Every finding on record at Logan Elm Health Care Center

Based on medical record review and staff interview, the facility failed to ensure pre-admission screening and resident review (PASARR) was completed and updated to reflect a new qualifying diagnosis for a resident. This affected one (#5) of one resident reviewed for PASARR. The facility census was 88.Findings include:Record review for Resident #5 revealed the resident was admitted to the facility on [DATE]. Diagnoses included vascular dementia, hallucinations, and depression. Review of current and active diagnoses included a new diagnosis of unspecified psychosis not due to a substance or known physiological condition was added on 03/18/25.Review of the most recent PASARR documentation provided by the facility for Resident #5 revealed it was completed prior to admission on [DATE], with no further documentation which reflected the addition of the new diagnosis.Interview with Social Services Director #370 on 03/09/26 at 3:32 P.M. verified the last PASARR for Resident #5 was completed on 08/07/24. She verified a new diagnosis of unspecified psychosis was added on 03/18/25, and a new PASARR had not been completed.

Based on observation, staff interview, and policy review, the facility failed to store their food in a manner that protects against contamination and spoilage. This had the potential to affect 78 out of 81 resident residing in the facility with three residents on nothing by mouth (NPO) diets. The facility census was 81. Findings include: During the initial kitchen observation on 02/03/25, from 9:30 A.M. to 9:55 A.M., conducted with Dietary Supervisor #39, the following unlabeled and undated food items were observed in the freezer: 16 frozen pizzas (unlabeled and undated) 2 unidentified logs of meat (unlabeled and undated) 3 bags of chicken strips (unlabeled and undated) 3 bags of vegetables (unlabeled and undated) Further observation of the dry storage area revealed: 13 open pie crusts (unlabeled and undated) 3 bags of granola (unlabeled and undated) 1 bag of marshmallows with a manufacturer's use-by date of 12/01/24 Interview with Dietary Supervisor #39 confirmed that all observed food items should have been labeled and dated according to facility policy. Review of the facility ' s Date Marking for Food Safety policy states the following: All food shall be clearly marked to indicate the date or day by which it must be consumed or discarded. The individual opening or preparing a food item shall be responsible for date marking it at the time of opening or preparation. The marking system shall include a color-coded label, the date of opening, and the discard date. The discard date must not exceed the manufacturer ' s use-by date or four days, whichever is earliest. The date of opening or preparation counts as day one.

Based on staff interview, observation, and record review, the facility failed to ensure residents attended activities that meets their needs. This affected one (Resident #13) of one resident reviewed for activities. The facility census was 80. Findings include: Record review of Resident #13 revealed an admitted [DATE] with pertinent diagnoses of: hereditary ataxia, personal history of pulmonary embolism, dietary counseling and surveillance, acute pulmonary edema, vascular dementia, abnormal posture, muscle wasting and atrophy, muscle weakness, major depressive disorder, frequency of micturition, dry eye syndrome, presence of functional implant, osteoarthritis, restlessness and agitation, hypothyroidism, hypertension, insomnia, hyperlipidemia, osteopetrosis, dysphagia, anxiety disorder, gastrostomy status, and vascular dementia. Review of the 12/09/24 quarterly Minimum Data Set (MDS) assessment revealed the resident was severely cognitively impaired and was dependent for activities of daily living. Review of the 03/04/24 activity plan of care revealed Resident #13 needs one-on-one intervention to promote sensory and social stimuli, resident non verbal. The goal was is will respond with range of eye contact, holding sensory items, verbal response, facial expression (smile, frown), eye contact, move with the music. Observations on 02/04/25, 02/05/25 and 02/06/25 revealed Resident #13 was not seen in group activities or one on one activities. Review of Resident #13 activity log from 12/01/24 to 1/31/25 revealed Resident #13 was documented as attending one activity during the two month time frame. Interview with Activity Personnel #9 on 02/06/25 at 8:37 A.M. verified Resident #13 was documented as only having one activity completed from 12/01/24 to 1/31/25.

Based on record review, staff interview, and resident observation, the facility failed to maintain accurate medical records for Resident #21. This affected one (Resident #21) out of 24 residents whose medical records were reviewed. The facility census was 81. Findings include: Review of Resident #21 ' s medical record revealed an admitted [DATE] with diagnoses including unspecified dementia, anxiety disorder, cognitive communication deficit, essential tremor, cerebral infarction (unspecified), history of transient ischemic attack (TIA), history of other diseases of the nervous system, muscle weakness, unsteadiness on feet, abnormalities of gait and mobility, and need for assistance with personal care. Review of the annual Minimum Data Set (MDS) 3.0 assessment, completed on 01/01/25, documented a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. Review of physician orders for Resident #21 revealed an order for honey zinc cream to the buttocks every four hours and with incontinence episodes, with a start date of 09/14/24. Review of progress notes revealed a skin note dated 09/12/24 at 4:09 P.M., documenting that a restorative certified nursing aide (CNA) called a nurse into Resident #21 ' s room to assess a newly identified area on the left buttock. The note described a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister) pressure ulcer on the left buttock measuring 3.8 cm x 2.2 cm x 0.1 cm, with blanchable redness to the surrounding area and right buttock. Review of skin assessments showed that weekly skin assessments were completed on 09/23/24, 09/30/24, 10/07/24, 10/14/24, 10/21/24, 10/28/24, 11/04/24, 11/11/24, 11/18/24, 11/25/24, 12/02/24, 12/09/24, 12/16/24, 12/26/24, 12/30/24, 01/09/25, 01/13/25, 01/20/25, and 01/27/25. Each of these assessments documented the Stage II pressure ulcer with the same measurements (3.8 cm x 2.2 cm x 0.1 cm) and described it as a partial-thickness skin loss with exposed dermis. Interview on 02/05/25 at 2:28 P.M. with Registered Nurse (RN) #169 revealed that Resident #21 ' s pressure ulcer had healed within a few days of its identification in September and was reclassified as Moisture-Associated Skin Damage (MASD) by the week of 09/16/24. RN #169 stated she was unsure why the weekly skin assessments continued to document an active Stage II pressure ulcer. She confirmed that the continued documentation of an unhealed Stage II pressure ulcer in the medical record was inaccurate. Observation on 02/05/25 at 3:00 P.M. by a surveyor confirmed that Resident #21 did not have an active pressure ulcer. The surveyor observed redness on the buttocks, and a nurse applied honey zinc cream per physician orders.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, facility Self-Reported Incident (SRI) review, staff interview, and facility policy review, the facility failed to ensure residents were free from neglect. The facility failed to ensure residents (Resident #22, #48, #76, and #94) received medication as ordered. In addition, the facility failed to ensure residents (Resident #74 and #128) were assisted out of bed for scheduled smoking breaks, and residents were provided incontinence care in a timely manner. This affected six residents (Resident #22, #48, #76, #94,#74 and #128) out of six residents reviewed for medication administration and abuse/neglect. The facility census was 84. Findings include: 1. Review of the medical record for Resident #22 revealed an admitted [DATE]. Diagnoses included multiple sclerosis, bipolar disorder, and anxiety disorder. Review of the electronic medication administration record (EMAR) for Resident #22 revealed during the evening (8:00 P.M.) on 02/23/24 and 02/26/24 the following medication was scheduled to be administered and were documented by Licensed Practical Nurse (LPN) #38 to be administered: Depakote Oral tablet Delayed Release 250 milligram (mg), give one capsule by mouth at bedtime for bipolar disorder, Melatonin oral tablet, give 3 mg by mouth at bedtime for insomnia, and Venlafaxine Hydrochloride (HCL) tablet, give 50 mg by mouth at bedtime for depression. 2. Review of the medical record for Resident #48 revealed an initial admitted [DATE] and a re-entry date of 02/04/24. Diagnoses included chronic obstructive pulmonary disease, hypothyroidism, type two diabetes, and heart failure. Review of Resident #48's EMAR for evening medication (8:00 P.M.) that were scheduled to be administered 02/23/24 and 02/26/24 and were documented by the nurse to be administered by LPN #48 included: Atorvastatin Calcium oral tablet 40 mg, give one tablet by mouth at bedtime for hyperlipidemia, Pantoprazole Sodium oral tablet delayed release 20 mg, give one tablet by mouth at bedtime for gastroesophageal reflux disease (GERD), Primidone oral tablet, give 100 mg by mouth at bedtime for hand tremors, and Zinc oral tablet 50 mg, give one tablet by mouth at bedtime for supplement. 3. Review of the medical record for Resident #76 revealed an admitted [DATE]. Diagnoses included hyperlipidemia, heart failure, and major depressive disorder. Review of the EMAR for Resident #76 with medication scheduled in the evening hours (8:00 P.M.) administered 02/23/24 and 02/26/24 included documentation by LPN #48 that medication were administered included: Atorvastatin Calcium oral tablet, give 40 mg by mouth at bedtime for hyperlipidemia, Gabapentin oral capsule, give 300 mg by mouth at bedtime for pain, and Sucralfate oral tablet, give 1 gram by mouth four times a day for GERD. 4. Review of the medical record for Resident #94 revealed an initial admitted [DATE] and a re-entry date of 02/02/24. Diagnoses included dementia, hyperlipidemia, depression, and GERD. Review of Resident #94's EMAR for the evening hours (8:00 P.M.) for 02/23/24 and 02/26/24 revealed the following medication was documented by LPN #48 as being administered: Donepezil HCL oral tablet 10 mg, give one tablet by mouth at bedtime for dementia, Pravastatin Sodium oral tablet 20 mg, give one tablet by mouth at bedtime for high cholesterol, and Metformin HCL oral tablet 1000 mg, give one tablet by mouth two times a day for diabetic mellitus. Review of the SRI number 244727 revealed an allegation of neglect. Residents involved included Resident #22, #48, #76, and #94 with no noted ill effects. During a medication audit, it was discovered that a nurse did not administer certain medications as ordered by the physician. The employee was questioned and was terminated from her employment with the facility, additionally the Ohio Board of Nursing was notified. Review of SRI statements revealed that on 02/07/24 the Director of Nursing (DON) was notified by Registered Nurse (RN) #10 of a concern that three residents were stating they were not receiving their medications, in particular their Synthroid (medication used to treat a condition called hypothyroidism or low thyroid). Upon review of the EMAR, all medications were signed off by the assigned nurse, LPN #48 as given. Review of the SRI investigation timeline revealed that on 02/07/24 a statement from a RN #10 regarding concerns for medications being passed on Elm hallway/night shift by a specific nurse LPN #48. On 02/09/24, a resident's treatment on Elm hallway was signed off but not completed by LPN #48. On 02/14/24, Resident #22's ( who resided on Elm hallway) Depakote (a anticonvulsant medication) level received and showed a low result. This prompted medication audits on the cart, as resident's larger Depakote dose is administered on night shift. On 02/22/24, nurse medication administration audit started (night shift scheduled medications selected on 5 different residents on Elm hallway) as this was the first time said nurse worked a shift where medication could be correctly counted and monitored. On 02/23/24, medications were counted and discrepancies were noted but may not have been 100% accurate as medications were filled/received from pharmacy. On 02/26/24 the nurse medication audit continued. On 02/27/24, the medications were counted with discrepancies with LPN #48 and LPN #48 was suspended pending further investigation. Continued review of the facility's SRI investigation revealed Resident #76 did not received Mirtazapine 7.6 mg, Resident #94 did not receive scheduled medication Pravastatin 20 mg and Donepezil 10 mg, Resident #48 did not receive Primidone 100 mg, and Resident #22 did not receive scheduled Depakote 250 mg. All medication was ordered to be administered at 8:00 P.M. and was not administered on 02/23/2024 and 02/26/2024. Interview on 03/28/24 with the DON revealed when she was made aware of the concern that medication was not being administered, a medication administration audit and medication cart audit was started. Before the evening shift on 02/23/24 and 02/26/24 the evening medications for noted residents were counted to see how many medication remained, then the next morning a count was completed again and was noted to be the same where if the medication was administered, there should be one missing from the medication card. The DON claimed she personally spoke with LPN #48 who confirmed she did not administer the medication and could not give a clear explanation as to why she did not administer the medication and only claimed she had a lot going on at home. All residents affected by this incident were assessed and the Medical Director completed their own assessment and labs were checked with no negative outcome. LPN #48 was released from her duties and the incident was reported to Ohio Department of Health and Ohio Board of Nursing. Review of the facility policy titled 5 Rights of Medication Use. no date noted revealed When passing medication, make sure we are practicing the 5 Rights', look at the resident's picture/room number, read the drug label (verify x 3) for the correct medication/dose/route against the order in the MAR, check the physician's order is in the chart. Make sure medications are passed at the time they are scheduled to be gives. 5. Review of the medical record for Resident #74 revealed an admitted [DATE]. Diagnoses included anxiety, type two diabetes, and cellulitis of the left lower extremity. Review of Resident #74's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental status (BIMS) score of 15 out of 15 indicating an intact cognition for daily decision-making abilities. 6. Review of the medical record for Resident #128 revealed an admitted [DATE]. Diagnoses included muscle weakness, unsteadiness on feet, and depression. Review of Resident #128's quarterly MDS 3.0 assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating an intact cognition for daily-decision making ability. Review of the facility's SRI dated 03/08/24 revealed an allegation of emotional/verbal abuse allegation noting that a staff member made some inappropriate remarks about a couple of patients to staff. State tested Nursing Assistant (STNA) #50 intentionally deceived a patient by stating that smoking was canceled so she did not have to get her up. STNA #50 admitted this to a co-worker and asked the co-worker to also deceive the patient and support her story that smoking was canceled. Smoking had not been canceled as weather conditions were appropriate and within the smoking policy guidelines. During the course of the investigation, it was also discovered that in addition to failing to get this patient up, STNA #50 also did not provide incontinence care to another patient who had to wait an extended period of time for someone to help her. These two different residents labeled STNA #50 as having a bad attitude and was snotty STNA #50 is a weekend only staff member and was placed on suspension on 03/08/24 when this incident was brought to the attention of the DON. STNA #50 had not worked since the date of the incident. Interview and statements were obtained from staff working that day who may have had insight into the incident. Additionally, a skin assessment on all patients with a BIMS of 9 or less was completed by the wound nurse and all residents with a BIMS of 10 or above was interviewed. Also, all staff were re-educated regarding the abuse policy. The two nurses initially involved in the complaint were counseled and educated by the administrator on timely reporting of any suspicion of abuse. After the investigation was completed, the facility substantiated the allegation. It was determined by the facility investigator that verbal abuse could not be substantiated, however it was felt that STNA #50's failure to get a patient up and provide incontinence care to another patient was grounds for termination. The failure to provide the care for patients' needs is substantiated. Review of the resident interview completed on 03/11/24 with Resident #74 revealed the following questions and answers. Has a staff member ever refused to provide care for you? No. Do you feel safe here? Yes. Has anyone ever mistreated you? Yes, refused to change. Review of the resident interview completed on 03/11/24 with Resident #128 revealed the following questions and answers. Has a staff member ever refused to provide care for you? Yes. Do you feel safe here? Yes. Has anyone ever mistreated you? No. Review of a staff statement completed by LPN #68 dated 03/08/24 revealed STNA #50 consistently has a negative attitude with residents, she has left call lights unanswered for 30-45 minutes and when investigated by nurse, both aides were found sitting in the lounge on the hall. STNA #50 has admitted to lying to residents about activities and not taking resident who smoke out so she did not have to get this resident out of bed. Residents have confronted this STNA multiple times on the amount of time it has taken her to answer call lights leaving them soaked in urine and stool for over an hour. She stated to this resident that she has other people to take care of which caused this resident to become agitated. STNA #50 then walked out of the residents room for another 30 plus minutes until the nurse answered the call light and was informed by the resident and got aides from lounge to change the resident. Review of the staff statement completed by Activity Assistant #3 created on 03/08/24 revealed that on Sunday 03/03/24, Activity Assistant was walking inside from taking residents who smoke out for the 9:30 A.M. smoke break and was walking passed STNA #50 and told me that if Resident #128 asks if the resident who smoke went out to smoke at 9:30 A.M. to tell her no. Activity Assistant #3 then asked why and STNA #50 replied because I told her you guys didn't do out to smoke so I didn't have to get her up. Activity Assistant #3 reported what was said to the nurse that day. Review of staff statement created by the DON on 03/08/24 revealed, that the DON interviewed Resident #128 and asked if she was concerned with the care she received at the facility. Resident #128 stated that she sometimes wants to be gotten up for the smoking times and is not always able to get up out of bed. Resident #128 stated that on 03/03/24 that she was not gotten up for the 9:30 A.M. smoking time and that she wanted to. Resident #128 stated that overall, she received good care but that STNA #50 has a bad attitude and does not like to get her up. Review of staff statement created by DON on 03/08/24 revealed, the DON interviewed Resident #74 and asked if she was concerned with the care she received at the facility. Resident #74 stated that she only had had one problem and that was that she did not receive care timely from STNA #50. Resident #74 stated that on the weekend of 03/02/24 and 03/03/24 STNA #50 refused to change her and walked out and after about 40 minutes a nurse came in her room and she reported the issue to the nurse and the nurse provided incontinence care. Review of the staff statement completed by RN #80 dated 03/11/24 revealed On Sunday 03/03/24, RN #80 was the supervisor. Activity Assistant #3 told RN #80 that earlier in the day for the 9:30 A.M. smoke break that STNA #50, the staff member on Elm stated that she told Resident #128 that they weren't going out to smoke so that she didn't have to get her up and laughed. STNA #50 claimed she did not say that and that Resident #128 was asleep. RN #80 revealed she didn't hear anymore about it until Friday 03/15/24 when another staff member stated that after the 3:30 P.M. smoke break on Sunday 03/03/24 STNA #50 refused to assist Resident #128 back into bed and she had an episode of incontinence that was not cleaned up for three hours. Review of the facility's SRI summary of events included: the Administrator was notified on 03/08/24 and initial SRI completed. The alleged employee, STNA #50 was placed on suspension pending investigation. The allegation of abuse was that this employee voiced inappropriate things to staff and purposefully lied to a resident about smoking so that she would not have to get this resident up. During initial reporting, it was noted also that this same aide failed to provide incontinence care to another resident who had to wait and have the service provided by a nurse. Statements from co-workers present at the time of the incident were obtained on 03/08/24. The DON completed interviews with both residents identified on 03/8/24. Both residents indicated they feel safe in the facility but both also reported that the aide in question, STNA #50 was 'snotty' and had a bad attitude. STNA #50 was released from employment for failure to get a patient up and to provide incontinence care. Interview on 03/28/24 at 2:00 P.M. with the DON confirmed STNA #50 was terminated from the facility due to her attitude and failure to provide incontinence care to residents. Review of facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, no date noted revealed Resident have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. The deficient practice was corrected on 03/13/24 when the facility implemented the following corrective actions: On 02/27/24, LPN #48 was suspended pending further investigation from DON and Administrator. On 03/01/24, LPN #48 was terminated and was reported to the Ohio Board of Nursing per DON and Administrator. On 03/01/24, A Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON, and MD and the residents who were affected by the failure to administer the medications were reviewed with the facilities response to the incident including but not limited to: Investigation including interviews with alert residents, SRI completion, suspension of employee, termination of employee, Education of nursing staff on Medication administration-provided to QA Committee, Medication Audits, and Our Abuse Policy review with staff. On 03/04/24, Skin assessments were completed by Wound Nurse #100 on all residents with a BIMS of 9 or less and all residents were interviewed by the DON on timely medication administration and care concerns. On 03/04/24, Weekly medication audits 3 times a week for 4 weeks and then monthly x 3 thereafter per the DON. On 03/04/24, STNA #50 was placed on suspension per the DON and Administrator. On 03/05/24, Education was done to all licensed nurses on the 5 rights of medication usage/standard for safe medication practices also on abuse timing and reporting per the DON. On 03/06/24, the Medical Director assessed each affected resident and labs were completed with no concerns. On 03/06/24, an all staff meeting was held and abuse policy was reviewed at this time per Administrator. On 03/11/24 and 03/12/24, Residents were assessed and interviewed on feeling safe, being refused care and any mistreatments from staff by the Social Service Designee. On 03/12/24, Call light audit 3 times a week for 4 weeks then monthly for 2 months to be completed by the DON or designee. On 03/12/24, Audit on smokers gotten up timely to smoke 3 times a week for 4 weeks then monthly times 2 months by the DON or designee. On 03/12/24, a mass text message was sent by the Administrator to all staff members regarding abuse and the importance of reporting abuse directly to the supervisor, DON, and Administrator. On 03/12/24, STNA #50 was terminated by the Administrator. On 03/13/24, education continued to all staff on abuse and timely reporting abuse by the DON and designee. This deficiency represents non-compliance investigated under Complaint Number OH00151648.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on self-reported incident (SRI) review, staff interview, and facility policy review, the facility failed to timely report a staff member refusing to provide timely care and assistance out of bed. This affected two (Resident #74 and #128) of the six residents reviewed for timely reporting of incidents. The facility census was 84. Findings include: 1. Review of the medical record for Resident #74 revealed an admitted [DATE]. Diagnoses included anxiety, type two diabetes, and cellulitis of the left lower extremity. Review of Resident #74's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental status (BIMS) score of 15 out of 15 indicating an intact cognition for daily decision-making abilities. 2. Review of the medical record for Resident #128 revealed an admitted [DATE]. Diagnoses included muscle weakness, unsteadiness on feet, and depression. Review of Resident #128's quarterly MDS 3.0 assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating an intact cognition for daily-decision making ability. Review of the facility's SRI dated 03/08/24 revealed an allegation of emotional/verbal abuse allegation noting that a staff member made some inappropriate remarks about a couple of patients to staff. State tested Nursing Assistant (STNA) #50 intentionally deceived a patient by stating that smoking was canceled so she did not have to get her up. STNA #50 admitted this to a co-worker and asked the co-worker to also deceive the patient and support her story that smoking was canceled. Smoking had not been canceled as weather conditions were appropriate and within the smoking policy guidelines. During the course of the investigation, it was also discovered that in addition to failing to get this patient up, STNA #50 also did not provide incontinence care to another patient who had to wait an extended period of time for someone to help her. These two different residents labeled STNA #50 as having a bad attitude and was snotty STNA #50 is a weekend only staff member and was placed on suspension on 03/08/24 when this incident was brought to the attention of the Director of Nursing (DON). STNA #50 had not worked since the date of the incident. Interview and statements were obtained from staff working that day who may have had insight into the incident. Additionally, a skin assessment on all patients with a BIMS of 9 or less was completed by the wound nurse and all residents with a BIMS of 10 or above was interviewed. Also, all staff were re-educated regarding the abuse policy. The two nurses initially involved in the complaint were counseled and educated by the administrator on timely reporting of any suspicion of abuse. After the investigation was completed, the facility substantiated the allegation. It was determined by the facility investigator that verbal abuse could not be substantiated, however it was felt that STNA #50's failure to get a patient up and provide incontinence care to another patient was grounds for termination. The failure to provide the care for patients' needs is substantiated. Review of the resident interview completed on 03/11/24 with Resident #74 revealed the following questions and answers. Has a staff member ever refused to provide care for you? No. Do you feel safe here? Yes. Has anyone ever mistreated you? Yes, refused to change. Review of the resident interview completed on 03/11/24 with Resident #128 revealed the following questions and answers. Has a staff member ever refused to provide care for you? Yes. Do you feel safe here? Yes. Has anyone ever mistreated you? No. Review of a staff statement completed by Licensed Practical Nurse (LPN) #68 dated 03/08/24 revealed STNA #50 consistently has a negative attitude with residents, she has left call lights unanswered for 30-45 minutes and when investigated by nurse, both aides were found sitting in the lounge on the hall. STNA #50 has admitted to lying to residents about activities and not taking resident who smoke out so she did not have to get this resident out of bed. Residents have confronted this STNA multiple times on the amount of time it has taken her to answer call lights leaving them soaked in urine and stool for over an hour. She stated to this resident that she has other people to take care of which caused this resident to become agitated. STNA #50 then walked out of the residents room for another 30 plus minutes until the nurse answered the call light and was informed by the resident and got aides from lounge to change the resident. Review of the staff statement completed by Activity Assistant #3 created on 03/08/24 revealed that on Sunday 03/03/24, Activity Assistant was walking inside from taking residents who smoke out for the 9:30 A.M. smoke break and was walking passed STNA #50 and told me that if Resident #128 asks if the resident who smoke went out to smoke at 9:30 A.M. to tell her no. Activity Assistant #3 then asked why and STNA #50 replied because I told her you guys didn't do out to smoke so I didn't have to get her up. Activity Assistant #3 reported what was said to the nurse that day. Review of staff statement created by the DON on 03/08/24 revealed, that the DON interviewed Resident #128 and asked if she was concerned with the care she received at the facility. Resident #128 stated that she sometimes wants to be gotten up for the smoking times and is not always able to get up out of bed. Resident #128 stated that on 03/03/24 that she was not gotten up for the 9:30 A.M. smoking time and that she wanted to. Resident #128 stated that overall, she received good care but that STNA #50 has a bad attitude and does not like to get her up. Review of staff statement created by DON on 03/08/24 revealed, the DON interviewed Resident #74 and asked if she was concerned with the care she received at the facility. Resident #74 stated that she only had had one problem and that was that she did not receive care timely from STNA #50. Resident #74 stated that on the weekend of 03/02/24 and 03/03/24 STNA #50 refused to change her and walked out and after about 40 minutes a nurse came in her room and she reported the issue to the nurse and the nurse provided incontinence care. Review of the staff statement completed by RN #80 dated 03/11/24 revealed On Sunday 03/03/24, RN #80 was the supervisor. Activity Assistant #3 told RN #80 that earlier in the day for the 9:30 A.M. smoke break that STNA #50, the staff member on Elm stated that she told Resident #128 that they weren't going out to smoke so that she didn't have to get her up and laughed. STNA #50 claimed she did not say that and that Resident #128 was asleep. RN #80 revealed she didn't hear anymore about it until Friday 03/15/24 when another staff member stated that after the 3:30 P.M. smoke break on Sunday 03/03/24 STNA #50 refused to assist Resident #128 back into bed and she had an episode of incontinence that was not cleaned up for three hours. Review of the facility's SRI summary of events included: the Administrator was notified on 03/08/24 and initial SRI completed. The alleged employee, STNA #50 was placed on suspension pending investigation. The allegation of abuse was that this employee voiced inappropriate things to staff and purposefully lied to a resident about smoking so that she would not have to get this resident up. During initial reporting, it was noted also that this same aide failed to provide incontinence care to another resident who had to wait and have the service provided by a nurse. Statements from co-workers present at the time of the incident were obtained on 03/08/24. The DON completed interviews with both residents identified on 03/8/24. Both residents indicated they feel safe in the facility but both also reported that the aide in question, STNA #50 was 'snotty' and had a bad attitude. STNA #50 was released from employment for failure to get a patient up and to provide incontinence care. Interview on 03/28/2024 at 2:00 P.M. with the DON confirmed STNA #50 was terminated from the facility due to her attitude and failure to provide incontinence care to residents. Review of facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, no date noted revealed Facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health (ODH) in accordance with the procedure in this policy. The deficient practice was corrected on 03/13/24 when the facility implemented the following corrective actions: On 02/27/24, LPN #48 was suspended pending further investigation from DON and Administrator. On 03/01/24, LPN #48 was terminated and was reported to the Ohio Board of Nursing per DON and Administrator. On 03/01/24, A Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON, and MD and the residents who were affected by the failure to administer the medications were reviewed with the facilities response to the incident including but not limited to: Investigation including interviews with alert residents, SRI completion, suspension of employee, termination of employee, Education of nursing staff on Medication administration-provided to QA Committee, Medication Audits, and Our Abuse Policy review with staff. On 03/04/24, Skin assessments were completed by Wound Nurse #100 on all residents with a BIMS of 9 or less and all residents were interviewed by the DON on timely medication administration and care concerns. On 03/04/24, Weekly medication audits 3 times a week for 4 weeks and then monthly x 3 thereafter per the DON. On 03/04/24, STNA #50 was placed on suspension per the DON and Administrator. On 03/05/24, Education was done to all licensed nurses on the 5 rights of medication usage/standard for safe medication practices also on abuse timing and reporting per the DON. On 03/06/24, the Medical Director assessed each affected resident and labs were completed with no concerns. On 03/06/24, an all staff meeting was held and abuse policy was reviewed at this time per Administrator. On 03/11/24 and 03/12/24, Residents were assessed and interviewed on feeling safe, being refused care and any mistreatments from staff by the Social Service Designee. On 03/12/24, Call light audit 3 times a week for 4 weeks then monthly for 2 months to be completed by the DON or designee. On 03/12/24, Audit on smokers gotten up timely to smoke 3 times a week for 4 weeks then monthly times 2 months by the DON or designee. On 03/12/24, a mass text message was sent by the Administrator to all staff members regarding abuse and the importance of reporting abuse directly to the supervisor, DON, and Administrator. On 03/12/24, STNA #50 was terminated by the Administrator. On 03/13/24, education continued to all staff on abuse and timely reporting abuse by the DON and designee. This deficiency represents non-compliance identified during investigation for Complaint Number OH00151648.

Based on record review, observation, staff interview and facility policy review, the facility failed to maintain infection control practices during dressing changes. This affected one (#21) of three residents reviewed for pressure ulcers. The facility census was 85. Findings include: Review of the medical record for Resident #21 revealed an initial admitted [DATE] with the latest readmission of 07/14/23 with diagnoses including sepsis due to methicillin resistant staphylococcus aureus, acute and chronic respiratory failure with hypoxia, diabetes mellitus, chronic obstructive pulmonary disease (COPD), neuromuscular dysfunction of bladder, congestive heart failure, polyneuropathy, hypertension, encounter for palliative care, osteoarthritis, benign prostatic hyperplasia with lower urinary tract symptoms, retention of urine, necrotizing fasciitis, anemia and cardiomyopathy. Review of the resident's admit/readmit assessment dated [DATE] revealed the resident was admitted to the facility with a Stage III (Full thickness tissue loss). Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) pressure ulcer to left buttocks measuring 3.0 centimeters (cm) by 1.8 cm by 0.1 cm, a vascular wound to the left groin measuring 2.0 cm by 2.0 cm by 0.1 cm. The assessment also indicated the resident has an indwelling urinary catheter. Review of the resident's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident has not cognitive deficit. The resident had an indwelling urinary catheter and was always incontinent of bowel. The assessment indicated the resident was at risk for skin breakdown and had one Stage III pressure ulcer present on admission. The facility implemented pressure reducing device to bed/chair, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, surgical wound care, application of nonsurgical dressings and applications of ointments/medications other than to feet. Review of the weekly skin observation dated 12/26/23 revealed the Stage III pressure ulcer to the left ischium measured 2.9 centimeters (cm) by 1.3 cm by 2.5 cm with undermining (the destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface) present at 12 o'clock at the depth of 2.7 cm. The wound was describes as being beefy red with a large amount of serosanguinous drainage. The facility determined the wound had improved. Review of the weekly observation dated 12.26.23 revealed incision and drainage of abscess wound to the resident's right groin revealed the wound measured 1.5 cm by 0.8 cm by 1.5 cm. The wound was described as granulation tissue with a moderate amount of serosanguinous drainage. Review of the monthly physician orders for December 2023 identified orders dated 07/18/23 cleanse suprapubic catheter with normal saline (NS) and apply slit gauze twice daily and as needed, 12/04/23 lightly pack right groin wound with VASHE soaked packing strip and cover with foam dressing daily and as needed and 12/11/23 cleanse wound to left ischium with NS, apply mesalt (ensure undermining is packed) cover with absorbent pad then foam daily and as needed. Observation on 12/28/23 at 9:18 A.M. of Registered Nurse (RN) #154 provide physician ordered dressing changes for Resident #21 revealed the RN placed all supplies on the resident's bedside table without being cleansed or a barrier being placed. RN #154 then washed her hands and exited the room for a large pair of gloves. RN #154 entered the room and donned the gloves. Resident #21 was positioned, RN #154 removed the split drainage sponge from the resident's suprapubic catheter. RN #154 cleansed the stoma site with normal saline (NS) and placed a clean split drainage sponge on the stoma. RN #154 then removed the visibly soiled dressing to the right groin with the same gloves used to complete the treatment to the suprapubic stoma. RN #154 then cleansed the wound with NS and four by four (4X4), packed the wound with lightly packed VASHE soaked packing using a sterile Q-tip. RN #154 then covered the wound with a foam dressing. Resident #21 was then positioned on his right side. Resident #21 has no dressing on the stage III pressure ulcer. RN #154 cleansed the Stage III pressure ulcer with NS and 4X4 using the same gloves. RN #154 then packed the wound with Mesalt and covered with a foam dressing. RN #154 then removed the gloves and washed her hands. The observations revealed RN #154 wore the same gloves for treatment to the Resident #21's suprapubic catheter, right groin abscess and stage III pressure ulcer. Interview on 12/28/23 at 9:25 A.M., interview with RN #154 verified the same soiled gloves where used to provide the physician ordered treatment to Resident #21's suprapubic catheter, right groin abscess and stage III pressure ulcer. Review of the facility policy titled, Hand Hygiene, dated 06/23 revealed staff will perform hand hygiene when indicated using proper technique consistent with accepted standards of practice. Hand hygiene is indicated and will be performed under the condition listed in, but not limited to, after handling contaminated objects and before and after handling clean or soiled dressings. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on interview, review of missing property report, review of self-reported incidents (SRI), and review of facility policy, the facility failed to report suspicion of misappropriation of a residents property including money. This affected one (Resident #64) of the three residents reviewed for abuse. The facility census was 73. Findings include: Review of the medical record for Resident #64 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 03/29/22 at 10:29 A.M. with Resident #64 revealed a few months ago she noticed she had $60.00 dollars missing from her bag that was in her wheeled walker. Resident #64 claimed she reported to the management staff and a staff member took all her information. Review of the Missing Property Report dated 12/06/21 revealed a report was completed for Resident #64. Description of the item missing revealed $60.00 dollars in the form of three twenties. Resident states her daughter gave it to her in a envelope. The last place the money was seen was under the lift seat of Resident #64's walker. Resident #64 did not have a roommate at the time and staff interviewed was not aware the resident had money. Resident #64's room was searched, and the money was not located. Family was notified on 12/09/21 and a police report was not filed. Review of facility SRIs revealed no SRI had been submitted regarding Resident #64's allegation of misappropriation. Interview on 03/31/22 at 11:30 A.M. with the Administrator revealed a Self-Reported Incident had not been completed and the proper state agencies had not been informed of the misappropriation allegation. Review of undated facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revealed Misappropriation of Resident Property is the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. When possible, the state agency would be notified. Facility would submit a SRI.

Based on medical record review, resident and staff interview, and facility policy review, the facility failed to provide all fall interventions to prevent residents from falling. This affected two (#2 and #7) of three resident falls reviewed. The census was 96. Findings include: 1. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her Brief Interview for Mental Status (BIMS) score was 14, which indicated she was cognitively intact. The assessment was completed on 11/12/19. Review of Resident #2's Minimum Data Set (MDS) assessment, Section G dated 11/14/19 revealed the resident needed extensive assistance with two person assistance for all transfers. Review of Resident #2's care plan revealed the resident is at risk for falls related to recent open reduction internal fixation (ORIF) of left hip, unable to ambulate, [MEDICAL CONDITION], potential for adverse effects of medications, history of diabetes mellitus, end stage [MEDICAL CONDITION] with [MEDICAL TREATMENT] three times a week, hypertension, muscle weakness, on fluid restriction, oxygen needed at times and history of falls. Interventions include anti-tippers to wheelchair, physical therapy evaluation for sit/stand lift for toileting (dated 12/30/19), sit to stand lift for all transfers, and call light within reach. In review of her plan of care, there was no intervention related to the number of staff that needed to assist her with activities of daily living (ADLs) including mobility or transfers. Review of Resident #2 medical records revealed on 12/29/19, she was being assisted in the shower room by one aide. While being assisted by one aide, she fell to the floor, causing an injury and pain to her left knee and hip. An x-ray was completed after the fall and revealed no fracture; the facility would monitor and deal with the pain. 2. Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her BIMS score was 12, which indicated she was cognitively intact. The assessment was completed on 12/07/19. Review of Resident #7's MDS assessment, section G dated 10/01/19, it revealed that she was to have extensive assistance with two person physical assistance with all transfers. Further review of Resident #7's MDS assessment, Section G dated 12/07/19, revealed she was to have extensive assistance with two person physical assistance with all transfers. Review of Resident #7's care plan revealed the resident is high risk for falls related to a history of falls, weakness, poor balance unaware of safety needs, vision/hearing problems, shortness of breath with minimal exertion, potential for adverse effects of medications ([MEDICATION NAME] and [MEDICATION NAME] daily). [DIAGNOSES REDACTED]. Interventions included physical therapy evaluation if indicated (11/29/19) and call light within reach. Review of Resident #7 medical records revealed she had two falls in the last 30 days. On 12/06/19, one aide was assisting Resident #7 to the bathroom. The aide noticed that Resident #7 wheelchair was in the bathroom, left Resident #7 unattended and unassisted to take the wheelchair out, and Resident #7 fell . Also, on 12/19/19, Resident #7 was being transferred by one aide, without a gait belt. While being transferred by one aide, Resident #7 fell backwards and hit her head and back. Also, the aide that was transferring Resident #7 was disciplined and re-trained to transfer this resident with two residents. Interview with State tested Nursing Aide (STNA) #104 and Registered Nurse (RN) #107 on 01/10/20 at 1:18 P.M. and 1:40 P.M. revealed Resident #2 and Resident #7 are currently in need of two person assistance for all transfers and mobility. Also, they both confirmed that Resident #2 was to have two person assistance for all transfers and mobility for quite a while. STNA #104 stated she has been an aide since about (MONTH) 2019 and Resident #2 has needed two person physical assistance for transfers and mobility since then. Interview with Resident #2 on 01/10/20 at 1:25 P.M. confirmed when she fell in the shower room, there was only one staff assisting her. She felt the staff that was assisting her in the shower room was overconfident with her abilities. She told the aide that she needed two people; the aide didn't listen. Her shoulder is fine, but her hip is still hurting. Interview with Director of Nursing and MDS Nurse #110 on 01/10/20 at 2:44 P.M. confirmed that there was only one aide with Resident #2 when she fell in the shower, and only one resident for each of Resident #7 falls. They both stated that Resident #7 did not need two person assistance for transfers and mobility at the time of her 12/06/19 fall, but they also confirmed that her MDS on 10/01/19 and 12/07/19 stated she needed two person assistance. Review of facility, Managing Falls and Fall Risk policy (undated) revealed, based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes can not be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. Monitoring subsequent falls and fall risk. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist continue to present a risk for falling or injury due to falls. This deficiency substantiates Complaint Number OH 223.

Based on medical record review and staff interview, the facility failed to ensure transfer/discharge notice was given to residents failed to ensure the ombudsman was notified for hospital admissions. This affected two (Resident #86 and Resident #71) of two residents reviewed for hospitalization during the annual survey. The census was 93. Findings include: 1. Medical record review for Resident #86 revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #86 revealed he was cognitively intact. His functional status revealed he required extensive assistance for bed mobility, transfers, toileting and supervision for eating. Review of Resident #86's progress note dated 02/07/19 revealed Resident #86 was on a leave of absence. Further review of notes dated 02/22/19 revealed a re-admission to the facility from the hospital. The notes were silent for a transfer/discharge notice given to the resident. The record was also silent for notification to the ombudsman as well. Review of progress note dated 03/07/19 for Resident #86 revealed he was sent out to the hospital. Further review of note revealed no documented evidence of a transfer/discharge notification to the resident or notification to the ombudsman. Interview with the Administrator on 06/06/19 at 4:59 P.M., confirmed he did not give notification of transfer/discharge to Resident #86 or inform the ombudsman of the hospital admissions for the resident. 2. Review of Resident #71's medical record revealed an admission date of [DATE]. The resident was admitted with [DIAGNOSES REDACTED]. She was alert and oriented to self only. Review of Resident #71's MDS assessment revealed she was totally dependent on staff for activities of daily living. A care plan relative to her medical and psychological needs revealed individualized interventions with measurable goals. Review of resident #71's medical record revealed she was transported to the hospital on [DATE] and was admitted . She was a Medicaid bed hold. Interview on 06/05/19 at 11:00 A.M., with the Business Office Manager (BOM) #110 revealed a letter of discharge with appeal rights was not given to the resident or the residents representative. Review of the Discharge Planning Policy (no date) revealed procedures for residents returning to the community. The policy and procedures did not address the procedures for transferring a resident to another facility.

Based on medical record review, staff interview and policy review, the facility failed to ensure a gradual dose reduction (GDR) was attempted for Resident #55 and #69. The facility also failed to ensure [MEDICATION NAME] was reviewed in 14 days and had an end date for Resident #237. This affected three (Resident #55, #69, and #237) of five residents reviewed for unnecessary medications during the annual survey, The facility census was 93. Findings include: 1. Medical record review for Resident #55 revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of care plan dated 04/06/18 for Resident #55 revealed the resident used psychotic medications. The intervention was for the physician to consider a dosage reduction when clinically appropriate at least quarterly. Review of physician orders [REDACTED].#55 was prescribed Nuplazid 34 milligram (mg) (atypical anti-psychotic) medication. Review of the medical record revealed it was silent for a GDR for Nuplazid for Resident #55. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was rarely or never understood. Her functional status included limited assistance for bed mobility, transfers, supervision for eating and extensive assistance for eating. Interview with Quality Assurance Registered Nurse (QARN) #200 on 06/06/19 at 3:15 P.M., verified there wasn't a GDR attempted for Resident #55. 2. Medical record review for Resident #69 revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of care plan dated 11/21/18 for Resident #69 revealed the resident used anti-depressant medications. The intervention was to monitor for opportunity to decrease or discontinue the medication Review of quarterly MDS assessment dated [DATE] revealed Resident #69 was cognitively intact. Her functional status included supervision for bed mobility, transfers, eating and extensive assistance for toileting. Review of physician orders [REDACTED].#69 revealed [MEDICATION NAME] 20 mg daily for mood. Review of the medical record for Resident #69 released it was silent for a GDR for [MEDICATION NAME]. Interview with QARN #200 on 06/06/19 at 3:20 P.M. verified there should have been GDR attempt for [MEDICATION NAME] for Resident #69. Review of policy entitled Free from Unnecessary [MEDICAL CONDITION] Medications/As Needed Use (undated) revealed after a prescribing physician has initiated a [MEDICAL CONDITION] medication , the facility must attempt a GDR in two separate quarters (with at least one month between the attempts) unless clinically contraindicated. 3. Review of medical record for Resident #237 revealed an admission date of [DATE]. The resident was admitted with [DIAGNOSES REDACTED]. Resident #237 was alert and oriented to person, place, and time and required one person assist with activities of daily living. A care plan relative to her medical and psychological needs revealed individualized interventions with measurable goals. Review of the Note to Attending Physician /Prescriber on 03/01/19 and 03/29/19 from the pharmacy requested Resident #237's physician to put a duration on the [MEDICATION NAME] and to review the medication every 14 days and indicate why the medication was continually given as needed. Review of Resident #237's Medication Review Report from 04/01/19 to 06/01/19 revealed she was prescribed [MEDICATION NAME] Tablet 0.5 milligrams (mg); one tablet by mouth every six hours as needed for anxiety with no end date. Review of Resident #237's medical record including the physician progress notes [REDACTED]. Review of the Medication Administration Record [REDACTED]. On 06/04/19 at 02:53 P.M., interview with the QARN #200 confirmed the physician did not document the reason for the continuation of the medication [MEDICATION NAME]. Review of the Free from Unnecessary [MEDICAL CONDITION] Medications and as Needed Use Policy (no date) revealed as needed (prn) orders for [MEDICAL CONDITION] drugs will be limited to 14 days except if the attending or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, then he/she will document their rationale in the resident's medical record , indicate the duration for the PRN order, and evaluate the resident for the appropriateness of that medicine.

Based on medical record review and staff interview, the facility failed to ensure advanced directive wishes were consistent and accurate throughout the medical record. This affected one (Resident #72) of one Resident reviewed for advanced directives. The facility census was 93. Findings include: Review of Resident #72's medical record revealed an admission date of [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a Physician order [REDACTED].#72 was to be a Do Not Resuscitate Comfort Care (DNRCC) code status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was rarely or never understood and required extensive assistance for bed mobility, transfers, walking in corridor, dressing, and personal hygiene. Review of Resident #72's medical record on 06/04/19 at 10:25 A.M. revealed a sticker on the front inside of the chart that indicated the resident was full code. There was not a DNR identification form in the chart. Staff interview with Registered Nurse (RN) #200 on 06/04/19 at 10:35 A.M., verified there was a full code sticker on the front inside of the chart, and no state DNR identification form. RN #300 verified Resident #72 was a DNRCC code status. Interview with the Director of Nursing (DON) on 06/04/19 at 1:55 P.M., verified Resident #72 would be a full code unless the state DNR identification form was signed.

Based on record review and staff interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASSR) was completed timely. This affected one (Resident #72) of one Resident reviewed for preadmission screening. The facility census was 93. Findings include: Review of Resident #72's medical record revealed an admission date of [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was rarely or never understood and required extensive assistance for bed mobility, transfer, walking in corridor dressing, and personal hygiene. Review of the medical record on 06/04/19 at 10:25 A.M. revealed Resident #72 had a notice of PASSR determination dated 08/14/18 indicating she was an emergency admission to the facility for a seven day period. The form indicated the nursing facility and county board shall assist the resident with alternative placement options, services, and resources prior to the completion of her nursing facility stay. Interview with the Social Services Designee (SSD) #305 on 06/04/19 at 1:05 P.M., verified Resident #72's nursing facility placement was only supposed to be for seven days and that she was still residing in the facility. She stated it was an oversight on the facility's part and they should have sent in a new PASSR.

Based on medical record review, staff interview and policy review, the facility failed to ensure the physician responded to a recommendation by the pharmacist for Resident #55 and #69. This affected two (Resident #55 and #69) of five residents reviewed for unnecessary medications during the annual survey, The facility census was 93. Findings include: 1. Medical record review for Resident #55 revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of care plan dated 04/06/18 for Resident #55 revealed the resident used psychotic medications. The intervention was for the physician to consider a dosage reduction when clinically appropriate at least quarterly. Review of physician orders [REDACTED].#55 was prescribed Nuplazid 34 milligram (mg) (atypical anti-psychotic) medication. Review of note to the attending physician/prescriber (pharmacy recommendations) dated 03/20/19 revealed Resident #55 had been taking Nuplazid since 11/08/18. The document further indicated to please evaluate the potential for a dose reduction at that time to determine the lowest effective dose. If clinically contraindicated, please provide a brief note. The note was absent for addressing this medication. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was rarely or never understood. Her functional status was limited assistance for bed mobility, transfers, supervision for eating and extensive assistance for eating. Interview with Quality Assurance Registered Nurse (QARN) #200 on 06/06/19 at 3:15 P.M., verified the physician should have addressed the pharmacy recommendations dated 03/20/19. 2. Medical record review for Resident #69 revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of physician orders [REDACTED].#69 revealed [MEDICATION NAME] 20 mg daily for mood. Review of care plan dated 11/21/18 for Resident #69 revealed the resident used anti-depressant medications. The intervention was to monitor for opportunity to decrease or discontinue the medication. Review of note to the attending physician/prescriber dated 04/06/19 revealed Resident #69 had been taking [MEDICATION NAME] since 11/06/18. The recommendation further revealed to please evaluate the potential for a dose reduction at that time to determine the lowest effective dose. If clinically contraindicated, please provide a brief note. The note was absent for addressing this medication. Review of quarterly MDS dated [DATE] revealed Resident #69 was assessed with [REDACTED]. Interview with QARN #200 on 06/06/19 at 3:20 P.M. verified the physician should have addressed the pharmacy recommendations dated 04/16/19. Review of policy entitled Free from Unnecessary [MEDICAL CONDITION] Medications/As Needed Use not dated revealed when evaluating the resident's progress, the attending physician should review the plan of care, orders, and the resident's response to the medications and decide whether to continue, modify, or stop a medication.

Based on review of facility self-reported incident (SRI), review of police report, review of facility policies, and staff interviews, the facility failed to implement their abuse/misappropriation policy to ensure residents were free from misappropriation of medications. This affected two (#200 and #202) of three residents reviewed for misappropriation. The facility census was 80. Findings included: Review of the facility SRI, dated 05/22/18 revealed during a shift to shift narcotic medication count, an incorrect medication count was found. Review of staff witness statements included in the investigation of the SRI revealed on 05/22/18, Licensed Practical Nurse (LPN) #46 made a statement stating she had left her medication cart, and the narcotic box unlocked during her shift. In addition, statements from facility staff revealed one complete card of [MEDICATION NAME] (narcotic pain medication) with eight tablets, were missing for Resident #200. Also found missing were four tablets of [MEDICATION NAME] (an anti-anxiety medication) and a complete card, containing 10 tablets of [MEDICATION NAME] (a narcotic pain medication) for Resident #201. Review of the police report (# 05-18-104-IF- ) dated 05/22/18 at 7:00 A.M., revealed LPN #46 had left the facility prior to the police's arrival. The report revealed LPN #46 had left the facility to go for a drug screening, however, did not actually show up for the screening. LPN #46's employer who was a contract agency, reported LPN #46 had a negative drug screening later that day. The police report additionally revealed facility staff, Registered Nurse (RN) #47 refused to take a drug screening. On 06/11/18 at 9:45 P.M., interview with the Director of Nursing (DON) revealed the facility had confirmed multiple controlled medications were found missing during a shift to shift medication count on 05/22/18. The DON revealed a count of the narcotics was correct on 05/21/18 completed by LPN #112 and RN #47. The medication count on 05/22/18 for the 7:00 A.M., to 7:00 P.M., shift was completed with LPN #46 and RN #47. The medication count was found to be incorrect. The DON confirmed there was missing [MEDICATION NAME], and [MEDICATION NAME]. LPN #46 denied any knowledge of missing medications. The DON revealed the police were notified, and prior to the police arriving at the facility, LPN #46 left the building. Additionally, the DON revealed LPN #46 and RN#47 were terminated. In a subsequent interview on 06/11/18 at 2:38 P.M., the DON confirmed Resident #200 and #202 had missing narcotic medication missing on 05/22/18. She further revealed the residents were assessed, and had no adverse effects from the missing medications. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 06/01/18, revealed a resident had the right to be free from abuse, neglect, exploitation, and misappropriation. Review of the facility's policy titled Controlled Substances, dated 01/2018, revealed the facility would ensure controlled substances were kept in a locked environment. This deficiency substantiates self-reported incident Control Number OH 237.

Based on review of facility self-reported incident (SRI), review of police report, review of facility policy, and staff interviews, the facility failed to ensure residents were free from misappropriation of medications. This affected two (#200 and #202) of three residents reviewed for misappropriation. The facility census was 80. Findings included: Review of the facility SRI, dated 05/22/18 revealed during a shift to shift narcotic medication count, an incorrect medication count was found. Review of staff witness statements included in the investigation of the SRI revealed on 05/22/18, Licensed Practical Nurse (LPN) #46 made a statement stating she had left her medication cart, and the narcotic box unlocked during her shift. In addition, statements from facility staff revealed one complete card of [MEDICATION NAME] (narcotic pain medication) with eight tablets, were missing for Resident #200. Also found missing were four tablets of [MEDICATION NAME] (an anti-anxiety medication) and a complete card, containing 10 tablets of [MEDICATION NAME] (a narcotic pain medication) for Resident #201. Review of the police report (# 05-18-104-IF- ) dated 05/22/18 at 7:00 A.M., revealed LPN #46 had left the facility prior to the police's arrival. The report revealed LPN #46 had left the facility to go for a drug screening, however, did not actually show up for the screening. LPN #46's employer who was a contract agency, reported LPN #46 had a negative drug screening later that day. The police report additionally revealed facility staff, Registered Nurse (RN) #47 refused to take a drug screening. On 06/11/18 at 9:45 P.M., interview with the Director of Nursing (DON) revealed the facility had confirmed multiple controlled medications were found missing during a shift to shift medication count on 05/22/18. The DON revealed a count of the narcotics was correct on 05/21/18 completed by LPN #112 and RN #47. The medication count on 05/22/18 for the 7:00 A.M., to 7:00 P.M., shift was completed with LPN #46 and RN #47. The medication count was found to be incorrect. The DON confirmed there was missing [MEDICATION NAME], and [MEDICATION NAME]. LPN #46 denied any knowledge of missing medications. The DON revealed the police were notified, and prior to the police arriving at the facility, LPN #46 left the building. Additionally, the DON revealed LPN #46 and RN#47 were terminated. In a subsequent interview on 06/11/18 at 2:38 P.M., the DON confirmed Resident #200 and #202 had missing narcotic medication missing on 05/22/18. She further revealed the residents were assessed, and had no adverse effects from the missing medications. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 06/01/18, revealed a resident had the right to be free from abuse, neglect, exploitation, and misappropriation. Review of the facility's policy titled Controlled Substances, dated 01/2018, revealed the facility would ensure controlled substances were kept in a locked environment. This deficiency substantiates self-reported incident Control Number OH 237.

Based on observation, staff interview and policy review, the facility failed to ensure food was prepared in a safe and sanitary manner. This had the potential to affect nine (Residents #3, #8, #17, #27, #34, #49, #60, #65, and #227) who eat pureed food at each meal. The census was 80. Findings include: Observations on 05/16/18 at 11:19 A.M. and 11:21 A.M. revealed Cook #14 taking food temperatures. She placed the clean shaft of the digital thermometer into the pureed pasta salad. She left the thermometer in the pan by itself, where it fell completely into the food. After being in the pan of pureed pasta salad for one minute, Cook #14 grabbed the thermometer out of the pan. She rinsed the entire thermometer off with water from the sink, used an alcohol swab to clean off the shaft of the thermometer, and then stuck it back in the pan of pureed pasta salad because the temperature had not been obtained. She left the thermometer in the pan by itself again and it fell completely in the food again. After being in the pan for approximately 30 seconds, she grabbed it again with a gloved hand and completed the same cleaning process again. Prior to getting the temperature of pureed pasta salad, she had taken the temperature of three other food items. At no point in the process did Cook #14 clean the head of the thermometer prior to or after taking the temperature of the pureed pasta salad. Interview with Cook #14 on 05/16/18 at 11:25 A.M. confirmed the entire thermometer fell into the pan of pureed pasta salad twice. She confirmed the head of the thermometer had not been cleaned. Review of the facility's list of resident's who were on pureed diets revealed Resident #3, #8, #17, #27, #34, #49, #60, #65, and #227 received a puree diet. Review of the facility's policy on food temperature, dated 01/13/16, revealed the temperatures of the food items will be taken and properly recorded for each meal. Part of the procedure of taking food temperatures include taking temperatures with a clean, sanitized, and air dried thermometer that is accurate within two degree Fahrenheit.

Based on medical record review, observation and staff interview, the facility failed to promote and protect the rights of the residents and treat the resident with dignity and respect in regards to visible labeling of health information on resident's wheelchairs and in resident rooms. This affected four (#9, #15, #49, and #56) of six residents reviewed for resident rights. The facility census was 80. Findings include: 1. Medical record review of Resident #9 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment, dated 04/24/18, revealed the resident was rarely or never being understood. Observation on 05/15/18 at 9:19 A.M. revealed Resident #9's wheelchair was labeled with the resident's name visible on the back of the chair. Visible labels were also noted on the side of the wheelchair and stated Resident #9's name and the weight of the wheelchair with and without the leg rests. Interview with Stated tested Nursing Aide (STNA) #92 verified the findings at the time of the observation. Observation on 05/16/18 at 8:36 A.M. revealed multiple signs noted above the resident's bed. The signs stated family will do laundry, stop taking her clothes, and no blood pressures in right arm. Interview with STNA #101, at the time of the observation, confirmed multiple signs above the bed which included signs regarding laundry. The STNA reported the laundry signs were placed by the resident's family and the sign regarding no blood pressures in right arm was placed by the facility. 2. Medical record review of Resident #15 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 05/11/18, revealed the resident was rarely understood. 3. Medical Record review of Resident #49 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 05/17/18 at 8:01 A.M. revealed Resident #15 and Resident #49's names and wheelchair weights were written on post it type notes and taped to back of the resident's wheelchairs, and was visible from behind their chairs. Interview with STNA #75 verified the findings at the time of the observation. The STNA reported the weights were posted on the chairs so when the residents were weighted in their wheelchairs, they know how much to subtract from the resident's weights. 4. Medical Record review of Resident #56 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment revealed the resident was rarely understood. Observation on 05/16/18 at 8:38 A.M. revealed a sign above Resident #56's bed stating to keep head of bed elevated 45 degrees at all times. Interview with STNA #101 confirmed the sign above the bed was visible from the doorway and the facility placed signed at the time of the observation

Based on record review and staff interview, the facility failed to follow their abuse policy regarding completing a thorough investigation on an abuse allegation. This affected one (#45) of three residents reviewed for abuse. The census was 80. Findings include: Record review for Resident #45 revealed the most recent admission to the facility was on 02/07/18. Review of her Brief Interview for Mental Status (BIMS) assessment, dated 04/08/18, revealed the resident was severely cognitively impaired. Review of the facility's Self-Reported Incident (SRI) Control Number 6, dated 12/27/17, revealed Resident #45 made an allegation of sexual abuse against an unknown staff person. She made the allegation that she received, sharp and painful treatment to her vaginal area. The facility had documented interviews for Resident #45's family member and one staff person. There was no documented evidence other residents or staff interviews were completed. Interview with Director of Nursing (DON) on 05/17/18 at 3:57 P.M. confirmed they did not document interviews they completed with other staff and/or residents about allegations of sexual abuse. Interview with Administrator on 05/17/18 at 4:11 P.M. confirmed the facility should thoroughly investigate all allegations of abuse. He confirmed they only have one abuse policy and it stated the facility was to investigate the allegations. Review of the facility's undated policy on abuse, neglect, exploitation, and misappropriation of resident property revealed it was the facility's policy to investigate all allegations of abuse, neglect, exploitation, and misappropriation of property, including injuries of unknown origin, in accordance with this policy.

Based on record review and staff interview, the facility failed to complete a thorough investigation regarding an abuse allegation. This affected one (#45) of three residents reviewed for abuse. The census was 80. Findings include: Record review for Resident #45 revealed the most recent admission to the facility was on 02/07/18. Review of her Brief Interview for Mental Status (BIMS) assessment, dated 04/08/18, revealed the resident was severely cognitively impaired. Review of the facility's Self-Reported Incident (SRI) Control Number 6, dated 12/27/17, revealed Resident #45 made an allegation of sexual abuse against an unknown staff person. She made the allegation that she received, sharp and painful treatment to her vaginal area. The facility had documented interviews for Resident #45's family member and one staff person. There was no documented evidence other residents or staff interviews were completed. Interview with Director of Nursing (DON) on 05/17/18 at 3:57 P.M. confirmed they did not document interviews they completed with other staff and/or residents about allegations of sexual abuse. Interview with Administrator on 05/17/18 at 4:11 P.M. confirmed the facility should thoroughly investigate all allegations of abuse. He confirmed they only have one abuse policy and it stated the facility was to investigate the allegations. Review of the facility's undated policy on abuse, neglect, exploitation, and misappropriation of resident property revealed it was the facility's policy to investigate all allegations of abuse, neglect, exploitation, and misappropriation of property, including injuries of unknown origin, in accordance with this policy.

Based on observation, record review and staff interview the facility failed to use assistive devices (a hoyer lift) during a transfer per the plan of care. This affected one resident (#19) of three reviewed for hoyer lift transfers. This resulted in harm to Resident #19 who sustained a fractured right humerus and increased pain with the use of narcotic pain medication. The facility census was 98. Findings include: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] revealed an assessment that indicated Resident #19 was severely impaired for daily decision making, total dependence with two person assist for all transfers, an unsteady balance during transfers and no reported falls in the past 90 days and no pain during the assessment period. A review of the Plan Of Care (POC) for potential for skin breakdown related to decreased mobility dated 06/04/14 revealed an intervention for up with hoyer lift. The Potential for Fall POC dated 06/04/14 revealed an intervention for a two person assist with all transfers with the use of a hoyer lift for transfers. Reviews of the physician order [REDACTED]. Review of the nurses notes dated 09/19/14 at 6:28 A.M. revealed the nurse was called to the resident's room to help with positioning and staff noted the resident guarding the right arm. Resident #19 yelled out in pain when repositioned. The resident refused an attempt to assess the right arm and was given Tylenol for pain. The primary care physician was called. During a further assessment the residents' right arm and shoulder was swollen with increased warmth. At 7:16 A.M., the primary physician returned the call and an order was given to obtain an x ray of the right arm and the shoulder. Review of the nurses noted dated 09/19/14 at 11:29 A.M., revealed Resident #19 was sent to the emergency room for evaluation and treatment. Review of the emergency room report dated 09/19/14 at 12:14 P.M., revealed a physician assessment that indicated "she apparently fell and now has pain in the right shoulder. An x-ray from the facility showed a right humerus fracture." Review of the hospital x-ray report dated 09/19/14 at 1:30 P.M., revealed a history of pain after a fall with an x-ray of the right shoulder and right humerus that revealed a minimally displaced proximal right humerus fracture. Review of the Accident/Incident Report dated 09/18/14 revealed at 3:30 P.M. "during a transfer from the wheel chair to the bed with a two person assist, the residents' arm was pinned under her body and staff heard a "pop" in the right arm. The arm was assessed with [REDACTED]. The investigation further revealed a mock evacuation of the facility was conducted on 09/18/14. Resident #19 was transferred from her bed to the wheel chair by therapy with three person lift transfer utilizing the cloth underpad and was placed in her wheel chair to evacuate out of the building. A hoyer lift had not been utilized for the transfer as it was used elsewhere. No hoyer lift pad was placed in the wheel chair for the return transfer. After the evacuation drill Licensed Practical Nurse (LPN) #55 and LPN #56 assisted Resident #19 to her bed without the use of a hoyer lift. They performed a two person stand pivot, they sat the resident on the side of the bed with one supporting her shoulders and one supporting her legs, they pivoted the resident into a lying position. During the procedure, Resident #19's right flaccid arm went under her and the nurses heard a "pop" sound. During a review of the Medication Administration Record (MAR) for the month of September 2014 revealed from 09/18/14 to 09/25/14, Resident #19 complained of pain and was medicated with Vicodin (narcotic analgesic pain medication) 5/300 mg and/or Tylenol 500 mg given five times. Reviews of the previous two MAR's (July and August 2014) revealed the resident was not medicated for pain. On 09/25/14 at 8:58 A.M., observations of Resident #19 revealed the resident refused to get out of bed due to pain. At 9:49 A.M., observations of Resident #19 revealed the resident lying in bed with a sling on the right arm. The resident refused to get out of bed at both times due to pain. On 09/25/14 at 11:09 A.M., an interview with the Director of Nursing (DON) confirmed Resident #19 was transferred during the mock evacuation drill without the use of a hoyer lift. The DON further confirmed that Resident #19 was returned to her bed without the use of a hoyer lift and her arm was pinned under her and resulted in a fracture of the right humerus. The DON confirmed that the staff failed to use a hoyer lift to transfer Resident #19 to the wheelchair and then back to bed which resulted in a right humerus fracture. The DON further confirmed Resident #19 has had pain and discomfort daily since her right humerus was fractured.

Based on staff and resident interview, record and facility policy review, the facility failed to use an assistance device, a gait belt, during transfer which resulted in Resident #105 sustaining a fall with a fracture and subsequent hospitalization and increased pain and use of pain medications. This affected one (Resident #105) of four Residents sampled for accident hazards. The facility census was 85. Findings include: Record review of Resident #105 revealed an admission date of [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set (MDS) assessment tool dated 04/18/13 revealed Resident #105 was cognitively intact and required one person physical assist with transfers, walking in her room and the corridor, dressing and toilet use. The Resident used a walker and a wheelchair to aid in mobility and was frequently incontinent of bowel and bladder. Review of the plan of care dated 04/26/13 revealed that Resident #105 was care planned for potential for injury, trauma and falls related to weakness, decreased mobility, poor balance, history of falls, and resident has hypotension at times. Interventions include use a wheelchair as needed, one person assist with ambulation and anticipate needs. Review of the Falls Investigation dated 04/07/13 revealed Resident #105 had a fall on 04/07/13 at 2:30 P.M. she was found on the floor near the door in her room. She reported she had gotten up to assist her roommate and lost her balance and slid to the floor. Review of the physical therapy daily treatment note dated 04/15/13 at 4:02 P.M. revealed Resident #105 complained of dizziness upon standing up and nursing was notified. Blood pressure was standing 116/51, seated 140/82, standing again 93/53 and seated 114/67. Resident #105 complains of "wooziness" with each standing attempt, nursing was notified and they stated they were aware. Review of the physical therapy daily treatment note dated 04/16/13 at 4:04 P.M. revealed Resident #105 continues to display signs of orthostatic hypotension with dizziness and drop in blood pressure. Nursing is aware. Review of the physical therapy daily treatment note dated 05/02/13 at 3:03 P.M. revealed Resident #105's blood pressure was as follows: seated 89/48, unable to stand or ambulate due to low blood pressure. Nursing was notified of blood pressure reading. Review of the physical therapy daily treatment note dated 05/03/13 at 3:57 P.M. revealed Resident #105 attempted to stand and complained of dizziness requiring return to seated position blood pressure was 89/53. Notified nursing of blood pressure and dizziness. Review of the Nurses Notes dated 05/06/13 at 9:13 A.M. revealed fax sent to the physician in regards to blood pressures dropping when standing. Resident #105 states she gets dizzy when standing. Review of the Nurses Notes dated 05/07/13 at 11:39 A.M. revealed at 11:25 A.M. this nurse called to therapy room Resident #105 was on floor. State tested Nurse Aide (STNA) was getting residents weight and Resident #105 got dizzy. Resident #105 did not hit her head but fell on right hip and was complaining of right hip pain. The physician was notified and the Resident was sent to local hospital emergency room . Review of the falls investigation worksheet dated 05/07/13 revealed that Resident #105 had a fall on 05/07/13 at 11:25 A.M. in the therapy room. Resident #105 was getting weighed by an STNA and Resident #105 got dizzy and fell on her right hip. The Resident complained of right hip pain and was sent to the hospital for evaluation. Review of the Nurses Notes dated 05/08/13 at 08:17 A.M. revealed resident #105 was admitted to hospital with [DIAGNOSES REDACTED]. Review of the Employee memorandum dated 05/09/13 revealed STNA #13 received a written warning due to not using a gait belt on Resident #105 while placing her on a scale, the resident had a syncope episode and lost balance and fell sustaining an injury. Review of the hospital records dated 05/11/13 at 1:40 P.M. revealed a minimally displaced right inferior pubic ramus fracture. Review of the Nurse Notes dated 05/14/13 at 8:56 P.M. revealed resident #105 was readmitted to the nursing facility from the hospital. Record review of the five day Minimum Data Set assessment tool dated 05/21/13 revealed that after re- admission to the facility after Resident #105's fall on 05/07/13, the Resident was still cognitively intact but required two person assist for transfers, walking in room and corridor, and toilet use. Interview with STNA #13 on 06/27/13 at 1:30 P.M. revealed that on 05/07/13 she took Resident # 105 down in a wheelchair to the therapy room to be weighed on the scale. STNA #13 stood Resident #105 up to weigh her and Resident #105 lost her balance and fell . STNA #13 admitted that she did not use a gait belt to transfer Resident #105. STNA # 13 further revealed that it is facility policy to use a gait belt to transfer Residents who require assistance and that she should of used a gait belt during the transfer of Resident #105. STNA #13 stated she was aware that Resident #105 would get dizzy upon standing up and that STNA #13 received discipline for the incident and agreed she should have been disciplined. Interview on 06/27/13 at 2:00 P.M. with Resident #105 revealed on the day of her fall on 05/07/13 at about 11:30 A.M., STNA #13 came to her room to take Resident #105 to get weighed. The Resident asked STNA #13 to help her get her non-skid socks on and STNA #13 said she would not need them since she was in the wheelchair and she was only going to be out of the wheelchair for a minute. STNA #13 took Resident #105 down to the therapy room in a wheelchair. Resident #105 verified that STNA #13 did not place a gait belt on her to assist with the transfer. STNA #13 assisted Resident #105 to stand up at which time the Resident told STNA #13 she was getting lightheaded. Resident #105 stated the next thing she knew she was laying down on the scale and was having unbearable pain in her right hip. The Resident laid on the scale until the ambulance arrived and transported her to the hospital. Staff Interview with Physical Therapy Program Director #15 on 06/27/13 at 2:45 P.M. revealed the therapy staff was having issues with Resident #105's blood pressure and that nursing staff were educated about the Residents blood pressure dropping. Physical Therapy Program Director #15 further revealed that Resident #105 was not doing any walking and was wheelchair bound due to the drops in blood pressure making it unsafe for the Resident to use a walker. She also revealed and that gait belts were always used to help with transfers and safety for Resident #105 while in therapy. Interview with The Administrator on 06/28/13 at 9:20 A.M. revealed the current gait belt transfer policy has been in effect since at least 2008. Review of an undated facility policy titled gait belt transfer policy revealed it is the policy of the facility to use gait belts when transferring or ambulating residents needing staff intervention. The purpose of the gait belt is to provide increased security and safety for the resident and the staff, to prevent injury during gait training, and transferring of residents. Interview with Resident #105 on 06/28/13 at 9:30 A.M. revealed she still has pain in her right hip that is an eight or a nine (on a scale of zero to ten with ten being the highest). The Resident states that since her fall she has missed out on numerous family events and did not get to go with her granddaughter to pick out her wedding dress. Review of the medication record for the date of 04/01/13 to 05/06/13 revealed the use of as needed pain medicine acetaminophen 650 milligrams(mgs) 17 times during this time period. Resident #105 also used the as needed pain medication hydrocodone with acetaminophen 5/325 mgs five times during this time period with the last time being documented on 04/13/13. Resident #105's pain was rated either a five or a six (on a scale of zero to ten with ten being the highest) during the 22 times she received pain medications before her fall. These pain medications were for right arm pain from a fall at the hospital according to the Resident. Review of the medication record for the date of 05/14/13 to 06/19/13 revealed the use of as needed pain medicine acetaminophen 650 milligrams(mgs) 45 times during this time period. Resident #105 also used the as needed pain medication hydrocodone with acetaminophen 5/325 mgs eight times during this time period. On 05/17/13 Resident #105 was visited by the physician and her pain medicine was increased to hydrocodone with acetaminophen 10/325 mgs which was taken 13 times till it was discontinued on 05/28/13 due to nausea when taking the medicine. On 06/04/13 a facsimile was sent to Resident #105's physician requesting something stronger for pain due to the pelvic fracture and tramadol 50 mg was ordered of which four doses were taken. Resident #105's pain was rated either a six or a seven (on a scale of zero to ten with ten being the highest) during the 70 times she received pain medications after her re-admission to the facility on [DATE].