Every finding on record at Life Care Center of Westlake

Based on observations, interviews, and review of facility policy, the facility failed to ensure a clean, sanitary, and homelike environment for residents. This affected 20 residents (Residents #87, #34, #45, #56, #7, #100, #16, #88, #107, #5, #43, #405, #67, #44, #31, #66, #25, #92, #78, and #13) and had the potential to affect all 103 residents residing in the facility.Findings include:During an observation and interview on 06/08/26 at 1:22 P.M. with Floor Tech #401, the following concerns were identified and verified at the time of the observations:-Floor trim and hand railings throughout the building were dusty and dirty.-Carpet was heavily stained throughout the building, including the following areas: a. Between rooms [ROOM NUMBERS] b. Outside room [ROOM NUMBER] c. Near the 200 Hall nurse's station, staff restroom, and utility room d. Near the staff restroom e. Outside room [ROOM NUMBER] f. Between rooms [ROOM NUMBERS] g. Outside room [ROOM NUMBER] h. Outside nursing station 4-5 i. Outside room [ROOM NUMBER] j. Outside room [ROOM NUMBER] k. Outside room [ROOM NUMBER] l. Hall 400 leading into the dining room m. Between rooms [ROOM NUMBERS] n. Multiple stained areas in the dining room-Dried splatter was present on the wall and floor trim between rooms [ROOM NUMBERS], and on the wall near the 200 Hall nurse's station.-Wood vinyl flooring had holes and dents in the rooms of Residents #87 and #34; Residents #45 and #56; and Residents #7 and #100.-Resident #16's room had dust and debris on the floor vent, scuffed paint by the bed, and an empty bed with multiple wall scuffs.-Resident #88's room had an air-conditioning unit that was not fully sealed, allowing visibility to the outside. The ceiling light was not fully attached.-Residents #107 and #5's room had two holes in the closet wall, a dusty and unattached floor vent, multiple wall scuffs, a metal wall protector not fully attached, stains and splatter on the ceiling, and a very sticky floor. Floor Tech #401 stated housekeeping was using too many chemicals when mopping. A brown hanging object appearing to be a fly trap, containing multiple dead bugs, had been present since Resident #107 moved in.-Residents #43 and #405's room had an extremely sticky floor and black sticky residue on the windowsill. The blinds were broken and bent.-Resident #67's room had splatter on the wall and a window AC unit held together with peeling tape; the front cover was unattached.-Resident #44's room had a wall mounted fan with heavy dust buildup that dispersed dust when running.-Residents #31 and #66's room had a nightstand missing trim on all sides, multiple wall scrapes behind the bed, debris on the floor and floor vent, and an unattached vent in the corner.-Residents #25 and #92's room had wall splatter and an extremely dusty floor vent.-Residents #78 and #13's room had dust and debris on the floor vent, an AC unit with a loose cover on the right side, and dried splatter on the wall near Resident #13's bed.Review of the facility's Housekeeping - General Policy (reviewed 04/01/26) stated:- The resident has a right to a safe, clean, comfortable and homelike environment.- The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.This deficiency represents noncompliance investigated under Complaint Numbers 3003589 and 2974482.

Based on observation, record review, interview, and review of the facility policy, the facility failed to ensure a medication error rate of less than 5 percent. This affected two residents (Resident #19 and Resident #30) out of five residents observed during medication administration. The facility census was 103.Findings include:An observation of three licensed nurses (Licensed Practical Nurse (LPN) #110, LPN #111, and LPN #112) administering medications to five residents (Resident #19, Resident #27, Resident #30, Resident #31, and Resident #55) revealed 36 opportunities for medication errors, with 20 errors observed. This resulted in a medication error rate of 56 percent.1. A review of Resident #30's clinical record revealed an admission date of 12/30/22 with diagnoses including cerebral palsy, dementia, epilepsy, functional dyspepsia, contracted right wrist, fracture of thoracic vertebra number 11 and 12, anxiety, eye disease, constipation, allergic rhinitis, cervicalgia, constipation, malnutrition, severe intellectual disabilities, gastroesophageal reflux disease, iron deficiency anemia, insomnia, and partial intestinal obstruction.A review of Resident #30's care plan indicated impaired cognitive ability/thought processes related to dementia. The resident lived on the memory care unit, was nonverbal except for crying out, and required assistance with all activities of daily living.During an observation on 06/03/26 at 8:30 A.M., Licensed Practical Nurse (LPN) #110 was seen administering medications to Resident #30. LPN #110 failed to follow the five rights of medication administration. She retrieved a cup of crushed oral medications and a 30-milliliter (ml) cup of liquid medication from the medication cart. She stated she had dispensed and crushed the medications earlier that morning, then administered the liquid medications and the crushed medications mixed in pudding to Resident #30. LPN #110 acknowledged that preparing medications ahead of time and storing them in the medication cart was not consistent with facility policy or nursing standards of practice. When asked to identify the medications administered, she reviewed Resident #30's electronic medical record and listed the morning medications she had pre-poured and stored, which included:Ativan 0.5 milligrams (mg) (antianxiety) oral tabletRisperdal oral solution 1.0 ml (antipsychotic)Cholecalciferol 2,000-unit oral capsule (Vitamin D3 supplement)Divalproex 125 mg delayed-release sprinkles (antiepileptic), two capsulesDocusate sodium 100 mg tablet (stool softener)Gabapentin 100 mg oral tablet (anticonvulsant)Lactulose 10 grams/15 ml, 30 ml oral solution (laxative)Linaclotide 290 microgram (mcg) oral capsule (gastrointestinal agent)Loratadine 10 mg oral tablet (antihistamine)Senna 8.6 mg oral tablet (stimulant laxative)Tizanidine 2 mg oral tablet (muscle relaxant)Acetaminophen 500 mg, two tablets (analgesic)Phenobarbital 97.2 mg oral tablet (anticonvulsant)A review of Resident #30's physician orders dated 06/01/26 to 06/30/26 confirmed these medications were scheduled for morning administration.An interview on 06/03/26 at 3:30 P.M. with Unit Manager Registered Nurse (UMRN) #114 confirmed the above findings and that LPN #110 should not have prepared medications in advance.2. A review of Resident #19's clinical record revealed an admission date of 05/17/19 with diagnoses including Alzheimer's disease, dementia, seizures, dystonia, major depressive disorder, diabetes mellitus type 2, fatigue, abnormal involuntary movements, incisional hernia, abnormal auditory perceptions, anxiety, allergic rhinitis, gastroesophageal reflux disease, vitamin D deficiency, and constipation.indicated severe cognitive impairment. The resident was rarely or never understood and had a Brief Interview for Mental Status (BIMS) score of 99.During an observation on 06/03/26 at 8:35 a.m., LPN #110 was seen administering medications to Resident #19 and again failed to follow the five rights of medication administration. She obtained a cup of crushed oral medications from the medication cart and stated she had dispensed and crushed them earlier that morning. She then administered the crushed medications mixed in pudding to Resident #19. LPN #110 acknowledged that preparing medications in advance and storing them in the medication cart was not consistent with facility policy or nursing standards of practice. When asked to identify the medications administered, she reviewed Resident #19's electronic medical record and listed the following morning medications she had pre-crushed and stored:Sertraline hydrochloride 25 mg tablet (antidepressant)Sertraline 50 mg tablet (antidepressant)Depakote sprinkles delayed-release 125 mg capsule (anticonvulsant/mood stabilizer)Docusate sodium 100 mg oral tablet (stool softener)Loratadine 10 mg tablet (antihistamine)Senna 8.6 mg oral tablet (stimulant laxative)Alprazolam 0.25 mg tablet (antianxiety)A review of Resident #19's physician orders dated 06/01/26 to 06/30/26 confirmed these medications were scheduled for morning administration.An interview on 06/03/26 at 3:30 P.M. with UMRN #114 verified the findings and stated LPN #110 should not have prepared medications ahead of time.A review of the facility's policy titled General Dose Preparation and Medication Administration, effective 12/01/07, indicated staff were required to follow facility procedures, applicable law, and the State Operations Manual (SOM) when administering medications. The policy stated:- Dose preparation areas must be well lit, and medication carts must be clean and organized.- Medications must be prepared for only one resident at a time, using the three-way check (medication, medication administration record (MAR), and prescription label).- Staff must avoid touching medications with bare hands.- Any medication not in protective packaging or dropped must be discarded according to policy.- Staff must not leave medications unattended.This deficiency represents non-compliance investigated under Complaint Numbers 3003589 and 2974482.

Based on record review, observation, interview, and review of the American Nurses Association Code of Ethics, the facility failed to ensure Resident #7's indwelling urinary catheter drainage bag was covered to maintain privacy. This affected one resident (Resident #7) out of two residents reviewed for respect and dignity. The facility census was 103.Findings include:A review of Resident #7's clinical record revealed an admission date of 02/12/25 with diagnoses including vascular dementia with mood disturbance and anxiety, fracture of the fourth cervical vertebra of the neck, nasal bones, wrist and three fingers of the right hand following a fall, osteoarthritis, cerebral infarction (stroke), heart disease secondary to high blood pressure, congestive heart failure, heart arrhythmia, malnutrition, venous insufficiency, anemia, high cholesterol and blood pressure, cataracts, asthma, depression and history of brain cancer.Resident #7's plan of care initiated 04/09/26 indicated Resident #7 had an indwelling urinary catheter due to a stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle; slough may be present on some parts of the wound bed often include undermining and tunneling) contaminated by urine. Interventions on the plan of care indicated to provide catheter care every shift, position the catheter drainage bag below the level of the bladder, check for kinks throughout the shift and as needed, keep the drainage bag covered to preserve dignity, change as ordered, maintain enhanced barrier precautions (EBP) when providing direct care, and report any signs/symptoms of urinary tract infection (UTI).A review of Resident #7's physician orders dated 06/01/26 to 06/30/26 revealed to maintain an indwelling urinary catheter to straight drainage and change for infections, obstruction or when the closed system is compromised. An observation of Resident #7 on 06/04/26 at 9:50 A.M. revealed the door to her room was open, and a urine drainage bag was visible to the staff/visitors from the hallway. The urine drainage bag had approximately 400 milliliters of dark brown urine that was hanging from the bed frame of Resident #7's bed clearly visible from the hallway. An interview with Certified Nursing Assistant (CNA) #118 on 06/04/26 at 9:50 A.M. verified the above observation and stated she was unaware the urine drainage bag should be covered for privacy and dignity.A review of the American Nurses Association Code of Ethics. dated 01/29/25, indicated nurses were responsible for protecting a resident's/patient's dignity, privacy and respect during all aspects of care.This deficiency represents non-compliance investigated under Complaint Numbers 3003589 and 2974482.

Based on record review and interview, the facility failed to ensure Resident #104's comprehensive care plan included a care plan with individualized interventions to manage Resident #104's behaviors. This affected one resident (Resident #104) out of three residents reviewed for behaviors. The facility census was 103.Findings include:A review of Resident #104's clinical record revealed an admission date of 11/04/25 with diagnoses including adult failure to thrive, dementia with psychotic disturbance, legal blindness, glaucoma, old heart attack, heart arrhythmias, low magnesium level, chronic kidney disease with heart failure, high blood pressure, malnutrition, cognitive communication deficit, prediabetes mellitus, degenerative nervous system disease, headache, anemia, osteoarthritis of both knees, Crohn's disease, high cholesterol, anxiety, depression, degenerative spine disease with lumbar region back pain.A review of Resident #104's plan of care initiated on 11/12/25 indicated Resident #104 resided on the secured memory care nursing unit (Oasis unit) with interventions including Resident #104 planned for a long term stay at the facility and provided services according to her care plan. There was no plan of care with individualized interventions developed on Resident #104's care plan to address Resident #104's physically aggressive behaviors, refusals of care and accusatory behaviors.A review of Resident #104's progress note dated 05/07/26 indicated Resident #104 refused to allow the phlebotomist to draw her blood and was very argumentative when staff attempted to explain the importance of laboratory tests.During interviews with staff on 06/03/26 between 10:30 A.M. and 11:15 A.M., Unit Manager Registered Nurse (UMRN) #114, Certified Nursing Assistant (CNA) #115, CNA #116 reported that Resident #104 displayed behaviors such as falsely accusing staff of stealing personal items and remaining preoccupied with these accusations for several days, refusing care including laboratory blood draws, and hitting or swatting other residents when irritated.During an interview with UMRN #114 on 06/03/26 at 10:41 A.M. verified the above findings and agreed Resident #104 had no interventions in her care plan to address the behaviors she exhibited in the facility.This deficiency was an incidental finding identified during the complaint investigation.

Based on observation, interview, review of the Nursing Rights of Medication Administration, and review of the facility policy, the facility failed to ensure that nursing services were provided in accordance with professional standards of practice when one licensed practical nurse (LPN) #110 did not follow accepted nursing standards for the preparation and administration of medications for two residents (Resident #19 and Resident #30) of five residents observed for medication administration. The facility census was 103.Findings include:On 06/03/26 at approximately 8:30 A.M., during a medication administration observation, LPN #110 was observed retrieving a cup of crushed medications and a 30 milliliter (ml) cup of liquid medication from the medication cart for Resident #30. LPN #110 stated she had dispensed, crushed, and stored the medications earlier that morning. She then administered the liquid medication and the crushed medications mixed in pudding. LPN #110 acknowledged that pre preparing medications and storing them in the cart was not consistent with facility policy or nursing standards of practice.On 06/03/26 at approximately 8:35 A.M., during a second observation, LPN #110 was again seen retrieving a cup of crushed medications from the medication cart for Resident #19. She stated she had crushed and prepared these medications earlier that morning. She administered the crushed medications mixed in pudding. LPN #110 again confirmed that preparing medications in advance and storing them in the cart was not in accordance with nursing standards or facility policy.When asked to identify the medications she had administered to Residents #19 and #30, LPN #110 was unable to identify them without returning to the electronic medical record and reviewing the medication list she had pre poured. This practice is inconsistent with professional nursing standards that require medications to be prepared and administered immediately prior to giving them to ensure accuracy and adherence to the five rights of medication administration.An interview with Unit Manager Registered Nurse (UMRN) #114 on 06/03/26 at 3:30 P.M. confirmed that LPN #110's practices did not meet professional standards. UMRN #114 stated that LPN #110 should not have pre prepared or stored medications in the medication cart and confirmed that these actions were inconsistent with nursing standards and facility expectations.A review of the nursing standard of practice titled Nursing Rights of Medication Administration: dated 09/04/23 revealed the five rights are essential safety checks that healthcare professionals use to prevent medication errors and ensure effective treatment. Each right represents a verification step before administering any medications. The following are the five rights of medication administration:1. Right Patient: Confirm the patient's identity using at least two identifiers, such as full name and date of birth , to prevent mix-ups, especially in settings with multiple patients.2. Right Drug: Ensure the medication being administered matches the prescription exactly. Check the label against the order, verify it is not a look-alike or sound-alike drug, and confirm the patient has no known allergies,3. Right Dose: Verify that the amount of medication corresponds to the prescribed dose. Dose errors are common and can range from minor to life-threatening depending on the drug 4. Right Route: Administer the medication via the prescribed method, whether oral, intravenous, injection, topical, or other. Using the wrong route can cause serious harm.5. Right Time: Give the medication at the correct time and frequency. Some medications require administration with food, on an empty stomach, or at consistent intervals to maintain therapeutic levels. Following these rights helps reduce adverse drug events and ensures patient safety. While additional rights such as right documentation, right indication, and right patient response exist, the original five remain the global standard in clinical practice.A review of the policy titled General Dose Preparation and Medication Administration, effective 12/01/07, indicated that medications must be prepared for only one resident at a time immediately prior to administration, using required checks, and must not be left unattended. LPN #110 failed to follow these professional standardsThis deficiency represents non-compliance investigated under Complaint Numbers 3003589 and 2974482

Based on record review, interview, and review of the facility policy, the facility failed to ensure physician orders for daily weights were updated and implemented for Resident #105, failed to ensure Resident #106's weight was obtained to ensure an accurate weight was obtained, and failed to ensure a physician order was obtained prior to the application of a wound dressing to Resident #24's wound. This affected two residents (Resident #105 and #106) of three residents reviewed for weight loss and one resident (Resident #24) out of three residents reviewed for wound care. The facility census was 103. Findings include: 1. Record review for Resident #105 revealed resident was admitted on [DATE] and discharged on 05/18/26 with diagnosis that included: heart failure with preserved ejection fraction, history of subsegmental pulmonary embolism and bilateral deep vein thrombosis (on therapeutic lovenox), chronic kidney disease III, history of roux-en-y gastric bypass complicated by chronic diarrhea and malnutrition, cirrhosis with ascites and anasarca, chronic anemia with known cecal tubulovillous adenoma, remote CVA and chronic dizziness, repeated falls, hyperkalemia, hypocalcemia, chronic respiratory failure with hypoxia, severe protein calorie malnutrition, type 2 diabetes, chronic diastolic heart failure, myocardial infraction typeII, memory deficit following cerebral infraction and major depressive disorder. Review of Resident #105 Weight Summary in the vital tab revealed the following weights:-02/01/26: 158.8 pounds (Lbs)-03/04/26: 121.0 Lbs-03/12/26: 122.0 Lbs-03/24/26: 107.2 Lbs-04/01/26: 106.9 Lbs-04/09/26: 106.0 Lbs-04/16/26: 111.0 Lbs-04/26/26: 121.6 Lbs A physician order dated 03/31/26 directed staff to obtain daily weights for Resident #105. Registered Nurse Unit Manager (RNUM) #404 signed the order on 03/31/26 acknowledging receipt. A corresponding progress note dated 03/31/26 documented that the nurse practitioner had placed an order for daily weights. Review of Resident #105's the medication administration record (MAR) for March and April 2026 revealed no daily weight orders had been entered. Review of the vital signs tab in the electronic medical record confirmed weights continued to be obtained weekly instead of daily as ordered. During an interview on 06/09/26 at 3:46 P.M., the Assistant Director of Nursing (ADON) #403 confirmed these findings. 2. A review of Resident #106's clinical record revealed an admission date of 01/26/26 with diagnoses including traumatic subdural hemorrhage, depression, meniscus of the knee joint tear, enlarged prostate, glaucoma, transient ischemic attack, stroke, respiratory disease, diabetes mellitus, heart failure, high blood pressure, obstructive sleep apnea, high cholesterol, cleft hard palate with cleft lip. A review of Resident #106's admission nutrition/dietary progress note dated 01/27/26 showed an admission weight of 182 pounds. The dietitian recommended a protein supplement to support wound healing, a Med Pass supplement to address poor appetite, and noted Resident #106's preference to receive fruit with all meals. The dietitian further documented that the resident was at risk for malnutrition due to chronic disease and that his weight should be monitored. A review of Resident #106's weight change note dated 03/03/26 identified an 8.8% weight loss in 30 days, decreasing from 182 pounds (02/01/26) to 166.4 pounds (03/01/26). The dietitian recommended obtaining another weight for accuracy and planned to follow up on 03/05/26. Record review showed the follow up weight was never obtained. Resident #106 was discharged to the hospital on [DATE]. In an interview on 06/04/26 at 8:53 A.M., Nutrition Associate #117 stated he had requested a repeat weight on 03/03/26 for verification, but the weight was not obtained before discharge. He confirmed no follow up dietary assessment occurred after 03/03/26. During an interview on 06/08/26 at 3:45 P.M., the Director of Nursing (DON) acknowledged the findings and stated nursing staff had not been informed that an additional weight was needed. Review of the facility policy titled Nutritional Intake (reviewed 09/05/25) showed the facility is required to ensure residents maintain acceptable nutritional parameters and receive appropriate monitoring and interventions based on comprehensive assessment. 3. A review of Resident #24's clinical record revealed an admission date of 12/15/25 with diagnoses including Alzheimer's disease, dementia, type 2 diabetes mellitus, cutaneous abscess of right axilla, methicillin susceptible staphylococcus aureus infection, hypertensive (high blood pressure) chronic kidney disease, high cholesterol, anemia, hypothyroidism, major depressive disorder, hypertensive heart disease, and osteoarthritis. Review of the June 2026 physician orders revealed no active order for wound dressing application to the right axilla. The previous wound treatment order had been discontinued on 06/02/26. An observation on 06/08/26 at 9:30 A.M. showed Registered Nurse (RN) #114 applying calcium alginate and a border gauze dressing to the resident's right axilla wound. RN #114 removed the prior dressing dated 06/07/26 and discarded it. During an interview 06/08/26 at 11:35 A.M., RN #114 confirmed Resident #24 did not have a current physician order for the wound treatment she applied. Review of the facility's policy titled Wound Assessment and Wound Report (revised 11/30/23) requires staff to verify the treatment order at the bedside and specifies that a valid treatment order must be in place for all products applied to a wound. This deficiency represents non-compliance investigated under Complaint Number 3003589.

Based on record review and staff interviews, the facility failed to ensure staff documented bladder retraining program interventions as outlined in Resident #105's plan of care. This failure affected one resident (Resident #105) out of three residents reviewed for incontinence care. The facility census was 103.Findings include:Record review for Resident #105 showed she was admitted on [DATE] and discharged on 05/18/26 with multiple chronic and complex medical conditions, including heart failure with preserved ejection fraction, pulmonary embolism, bilateral deep vein thrombosis (on therapeutic Lovenox), chronic kidney disease III, a history of Roux en Y gastric bypass with chronic diarrhea and malnutrition, cirrhosis with ascites, chronic anemia, remote CVA, chronic dizziness, repeated falls, hyperkalemia, hypocalcemia, chronic respiratory failure with hypoxia, severe protein calorie malnutrition, type II diabetes, chronic diastolic heart failure, myocardial infarction type II, memory deficits following cerebral infarction, and major depressive disorder. Review of the Evaluation for Bowel and Bladder Training dated 11/18/25 showed the resident scored a 10, indicating she was a candidate for toileting, timed voiding, or scheduled voiding.Review of the care plan dated 11/19/25 documented that Resident #105 was incontinent of bladder. Interventions included a Bladder Retraining Program directing staff to offer and assist with toileting upon rising, before and after meals, at bedtime (HS), and as needed (PRN).Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] showed Resident #105 required moderate assistance with toileting and was frequently incontinent of bowel and occasionally incontinent of bladder. The assessment indicated no for a trial urinary toileting program.During an interview on 06/08/26 at 4:57 P.M., MDS Nurse #402 reported that Resident #105 was not on a bladder or bowel toileting program. She stated that she does not determine who is on such programs; she only enters information into the MDS. She further stated that the Bladder Retraining Program listed in the care plan was only a care plan header and not an active toileting program.During an interview on 06/08/26 at 5:25 P.M., the Director of Nursing (DON) also stated the intervention was only a care plan header and confirmed the resident was not on a bladder retraining program. The facility was unable to provide documentation showing that incontinence care was provided as directed in the care plan.This deficiency represents non-compliance investigated under Complaint Numbers 3003589 and 2974482.

Based on record review, interview and facility policy review, the facility failed to ensure fall interventions were in place and failed to ensure a thorough fall investigation was conducted for Resident #15. This affected one (Resident #15) of three residents reviewed for accidents. The facility census was 100.Findings include: Review of the medical record for Resident #15 revealed an admission date of 02/12/25. Diagnoses included vascular dementia, anxiety, osteoarthritis of right shoulder, congestive heart failure, contracture of right hand, dysphagia and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had impaired cognition. The resident was dependent on staff for bed mobility, transfers, and ambulation. Review of the plan of care dated 01/02/26 revealed Resident #15 was at risk for falls due to dementia with cognitive deficits, anxiety and depression with behaviors and a history of falls. Interventions included nonskid socks at all times, a low bed for safety, bed against the wall, and a fall mat to the floor next to the bed.Review of the fall risk assessment dated [DATE] revealed Resident #15 was at a high risk for falls.Review of physician orders for February 2026 identified orders for a mat to the left side of the bed, bilateral gab bars, and Resident #15 was to be assisted out of bed early in the morning.Review of the nurse's notes dated 02/13/26 at 10:38 P.M. Registered Nurse (RN) #347 entered Resident #15's room to administer evening medications and heard screaming. (Resident #90, who has cognitive impairment who wanders throughout the unit, in and out of other resident's rooms and plays with bed remotes, was in Resident #15's room at the time RN #347 entered the room). Resident #15 was observed lying on the floor in a pool of blood actively bleeding from the right side of her forehead and nose. The resident was assessed, and Emergency Medical Services (EMS) was called. The Director of Nursing (DON), physician and family were notified. The progress note did not state Resident #90 was found in Resident #15's room. (Per interview below with RN #347, Resident #90, who has cognitive impairment who wanders throughout the unit, in and out of other resident's rooms and plays with bed remotes, was in Resident #15's room at the time RN #347 entered the room. Resident #90 was care planned for frequent wandering into other residents' rooms and was combative with redirection).Review of the fall investigation dated 02/13/26 revealed witness statements from the DON and Certified Nursing Assistant (CNA) #252. There were no witness statements from CNA # 280, RN #347 or CNA #285, who were also working at the time of the incident. The risk report listed predisposing environmental factors as other. The risk report stated to describe other. There was no documentation of the other predisposing factors. There was no documentation to indicate if the fall mat was in place. There was no documentation that Resident #90 was found in Resident #15's room at the time of the fall and/or that Resident #90 was care planned for frequent wandering into other residents' rooms and was combative with redirection.Interview on 02/23/26 at 6:34 A.M. RN #349 started on 02/13/26 at 6:45 P.M. and she and CNA #252 put Resident #15 to bed. The bed was in the lowest position with one bolster on the left side due to Resident #15 having an order for the bed to be against the wall when they left the room. After 7:00 P.M. she heard a scream, and she and CNA #280 entered the room and found the bed in a medium position. CNA #252 got towels and applied pressure, and EMS was called. RN #349 stated Resident #90 was in Resident #15's room at the time of the incident, and she plays with bed remotes and was particular to this room. RN #349 stated she did not write out a witness statement due to the progress note being her statement.Interview with the DON on 02/25/26 at 3:32 P.M. verified there was an order for mat to floor, and it was not in place at the time of Resident #15's fall. The DON also verified the fall investigation lacked information including predisposing factors and did not contain all witness statements from all staff on the unit.Review of the facility policy titled Fall Management, dated 06/04/20, revealed avoidable accident include implantation of interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current standard of practice in order to eliminate the risk or reduce the risk of an accident.This deficiency represents non-compliance investigated under Master Complaint Number 2787463 and Complaint Number 274652.

Based on interview and record review, the facility failed to ensure accurate documentation related to behaviors in Resident #90's medical record This affected one (Resident #90) of three residents reviewed for accuracy of documentation related to behaviors. The facility census was 100.Findings include:Review of the medical record for Resident #90 revealed an admission date of 10/07/22. Diagnoses included Alzheimer's, wandering, anxiety, type II diabetes, and depression.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 had impaired cognition. The resident was independent for ambulation and required assistance for toilet and shower transfers. Resident #90 had inattention and disorganized thinking behavior that was continuously present and did not fluctuate. Additional behaviors included physical, verbal, wandering, and behaviors directed towards others hitting or scratching, and rummaging.Review of the plan of care for Resident #90 dated 01/22/26 revealed the resident had behavior problems related to frequent wandering into other residents' rooms and was combative with redirection. Interventions included intervene as necessary to protect the rights and safety of others. Document interventions and provide sensory items and domestic chores as needed.Review of the progress notes for Resident #90 dated from 01/23/26 through 2/20/26 revealed no behavior notes stating Resident #90 was found in Resident #15's room playing with Resident#15's bed remote and/or bed bolster. (Staff alleged that Resident #90 was in Resident #15's room playing with Resident #15's bed remote and bed bolster on 02/13/26 at the time of Resident #15's fall).Review of the behavior tracking task for Resident #90 from 01/23/26 through 02/23/26 revealed there was no documentation of behaviors on 02/13/26. Review of the Interdisciplinary Team (IDT) summary note for Resident #15 dated 02/16/26 revealed the Resident #15 was found on the floor bleeding and yelling out. The certified nursing assistant (CNA) and nurse report that they had recently assisted Resident #15 to bed and positioned her according to her plan of care (low bed, bed against wall and bolster to the open side of the bed). The bed was in a low position. After re-entering room, Resident #15's bed was found in a different position than previously set and there was another resident (Resident #90) found in the room.Interview with the Director of Nursing (DON) on 02/25/26 at 3:32 P.M. stated the nurses do behavior tracking in the progress notes and CNA's document behaviors under task tab of the electronic medical record. The DON verified there was no behavior note in Resident #90's medical record for 02/13/25 stating she was in Resident #15's room playing with her bed remote or bed bolster at the time of Resident #15's accident as alleged.The deficiency represents non-compliance investigated under Complaint Number 2746452.

Based on resident record review, resident interview, staff interviews, Self-Reported Incident (SRI) review, and facility policy review, the facility failed to implement policy and procedure for an allegation of verbal abuse. This affected one resident (#20) of three residents reviewed for verbal abuse. The facility census was 99.Findings include: Review of the medical record for Resident #20 revealed she was admitted to the facility on [DATE] with diagnoses of malignant neoplasm of endometrium, malignant neoplasm of cerebral meninges, and dementia.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was alert and oriented to person, place and time and was modified independent for tasks regarding daily life.Review of the care plan dated 12/03/25 revealed Resident #20 had a behavior problem related to refusal of care and medications and was accusatory toward staff. Interventions included, but was not limited to, allowing Resident #20 to verbalize her needs, two staff present for all care, and observing for behavior episodes while attempting to determine the underlying cause considering location, time of day, persons involved, and situations. Interview on 12/09/25 at 2:45 P.M. with Resident #20 revealed she was not treated with respect and dignity during her stay at the facility. There were Certified Nursing Assistants (CNAs) that were vicious towards her and used profanity when speaking to her or when providing care. The CNAs involved typically worked the night shift, but she did not want to say their names as she was worried they would find out. Resident #20 described the CNAs involved as being African American women of average size and worked on nights. Resident #20 also revealed she had reported it to staff before with no resolution.Interview on 12/10/25 at 9:04 A.M. with CNA #445 revealed Resident #20 had informed her that staff were rude to her and not treating her right. Resident #20 also stated it was during the second and third shifts that staff would treat her rudely and make her uncomfortable. CNA #445 did not recall the day or time but did inform the nurse at the time Resident #20 informed her.Interview on 12/10/25 at 9:29 A.M. with CNA #409 revealed Resident #20 had reported to her that staff were being rude and using profanity towards her, usually on the night shift. Resident #20 did not feel comfortable saying the actual names of staff. CNA #409 stated she immediately reported it to the nurse at the time.Interview on 12/10/25 at 12:09 P.M. with Licensed Practical Nurse (LPN) #312 revealed Resident #20 informed her that staff were rude and short with her. LPN #312 stated she reported it to the Administrator.Interview on 12/10/25 at 11:44 A.M. with the Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) #329 revealed all staff were educated and in-serviced regarding the abuse policies and protocols. The Administrator stated once an allegation of abuse was reported, the alleged perpetrator was suspended pending investigation, an SRI was initiated and an investigation was started. The Administrator, DON, and ADON #329 revealed they were unaware of any allegations of abuse regarding Resident #20 however, they were aware that Resident #20 claimed abuse at a previous facility. ADON #329 questioned about what administrative staff were informed of the alleged abuse due to not being aware of the allegation, however, confirmed and verified regardless of what staff were informed, all allegations of abuse should be reported and investigated.Interview on 12/10/25 at 2:33 P.M. with Social Worker Case Manager (SWCM) #459 revealed Resident #20 had been admitted to the hospital and subsequently readmitted to the facility. During her hospital stay, Resident #20 informed SWCM #459 that she was being verbally abused in the facility and it had been occurring daily. SWCM #459 stated Resident #20 did not want to reveal the names of facility staff who she identified as CNAs. SWCM #459 contacted the facility on 10/27/25 and informed them of the alleged verbal abuse to ensure they completed their own thorough investigation. SWCM #459 also revealed he informed the facility's Hospital Liaison (HL), HL #460, about Resident #20's allegation of verbal abuse.Interview on 12/11/25 at 10:37 A.M. with HL #460 revealed he visited various local hospitals to speak with case managers regarding facility residents' plans for either discharge or to return to the facility. HL #460 spoke to SWCM #459 regarding Resident #20's stay at the facility and financial liability concerns. HL #460 recalled speaking mostly in regard to Resident #20 returning to the facility and there was a possibility SWCM #459 could have mentioned Resident #20's allegation of verbal abuse. HL #460 revealed being customer service focused during the encounter with SWCM #459 and could have overheard the information. HL #460 stated being aware of the abuse policies and protocols and could not confirm or deny he was informed of Resident #20's allegation of verbal abuse.Review of the Ohio Department of Health (ODH) certification and licensure webpage for reporting abuse, neglect, and/or misappropriation, revealed no SRIs related to an allegation of verbal abuse regarding Resident #20.Review of the facility document titled, Abuse-Conducting an Investigation, reviewed 06/17/24, revealed the facility had a policy in place that all allegations of abuse would be reported to the Administrator, investigated, further abuse prevented, and reported to the State Survey Agency within five working days of the incident. Review of the document revealed the facility did not implement the policy regarding Resident #20's abuse allegation.This deficiency represents non-compliance investigated under Complaint Number 2655251.

Based on resident record review, resident interview, staff interviews, Self-Reported Incident (SRI) review, and facility policy review, the facility failed to report an allegation of verbal abuse. This affected one resident (#20) of three residents reviewed for verbal abuse. The facility census was 99.Findings include:Review of the medical record for Resident #20 revealed she was admitted to the facility on [DATE] with diagnoses of malignant neoplasm of endometrium, malignant neoplasm of cerebral meninges, and dementia.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was alert and oriented to person, place and time and was modified independent for tasks regarding daily life.Review of the care plan dated 12/03/25 revealed Resident #20 had a behavior problem related to refusal of care and medications and was accusatory toward staff. Interventions included, but was not limited to, allowing Resident #20 to verbalize her needs, two staff present for all care, and observing for behavior episodes while attempting to determine the underlying cause considering location, time of day, persons involved, and situations. Interview on 12/09/25 at 2:45 P.M. with Resident #20 revealed she was not treated with respect and dignity during her stay at the facility. There were Certified Nursing Assistants (CNAs) that were vicious towards her and used profanity when speaking to her or when providing care. The CNAs involved typically worked the night shift, but she did not want to say their names as she was worried they would find out. Resident #20 described the CNAs involved as being African American women of average size and worked on nights. Resident #20 also revealed she had reported it to staff before with no resolution.Interview on 12/10/25 at 9:04 A.M. with CNA #445 revealed Resident #20 had informed her that staff were rude to her and not treating her right. Resident #20 also stated it was during the second and third shifts that staff would treat her rudely and make her uncomfortable. CNA #445 did not recall the day or time but did inform the nurse at the time Resident #20 informed her. CNA #445 confirmed she was aware of the abuse policies and protocols. Interview on 12/10/25 at 9:29 A.M. with CNA #409 revealed Resident #20 had reported to her that staff were being rude and using profanity towards her, usually on the night shift. Resident #20 did not feel comfortable saying the actual names of staff. CNA #409 stated she immediately reported it to the nurse at the time. CNA #409 confirmed she was aware of the abuse policies and protocols. Interview on 12/10/25 at 12:09 P.M. with Licensed Practical Nurse (LPN) #312 revealed Resident #20 informed her that staff were rude and short with her. LPN #312 stated she reported it to the Administrator. LPN #312 confirmed she was aware of the abuse policies and protocols. Interview on 12/10/25 at 11:44 A.M. with the Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) #329 revealed all staff were educated and in-serviced regarding the abuse policies and protocols. The Administrator stated once an allegation of abuse was reported, the alleged perpetrator was suspended pending investigation, an SRI was initiated and an investigation was started. The Administrator, DON, and ADON #329 revealed they were unaware of any allegations of abuse regarding Resident #20 however, they were aware that Resident #20 claimed abuse at a previous facility. ADON #329 questioned about what administrative staff were informed of the alleged abuse due to not being aware of the allegation, however, confirmed and verified regardless of what staff were informed, all allegations of abuse should be reported and investigated.Interview on 12/10/25 at 2:33 P.M. with Social Worker Case Manager (SWCM) #459 revealed Resident #20 had been admitted to the hospital and subsequently readmitted to the facility. During her hospital stay, Resident #20 informed SWCM #459 that she was being verbally abused in the facility and it had been occurring daily. SWCM #459 stated Resident #20 did not want to reveal the names of facility staff who she identified as CNAs. SWCM #459 contacted the facility on 10/27/25 and informed them of the alleged verbal abuse to ensure they completed their own thorough investigation. SWCM #459 also revealed he informed the facility's Hospital Liaison (HL), HL #460, about Resident #20's allegation of verbal abuse.Interview on 12/11/25 at 10:37 A.M. with HL #460 revealed he visited various local hospitals to speak with case managers regarding facility residents' plans for either discharge or to return to the facility. HL #460 spoke to SWCM #459 regarding Resident #20's stay at the facility and financial liability concerns. HL #460 recalled speaking mostly in regard to Resident #20 returning to the facility and there was a possibility SWCM #459 could have mentioned Resident #20's allegation of verbal abuse. HL #460 revealed being customer service focused during the encounter with SWCM #459 and could have overheard the information. HL #460 stated being aware of the abuse policies and protocols and could not confirm or deny he was informed of Resident #20's allegation of verbal abuse.Review of the Ohio Department of Health (ODH) certification and licensure webpage for reporting abuse, neglect, and/or misappropriation, revealed no SRIs related to an allegation of verbal abuse regarding Resident #20.Review of the facility document titled, Abuse-Conducting an Investigation, reviewed 06/17/24, revealed the facility had a policy in place that all allegations of abuse would be reported to the Administrator, investigated, further abuse prevented, and reported to the State Survey Agency within five working days of the incident. Review of the document revealed the facility did not implement the policy by reporting Resident #20's abuse allegation.This deficiency represents non-compliance investigated under Complaint Number 2655251.

Based on resident record review, resident interview, staff interviews, Self-Reported Incident (SRI) review, and facility policy review, the facility failed to respond appropriately to an allegation of verbal abuse. This affected one resident (#20) of three residents reviewed for verbal abuse. The facility census was 99.Findings include:Review of the medical record for Resident #20 revealed she was admitted to the facility on [DATE] with diagnoses of malignant neoplasm of endometrium, malignant neoplasm of cerebral meninges, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was alert and oriented to person, place and time and was modified independent for tasks regarding daily life. Review of the care plan dated 12/03/25 revealed Resident #20 had a behavior problem related to refusal of care and medications and was accusatory toward staff. Interventions included, but was not limited to, allowing Resident #20 to verbalize her needs, two staff present for all care, and observing for behavior episodes while attempting to determine the underlying cause considering location, time of day, persons involved, and situations. Interview on 12/09/25 at 2:45 P.M. with Resident #20 revealed she was not treated with respect and dignity during her stay at the facility. There were Certified Nursing Assistants (CNAs) that were vicious towards her and used profanity when speaking to her or when providing care. The CNAs involved typically worked the night shift, but she did not want to say their names as she was worried they would find out. Resident #20 described the CNAs involved as being African American women of average size and worked on nights. Resident #20 also revealed she had reported it to staff before with no resolution. Interview on 12/10/25 at 9:04 A.M. with CNA #445 revealed Resident #20 had informed her that staff were rude to her and not treating her right. Resident #20 also stated it was during the second and third shifts that staff would treat her rudely and make her uncomfortable. CNA #445 did not recall the day or time but did inform the nurse at the time Resident #20 informed her. CNA #445 confirmed she was aware of the abuse policies and protocols. Interview on 12/10/25 at 9:29 A.M. with CNA #409 revealed Resident #20 had reported to her that staff were being rude and using profanity towards her, usually on the night shift. Resident #20 did not feel comfortable saying the actual names of staff. CNA #409 stated she immediately reported it to the nurse at the time. CNA #409 confirmed she was aware of the abuse policies and protocols. Interview on 12/10/25 at 12:09 P.M. with Licensed Practical Nurse (LPN) #312 revealed Resident #20 informed her that staff were rude and short with her. LPN #312 stated she reported it to the Administrator. LPN #312 confirmed she was aware of the abuse policies and protocols. Interview on 12/10/25 at 11:44 A.M. with the Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) #329 revealed all staff were educated and in-serviced regarding the abuse policies and protocols. The Administrator stated once an allegation of abuse was reported, the alleged perpetrator was suspended pending investigation, an SRI was initiated and an investigation was started. The Administrator, DON, and ADON #329 revealed they were unaware of any allegations of abuse regarding Resident #20 however, they were aware that Resident #20 claimed abuse at a previous facility. ADON #329 questioned about what administrative staff were informed of the alleged abuse due to not being aware of the allegation, however, confirmed and verified regardless of what staff were informed, all allegations of abuse should be reported and investigated. Interview on 12/10/25 at 2:33 P.M. with Social Worker Case Manager (SWCM) #459 revealed Resident #20 had been admitted to the hospital and subsequently readmitted to the facility. During her hospital stay, Resident #20 informed SWCM #459 that she was being verbally abused in the facility and it had been occurring daily. SWCM #459 stated Resident #20 did not want to reveal the names of facility staff who she identified as CNAs. SWCM #459 contacted the facility on 10/27/25 and informed them of the alleged verbal abuse to ensure they completed their own thorough investigation. SWCM #459 also revealed he informed the facility's Hospital Liaison (HL), HL #460, about Resident #20's allegation of verbal abuse. Interview on 12/11/25 at 10:37 A.M. with HL #460 revealed he visited various local hospitals to speak with case managers regarding facility residents' plans for either discharge or to return to the facility. HL #460 spoke to SWCM #459 regarding Resident #20's stay at the facility and financial liability concerns. HL #460 recalled speaking mostly in regard to Resident #20 returning to the facility and there was a possibility SWCM #459 could have mentioned Resident #20's allegation of verbal abuse. HL #460 revealed being customer service focused during the encounter with SWCM #459 and could have overheard the information. HL #460 stated being aware of the abuse policies and protocols and could not confirm or deny he was informed of Resident #20's allegation of verbal abuse. Review of the Ohio Department of Health (ODH) certification and licensure webpage for reporting abuse, neglect, and/or misappropriation, revealed no SRIs related to an allegation of verbal abuse regarding Resident #20. Review of the facility document titled, Abuse-Conducting an Investigation, reviewed 06/17/24, revealed the facility had a policy in place that all allegations of abuse would be reported to the Administrator, investigated, further abuse prevented, and reported to the State Survey Agency within five working days of the incident. Review of the document revealed the facility did not implement the policy and respond appropriately to Resident #20's abuse allegation. This deficiency represents non-compliance investigated under Complaint Number 2655251.

Based on review of employee personnel files, staff interviews, and facility policy review, the facility failed to ensure three of five sampled staff members were certified in Cardio-Pulmonary Resuscitation (CPR). This had the potential to affect all residents residing in the facility. The facility census was 99.Findings include: 1. Review of the personnel file for Certified Nursing Assistant (CNA) #445 revealed she was hired on [DATE]. CNA #445 had no current CPR certification.Interview on [DATE] at 3:20 P.M. with CNA #445 revealed she was not currently certified in CPR. CNA #445's CPR certification expired in [DATE].2. Review of the personnel file for Registered Nurse (RN) #301 revealed she was hired on [DATE]. RN #301 had no current CPR certification.Interview on [DATE] at 3:25 P.M. with RN #301 revealed she was not currently certified in CPR. RN #301's CPR certification expired in [DATE].3. Review of the personnel file for Licensed Practical Nurse (LPN) #312 revealed she was hired on [DATE]. LPN #312 had no current CPR certification.Interview on [DATE] at 3:30 P.M. with the Director of Nursing (DON) verified CNA #445, RN #301 and LPN #312 were not currently certified in CPR. The DON revealed she was aware CNA #445's CPR certification expired in [DATE] and RN #301's CPR certification expired in [DATE]. The DON stated she was not aware of the date of expiration for LPN #312. The DON confirmed CNA #445, LPN #312, and RN #301 were all still currently on the schedule and actively working shifts throughout the facility. Review of the facility policy titled, Cardiopulmonary Resuscitation (CPR) Policy, revised [DATE] revealed the facility would ensure staff would be properly trained and/or certified in CPR to be able to provide CPR until emergency medical services arrived, and staff were to maintain current CPR certification. This deficiency represents non-compliance investigated under Complaint Number 1369332 (OH00164444).

Based on review of employee personnel files and staff interviews, the facility failed to ensure two of five staff members received annual performance reviews. This had the potential to affect all residents residing in the facility. The facility census was 99.Findings include: 1. Review of the personnel file for Certified Nursing Assistant (CNA) #445 revealed she was hired on 09/24/20. CNA #445 did not have a current annual performance review in place.Interview on 12/11/25 at 3:20 P.M. with CNA #445 revealed she did not have a current annual review completed.2. Review of the personnel file for CNA #331 revealed she was hired on 06/24/11. CNA #331 did not have a current annual performance review in place.Interview on 12/11/25 at 3:30 P.M. with the Director of Nursing (DON) confirmed CNAs #331 and #445 did not have annual performance reviews in place. The DON verified both CNAs were still currently on the schedule and actively working shifts throughout the facility. After evidence of annual performance reviews was requested, the DON stated that CNA #445 was currently actively participating in her annual review at the time of the interview and CNA #331 would receive her annual review soon. This deficiency represents non-compliance investigated under Complaint Number 1369332 (OH00164444).

Based on observation, record review, and interview, the facility failed to administer medications according to physician orders and manufacturer instructions. This affected two residents (#16 and #21) out of three residents reviewed for medication administration. The facility census was 99.Findings include:1. Observation of a medication administration pass for Resident #16 on 12/09/25 at 10:00 A.M. by Registered Nurse (RN) #301 revealed the nurse drew one pill out of a digoxin 125 microgram (mcg) container which had attached pharmacist instructions to hold the medication if the heart rate was under 60 beats per minute (BPM). The nurse administered the medication without checking the resident's heart rate.Record review of Resident #16 revealed an order dated 11/27/25 for 125 mcg of digoxin to be given daily for heart failure, and to hold the dose for a heart rate under 60 BPM.Interview on 12/09/25 at 10:08 A.M. with RN #301 confirmed the above findings, and verified Resident #16's heart rate was not checked prior to medication administration. Observation at the time of the interview revealed the nurse assessed the resident's heart rate and found it to be above 60 BPM.2. Observation of a medication administration pass for Resident #21 on 12/09/25 at 10:13 A.M. by RN #301 revealed the nurse drew a Dulera inhaler (a combination medication typically used for asthma treatment) from the medication cart and stated the resident was to receive two actuations (puffs). The nurse brought the inhaler in for Resident #21 (who was sitting at their bedside), set the inhaler down on the tray table, and entered the bathroom to wash her hands. While the nurse washed her hands, Resident #21 picked up the inhaler, put the mouthpiece between their lips, pushed the actuator twice rapidly, then took a sharp breath and exhaled without holding their breath. RN #301 returned from the bathroom after the resident finished administering the inhaler and then continued with her medication administration pass. Neither the resident nor the nurse shook the inhaler before use, and the resident did not rinse and spit after using the inhaler. Record review of Resident #21 revealed an order dated 07/01/25 for two puffs of Dulera inhalation to be given twice per day.Review of the manufacturer's patient information form for Dulera dated June 2025 revealed users should shake the inhaler before use, wait 30 seconds between puffs, inhale slowly with each puff and hold the breath for ten seconds, and rinse the mouth after use.Interview on 12/09/25 at 12:41 P.M. with RN #301 confirmed the above findings.Review of the medication administration policy dated 04/01/22 revealed inhalers were to be shaken before use. After one puff, the user was to wait either one minute or according to manufacturer instructions before taking another.The above findings identified two medication errors out of 33 medication administrations observed, creating a total error rate of 6.1%.This deficiency represents noncompliance investigated under Complaint Number 2562490.

Based on medical record review, staff interview and facility policy review, the facility failed to monitor Resident #97 for injuries after a fall. This affected one resident (#97) of three resident injuries reviewed. The facility census was 94. Findings Include: Resident #97 was admitted to the facility on [DATE] with diagnoses including dementia, depression, insomnia, drug induced subacute dyskinesia, mixed hyperlipidemia, urinary incontinence, and constipation. Review of the Minimum Data Set (MDS) assessment, dated 12/08/24, revealed Resident #97 had severe cognitive impairment. Review of the progress notes, dated 12/05/24, revealed Resident #97 was found with her knees on the ground, legs out of her bed, and head/torso still lying on her bed. Staff documented that there was discoloration to Resident #97's knees and a small area to her right elbow. There was no other documentation to describe what the injuries/areas looked like. Review of Resident #97 medical records, including bath/shower records, skin assessments, progress notes, fall investigation documents, or other medical records, found no documentation of follow up to the discoloration to her knees and an area to her right elbow. The next documentation that was found was a bath/shower log on 12/08/24, which had no skin issues documented on it. Interview with the Director of Nursing (DON) on 01/10/25 at 1:45 P.M. and 2:20 P.M. revealed documentation supported that after staff found Resident #97 on the floor on 12/05/24, she had discoloration to her knees and an area to her right elbow. She confirmed she does not know the extent of the injuries or discoloration. She confirmed there was no documentation to support monitoring being done for these areas to determine if they were injuries or if they simply were marks on her body from falling out of bed. She confirmed when there were documented areas on a resident's body, routine monitoring should be completed until the area has been resolved. Review of the facility Basic Skin Management policy, dated 11/21/24, revealed upon admission, residents have a risk assessment completed. It is completed weekly for the first four weeks of admission, and then monthly after that. All residents have preventative measures in place that include pressure redistribution mattresses on all beds, wheelchair cushions, heel boots, or suspension if needed, frequent repositioning per Certified Nurse Aides (CNAs) and activity of daily living (ADL) care, incontinent care provided with skin cleansers/wipes, and barrier cream application if needed. It is the responsibility of the CNAs and therapy department to notify nursing if a change to a resident's skin is identified. Notification may be entered into the electronic medical record (EMR) and will alert nurse on the EMR dashboard. Orders are required for skin and wound care. Nursing administration should monitor the wound care program daily utilizing EMR to review timely completion of daily assessments. This deficiency represents noncompliance investigated under Master Complaint Number OH00161130.

Based on medical record review, review of a facility investigation, review of email documents, review of self-reported incidents (SRIs), and review of a facility policy, the facility failed to ensure residents were free from misappropriation. This affected one (#75) of four residents reviewed for misappropriation. The facility census was 95. Findings Include: Review of Resident #75's medical record revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), pneumonia and epilepsy. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #75 was cognitively intact and required one-person physical assistance for his activities of daily living. Further review of the medical record revealed Resident #75 was discharged to a nursing facility closer to his family on 07/15/24. Review of a self-reported incident dated 07/10/24 revealed, on 7/10/24, a detective visited the facility to discuss an investigation that was occurring with his agency, and reported a box of Zofran (anti-nausea medication) prescribed to Resident #75 had been found at the house of a facility staff member, Licensed Practical Nurse (LPN) #975. The detective indicated the medication was discovered during a search of LPN #975's home and was taken as evidence. The label on the medication indicated it belonged to Resident #75. The detective further informed the facility he interviewed Resident #75 and he acknowledged that it was his medication from home that was brought to the facility. Review of an undated facility investigation document revealed a detective came to the facility on [DATE] to investigate a box of Zofran in Resident #75's name. There medication prescription was for 30 pills, there were 28 pills in the box, and the box was enclosed in an evidence bag. The detective asked to speak to Resident #75 with facility staff present during the interview. During the interview, Resident #75 told the detective he got the medications at home via mail and when he went to the hospital, his private duty nurse packed his medications up and sent them to the hospital with the resident. When Resident #75 arrived to the facility from the hospital the box of medication also came to the facility and was placed in the medication room. Further review of the investigation document revealed Resident #75 was admitted to the facility around shift change and the admitting nurse remember the resident coming with bottles of medications and also came with narcotic medications which were inventoried and then destroyed due to new orders. The next nurse completed the rest of Resident #75's admission, and that nurse was LPN #975. Review of an email document from LPN #975 dated 07/12/24 at 1:13 A.M. revealed LPN #975 confessed to taking Resident #75's Zofran from the facility to use for personal use with intension to return it to the facility. Interview with the Administrator on 09/14/24 at 11:11 A.M. confirmed a detective came to the facility to investigate LPN #975 being in possession of Resident #75's Zofran and, through investigation, it was verified the medication was taken from the facility by LPN #975. Review of the policy titled, Abuse-Identification Types, dated 7/18/23, revealed the resident has the right to be free from abuse, neglect, and misappropriation of resident property This deficiency represents non-compliance investigated under Complaint Number OH00156875.

Based on record review, staff interview, and facility policy review the facility failed to ensure an allegation of staff to resident abuse was reported to the state agency as required. This affected one resident (#80) of three residents reviewed for abuse. The facility census was 102. Findings Include: Resident #80 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, dementia with other behavioral disturbance, generalized anxiety disorder, and chronic obstructive pulmonary disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #80 had moderately impaired cognition and was independent for ambulation. Interview on 02/29/24 at 10:00 A.M. with Human Resources Director (HR) #204 revealed that there was an incident this past weekend that involved Resident #80 and a dietary staff member. HR #204 stated that he is investigating the incident of Dietary Aide (DA) #214 holding a resident's wrist, but it wasn't abuse. Interview on 02/29/24 at 11:06 A.M. with Director of Nursing (DON) revealed that she heard about an incident on Monday (02/26/24) where a dietary employee grabbed Resident #80's wrist after Resident #80 asked for something. We are investigating it. Interview on 02/29/24 at 12:37 P.M. with Registered Nurse (RN) #208 revealed that he learned about the incident on Monday (02/26/24) morning. He stated that he was not on call over the weekend but heard there was an altercation between an employee and Resident #80 when Resident #80 wanted something specific from the kitchen. Resident #80 went to the kitchen and an employee put her hand on Resident #80's wrist. On Monday around 1:00 P.M., Resident #80 was walking near the office, and he assessed Resident #80's arms, there were no marks, and Resident #80 did not complain of pain. Review of the soft file for the incident on 02/25/24 revealed that there were three statements from staff regarding the incident. Review of the unsigned, undated statement with the name of Cook #213 printed on top with an incident dated 02/25/24 revealed that on Sunday (02/25/24) afternoon while on tray line, DA #214 stated that Resident #80 bothered her several times while delivering food carts to the units. Cook #213 told DA #214 to give her whatever she wants because it's Resident #80's residence and she was allowed. DA #214 stated to Cook #213 that she didn't care what Resident #80 wanted because Resident #80 comes to the kitchen a lot. DA #214 stated that Resident #80 was bothering her for stuff and stated that Resident #80 was acting aggressive, and that DA #214 would not fight Resident #80 because she would go to jail for homicide. Review of the statement dated 02/28/24 at 10:31 A.M. from Licensed Practical Nurse (LPN) #217 revealed that he did not have any employee or resident come to him about abuse. Review of the statement dated 02/27/24 from Cook #216 revealed that Resident #80 was asking for a popsicle and DA #214 told Resident #80 that she would have to wait because we were busy. Cook #216 got a popsicle for Resident #80. Cook #216 wrote that he did not see anyone hit anyone but saw Resident #80 raise her hand to DA #214 and overheard DA #214 saying, I am not playing with her. I'm not her child, and she better not put her hands on me. Interview on 02/29/24 at 1:10 P.M. with the Administrator revealed that he was made aware of the incident on Monday by HR #204. The Administrator stated that through their investigation, it was a customer service issue and not abuse, so it did not have to be reported. The Administrator stated that the dietary employee was suspended pending the outcome of the investigation, and HR #204 is still investigating. The Administrator verified that the investigation included three statements. Interview on 02/29/24 at 1:40 P.M. with Dietary Manager #211 revealed that she was informed about the incident on Monday (02/26/24) around 8:30 A.M. She heard from Cook #213 and DA #215 that Resident #80 came to the dietary door and asked DA #214 for a popsicle. Resident #80 put her hand up and DA #214 held Resident #80's wrist to keep her from hitting her. Resident #80 had been asking for popsicles a lot because her teeth were pulled several weeks ago. DM #211 stated that she told her staff that residents should not be denied anything if it was available. DM #211 stated that she reported to HR #204 because the Administrator was in a meeting. DM #211 stated that HR #204 told her to take DA #214 off the schedule until the investigation is completed. Review of the Ohio Department of Health's Gateway system revealed no self-reported incident related to the allegation of DA #214 holding Resident #80's arms. Review of the undated facility policy titled, Protection of Residents: Reducing the Treat of Abuse and Neglect, revealed that the facility must ensure all alleged violations involving abuse are reported immediately for serious injury and 24-hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and other officials including to the state agency. This deficiency represents non-compliance investigated under Complaint Number OH00150994.

Based on record review and interviews the facility failed to ensure physician orders were followed to hold Resident #100's tube feed in preparation for a dentist appointment. This affected one resident (Resident #100) of three reviewed for quality of care. Findings include: Record review of Resident #100 revealed an initial admitted [DATE] and readmission of 07/29/23. She was discharged on [DATE]. Diagnoses included metabolic encephalopathy, anoxic brain damage, pneumonia and sepsis. Review of the progress noted dated 01/09/24 at 10:38 A.M. revealed the resident's tube feeding was to be stopped at midnight related to dental appointment on 01/15/24. Review of Resident #100's physician orders for 01/14/24 revealed the resident was to be NPO (nothing by mouth) after midnight and the tube-feed was to be held. Review of the Medication Administration Record for January 2024 revealed the order for NPO status on 01/14/24 was signed off by Licensed Practical Nurse (LPN) #223. Interview on 02/06/24 at 1:18 P.M. with LPN #223 revealed she was told Resident #100 had an appointment the next morning but was not told about the NPO status. LPN #223 stated she was told to sign off on orders early to make it easier for next person covering the shift. She did not recall who told her this. She stated she overlooked the order for NPO. Interview on 02/06/24 at 2:27 P.M. with LPN #222 revealed she did not receive report about the NPO status for Resident #100. She stated the orders were already signed off by LPN #223 and nothing was lit up in the Medication Administration Record (MAR). Interview on 02/06/24 at 2:44 P.M. with Assistant Director of Nursing (ADON) revealed the expectation was orders would be administered as ordered. Review of an internal investigation conducted by the Director of Nursing (DON) on 01/17/24 after son called complaining of a missed appointment revealed the investigation had statements from both LPN #222 and LPN #223 confirming information in above interviews. This deficiency represent non-compliance investigated under Complaint Number OH00150118 and Complaint Number OH00150264.

Based on interview and record review, the facility failed to ensure Resident #29 received adequate foot care to regularly trim toenails. This affected one resident (Resident #29) out of three residents reviewed for foot care. Findings include: Record review of Resident #29 revealed an admitted [DATE]. Diagnoses included Alzheimer's Disease, major depressive disorder and diabetes mellitus type 2. Review of Resident #29's medical record including Certified Nurse Practitioner's monthly notes from August 2023 through February 2024 revealed no indication the resident's toenails were trimmed or evidence the resident was assessed for podiatry needs. There was no indication of refusals or attempts to cut the resident's toenails. Interview on 02/05/24 from 10:00 A.M. to 10:17 A.M. with Licensed Practical Nurse (LPN) #203 and LPN #205 revealed they did not believe Resident #29 was seen by a podiatrist. They stated a podiatrist would need to cut the resident's toenails because they were diabetic. Interview on 02/05/24 at 10:13 A.M. with Certified Nurse Practitioner (CNP) #225 stated he visited Resident #29 monthly. He stated he trimmed her toenails on this day because LPN #203 told him surveyor was inquiring. He stated the last time he trimmed her toenails was August 2023. Interview on 02/05/24 at 12:41 P.M. with Assistant Director of Nursing (ADON) #200 revealed her expectation was residents with diabetes mellitus should be assessed for podiatry needs monthly. Review of the facility policy titled Nail Care, dated 8/23/23 revealed the facility should make arrangements for podiatry care. This deficiency represent non-compliance investigated under Complaint Number OH00150118 and Complaint Number OH00150264.

Based on record review and interview, the facility failed to verify and administer one resident's (Resident #103) pain medication in a timely manner. This affected one (Resident #103) of a four residents reviewed for pain. Actual harm occurred when Resident #103, who was admitted on [DATE] status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 84. Findings include: Resident #103 was admitted to the facility 12/11/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #103's Minimum Data Set Assessment (MDS) 3.0 assessment dated [DATE] revealed Resident #103 had severe cognitive impairment. She required extensive assistance of two staff for all activities of daily living including toileting and bed transfers. Review of Resident #103's admitting physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] · [MEDICATION(S)] 300 milligrams (mg) to be give three times a day for pain. The order was written on 12/11/21. · Acetaminophen 1000 mg given three times a day for pain. The order was written on 12/11/21. · Oxycodone 5 mg give one tablet every four hours as needed for pain. The order was written on 12/11/21. Review of Resident #103's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with LPN #221 on 12/15/21 at 2:41 P.M. stated when she worked on 12/11/21 Resident #103 had just been admitted . She stated when she came back on the morning of 12/13/21, Resident #103 was yelling out in pain and she had not received any type of pain medication since her admission on 12/11/21. Review of Resident #103's medical record revealed the admitting orders were not verified by staff until 12/13/21. This deficiency substantiates Complaint Numbers OH 291, OH 801, OH 183 and OH 739.

Based on interview, record review, and policy review, the facility failed to provide adequate supervision for one resident, Resident #81. Actual harm occurred when Resident #81, who required one-on-one supervision, was not properly supervised, and fell resulting in a fractured tibia. This affected one resident, Resident #81, of three residents reviewed for behaviors. The facility census was 80. Findings Include: Review of the medical record for Resident #81 revealed an admitted [DATE]. Diagnoses included [CONDITION(S)], autistic disorder, attention-deficit [CONDITION(S)] disorder, unspecified type, fetal alcohol syndrome, and [CONDITION(S)]. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 08/19/21, revealed the resident had severely impaired cognition and required extensive assistance with two plus persons physical assist for bed mobility, transfers, dressing, toilet use, and personal hygiene; required limited assistance with one-person physical assist for eating, and was always incontinent of urine and bowel. The assessment indicated no use of alarms or restraints with the resident. Review of the plan of care dated 08/19/21 revealed Resident #81 was at risk of injury to self and others and falling due to impulsiveness and history of behaviors with self-harm and intellectual disability. The behaviors consisted of hitting his head repeatedly against wall, throwing objects across room, throwing himself out of bed, flailing arms, removing secured items from walls, wandering into other resident rooms, removing brief and playing in feces, and disrobing clothes. Interventions included providing Resident #81 with one-to-one supervision and monitoring to assist in deescalating behaviors. During an initial tour of the facility on 08/30/21 from 9:58 A.M. to 10:30 A.M., Resident #81 was observed on the hallway floor surrounded by four nursing staff. Resident #81 was sitting up on the floor, two doors down from his room, near a med cart. Resident #81 had on a shirt, no pants or underwear. A cast was observed on Resident #81's right foot that extended from his toes to just above the right knee. Nursing staff was observed covering Resident #81 with a blanket and getting him into a wheelchair. Once Resident #81 was in the wheelchair, nursing staff wheeled him back to his room. At the doorway to the resident's room, Resident #81 was observed to lean forward, without warning, and scoot self out of wheelchair to the floor and proceeded to scoot/crawl into his room. Interview on 08/30/21 at 10:30 A.M. with the Administrator and the Director of Nursing (DON), confirmed Resident #81 had a cast on his right leg related to a fall on 08/21/21. Review of Resident #81's Admission Fall Risk Evaluation, dated 08/12/21, revealed a fall risk score of 17.0 indicating the resident was a fall risk and interventions should be initiated. Review of Resident #81's progress note dated 08/21/21 at 4:26 A.M. revealed Resident #81 had fallen out of a Broda chair (a heavy wheelchair that tilts and reclines) and was found by Registered Nurse (RN) #215 on the floor with the Broda chair tipped upward. Resident #81 was evaluated by RN #215 and found no apparent bruising or injuries related to the fall. Review of Resident #81's progress note dated 08/25/21 at 5:27 P.M. revealed Resident #81 complained of increased pain in right foot. Order was obtained for an in-house x-ray of the right ankle and right foot. Review of Resident #81's progress note dated 08/26/21 at 12:50 P.M. revealed Resident #81 had a right leg fracture. Review of Resident #81's progress note dated 08/27/21 at 1:37 P.M. revealed Resident #81 was transferred to an orthopedic surgeon, evaluated, and placed in a cast for a right tibia (shin bone) fracture. Interview on 09/01/21 at 12:49 P.M. with the DON revealed Resident #81 had been asleep in the Broda chair, unsupervised, in his room with the door open, when the fall occurred. The DON verified Resident #81 had a history of being impulsive, moving about, and crawling out of bed prior to the fall on 08/21/21. The DON stated one-on-one supervision was started around 08/15/21 or 08/16/21 due to Resident #81's increased behaviors, but the facility was unable to provide the resident with one-to-one supervision, 24-hours per day, due to staffing. The DON revealed she was unaware Resident #81 was being placed in a Broda chair without one-to-one supervision, and further stated, it was poor judgement on the part of staffing, I would not have placed him in a Broda chair. This citation substantiates Complaint Number OH 051 and Complaint Number OH 038.