Every finding on record at Majestic Care of Middletown LLC

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure safe resident smoking. This affected two Residents (#103, #152) out three Residents (#57, #103, #152) reviewed for smoking. The facility identified 22 Residents (#01, #07, #08, #11, #15, #25, #30, #38, #40, #43,#45,#48, #53, #55,#57, #67, #68, #72, #79, #91, #101, #112) who are smokers at the facility. The facility census was 128. Findings Include:1.Medical record review for Resident #103 revealed he was admitted to the facility on [DATE]. Resident #103 did reside on the memory care secured unit from 07/02/25 until he was moved off the memory care unit effective 10/12/25. His diagnoses include chronic obstructive pulmonary disease (COPD), emphysema, atherosclerotic heart disease, hyperlipidemia, insomnia, anxiety disorder, and vascular dementia. Resident #103 required a court appointed guardian to oversee his care. Review of the Minimum Data Set (MDS) assessment for Resident #103, dated 04/02/26, revealed he had moderately impaired cognition. Resident #103 was dependent on staff for medication administration. He was required set-up assistance from staff with eating. He required supervision from staff with oral hygiene, toilet use, upper body dressing, lower body dressing, putting on shoes, and personal hygiene. Resident #103 required moderate assistance from staff with bathing.Review of the most recent smoking evaluation for Resident #103 titled, Safe Smoking Review, dated 04/04/36, revealed Resident #103 was able to self-smoke safely. Review of the progress notes for Resident #103 revealed nothing documented about the findings from 04/30/26.Observation on 04/30/26 at 1:08 P.M. of Resident #103 in his bed with a beside table over the bed and it was covered with loose tobacco. A large cigar box was observed on the tabletop full of rolled cigarettes and cigarette papers scattered all around. A paper coffee cup was on the bedside table along with the lid to the paper cup. The lid to the paper coffee cup contained 10 cigarette butts.Interview on 05/01/26 at 1:08 P.M. with Resident #103 revealed he rolls his own cigarettes. Resident #103 revealed he does not smoke cigarettes in his room instead he brings them in from the smoking area.Interview on 04/30/26 at 4:02 P.M. with the Administrator as she walked toward Resident #103's room revealed she was surprised to hear that Resident #103 rolled his own cigarettes. The Administrator stated Resident #103 recently moved from the secured memory care unit onto his current non secured unit. The Administrator revealed Resident #103 was on the memory care unit related to his poor judgement and desire to elope.Interview on 04/30/26 with the Administrator and Resident #103 in his room revealed the Administrator questioned Resident #103 on where he got his cigarettes from. Resident #103 explained he rolls his own cigarettes. The Administrator questioned if Resident #103 got the items to roll his cigarettes from his nephew. Resident #103 denied getting them from his nephew. Resident #103 explained the reason he had the cigarette butts in the plastic coffee cup lid in his room was because he smokes the cigarettes and placed the butts in his pocket. Resident #103 explained he brings them to his room and will put them in his plastic trash can with a plastic liner. As the Administrator walked out of Resident #103 's room she revealed she had no words for what was observed in Resident #103's room.Interview with the Administrator on 05/01/26 at 11:57 A.M. confirmed Resident #103 required a guardian for his care. The Administrator confirmed the facility had failed to document the observation of smoked cigarette butts and smoking items she observed on 04/30/26 at 4:02 P.M. in Resident #103's room. The Administrator confirmed the facility did not reassess Resident #103 following the findings in Resident #103's room. The Administrator confirmed the care plan for Resident #103 stated the staff will keep Resident #103's cigarettes.Review of the smoking care plan for Resident #103, initiated 06/19/25, with a goal to comply with the facility smoking policy revised on 03/27/26 revealed the smoking interventions included, complete smoking assessments quarterly and as needed, instruct Resident #103 about smoking hazards, instruct Resident #103 about the smoking policy including smoking designated areas, times, and safety concerns, notify the nurse immediately if suspected that Resident #103 had violated the facility smoking policy, and smoking material are to be kept with the nursing staff.2. Medical record review for Resident #152 revealed she was admitted the facility on 02/06/25 and discharged from the facility on 02/26/26. Her diagnoses included, nontraumatic intracranial hemorrhage, dysphagia, lymphoid leukemia, anxiety disorder, COPD, essential primary hypertension, and insomnia.Review of the MDS assessment for Resident #152, dated 02/26/25, revealed she was cognitively intact. Resident #152 was dependent on staff for medication administration. Resident #152 required set up assistance from staff with eating, oral hygiene, toilet use, bathing, lower body dressing, putting on shoes and oral hygiene.Review of the assessment titled, Safe Smoking Review, for Resident #152 dated 01/30/26, revealed Resident #152 was determined to be a safe smoker and followed the smoking policy.Review of the progress notes for Resident #152 dated 12/16/25 at 1:07 P.M., authored by the former Director of Nursing (DON) #506, revealed Resident #152 was smoking outside the designated smoking area and was now identified as a supervised smoker. On 12/24/25 at 2:30 P.M. a note authored by the Social Service Director (SSD) #204 revealed a psychosocial note was completed for Resident #152 to follow up on the incident that occurred on 12/23/25 when Resident #152 reported former DON #506 yelled at embarrassed Resident #152 in the smoking area. Resident #152 appeared stable with no signs of distress.Review of the smoking care plan for Resident #152 initiated on 02/07/25 through review date 03/0726 revealed Resident #152 was an independent smoker. The goal was listed to comply with the facility smoking policy. The interventions included the following: complete smoking assessments quarterly or as needed, instruct Resident about smoking hazards, instruct resident about the smoking policy, notify the nurse immediately if suspected violation of the smoking policy, smoking material to be kept with the resident. Interview with the Administrator on 04/30/26 at 10:40 A.M. confirmed the former DON and herself observed Resident #152 smoking out-front of the facility a few days prior to the incident on 12/23/25 and Resident #152 became a supervised smoker. The Administrator revealed the smoking assessments, care plans, and documentation would be nursing's responsibility not hers (the Administrator). The Administrator was not able to say why Resident #152 was never assessed as a supervised smoker or how Resident #152 was permitted to keep her cigarettes and lighter for the incident that occurred on 12/23/25.Review of the facility smoking policy titled, Smoking, dated 02/14/25, confirmed the purpose of the facility policy was to establish a safe environment for Residents to smoke in a designated area. Residents that meet the criteria to smoke independently will be allowed to do so within the guidelines. Smoking is only permitted in designated smoking areas. The smoking areas must provide suitable noncombustible ashtrays. The smoking area must be provided with metal containers equipped with self-closing covers for the disposal of cigarette butts and ashes. Violation of the smoking policy creates a potential risk to Resident's health and safety. Residents who are found to be non-compliant with this policy (i.e. smoking in enclosed areas or non-designated smoking areas) are considered a safety risk to all. An immediate meeting will occur with the Resident to discuss options up to and including discharge from the facility for safety reasons.Because of the risk to resident health and safety, if the facility observes or has evidence of the violation of the smoking policy, the facility will evaluate the need for appropriate level of supervision, evaluate the need to restrict smoking privileges or issue a discharge notice.

Based on record review, staff interview, review of self-reported incident (SRI), and facility policy review, the facility failed to ensure residents were free from verbal abuse. This affected one, (Resident #152) out of three (Residents #07, #45, #152) reviewed for abuse. The facility census was 128. Findings include:Medical record review for Resident #152 revealed she was admitted to the facility on [DATE] and discharged from the facilityto home on [DATE]. Her diagnoses included nontraumatic intracranial hemorrhage, dysphagia, lymphoid leukemia, anxiety disorder, Chronic Obstructive Pulmonary Disease (COPD), essential primary hypertension, and insomnia.Review of the Minimum Data Set (MDS) assessment for Resident #152, dated 02/26/25, revealed she was cognitively intact. Resident #152 was dependent on staff for medication administration. Resident #152 required set up assistance from staff with eating, oral hygiene, toilet use, bathing, lower body dressing, putting on shoes and oral hygiene.Review of the assessment titled, Safe Smoking Review, for Resident #152, dated 12/15/25, and signed 12/21/25 revealed Resident #152 was marked as a safe smoker. A second Safe Smoking Review, dated 01/30/26, revealed Resident #152 was determined to be a safe smoker and followed the smoking policy.Review of the smoking care plan for Resident #152, date initiated 02/07/25 through review date 03/06/26 revealed Resident #152 was a smoker. The goal was to adhere to the smoking policy daily. The interventions listed were as followed: complete smoking assessment quarterly and as needed, instruct resident about smoking risk, instruct resident about the facility smoking policy, notify the nurse immediately if you suspect the resident has violated the smoking policy, observed Resident's clothing and skin for any cigarette burns, smoking material is to be kept with the Resident.Review of the progress notes for Resident #152 dated 12/16/25 at 1:07 P.M., authored by the former Director of Nursing (DON) #506, revealed Resident #152 was smoking outside the designated smoking area and was now identified as a supervised smoker. On 12/24/25 at 2:30 P.M. a note authored by the Social Service Director (SSD) #204 revealed a psychosocial note was completed for Resident #152 to follow up on the incident that occurred on 12/23/25 when Resident #152 reported DON #506 yelled at embarrassed Resident #152 in the smoking area. Resident #152 appeared stable with no signs of distress.Review of the facility Self- Reported Incident (SRI) #269011, dated 12/23/25 at 7:23 P.M., revealed a discovery date of 12/23/25 of an allegation of emotional/verbal abuse from the former Director of Nursing (DON)#506 and Resident #152. On 12/23/25 at 12:15 P.M. Resident #152 alleged DON #506 was verbally aggressive toward her while in the hallway. Resident #152 revealed she was outside in the designated smoking area and she was approached by DON #506. DON #506 began to yell at Resident #152 stating Resident #152 was supposed to be supervised smoker. The DON followed Resident #152 to Resident #152's hallway and continued telling Resident #152 she was not permitted to smoke without supervision. The DON advised the nurse on duty (Licensed Practical Nurse (LPN) # 254) that Resident #152 is a supervised smoker and continued to smoke in the nonsmoking areas. Resident #152 was upset and embarrassed by the action of DON #506. DON #506 denied any intent for harm or disrespect. DON #506 revealed her goal was to keep Resident #152 safe. The facility completed an investigation of the alleged incident between DON #506 and Resident #152. The facility substantiated the allegation of verbal/emotional abuse.Interview with LPN #254 on 04/30/26 at 10:46 A.M. revealed she was Resident #152's nurse on 12/23/25 in the afternoon. LPN #254 stated she was at the nurse's station and observed the former DON walking behind Resident #152 and yelling at Resident #152 in an aggressive loud voice. The DON yelled LPN #254's name down the hall and loudly told LPN #254 that Resident #152 was a supervised smoker and cannot be outside smoking unsupervised. Resident #152 was crying in the hallway and the DON #506 stormed off. LPN #254 stated she told Resident #152 she would get a concern form for her to fill out. As LPN #254 walked toward Resident #152, DON #506 returned and yelled down the hall to LPN #254 that Resident #152 was not permitted to have her cigarettes and lighter. LPN #254 heard DON #506 tell Resident #152 not to make DON #506 out to be the bad guy because she has to take her cigarettes. LPN #254 stated Resident #152 told her she did not know she was a supervised smoker. LPN #254 stated she (herself) was not aware that Resident #152 was a supervised smoker. LPN #254 revealed both herself and Resident #152 were very shaken up about the actions of DON #506. LPN #254 revealed she thought DON #506 was verbally and emotionally abusive toward Resident #152.Interview on 04/20/26 at 11:09 A.M. with Minimum Data Set (MDS) RN #206 revealed he was at the clinical meeting on 12/23/25 from 10:30 A.M. until close to noon. MDS #206 reported he observed Resident #152 smoking close to the door and not in the smoking area. MDS #206 reported he observed former DON #506 yell out the door to Resident #152 that she could not smoke by the door. Approximately twenty minutes later MDS #206 reported he observedformer DON #506 shouting at Resident #152 she was not to be smoking by the facility door. MDS #206 reported he felt former DON #506 was very inappropriate for yelling at Resident #152 in front of staff and other residents who were in the smoking area.Interview on 04/30/26 at 11:15 P.M. interview with the Social Service Director (SSD) #204 revealed on 12/23/25 at around 10:00 A.M. (from the clinical meeting) she observed Resident #152 in the smoking area. SSD #204 observed former DON #506 shout at Resident #152 and tell her that she is a supervised smoker. Former DON #506 threatened to take Resident #152's cigerettes. She observed former DON #506 leave the meeting to go Resident #152's nurse. SSD #204 revealed she followed up with Resident #152 on 12/24/25 for a psycho-social visit and Resident #152 reported she was embarrassed by former DON #506 action when she yelled at Resident #152 across the courtyard. SSD #152 reported the behavior of former DON #506 toward Resident #152 was inappropriate. Interview on 04/20/26 at 11:27 A.M. with the Assistant Director of Nursing (ADON) #207 revealed on 12/23/25 around 10:30 A.M. she was in the clinical meeting and observed Resident #152 smoking outside unsupervised and was supposed to be a supervised smoker. ADON #207 observed former DON #506 open the door and yelled at Resident #152 that she was a supervised smoker. ADON #207 revealed former DON #506 threatened to take Resident #152's smoking items. ADON #207 revealed former DON #506 sat down and then got back up and yelled again at Resident #152. ADON#207 revealed she felt former DON #506 belittled Resident #152. ADON #207 revealed former DON #506 was in appropriate when she yelled at Resident #152 in front of other residents and the tone former DON #506 used toward Resident #127. ADON #207 reported the meeting ended and she did not see what happened after the smoking incident.Interview on 04/30/26 at 12:07 P.M. interview with Unit Manager (UM) #261 revealed she was at the clinical meeting on 12/23/25 between 10:00 A.M. and 12:00 Noon. UM #261 observed Resident #152 outside smoking. UM #261 observed former DON #506 open the door and scolded Resident #152 like a child. UM #261 observed former DON #506 threaten to take Resident #152's smoking privileges. UM #261 stated former DON #506's tone toward Resident #152 was degrading and it was done in front of other Residents. UM #261 revealed about twenty minutes later she observed former DON #506 scold Resident #152 for a second time at the nurse's station. The former DON was yelling at Resident #152. UM #261 stated she observed Resident #152 cry. UM #261 observed Resident #152 tell the former DON she cannot treat Resident #152 like a child and Resident #152 stated she was embarrassed.Interview on 04/30/26 at 12:19 P.M. with former DON #506 confirmed she attended a meeting on 12/23/25. Former DON #506 denied any incident occurred during the clinical meeting. The former DON stated she was seated in the conference room and observed Resident #152 who was a supervised smoker smoking outside unsupervised. Former DON #506 stated she waived Resident #152 toward her. Former DON #506 revealed Resident #152 had been told several times she was a supervised smoker. Former DON #506 told Resident #152 that she had to be a supervised smoker. Former DON #506 stated Resident #152 told her she had just lost her mother and began to cry. The former DON confirmed she told LPN #254 that Resident #152 had to provide LPN #254 with her cigarettes because Resident #152 is a supervised smoker. Former DON #506 denied yelling at Resident #152 in front of other Residents. Former DON #506 denied yelling or belittling Resident #152 in the hallway at the nurse's station.Interview with the Administrator on 04/30/26 at 10:40 A.M. confirmed the former DON and herself observed Resident #152 smoking out-front of the facility a few days prior to the incident on 12/23/25 and Resident #152 became a supervised smoker. The Administrator revealed the smoking assessments, care plans, and documentation would be nursing's responsibility not hers (the Administrator). The Administrator was not able to say why Resident #152 was never assessed as a supervised smoker or how Resident #152 was permitted to keep her cigarettes and lighter for the incident that occurred on 12/23/25.Subsequent interview with the Administrator on 05/01/26 at 11:59 P.M. confirmed former DON #506 was suspended pending the investigation from the incident on 12/23/25. The facility had determined the incident between former DON #506 and Resident #152 was staff to resident verbal abuse. The Administrator revealed the facility had planned to terminate former DON #506's employment immediately, however, former DON #506 quit and the notice was accepted. Review of the former DON #506 employee file revealed she was hired at the facility on 09/08/25. Review of former DON #506's termination paperwork revealed, former DON #506 was suspended pending investigation on 12/23/25, for a resident abuse allegation. The matter was treated as a Self Reported Incident (SRI). Upon investigation, the matter was substantiated. Subsequently a determination was made to end the employment relationship related to facility policy. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation, dated 07/01/25 confirmed the residents at the facility have the right to be free from abuse, mistreatment, neglect, exploitation, and misappropriation. In the case of care team member to resident abuse, neglect, mistreatment, or misappropriation of resident property, the facility will follow the facility's procedure for disciplining or dismissing a care team member. The facility will report results of the investigation to the appropriate licensing agencies and registries (e.g. Board of Nursing, nurse aide registry).

Based on observation, staff interview, and policy review, the facility failed to ensure food storage areas were clean and food items were store appropriately. This had the potential to affect all residents that eat food from the kitchen. The facility identified eight (Residents #57, #89, #92, #101, #108, #122, #134, and #139) residents that did not eat food from the kitchen. The facility also failed to ensure resident refrigerators were clean. This affected Resident #36. The census was 148. Findings include: 1. During an observation on 06/02/25 at 9:03 A.M., the refrigerator in the kitchen had food storage shelves were dirty and covered in debris. The shelves had spots of a blackish green substance. Several milk cartons were in a plastic tub in the refrigerator. The milk cartons were sitting in water. No ice was in the tub. 2. During an observation 06/02/25 at 9:08 A.M., the dry storage area in the kitchen had a large plastic container containing dry cereal that was on a roll cart. The container did not have a lid. A rubber floor mat was near the cart was above the level of the cereal. The room as dirty and the floor was covered in debris. Several plastic bowls containing dry cereal were on the cart. The bowls were not labeled or dated. During an interview on 06/02/25 at 9:11 A.M., Dietary Manager (DM) #610 confirmed the above observations. 3. During an observation on 06/02/25 at 10:30 A.M., Resident #36's refrigerator had spilled cranberry juice in the bottom of the refrigerator with multiple dead, black bugs in the spilled juice. During an interview at the time of the observation, Certified Nursing Assistant (CNA) #513 verified the above observation. spilled cranberry juice and dead bugs in the refrigerator in the room of Resident #36. Review of the facility policy titled, Food Storage: Dry Goods, dated 2023, revealed storage areas will be neat, arranged for easy identification, and date marked as appropriate. Review of the facility policy titled, Food Storage: Cold Foods, revised February 2023, revealed all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility policy titled, Environment, revised September 2017, revealed all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. All food contact surfaces will be cleaned and sanitized after each use.

Based on record review, observation, interview and policy review, the facility failed to have a Legionella prevention program. This had the potential to affect all residents of the facility. The facility also failed to to ensure staff changed gloves and washed their hands appropriately during incontinence care. This affected one (Resident #97) of three residents reviewed for incontinence. The census was 148. Findings include: 1. Review of the facility's water management documentation revealed no evidence of an implemented Legionella prevention plan. There was no documentation of any members designated to manage a Legionella prevention plan. There was no documentation of any control measures being put in place to prevent Legionella. During an interview on 06/04/25 at 3:35 P.M., Maintenance Supervisor (MS) #496 and the Administrator stated there was not an implemented Legionella prevention plan. MS #496 confirmed there was no documentation of any control measures in place to prevent Legionella. Review of the facility's policy titled Water Management Program, dated 05/15/25, revealed the water management program (WMP) is-a multi-faceted process designed to reduce the growth and spread of opportunistic bacteria. The WMP includes developing a team, describing building water systems, identifying areas or devices where opportunistic bacteria such as Legionella might grow or spread to people, control measures, and remediation interventions when control measures are not met. 2. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of intracerebral hemorrhage, hemiplegia and hemiparesis, morbid (severe) obesity, encephalopathy and depression. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #19 had no cognitive impairment, range of motion impairments on one side, upper and lower extremities and was always incontinent of bowel and bladder. The resident required set up assistance for eating, dependent for dressing and maximal assistance for oral and personal hygiene, toileting, bathing, bed mobility and transfers. Review of physician orders for Resident #97 revealed an order dated 01/01/25 to cleanse the suprapubic catheter site with soap and water and apply a drain sponge every shift. During an observation on 06/03/25 at 4:25 P.M., Resident #97, who was under Enhanced Barrier Precautions (EBP), received catheter care and incontinence care in bed from Certified Nursing Assistant (CNA) #541. The resident was provided with catheter care and then bowel incontinence care. After catheter care and bowel incontinence care was provided, CNA #541, still wearing the gloves to provide catheter and incontinence care, touched the bathroom doorknob, bathroom sink faucet, applied a clean brief, pulled the resident's pajama bottoms up, and touched the wheelchair handles to move the wheelchair to the resident's bedside. CNA #541 doffed the gown and dirty gloves and left the room without washing and/or sanitizing her hands. Review of the EBP signage posted near the door to the room of Resident #97 revealed everyone must clean their hands, including before entering and when leaving the room. During an interview on 01/22/25 at 2:55 P.M., CNA #541 verified she did not change her gloves after completing incontinence care and before she touched the bathroom doorknob, bathroom sink faucet handle, application of clean brief on resident, pulling the resident's pajama bottoms up and touching the resident's wheelchair handles. She also verified she did not sanitize and/or wash her hands before leaving the resident's room. Review of the policy titled, Enhanced Barrier Precautions, dated 03/20/24, revealed it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Review of the policy titled, Handwashing-Hand Hygiene, revised 03/05/25, revealed the purpose of the policy and procedure was to prevent the spread of infections through proper hand hygiene. Care team members must wash their hands for twenty (20) seconds using antimicrobial or non-microbial soap and water or use of an alcohol-based hand rub before and after direct contact with residents and after removing gloves. This deficiency represents non-compliance investigated under Complaint Number OH00164818.

Based on observation, record review, staff interviews, and policy review, the facility failed to ensure insulin vials were properly labeled and stored. This affected three (Residents #23, #29 and #128) of the 26 residents with medications stored in the Aspen medication cart. The facility census was 148. Findings include: During an observation of the Aspen medication cart on 06/04/25 at 8:48 A.M., Licensed Practical Nurse (LPN) #521 found Resident #23's Lantus insulin pen-injector was not dated when removed from the refrigerator and placed in the medication cart for administration; Resident #29's Glargine insulin pen-injector was not dated when removed from the refrigerator and placed in the medication cart for administration; and Resident #128's Tresiba pen-injector was not dated when removed from the refrigerator and placed in the medication cart for administration. During an interview at the time of the observation, LPN #521 verified none of the pens were dated when removed from stock. During an interview on 06/04/25 at 9:04 A.M, the Director of Nursing verified insulin vials and insulin pen-injectors are to be dated when removed from the refrigerator and placed in the medication cart for administration. During an interview on 06/05/25 at 2:43 P.M., Consulting Pharmacist #900 verified insulin vials/pen-injectors are to be dated when removed from refrigerated storage and placed in the medication cart for use. Review of the policy titled, Storage of Medications, revised August 2020, revealed certain medications or package types, such as intravenous (IV) solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, and blood sugar testing solutions and strips require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency.

Based on record review and staff interview, the facility failed to followed ordered pharmacy recommendations. This affected one (Resident #135) of five residents review for unnecessary medications. The census was 148. Findings include: Review of Resident #135's medical record revealed an admission date of 11/15/24. Diagnoses listed included tremors, anemia, depression, chronic pain syndrome, thrombocytopenia, anxiety, tracheostomy, and type two diabetes mellitus. Review of a pharmacy recommendation dated 04/08/25 revealed a recommendation was made for as needed (PRN) Narcan (narcotic reversal medication) to be on hand due to Resident #135 having current orders for an opioid (Oxycodone) along with a benzodiazepine (Clonazepam). This combination increases the risk of life-threatening overdose. The pharmacy recommendation was documented as accepted with a verbal order from physician. Review of physician orders revealed Narcan PRN was not ordered for Resident #135 until 06/04/25. During an interview on 06/05/28 at 8:18 A.M. the Director of Nursing (DON) confirmed PRN Narcan was not ordered until 06/04/25. The DON confirmed PRN Narcan was not ordered timely and was not ordered until Resident #135's pharmacy recommendations were requested.

Based on observation, record review, and interview, the facility failed to nail care for residents. This affected two (Residents #32 and #100) of three residents reviewed for care and services. The facility census was 148. Findings include: 1. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses of Alzheimer's dementia, Parkinson's disease, diabetes mellitus type II, bipolar disorder and psychotic disorder. Review of the Minimum Data Set (MDS) significant change assessment dated [DATE] revealed Resident #32 had significant cognitive impairment and was always incontinent of bowel and bladder. The resident required set up assistance with eating, oral and personal hygiene, maximal assistance with bed mobility and was dependent for toileting, bathing, dressing and transfers. During an observation on 06/02/25 at 4:33 P.M., Resident #32 was sitting in her wheelchair at the overbed table dressed in clean and seasonal appropriate personal clothing. All the resident's fingernails were long and jagged with an unknown material under the nails. Interview with the resident was attempted, but not possible due to the resident's cognitive impairment. 2. Review of the medical record revealed Resident #100 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type II, rhabdomyolysis, rib fracture (one), metabolic encephalopathy and alcohol dependence. Review of the Minimum Data Set (MDS) Medicare five-day assessment dated [DATE] revealed Resident #100 had moderate cognitive impairment and was always continent of bowel and occasionally incontinent of bladder. The resident required set up assistance with eating, supervision with oral hygiene and bed mobility and moderate assistance with toileting, bathing, dressing and transfers. During an observation on 06/02/25 at 5:25 P.M., Resident #100 revealed resident sitting in his wheelchair at the overbed table eating supper and watching television, dressed in clean and seasonal appropriate personal clothing. All the resident's fingernails were long and jagged with an unknown material under the nails. During an interview at the time of the observation, Resident #100 stated he would like nail care to be completed by the nursing staff. During an observation and subsequent interview on 06/03/25 at 1:22 P.M., the Director of Nursing (DON) verified the fingernails of Residents #32 and #100 were long, jagged, dirty and in need of care.

Based on observation and staff interview, the facility failed to ensure a safe, functional, and homelike environment for the residents. This affected three (Residents #54, #81 and #116) of the three residents reviewed for a homelike environment. The facility census was 148. Findings include: Observation of the resident rooms on 06/04/25 from 1:10 P.M. to 1:22 P.M. with Maintenance Director #510 revealed the following: a) Resident #54's room had a damaged, brown and black discolored ceiling tile above the resident's bed. b) Resident #81's room had three damaged, brown and black discolored ceiling tiles above the resident's bed, one broken ceiling tile with a portion of the ceiling tile missing, and one entire ceiling tile, approximately three feet by four feet that was missing. c) Resident #116's room had three damaged, brown and black discolored ceiling tiles above the resident's bed. Interview on 06/04/25 at 1:22 P.M. with Maintenance Director #510, verified Residents #54, #81 and #116's room conditions.

Based on observation, medical record review, resident and staff interview, and policy review, the facility failed to ensure a resident with a colostomy was provided appropriate and adequate care. This affected one (#10) of three residents reviewed for ostomies. The census was 128. Findings include: Review of the medical record for Resident #10 revealed a most recent admitted [DATE]. Diagnoses included malignant carcinoid of the stomach, severe protein calorie malnutrition, chronic obstructive pulmonary disease (COPD), and colostomy. Review of Resident #10's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with intact cognition, required set up for eating, and was dependent for toileting hygiene and transfers. Review of a physician order for Resident #10 dated 01/05/23 revealed colostomy care orders to clean the colostomy with soap and water, pat dry, apply skin prep around the stoma site, and apply the pouch every shift. Further review of the physician order revealed for staff to change the pouch when it was one-third to one-half full and as needed. Review of a care plan dated 03/15/23 revealed Resident #10 had an alteration in gastro-intestinal status related to colostomy with an intervention to provide colostomy care as ordered and as needed. Review of a physician order dated 03/19/24 revealed Resident #10 was ordered Miralax (a laxative) 17 grams oral powder once daily by mouth for constipation. Review of a progress note dated 11/18/24 revealed Resident #10 was noted with a rash on the left side of his abdomen with a new order for a combination topical treatment of one part Mylanta and triad paste, mixed well, and applied to the rash every shift. Review of Resident #10's bowel elimination documentation between 01/06/25 and 02/04/25 revealed 18 days that were documented the resident had loose stool or diarrhea. Interview on 02/03/25 at 12:55 P.M. with Resident #10 revealed staff did not always replace his colostomy timely when it leaked and it caused a rash. Interview and observation on 02/03/25 at 2:46 P.M. with Licensed Practical Nurse (LPN) #17 revealed she had a concern the night shift did not always empty Resident #10's colostomy pouch timely, and stated the pouch leaked once or twice a week. Observation of the resident's colostomy appliance revealed liquid stool was contained in the bag. Further observation revealed an approximately five millimeter (mm) circular raised area under the left side of the stoma covering an approximately one inch linear area. There was another patch of similar-looking raised circular areas on the resident's left side covering an approximate five inch long by three inch wide area. LPN #17 confirmed Resident #10's rash and stated the rash had shown improvement since her last observation. Interview on 02/03/25 at 3:25 P.M. with Certified Nurse Aide (CNA) #20 revealed she gave Resident #10 a bath earlier in the day, acknowledged the resident had a rash, and indicated it was not a new finding. CNA #20 stated Resident #10's colostomy bag leaked often and he would frequently need cleaned when she arrived at the facility. Interview and observation on 02/04/25 at 8:33 A.M. with the Director of Nursing (DON) revealed Resident #10 was lying in bed on his back and pulled back his bed covers to reveal his colostomy appliance. The colostomy bag was approximately one quarter full of liquid stool with no leaking observed. Continued observation revealed Resident #10 rolled to his right side to show a bath towel was placed under him and was saturated in a brown liquid. The DON acknowledged a towel should not be placed under a resident, and added she would expect to see a Chux pad (absorbent pad) used. The DON stated one side of Resident #10's colostomy stoma was almost flush with his abdomen which caused an issue with a proper fit for the appliance. Interview on 02/04/25 at 8:53 A.M. with Wound Nurse (WN) #22 revealed she was aware Resident #10 had a rash and stated it was caused by the gastric juices which would come into contact with his skin. WN #22 stated he has had the rash in the past, but it resolved and had just been informed it had reappeared the previous night. Observation of Resident #10 with WN #22 on 02/04/25 at 11:50 A.M. revealed the resident had just returned from an appointment and was seated in his wheelchair. WN #22 pulled back the resident's gown and asked him to shift to his right side in order to reveal the rash on his left side. As Resident #10 shifted in the seat, the colostomy came loose and liquid stool poured out. WN #22 used a towel to absorb the liquid and then removed the appliance in preparation of replacing it. As she did, she indicated the hole cut into the old wafer (piece of the pouching system which provides a skin barrier and sticks to the body) was cut too big. WN #22 also noted paste was used to secure the wafer and she explained the paste was not needed as the wafer adhesive was heat activated. WN #22 stated the nurse that worked the previous evening was Resident #10's usual nurse. Interview on 02/04/25 at 12:40 P.M. with LPN #26 revealed Resident #10's colostomy leaking was an ongoing issue and she had to change the appliance every day or two. LPN #26 acknowledged the resident had a rash for months which would come and go, and WN #22 had been aware of it. Interview on 02/04/25 at 3:12 P.M. with the DON verified there was no documentation of a rash on Resident #10's admission skin assessment and confirmed the first documentation of the rash in the resident's medical record was 11/18/24. The DON acknowledged, despite her own conversations with staff regarding the rash, and the confirmations that the rash came and went, there was no further documentation of it. The DON stated a different appliance may be beneficial for Resident #10 to prevent leaking. Review of the facility policy titled, Ostomy Care, dated 01/02/24, revealed the surrounding skin of the ostomy will be monitored for excoriation, abrasion, and breakdown. Changes with the pouching system will be made as appropriate, and for ongoing pouching problems appropriate referrals such as ostomy nurses would be made. This deficiency represents non-compliance investigated under Complaint Number OH00161868.

Based on observation, record review, resident interviews, staff interviews, and policy review, the facility failed to ensure the outdoor smoking area was reasonably accessible to residents and had protection from weather. This directly affected one (#110) of three residents reviewed for accommodation of needs while smoking, with the potential to affect 26 unsupervised residents who smoke. The facility identified a total of 33 residents smoking. The facility census was 134. Findings include: Review of the medical record for Resident #110 revealed an admitted [DATE]. Diagnoses included acute respiratory failure with hypoxia, cardiomyopathy, chronic obstructive pulmonary disease, congestive heart failure, hypotension, anemia, hyperlipidemia, and unspecified dementia, and unspecified severity with other behavioral disturbances. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 was cognitively intact. Resident #110 was assessed to require setup assistance for eating, oral hygiene, upper body dressing, and personal hygiene, partial/moderate assistance for toileting, bathing, lower body dressing, and transfer, and supervision for bed mobility. Interview on 01/17/25 at 9:51 A.M., with the Administrator and Director of Nursing (DON) revealed the door to the smoking area was manual door that required physical opening and did not have an automatic opener. The DON stated most residents went out in groups and staff would assist as needed. Both staff verified there is no means of communication devices for residents to request assistance back into the facility. Interviews on 01/17/25 from 10:56 A.M. to 2:18 P.M., with Residents #69, #117, and #136 revealed the door to the smoking area was heavy and challenging for residents to pass through. Observation on 01/17/25 at 11:01 A.M., of the outdoor smoking area, revealed Resident #110 was having difficulty opening the door to enter the facility, while trying to maneuver his manual wheelchair through the threshold. There was no doorbell or communication device observed that would allow residents to call for assistance if they needed assistance with the door to come back into the facility. The smoking area was an enclosed courtyard with a canopy area without the canopy on. Interview on 01/17/25 at 11:03 A.M., with Resident #110 revealed the door was not equipped with an accessible button to automatically open the door, which caused difficulty with entering and exiting the smoking area. Interview on 01/17/25 at 1:00 P.M., with the Administrator and DON revealed there is no means of communication devices for residents to request assistance back into the facility and the facility has not had any residents caught outside. Both staff revealed the canopy was taken down for the colder months and would be put back up and there is not an area to protect residents from weather. Review of the policy titled Physical Environment, dated 12/12/23, revealed it was the policy of the facility to be equipped to provide a safe and functional environment for residents. This deficiency represents non-compliance investigated under Master Complaint Number OH00161683.

Based on medical record review, observation, staff interview and policy review, the facility failed to implement their infection control policy during medication administration. This affected one (#114) of three residents observed for medication administration. The facility census was 135. Findings include Review of the medical record for Resident #114 revealed an admission on 08/07/24. Diagnoses include Coronavirus Disease 2019 (COVID-19), infection following surgical procedure, type two diabetes mellitus, depression and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #114 was cognitively intact. Resident #114 required staff assistance for completion of toileting, transfers, and bed mobility tasks. Review of the active physician orders for Resident #114 for the month of December 2024 revealed and order for cholecalciferol tablet 1000 units one tablet one time a day dated 11/13/24, ferrous sulfate tablet 325 milligrams (mg) one tablet daily dated 10/27/24, famotidine tablet 20 mg one tablet daily dated 10/05/24, multivitamin one tablet by mouth daily dated 10/10/24, multivitamin with minerals one tablet by mouth daily dated 11/14/24, transdermal scop 1.5 mg transdermal patch apply one patch transdermally one time a day every three days dated 10/05/24, duloxetine capsule 60 mg give one tablet daily dated 10/05/24, sitagliptin phosphate 100 mg one tablet daily dated 10/05/24, Jardiance 25 mg tablet give one tablet daily dated 10/05/24, and oxybutynin chloride extended release 10 mg give one tablet daily dated 11/15/24. Observation on 12/31/24 at 10:52 A.M. of Licensed Practical Nurse (LPN) #129 administering medications to Resident #114 revealed LPN #129 dropped one pill onto the floor, picked the pill up and handed it to Resident #114 for administration. Resident #114 accepted the medication and put it into her mouth and swallowed it. Interview on 12/31/24 at 10:57 A.M. with LPN #129 verified she dropped one pill (duloxetine) onto the residents' floor, picked it up and administered it to Resident #114. Interview on 12/31/23 at 11:27 A.M. with Director of Nursing (DON) verified the nurse should not have administered the medication that was dropped onto the floor. The DON verified the medication should have be destroyed and a replacement tablet offered to the resident. Review of the facility policy titled Medication Administration dated 01/02/24, revealed medication will be administered in accordance with professional standards of practice and in a manner to prevent contamination or infection. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, staff interview and policy review, the facility failed to follow physicians' orders for medication administration with blood pressure parameters which resulted in significant medication errors. This affected one (#37) of three residents reviewed for medication administration. The facility census was 135. Finding include: Medical record review for Resident #37 revealed an admission on 11/15/24 with diagnoses including but not limited to chronic respiratory failure, hypotension, hypertension and dependence of respirator with tracheostomy status. Review of the Minimum Data Set (MDS) assessment for Resident #37 revealed an intact cognition. Resident #37 required staff assistance for toileting, bed mobility and eating. Transfers not attempted for safety reasons. Review of the plan of care for Resident #37 revealed resident is at risk for impaired cardiac output related to diagnosis of hypertension and hypotension. Interventions include vital signs as ordered, observe for cardiac dysfunction, and administer medications as ordered. Review of the active physician orders for Resident #37 revealed an order for Midodrine oral tablet 5 milligrams giver one tablet by mouth three times a day for hypotension hold for systolic blood pressure over 120. Review of the medication administration record for Resident #37 for the month of December 2024 revealed a blood pressure recording of 121/55 on 12/01/24, a blood pressure of 125/66 on 12/10/24, a blood pressure of 149/79 on 12/14/24, a blood pressure of 125/80 on 12/15/24, a blood pressure of 127/69 on 12/20/24, a blood pressure reading on 12/20/24 of 128/66, a blood pressure of 149/83 on 12/24/24, a blood pressure of 132/78 on 12/28/24, a blood pressure of 124/77 on 12/29/24 with documentation of Resident #37's Midodrine being administered by nurse. Interview on 12/30/24 at 3:00 P.M. with Director of Nursing (DON) verified the documentation for Resident #37 revealed medication (Midodrine) was signed for as administered on days when documented blood pressure was out of the ordered parameters and should have been held. The DON confirmed Resident #37's Midodrine is order to increase the residents blood pressure. Review of the facility policy titled Medication Administration dated 01/02/24 revealed obtain and record vital signs, when applicable or per physicians order when applicable hold the medication for those vital signs outside of the physicians prescribed parameters. This deficiency represents non-compliance investigated under Complaint Numbers OH00160511 and OH00161077.

Based on medical record review, staff interview and policy review, the facility failed to ensure care conferences were completed as required. This affected one (#137) of three residents reviewed for care conferences. The facility census was 135. Findings included Medical record review for Resident #137 revealed an admission on 12/20/22 and a discharge on 11/03/24. Diagnoses including acute diastolic (congestive) heart failure, venous insufficiency (chronic) (peripheral), vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #137 revealed an impaired cognition. Resident #137 required supervision for eating and total staff dependence for bed mobility, transfers and toileting. Review of the plan of care for Resident #137 revealed the resident exhibits behaviors including refusing care, showers, turning and repositioning, medications and wound care. Interventions include encourage family involvement, approach in a friendly manner, maintain a safe environment, and positive feedback for good behavior. Review of Resident #137's progress notes dated 02/21/24 to 12/31/24 revealed only one care conference meeting between facility staff and resident which was held on 02/21/24. Interview on 12/31/24 with the Director of Nursing (DON) verified the medical record was silent for any care conference since 02/21/24 for Resident #137. The DON verified the residents should have had a care conference quarterly and aligning with the completion of the MDS assessment. Review of the facility policy titled Care Conference dated 12/12/23, stated care conferences will be scheduled to include the resident, resident representative and interdisciplinary team as soon as possible after admission, routinely and with a change in condition. Additionally the facility will provide the resident and resident representative advance notice of care conferences. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, staff interviews and policy review, the facility failed to notify a resident representative of change in health care status. This affected one (#137) of three residents reviewed for change in condition. The facility census was 35. Findings include: Medical record review for Resident #137 revealed an admission on [DATE] and a discharge on [DATE] to hospital. Resident #137 expired on [DATE] under hospice care. Diagnoses including acute diastolic (congestive) heart failure, venous insufficiency (chronic) (peripheral), vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #137 revealed an impaired cognition. Resident #137 required supervision for eating and total staff dependence for bed mobility, transfers and toileting. Review of the plan of care for Resident #137 revealed the resident exhibits behaviors including refusing care, showers, turning and repositioning, medications and wound care. Interventions include encourage family involvement, approach in a friendly manner, maintain a safe environment, and positive feedback for good behavior. Review of the physicians orders for Resident #137 revealed an order dated [DATE] for STAT (urgent) complete blood count (CBC) with differentials, complete metabolic profile (CMP) and an ammonia level for one time only for change in condition, an order for stat chest x-rays one time only for increased confusion dated [DATE]. Review of the progress notes for Resident #137 dated [DATE] at 3:50 P.M. revealed the resident noted to have increased confusion stating he is seeing things that he knows are not there. Vital signs were obtained, and nurse practitioner was notified on changes regarding hallucinations, increased confusion and refusing to eat breakfast and lunch. Further record review revealed there was no documentation Resident #137's representative was notified of the residents change of condition or new orders. Review of the progress note for Resident #137 dated [DATE] at 4:32 P.M. revealed nurse practitioner was made aware of changes in condition, confusion, hallucinations, and vital signs. New orders received for stat CBC with differentials, CMP, ammonia levels, an electromagnetic radiation (X-ray) of the chest and a urinalysis with culture and sensitivity. Further record review revealed there was no documentation Resident #137's representative was notified of the residents change of condition or new orders. Review of the progress notes for Resident #137 dated [DATE] at 8:00 A.M. revealed nursing staff was alerted that the resident did not look good. Pulse oximeter was 82 percent on room air. Resident #137 blood pressure was ,d+[DATE]. Head of bed was elevated and oxygen initiated. Oxygen saturation levels increase to 90 percent only to fall again. A rebreather mask was applied with oxygen saturation rate increasing to 96 percent. Nurse practitioner was notified with orders to call 911. Family was notified of change in condition at 8:08 A.M. and Resident #137 was transferred to the hospital at 8:20 A.M. Interview on [DATE] at 1:20 P.M. with the Assistant Director of Nursing (ADON) verified the family should have been notified when the change in condition occurred on [DATE] and was not. ADON verified the documentation was silent for family notification until transfer to the hospital on [DATE]. Review of the facility policy titled Change in Condition/Physician Notification, dated [DATE] revealed the nurse will notify the physician and the resident/representative when a significant change in the resident's physical, mental, or psychosocial status occurs. This deficiency represents non-compliance investigated under Complaint Number OH00160511.

Based on observation, medical record review, staff interview, and policy review, the facility failed to perform timely and adequate incontinence care and failed to ensure physician orders were followed for use of incontinence products. This affected four (#14, #43, #108 and #116) out of five residents reviewed for incontinence. The facility census was 142. Findings include: 1. Review of Resident #14's medical record revealed an admitted [DATE] with a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. Review of the Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact and required substantial assistance with toileting. Review of the care plan dated 01/02/24 revealed Resident #14 required assistance from staff for incontinence care with an intervention to check routinely for incontinence and provide incontinence care as needed. 2. Review of Resident #43's medical record revealed an admitted [DATE] with a diagnosis of unspecified chronic obstructive pulmonary disease. Review of the MDS assessment dated [DATE] revealed Resident #43 was cognitively intact and was dependent on staff for toileting. Review of the care plan dated 01/03/24 revealed Resident #43 had episodes of bowel and bladder incontinence with an intervention to check routinely for incontinence and provide incontinence care as needed. 3. Review of Resident #116's medical record revealed an admitted [DATE] with diagnoses of acute and chronic respiratory failure and anoxic brain damage. Review of the MDS assessment dated [DATE] revealed Resident #116 had a memory problem and was dependent on staff for all care. Review of the care plan dated 03/15/23 revealed Resident #116 had episodes of incontinence of bladder and bowel with an intervention to check routinely for incontinence and provide incontinence care as needed. 4. Review of Resident #108's medical record revealed an admitted [DATE] with diagnoses of unspecified chronic obstructive pulmonary disease, vascular dementia, and anxiety. Review of the MDS assessment dated [DATE] revealed Resident #108 was assessed with severe cognitive impairment and required substantial assistance for toileting. Review of the care plan dated 09/22/23 revealed Resident #108 had episodes of incontinence of bladder and bowel with an intervention to check routinely for incontinence and provide incontinence care as needed. Review of Resident #108's physician orders revealed an order dated 01/04/24 for the resident to not have any briefs on while in bed every shift but may use disposable absorbent pads (Chux). Observation on 05/28/24 at 8:22 A.M. revealed Resident #14, Resident #43, Resident #108, and Resident #116's incontinence briefs were noted with heavy moisture present. Interview on 05/28/24 at 9:22 A.M. with State tested Nurse Aide (STNA) #342 revealed incontinence care should be done every two hours, but was not always able to get it done that soon. Observation on 05/28/24 at 9:34 A.M. revealed Resident #14, Resident #43, Resident #108, and Resident #116's incontinence briefs revealed each resident remained wet with heavy moisture present and the briefs were bulging. Interview on 05/28/24 at 9:34 A.M. with STNA #342 confirmed she had not changed or completed peri-care on Resident #108 at all that shift and confirmed she began her shift at 7:00 A.M. STNA #342 also confirmed Resident #108 had an incontinence brief on. Interview on 05/28/24 at 9:35 A.M with Licensed Practical Nurse (LPN) #340 stated residents need incontinence care every two hours at a minimum. LPN #340 stated STNA #342 was told twice that shift to change Resident #108 due to the resident being wet and confirmed it had not been completed. Interview with LPN #340 confirmed Resident #108's incontinence brief was wet, bulging, and full of urine. LPN #340 also confirmed Resident #108 was wearing a brief and had a physician order not to wear a brief in bed. Interview on 05/28/24 at 9:44 A.M. with LPN #355 confirmed Resident #14, Resident #43, and Resident #116 remain wet and peri-care was not completed since the start of the shift at 7:00 A.M. Interview on 05/28/24 at 9:45 A.M. with STNA #321 confirmed incontinence care had not been done that shift for Resident #14, Resident #43, and Resident #116. Interview on 05/23/24 at 10:39 A.M. with STNA #321 confirmed she completes incontinence rounds every four hours. Interview on 05/29/24 at 2:21 P.M. with LPN #306 confirmed Resident #108 did wear an incontinence brief while in bed and confirmed the resident had a physician order for no incontinence briefs while in bed. LPN #306 confirmed staff did not follow the resident's physician order by putting the brief on Resident #108 while in bed. Interview on 05/29/24 at 2:24 P.M. with Unit Manager LPN #335 confirmed staff put a hypoallergenic brief while in bed on Resident #108 due to the resident having heavy urinary incontinence and confirmed there was a physician order dated 01/04/24 for no briefs while in bed and staff may use a disposable chux. Review of the perineal care policy dated 02/18 revealed the purpose of the procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. This deficiency represents non-compliance investigated under Master Complaint Number OH00154225 and Complaint Number OH00153635, and represents continued non-compliance from the survey dated 02/14/24.

Based on observation, resident and staff interview, medical record review, and policy review, the facility failed to provide residents with a palatable meal with appetizing temperatures. This affected two (#69 and #113) of three residents reviewed for meals. The facility census was 142. Findings include: 1. Review of the medical record for Resident #69 revealed an admitted [DATE] with diagnoses of acquired clubfoot to the right foot, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the right dominant side, and mild protein-calorie malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 was cognitively intact and required supervision assistance with eating. Interview on 05/23/24 at 11:28 A.M. with Resident #69 revealed the food was not favorable and it was usually cold when it should be hot. 2. Review of the medical record for Resident #113 revealed an admitted [DATE] with diagnoses of heart failure, and unspecified and chronic obstructive pulmonary disease. Review of the MDS assessment dated [DATE] revealed Resident #113 was cognitively intact and had no functional impairment to bilateral upper and lower extremities. Observation on 05/28/24 at 1:24 P.M. revealed a sample food test tray was placed on the cart, and at 1:42 P.M. the test tray was removed from cart and food temperatures were obtained by Account Manager Healthcare Services (AMHS) #401. Further observation revealed the temperature of the barbequed meat was 121.0 degree Fahrenheit (F), baked beans were 110 degrees F, spinach was 60.2 degrees F, fruit was 60.3 degree F, and milk was 43.3 degrees F. A sampling of the food revealed the food items were cold to taste, the milk was luke warm, and food items were not palatable. Interview on 05/28/24 at 1:25 P.M. with AMHS #401 confirmed the food and milk temperatures from the test tray where not at an appropriate level to serve. Interview on 05/28/24 at 2:46 P.M. with Resident #69 confirmed she did not eat much of her lunch today because it was cold. Resident #69 reported she did not ask for anything else and that staff did not ask her if she wanted something else. Interview on 05/28/24 at 2:49 P.M. with Resident #113 confirmed the food was cold at lunch today and he did not eat much. Resident #113 stated he received his food tray last during meals and it was always cold. Review of the undated food and nutrition services policy revealed each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. This deficiency represents non-compliance investigated under Master Complaint Number OH00154225.

Based on medical record review, staff interview, and policy review, the facility failed to notify the physician or nurse practitioner of significant weight changes and wound treatment refusals. This affected one (#26) of three residents reviewed for nutrition and one (#108) of three residents reviewed for wounds. The facility census was 142. Findings include: 1. Review of the medical record for Resident #26 revealed an admitted [DATE] with diagnoses of unspecified dementia with other behavioral disturbance and psychotic disorder with delusions due to known physiological condition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had severe cognitive impairment and required supervision assistance with eating. Review of the care plan dated 03/29/24 revealed Resident #26 had a potential for nutritional risk with interventions to obtain weights as ordered/indicated and notify the physician of significant weight changes. Review of Resident #26's weight record revealed the resident weighed 223.0 pounds (lbs.) on 10/04/23 and weighed 182.0 lbs. on 05/01/24 which represented an 18.39 percent (%) weight loss over approximately six months. Review of Resident #26's progress notes revealed no charting present of notification to the physician of the significant weight loss. Interview on 05/29/24 at 3:01 P.M. with Regional Nurse Consultant #320 confirmed the physician was not notified of the weight loss for Resident #26 as care planned. 2. Review of the medical record for Resident #108 revealed an admitted [DATE] with diagnoses of chronic obstructive pulmonary disease, vascular dementia, and anxiety . Review of the MDS assessment dated [DATE] revealed Resident #108 had severe cognitive impairment, required partial assistance for oral hygiene and personal hygiene, required substantial assistance for toileting and dressing, and was dependent on staff for bathing, bed mobility, and transfers. Further review of the MDS assessment revealed Resident #108 was assessed with one stage four pressure ulcer (full-thickness skin and tissue loss). Review of physician orders for Resident #108 revealed an order dated 04/26/24 for treatment to the right buttocks wound to be cleansed with normal saline, pat dry, apply calcium alginate ag rope (be sure to loosely pack into undermining and tunnels), cover with dry dressing, and change daily and as needed. The order further identified to notify the nurse practitioner (NP) personally with every refusal of treatments. Review of Resident #108's progress notes revealed progress notes on 05/22/24 at 4:58 A.M. and on 05/26/24 at 10:15 P.M. that wound treatments were refused due to pain. Further review of the progress notes revealed no documentation of the physician or nurse practitioner being notified of the refusal of treatments. Interview on 05/29/24 at 2:21 P.M. with Licensed Practical Nurse (LPN) #306 confirmed Resident #108 refused her treatments to her right buttocks on 05/22/24 and 05/26/24 when the calcium alginate treatment was applied. LPN #306 also confirmed the physician or nurse practitioner was not notified when the Resident #108 refused, and verified there was a physician order dated 04/26/24 for the NP to be personally notified of every wound treatment refusal. Interview on 05/29/24 at 2:24 P.M. with Unit Manager LPN #335 confirmed the NP was not notified of Resident #108's wound treatment refusals as ordered. Review of the change in condition policy dated 10/19 revealed the charge nurse was responsible for notification of physician and responsible party prior to end of the shift. If the physician has not returned the call by the end of the shift, the oncoming nurse will be notified for follow up. This deficiency represents continued non-compliance from the survey dated 02/14/24 and 04/29/24.

Based on medical record review, death certificate review, policy review, dialysis center record review, physician interview, staff interview, and dialysis center staff interview, the facility failed to ensure Resident #06, with a diagnosis of end-stage renal disease (ESRD), received scheduled hemodialysis treatments as ordered by the physician. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death when Resident #06 went four days without hemodialysis treatments due to the facility's failure to communicate and coordinate continuity of care with the dialysis center, failure to transport the resident to hemodialysis treatments and failure to notify the physician of the resident not receiving ordered treatments. Resident #06 suffered cardiopulmonary arrest and expired in the facility on [DATE]. This affected one (Resident #06) of five residents (#06, #07, #08 #139 and #162) reviewed for hemodialysis services in an outpatient setting. The facility also failed to ensure communication was maintained with the dialysis center concerning pre- and post-dialysis treatments for three additional residents (#07, #08, #139) receiving hemodialysis that placed the residents at risk for the potential for more than minimal harm that was not Immediate Jeopardy. The facility census was 138. On [DATE] at 4:59 P.M., the Director of Nursing (DON) and Regional Nurse Consultant (RNC) #200 were notified Immediate Jeopardy began on [DATE] when Resident #06 did not attend scheduled dialysis on [DATE] and [DATE]. The facility staff were not aware of the appointments or that he did not receive his scheduled dialysis treatments. The facility staff were unaware of the dialysis schedule for [DATE] and were unaware transportation did not arrive on [DATE] to take Resident #06 to dialysis. The physician was never notified Resident #06 missed two dialysis appointments. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] through [DATE], the DON and RNC #200 completed a chart review of Residents #07 and #139. The facility reviewed the process and protocol for dialysis on [DATE]. See the following: Infection Preventionist Support Staff (IPSS) #215 designee re-educated all licensed nurses on [DATE] to communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: a. Physician/treatment orders, laboratory values, and vital signs. b. Advance Directives and code status; specific directives about treatment choices; and any changes or need for further discussion with the resident/representative, and practitioners. c. Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered. d. Dialysis treatment provided and resident's response, including declines in functional status, falls, and the identification of symptoms that may interfere with treatments. e. Dialysis adverse reactions/complications and/or recommendations for follow up observations and monitoring, and/or concerns related to the vascular access site. f. Changes and/or declines in condition unrelated to dialysis. g. The occurrence or risk of falls and any concerns related to transportation to and from the dialysis facility. On [DATE], the DON completed a review of Residents #07 and #139 who were receiving dialysis services to ensure transportation was set with details, the appointment is listed on the shared calendar, and there were no barriers to receiving services. The facility noted Residents #07 and #139 were in compliance on [DATE]. On [DATE], the facility will immediately contact and communicate with the attending physician, resident/representative, and designated dialysis staff (i.e., nephrologist, registered nurse) any significant changes in the resident's status related to clinical complications or emergent situations that may impact the dialysis portion of the care plan. On [DATE], IPSS #215 and Clinical Leadership which included Registered Nurses (RN) #150 and #235, Licensed Practical Nurses (LPN) #220, #225, #230, and #235 educated licensed nurses on their responsibility to ensure that residents appointments are arranged, to review the calendar and communicate appointment needs to staff on duty, transport is set up, transport is monitored to ensure arrival at scheduled time, and secondary plan is in place and initiated immediately if transport is not on time. The education was expected to be completed by [DATE]. Any staff who are not educated will be educated prior to the start of their next scheduled shift. On [DATE], IPSD #215 and Clinical Leadership team RNs #150 and #235 and LPN #220, #225, #230, and #235 will educate licensed nurses on conducting risk benefit conversations for the following protocol: In the event of resident refusal, the nurse on duty will re-educate on the importance of obtaining the treatment, if the resident continues to make the same choice-the nurse will notify the unit manager and DON. The resident will be re-encouraged-the nurse will conduct a risk conversation with the resident which includes, continued kidney failure, organ failure, heart attack, inability for the body to filter toxins, and imminent death. The risk/benefit conversation will be documented in the medical record. On [DATE], IPSD #215 and Clinical Leadership team RN #150 and #235, LPN #220, #225, #230, and #235 will educate licensed nurses on notification: Any and all changes of condition including missing a dialysis treatment must be communicated to the provider, the response of the provider must all be documented. All new orders will be notified to the resident and/or responsible party. On [DATE], IPSD #215 and Clinical Leadership team RN #150 and #235, LPN #220, #225, #230, and #235 will educate licensed nurses on dialysis documentation: Pre and Post dialysis Evaluation to be completed with assessment of the resident dialysis access site listed on the form-completed prior to and after each dialysis session by the nurse. Nurses will utilize a dialysis communication binder to communicate these reports to the respective dialysis clinic. The DON will review residents on dialysis weekly to ensure the resident received dialysis, transport secured, evaluations completed, and dialysis procedure compliant with policy, to be completed three times per week times four weeks, then monthly times two months. Quality Assurance and Performance Improvement (QAPI) was implemented to gather and process information from the audits. Audit findings will be completed and reported at the monthly Quality Assessment and Assurance (QAA) meeting for two months. On [DATE] through [DATE], Clinical Leadership RNs #150 and #235 and LPNs #220, #225, #230, and #235 completed hemodialysis competencies on all licensed nurses. Any licensed nurses who were not educated on the competency will receive competency prior to their next scheduled shift. On [DATE], the DON audited Residents #07, #08, #139 and #162 currently residing in the facility to ensure that residents received scheduled dialysis services, or if the resident did not receive dialysis services the physician/dialysis were notified; a risk benefit conversation was conducted regarding the risk of not receiving dialysis services, and there was communication between the facility, physician, and dialysis to ensure that dialysis provisions were provided. On [DATE] through [DATE], the DON and Clinical Leadership team RN #150 and #235 and LPN #220, #225, #230, and #235 obtained proof of dialysis visits from dialysis centers (Fresenius/DaVita) to validate compliance with dialysis provisions and services, with continued compliance validated. On [DATE], the DON and Clinical Leadership RN #150 and #235 and LPN #220, #225, #230, and #235 will re-educate the staff on dialysis protocol, communication process by [DATE]. Any staff not educated prior to [DATE] will be educated prior to their next scheduled shift. On [DATE], the DON and Clinical Leadership RN #150 and #235 and LPN #220, #225, #230, and #235 educated the medical records staff on obtaining dialysis documentation if the clinic does not send the visit notes. Ongoing Monitoring: Clinical Leadership RN #150 and #235 and LPN #220, #225, #230, and #235/designees will audit all current dialysis residents to ensure dialysis communication, and documentation, are completed for residents receiving dialysis weekly times four weeks, then monthly times two months. On [DATE], the QAPI committee reviewed the plan for education and ongoing monitoring for Dialysis Services in accordance with policy and regulations. During interviews on [DATE] at 4:30 P.M. with RN #160, [DATE] at 2:00 P.M. with LPN #250 and [DATE] at 12:49 P.M. with LPN #255, revealed they were educated on dialysis communication. Although the Immediate Jeopardy was removed on [DATE], 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 is still in the process of implementing their corrective action plan including monitoring to ensure on-going compliance. Findings include: 1. Medical record review for Resident #06 revealed an admitted [DATE]. Medical diagnoses included end stage renal disease, heart failure, orthostatic hypotension, hemiplegia, seizure disorder, chronic embolism, and thrombosis of unspecified veins. Review of the care plan dated [DATE] revealed Resident #06 required hemodialysis on Tuesday, Thursday, and Saturday at 7:45 A.M. Interventions were to administer medications as ordered, assess bruit, and thrill every shift, diet as ordered, dressing changed per physician order, notify dialysis of any changes to resident's condition or abnormal findings related to access site, and vital signs as ordered and indicated and notify the physician of significant abnormalities. Review of the quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #06 was cognitively intact. Review of last visit with Nephrologist Nurse Practitioner (NNP) #300 dated [DATE] revealed Resident #06 was seen and examined. The resident had edema, shortness of breath which was stable, respirations were unlabored, and the resident stated he was overall doing well and denied any needs. There was a discussion about the need for hemodialysis as prescribed and a low potassium diet. His potassium was 5.6 milliequivalents per liter (mEq/L) which was high (Normal for an adult is 3XXX,d+[DATE].2 mEq/L). Review of progress notes dated [DATE] revealed Resident #06 went out to the hospital with complaints of pain in the dialysis port area of the chest. He had his port changed and came back to the facility on [DATE] with orders to see the surgeon in two days for a follow-up appointment. Resident #06's medical record contained no documentation from the appointment with the surgeon. Review of the dialysis calendar for Resident #06 revealed his dialysis appointments were missed on [DATE] and on [DATE]. There was no physician order for dialysis to be performed on [DATE]. Review of the progress notes dated [DATE] and [DATE] revealed no documentation regarding dialysis appointments or physician notification. Review of the progress notes dated [DATE] at 7:31 P.M. revealed vital signs were taken, and they were normal. At 10:45 P.M., Resident #06 was moved up in bed and repositioned. He requested ice and this was given. At 11:39 P.M., medication was taken to the room by LPN #255 and Resident #06 was found unresponsive. The code was called at 11:40 P.M. Cardiopulmonary resuscitation (CPR) was started and 911 was called. On [DATE] at 12:17 A.M., Resident #06 was pronounced dead. Review of the facility's investigation into Resident #06's missed dialysis appointments, dated [DATE], documented on [DATE] Resident #06 went to the surgeon's appointment at 11:30 A.M. His dialysis was canceled on [DATE] and rescheduled for [DATE]. Transport Scheduler (TS) #301 stated she reported this schedule change to Resident #06 and Unit Manager (UM) #302. On [DATE] there was an 8:00 A.M. pickup time for the dialysis and LPN #303 was not aware of the makeup appointment. An interview with the transport company revealed they were at the facility on [DATE] and no one was waiting up front. The transport company called three times to the facility and there wasn't an answer and the driver waited for 15 minutes and left. The receptionist wasn't aware of any calls on [DATE] and turned the phones on at 8:00 A.M. and sometimes 7:45 A.M. On [DATE] at 6:55 A.M., Resident #06 was noticed sitting in the lobby waiting for dialysis transport and at approximately 07:45 A.M. the night shift nurse took the call from dialysis and told them she thought he was already gone. At 8:30 A.M., the night shift left through the front lobby and noticed Resident #06 in the front of the facility and notified LPN #303 to call dialysis. At 10:30 A.M., LPN #303 discovered Resident #06 laying in his bed and stated transport didn't pick him up. Review of the written statement dated [DATE] from LPN #303 revealed she worked on [DATE] and didn't know Resident #06 had a makeup day for dialysis. She didn't receive any calls from dialysis on [DATE]. She stated she saw him in the lobby on [DATE] at 6:50 A.M. when she came to work. She was not sure when he was normally picked up for dialysis. She found him in his bed at 10:30 A.M. and she asked him if he had gone to dialysis, and he said no. Review of the written statement dated [DATE] from State tested Nursing Aide (STNA) #304 revealed she worked the night of [DATE]. She took a call from the dialysis center and told them he was already gone to dialysis. She documented when she was leaving her shift on the morning of [DATE] she saw Resident #06 sitting in the lobby and she told LPN #303 to call dialysis and let them know he was still in the facility. During an interview on [DATE] at 11:12 A.M., Social Worker (SW) #305 from the dialysis center confirmed Resident #06 missed his appointments on [DATE] and [DATE]. During an interview on [DATE] at 12:49 P.M., LPN #255 stated Resident #06 told her the evening of [DATE] he didn't feel well. She took his vital signs with no concerns. She said she went back to check on him and he wanted to be pulled up in the bed, so she pulled him up and gave him ice water. She stated the aide went in again and provided ice water and he was ok. She said he coded shortly after and was pronounced dead. She wasn't aware he missed two dialysis appointments that week. During an interview on [DATE] at 1:47 P.M., RN #235 stated she was the former unit manager. She stated she was the only supervisor on duty the night of [DATE] when Resident #06 coded. She stated she didn't know the resident had missed two dialysis appointments. During an interview on [DATE] at 4:25 P.M., TS #301 stated she took Resident #06 to the surgeon's appointment on [DATE]. The surgeon stated he wanted the resident to have dialysis on [DATE]. She told UM #302 what the doctor's order was as soon as she returned to the facility with the resident on [DATE]. She said the UM said, all right. During an interview on [DATE] at 4:30 P.M., RDCS #200 and the DON confirmed there wasn't an order for dialysis for [DATE] put into the computer. UM #302 didn't tell LPN #303 about the rescheduled dialysis appointment for [DATE]. They confirmed transportation didn't pick up Resident #06 on [DATE] due to insurance problems even though the resident had been using the transportation company the insurance wanted him to use. They confirmed the physician wasn't notified concerning missing these two dialysis treatments. UM #302 was terminated, and LPN #303 resigned from the facility. During an interview on [DATE] at 9:37 A.M., NNP #300 stated Resident #06 didn't seem unstable when she saw him on [DATE]. She said the dangers of missing dialysis appointments were elevated potassium which could cause his heart to stop without any warning. She stated his potassium ran on the high side at times. The other danger was fluid overload which can cause pulmonary edema and elevated creatinine levels. All the levels of toxins in his body would rise. She stated the expectation of the facility would be to notify the dialysis center if he couldn't make it to the appointment so it could be rescheduled. During an interview on [DATE] at 9:48 A.M., RDCS #200 confirmed UM #302 knew about the appointment for [DATE] and didn't put the order into the computer. She confirmed UM #302 didn't know about the resident's chair time at the dialysis center and being a unit manager should have known about this. During an interview on [DATE] at 2:04 P.M., NP #307 stated she wasn't notified Resident #06 had missed dialysis appointments on [DATE] and [DATE]. She stated it would be the expectation staff would notify her of missed treatments. Attempts were made to contact LPN #303, UM #302 and STNA #304 via telephone. All phone numbers provided had been disconnected. 2. Medical record review for Resident #139 revealed an admitted [DATE]. Medical diagnoses included end stage renal disease. Review of the care plan dated [DATE] revealed he required hemodialysis, and it was scheduled for Monday, Wednesdays, and Fridays. Interventions included to assess bruit, diet as ordered, do not draw blood, or take blood pressure in arm with graft, enhanced barrier precautions, change dressing change per physician orders, labs as ordered and report to doctor and dialysis as needed and notify dialysis of changes in resident condition or abnormal findings related to access site. Review of the dialysis calendar revealed Resident #139 went to dialysis on [DATE]. Record review revealed no documentation regarding the dialysis treatment on [DATE]. The communication binder for dialysis contained no pre or post dialysis form for the treatment on [DATE]. 3. Medical record review for Resident #07 revealed an admitted [DATE]. Medical diagnoses included renal insufficiency. Review of the care plan dated [DATE] revealed she required hemodialysis, and it was scheduled for Monday, Wednesdays, and Fridays. Interventions included to assess bruit, diet as ordered, do not draw blood, or take blood pressure in arm with graft, change dressing change per physician orders, labs as ordered and report to doctor and dialysis as needed and notify dialysis of changes in resident condition or abnormal findings related to access site. Review of the dialysis calendar revealed Resident #07 had dialysis on [DATE], [DATE] and [DATE]. The communication binder for dialysis contained no pre or post dialysis form for the treatment dates listed above. 4. Medical record review for Resident #08 revealed an admitted [DATE]. His medical diagnoses included renal insufficiency. Review of the care plan dated [DATE] revealed Resident #08 required hemodialysis three times a week on Tuesday, Thursday, and Saturday. Interventions included to assess bruit, diet as ordered, do not draw blood, or take blood pressure in arm with graft, change dressing change per physician orders, Enhanced Barrier Precautions, labs as ordered and report to doctor and dialysis as needed and notify dialysis of changes in resident condition or abnormal findings related to access site. Review of the dialysis calendar revealed Resident #08 had dialysis on [DATE]. The communication binder for dialysis contained no pre or post dialysis form for the treatment on [DATE]. During an interview on [DATE] at 3:00 P.M., RDCS #200 verified there was missing documentation in the chart and in the dialysis binders for the residents but said all these residents did go to the dialysis center for their treatments. Review of the policy titled Dialysis Care, dated [DATE], revealed the facility will assure that each resident that requires dialysis services, receives such services that are consistent with professional standards. Including: Continued assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at an off-site dialysis center. Assessment of the resident before, during, and after dialysis treatments. Collaboration with the dialysis facility's plan of care. The facility will assist in transportation arrangements to and from the dialysis center. This deficiency represents non-compliance investigated under Complaint Number OH00152921.

Based on medical record review, resident interview, staff interview, review of facility self-reported incidents (SRI), and review of facility policy, the facility failed to prevent physical abuse. This affected one (Resident #65) of three residents reviewed. The census was 138. Findings include: Review of Resident #65's medical record revealed an admitted [DATE]. Diagnoses listed included depressive mood disorder, anxiety disorder, hypertension, dependence of respiratory ventilator, type two diabetes mellitus, morbid obesity, and respiratory failure. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was cognitively intact. Review of a care plan initiated 02/13/23 revealed Resident #65 exhibits behavior symptoms of abusive language and physical aggression directed towards Care Team Members, also makes false accusations of staff, has manipulative behaviors, refuses care, and refuses bed baths and showers. Resident #65 has diagnoses of of mood disorder and anxiety disorder. Interventions listed included administer medications as ordered, allow resident to vent (express) feelings/needs, approach resident in a calm and friendly manner, assess resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. treat as indicated, document behaviors per behavior management program, explain to resident what you are going to do before initiating task, if resident becomes combative or resistive, postpone care/activity and allow resident to regain their composure, re-approach as needed, maintain a safe environment for resident, pay attention to Resident #65's non-verbal cues, such as her facial expressions, body language, and tone of voice, to better understand their emotions and experiences, provide resident personal space, and remain calm and create a reassuring environment for Resident #65. Review of a facility self-reported incident (SRI) dated 04/03/24 revealed Resident #65 stated she feels unsafe due a verbal altercation with a staff member, Registered Nurse (RN) #100). Resident #65 was interviewed. Resident #65 stated she was at the nurse's station with headphones in RN #100 said you can ' t be up here at the nurse ' s station due to HIPAA (Health Insurance Portability and Accountability Act). Resident #65 stated that an aide assisted her by the door of her room per RN #100's request. Resident #65 reported that her and RN #100 were arguing back and forth. Resident #65 reported RN #100 was walking away and she called the RN #100 a expletive. Resident #65 reported that RN #100 attempted to assist her into her room after she yelled the expletive. Resident #65 stated she held onto to the door frame to prevent RN #100 from getting her into the room. Resident #65 reported that RN #100 stated I ' m going to get your fat expletive in here one way or another. Resident #65 then stated she grabbed her thermal cup, unscrewed the lid, and dumped water on Resident #65. Resident #65 reported that after she dumped water Resident #100 left the room. Interview with RN #100 revealed that Resident #65 was at nurses station and she was concerned with HIPAA. RN #100 had asked about moving Resident #65 to the lounge or by her room. RN #100 reported that Resident #65 began cursing and yelling at her calling her profanities. RN #100 reported she Resident #65 to her room, during this Resident #65 poured water on her and hit her with a cup. RN #100 denied calling the resident any profanities. STNA #130 was interviewed and reported that Resident #65 by the nurses station. The unit manager (RN #100) came to the nurses station and had asked if Resident #65 could go to the lounge area or by her room. Resident #65 started yelling and cussing. RN #100 stated this was disrupting resident peace and asked for Resident #65 to be moved into her room. Resident #65 proceeded to speak louder and RN #100 started to speak louder STNA #130 stated she could not make out what they were saying. STNA #130 stated that RN #100 assisted Resident #65 into her room and Resident #65 was applying resistance with the wall/doorframe with her hands and feet. Resident #65 foot was X-rayed due to reporting pain after potentially hitting it on her doorframe. A report was filed with local police on 04/08/24. RN #100 was suspended and resigned on 04/03/24. Review of progress notes dated 04/03/24 at 5:21 P.M. revealed the social worker engaged with Resident #65 following an incident that occurred. The social worker provided support to Resident #65 resident and allowed Resident #65 to vent (express feelings) openly without interruption. Resident #65 reported she was feeling better and has calmed down. The social worker reported to Resident #65 that's he would come check in with her again tomorrow. Review of progress notes dated 04/04/224 at 6:35 P.M. Resident #65 asked nurse to look at her right foot. Resident #65 stated that during an altercation with RN #100 that her foot was hit on the door frame. Resident #65 reported outer foot and toe pain. Redness and swelling was noted. Review of right foot X-ray results dated 04/05/24 revealed no acute findings. Review of progress notes dated 04/08/24 revealed the social worker contacted the local police department to file a police report about the incident between Resident #65 and an employee that occurred on 04/03/24. During an interview on 04/17/24 at 11:55 A.M. Resident #65 stated she was involved in an altercation with RN #100 on 04/03/24. Resident #65 was sitting in her wheelchair across from the nursing station by a mirror. RN #100 told her she couldn't sit there do to hearing other patient information. RN #100 had State tested Nursing Assistant (STNA) #130 move Resident #65 by her room. While being wheeled by STNA #130 Resident #65 told RN #100 I know what you did to that girl two weeks ago, referring to an altercation RN #100 had with another staff member. RN #100 said to Resident #65 you are going to your room now and took the wheelchair from STNA #130. RN #100 then tried to pull Resident #65 backwards through her doorway. Resident #65's legs were banging against the doorway an she was trying to hold on to prevent entering her room. RN #100 called her a fat expletive and that's when Resident #65 throw her water container at RN #100. During a phone interview on 04/17/24 at 2:37 P.M. STNA #130 stated on 04/03/24 Resident #65 was sitting across form the nursing station. RN #100 asked STNA #130 to move Resident #65 from the nursing station due to being able to hear other patient information. STNA #130 moved Resident #65 to her doorway. On the way Resident #65 told RN #100 I know what you did to that girl and called her a expletive. RN #100 then said she now wanted Resident #65 in her room and they both were yelling at each other. RN #100 tried to pull Resident #65 through her doorway. Resident #65 was holding on to the doorway with her hands and feet. STNA #130 tried to calm Resident #65 down. Scheduler #170 came up and said to STNA #130 asked her to get someone to report too. Scheduler #170 told STNA #130 to not get anyone right now. STNA #130 did not agree and went and reported the incident. During an interview on 04/17/24 at 3:36 P.M. the Director of Nursing (DON) and Regional Nurse Consultant (RNC) #200 confirmed Resident #65 reported concerns with an altercation with RN #100. Both the DON and RNC #200 confirmed STNA #130 reported that Resident #65 resisted being put in her room by RN #100 by holding on to her doorway. Resident #65 foot was X-rayed due to soreness reported after the altercation with RN #100. Both the DON and RNC #200 confirmed RN #100 did not Resident #65's care plan interventions by not letting postponing care and letting Resident #65 regain her composure after being verbally aggressive on 04/03/24. During a phone interview on 04/18/24 at 12:08 P.M. RN #100 denied abusing Resident #65. RN #100 that Resident #65 was sitting by the nursing station on 04/03/24 and told her she couldn't sit up there due to HIPAA concerns, there were other places to sit. RN #100 wheeled Resident #65 to her room. Resident #65's wheelchair is same size as doorway and had to roll her backwards into the room to get out of the doorway. RN #100 confirmed Resident #65 did not want to be in her room, but was being disruptive to other residents by yelling. Resident #65 threw a metal water cup an hit her. RN #100 denied seeing Resident #65 resist by holding on to the doorway with her hands and feet. Resident #65 had hit other staff recently. RN #100 resigned due to facility not doing enough to protect staff. Review of the facility policy titled Abuse Prevention Program dated revised March 2021 revealed residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's symptoms. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. This deficiency represents non-compliance investigated under Complaint Number OH00152641.

Based on medical record review, resident interview, staff interview, the facility failed to ensure the physician was notified when medications were not available due to a national shortage. This affected one (Resident #65) of three residents reviewed. The census was 138. Findings include: Review of Resident #65's medical record revealed an admitted [DATE]. Diagnoses included type II diabetes. Review of physician orders revealed an order dated 03/01/24 for Mounjaro subcutaneous pen-injector (diabetic medication) five milligrams (mg) per 0.5 milliliter (ml) inject one time day every Friday for four weeks. Review of medication administration records revealed Mounjaro was not administered due to not being available on 03/15/24, 03/22/24, and 03/29/24. Review of progress revealed no documentation of Resident #65's physician being notified of Mounjaro not being available on 03/15/24, 03/22/24, and 03/29/24. During an interview on 04/17/24 at 3:26 P.M. the Director of Nursing (DON) and Regional Nurse Consultant (RNC) #200 confirmed Resident #65 missed Mounjaro administrations on 03/15/24, 03/22/24, and 03/29/24 due to a national shortage. Both confirmed there was no documentation of Resident #65's physician being notified of the shortage of the medication. This deficiency represents non-compliance investigated under OH000152641 and is an example of continued noncompliance from the survey dated 02/14/24.

Based on medical record review, review of hospital documentation, review of a fall investigation, observations, staff interviews, and policy review, the facility failed to provide adequate assistance and supervision while a resident was sitting on the side of the bed, to prevent the resident from falling. This resulted in Actual Harm when Resident #06 was left unassisted on the side of the bed and the resident had an avoidable fall off the bed. Resident #06 sustained fractures of the femur and humerus which required surgical intervention. The affected one (#06) out of three residents reviewed for falls. Additionally, the facility failed to provide adequate supervision to Resident #91 while he smoked, which placed the resident at risk for more than minimal harm. This affected one (#91) of three resident reviewed for smoking. The facility census was 145. Findings included: 1. Review of the medical record for Resident #06 revealed an admitted [DATE] with medical diagnoses of depression, congestive heart failure, anxiety, and dementia. Review of the medical record for Resident #06 revealed a quarterly Minimum Data Set (MDS) assessment, dated 02/06/24 which indicated Resident #06 was severely cognitively impaired and was dependent for toilet hygiene, oral care and bathing and required substantial/maximum staff assistance with transfers and going from lying to sitting on the side of the bed. Review of the medical record for Resident #06 revealed Fall Risk assessments, dated 12/21/23 and 02/13/24 which indicated Resident #06 was at high risk for falls. Review of the medical record for Resident #06 revealed an Activities of Daily Living (ADL) care plan which indicated Resident #06 needs assistance with ADL's due to weakness, impaired cognition, and impaired mobility. Interventions included provide staff assistance with bed mobility. Further review revealed Resident #06 was at risk for falls related to dementia with poor safety awareness, agitation, anxiety, and weakness. The interventions included to provide staff assistance with bed mobility as needed and elevated perimeter mattress. Review of the medical record for Resident #06 revealed a nurse progress note dated 02/13/24 at 9:30 A.M. which indicated the nurse was notified by State tested Nursing Assistant (STNA) #03 that Resident #06 was lying on the floor next to the bed and complained of bilateral knee pain and left shoulder pain. The note stated STNA #03 reported Resident #06 was sitting on the side of the bed for morning care and the STNA turned to reach for Resident #06's dentures when she fell off the side of the bed. Further review of the medical record revealed a nurse progress note, dated 02/14/24 at 3:43 A.M. which stated Resident #06 was admitted to the hospital for a distal femoral fracture. Review of the facility fall investigation for Resident #06 revealed on 02/13/24 the nurse was notified by STNA #03 that while performing morning care, Resident #06 fell off the side of the bed when the STNA went to reach for Resident #06's dentures. Review of the medical record revealed a hospital physician progress note, dated 02/19/24, which documented Resident #06 was admitted to hospital on 02/14/24 after having an unwitnessed fall. The note stated Resident #06 had a left periprosthetic distal femur fracture and nondisplaced fracture of the left medial humerus. The note documented Resident #06 underwent open reduction internal fixation of left femur on 02/15/24. Interview on 03/14/24 at 1:05 P.M. with STNA #31 stated she routinely provided care to Resident #06 prior to her fall when Resident #06 resided on the dementia unit. STNA #31 stated Resident #06 required two persons assistance with bed mobility because of poor stability and lack of safety awareness prior to her fall on 02/13/24. Interview on 03/14/24 at 1:35 P.M. with STNA #03 confirmed she was the STNA providing care for Resident #06 on 02/13/24 when Resident #06 fell off the side of the bed. STNA #03 stated she left Resident #06 sitting on the side of the bed without any physical support while she turned and took a few steps away from the bed to wash Resident #06's dentures in the sink. STNA #03 stated she left Resident #06 on the side of the bed for just a few seconds before she fell . Review of the facility policy titled, Fall Management, revised June 2023, revealed the purpose of the policy was to prevent injuries related to falls and a care plan would be developed at the time of admission with specific care plan interventions to address each resident's risk factors. 48570 2. Review of the medical record revealed Resident #91 was admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease, type 2 diabetes mellitus, centrilobular emphysema, major depressive disorder, nicotine dependence, disorganized schizophrenia, and vascular dementia with other behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/11/24, revealed Resident #91 had memory problems, with staff interview completed. The assessment revealed the resident's cognitive skills for daily decision making was moderately impaired with decisions poor, cues/supervision required. The resident required moderate/partial assistance with one staff assistance for bed mobility, dressing, toileting and transfers. Review of Care Plan revealed Resident #91 is a smoker and staff to assist/supervise resident who going out to smoke. Observation on 03/07/24 at 4:28 P.M. revealed eight residents, including Resident #91, outside smoking without supervision, no staff member present. Observations of the facility Smoking Policy hanging on exit door to smoking area revealed all residents will be monitored while smoking. Interview on 03/07/24 at 4:32 P.M. with Memory Care Coordinator (MCC) #19 confirmed there were eight residents outside smoking without supervision. MCC #19 stated there are some residents who can smoke independently. MCC #19 confirmed Resident #91 was outside smoking without supervision and that he requires supervision while smoking. Interview with MCC #19 confirmed nurses give Resident #91 his cigarettes when asked even though he is a supervised smoker. Review of Smoking Policy dated September 2022 revealed residents that meet the criteria to smoke independently will be allowed to do so within the guidelines. Residents that require supervision to smoke: C. Supervision must be provided to residents during smoking times. Smoking materials (cigarettes and lighter) are kept and distributed by staff. This deficiency represents non-compliance investigated under Complaint Number OH00151871.

Based on medical record review, staff interview, review of the fall investigation, and policy review, the facility failed to ensure a resident received timely treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Subsequently, Resident #57 was sent to the hospital for surgical repair of the left femur. This affected one resident (#57) out of three residents reviewed for falls. The facility census was 146. Findings included: Review of the medical record revealed Resident #57 was readmitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #57 had severe cognitive impairment and required extensive assistance with bed mobility, transfers, locomotion, eating, and attending activities. Review of the fall investigation report dated 03/18/22 at 10:30 P.M., completed by Licensed Practical Nurse (LPN) #89, revealed Resident #57 had a witnessed fall. The report revealed the State tested Nursing Assistant (STNA) #170 was sitting beside the resident when the resident stood up and fell to the floor on her left side. LPN #89 documented a head-to-toe assessment was completed and the resident had no injuries and no limited range of motion to all extremities. Review of the nursing progress notes revealed on 03/19/22 at 11:14 P.M. the night nurse LPN #03 documented a change in condition. Resident #57 was lying on right side and called out when staff tried to change brief. Resident #57 fell on left side on 03/18/22 at 10:30 P.M., no apparent injuries were documented by the nurse. Resident was a fall risk and staff reported prior to the incident on 03/18/22 the resident was able to stand and pivot with assistance of two staff and has been observed crawling in room on the fall matt. Current assessment revealed [CONDITION(S)] to the left upper leg, resident lying in bed on right side with left leg slightly bent. Resident #57 reported she could not move her left leg related to pain. The resident called out in pain with any movement to the left leg. The telehealth (on call physician) notified and awaited a return call. Review of the telehealth note dated 03/20/22 at 1:20 A.M., the telehealth Physician #400, who was on-call, responded and documented in the electronic health record (EHR) and communicated to LPN #03 to order STAT (immediate) two view Xray of the left hip and femur and ordered Tylenol as needed for pain. Review of the Xray order submitted to the mobile Xray company revealed LPN #03 ordered the Xray on 03/20/22 at 1:39 A.M. Review of the Xray results faxed to the facility on [DATE] at 12:57 P.M., revealed Resident #57 had an angulated fracture at the shaft of the left femur. Review of the telehealth progress note revealed Physician #410, who was on-call, documented in Resident #57's EHR dated 03/21/22 at 3:55 A.M. (15 hours after the facility received the fax notification from the mobile Xray company) revealed notification by LPN #03 of the angulated fracture at the midshaft of the left femur. Physician #410 ordered Resident #57 be sent to the hospital for evaluation of the new femur/hip fracture, via regular transportation. Review of the nurse note dated 03/21/22 at 3:59 A.M., nightshift LPN #03 documented Resident #57 lying in bed without complaints of left hip/leg pain. Tylenol effective. Left leg remained swollen, and the resident guarded leg during care. Xray results called to the telehealth Physician with new orders to send to the hospital for evaluation. Review of the nurse note dated 03/21/22 at 4:26 A.M., LPN #3 documented, transportation arrangements with an ambulance company was scheduled between 10:30 A.M., and 11:00 A.M. Review of the nurse note dated 03/21/22 at 10:34 A.M., LPN #09 documented resident was sent out to the hospital at this time via stretcher. (Six hours after LPN #03 received orders to send Resident #57 to the hospital for evaluation). Review of the nurse note dated 03/21/22 at 3:01 P.M. LPN #9 documented Resident admitted to the local hospital for surgical repair in the A.M. During a telephone interview on 06/06/22 at 3:36 P.M., STNA #170 stated Resident #57 was usually very active and frequently attempted to get out of the bed or out of her wheelchair unassisted and required one to one supervision most of the time. STNA #170 stated when she returned to work the night of 03/19/22, Resident #57 was already in bed, which was very usual, and when she provided incontinence care the resident complained of pain in her left leg and did not want to move and was not her normal active self. STNA #170 stated she alerted LPN #03. STNA #170 stated Resident #57 rested that night and only complained of pain when provided incontinence care or with movement of her left leg. STNA #170 stated she was surprised when she returned to work the night of 03/20/22 and Resident #57 was still in the facility and was in bed when she arrived. STNA #170 stated the resident did not attempt to get out of bed and only complained of pain when she provided care or repositioned the resident. During a telephone interview on 06/14/22 at 11:23 A.M., the night nurse, LPN #03 revealed on the morning of 03/20/22 during the end of shift report she informed the oncoming day shift nurse LPN #39 that STAT Xray orders had been made for Resident #57's left hip and femur. LPN #03 stated when she returned to work that night on 03/20/22 she asked the dayshift nurse, LPN #39, if the results of the Xray taken that morning were received. LPN #03 stated LPN #39 informed her she had not received the results and she would check the supervisor's office fax machine on her way out of the facility and let her know if the Xray results were received. LPN #03 stated she had not received any notification from LPN #39, so she assumed the Xray results were not available. LPN #03 stated she was busy the beginning of her shift and when she had the opportunity to follow up with the Xray results, she found the results on the fax machine in the supervisor's office and immediately notified next telehealth Physician #410. LPN #03 stated she was not certain of the exact time she notified the telehealth Physician #410 but was aware it was after 3:00 A.M., on 03/21/22. LPN #03 stated the nights she worked on 03/19/22 and 03/20/22 resident #57 complained of pain only when she was provided care or with movement of her left leg. LPN #03 stated there was no increased swelling or redness noted, and the Tylenol was effective for pain. During a telephone interview on 06/14/22 at 2:03 P.M., the dayshift nurse, LPN #39, revealed she was Resident #57's assigned nurse on 03/20/22. LPN #39 stated she could not remember the exact time but confirmed the Xray was obtained for Resident #57 that morning. LPN #39 could not remember the time she had checked the fax machine in the supervisor's office earlier that day before lunch and there was no fax. LPN #39 stated she checked the fax machine once that day and did not check for the fax when her shift ended, or on her way out of the facility. LPN #39 stated Resident #57 did not get out of bed on 03/20/22 while awaiting the results of the Xray and rested comfortably in bed and only complained of pain with movement of her left leg when staff were providing care, the Tylenol was effective for her pain. During a telephone interview on 06/14/22 at 2:31 P.M., the Administrator confirmed Resident #57's Xray results were received by the facility on 03/20/22 at 12:57 P.M. and not communicated to Physician #410 until 03/21/22 at 3:55 A.M. The Administrator stated Resident #57 was transported by regular transport ambulance because the local hospitals have requested that nine-one-one (911) be called for emergencies only and Resident #57 was stable and not in acute distress. Review of the facility policy titled Lab and Diagnostic Test Results-Clinical Protocol, revised November 2018 revealed section titled Review by Nursing Staff. 1. When test results are reported to the facility, a nurse will first review the results. a. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. This deficiency substantiates Complaint Number OH 090.

Based on medical record review, staff interview, and interview with Certified Nurse Practitioner (CNP) #199, Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in Immediate Jeopardy when Resident #170 sustained serious life-threatening injuries during a fall with a head injury. Resident #170 was sent to an acute care hospital and was later transferred to a Level II Trauma center via care flight, due to having a non-displaced fracture of the occipital bones near the midline (fracture at the base of the skull). She also had an extensive subarachnoid hemorrhage with left frontal intraparenchymal hemorrhage (bleeding in the space that surrounds the brain) with surrounding [CONDITION(S)] (observable swelling from fluid accumulation in body tissues). She had left cerebral convexity subdural involving the left frontal, the left parietal, and the left temporal lobes (a collection of blood outside the brain). She was subsequently admitted to Hospice inpatient care per the electronic record. This affected one resident (#170) of four residents reviewed for falls with injury. The facility identified five residents (#22, #148, #162, #167, and #170) who sustained a fall with injury requiring transport to the hospital. The facility census was 169. On 11/10/21 at 12:26 P.M., the Administrator, Regional Director of Clinical Services #200, and the Unit Manager Registered Nurse (RN) #139 were notified the Immediate Jeopardy began on 09/26/21 at 10:30 A.M. when Licensed Practical Nurse (LPN) #81 did not send Resident #170 to the ER immediately when the resident had a change of condition following a fall with head injury. This caused a delay in the care of a critically injured resident who suffered severe life-threatening injuries as a result of trauma to the skull with fractures and bleeding in the brain. She was sent to the ER via a non-emergent transport company on 09/26/21, where she was diagnosed with the following conditions: a subarachnoid hemorrhage, an intraparenchymal hemorrhage, a subdural hemorrhage, a subfalcine herniation (a midline shift of brain tissue), and an occipital bone fracture. Resident #170 was initially seen in the local hospital ER and then transferred via care flight to a Level II Trauma Center. The Immediate Jeopardy was removed on 11/11/21, when the facility implemented the following corrective actions: · On 09/26/21, Medical Director #201 and CNP #199 were made aware of the incident and follow-up to review corrective actions. · On 09/27/21, the Director of Nursing (DON) initiated education for all licensed nursing staff on the procedure for neurological checks assessment for witnessed falls resulting in head impact, and all unwitnessed falls. This education was completed on 10/01/21. The education was included in the orientation for all newly hire nurses. · On 09/27/21 through 10/23/21, the Administrator, the DON, Regional Director of Clinical Services #200, LPN Unit Manager #92 and RN Minimum Data Set (MDS) Coordinator #70 audited all witnessed falls with head impact and all unwitnessed falls to ensure compliance. They found no identified concerns. · Licensed Nursing staff will continue to be educated on policies/procedures including falls and neuro checks, as assigned during monthly education assignments and skills checks (both in person and on-line), and as needed. The DON and/or designee will be responsible to complete skills checks on the above randomly every month (five nurses per month). The audit results will be submitted to the Quality Assurance Performance Improvement (QAPI) committee for review and recommendation. · All resident falls occurring in the facility will be audited the following business day. If the fall occurs on the weekend, the nurse manager on call or the scheduled weekend supervisor will audit the fall for compliance to ensure proper procedures were followed and documented per policy. The DON and/or designee will be responsible to ensure this is completed as part of the daily clinical meeting process. This will be an on-going process with no end date. · On 09/29/21, an ad-hoc QAPI committee meeting was held related to falls with injuries and neurological checks related to the incident and was facilitated by the Administrator. The following required staff members in attendance included the DON, Dietary Manager #149, MDS Coordinator #70, Activities Director #75, Regional Director of Clinical Services #200, Maintenance Director #04, LPN Unit Manager #92, and Ancillary/Transportation Specialist (Transportation Aide) #74. The Administrator will be responsible to share the meeting results with Medical Director #201 during the normally scheduled QAPI meeting process November 2021. · Interviews on 11/10/21 at 4:45 P.M. with RN #11, RN #15, and LPN #16, all verified they received in-service training on falls and neurological checks and had no concerns. Although the Immediate Jeopardy was removed on 11/11/21, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy), as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #170 was admitted to the facility on [DATE] and discharged to the hospital on 09/27/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #170 had moderate cognitive impairment. Resident #170 required limited assistance of one staff for bed mobility, transfer, and dressing. She required supervision and setup help for walking. She required supervision of one staff for locomotion and eating. She required extensive assistance of one staff for toilet use and personal hygiene and was totally dependent on one staff for bathing. Review of the care plan revealed she had a care plan addressing her potential for uncontrolled bleeding initiated 09/04/20. She was prone to bruise easily related to her anticoagulant therapy for management of [CONDITION(S)]. The interventions included assessing for any bleeding that may occur, notify the physician as needed, and avoid injury. She also had a fall care plan addressing her potential for injuries/falls related to her history of falling with a head injury, dementia, [CONDITION(S)], and arthritis. Interventions included to encourage her to always wear non-skid footwear at all times, encouraging her to ask/use call light for assistance, ensuring the call light was within reach, observing and reporting unsafe conditions, observing for signs and symptoms of pain/medicate per physician orders, evaluation and treatment as ordered/as needed by physical therapy and occupational therapy, and a stop sign to her bedroom door for safety. Review of the physician order dated 07/03/21, revealed Resident #170 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [MEDICATION(S)] prescribing information sheet revealed it was a factor Xa inhibitor which increases the risk of bleeding and can cause serious, potentially fatal, bleeding. Review of the progress note dated 09/25/21 at 7:00 P.M., documented at 6:20 P.M., State tested Nursing Assistant (STNA) #130 reported Resident #170 was lying on the dining room floor on her back. The resident ' s beaded necklace was under her head. Her upper denture was noted protruding from her mouth. Her eyes were closed, she was lethargic, responded with words; however, would not open her eyes. An open area was noted to the back of her head. Her walker was in front of her. Pressure was applied with first aid provided to the area on her head. Resident #170 was assisted to a sitting position. The resident was talking to staff but still not opening her eyes. Neurological checks were started. She was assisted to a wheelchair and then assisted to her room. The resident was noted with blood-tinged sputum; however, no open areas were noted to her cheek or gums. She had a small emesis of undigested food at 6:52 P.M. She was assisted to bed with the assistance of two staff. She had a small amount of blood-tinged [MEDICATION(S)] from her left nostril. Her blood pressure at the time of the fall was 89/54 millimeters of mercury (mm/Hg) and upon recheck at 6:55 P.M. was 81/50 mm/Hg. Resident #170 was fully alert and sitting up in bed. Review of the progress note dated 09/25/21 at 7:19 P.M. revealed the Telehealth service was contacted and awaiting a call back. Resident #170 ' s blood pressure was rechecked at 7:22 P.M. and was 114/72 mm/Hg. Neurological checks continued and the resident had no further emesis or red tinged sputum. At 8:26 P.M. the telehealth doctor was updated and requested a non-emergent head Computed Tomography (CT) scan, and if there were any neurological changes to send Resident #170 immediately to the ER. LPN #126 contacted the local ER Registered Nurse to schedule a non-emergent transport for a CT scan. The nurse was told the scan would be completed in the ER if the resident would go due to her being over 65 and on [MEDICATION(S)]. Review of the progress note dated 09/25/21 at 8:50 P.M. revealed the non-emergency transport companies the facility used had no available squads. One of the non-emergent transportation companies could transport Resident #170 at approximately noon the next day to the local ER for the non-emergent CT scan. Neurological checks continued and they were to send the resident to the ER immediately if she had neurological changes. The non-emergent transport company was to be notified by 8:00 A.M. on 09/26/21 to set up the transport. Review of the next progress note dated 09/26/21 at 10:30 A.M. revealed Resident #170 was lying in bed. She responded with only huh when talked to and no other response was noted. Her skin was pale, but warm to touch. There was no bleeding or emesis noted. Her blood pressure was 107/58 mm/Hg, and her pulse rate was 138 beats per minute. She had oxygen on per nasal canula with an oxygen saturation rate of 94%. Her respiratory rate was 16 breaths per minute. There was an appointment for transport at 11:00 A.M. Review of the progress note dated 09/26/21 at 11:19 A.M. revealed Resident #170 was unable to swallow medications at this time and left the facility with the non-emergent transport for the local hospital for the test related to the previous fall. Review of the progress note dated 09/26/21 at 2:53 P.M. revealed the local hospital contacted the facility with an update on Resident #170. The local hospital reported Resident #170 had been transferred to a Level II Trauma Center. The progress notes on 09/29/21 revealed the social worker from the hospital called the facility and reported Resident #170 was admitted to an in-house hospice unit and would not return to the facility. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] .M., Resident #170 was fully conscious (awake, aware, and oriented), had full range of motion, had an oriented verbal response, spontaneously opened her eyes and had a pulse rate of 88 beats per minute. On 09/26/21 at 9:50 A.M., Resident #170 was lethargic, had impaired range of motion in her right arm, spontaneously opened her eyes, had incomprehensible speech, and had a pulse rate of 138 beats per minute. At the bottom of the post-fall neurological assessment flow sheet there were instructions to notify the medical doctor immediately if any part of the assessment were not within normal limits of the resident ' s baseline. It also documented to call nine-one-one (911) if there was an emergency. Review of the fall investigation (undated) revealed Resident #170 fell from a standing position while attempting to walk. The fall was not witnessed by any staff and only heard. Review of the Patient Care Report from the non-emergent transport company on the date of service, 09/26/21, revealed they arrived at the facility on 09/26/21 at 10:54 A.M. They were in Resident #170 ' s room at 10:57 A.M. The report indicated they left the facility at 11:16 A.M. and arrived at the local hospital at 11:52 A.M. The assessment revealed she was confused. The narrative indicated the transport was dispatched on a non-emergent ER transport going from the facility to the local hospital ER. Resident #170 was documented as going due to the complaint of a fall. The nurse stated the resident had fallen the day before around 6:30 P.M. and had hit her head when she fell . The resident had an abrasion on the back of her head with dried blood on and around her pillow. The report indicated she was on blood thinners. The nurse reported the resident was normally verbal. It was noted the resident only responded with the word huh. Her vitals were assessed as follows: blood pressure 149/86 mm/Hg, pulse 71 beats per minute, respiratory rate of 18 breaths per minute, and oxygen saturation rate of 97% on supplemental oxygen per nasal canula at two liters per minute. Resident #170 was transported to the local hospital ER. Review of the local hospital emergency department report dated 09/26/21 revealed Resident #170 was diagnosed with a non-displaced fracture involving the occipital bones near the midline. She also had an extensive subarachnoid hemorrhage with left frontal intraparenchymal hemorrhage with surrounding [CONDITION(S)]. She had left cerebral convexity subdural involving left frontal, left parietal and left temporal lobes. Some of the other diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #170 was transferred to the Level II Trauma Center via care flight for further treatment. Review of the Level II Trauma Center hospital record with an admitted [DATE] revealed Resident #170 was admitted as a trauma alert following a fall at her living facility. It indicated she presented to the emergency department the day following the fall per Emergency Medical Services (EMS) reports. She was on [MEDICATION(S)] and was found to have a large subdural hemorrhage with associated midline shift. She was also found to have extensive subarachnoid and intraparenchymal hemorrhages. Further injuries included a posterior scalp laceration and an incidental finding of a seven-millimeter saccular aneurysm of the left internal carotid. She was seen by neurosurgery shortly after presentation. They had a frank discussion with the patient ' s family about her prognosis and potential for meaningful recovery. Considering this information, she was made a Do Not Resuscitate with Comfort Care (DNR CC) with plans for ongoing basic medical care but no aggressive measures. She was ultimately discharged on [DATE] to a hospice facility with plans for ongoing comfort care measures. At the time of discharge her Glasgow Coma Scale (GCS) improved to 12 with increasing responsiveness but still with significant neuro deficits and inability to feed or care for herself. An interview on 11/10/21 at 11:17 A.M., CNP #199 revealed the facility used an out of state telehealth company after 6:00 P.M. on weekdays and all weekend until 7:00 A.M. on Mondays. She revealed her expectation was Resident #170 would have been sent out immediately due to her change of condition. She indicated she was not aware of any corrective action regarding the resident ' s fall. On 11/10/21 at 1:41 P.M., Licensed Practical Nurse (LPN) #81, who was the nurse on duty when Resident #170 was sent to the hospital, was contacted and a message was left with a contact number for a return call. A return call was not received. A second call was made on 11/15/21 at 3:16 P.M. in an attempt to speak with LPN #81, and another message was left. During a telephone interview on 11/15/21 at 2:39 P.M., the former DON said she received a call regarding Resident #170 on the night of her fall (09/25/21). The LPN working (#126) told her the resident ' s vital signs were stable and she had no other symptoms besides a small laceration to the back of her head that was like a scratch. She indicated generally she would have the resident sent out due to her hitting her head and being on an anticoagulant, but with the information she was provided, she had the nurse reach out to the Telehealth doctor to see what they wanted done. She revealed if she was aware of the resident ' s actual symptoms, (the lethargy, the blood-tinged sputum, the blood from her left nostril and emesis) she would have instructed the nurse to send her out to the ER right away. She indicated all that she was aware of was that they ordered a routine CT scan. She later found out the resident had a subdural hematoma. She revealed the staff had not called the physician or the CNP to let them know of her change in condition. She indicated the policy was changed afterward to have all residents sent out if they hit their head and were taking a blood thinner. She said she also did not receive a call when the resident had a change of condition. She found out the next day (09/27/21) when the admissions staff let her know the resident was admitted to the hospital with a subdural hematoma. She revealed her expectation would be that the resident would have been sent out immediately the morning she had a change of condition instead of waiting for the scheduled transport. She said she provided education to all nursing staff regarding falls, neuro checks and subdural hematomas which would have been completed on 10/01/21 at 10:00 P.M. when the last night shift nurses were in-serviced. A telephone interview on 11/16/21 at 10:14 A.M. with Medical Director #201 revealed he was aware Resident #170 had fallen, went to the hospital, and later passed away; however, was not directly involved in the QAPI process or in a meeting. He indicated he would review his correspondence to see if he had been made aware. A return call was received from him on 11/16/21 at 10:42 A.M. and he revealed there was no notification to him about an official QAPI meeting on 09/29/21. He indicated there had been no communication with him regarding a plan of correction or corrective action related to the fall. Review of the facility policy titled, Change in a Resident ' s Condition or Status reviewed on 07/2018, revealed the Nurse Supervisor shall notify the resident ' s attending physician, consistent with medical director and physician policies, when (including but not limited to): a) The resident is involved in any accident or incident which results in an injury including injuries of an unknow source; and b) There is a significant change in the resident ' s physical, mental or psychosocial status. Review of the facility undated policy titled, Falls-Clinical Protocol revealed under the section Assessment and Recognition that the nurse shall assess and document/report the following (including but not limited to) vital signs; recent injury, especially fracture of head injury; musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; change in cognition; neurological status; pain; precipitating factors, details on how fall occurred; all current medications; and all active diagnoses. Under the section Monitoring and Follow-Up that The staff, with the physician ' s guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. This deficiency substantiates Complaint Number OH 776.