Every finding on record at Lincoln Crawford Care Center

Based on interview, record review, and facility policy review, the facility failed to implement their policy for abuse prohibition for 1 (Resident #55) of 2 residents. Specifically, a dietary aide (DA) witnessed Resident #95 attempt to hit Resident #55 in the dining room on 05/26/2025. The staff member separated the residents and directed them to return to the unit where they resided; however, the incident was not reported to the Director of Nursing (DON), the nurse supervisor on duty, or Administrator as required per facility policy. Once Resident #55 returned to their room, the resident stated that Resident #95 struck them in their head with a cane. The failure resulted in a Actual Harm when Resident #55 sustained a laceration to the head with an arterial bleed and a right arm fracture which coupled with previous left arm paralysis, left Resident #55 unable to use their upper extremities and dependent on staff for all activities of daily living.Findings include: The facility document titled, Abuse and Neglect Protocol revised 06/13/2021, revealed, It is the responsibility of our employees, facility consultants, Attending Physician's, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. The policy revealed, 4. Employees, facility consultants and/or Attending Physicians must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. In the absence of the Director of Nursing Services such reports may be made to the Nurse Supervisor on duty. 5. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing Services. The following information should be reported: a. The name(s) of the resident(s) to which the abuse or suspected abuse occurred; b. The date and time that the incident occurred; c. Where the incident took place; d. The name(s) of the person(s) allegedly committing the incident, if known; e. The name(s) of any witnesses to the incident; f. The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, etc.); and g. Any other information that may be requested by management. Per the policy, 8. The Administrator or Director of Nursing Services must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing Services must be called at home or must be paged and informed of the incident. 9. When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to the facility management regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in this policy.An admission Record indicated the facility originally admitted Resident #55 on 02/18/2014. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia (paralysis) and hemiparesis following a cerebral infarction affecting the nondominant left side and cerebrovascular disease. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/09/2025, revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed Resident #55 had limitations in range of motion of the upper extremity on one side of the body. Resident #55's Care Plan Report included a focus area initiated 05/21/2020, that indicated the resident was at risk for developing complications secondary to an ADL self-care performance deficit. Interventions directed one staff member to provide setup/clean-up assistance with eating, personal hygiene and oral care (initiated 05/21/2020); supervision/touching assistance with toileting and transfers from sitting to standing positions, chair/bed-to-chair transfers, and toilet transfers (initiated 08/16/2020); and partial/moderate assistance for showers/bathing (initiated 05/21/2020). The Care Plan Report also included a focus area initiated 05/21/2020, that indicated Resident #55 was at risk for complications secondary to limited physical mobility related to a stroke and weakness. Interventions directed staff to have the resident use a wheelchair for locomotion (initiated 05/21/2020) and provide supervision and staff set up for mobility (initiated 10/14/2020). An admission Record indicated the facility admitted Resident #95 on 06/29/2023. According to the admission Record, the resident had a medical history that included diagnoses of peripheral vascular disease, depressive disorder, and mild cognitive impairment. A quarterly MDS, with an ARD of 03/04/2025, revealed Resident #95 had a BIMS score of 15, which indicated the resident had intact cognition. During an interview on 08/05/2025 at 1:34 PM, Resident #55 stated that a couple months prior, while downstairs in the cafeteria area speaking with Resident #62, and waiting for their meal to be delivered, Resident #95 approached them and bumped their wheelchair several times, despite having ample room to get around. Resident #55 stated they initially attempted to move closer toward the table to give Resident #95 room to get around the wheelchair, but Resident #95 continued to bump their wheelchair and attempted to hit them. Resident #55 stated that at that time, they began to roll their wheelchair backward and tried to use their foot to tap Resident #95's knee in an attempt to get the resident to stop, back off, and go around. Per Resident #55, a female staff member came from the kitchen when Resident #62 yelled for help. Resident #55 stated the staff member told them they had to move and go upstairs. Resident #55 stated Resident #95 left the dining area first and they returned to the unit later. Resident #55 stated they recalled getting off the elevator on the 300 Hall unit where they resided and started down the hallway towards their room. Resident #55 stated they passed Resident #95, who was seated in their wheelchair in the hallway outside their room. Resident #55 stated they cautiously passed Resident #95 but did not speak and went into their room. Resident #55 stated that once in the room they turned around, and Resident #95 was coming toward them with a metal cane and struck them a couple of times to the right side of their head. Per Resident #55, they tried to keep Resident #95 from hitting them with the cane again. Resident #55 stated their head was bleeding. Per Resident #55, Resident #95 told them that they had better tell the nurse that they fell or things would be worse. Resident #55 stated they became very apprehensive and more guarded and went to the nurse's station and told staff that they needed help. Resident #55 stated they had not been out of their wheelchair and did not fall. Resident #55 stated that a nurse placed towels on their head, but the bleeding did not stop before going to the hospital. Resident #55 stated they were too afraid to say anything before they left the facility because they was afraid the situation might get worse. Resident #55 stated at the hospital, they had to get staples in their head and they learned that their right arm/wrist was broken and had to get a cast. Resident #55 stated that upon return to the facility, they asked for a different room, away from Resident #95. During an interview on 08/06/2025 at 8:47 AM, Resident #62 stated they were at a table in the dining room speaking with Resident #55 when Resident #95 approached them and hit Resident #55. Resident #62 stated they screamed for help because they were concerned that Resident #95 would harm Resident #55. During an interview on 08/06/2025 at 11:35 AM, Dietary Aide (DA) #21 stated she was working in the dietary department on the meal service tray line on 05/26/2025 when she heard a scream from Resident #62. Per DA #21, Resident #62 yelled for Resident #95 to stop. DA #21 stated that as she proceeded out of the swinging doors of the dietary department, she saw Resident #55 seated in their wheelchair and Resident #95 was in front of Resident #55, swinging at the resident. DA #21 stated she pulled Resident #55 backward and told the residents to go upstairs. She stated she then returned to the kitchen and began her cleaning duties. DA #21 stated that later that evening at approximately 8:00 PM, she was getting ready to leave the facility when she saw Resident #55 on a stretcher with a bloody head. During an interview on 08/06/2025 at 8:36 AM, DA #22 stated she recalled Resident #55 and Resident #95 were in the dining room and there was a lot of noise. She stated that she was working on the tray line with DA #21 and they heard a resident yelling for help. DA #22 stated she heard DA #21 leave the tray line and then heard DA #21 yell for the residents to stop. DA #22 stated that when she approached the door, she could hear Resident #95 cursing at DA #21 and heard DA #21 tell Resident #55 to move backwards, and Resident #55 immediately moved out of the way. Per DA #22, DA #21 stated that Resident #95 was getting ready to go after Resident #55 when she yelled. DA #22 stated that Resident #55 seemed to be glad that someone came so they could get away. DA #21 stated that it was the first time she had seen the residents escalate to that degree and it scared her. She stated that following the interaction, both she and DA #21 returned to the kitchen and began breaking down the tray line and cleaning the kitchen for the night and stated neither of them reported the incident. During an interview on 08/08/2025 at 8:12 AM, the Director of Rehabilitation (DOR) stated that prior to hospitalization, Resident #55 was able to walk with a hemi-cane (a type of walker designed for use for individuals with one-sided weakness) during therapy. The DOR stated therapy evaluated Resident #55 the day they returned from the hospital and because the resident could not bear weight to their right arm and had residual effects in their left arm from a prior stroke, Resident #55 was left dependent on staff for all activities of daily living. The DOR stated Resident #55 could also no longer use their hemi-walker, which left Resident #55 completely dependent for all care. During an interview on 08/08/2025 at 11:07 AM, the DON stated staff were trained to notify a member of management immediately if there was confirmed or suspected case of abuse. The DON stated she expected the staff to separate the residents and report incidents to management. The DON stated they did not learn of the incident in the dining room on 05/26/2025, during their investigation of Resident #55's abuse allegation. During an interview on 08/08/2025 at 12:04 PM, the Administrator stated abuse was anything verbal, physical, emotional, or mental that caused intentional harm to the other person. The Administrator stated that he believed repeated bumping of the wheelchairs and Resident #95 cursing at Resident #55 to be situational and not abusive in nature; however, he stated that when Resident #95 attempted to hit Resident #55, that would be considered abusive. The Administrator stated that he was not aware that Resident #95 was swinging at Resident #55 in the dining room on 05/26/2025. He stated if staff witnessed the event, they were to separate the residents and ensure the residents were safe, then report it to the DON or the Administrator. He stated he expected the staff to have reported the situation immediately.

Based on interview, record review, and facility document and policy review, the facility failed to protect 3 (Resident #55, Resident #58, and Resident #53) of 3 residents ' right to be free from physical/mental abuse by another resident. On 05/26/2025, before the evening meal in the dining room, dietary staff observed Resident #95 attempt to hit their roommate, Resident #55. Dietary staff separated the residents and instructed the residents to go upstairs. Later that evening, staff transferred Resident #55 to the emergency department (ED) due to bleeding from the resident ' s head. While at the ED, Resident #55 stated that Resident #95 hit them multiple times with a cane. This resulted in Actual Harm when Resident #55 was hospitalized and diagnosed with a fractured right arm, received six sutures to a laceration to their head, and was diagnosed with acute blood loss anemia. The failure to protect Resident #55 from abuse resulted in injuries which left Resident #55 being dependent on staff for all activities of daily living (ADL) due to the resident ' s inability to use their upper extremities. In addition, on 06/18/2025 at 7:30 PM in the facility's courtyard, Resident #53 reported hearing Resident #58 talking about them and when Resident #53 approached Resident #58, Resident #58 called Resident #53's family member an expletive and pushed Resident #53 away. Resident #53 then hit Resident #58 in the face, and Resident #53 placed their hands around Resident #58's neck. Resident #31 separated Resident #53 and Resident #58.Findings included: A facility document titled, Abuse and Neglect Protocol, revised 06/13/2021, revealed, Our residents have the right to be free from abuse, neglect misappropriation of resident property, exploitation, corporal punishment, physical or chemical restraints imposed for purpose of discipline or convenience, and not required to treat the resident's medical symptoms, and involuntary seclusion. The policy revealed 1. Our facility does not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff or other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. 2. To help with recognition of incidents of abuse, the following definitions of abuse are provided. a. 'Abuse' is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy revealed, 'Willful,' as used in this definition of abuse, means the individual must have acted deliberately. b. 'Verbal abuse' is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. e. 'Mental abuse' is defined as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. 1. An admission Record indicated the facility originally admitted Resident #55 on 02/18/2014. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia (paralysis) and hemiparesis following a cerebral infarction affecting the nondominant left side and cerebrovascular disease. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/09/2025, revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed Resident #55 had limitations in range of motion of the upper extremity on one side of the body. Resident #55's Care Plan Report included a focus area initiated 05/21/2020, that indicated the resident was at risk for developing complications secondary to an ADL self-care performance deficit. Interventions directed one staff member to provide setup/clean-up assistance with eating, personal hygiene and oral care (initiated 05/21/2020); supervision/touching assistance with toileting and transfers from sitting to standing positions, chair/bed-to-chair transfers, and toilet transfers (initiated 08/16/2020); and partial/moderate assistance for showers/bathing (initiated 05/21/2020). The Care Plan Report also included a focus area initiated 05/21/2020, that indicated Resident #55 was at risk for complications secondary to limited physical mobility related to a stroke and weakness. Interventions directed staff to have the resident use a wheelchair for locomotion (initiated 05/21/2020) and provide supervision and staff set up for mobility (initiated 10/14/2020). Resident #55's Medication Administration Record dated 05/2025 revealed Resident #55 received clopidogrel bisulfate (an antiplatelet medication) 75 mg (milligram) tablet one time a day related to other cerebrovascular disease and apixaban (an anticoagulant medication) 5 mg tablet twice a day for atrial fibrillation from 05/01/2025 through the morning dose on 05/26/2025. An admission Record indicated the facility admitted Resident #95 on 06/29/2023. According to the admission Record, the resident had a medical history that included diagnoses of peripheral vascular disease, depressive disorder, and mild cognitive impairment. A quarterly MDS, with an ARD of 03/04/2025, revealed Resident #95 had a BIMS score of 15, which indicated the resident had intact cognition. Resident #55's Progress Notes dated 05/26/2025 at 7:37 PM, revealed the resident's roommate (Resident #95) reported to the nurse's aide during report rounds that Resident #55 hit their head multiple times on their bedframe causing a massive head bleed. The notes revealed staff called 911 and sent Resident #55 to the emergency room (ER) for further evaluation. Resident #55's Trauma Surgery H&P [History and Physical] dated 05/26/2025 at 10:45 PM, revealed Resident #55 sustained a fall from standing height, and a trauma alert was received because the resident took anticoagulant medication. Per the H&P, the resident had a three-centimeter (cm) laceration to the forehead with a hematoma (a localized collection of blood) and an arterial bleed, and the resident had a right ulna fracture (the bone from the elbow to the little finger side of the wrist). Per the H&P, the ulna bone was minimally displaced, mildly angulated, and mildly comminuted (the bone was broken in two or more places and usually resulted from trauma). Per the H&P, Resident #55 admitted to the hospital to trauma services. The hospital Trauma/Critical Ill Assessment dated 05/26/2025 at 9:11 PM, indicated an ambulance brought Resident #55 in for an evaluation of injuries from fall. The assessment revealed at 2:00 AM, Resident #55 reported to a registered nurse (RN) that their roommate (Resident #98) assaulted them and they did not fall. The assessment revealed a social worker spoke with the resident to confirm what the resident reported to the RN. Per the assessment, Resident #55 wanted to speak to the police about what happened, and the social worker notified the police department. The hospital ED Notes Addendum dated 05/27/2025 at 1:15 AM, revealed Resident #55 informed an RN that they did not fall but was actually assaulted by their roommate. Per the note, Resident #55 stated their roommate went to hit them with a metal walker, and they attempted to block, which caused the radial fracture and head laceration. Resident #55's Inpatient Surgery Discharge Summary dated 05/28/2025 at 11:52 AM, revealed Resident #55 presented after a reported fall from standing height at the facility. Resident #55 then told team members that they was assaulted by their roommate and did not fall. According to the discharge summary, trauma staff repaired the resident's head laceration with six sutures/stiches, and the resident had a follow up appointment at the trauma clinic to remove the sutures. Per the discharge summary, the resident had acute blood loss anemia and education was provided for post-traumatic stress disorder. The discharge summary also revealed that plastic surgery placed a splint on the resident's right arm, and the resident should not bear weight, avoid heavy lifting in the right extremity, and attend a follow up appointment. The discharge summary indicated the resident should take acetaminophen and Robaxin (a muscle relaxant) for pain control. The Self-Reported Incident Form dated 05/27/2025, revealed on 05/26/2025 at 7:30 PM, Resident #55 was found bleeding. At the time of the incident, Resident #55, who was generally verbally expressive, declined to offer an explanation to the staff related to the incident. The report revealed the facility sent Resident #55 to the hospital and at that time, the resident reported their roommate (Resident #95) assaulted them. According to the report, Resident #95, the roommate, reported that Resident #55 fell from their wheelchair and they helped Resident #55 back into their chair. An untitled, typed document revealed the Director of Nursing (DON) interviewed Resident #55, upon return from the hospital on [DATE] at approximately 3:00 PM. The document revealed the resident stated that their roommate, Resident #95 assaulted them with a cane. Per the document, Resident #55 stated Resident #95 hit them on the right side of the forehead then the resident put up their right arm to protect their head, and Resident #95 continued to hit Resident #55's wrist with the cane. Per the document, Resident #55 denied falling. An untitled, typed document revealed the Administrator, DON, and Assistant DON interviewed Resident #95 on 05/27/2025 at 10:30 AM and asked the resident what happened to Resident #55. According to the document, Resident #95 stated they were sitting in the hallway when Resident #55 attempted to stand, lost their balance, hit their head on the bed frame when they fell to the ground, and the resident's head began to bleed. Resident #95 stated they did not know how Resident #55 got off the floor. Per the document, Resident #95 stated that Certified Nurse Aide (CNA) #19 cleaned the blood off the floor. According to the document, the DON assessed Resident #95's walker and cane, and both residents' beds, and did not see any blood on any of the equipment. The document revealed Resident #95 became upset and denied hitting Resident #55 and any altercation with the resident. An untitled, typed document dated 05/28/2025, signed by the Administrator, and labeled as an in Hospital Room visit, revealed that on the afternoon before the incident Resident #55 was sitting in the dining room talking to Resident #62 when Resident #95 (in wheelchair) bumped into Resident #55's wheelchair. Per the document, Resident #55 reported that this action was intentional because there was ample space and that Resident #95 made it like it was Resident #55's fault because they were blocking the aisle. The document revealed that Resident #95 tried to punch Resident #55 on the chin; subsequently, Resident #55 tried to kick, more like nudge, Resident #95 in the knee several times. Resident #95 kept pushing their way through with their wheelchair and Resident #55 kept backing up in their wheelchair. Per the document, a staff member came out of the kitchen area and told them that they had to move. According to the document, Resident #95 then became confrontational with the staff member. The note further revealed that at approximately 6:00 PM, Resident #55 went up the elevator and down the hallway, passed Resident #95, and said excuse me to Resident #95 before entering their room. Per the document, Resident #55 reported that Resident #95 entered the room with a cane in their hand and began swinging the cane. The document revealed that Resident #55 put up their hand to block after being hit on the head, which was when the fracture occurred. According to Resident #55, there was clothing on the bed and Resident #95 instructed Resident #55 to place it on their head and apply pressure, then Resident #55 left the room and went to the nurse station. Resident #55 approached an aide who removed the clothing from the resident's head and replaced it with fresh towels. Per the note, at this time, Resident #95 returned to the room area. The note revealed that Resident #95 reported to staff that Resident #55 fell and also told Resident #55 to say they fell. Per the note, Resident #55 stated to go along with Resident #95, that's what I said. That's why I told the nurse I fell. During an interview on 08/05/2025 at 1:34 PM, Resident #55 stated that a couple months prior, while downstairs in the cafeteria area speaking with Resident #62, and waiting for their meal to be delivered, Resident #95 approached them and bumped their wheelchair several times, despite having ample room to get around. Resident #55 stated they initially attempted to move closer toward the table to give Resident #95 room to get around the wheelchair, but Resident #95 continued to bump their wheelchair and attempted to hit them. Resident #55 stated that at that time, they began to roll their wheelchair backward and tried to use their foot to tap Resident #95's knee in an attempt to get the resident to stop, back off, and go around. Per Resident #55, a female staff member came from the kitchen when Resident #62 yelled for help. Resident #55 stated the staff member told them they had to move and go upstairs. Resident #55 stated Resident #95 left the dining area first and they returned to the unit later. Resident #55 stated they recalled getting off the elevator on the 300 Hall unit where they resided and started down the hallway towards their room. Resident #55 stated they passed Resident #95, who was seated in their wheelchair in the hallway outside their room. Resident #55 stated they cautiously passed Resident #95 but did not speak and went into their room. Resident #55 stated that once in the room they turned around, and Resident #95 was coming toward them with a metal cane and struck them a couple of times to the right side of their head. Per Resident #55, they tried to keep Resident #95 from hitting them with the cane again. Resident #55 stated their head was bleeding. Per Resident #55, Resident #95 told them that they had better tell the nurse that they fell or things would be worse. Resident #55 stated they became very apprehensive and more guarded and went to the nurse's station and told staff that they needed help. Resident #55 stated they had not been out of their wheelchair and did not fall. Resident #55 stated that a nurse placed towels on their head, but the bleeding did not stop before going to the hospital. Resident #55 stated they were too afraid to say anything before they left the facility because they was afraid the situation might get worse. Resident #55 stated at the hospital, they had to get staples in their head and they learned that their right arm/wrist was broken and had to get a cast. Resident #55 stated that upon return to the facility, they asked for a different room, away from Resident #95. During an interview on 08/06/2025 at 8:47 AM, Resident #62 stated they were at a table in the dining room speaking with Resident #55 when Resident #95 approached them and hit Resident #55. Resident #62 stated they screamed for help because they were concerned that Resident #95 would harm Resident #55. During an interview on 08/06/2025 at 11:35 AM, Dietary Aide (DA) #21 stated she was working in the dietary department on the meal service tray line on 05/26/2025 when she heard a scream from Resident #62. Per DA #21, Resident #62 yelled for Resident #95 to stop. DA #21 stated that as she proceeded out of the swinging doors of the dietary department, she saw Resident #55 seated in their wheelchair and Resident #95 was in front of Resident #55, swinging at the resident. DA #21 stated she pulled Resident #55 backward and told the residents to go upstairs. She stated she then returned to the kitchen and began her cleaning duties. DA #21 stated that later that evening at approximately 8:00 PM, she was getting ready to leave the facility when she saw Resident #55 on a stretcher with a bloody head. During an interview on 08/06/2025 at 8:36 AM, DA #22 stated she recalled Resident #55 and Resident #95 were in the dining room and there was a lot of noise. She stated that she was working on the tray line with DA #21 and they heard a resident yelling for help. DA #22 stated she heard DA #21 leave the tray line and then heard DA #21 yell for the residents to stop. DA #22 stated that when she approached the door, she could hear Resident #95 cursing at DA #21 and heard DA #21 tell Resident #55 to move backwards, and Resident #55 immediately moved out of the way. Per DA #22, DA #21 stated that Resident #95 was getting ready to go after Resident #55 when she yelled. DA #22 stated that Resident #55 seemed to be glad that someone came so they could get away. DA #21 stated that it was the first time she had seen the residents escalate to that degree and it scared her. She stated that following the interaction, both she and DA #21 returned to the kitchen and began breaking down the tray line and cleaning the kitchen for the night and stated neither of them reported the incident. During an interview on 08/06/2025 at 7:53 PM, CNA #28 stated she was on duty on the night shift on 05/26/2025, and shortly after arriving on duty at 7:00 PM, Resident #55 was in a wheelchair, and their head was bleeding. She stated she notified an unidentified nurse, retrieved towels, and applied them to the resident's head to attempt to clean blood from the resident's face. She stated she recalled quite a bit of blood being on the resident's head and clothing, and on the floor. CNA #28 stated she also recalled Resident #95 sitting outside their door, saying something inappropriate, but could not remember what the resident said. CNA #28 stated that when she asked Resident #95 what happened, the resident stated that Resident #55 fell; however, she did not believe that Resident #55 would have been able to independently get up if they fell. During an interview on 08/06/2025 at 7:17 PM, Licensed Practical Nurse (LPN) #16 stated she was on duty covering a shift on the night of 05/26/2025 beginning at 7:00 PM. LPN #16 indicated that shortly after shift change, she was at the nurses' station when an unidentified nurse aide notified her that Resident #55 was in the hallway bleeding from their head. She stated she was not the assigned nurse to either Resident #55 or Resident #95; however, she was assigned to the 300 unit that night. LPN #16 stated that with her knowledge that Resident #55 was on a blood thinner and she and LPN #15 gathered dressing supplies and headed towards Resident #55. Per LPN #16, Resident #55 was bleeding pretty significantly when she arrived to assess the resident. LPN #16 stated Resident #55 was unable to describe what occurred. LPN #16 stated they applied pressure to the resident's head and contacted emergency medical services (EMS) to transport as quickly as possible. LPN #16 stated that following Resident #55's departure to the hospital, both she and LPN #15 asked Resident #95 what occurred, and the resident stated that Resident #55 fell and hit their head on the footboard of the bed. LPN #16 stated she recalled seeing blood stains on the floor in the room far enough away from the resident's bed that it did not appear the resident hit the end of the bed. LPN #16 stated that both she and LPN #15 looked at the footboard and all over the bed but did not see any blood on the bed. LPN #16 stated she found it hard to believe and did not think Resident #55 would be able to get up from the floor and back to their wheelchair independently after a fall or with the injuries the resident sustained. According to LPN #16, no one reported an altercation occurred prior to the incident. Per LPN #16 she did not learn of the allegation of assault until LPN #15 called the hospital to obtain a report on Resident #55. During an interview on 08/08/2025 at 3:13 PM, CNA #19 stated Resident #95 told her that Resident #55 fell. CNA #19 stated she remembered seeing Resident #55 on 05/26/2025 in the hallway with their head bleeding and the resident would not say what happened. She stated Resident #95 kept saying Resident fell and hit their head on the footboard of the bed; however, per CNA #19, there was no blood in the area. During an interview on 08/08/2025 at 8:12 AM, the Director of Rehabilitation (DOR) stated that prior to hospitalization, Resident #55 was able to walk with a hemi-cane (a type of walker designed for use for individuals with one-sided weakness) during therapy. The DOR stated therapy evaluated Resident #55 the day they returned from the hospital and because the resident could not bear weight to their right arm and had residual effects in their left arm from a prior stroke, Resident #55 was left dependent on staff for all activities of daily living. The DOR stated Resident #55 could also no longer use their hemi-walker, which left Resident #55 completely dependent for all care. During an interview on 08/08/2025 at 11:07 AM, the DON stated if Resident #55 fell on the floor, she did not think the resident would have been able to get off the floor without staff assistance. The DON stated that when they interviewed Resident #95 on 05/26/2025, the resident stated that Resident #55 hit their head on the footboard when they fell. The DON stated that Resident #55 did not tell them what happened when the incident occurred but reported to the hospital that their roommate assaulted them. Per the DON, the facility investigated, and looked at the cane, walker, and bed frame and they did not find any blood. She stated that because Resident #55 had some dementia, they did not credit the resident as having accountability. During an interview on 08/08/2025 at 12:04 PM, the Administrator stated abuse was anything verbal, physical, emotional, or mental that caused intentional harm to another resident. The Administrator indicated he was aware there had been some interactions that occurred in the dining room, but he was not aware Resident #95 attempted to hit Resident #55 while in the dining room. He stated the example of Resident #95 attempting to hit Resident #55 would be considered an example of potential abuse, and if the episode was witnessed, the residents should be separated to ensure safety, then the staff member should notify the DON or the Administrator. According to the Administrator, he visited Resident #55 in the hospital, and the resident told him about being attacked by their roommate. The Administrator stated he placed Resident #95 on one-to-one supervisor the morning of 05/27/2025, when he was notified of the incident, and the resident remained on one-to-one supervision for caution until the danger passed. The Administrator indicated he did not think Resident #95 needed to remain on one-to-one supervision after Resident #55 returned to the facility on the following day, 05/28/2025, because he thought the events that occurred were more behavioral. Per the Administrator, the facility did not substantiate abuse. He stated he was unable to determine whether the case was behavioral, or abuse and he felt that the situation was reactive as opposed to abusive based on his investigation. 2. An admission Record revealed the facility admitted Resident #53 on 01/04/2023. According to the admission Record, the resident had a medical history that included a diagnosis of tobacco use. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/25/2025, revealed Resident #53 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #53's Care Plan Report revealed a focus area initiated 01/04/2023, that indicated the resident was a smoker. An admission Record revealed the facility admitted Resident #58 on 05/03/2025. According to the admission Record, the resident had a medical history that included diagnoses of depression, anxiety disorder, and post-traumatic stress disorder. An admission MDS, with an ARD of 05/09/2025, revealed Resident #58 had a BIMS score of 15, which indicated the resident had intact cognition. Resident #58's Care Plan Report included a focus area initiated 05/23/2025, that indicated the resident was a smoker The facility Self-Reported Incident Form, dated 06/18/2025, indicated an incident of physical abuse, a resident as a victim, and another resident as the alleged perpetrator. The facility Narrative Summary of Incident revealed on 06/18/2025 at 7:30 PM, Resident #53 came to a nurse and reported an altercation with Resident #58 in the courtyard, and the nurse confirmed that both residents were safe and separated. The summary indicated Resident #58 reported Resident #53 approached them unprovoked, hit them #58 in the face, and placed their hands around their neck. The summary indicated Resident #53 reported hearing Resident #58 talking about Resident #53, and when Resident #53 approached, Resident #58 called Resident #53's family member an expletive and pushed Resident #53 away. The summary indicated Resident #53 directed physical force at Resident #58, and another resident separated the two residents in the courtyard. The summary indicated there were no other witnesses to the alleged event. The summary indicated the Director of Nursing (DON) and Administrator were notified of the incident. The summary indicated the police were called per both residents' requests. The summary indicated Resident #58 declined to go to the emergency room. The Conclusion indicated the facility unsubstantiated the allegation, the evidence was inclusive, and abuse, neglect, and misappropriation were not suspected. During an interview on 08/07/2025 at 8:50 AM, Resident #53 stated they remembered the incident with Resident #58 outside in the courtyard after smoking time. Resident #53 stated several residents were present. Resident #53 stated they were unsure if any staff were present, maybe a staff member who worked on the second floor was there, but the resident could not remember the staff member's name. Resident #53 stated that Resident #58 was talking about their family member and started to shake their head. Resident #53 stated Resident #31 intervened to separate them. Resident #53 stated there were no other times when they hit someone. Resident #53 stated they told the nurse about the fight. During an interview on 08/07/2025 at 1:20 PM, Resident #31 stated there had been some altercations during the smoke breaks, and they would get in between the residents involved because they did not like violence. Resident #31 stated the day Resident #53 and Resident #58 got into it, they had been out smoking, and they were arguing back and forth, Resident #58 called Resident #53's family member an expletive, and Resident #53 punched Resident #58, then Resident #58 punched Resident #53, and Resident #53 tried to choke Resident #58. Resident #31 stated they got in between the two residents to break it up. A quarterly MDS, with an ARD of 07/07/2025, revealed Resident #31 had a BIMS score of 15, which indicated the resident had intact cognition. During an interview on 08/07/2025 at 10:55 PM, Registered Nurse (RN) #12 stated in June 20205 or July 2025 an incident happened at shift change in the courtyard when Resident #53 and Resident #58 were arguing. RN #12 stated she did not witness any hands-on interaction between the two residents. RN #12 stated each resident claimed they were the victim and the other was the aggressor. RN #12 stated she separated the residents, interviewed each of the residents, and called the DON. RN #12 stated Resident #58 stated Resident #53 started it. RN #12 stated both residents were offered to change rooms, but they refused, and 1:1 observation was provided for Resident #58. During an interview on 08/08/2025 at 11:39 AM, the DON stated she knew there had been a verbal altercation, could not remember exactly how it started, but knew Resident #58 said something about Resident #53's family member and then the residents started arguing and it escalated. The DON stated it happened in the courtyard, she did not remember if any staff were present, and there were other residents outside to include Resident #31. The DON stated Resident #31 tried to break it up. The DON stated her expectation was to make sure the residents felt safe. During an interview on 08/08/2025 at 12:35 PM, the Administrator stated he was notified almost instantly, at about 8:00 PM, of the incident.

Based on observation, interview, record review, facility policy, and facility document review, the facility failed to consistently implement a program to ensure resident safety while smoking for 6 (Residents #6, #9, #4, #24, #31, and #49) of 29 residents who smoked. Specifically, the facility failed to ensure residents did not keep smoking materials in their possession and did not give smoking materials to other residents per the facility's smoking policy and smoking agreement. Findings included:A facility policy, Smoking Policy – Residents, revised 07/2017, revealed This facility shall establish and maintain safe resident smoking practices. The policy interpretation and implementation directed, 1. Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. 9. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. 13. Residents [sic] privileges are not permitted to keep cigarettes, e-cigarettes, pipes, tobacco, lighters, matches, and other smoking articles in their possession. Residents are not permitted to give smoking articles to other residents. 15. The facility maintains the right to confiscate smoking articles found in violation of our smoking policy. 1. An admission Record indicated the facility admitted Resident #6 on 10/17/2024. According to the admission Record, Resident #6 had diagnoses that included dementia, chronic obstructive pulmonary disease, tobacco use, bipolar disorder, and anxiety. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2025, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #6 had not exhibited any behaviors during the assessment period. A Smoking Safety Evaluation completed on 08/05/2025 indicated Resident #6 was able to smoke unsupervised, followed the smoking guidelines per policy, and returned smoking materials for storage. The smoking evaluation indicated that the facility stored Resident #6's smoking materials. Resident #6's care plan included a focus area initiated 11/06/2024 for smoking. The care plan indicated Resident #6 would not smoke without supervision. Interventions included educating the resident on the facility smoking policy and protocol, and to monitor/document/report any instances of noncompliance. An observation on 08/04/2025 at 1:34 PM revealed a pack of cigarettes on Resident #6's bed. In an interview at that time, Resident #6 stated staff kept their lighter and the resident was not supposed to keep the cigarettes. Resident #6 stated they were going to turn their cigarettes in to staff. In an interview on 08/06/2025 at 10:53 AM, Resident #6 stated they knew they were supposed to turn their cigarettes into staff, but the resident was not feeling well so had kept them and turned them in later. 2. An admission Record indicated the facility admitted Resident #9 on 05/16/2019. According to the admission Record, Resident #9 had diagnoses that included flaccid hemiplegia affecting nondominant side, psychotic disorder, nicotine dependence, and post-traumatic stress disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/18/2025, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #9 had not exhibited any behaviors during the assessment period. A Smoking Safety Evaluation completed on 08/05/2025 indicated Resident #9 required supervision while smoking, The resident followed the smoking guidelines per policy and returned smoking materials for storage. The smoking evaluation indicated that the facility stored Resident #9's smoking materials. Resident #9's care plan included a focus area initiated 05/16/2019 for smoking. The care plan indicated that Resident #9 would not smoke without supervision. Interventions included educating the resident on the facility smoking policy and protocol, and to monitor/document/report any instances of noncompliance. An observation on 08/06/2025 at 4:01 PM revealed Resident #9 asking a certified nurse aide (CNA) to get their cigarettes from their room. The CNA notified Resident #9 that she had to keep the cigarettes and take them downstairs for the resident. The CNA followed Resident #9 down in the elevator. The resident became irate, and once they were in the dining room, Resident #9 grabbed the cigarettes out of the CNA's hand. In an interview at that time, Resident #9 stated the cigarettes belonged to another resident. Resident #9 then went outside to the smoking area with the cigarettes. In an interview on 08/05/2025 at 9:00 AM, the Smoke Guard (SG) stated her responsibilities included cleaning up the smoking area and staying outside with the smokers. The SG stated she would light residents' cigarettes and supervise residents while they were outside smoking. The SG stated she had a daily smoking list of which residents smoked. The SG stated the Activities Director (AD) or Dietary Manager (DM) updated the smoking list. The SG stated that she used the smoking list to keep track of who she had given cigarettes to. The SG stated if residents took cigarettes outside of the smoking area she reported it to the DM or AD. In an interview on 08/06/2025 at 9:03 AM, Activity Assistant (AA) #14 stated she sometimes supervised the smokers. AA #14 stated none of the residents were supposed to keep their cigarettes. AA #14 stated if a resident did not want to give her their cigarettes, she would report it to the DM or Assistant DM. In an interview on 08/06/2025 at 9:10 AM, the DM stated she did the scheduling to ensure someone was supervising the smokers. The DM also stated her responsibilities included training the smoke guard. The DM stated if a resident did not want to turn in their cigarettes, she reported it to the Administrator (ADM) and Director of Nursing (DON). The DM stated she maintained the daily smoking list based on any new admissions who needed to be added or anyone who was discharged and needed to be removed. In an interview on 08/07/2025 at 4:40 PM, the Administrator (ADM) stated that no formal training was provided for other staff members who covered the smoking area when the full-time smoke guard was not there. In an interview on 08/08/2025 at 9:32 AM, CNA #12 stated that it was her second day working at the facility, but she knew that residents went out back to smoke and that residents were not allowed to keep their own cigarettes. In an interview on 08/08/2025 at 9:38 AM, Registered Nurse (RN) #10 stated residents smoked outside in the smoking area. RN #10 stated residents were not supposed to keep their cigarettes on them, but some would try to sneak them. RN #10 stated if she saw a resident with cigarettes, she would take them and return the cigarettes to the cart. In an interview on 08/08/2025 at 10:11 AM, the Assistant Director of Nursing (ADON) stated she completed the smoking assessments after interviewing the residents and watching them smoke. The ADON stated that sometimes she would watch the residents smoke or the SG would watch the residents smoke. The ADON stated the smoke guard could also report any concerns and make recommendations. The ADON stated the smoking assessments were completed upon admission and quarterly. The ADON stated that anyone in management could update the daily smoking list. The ADON stated the purpose of the list was so the smoke guard knew which residents smoked and which residents had cigarettes. The ADON stated that when completing the smoking assessment, she determined that the resident followed the policy based on if the resident had been caught buying their own cigarettes or keeping their cigarettes. The ADON stated if a resident was identified as being non-compliant, they would update the resident's care plan with their noncompliance. The ADON initially stated Resident #9 followed the smoking policy. The ADON then confirmed that she would not be surprised to hear that Resident #9 had cigarettes in their room and had become irate when the CNA would not give them the cigarettes and grabbed the cigarettes out of the CNA's hand. In an interview on 08/08/2025 at 11:33 AM, the Administrator (ADM) stated his expectation was that residents would turn in their cigarettes to the smoke guard to be locked in a cart. The ADM stated residents should not be sharing cigarettes with other residents. The ADM stated if staff observed a resident with smoking supplies, the staff should try to take the cigarettes and report it to management. The ADM stated all the current smokers should be on the daily smoking list. The ADM stated it was a challenge to manage the smoking program. The ADM stated residents frequently went out of the facility and bought cigarettes or tried to keep their own cigarettes. The ADM stated they had implemented the smoke guard position to help supervise the smoking. 3. An admission Record for Resident #24 revealed the resident was admitted on [DATE] with diagnoses that included local infection of the skin and subcutaneous tissue, methicillin susceptible staphylococcus aureus (MRSA) infection, morbid obesity due to excessive calories, and opioid use. An admission Minimum Data Set (MDS), with an Assessment Reference Date of 07/24/2025, revealed the resident had a Brief Interview for Mental Status score of 15, indicating no cognitive impairment. The resident had not exhibited any behaviors. The resident used a walker for ambulation with no impairments on the upper or lower extremities. The resident currently used tobacco. A Smoking Safety Evaluation, dated 07/20/2025, revealed the resident did smoke. The direct observation section indicated the resident returned smoking materials for storage. The summary of the evaluation indicated the resident required supervised smoking, did not require a smoking apron, the facility stored the smoking materials, and the resident was educated on the facility's smoking policies and procedures. The evaluation indicated the resident's plan of care remained appropriate. A Smoking Agreement, signed by Resident #24 on 07/24/2025, revealed To accommodate the needs of our residents, [the facility] allows residents to smoke while residing at [the facility]. Considering the dangers associated with smoking, it is imperative that [the facility's] smoking rules are adhered to at all times. The smoking rules included: 2. Cigarettes and lighting materials will be kept locked at the Nurses Station. 3. Cigarettes and lighting materials may not be kept in the resident's possession at any time. 7. Cigarettes may be ignited only by a staff member or designee. 11. Failure to adhere to safe smoking practices may result in a denial of smoking privileges at [the facility]. Family and residents will be kept informed of issues that arises. Further, I have read and understand the smoking rules of [the facility]. I agree to adhere to [these] rules at all times. I understand that these rules were implemented for my safety as well as the safety of the residents and staff at [the facility]. Smoking is allowed as a privilege. Failure to keep these rules may result in a denial [of] the privilege to smoke. In addition, if at any time my physician and/or Director of Nursing (DON) determine that smoking may cause significant harm to myself or other residents (examples of this are: smoking while receiving oxygen, inability to hold a cigarette in a stable manner, etc.) I will discontinue smoking activity at [the facility].A Smoker List 08/01/2025, provided by the facility as their list of known smokers, revealed that Resident #24 was on the list. A Daily Smoking List used by the Smoke Guard to know which residents had been assessed for safe smoking for 08/05/2025 through 08/08/2025 revealed that Resident #24 was not on the list. The top of the page read, Under the 'start' column, enter the 'Ending' number of cigarettes from the previous day. At each break, record the number of cigarettes smoked. If any cigarettes were added to the resident's box, enter that number and the 'Added' column. At the end of the day subtract from the 'start' number, the number of cigarettes smoked, and add the number of cigarettes added, and put the new under the 'Ending' column. You must ensure that residents turn in any extra cigarettes and/or lighters before entering the building! During an observation and interview on 08/04/2025 at 2:12 PM, Resident #24 was in their room walking to the bathroom. The resident had a cigarette lighter hanging off the front of their shirt with a nametag clip. Resident #24 stated that the resident kept the lighter, but the resident's spouse kept their cigarettes, and they were not there at that time. The staff kept everyone else's smoking materials. Resident #24 then asked if they were not supposed to have it, and if it should be hanging out of their shirt. Then the resident fumbled with it to put it back inside the shirt. An observation on 08/07/2025 at 1:15 PM revealed that Resident #24 was outside smoking. 4. An admission Record revealed Resident #4 was admitted on [DATE] with diagnoses that included acute kidney failure, type 2 diabetes mellitus, vascular dementia, mood disorder, and insomnia. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/05/2025, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had no cognitive impairment. The resident had no impairments of either the upper or lower extremities and used a walker and a wheelchair for ambulation. The resident was a current tobacco user. Resident #4's Care Plan Report revealed the resident was a smoker, with interventions that included to educate the resident on the facility's smoking policies and protocol, and to monitor/document/report any instances of noncompliance. A Smoking Safety Evaluation, dated 08/01/2025, revealed Resident #4 was a current smoker. The resident did not have any limitations of the upper and lower extremities. A direct observation indicated the resident returned smoking materials for storage. The evaluation indicated the resident required supervised smoking, did not require a smoking apron, and the facility stored the resident's smoking materials. A Smoking Agreement, signed by Resident #4 on 05/06/2023, revealed To accommodate the needs of our residents, [the facility] allows residents to smoke while residing at [the facility]. Considering the dangers associated with smoking, it is imperative that [the facility's] smoking rules are adhered to at all times. The smoking rules included: 2. Cigarettes and lighting materials will be kept locked at the Nurses Station. 3. Cigarettes and lighting materials may not be kept in the resident's possession at any time. 7. Cigarettes may be ignited only by a staff member or designee. 11. Failure to adhere to safe smoking practices may result in a denial of smoking privileges at [the facility]. Family and residents will be kept informed of issues that arises. Further, I have read and understand the smoking rules of [the facility]. I agree to adhere to [these] rules at all times. I understand that these rules were implemented for my safety as well as the safety of the residents and staff at [the facility]. Smoking is allowed as a privilege. Failure to keep these rules may result in a denial [of] the privilege to smoke. In addition, if at any time my physician and/or Director of Nursing (DON) determine that smoking may cause significant harm to myself or other residents (examples of this are: smoking while receiving oxygen, inability to hold a cigarette in a stable manner, etc.) I will discontinue smoking activity at [the facility]. 5. An admission Record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, schizophrenia, bipolar disorder, major depressive disorder, post-traumatic disorder, and disease of the spinal cord. A Smoking Safety Evaluation, dated 03/08/2025, revealed Resident #49 was a current smoker. The resident did not have any limitations. The resident required supervision while smoking, did not require a smoking apron, and the facility stored the smoking materials. A quarterly MDS, with an ARD of 05/13/2025, revealed Resident #49 had a BIMS of 15, which indicated no cognitive impairment and no behaviors. The resident used a wheelchair for mobility. A Smoking Agreement, signed by Resident #49 on 02/13/2025, revealed that To accommodate the needs of our residents, [the facility] allows residents to smoke while residing at [the facility]. Considering the dangers associated with smoking, it is imperative that [the facility's] smoking rules are adhered to at all times. The smoking rules included: 2. Cigarettes and lighting materials will be kept locked at the Nurses Station. 3. Cigarettes and lighting materials may not be kept in the resident's possession at any time. 7. Cigarettes may be ignited only by a staff member or designee. 11. Failure to adhere to safe smoking practices may result in a denial of smoking privileges at [the facility]. Family and residents will be kept informed of issues that arises. Further, I have read and understand the smoking rules of [the facility]. I agree to adhere to [these] rules at all times. I understand that these rules were implemented for my safety as well as the safety of the residents and staff at [the facility]. Smoking is allowed as a privilege. Failure to keep these rules may result in a denial [of] the privilege to smoke. In addition, if at any time my physician and/or Director of Nursing (DON) determine that smoking may cause significant harm to myself or other residents (examples of this are: smoking while receiving oxygen, inability to hold a cigarette in a stable manner, etc.) I will discontinue smoking activity at [the facility]. An observation on 08/05/2025 at 9:22 AM revealed Resident #4 walking with a walker through the dining room towards the elevator. As Resident #4 passed by Resident #49 in the hallway by the elevator, Resident #4 had two cigarettes that the resident passed to Resident #49 in a secretive manner. No staff were around or witnessed the exchange. 6. An admission Record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses that included unspecified injury of the cervical spinal cord, quadriplegia, chronic pain syndrome, major depressive disorder, generalized anxiety, and muscle wasting and atrophy. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/07/2025, revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Resident #31's Care Plan Report revealed a focus area, initiated on 06/07/2023, that indicated the resident was a smoker. The interventions included to educate the resident on the facility smoking policies and protocols and that the resident required a smoking apron when smoking and was non-compliant with using the apron. The care plan also included a focus area, initiated on 07/10/2023, that indicated the resident was at risk for developing complications secondary to being non-compliant with care, medications, and treatments as ordered or recommended. On 02/27/2025, the plan was revised to add that the resident was non-compliant with using a smoking apron. A Smoking Safety Evaluation, dated 07/16/2025, revealed Resident #31 did smoke. The resident had limitations of the upper and lower body with a weak grasp and dropped items. The resident returned smoking materials for storage, required supervision with smoking and a smoking apron, and the facility stored the resident's smoking materials. A Smoking Agreement, signed by Resident #31 on 05/26/2023, revealed that To accommodate the needs of our residents, [the facility] allows residents to smoke while residing at [the facility]. Considering the dangers associated with smoking, it is imperative that [the facility's] smoking rules are adhered to at all times. The smoking rules included: 2. Cigarettes and lighting materials will be kept locked at the Nurses Station. 3. Cigarettes and lighting materials may not be kept in the resident's possession at any time. 7. Cigarettes may be ignited only by a staff member or designee. 11. Failure to adhere to safe smoking practices may result in a denial of smoking privileges at [the facility]. Family and residents will be kept informed of issues that arises. Further, I have read and understand the smoking rules of [the facility]. I agree to adhere to [these] rules at all times. I understand that these rules were implemented for my safety as well as the safety of the residents and staff at [the facility]. Smoking is allowed as a privilege. Failure to keep these rules may result in a denial [of] the privilege to smoke. In addition, if at any time my physician and/or Director of Nursing (DON) determine that smoking may cause significant harm to myself or other residents (examples of this are: smoking while receiving oxygen, inability to hold a cigarette in a stable manner, etc.) I will discontinue smoking activity at [the facility]. An observation on 08/07/2025 at 2:01 PM revealed Resident #31 was in the hallway by the receptionist desk with two cigarettes in their lap. Observation and interview on 08/05/2025 at 9:00 AM revealed the Smoke Guard (SG) came in to work at 7:00 AM and stayed outside with the smokers. She indicated she lit the residents' cigarettes. The SG stated some could light their own, but they were not supposed to keep their lighters on them. The SG stated the residents were not supposed to keep cigarettes either, but some were sneaky. She stated she walked around and kept an eye on the residents to ensure they were not keeping their cigarettes. If the residents did keep them, she reported them to the Activity Director (AD) or the Dietary Manager (DM). She stated she had a daily smoking list and marked it down when she gave the residents cigarettes. She stated activities and dietary staff updated the list. During an interview on 08/07/2025 at 3:38 PM, Laundry Aide (LA) #27 stated she covered the evenings for the SG and would be there until 8:00 PM. LA #27 indicated she had received training on giving the residents their cigarettes. She stated they were supposed to keep the residents' cigarettes locked in the cart, but some would not give them up. If they did not give them up, she would report them to nursing. She stated she would not fight with the residents over their cigarettes. During an interview on 08/08/2025 at 9:14 AM, the SG stated she came in at 6:30 AM. An observation of the smoking cart at the time of the interview revealed there were five packs of cigarettes in the top drawer. She stated that residents were not supposed to take cigarettes out of the smoking area, but every once in a while they would get past her. She stated she tried to stop them, but was not going to fight them. She stated she would give the residents two free cigarettes and if they did not smoke the free cigarettes she provided, she took them back and put them back in the pack for someone else to smoke. During an interview on 08/08/2025 at 10:11 AM, the Assistant Director of Nursing (ADON) stated the facility policy was that the facility kept the residents' cigarettes. If they found out residents were buying their own cigarettes or keeping their cigarettes, they completed room sweeps and updated the care plan with their noncompliance. During an interview on 08/08/2025 at 11:39 AM, the Director of Nursing (DON) stated that on admission they completed smoking assessments, went over the smoking policy with the residents to make sure they understood, and had them sign the consent form. They kept the residents' cigarettes to keep them on the cart. At smoke time, residents were given their materials to smoke then the residents were to turn them back in once the smoke break was over. She stated residents should not have smoking materials on their person. The DON stated residents should not be sharing their cigarettes. During an interview on 08/08/2025 at 11:33 AM and a follow up at 12:35 PM, the Administrator stated his expectation for smoking was that residents would turn in their cigarettes at the end of the smoke break and that staff should keep them locked in the cart. Residents' cigarettes should not be shared with anyone else. If staff saw a resident with smoking paraphernalia, staff should attempt to take it and report to management. The Administrator stated it was a challenge to manage smoking. The Administrator stated residents would come and go and sometimes bring smoking materials in or try to keep them. The Administrator indicated it was hard to search them all the time, that residents were really good at hiding stuff, and that was why they put the smoke guard in place.

Based on observation, interview, and facility policy review, the facility failed to ensure 1 (300 hall) of 2 shower rooms were maintained in a clean condition. Findings included:An undated facility policy titled, Bathrooms revealed 1. Bathrooms, including showers, whirlpools, century baths, commodes, etc., will be cleaned daily in accordance with our established procedures.An observation on 08/04/2025 at 1:54 PM revealed the 300 hall shower room had pieces of cotton from a wound dressing on the shower floor in stall #1, the floor throughout the entire shower room appeared with a thick brown grime substance on the tiles, a large shower chair with a broken seat which exposed a jagged and sharp appearance along the inner ring, a shower bench/riser with dirty areas and white substance in spots on the seat and rusty metal legs, and multiple open and unlabeled bottles of body wash, peri-wash, and deodorant. The shower nozzle from the shower head was hanging in the downward position to the floor and thick black hair covering all the drains in the three shower stalls. A toilet located in the common area with no curtain for privacy contained feces and thick brownish rings in the inside of the toilet bowl and a hand washing sink that contained a rust color rings in the basin of the sink with a large puddle of water in the floor between the toilet and the sink. An observation and interview with the Administrator present on 08/05/2025 at 4:13 AM revealed the 300 hall shower room remained in the same appearance as the above observation from the day prior. The Administrator acknowledged there should not have been a cotton dressing on the floor in the stalls, he stated the toilet should have been cleaned and feces should not remain in the toilet. He stated the broken chair should be taken out of use and not remain in the shower room. He also verified there should not be water standing in the floor and the sink should have been cleaned from the brown substance in the sink basin. He stated he would expect the shower room to be cleaned by the nursing department and sanitized at all times for bathing to be a good experience for each resident during their use. An observation and interview were conducted with the Housekeeping Director (HD) on 08/08/2025 at 10:56 AM. The HD observed and revealed the 300 hall shower room was to be cleaned by the housekeeper assigned to the 300 hall odd numbered rooms. She stated the shower room was to be cleaned daily by the assigned housekeeper. The HD acknowledged the floor was dirty and stated the floors should be mopped and the drains checked daily, although she stated housekeeping was not responsible for removing hair from the clogged drain and she was unsure who was responsible for that portion of drain checks. She stated the water standing in the floor was from the sink or toilet leaking which caused the puddle to reform each time it was mopped. During an interview on 08/08/2025 at 10:56 AM, the Director of Nursing (DON) indicated she would expect the shower rooms to be cleaned by the aides after each resident use by picking up the personal items used and tidying up the area, then housekeeping was to mop and sanitize the rest of the shower room at least one to two times per day. This deficiency represents non-compliance investigated under Complaint Number 1348402 (OH00167337) and 1348400 (OH00166666).

Based on interview, record review, document review, and facility policy review, the facility failed to have evidence that an allegation of abuse was thoroughly investigated for 1 (Resident #55) of 3 sampled residents reviewed for abuse. Specifically, on 05/26/2025, Resident #55 was transferred to the emergency department (ED) due to bleeding from their head. Prior to leaving the facility, Resident #55 did not report how the injury occurred; however, the resident's roommate, Resident #95 reported that the resident sustained the injuries from a fall. After arrival at the ED, where Resident #55 was diagnosed with a fractured right arm, a laceration to the head with an arterial bleed, and acute blood loss anemia, the resident told hospital staff that the injuries were a result of Resident #95 hitting them multiple times with a cane. The facility investigation revealed no documented evidence that the facility interviewed all staff who had knowledge of the incident and no documented evidence that they interviewed a resident who witnessed an altercation between the residents. The facility investigation also revealed that even though Resident #55 consistently reported that their injuries resulted from Resident #95 hitting them with a cane and there was no evidence that Resident #55 fell, the facility determined that Resident #55's story was inconsistent, and abuse was not suspected and unsubstantiated. The facility also failed to thoroughly investigate an incident of resident-to-resident abuse for 2 residents (Resident #53 and Resident #58) of 3 sampled residents reviewed for abuse. The facility further failed to provide protection to other residents in the facility. Specifically, Resident #31, a witness to the incident, was not interviewed during the investigation, and the facility provided one-to-one observation for the victim but not the alleged perpetrator.Findings included: A facility document titled, Abuse and Neglect Protocol, revised 06/13/2021, revealed, All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. The policy revealed, 13. The individual conducting the investigation will, as [sic] a minimum: e. Review the completed documentation forms; f. Review the resident's medical record to determine events leading up to the incident; g. Interview the person(s) reporting the incident; h. Interview any witnesses to the incident; i. Interview the resident (as medically appropriate); j. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; k. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; l. Interview the resident's roommate, family members, and visitors; m. Interview other residents to whom the accused employee provides care or services; and n. Review all events leading up to the alleged incident. o. Preserve all audio and video recordings of incident, if available/applicable. The policy also revealed, 15. Witness reports will be obtained in writing. Witnesses will be required to sign and date such reports. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. 1. An admission Record indicated the facility originally admitted Resident #55 on 02/18/2014. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia (paralysis) and hemiparesis following a cerebral infarction affecting the nondominant left side and cerebrovascular disease. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/09/2025, revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed Resident #55 had limitations in range of motion of the upper extremity on one side of the body. Resident #55's Care Plan Report included a focus area initiated 05/21/2020, that indicated the resident was at risk for developing complications secondary to an ADL self-care performance deficit. Interventions directed one staff member to provide setup/clean-up assistance with eating, personal hygiene and oral care (initiated 05/21/2020); supervision/touching assistance with toileting and transfers from sitting to standing positions, chair/bed-to-chair transfers, and toilet transfers (initiated 08/16/2020); and partial/moderate assistance for showers/bathing (initiated 05/21/2020). The Care Plan Report also included a focus area initiated 05/21/2020, that indicated Resident #55 was at risk for complications secondary to limited physical mobility related to a stroke and weakness. Interventions directed staff to have the resident use a wheelchair for locomotion (initiated 05/21/2020) and provide supervision and staff set up for mobility (initiated 10/14/2020). An admission Record indicated the facility admitted Resident #95 on 06/29/2023. According to the admission Record, the resident had a medical history that included diagnoses of peripheral vascular disease, depressive disorder, and mild cognitive impairment. A quarterly MDS, with an ARD of 03/04/2025, revealed Resident #95 had a BIMS score of 15, which indicated the resident had intact cognition. The Self-Reported Incident Form dated 05/27/2025, revealed on 05/26/2025 at 7:30 PM, Resident #55 was found bleeding. At the time of the incident, Resident #55, who was generally verbally expressive, declined to offer an explanation to the staff related to the incident. The report revealed the facility sent Resident #55 to the hospital and at that time, the resident reported their roommate (Resident #95) assaulted them. According to the report, Resident #95, the roommate, reported that Resident #55 fell from their wheelchair and they helped Resident #55 back into their chair. Resident #55's Trauma Surgery H&P [History and Physical] dated 05/26/2025 at 10:45 PM, revealed Resident #55 sustained a fall from standing height, and a trauma alert was received because the resident took anticoagulant medication. Per the H&P, the resident had a three-centimeter (cm) laceration to the forehead with a hematoma (a localized collection of blood) and an arterial bleed, and the resident had a right ulna fracture (the bone from the elbow to the little finger side of the wrist). Per the H&P, the ulna bone was minimally displaced, mildly angulated, and mildly comminuted (the bone was broken in two or more places and usually resulted from trauma). Per the H&P, Resident #55 admitted to the hospital to trauma services. The hospital ED Notes Addendum dated 05/27/2025 at 1:15 AM, revealed Resident #55 informed an RN that they did not fall but was actually assaulted by their roommate. Per the note, Resident #55 stated their roommate went to hit them with a metal walker, and they attempted to block, which caused the radial fracture and head laceration. Resident #55's hospital nursing note dated 05/27/2025 at 4:43 AM, revealed when staff asked Resident #55 what happened, the resident stated their roommate hit [them] with a cane. Resident #55's Inpatient Surgery Discharge Summary dated 05/28/2025 at 11:52 AM, revealed Resident #55 presented after a reported fall from standing height at the facility. Resident #55 then told team members that they was assaulted by their roommate and did not fall. According to the discharge summary, trauma staff repaired the resident's head laceration with six sutures/stiches, and the resident had a follow up appointment at the trauma clinic to remove the sutures. Per the discharge summary, the resident had acute blood loss anemia and education was provided for post-traumatic stress disorder. The discharge summary also revealed that plastic surgery placed a splint on the resident's right arm, and the resident should not bear weight, avoid heavy lifting in the right extremity, and attend a follow up appointment. The discharge summary indicated the resident should take acetaminophen and Robaxin (a muscle relaxant) for pain control. Resident #95's One on one document revealed the facility began supervising the resident on 05/27/2025 at 10:00 AM and documented that staff observed the resident every fifteen minutes for 45 hours. During an interview on 08/05/2025 at 1:34 PM, Resident #55 stated that a couple months prior, while downstairs in the cafeteria area speaking with Resident #62, and waiting for their meal to be delivered, Resident #95 approached them and bumped their wheelchair several times, despite having ample room to get around. Resident #55 stated they initially attempted to move closer toward the table to give Resident #95 room to get around the wheelchair, but Resident #95 continued to bump their wheelchair and attempted to hit them. Resident #55 stated that at that time, they began to roll their wheelchair backward and tried to use their foot to tap Resident #95's knee in an attempt to get the resident to stop, back off, and go around. Per Resident #55, a female staff member came from the kitchen when Resident #62 yelled for help. Resident #55 stated the staff member told them they had to move and go upstairs. Resident #55 stated Resident #95 left the dining area first and they returned to the unit later. Resident #55 stated they recalled getting off the elevator on the 300 Hall unit where they resided and started down the hallway towards their room. Resident #55 stated they passed Resident #95, who was seated in their wheelchair in the hallway outside their room. Resident #55 stated they cautiously passed Resident #95 but did not speak and went into their room. Resident #55 stated that once in the room they turned around, and Resident #95 was coming toward them with a metal cane and struck them a couple of times to the right side of their head. Per Resident #55, they tried to keep Resident #95 from hitting them with the cane again. Resident #55 stated their head was bleeding. Per Resident #55, Resident #95 told them that they had better tell the nurse that they fell or things would be worse. Resident #55 stated they became very apprehensive and more guarded and went to the nurse's station and told staff that they needed help. Resident #55 stated they had not been out of their wheelchair and did not fall. Resident #55 stated that a nurse placed towels on their head, but the bleeding did not stop before going to the hospital. Resident #55 stated they were too afraid to say anything before they left the facility because they was afraid the situation might get worse. Resident #55 stated at the hospital, they had to get staples in their head and they learned that their right arm/wrist was broken and had to get a cast. Resident #55 stated that upon return to the facility, they asked for a different room, away from Resident #95. During an interview on 08/06/2025 at 8:47 AM, Resident #62 stated they were at a table in the dining room speaking with Resident #55 when Resident #95 approached them and hit Resident #55. Resident #62 stated they screamed for help because they were concerned that Resident #95 would harm Resident #55. During an interview on 08/06/2025 at 11:35 AM, Dietary Aide (DA) #21 stated she was working in the dietary department on the meal service tray line on 05/26/2025 when she heard a scream from Resident #62. Per DA #21, Resident #62 yelled for Resident #95 to stop. DA #21 stated that as she proceeded out of the swinging doors of the dietary department, she saw Resident #55 seated in their wheelchair and Resident #95 was in front of Resident #55, swinging at the resident. DA #21 stated she pulled Resident #55 backward and told the residents to go upstairs. She stated she then returned to the kitchen and began her cleaning duties. DA #21 stated that later that evening at approximately 8:00 PM, she was getting ready to leave the facility when she saw Resident #55 on a stretcher with a bloody head. During an interview on 08/06/2025 at 8:36 AM, DA #22 stated she recalled Resident #55 and Resident #95 were in the dining room and there was a lot of noise. She stated that she was working on the tray line with DA #21 and they heard a resident yelling for help. DA #22 stated she heard DA #21 leave the tray line and then heard DA #21 yell for the residents to stop. DA #22 stated that when she approached the door, she could hear Resident #95 cursing at DA #21 and heard DA #21 tell Resident #55 to move backwards, and Resident #55 immediately moved out of the way. Per DA #22, DA #21 stated that Resident #95 was getting ready to go after Resident #55 when she yelled. DA #22 stated that Resident #55 seemed to be glad that someone came so they could get away. DA #21 stated that it was the first time she had seen the residents escalate to that degree and it scared her. She stated that following the interaction, both she and DA #21 returned to the kitchen and began breaking down the tray line and cleaning the kitchen for the night and stated neither of them reported the incident. During an interview on 08/06/2025 at 7:53 PM, CNA #28 stated she was on duty on the night shift on 05/26/2025, and shortly after arriving on duty at 7:00 PM, Resident #55 was in a wheelchair, and their head was bleeding. She stated she notified an unidentified nurse, retrieved towels, and applied them to the resident's head to attempt to clean blood from the resident's face. She stated she recalled quite a bit of blood being on the resident's head and clothing, and on the floor. CNA #28 stated she also recalled Resident #95 sitting outside their door, saying something inappropriate, but could not remember what the resident said. CNA #28 stated that when she asked Resident #95 what happened, the resident stated that Resident #55 fell; however, she did not believe that Resident #55 would have been able to independently get up if they fell. During an interview on 08/06/2025 at 7:17 PM, Licensed Practical Nurse (LPN) #16 stated she was on duty covering a shift on the night of 05/26/2025 beginning at 7:00 PM. LPN #16 indicated that shortly after shift change, she was at the nurses' station when an unidentified nurse aide notified her that Resident #55 was in the hallway bleeding from their head. She stated she was not the assigned nurse to either Resident #55 or Resident #95; however, she was assigned to the 300 unit that night. LPN #16 stated that with her knowledge that Resident #55 was on a blood thinner and she and LPN #15 gathered dressing supplies and headed towards Resident #55. Per LPN #16, Resident #55 was bleeding pretty significantly when she arrived to assess the resident. LPN #16 stated Resident #55 was unable to describe what occurred. LPN #16 stated they applied pressure to the resident's head and contacted emergency medical services (EMS) to transport as quickly as possible. LPN #16 stated that following Resident #55's departure to the hospital, both she and LPN #15 asked Resident #95 what occurred, and the resident stated that Resident #55 fell and hit their head on the footboard of the bed. LPN #16 stated she recalled seeing blood stains on the floor in the room far enough away from the resident's bed that it did not appear the resident hit the end of the bed. LPN #16 stated that both she and LPN #15 looked at the footboard and all over the bed but did not see any blood on the bed. LPN #16 stated she found it hard to believe and did not think Resident #55 would be able to get up from the floor and back to their wheelchair independently after a fall or with the injuries the resident sustained. According to LPN #16, no one reported an altercation occurred prior to the incident. Per LPN #16 she did not learn of the allegation of assault until LPN #15 called the hospital to obtain a report on Resident #55. During an interview on 08/08/2025 at 3:13 PM, CNA #19 stated Resident #95 told her that Resident #55 fell. CNA #19 stated she remembered seeing Resident #55 on 05/26/2025 in the hallway with their head bleeding and the resident would not say what happened. She stated Resident #95 kept saying Resident fell and hit their head on the footboard of the bed; however, per CNA #19, there was no blood in the area. During an interview on 08/08/2025 at 8:12 AM, the Director of Rehabilitation (DOR) stated that prior to hospitalization, Resident #55 was able to walk with a hemi-cane (a type of walker designed for use for individuals with one-sided weakness) during therapy. The DOR stated therapy evaluated Resident #55 the day they returned from the hospital and because the resident could not bear weight to their right arm and had residual effects in their left arm from a prior stroke, Resident #55 was left dependent on staff for all activities of daily living. The DOR stated Resident #55 could also no longer use their hemi-walker, which left Resident #55 completely dependent for all care. The facility investigation revealed no documented evidence that the facility interviewed Resident #62, DA #21, DA #22, CNA #19, or LPN #16 as part of their investigation. According to the report, the facility unsubstantiated abuse, and indicated Evidence is inconclusive and Abuse, neglect or misappropriation is not suspected. During an interview on 08/08/2025 at 11:07 AM, the DON stated if Resident #55 fell on the floor, she did not think the resident would have been able to get off the floor without staff assistance. The DON stated that when they interviewed Resident #95 on 05/26/2025, the resident stated that Resident #55 hit their head on the footboard when they fell. The DON stated that Resident #55 did not tell them what happened when the incident occurred but reported to the hospital that their roommate assaulted them. Per the DON, the facility investigated, and looked at the cane, walker, and bed frame and they did not find any blood. She stated that because Resident #55 had some dementia, they did not credit the resident as having accountability. During an interview on 08/08/2025 at 12:04 PM, the Administrator stated abuse was anything verbal, physical, emotional, or mental that caused intentional harm to another resident. The Administrator indicated he was aware there had been some interactions that occurred in the dining room, but he was not aware Resident #95 attempted to hit Resident #55 while in the dining room. He stated the example of Resident #95 attempting to hit Resident #55 would be considered an example of potential abuse, and if the episode was witnessed, the residents should be separated to ensure safety, then the staff member should notify the DON or the Administrator. According to the Administrator, he visited Resident #55 in the hospital, and the resident told him about being attacked by their roommate. The Administrator stated he placed Resident #95 on one-to-one supervisor the morning of 05/27/2025, when he was notified of the incident, and the resident remained on one-to-one supervision for caution until the danger passed. The Administrator indicated he did not think Resident #95 needed to remain on one-to-one supervision after Resident #55 returned to the facility on the following day, 05/28/2025, because he thought the events that occurred were more behavioral. Per the Administrator, the facility did not substantiate abuse. He stated he was unable to determine whether the case was behavioral, or abuse and he felt that the situation was reactive as opposed to abusive based on his investigation. 2. An undated facility document titled Resident to Resident Altercation Checklist revealed that: all residents involved should be interviewed; interviews and written statements should be obtained from all staff members present in the facility; and appropriate interventions should be put into place to prevent future incidents. The Resident to Resident Altercation Checklist did not indicate how they would ensure the safety of any other residents in the facility. An admission Record revealed the facility admitted Resident #53 on 01/04/2023. According to the admission Record, the resident had a medical history that included a diagnosis of tobacco use. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/25/2025, revealed Resident #53 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #53's Care Plan Report revealed a focus area initiated 01/04/2023, that indicated the resident was a smoker. An admission Record revealed the facility admitted Resident #58 on 05/03/2025. According to the admission Record, the resident had a medical history that included diagnoses of depression, anxiety disorder, and post-traumatic stress disorder. An admission MDS, with an ARD of 05/09/2025, revealed Resident #58 had a BIMS score of 15, which indicated the resident had intact cognition. Resident #58's Care Plan Report included a focus area initiated 05/23/2025, that indicated the resident was a smoker The facility Self-Reported Incident Form, dated 06/18/2025, indicated an incident of physical abuse, a resident as a victim, and another resident as the alleged perpetrator. The facility Narrative Summary of Incident revealed on 06/18/2025 at 7:30 PM, Resident #53 came to a nurse and reported an altercation with Resident #58 in the courtyard, and the nurse confirmed that both residents were safe and separated. The summary indicated Resident #58 reported Resident #53 approached them unprovoked, hit them #58 in the face, and placed their hands around their neck. The summary indicated Resident #53 reported hearing Resident #58 talking about Resident #53, and when Resident #53 approached, Resident #58 called Resident #53's family member an expletive and pushed Resident #53 away. The summary indicated Resident #53 directed physical force at Resident #58, and another resident separated the two residents in the courtyard. The summary indicated there were no other witnesses to the alleged event. The summary indicated the Director of Nursing (DON) and Administrator were notified of the incident. The summary indicated the police were called per both residents' requests. The summary indicated Resident #58 declined to go to the emergency room. The Conclusion indicated the facility unsubstantiated the allegation, the evidence was inclusive, and abuse, neglect, and misappropriation were not suspected. An untitled, facility document, dated beginning 06/19/2025 at 7:00 AM, with Resident #58's name handwritten across the top indicated 15 minute intervals checks for the resident's activity for 24 hours. The facility did not provide a log of resident activity checks for Resident #53. During an interview on 08/07/2025 at 1:20 PM, Resident #31 stated there had been some altercations during the smoke breaks, and they would get in between the residents involved because they did not like violence. Resident #31 stated the day Resident #53 and Resident #58 got into it, they had been out smoking, and they were arguing back and forth, Resident #58 called Resident #53's family member an expletive, and Resident #53 punched Resident #58, then Resident #58 punched Resident #53, and Resident #53 tried to choke Resident #58. Resident #31 stated they got in between the two residents to break it up. A quarterly MDS, with an ARD of 07/07/2025, revealed Resident #31 had a BIMS score of 15, which indicated the resident had intact cognition. During an interview on 08/07/2025 at 10:55 PM, Registered Nurse (RN) #12 stated in June 20205 or July 2025 an incident happened at shift change in the courtyard when Resident #53 and Resident #58 were arguing. RN #12 stated she did not witness any hands-on interaction between the two residents. RN #12 stated each resident claimed they were the victim and the other was the aggressor. RN #12 stated she separated the residents, interviewed each of the residents, and called the DON. RN #12 stated Resident #58 stated Resident #53 started it. RN #12 stated both residents were offered to change rooms, but they refused, and 1:1 observation was provided for Resident #58. The facility investigation documents included interviews with Resident #53 and Resident #58 but did not include an interview with Resident #31. During an interview on 08/08/2025 at 11:39 AM, the DON stated she knew there had been a verbal altercation, could not remember exactly how it started, but knew Resident #58 said something about Resident #53's family member and then the residents started arguing and it escalated. The DON stated it happened in the courtyard, she did not remember if any staff were present, and there were other residents outside to include Resident #31. The DON stated Resident #31 tried to break it up. The DON stated her expectation was to make sure the residents felt safe. During an interview on 08/07/2025 at 11:40, the Administrator stated their policy directed them to provide 1:1 observation for the aggressor after a resident to resident altercation, but this was a special case and Resident #58 could be aggressive toward other residents. The Administrator stated they should have provided 1:1 observation for the aggressor. The Administrator stated the facility did not provide 1:1 observation for both residents as he directed. During an interview on 08/08/2025 at 12:35 PM, the Administrator stated they should include interviews with all the witnesses. During an interview on 08/08/2025 at 3:08 PM, the Administrator stated he expected staff to interview anyone who was at the facility at that time and he did not realize they had not interviewed everyone in the facility.

Based on interview, record review, and facility document and policy review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, Form CMS [Centers for Medicare & Medicaid Services] - 10055) for 1 (Resident #14) of 3 residents reviewed for Medicare Beneficiary Protection Notification when discharged from Medicare Part A Services with benefit days remaining.Findings included:A facility policy titled, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, dated 03/28/2023, indicated, 2. The facility issues the Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) for the following triggering events, and the policy continued, 3. Termination - In the situation in which the facility proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF ABN is issued to the beneficiary before such extended care items or services are terminated.An admission Record revealed the facility admitted Resident #14 on 08/12/2024. According to the admission Record, the resident had a medical history that included diagnoses of seizures, congestive heart failure, and chronic respiratory failure with hypoxia.An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/04/2025, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident was independent with eating, required supervision or touching-assistance with toileting, and required partial/moderate assistance with showers.Resident #14's Care Plan Report included a focus area, revised 02/14/2025, that indicated the resident was at the facility for short term rehabilitation and would have a safe discharge to the community after completing rehabilitation with skilled nursing care and therapy. Interventions directed staff: to set up home health for the resident to continue services upon discharge; for social services to coordinate with therapy to ensure all required durable medical equipment (DME) was ordered; to provide education regarding diagnosis and medications so the resident could verbalize understanding; and to ensure the resident would follow up with a primary care physician (PCP) after discharge in a timely manner.A Beneficiary Notice Scenarios for Surveyors form completed by the facility revealed Resident #14 had a Medicare Part A Skilled Services Episode start date of 02/01/2025, and the last covered day of Part A Service was 03/14/2025. The Beneficiary Notice Scenarios for Surveyors revealed the SNF ABN form was not provided to Resident #14, and an unsigned, handwritten explanation revealed, unable to find an ABN and would have to think it may not have been done. During an interview on 08/06/2025 at 10:51 AM, the former Social Service Director (SSD) stated she was responsible for providing beneficiary notices to residents when she worked at the facility from Labor Day in 2024 until she left in June 2025. The former SSD stated a resident should be provided and sign a SNF ABN and a Notice of Medicare Non-Coverage (NOMNC) when discharged from Medicare Part A services and when the resident continued to remain in the facility. The former SSD stated she was not sure why the ABN was not provided to Resident #14 and was not sure where it was. The former SSD stated Resident #14 should have signed both the SNF ABN and NOMNC forms. During an interview on 08/06/2025 at 11:08 AM, the Business Office Manager (BOM) stated she did not normally complete the beneficiary protection notices but had helped complete the notices. The BOM stated the Administrator and Administrator in Training (AIT) were currently completing the beneficiary protection notices, and the former SSD was responsible for ensuring Resident #14 received and signed the beneficiary notices. The BOM stated SNF ABN and NOMNC forms should be provided to residents who were discharged from Medicare Part A and remained in the facility. The BOM stated Resident #14 should have signed a NOMNC and an ABN when their coverage was ending and they remained at the facility. The BOM stated that in February 2025 and March 2025, the former SSD was responsible for completing both the NOMNC and ABN for Resident #14.During an interview on 08/06/2025 at 11:16 AM, the Director of Nursing (DON) stated the Administrator and BOM were currently responsible for completing and providing residents with the NOMNC and ABN. The DON stated both the NOMNC and SNF ABN should be provided to a resident prior to discharge from Medicare Part A services and who remained in the facility. The DON stated she was not sure why Resident #14 did not receive an SNF ABN. The DON stated she expected safe resident discharges.During an interview on 08/06/2025 at 1:52 PM, the Administrator stated the interdisciplinary team (IDT), composed of the Administrator DON, Assistant DON, SSD, MDS nurse, therapy department, and the dietary department, met every week and discussed the residents who were in therapy and when they were close to their skilled services ending. The Administrator stated the IDT decided when it was time to issue an ABN and NOMNC. The Administrator stated the SSD was responsible for ensuring beneficiary protection notices were provided to residents, but they had not had an SSD since June 2025. The Administrator stated he provided the beneficiary notices to residents. The Administrator stated the former SSD was responsible for providing Resident #14 with the NOMNC and SNF ABN. The Administrator stated Resident #14 did not receive the SNF ABN form probably because the former SSD did not provide the ABN to the resident. The Administrator stated he expected Resident #14 to receive a NOMNC and SNF ABN prior to discharge from their skilled services while remaining in the facility.

Based on interview, record review, facility document review, and facility policy review, the facility failed to report an incident of abuse to the Administrator and to the state survey agency within two hours for 1 (Resident #55) of 2 residents reviewed for abuse. Resident #55 was struck on the head with a metal cane by Resident #95, which resulted in bleeding from a head injury requiring transfer to the hospital for evaluation.Findings included: The facility document titled, Abuse and Neglect Protocol, revised 06/13/2021, revealed, It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. 4. Employees, facility consultants and/or Attending Physicians must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. In the absence of the Director of Nursing Services such reports may be made to the Nurse Supervisor on duty. 6. Any staff member or person affiliated with the facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report, or cause a report to be made of, the mistreatment or offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information.8. The Administrator or Director of Nursing Services must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing Services must be called at home or must be paged and informed of the incident. 12. If an incident of suspected abuse occurs, facility shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury to designated state agency. The facility's abuse policy did not indicate that alleged violations involving abuse are to be reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse, with or without serious bodily injury. The facility's policy indicated that for an incident of suspected abuse, if the events that caused the suspicion results in serious bodily injury, then it should be reported immediately but not later than 24 hours.An admission Record indicated the facility admitted Resident #55 to the facility on [DATE] with a recent readmission of 05/09/2020. According to the admission Record, the resident had a medical history with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side, other cerebrovascular disease, post-traumatic stress disorder (PTSD), adjustment disorder, and depression.An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/09/2025, revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 15. The MDS also indicated Resident #55 had no behaviors, utilized a wheelchair for mobility and required supervision or touch assistance for transfers, did not ambulate, and received an anticoagulant. An admission Record indicated the facility admitted Resident #95 to the facility on [DATE]. According to the admission Record, the resident had a medical history with diagnoses that included peripheral vascular disease, major depressive disorder, mild cognitive impairment, mood disorder due to known physiological condition with depressive features, and depression. A quarterly MDS, with an ARD of 03/04/2025, revealed Resident #95 had a BIMS score of 15. The MDS also indicated Resident #95 had no behaviors, utilized a wheelchair for mobility, could ambulate 10 feet in room, corridor, or similar apace, could ambulate 50 feet with two turns with supervision or touching assistance, and required supervision or touching assistance for wheeling 50 feet with two turns and substantial or maximum assistance for wheeling 150 feet in corridor or similar space. A State Reportable Incident Report (SRI) dated 05/27/2025 indicated Resident #55 had made an allegation of physical abuse against another resident. The document revealed Resident #55 was found bleeding. At the time of the incident, Resident #55, who was generally verbally expressive, declined to offer an explanation related to the incident to staff present. Resident #55 was sent to the hospital and at that time, the resident reported there had been an assault by the roommate. Resident #55's roommate, Resident #95, reported that Resident #55 had fallen from the wheelchair. The SRI's summary of the incident revealed that on 05/26/2025 at 7:30 PM in room [ROOM NUMBER], Resident #55 reported bleeding to the nurse. Resident #55's roommate, Resident #95, reported that Resident #55 fell and was injured, and Resident #95 had helped Resident #55 back into the resident's chair. Interviews with staff revealed there were no audible screams, shouts, scuffling, or anything that would indicate an altercation. Resident #55 was sent out with the squad (emergency medical services) to the hospital. The resident reported to the hospital that the resident was assaulted by their roommate. A confirmation email dated 05/27/2025 at 12:20 PM revealed the state agency had received the initial state reportable incident for incident #260864. A confirmation email dated 05/30/2025 at 4:10 PM revealed the state agency had received the final facility reported incident for incident #260864. During an interview on 08/05/2025 at 1:34 PM, Resident #55 was asked about the incident on 05/26/2025. Resident #55 explained that a couple months ago, they had been downstairs in the cafeteria area speaking with a female resident, whom which Resident #55 identified to be Resident #62, while they both waited for their supper to be delivered. Resident #55 indicated that while the two residents were talking, Resident #95 approached them and began to bump Resident #55's wheelchair, despite ample room being available to get around without collision. Resident #55 stated they initially attempted to move closer towards the table to give Resident #95 room to get around the wheelchair, but Resident #95 refused, continued to bump Resident #55's wheelchair, and began swinging their upper extremity at Resident #55. Resident #55 stated that at that time, they began to roll their wheelchair backward as Resident #95 continued to swing at them, and Resident #62 became frightened and yelled for help. Resident #55 stated that at about that time, the resident used their leg to try to nudge Resident #95's knee to get them to back off them, and Dietary Aide (DA) #21 a female staff member approached from the kitchen. DA #21 informed both residents that they needed to return to their units upstairs. Resident #55 indicated Resident #95 left the dining area before Resident #55 did that evening and later when Resident #55 returned to the unit, Resident #55 indicated they recalled getting off the elevator on the 300 Hall unit, where they resided as roommates, and started down the hallway towards the room. Resident #55 indicated they passed Resident #95, who was seated in their wheelchair in the hallway at the time. Resident #55 cautiously passed Resident #95 to proceed into their shared room, not speaking to Resident #95 at the time. Resident #55 indicated that once in the room they turned around and Resident #95 had entered and began swinging their metal cane, making contact with Resident #55's head a couple times. On the next swing of the cane, Resident #55 blocked the cane from making contact with their head by using their right upper extremity, which was struck by the metal cane. Resident #55 indicated the resident realized at that time they were bleeding from the head and Resident #95 told Resident #55 to tell the staff nurse that the resident had sustained a fall or things would get worse. Resident #55 left the room to seek assistance for their bleeding head. When the surveyor clarified whether Resident #55 had fallen, Resident #55 informed the surveyor they had never been out of their wheelchair nor hit their head during the events. Resident #55 stated they did not tell staff about the assault immediately out of fear of the situation becoming worse in the future. During an interview on 08/06/2025 at 8:47 AM about the incident on 05/26/2025, Resident #62 stated they were seated at a table in the dining room speaking with Resident #55 when Resident #95 approached them and hit Resident #55, causing fear. Resident #62 said they summoned for help. During an interview on 08/06/2025 at 11:35 AM, DA #21 revealed she was working in the dietary department on the meal service tray line on 05/26/2025 when she heard a scream from Resident #62, which she recalled was initially for Resident #95 to STOP. DA #21 stated that as she proceeded out of the swinging doors of the dietary department, Resident #55 was seated in their wheelchair, and DA #21 saw Resident #95 swing at Resident #55. DA #21 stated that when she saw Resident #95 swinging their hand to hit Resident #55, she attempted to pull Resident #55's wheelchair backwards. She stated she then returned to the kitchen and began her cleaning duties she had to complete before she could leave for her shift that evening. DA #21 stated later that evening, at approximately 8:00 PM, she was getting ready to leave the building for her shift when she saw Resident #55 on a stretcher with their head bloody and busted up pretty badly. DA #21 indicated Resident #95 was a much larger resident than Resident #55, and she felt Resident #55 would have been defenseless against Resident #95. DA #21 indicated she had not been interviewed or asked about the events since she witnessed the incident, and she did not report the incident to anyone at the time the event occurred. During an interview on 08/06/2025 at 8:36 AM, DA #22 revealed she was working in the dietary department on the meal service tray line on 05/26/2025 when she heard a lot of noise. She heard a resident yelling for help and saw DA #21 leave the tray line then heard DA #21 holler for the residents to stop. DA #22 stated when she approached the door, she could hear Resident #95 cursing at DA #21 and heard DA #21 tell Resident #55 to move backwards, and Resident #55 moved backwards. She stated that following the interaction, both she and DA #21 returned to the kitchen and began breaking down the tray line and cleaning the kitchen for the night and stated neither of them reported the event at the time because they were busy completing their nightly duties.During an interview on 08/06/2025 at 7:17 PM, LPN #16 revealed she was an agency employee and was on duty covering a shift on the night of 05/26/2025 beginning at 7:00 PM. LPN #16 indicated that shortly after shift change, she was at the nurses' station when an unidentified nurse aide notified her that Resident #55 was in the hallway bleeding from their head. She stated she was not the assigned nurse to either Resident #55 or Resident #95; however, she was assigned to the 300 Hall unit that night, and with her knowledge that Resident #55 was on a blood thinner, both she and LPN #15 gathered some dressing supplies and headed towards Resident #55, whom they located with a pretty significant amount of bleeding present when they arrived. LPN #16 stated Resident #55 was unable to verbalize what had occurred at the time, but she knew she needed to get the resident urgent treatment, so they applied pressure to the head and contacted emergency medical services (EMS) to transport as quickly as possible. LPN #16 stated that following Resident #55's departure to the hospital, both she and LPN #15 went down to the resident's room where Resident #55 and Resident #95 resided to ask Resident #95 what had occurred. LPN #16 indicated Resident #95 informed them that Resident #55 had fallen and hit their head on the footboard of the bed. LPN #16 indicated both she and LPN #15 looked at the footboard and the bed and did not see any blood on the bed. They found the information provided by Resident #95 less than believable because she did not think Resident #55 would be able to get up from the floor without staff assistance in the event of a fall. LPN #16 recalled seeing blood stains on the floor in the room far enough away from the resident's bed that it did not appear the resident hit the end of the bed. Blood was in the hallway and all over Resident #55's clothing that night. LPN #16 stated that at the time of the event, Resident #55 was bleeding too significantly from the head and she was unable to assess the puncture wound on the head prior to discharge. She stated she had not been made aware of any interaction that had occurred prior to the event that may have caused the escalation that night. LPN #16 stated she learned of the allegation of assault when LPN #15 called the hospital to obtain report and was notified at that time, but they did not notify anyone until it was passed along to the oncoming nurse at shift-to-shift report in the morning. In an interview on 08/08/2025 at 12:04 PM, the Administrator stated he learned of the event the following morning and felt the event had been reported timely to the state agency.

Based on observation, interview, record review, and facility policy review, the facility failed to keep fingernails trimmed and clean for a resident (Resident #33) who was dependent on staff for activities of daily living (ADLs). Findings included: A facility policy titled, Care of Fingernails/Toenails, revised 10/2010 indicated, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. The policy indicated, Nail care includes daily cleaning and regular trimming. The policy further indicated Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.An admission Record revealed the facility admitted Resident #33 on 05/05/2021. The admission Record indicated that Resident #33 had diagnoses that included type 2 diabetes mellitus, dementia, atherosclerotic heart disease, and chronic kidney disease. A quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 04/30/2025, revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated Resident #33 had not rejected care during the evaluation period. The MDS further indicated that Resident #33 required setup assistance with personal hygiene and partial to moderate assistance with bathing. Resident #33's Care Plan Report included a focus area revised 11/11/2021 that indicated the resident was at risk for complications related to an activities of daily living (ADL) performance deficit and was at increased risk for decline in function. Interventions included checking nail length and trimming and cleaning nails on bath day and as needed. An observation on 08/04/2025 at 1:57 PM revealed Resident #33 had long fingernails. Several of the resident's fingernails appeared 3/4 - 1 inches long. In an interview at that time, Resident #33 stated that they were waiting on staff to trim their nails, and that they did not usually keep them that long. An observation on 08/06/2025 at 10:21 AM revealed Resident #33 in the activity room on the 3rd floor. Resident #33's fingernails continued to be dirty, long, and jagged. In an interview at that time, the resident stated the resident needed to get staff to trim their nails. Resident #33 stated staff trimmed their nails whenever they want to. In an interview on 08/06/2025 at 10:23 AM, Certified Nurse Aide (CNA) #8 stated this was her first day working at the facility, and they did not tell her anything about trimming fingernails. CNA #8 looked at Resident #33's nails and stated that they needed trimmed and cleaned. CNA #8 offered to trim and clean the resident's nails that day, and Resident #33 agreed. In an interview on 08/06/2025 at 10:26 AM, Registered Nurse Unit Manager (RN UM) #9 stated CNAs were supposed to trim fingernails on shower days and as needed. RN UM #9 looked at Resident #33's nails. Resident #33 stated the middle nail had broken off. RN UM #9 asked Resident #33 if they wanted their fingernails trimmed. Resident #33 stated they would like their fingernails trimmed. Resident #33's shower sheets for the previous two weeks indicated the resident had refused showers four out of five days. The resident's shower sheets indicated Resident #33 had received a shower and nail trimming on 07/22/2025. In an interview on 08/07/2025 at 3:11 PM, CNA #1 stated the CNAs trimmed residents' fingernails unless the resident was diabetic, and then the nurse trimmed them. CNA #1 stated the nurse would tell her who was diabetic. CNA #1 stated Resident #33 would let her file their fingernails but would not let her cut them. In an interview on 08/08/2025 at 9:38 AM, RN #10 stated residents' fingernails were trimmed on their shower days or upon request. RN #10 stated if a resident was diabetic, the nurse would trim their nails. RN #10 stated she was not sure if the CNAs or the nurses trimmed Resident #33's nails. In an interview on 08/08/2025 at 9:40 AM, RN UM #9 asked RN #10 if Resident #33 was diabetic. RN #10 stated Resident #33 was not diabetic. RN UM #9 stated the CNAs would trim Resident #33's fingernails. RN #10 stated Resident #33 refused care, and their care plan reflected that the resident frequently refused care. RN #10 stated she was not sure when the care plan was updated to reflect noncompliance or refusal of care.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure a wound treatment was completed as ordered. This affected one resident (#81) of three residents reviewed. The facility census was 85. Findings Included: Review of the medical record revealed Resident #81 admitted on [DATE]. Diagnoses included chronic osteomyelitis right ankle and foot, and diabetes mellitus. Review of the minimum data set assessment (MDS) dated [DATE] revealed Resident #81 was cognitively intact with a Brief Interview of Mental Status score of 15. Review of physician order dated 08/14/24 revealed right heel wound care was ordered as follows: cleanse with normal saline and pat dry. Apply betadine and let air dry, apply calcium alginate with silver to the wound bed, cover with abdominal dressing, then wrap with Kerlix and apply ace wrap to right foot every day. Interview on 08/26/24 at 9:50 A.M. with Resident #81 revealed his dressing to his right heel had not been changed in a couple of days. Observation of wound care for Resident #81 on 08/26/24 at 1:55 P.M. performed by Licensed Practical Nurse (LPN) #246 revealed the nurse removed the dressing on the resident which was observed to be a blue hydrofera sponge and not the ordered calcium alginate with silver to the wound bed, the dressing was covered with an abdominal dressing and Kerlix. The dressing that was removed was not dated. LPN #246 removed the old dressing and dressed Resident #81's wound as ordered. Interview with LPN #246 confirmed the wound treatment that was removed was the not the ordered treatment for Resident #81. Interview on 08/26/24 at 2:59 P.M. via telephone with LPN #339 revealed she had not completed the treatment to Resident #81's right heel on 08/25/24 as ordered. LPN #339 stated it was her first time working at the facility and she had a long medication pass and did not have time to perform the treatment. LPN #339 stated she was unable to perform Resident #81's treatment and but she did sign off the treatment in the treatment record as if it was completed. Interview on 08/26/24 at 3:15 P.M. with Director of Nursing (DON) verified it was not acceptable to not complete treatments as order by physician. Review of facility policy titled Wound Care dated 10/2010 revealed that the purpose of this procedure was to provide guidelines for the care of wounds by licensed nursing staff to promote healing. Verify that there was a physician's order for the procedure. Assemble the equipment and supplies as needed, dressing materials for wound, disposable clothes as indicated, antiseptic, and personal protective equipment that included gowns, gloves, and mask as needed. Wash and dry hands thoroughly. Place gloves on to remove tape and dressing. Pull gloves over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly. Put on gloves. Clean or irrigate the wound. Dress the wound and apply directly to wound area. [NAME] tape with initials, time, and date and apply to the dressing. This deficiency represents non-compliance investigated under Complaint Number OH00156403.

Based on record review, resident and staff interview the facility failed to treat one (#48) of three reviewed in a dignified manner. The facility census was 85. Findings Included: Review of the medical record revealed Resident #48 was admitted [DATE]. Diagnoses included vascular dementia, type two diabetes, and lumbago with sciatica. Review of the minimum data set (MDS) dated [DATE] revealed Resident #48 had a Brief Interview of Mental Status score of 08 that indicated the resident was cognitively impaired. Review of email dated 08/05/24 written by the Administrator revealed he had spoken to the Dietician #204 with the referencing an encounter with Resident #48. The Dietician stated she had realized what she had said, was very sorry and that the phrase was her common refrain when giving a banana to her grand kids. Dietician #204 was extremely remorseful, almost to the point of tears. Administrator stated that he comfortably says that she had no negative intention or connotation with her comment. Interview on 08/26/24 at 10:10 A.M. with Dietician #204 revealed Resident #48 who was sitting in gathering room off the elevator had stated he would like a snack. Dietician #204 stated she went to kitchen and got Resident # 48 a banana to give him. Dietician # 204 confirmed she approached Resident # 48 and said does the monkey wanted a banana and handed the banana to the resident. Dietician # 204 stated she meant nothing by this, and felt horrible, but this was something she had said to her grand kids and meant no harm from saying this. Dietician # 204 stated she had told the Administrator what had happened and explained she had not meant harm. Interview on 08/26/24 at 11:08 A.M. with Cooperate Administrator (CA) #277 who stated that she did speak with Administrator who was not at the facility on this day and verified Dietician #204 had come to him right away to explain the situation and felt bad. CA #277 stated that the Administrator revealed the Assistant Director of Nursing (ADON) #261 had investigated the incident and interview the staff. Review of facility State tested Nursing Assistant (STNA) interview completed by the facility dated 08/26/24 revealed STNA #296 stated she was on the elevator on 08/05/24 around 11:30 A.M. when Dietician #204 had got on the elevator with a banana. Dietician #204 had asked STNA #296 if she had seen Resident #48, which STNA #296 had directed to location in dinning room. STNA #296 stated when elevator door open Dietician #204 had approached Resident #48 and peeled back the banana to hand Resident #48. STNA #296 stated Dietician #204 said to Resident #48 I have a banana for the monkey. STNA #296 stated Dietician #204 handed Resident #48 the banana. STNA #296 stated she told the ADON #261 right away of the concern. STNA #296 stated Resident #48 had a confused disappointed look on his face. Interview on 08/26/24 at 12:58 P.M. with Resident #48 the resident stated no staff call him names, or disrespect him in any manner at the facility. Resident #48 stated this included management and Dietician #204. Resident #48 stated he had no concerns related to allegation of abuse. Interview on 08/27/24 at 2:23 P.M. with ADON #261 stated that STNA #296 reported to her Dietician #204, make a comment to Resident #48 like hears the banana for my monkey. ADON #261 stated she had notified human resources and the Administrator who had then spoke to the Dietician #204. Dietician #204 had stated no harm was meant by the phrase. Interview on 08/27/24 at 3:02 P.M. with STNA #296 who stated she had seen Dietician #204 walk over to Resident #48, who was a black man, hears the banana for my monkey. STNA #296 no person should be called an animal. STNA #296 stated that the Dietician #204 was unprofessional when calling Resident #48 an animal. No staff should ever do this. STNA #296 stated the facility had lost her written statement that was given on 08/05/24. STNA #296 confirmed that facility had just got a written statement from her yesterday. STNA #296 stated the facility did not investigate this concern. Interview on 08/27/24 at 3:27 P.M. with the Administrator revealed he was told about the incident on 08/05/24 by the ADON and had a written statement regarding the incident on 08/05/24. Administrator stated he only had spoken to Dietician #204, and any other staff verbally. Review of the facility document titled Resident Rights undated revealed that the resident had rights by federal and state laws guarantee of certain basic rights to all residents of this facility. These rights included resident(s) to be treated with respect, kindness, and dignity. This deficiency represents non-compliance investigated under Complaint Number OH00156603.

Based on observation, interview, and facility policy review, the facility failed to ensure enhanced barrier precautions were implemented and the facility failed to complete hand hygiene during wound care. This affected one resident (#81) of three residents reviewed. The facility census was 85. Findings Included: Review of the medical record revealed Resident #81 admitted to the facility on [DATE]. Diagnoses included chronic osteomyelitis right ankle and foot, and diabetes mellitus. Review of the minimum data set assessment (MDS) dated [DATE] revealed that Resident #81 was cognitively intact with a Brief Interview of Mental Status score of 15. Review of physician order dated 08/14/24 revealed that Resident #81 treatment for the right heel was as follows: cleanse with normal saline and pat dry. Apply betadine, let air dry, apply calcium alginate with silver to wound bed, cover with an abdominal dressing, [NAME] with Kerlix and apply ace wrap to right foot every day. Interview on 08/26/24 at 9:50 A.M. with Resident #81 stated his dressing had not been changed to his right heel in a couple of days. Observation of wound care for Resident #81 on 08/26/24 at 1:55 P.M. performed by Licensed Practical Nurse (LPN) #246 who was wearing gloves as her only personal protective equipment (PPE), revealed the nurse removed the dressing on the resident which was observed to be a blue hydrofera sponge and not the ordered calcium alginate with silver to the wound bed, the dressing was covered with an abdominal dressing and Kerlix. The dressing that was removed was not dated. After LPN #246 removed the the old dressing the nurse was observed to doff her gloves which revealed another pair of gloves on her hands under the gloves she had just removed. The nurse proceeded to clean Resident #81's right heel then doffed the gloves on her hands and don new gloves without performing hand hygiene. LPN #246 completed the wound dressing as ordered. Interview with LPN #246 confirmed the wound dressing that was removed was the not the ordered treatment. LPN #246 confirmed she did not perform hand hygiene during the wound treatment, and the nurse confirmed gloves were the only PPE she wore while providing the wound care to Resident #81 and not the required personal protective equipment for a resident in enhanced barrier precautions. Interview on 08/26/24 at 3:15 P.M. with Director of Nursing (DON) verified it was not acceptable to not wear the correct personal protective equipment required during wound care and to not perform hand hygiene. Review of facility policy titled Wound Care dated 10/2010 revealed that the purpose of this procedure was to provide guidelines for the care of wounds by licensed nursing staff to promote healing. Verify that there was a physician's order for the procedure. Assemble the equipment and supplies as needed including dressing materials for wound, disposable clothes as indicated, antiseptic, and personal protective equipment that included gowns, gloves, and mask as needed. Wash and dry hands thoroughly. Place gloves on to remove tape and dressing. Pull gloves over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly. Put on gloves. Clean or irrigate the wound. Dress the wound and apply directly to wound area. [NAME] tape with initials, time, and date and apply to the dressing. Review of the facility policy titled Enhanced Barrier Precautions dated 08/2022 revealed enhanced barrier precautions are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. Residents who were high contact resident care activities that required the use of gown and gloves for enhance barrier precautions include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use like central line, feeding tube, and wound care. Review of the facility policy titled Handwashing or Hand Hygiene dated 10/2023 revealed that indications for hand hygiene are as followed: for immediately before touching a resident, before performing an aseptic task, after contact with blood, body fluids, or contaminated surfaces, after touching a resident, after touching resident's environment, before moving from work on a soiled body site to a clean body site on the same resident, and immediately after glove removal.

Based on medical record review, staff interview, observations, and policy review, the facility failed to appropriate treatment and services for care of a resident who was incontinent of bowel and had a indwelling urinary catheter. This affected one (#45) of three residents reviewed for incontinence and catheter care. The facility identified there were 48 residents who were incontinent of bowel and five residents with indwelling catheters. Findings include: Medical record review for Resident #45 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, coronary artery disease, peripheral vascular disease, contractures to his bilateral lower extremities, and neurogenic bladder. Review of the care plan dated 08/16/23 revealed Resident #45 was at risk for developing complications secondary to having bowel incontinence and having an indwelling urinary catheter. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was cognitively intact. Resident #45 required substantial/maximal assistance from staff for toileting. Observation of incontinence care for Resident #45 on 05/08/24 at 9:17 A.M. revealed State tested Nursing Assistant (STNA) #100 revealed she placed on a gown, mask and gloves and proceeded to go through a drawer looking for wipes. She proceeded to remove the brief and used wipes to wipe the scrotum and the resident's bottom with the wipes and kept taking wipes out of the package because she kept removing feces and bloody drainage from a rash. She continued with a soapy cloth and wiped the resident clean and dried him. She proceeded to the front of him and took the tubing connector of the catheter that drained the urine down to the bag and cleaned it. She didn't clean around the penis, or the tubing coming out of the penis and never changed her gloves through the entire process. Interview with the STNA #100 on 05/08/24 at 10:00 A.M. revealed she performed indwelling catheter care and incontinence care for Resident #45 during the observation and confirmed she didn't change her gloves from dirty to clean, clean the penis or clean the tubing coming out of the penis. She said this wasn't her normal practice. Review of the policy titled Perineal Care dated 10/01/20 revealed the purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. For a male resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area starting with urethra and working outward. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about three inches. Gently rinse and dry the area.) (1) Retract foreskin of the uncircumcised male. (2) Wash and rinse urethral area using a circular motion. (3) Continue to wash the perineal area including the penis, scrotum and inner thighs. Do not reuse the same washcloth or water to clean the urethra. c. Thoroughly rinse perineal area in same order, using fresh water and clean washcloth. (Note: If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter.) d. Gently dry perineum following same sequence. e. Reposition foreskin of uncircumcised male. f. Instruct or assist the resident to turn on his side with his upper leg slightly bent, if able. g. Rinse washcloth and apply soap or skin cleansing agent. h. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. i. Dry area thoroughly. 11. Discard disposable items into designated containers. 12. Remove gloves and discard into a container. Wash and dry your hands thoroughly. Review of the policy titled Catheter Care-Urinary dated 09/01/14 revealed for a male resident: use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return foreskin to normal position. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to a proximately four inches outward. This deficiency represents non-compliance investigated under Complaint Number OH00152397.

Based on record review, staff interview, and policy review, the facility failed to accurately complete an updated pre-admission screening and resident review (PASARR) for residents with a diagnosis change. This affected one (#27) of three residents reviewed for PASARR. The facility census was 83. Findings include: 1. Review of the medical record for Resident #27 revealed an admitted [DATE]. Diagnoses included progressive multifocal leukoencephalopathy (PML), parkinson's disease, major depressive disorder, bipolar disorder, anxiety disorder, and schizoaffective disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. This resident was assessed to require supervision with toileting and transfers, and partial assistance with bathing and dressing. Review of the physician order dated 03/15/24 revealed Resident #27 was ordered Risperdal 0.5 milligrams (mg), give one tablet by mouth two times a day for depression. Review of the physician order dated 03/15/24 revealed Resident #27 was ordered Zoloft 50 mg, give one tablet by mouth one time a day for depression. Review of the PASARR dated 09/04/19 for Resident #27 was the most current PASARR. The PASARR was not updated after new mental health diagnoses. Interview on 03/20/24 at 3:39 P.M., with the Administrator verified Resident #27's PASARR was not updated after a diagnosis change. Review of the policy titled, Admissions - From Other Healthcare Facilities, dated March 2017, revealed residents from other healthcare facilities may be admitted upon receipt of appropriate documentation including the PASARR.

Based on review of the medical record, staff interviews, and policy review, the facility failed to complete care conferences as required. This affected two residents (#27 and #58) of 24 residents reviewed. The facility census was 83. Findings include: 1. Review of the medical record for Resident #27 revealed an admitted [DATE]. Diagnoses included progressive multifocal leukoencephalopathy (PML), parkinson's disease, major depressive disorder, bipolar disorder, anxiety disorder, and schizoaffective disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. This resident was assessed to require supervision with toileting and transfers, and partial assistance with bathing and dressing. Review of the medical record for Resident #27 revealed a care conference had been completed on 07/12/23, 01/04/24, and 02/28/24 for the last 12 months. Interview on 03/21/24 at 10:44 A.M., with Social Services Director (SSD) #23 verified Resident #27 did not have regular quarterly care conferences for the last 12 months. 2. Review of the medical record for Resident #58 revealed an admitted [DATE]. Diagnoses included sepsis, hypertension, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of eight. This resident was assessed to require setup for eating, supervision with toileting and dressing, substantial assistance with bathing, and partial assistance with transfers. Review of the medical record for Resident #58 revealed a care conference had been completed on 09/25/23, 02/09/24, and 02/24/24 for the last 12 months. Interview on 03/21/24 at 10:39 A.M. with SSD #23 verified Resident #58 did not have regular quarterly care conferences for the last 12 months. Review of the policy titled, Care Planning - Interdisciplinary Team, dated March 2022, revealed the interdisciplinary team was responsible for the development of resident care plans. Care plan meetings were scheduled at the best time of the day for the resident and family when possible.

Based on observations, medical record review, staff interviews, and policy review, the facility failed to ensure a safe, clean, and home-like environment. This affected two (#2 and #27) of 24 residents reviewed for environment. The facility census was 83. Findings include: 1. Review of the medical record for Resident #2 revealed she was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus with other diabetic kidney complication, other sequelae of cerebral infarction, chronic kidney disease stage three, schizophrenia, morbid obesity due to excess calories, major depressive disorder, neuromuscular dysfunction of bladder, chronic obstructive pulmonary disease, cerebral ischemia, hyperlipidemia, and dysphagia following cerebral infarction. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/11/24, revealed this resident had severely impaired cognition. This resident was assessed to require moderate assistance with eating and oral hygiene, maximal assistance with bed mobility, and was dependent on staff for dressing, personal hygiene, transfer, toileting, and bathing. Observation on 03/21/24 at 11:50 A.M., revealed there was a vertical gash with missing drywall and chipped paint in the wall near the baseboard behind the head of Resident #2's bed, which was visible when standing next to the bed. Interview on 03/21/24 at 12:00 P.M., with Licensed Practical Nurse (LPN) #11 confirmed the gash in the wall in Resident #2's room. 2. Review of the medical record for Resident #27 revealed an admitted [DATE]. Diagnoses included progressive multifocal leukoencephalopathy (PML), parkinson's disease, major depressive disorder, bipolar disorder, anxiety disorder, and schizoaffective disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. This resident was assessed to require supervision with toileting and transfers, and partial assistance with bathing and dressing. Observations throughout the annual survey (03/18/24 - 03/21/24) revealed Resident #27's bed sheets had scattered brown substance at the head of the bed. Observations throughout the annual survey (03/18/24 - 03/21/24) revealed Resident #27's wall behind her bed had scattered brownish-orange substance on the wall and the overhead light. The substance was scattered from the head of the bed to the foot of the bed. Interview on 03/21/24 at 11:44 A.M., with State tested Nurses Aide (STNA) #33 verified the sheets were soiled and the wall and overhead light had a substance scattered on the wall and light. Review of the policy titled, Quality of Life - Homelike Environment, dated May 2017, revealed resident were provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, staff interviews, and review of the facility policy, the facility failed to ensure a contracted entity had appropriate State of Ohio required credentials for provision of services for residents. This deficiency affected four (Residents #13, #22, #72, and #80) out of four residents that were reviewed for medications administered by a contracted ancillary provider. This also affected 11 current residents (Residents #1, #3, #4, #8, #14, #37, #71, #75, #76, #87, and #90) and 16 discharged residents (Residents #100, #101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114, and #115) that were identified by the facility as having received medication from the unlicensed source. The census was 90. Findings include: 1. Review of the medical record for Resident #13 revealed he was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, major depressive disorder, hyperlipidemia, obesity, and diabetes mellitus due to underlying condition with diabetic neuropathy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/17/23, revealed Resident #13 had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require limited assistance for bed mobility, transfer, dressing, and toilet use as well as supervision for personal hygiene and eating. Review of the plan of care revised on 08/17/23 revealed the resident was at nutritional risk related to diagnoses of diabetes mellitus, chronic obstructive pulmonary disease, hyperlipidemia, and depression. The resident was also at risk for dehydration related to diuretic use. Interventions included monitoring intakes, labs, weights and skin assessments, and observing signs/symptoms of dehydration. Review of the physician orders dated 06/05/23, 07/18/23, 08/15/23, and 09/19/23 revealed orders for nutrition Agency #700 IV therapy infusion one time (500 milliliters (ml)) 0.9 % normal saline at 500 ml/hour (total additive volume 27.4 ml) with vitamin c 5 grams (gm), B complex, {[NAME] 200 milligrams (mg), Rib 4 mg, Nia 200 mg, Dex 4 mg, Pyr 4 mg, B5 250 mg, Methyl 2 mg, Magnesium Chloride 1000 mg, Calcium Chloride 200 mg, Zinc 10 mg, Glutamine 150 mg, Arg 500 mg, [NAME] 150 mg, [NAME] 250 mg, Cit 250 mg, and BCAA 2 ml}. 2. Review of the medical record for Resident #22 revealed she was admitted to the facility on [DATE]. Diagnoses included renovascular hypertension, other cerebral infarction, psychotic disorder with delusions due to known physiological condition, major depressive disorder, vascular dementia unspecified severity with other behavioral disturbance, anorexia, generalized anxiety disorder, nutritional anemia, chronic kidney disease stage three, atherosclerosis of renal artery, mixed hyperlipidemia, renal osteodystrophy, and unspecified severe protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/03/23, revealed Resident #22 had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, and toilet use, limited assistance for personal hygiene, and supervision for eating. Review of the plan of care revised on 08/29/23 revealed the resident was at risk for decline in nutritional status due to diagnoses of protein-calorie malnutrition, chronic kidney disease stage three, hyperlipidemia, anemia, and metabolic encephalopathy. Interventions included house supplements, monitoring intakes, labs, weights and skin assessments, vitamins and minerals as ordered, and observe for signs/symptoms of dehydration. Review of the physician orders dated 06/05/23, 07/18/23, 08/15/23, and 09/19/23 revealed orders for nutrition Agency #700 IV therapy infusion one time (500 milliliters (ml)) 0.9 % normal saline at 500 ml/hour (total additive volume 27.4 ml) with vitamin c 5 grams (gm), B complex, {[NAME] 200 milligrams (mg), Rib 4 mg, Nia 200 mg, Dex 4 mg, Pyr 4 mg, B5 250 mg, Methyl 2 mg, Magnesium Chloride 1000 mg, Calcium Chloride 200 mg, Zinc 10 mg, Glutamine 150 mg, Arg 500 mg, [NAME] 150 mg, [NAME] 250 mg, Cit 250 mg, and BCAA 2 ml}. 3. Review of the medical record for Resident #72 revealed he was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, other sequelae of cerebral infarction, major depressive disorder, morbid (severe) obesity due to excess calories, cardiomyopathy, anemia, hyperlipidemia, vitamin d deficiency, and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/07/23, revealed Resident #72 had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, and toilet use as well as supervision for personal hygiene and eating. Review of the plan of care revised on 10/17/23 revealed the resident was at risk for decline in nutritional status due to congestive heart failure, anemia, obesity, vitamin d deficiency, and prediabetes. The resident was also at risk for dehydration related to diuretic therapy. Interventions included house supplements, monitoring intakes, labs, weights and skin assessments, and observing for signs/symptoms of dehydration. Review of the physician orders dated 06/05/23, 07/18/23, 08/15/23, and 09/19/23 revealed orders for Agency #700 IV therapy infusion one time 500 ml 0.9% normal saline at 500 ml/hour (total additive volume 30.4 ml) with vitamin c 5 gm, B complex, {{[NAME] 200 milligrams (mg), Rib 4 mg, Nia 200 mg, Dex 4 mg, Pyr 4 mg, B5 250 mg, Methyl 2 mg, Biotin 20 mg, Magnesium Chloride 1000 mg, Calcium Glutamine 200 mg, Zinc 10 mg, Glutamine 150 mg, Arg 500 mg, [NAME] 50 mg, [NAME] 250 mg, Cit 250 mg, [NAME] 100 mg, and Gly 100 mg}. 4. Review of the medical record for Resident #80 revealed she was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, unspecified convulsions, other specified anemias, mixed hyperlipidemia, and chronic obstructive pulmonary disease. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 05/25/23, revealed Resident #80 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 04. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, and eating, and was totally dependent on staff for toilet use and personal hygiene. Review of the plan of care revised on 09/19/23 revealed the resident was at nutritional/hydration risk due to diagnoses of hypertension, hyperlipidemia, cerebrovascular accident, and anemia. Interventions included monitoring intakes, labs, skin assessments and weights, and observing for signs/symptoms of dehydration. Review of the physician order dated 06/05/23 revealed an order for Agency #700 IV therapy infusion one time 500 ml 0.9% normal saline at 500 ml/hour (total additive volume 30.4 ml) with vitamin c 5 gm, B complex, {{[NAME] 200 milligrams (mg), Rib 4 mg, Nia 200 mg, Dex 4 mg, Pyr 4 mg, B5 250 mg, Methyl 2 mg, Biotin 20 mg, Magnesium Chloride 1000 mg, Calcium Glutamine 200 mg, Zinc 10 mg, Glutamine 150 mg, Arg 500 mg, [NAME] 50 mg, [NAME] 250 mg, Cit 250 mg, [NAME] 100 mg, and Gly 100 mg}. Interview with Representative #405 for the ancillary provider (Agency #700) stated they did not have State of Ohio TDDD licensure. He stated they were a Medical Entity, with a Medical Director licensed in the State of Ohio. Every other state in which they provided services did not require a special TDDD license and after about three months of providing services in the Ohio area, they learned Ohio was an exception. He stated they applied for the license and were told they could continue providing services, license approval would take days. He stated an audit was conducted, and the Board of Pharmacy reported them. Simultaneously, the group had decided to stop providing services in Ohio unrelated to the licensure concerns. They rescinded their application for licensure. He stated they provided five specialized infusions that could be specialized based on resident needs. The intervention was created a couple of years ago and found to be beneficial for residents with chronic urinary tract infections (UTI), residents who did not eat or drink well, and/or weight loss concerns. He stated they presented the program to facility ownership. Interview on 12/06/23 at 11:45 A.M. with the Administrator revealed the facility's corporate staff arranged the services with Agency #700. The Administrator stated he was unaware the provider lacked a TDDD license for the State of Ohio to provide medications. Interview on 12/06/23 at 11:48 A.M. with the Director of Nursing (DON) revealed corporate notified the facility that services from Agency #700 IV would no longer be utilized but provided no further information. The DON stated she was unaware the provider lacked a TDDD license for the State of Ohio to supply medications. The DON verified the above listed residents received the medications and denied any residents experienced any adverse outcomes. Review of the State of Ohio Terminal Distributor Licensure of Prescriber Practices https://www.pharmacy.ohio.gov/, dated 08/24/23, revealed a TDDD license allows a business entity to purchase, possess, and/or distribute dangerous drugs at specific locations. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, Emergency Medical Services (EMS) organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. Dangerous drugs are defined in the Ohio Revised Code as any drug that meets any of the following: 1. Requires a subscription; 2. Bears on the label a Federal Legend (Rx Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. Ohio Revised Code (ORC) 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor shall sell dangerous drugs to anyone other than the following: (1) a licensed terminal distributor of dangerous drugs; (2) Any person exempt from licensure as a terminal distributor of dangerous drugs under section 4729.541 of the Revised Code (3) a licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business. In general, the exemptions to Ohio's TDDD licensure requirements do not apply if the prescriber practice is engaged in drug compounding. Compounding is defined as the preparation, mixing, assembling, packaging, and labeling of one or more drugs. Compounding includes the combining, admixing, diluting, reconstituting, or otherwise altering of a drug or bulk drug substance. Review of the facility policy titled Administrative Management (Governing Board), revised 04/2011, revealed the governing board was responsible for the management and operation of the facility. The deficient practice was corrected on 11/20/23 when the facility implemented the following corrective actions: By 09/19/23, Agency #700 IV infusions were no longer being utilized. By 11/20/23, all residents that received Agency #700's IV infusions were assessed with no negative outcomes noted. By 11/20/23, education was provided to Corporate Staff, the Administrator, DON, and Medical Director related to utilizing providers with proper credentials. By 11/20/23, all contracted suppliers were reviewed for appropriate credentials and will be reviewed annually moving forward. Interview on 12/06/23 at 1:33 P.M. with the Administrator and DON confirmed education was received regarding TDDD licenses and only using providers with appropriate credentials. This deficiency represents non-compliance investigated under Complaint Number OH00148171.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, and staff interviews, the facility failed to ensure medications administered Intravenously (IV) were obtained from a source with a Terminal Distributor of Dangerous Drugs (TDDD) license (which allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location) specific to the State of Ohio. This deficiency affected four (Residents #13, #22, #72, and #80) out of four residents reviewed for IV medication administration. This also affected 11 current residents (Residents #1, #3, #4, #8, #14, #37, #71, #75, #76, #87, and #90) and 16 discharged residents (Residents #100, #101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114, and #115) that were identified by the facility as having received IV medication from the unlicensed source. The census was 90. Findings include: 1. Review of the medical record for Resident #13 revealed he was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, major depressive disorder, hyperlipidemia, obesity, and diabetes mellitus due to underlying condition with diabetic neuropathy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/17/23, revealed Resident #13 had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. The resident was assessed to require limited assistance for bed mobility, transfers, dressing, and toilet use as well as supervision for personal hygiene and eating. Review of the plan of care revised on 08/17/23 revealed the resident was at nutritional risk related to diagnoses of diabetes mellitus, chronic obstructive pulmonary disease, hyperlipidemia, and depression. The resident was also at risk for dehydration related to diuretic use. Interventions included monitoring intakes, labs, weights and skin assessments, and observing signs/symptoms of dehydration. Review of the physician orders dated 06/05/23, 07/18/23, 08/15/23, and 09/19/23 revealed orders for nutrition Agency #700 IV therapy infusion one time (500 milliliters (ml)) 0.9 % normal saline at 500 ml/hour (total additive volume 27.4 ml) with vitamin c 5 grams (gm), B complex, {[NAME] 200 milligrams (mg), Rib 4 mg, Nia 200 mg, Dex 4 mg, Pyr 4 mg, B5 250 mg, Methyl 2 mg, Magnesium Chloride 1000 mg, Calcium Chloride 200 mg, Zinc 10 mg, Glutamine 150 mg, Arg 500 mg, [NAME] 150 mg, [NAME] 250 mg, Cit 250 mg, and BCAA 2 ml}. 2. Review of the medical record for Resident #22 revealed she was admitted to the facility on [DATE]. Diagnoses included renovascular hypertension, other cerebral infarction, psychotic disorder with delusions due to known physiological condition, major depressive disorder, vascular dementia unspecified severity with other behavioral disturbance, anorexia, generalized anxiety disorder, nutritional anemia, chronic kidney disease stage three, atherosclerosis of renal artery, mixed hyperlipidemia, renal osteodystrophy, and unspecified severe protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/03/23, revealed Resident #22 had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 11. The resident was assessed to require extensive assistance for bed mobility, transfer, dressing, and toilet use, limited assistance for personal hygiene, and supervision for eating. Review of the plan of care revised on 08/29/23 revealed the resident was at risk for decline in nutritional status due to diagnoses of protein-calorie malnutrition, chronic kidney disease stage three, hyperlipidemia, anemia, and metabolic encephalopathy. Interventions included house supplements, monitoring intakes, labs, weights and skin assessments, vitamins and minerals as ordered, and observe for signs/symptoms of dehydration. Review of the physician orders dated 06/05/23, 07/18/23, 08/15/23, and 09/19/23 revealed orders for nutrition Agency #700 IV therapy infusion one time (500 milliliters (ml)) 0.9 % normal saline at 500 ml/hour (total additive volume 27.4 ml) with vitamin c 5 grams (gm), B complex, {[NAME] 200 milligrams (mg), Rib 4 mg, Nia 200 mg, Dex 4 mg, Pyr 4 mg, B5 250 mg, Methyl 2 mg, Magnesium Chloride 1000 mg, Calcium Chloride 200 mg, Zinc 10 mg, Glutamine 150 mg, Arg 500 mg, [NAME] 150 mg, [NAME] 250 mg, Cit 250 mg, and BCAA 2 ml}. 3. Review of the medical record for Resident #72 revealed he was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, other sequelae of cerebral infarction, major depressive disorder, morbid (severe) obesity due to excess calories, cardiomyopathy, anemia, hyperlipidemia, vitamin d deficiency, and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/07/23, revealed Resident #72 had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, and toilet use as well as supervision for personal hygiene and eating. Review of the plan of care revised on 10/17/23 revealed the resident was at risk for decline in nutritional status due to congestive heart failure, anemia, obesity, vitamin d deficiency, and prediabetes. The resident was also at risk for dehydration related to diuretic therapy. Interventions included house supplements, monitoring intakes, labs, weights and skin assessments, and observing for signs/symptoms of dehydration. Review of the physician orders dated 06/05/23, 07/18/23, 08/15/23, and 09/19/23 revealed orders for Agency #700 IV therapy infusion one time 500 ml 0.9% normal saline at 500 ml/hour (total additive volume 30.4 ml) with vitamin c 5 gm, B complex, {{[NAME] 200 milligrams (mg), Rib 4 mg, Nia 200 mg, Dex 4 mg, Pyr 4 mg, B5 250 mg, Methyl 2 mg, Biotin 20 mg, Magnesium Chloride 1000 mg, Calcium Glutamine 200 mg, Zinc 10 mg, Glutamine 150 mg, Arg 500 mg, [NAME] 50 mg, [NAME] 250 mg, Cit 250 mg, [NAME] 100 mg, and Gly 100 mg}. 4. Review of the medical record for Resident #80 revealed she was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, unspecified convulsions, other specified anemias, mixed hyperlipidemia, and chronic obstructive pulmonary disease. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 05/25/23, revealed Resident #80 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 04. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, and eating, and was totally dependent on staff for toilet use and personal hygiene. Review of the plan of care revised on 09/19/23 revealed the resident was at nutritional/hydration risk due to diagnoses of hypertension, hyperlipidemia, cerebrovascular accident, and anemia. Interventions included monitoring intakes, labs, skin assessments and weights, and observing for signs/symptoms of dehydration. Review of the physician order dated 06/05/23 revealed an order for Agency #700 IV therapy infusion one time 500 ml 0.9% normal saline at 500 ml/hour (total additive volume 30.4 ml) with vitamin c 5 gm, B complex, {{[NAME] 200 milligrams (mg), Rib 4 mg, Nia 200 mg, Dex 4 mg, Pyr 4 mg, B5 250 mg, Methyl 2 mg, Biotin 20 mg, Magnesium Chloride 1000 mg, Calcium Glutamine 200 mg, Zinc 10 mg, Glutamine 150 mg, Arg 500 mg, [NAME] 50 mg, [NAME] 250 mg, Cit 250 mg, [NAME] 100 mg, and Gly 100 mg}. Interview with Representative #405 for the ancillary provider (Agency #700) stated they did not have a State of Ohio TDDD licensure. He stated they were a Medical Entity, with a Medical Director licensed in the State of Ohio. Every other state in which they provided services did not require a special TDDD license and after about three months of providing services in the Ohio area, they learned Ohio was an exception. He stated they applied for the license and were told they could continue providing services, license approval would take days. He stated an audit was conducted, and the Board of Pharmacy reported them. Simultaneously, the group had decided to stop providing services in Ohio unrelated to the licensure concerns. They rescinded their application for licensure. He stated they provided five specialized infusions that could be specialized based on resident needs. The intervention was created a couple of years ago and found to be beneficial for residents with chronic urinary tract infections (UTI), residents who did not eat or drink well, and/or weight loss concerns. He stated they presented the program to facility ownership. Interview on 12/06/23 at 11:45 A.M. with the Administrator revealed the facility's corporate staff arranged the services with Agency #700. The Administrator stated he was unaware the provider lacked a TDDD license for the State of Ohio. Interview on 12/06/23 at 11:48 A.M. with the Director of Nursing (DON) revealed corporate notified the facility that services from Agency #700 would no longer be utilized but provided no further information. The DON stated she was unaware the provider lacked a TDDD license for the State of Ohio. The DON verified the above listed residents received the IV medications and denied any residents experienced any adverse outcomes. Review of the State of Ohio Terminal Distributor Licensure of Prescriber Practices https://www.pharmacy.ohio.gov/, dated 08/24/23, revealed a TDDD license allows a business entity to purchase, possess, and/or distribute dangerous drugs at specific locations. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, Emergency Medical Services (EMS) organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. Dangerous drugs are defined in the Ohio Revised Code as any drug that meets any of the following: 1. Requires a subscription; 2. Bears on the label a Federal Legend (Rx Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. Ohio Revised Code (ORC) 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor shall sell dangerous drugs to anyone other than the following: (1) a licensed terminal distributor of dangerous drugs; (2) Any person exempt from licensure as a terminal distributor of dangerous drugs under section 4729.541 of the Revised Code (3) a licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business. In general, the exemptions to Ohio's TDDD licensure requirements do not apply if the prescriber practice is engaged in drug compounding. Compounding is defined as the preparation, mixing, assembling, packaging, and labeling of one or more drugs. Compounding includes the combining, admixing, diluting, reconstituting, or otherwise altering of a drug or bulk drug substance. The deficient practice was corrected on 11/20/23 when the facility implemented the following corrective actions: By 09/19/23, Agency #700 infusions were no longer being utilized. By 11/20/23, all residents that received Agency #700's infusions were assessed with no negative outcomes noted. By 11/20/23, education was provided to Corporate Staff, the Administrator, DON, and Medical Director related to utilizing providers with proper credentials. By 11/20/23, all contracted suppliers were reviewed for appropriate credentials and will be reviewed annually moving forward. Interview on 12/06/23 at 1:33 P.M. with the Administrator and DON confirmed education was received regarding TDDD licenses and only using providers with appropriate credentials. This deficiency represents non-compliance investigated under Complaint Number OH00148171.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, and staff interviews, the facility failed to ensure medications were obtained from a source with a Terminal Distributor of Dangerous Drugs (TDDD) license (which allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location) specific to the State of Ohio. This deficiency affected four (Residents #13, #22, #72, and #80) out of four residents that were reviewed for medications administered by a contracted ancillary provider. This also affected 11 current residents (Residents #1, #3, #4, #8, #14, #37, #71, #75, #76, #87, and #90) and 16 discharged residents (Residents #100, #101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114, and #115) that were identified by the facility as having received medication from the unlicensed source. The census was 90. Findings include: 1. Review of the medical record for Resident #13 revealed he was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, major depressive disorder, hyperlipidemia, obesity, and diabetes mellitus due to underlying condition with diabetic neuropathy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/17/23, revealed Resident #13 had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require limited assistance for bed mobility, transfer, dressing, and toilet use as well as supervision for personal hygiene and eating. Review of the plan of care revised on 08/17/23 revealed the resident was at nutritional risk related to diagnoses of diabetes mellitus, chronic obstructive pulmonary disease, hyperlipidemia, and depression. The resident was also at risk for dehydration related to diuretic use. Interventions included monitoring intakes, labs, weights and skin assessments, and observing signs/symptoms of dehydration. Review of the physician orders dated 06/05/23, 07/18/23, 08/15/23, and 09/19/23 revealed orders for nutrition Agency #700 IV therapy infusion one time (500 milliliters (ml)) 0.9 % normal saline at 500 ml/hour (total additive volume 27.4 ml) with vitamin c 5 grams (gm), B complex, {[NAME] 200 milligrams (mg), Rib 4 mg, Nia 200 mg, Dex 4 mg, Pyr 4 mg, B5 250 mg, Methyl 2 mg, Magnesium Chloride 1000 mg, Calcium Chloride 200 mg, Zinc 10 mg, Glutamine 150 mg, Arg 500 mg, [NAME] 150 mg, [NAME] 250 mg, Cit 250 mg, and BCAA 2 ml}. 2. Review of the medical record for Resident #22 revealed she was admitted to the facility on [DATE]. Diagnoses included renovascular hypertension, other cerebral infarction, psychotic disorder with delusions due to known physiological condition, major depressive disorder, vascular dementia unspecified severity with other behavioral disturbance, anorexia, generalized anxiety disorder, nutritional anemia, chronic kidney disease stage three, atherosclerosis of renal artery, mixed hyperlipidemia, renal osteodystrophy, and unspecified severe protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/03/23, revealed Resident #22 had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, and toilet use, limited assistance for personal hygiene, and supervision for eating. Review of the plan of care revised on 08/29/23 revealed the resident was at risk for decline in nutritional status due to diagnoses of protein-calorie malnutrition, chronic kidney disease stage three, hyperlipidemia, anemia, and metabolic encephalopathy. Interventions included house supplements, monitoring intakes, labs, weights and skin assessments, vitamins and minerals as ordered, and observe for signs/symptoms of dehydration. Review of the physician orders dated 06/05/23, 07/18/23, 08/15/23, and 09/19/23 revealed orders for nutrition Agency #700 IV therapy infusion one time (500 milliliters (ml)) 0.9 % normal saline at 500 ml/hour (total additive volume 27.4 ml) with vitamin c 5 grams (gm), B complex, {[NAME] 200 milligrams (mg), Rib 4 mg, Nia 200 mg, Dex 4 mg, Pyr 4 mg, B5 250 mg, Methyl 2 mg, Magnesium Chloride 1000 mg, Calcium Chloride 200 mg, Zinc 10 mg, Glutamine 150 mg, Arg 500 mg, [NAME] 150 mg, [NAME] 250 mg, Cit 250 mg, and BCAA 2 ml}. 3. Review of the medical record for Resident #72 revealed he was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, other sequelae of cerebral infarction, major depressive disorder, morbid (severe) obesity due to excess calories, cardiomyopathy, anemia, hyperlipidemia, vitamin d deficiency, and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/07/23, revealed Resident #72 had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, and toilet use as well as supervision for personal hygiene and eating. Review of the plan of care revised on 10/17/23 revealed the resident was at risk for decline in nutritional status due to congestive heart failure, anemia, obesity, vitamin d deficiency, and prediabetes. The resident was also at risk for dehydration related to diuretic therapy. Interventions included house supplements, monitoring intakes, labs, weights and skin assessments, and observing for signs/symptoms of dehydration. Review of the physician orders dated 06/05/23, 07/18/23, 08/15/23, and 09/19/23 revealed orders for Agency #700 IV therapy infusion one time 500 ml 0.9% normal saline at 500 ml/hour (total additive volume 30.4 ml) with vitamin c 5 gm, B complex, {{[NAME] 200 milligrams (mg), Rib 4 mg, Nia 200 mg, Dex 4 mg, Pyr 4 mg, B5 250 mg, Methyl 2 mg, Biotin 20 mg, Magnesium Chloride 1000 mg, Calcium Glutamine 200 mg, Zinc 10 mg, Glutamine 150 mg, Arg 500 mg, [NAME] 50 mg, [NAME] 250 mg, Cit 250 mg, [NAME] 100 mg, and Gly 100 mg}. 4. Review of the medical record for Resident #80 revealed she was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, unspecified convulsions, other specified anemias, mixed hyperlipidemia, and chronic obstructive pulmonary disease. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 05/25/23, revealed Resident #80 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 04. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, and eating, and was totally dependent on staff for toilet use and personal hygiene. Review of the plan of care revised on 09/19/23 revealed the resident was at nutritional/hydration risk due to diagnoses of hypertension, hyperlipidemia, cerebrovascular accident, and anemia. Interventions included monitoring intakes, labs, skin assessments and weights, and observing for signs/symptoms of dehydration. Review of the physician order dated 06/05/23 revealed an order for Agency #700 IV therapy infusion one time 500 ml 0.9% normal saline at 500 ml/hour (total additive volume 30.4 ml) with vitamin c 5 gm, B complex, {{[NAME] 200 milligrams (mg), Rib 4 mg, Nia 200 mg, Dex 4 mg, Pyr 4 mg, B5 250 mg, Methyl 2 mg, Biotin 20 mg, Magnesium Chloride 1000 mg, Calcium Glutamine 200 mg, Zinc 10 mg, Glutamine 150 mg, Arg 500 mg, [NAME] 50 mg, [NAME] 250 mg, Cit 250 mg, [NAME] 100 mg, and Gly 100 mg}. Interview with Representative #405 for the ancillary provider (Agency #700) stated they did not have State of Ohio TDDD licensure. He stated they were a Medical Entity, with a Medical Director licensed in the State of Ohio. Every other state in which they provided services did not require a special TDDD license and after about three months of providing services in the Ohio area, they learned Ohio was an exception. He stated they applied for the license and were told they could continue providing services, license approval would take days. He stated an audit was conducted, and the Board of Pharmacy reported them. Simultaneously, the group had decided to stop providing services in Ohio unrelated to the licensure concerns. They rescinded their application for licensure. He stated they provided five specialized infusions that could be specialized based on resident needs. The intervention was created a couple of years ago and found to be beneficial for residents with chronic urinary tract infections (UTI), residents who did not eat or drink well, and/or weight loss concerns. He stated they presented the program to facility ownership. Interview on 12/06/23 at 11:45 A.M. with the Administrator revealed the facility's corporate staff arranged the services with Agency #700. The Administrator stated he was unaware the provider lacked a TDDD license for the State of Ohio to provide medications. Interview on 12/06/23 at 11:48 A.M. with the Director of Nursing (DON) revealed corporate notified the facility that services from Agency #700 would no longer be utilized but provided no further information. The DON stated she was unaware the provider lacked a TDDD license for the State of Ohio to supply medications. The DON verified the above listed residents received the medications and denied any residents experienced any adverse outcomes. Review of the State of Ohio Terminal Distributor Licensure of Prescriber Practices https://www.pharmacy.ohio.gov/, dated 08/24/23, revealed a TDDD license allows a business entity to purchase, possess, and/or distribute dangerous drugs at specific locations. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, Emergency Medical Services (EMS) organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. Dangerous drugs are defined in the Ohio Revised Code as any drug that meets any of the following: 1. Requires a subscription; 2. Bears on the label a Federal Legend (Rx Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. Ohio Revised Code (ORC) 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor shall sell dangerous drugs to anyone other than the following: (1) a licensed terminal distributor of dangerous drugs; (2) Any person exempt from licensure as a terminal distributor of dangerous drugs under section 4729.541 of the Revised Code (3) a licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business. In general, the exemptions to Ohio's TDDD licensure requirements do not apply if the prescriber practice is engaged in drug compounding. Compounding is defined as the preparation, mixing, assembling, packaging, and labeling of one or more drugs. Compounding includes the combining, admixing, diluting, reconstituting, or otherwise altering of a drug or bulk drug substance. The deficient practice was corrected on 11/20/23 when the facility implemented the following corrective actions: By 09/19/23, Agency #700 infusions were no longer being utilized. By 11/20/23, all residents that received Agency #700's infusions were assessed with no negative outcomes noted. By 11/20/23, education was provided to Corporate Staff, the Administrator, DON, and Medical Director related to utilizing providers with proper credentials. By 11/20/23, all contracted suppliers were reviewed for appropriate credentials and will be reviewed annually moving forward. Interview on 12/06/23 at 1:33 P.M. with the Administrator and DON confirmed education was received regarding TDDD licenses and only using providers with appropriate credentials. This deficiency represents non-compliance investigated under Complaint Number OH00148171.

Based on record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were prepared/stored in a safe manner and per professional standards of care. This affected two (#40 and #42) of seven residents reviewed for medications. The census was 85. Findings include: 1. Review of the medical record for Resident #40 revealed an admitted [DATE] with a diagnosis of unspecified intracranial injury. Review of the Minimum Data Set (MDS) assessment for Resident #40 dated 11/16/22 revealed the resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADL's). Review of the December 2022 monthly physician orders for Resident #40 revealed orders for Tramadol 50 milligram (mg) tablet per gastrostomy tube at 9:00 A.M. and Ativan one mg per g-tube at 9:00 A.M. 2. Review of the medical record for Resident #42 revealed and admitted [DATE] with a diagnosis of multiple sclerosis (MS). Review of the MDS assessment for Resident #42 dated 11/22/22 revealed the resident was cognitively impaired and was totally dependent on the assistance of one to two staff with ADL's. Review of the December 2022 monthly physician orders for Resident #42 revealed orders for Tramadol 50 mg tablet per gastrostomy tube at 9:00 A.M. Observation on 12/09/22 at 8:39 A.M. with Licensed Practical Nurse (LPN) #100 revealed there were approximately 25 plastic cups on top of the Third Floor Even medication cart. The cups had residents' first names written on them with marker. A cup with Resident #40's first name contained three pills, and a cup with Resident #42's first name contained one pill. LPN #110 was standing at the cart with the plastic cups when the surveyor approached nurse for an interview. Interview on 12/09/22 at 8:39 A.M. with LPN #110 confirmed she had labeled plastic cups with the first names of all her assigned residents on the Third Floor Even cart. LPN #110 further confirmed she had pulled medications for Resident #40 which included: Tramadol 50 mg, Ativan one mg, and Claritin 10 mg. LPN #110 confirmed Resident #40 did not have an order for Claritin. LPN #110 confirmed she then pulled medication for Resident #42 which included Tramadol 50 mg. LPN #110 confirmed she had not signed out the controlled substance medications, Tramadol and Ativan, upon removing them from the compartment in the cart for medication storage. Observation on 12/09/22 at 8:43 A.M. with LPN #110 revealed nurse took the empty plastic cups and the cups containing medications for Residents #40 and #42 and placed them in the top drawer of the cart. LPN #100 then left the floor. Further observation revealed LPN #110 administered medications to Residents #43 at 8:43 A.M., to Resident #45 at 8:48 A.M., to Resident #46 at 8:54 A.M., to Resident #50 at 9:05 A.M. for a total of 28 medication opportunities. Interview on 12/09/22 at 9:10 A.M. with LPN #110 confirmed her usual practice in administering medications was to label cups with all the resident's names on them and then to pull all the controlled substances for administration for all the residents on the assignment first and then she would add in the other non-controlled substance medications as she went from room to room to administer medications. Interview on 12/09/22 at 10:19 A.M. with LPN #100 confirmed LPN #110 had preset medications for Residents #40 and #42 and this included controlled substance medications. LPN #100 confirmed nurses should not preset medications to help prevent medication errors. LPN #100 confirmed medications should be given for one resident at a time before going on to the next resident. LPN #100 confirmed controlled substances needed to be signed out when removed from storage and should be administered as opposed to being repackaged and stored in top drawer of the cart. Interview on 12/09/22 at 10:55 A.M. with Registered Nurse (RN) #130, the facility Assistant Director of Nursing (ADON) confirmed she had head about LPN #110 improperly handling (presetting) and improperly storing controlled substance medications. RN #130 confirmed the facility would provide corrective education for LPN #110 because she had violated the facility policies. Review of the facility policy titled Administering Medications dated April 2019 revealed the individual administering the medication initials the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones. Medications are administered in a safe and timely manner, and as prescribed. Review of the facility policy titled Storage of Medications dated April 2019 revealed the facility stores all drugs and biological's in a safe, secure, and orderly manner. Drugs and biological's are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. Review of the facility policy titled Controlled Substances undated revealed controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review, resident and staff interviews, and review of the facility policy, the facility failed to ensure resident medications were available for administration as ordered. This affected two (#25 and #40) of three residents reviewed for medication administration. The census was 85. Findings include: 1. Review of the medical record for Resident #25 revealed an admitted [DATE] with diagnoses including acute congestive heart failure (CHF), hypertension (HTN), intervertebral disc degeneration, diabetes mellitus (DM), ischemic cardiomyopathy, atherosclerotic heart disease, generalized anxiety disorder, and radiculopathy. Review of the care plan for Resident #25 dated 04/14/20 revealed the resident had a diagnosis of anxiety disorder. Interventions included the following: administer medications as ordered, monitor/document for side effects and effectiveness, anticipate and meet the resident's needs, caregivers to provide opportunity for positive interaction, attention. Review of the Minimum Data Set (MDS) assessment for Resident #25 dated 11/07/22 revealed resident was cognitively intact and was independent with activities of daily living (ADL's). Further review of the December 2022 monthly physician orders for Resident #25 revealed an order dated 01/09/22 for the resident to receive Xanax routinely at bedtime once daily for treatment of generalized anxiety disorder. Review of the progress note for Resident #25 dated 11/27/22 revealed the facility was pending a script for the resident's Xanax. Review of the controlled substance sheets for Resident #25's Xanax revealed doses for 11/26/22 and 11/27/22 were not documented as administered. Review of the emergency box records revealed a dose of Xanax was pulled on 11/26/22 for administration to Resident #25. Interview on 12/09/22 at 9:28 A.M. with Resident #25 confirmed the facility did not renew the prescription for his routine Xanax in November of 2022 and on at least one or two nights he did not receive his routine dose of Xanax which caused him undue anxiety and nervousness. Interview on 12/09/22 at 12:15 P.M. with Registered Nurse (RN) #130 confirmed routine doses of Xanax for Resident #25 were not documented as administered on 11/26/22 and 11/27/22. RN #130 further confirmed she would check the emergency box supply to determine if any doses were pulled from the emergency supply for Resident #25. Interview on 12/09/22 at 3:00 P.M. with RN #130 confirmed the facility pulled a dose of Xanax from the emergency supply for Resident #25 on 11/26/22 but confirmed the facility had no documentation the resident received a dose of Xanax on 11/27/22. 2. Review of the medical record for Resident #40 revealed an admitted [DATE] with a diagnosis of unspecified intracranial injury. Review of the care plan for Resident #40 dated 10/20/22 revealed resident was at risk for developing complications secondary to being on pain medication therapy related to disease process. Interventions included the following: administer medications as ordered, ask physician to review medication if side effects persist, monitor respiratory rate, depth, and effort after administration of pain medications, monitor for altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus, respiratory distress, sedation, urinary retention. observe for adverse reactions with every interaction with the resident, monitor for increased risk for falls. Review of the MDS assessment for Resident #40 dated 11/16/22 revealed the resident was cognitively impaired and required extensive assistance of one staff with ADL's. Further review of the December 2022 monthly physician orders for Resident #40 revealed an order dated 01/25/22 for the resident to receive Tramadol routinely twice daily for pain. Review of the progress notes for Resident #40 dated 12/02/22 and 12/03/22 revealed the resident's Tramadol was not available for administration. Review of the controlled substance sheets for Resident #40's Tramadol revealed doses for 12/02/22 at 9:00 A.M. and at 9:00 P.M., 12/03/22 at 9:00 A.M. and 9:00 P.M. and 12/04/22 at 9:00 A.M. were not documented as administered. Review of the emergency box records revealed there were no doses of Tramadol pulled for Resident #40 from 12/02/22 to 12/04/22. Interview on 12/09/22 at 12:15 P.M. with RN #130 confirmed routine doses of Tramadol for Resident #40 were not documented as administered on 12/02/22 at 9:00 A.M. and at 9:00 P.M., 12/03/22 at 9:00 A.M. and 9:00 P.M. and 12/04/22 at 9:00 A.M. RN #130 further confirmed she would check the emergency box supply to determine if any doses were pulled from the emergency supply for Resident #40. Interview on 12/09/22 at 3:00 P.M. with RN #130 confirmed the facility had not pulled any doses of Tramadol from the emergency supply for Resident #40 on 12/02/22 through 12/04/22. Review of the facility policy titled administering medications dated April 2019 revealed medications are administered in a safe and timely manner, and as prescribed. This deficiency represents non-compliance investigated under Complaint Number OH00137890.

Based on record review, observation, staff interview, and review of facility policy and procedure for pressure ulcers/skin breakdown, and review of hospital discharge records, the facility failed to ensure one resident received necessary treatment and services to promote healing of an existing pressure ulcer. This resulted in actual harm to Resident (#45) when she was readmitted from the hospital with a Stage three pressure ulcer. The facility failed to implement orders for 11 days and failed to thoroughly assess the pressure ulcer for 20 days. The pressure ulcer increased in stage to an unstageable. This affected one Resident (#45) of six reviewed for pressure ulcers. The facility identified six residents with pressure ulcers. The facility census was 85. Findings include: Resident #45 was originally admitted to the facility in (MONTH) of (YEAR) and readmitted from the hospital on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #45's most recent Minimum Data Set (MDS) assessment dated [DATE] was reviewed revealed the resident had good memory and recall skills, and required extensive assistant of one to two staff persons to complete all activities of daily living (ADL's). She was dependent for bed mobility and transferring from one surface to another. Resident #45 did not walk, and used a wheel chair for mobility in and out of her room. The resident was assessed as having no unhealed pressure sores. Review of Resident #45's hospital discharge records, including the continuity of care (C[NAME]) form, dated 11/22/18 revealed the resident was admitted to the facility on [DATE] with a Stage 3 pressure ulcer to her right ischium. The measurement of the pressure ulcer to the right ischium at discharge was documented as being 5.0 centimeters (cm) in length by 1.0 cm in width, and the depth was unable to determine. The documented treatment to the pressure area at the time of discharge was as follows: cleanse wound with normal saline every three days. Place [MEDICATION NAME] ([MEDICATION NAME] ointment) to wound bed. Place border foam dressing as secondary dressing. Change dressing every three days and as needed. Expect increase in drainage on dressing with use of [MEDICATION NAME] ointment. Review of Resident #45's nursing progress notes on re-admission from the hospital dated 11/22/18 at 5:45 P.M. and completed by Registered Nurse (RN) #509 revealed the resident arrived from the hospital with an open area to her left knee and upper right posterior thigh, both were covered with a dry and intact dressing. Review of Resident #45's nursing re-admission assessment dated [DATE] identified the presence of a pressure ulcer to the resident's right gluteal fold. There was no other assessment of the pressure ulcer i.e. size and depth, presence of exudates or necrotic tissue, or any other information regarding the pressure ulcer or a prescribed treatment. There were no new orders evident in the resident's medical records to indicate the resident's was receiving the hospital prescribed pressure ulcer treatment, or any other treatment at the time of re-admission. Review of Resident #45's nursing progress notes from 11/22/18 through 12/03/18 failed to reveal any documentation of physician notification of the resident having a pressure ulcer to her right ischium. The only evidence of notification was a physician's orders [REDACTED]. Review of Resident #45's nursing progress notes dated 12/03/18 revealed the resident's physician ordered to cleanse the open area to the right gluteal fold with normal saline, apply calcium alginate to the area and dressing every night shift for wound care. The telephone order was confirmed by Licensed Practical Nurse (LPN) #504. Review of Resident #45's nursing progress notes revealed an entry by the wound care nurse, LPN #504 on 12/12/18. LPN #504 documented she was altered by a nurse that Resident #45 had an open area to her right buttock. She noted the Wound Physician was present for rounds this date and assessed the area with LPN #504 present. LPN #504 documented there was an unstageable pressure injury to the resident's right ischial tuberosity. The resident stated she did not know the area was there, and that it started bothering her earlier today. LPN #504 documented the Wound Physician would follow the resident weekly for wound management, new orders were initiated, and new orders were also received for a low air loss mattress, and several laboratory tests. She noted the resident's primary care physician and family were also made aware. LPN #504 also documented she alerted therapy to evaluate Resident #504's wheelchair positioning as the resident preferred to be up in her wheelchair all day and for all meals, to ensure proper positioning in the wheel chair. Review of Wound Physician's progress notes for Resident #45 dated 12/12/18 revealed physician assessment of the pressure ulcer. The physician documented the pressure ulcer stage as unstageable (depth obscured) with measurements and description as follows: 5.5 centimeters (cm) in length by 3.1 cm in width. The physician described the wound bed composition as 15% granulation, 15% slough, and 70% eschar. He noted the wound onset date as 11/23/18. Review of Resident #45's nursing progress notes dated 12/27/18 and completed by LPN #504 revealed the resident was not seen by the wound Physician yesterday (12/26/18) due to being at therapy at the time he was here. She documented she assessed the pressure ulcer and noted an increase in the measurement to the wound with slough/eschar covering with a small amount of granulation at the edges. LPN #504 noted the wound had moist and boggy slough, and it was currently being treated with Santyl (a [MEDICATION NAME] ointment). She noted there was no drainage noted to the previous dressing, and there was a slight odor. On 01/22/19, at 3:00 P.M., at completion of an interview with Resident #45 it was observed the control box for the resident's specialty low air loss mattress (for pressure ulcer prevention/improvement) was making a beeping noise. RN #509 was asked to come to the resident's room to check the control box. RN #509 looked at the control panel and stated the bed firmness was set for someone that was 300 pounds. She stated the control panel was to be set for the resident's weight, she would check her current weight and set it accordingly. Review of Resident #45's medical record revealed the resident stood five feet six inches tall and weighed 132 pounds. On 01/24/19 at 1:57 P.M. LPN #504 was observed to perform the physician ordered treatment to Resident #45's pressure ulcer. There was a low air loss mattress to the bed. The resident was positioned on her left side, and her right ischium was cleansed with normal saline. Observation of the pressure sore revealed an approximate two inch diameter unstageable pressure sore of which 50% of the wound was covered with tan slough. There was some odor from the wound, but no other signs or symptoms of infection. LPN #504 applied skin prep around the wound, a [MEDICATION NAME] ointment was applied to the wound bed, and the wound covered with moistened saline gauze followed by a wound pad. The resident was observed to be comfortable throughout the procedure. An interview was conducted with LPN #504 on 01/24/19 at 2:31 P.M. regarding Resident #45's pressure ulcer and when it was first noted. She explained nursing staff were originally identified the location as the right gluteal fold on 11/22/18, as the electronic health record did not include right ischial tuberosity as an option when identifying the location of the wound. LPN #504 reported the resident's pressure ulcer on her right ischial tuberosity was present when she was readmitted to the facility after a hospitalization on [DATE]. She reported the pressure ulcer was not measured or thoroughly assessed until 12/12/18 when she was made aware and the Wound Physician saw the resident. LPN #504 reported the procedure was to observe and measure the pressure ulcer weekly which was not done until 12/12/18. A follow-up interview was conducted with LPN #504 on 01/24/19 at 3:08 P.M. regarding when the pressure ulcer to the resident's right ischium was first treated and the attending physician notified of the presence of Resident #45's pressure ulcer. She reported that LPN #614 did contact the resident's physician for a treatment order on 12/03/18, but again affirmed there was no documentation to support the resident's physician was notified regarding the presence of the pressure ulcer or a pressure ulcer treatment in place until 12/03/18. LPN #504 when queried again regarding when thorough assessment and documentation of the resident's pressure ulcer occurred she reported that it was not until 12/12/18. When queried as to why it took so long between discovering an open area, alerting the physician, and obtaining a treatment, LPN #504 reported there had recently been a transition away from her doing all the pressure ulcer dressing changes. She stated now staff nurses were performing wound treatments on their own residents, and conjectured that when this occurred some nurses might have been under the assumption that she (LPN #504) was still obtaining and performing all wound care treatments, which was not the case. The facility's policy and procedure titled Pressure Ulcers/Skin Breakdown-Clinical Protocol was requested and reviewed. Review of the assessment and recognition section of the procedure specified in reference to assessing pressure ulcers, that the nurse shall describe and document full assessment of the pressure sore including location, stage, length, width, depth and the presence of exudates or necrotic tissue. In addition, the nurse was to completed a assessment of the resident's pain, mobility status, current treatments, support surfaces, and all active diagnoses. The procedure specified that staff will examine the skin of a new admission for ulcerations or alterations in skin within two hours of admission. The physician will assist the staff to determine etiology and characteristics of the skin alteration.

Based on medical record review, staff interview, resident interview and review of a facility policy, the facility failed to ensure a resident was provided with appropriate assistance during transfers resulting in an avoidable fall. This resulted in actual harm for one resident (#2) when staff attempted to utilize a sit to stand mechanical lift requiring two staff members and only one staff member was present. Consequently, Resident #2 landed on the floor and sustained a left [MEDICAL CONDITION]. This affected one (#2) of three residents reviewed for falls. The facility identified 16 residents who required mechanical lifts for assistance for transfer and / or bed mobility. The facility census was 88. Findings include: Review of Resident #2's medical record revealed a readmission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of Resident #2's quarterly fall assessments dated 01/24/17, 04/06/17, 07/10/17, and 03/07/18 indicated the resident was assessed at high risk for falls. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was noted to have severe cognitive impairment, moved or spoke slowly and or was noted as fidgety or restless. Continued MDS review for Resident #2 revealed she required total staff assistance for bed mobility, transfers, locomotion on and off the unit, toileting, and personal hygiene. She was assessed to require extensive assistance with dressing and eating. Resident #2's plan of care included an Activities of Daily Living (ADL) care plan deficit related to limited mobility and muscle weakness which indicated the resident was dependent times two for transfers using mechanical lift, may use sit to stand. Review of the (MONTH) (YEAR) physician order [REDACTED].#2 revealed an order indicating staff may use a Hoyer (mechanical) lift for all transfers as needed with staff assist of two, resident able to use sit to stand at times. Review of the progress notes for Resident #2 dated 10/23/18 at 6:15 A.M., revealed while attempting to put on the stand up lift, the resident slid off the bed which resulted in State tested Nurse Aide (STNA) #1 having to lower the resident to the floor safely. The floor was documented as being dry, the room well lit, the roommate was present and attempted to help. Resident #2 was alert and oriented, vital signs were stable, no injury noted, and the resident was assisted by three staff members into the wheelchair. Review of a progress note late entry dated 10/25/18 at 5:11 P.M. by Licensed Practical Nurse (LPN) #10 revealed STNA #1, informed the nurse Resident #2 slid off the bed while the STNA was putting a Hoyer (pad to assist with transfers) underneath her and the STNA #1 had to lower the resident onto the floor. Per the STNA, the roommate attempted to help as she lowered resident onto the floor from the bed. The nurse entered the room and witnessed the resident laying on the floor supine tilted on her right side with her back leaning against the bed and resting on the metal portion of the bedside table. Vital signs were stable, range of motion to extremities was assessed as within normal limits. The nurse and another STNA waited at the bedside while STNA #1 went to find the right size Hoyer pad for the resident. The resident was transferred safely from the floor into the wheelchair with three staff members and denied pain at that time. Review of Resident #2's x-ray results dated 10/25/18 indicated the resident had a left intertrochanteric fracture with mild displacement. Review Resident #2's hospital discharge note dated 10/30/18 revealed the resident was admitted to the hospital on [DATE] for a closed left intertrochanteric femur fracture with surgery for [REDACTED]. The resident was discharged back to the facility on [DATE]. Interview on 10/30/18 at 10:05 A.M. with Resident #2's roommate (Resident #10) revealed she as in the room the day of Resident #2's incident. Resident #2 had been sitting on the edge of the bed and there was only one STNA in the room at the time of the incident. Resident #10 stated Resident #2 started leaning forward, slid off the edge of the bed and STNA #1 and Resident #10 were the only ones in the room. Resident #2 slid off and landed on her left hip. Resident #10 stated usually two STNA's work together to assist Resident #2 but that time, only STNA #1 was there working with Resident #2. Resident #10 stated STNA #1 asked Resident #10 for help. Resident #10 stated after Resident #2 slid off the bed two STNA's came in to help and a couple days later Resident #2 went out to the hospital. Interview on 10/30/18 at 10:25 A.M. with Registered Nurse (RN) #5 verified Resident #2 was not able to get in and out of bed independently and required transfers via a mechanical lift. RN #5 also verified the lift required a minimum of two staff assistance. RN #5 stated she spoke to Resident #2 a day after the incident that occurred on 10/23/18. RN #5 stated Resident #2 complained of leg pain. Upon assessment, Resident #2 didn't want the RN to touch her left leg. RN #5 contacted the physician for an x-ray. The first x-ray showed no fracture but needed to be repeated as the x-ray technician explained to her the prior X-ray had been rejected. RN #5 stated the repeat X-ray showed a [MEDICAL CONDITION]. RN #5 notified the physician and Resident #2 was sent to the local hospital. Interview on 10/30/18 at 12:45 P.M. with Therapy Manager (TM) #88 revealed Resident #2 couldn't get out of bed independently. TM #88 stated at one time the resident required a Hoyer lift, but had graduated to a sit to stand mechanical lift. TM #88 indicated two staff personnel were required to use a mechanical lift (Hoyer or Sit to stand) and verified for one staff person to use a mechanical lift (Hoyer or Sit to stand) was deemed unsafe. Interview on 10/30/18 at 1:00 P.M with the Director of Nursing (DON), revealed on 10/23/18 STNA #1 was in the process of trying to get Resident #2 to the sit to stand lift and the resident was sitting on the edge of the bed with the sit to stand lift in front of the resident and the sling behind the resident, but not yet connected. Resident #2 began to slide off the bed and was lowered to the floor per STNA #1. The DON verified STNA #1 was by herself with no other staff present. The DON further stated on 10/24/18 an x-ray of Resident #2's hip, pelvis and femur was obtained due to her pain as the nurse had noticed a change in her condition. On 10/25/18 at 12:27 P.M. with a pain score of 10 out of 10, Resident #2 received a dose of [MEDICATION NAME] (pain medication) 50 milligrams (mg) by mouth. On 10/25/18, the results of the repeat x-ray revealed a left [MEDICAL CONDITION] and osteopenia. The DON also verified the resident was sent to the local hospital and required surgery for [REDACTED]. Review of facility policy titled Lifting Machine, Using a Mechanical revised (MONTH) (YEAR) stated at least two nursing assistants are needed to safely move a resident with a mechanical lift. This deficiency substantiates Complaint Number OH 879.