Every finding on record at London Health & Rehab Center

Based on observation and interview, the facility failed to ensure a homelike environment after receiving vendor recommendations. This affected eight of ten rooms observed in the facility. The facility census was 74.Findings include:1. Review of the medical record for Resident #24 revealed an admission date of 01/23/26 with diagnoses of multiple sclerosis, depression, muscle weakness, fatigue, orthostatic hypotension, and transient ischemic attack. Observation on 02/20/26 at 9:25 A.M. of Resident #24 ' s room revealed uncovered soffits located above windows with structured covered fabric window valances. When walking up to look behind the valance, pipes displayed various shapes and sizes with deep gray to black speckled staining. Pipes were covered with layers of white flaking paint-like material and some discoloration appeared to be related to the layers of paint on piping. Interview and observation of Resident #24 ' s room on 02/20/26 at 11:47 A.M. with Maintenance Director #131 confirmed various staining present on pipes above resident windows located behind the window valance.2. Review of the medical record for Resident #22 revealed an admission date of 11/14/25 with diagnoses of hemiplegia, pain, dysphasia, chronic kidney disease, and major depressive disorder. Observation on 02/20/26 at 9:27 A.M. of Resident #22 ' s room revealed uncovered soffits located above windows with structured covered fabric window valances. When walking up to look behind the valance, pipes displayed various shapes and sizes with deep gray to black speckled staining. Pipes were covered with layers of white flaking paint-like material and some discoloration appeared to be related to the layers of paint on piping. Interview and observation of Resident #22 ' s room on 02/20/26 at 11:46 A.M. with Maintenance Director #131 confirmed various staining present on pipes above resident windows located behind the window valance.3. Review of the medical record for Resident #23 revealed an admission date of 02/11/24 with diagnoses of syncope and collapse, muscle weakness, dysphagia, cognitive communication deficit, and seizures. Observation on 02/20/26 at 9:27 A.M. of Resident #23 ' s room revealed uncovered soffits located above windows with structured covered fabric window valances. When walking up to look behind the valance, pipes displayed various shapes and sizes with deep gray to black speckled staining. Pipes were covered with layers of white flaking paint-like material and some discoloration appeared to be related to the layers of paint on piping. Interview and observation of Resident #23 ' s room on 02/20/26 at 11:46 A.M. with Maintenance Director #131 confirmed various staining present on pipes above resident windows located behind the window valance.4. Review of the medical record for Resident #27 revealed an admission date of 05/06/23 with diagnoses of chronic obstructive pulmonary disease, vascular dementia, systolic heart failure, cognitive communication deficit, muscle weakness, emphysema, dysphagia, acute kidney failure, and altered mental status. Observation on 02/20/26 at 9:30 A.M. of Resident #27 ' s room revealed uncovered soffits located above windows with structured covered fabric window valances. When walking up to look behind the valance, pipes displayed various shapes and sizes with deep gray to black speckled staining. Pipes were covered with layers of white flaking paint-like material and some discoloration appeared to be related to the layers of paint on piping. Interview and observation of Resident #27 ' s room on 02/20/26 at 11:49 A.M. with Maintenance Director #131 confirmed various staining present on pipes above resident windows located behind the window valance.5. Review of the medical record for Resident #28 revealed an admission date of 01/27/26 with diagnoses of cerebral infarction, encephalopathy, seizures, dysphagia, altered mental status, and cognitive communication deficit.Observation on 02/20/26 at 9:30 A.M. of Resident #28 ' s room revealed uncovered soffits located above windows with structured covered fabric window valances. When walking up to look behind the valance, pipes displayed various shapes and sizes with deep gray to black speckled staining. Pipes were covered with layers of white flaking paint-like material and some discoloration appeared to be related to the layers of paint on piping.Interview and observation of Resident #28 ' s room on 02/20/26 at 11:49 A.M. with Maintenance Director #131 confirmed various staining present on pipes above resident windows located behind the window valance.6. Review of the medical record for Resident #29 revealed an admission date of 02/11/26 with diagnoses of muscle weakness, adult failure to thrive, dysphagia, altered mental status, sepsis, and glaucoma.Observation on 02/20/26 at 9:30 A.M. of Resident #29 ' s room revealed uncovered soffits located above windows with structured covered fabric window valances. When walking up to look behind the valance, pipes displayed various shapes and sizes with deep gray to black speckled staining. Pipes were covered with layers of white flaking paint-like material and some discoloration appeared to be related to the layers of paint on piping.Interview and observation of Resident #29 ' s room on 02/20/26 at 11:49 A.M. with Maintenance Director #131 confirmed various staining present on pipes above resident windows located behind the window valance.7. Review of the medical record for Resident #30 revealed an admission date of 02/05/26 with diagnoses of pulmonary hypertension, acute respiratory failure, adult failure to thrive, dysphagia, and acute kidney failure. Observation on 02/20/26 at 9:31 A.M. of Resident #30 ' s room revealed uncovered soffits located above windows with structured covered fabric window valances. When walking up to look behind the valance, pipes displayed various shapes and sizes with deep gray to black speckled staining. Pipes were covered with layers of white flaking paint-like material and some discoloration appeared to be related to the layers of paint on piping.Interview and observation of Resident #30 ' s room on 02/20/26 at 11:49 A.M. with Maintenance Director #131 confirmed various staining present on pipes above resident windows located behind the window valance.8. Review of the medical record for Resident #16 revealed an admission date of 04/10/18 with diagnoses of Type Two Diabetes Mellitus, glaucoma, pain, acute diastolic heart failure, acute respiratory failure with hypoxia, metabolic encephalopathy, cognitive communication deficit, and dysphagia. Observation on 02/20/26 at 9:35 A.M. of Resident #16 ' s room revealed uncovered soffits located above windows with structured covered fabric window valances. When walking up to look behind the valance, pipes displayed various shapes and sizes with deep gray to black speckled staining. Pipes were covered with layers of white flaking paint-like material and some discoloration appeared to be related to the layers of paint on piping.Interview and observation of Resident #16 ' s room on 02/20/26 at 11:44 A.M. with Maintenance Director #131 confirmed various staining present on pipes above resident windows located behind the window valance.9. Review of the medical record for Resident #71 revealed an admission date of 09/20/24 with diagnoses of chronic obstructive pulmonary disease, dysphagia, muscle weakness, hypertension, heart failure, chronic kidney disease, shortness of breath, cognitive communication deficit, and dementia. Observation on 02/20/26 at 9:38 A.M. of Resident #71 ' s room revealed uncovered soffits located above windows with structured covered fabric window valances. When walking up to look behind the valance, pipes displayed various shapes and sizes with deep gray to black speckled staining. Pipes were covered with layers of white flaking paint-like material and some discoloration appeared to be related to the layers of paint on piping.Interview and observation of Resident #71 ' s room on 02/20/26 at 11:41 A.M. with Maintenance Director #131 confirmed various staining present on pipes above resident windows located behind the window valance.10. Review of the medical record for Resident #72 revealed an admission date of 12/25/23 with diagnoses of heart failure, Type Two Diabetes Mellitus, encephalopathy, dysphagia, cerebral infarction, adult failure to thrive, and transient ischemic attack. Observation on 02/20/26 at 9:38 A.M. of Resident #72 ' s room revealed uncovered soffits located above windows with structured covered fabric window valances. When walking up to look behind the valance, pipes displayed various shapes and sizes with deep gray to black speckled staining. Pipes were covered with layers of white flaking paint-like material and some discoloration appeared to be related to the layers of paint on piping.Interview and observation of Resident #72 ' s room on 02/20/26 at 11:41 A.M. with Maintenance Director #131 confirmed various staining present on pipes above resident windows located behind the window valance.11. Review of the medical record for Resident #14 revealed an admission date of 02/04/26 with diagnoses of dysphagia, weakness, parkinsonism, and chronic obstructive pulmonary disease. Observation on 02/20/26 at 9:41 A.M. of Resident #14 ' s room revealed uncovered soffits located above windows with structured covered fabric window valances. When walking up to look behind the valance, pipes displayed various shapes and sizes with deep gray to black speckled staining. Pipes were covered with layers of white flaking paint-like material and some discoloration appeared to be related to the layers of paint on piping. Interview and observation of Resident #14 ' s room on 02/20/26 at 11:45 A.M. with Maintenance Director #131 confirmed various staining present on pipes above resident windows located behind the window valance.12. Review of the medical record for Resident #73 revealed an admission date of 01/29/25 with diagnoses of chronic diastolic heart failure, chronic obstructive pulmonary disease, acute kidney failure, dysphagia, traumatic subdural hemorrhage, and cognitive communication deficit.Observation on 02/20/26 at 9:42 A.M. of Resident #73 ' s room revealed uncovered soffits located above windows with structured covered fabric window valances. When walking up to look behind the valance, pipes displayed various shapes and sizes with deep gray to black speckled staining. Pipes were covered with layers of white flaking paint-like material and some discoloration appeared to be related to the layers of paint on piping.Interview and observation of Resident #73 ' s room on 02/20/26 at 11:43 A.M. with Maintenance Director #131 confirmed various staining present on pipes above resident windows located behind the window valance.13. Review of the medical record for Resident #74 revealed an admission date of 01/02/24 with diagnoses of cerebral infarction, aphasia, muscle weakness, and dysphasia.Observation on 02/20/26 at 9:42 A.M. of Resident #74 ' s room revealed uncovered soffits located above windows with structured covered fabric window valances. When walking up to look behind the valance, pipes displayed various shapes and sizes with deep gray to black speckled staining. Pipes were covered with layers of white flaking paint-like material and some discoloration appeared to be related to the layers of paint on piping.Interview and observation of Resident #74 ' s room on 02/20/26 at 11:43 A.M. with Maintenance Director #131 confirmed various staining present on pipes above resident windows located behind the window valance.Interview on 02/20/26 at 11:42 A.M. with the Director of Maintenance confirmed the discoloration does not align with a homelike environment. He stated he is unable to remedy the discoloration with paint due to recurrence. The resolution to the issue is to install insulation and a drop ceiling to conceal the discoloration. He confirmed a contractor was in earlier in the summer season to evaluate the issue and found no immediate concerns. However, a recommendation was made to provide an aesthetic improvement. Interview on 02/20/26 at 12:11 P.M. with Contractor Director and Manager #500 revealed the staining is due to condensation during hot and cold months, poses no health risk to residents, and is not mold. The pipe is covered in pipe wrap which is a fiberglass substance that provides no food source for mold and is not an opportunistic material for mold growth. Interview on 02/20/26 at 12:15 P.M. with the Administrator revealed the facility had been aware of the issue since late summer or early fall. The administrator stated the project is large and pending due to staffing. The facility ensured the issue poses no health risk to residents and received vendor recommendations for aesthetic resolution including air blocks, insulation, and a drop ceiling while maintaining fireproof standards.Review of the resident handbook dated 07/14/11 revealed the facility promotes a homelike environment and will make every attempt to accommodate reasonable requests to individualize residents ' living spaces.This deficiency represents non-compliance investigated under Complaint Number 26611454.

Based on interview and record review, the facility failed to ensure the COVID-19 vaccine was offered or provided to facility staff. This had the potential to affect all 70 residents residing in the facility. The facility census was 70. Findings include: Review of the staff respiratory virus information fact sheet and acknowledgement, dated 10/06/23, revealed the facility would not be administering the updated COVID-19 vaccine to team members at the facility. Interview with Corporate Registered Nurse (CRN) #500 on 05/29/25 at 12:51 P.M. confirmed the COVID-19 vaccination was available at the facility and further verified the facility did not offer or provide the COVID-19 vaccination to the facility staff.

Based on observation, staff interview, and medical record review, the facility failed to ensure resident rooms were maintained in a safe, comfortable, and homelike manner. This affected four (#5, #12, #41, and #47) of 70 residents residing in the facility. The facility census was 70. Findings include: 1. Observation of the facility on 05/29/25 at 10:13 A.M. revealed there was exposed drywall with black spots on it in the corner of Resident #12, Resident #41, and Resident #47's room near the window. There was also a television that was on a wall mount that was removed from the wall with the screws exposed that was sitting on a night stand in Resident #12, Resident #41, and Resident #47's room. Interview with Maintenance Director (MD) #17 on 05/29/25 at 10:13 A.M. verified there was exposed drywall with black spots on it in the corner of Resident #12, Resident #41, and Resident #47's room near the window. MD #17 also confirmed there a television that was on a wall mount that was removed from the wall with the screws exposed that was sitting on a night stand in Resident #12, Resident #41, and Resident #47's room. MD #17 stated the windows in the resident rooms needed to be replaced due to leaks and that caused the issue with the drywall. 2. Review of Resident #5's medical record revealed an admission date of 01/02/25 with pertinent diagnoses including unspecified fracture of the shaft of the left tibia, anemia, unspecified intellectual disabilities, epilepsy, cerebral palsy, cognitive communication deficit, and depression. Observation on 05/27/25 at 1:47 P.M. revealed gouges in the drywall by Resident #5's bed. Interview on 05/29/25 at 10:11 A.M. with MD #17 verified the gouges in the wall by Resident #5's bed. This deficiency represents non-compliance investigated under Complaint Number OH00164426.

Based on observation, staff interview, review of a resident census, review of drug manufacturer instructions for use, and policy review, the facility failed to ensure medications were labeled and stored in a safe and secure manner. This had the potential to affect 14 (#3, #4, #7, #18, #25, #30, #40, #42, #58, #62, #225, #226, #227, and #228) of 70 residents residing in the facility. The census was 70. Findings include: 1. Observation of the 203 hall medication cart on 05/28/25 starting at 9:14 A.M. revealed there were five (5) loose pills that were a variety of shapes and colors in the medication cart with no identification to which residents the medications belonged to. Continued observation of the medication cart at 9:17 A.M. revealed there was an opened Incruse Ellipta 62.5 microgram (mcg) inhaler prescribed to Resident #7 without a date when it was opened. Review of a resident census dated 05/29/25 revealed five (#3, #7, #18, #30, and #58) resident's medications were stored in the 203 hall medication cart. Interview with Licensed Practical Nurse (LPN) #70 on 05/28/25 at 9:18 A.M. verified that the Incruse Ellipta 62.5 mcg inhaler for Resident #7 was open and undated and at 9:21 A.M. verified the 5 loose pills with no resident identification in the 203 hall medication cart. 2. Observation of the 204 hall medication cart on 05/28/25 at 9:25 A.M. revealed there was an opened Incruse Ellipta 62.5 mg inhaler prescribed to Resident #62 without a date. Interview with LPN #70 on 05/28/25 at 9:25 A.M. verified that the Incruse Ellipta 62.5 mcg inhaler for Resident #62 was open and undated. 3. Observation of the 105 hall medication cart on 05/28/25 starting at 9:32 A.M. revealed there were six (6) loose pills that were a variety of shapes and colors in the medication cart with no identification to which residents the medications belonged to. Continued observation at 9:34 A.M. revealed there was an opened Trelegy Ellipta 100 mcg inhaler prescribed to Resident #227 without a date. Review of a resident census dated 05/29/25 revealed eight (#4, #25, #40, #42, #225, #226, #227, and #228) resident's medications were stored in the 105 hall medication cart. Interview with LPN #11 on 05/28/25 at 9:39 A.M. verified there were 6 loose pills that were a variety of shapes and colors with no resident identification in the 105 hall medication cart. Review of the manufacturer instructions for use for Incruse Ellipta, revised December 2023, revealed the medication should be discarded after six weeks after opening the foil tray or when the counter reads 0 (after all blisters have been used, which ever comes first. Review of the manufacturer instructions for use for Trelegy Ellipta, revised December 2002, revealed the medication should be discarded after six weeks after opening the foil tray or when the counter reads 0 (after all blisters have been used, which ever comes first. Review of the facility's policy titled, Storage and Expiration Dating of Medications and Biologicals, with a revision date of 08/01/24, revealed the facility staff should record the date opened on the primary medication container (i.e., vial, bottle, inhaler) when the medication has a shortened expiration date once opened. Further review revealed the facility should ensure the medications and biologicals for each resident are stored in the containers in which they were originally received.

Based on medical record review, hospital record review, staff interview, and review of facility policy, the facility failed to ensure appropriate antibiotics were ordered for the treatment of infections. This affected one (#23) of four residents reviewed for antibiotic stewardship. The facility census was 70. Findings include: Review of the medical record for Resident #23 revealed an admission date of 06/22/22. Diagnoses included chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute and chronic respiratory failure with hypoxia, other membranous urethral stricture, Parkinson's disease with dyskinesia, cognitive communication deficit, obstructive and reflux uropathy, benign prostatic hyperplasia with lower urinary tract symptoms, type II diabetes mellitus without complications, morbid obesity, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/16/25, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment indicated the resident was always incontinent of bowel and had an indwelling urinary catheter. The resident was (staff) dependent for toileting and personal hygiene. Further review revealed Resident #23 had a urinary tract infection (UTI) in the last 30 days. Review of the current plan of care revealed Resident #23 received catheter care with goals to maintain catheter patency and prevent infection. Interventions included Foley catheter changes as needed and catheter care every shift, including anchoring tubing and cleansing the catheter and perineal area with soap and water. Review of the current physician orders revealed Resident #23 had orders for Foley catheter care every shift and catheter changes as needed. The resident had an order initiated on 04/20/25 for Bactrim DS (sulfamethoxazole-trimethoprim) (antibiotic) 800-160 milligrams (mg) twice daily for treatment of a UTI. Review of the Medication Administration Record (MAR) for April 2025 confirmed Resident #23 was administered Bactrim, as ordered, for treatment of a UTI. Review of hospital records, dated 04/20/25, revealed Resident #23 had a urine culture with growth of greater than 100,000 colony-forming units per milliliter (CFU/mL) mixed microbes but noted suspected contamination during collection and recommended recollection and further work up. Further review revealed no sensitivity testing was performed, and no follow-up urine culture was completed to verify the appropriateness of Bactrim therapy for a UTI. Further review of Resident #23's medical record revealed no evidence any additional urine cultures, including sensitivity testing, were completed to determine the appropriateness of Bactrim to treat the resident's UTI. Interview on 05/29/25 at 11:07 A.M. with Licensed Practical Nurse (LPN) #52 verified there was no culture and sensitivity testing performed to confirm if Bactrim was an appropriate treatment for Resident #23's UTI diagnosed on [DATE]. Review of the facility policy titled, Antimicrobial Stewardship Program Policy, revised 06/26/24, revealed that the Infection Prevention and Control Committee oversees antibiotic use, emphasizing appropriate prescribing. Specifically, for UTIs, the policy mandated the use of revised McGeer's Criteria to confirm the necessity and appropriateness of antibiotic treatment, ensuring clinical and diagnostic testing aligns with infection-specific protocols to minimize unnecessary or inappropriate antibiotic use.

Based on medical record review, witness statements, staff and resident interviews, and policy review the facility failed to ensure respect and dignity was implemented for the residents. This affected two (#57 and #62) of two residents reviewed for dignity and respect. The census was 70. Findings included: 1. Medical record review for Resident #57 revealed an admission date of 09/09/24. Medical diagnoses included cerebral vascular accident (CVA). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 was moderately cognitively impaired. His functional status was substantial/maximal assistance for eating and bed mobility, and he was dependent for toileting and for transfers. He was always incontinent for bowel and bladder. Review of the progress notes dated 05/02/25 for Resident #57 revealed they were silent for respect and dignity issues. Review of witness statement dated 05/02/25 revealed Social Service Designee (SSD) #48 interviewed Resident #57 who reported he didn't have his call light on this date and turned up his television to get someone's attention and his roommate turned on his call light and the Certified Nursing Aide (CNA) # came into the room and his depends were soaked and he couldn't remember the comment she made to him but reported she doesn't like me. Review of a witness statement by CNA #51 dated 05/02/25 revealed between 7:00 A.M. and 7:30 A.M. revealed CNA #51 was assisting CNA #90 with changing Resident #57 and CNA #90 got mad at the resident because she had just changed the resident and had to do it again. CNA #51 reported CNA #90 said to the resident in a rude way I just know you're going to do it again and when the resident asked her why did you say that the aide responded she couldn't explain it, she just knows. Review of the witness statement dated 05/02/25 by Resident #57's family revealed CNA #90 was rude to the resident this morning and the family was told after the last time the aide did this, it would not happen again and now it is happening again. The family reported if the aide didn't like her job she needed to get another one. Review of Disciplinary Action Form dated 05/02/25 revealed CNA #90 was educated on facility policies, job duties, and job description. This was the final major offense #16 actions detrimental to resident care due to a complaint from the family and Resident #57. The CNA was also reducated on the attendance policy. Interview with the family member on 05/28/25 at 2:47 P.M. revealed the first time which he couldn't remember the date CNA #90 had to change Resident #57 and the aide told the resident you are a grown man urinating in your pants and that he acted like a little baby The family notified the previous DON and was told it wouldn't happen again. The family reported it happened again on 05/02/25 after another resident told him Resident #57 was treated badly when the CNA #90 changed the resident and belittled and scolded him for wetting his pants and this made the resident cry and wasn't himself for a couple of days after that. He reported this to the previous DON and was told the aide would not be working with the resident again. He felt like this abusive to the resident. Interview with Resident #57 on 05/28/25 at 4:19 P.M. revealed the CNA #90 was mean to him twice and told him he was a grown man and you shouldn't be wetting yourself and made him cry but he couldn't remember the time it made him cry. He reported the second time CNA #51 was in the room and the CNA #90 told him over and over again in a mean tone she knew she was going to have to keep changing him. The resident reported he thought it could be abuse or respect and dignity. Interview with Resident #57's room mate Resident #23 on 05/28/25 at 4:25 P.M. revealed CNA #90 got upset with Resident #57 because he was wetting in the bed. He reported the aide told Resident #57 you are a grown man and you shouldn't be doing that. He reported another time the CNA #90 told Resident #57 you know how hard I work and I have to come in here and clean up your bed and said don't do it again. Resident #23 reported Resident #57 cried his eyes out after this time. Resident #23 reported he told the family of the incidents, but didn't report it to the facility. He revealed he didn't know the dates of either incident. He felt like it was abusive and thought CNA #90 was way out of like the way she spoke to Resident #57. Interview with the Administrator on 05/29/25 at 6:55 A.M. revealed he thought the incident that happened on 05/02/25 with Resident #57 was disrespectful and the CNA #90 was unprofessional. He stated he wrote up the CNA #90 on 05/02/25 for her behavior. He didn't remember the other incident being brought to his attention and maybe the previous DON handled it. Interview with CNA #51 on 05/29/25 at 7:21 A.M. revealed she came into work on 05/02/25 and CNA #90 asked her to help get Resident #57 changed and out of bed. She reported CNA #90 was upset because Resident #57 was wet again and the aide kept telling the resident over and over again she knew she was going to have to change him again and again. The resident said why and the CNA said she couldn't tell him why. CNA #51 reported the resident didn't cry over this incident but was quiet for the rest of the day and didn't urinate the rest of the day. She reported she thought it was rude to the resident the way CNA #90 spoke to him and it hurt his feelings. 2. Medical record review for Resident #62 revealed an admission date of 06/14/24. Medical diagnoses included cerebrovascular attack (CVA) and depression. Review of the quarterly MDS dated [DATE] revealed Resident #62 was rarely or never understood. His functional status was supervision or touching assistance for eating, dependent for toileting, bed mobility, and transfers. He was frequently incontinent for bowel and bladder. Review of progress notes dated 05/21/25 revealed there wasn't any notes related to this incident. Review of the witness statement by Resident #02 on 05/21/25 revealed during resident council meeting the night shift CNA #90 was unprofessional when speaking to Resident #02 and #62. Resident #02 asked the aide to dispose of trash that had vomit in it and when she answered the call light she told the residents what do you want, I'm busy and can't keep coming into your room. The statement further revealed the CNA #90 didn't come back and empty the trash until her shift was over which left the two residents smelling vomit all night. Interview with Resident #02 during resident council meeting on 05/28/25 at 11:00 A.M. reported Resident #62 wasn't able to take care of himself. He reported on 05/21/25 Resident #62 was sick and vomited in the trash can in their room and it was requested to be emptied. The CNA #90 came into the room on her cell phone the entire time of the conversation and told the two residents I don't want to come in here every half an hour to empty this bag, what do I have to do babysit you she walked out of the room and didn't come back for up to three hours to empty the trash. Resident #02 felt this was abusive and reported it to the Administrator. Attempted an interview with Resident #62 on 05/28/25 at 1:02 P.M. revealed he could not be understood. Interview with the Administrator on 05/29/25 at 6:55 A.M. revealed he thought the incident that happened on 05/21/25 with Resident #62 was disrespectful and the CNA #90 was unprofessional. He stated he had made a call to corporate to terminate the CNA #90 but had not heard back from them. Review of the policy entitled Resident Rights and Facility Responsibilities undated revealed the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect an promote the rights of the resident.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure a resident's fluid restriction was followed according to physician orders. This affected one (#29) of four residents reviewed for nutrition. The facility census was 70. Findings include: Medical record review for Resident #29 revealed an admission date of 05/06/23. Diagnoses included chronic obstructive pulmonary (COPD), vascular dementia, and congested heart failure (CHF). Review of the physician orders for Resident #29 dated 01/20/25 revealed a fluid restriction of 2,000 cubic centimeters (cc) for a 24-hour period. Dietary was to provide a total 1,560 cc per day, which was spread out to 600 cc at breakfast, 480 cc at lunch, and 480 cc at dinner. Nursing was to provide a total 440 cc per day, which was spread out 240 cc on first shift and 200 on second shift. Review of the care plan dated 03/18/25 revealed Resident #29 was at risk for nutrition/hydration related to CHF. Interventions were to monitor for signs and symptoms of dehydration and fluid overload. Encourage adequate fluid intake. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was cognitively intact and required setup or clean-up assistance from staff for eating, Observation of Resident #29's breakfast tray on 05/28/25 at 8:05 A.M. revealed she had a 480 cc container of pop on the table and she was served a 480 cc of orange juice and 480 cc of hot tea. Interview with the Certified Nursing Aide (CNA) #72 on 05/28/25 at 8:08 A.M. revealed Resident #29 was served 480 cc of hot tea and 480 cc of orange juice to Resident #29. CNA #72 stated she didn't know Resident #29 was on a fluid restriction. Review of the policy titled Intake and Output Policy dated 10/28/24 revealed: the licensed nurse will record intake and/or output for their shift as indicated on the intake and output record. At the end of the 24-hour period, the licensed nurse will total the intake and/or output on the Intake/Output Record. When intake is being recorded for fluid restrictions purposes, the licensed nurse will verify the resident has received the recommended amount and will investigate any variances. Signs and symptoms of decreased (fluid) intake and significant variances between intake and output will be communicated to the provider.

Based on medical record review, review of an arbitration agreement, and staff interview, the facility failed to ensure residents were explained binding arbitration agreements in a form and manner the resident can understand prior to signing them. This affected one resident (#43) of three residents reviewed for arbitration agreements. The facility census was 71. Findings include: Review of the medical record for Resident #43 revealed the resident was admitted on [DATE] with diagnoses of unspecified dementia, hypocalcemia, encephalopathy, unspecified visual loss, atelectasis, muscle weakness, cognitive communication deficit, hallucinations, anemia, and dysphagia. Review of Resident #43's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) of 03. Review of an arbitration agreement document revealed the parties understood, acknowledged, and agreed by entering into the arbitration agreement they are voluntarily selecting arbitration as the method of resolving their disputes. By signing the arbitration agreement, they are agreeing the parties, intending to be legally bound, have been explained the agreement and each understands it as written and signs it effective as of the date above. Further review revealed Resident #43 signed the agreement on 06/24/24. The facility representative that signed the agreement was Admissions Coordinator (AC) #36 on 06/24/24. Interview with AC #36 on 05/28/25 at 12:06 P.M. revealed she tried to contact family and the Power of Attorney (POA) at time of Resident #43's admission; however, she was unable to get a response. AC #36 confirmed she was aware of Resident #43 being cognitively impaired and allowed Resident #43 to sign the arbitration agreement. AC#36 verified that signing the agreement was not a requirement for admissions into the facility.

Based on observation, staff interview, medical record review and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff donned personal protective equipment (PPE) during care for a resident on Enhanced Barrier Precautions (EBP) This affected one (#18) of one resident reviewed for EBP. The facility identified 14 residents on EBP. The facility census was 70. Findings include: Review of Resident #18's medical record revealed an admission date of 01/03/25. Diagnoses included cerebrovascular disease, displaced fracture of shaft of humerus (right arm), obstructive and reflux uropathy, dysphagia, cognitive communication deficit, difficulty in walking, arteriosclerotic heart disease of native coronary coronary artery, age related physical debility, and wedge compression fracture of first lumbar vertebrae. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/13/25, revealed Resident #18 was severely cognitively impaired and utilized a wheelchair to aid in mobility. Resident #18 had an indwelling catheter. Review of a physician order dated 02/12/25 revealed Resident #18 had an order for foley catheter care every shift. Further review revealed an order dated 05/15/25 for the resident to be on EBP due to foley catheter every shift. Observation on 05/28/25 at 11:27 A.M. of catheter care provided to Resident #18 by Certified Nursing Assistant (CNA) #72 and CNA #75 revealed a sign on the resident's door stating the resident was on EBP and to wear gloves and a gown for high contact care activities. Continued observation revealed CNA #72 and CNA #75 did not don gloves or a gown, and proceeded to provide catheter care for Resident #18. Interview with CNA #72 on 05/28/25 at 11:36 A.M. verified Resident #18 was on EBP and further confirmed she did not wear PPE, including gloves or a gown, while completing catheter care for the resident. Interview with CNA #75 on 05/28/25 at 11:37 A.M. verified Resident #18 was on EBP and further confirmed she did not wear PPE, including gloves or a gown, while completing catheter care. Review of CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. Review of the facility Enhanced Barrier Precautions policy, dated 05/19/25, revealed EBP were intended to prevent the transmission of multi-drug-resistant organisms (MDROs) via contaminated hands and clothing of healthcare workers to high-risk residents during high contact activities. High-risk residents included those with chronic wounds and indwelling devices (such as urinary catheters) and for all those colonized or infected with a MDRO currently targeted by the CDC. High contact care activities included activities that could result in the transfer of MDROs to the hands and clothing of healthcare personnel, even when blood and body fluid exposure was not anticipated, and included device care or use.

Based on record review, observation, policy review, and resident and staff interviews, the facility failed to ensure fall interventions were in place for a resident who was at a high risk for falls and had a recent fall in the facility. This affected one (Resident #40) of seven residents reviewed for falls. The facility census was 70. Findings include: Review of the medical record for Resident #40 revealed a date of admission of 11/30/22. Diagnoses included disorder of brain, delusional disorders, cerebral infarction, tremor, muscle weakness, and paranoid schizophrenia. Review of the plan of care dated 08/20/24 revealed Resident #40 was at risk for falls due to cognitive impairment, muscle weakness, and unsteady gait. Interventions included educating the resident on fall prevention, performing daily checks to ensure interventions were in place, and verifying interventions during morning rounds. Specific fall interventions included a fall mat at bedside, hipsters on at all times as tolerated, bed against the wall, bilateral grab bars, non-skid strips, perimeter mattress, pressure-reducing cushion, Dycem (non-slip mat) on wheelchair, grippy socks, bed in low position with brakes on, call light within reach, and physical and occupational therapy evaluation and treatment. Review of the Fall Risk assessment dated [DATE] revealed Resident #40 was at high risk for falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had impaired cognition. Resident #40 was dependent on staff for toileting and maximum assistance from staff for bed mobility and transfers. Review of May 2025 physician orders for Resident #40 revealed there were orders for the fall mat, hipsters, Dycem on the wheelchair, perimeter mattress, grippy socks, bed in low position with brakes on, and other fall prevention interventions. Review of the nursing note dated 05/10/25 at 2:50 A.M. revealed Resident #40 was found on her knees, propped on the side of the bed, alert and oriented, and stated she could not sleep due to the roommate's snoring. No injuries were noted. The resident was assisted back to bed by staff. Review of the fall investigation dated 05/10/25 revealed Resident #40 was found out of bed. At the time of the fall, fall interventions, including the fall mat, hipsters, and perimeter mattress, were in place. The investigation determined the resident was noncompliant with calling for assistance, but no new interventions were added. Staff interviews indicated that ongoing monitoring and resident education were in place. Observation and interview on 05/27/25 at 10:26 A.M. revealed Resident #40 was sitting in her wheelchair with no Dycem in place. Activities Director #3, Certified Nursing Assistant (CNA) #75, and CNA #72 assisted Resident #40 to stand and observed there was no Dycem on the wheelchair. At 10:30 A.M., Activities Director #3, CNA #75, and CNA #72 confirmed there was no Dycem in place on Resident #40's wheelchair. Resident #40 stated she did not recall being educated on placing the Dycem on her wheelchair prior to sitting in it. Observation and interview on 05/28/25 at 8:39 A.M. revealed Resident #40 was eating breakfast in bed with no fall mat in place on the floor. CNA #75 confirmed the fall mat was not in place while Resident #40 was eating. Resident #40 stated the staff did not place the fall mat during the day and only placed it at night because she became confused during the night. Review of the facility policy titled Fall Prevention and Management Policy (revised 08/06/24) revealed residents will be assessed for fall risk(s) on admission, quarterly, and as needed. If risks are identified, preventive measures will be put in place and care planned. All falls will be reviewed and investigated. Individualized interventions will be implemented based on this assessment and care planned accordingly. The policy further defined a fall as unintentionally coming to rest on the ground, floor, or other lower level. An episode where a resident lost his/her balance and would have fallen if not for another person or if he/she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. This deficiency represents non-compliance investigated under Complaint Number OH00165175.

Based on medical record review, witness statement review, staff and resident interviews and policy review, the facility failed to ensure an allegation of staff-to-resident abuse was investigated thoroughly. This affected one (#62) of two residents reviewed for abuse. The facility census was 70. Findings include: Medical record review for Resident #62 revealed an admission date of 06/14/24. Diagnoses included cerebrovascular attack (CVA) and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was rarely or never understood and was dependent on staff for bed mobility and transfers. Review of a witness statement dated 05/24/25 on night shift from Resident #62 and Resident #2 revealed on 05/24/25, Resident #62 pushed his call light and 20-minutes later, Certified Nursing Assistant (CNA) #90 came to the room on her cell phone. CNA #90 stated Now what do you want? Resident #62 motioned with his hands and CNA #62 said I know you want a shower but it is going to be a couple of hours and she would be back and not to ring the call light anymore. Resident #62 put his hands as to say thank you and CNA #90 said don't you touch me I am four months pregnant this is a professional job and I am a professional at this job. CNA #90 then exited the room and came back around midnight. CNA #90 told Resident #62 she was ready to shower him, but he was going to have to help her because she wasn't going to lift him by herself. When CNA #90 picked Resident #62 up to transfer him to the chair, she flopped him down in the shower chair and then sat down in a chair in the room and there were puzzles in the chair. Resident #2 said you broke my puzzles and CNA #90 said they shouldn't be in the chair and continued to sit on them for another five minutes while talking on her phone with the speaker on while Resident #62 was sitting in the shower chair naked without any cover over him. As CNA #90 took Resident #62 down the hall, Resident #62 was trying to cover his private parts. CNA #90 brought him back wet and left him in the shower chair in the room while she was talking on the phone and telling the other person on the phone she didn't need this job. Resident #62 started drying himself and when CNA #90 was finished on the phone, she helped him dry off and then placed him back into a dirty bed. Resident #62 put his hand up to gesture thank you and CNA #90 yelled at him don't touch me I am four months pregnant and I will slap you. She left the room. The facility did not have any other resident or staff interviews from night shift for 05/24/25 to review if other residents or staff witnessed the allegation of abuse. Attempted an interview with Resident #62 on 05/28/25 at 1:02 P.M. revealed he could not be understood. Interview with Resident #2 on 05/28/25 at 1:15 P.M. revealed he remembered the incident he reported on 05/24/25 and provided the details he had in his witness statement. Interview with Human Resource Director (HR) #8 on 05/28/25 at 1:41 P.M. revealed she was notified on 05/24/25 that Resident #2 had a complaint about Resident #62 and interaction with CNA #90 on 05/24/25. She stated the facility had contacted the corporate to terminate the staff member after the complaint on 05/21/25 but didn't hear back from them. She stated she called the corporate office on 05/24/25 and got the permission to terminate the aide and CNA #90 was terminated. She reported she told the Administrator they were going to terminated CNA #90 but didn't speak with him personally about it until 05/27/25. Interview with the Administrator on 05/28/25 at 2:24 P.M. revealed it was reported to him CNA #90 was going to be terminated on 05/24/25 but nothing about the abuse part of the statement. He reported he didn't know anything about the allegation until 05/27/25 and had barely read the statements. He verified there were no residents or staff interviewed who may had seen Resident #62 being transported down the hall naked. He confirmed he didn't conduct a thorough investigation. Review of the policy titled Ohio Resident Abuse Policy dated 07/14/20 revealed all allegations of Abuse, Neglect, Involuntary Seclusion, Injuries of Unknown Source, and Misappropriation of resident property must be investigated immediately.

Based on medical record review, review of Self-Reported Incidents (SRI), witness statement review, staff and resident interviews, and policy review, the facility failed to ensure an allegation of staff-to-resident abuse was reported to the State Survey Agency, Ohio Department of Health (ODH). This affected one (#62) of two residents reviewed for abuse. The facility census was 70. Findings include: Medical record review for Resident #62 revealed an admission date of 06/14/24. Diagnoses included cerebrovascular attack (CVA) and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was rarely or never understood and was dependent on staff for bed mobility and transfers. Review of a witness statement dated 05/24/25 on night shift from Resident #62 and Resident #2 revealed on 05/24/25, Resident #62 pushed his call light and 20-minutes later, Certified Nursing Assistant (CNA) #90 came to the room on her cell phone. CNA #90 stated Now what do you want? Resident #62 motioned with his hands and CNA #62 said I know you want a shower but it is going to be a couple of hours and she would be back and not to ring the call light anymore. Resident #62 put his hands as to say thank you and CNA #90 said don't you touch me I am four months pregnant this is a professional job and I am a professional at this job. CNA #90 then exited the room and came back around midnight. CNA #90 told Resident #62 she was ready to shower him, but he was going to have to help her because she wasn't going to lift him by herself. When CNA #90 picked Resident #62 up to transfer him to the chair, she flopped him down in the shower chair and then sat down in a chair in the room and there were puzzles in the chair. Resident #2 said you broke my puzzles and CNA #90 said they shouldn't be in the chair and continued to sit on them for another five minutes while talking on her phone with the speaker on while Resident #62 was sitting in the shower chair naked without any cover over him. As CNA #90 took Resident #62 down the hall, Resident #62 was trying to cover his private parts. CNA #90 brought him back wet and left him in the shower chair in the room while she was talking on the phone and telling the other person on the phone she didn't need this job. Resident #62 started drying himself and when CNA #90 was finished on the phone, she helped him dry off and then placed him back into a dirty bed. Resident #62 put his hand up to gesture thank you and CNA #90 yelled at him don't touch me I am four months pregnant and I will slap you. She left the room. Review of the facilities SRIs revealed this allegation of abuse involving Resident #62 and CNA #90 was not reported to ODH. Attempted an interview with Resident #62 on 05/28/25 at 1:02 P.M. revealed he could not be understood. Interview with Resident #2 on 05/28/25 at 1:15 P.M. revealed he remembered the incident he reported on 05/24/25 and provided the details he had in his witness statement. Interview with the Administrator on 05/28/25 at 2:24 P.M. revealed it was reported to him CNA #90 was going to be terminated on 05/24/25 but nothing about the abuse part of the statement. He reported he didn't know anything about the allegation until 05/27/25 and verified he did not file a SRI and stated he should have reported it. Review of the policy titled Ohio Resident Abuse Policy dated 07/14/20 revealed all allegations of Abuse, Neglect, Involuntary Seclusion, Injuries of Unknown Source, and Misappropriation of resident property must be reported immediately to the Administrator, Director of Nursing (DON) and to the applicable State Agency.

Based on observations, staff interview and policy review, the facility failed to store food in a sanitary manner. This had the potential to affect 58 of 58 residents who receive food from the kitchen. The census was 58. Findings include: Observation on 10/11/22 at 9:00 A.M., of the kitchen, revealed three extra large bins, containing flour, food thickener and sugar. In each bin, a large scoop was stored inside each bin. This observation was verified by the Dietary Manager #50. Observation on 10/11/22 at 9:15 A.M., of the walk-in refrigerator revealed a pound of butter block opened, in a bag not sealed with no date. An open package of hot dogs sitting on a metal shelf, not sealed, or dated. Observation on 10/12/22 at 11:10 A.M., of the kitchen, revealed three extra large bins, containing flour, food thickener and sugar. The sugar bin revealed three lumps of a brown like substance. Interview on 10/12/22 at 11:45 A.M., with Dietary Manager #50 revealed the contents of each binned was not disposed of after discovering the scoops being stored inside each bin. The dietary staff continued to use the contents for cooking on 10/11/22, 10/12/22 and 10/13/22. Review of the policy titled Storage of Food Policy, updated 02/19/19 revealed refrigerated open items must have a label showing the name of the food and the date it should be consumed, and in a sealed container.

Based on observations and staff interviews, the facility failed to ensure kitchen equipment maintained in working condition and safe. This had the potential to affect 58 of 58 residents. The census was 58. Findings include: Observation on 10/12/22 at 11:00 A.M., of the kitchen revealed the steamer was not working and the convention oven was not working. Observation of a cookie sheet with a little bit of water covering the bottom of the sheet pan sat on the free-standing grill , the water was steaming. Ten minutes later a smell of something burnt was filtered throughout the kitchen. Dietary Aid #10 removed the pan from the grill because the liquid evaporated and formed a dry crusted black substance while sitting on the grill while it was turned on. Interview on 10/12/22 at 11:40 A.M., with the Regional Dietician #65 revealed the steamer was not working, two stove burners were not working, and the conventional oven was out of order. They were using the grill to keep the food warm. Observations on 10/12/22 at 3:10 P.M., with Maintenance Supervisor (MS) #16 confirmed the steamer had stopped working on 10/12/22 A.M. and he was just notified. The conventional oven has been out of order for at least six weeks. The gas stove and oven combo work fine. MS #16 verified the stove top only has one knob to turn the burners on. To turn on each burner, one must pull the knob off of the one gas regulator stem and place it on each burner gas regulator stem to ignite each burner and adjust the flame for cooking. He confirmed an order for a new stove had not been purchased. The oven/stove top is functional with utilizing the one knob. Dietary Manager # 50 commented she was not using all burners on the stove, because she could not get them to turn on, that is why she was using the grill.

Based on observation, staff interviews, National Dysphasia Diet: Standardization for Optimal Care guideline review, menu spreadsheet review and recipe review, the facility failed to prepare residents' food to meet individual needs. This had the potential to affect six (#8, #9, #45, #52, #53 and #311) residents who receive mechanical soft diet and seven (#10, #20, #31, #38, #43, #55 and #209) residents who receive puree diets. The facility census was 58. Findings include: 1. Observation on 10/12/22 at 11:10 A.M., with Dietary Aide #34 was preparing cupcakes for the mechanical and puree diets. She placed 13 baked cupcakes into the robot-coupe canister added two tablespoons of chocolate frosting for each cupcake into the canister. She blended the cupcakes and frosting until it formed a thick mixture. To thin the mixture, she added an unmeasured amount of water into the cupcake mixture. She explained, she was instructed to serve the residents who receive a mechanical soft diet a puree cupcake for their lunch dessert. Interview on 10/12/22 at 11:25 A.M., with the Regional Dietician #65 confirmed they will serve the residents who receive a mechanical soft diet a puree cupcake. The dietary staff are following the National Dysphasia Diet: Standardization for Optimal Care guidelines. Review of the undated National Dysphasia Diet: Standardization for Optimal Care guidelines recommended soft, moist cakes with icing are recommended for a resident who is in transition from a puree texture to more solid textures. Review of the Cupcake Yellow Chocolate Frosting recipe #57 revealed a mechanical soft diet is a Dysphagia Diet Level 6 (IDDSI Level 6): the food is Soft and Bite-Sized Foods Diet. It consists of many ordinary foods that are soft and easy to chew. Foods can be eaten with a fork or spoon. Foods are soft and fork-tender; they are moist. but there is no separate thin liquid present. Chop/Cut food into pieces =15 millimeter (mm) in size. Use a fork pressure test to confirm texture is within IDDSI Level 6 specifications. 2. Observation on 10/12/22 at 11:35 P.M., of Dietary Cook #45 placing seven servings of prepared no beans chili into the Robot Coupe (food processor). She explained, the chili is bean less because you cannot puree the kidney beans. Regional Dietician #56 verified at this time there was no beans in the chili. Interview on 10/12/22 at 3:00 P.M., with Regional Dietician #65 revealed they purchased cupcakes and served at lunch for residents who are on a mechanical soft diet and confirmed they pureed diets should have contained the beans. Review of the Chili Beef with Beans Recipe #301 revealed for puree diets measure desired number of servings (all chili ingredients) into a food processor. Blend until smooth. Use the Fork Drip Test and the spoon tilt test to confirm the texture. Review of the Day 14 lunch menu spread sheet revealed residents who are on puree diets are to receive puree beef chili with beans, scoop #10.

Based on record review, staff interview and policy review, the facility failed to notify the Ombudsman in writing of discharges to the hospital. This affected two (#6 and #14) of three residents reviewed for hospitalization . The facility census was 58. Findings include: 1. Record review of Resident #14's medical record revealed an admitted [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a progress note dated 06/27/22 at 9:00 A.M., revealed Resident #14 with a low grade fever since this morning. Tremors have worsened over this shift. Primary Care Physician recommended to send to the emergency room . Review of Resident #14's medical record revealed she was at the hospital from 06/27/22 to 07/13/22 and there was no evidence the ombudsman was notified of the transfer. Interview on 10/13/22 at 10:46 A.M., with Director of Social Services #51 confirmed the facility had not been sending notifications to the Long-Term Care Ombudsman regarding transfers and discharges. This included Resident #14's 06/27/22 discharge. 2. Review of the medical record for Resident #6 revealed the resident was admitted to the facility on [DATE], discharged on [DATE], and readmitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment, dated 07/03/22, revealed this resident had moderately impaired cognition. This resident was assessed to require extensive assistance for bed mobility, transfer, eating, dressing, toileting, and personal hygiene. Review of the nursing progress note dated 09/05/22 revealed Resident #6 was transported to the hospital due to altered mental status. Review of the notifications to the Office of the State Long-Term Care Ombudsman revealed the facility had not been sending notification as required. Interview on 10/13/22 at 10:46 A.M., with Director of Social Services #51 confirmed the facility had not been sending notification to the Long-Term Care Ombudsman regarding transfers and discharges. Review of the policy titled Resident Discharge/Transfer Letter dated 10/05/17 revealed the facility will complete discharge letters appropriately and according to all federal, state, and local regulations. Social Service or designee will assure the original discharge/transfer letter is given to Resident or guardian/sponsor. Copies will be sent to Department of Health, and Ombudsman Office. For emergency transfers, one list can be sent to the Ombudsman at the end of the month.

Based on observation, staff interviews, resident interview and policy review, the facility failed to implement the smoking policy to ensure residents did not have possession of cigarettes and lighter. This affected two (#19 and #24) of the three residents reviewed for smoking. The facility identified five residents smoke. The facility census was 58. Findings include: 1. Review of Resident #19's medical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 07/26/22 quarterly Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and the area to indicate if the resident was a smoker was left blank. Interview on 10/11/22 at 1:11 P.M., with Resident #19 revealed she was an unsupervised smoker and she keeps her cigarettes and lighter in her room. Interview on 10/13/22 at 10:00 A.M., with Registered Nurse #33 revealed the facility has a locked box they keep cigarettes in and there was three residents cigarettes in there. The facility has five smokers total. Observation on 10/13/22 at 10:09 A.M., revealed Registered Nurse #33 found two packs of cigarettes in Resident #19's bedside drawers and one pack of cigarettes and a lighter in the resident's purse. 2. Record review of Resident #24's medical record revealed an admission 09/06/19, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS assessment dated [DATE] revealed the resident was cognitively intact and the area to indicate if the resident was a smoker was left blank. Interview on 10/11/22 at 11:52 A.M., with Resident #24 revealed he is an unsupervised smoker and keeps his own cigarettes and lighter. Observation on 10/13/22 at 10:11 A.M., revealed Registered Nurse #33 found eight cigarettes and a lighter in Resident #24's room. Review of the policy titled Resident Smoking Policy dated 08/22/22 revealed no resident will maintain or store smoking materials on their person or their room. Resident smoking materials will be retained by facility staff and distributed to the residents or supervising staff at designated smoking times.

Based on observation, staff interview, and review of the facility meal spreadsheets, the facility failed to ensure the meal menu was followed for residents who received mechanical soft and pureed diets. This affected six residents (#21, #34, #39, #42, #50, and #51) out of six residents who received a mechanical soft diet, and three residents (#04, #26, and #49) out of three residents who received a pureed diet. The facility census was 58. Findings Include: Review of the meal spreadsheet dated 08/29/22 revealed residents who received mechanical soft diets were to receive ground pork chops with gravy and puree diets should received pureed pork chops with gravy. Observation on 08/29/22 at 11:09 A.M., of the puree/mechanical soft process revealed the cook prepared meat loaf for these residents instead of pork. She ground the meat loaf and pureed the meat loaf into separate containers. Interview on 08/29/22 at 11:09 A.M., with the Dietary Manager #129 verified she was not going to have enough pork for the residents who received a puree and mechanical soft diet and that was why they had not received the pork meal. Observation on 08/29/22 at 11:50 A.M. during tray line revealed the mechanical soft and the pureed meatloaf was served to residents receiving such diets. During the course of the survey, Dietician #172 identified six residents (#21, #34, #39, #42, #50, and #51) who received the mechanical soft diet and three residents (#04, #26, and #49) who received a pureed diet during the lunch meal on 08/29/22. This deficiency substantiates Master Complaint Number OH 177 and Complaint Number OH 875.

Based on medical record review, observations, staff interview and policy review, the facility failed to ensure fall interventions were implemented as care planned. This affected one (#1) of three residents reviewed for falls. The census was 57. Findings include: Review of the medical record for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #1 was moderately cognitively impaired and required extensive assistance with activities of daily living. Review of Resident #1's medical record revealed he had an unwitnessed fall on 11/02/20 and received no injuries. Review of the fall investigation dated 11/02/20 revealed Resident #1 was found sitting on his fall mat directly next to his bed. Resident #1's physician and responsible party were notified of the fall and all fall interventions were in place at the time of the fall. Review of the Interdisciplinary Team meeting note dated 11/03/20 revealed a new fall intervention of hipsters (soft, impact-absorbing pads over the hip area to minimize damage from a fall) was added to the care plan. Review of the comprehensive care plan revealed Resident #1 was at risk for falls with fall interventions that included hipsters on at all times, except during care. Interview with Registered Nurse (RN) #100 on 11/23/20 at 1:55 P.M. revealed fall interventions for residents can be found in a care plan guide which both nurses and nurse aides can access. Interview with State tested Nursing Aide (STNA) #105 and Licensed Practical Nurse (LPN) #110 on 11/23/20 at 3:05 P.M. revealed STNA #105 had provided care to Resident #1 earlier in the day and he was not wearing hipsters at that time. STNA #105 was unaware of what hipsters were and did not know the resident was supposed to be wearing them. STNA #105 and LPN #110 were unable to find hipsters in the care plan guide for Resident #1. Observation of Resident #1 on 11/23/20 at 3:06 P.M. revealed he was not wearing hipsters. Interview with STNA #200 at the time of the observation verified the resident was not wearing hipsters. When STNA #200 asked the resident about putting on the hipsters, Resident #1 stated STNA #200 could assist him in putting on the hipsters. Interview with LPN #300 on 11/24/20 at 11:04 P.M. revealed fall interventions can be found on the care plan guide. The interview further revealed staff must add fall interventions located in the physician orders [REDACTED]. Review of the policy titled Fall Prevention and Management Policy Revised 12/09/19, revealed fall risk assessments will be completed on admission, quarterly, after any fall, and as needed. Individualized interventions will be implemented based on this assessment and care planned accordingly. Falls will be reviewed by an interdisciplinary team and any new interventions identified will be implemented and the care plan updated as necessary. This deficiency substantiates Complaint Number OH 181.

Based on medical record review, staff interview and policy review, the facility failed to provide residents with bed hold notifications when the resident was transferred to hospital. This affected two (#8 and #60) residents of two residents reviewed for hospitalization s. The facility census was 58. Findings include: 1. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment and required extensive assist with bed mobility, transfers, dressing, toilet use and personal hygiene and required supervision with eating. Further review of the medical record revealed resident was sent to the hospital on [DATE] for a significant change in condition, and no verification was found in the medical record that the facility provided the resident with the bed hold policy and reserve bed payment when transferred. Interview conducted on 01/02/20 at 1:33 P.M. with Clinical Quality Coordinator #300 verified Resident #8 was transferred out of the facility on 12/30/19 to the hospital and the resident was not provided the required bed hold policy with reserve bed payment when transferred. 2. Review of medical record for Resident #60 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] revealed Resident #60 required one person assist with activities of daily living. A care plan relative to medical and psychological needs revealed individualized interventions with measurable goals. A review of the progress notes from 10/15/19 through 10/20/19 revealed Resident #60 was discharged to the hospital on [DATE] with the intent to return to the facility. Review of Resident #60's closed medical record revealed Resident #60 or her representative did not receive a bed hold notice. On 01/02/20 at 09:59 [NAME]M. interview with the Regional Clinical Director #302 confirmed Resident #60 received a transfer letter but did not receive a bed hold notification when she went to the hospital on [DATE]. Review of the facility Discharge /Transfer Letter Policy dated 10/05/17 documented when a resident is sent to the hospital, the resident or the resident's responsible party will receive a bed hold notice, indicating how many bed holds are left and the bed hold rate, along with the discharge/transfer letter.

Based on observations, medical record reviews, review of Centers for Disease Control (CDC) information concerning effects of heat, review of historical temperature data, interviews with residents, families, facility staff, the Ombudsman, the Heath Commissioner and Director of the Emergency Management Agency (EMA) for the county, the City Police Department Dispatcher, the President of the Temperature Control Company, a physician and Medical Director of the facility, and review of facility policy, the facility failed to ensure comfortable and safe temperatures were maintained throughout the facility when temperatures exceeded 88 degrees Fahrenheit (F) in resident rooms and common areas. Additionally, the facility failed to have an emergency contingency plan in place related to excessive heat that directed staff what to do to ensure the health and safety of all residents in the facility. This resulted in Immediate Jeopardy for two (#4 and #5) of seven residents reviewed for hospitalization due to experiencing actual harm resulting in dehydration requiring treatment with intravenous (IV) fluids. Furthermore, the facility's failure to have developed and implemented an emergency contingency plan placed the other 59 residents at risk for the likelihood of serious imminent harm by not monitoring resident's individual room temperatures and monitoring the residents for signs and systems of heat related outcomes. On 07/25/16 at 6:00 P.M., the Licensed Nursing Home Administrator (LNHA) and the Corporate Registered Nurse (RN) were notified Immediate Jeopardy began on 07/12/16 when the facility first became aware that one of the two air conditioning (AC) units had a broken compressor rendering it non-functional. Two residents were subsequently hospitalized due to dehydration and required treatment with intravenous (IV) fluids after becoming lethargic and unresponsive due to the extreme heat of the facility on 07/23/16 and 07/24/16. The facility chose not to replace the broken compressor until 07/27/16 and had no emergency contingency plan for extreme heat developed and implemented and was not monitoring the temperatures of residents ' individual rooms or monitoring residents for any signs and symptoms of heat related concerns. The Immediate Jeopardy was removed on 07/26/16 at 6:00 A.M. when the facility implemented the following corrective actions: · On 07/25/16 at 6:00 P.M., 20 portable AC units were placed throughout the facility in hallways and resident common areas. · On 07/25/16 at 6:00 P.M., in-service education on the symptoms and treatment of [REDACTED]. Staff not on site would receive training prior to working their shift. · On 07/25/16 at 6:15 P.M., ten (10) additional staff members were called in to assist with assessing and moving residents to cooler areas within the facility. · On 07/25/16 by 6:25 P.M., all residents had a head to toe assessment completed to assess for symptoms related to heat. These assessments continued every four hours until ambient temperatures were within normal limits. · On 07/25/16 at 6:30 P.M., the facility contacted a heating and cooling company and ordered a portable chiller and generator to be delivered to the facility. · On 07/25/16 at 6:45 P.M., the facility created a cool room in the dining room and therapy room with the portable AC units and encouraged residents to use these rooms. All residents had a fan in their rooms. · On 07/25/16 at 7:00 P.M., all residents on the 400 hall were moved to empty beds and rooms on the 100, 200 and 300 halls. The portable AC units were consolidated to those three units to reduce the amount of square footage to cool. The Medical Director and attending physicians were notified of the temperature issues. Temperatures would be monitored and recorded hourly at station one's nurse station, 100 hall, 200 hall, 300 hall, dining room, therapy room and two resident rooms on each hall until temperatures return to normal limits for four days and then routinely thereafter. · On 07/26/16 at 5:40 A.M., the portable chiller was functioning and began to cool air temperatures within the facility. · On 07/26/16 at 3:00 P.M., the facility had notified all current residents families of the temperature issue. · Temperatures taken on 07/25/16 and 07/26/16 between 8:00 A.M. and 1:50 P.M. revealed all areas of the facility, including resident rooms were between 68 degrees F and 77 degrees F. All resident rooms had cool air blowing through the registers. · On 07/27/16 from 9:25 A.M. until 10:36 A.M., interviews with Licensed Practical Nurse (LPN) #61 and #9, and State tested Nursing Assistants (STNA) #93 and #82 revealed they all had training on recognizing and treating signs and symptoms of heat exhaustion and heat stroke and were able to verbalize how to monitor residents. · On 07/27/16 at 11:15 A.M., the purchased compressor arrived at the facility and installation began. · On 07/27/16 at 12:00 P.M., the facility developed an Equipment Malfunction Protocol. Although the Immediate Jeopardy was removed on 07/26/16 at 6:00 A.M., the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance until it was corrected on 07/27/16 at 12:00 P.M. Findings include: On 07/25/16 at 4:30 P.M. upon entrance to the facility, it was noted the air was hot and humid. Further observation at 4:35 P.M. revealed a mounted digital thermostat beside the nurse's station between the 100 hall and 200 halls measured an air temperature of 88 degrees F. Residents were observed lying in their beds with no covers on and fans blowing on them. Residents were also sitting in wheel chairs in front of fans and portable AC units. Interview on 07/25/16 at 4:54 P.M. with Resident #21 and her husband revealed for the past five days it had been very hot in the facility and he brought in a fan for the resident. Interview on 07/25/16 at 5:02 P.M. with Resident #46 revealed she thought residents had been sent out to the hospital due to the heat and it had been hot in the facility for weeks. During the interview, Resident #46 pleaded for help and begged to get the problem fixed. Resident #46 repeatedly stated it was so hot. Resident #46 was in a sleeveless dress in a wheelchair sitting by a portable AC unit. Resident #46's arms were red and the hair around her head was wet from sweating. Interview on 07/25/16 at 5:05 P.M. with STNA #36 revealed it had been hot all day and over the weekend (7/23 and 7/24). STNA #36 stated all the STNAs were trying their best to keep residents cool and keep up emptying the water that collected at the bottom of the portable AC units. Observations on 07/25/16 at 5:19 P.M. with Maintenance Supervisor (MS) #19 revealed the area at the nurse 's station between the 100 and 200 halls measured 87 degrees F, resident room [ROOM NUMBER] was 87 degrees F, resident room [ROOM NUMBER] was 87 degrees F, resident room [ROOM NUMBER] was 88 degrees F, the dining room on the 300 hall was 88 degrees F and resident room [ROOM NUMBER] was 87 degrees F. The temperatures were taken with a non-contact infrared thermometer. MS #19 stated the thermometer took surface temperatures and that was what he used to measure the temperature in the building. Interview with the Regional RN, Director of Nursing (DON) and LNHA on 07/25/16 at 5:25 P.M. revealed the compressor on their AC unit went out and a new one was ordered on [DATE] and would arrive in two to three days. The LNHA confirmed the compressor went out on 07/12/16 and the replacement compressor was not ordered until 07/21/16. She further confirmed the compressor was not ordered as rush shipping which would have put the unit at the facility in one to two days. Instead, the compressor was ordered standard shipping and would arrive between three to five days. The LNHA stated there had not been any maintenance performed on their heating and cooling system and confirmed it was the facility policy to have the maintenance done quarterly. The LNHA further confirmed the facility had no emergency plan for high heat in the facility. Interview on 07/26/16 at 8:37 A.M. with the President of the Temperature Control Company revealed MS #19 first requested a quote for a new compressor on 07/12/16. The president stated he sent the MS a quote on 07/13/16, however did not receive approval to place the order until 07/21/16. The president of the company further stated the MS stated to order the compressor standard shipping instead of rush shipping. Interview on 07/26/16 at 9:08 A.M. with STNA #91 revealed she had worked over the weekend (07/23 and 07/24) and described it as being very hot. STNA #91 stated the nurses directed the STNAs to pass ice and water and to take the temperature of the resident if they looked hot. Interview on 07/26/16 at 9:38 A.M. with Ombudsman #102 revealed she had been at the facility on 07/14/16 on an unrelated complaint and noted the heat when she walked into the facility. Several residents expressed to her that they wish the AC would get fixed. Ombudsman #102 was told by administration the AC would be fixed within two weeks. Interview on 07/26/16 at 9:50 A.M. with the family member of Resident #2 revealed on 07/19/16 she noticed the heat and began questioning administration. She stated the nurses, the DON and the administrator were rude to her. Interview on 07/25/16 at 4:54 P.M. with Resident #21 and her husband revealed for the past five days, it had been very hot in the facility and he brought in a fan for the resident. Interview on 07/26/16 at 9:54 A.M. with family member of Resident #3 stated the facility had been hot for four weeks. Over the weekend (07/23 and 07/24) she reported her mother had a free standing thermometer in her room that only goes up to 90 degrees F and the thermometer was reading 90 degrees F. Staff kept telling her they were putting work orders in for the broken AC. The family member did state the facility brought in the portable AC units over the weekend and the police entered the facility on 07/23/16 and made the facility obtain fans for all the residents. The family member reported that around 6:00 A.M. on 07/24/16 the temperature in the facility was 85 degrees F. Interview on 07/26/16 at 11:30 A.M. with the City Police Department Dispatcher revealed Sargent #103 responded to the facility on [DATE] at 5:12 P.M. due to a staff member of the facility complaining of the high heat. Sargent #103 confirmed the AC was not working upon arrival and found the temperature in the facility to be 85 degrees F. Sargent #103 had the facility contact the LNHA. The LNHA told Sargent #103 that donated fans were being brought in and the compressor had been ordered to fix the AC. Sargent #103 then involved the Emergency Management Agency (EMA) of the county to assist the facility in some other interventions to keep the residents cool. Interview on 07/26/16 at 11:32 A.M. with Director #104 of the EMA of the county stated Sargent #103 contacted him on 07/23/16 at 5:36 P.M. regarding the rising temperatures of the facility. Sargent #103 reported to him there were only box fans at the facility with rising temperatures. Director #104 stated he had offered in the past for the facility to participate with the EMA for a plan when situations of having no AC with high heat outside occurred. However he never received a response from the facility to participate in developing a plan. Director #104 did suggest renting the portable AC units to the facility, which the facility did on 07/23/16 at 9:00 P.M. Interview on 07/26/16 at 11:43 A.M. with STNA #46 revealed she worked on 07/22/16, 07/23/16 and 07/24/16 and described the facility as extremely hot. STNA #46 reported at one point the temperature in the facility was 86 degrees F. She further stated someone from the facility had called the police stating to them that it was not safe for the residents in the facility. STNA #46 believed there were a couple of residents sent out to the emergency room due to the heat and believed it was Resident #4 and Resident #5 who resided on the 300 hall. STNA #46 stated it had been hot in the facility for about a month. STNA #46 reported the administration has been telling staff they were not getting a new AC unit for a couple of months (September 2016) since this was when they were remodeling. STNA #46 stated she had no instruction from administration regarding monitoring residents during the high heat in the facility. On 07/26/16 at 12:35 P.M., interview with a facility physician (#107) revealed he was the physician of several residents of the facility. He stated he went to the facility on [DATE] in the afternoon and it was extremely hot. Physician #107 stated no administrative staff was in the building at that time. He stated he spoke to a nurse who was told by the administration of the facility to call the community to see if anyone could donate fans to the facility. Interview on 07/26/16 at 3:38 P.M. with a family member of Resident #42 revealed the weekend of 07/23 and 07/24 was terrible due to the heat and it was hard on Resident #42 due to her having a tracheostomy. On 07/26/16 at 6:50 P.M., interview with the Medical Director revealed he was not made aware of the extreme heat temperatures in the facility until 07/25/16. He was unaware the compressor was not working on 07/12/16 when the facility called a temperature control company to get a quote for a new one. He then stated he was told the facility placed 15 AC units throughout the facility on 07/23/16, however they were not helping and then the facility eventually got a chiller unit to help cool the building on 07/26/16. He stated he was not aware of any resident who had to be sent out due to the heat. He further stated he was not aware the facility did not have an emergency contingency plan and policy or procedure regarding excessive heat temperatures. He stated his expectations would be for the facility to provide measures to rectify the situation and make the residents safe and comfortable immediately. Interview on 07/27/16 at 8:25 A.M. with MS #19 confirmed he ordered the new compressor to be shipped standard shipping instead of rush shipping on 07/21/6. He confirmed he only took temperatures in the hallways and not in the resident rooms. He stated the heat made it miserable in the facility over the weekend of 07/23 and 07/24. MS #19 stated there were two AC units that cooled the building and the one unit became non-functional when the compressor broke. MS #19 stated he was under the impression the one AC unit would be able to cool the facility. He further stated he was not aware that quarterly maintenance was to be performed on the heating and cooling units and this had not been done. Interview on 07/27/16 at 8:41 A.M. with Health Commissioner (HC) #109 of the county revealed she had received a call on 07/24/16 (Sunday) in the evening from the police about the heat in the facility. HC #109 stated herself and her DON went to the facility on [DATE] (Monday) morning to find no cool air in the resident portion of the building. HC #109 stated she saw the portable AC units, however questioned if they were effective. HC #109 stated the facility did not have a plan in place for the situation of high heat in the building. Interview on 07/27/16 at 10:44 A.M. with Technician #100 who was employed by the Temperature control Company and was at the facility installing the new compressor, stated the facility first contacted the company on 07/12/16 and requested a quote for a new compressor. The facility was provided a quote on 07/13/16. He further confirmed the company didn't receive approval to order the compressor until 07/21/16. Technician #100 verified the facility had two AC units and the one was non-functional due to the compressor not working. Technician #100 stated one of the AC units would cool the building in 70 degree F to up to 80 degree F temperatures, however not over 80 degrees F temperatures with high humidity. Review of the London, Ohio forecast from weatherchannel.com revealed: 07/12/16: high temperature 89 degrees F; average humidity 80% 07/13/16: high temperature 91 degrees F; average humidity 83% 07/14/16: high temperature 83 degrees F; average humidity 91% 07/15/16: high temperature 86 degrees F; average humidity 85% 07/16/16: high temperature 82 degrees F; average humidity 77% 07/17/16: high temperature 86 degrees F; average humidity 82% 07/18/16: high temperature 86 degrees F; average humidity 94% 07/19/16: high temperature 86 degrees F; average humidity 79% 07/20/16: high temperature 87 degrees F; average humidity 72% 07/21/16: high temperature 89 degrees F; average humidity 80% 07/22/16: high temperature 84 degrees F; average humidity 89% 07/23/16: high temperature 90 degrees F; average humidity 88% 07/24/16: high temperature 91 degrees F; average humidity 88% 07/25/16: high temperature 93 degrees F; average humidity 82% 07/26/16: high temperature 84 degrees F; average humidity 84% According to the CDC (emergency.cdc.gov/disasters/extreme heat/older-adults-heat.asp) people suffer heat-related illness when the body's temperature control system is overloaded. The body normally cools itself by sweating. But under some conditions, sweating just isn't enough. In such cases, a person 's body temperature rises rapidly. Very high body temperatures may damage the brain or other vital organs. Several factors affect the body 's ability to cool itself during extremely hot weather. When the humidity is high, sweat will not evaporate as quickly, preventing the body from releasing heat quickly. Other conditions that can limit the ability to regulate temperature include old age, youth (age 0-4), obesity, fever, dehydration, heart disease, mental illness, poor circulation, sunburn, and prescription drug use and alcohol use. Interview on 07/27/16 at 11:55 A.M. with Corporate RN #105 revealed she was unaware if the facility had a policy on safe and comfortable temperatures for residents, however verified they go by federal regulations. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nurse's notes dated 07/24/16 at 9:20 P.M. revealed Resident #5 was unresponsive. Resident #5 had a blood pressure of 78/32 millimeters/mercury (mmHG). Normal blood pressure readings are 120/70 mmHG. The resident had a pulse of 52 beats per minute and a temperature of 99.1 degrees F. Nurse #62 documented the resident was noted to have a decreased level of consciousness and personality changes. Further documentation revealed Resident #5 was lethargic and felt hot. The family was notified and wanted the resident sent to the Emergency Department (ED) for evaluation and treatment. Review of hospital records revealed Resident #5 arrived at the hospital with altered mental status and per nursing staff at the facility, the air conditioning had been out at the facility for three weeks and there were concerns the resident was overheated. The resident was admitted to the hospital for dehydration and received IV fluids for treatment. Resident #5 was still hospitalized as of 07/27/16. Interview on 07/26/16 at 12:33 P.M. with the family member of Resident #5 revealed she came in for lunch on 07/24/16 and Resident #5 was not talking at all which was unusual for her. It was very hot in the facility. Resident #5's pulse was taken and it was around 40 beats per minute. The family member requested Resident #5 to be sent out to the hospital. The family member stated the hospital told her Resident #5 was dehydrated, was put on IV fluids and was still at the hospital. Hospital staff told the family member they had been given information in report from facility staff, the AC had been out for three weeks. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nurse's notes dated 07/23/16 at 6:19 P.M. revealed Resident #4 was found lethargic and unresponsive. Resident #4 had a blood pressure reading of 106/65 mmHG. Resident #4's pulse was 76 beats per minute and had a temperature of 98 degrees. Orders were obtained to send Resident #4 to the ED for treatment and evaluation. Review of hospital records revealed upon arrival to the ED Resident #4 was noted with altered mental status and per the Emergency Medical Service (EMS) the facility where Resident #4 came from had a malfunctioning air conditioner. The EMS reported it was very hot in the facility. Upon arrival to the facility, the EMS found Resident #4 slumped over in a chair. Resident #4 was admitted with syncopal (fainting) episode, possibly secondary to dehydration and acute renal failure from dehydration. Resident #4 received IV fluids for treatment. Resident #4 was still hospitalized as of 07/27/16. Interview on 07/26/16 at 2:00 P.M. with LPN #11 revealed she worked 07/20/16, 07/23/16 and 07/24/16. LPN #11 stated Resident #4 was sent out to the hospital on [DATE]. LPN #11 stated they could not arouse Resident #4 and it was like a sauna in his room. LPN #11 stated she could not listen to Resident #4's lungs because his breathing was so shallow. LPN #11 stated administration gave no direction on what do with the AC being out. She further stated the LNHA and MS #19 came into the facility on the weekend after calling them multiple times, however were only in the building a couple of hours. LPN #11 stated she was under the impression the AC was not getting fixed until September 2016. LPN #11 stated she called the hospital to check on Resident #4 and was told after he had been given a bag of fluids he perked up. The hospital staff further stated Resident #4 was dehydrated and the heat probably played a factor. On 07/26/16 at 2:36 P.M., interview with LPN #62 stated she worked the 7:00 P.M. to 7:00 A.M. shift and worked the 300 and 400 halls. LPN #62 stated when she arrived at the facility on 07/23/16 at 7:00 P.M. there was an ambulance at the facility. LPN #62 stated she was told in report from LPN #11 Resident #4 was unresponsive, had a low blood pressure, was lethargic and was being sent to the hospital for treatment. LPN #62 stated she received a report later in her shift that Resident #4 was being admitted due to being dehydrated from the heat and was receiving IV fluids. After 9:00 P.M. on 07/23/16 there were 15 portable A/C units brought in and placed throughout the building, however they were not cooling down the building at all. At 9:15 P.M., another resident (#5) became lethargic, had low blood pressure, and was unresponsive. She then called the family to notify them of the change in condition and the family stated they wanted her sent to the hospital as they had been in visiting earlier and knew how hot the facility was. The hospital called her later with a report stating Resident #5 would be admitted with the [DIAGNOSES REDACTED]. LPN #62 stated the facility was very hot and it was actually cooler outside on 07/23/16 and 07/24/16. LPN #62 specifically stated 07/23/16 was unbearable. LPN #62 stated the facility had been hot for several weeks, and staff and residents were sweating through their clothes. The residents were saying they were very uncomfortable. STNA's brought in tank tops and cut off T-shirts for residents to wear to try and make them a little more comfortable. She further stated fans were brought in via donations from the community and the facility also purchasing some. Review of an undated Emergency Preparedness Plan revealed the plan would be maintained and updated to provide instruction detailing appropriate responses by the facility for disaster situations. Each employee would be trained in orientation and annually to follow all guidelines related to emergency situations. In the event of an emergency, the administrator was in charge and the maintenance department should refer to vendor lists for any additional emergency supplies that may be identified as needed to maintain the facility in emergency conditions. Director #104 and his phone number were listed as the contact for the local Deputy Coordinator of Emergency services. The policy further revealed that preventative maintenance will occur quarterly for heating and cooling units and repair and upkeep will occur in a timely manner. This deficiency substantiates complaint number OH 704, OH 708, OH 710, OH 731.

Based on observations, medical record reviews, review of Centers for Disease Control (CDC) information concerning effects of heat, review of historical temperatures data, interviews with residents, families, facility staff, the Ombudsman, the Heath Commissioner and Director of the Emergency Management Agency (EMA) for the county, the City Police Department Dispatcher, the President of the Temperature Control Company, a physician and Medical Director of the facility, and review of facility policy, the facility failed to have an emergency contingency plan in place related to excessive heat that directed staff what to do to ensure the health and safety of all residents in the facility. The facility failed to ensure comfortable and safe temperatures were maintained throughout the facility when temperatures exceeded 88 degrees Fahrenheit (F) in resident rooms and common areas. This resulted in Immediate Jeopardy for two (#4 and #5) of seven residents reviewed for hospitalization due to experiencing actual harm resulting in dehydration requiring treatment with intravenous (IV) fluids. Furthermore, the facility's failure to have developed and implemented an emergency contingency plan placed the other 59 residents at risk for the likelihood of serious imminent harm by not monitoring resident's individual room temperatures and monitoring the residents for signs and systems of heat related outcomes. On 07/25/16 at 6:00 P.M., the Licensed Nursing Home Administrator (LNHA) and the Corporate Registered Nurse (RN) were notified Immediate Jeopardy began on 07/12/16 when the facility first became aware that one of the two air conditioning (AC) units had a broken compressor rendering it non-functional. Two residents were subsequently hospitalized due to dehydration and required treatment with intravenous (IV) fluids after becoming lethargic and unresponsive due to the extreme heat of the facility on 07/23/16 and 07/24/16. The facility chose not to replace the broken compressor until 07/27/16 and had no emergency contingency plan for extreme heat developed and implemented. The facility furthermore was not monitoring the temperatures of residents' individual rooms or monitoring residents for any signs and symptoms of heat related concerns. The Immediate Jeopardy was removed on 07/26/16 at 6:00 A.M. when the facility implemented the following corrective actions: · On 07/25/16 at 6:00 P.M., 20 portable AC units were placed throughout the facility in hallways and resident common areas. · On 07/25/16 at 6:00 P.M., in-service education on the symptoms and treatment of [REDACTED]. Staff not on site would receive training prior to working their shift. · On 07/25/16 at 6:15 P.M., ten (10) additional staff members were called in to assist with assessing and moving residents to cooler areas within the facility. · On 07/25/16 by 6:25 P.M., all residents had a head to toe assessment completed to assess for symptoms related to heat. These assessments continued every four hours until ambient temperatures were within normal limits. · On 07/25/16 at 6:30 P.M., the facility contacted a heating and cooling company and ordered a portable chiller and generator to be delivered to the facility. · On 07/25/16 at 6:45 P.M., the facility created a cool room in the dining room and therapy room with the portable AC units and encouraged residents to use these rooms. All residents had a fan in their rooms. · On 07/25/16 at 7:00 P.M., all residents on the 400 hall were moved to empty beds and rooms on the 100, 200 and 300 halls. The portable AC units were consolidated to those three units to reduce the amount of square footage to cool. The Medical Director and attending physicians were notified of the temperature issues. Temperatures would be monitored and recorded hourly at station one ' s nurse station, 100 hall, 200 hall, 300 hall, dining room, therapy room and two resident rooms on each hall until temperatures return to normal limits for four days and then routinely thereafter. · On 07/26/16 at 5:40 A.M., the portable chiller was functioning and began to cool air temperatures within the facility. · On 07/26/16 at 3:00 P.M., the facility had notified all current residents' families of the temperature issue. · Temperatures taken on 07/25/16 and 07/26/16 between 8:00 A.M. and 1:50 P.M. revealed all areas of the facility, including resident rooms were between 68 degrees F and 77 degrees F. All resident rooms had cool air blowing through the registers. · On 07/27/16 from 9:25 A.M. until 10:36 A.M., interviews with Licensed Practical Nurse (LPN) #61 and #9, and State tested Nursing Assistant (STNA) #93 and #82 revealed they all had training on recognizing and treating signs and symptoms of heat exhaustion and heat stroke and were able to verbalize how to monitor residents. · On 07/27/16 at 11:15 A.M., the purchased compressor arrived at the facility and installation began. · On 07/27/16 at 12:00 P.M., the facility developed an Equipment Malfunction Protocol. Although the Immediate Jeopardy was removed on 07/26/16 at 6:00 A.M., the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance until it was corrected on 07/27/16 at 12:00 P.M. Findings include: On 07/25/16 at 4:30 P.M. upon entrance to the facility, it was noted the air was hot and humid. Further observation at 4:35 P.M. revealed a mounted digital thermostat beside the nurse's station between the 100 hall and 200 halls measured an air temperature of 88 degrees F. Residents were observed lying in their beds with no covers on and fans blowing on them. Residents were also sitting in wheel chairs in front of fans and portable AC units. Interview on 07/25/16 at 4:54 P.M. with Resident #21 and her husband revealed for the past five days it had been very hot in the facility and he brought in a fan for the resident. Interview on 07/25/16 at 5:02 P.M. with Resident #46 revealed she thought residents had been sent out to the hospital due to the heat and it had been hot in the facility for weeks. During the interview, Resident #46 pleaded for help and begged to get the problem fixed. Resident #46 repeatedly stated it was so hot. Resident #46 was in a sleeveless dress in a wheelchair sitting by a portable AC unit. Resident #46's arms were red and the hair around her head was wet from sweating. Interview on 07/25/16 at 5:05 P.M. with STNA #36 revealed it had been hot all day and over the weekend (7/23 and 7/24). STNA #36 stated all the STNAs were trying their best to keep residents cool and keep up emptying the water that collected at the bottom of the portable AC units. Observations on 07/25/16 at 5:19 P.M. with Maintenance Supervisor (MS) #19 revealed the area at the nurse's station between the 100 and 200 halls measured 87 degrees F, resident room [ROOM NUMBER] was 87 degrees F, resident room [ROOM NUMBER] was 87 degrees F, resident room [ROOM NUMBER] was 88 degrees F, the dining room on the 300 hall was 88 degrees F and resident room [ROOM NUMBER] was 87 degrees F. The temperatures were taken with a non-contact infrared thermometer. MS #19 stated the thermometer took surface temperatures and that was what he used to measure the temperature in the building. Interview with the Regional RN, Director of Nursing (DON) and LNHA on 07/25/16 at 5:25 P.M. revealed the compressor on their AC unit went out and a new one was ordered on [DATE] and would arrive in two to three days. The LNHA confirmed the compressor went out on 07/12/16 and the replacement compressor was not ordered until 07/21/16. She further confirmed the compressor was not ordered as rush shipping which would have put the unit at the facility in one to two days. Instead, the compressor was ordered standard shipping and would arrive between three to five days. The LNHA stated there had not been any maintenance performed on their heating and cooling system and confirmed it was the facility policy to have the maintenance done quarterly. The LNHA further confirmed the facility had no emergency plan for high heat in the facility. Interview on 07/26/16 at 8:37 A.M. with the President of the Temperature Control Company revealed MS #19 first requested a quote for a new compressor on 07/12/16. The president stated he sent the MS a quote on 07/13/16, however did not receive approval to place the order until 07/21/16. The president of the company further stated the MS stated to order the compressor standard shipping instead of rush shipping. Interview on 07/26/16 at 9:08 A.M. with STNA #91 revealed she had worked over the weekend (07/23 and 07/24) and described it as being very hot. STNA #91 stated the nurses directed the STNA's to pass ice and water and to take the temperature of the resident if they looked hot. Interview on 07/26/16 at 9:38 A.M. with Ombudsman #102 revealed she had been at the facility on 07/14/16 on an unrelated complaint and noted the heat when she walked into the facility. Several residents expressed to her that they wish the AC would get fixed. Ombudsman #102 was told by administration the AC would be fixed within two weeks. Interview on 07/26/16 at 9:50 A.M. with the family member of Resident #2 revealed on 07/19/16 she noticed the heat and began questioning administration. She stated the nurses, the DON and the administrator were rude to her. Interview on 07/25/16 at 4:54 P.M. with Resident #21 and her husband revealed for the past five days, it had been very hot in the facility and he brought in a fan for the resident. Interview on 07/26/16 at 9:54 A.M. with family member of Resident #3 stated the facility had been hot for four weeks. Over the weekend (07/23 and 07/24) she reported her mother had a free standing thermometer in her room that only goes up to 90 degrees F and the thermometer was reading 90 degrees F. Staff kept telling her they were putting work orders in for the broken AC. The family member did state the facility brought in the portable AC units over the weekend and the police entered the facility on 07/23/16 and made the facility obtain fans for all the residents. The family member reported that around 6:00 A.M. on 07/24/16 the temperature in the facility was 85 degrees F. Interview on 07/26/16 at 11:30 A.M. with the City Police Department Dispatcher revealed Sargent #103 responded to the facility on [DATE] at 5:12 P.M. due to a staff member of the facility complaining of the high heat. Sargent #103 confirmed the AC was not working upon arrival and found the temperature in the facility to be 85 degrees F. Sargent #103 had the facility contact the LNHA. The LNHA told Sargent #103 that donated fans were being brought in and the compressor had been ordered to fix the AC. Sargent #103 then involved the Emergency Management Agency (EMA) of the county to assist the facility in some other interventions to keep the residents cool. Interview on 07/26/16 at 11:32 A.M. with Director #104 of the EMA of the county stated Sargent #103 contacted him on 07/23/16 at 5:36 P.M. regarding the rising temperatures of the facility. Sargent #103 reported to him there were only box fans at the facility with rising temperatures. Director #104 stated he had offered in the past for the facility to participate with the EMA for a plan when situations of having no AC with high heat outside occurred. However he never received a response from the facility to participate in developing a plan. Director #104 did suggest renting the portable AC units to the facility, which the facility did on 07/23/16 at 9:00 P.M. Interview on 07/26/16 at 11:43 A.M. with STNA #46 revealed she worked on 07/22/16, 07/23/16 and 07/24/16 and described the facility as extremely hot. STNA #46 reported at one point the temperature in the facility was 86 degrees F. She further stated someone from the facility had called the police stating to them that it was not safe for the residents in the facility. STNA #46 believed there were a couple of residents sent out to the emergency room due to the heat and believed it was Resident #4 and Resident #5 who resided on the 300 hall. STNA #46 stated it had been hot in the facility for about a month. STNA #46 reported the administration has been telling staff they were not getting a new AC unit for a couple of months (September 2016) since this was when they were remodeling. STNA #46 stated she had no instruction from administration regarding monitoring residents during the high heat in the facility. On 07/26/16 at 12:35 P.M., interview with a facility physician (#107) revealed he was the physician of several residents of the facility. He stated he went to the facility on [DATE] in the afternoon and it was extremely hot. Physician #107 stated no administrative staff was in the building at that time. He stated he spoke to a nurse who was told by the administration of the facility to call the community to see if anyone could donate fans to the facility. Interview on 07/26/16 at 3:38 P.M. with a family member of Resident #42 revealed the weekend of 07/23 and 07/24 was terrible due to the heat and it was hard on Resident #42 due to her having a [MEDICAL CONDITION]. On 07/26/16 at 6:50 P.M., interview with the Medical Director revealed he was not made aware of the extreme heat temperatures in the facility until 07/25/16. He was unaware the compressor was not working on 07/12/16 when the facility called a temperature control company to get a quote for a new one. He then stated he was told the facility placed 15 AC units throughout the facility on 07/23/16, however they were not helping and then the facility eventually got a chiller unit to help cool the building on 07/26/16. He stated he was not aware of any resident who had to be sent out due to the heat. He further stated he was not aware the facility did not have an emergency contingency plan and policy or procedure regarding excessive heat temperatures. He stated his expectations would be for the facility to provide measures to rectify the situation and make the residents safe and comfortable immediately. Interview on 07/27/16 at 8:25 A.M. with MS #19 confirmed he ordered the new compressor to be shipped standard shipping instead of rush shipping on 07/21/6. He confirmed he only took temperatures in the hallways and not in the residents' rooms. He stated the heat made it miserable in the facility over the weekend of 07/23 and 07/24. MS #19 stated there were two AC units that cooled the building and the one unit became non-functional when the compressor broke. MS #19 stated he was under the impression the one AC unit would be able to cool the facility. He further stated he was not aware that quarterly maintenance was to be performed on the heating and cooling units and this had not been done. Interview on 07/27/16 at 8:41 A.M. with Health Commissioner (HC) #109 of the county revealed she had received a call on 07/24/16 (Sunday) in the evening from the police about the heat in the facility. HC #109 stated herself and her DON went to the facility on [DATE] (Monday) morning to find no cool air in the resident portion of the building. HC #109 stated she saw the portable AC units, however questioned if they were effective. HC #109 stated the facility did not have a plan in place for the situation of high heat in the building. Interview on 07/27/16 at 10:44 A.M. with Technician #100 who was employed by the Temperature control Company and was at the facility installing the new compressor, stated the facility first contacted the company on 07/12/16 and requested a quote for a new compressor. The facility was provided a quote on 07/13/16. He further confirmed the company didn't receive approval to order the compressor until 07/21/16. Technician #100 verified the facility had two AC units and the one was non-functional due to the compressor not working. Technician #100 stated one of the AC units would cool the building in 70 degree F to up to 80 degree F temperatures, however not above 80 degrees F with high humidity. Review of the London, Ohio forecast from weatherchannel.com revealed: 07/12/16: high temperature 89 degrees F; average humidity 80% 07/13/16: high temperature 91 degrees F; average humidity 83% 07/14/16: high temperature 83 degrees F; average humidity 91% 07/15/16: high temperature 86 degrees F; average humidity 85% 07/16/16: high temperature 82 degrees F; average humidity 77% 07/17/16: high temperature 86 degrees F; average humidity 82% 07/18/16: high temperature 86 degrees F; average humidity 94% 07/19/16: high temperature 86 degrees F; average humidity 79% 07/20/16: high temperature 87 degrees F; average humidity 72% 07/21/16: high temperature 89 degrees F; average humidity 80% 07/22/16: high temperature 84 degrees F; average humidity 89% 07/23/16: high temperature 90 degrees F; average humidity 88% 07/24/16: high temperature 91 degrees F; average humidity 88% 07/25/16: high temperature 93 degrees F; average humidity 82% 07/26/16: high temperature 84 degrees F; average humidity 84% According to the CDC (emergency.cdc.gov/disasters/extreme heat/older-adults-heat.asp) people suffer heat-related illness when the body ' s temperature control system is overloaded. The body normally cools itself by sweating. But under some conditions, sweating just isn't enough. In such cases, a person 's body temperature rises rapidly. Very high body temperatures may damage the brain or other vital organs. Several factors affect the body' ability to cool itself during extremely hot weather. When the humidity is high, sweat will not evaporate as quickly, preventing the body from releasing heat quickly. Other conditions that can limit the ability to regulate temperature include old age, youth (age 0-4), obesity, fever, dehydration, [MEDICAL CONDITION], mental illness, poor circulation, sunburn, and prescription drug use and alcohol use. Interview on 07/27/16 at 11:55 A.M. with Corporate RN #105 revealed she was unaware if the facility had a policy on safe and comfortable temperatures for residents, however verified they go by federal regulations. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nurse's notes dated 07/24/16 at 9:20 P.M. revealed Resident #5 was unresponsive. Resident #5 had a blood pressure of 78/32 millimeters/mercury (mmHG). Normal blood pressure readings are 120/70 mmHG. The resident had a pulse of 52 beats per minute and a temperature of 99.1 degrees F. Nurse #62 documented the resident was noted to have a decreased level of consciousness and personality changes. Further documentation revealed Resident #5 was lethargic and felt hot. The family was notified and wanted the resident sent to the Emergency Department (ED) for evaluation and treatment. Review of hospital records revealed Resident #5 arrived at the hospital with altered mental status and per nursing staff at the facility, the air conditioning had been out at the facility for three weeks and there were concerns the resident was overheated. The resident was admitted to the hospital for dehydration and received IV fluids for treatment. Resident #5 was still hospitalized as of 07/27/16. Interview on 07/26/16 at 12:33 P.M. with the family member of Resident #5 revealed she came in for lunch on 07/24/16 and Resident #5 was not talking at all which was unusual for her. It was very hot in the facility. Resident #5's pulse was taken and it was around 40 beats per minute. The family member requested Resident #5 to be sent out to the hospital. The family member stated the hospital told her Resident #5 was dehydrated, was put on IV fluids and was still at the hospital. Hospital staff told the family member they had been given information in report from facility staff, the AC had been out for three weeks. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nurse's notes dated 07/23/16 at 6:19 P.M. revealed Resident #4 was found lethargic and unresponsive. Resident #4 had a blood pressure reading of 106/65 mmHG. Resident #4's pulse was 76 beats per minute and had a temperature of 98 degrees. Orders were obtained to send Resident #4 to the ED for treatment and evaluation. Review of hospital records revealed upon arrival to the ED Resident #4 was noted with altered mental status and per the Emergency Medical Service (EMS) the facility where Resident #4 came from had a malfunctioning air conditioner. The EMS reported it was very hot in the facility. Upon arrival to the facility, the EMS found Resident #4 slumped over in a chair. Resident #4 was admitted with syncopal ([MEDICAL CONDITION]) episode, possibly secondary to dehydration and acute [MEDICAL CONDITION] from dehydration. Resident #4 received IV fluids for treatment. Resident #4 was still hospitalized as of 07/27/16. Interview on 07/26/16 at 2:00 P.M. with LPN #11 revealed she worked 07/20/16, 07/23/16 and 07/24/16. LPN #11 stated Resident #4 was sent out to the hospital on [DATE]. LPN #11 stated they could not arouse Resident #4 and it was like a sauna in his room. LPN #11 stated she could not listen to Resident #4's lungs because his breathing was so shallow. LPN #11 stated administration gave no direction on what do with the AC being out. She further stated the LNHA and MS #19 came into the facility on the weekend after calling them multiple times, however were only in the building a couple of hours. LPN #11 stated she was under the impression the AC was not getting fixed until September 2016. LPN #11 stated she called the hospital to check on Resident #4 and was told after he had been given a bag of fluids he perked up. The hospital staff further stated Resident #4 was dehydrated and the heat probably played a factor. On 07/26/16 at 2:36 P.M., interview with LPN #62 stated she worked the 7:00 P.M. to 7:00 A.M. shift and worked the 300 and 400 halls. LPN #62 stated when she arrived at the facility on 07/23/16 at 7:00 P.M. there was an ambulance at the facility. LPN #62 stated she was told in report from LPN #11 Resident #4 was unresponsive, had a low blood pressure, was lethargic and was being sent to the hospital for treatment. LPN #62 stated she received a report later in her shift that Resident #4 was being admitted due to being dehydrated from the heat and was receiving IV fluids. After 9:00 P.M. on 07/23/16 there were 15 portable A/C units brought in and placed throughout the building, however they were not cooling down the building at all. At 9:15 P.M., another resident (#5) became lethargic, had low blood pressure, and was unresponsive. She then called the family to notify them of the change in condition and the family stated they wanted her sent to the hospital as they had been in visiting earlier and knew how hot the facility was. The hospital called her later with a report stating Resident #5 would be admitted with the [DIAGNOSES REDACTED]. LPN #62 stated the facility was very hot and it was actually cooler outside on 07/23/16 and 07/24/16. LPN #62 specifically stated 07/23/16 was unbearable. LPN #62 stated the facility had been hot for several weeks, and staff and residents were sweating through their clothes. The residents were saying they were very uncomfortable. STNA's brought in tank tops and cut off T-shirts for residents to wear to try and make them a little more comfortable. She further stated fans were brought in via donations from the community and the facility also purchasing some. Review of an undated Emergency Preparedness Plan revealed the plan would be maintained and updated to provide instruction detailing appropriate responses by the facility for disaster situations. Each employee would be trained in orientation and annually to follow all guidelines related to emergency situations. In the event of an emergency, the administrator was in charge and the maintenance department should refer to vendor lists for any additional emergency supplies that may be identified as needed to maintain the facility in emergency conditions. Director #104 and his phone number were listed as the contact for the local Deputy Coordinator of Emergency services. The policy further revealed that preventative maintenance will occur quarterly for heating and cooling units and repair and upkeep will occur in a timely manner. This deficiency is an example of continued non-compliance from the survey dated 05/26/16. This deficiency substantiates complaint number OH 704, OH 708, OH 710, OH 731.

Based on record review, review of hospital records, observation, staff interviews, and facility policy review, the facility failed to ensure resident's falls were thoroughly investigated and a care planned intervention in place. This resulted in harm when a confused Resident (#74) ambulated unassisted with inappropriate foot wear, fell and sustained a large hematoma (bruise) to the forehead and a hip fracture. In addition, the facility failed to ensure a care planned intervention for a Resident (#69) was in place as ordered. This affected two residents of three reviewed for falls. The facility census was 63. Findings included: 1. Record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive assessment dated [DATE], revealed the resident was severely cognitively impaired and needed extensive assistance for all activities of daily living, except limited assistance for walk in corridor, and supervision for eating. Review of the Fall/Injury Assessment: Prevention and Management Care Plan dated 05/14/15 (last reviewed 02/06/16) included the resident was at risk for falls related to having a history of falls. Interventions included on 07/06/15 was for non-skid socks. After a fall on 03/11/16 interventions in place were for the resident to wear non-skid socks or a form of footwear at all times. Review of updated electronic care plan dated 03/23/16, revealed Resident #74 was at risk for falls/with impaired safety, related to [DIAGNOSES REDACTED]. Interventions included ambulation devices as needed, proper footwear, evaluate for unsteady gait, assess cognitive status, and maintain a safe environment. Review of nursing note dated 05/07/16 at 11:00 P.M. revealed the resident was witnessed stepping out of her doorway into the hall by a State tested Nursing Assistant (STNA). The resident lost her balance and fell to the floor. The resident was noted with a large hematoma to the forehead. The resident complained of pain in the left wrist and hip. Immediate intervention was shoes were applied. Complete assessment made and notification of the physician and family was noted. An order was obtained for immediate x-rays. Review of fall investigation dated 05/07/16 revealed the resident fell due to a loss of balance. Resident had dementia with poor safety awareness and gait. Resident was sent to the emergency room for evaluation. No further information was on the form. Review of Radiology report dated 05/08/16 at 2:51 A.M. revealed Resident #74 had a fracture of the left femoral neck with mild displacement (hip fracture). The hospital records revealed the resident required surgery. Interview on 05/25/16 at 2:40 P.M. with the Director of Nursing (DON) confirmed the investigation provided for review of the fall on 05/07/16 did not include any statements from staff, no indication if the resident's call light was on/off, no other information regarding if the interventions were in place at the time of fall. The DON confirmed a thorough investigation was not completed. At 3:02 P.M. the DON confirmed there were no statements available for review regarding the fall. Interview on 05/25/16 3:50 P.M. with Resident t#74 confirmed she had a recent fall, however, could not recall what had happened. Interview on 05/26/16 at 2:47 P.M. with Physical Therapist #82 confirmed if Resident #74 did not have proper footwear or non-skid socks on while ambulating, it would increase her chances of falling. Telephone interview on 05/25/16 3:24 P.M. with Licensed Practical Nurse (LPN) #34 revealed she was at the facility when Resident #74 fell on [DATE]. LPN #34 stated the resident had been in bed and she got up and ambulated unassisted. LPN #34 further stated Resident #74 was wearing pajamas and socks, however they were not grippy (non-skid) socks. The LPN stated STNA #57 witnessed the fall, and wrote a statement, and she had directed the STNA to put the statement in the Unit Manager's box. LPN #34 further revealed she reported the fall to management, however no one had further discussed the fall with her, or asked her to write a statement. LPN #34 confirmed Resident #74 was unable to put her own socks on, or dress herself. The resident required complete assistance, however the resident could stand and pivot to use the bathroom. Review of Fall Management Program dated September 2015, revealed the purpose was to provide a systemic review of the resident to determine risk for falls and develop appropriate interventions. The program included review of the resident's risk factors, planned service plan and interventions that are resident specific, and continuous review of effectiveness of the service plan and interventions. A fall review was to be completed after returning from hospitalization . Interventions/Service Plan will be reviewed/revised in conjunction with the fall review or whenever a resident fall occurs. Facility staff need to be aware of the resident specific resident interventions to minimize falls. The fall interventions will be reviewed for continued effectiveness. Interventions will be reviewed with the staff for compliance. Investigations should be a careful review and analysis of the possible contributing factors to the fall. All resident falls will be investigated, reported, and documented. Administrative Staff will analyze results for trends and patterns for example time of day, and location. 2. Record review revealed Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of care plans revealed the resident was at risk for falls characterized by history of falls, injury and multiple risk factors related to impaired balance, weakness, unsteady gait, incontinence , and medication regimen. Fall interventions included,pressure relieving cushion when up in chair and dycem to wheel chair. Care plan conference summary dated 05/06/16 revealed Resident #69 was a high fall risk. Review of physician telephone order dated 05/01/16 revealed an order for [REDACTED]. Observation of Resident #69 on 05/24/16 at 5:21 P.M. revealed the resident was sitting in her wheelchair in the dining room. The dycem was not in the chair. On 05/25/16 at 4:31 P.M. observation of State tested Nursing Assistant (STNA) #87 and STNA #88 revealed they go Resident #69 out of bed and transferred her to her wheelchair. The dycem was not in place. Interview and verification with STNA #87 and #88 on 05/25/16 at 5:30 P.M. revealed they did not place dycem to seat of resident's wheelchair when getting her up out of bed and was not aware that dycem was to be in place to her wheelchair. Interview and verification with Licensed Practical Nurse (LPN) # 36 on 05/25/16 at 5:31 P.M. reveled the dycem was to be in place to residents wheel chair.

Based on observation, interview and record review the facility failed to ensure Resident #10 received cardiac medications after a stent placement. This resulted in harm when Resident #10's stent occluded resulting in Resident #10 being hospitalized and requiring additional cardiac catheterization. This affected one of three sampled residents. The facility census was 71. Findings include: Review of the medical record revealed Resident #10 was originally admitted on [DATE]. A comprehensive assessment dated [DATE] revealed she was mildly cognitively impaired. Further review of assessment revealed she was an extensive assistance for bed mobility, transfer, personal hygiene, and toilet use, walk in room and in corridor did not occur, locomotion on and off the unit did not occur and eating required supervision. The assessment revealed she had an indwelling Foley catheter and she was frequently incontinent of bowel. Her [DIAGNOSES REDACTED]. Review of progress notes revealed on 01/17/16 at 10:55 P.M. a change of condition was noticed the Resident #10 was complaining of chest pain. It was charted in the note to send resident to the hospital for evaluation. Review of hospital preliminary report dated 01/18/16 at 11:51 P.M. revealed based on Resident #10's clinical history and mild elevation of troponin-I level of up to 0.290, she was advised to undergo a cardiac catheterization/possible percutaneous intervention. It was documented the Resident #10 was to be transferred to another nearby hospital for the above intervention. Resident #10 had a stent placed. Review of after visit summary from a nearby hospital dated 01/20/16 revealed [MEDICATION NAME] 75 milligrams (mg) once a day and Aspirin [MEDICATION NAME] Coated 325 mg once a day was ordered in the hospital and recommended they be continued for Resident #10. Review of progress notes dated 01/20/16 at 7:34 P.M. revealed Resident #10 returned to the facility, the medications were completed and the orders were verified with physician. Review of the MAR from 01/20/16 to 01/25/16 revealed [MEDICATION NAME] 75mg or Aspirin 325 mg once a day was not ordered or given to Resident #10. Review of physician orders [REDACTED]. There was no documentation of any order from the resident's return to facility until Licensed Practical Nurse (LPN) #36 wrote an order on 02/01/16 at 1:41 P.M. stating a clarification note from 01/20/16 orders from Physician #1 was to resume medications and treatments from prior to hospital transfer. Review of progress notes from 01/20/16 through 01/24/16 for Resident #10 revealed no concerns. Review of progress notes on 01/25/16 at 1:15 P.M. the nurse went into Resident #10's room and she was having chest pain that was sharp, stabbing, and radiating down both arms, the physician was called and an order received to send the resident to nearby hospital. Review of hospital records preliminary report dated 01/25/16 revealed the Resident #10 was brought to the Catheterization Laboratory emergently and underwent a cardiac catheterization. The resident was noted to have 100% occlusion of the mid right coronary artery vessel with thrombus in the stented area. The artery was dilated and a 2.7 X 33 stent was placed with good results. Interview with the admitting LPN #36 on 02/01/16 at 2:40 P.M. revealed she readmitted Resident #10 on 01/20/16. She stated that she texted the physician, (which is how he prefers to be notified, per LPN #36) of the residents arrival to facility. She further revealed the physician wanted to know what the resident went out to hospital for LPN #36 stated that she she texted the physician she didn't get report from the hospital and the [DIAGNOSES REDACTED]. LPN #36 revealed the physician texted her on her personal cell phone, to resume the medications the resident was on before she went to the hospital on [DATE]. LPN #36 stated she proceeded to write on new MAR indicated [REDACTED]. She stated that she didn't talk to the physician via telephone about the [MEDICATION NAME] and Aspirin because he only liked to be texted for needs of the facility and stated she should have called the physician at that time. LPN # 36 further verified she should have just called the physician via telephone and went over all the medications. She reported the resident was coming back to facility on 02/01/16 and she took the report from the hospital for the resident, which she reported there was a stent placed in the Resident #10 on the hospital stay from 01/17/16 through 01/20/16 and the stent became occluded because the facility did not give the ordered [MEDICATION NAME] 75 mg every day. Interview with LPN #37 on 02/01/16 at 3:10 P.M. revealed it is a policy when there is a new admission, the physician is called and the medication list from the hospital is reconciled with the physician at that time and if it was Physician #1 she would contact by telephone for a new admission. She further revealed she then writes in a new MAR indicated [REDACTED]. Interview with Registered Nurse (RN) #50 on 02/01/16 at 4:15 P.M. revealed when there is an admission from the hospital the physician is called and told of the admission and then the medications are reconciled against what the hospital is recommending to continue. She further revealed if the resident is known to the facility, then the medications are reviewed from before the admission and anything new that has been added from the hospital is reviewed by the physician. She further revealed Physician #1 would be called by telephone and not texted for a new admission. Interview with Physician #1 on 02/02/16 at 9:00 A.M. via telephone revealed he was aware of the stent being placed on 01/19/16 for Resident #10 and he would have continued with the recommended [MEDICATION NAME] and Aspirin on 01/20/16, but couldn't remember if he placed Resident #10 on the [MEDICATION NAME] and Aspirin. Interview with Physician #1 on 02/02/16 at 10:00 A.M. in person revealed he knew Resident #10 had a stent placed on 01/19/16, and that he would recommend continuing [MEDICATION NAME] and he couldn't remember if he placed Resident #10 on the [MEDICATION NAME]. He further revealed his practice for an admission to the facility was for the nurse to telephone him and either goes through each and every medication that is listed on the hospital discharge or to just mention the medications that have changed while being in the hospital. Observation on 02/01/16 at 5:15 P.M. of Resident #10 revealed she was lying in bed awake. Interview on 02/01/16 at 5:15 P.M. with Resident #10 revealed she would shake her head to my questions. She revealed by shaking her head yes she returned back to facility on 02/01/16 from the hospital, she didn't know if she had surgery and she further revealed she shook her head yes when asked if she went to the hospital and pointed to her heart when asked why she went to the hospital. Interview with the Director of Nursing (DON) on 02/02/16 at 10:00 A.M. revealed that LPN #36 stated that she had erased all of her text messages from Physician #1 on the evening of 02/01/16. Review of admission policy revealed the residents Attending Physician must provide the following information for immediate care of the resident including medication orders, including as necessary a medical condition or problem associated with each medication. This deficiency substantiates Complaint Number OH 499.

Based on clinical record reviews, hospital record review, observations and facility staff interviews the facility failed to ensure a resident had adequate hydration status. This resulted in harm when the resident was admitted to the hospital, in the intensive care unit, for dehydration. The resident required six liters of fluid before gall bladder surgery could be done. This affected one resident out of three residents sampled for dehydration (Resident #78). The facility census was 74. Findings include: Clinical record review revealed Resident #78 was admitted to the facility on [DATE]. Review of the resident's cumulative [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS assessment completed on 11/21/13 revealed the resident had short term memory problems and was moderately impaired cognitively. Review of nutrition progress note dated 11/18/13 revealed Resident #78's weight had been trending down and had a twelve pound weight loss in thirty days. Resident #78 required encouragement to increase fluids. On 12/10/13 nutrition progress note revealed Resident #78 had a five pound weight loss. Her meal intakes were noted to be 25% to 50%. Her intakes had not changed since last review, however [MEDICATION NAME] (a medication often used to increase appetite) was recently implemented. Review of communication form and progress note dated 01/16/14 revealed Resident #78 had a change in condition in health status. The change was noted to be confusion, slurred speech and jerky movements. The treatment for [REDACTED]. The communication form/progress note further revealed the resident had a history of [REDACTED]. The registered nurse was noted to agree with the possibility of the resident suffering from dehydration. The resident's physician was notified at 6:00 P.M. by phone and again at 11:00 P.M. and in addition was paged at that time. Further review of the clinical record revealed the physician never returned the calls or page. The clinical record further revealed Resident #78 was sent to the local emergency room and admitted to the hospital on [DATE] (two days later) when the resident's health status continued to decline. Review of hospital's history and physical report dated 01/19/14 revealed Resident #78 arrived to the emergency room with low blood pressure, jaundice (yellow skin) [MEDICAL CONDITION]. The resident was noted to be confused and unable to give a history. Resident #78 was noted with low urinary output despite being given six liters of fluid. Her labs showed acute kidney injury (AKI). The hospital report further revealed the resident would need vigorous fluid resuscitation, was in critical condition and was placed in the intensive care unit. Observations made during tour of the facility on 02/10/14 revealed eight residents residing on the 300 hall were without water pitchers. The resident's rooms were observed without any fluids. Interview with Resident #66 on 02/10/14 at 9:30 A.M. revealed her water pitcher had been gone for a couple of days and it happened all the time. Review of resident council minutes for the month of December 2013 revealed a complaint that ice water was not being delivered routinely. Interview with STNA #5 on 02/10/14 at 9:45 A.M., who was assigned to the 300 hall, revealed first shift STNAs were supposed to fill the resident's water pitchers twice a day. Second shift were to fill them twice as well. In addition, second shift were to take the water pitchers to the kitchen at the end of the shift to be cleaned and disinfected. The water pitchers should then be brought back to the resident's rooms and filled with ice water. STNA #5 revealed there was no reason why a resident should not have a pitcher of ice water in their room, unless they had specific orders not to. STNA #5 went to the kitchen and revealed the water pitchers were not there. The STNA then ensured the residents were supplied Styrofoam cups with ice water until water pitchers could be found. The STNA further revealed when coming on shift, water pitchers have been missing many times. Interview with the RCDO #1 on 02/11/14 at 9:15 A.M. confirmed the physician never responded to the two phone calls and page on 01/16/14, regarding the decline in health status of Resident #78 and dehydration concern. The RCDO further revealed the resident was sent out to the hospital on [DATE], two days later for an evaluation and treatment. This deficiency substantiates Complaint Number OH 449 and OH 426.

Based on clinical record reviews, observation, facility staff interviews and review of facility policy, the facility failed to protect and ensure two residents were not abused physically and psychosocially, multiple times. This also resulted in harm when Resident #62 was repeatedly frightened when a male resident came in her room and induced panic over a four month time frame. This affected two residents (#76, #62) out of eight sampled for abuse on the locked unit. The census on the locked unit was 21. This had the potential to affect all the residents on the locked unit. The facility census was 74. Findings include: 1. Clinical record review revealed Resident #62 was admitted to the facility on [DATE]. Review of the cumulative [DIAGNOSES REDACTED]. Review of Resident #62's latest minimum data set (MDS) assessment revealed Resident #62 was moderately impaired cognitively. Further review of the MDS revealed the resident was ambulatory with a walker. Review of Resident#62's plan of care related to mood and behavior revealed remind the resident to speak with staff if other residents are agitating her, suggest the resident move to a new area if she is near a behavioral resident and it is upsetting to her. Review of Resident #62's progress notes dated 10/14/13 revealed Resident #62 had a verbal altercation as Resident #76 tried to enter her room. Resident #76 pushed on the door trying to open it as Resident P.M. progress note revealed Resident #62 was in the common area. She was noted to be pleasant and cooperative with staff. The resident became frightened when Resident #76 wandered near her. Resident #62 got up from her chair and began yelling for staff to help her get him away from her. Staff attempted to keep the two separated. At 10:40 P.M. Resident #62 was noted to be resting in her bed, she was noted to be agitated and stated she spent the entire day being scared of Resident #76. Staff explained to Resident #62 they (staff) "will do their best to protect her". On 11/25/13 at 11:30 P.M. it was noted Resident #76 wandered into Resident #62's room causing Resident #62 to become very upset. On 12/12/13 at 10:45 P.M. it was noted Resident #62 was resting in bed when she became upset and began yelling when Resident #76 wandered into her room. On 12/14/13 at 6:45 P.M. Resident #62 became upset with Resident #76 for wandering in her room. Resident #62 was noted to be scared and shaking. Staff separated the two residents. On 12/20/13 Resident #62 began yelling for help, in a panic, due to Resident #76 being in her room. Resident #62 was noted to be hard to console. She was noted to be anxious and upset. Resident #76 was directed to the common area. On 01/18/14 at 8:20 P.M. the progress note revealed staff responded to Resident #62 yelling and screaming that Resident #76 was in her room. Staff removed Resident #76 from her room. Resident #62 revealed she bumped the side of her head trying to get the resident out of her room. Observation of Resident #76 on 02/11/14 at 3:30 P.M. revealed there were four female residents sitting at a table in the common area. Resident #76 was walking around the table where the four female residents were sitting. When Resident #76 began walking toward Resident #62 she began yelling for him to get away. Resident #62 was shaking and trying to get away from him. No staff member was present at that time. The nurse assigned to the unit was on lunch break. One State tested Nurse Aide (STNA) was in the shower/bath room assisting a resident. The other STNA was assisting a resident in their room. Interview with Resident #62 on 02/12/14 at 2:45 P.M. revealed the resident was in her room, sitting in her chair. Resident #62 revealed she was very afraid of Resident #76. Resident #62 revealed she hides in her room when Resident #76 comes in her room, stating she is scared to death of him. Resident #62 revealed he has tried to hit her and comes in her room almost everyday and frightens her. Interview with STNA #15 on 02/11/14 at 3:25 P.M. revealed she was assigned to the locked unit where Resident #62 and Resident #76 resided. STNA #15 revealed Resident #76 constantly went in and out of residents' rooms, mostly females. STNA #15 further revealed the female residents were frightened of him and they did not like it when the resident entered their room. They (the residents) tried to get away from him whenever he came towards them. STNA #15 revealed Resident #76 was very quick and wandered up and down the hall and into resident rooms all day long. Interview with Licensed Practical Nurse (LPN #45) on 02/13/14 at 8:35 a.m. revealed Resident #76 wandered in and out of resident's rooms on a daily basis. LPN #45 further revealed Resident #76 knew which female residents were afraid of him and he targeted them. 2. Clinical record review revealed Resident #76 was admitted to the facility on [DATE]. Review of Resident #76's cumulative [DIAGNOSES REDACTED]. Further review of the clinical record revealed the resident was admitted from a local psychiatric hospital where it was noted the resident had a history of [REDACTED]. Review of the latest annual minimum data set (MDS) assessment dated [DATE] revealed the resident had short and long term memory problems and was moderately impaired cognitively. Resident #76 was noted to ambulate on his own without any assistive devices. He required supervision with a one person assist during locomotion on the unit. Review of Resident #76's plan of care related to behavioral symptoms, physical, verbal behaviors, rejects care and socially inappropriateness revealed intervention as follows; attempt to keep resident engaged in activities that do not require a lengthy attention span, separate immediately if altercation occurs and approach redirection with an activity of interest. Review of progress note completed by the former Social Service Worker dated 10/07/13 revealed Resident #76's spouse was provided names and numbers of several facilities with locked units for possible alternate placement. A facility scheduled an onsite visit and denied the resident due to disruptive behaviors. Review of the behavior detail report from 11/25/13 through 02/10/14 revealed Resident #76 exhibited 69 behaviors, almost on a daily basis. The behaviors were noted to be wandering, physically abusive, rejects care and socially inappropriate behaviors. Review of progress note dated 01/11/14 at 6:15 P.M. revealed Resident #76 was found laying on the floor and an X-ray technician that was in the room was upset. Review of the self reported incident created 01/13/14 at 10:22 A.M. revealed Resident #76 followed an x-ray technician into a females room, who was ordered an x-ray. Resident #76 began messing with the equipment. The X-ray technician asked Resident #76 to not touch the equipment and Resident #76 began to swing at the technician. As the X-ray technician tried to keep him from swinging and messing with the equipment Resident #76 became more agitated. The X-ray technician tried to walk around Resident #76 and Resident #76 followed him out the door, falling near the door way, still kicking. It was determined Resident #76 did fall near the bathroom. LPN #45 and STNA #8 on duty were not in the room and only witnessed the X-ray technician pulling Resident #76 out of the room while on the floor. The physician, family and police were notified. Interview with STNA #8 on 02/12/14 at 4:00 P.M. revealed the she was in the dining room during the incident on 01/11/14. STNA #8 revealed she heard the X-ray technician yell, "Get this man out of this room". STNA #8 further revealed by the time she got down the hallway to the room, the x-ray technician was pulling Resident #76 out of the room by his arms and wrists. Resident #76 was on the floor while being pulled by the X-ray technician. The STNA further revealed there were only two staff members on the unit at the time of the incident, herself and LPN #45. She revealed the other STNA assigned to the unit was off the unit at the time of the incident. STNA #8 revealed the hallway was not visible to where she was sitting, nor was it visible to LPN #45 who was at the nurse's station, when the incident occurred. STNA #8 revealed she assisted Resident #76 up from the floor and to his room. She revealed he was scared and shaken up. STNA #8 further revealed now when someone comes in the unit when she is working, that is not familiar with the residents on the locked unit, she makes sure to try and go with them. Interview with LPN #45 on 02/13/14 at 8:35 A.M. revealed she was the nurse on duty the night of the incident on 01/11/14 between Resident #76 and the x-ray technician from an outside company. LPN #45 revealed she was inside the nurses's station when she heard the x-ray technician yell, "come get this man out of here". The next thing LPN #45 revealed she heard was STNA #8 say, "stop, you can't pull on him like that". By the time LPN #45 got down to the room (halfway down the hallway) the x-ray technician was stepping over Resident #76 who was still laying on the floor. LPN #45 confirmed herself and STNA #8 were the only ones on the unit during the time of the incident and neither one of them were able to visibly see where Resident #76 was. LPN #45 confirmed Resident #76 wanders in and out of residents rooms on a daily basis and requires constant supervision. Review of facility policy titled, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source and Misappropriate of Resident Property, dated October 1999 and revised April 2012 and 2013 revealed, the facility prohibits the mistreatment, neglect and abuse of residents and misappropriation of property by anyone, including staff, family, friends, etc. The facility has designed and implemented processes which strive to ensure the prevention and reporting resident abuse, neglect, mistreatment and/or misappropriation of property. The Administrator is responsible for the assurance of the policy. The policy further revealed the facility will ensure prevention of abuse by ongoing supervision of residents and staff, observation of care delivery, observation and recognition of signs of resident to resident and/or resident to staff frustration or stress. The facility will identify, correct and intervene in situations where abuse, neglect and/or mistreatment are more likely to occur by analysis of secluded areas of the center, sufficient staffing/supervision on each shift to meet the needs of the residents. This deficiency substantiates Complaint Number OH 429.

Based on clinical record reviews, observation, facility staff interviews and review of facility policy, the facility failed to ensure a resident was not abused psychologically for over four months causing her panic and fear. This resulted in harm when Resident #62 lived in fear and in a panic mode for over four months. This affected one resident out of eight sampled for abuse on the locked unit, where both residents resided. The census on the locked unit was 21. The facility census was 74. Findings include: Resident #62 was admitted to the facility on [DATE]. Review of the cumulative [DIAGNOSES REDACTED]. Review of Resident #62's latest minimum data set (MDS) assessment revealed Resident #62 was moderately impaired cognitively. Further review of the MDS revealed the resident was ambulatory with a walker. Review of Resident#62's plan of care related to mood and behavior revealed to remind the resident to speak with staff if other residents are agitating her, suggest the resident move to a new area if she in near a behavioral resident and is upsetting to her. Review of Resident #62's progress notes dated 10/14/13 revealed Resident #62 had a verbal altercation as Resident #76 tried to enter her room. Resident #76 pushed on the door trying to open it as Resident #62 pushed and yelled at him to get out. Staff intervened and separated the two residents. Later in the evening Resident #62 was noted to stand up from the dinner table and rush to get away from Resident #76 as he approached her again. Resident #76 grabbed the resident's chair and taunted her. Other staff were alerted to watch the two residents more closely and to keep them away from each other. On 11/21/13 at 1:45 P.M. progress note revealed Resident #62 was in the common area. She was noted to be pleasant and cooperative with staff. The resident became frightened when Resident #76 wandered near her. Resident #62 got up from her chair and began yelling for staff to help her get him away from her. Staff attempts to keep the two separated. At 10:40 P.M. Resident #62 was noted to be resting in her bed, she was noted to be agitated and stated she spent the entire day being scared of Resident #76. Staff explained to Resident #62 that staff "will do their best to protect her". On 11/25/13 at 11:30 p.m. it was noted Resident #76 wandered into Resident #62's room causing Resident #62 to become very upset. On 12/12/13 at 10:45 p.m. it was noted Resident #62 was resting in bed when she became upset and began yelling when Resident #76 wandered into her room. On 12/14/13 at 6:45 p.m. Resident #62 became upset with Resident #76 for wandering in her room. Resident #62 was noted to be scared and shaking. Staff separated the two residents. On 12/20/13 Resident #62 began yelling for help, in a panic, due to Resident #76 being in her room. Resident #62 was noted to be hard to console. She was noted to be anxious and upset. Resident #76 was directed to the common area. On 01/18/14 at 8:20 P.M. the progress note revealed staff responded to Resident #62 yelling and screaming that Resident #76 was in her room. Staff removed Resident #76 from her room. Resident #62 revealed she bumped the side of her head trying to get the resident out of her room. Observation of Resident #76 on 02/11/14 at 3:30 P.M. revealed there were four female residents sitting at a table in the common area. Resident #76 was walking around the table where the four female residents were sitting. When Resident #76 began walking toward Resident #62 she began yelling for him to get away. Resident #62 was shaking and trying to get away from him. No staff member was present. The nurse assigned to the unit was on lunch break. One state tested nurse aide (STNA) was in the shower/bath room assisting a resident. The other STNA was assisting a resident in their room. Interview with Resident #62 on 02/12/14 at 2:45 P.M. revealed the resident was in her room, sitting in her chair. Resident #62 revealed she is very afraid of Resident #76. Resident #62 revealed she hides in her room when Resident #76 comes in her room, stating she is scared to death of him. Resident #62 revealed he has tried to hit her and comes in her room almost everyday and frightens her. Interview with state tested nursing assistant (STNA #15) on 02/11/14 at 3:25 P.M. revealed she was assigned to the locked unit where Resident #62 and Resident #76 resided. STNA #15 revealed Resident #76 constantly went in and out of resident's rooms, mostly females. The STNA further revealed the female residents were frightened of him and they do not like it when he entered their room. STNA #15 stated the residents try to get away from him whenever he comes towards them. STNA #15 revealed Resident #76 was very quick and wandered up and down the hall and resident rooms all day long. Interview with Licensed Practical Nurse (LPN #45) on 02/13/14 at 8:35 A.M. revealed Resident #76 wandered in and out of resident's rooms on a daily basis. LPN #45 further revealed Resident #76 knew which female residents were afraid of him and he targeted them. Clinical record review revealed Resident #76 was admitted to the facility on [DATE]. Review of Resident #76's cumulative [DIAGNOSES REDACTED]. Further review of the clinical record revealed the resident was admitted from a local psychiatric hospital where it was noted the resident had a history of [REDACTED]. Review of the latest annual minimum data set (MDS) assessment dated [DATE] revealed the resident had short and long term memory problems and was moderately impaired cognitively. Resident #76 was noted to ambulate on his own without any assistive devices. He required supervision with a one person assist during locomotion on the unit. Review of Resident #76's plan of care related to behavioral symptoms, physical, verbal behaviors, rejects care and socially inappropriateness revealed intervention as follows; attempt to keep resident engaged in activities that do not require a lengthy attention span, separate immediately if altercation occurs and approach redirection with an activity of interest. Review of progress note dated 06/28/13 at 2:00 A.M. revealed a STNA tried to redirect Resident #76 after he came out of his room with no depends on and a depends in his hand. Resident #76 was noted to punch the STNA in the chest. On the same day at 5:00 P.M. progress note revealed Resident #76 threw a shoe at another resident, hitting the resident on the forearm. Review of progress note completed by the former Social Service Worker (SSW) dated 10/07/13 revealed Resident #76's spouse was provided names and numbers of several facilities with locked units for possible alternate placement. A facility scheduled an onsite visit and denied the resident due to disruptive behaviors. On 11/20/13 SSW progress note revealed Resident #76 had the following behavioral symptoms; wandering, physical behavior toward other, grabbing staff during care. The progress note further revealed the resident has had an increase in behaviors. The Resident was noted to be wandering, exit seeking and has been more difficult to direct. At time redirection will result in increased agitation and resident physically grabs and hold staff tightly in resistance. It was noted Resident #76 no longer knows where his room is. Review of the behavior detail report from 11/25/13 through 02/10/14 revealed Resident #76 exhibited 69 behaviors, almost on a daily basis. The behaviors were noted to be wandering, physically abusive, rejects care and socially inappropriate behaviors. Interview with the Regional Director of Clinical Operations (RDCO #1) on 02/11/14 at 9:15 A.M. revealed the facility had attempted to find other placement for Resident #76 in the past, however have been unsuccessful due to his behaviors. Interview with the Regional Clinical Director of Operations (RCDO #1) on 02/11/14 at 9:15 A.M. confirmed the physician was never notified of the above increase in Resident #76's behaviors. Review of facility policy titled, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source and Misappropriate of Resident Property, dated October 1999 and revised April 2012 and 2013 revealed, the facility prohibits the mistreatment, neglect and abuse of residents and misappropriation of property by anyone, including staff, family, friends, etc. The facility has designed and implemented processes which strive to ensure the prevention and reporting resident abuse, neglect, mistreatment and/or misappropriation of property. The Administrator is responsible for the assurance of the policy. The policy further revealed the facility will ensure prevention of abuse by ongoing supervision of residents and staff, observation of care delivery, observation and recognition of signs of resident to resident and/or resident to staff frustration or stress. The facility will identify, correct and intervene in situations where abuse, neglect and/or mistreatment are more likely to occur by analysis of secluded areas of the center, sufficient staffing/supervision on each shift to meet the needs of the residents. This deficiency substantiates Complaint Number OH 429.

Based on medical record review, observation, staff interview, review of fall incident investigations and review of facility policy related to falls and injuries, the facility failed to implement safety interventions and provide adequate supervision to prevent falls for one resident (#39) who suffered eight falls in the last five months. This resulted in Immediate Jeopardy for one of five residents reviewed for falls when Resident #39's last fall resulted in multiple fractures to her face, left eye pro[DIAGNOSES REDACTED] (eye dislocation) and two large (baseball sized) hematomas, one to her left eye and one under her chin. The facility identified 15 residents at risk for falls. The facility census was 81. On 01/31/13 at 1:53 P.M., the Administrator, Director of Nursing (DON) and Corporate Nurse (CN) #1 were notified Immediate Jeopardy began on 10/26/12 at 6:10 A.M., when Resident #39 suffered a sixth fall from her wheelchair, resulting in an injury to her head, which subsequently sent her to the emergency room . On 11/07/12 at 2:44 P.M., the resident suffered a seventh fall from her wheelchair which resulted in a large bruise to her right buttock that was tender and painful to touch. On 01/20/13, Resident #39 suffered an eighth fall from her wheelchair when she was found on the floor with a laceration around her left eye, the eye was swollen and bleeding, the resident was bleeding from her nose and she sustained multiple fractures to her face. The Immediate Jeopardy was removed on 01/31/13 at 2:10 P.M. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level Two (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy), until the deficiency was corrected on 02/02/13, when Resident #39 was placed on one-on-one supervision at all times and the facility implemented the following corrective actions: ? On 01/31/13 at 2:10 P.M., Resident #39 was placed on one-on-one supervision; a therapy screen was completed with a recommendation for a Physical Therapy (PT) evaluation; a pharmacy review was completed with recommendations for the physician to evaluate Resident #39's medications; and the resident's care plan was updated and new interventions implemented. ? On 01/31/13, all staff were educated on fall and wound prevention. ? On 01/31/13, nursing administration assessed all residents for fall risk and care plans and interventions were reviewed for all residents of the facility. ? On 02/01/13, Resident #39's physician addressed the recommended medication adjustments and PT completed an evaluation and treatment plan. ? On 02/01/13, State tested Nursing Assistants (STNA's) and nurses were monitoring all residents with high fall risks on an hourly basis. ? On 02/02/13, Registered Nurse #200, STNA's #201, #202, #203, #204, and #205 and Licensed Practical Nurses (LPN) #206 and #207 were able to articulate the contents of the education inservice on fall and wound prevention. Findings include: Medical record review revealed Resident #39 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Safety Device Data Collection report dated 08/27/12, revealed the resident had a seat belt to her wheelchair to maintain safety. It was documented the resident could not easily remove the seatbelt and it was used as a restraining safety device. The rationale for the seatbelt was so the resident would not be able to transfer herself independently. The resident's comprehensive plan of care for falls dated 08/27/12, revealed the resident was a risk for fall/injury related to her history of falls, due to her medical [DIAGNOSES REDACTED]. Her goal was to be free of a serious injury, if a fall would occur, her falls would be decreased with the use of a personal safety alarm and a seatbelt to her wheelchair. Interventions in place included a two person assist with transfers due to behaviors and increased supervision, however, the plan of care did not specify who or what the increased supervision included. Further interventions were for a personal safety alarm to her bed. Review of a progress note dated 10/26/12 at 6:10 A.M., by Registered Nurse (RN) #8 revealed Resident #39's alarm was sounding and the resident was found sitting on the floor facing her bathroom with her wheelchair in the doorway. The wheelchair seatbelt was not latched. According to the progress note the STNA #82 revealed she applied the self-releasing seat belt prior to leaving her alone in her room Resident #39 was noted with a half inch bump to the right frontal side of her head that was bleeding. The progress note further revealed Resident #39 stated the bump on her head "hurt a whole lot". The resident was sent to the local emergency room for an evaluation. Review of the final outcome of the fall investigation completed on 10/26/12, revealed Resident #39 fell due to an attempt to transfer by herself. It was also noted the resident has a history of falls and a trend had been identified. There was no documented evidence of any new safety interventions that were put in place related to falls for Resident #39. Review of a progress note dated 11/07/12 at 2:44 P.M., by RN #18 revealed Resident #39's family member summoned nursing staff into the resident's room and stated the resident leaned forward in her wheelchair and the alarm seatbelt came off of her but did not alarm. The resident was observed lying on her right side on the floor. The family member further stated Resident #39 was trying to get something out of the bottom drawer of her dresser. Review of the fall investigation report completed 11/07/12, revealed Resident #39 complained of pain on her right buttock and it was tender to touch. She had a bruise to her right buttock which measured 10 centimeters (cm) by 15 cm. The summary of investigation revealed Resident #39 was up in her wheelchair with her seatbelt on and the alarm was not turned on. The resident leaned forward too far, the seatbelt came undone and she fell into a sitting position on the floor. STNA #82 had latched the seatbelt, however, failed to turn the seatbelt alarm on. The final outcome of the investigation revealed the STNA was unaware the seatbelt alarm did not automatically activate when the seatbelt was fastened. A trend was noted to be identified again as the resident had falls in the past that require safety devices. The STNA reviewed the alarm placement and setup. At that time, no new safety interventions were identified or put in place for Resident #39. Review of the resident's quarterly assessment dated [DATE], revealed the resident had short and long term memory problems and was moderately impaired for decision making. She was an extensive two person assist with transfers. The assessment further indicated Resident #39 had a history of [REDACTED]. Review of the progress note dated 01/20/13 at 2:45 P.M., by RN #8 revealed Resident #39 was found on the floor in her room by the closet with the wheelchair beside her. The resident had a laceration around her left eye and it was swollen. Her broken glasses were noted on the floor with blood on them. Resident #39 was bleeding from her nose and from the laceration to her left eye. Resident #39's front releasing seatbelt was unfastened and not alarming. The resident was sent to the local emergency room for an evaluation. Review of the fall investigation dated 01/20/13, revealed a head injury was suspected and the resident was confused. The location of the injury was her left orbit. The resident's prior activity to the fall was sitting in her wheelchair. The summary of the investigation revealed Resident #39 fell from her wheelchair and the left side of her face was swollen and bruised with a laceration to the left eye/cheek area. The resident attempted self-transfer which resulted in the fall. The reason for the fall was the alarm was not turned on after the seatbelt was latched. Again, a trend was identified due to the resident's past falls and attempts to self-transfer from her wheelchair. There were no new safety interventions identified or put in place related to falls for Resident #39. At 4:30 P.M., Resident #39 returned to the facility from the local emergency room where she was treated for [REDACTED]. Resident #39's physician was notified by RN #4 of her return and the facility was waiting on a call back. At 7:00 P.M., a second attempt was made to notify the physician of Resident #39's return regarding her swollen face with lacerations. On 01/22/13 at 4:30 P.M., the physician was notified of the resident's continued watering and bleeding from the left eye. The physician ordered a Computerized Tomography Scan (CAT) scan of her head due to her left cheek laceration, left eye swelling with bleeding and possible foreign body from broken glasses. Review of the progress note documented by the Director of Nursing (DON) dated 01/20/13, revealed Resident #39 has Parkinson's disease, her gait is not steady and the resident does not have the patience to wait for assistance. Further review of Resident #39's medical record revealed she had suffered five falls prior to the three noted above, with four of them due to falling from her wheelchair. Review of the Radiology report of the CAT scan completed on 01/24/13, revealed a comminuted fracture of the floor of the left orbit; the fracture shows slight superior displacement; air is seen in the left orbit and there is near complete opacification of the left maxillary sinus. The report further noted the resident had sustained left pro[DIAGNOSES REDACTED] (displacement of the eye), a slightly posteriorly depressed fracture of the anterior wall and wall of the left maxillary sinus is seen. Clinical information revealed the resident fell five days ago, has severe swelling/edema, discoloration and bruising on the entire left side of face. Observation of Resident #39 on 01/27/13 at 9:30 A.M., revealed the resident was in her wheelchair on the 100 hall, with her seatbelt in place. She was seated next to the nurse's medication cart. Her entire face was bruised with a baseball sized hematoma to her left eye and under her chin. Both of her arms were completely bruised, as was her chest. She was observed crying and moaning. Observation of Resident #39's room revealed she could not be seen or supervised from the nurse's station. In order to see the resident, staff would have to enter the resident's room. Interview with RN #4 on 01/28/13 at 10:05 A.M., revealed she was the nurse assigned to the care of Resident #39 on 01/20/13, during the time of her fall. She stated she had just walked out of the resident's room between 2:30 P.M., and 2:45 P.M., and the resident was sitting in her wheelchair. She stated she only got a few feet down the hallway when she heard a noise and yells for help coming from Resident #39's room. RN #4 stated Resident #39 was on the floor with her wheelchair beside her and the resident was in a pool of blood with lacerations to her face. She stated the resident's glasses were broken and fragments of glass were noted from the glasses. RN #4 was still at the facility when Resident #39 returned to the facility on [DATE]. RN #4 stated she was surprised the emergency room did not complete any X-rays due to the severity of her injuries. She stated she phoned the resident's physician and received no response after two attempts to update him of her status. Observation on 01/28/13 at 4:30 P.M., revealed Resident #39 in her wheelchair with the seatbelt on, in her room. A family member was at her side visiting. The family member stated he was notified when the resident fell and was told she was in her room, in her wheelchair alone, when she fell . He further stated she has fallen many times in the year she has been here. During an interview on 01/29/13 at 10:00 A.M., with RN #81, the Unit Manager on the hall where the resident resides, revealed no new safety interventions or increase in supervision had been put in place when Resident #39 returned to the facility on [DATE], after her fall. Observation of Resident #39 on 01/29/13 at 10:12 A.M., revealed the resident was in her room in her wheelchair, with the seatbelt attached. She was moaning and yelling loudly, asking for someone to please help her with her sores. Tears were running down her face. Observation of Resident #39 on 01/30/13 at 11:00 A.M., revealed the resident was in her room by herself, sitting in her wheelchair, leaning over trying to pick candy up off the floor. She had both her shoes and socks off and her call light was not in reach. Interview with STNA #54 on 02/06/13 at 9:20 A.M., revealed she was in the facility on the day Resident #39 fell (01/20/13). She stated she was in the conference room around the corner from the hallway where the resident resides. She was asked to assist in getting the resident up. STNA #54 stated when she entered Resident #39's room the resident was still partially in her wheelchair on the floor with the wheelchair on its side. There was blood on the floor and blood on the resident's face. STNA #54 stated she is assigned to the care of Resident #39 on occasion and she does not routinely use her call light. STNA #54 further stated Resident #39 usually just goes ahead and tries to do things on her own. Review of facility's policy entitled Falls and Injuries Program Procedure, dated November 1998, revealed the facility will revise the resident's Plan of Care and/or center practices to reduce the likelihood of another fall. Determining casual factors leading to a resident fall is necessary to provide consistent intervention to help prevent future occurrences. Determine appropriate interventions for identified risk factors; implement interventions to reduce risk in residents with irregular gait imbalance and weakness, such as Parkinson's disease. Further review of the policy revealed to assess the resident's ability to utilize the call light and to make it accessible to the resident.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to protect a resident from an injury of unknown origin resulting in skin trauma with exposed tendon for one resident, failed to ensure a resident's pain was adequately managed, and failed to provide timely care, resulting in actual harm for both residents. This affected two (#23 and #120) residents. Four residents were reviewed for pain and five residents reviewed for skin traumas. The facility census was 81. Findings include: 1. Clinical record review revealed Resident #23 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the quarterly assessment dated [DATE], revealed Resident #23 had moderate cogintive impairment. The assessment further revealed she was at risk of developing pressure ulcers and currently did not have any pressure ulcers. Her latest Braden Risk Assessment Scale dated 01/28/13, revealed she was at a moderate risk for developing pressure areas. Review of an incident report dated 01/17/13 at 7:45 P.M., revealed RN (Registered Nurse) #20 was called into Resident #23's room by State tested Nursing Assistant (STNA) #67 due to an area found on the back of her knee. It was noted Resident #23's leg strap to her indwelling urinary catheter bag was tight and had brown drainage on it. On inspection, a trauma wound was found measuring 8 centimeters by 10 centimeters and 0.6 centimeters in depth, with a moderate amount of drainage. At the base of the wound white tendons could be seen with raised edges noted. The surrounding wound was a large area of excoriation of the skin. The RN further noted it looked like a trauma wound rather than a pressure ulcer. The leg strap was near the wound but was not touching it. The wound was in the fold on the back of her left knee. The DON was notified of the wound. Review of progress notes dated 01/22/13, five days after the wound was discovered and completed by the Director of Nursing (DON), revealed upon investigation, the wound is a linear cut from the result of repositioning of the leg strap, resulting an injury. Staff was advised on proper placement of the catheter tubing. The treatment to the wound was completed by Registered Nurse (RN) #18, who is also the wound nurse, on 01/31/13 at 1:30 P.M. The treatment was observed and revealed the area to the back of her left knee was open and tendons were exposed. The resident complained of pain during the treatment. There was no evidence the resident received any pain medication prior to her treatment. RN #18 revealed she sent a culture of her wound, due to the increased bleeding and it looked to be infected. Interview with the DON on 01/31/13 at 6:45 a.m., revealed after reviewing the wound/trauma to the back of Resident #23's left leg (two weeks after it was discovered), she now has determined the wound/trauma did not occur as originally thought from the leg strap. The DON revealed she now believes it was most likely due to her mechanical lift pad. She further revealed she did not complete an injury of unknown origin investigation when the wound/trauma was first observed on 01/17/13. The DON revealed after speaking with staff (two weeks after the incident) feels the wound could have been from the mechanical lift pad instead of the leg strap. She stated "the strap was not on the wound itself, it was above the wound." So now she thinks it could have happened with the mechanical lift pad. On 01/31/13 (two weeks after wound was found) a statement was received from STNA #67. The statement revealed she was the STNA who first reported the area to the nurse on duty. The statement further revealed she wasn't sure how it happened. She revealed the catheter leg strap was down towards her knee, the area behind her knee was large wound with bloody drainage. Review of the wound culture dated 02/02/13, revealed the wound was positive for proteus mirabilis (infection) with heavy growth noted. On 02/03/13, a physician's orders [REDACTED]. The order further revealed an order for [REDACTED]. An order was received to cleanse the left posterior knee with normal saline, pat dry, apply a thin layer of [MEDICATION NAME] cream, apply hydrafera blue packing, cover with 4 x 4 drainage sponge/gauze, wrap with [MEDICATION NAME], change daily and as needed. 2. Resident #120 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #120 was readmitted on [DATE], with [DIAGNOSES REDACTED]. The assessment dated 01/09/13 revealed the resident was cognitively intact and needed extensive assistance for all activities of daily living. Review of Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s admission, included the last pain medication administered was [MEDICATION NAME]-[MEDICATION NAME] 5-325 milligrams (mg), two tabs orally on 01/21/13 at 5:22 P.M. Review of a physician signed written prescription, which came with the resident from the hospital and was dated 01/21/13, revealed an order for [REDACTED]. Review of the Nursing Comprehensive Admission Data Collection and assessment dated [DATE] at 7:30 P.M., revealed resident was alert and oriented to person, place, and time. The resident reported pain at that time and that pain has been present in the past month. Review of the pain data collection and assessment dated [DATE], revealed the resident voiced a pain rating of nine out of ten on a one to ten scale. It was noted the resident voiced a complaint "that hurts". Description of the pain from the previous five days revealed chronic generalized pain, and post-surgical pain. The resident reports that [MEDICATION NAME] and repositioning help relieve the pain. It was identified that the resident was frequently experiencing pain to her front abdomen and occasionally experiencing pain to the back of her left shoulder. It was documented Resident #120 reported that over the past five days her day to day activities had been limited because of pain that included Resident #120 being withdrawn from activities, change in physical activity, and anxiety. Review of nursing notes dated 01/21/13 at 7:30 P.M., does not indicate the resident was assessed for or received any pain medications. Review of a facsimile of a Schedule II Controlled Medication prescription dated 01/22/13 at 3:29 P.M,. revealed [MEDICATION NAME] 10/500 mg by mouth every six hours as needed was requested from the pharmacy with a check in the box indicating "to be sent today". Review of the Proof of Delivery from the pharmacy dated 01/22/13 for Resident #120 revealed [MEDICATION NAME]/[MEDICATION NAME] 10/500 mg tablets were delivered on 01/22/13 at 11:25 P.M. Review of the nursing notes on 01/22/13 at 11:25 P.M., revealed the resident was in bed agitated and complained of pain of a nine on a scale of one to ten. Resident # 120 received [MEDICATION NAME] for pain and [MEDICATION NAME] for anxiety. Review of Pain Management Care plan dated 01/23/13, revealed Resident #120 has acute and persistent chronic pain. Goals for pain management included an improvement of immediate pain to a tolerated level so resident can function in daily life, no decline in activity, and to have no complaints of pain when question. Interventions for pain medication include to administer pain medication as ordered, and assess for verbal and non verbal signs and symptoms of distress or pain unrelieved by ordered treatments/medications. Interview with Resident #120 on 01/29/13 8:53 A.M., revealed that there were problems getting her pain medications in a timely manner upon admission on 01/21/13. Resident #120 stated, "I felt like an old dog waiting to die. I insisted they send me out to the emergency room at the hospital and the facility refused. I had to wait more than 24 hours for pain medication". Interview on 01/31/13 at 12:03 P.M., with the Director of Nursing (DON) revealed the admission assessment was to be completed within 24 hours of admission to the facility, and the resident had reported pain being a nine on a scale of one to ten. The DON confirmed there is a problem with the process of getting narcotics from the pharmacy in a timely manner due to the fact the pharmacy needs a written prescription from a physician. This deficiency substantiated Complaint Number OH 743.

Based on observations, record reviews, and staff interviews, the facility failed to prevent the development of an avoidable pressure ulcer and failed to provide timely treatment to promote healing of an unavoidable pressure ulcer. This resulted in harm for one sampled resident (#53) who developed an avoidable pressure ulcer from an incontinent brief pulled too tight. One sampled resident (#56) was discovered with an unavoidable pressure ulcer and did not receive treatment to the ulcer for two days. The sample was six. The facility identified eight residents with pressure ulcers, seven which were in-house acquired. Findings include: 1. On 10/04/11 a record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set ((MDS) dated [DATE] revealed a cognitive assessment with memory problems and moderately impaired decision making. Resident #53 was a total two person assist with transfers, dressing and toileting. The bowel and bladder assessment revealed the resident was always incontinent of bowel and bladder. The assessment contained no documentation of current or healed pressure ulcers. The skin treatment listed a pressure reduction cushion in the wheelchair and a pressure reduction mattress in bed. The resident was free of infections for the past 30 days prior to the assessment date. The Braden Risk Assessment Score was 15 which indicates a low risk for the development of pressure sores. A review of the facility identified list of pressure ulcers revealed Resident #53 had a stage IV in house acquired pressure ulcer on the lower left buttock. A review of the skin grid dated 08/08/11 revealed the pressure area was initially discovered at a stage II and was a red purple open area that measured 1.2 centimeters (cm) x 1.6 cm x 0.2 cm without drainage. A review of the monthly Clinical Review progress note dated 08/09/11 revealed the area was caused from an incontinence brief pulled too tightly causing pressure in the buttock and thigh area. The area was increased to unstageable on 08/16/11 and measured 2.2 cm x 2.0 cm and covered with yellow slough. On 08/21/11 the ulcer continued unstageable with slough, drainage and a foul odor. On 08/29/11 the Clinical Review progress note revealed the buttock wound was positive for Proteus Mirabilis and Escherichia Coli (gastrointestinal tract bacterial organisms). A surgical consult report dated 08/29/11 identified a left buttock decubitus of grade (stage) three/four deep decubitus ulcer and it was surgically debrided of necrotic tissue and would need aggressive treatment to heal. Continued review of the skin grid sheet for Resident #53, dated 09/06/11, revealed the left buttock wound as unstageable with measurements of 5.0 cm x 4.2 cm x 4.0 cm. A lab culture of the left buttock pressure ulcer dated 09/10/11 revealed it was still positive for Proteus Mirabilis and Escherichia Coli with heavy growth. Observation of the dressing change for Resident #53 completed on 10/05/11 at 11:10 A.M. for the left buttock revealed an area in the crease of the left buttock which measured 3.3 cm x 4.0 cm x 3.9 cm, and was beefy red in color with a white center deep in the wound. A foul odor was noted when the old dressing was removed. On 10/05/11 at 11:10 A.M. an interview with Licensed Practical Nurse (LPN) #102 revealed she was unsure of the cause of the area. Interview on 10/06/11 at 10:00 A.M. with the Director of Nursing confirmed the area was caused by the incontinent brief being pulled tight around the leg. 2. Resident #56 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent comprehensive assessment, dated 08/15/11, identified the resident as non-ambulatory, with short and long term memory loss and severe cognitive impairment regarding daily decision making, needed extensive assist of two staff for all daily living activities, and had contractures of the legs and arms. Review of the nurse aide skin detail report revealed the aide found a new skin problem on 09/18/11 on the coccyx and reported it to the nurse. The first documentation in the nurse's notes concerning the area on the coccyx was dated 09/21/11, when the nurse documented the presence of an unavoidable stage II pressure ulcer. The area measured 4.0 cm by 1.5 cm. and was .3 cm deep. The skin documentation reflected the skin nurse assessed the wound on 09/20/11, and orders for the care of the wound were received on 09/20/11. There was a two day delay in treatment between the time the wound was found and the time the wound treatment was started. The resident was observed seated in her speciality wheelchair in the common area of the secure unit on 10/04/11 at 9:20 A.M. Her feet were on a padded contour foot rest, a pillow was between her knees, and a pommel cushion was in the wheelchair. She wore geri sleeves and legs as protection from skin tears. Her legs were drawn up toward her chest, her arms were crossed over her chest, and her head tilted toward the right. She did not voluntarily move or speak. On 10/04/11 at 4:00 P.M., the wound on the coccyx was observed with the wound nurse. Current measurements were 4 cm by .5 cm, with yellow slough in the center and was unstageable as the depth could not be measured. The resident was on an antibiotic for a wound infection. Registered Nurse (RN) #13 was interviewed at 3:05 P.M. on 10/07/11 and was unable to give a reason for the difference between the discovery date, and the date treatment started for the coccyx wound.

Based on record review, family and staff interview, and review of a self reported incident report, the facility failed to ensure one (#81) of four sampled residents was transferred in a safe manner to prevent a fracture of the right tibia. Findings include: Record review revealed Resident #81 was originally admitted to the facility on [DATE]. Review of the accumulative [DIAGNOSES REDACTED]. She used a wheelchair for mobility with the assistance of one staff member. According to her care plan dated 09/26/10, the resident had multiple joint degeneration and a history of a right knee replacement. Care planned interventions included the use of two staff members for transfers using a gait belt or stand up lift. According to a nursing note that was a "late entry" for 04/16/11, at 7:00 P.M., State tested Nurse Aide (STNA) #21 reported to Registered Nurse (RN) #100 the resident was having pain in her lower leg and she noticed a bruise above the right lower leg. The doctor was notified and the resident sent to the hospital on [DATE] at 1:30 A.M. Review of a physician's progress noted dated 04/21/11 revealed the resident had a fractured right tibia with severe ecchymosis (bruising and swelling) that extended down to her foot. Review of a self reported incident report revealed on 04/16/11 at 8:00 P.M., the Resident #81 was transfered to her bed from the wheelchair by STNA #21. After the transfer, a bruise was noted to the resident's right calf. The report stated it was confirmed in the hospital the resident had deep vein thrombosis of her lower right extremity and a fracture of the right proximal tibia at the level of the distal aspect of the tribal knee prosthesis. The self reported incident documented the fracture was a result of the transfer by STNA #21. The facility provided education to STNA #21 regarding appropriate transfers. STNA#21's witness statement regarding the incident acknowledged she transferred the resident by herself from the wheelchair to the bed. The witness statement from Registered Nurse (RN) #100 documented Resident #81 was "minimal weight bearing by herself" during transfers. Interview with the Director of Nursing on 04/29/11 at 9:35 A.M. revealed Resident #81 did not bear any weight on her left leg during the transfer on 04/16/11. This caused the resident to put too much weight on her right leg during the pivot from the wheelchair to the bed. Interview on 04/29/11 at 10:15 A.M. with Resident #81's daughters (who share power of attorney for the resident), revealed the resident was non weight bearing. They expressed one staff person transferring their mother was not a safe transfer and that's how her leg fractured. Interview with STNA #21 by phone on 04/29/11 at 1:00 P.M. confirmed she transferred Resident #81 by herself from the wheelchair to her bed the evening of 04/16/11. She stated she had always transferred the resident by herself using a gait belt. She stated the resident began complaining of pain in her leg after the transfer and she reported that to RN #30 around 8:00 P.M. on 04/16/11. This citation substantiates complaint #OH 610.

Based on observation, record review, incident report review and interview, the facility failed to adequately supervise one of three sampled cognitively impaired residents (#71) on the dementia unit who had physically abusive behaviors toward other residents. This caused harm to two residents: Resident #94 sustained scratches to her right eye, legs and bruises to her arms; Resident #92 displayed signs of psychological and physical harm when Resident #71 grabbed her face and pulled her hair. Also, Resident #106 was pushed to the floor without provocation. Findings include: Record review of Resident #71's nursing notes dated 04/01/10 at 12:20 P.M. revealed Resident #71 approached a visitor and struck her in the chest three times. At that time, physician orders [REDACTED]. The resident was sent to the hospital on [DATE] due to multiple incidents of aggressiveness and physical violence against other residents, staff and visitors. Review of the 08/10 physician order [REDACTED]. The record also stated upon re-admission to the facility on [DATE], the resident was placed in a private room on the facility's locked dementia unit. A significant change Minimum Data Set ((MDS) dated [DATE] stated the cognitively impaired resident had short and long term memory losses and moderately impaired decision making capabilities. The MDS also stated the resident experienced an unpleasant mood in the morning, crying, tearfulness, repetitive physical movements, and insomnia. The resident also had behavior problems including physical abuse and resistiveness to care. A care plan dated 05/17/10 addressed verbal and physical abuse with interventions including: look for anxious behaviors; provided alternate tasks, actions, or redirection to accommodate behaviors that were escalating; provide redirection; move the resident to another area; use a calm, gentle voice when speaking to resident; and administer medications per the psychiatrist orders. Review of admission criteria for the dementia unit revealed the following criteria: age 50 and over with [DIAGNOSES REDACTED]. with secondary dementia. The admission criteria stated residents not eligible for admission to the unit included those residents with the [DIAGNOSES REDACTED]. The record did not include and assessment of how Resident #71 met admission criteria to the dementia unit, when her [DIAGNOSES REDACTED]. Review of an incident report dated 07/19/10 at 9:30 P.M. revealed the nurse heard yelling in a room. Upon entering the room, Resident #71 was observed holding Resident #94's arms while yelling at her. The nurse observed scratches under Resident 94's right eye, scratches on her lower legs and bruises on her arms. Resident #71 was assessed with [REDACTED]. The resident's psychiatrist was notified of the resident's physical abuse toward Resident #94 with no new orders. Resident #71's record did not include documentation of increased supervision provided for Resident #71 to protect other residents from harm. Review of an incident report dated 07/30/10 at 4:30 P.M. revealed Resident #92 was seated in her wheelchair ranting and yelling out. The incident report stated Resident #71 approached Resident #92, started hitting and slapping her on the face and head. The residents were separated and Resident #71 was walked to her room with one on one support until the resident was calm. The record did not include interventions to prevent aggression toward other residents or increased supervision to protect other residents from harm. On 08/02/10 at 1:30 P.M., family member #20 was interviewed. She stated she observed Resident #71 on several occasions strike other residents. She stated she was afraid of Resident #71 and tried to keep away from her. On 08/02/10 at 3:56 P.M. the surveyor was seated in the dining room. Resident #92 was seated close by in her wheelchair talking to herself in a confused manner. Without warning, Resident #71 approached Resident #92, grabbed her right eye socket and began pulling on it. Resident #92 cried out and screamed, "Ouch, ouch, ouch!" Resident #92 tried to strike Resident #71, who was standing over her. Licensed Practical Nurse (LPN) #15 ran to the residents, stood between them and tried to loosen Resident #71's hand grip on Resident #92. As LPN #15 held Resident #71's hands, the resident shook her right hand free and pulled Resident 92's hair, jerking 92's head backward abruptly. The social worker arrived on the unit and sat with Resident #71 to attempt engagement in an activity. After five minutes, Resident #71 stood up and paced in the hallway. There was no further one on one supervision observed. During interview with LPN #15 at that time, she stated Resident #71 threatened and hit other residents and had to be watched closely. The care plan did not include the need for increased supervision to protect other residents from harm. Review of an incident report dated 08/03/10 at 12:30 P.M. revealed Resident #71 was observed standing over another resident who was lying on the floor (R #106). Resident #71 stated she pushed Resident #106 down. At that time, the residents were separated and Resident #71 was placed on continuous one on one supervision. The psychiatrist was notified and ordered an anti-convulsant medication also used to control behaviors (Depakote 500 mg now and then Depakote 500 mg twice daily) and lab work including a complete blood count with differential, an ammonia level, a Depakote level, and a urinalysis. During interview with the Director of Nursing (DON) on 08/03/10 at 5:00 P.M., she stated the facility was attempting to place the resident either at a hospital or other facility better suited to care for her needs and diagnoses. The DON further stated she was aware of the facility's dementia unit protocol that stated not to accept residents to the unit who have a Korsakoff dementia. She also stated the resident was not placed on continuous one on one supervision until after the 08/03/10 incident. On 08/04/10 at 9:30 A.M. attempts were made to interview residents who resided on the locked dementia unit. The residents were unable to answer short, direct questions regarding the above incidents due to their cognitive impairment and confusion.