-law was present during the assessment. Resident #76 was observed with a light purple quarter-sized area to the left bicep region and a light purple/green half-dollar sized bruise to the right bicep region. The areas of bruising to both arms were directly in line with edges of the underlying Hoyer (mechanical lift) pad in the Broda chair. The area of bruising noted to the right wrist was light/medium purple and presented as petechiae (tiny spots of bleeding). The son-in-law reported Resident #76 had a history of bruising related to very fragile skin. The note indicated a plan to implement a larger Hoyer pad for transfers. 2. Review of Resident #85's medical record revealed diagnoses including chronic pain and vascular dementia. Review of physician's orders dated 02/16/26 revealed if Resident #85 did not have a bowel movement in 48 hours, four ounces of high fiber juice or prune juice was to be administered. Results were to be documented. If there were no results from the high fiber juice, 30 milliliters of Milk of Magnesia (laxative) was to be administered. If there were no results from the Milk of Magnesia, one Dulcolax suppository (laxative) was to be administered after an abdominal evaluation. An admission MDS dated [DATE] indicated Resident #85 was severely cognitively impaired. Resident #85 was assessed as always being incontinent of bowel. Review of Resident #85's bowel movement records revealed bowel movements were recorded on 02/17/26, 02/22/26 and 02/24/26. As of the morning of 03/03/26, there was no evidence orders for the high fiber juice, Milk of Magnesia or Dulcolax suppository were implemented as ordered. On 03/03/26 at 3:10 P.M., Certified Nursing Assistant (CNA) #521 stated Resident #85's bowels moved that day. Resident #85 was incontinent and dependent on staff for toileting hygiene. On 03/04/26 at 10:23 A.M., Corporate Quality Assurance (QA) Registered Nurse (RN) #499 verified, after reviewing bowel movement records for February and March 2026 medication administration records, staff did not implement orders for bowel protocol. On 03/05/26 at 11:35 A.M., RN #589 stated a report was run on a daily basis for those residents who did not have a bowel movement recorded for two full days and a list was provided to the floor nurses. The floor nurses were expected to implement the facility's bowel protocol. RN #589 verified there was no evidence of the bowel protocol/orders being followed for Resident #85.Review of the facility's Bowel Movement Protocol Policy (dated May 2025) revealed the unit nurse would monitor the bowel movement records and bowel alerts and would follow the facility bowel protocol unless a specific bowel protocol was ordered/care planned for a specific resident. Night shift nurses were responsible for listing all residents who had not had a bowel movement in 48 hours based on the clinical alerts in the electronic health record. The list was to be provided to the dayshift nurse who would administer high fiber juice with the morning medication pass and would document any results. If no results that afternoon the dayshift nurse would complete an abdominal assessment including assessment of bowel sounds. If bowel sounds were present, the nurse was to administer Milk of Magnesia with the afternoon (4:00 P.M.) medication pass and document the results. If there were no results from the Milk of Magnesia, the night nurse was to complete an abdominal assessment including bowel sounds and administer a Dulcolax rectal suppository with the early morning med pass (6:00 A.M.) If there were no results from the suppository, the day shift nurse was to do an abdominal assessment and administer a fleets enema or soap suds enema by the afternoon med pass. If there were no results from the enema within one hour, the physician/practitioner would be notified for further orders. 3. Record review of Resident #105 admitted on [DATE] with a diagnoses of encounter for orthopedic aftercare following surgical amputation, acquired absence of other right toe(s), other acute osteomyelitis, right ankle and foot, cellulitis of right lower limb, vitamin D deficiency, type two diabetes mellitus with diabetic neuropathy, type two diabetes mellitus with other skin complications, non-pressure chronic ulcer of other part of right foot with unspecified severity, muscle weakness (generalized), difficulty in walking, not elsewhere classified, mixed hyperlipidemia, essential (primary) hypertension, unspecified contact dermatitis due to plants, except food, other specified symptoms and signs involving the circulatory and respiratory systems, morbid (severe) obesity due to excess calories, mild intermittent asthma, polyneuropathy, local infection of the skin and subcutaneous tissue. Review of the physician orders revealed an order dated 02/24/26 to change Resident #105's PICC line dressing weekly on Mondays (start 03/02/26).Observation on 03/02/26 at 9:59 A.M. of Resident #105's PICC line dressing was dated 02/23/26. The PICC line dressing was observed with dried blood under the sterile dressing. Observation on 03/04/26 at 2:20 P.M. revealed Resident #105's PICC line dressing was dated for 02/23/26 with dried blood under the dressing.Interview on 03/04/26 at 8:53 A.M. with LPN #536 confirmed Resident #105's PICC line dressing was dated 02/23/26 and had not been changed on 03/02/26 per physician orders.

Based on observations, medical record review, and interview, the facility failed to implement pressure-relieving interventions for one (Resident #76) of five residents reviewed for pressure ulcers. The facility census was 101.Findings include:Review of Resident #76's medical record revealed diagnoses including chronic anemia, dementia, and right hip fracture. Resident #76 was admitted to the facility on [DATE] with an unstageable pressure ulcer (full-thickness wound whose depth cannot be determined because it is obscured by slough, eschar, or a non-removable dressing) to the right heel. Slough is dead tissue in the wound. Eschar is necrotic tissue. On 06/27/25, an order was written to offload heels in bed for preventative skin care. A plan of care initiated 07/07/25 indicated Resident #76 had potential/actual impairment to skin integrity related to incontinence, muscle wasting and atrophy, muscle weakness, fracture, hypertension, hypothyroidism, dementia, deep vein thrombosis, depression and anemia. Interventions included identifying potential causative factors and eliminating/resolving them where possible. On 08/11/25 an order was written for a wedge cushion under her feet when in the Broda chair. A wound assessment dated [DATE] indicated the right heel pressure ulcer was resolved. The orders for the wedge cushion under the feet in the Broda chair and offloading the heels in the bed continued. On 03/02/2026 at 10:53 A.M., Resident #76 was observed sitting in a Broda chair in her room. There were two signs posted on the walls (one above the bed and one by the bathroom door) to apply a boot when up in the wheelchair. Resident #76's left foot was resting on the foot of the Broda chair with no wedge observed. On 03/03/26 at 10:15 A.M., Certified Nursing Assistant (CNA) #623 revealed there was a boot on Resident #76's right foot while sitting in the Broda chair but there was no wedge or devices to alleviate pressure on the left heel which was resting on the foot of the chair. On 03/03/26 at 2:05 P.M., Licensed Practical Nurse (LPN) #560 verified Resident #76, who was lying in bed, had a boot on the right foot but her left foot was resting on the surface of the mattress.

Based on observation, record review, interview and facility policy review, the facility failed to implement appropriate infection control protocols during medication administration for Resident #19 and failed to wear appropriate personal protective equipment (PPE) while administering intravenous (IV) medication to Resident #105. This affected two residents (#19 and #105) out of four residents reviewed for infection control. The facility census was 101.Findings include:1. Review of the medical record for Resident #19 revealed an admission date of 10/25/24 with diagnoses including adjustment disorder, anxiety disorder, type two diabetes mellitus, altered mental status, and dementia with agitation.Review of the care plan revised 11/25/25 revealed Resident #19 had impaired cognitive function and thought processes related to impaired decision making and dementia. Interventions included administering medications as ordered and monitoring for effectiveness.On 03/03/26 at 8:49 A.M., an observation revealed Registered Nurse (RN) #559 was administering medications to Resident #19. The pills were in a small plastic cup, and RN #559 was using a plastic spoon to remove the pills from the plastic cup one at a time to administer the medications to Resident #19. While doing so, RN #559 dropped one pill onto the blanket on Resident #19's lap. RN #559 picked the pill up off the blanket with her bare hand, placed the pill back in the plastic cup with the other pills, then used the plastic spoon to administer the remainder of Resident #19's pills.On 03/03/26 at 8:50 A.M., an interview with RN #559 verified she dropped one pill, picked it up with her bare hand, put it back in the plastic cup with other pills, and administered the dropped pill and remaining pills to Resident #19. RN #559 said picking the pill up off the blanket was a reflex and that was not proper protocol.2. Review of Resident #105's medical record revealed diagnoses including type two diabetes mellitus with a foot ulcer, local infection of the skin and subcutaneous tissue, and acquired absence of right toe(s) and osteomyelitis (serious bone infection) of the right ankle and foot. On 02/07/26 an order was written for Enhanced Barrier Precautions (EBP) during high contact resident care activities while Resident #105 had an indwelling medical device or chronic wound. On 02/24/26, an order was written for vancomycin HCl (antibiotic) 1500 milligrams (mg) IV in the mornings related to osteomyelitis. On 02/24/26, an order was written to change the Peripherally Inserted Central Catheter (PICC)/midline cap and dressing weekly every Monday. On 03/03/26 at 8:20 A.M., Licensed Practical Nurse (LPN) #536 was observed administering the vancomycin to Resident #105. No gown was worn during the administration of the vancomycin through a PICC. On 03/03/26 at 8:24 A.M., LPN #536 verified she did not wear a gown while administering the vancomycin. Review of the facility's EBP policy (dated March 2024) revealed EBP was indicated for indwelling medical devices including central line IV access. This deficiency represents non-compliance investigated under Master Complaint Number 2724622 and Complaint Number 2715174.

Based on closed record review, interview and facility policy review, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent, accurately and timely assess, promote healing and prevent pressure ulcer/wound infection from occurring. This affected one (Resident #95) of three residents reviewed for pressure ulcers. The facility census was 93. Actual Harm occurred on 07/03/25 when Resident #95 was assessed to have an acute change in condition requiring hospitalization. Upon hospital assessment, the resident was assessed to have a Stage II pressure ulcer to the sacrum with extensive gas forming soft tissue infection at the lower back extending to the tip of the coccyx measuring 9.0 centimeters (cm) by 2.3 cm by 16.1 cm. Prior to the development of the pressure ulcer infection, the facility failed to ensure effective ongoing monitoring and adequate interventions were in place to prevent the wound infection and subsequent hospitalization for treatment. Findings include:A review of Resident #95's closed clinical record revealed an admission date of 05/08/25 with diagnoses including left above the knee amputation, severe protein-calorie malnutrition, acute respiratory failure with hypoxia, pleural effusion, necrotizing fasciitis (Bacterial infection that rapidly destroys the skin, fat, and soft tissues surrounding muscles.), diabetes mellitus, hypothyroidism, high blood pressure, and gastroesophageal reflux disease. Resident #95 was discharged from the facility on 07/25/25. A review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #95 was cognitively intact. The assessment revealed the resident had no behaviors and she was assessed to be dependent on staff for toileting hygiene, transfers, and showers. The assessment revealed the resident required partial to moderate assistance with bed mobility, was always incontinent of urine and frequently incontinent of bowel. The resident was assessed to be at risk for pressure ulcer development, had no pressure ulcers, and had moisture associated skin damage (MASD). The assessment included the resident had pressure reducing devices to the bed and chair. A review of Resident #95's plan of care initiated on 05/19/25 revealed Resident #95 was at risk for the development of pressure ulcers related to limited mobility, left below the knee amputation with noted episodes of refusing boots to offload pressure to the heels and moisture associated buttocks/sacrum, thin fragile skin, and multiple bony prominences. The plan of care indicated on 05/20/25 Resident #95 frequently chose not to be repositioned, removed pillows when used to assist with side positioning, removed pressure reduction boots and informed the staff I move around plenty. The goal of the plan of care was for Resident #95 to have intact skin, free of redness, blisters or discoloration. Interventions on the plan of care included administering medications/treatments as ordered by the physician and monitor for side effects and effectiveness. Follow the facility policies/protocols for the prevention of skin breakdown, including the use of pressure reducing mattress to the bed, inform family/caregivers of any new area of skin breakdown, monitor nutritional status, serve diet as ordered, monitor food intake and record, monitor/document/report as needed any changes in skin appearance, color, wound healing, signs and symptoms of infection, wound size measurements and stage of wound, obtain and monitor laboratory/diagnostic work as ordered and report results to the physician, and treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. A review of Resident #95's physician's orders revealed an ordered dated 05/19/25 to cleanse coccyx with normal saline, pat dry, apply Allevyn Life dressing (dressing for the prevention and treatment of pressure injuries and other wounds) to the coccyx to pad and protect the area every other day and as needed for preventative treatment every night shift (11:00 P.M. to 7:00 A.M.). The order was noted due to the resident's history of a healed pressure ulcer to this area. The order indicated to sign and date the dressing when completed. A review of Resident #95's medical record revealed a skin evaluation assessment dated [DATE]. The assessment included the area was cleaned with normal saline, pat dried and a dry dressing was applied as ordered to pad and protect. The assessment note included the resident's skin was intact and the dressing remained dry and intact. A review of Resident #95's weekly skin evaluation/assessment dated [DATE], completed by Licensed Practical Nurse (LPN) #100, documented the resident had no new areas of skin breakdown identified, and dressing was intact to the coccyx. The evaluation included the resident's skin was intact with no new issues. The assessment indicated Resident #95 was at risk for the development of pressure ulcers. (However, there was no evidence the dressing that was in place at the time of the assessment on this date (used to pad and protect) was actually removed during this skin evaluation to determine if the resident had skin breakdown to the coccyx). This was the last weekly skin evaluation documented prior to the resident being transferred 07/03/25 hospitalization. A review of Resident #95's progress note dated 07/03/25 revealed at 9:06 A.M. the nurse found Resident #95 moaning in pain and lethargic. Resident #95's blood sugar was obtained, and the result was 36 milligrams/diluent (mg/dL). Orange juice was provided, blood sugar was re-checked, and the reading was 27 mg/dL. Glucagon was administered, the blood sugar was checked and the glucometer read low. The physician was notified and 911 was called. While waiting for emergency medical services (EMS) Resident #95's blood sugar was checked, and the result was 51 mg/dL and moments later was 24 mg/dL. Resident #95 was transferred to the hospital. A review of Resident #95's hospital emergency room documentation dated 07/03/25 revealed the resident had a Stage II pressure ulcer (the top layer of skin (epidermis) is broken; it looks like a shallow open sore. There may be mild swelling, oozing or pus.) the size of a quarter with surrounding erythema (redness), warmth, induration (a hardening or thickening of the tissue surrounding the wound.). A computerized tomography (CT) scan with contrast was obtained which revealed the presence of extensive gas forming soft tissue infection at the lower back extending to the tip of the coccyx measuring 9.0 centimeters (cm) by 2.3 cm by 16.1 cm pressure ulcer at the sacrum with no definitive osteomyelitis. Resident #95's blood sugar continued to drop, and she was administered dextrose 10 percent, antibiotics were started, and the hospital nurse informed the facility Resident #95 would be admitted to the hospital with diagnoses of sepsis with acute hypoxic respiratory failure without septic shock, necrotizing soft tissue infection, acute respiratory failure with hypoxia, pneumonia of the right lower lobe due to infectious organism, acute cystitis without hematuria. The hospital documentation did not state if there was a dressing to Resident #95's sacrum/coccyx upon arrival to the hospital. Resident #95 was hospitalized until 07/12/25, at which time she returned to the facility. The resident was discharged to the hospital again on 07/25/25 due to a low hemoglobin level with no active sign of bleeding and did not return to the facility. An interview with Wound Registered Nurse (WRN) #103, the facility wound nurse, on 09/09/25 at 1:41 P.M. revealed she had assessed the resident upon admission and the resident did not have any pressure ulcers. WRN revealed the floor nurses were then responsible to complete weekly skin assessments/evaluations and should notify her if a resident developed or had a pressure ulcer develop following admission. During the interview, WRN #103 verified the skin evaluation/assessments dated 06/16/25 and 06/30/25 were incomplete as they failed to include evidence the staff completed the assessments had actually looked at the resident's skin under the dressing that was in place. WRN #103 was unable to provide any information as to when the pressure ulcer had actually developed. WRN #103 agreed the weekly skin assessment dated [DATE] indicated the coccyx dressing was intact but there was no actual skin assessment of the area underneath the dressing documented in Resident #95's medical record. WRN #103 verified on 07/03/25 the resident was admitted to the hospital and the hospital first identified the resident had an infected Stage II pressure area. She stated the nurses should have removed the dressing to assess the resident's skin prior to have identified this ulcer sooner. WRN #103 revealed staff were documenting they were changing the resident's dressing every other day as ordered; however, there was no documentation of an actual description of the resident's coccyx under the pad and protect dressing during the resident's stay in the facility. During the interview, WRN #103 revealed she did not personally see Resident #95 for wound care because the facility staff had not identified the resident had a Stage II pressure ulcer or that the ulcer was infected prior to the resident being transferred to the hospital on [DATE]. An interview with Physician #102 (Infectious Disease Physician) on 09/09/25 at 4:05 P.M. revealed Resident #95 had a pressure ulcer located on the coccyx upon her arrival to the hospital. Surgery was performed to debride the coccyx area. The physician revealed the pressure ulcer had become infected during the resident's stay at the extended care facility. An interview with LPN #100 on 09/09/25 at 4:25 P.M. revealed she had completed the most recent weekly skin evaluation on 06/30/25 prior to Resident #95's admission to the hospital on [DATE]. During the interview, LPN #100 stated she did not actually remove the pad and protect dressing to Resident #95's coccyx to inspect the area for skin breakdown. LPN #100 stated she was unable to say if Resident #95's coccyx area had developed a pressure ulcer at the time the assessment was completed. An interview with LPN #101 on 09/11/25 at 7:40 A.M. revealed he had completed Resident #95's preventative wound treatment on 06/30/25. During the interview, LPN #101 stated he was unable to remember what the resident's coccyx area looked like at the time. An interview with Quality Assurance Nurse (QAN) #104 on 09/09/25 at 3:00 P.M. verified the above findings and agreed the facility staff failed to ensure adequate and ongoing assessments were being completed for Resident #95. QAN #104 also verified the assessment/evaluation documented on 06/30/25 was not comprehensive or complete to ensure the resident's skin had actually be assessed under the pad and protect dressing that was in place. The facility policy and procedure titled Pressure Ulcer Prevention and Care Protocol revised 1/2025 revealed the licensed nursing staff would use the following criteria as part of the resident's comprehensive assessment to determine risk of pressure ulcer development and development of the resident's plan of care. Risks and complications unique to the resident would be documented on the resident's individualized plan of care. The prevention and care interventions developed through the assessment would be noted on the plan of care and followed by the direct care staff. The risk assessment criteria included: A head-to-toe examination of the skin for Stage I or greater pressure ulcer, scar over a bony prominence (healed pressure ulcers), or non-removable dressing/device and any alteration in skin condition. Review of medical history/medical record for co-morbid conditions Assessment of oxygen transport/tissue perfusion and BP Advanced Age Ability to move, turn, transfer and ambulate Presence of Trauma, Tremors, Spasticity Incontinence/skin moisture Medication review Treatments such as Chemotherapy, Radiation, Dialysis Nutritional status and hydration Hygiene Review laboratory data Cognitive status Psychosocial status Behaviors Refusal of care This deficient practice represents noncompliance investigated under Master Complaint Number 2608745 and Complaint Numbers 2604131 and 1334558 (OH00167327).

Based on record review, observation, interview and facility policy review, the facility failed to ensure staff performed hand hygiene to prevent the cross contamination of germs during Resident #61 and Resident #44's medication administration and Resident #58's incontinence care. This affected two (Residents #61 and #44) out of seven residents observed for medication administration and one (Resident #58) out of three residents reviewed for incontinence care. The facility census was 93. Findings include:1. A review of Resident #61's medical record revealed an admission date of 01/22/25 with diagnoses including dementia, chronic kidney disease, anxiety, gastroesophageal reflux disease, depression, high blood pressure, cerebral vascular disease with stroke, influenza, encephalopathy, high cholesterol, and urinary tract infection. Resident #61's Medication Administration Record (MAR) dated 09/01/25 to 09/30/25 indicated to administer the following medications orally during the evening: Multivitamin one tablet (supplement) Cyproheptadine hydrochloride 4 milligrams (mg) (antihistamine) 2. A review of Resident #44's medical record revealed an admission date of 07/19/25 with diagnoses including atherosclerotic heart disease, aortocoronary bypass graft, cerebral vascular disease with stroke, heart disease with heart failure, heart arrhythmias, prosthetic heart valve, kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, bone, digestive organ and prostate cancer, anemia, high blood pressure and cholesterol, gastroesophageal reflux disease, vitamin D deficiency, obesity, sleep apnea, reflex uropathy with urinary tract infection. A review of Resident #44's MAR dated 09/01/25 to 09/30/25 indicated to administer the following medications in the evening orally: Tamsulosin 0.4 mg (medication to treat benign prostatic hypertrophy) An observation on 09/08/25 between 3:30 P.M. and 4:00 P.M. of Licensed Practical Nurse (LPN) #100 administer medications to Resident #61 and Resident #44 revealed a failure to perform hand hygiene to prevent the spread of germs. LPN #100 administered medications to Resident #81 and did not perform hand hygiene and approached the medication cart. LPN #100 proceeded to obtain and dispense Resident #61's medications from the medication cart into a medication cup. LPN #100 then entered Resident #61's room and administered the cup of medications to Resident #61. LPN #100 exited Resident #44's room and did not perform hand hygiene and proceeded to obtain Resident #44's medications from the medication cart. LPN #100 was stopped and asked to perform hand hygiene before obtaining the medications from the medication cart. An interview with LPN #100 on 09/08/25 at 4:00 P.M. verified she had failed to perform hand hygiene between Resident #81's, Resident #61's and Resident #44's medication administration task. 3. A review of Resident #97's medical record revealed an admission date of 09/05/25 with diagnoses including heart attack, respiratory failure, obstructive sleep apnea, morbid obesity, venous insufficiency, constipation, heart failure, chronic right/left calf ulcers, dermatophytosis, soft tissue disorder, lymphedema, and plasma-protein disorder. Resident #97's immediate needs plan of care initiated on 09/05/25 indicated Resident #97 had bowel and bladder incontinence, needed two staff to assist her with toileting needs. An observation on 09/10/25 at 7:35 A.M. of Certified Nursing Assistant (CNA) #104 and CNA Supervisor (CNAS) #105 assist Resident #97 with incontinence care revealed a failure to perform hand hygiene to prevent the spread of germs. CNA #104 gathered the supplies needed for the task and placed the items on the over-the-bed table. CNA #104 donned a pair of gloves and proceeded to clean Resident #97's perineal area and buttocks of feces using several wet disposable wipes. CNA #104 did not remove her soiled gloves and perform hand hygiene upon completing the incontinence care task. CNA #104 then proceeded to assist the resident with donning heel protector boots, a pair of pants and placed the Hoyer (mechanical lift) pad under Resident #97 preparing to transfer Resident #97 to her wheelchair using the same soiled gloved hands she used for the incontinence care task. An interview with CNA #104 on 09/10/25 at 8:00 A.M. verified the above findings and agreed she should have removed her soiled gloves and performed hand hygiene after completing Resident #97's incontinence care. The facility policy and procedure titled Handwashing/Hand Hygiene dated 11/2024 indicated the policy was all personnel shall follow our established handwashing/hand hygiene procedures to prevent the spread of infection and disease to other residents, personnel and visitors. This policy is based on Centers for Disease Control and Prevention (CDC) guidance for healthcare providers. Employees must perform appropriate fifteen (15) second handwashing using antimicrobial or non-antimicrobial soap and water under the following conditions: a. When hands are visibly dirty or soiled with blood or other body fluids.b. After caring for a person with known or suspected infectious diarrhea.c. After known or suspected exposure to spores, e.g. B. anthracis, c. difficile outbreaks.d. Before eating and after using a restroom If hands are not visibly soiled, use of an alcohol-based hand rub containing 60-95% ethanol or isopropanol is acceptable for all the following situations: a. Before contact with residents.b. Before preparing or handling medications.c. Before handling clean dressings/treatment items. d. Before performing an aseptic task (placing an indwelling catheter or handling invasive medical devices);e. After contact with resident's intact skin. f. After contact with blood, body fluids, secretions, mucous membranes, or contaminated surfaces; (if hands are not visibly soiled). g. After contact with inanimate objects in the immediate vicinity of the resident; and h. Before handling food trays, between trays if touching the resident or other objects other than setting up the meal tray and before feeding the residenti. Immediately after glove removal. J. Before moving from work on a soiled body site to a clean site on the same resident. The purpose of the policy was to reduce the incidence of healthcare associated infections. This deficient practice represents noncompliance investigated under Master Complaint Number 2608745 and Complaint Number 2604131.

THE FOLLWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of video recorded evidence, review of the facility self-reported incident, review of facility policy, observation and interview, the facility failed to ensure Resident #16 was free from humiliation, intimidation and verbal and physical abuse by staff. Using the reasonable person concept, actual harm occurred on 07/14/24 when Resident #16, who was cognitively impaired and dependent on staff for all activities of daily living (ADL), was forcefully rolled onto his right side for incontinence care by State tested Nursing Assistant (STNA) #434 causing Resident #16's face to go into a pillow requiring him to move his head to yell let me breathe. STNA #434 repeatedly poked him in his ear with his dirty gloves he used to provide incontinence care causing Resident #16 to become agitated and yell get out of here. STNA #435 and #436 were present in the room and did not stop the abuse nor report it. This affected one resident ( Resident #16) of the three residents reviewed for abuse. The total census was 103. Findings include: Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting non-dominant side, dysphagia, anxiety, obstructive hydrocephalus, palmar fascial fibromatosis, muscle wasting, difficulty walking, transient cerebral ischemic attack, epileptic seizure, major depression, and chronic obstructive pulmonary disease. The resident was receiving hospice services. Review of the Minimum Data Set (MDS) 3.0 annual assessment dated [DATE] revealed Resident #16 was cognitively impaired , hearing impaired and needed a hearing aid. Resident #16 had clear speech and was able to make self-understood and sometimes understood others. Physical and verbal behavior symptoms were present one to three days but did not interfere with resident care, and there was no behavior impact on others. Rejection of care occurred one to three days. Resident #16 was dependent for feeding, oral hygiene, toilet hygiene, bathing and dressing. Resident #16 was dependent on staff to roll left to right in bed, sit on side of the bed, lay back in bed and did not sit to stand. Resident #16 was dependent of staff for transfers and was always incontinent of urine and bowel. Review of the plan of care dated 07/05/24 revealed Resident #16 could be verbally aggressive. Interventions included administer medication, anticipate resident needs, assess resident coping skills, assess understanding of the situation, allow time for resident to express self and feelings towards situation, give resident choices, positive feedback for good behavior, engage calmly in conversation, and staff to walk away calmly and approach later. Review of a progress note dated 07/15/24 at 12:45 P.M. authored by the Administrator revealed Resident #16's Power of Attorney (POA) was notified by the Administrator that the Ombudsman's office had sent the Administrator a video (date sent was not in this note) and it was reviewed. The employees in the video were suspended, the Ohio Department of Health ( ODH) was notified, a head-to-toe assessment was done on Resident #16, the Nurse Practitioner ( NP) and Hospice were notified. The NP assessed the resident, and a full staff education was completed. Review of the facility SRI and related investigation dated 07/15/24 revealed on 07/15/24 at 12:06 P.M. the Ombudsman office called the Administrator and said the family of Resident #16 had sent them a video showing abuse. The Ombudsman office sent the video to the Administrator and the video was seven minutes long and time stamped for 07/14/24 at 3:30 P.M. The video showed events that would be investigated as verbal/emotional abuse. Three State tested Nurse Assistants (STNA) #434, #435 and #436 were immediately suspended from work pending investigation. The facility immediately completed a head-to-toe assessment of the resident, notified the physician and the resident would be seen by the NP on 07/15/24. The Administrator and Director of Nursing (DON) spoke to the family about the allegation. The DON attempted to ask the resident about the events of the allegation, and he was unable to articulate how he felt or answer questions which was in line with his usual state of mind. Review of the video showed STNA #434 roll the resident on his side in a way that caused the resident to groan and become upset. STNA #434 was shown touching the resident's face repeatedly causing the resident to become agitated. One of the other STNA in the room stated where the (expletive) is his hearing aid and the third STNA in the room was a witness to the incident and did not report it. STNA #434 was heard making statement you know I don't play with him, (expletive) and speaking disrespectfully to the resident. The facility substantiated abuse and terminated the employment of all three STNA on 07/17/24. Further review of the facility investigation revealed a statement written by the DON dated 07/15/24 indicating Hospice was notified on 07/15/24 at 3:30 P.M., of the incident and that the investigation process was explained to Hospice. Review of a Weekly Skin Evaluation dated 07/15/24 at 1:01 P.M. revealed Resident #16 had no new skin areas identified, and no new open areas identified. Review of a progress note dated 07/15/24 authored by Nurse Practitioner (NP) #438 revealed Resident #16 did not appear to be in any acute distress, his behaviors had been stable and Resident #16 denied pain. Review of a written statement dated 07/17/24 obtained from STNA #434 revealed STNA #434 stated he did not need to see the video, as the facility already fired him. STNA #434 gave his badge to the Administrator. Review of a written statement from STNA #436 on 07/17/24 revealed on 07/14/24 she entered Resident #16's room with a Hoyer lift. STNA #436 confirmed she stated, where the (expletive) is his hearing aid. STNA #436 indicated she was not aware verbal or emotional abuse had happened. Review of a witness statement by STNA #435 on 07/17/24 revealed she confirmed she worked on 07/14/24 with Resident #16 and made no further comment after watching the video of care Resident #16 received that day of the incident. Interview on 08/22/24 at 9:30 A.M. with Ombudsman #429 revealed Resident #16's family contacted the Ombudsman office on 07/15/24 regarding video footage they witnessed on 07/14/24. The Ombudsman stated Resident #16 was upset when STNA # 434 continued to poke the resident in the ear. STNA # 435 laughed when STNA #434 poked his finger in the resident's ear. The Ombudsman stated STNA # 434 cleaned Resident #16's peri area with a gloved hand and used the same gloved hand to poke the resident's nose and ear. The Ombudsman state the female aids in the room dismissed the behavior of STNA #434. The Ombudsman stated a reasonable person would be upset by the actions of the staff members. The Ombudsman also stated during the video a female aid stood in front of the camera and it was possible, but not certain, a slap sound was heard, and after that Resident #16 went quiet. Interview on 08/22/24 at 10:14 A.M. with Resident #16's POA revealed the family had a camera in the resident's room because Resident #16 was too cognitively impaired to speak up for himself. The POA stated Resident #16 was visibly upset STNA #434 was rough with changing Resident #16 diaper and STNA #434 put his fingers in resident's ear to get the resident's attention. The POA stated it looked like Resident #16 was visibly upset and did not like how rough STNA # 434 was after changing his brief. POA stated she observed STNA #434 use the same gloved hand to wipe the resident's peri-area then put his finger in the resident's ear and by the mouth. POA stated they heard a smack at the end of the video. The POA stated other staff that entered the room did not stop STNA #434's treatment of the resident. Interview on 08/22/24 at 10:37 A.M. with Resident # 16's family member #432 revealed it appeared STNA #434 antagonized her brother by putting their finger in the resident's ear twelve to thirteen times. Family member # 432 stated Resident #16 was uncomfortable with his care. Interview on 08/22/24 at 11:38 A.M. with STNA #435 confirmed they watched the video of STNA #434 poke Resident #16 in the ear and the care Resident #16 received and realized it was abuse. STNA #435 stated they regretted not reporting the incident. Observation on 08/22/24 at 12:45 P.M. with The Administrator and the DON of the video submitted by the Ombudsman revealed camera footage of Resident #16 in his room and the video captured footage on 07/14/24. The Administrator and the DON confirmed STNA #434 poked Resident #16 in the ear twelve times. Resident #16 would yell get out of here when poked in the ear. STNA #434 put his finger in Resident #16's left ear multiple times for unknown reasons which appeared to upset Resident #16. STNA #434 did not explain care that was done. STNA #434 opened Resident #16's brief and provided peri area care and continued to poke Resident #16 in the ear with the same gloved hand. It was verified by The Administrator STNA #434 forcefully rolled Resident #16 onto his right side with his face in a pillow. Resident #16 had to move his head to speak. STNA #434 made a comment to Resident #16 I ain't playing with you, you know that. and you want to be real? Guess what. Resident #16 yelled out let me breath. STNA #434 stated you breath with your mouth not with your back and made a comment you ain't gonna be rude to me. S*** Resident #16 asked STNA #434 not be tough when rolling him, STNA stated I am tough A female STNA entered Resident #16 room ( STNA # 435 ) and stated, we have to be though when you don't listen STNA #435 laughed when STNA # 434 would stick his finger in Resident #16's ear and face. Another female STNA # 436 entered Resident #16 room with a Hoyer lift. Female STNA #436 was in front of the camera when more yelling continued by Resident #16, the resident went quiet after STNA # 434 stated don't play with me the video ended. There was no slapping noise evidenced in the video as was reported by Resident #16's family and the Ombudsman. Interview with The Administrator on 08/22/24 at 12:45 P.M. revealed the facility was notified by the Ombudsman on 07/15/24 at 12:09 P.M. regarding an incident that happened 07/14/24. STNA # 434 was immediately suspended and after review of the video submitted by the Ombudsman STNA # 435 and # 436 were suspended. The Administrator stated this was not appropriate treatment towards a resident and verified because of the investigation the abuse was substantiated. Interview on 08/22/24 at 2:21 P.M. with Resident #16 was conducted to determine if he remembered anything about the incident on 07/14/24. Resident #16 stated he did remember and said he felt shaky and stated, I never know what he was going to do and stated he did not like to be poked in the ear. Observation of the room at the time of the interview revealed a camera was fixed to the wall. Resident #16 was resting in his bed and had no behaviors at the time of the observation. Interview on 08/22/24 at 2:40 P.M. with STNA #434 confirmed he worked 07/14/24 with Resident #16. STNA #434 verified his behavior was not appropriate towards Resident #16. STNA #434 stated he had no reason to poke Resident #16's ear as much as they did. STNA #434 also stated he was frustrated with Resident #16 on 07/14/24. Interview was attempted with STNA #436 on 08/22/24 at 11:07 A.M. and 5:00 P.M. but the phone was no longer in service. Review of the facility policy titled Resident Abuse Prevention Practices, dated 11/2023, revealed abuse was defined as knowingly causing physical harm to the resident and included the willful infliction of intimidation and mental anguish by a caretaker. Physical abuse included hitting, slapping, pinching or kicking and rough corporal punishment. Verbal abuse included any use of oral disparaging and/or derogatory terms to the residents regardless of their ability to comprehend or their disability. Mental abuse included but was not limited to humiliation, harassment, threats of punishment or deprivation. Mistreatment was defined as to inappropriately treat or exploit a resident. Staff must report suspicion of abuse immediately to a supervisor. The deficient practice was corrected on 07/15/24 when the facility implemented the following corrective actions: Protection of immediate resident safety by suspending STNA # 434, # 435 and #436 following appropriate abuse prohibition on 07/15/24. Termination of employment on 07/17/24. The Physician and Nurse Practitioner (NP) were notified. The NP was in the facility and performed a bedside evaluation on Resident #16 and the Registered Nurse performed a physical assessment on 07/15/24 without any findings of physical injuries. All residents with a Brief Interview for Mental Status (BIMS) score of eight or less were assessed for signs of abuse without findings on 07/15/24. All residents with a BIMS of nine for greater were interviewed for concerns of abuse without findings on 07/15/24. Staff re-education by the Administrator for abuse prevention and reporting was completed on 07/15/24 or prior to next working shift for all 164 staff. The facility Director of Nursing held an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting with QAPI members to develop a plan on 07/15/24. The facility filed an SRI with ODH on 07/15/24. Hospice was notified of the findings on 07/15/24 for coordination of care. Additional re-education for behaviors and combative care was initiated on 07/17/24 with all staff and will be completed on 07/24/24. The facility Director of Nursing/Designee began random staff competencies on 07/17/24 and will continue twice weekly for three weeks. Findings will be reviewed in scheduled QAPI meetings. The facility Director of Nursing/Designee began random observations of staff to resident interactions on 07/17/24 to ensure dignity and respect was provided and will continue twice weekly for three weeks. Findings will be reviewed in scheduled QAPI meetings. Weekly ongoing audits on staff abuse competencies began on 07/17/24 and would continue twice weekly for three weeks. Findings would be reviewed in scheduled QAPI meeting. Random observation by the DON/designee of all staff to resident interactions began on 07/17/24 to ensure dignity and respect and abuse prohibition and would continue twice weekly for three weeks. Findings would be reviewed in scheduled QAPI meetings. As of the date of the survey on 08/29/24 no other instances of abuse had been identified. This deficiency represents noncompliance investigated under Complaint Number OH00156377

Based on record review, interviews, and the Centers for Medicare & Medicaid Services (CMS) website, the facility failed to allow Resident #95 to return to the facility after being sent out to the hospital. This affected one resident (#95) out of three residents reviewed for discharge. The facility census was 94. Findings include: Review of the closed medical record for Resident #95 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included displaced fracture of medial condyle of left femur, delusional disorders, unspecified disorder due to known physiological condition, unspecified mental disorder due to known physiological condition, and bipolar disorder. Review of the discharge return not anticipated Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #95 was cognitively intact. The resident required set up or clean up assistance for eating and oral hygiene; supervision or touch assistance for upper body dressing and personal hygiene; and was dependent on staff for toileting, shower/bathe self, lower body dressing, and putting on and taking off footwear. For mobility, the resident required partial/moderate assistance for sitting to lying and lying to sitting and was dependent on staff for chair/bed to chair transfer and tub/shower transfer. Review of the progress note dated 07/17/24 and time stamped at 12:55 P.M. for Resident #95 revealed on 07/17/24 with physician at bedside, the resident requested to go to the hospital and be evaluated because she felt the physician was an [expletive] idiot and had the worst cramps of her life. The resident stated she didn't wish to return to the facility at that time. Resident Rights were reviewed with the resident, and she was assured that the choice of placement was her right. Review of the late entry progress noted dated 07/18/24 and time stamped at 2:30 A.M. revealed Resident #95 was returning via stretcher from hospital. Transportation staff stated the resident did not get admitted to the hospital and it was our responsibility to still 'house' the resident. Resident #95 stated she had no idea she was not allowed to return to the facility. The Director of Nurse (DON) was called and confirmed Resident #95 was not to return. The transportation staff left the facility with the resident and stated the facility would be hearing from the hospital and from their transportation company. Interview on 07/30/24 at 10:47 A.M. and 3:46 P.M. with Ombudsman # 500 revealed Resident #95 called the Ombudsman's office on Friday, 07/19/24, from the hospital emergency room stating on Wednesday, 07/17/24, she had been sent out to the hospital for constipation. The ambulance brought her back to the facility at three in the morning (on 07/18/24), and the facility wouldn't take her back. The resident stated the emergency room didn't know what to do with her. The ombudsman asked if she wanted her to call the Administrator, the resident said yes. When the ombudsman spoke with the Administrator, the Administrator stated the resident was problematic, hadn't wanted to come back to the facility, and had signed something stating she didn't want to come back. The ombudsman stated she didn't think the facility had done the right thing, felt the facility should have taken her back and helped the resident find alternate placement. The ombudsman confirmed the facility had never reached out to her about not bringing the resident back until she had reached out to the Administrator on Friday, 07/19/24. Interview on 07/30/24 at 1:00 P.M. with Resident #95 revealed they (the hospital) discharged me at three o'clock in the morning (on 07/18/24). They (the facility) said I signed something that I didn't want to come back to the facility. They (the facility) are full of [expletive]. Review of the resident progress notes in the medical record and interview with Corporate Quality Assurance Registered Nurse (RN) #501 on 07/30/24 at 3:41 P.M. and at 4:35 P.M. confirmed that even though Resident #95 stated she hadn't wanted to come back to the facility when she went to the hospital, she had the right to change her mind. There was nothing noted in the resident's progress notes indicating the facility couldn't meet the welfare, health, or safety of the resident or others if the resident did return to the facility. There was no proof the facility had been collaborating with the hospital on alternate placement or the resident had signed a document stating she didn't want to return to the facility. Corporate Quality Assurance RN #501 confirmed the facility did have open beds on 07/18/24. Review of Your Rights and Protection as a Nursing Home Resident located at Your Resident Rights and Protections (cms.gov) revealed as a nursing home resident, the resident had a right to participate in the decisions that affect care. The nursing home must provide discharge planning, and the nursing home couldn't make a resident leave the nursing home unless any of the following were true: It's necessary for the welfare, health, or safety of the resident or others. The resident's health had improved to the point that nursing home care was no longer necessary. The nursing home hadn't been paid for services the resident received. The nursing home closed. This deficiency represents non-compliance investigated under Complaint Number OH00155720.

Based on interview, schedule review, Payroll Based Journal (PBJ) review and Facility Annual Assessment review, that facility failed to ensure there was adequate Registered Nurse (RN) coverage for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 101 residents residing in the facility. Findings include: Review of the PBJ Staffing Data Report CASPER Report 1705D 10/01/23 though 12/31/23 revealed the facility had four or more days within the quarter with no RN coverage and had a one-star staffing rating. Review of the Nursing Assignment forms for 10/15/23, 10/29/23, 11/05/23, 11/11/23, 11/12/23, 11/22/23, 11/23/24, 11/25/23, 11/26/23, 12/02/24, 12/03/23, 12/10/23, and 01/20/24, revealed there were no RN's present working in the facility. Review of the Facility Annual Assessment, dated 03/01/24, revealed under licensed nurses the facility would have one full time Director of Nursing, two full time Clinical Directors and under the area of RN they would have two full time Minimum Data Set (MDS) RNs plus 200-336 hours of a RN per two weeks. The facility assessment did not reference that they would have at least eight consecutive hours a day seven days a week as required. On 04/30/24 at 3:50 P.M., and on 05/01/24 at 10:38 A.M. an interview with Regional Administrator #650 verified the facility was without a RN on the days listed above and verified the PBJ Report was accurate. 49774

Based on observation, record review, interview, facility policy review and Centers for Disease Control and Prevention (CDC) guidance review, the facility failed to ensure Contact Precautions were implemented as ordered for Resident #22. This affected one resident (#22) of five residents reviewed for infection control and had the potential to affect all 50 additional residents (#3, #4, #7, #8, #10, #11, #13, #14, #16, #17, #19, #23, #24, #26 #29, #30, #31, #33, #37, #39, #41, #42, #43, #48, #50, #53, #55, #56, #58, #59, #60, #62, #63, #65, #68, # 69, #71, #75, #76, #79, #80, #85, #88, #96, #255, #256, #257, #305, #307 and #405) residing on the East Wing. The facility census was 101. Findings include: Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses including dementia, depression, diabetes, breast cancer, and Parkinson's disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was moderately cognitively impaired. She required set up help for eating, supervision for oral hygiene and personal hygiene, and substantial assistance for toileting and showering. The resident was always incontinent of bowel and bladder. Review of the physician's orders for April 2023 revealed Resident #22 was on Contact Precautions for Escherichia coli (E. coli), a bacteria found in the environment, foods, and intestines, and extended-spectrum beta-lactamases (ESBLs), enzymes produced by some bacteria that make them resistant to many antibiotics in the urine. The order began on 04/23/24. Observation on 04/30/24 at 11:01 A.M. revealed a sign on Resident #22's door that states enhanced barrier precautions (EBP) were in place. Resident #22's roommate was on EBP. There was no sign on Resident #22's door for Contact Precautions. Observation on 04/30/24 at 10:16 AM revealed Resident #22 was up in a wheelchair in the common area resting. Interview on 04/30/24 at 11:01 A.M. with Licensed Practical Nurse (LPN) #601 confirmed Resident #22 was on Contact Precautions for ESBL and E. coli. She confirmed Resident #22 was not in her room and believed it was because the isolation had ended. She confirmed the order for Contact Precautions was still active. Review of the facility policy titled Contact Precautions, dated March 2020, revealed the facility would use contact precautions for residents known or suspected to have infectious diseases transmitted by direct resident contact or contact with items in the resident's environment. Contact Precautions will be used in addition to standard precautions for residents with specific infections that could be transmitted by direct or indirect contact. Review of the CDC guidance revealed Contact Precautions require the use of gown and gloves on every entry into the resident's room, regardless of the level of care being provided to the resident. The resident is given dedicated equipment and placed in a private room. When private rooms are not available, some residents (e.g., residents with the same pathogen) may be roomed together. Residents on Contact Precautions are recommended to be restricted to their rooms except for medially necessary care, including restriction from participation in group activity. Contact Precautions are generally intended to be limited and, when implemented, should include a plan for discontinuation or de-escalation. EBP requires the use of gowns and gloves only for high-contact resident care activities. Residents are not restricted to their rooms and do not require placement in a private room. EBP also allows residents to participate in group activities. EBP do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of the residents stay in the facility or until resolution of a wound or discontinuation of the indwelling medical device that placed them at higher risk.

Based on observation, interview and facility policy review, the facility failed to ensure staff spoke to Resident #15 in a dignified manner. This affected one resident (#15) of three residents reviewed for dignity had the potential to affect all residents in the facility. The facility census was 101. Findings include: Review of the medical record revealed Resident #15 was admitted on [DATE] with diagnoses including chronic respiratory failure, congestive heart failure, diabetes mellitus type two, depression, anxiety, hypertension, and morbid obesity. Resident #15 was also on Enhanced Barrier Precautions (EBP). Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was cognitively intact and had occasional bladder incontinence and frequent bowel incontinence. On 04/30/24 at 9:15 A.M. an observation revealed State tested Nurse Aide (STNA) #561 standing at the doorway of Resident #15 and hollering into the room asking the resident what was needed. Resident #15 was requesting different incontinence briefs and asked STNA #561 to come into the room. STNA #561 then hollered into the room that she was not coming in because she did not want to put on an isolation gown just to walk back out again and again asked Resident #15 what she wanted from the doorway. Licensed Practical Nurse (LPN) #578 was standing in the hallway and verified that STNA was hollering into the room of Resident #15 regarding her briefs at the time of the observation. On 04/30/24 at 9:15 A.M. observation of Resident #15's door revealed an EBP sign that stated gowns needed to be worn only when providing direct personal care. A review of the policy titled, Enhanced Barrier Precautions, dated March 2024, revealed personal protective equipment (gowns, gloves, and masks) was only necessary when performing high contact care activities. Personal protective equipment was not needed if entering the resident's room to talk. A review of the policy titled, Dignity, Respect and Privacy, dated June 2016, revealed all residents in the facility will be treated with kindness, dignity, and respect whenever talked with, cared for, or talked about. This deficiency represents noncompliance investigated under Complaint Number OH00152199.

45441 Based on record review, interview, facility self-reported incident (SRI) review and facility policy review, the facility failed to implement their abuse policy regarding thoroughly investigating an injury of unknown origin for Resident #8 and an allegation of staff-to-resident abuse for Resident #77. This affected two residents (#8 and #77) of three residents reviewed for abuse and had the potential to affect all 101 residents residing in the facility. Findings include: 1. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including dementia, acute kidney failure, anxiety disorder, and adult failure to thrive. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was severely cognitively impaired. She required limited assistance of one person for transfers, dressing, eating, toilet use, and hygiene. Review of the facility SRI tracking number 241607 dated 11/29/23 revealed on the afternoon of 11/29/24 a bruise was noted under Resident #8's right eye and brought to the attention of the nurse. An SRI was submitted at that time. The investigation revealed the resident had severe cognitive impairment and had been getting suppositories and often tried to self-transfer to use the restroom. On 11/28/23 at 2:30 P.M. the resident was found in her bathroom with her head against the wall after trying to clean herself up from an uncontrolled bowel movement on her way there. She did not complain of any pain or discomfort and there were no witnesses to the incident. In the following days the bruise spread to under the resident's left eye and a tooth in her lower jaw fell out. The investigation concluded the resident bumped her face in the bathroom on the wall or handrail while toileting herself. The investigation did not include signed and dated witness statements of staff working at the time the injury, interviews or skin assessments of other residents, an assessment of Resident #8 or any education regarding injuries of unknown origin. Review of the nursing progress notes dated 12/01/23 revealed Resident #8 was missing most of a tooth on the bottom of her mouth. The resident had no information about the cause of the broken tooth. She had no pain and no problem eating. The physician and family were notified. Interview on 05/02/24 at 9:28 A.M. with the Administrator revealed the bruise was discovered in the common area. He confirmed the investigation revealed Resident #8 was found in her bathroom but had no written witness statements to attest to either of the above. He also confirmed he had no witness statements signed or dated by staff interviewed regarding the incident. He had no documented evidence other residents were interviewed or assessed for potential abuse. Interview on 5/02/24 at 9:31 A.M. with Registered Nurse (RN) #648 confirmed there were no witness statements from staff working at the time the injury was found and no assessment of Resident #8. 2. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses including amyotrophic lateral sclerosis (ALS), major depressive disorder, anxiety, and muscle weakness. Review of the facility SRI tracking number 244231 dated 02/15/24 revealed an allegation of staff-to-resident abuse was made by Resident #77. She stated on 02/08/24 at 7:15 P.M. State tested Nurse Aide (STNA) #608 purposely pulled her hair while removing her glasses strap stating it hurt because it was the hair behind her ear. The Administrator tried to call STNA #608 multiple times, and she had not answered her phone. The Administrator came to the facility on [DATE] and 02/18/24 to meet with STNA #608 before she started her scheduled shift. On 02/17/24, STNA #608 did not show up for work, and on 02/18/24, STNA #608 she came to the facility and told a nurse she was sick and left before the Administrator arrived. Her next scheduled day was 02/20/24, and again she did not show up for work. After interviewing other staff and residents, there were no other complaints regarding STNA #608's care practices. Through the investigation with Resident #77, who had been in contact with the ombudsman's office, she mentioned the incident to the ombudsman, but said she apologized to STNA #608, and they had worked it out. The resident has a diagnosis of ALS, and the Administrator was talking to her about an upcoming meeting when the incident was brought to his attention. Due to Resident #77's condition, she wears a glasses strap to keep her glasses from falling down. The strap has rubber rings on both ends that go around the bow of the glasses. Her hair had allegedly been pulled by the rubber when STNA #608 tried to remove the glasses. Due to STNA #608's avoidance of the Administrator, the facility terminated her employment. The facility's investigative documentation consisted of the SRI report form, one typed page with a statement from Resident #77, and one handwritten page with partial documentation of staff interviews. No other documentation was provided regarding the investigation of the alleged staff-to-resident physical abuse. On 05/02/24 at 12:28 P.M., interview with the Administrator verified the lack of documentation included in the facility's investigation of the SRI involving Resident #77. On 05/02/24 at 1:06 P.M., interview with Nurse Aide Supervisor #534 verified the documentation of the facility's investigation of the SRI involving Resident #77. She confirmed that no skin assessments were completed for Resident #77 regarding this incident. Review of the facility's policy titled Resident Abuse Prevention Practices, dated 09/2019, revealed alleged, suspected, or observed abuse, neglect, and/or mistreatment of a resident would be thoroughly investigated by the Administrator and Director of Nursing or designee. The investigation would begin immediately, the resident would be examined for injury at the time of complaint, appropriate medical attention would be given as necessary, and written statements would be taken and interviews conducted with anyone involved or witnessing the event (including alleged victim, alleged perpetrator, and witnesses who may have knowledge of the allegation).

45441 Based on record review, interview, facility self-reported incident (SRI) review and facility policy review, the facility failed to thoroughly investigate an injury of unknown origin for Resident #8 and an allegation of staff-to-resident abuse for Resident #77. This affected two residents (#8 and #77) of three residents reviewed for abuse and had the potential to affect all 101 residents residing in the facility. Findings include: 1. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including dementia, acute kidney failure, anxiety disorder, and adult failure to thrive. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was severely cognitively impaired. She required limited assistance of one person for transfers, dressing, eating, toilet use, and hygiene. Review of the facility SRI tracking number 241607 dated 11/29/23 revealed on the afternoon of 11/29/24 a bruise was noted under Resident #8's right eye and brought to the attention of the nurse. An SRI was submitted at that time. The investigation revealed the resident had severe cognitive impairment and had been getting suppositories and often tried to self-transfer to use the restroom. On 11/28/23 at 2:30 P.M. the resident was found in her bathroom with her head against the wall after trying to clean herself up from an uncontrolled bowel movement on her way there. She did not complain of any pain or discomfort and there were no witnesses to the incident. In the following days the bruise spread to under the resident's left eye and a tooth in her lower jaw fell out. The investigation concluded the resident bumped her face in the bathroom on the wall or handrail while toileting herself. The investigation did not include signed and dated witness statements of staff working at the time the injury, interviews or skin assessments of other residents, an assessment of Resident #8 or any education regarding injuries of unknown origin. Review of the nursing progress notes dated 12/01/23 revealed Resident #8 was missing most of a tooth on the bottom of her mouth. The resident had no information about the cause of the broken tooth. She had no pain and no problem eating. The physician and family were notified. Interview on 05/02/24 at 9:28 A.M. with the Administrator revealed the bruise was discovered in the common area. He confirmed the investigation revealed Resident #8 was found in her bathroom but had no written witness statements to attest to either of the above. He also confirmed he had no witness statements signed or dated by staff interviewed regarding the incident. He had no documented evidence other residents were interviewed or assessed for potential abuse. Interview on 5/02/24 at 9:31 A.M. with Registered Nurse (RN) #648 confirmed there were no witness statements from staff working at the time the injury was found and no assessment of Resident #8. 2. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses including amyotrophic lateral sclerosis (ALS), major depressive disorder, anxiety, and muscle weakness. Review of the facility SRI tracking number 244231 dated 02/15/24 revealed an allegation of staff-to-resident abuse was made by Resident #77. She stated on 02/08/24 at 7:15 P.M. State tested Nurse Aide (STNA) #608 purposely pulled her hair while removing her glasses strap stating it hurt because it was the hair behind her ear. The Administrator tried to call STNA #608 multiple times, and she had not answered her phone. The Administrator came to the facility on [DATE] and 02/18/24 to meet with STNA #608 before she started her scheduled shift. On 02/17/24, STNA #608 did not show up for work, and on 02/18/24, STNA #608 she came to the facility and told a nurse she was sick and left before the Administrator arrived. Her next scheduled day was 02/20/24, and again she did not show up for work. After interviewing other staff and residents, there were no other complaints regarding STNA #608's care practices. Through the investigation with Resident #77, who had been in contact with the ombudsman's office, she mentioned the incident to the ombudsman, but said she apologized to STNA #608, and they had worked it out. The resident has a diagnosis of ALS, and the Administrator was talking to her about an upcoming meeting when the incident was brought to his attention. Due to Resident #77's condition, she wears a glasses strap to keep her glasses from falling down. The strap has rubber rings on both ends that go around the bow of the glasses. Her hair had allegedly been pulled by the rubber when STNA #608 tried to remove the glasses. Due to STNA #608's avoidance of the Administrator, the facility terminated her employment. The facility's investigative documentation consisted of the SRI report form, one typed page with a statement from Resident #77, and one handwritten page with partial documentation of staff interviews. No other documentation was provided regarding the investigation of the alleged staff-to-resident physical abuse. On 05/02/24 at 12:28 P.M., interview with the Administrator verified the lack of documentation included in the facility's investigation of the SRI involving Resident #77. On 05/02/24 at 1:06 P.M., interview with Nurse Aide Supervisor #534 verified the documentation of the facility's investigation of the SRI involving Resident #77. She confirmed that no skin assessments were completed for Resident #77 regarding this incident. Review of the facility's policy titled Resident Abuse Prevention Practices, dated 09/2019, revealed alleged, suspected, or observed abuse, neglect, and/or mistreatment of a resident would be thoroughly investigated by the Administrator and Director of Nursing or designee. The investigation would begin immediately, the resident would be examined for injury at the time of complaint, appropriate medical attention would be given as necessary, and written statements would be taken and interviews conducted with anyone involved or witnessing the event (including alleged victim, alleged perpetrator, and witnesses who may have knowledge of the allegation).

Based on record review and interview, the facility failed to develop a comprehensive care plan for the care and maintenance of an enteral feeding tube for Resident #92. This affected one resident (#92) of two residents reviewed for enteral feedings. The facility census was 101. Findings include: Review of the medical record for Resident #92 revealed an admitted [DATE] with diagnoses including muscle wasting and atrophy, dysphagia, dementia, and chronic kidney disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #92 received 51% or more calories per day and 501 ml or more fluid per day from tube feeding. Review of the order history for Resident #92 revealed she had consistently had physician's orders for enteral feedings or flushes since 12/18/23. Current physician's orders included nothing by mouth (NPO) effective 04/09/24, check enteral tube placement every eight hours effective 04/25/24, cleanse enteral feeding site with soap and water every night shift effective 04/25/24, change syringe every night shift effective 04/25/24, observe for signs of dehydration, nausea, vomiting, distention, diarrhea, reflux, constipation, and breath sounds every shift effective 04/25/24, change enteral feeding tube as needed effective 04/25/24, auto water flush enteral tube at 50 milliliters (ml) per hour effective 04/29/24, and continuous enteral feeding of Fibersource HN at 55 ml per hour effective 04/29/24. Review of the comprehensive care plan revised 04/25/24 revealed there was no care plan in place for Resident #92's enteral feeding tube. On 05/01/24 at 4:41 P.M., interview with Corporate Quality Assurance (QA) Nurse #648 verified there was no care plan developed for the enteral feeding tube for Resident #92.

Based on observation, interview, record review and facility policy review the facility failed to provide oral care for Resident #23 and fingernail care for Resident #50. This affected two residents (#23 and #50) of 83 residents observed for assistance with personal care. The facility census was 101. Findings include: 1. Review of the medical record revealed Resident #23 was admitted on [DATE] with diagnoses including chronic kidney disease, acute kidney failure, diabetes mellitus type two, cerebral infarct, and muscle wasting. Review of the Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. A care plan dated 03/01/24 revealed Resident #23 needed the assistance of two people for bathing, grooming, and hygiene. A review of Resident #23 shower sheets revealed the most recent shower was 04/24/24. On 04/29/24 at 9:42 A.M. an observation and interview of Resident #23 revealed a white buildup between his lower teeth. Resident #23 stated staff had not assisted him to brush his teeth that day. On 04/30/24 at 1:00 P.M. an interview and observation of Resident #23 revealed a white buildup between his lower teeth. Resident #23 stated he had not had his teeth brushed again. On 04/30/24 at 2:15 PM interview with Corporate Quality Assurance Registered Nurse (QARN) #648 revealed tooth brushing was to be done in the morning and evening. QARN #648 verified there was no documented evidence in Resident #23's medical record to support oral care that had been completed or refused by Resident #23. Review of the facility policy titled, A.M. Care (Morning Care) and P.M. Care (Bedtime Care), both dated January 2022, revealed staff were to assist with oral hygiene. 2. Review of the medical record revealed Resident #50 was admitted [DATE] with diagnoses including unspecified dementia, depression, weakness, hypertension, and diabetes mellitus type two. Review of the Admission MDS assessment dated [DATE] revealed Resident #50 had moderate cognitive impairment. Review of the care plan dated 02/12/24 revealed Resident #50 needed the assistance of one person for bathing and hygiene. On 04/29/24 at 8:45 A.M. an observation of Resident #50 revealed the resident lying in bed. Resident #50 had long fingernails that were curling at the ends. There was a black substance underneath her fingernails. On 04/30/24 at 8:15 A.M. an observation of Resident #50 revealed fingernails ungroomed with a black substance underneath. On 04/30/24 at 1:45 PM. an observation during incontinence care revealed Resident #50 continued to have fingernails that were long and dirty. State tested Nurse Aide (STNA) #635 verified the unkept fingernails at the time of the observation. STNA #635 stated nail care was to be done with bathing and as needed. Review of the facility policy titled, Nails, Care of Fingernails, dated November 2021, revealed fingernail care will be done for the non-diabetic residents by the STNA during or after the resident's shower/bath and as needed. The STNA will examine the nails of the diabetic resident during their shower and inform the nurse of any issues with the resident's fingernails. The purpose of the policy is to promote cleanliness, prevent infection, injury, and odors and to improve appearance, promote self-esteem and contribute to a sense of wellbeing. This deficiency represents noncompliance investigated under Complaint Number OH00152199.

Based on observation, interview, record review and facility policy review the facility failed to provide proper positioning in a wheelchair as ordered for Resident #10. This affected one resident (#10) of 34 residents reviewed for positioning. The facility census was 101. Findings include: Review of the medical record revealed Resident #10 was admitted on [DATE] with diagnoses including hemiplegia following a cerebral infarction (a weakening of one side of the body following a stroke), epileptic seizures, depression, and chronic obstructive pulmonary disease. Significant orders included Hoyer lift (a mechanical lift used to transfer due to inability to transfer independently) for transfers, check residents left arm placement while in wheelchair to prevent being pinched inside of chair, and left arm to be elevated on pillow while in the wheelchair. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had severe cognitive impairment. Review of the plan of care dated 04/05/24 revealed Resident #10 was to have his left arm elevated on a pillow while in the wheelchair. On 04/29/24 at 12:40 P.M. an observation of Resident #10 revealed him sitting in the East common area in his wheelchair. Resident #10's left arm was wedged between his body and the wheelchair. On 04/30/24 at 7:30 A.M. an observation of Resident #10 revealed him in the main dining room for breakfast. Resident #10's left arm was resting on his lap. There was not a pillow present for positioning of the left arm as ordered. Interview with Licensed Practical Nurse (LPN) #572 verified there was no pillow for positioning as ordered at the time of the observation. Review of the facility policy titled, Wheelchair, Use Of, dated 02/2024, revealed, in point #8, to make sure all positioning devices were in place as ordered.

Based on observation, record review, interview and facility policy review, the facility failed to ensure hearing aides were ordered and available as needed for Residents #3 and #13). This affected two residents (#3 and #13) of three residents reviewed for communication concerns. The facility census was 101. Findings include: 1. Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, chronic pain, depression, end stage renal disease, hypertension, and unspecified hearing loss. Review of the audiology visit dated 09/18/23 for Resident #3 revealed the resident was referred by the facility for decreased hearing. She was recommended for hearing aids with follow up in one to three months. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact. She was independent with eating, required supervision for toileting, set up help for oral hygiene and personal hygiene and partial to moderate assistance for showering. She had minimal difficulty hearing and did not have hearing aids. Review of the care plan dated 01/28/24 revealed Resident #3 had a communication problem due to a hearing deficit. Interventions included anticipating the resident's needs, allowing adequate time to respond, repeating as necessary, using alternative communication tools as needed and referrals to audiology for hearing consults as needed. Review of the audiology visit dated 04/19/24 revealed Resident #3 was upset that she had never been fitted for hearing aids. Interview on 04/29/24 at 10:06 A.M. with Resident #3 revealed she was supposed to have hearing aids one year ago. She revealed she asked the Administrator about them a few months ago, and she was told they had not been ordered yet. The resident was tearful when discussing the matter. Interview on 05/01/24 at 12:53 P.M. with Registered Nurse (RN) #648 confirmed Resident #3's audiology report from 09/18/23 recommended the resident be fitting for hearing aids. RN #648 also confirmed this recommendation was never followed up on by the facility. 2. Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), muscle weakness, and anemia. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #13 was severely cognitively impaired. She required set up help for eating, oral hygiene, and personal hygiene and partial to moderate assistance for toileting and showering. She had minimal difficulty hearing and used a hearing aide. Review of the physician's orders for April 2024 revealed an order for the Resident #13 to have hearing aids in during the day. They were to be removed at night and placed on the charger. The order began 04/28/23. Review of the care plan dated 03/13/24 revealed Resident #13 would receive person centered care based on the physician's orders and the resident's choices. Interventions included bilateral hearing aids. Observation and interview on 04/29/24 at 8:56 A.M. with Resident #13 revealed she was very hard of hearing. She reported she used to have two hearing aids but now only had one and did not know where it was. Interview on 05/01/24 at 12:53 P.M. with RN #648 confirmed Resident #13 lost one of her hearing aids in August 2023, and the facility had not yet followed up with the resident or her family to see how they wanted to proceed with replacing the device. Review of the undated facility policy titled Vision and Hearing: Making Appointments, Transportation revealed the facility would ensure all residents received the proper treatment and assistive devices to maintain hearing abilities.

Based on observation, record review, interview, and facility policy review the facility failed to ensure Resident #77 was free of an accident hazard during a staff assisted transfer. Actual Harm occurred on 01/30/24 when Resident #77 suffered a second-degree burn (a burn that involves the first two layers of skin which may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin) that measured 15 centimeters (cm) in length by 7.5 cm width to her left lower leg from a portable oxygen tank that had been placed on her bed while staff were transporting the resident from her room to the shower room. The improper transport of the oxygen caused the tank to freeze to the resident's leg causing pain/discomfort and the burn. The burn required treatment with Silvadene cream (medication used to help prevent and treat wound infections for serious burns) and Kerlix gauze to the area daily. This affected one resident (#77) of three residents reviewed for accidents. The facility census was 97. Findings include: Review of the medical record for Resident #77 revealed an admitted [DATE]. Diagnoses included Amyotrophic Lateral Sclerosis (ALS) a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord, arthritis, depression, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 was cognitively intact. She required set up help for eating, oral hygiene, and personal hygiene, substantial or maximum assistance for showing or bathing, and was dependent on staff for toileting. Review of the progress note dated 01/30/24 at 3:03 P.M. revealed a State tested Nursing Assistant (STNA) informed the nurse that another STNA mistakenly left Resident #77's portable oxygen lying on its side next to Resident #77's left lower leg. The resident obtained a burn that measured 15 centimeters (cm) in length by 7.5 cm in width. The resident reported some discomfort and was medicated with Tylenol (analgesic). The area was slightly pink with no open areas or drainage. The nurse aide supervisor was notified and educated staff on proper handling of portable oxygen tanks. The physician, power of attorney (POA), and clinical director were notified. Review of the facility incident report dated 01/30/24 at 4:08 P.M. revealed the oxygen tank was removed from Resident #77 after discovery of the injury. Two witnesses were noted to have been involved; however, there were no witness statements included on the investigation. Review of the physician's orders for February 2023 revealed an order to cleanse the left lower leg burn and apply Silvadene cream (medication used to help prevent and treat wound infections for serious burns) and Kerlix gauze to the left lower calf daily. Review of a facility provided document titled Wound Tracking Grid - Initial assessment dated [DATE] revealed the resident's calf wound measured 6.0 cm in length by 2.0 cm in width. The skin tone was normal with an intact scab. Interview on 02/06/24 at 10:28 A.M. with the Administrator revealed on 01/30/24 an oxygen tank was placed on the bed while Resident #77 was being transported to the shower. The oxygen tank collected ice and froze to the resident's leg. The Administrator reported the tank was immediately disconnected and staff were in-serviced on safe transport of portable oxygen. He confirmed there should have been a hook for caddy available for transporting the oxygen. The Administrator revealed the nurse assessed the injury, and the resident's mother was notified. STNA #203 did not sign the in-service sign in sheet. Interview on 02/06/24 at 10:51 A.M. with Resident #77 revealed she told STNA #203 her leg hurt while being transported to the shower, but STNA #203 told her they were almost there and did not stop to look at the source of the pain. Interview on 02/06/24 at 12:40 P.M. with STNA #202 revealed on 01/30/24 STNA #203 placed the resident's oxygen tank on its side on the bed and it had ice on the outside. She confirmed oxygen should always be upright and never on its side. She revealed Resident #77 suffered a burn on her leg as a result of the oxygen tank touching her leg. Interview on 02/06/24 at 12:49 P.M. with STNA #203 revealed on 01/30/24 she was transporting Resident #77 to the shower and needed to take the resident's oxygen with her. She revealed the tank was hooked to the bed and stated she did not know it was touching her leg. She stated Resident #77 said her leg felt warm, but she did not see anything at the time. After the residents' shower she saw a burn on the resident's leg. She could not describe the size, shape, or color. She stated she let the nurse know immediately. Observation on 02/07/24 at 8:05 A.M. of wound care for Resident #77 revealed Licensed Practical Nurse (LPN) #207 provided appropriate care and treatment to Resident #77's left lower leg. The wound was scabbed over with no odor or drainage observed. Interview at the time of the observation with both LPN #207 and the resident confirmed the wound looked better and was healing well. The resident denied any pain as of this time. Review of the in-service titled OSHA - Environmental Safety dated 07/01/23 revealed staff were educated prior to the incident on proper oxygen use including oxygen tanks were to be stored in a stand or cart to prevent tipping or falling, portable tanks were to be kept in an upright position, and any frosted parts or connections were not to be touched. STNA #203 did not sign the in-service sign in sheet (hire date was 03/14/23). Review of the facility policy titled Oxygen, liquid dated January 2023 revealed portable oxygen tanks were to be kept in an upright position and should be carried by a shoulder strap, hung on the back of a wheelchair, or placed in a wheeled cart. No frosted parts or connectors were to be touched. This deficiency represents noncompliance investigated under Complaint Number OH00150765.

Based on medical record review and interview the facility failed to ensure therapy discharge recommendations were implemented in order to maintain a resident's mobility and range of motion (ROM) capabilities. This affected one (Resident #5) of 24 residents observed for limitations in range of motion. Actual harm occurred on 01/31/23 when Resident #5 presented with limitations in ROM after the facility failed to implement therapy recommendations for restorative nursing programs. Prior to 01/31/23, no ROM impairment had been identified and the resident was noted to be able to ambulate. On 01/31/23 an assessment noted a decrease in range of motion to the resident's right knee and bilateral ankles. An Occupational Therapy (OT) note, on 03/21/23 revealed Resident #5 had a significant decline in mobility and participation with activities of daily living with significant bilateral lower extremity contractures. Findings include: Review of Resident #5's medical record revealed diagnoses including Alzheimer's disease, peripheral vascular disease, and generalized muscle weakness. A nursing admission assessment dated [DATE] indicated Resident #5 ambulated with two or more assistants. No impairment in ROM was noted. Resident #5 received OT from 07/21/22 to 08/31/22. An OT discharge summary dated 08/31/22 did not reveal limitations in ROM. The discharge summary indicated recommendation for a restorative nursing program (RNP) for upper extremity strengthening and ROM. Resident #5 received Physical Therapy (PT) from 07/21/22 to 08/31/22. A PT discharge summary dated 08/31/22 indicated at the time of discharge Resident #5 was able to ambulate 75 feet with a wheeled walker with contact guard assistance but not consistently. A restorative ambulation program was established with the restorative nursing program for upper extremity exercises using a two pound dowel/fine motor tasks and gait training with a wheeled walker inconsistent for 75 feet with contact guard assistance. Resident #5 received OT from 11/01/22 to 12/02/22. The discharge summary indicated Resident #5 was trained on strategies and positioning maneuvers to improve independence with mobility, training on upper extremity strengthening to improve upper extremity strength needed for functional activities and transfers and training on wheelchair mobility to improve participation within environment. Resident #5 had self-limiting behaviors at times and required maximal encouragement for participation in therapy. Resident #5 was discharged to the restorative nursing program for upper extremity strengthening. Resident #5 received PT from 11/04/22 to 12/02/22. Resident #5 was discharged with a recommendation for a restorative ROM program including bilateral upper extremity therapeutic exercise using two pound dowel in all functional directions and wheelchair mobility. Resident #5 received PT from 01/31/23 to 03/06/23. When PT was started on 01/31/23 it was noted there had been a decrease in ROM to the right knee and both ankles compared to prior function. The discharge summary indicated Resident #5 was making consistent progress before being sent to the hospital. Resident #5 was evaluated by OT on 03/21/23 after being admitted to the hospital on 03/10/23 after a fall out of bed. The evaluation indicated Resident #5 had a significant decline in mobility and participation with activities of daily living with significant bilateral lower extremity contractures. Resident #5 was evaluated by PT on 03/17/23 with contractures of bilateral lower extremities more prominent due to prolonged bed rest. On 03/30/23 at 12:31 P.M., interview with Corporate Quality Assurance (QA) Nurse #577 revealed Resident #5 never had a restorative nursing program initiated. On 03/30/23 at 12:33 P.M., interview with Therapy Manager #598 indicated therapists made recommendations for restorative nursing programs when residents were discharged from therapy. Restorative recommendations were written on a restorative form and provided to the restorative nurse. On 03/30/23 at 1:54 P.M., interview with Licensed Practical Nurse (LPN) #812 (the facility restorative nurse) verified once residents were discharged from therapy she was provided with a referral form for restorative programs. LPN #812 verified Resident #5 never had a restorative nursing program initiated. LPN #812 indicated the reason the programs were not initiated was due to the number of residents already receiving programs and lack of enough staff to complete the recommended programs. Restorative aides would get reassigned to take an assignment on the unit or to provide showers. While reviewing the history of Resident #5 receiving therapy services then being discharged with no restorative programs initiated, Resident #5 had a history of experiencing declines and having to be added back to therapy caseload, LPN #5 reiterated the programs could not be initiated due to staffing and stated she had a list of resident on a waiting list for restorative programs. LPN #5 stated when she decided not to initiate restorative programs she would sometimes initiate a program for aides on the floor to complete. At 2:29 P.M., LPN #812 verified she had not initiated a program for floor aides to complete to prevent declines for Resident #5 between therapy sessions. This deficiency represents non-compliance investigated under Complaint Number OH00141011.

Based on observation, resident and staff interview, and clinical record review, the facility failed to address and provide necessary services to Resident #107 who had continued abdominal distention and pain that resulted in a hospitalization . This affected one of three residents reviewed for pain. The facility census was 97 residents. Findings include: Resident #107 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plans revealed no evidence of a care plan for abdominal pain and/or distention. However, review of the resident's physician's orders [REDACTED]. There was also a telephone order, dated 07/27/11, for a flat plate X-ray due to pain, abdominal distention, and diarrhea. Review of a nurse's note dated 07/08/11 at 8:20 A.M. revealed Resident #107 was started on Mirilax (a laxative) daily and as needed. An X-ray report dated 07/28/11 at 9:55 A.M. revealed the results were "normal abdomen," which was reported to the physician. The nurse's notes continued to document Resident #107 complaining of abdominal pain with distention. A nurse's note dated 07/27/11 at 8:00 P.M. revealed Resident #107's abdomen was tender and distended, she had diarrhea and she complained of abdominal pain. A nurse's note dated 07/28/11 at 11:15 A.M. revealed an X-ray of her abdomen was completed and and the results came back showing "no acute pathology." A nurse's note dated 08/05/11 at 7:15 A.M. revealed Resident #107 had three episodes of "watery stool," her abdomen was hard and distended. The nurses continued to document at 9:00 P.M. that bowel sounds were present and the resident's abdomen was hard and very distended. On 08/06/11 at 4:00 A.M. the nurse documented Resident #107's abdomen was hard and very distended, and the nurse "will monitor." A nurse's note dated 08/06/11 at 9:00 P.M. revealed Resident #107 had normal bowel sounds, her abdomen was hard and distended and the resident complained of tenderness when her stomach was palpated. The nurse's notes written on 08/07/11 at 9:00 P.M. and 08/08/11 at 2:00 A.M. and 1:30 P.M. continued to document the resident's abdomen being hard and distended. On 08/08/11 at 2:44 P.M. the surveyor observed Resident #107 while the resident was in bed. The resident pointed to her abdomen and said "look at my stomach, see how big it is, it hurts." Resident #107 revealed she had an X-ray done that said everything was "okay." The nurses notes continued to document on on 08/09/11 at 11:10 A.M. and on 08/10/11 at 4:00 A.M. that Resident #107's abdomen was hard and distended. On 08/10/11 at 7:50 A.M., the nurse wrote that the resident complained of feeling "full" but not having pain. The resident was medicated with Tylenol, per the resident's request, and the nurse documented "will monitor." On 08/10/11 at 8:45 A.M., the nurse documented the Tylenol was not effective and Resident #107 stated she still felt "full." During an interview on 08/10/11 at 10:05 A.M. Resident #107 stated, "My stomach hurts bad." The resident said she was given Tylenol from the nurse and her stomach had been hurting for a while. According to a nurse's note dated 08/10/11 at 1:50 P.M., the physician saw Resident #107, ordered a second abdominal X-ray, and the family was notified. A nurse's note dated 08/10/11 at 5:00 P.M. revealed an ultrasound was completed, and the results revealed there was no abdominal ascites and no acute pathology. This note also indicated the resident ate very little of her evening meal. The physician was notified of the test results and ordered the staff to send Resident #107 to the hospital for an evaluation. A nurse's note dated 08/10/11 at 11:15 P.M. revealed Resident #107 was admitted to the hospital with [REDACTED]. Review of the medical record, including nurse's notes, revealed no evidence to indicate the physician was notified of Resident #107's continued abdominal distention and discomfort between 07/28/11 and 08/10/11. On 08/11/11 at 7:30 A.M. an interview with Licensed Practical Nurse (LPN) #26 revealed another flat plate X-ray was done and an ultrasound was completed last night on Resident #107 and both tests were negative. The LPN revealed the physician was notified and informed of the results, the physician ordered the nurse to send Resident #107 to the hospital for an evaluation and the resident was admitted to the hospital last night (08/10/11) with an ileus. On 08/11/11 at 8:30 A.M. an interview with the director of nursing (DON) verified the medical record did not contain evidence to indicate the physician and the resident's family were informed of her continued abdominal distention and abdominal tenderness. The DON verified Resident #107 did not have a care plan initiated for her abdominal distention and tenderness, and the resident was sent to the hospital on [DATE] where she was admitted with an ileus.