Every finding on record at Mt Alverna Home Inc

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on Self-Reported Incident (SRI) review, medical record review, interview, and facility policy review, the facility failed to prevent resident-to-resident sexual abuse. This affected two residents (Residents #2 and #4) of four residents reviewed for abuse. The facility census was 147. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 02/16/24 with diagnoses that included Alzheimer's disease, dementia, anxiety, and adult failure to thrive. Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 was unable to complete the brief interview for mental status assessment and the staff assessment for mental status indicated severely impaired cognition. The MDS also indicated Resident #4 rejected care, required moderate assistance for toileting and bathing, required maximal assistance for personal hygiene, and required supervision assistance for transferring. Review of the current care plan revealed Resident #4 had a communication problem related to dementia dated 01/13/26 and required assistance with activities of daily living (ADLs) related to Alzheimer's dementia dated 04/16/26. Review of the progress note dated 06/12/26 revealed Resident #4 was observed in Resident #2's room and he was guiding her hands towards his penis. 2. Review of the medical record for Resident #2 revealed an admission date of 07/11/24 with diagnoses that included Alzheimer's disease, bipolar disorder, and major depressive disorder. Review of the Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #2 was cognitively impaired, required moderate assistance with toileting and personal hygiene, was independent with bed transferring, and required supervision assistance with walking. Review of the current care plan revealed Resident #2 had a history of sexual behaviors dated 01/10/25 with interventions that included educating on coping strategies, intervening as necessary to protect the rights and safety of others, and to redirect as needed. Review of the progress note dated 06/12/26 at 7:45 P.M. revealed a Certified Nursing Assistant (CNA) entered Resident #2's room and observed Resident #4 sitting on Resident #2's bed. Resident #2 was standing in front of Resident #4 with his pants down guiding her hands to his genitalia. When asked what he was doing, Resident #2 pulled up his pants and stated, Nothing. She was just playing around. Review of the progress note dated 06/13/26 at 10:09 A.M. revealed Psychiatrist #500 ordered Resident #2 sent to the hospital for evaluation due to increase in his behaviors. Review of SRI #275715 dated a facility self-reported incident (SRI) dated 06/13/26 revealed an allegation of sexual abuse involving Resident #4 who was observed by a staff member in the room of Resident #2 and Resident #4 was observed touching Resident #2's genital area. The incident occurred on 06/12/26 at 5:10 P.M. CNA #308 was searching for Resident #4 when she was not in her room and found her in Resident #2's room. Resident #4 was seated on the edge of Resident #2's bed near the footboard while Resident #2 stood in front of her with his pants down. Resident #2 was holding Resident #4's hands on his penis. When confronted, Resident #2 immediately pulled up his pants and stated that Resident #4 was just playing around. CNA #308 redirected Resident #4 from the room and observed no visible signs of pain, distress, discomfort or injury. Both residents were placed on every fifteen-minute checks. The family of both residents were notified, and a skin assessment of Resident #4 resulted in no injuries or signs of trauma. Resident #2 was sent to the hospital for evaluation due to concerns regarding inappropriate sexual behavior. An interview on 07/21/26 at 12:03 P.M. with CNA #308 who witnessed the incident revealed on 06/12/26, she was taking another resident to the bathroom and saw Resident #4 sitting on a couch near Resident #2's room. After she finished assisting the other resident, CNA #308 noticed Resident #4 was no longer on the couch, but her wheelchair was still there. CNA #308 checked in Resident #2's room and saw Resident #4 sitting on the bed and Resident #2 was standing up with his pants down and holding Resident #4's hands on his penis. When CNA #308 asked what was happening Resident #2 immediately pulled up his pants and said she was just playing around. An interview on 07/22/26 at 10:21 A.M. with the Administrator revealed Resident #4 did not have the ability to give consent for sexual activity due to her cognition. An interview on 07/22/26 at 11:03 A.M. with Resident #2 revealed he was unable to answer questions to provide reliable information.An interview on 07/22/26 at 11:10 A.M. with Resident #4 revealed she was unable to answer questions to provide reliable information giving mostly nonsensical verbal word formation. Review of facility policy titled, Abuse, Neglect and Exploitation, dated 11/21/24 revealed residents had the right to be free from abuse including from other residents, and sexual abuse was defined as non-consensual sexual contact of any type with a resident. The deficient practice was corrected on 06/29/26 when the facility implemented the following corrective actions: On 06/12/26 immediately following the incident Resident #4 was immediately escorted from Resident #2's room and nursing staff were notified. On 06/12/26 nursing staff initiated immediate interventions including placing Resident #2 and Resident #4 on fifteen-minute safety checks and ensured the residents remained separated. Licensed Practical Nurse (LPN) Supervisor #372 provided education to all staff on the interventions. On 06/12/26 Resident #2 and Resident #4's responsible parties were notified by Unit Manager (UM) #482. Physicians were notified including Psychiatrist #500 by LPN Supervisor #372. On 06/12/26 LPN Supervisor #372 and LPN Supervisor #409 completed a skin assessment on Resident #4, which resulted in no injuries or signs of trauma. On 06/13/26 Unit Manager (UM) #482 made follow-up calls to Resident #2 and Resident #4's responsible parties. On 06/13/26 Psychiatrist #500 ordered Resident #2 sent to the hospital for inpatient psychiatric evaluation. On 06/13/26 Assistant Director of Nursing (ADON) #398 provided all staff education on abuse policies which was completed on 07/22/26. From 06/13/26 until 06/18/26 during hospitalization Resident #2's medications were reviewed and adjusted by the physician, and no further inappropriate sexual behaviors were reported. On 06/18/26 Resident #2 returned to the facility unit and fifteen-minute safety checks were ongoing. Resident #4's room was moved and a male resident placed in her previous room. On 06/22/26 Resident #2 was seen by Psychiatrist #500 for routine follow-up. On 06/29/26 Resident #2 was seen by Psychiatrist #500 for worsening behaviors. His medications were adjusted, fifteen-minute checks were still ongoing, and the ongoing plan of care was to send the resident back to the hospital for evaluation for any escalating behaviors.This deficiency represents non-compliance investigated under self-reported incident investigation Control Number 3092895.

Based on medical record review, Self-Reported Incident (SRI) review, interview, and facility policy review, the facility failed to report an allegation of misappropriation in the appropriate time frame to the state agency. This affected one resident (Resident #15) of four residents reviewed for abuse. The census was 147.Findings include: Review of the medical record for Resident #15 revealed an admission date of 10/23/23 with diagnoses that included nontraumatic intracerebral hemorrhage (stroke), hemiplegia (severe or complete paralysis) and hemiparesis (mild to moderate weakness) left side, bipolar disorder, heart disease, and contracture (shortening of muscles or tendons that restricts joint movement) of multiple sites. Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 was cognitively intact, did not reject care, and was dependent on or required maximal assistance with most activities of daily living. Review of SRI #275576 revealed a discovery date of 06/10/26 was reported to the state agency for an allegation of misappropriation. A Certified Nursing Assistant (CNA) reported that during her conversation with Resident #15, he had given a nurse a check for $9,000.00. Based on the investigation, the resident consistently stated that he voluntarily gave the nurse the check of his own free will and denied being pressured, manipulated, coerced, deceived, or exploited. The investigation found no evidence that the nurse obtained the money through theft, deception, coercion or any unauthorized means.Review of witness statement forms included in SRI #275576 revealed two statements dated 05/21/26 which document the allegation of misappropriation was initially reported on 05/21/26 and not the discovery date as documented on the SRI incident form as 06/10/26. An interview on 07/29/26 at 11:37 A.M. with Administrator verified the allegation of misappropriation was discovered on 05/21/26 and not on 06/10/26 when the SRI was reported. Administrator stated he wanted to get the results of the investigation verified before reporting it to the state agency. Review of facility policy titled, Abuse, Neglect, and Exploitation, dated 11/21/24 revealed allegations of abuse, neglect, or exploitation were to be reported immediately to the state survey and certification agency through established procedures and time frames. This deficiency represents non-compliance investigated under self-reported incident investigation Control Number 3092895.

Based on resident interviews, staff interviews, facility documents and policy review, the facility failed to ensure residents were served a variety of meal choices. This had the potential to affect all residents residing in the facility except three Residents (#29, #54 and #125) who were identified by the facility as not receiving food by mouth (NPO) or from the kitchen. The facility census was 136.Findings include: Interview on 05/06/26 at 9:15 A.M. with Resident #24 revealed the food choices were always the same and rotated throughout each week. Resident #24 revealed she was served a lot of pasta and potatoes and little variations of alternatives. Resident #24 revealed the food quality had gone downhill over the last few months.Review of the weekly menu dated 05/03/26 through 05/09/26 revealed 5 out of 7 breakfast meals, 5 out of 7 lunch meals, and 4 out of 7 dinner meals, within the same week served a variation of potatoes. Review of the menu revealed the following:On 05/03/26 the breakfast meal consisted of breakfast potatoes, the lunch meal potato soup, and the dinner meal potato soup and sweet potatoes fries.On 05/04/26 the breakfast meal consisted of hashbrown patties, the lunch meal mash potatoes and gravy, and the dinner meal had herbed red potatoes.On 05/05/26 the lunch meal consisted of rosemary scalloped potatoes, and the dinner meal mashed potatoes.On 05/06/26 the breakfast meal consisted of tater tots, the lunch meal baked potatoes, and the dinner meal dill potatoes.On 05/07/26 the breakfast meal consisted of hashbrown patties.On 05/09/26 the breakfast meal consisted of corned beef hash and the lunch meal consisted of candied yams.Interview on 05/06/26 at 3:22 P.M. with Dietary Technician (DT) #829 revealed residents often complained about eating the same food items. DT #829 revealed kitchen staff just followed the menus provided and the dietary director was responsible for switching things around. DT #829 chuckled as he reviewed the number of different variations of potatoes that appeared on the menu multiple times throughout the week. DT #829 during review of the menus confirmed and verified the above findings at the time of the interview.This deficiency represents non-compliance investigated under Master Complaint Number 2724206.

Based on observations, resident interviews, staff interviews, and facility policy review, the facility failed to ensure meals were served in a timely manner to ensure proper temperature and failed to ensure hairnets were worn to ensure proper sanitation. This had the potential to affect all residents residing in the facility except three Residents (#29, #54 and #125) who were identified by the facility as not receiving food by mouth (NPO) or from the kitchen. The facility census was 136.Findings include: Interview on 05/05/26 at 1:48 P.M. with Certified Nurse Assistant (CNA) #927 revealed residents in the facility complained about cold and nasty food all the time. CNA #927 revealed staff had to call the kitchen all the time with resident complaints.Interview on 05/06/26 at 9:15 A.M. with Resident #24 revealed the food was never hot and it always arrived late. Resident #24 revealed the food quality had gone downhill over the last few months.Interview on 05/06/26 at 12:11 P.M. with Resident #109 revealed the food was always cold and he requested to have his tray warmed up or served first. Resident #109 revealed he preferred to eat in the dining room to ensure he received his meals first.Observation and interview on 05/06/26 at 11:40 A.M. with Dietary Technician (DT) #829 located in the kitchen revealed the facility served the dining rooms first and then room trays went last. Observation revealed the third floor cart was sent to the dining room at approximately 11:43 A.M.Observation on 05/06/26 at 11:50 A.M. with Dietary Aide (DA) #941 of the temperatures of the lunch meal revealed pasta with meat sauce was 157 degrees Fahrenheit (F), carrots were 170 degrees F, honey garlic chicken was 124 degrees F, baked potatoes was 174 degrees F, soup was 168 degrees F, the pureed mashed potatoes were 168 degrees F, and hamburger 160 degrees F.Observation and interview on 05/06/26 at 12:22 P.M. revealed Resident Care Assistant (RCA) #418 entered into the third floor kitchen without a hairnet and/or hair covering and entered the refrigerator. RCA #418 revealed she did not know she couldn't enter the kitchen without a hairnet because it was not the main kitchen. RCA #418 confirmed and verified the above findings at the time of the interview.Observation and interview on 05/06/26 at 12:53 P.M. of the lunch meal service with DA #941 revealed multiple plated hot food items sitting uncovered on the steam table and not being actively assembled onto trays or transported for service. The food remained on the steam table without staff intervention. DA #941 stated I'm not waiting on anything or additional items and indicated there was no specific reason for the delay in tray assembly or delivery when interviewed.Temperatures of the food items were taken on the steam table prior to service and again on a test tray at the time of meal delivery. The following temperature decreases were noted: the baked potato decreased from 174 to 147 degrees F, pasta with meat decreased from 157 to 143 degrees F, soup decreased from 168 to 134 degrees F, and the carrots decreased from 170 to 124 degrees degrees F. The carrots and soup were below the required hot holding temperature of 135 degrees F after serving the lunch meal, and the chicken measured below acceptable hot holding temperature at 134 degrees F prior to meal tray pass, indicating significant heat loss prior to service. Multiple food items were also observed to be lukewarm at the time of service.The test tray observation on 05/06/26 at 1:01 P.M. with DT #829 revealed the facility failed to maintain proper time and temperature control of hot foods and failed to ensure prompt service with potential to increase the risk that food entered the temperature danger zone and was not served at safe and palatable temperatures. DT #829 confirmed and verified the above findings at the time of the interview and observation.Review of the food committee minutes and resident council minutes dated February, March, and April 2026 revealed on 02/12/26, hot plates were tested and were currently being utilized for all meals. The minutes dated 03/12/26 revealed the pallets in the kitchen were new would make the food stay hot longer and the minutes dated 04/16/26 revealed residents reported the food was warmer. Review of the minutes revealed residents consistently voiced concerns regarding the temperature of their meals.Review of the facility document titled Personal Hygiene dated 10/25/22, revealed the facility had a policy in place that personal hygiene was an essential part of food safety and preventing the spread of bacteria that included, but not limited to, hair restraints. Review of the policy revealed hair must be appropriately restrained by using a hair net that competed covered all hair in any food production area.This deficiency represents non-compliance investigated under Master Complaint Number 2724206 and Complaint Numbers 2661047 and 2609451.

Based on observation, resident record reviews, staff interview, and facility policy review, the facility failed to ensure residents were treated with dignity during dining. This affected one resident (#30) of two reviewed for dignity. The facility census was 136.Findings include: 1.Review of the medical record for Resident #30 revealed she was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis, hypertension, and hyperlipemia.Review of Staff Assessment for Mental Status (SAMS) assessment revealed Resident #30 had a memory problem, had modified independence regarding task of daily life. Review of the SAMS assessment revealed Resident #30 was impaired on one side of the upper and lower extremities and was dependent on staff for activities of daily living (ADLs).Review of the care plan dated 02/08/22 revealed Resident #30 had a self-care performance deficit related to hemiplegia, aphasia, and muscle weakness and required the services and support of the facility with interventions that included set-up and clean-up assistance with eating and encouraged to engage in life of the facility and provide dining assistance.2.Review of the medical record for Resident #103 revealed she was admitted to the facility on [DATE] with diagnoses that included diverticulosis of the intestine, dementia, and impulse disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #103 had a Brief Interview for Mental Status (BIMS) score of 4 that indicated cognition impairment. Review of the MDS assessment revealed Resident #103 required some assistance from staff for ADLs.Review of the care plan dated 04/02/26 revealed Resident #103 had a self-care and mobility performance deficit related to diverticulosis with interventions that included provide dining assistance as needed.Observation on 05/06/26 at 12:00 P.M. revealed Residents #30 and #103 seated at a table together in the third floor dining room. Resident #103 was observed receiving her lunch meal tray and begin to eat. Resident #30 sat without her lunch meal tray. Observation on 05/06/26 at 12:14 P.M. revealed random residents eating their lunch meal being served their lunch trays. Resident #30 continued to sit with Resident #103 without a lunch tray.Observation on 05/05/26 at 12:20 P.M. revealed all other residents eating in the dining room received their lunch tray and Resident #30 received her tray last. Observation revealed Resident #103 completed her lunch meal and left from the dining room.Interview on 05/06/26 at 12:21 P.M. with Certified Nurse Assistant (CNA) #548 confirmed and verified the above findings at the time of the interview.Review of the facility document titled Dignity dated 04/01/23, revealed the facility had a policy in place that each resident would be treated with respect and dignity as well as care in a manner and in an environment that maintains or enhances the resident's quality of life.

Based on record review and interview, the facility failed to ensure Resident #139's new wound was identified and treated before developing a large size, becoming infected, and beginning to heal independent of facility action. This affected one of three residents reviewed for changes in status. The total census was 136. Findings include: Record review of Resident #139 revealed he was admitted [DATE] and discharged to home on [DATE]. His diagnoses included diabetes, venous insufficiency, and symbolic dysfunctions. His minimum data set assessment dated [DATE] revealed he had mild or no cognitive impairment and needed substantial or moderate assistance with toileting, bathing, and dressing the lower body. His admission assessment revealed he entered the facility with no edema and with wounds on his right and left toes and the top of his right foot. Records until 04/16/26 identified no evidence of any assessment, treatment, or acknowledgement of a wound to his right lateral leg.Record review of Resident #139 revealed a progress note dated 04/16/25 which said family was visiting and asked why his legs were swollen. The family also identified a healing wound to his right lateral leg. A skin/wound note the same day identified it as measuring 5 centimeters (cm) by 7 cm with a depth of 0.1 cm, with most areas scabbed over and a few with scant drainage. Progress notes the next day identified there was orange discoloration to the skin and antibiotics were ordered for infection of the wound. Review of his treatment record revealed dressings for the wound were ordered 04/17/26 and continued until discharge.Record review of Resident #139's wound assessment dated [DATE] revealed the wound was identified as an abrasion to the left lateral leg acquired in the facility measuring 5 cm by 7 cm by 0.1 cm. The wound bed was made of granulation tissue (a bumpy red or pink tissue associated with a wound already in the healing process, typically developing between three and seven days after the initial injury). Warmth and redness were noted as evidence of infection and the wound had light serosanguinous drainage. Pitting edema was noted around the wound. A freehand note identified the wound as being related to edema and cellulitis.Interview with Wound Nurse #613 on 05/07/26 at 9:07 A.M. revealed she recalled Resident #139 and said the left leg wound developed on an area hidden on the body by ace wraps. She said the wraps should have been taken off daily and changes in the skin should have been reported to her office. She confirmed resident #139's left leg wound was not identified until it was partway through the healing process, infected and edematous, and larger in size.This deficiency represents noncompliance investigated under Complaint Number 2587947.

Based on resident record review, resident interviews, staff interviews, and facility policy review, the facility failed to ensure restorative programs were implemented. This affected three residents (#24, #31, #130) of three reviewed for restorative services. The facility census was 136.Findings include: 1.Review of the medical record for Resident #24 revealed she was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (MS), contractures of the muscles, multiple sites, and scoliosis.Review of the physician orders dated 03/26/25 revealed an order for Passive Range of Motion (PROM) Bilateral Upper Extremities (BUE) and Active Assisted Range of Motion (AAROM) Bilateral Lower Extremities (BLE) 3-6 times per week in 15-minute sessions.Review of the physician orders dated 07/02/25 revealed an order for Resident #24 to wear bilateral dynamic Ankle-Foot Orthosis (AFO) splints BLE for contracture management to be worn for up to 2 hours during the day and only to be completed with therapy or restorative Certified Nurse Assistants (CNAs).Review of the physician orders dated 07/29/25 revealed an order for splint and/or brace bilateral ankle dynamic AFO brace 3-6 times weekly in 15-minutes sessions.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated she was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #24 was impaired on both sides, upper and lower extremities, and was dependent on staff for activities of daily living (ADLs).Review of the care plan dated 02/10/26 revealed Resident #24 had an ADL self-care performance deficit related to MS, impaired mobility, lack of coordination and weakness and contractures of the muscles with interventions that included, but not limited to, restorative ADL training 15-minute sessions 3-6 times per week, use of mechanical lift for transfers and 2 person care for ADLs.Review of the physical therapy (PT) Discharge summary dated [DATE] revealed Resident #24 had an established restorative program in place following her discharge from PT that consisted of ROM stretching and splinting.Review of the restorative splint and/or brace, ROM BUE, and PROM BLE program participation log dated 04/06/26 through 05/05/26 revealed Resident #24 received restorative services 8 times within 30 days. Review of the participation log revealed Resident #24 did not receive restorative services 3-6 times per week as ordered and care planned.2. Review of the medical record for Resident #31 revealed she was admitted to the facility on [DATE] with diagnoses that included dementia, mild protein-calorie malnutrition, and dysphagia.Review of the physician orders revealed an order dated 08/27/24 for restorative nursing ambulation of 30-50 feet using wheeled walker with contact guard assist in 15-minute sessions 3-6 times per week.Review of the physician orders dated 09/05/24 revealed an order for restorative nursing AROM BUE 15-minute sessions 3-6 times per week.Review of the physician orders dated 05/12/25 revealed an order for AROm BLE 15-minute sessions 3-6 times per week. Review of the care plan dated 01/20/26 revealed Resident #31 was at risk for falls related to weakness, poor safety awareness with interventions that included restorative program for ambulation and AROM BUE 15-minute sessions 3-6 times per week.Review of the MDS assessment dated [DATE] revealed Resident #31 had a BIMS score of 4 that indicated she was alert and oriented with cognition impairment. Review of the MDS assessment revealed Resident #31 was dependent on staff for ADLs. Review of the restorative walking, ROM AROM BLE, and ROM BUE program participation log dated 04/06/26 through 05/05/26 revealed Resident #31 received restorative services 11 times within 30 days. Review of the participation log revealed Resident #31 did not receive restorative services 3-6 times per week as ordered and care planned.3. Review of the medical record for Resident #130 revealed she was admitted to the facility on [DATE] with diagnoses that included dementia. Solitary pulmonary nodule, and hypertension.Review of the physician orders dated 02/22/24 revealed orders for restorative ambulation and toileting for 15-minte sessions 3-6 times per week.Review of the MDS assessment dated [DATE] revealed Resident #130 had a BIMS score of 15 that indicated she was alert and oriented to person, place and time. Review of the MDS assessment revealed Resident #130 was dependent on staff for ADLs.Review of the care plan dated 03/29/26 revealed Resident #130 required staff assistance with ADL care related to dementia, history of fractures, and difficulty in walking with interventions that included restorative nursing for ambulation and ADL training for toileting 15-minute sessions 3-6 times per week.Review of the restorative toileting training and walking program participation log dated 04/06/26 through 05/05/26 revealed Resident #130 received restorative services 11 times within 30 days. Review of the participation log revealed Resident #130 did not receive restorative services 3-6 times per week as ordered and care planned.Interview on 05/05/26 at 10:34 A.M. with Rehabilitation Aide (RA) #463 revealed she was a restorative aide but had a floor assignment instead due to staffing levels. RA #463 revealed she was scheduled to do restorative services every day but was pulled to the floor quite a bit. RA #463 revealed another staff member had to go home for a family emergency therefore, she was assigned to assist as a CNA. RA #463 revealed she gets pulled to the floor a lot more often lately. RA #463 confirmed and verified the above findings at the time of the interview.Interview on 05/05/26 at 10:51 A.M. with Licensed Practical Nurse (LPN) #625 revealed there were specific staff that addressed and were assigned to complete restorative services. LPN #625 revealed restorative staff completed walking, stretching, toileting, feeding, and other exercises assigned to individual programs for residents. LPN #625 revealed sometimes the restorative aides get pulled from their assignment to assist with ADLs as floor staff and the restorative programs were put off until another time. LPN #625 confirmed and verified the above findings at the time of the interview.Interview on 05/05/26 at 1:48 P.M. with CNA #927 revealed RA #745 was assigned to do restorative programs for designated residents. CNA #927 revealed RA #745 was assigned to restorative exercises but was pulled to complete ADLs as a floor CNA. CNA #927 revealed Resident #24 required restorative services and was unable to receive services at the time. CNA #927 revealed Resident #24 always asked if she would receive services each day, but she could not provide an answer because depending on the day and the number of staff available, restorative services would not get done. CNA #927 confirmed and verified the above findings at the time of the interview.Interview on 05/05/26 at 1:57 P.M. with Registered Nurse (RN) #519 revealed there was one restorative aide assigned to each floor. RN #519 revealed the one restorative aide assigned to the 3rd floor was pulled to the memory care unit due to not having enough staff to cover the unit. RN #519 revealed RA #745 was assigned to complete restorative services for the third floor unit and due to her no longer assigned as restorative aide, residents residing on the unit would not get services. RN #519 confirmed and verified the above findings at the time of the interview.Interview on 05/05/26 at 2:00 P.M. with RA #745 revealed residents who were assigned to restorative programs typically were seen by the therapy department first and then added to restorative as a maintenance program. RA #745 revealed RAs were unable to document services unless they completed at least 15-minute sessions with residents. RA #745 revealed she was assigned to the 3rd floor and sometimes she was pulled to work as CNA to help assist with meals and/or feeding, answering call lights, or complete full shifts if a staff member called off, went home early, or did not show up. RA #745 revealed she was pulled a lot to work as a floor CNA and were unable to complete restorative programs as required, needed, or requested. CNA #745 revealed Resident #24 was really tight and really needed restorative services and she always felt bad when she couldn't get to her. RA #745 revealed she did not consistently provide restorative services to Resident #24, #31, and #130. RA #745 confirmed and verified the above findings at the time of the interview.Interview on 05/06/26 at 9:15 A.M. with Resident #24 revealed she was supposed to receive restorative services multiple times per week, but she was getting very little exercise due to the facility not having enough floor staff and needing to pull the restorative staff to assist with resident ADL care. Resident #24 revealed she required restorative services to decrease pain and to slow the process of her MS symptoms. Interview on 05/06/26 at 2:00 P.M. with Director of Therapy (DOT) #471 revealed after residents completed therapy, the therapy department created restorative programs for the nursing department to complete as a continuation of therapy for maintenance. DOT #471 revealed Residents's#24, #31, and #130 were on restorative programs due to medical diagnoses to decrease and/or prevent decline. DOT #471 revealed there were not enough RAs due to them getting pulled to the floor all the time and not being able to keep up with the restorative programs. DOT #471 revealed residents and families called complaining that they were not getting the restorative services or were only getting services once a week. DOT #471 confirmed and verified the above findings at the time of the interview.Interview on 05/06/26 at 3:22 P.M. with Staffing Coordinator (SC) #900 revealed if the facility was short on floor staff, the RAs were pulled from their restorative programs to assist throughout the facility as CNAs. SC #900 revealed having appropriate floor staff to assist throughout the facility for ADLs was a priority and coverage was more important than restorative programs. SC #900 confirmed and verified the above findings at the time of the interview.Interview on 05/06/26 at 9:48 A.M. with Resident #130 revealed RA #745 was assigned to complete restorative exercises with her but that was only when she wasn't pulled to be an CNA for the day. Resident #130 revealed she needed to walk with RA #745 to help keep her in shape and without pain. Resident #130 revealed she did not get restorative services as ordered.Review of the medical records for Residents #24, #31, and #130 revealed the facility removed RAs from their assigned restorative roles and utilized them as CNAs due to ongoing low staffing levels. As a result, residents who were identified to receive restorative nursing services did not consistently receive those services as ordered and care planned which had the potential for risk and decline in functional abilities.Review of the facility document titled Restorative Nursing dated 09/01/23, revealed the facility had a policy in place to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Review of the policy revealed designated staff would be trained on basic and maintenance care that included maintaining proper positioning and body alignment, turning and repositioning, and exercising through passive or active range of motion and/or splint or brace assistance. Further review revealed resident's plan would include type of activities to be performed and frequency. Review of the facility document revealed the facility did not implement the policy.This deficiency represents non-compliance investigated under Master Complaint Number 2724206 and Complaint Number 2701574.

Based on resident record review, resident interview, staff interviews, and facility policy review, the facility failed to provide care and services to prevent a fall during a mechanical lift transfer. This affected one resident (#24) of three reviewed for falls. The facility census was 136.Findings include: Review of the medical record for Resident #24 revealed she was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (MS), contractures of the muscles, multiple sites, and scoliosis.Review of Resident #24's physician orders dated 01/23/25 revealed an order for two person care for ADLs.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated she was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #24 was impaired on both sides, upper and lower extremities, and was dependent on staff for activities of daily living (ADLs).Review of the care plan dated 02/10/26 revealed Resident #24 was at risk for falls and had and ADL self-care performance deficit related to MS, impaired mobility, lack of coordination and weakness and contractures of the muscles with interventions that included, but not limited to, follow fall protocol, educate staff on safety measures, use of mechanical lift for transfers and 2 person care for ADLs.Review of the incident log dated 03/05/26 through 05/05/26 revealed Resident #24 had a fall during staff assist incident dated 03/18/26 at 10:15 A.M.Review of the fall investigation revealed Resident #24 had a fall during staff assist on 03/18/26 at 10:15 A.M. Certified Nursing Assistant's (CNAs) #548 and #927 were transferring Resident #24 into her wheelchair when she slid out of the mechanical lift onto the floor with her head resting on the base of the mechanical lift. Resident #24 revealed she hit her head on the mechanical lift leg, denied pain and was transported to the hospital.Witness statement from CNA #548, dated 03/18/26, revealed she was positioned at Resident' #24 feet holding and guiding her legs, and CNA #927, who was positioned at the head of Resident #24 and guiding the mechanical lift, went to get her up, took her from over the bed and noticed she was slipping out of the mechanical lift. CNA #548 revealed Resident #24 was then lowered to the ground, and all hooks were in place before moving her.Witness statement from CNA #927, dated 03/18/26, revealed she was assisting CNA #548 get Resident #24 up for an appointment and when they moved her from the bed, noticed Resident #24 was slipping. CNA #927 reveled CNA #548 had Resident #24 legs as she lowered the mechanical lift while holding up under Resident #24. CNA #927 revealed all hooks were in place before moving her.Further review of the fall investigation revealed CNA #927 received competency training related to mechanical lift on 03/24/26 as a result of Resident #24 fall.Review of the incident note dated 03/18/26 at 11:01 A.M. revealed while CNAs #548 and #927 were using the mechanical lift to transfer Resident #24 from bed to wheelchair, one strap became unhooked and Resident #24 slid out of the sling headfirst and hit her head on the mechanical leg and landed on the floor. CNA notified Licensed Practical Nurse (LPN) #625 of the fall. Upon entering the room Resident #24 was on the floor lying on her back, with her head resting on the base of the mechanical lift. Resident #24 was assessed and vital signs were taken with no pian or injury noted. Resident #24 was taken to a local hospital per request. Mechanical lift was assessed for any damage or tears with none noted and in good condition.Review of the 72-hour post fall monitoring note dated 03/18/26 at 11:13 A.M. revealed Resident #24 denied any pain at the time of the fall and remained at baseline.Review of the alert note dated 03/18/26 at 2:37 P.M. revealed per the local hospital, Resident #24's diagnostic imaging and x-rays were negative, and Resident #24 would be returning to the facility with a pick-up time of 4:00 P.M.Review of the hospital discharge instructions dated 03/18/26 revealed Resident #24 had a diagnosis of an accidental fall, acute head injury, cervical strain, and contusion of the left shoulder. Review of the discharge paperwork revealed Resident #24 received x-rays of the left shoulder with no fractures or dislocation noted and imaging of the cervical spine, brain and head with no hemorrhage, infarction or abnormalities related to trauma.Review of the Occupational Therapy (OT) evaluation and plan of treatment dated 03/30/26 revealed Resident #24 was referred for services due to a recent fall from the mechanical left from bed to wheelchair resulting in Resident #24 striking her head and left shoulder.Interview on 05/06/26 at 9:15 A.M. with Resident #24 revealed she fell out of the mechanical lift while being transferred due to two CNA's chatting with each other and not paying attention. Resident #24 revealed the mechanical lift strap was not in place and before she had a chance to say anything, she fell backwards and hit her head and left shoulder on the leg of the mechanical lift. Resident #24 revealed 911 was called she was rushed to the hospital and although she had no injuries, she had a lot of pain and contusion of the shoulder.Interview on 05/05/26 at 1:48 P.M. with CNA #927 revealed she was helping transfer Resident #24 on the day she had a fall from the mechanical lift. CNA #927 revealed one the straps became undone and caused Resident #24 to slip out of the mechanical lift and onto the floor. CNA #927 revealed she was unsure how the strap became undone and was educated and retrained following the incident. CNA #927 confirmed and verified the above findings at the time of the interview.Interview on 05/07/26 at 10:00 A.M. with LPN #625 revealed she was the nurse on duty at the time of Resident #24 fall. LPN #625 revealed Resident #24 was preparing to go to the dentist at the time of her fall when two CNA's (#548 and #927) were transferring her via the mechanical lift, when she slipped out due to the strap becoming undone, and fell to the floor. LPN #625 revealed when she arrived at the room, Resident #24 was lying on the floor with her head on the base of the mechanical lift. LPN #625 revealed Resident #24 was assessed with no injuries noted and neuro checks put in place. LPN #625 revealed Resident #24 was subsequently sent to a local hospital for evaluation. LPN #625 revealed Resident #24 was monitored and provided a lidocaine patch upon her return for shoulder pain. LPN #625 revealed Resident #24 was sent to the hospital for evaluation following the fall and although she returned to the facility with no acute injury identified, Resident #24 continued to complain of left shoulder pain. LPN #625 confirmed and verified Resident #24 fall demonstrated failure to ensure she was transferred safely during use of the mechanical lift, placing her at risk for injury during transfer assistance. LPN #625 confirmed and verified the above findings at the time of the interview.Interview on 05/07/26 at 2:02 P.M. with the Director of Nursing (DON) revealed Resident #24 had a fall from the mechanical lift during a staff transfer and as a result the mechanical lift was taken out of service. The DON revealed the mechanical lift had no problem with the mechanisms and Resident #24 didn't drop to the floor but was lowered when staff noticed she was slipping. The DON revealed the maintenance department inspected the mechanical lift and had no issues. The DON stated, maybe the staff put the hooks on wrong. The DON confirmed and verified the above findings at the time of the interview.Review of the facility document titled Mechanical Lift Transfer undated, revealed the facility had a policy in place that designated residents would be assisted to transfer by mechanical lift for the safety and comfort for both residents and staff members. Review of the policy revealed staff were to use two employees, follow the manufacturer's instructions, assemble equipment, and position equipment for smooth transfer. Review of the facility document revealed the facility did not implement the policy.Review of the facility document titled Fall Prevention & Management Policy reviewed 10/23/24, revealed the facility had a policy in place to educate, manage risk factors, and implement appropriate interventions to reduce the risk of falls. Review of the facility document revealed the facility did not implement the policy.This deficiency represents non-compliance investigated under Complaint Number 2615273.

Based on observations, resident record review, staff interview, and facility policy review, the facility failed to ensure resident meal preferences were honored. This affected one resident (#109) of one reviewed for preferences. The facility census was 136.Findings include: Review of the medical record for Resident #109 revealed he was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, hemiplegia and hemiparesis affecting right dominant side, and hypertension.Review of the physician orders dated 03/05/25 revealed an order for Resident #109 to receive double portions for all meals with extra gravy.Review of the physician orders dated 04/03/25 revealed an order for general diet, regular texture and thin liquids.Review of the care plan dated 04/29/25 revealed Resident #109 had variable food intakes with need for supplementation with interventions that included honor food preferences.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #109 had a brief Interview for Mental Status (BIMS) score of 12 that indicated he was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #109 was impaired on one side and required some assistance from staff for activities of daily living (ADLs).Observation on 05/06/26 at 11:50 A.M. with Dietary Aide (DA) #941 of the lunch tray line revealed Resident #109's lunch meal was being plated. Certified Nurse Assistant (CNA) #548, as Resident #109 meal tray reached completion stated, Resident #109 gets two potatoes, and you only gave him one. DA #941, in response stated, I'm only giving him one because I don't know if we have enough. DA #941 revealed he was aware that Resident #109 were to be served double portions at all his meals, but he wasn't going to give him two potatoes when interviewed by the surveyor. Observation revealed Resident #109 lunch meal tray had one potato placed on his plate. DA #941 confirmed and verified the above findings at the time of the observation and interview.Review of the lunch meal ticket dated 05/06/26 revealed Resident #109 had a general diet with regular textures and thin liquids. Resident #109 lunch consisted of pasta fagioli soup, 2 baked potatoes, carrots, caramel marshmallow brownies, and honey garlic chicken thighs. Review of the meal ticket revealed Resident #109 was to receive double portions and to be served all his meals in the dining room.Observation on 05/06/26 at 12:18 P.M. revealed DA #941 providing Resident #109 a second potato after surveyor intervention. Review of the facility document titled Resident Services dated 05/01/28, revealed the facility had a policy in place that resident's rights and decisions would be honored and respected.

Based on record review, interview, and facility policy review, the facility failed to ensure blood glucose testing (BGT) was completed per the physician's order. This finding affected one (Resident #150) of three residents reviewed for BGT. The facility census was 140. Findings include: Review of Resident #150's medical record revealed the resident was admitted on [DATE] with diagnoses including encephalopathy, type two diabetes, and dementia. Resident #150 was discharged on 03/27/25. Review of Resident #150's physician orders revealed an order dated 03/11/25 (discontinued 03/22/25) for a general diet, soft and bite sized texture, thin liquid consistency; and an order dated 03/23/25 for a consistent carbohydrate diet, regular texture, thin liquid consistency (CCD). Review of Resident #150's physician orders revealed an order dated 03/11/25 (discontinued 03/15/25) for sliding scale insulin coverage. The order listed Humalog (fast acting insulin) and provided the following additional parameters: if the blood sugar was zero to 180 inject no insulin; 181 to 200 inject two units; 201 to 250 inject four units; 251 to 300 inject six units; 301 to 350 inject eight units; 351 to 400 inject 10 units; and call provider above 400 before meals and at bedtime. Review of Resident #150's progress note dated 03/14/25 at 12:36 P.M. revealed the power-of-attorney (POA) contacted the facility with concerns/requests. The POA was concerned that staff were waking the resident up during the night for care and medications. The resident requested medication administration times be changed to during the day while the resident was awake. The Nurse Practitioner (NP) was updated and agreeable with the time change. The POA also requested the resident should not be woken up for check and changes during the night as well as not be woken up for breakfast. Per the POA, the family was always in the building around breakfast time and would help the resident with meals if needed. The POA requested for the door to the room to be shut half way due to the light in the hallway. Review of Resident #150's physician orders revealed an order dated 03/15/25 (discontinued 03/21/25) for sliding scale insulin coverage. The order listed Humalog and provided the following additional parameters per sliding scale: if the blood sugar was zero to 180 inject no insulin; 181 to 200 inject two units; 201 to 250 inject four units; 251 to 300 inject six units; 301 to 350 inject eight units, 351 to 400 inject ten units and call provider if above 400 before meals and at bedtime. Review of Resident #150's Medication Administration Record (MAR) for March 2025 revealed the resident's blood sugar level was obtained on 03/17/25 at 9:06 A.M. with a result of 177. The Documentation Survey Report form revealed on 03/17/25 at 8:00 A.M. the resident consumed 75% to 100% of the breakfast meal. The BGT was obtained after the breakfast meal was completed. Review of Resident #150's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #150's physician orders revealed an order dated 03/21/25 (discontinued 03/25/25) for sliding scale insulin coverage. The order listed Humalog and provided the following additional parameters per sliding scale: zero to 180 no insulin; 181 to 200 inject two units; 201 to 250 inject four units; 251 to 300 inject six units; 301 to 350 inject eight units; 351 to 400 inject 10 units; and above four units call the provider two times a day before meals for morning and evening meals. Review of Resident #150's MAR for March 2025 revealed the blood sugar was completed on 03/21/25 at 10:10 A.M. with a result of 174. The Documentation Survey Report form dated 03/21/25 at 9:04 A.M. revealed the resident consumed 75% to 100% of the breakfast meal. The BGT was obtained after the breakfast meal was completed. Telephone interview on 07/02/25 at 1:53 P.M. with Licensed Practical Nurse (LPN) #828 confirmed the staff placed Resident #150's tray on her overbed table for the breakfast meal but did not wake the resident up. LPN #828 revealed she probably completed the BGT after the breakfast meal on 03/21/25 because the resident either woke up early or the resident's family woke up the resident and the resident started eating the breakfast meal and the staff did not realize it. LPN #828 confirmed she completed the BGT as soon as she realized the resident was eating the breakfast meal. Interview on 07/02/25 at 1:58 P.M. with the Director of Nursing (DON) confirmed staff completed Resident #150's BGTs on 03/17/25 and 03/21/25 after the breakfast meals were completed. Review of the Medication Administration policy dated 06/01/23 revealed medications were administered only by licensed nursing, medical, pharmacy or other personnel authored by state laws and regulations to administer medications. Medications were administered in accordance with written orders of the prescriber. This deficiency represents non-compliance investigated under Complaint Number OH00164078.

Based on observation, record review and staff interview the facility failed to ensure food was served and stored in a clean and sanitary manner. This had the potential to affect all 142 residents in the facility that consumed food from the kitchen. Findings Include: Observation of the kitchen area with Assistant Dietary Manager (ADM) #522 on 12/09/24 between 8:45 A.M. and 9:15 A.M. revealed the following that was observed and verified the time of discovery: 1. In the dry storage area an open packed of white rice with no date, an open bag of dinner rolls with no date, an open box of stuffing with no date, two containers of granulated sugar that were open with no date, an open box of bread crumbs with no date, and an open box of yellow cake with no date. 2. In the walk-in refrigerator two bags of open salad mix that were not sealed, an open package of pepperoni with no date, an open package of cheddar cheese with no date, an open package of tater tots with no date, and an open package of catfish with no date. 3. The fryer was noted to be extremely dirty with brown oil indicating the oil had gone bad and was not suitable for cooking food. ADM # 522 was stated I wouldn't eat out of that. Review of the undated dietary close down checklist posted on the dietary information board revealed before kitchen staff end their shift they are to ensure All items labeled & Dated-any items not labeled with date or name is to be discarded. Review of the undated procedure for dating food items posted on the outside of the [NAME] refrigerator and freezer All Opened Items Need To Be Put Into A Clear Bag Tied Off Or Container With A Lid. Placed A Label On Each Item Write The Items Name, Date It Was Opened and Expiration Date. This Must Be Followed For All Items.

Based on record review and staff interview, the facility failed to ensure a complete and accurate medical record for Resident #9. This affected one of twenty six sampled residents for medical record accuracy. Findings Include: Resident #9 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, heart failure and Parkinson's disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 was severely cognitive impaired and required hands on assistance of one staff person for completing activities of daily living such as toileting, transfers and bed mobility. The assessment further noted that Resident #9 required supervision for eating activities. Review of the most recent dietary notes dated 12/04/24 and 11/22/24 revealed concerns related to accuracy of weights related to a hospitalization and concerns related to variations of weights due to diuretic medications (medications that increase urination and can cause significant unintended weight loss quickly). No other dietary notations, assessments or other items were noted in Resident #9's medical for record for November and December 2024. Review of the census records for November 2024 and December 2024 revealed Resident #9 remained in the facility and was not sent to a hospital or any other acute care facility for any length of time. Interview with Dietary Technician (DT) #803 on 12/12/24 at 11:00 A.M. revealed (upon inquiry by the surveyor) DT #803 realized he had mixed up residents and had documented wrong resident's nutritional record into the medical of Resident #9. DT #803 was unsure what resident he documented the wrong information from.

Based on observations, interviews, staff training, and policy review, the facility failed to maintain a sanitary kitchen and failed to ensure food and liquids were stored in accordance with professional standards for food safety. This had the potential to affect all 142 residents residing in the facility and receiving food from the facility's main kitchen. Findings include: 1. Observations of the kitchen on 10/23/24 at 11:30 A.M. revealed wet and dry food debris that covered the floor of the entire kitchen. The garbage receptacle had a lid that split in the middle to allow trash to enter the can, the lid had a heavy layer of dry food debris covering the lid. The reach in refrigerator had dried food and liquid debris on the shelving. The dispensing spouts for the coffee maker had caked on dry liquid. A five-gallon bucket, which was located on the dirty side of the kitchen near the dishwasher, had broken porcelain plates and other miscellaneous items in it and it was filled with fruit flies. The observations of the kitchen were verified with Dietary Director (DD) #201. DD #201 then directed kitchen staff to start cleaning the floor. 2. Observations of the kitchen refrigerator on 10/23/24 at 11:50 A.M. with Dietary Aide (DA) #202 revealed an undated container with a small number of strawberries and grapes located at the back of the refrigerator. Interview on 10/23/24 at 11:50 A.M. with DA #202, revealed the container of strawberries and grapes were from last week and outwardly questioned why no one took it out of the refrigerator. 3. Observations of the kitchen refrigerator on 10/23/24 at 11:50 A.M. revealed eight undated containers of tomatoes and cucumbers. There were also two small individual serving sized milk containers that were opened and a half gallon of apple cider undated. The observations were verified by the Dietary Director (DD) #201. Interview on 10/23/24 at 11:50 A.M. with Dietary Aide (DA) #202 and DA #203 revealed the two small milk containers and the apple cider was from the staff. They stated the staff kept placing their personal items in the refrigerator. Review of the staff training dated 10/16/24 revealed [NAME] #200, DA #202 and DA #203 received education including kitchen sanitation and proper food storage. The trainings revealed the staff had either passed their orientation or demonstrated competency. Review of the facility policy titled, General Storage Guidelines, undated, indicated staff should label ready-to-eat foods prepped in-house that are held for more than 24-hours. Staff must label the name of the food and date by which it should be eaten or discarded. The policy also indicated that staff were to keep storage areas clean and dry, and they were to keep clean floors, walls and shelving in coolers, freezers, and dry-storage areas. This deficiency represents non-compliance investigated under Complaint Number OH00158730 and OH00157687.

Based on observations, interview, review of facility menu and review of staff training, the facility failed to follow menus in regard to portion sizes and recipes in regard to food preparation. This affected 29 (#78, #80, #81, #82, #83, #86, #87, #88, #89, #91, #93, #96, #100, #101, #103, #104 #107, #108, #112, #113, #114, #115, #116, #118, #122, #123, #124, #125, and Resident #126) of 49 residents residing on the east wing of the third floor. Findings include: Review of the menu for the current week revealed lunch on 10/23/24 was chicken dumpling soup, country fried chicken with gravy, roasted potatoes and carrots, pudding, and milk. The portion size of the chicken dumpling soup indicated an eight ounce serving and to use an orange-colored scoop. Observations of meal service on the third floor servery on 10/23/24 at 12:15 P.M. revealed staff were plating country fried steak without the gravy. During the observation Dietary Director (DD) #201 asked the staff why are you not putting gravy on the steak? Dietary Aide (DA) #202 stated the gravy is not on the meal ticket so I wasn't sure if I should put it on the steak. DD #201 stated you guys are killing me! DA #202 then stated, I don't have anything to serve the gravy with. DD #201 then directed DA #202 to use the scoop with the holes it, it should be able to keep enough gravy to cover the steak. DA #202 followed the direction provided; however, the gravy, which was watery (like an au jus), ran through the holes and did not cover the fried steak. DA #202 and DD #201 verified using the scoop with holes was not effective. Continued observations at approximately 12:17 P.M. revealed DA #203 ladling soup into small bowels using a green scoop which provided 4.5 ounces. Most of the bowels were observed to have mainly broth and little to no chicken, dumplings or vegetables. When questioned, DA #203 said I am using the correct scoop, if I fill the bowl with more chicken, dumplings and vegetables, we will run out of soup quickly. DD #201 verified the wrong scoop size was being used to portion the soup for the meal. Review of the recipe for the brown gravy revealed staff were to brown flour into shortening, add water or stock gradually, stirring constantly with a wire whip: cook until smooth and thickened. Interview on 10/23/24 at 2:14 P.M., [NAME] #200 revealed no flour was available so corn starch was used to thicken the gravy. [NAME] #200 stated I can't make it the right way if I don't have the stuff. Review of staff training dated 10/16/24 revealed [NAME] #200, DA#202 and DA #203 received education including kitchen sanitation, proper food storage, tray prep/meal prep, and proper food temperature maintenance and serving. Review of the facility census dated 10/23/24 revealed Residents #78, #80, #81, #82, #83, #86, #87, #88, #89, #91, #93, #96, #100, #101, #103, #104 #107, #108, #112, #113, #114, #115, #116, #118, #122, #123, #124, #125, and Resident #126) resided on the east wing of the third floor. This deficiency represents non-compliance investigated under Complaint Number OH00158730 and OH00157687.

Based on observations, resident interviews, staff interviews, review of facility menus, review of staff trainings, and review of policies and procedures, the facility failed to maintain appropriate and appetizing food temperatures. This had the potential to affect 29 (Resident #78, #80, #81, #82, #83, #86, #87, #88, #89, #91, #93, #96, #100, #101, #103, #104 #107, #108, #112, #113, #114, #115, #116, #118, #122, #123, #124, #125, and Resident #126) of 49 residents residing on the east wing of the third floor. Findings include: Interview on 10/23/24 at 8:37 A.M. with Resident #74 revealed foods that were supposed by hot were served warm. Interview on 10/23/24 at 8:53 A.M. with Resident #89 revealed the food was not hot. Observations of food preparation in the third floor servery on 10/23/24 at 12:22 P.M. revealed country fried steak and roasted potatoes with carrots being plated for meal delivery. After the foods were placed on a plate, a cover was placed on the plate and the plate placed on tray. Interview with Dietary Aide (DA) #202, at the time of the observation, revealed the facility stopped placing the plated meals on heating pallets. A test tray was requested. The test tray arrived onto the third floor east unit at 12:28 P.M. and was sampled at 12:39 P.M. with Wound Nurse #204. The country fried steak was salty, lukewarm and dry to taste and the potatoes and carrots were cool to taste. The temperature of the steak was 98 degrees Fahrenheit (F), and the carrots and potatoes were 78 degrees F. At the time of the test tray, Wound Nurse #204 confirmed the above findings. Interview on 10/23/24 at 1:00 P.M., with Dietary Director (DD) #201 revealed he had been working at the facility for approximately eight months. During those eight months DD #201 terminated half of the kitchen staff due to work performance. DD #201 stated he had been hiring and training staff on all aspects of kitchen procedures including storing and prepping food and infection control practices. DD #201 further revealed the kitchen staff were not conducting a tray line that was effective in keeping food warm. New procedures included taking the food to the serveries on each floor to plate, and once plated the food was covered a lid. DD #201 confirmed since the serving procedures changed, staff no longer used warming pallets. Review of staff training dated 10/16/24 revealed [NAME] #200, DA #202 and DA #203 received education including tray prep/meal prep, proper food temperature maintenance and serving. The trainings revealed the staff had either passed their orientation or demonstrated competency. Review of the facility's undated policy Guidelines for Holding Food, revealed food should be held at 135 degrees F or higher. Review of the facility's undated policy Serving Food Safely, revealed staff should follow the guidelines to maintain food at a safe temperature of 140 degrees F or above. It also indicated to remember the temperature rules to keep food hot (140 degrees F or above) with warming trays. Review of the facility census dated 10/23/24 revealed Residents #78, #80, #81, #82, #83, #86, #87, #88, #89, #91, #93, #96, #100, #101, #103, #104 #107, #108, #112, #113, #114, #115, #116, #118, #122, #123, #124, #125, and Resident #126) resided on the east wing of the third floor. This deficiency represents non-compliance investigated under Complaint Number OH00158730 and OH00157687.

Based on record review and interview, the facility failed to ensure physician's orders were followed timely to change the resident's suprapubic catheter (a catheter that drains urine from the bladder through a small incision in the abdomen). This affected one (Resident #64) of three residents reviewed for urinary catheters. The facility census was 144. Findings include: Review of the medical record for Resident #64 revealed an admitted [DATE] with diagnoses including multiple sclerosis (a potentially disabling disease of the brain and spinal cord) and neuromuscular dysfunction of the bladder (a condition where the muscles in the bladder wall do not contract and relax properly causing problems with urination). Review of the physician's orders for Resident #64 revealed she had an order dated 03/01/24 to change the suprapubic catheter on evening shift every 30 days and as needed for blockage related to urinary retention. This order was discontinued on 06/11/24. Resident #64 also had an order dated 07/12/24 to change the suprapubic catheter on the evening shift every 30 days and as needed for blockage related to urinary retention. Review of the Treatment Administration Record (TAR) for Resident #64 from 05/01/24 through 07/31/24 revealed staff had changed Resident #64's catheter on 05/30/24 and 07/12/24. Interview on 09/03/24 at 9:54 A.M. with Licensed Practical Nurse (LPN) #200 verified she had changed Resident #64's catheter order on 06/11/24. She stated she spoke to the resident who wanted her suprapubic catheter order changed so that dayshift staff performed this as she did not want to be awaken at night and also because LPN #200 was on dayshift. She stated Resident #64 told her that staff changed her catheter on 06/10/24 so LPN #200 set the next catheter change for 07/12/24. She verified there was no documentation to verify Resident #64 had her catheter changed on 06/10/24 or that the physician was updated. Interview on 09/03/24 at 10:00 A.M. with Resident #64 revealed she did not ask to have her catheter change to be moved to dayshift. She stated the staff were still changing her catheter on the evening shift. She stated there were plenty of times the staff had not changed her catheter as ordered. Resident #64 stated her urologist wanted her suprapubic catheter changed every 30 days or more often as needed. This deficiency represents non-compliance investigated under Complaint Number OH00155948.

Based on record review and interview, the facility failed to timely report potential mistreatment or abuse to the State Agency identified for Resident #92. This affected one (Resident #92) of three residents reviewed for abuse. The facility census was 145. Findings include: Review of the medical record for Resident #92 revealed an admitted [DATE] with diagnoses including hypertension, anxiety and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #92 had intact cognition. She had adequate hearing, clear speech, was able to understand others and make herself understood. Resident #92 had no behaviors and was incontinent of bowel and bladder. She required substantial to moderate assist with toileting hygiene. Review of the progress note dated 02/22/24 at 10:37 A.M. by Licensed Social Worker (LSW) #206 revealed Resident #92's daughter called stating she had concerns with something that happened during her mother's care. A family meeting was scheduled for 02/27/24 at 12:30 P.M. This was later changed to 02/27/24 at 10:00 A.M. Review of the facility Self-Reported Investigation (SRI) #244615 dated 02/27/24 revealed the facility was investigating the potential for neglect and mistreatment. Findings were as follows: -Statement from the Director of Nursing (DON) stated on 02/22/24 she was updated about a care concern with Resident #92. The DON spoke to Resident #92 who stated she did not like the way the State tested Nurse Aide (STNA) provided perineal care (cleaning of the perineal area after toileting). Resident #92 was unsure of what day this had happened but stated it was three days prior. She did not know the name of the STNA but provided a physical description of her. Resident #92 stated to the DON she had asked the STNA why she was cleaning her a certain way and the STNA stated that because she wore an incontinent brief and was incontinent, that urine would get up there (meaning the vagina). The STNA stated to the resident that she needed to open the folds in the perineal area to clean her properly. Resident #92 asked her to stop the care and the STNA complied. The DON discovered it was STNA #203 that had taken care of Resident #92. There was no evidence an SRI was filed on this day. -STNA #203's statement dated 02/23/24 revealed she had provided care for Resident #92. She stated during care the resident had stated ouch and told the aide that she did not have to do that during care. STNA #203 stated she explained to Resident #92 that she needed to be washed, rinsed and dried because she had been sitting in urine. Resident #92 stated to STNA #203 that she didn't need to put her finger there. STNA #203 stated to the resident that there was a proper way of being cleaned and you could not just take the wash cloth over the perineal area and call it clean. She denied placing her finger in Resident #92's vagina. -Administrator's statement dated 02/27/24 revealed he had attended a family care conference for Resident #92 as they had concerns with the care being provided. Resident #92's daughter asked if the police were updated and he stated that they had not because Resident #92 said she did not feel it was abuse, but rather a care issue. Resident #92's daughter stated she felt it was abuse as the STNA had put her fingers into her mother's vagina without any use of wipes or Vaseline. The Administrator stated during his interview with STNA #203 she had stated she was using a washcloth and actually had asked Resident #92 on her preference to wipes or a washcloth. The Administrator stated STNA #203 was on administrative leave pending the outcome of his investigation. -Licensed Practical Nurse (LPN) #202 statement dated 02/27/24 stated an STNA reported to her that Resident #92 wanted to speak with her. She talked to the resident with the resident's daughter in the room. Resident #92 stated she did not like the way one of the STNA's cleaned her up and she did not wish for her to take care of her any longer. LPN #202 assured her that the STNA would not be placed on her assignment. LPN #202 stated the resident and family were in agreement and were satisfied. Interview on 02/27/24 at 9:15 A.M. with Resident #92 revealed she felt she had never been abused while at the facility. She stated she felt STNA #203 had taken liberties during care and that herself and her daughters were having a care conference with the facility regarding the issue. Resident #92 stated she did not tell staff for a couple of days about what had happened and then decided to speak to the nursing manager on 02/21/24. She stated on 02/21/24 she spoke to LPN #202 related to the care provided by STNA #203. She stated she told her that during incontinence care, STNA #203 put her finger into her vagina while cleaning her. STNA #203 had told her she had bowel there and she wanted to clean her properly. When this surveyor asked her if she felt the STNA did not know how to properly perform perineal care or if she felt it was sexual abuse, Resident #92 stated she never thought about it being sexual abuse. Resident #92 felt that STNA #203 did not know how to properly clean residents. Interview on 02/27/24 at 11:07 A.M. with LPN #202 revealed she had spoken to Resident #92 on 02/21/24 about care performed by an STNA. LPN #202 stated Resident #92 had stated to her that an aide (she did not know which STNA it was or her name) was attempting to clean her and perform perineal care and while doing so had put her finger into her vagina. Resident #92 had stated to LPN #202 she didn't think it was done purposely but did not like how she was cleaning her. LPN #202 stated she did not update the DON until 02/22/24 on this concern. Interview on 02/27/24 at 11:20 P.M. with the DON revealed she had spoken to Resident #92 on 02/22/24 and she felt it was more of a care concern because the resident did not like the way the STNA had cleaned her up. The DON stated she had been interviewing staff and residents related to care and abuse since 02/22/24 and ensured STNA #203 was not on the schedule. Although the DON was investigating the incident since 02/22/24, there was no evidence a SRI was submitted to the State Agency untin 02/27/24. Interview on 02/27/24 at 11:20 A.M. with the Administrator revealed he did not report the incident with Resident #92 to the police or the State Agency as Resident #92 did not state it was abuse. He believed it was more of a care concern with STNA #203 not performing appropriate perineal care. The Administrator stated during the care conference held with the resident, family and other staff members earlier in the day, Resident #92's daughter stated she felt it was abuse and he was going to file an SRI with the State Agency and continue the investigation. Review of facility policy titled Abuse, Neglect and Exploitation, revised 03/07/18 revealed the facility response would be to complete a full body assessment of the resident, provide medical treatment if necessary, initiate an investigation immediately, notify the attending physician and resident's family and the medical director, obtain statements, place the accused associate on leave and contact the State Agency and local Ombudsman to report the alleged abuse. This deficiency represents non-compliance investigated under Complaint Number OH00151374.

Based on observation, interview, and record review the facility failed to provide palatable meals and failed to ensure food was served at adequate temperatures. This had the potential to affect all residents residing in the facility. The facility census was 151. Findings include: Interviews on 12/13/23 from 9:18 A.M. to 9:55 A.M. with Resident #128 and Resident #14 revealed their meals were cold at times. Interview on 12/13/23 at 3:11 P.M. with Resident #141 revealed his meals were almost always cold, including his soups and coffee. Interview 12/13/23 at 3:16 P.M. with State tested Nursing Assistants (STNAs) #208 and #210 revealed they were aware of multiple concerns related to cold foods. Interview on 12/13/23 at 3:20 P.M. with Resident #109 revealed his food was often cold. Resident #109 stated his family often provided him with food, and he had a microwave in his room to heat the food his family brought. Resident #109 stated, If it wasn't for my family, I would starve. Observation of meal service on 12/13/23 beginning at 4:45 P.M. revealed a pan of cut up chicken that was in chicken broth, a pan of cooked hamburgers that appeared to be old and dry, and a pan of golf ball sized dinner rolls that appeared to be dry and hard. Interview with Supervisor of Dining Services (SDS) #212 revealed meal plating usually began about 4:30 P.M. and she stated she had already obtained the temperatures of the food. Observation revealed a clipboard with no recorded temperature for the chicken or hamburgers, a temperature of 195 degrees Fahrenheit (F) for the soup, and the salad temperature of 35 degrees F. SDS #212 stated she had not written down the temperatures of the chicken; however, it was 183 degrees F, and she had not taken the temperature of the hamburgers or the pureed items. SDS #212 stated she was aware of concerns related to food temperatures and taste. A test tray was requested at 5:33 P.M. and was plated at 6:08 P.M., test tray consisted of a hamburger with a piece of unmelted cheese, French fries, and a bowl of soup. Test tray arrived to the floor at 6:12 P.M. and was received at 6:28 P.M. after the last resident tray was served. The temperature of the cheeseburger was 95 degrees F, French fries were 80 degrees F, and soup was 97 degrees F. Temperatures were verified by STNA #211. The test tray food was cold and lacking taste. Review of Resident Council Minutes for September and October 2023 revealed concerns related to cold food. This deficiency represents non-compliance investigated under Master Complaint Number OH00148622.

Based on observation, record review, and interview the facility failed to ensure timely meal service. This had the potential to affect all residents residing in the facility. The facility census was 151. Findings include: Review of the mealtime schedule revealed breakfast was served from 7:30 A.M. to 9:00 A.M., lunch was served from 12:00 P.M. to 1:00 P.M., and dinner was served from 5:00 P.M. to 6:30 P.M. Interviews on 12/13/23 from 9:18 A.M. to 9:55 A.M. with Resident #128 and Resident #14 revealed their meals were often late. Interview on 12/13/23 at 3:11 P.M. with Resident #141 revealed his meals were almost never on time. Interview on 12/13/23 at 3:16 P.M. with State tested Nursing Assistants (STNAs) #208 and #210 stated they worked from 7:00 A.M. to 7:00 P.M., and meals were often late. STNAs #208 and #210 stated there were occasions when the dinner meals were not served until between 6:30 P.M. and 6:45 P.M. Interview on 12/13/23 at 3:20 P.M. with Resident #109 revealed his meals were always late. At time of interview STNA #211 entered Resident #109's room to take his dinner order and stated the meals were always late. STNA #211 stated the dinner meals were served between 6:30 P.M. and 7:00 P.M. at times. Interview on 12/13/23 at 4:45 P.M. with Supervisor of Dining Services (SDS) #212 revealed meal plating usually began about 4:30 P.M.; however, the meal was behind today due to the lettuce she was going to use spoiled, and she had to cut new lettuce. SDS #212 stated meals were late on occasion. Dishwasher #213 stated on 12/12/23, he and SDS #212 were the only staff members present to prepare the meals. Observation on 12/13/23 at 6:42 P.M. revealed dinner trays were continuing to be served on the first floor. This deficiency represents non-compliance investigated under Master Complaint Number OH00148622.

Based on interview and self-reported incident report (SRI) review the facility failed to ensure residents were free from verbal abuse. This affected one resident (Resident #10) of one resident reviewed for abuse. The facility census was 145. Findings Include: Resident #10 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of SRI # 7, dated 07/24/22, revealed State tested Nurse Aide (STNA) #30 told Licensed Practical Nurse (LPN) #23 she overheard STNA #31 tell Resident #10 If I could strangle you with this call light and get away with it I would. STNA #31 left the room and Resident #10 asked STNA #30 to stay with her as she was scared. LPN #23 reported this to nursing supervisor Registered Nurse (RN) #10 who immediately placed STNA #31 on suspension pending the outcome of an investigation; STNA #31 was immediately escorted out of the building. RN #10 interviewed Resident #10 on 07/24/22. Resident #10 stated that STNA #30 was always mean to me and said STNA #3 stated she would strangle me with the call light and get away with it. The facility's investigation substantiated the allegation. STNA #31 never returned to the facility and was terminated on 08/03/22; STNA #31 was reported to the nurse aide registry for abuse. Interview with the Administrator on 10/19/22 at 11:10 A.M. revealed STNA #31 had only worked for the facility for a few weeks before she was terminated. They reported STNA #31 to the Nurse Aid Registry for abuse. This was an incidental finding during the investigation of Complaint Number OH 424.

Based on record review and interview the facility failed to assess and treat a pressure ulcer in a timely manner resulting actual harm for one resident (Resident #1) as evidenced by a Stage IV pressure ulcer (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole [rolled edges], undermining and/or tunneling often occur. Depth varies by anatomical location.) with infection requiring antibiotics. This affected one (Resident #1) of three residents reviewed for pressure ulcers. The census was 129. Findings Include: Review of the medical record for Resident #1 revealed an initial admitted [DATE] and readmitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission nursing assessment dated [DATE] identified Resident #1 was admitted with no areas of skin impairment. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 07/20/21, revealed Resident #1 had impaired cognition and required extensive assistance of one staff for bed mobility, transfers, ambulation. The assessment indicated Resident #1 had no pressure ulcers. Review of the Braden Scale pressure ulcer risk assessments dated 03/19/21, 06/08/21, 06/29/21 and 08/11/21 revealed Resident #1 was at mild risk for the development of pressure ulcers. Review of the nurse's notes dated 10/05/21 at 2:33 P.M. revealed staff had observed a pressure ulcer on Resident #1's coccyx measuring 9.0 centimeters (cm) by 5.0 cm by 1.0 cm. The Unit Manager and family were aware. Review of the nurse's notes dated 10/05/21 at 3:05 P.M. revealed Certified Nurse Practitioner (CNP) #61 wrote orders for wound treatment and [MEDICATION(S)] (antibiotic) 160 milligrams (mg) twice a day for 14 days for wound infection. Review of the nurse's notes dated 10/05/21 at 3:26 P.M., addendum, revealed pressure area noted to Resident #1's coccyx, old dressing removed, drainage and odor noted. Treatment orders obtained; new dressing/treatment applied. The physician, Director of Nursing (DON) notified. Turn and reposition every two hours, therapy referral was sent for cushion and positioning in current wheelchair. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse's notes dated 10/06/21 at 1:47 P.M. revealed CNP # 61 wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's plans of care revealed a plan of care was created related to an infection of the sacral wound dated 10/08/21. Review of the nurse's notes dated 10/11/21 at 2:48 P.M. revealed the Wound Physician (WP) was in to complete an initial assessment of the sacral wound. The sacral wound was debrided (excision of damaged/dead tissue from the wound). The WP determined the wound stage to be a Stage IV. A new wound order was written to cleanse the sacral wound with normal saline, pat dry, pack wound with ¼ strength Dakins solution, and cover with a foam dressing twice a day and as needed. Review of the WP's wound note dated 10/11/21 revealed directions treat the wound with sodium hypochlorite solution, Dakins twice a day for 30 days, apply sterile gauze sponge. The sacral wound measured 5.5 cm by 10.5 cm with moderate drainage, the surface area measured 57.75 cm with moderate drainage with 100 percent thick adherent devitalized necrotic tissue. Review of the WP's wound note dated 10/18/21 revealed Resident #1's sacral wound measured 6 cm by 11.5 cm by 2.3 cm and had moderate drainage. Interview on 11/09/21 at 11:01 A.M. with Unit Manager (UM) #60 revealed Resident #1's wound was not brought to her attention until 10/05/21. UM #60 verified there was no documentation on the treatment administration record (TAR) to indicate wound care had been completed from 10/01/21 through 10/05/21. UM #60 also stated that the Braden scale assessments for risk of pressure ulcers which were previously completed were not accurate, Resident #1 was at high risk for pressure ulcers, not mild risk. Interview on 11/09/21 at 1:30 P.M. with Registered Nurse (RN) #59 revealed she entered Resident #1's room on 10/05/21 with the daughter and a state tested nurse aide (STNA) and observed the wound. At that time there was a dressing over the wound that was soiled and there was an odor and a large amount of drainage. RN #59 stated she called CNP #61, the DON, wound team, and UM #60 and no one was aware of the wound on Resident #1's sacrum. RN #59 stated she worked with Resident #1 on 10/04/21 and no one notified her of the wound. Interview on 11/09/21 at 2:35 P.M. with the Administrator revealed Resident #1's wound was first observed on 10/02/21 by STNA #63, and the daughter observed the wound on 10/03/21. A dressing was applied sometime between 10/02/21 and 10/05/21 but they were unable to confirm who applied the dressing due to lack of documentation and reporting. The Administrator stated STNA #66 reported the wound to LPN #65 on 10/01/21, however, the physician, DON, UM #60 or family were not notified. The family was made aware of the wound on 10/03/21. Interview on 11/09/21 at 2:53 P.M. with LPN #65 revealed she did not remember STNA #66 telling her about Resident #1's wound on the sacrum. Interview on 11/10/21 at 11:18 A.M. with UM #60 revealed Resident #1's wound was observed on 10/01/21 by STNA #66 and STNA #66 reported the wound to LPN #65. UM #60 stated no wound treatments were started until 10/05/21, after it was observed by other staff and the daughter. Resident #1 was ordered [MEDICATION(S)] 800-160 mg twice a day from 10/05/21 to 10/08/21 and then [MEDICATION(S)] (antibiotic) 500 milligrams (mg) every 12 hours for 10 days for wound infection. Interview on 11/10/21 at 5:15 P.M. with STNA #66 revealed she was completing a bed bath for Resident #1 when her and another aide observed a wound on Resident #1's sacrum the size of a dime. STNA #66 stated she told LPN #65 and was directed to apply lotion on the wound until LPN #65 could assess the wound. STNA #66 stated she observed the wound again on 10/05/21 and the wound was the size of her fist, the wound dressing was dirty and soiled. Review of the TAR for October revealed no documentation identifying wound care was completed for Resident #1 from 10/01/21 to 10/05/21. This deficiency substantiates Complaint Number OH 964.

Based on observation, record review, review of a facility Self-Reported Incident (SRI), review of a facility investigation, review of an employee personnel record, facility policy and procedure review and interview the facility failed to ensure Resident #59 was free from physical abuse by a facility staff member. Actual Harm occurred on 08/12/21 when Resident #59, who was cognitively impaired and required extensive assistance/total dependence from two staff for bed mobility, toileting, transfers, dressing and bathing, sustained two fractures of the right extremity during personal care provided by State tested Nursing Assistant (STNA) #300. The resident required hospital intervention and was assessed to have pain as a result of the incident. This affected one Resident (#59) of four residents reviewed for abuse, neglect and misappropriation. Findings Include: Review of the medical record for Resident #59 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/13/21, a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/19/21, a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/16/21 revealed the resident had impaired cognition. The resident was dependent on two staff assistance for bed mobility, transfers and toileting, was dependent on one staff assistance for bathing, required extensive two staff assistance for dressing, required extensive one staff assistance for personal hygiene and supervision and setup assistance for eating. The assessment indicated the resident was always incontinent of bowel and bladder. Review of the plan of care, dated 07/20/21 revealed Resident #59 rejected or resisted care, had a communication deficit with delayed response at times, had a self-care deficit and required extensive assistance with bathing, hygiene, dressing, and grooming, was impatient at times for personal care while staff were assisting others, was incontinent. The care plan also noted the resident had a fracture with bruising of the right arm. Interventions included to remind resident of the potential risks with care refusals and coax but DO NOT FORCE compliance, ask simple yes/no questions and allow adequate time to respond, request clarification as needed, provide assistance with self-care as needed and provide verbal reminders while resident participates, maintain a consistent routine, provide incontinence care as needed, provide occupational therapy when appropriate and provide medications and treatments as ordered. Review of a facility Self-Reported Incident (SRI), dated 08/13/21 revealed the facility investigated an injury of unknown source which involved Resident #59. On 08/13/21 at 6:55 A.M., Resident #59 presented with a large bruise on the right forearm noticed by State tested Nursing Assistant (STNA) #302 while assisting the resident with dressing. STNA #302 question the resident what happened, and the resident looked away and would not answer the STNA. STNA #302 reported the bruise to Registered Nurse (RN) #303 who assessed and confirmed the bruise. RN #303 asked the resident what happened and again the resident looked downward and did not respond. RN #304 and the Director of Nursing (DON) examined and interviewed Resident #59. They determined the bruising was suspicious for fingermarks and a handprint. When questioned what happened, Resident #59 described a tall man who worked at the facility frequently harmed her during second shift the day prior. The resident demonstrated to RN #304 and the DON how the tall man grabbed the arm and shook it which caused pain. During the investigation, it was determined STNA #300 fit the description of Resident #59's alleged perpetrator, and when shown a picture of the aide, the resident positively identified STNA #300 as the employee who harmed her. The physician examined the resident and ordered x-rays of the right arm which revealed two fractures, an acute nondisplaced fracture of the distal humerus, and a nondisplaced fracture of the radial head. The physician also stated the bruising was suspicious for a hand mark and ordered for Resident #59 to receive evaluation and treatment at the local hospital emergency room . Review of a Resident Incident Report, dated 08/13/21 revealed assessment of Resident #59's right arm bruising was in a concerning pattern, and each area of bruising was dark purple in color. On 08/13/21, STNA #300 was interviewed by the Executive Director and RN #305. STNA #300 verified providing care for Resident #59 on 08/11/21 and on 08/12/21 for second shift and indicated the resident had complained of more pain than usual, had requested to lay down at the start of the shift, and had been more difficult to care for especially in the previous three days due to increased level of pain. STNA #300 denied remembering any injury or bruising. Based on the facility investigation, the allegation of physical abuse was substantiated. STNA #300 was terminated. However, law enforcement was not notified. Review of written statement from Licensed Practical Nurse (LPN) #306, dated 08/13/21 revealed the nurse received report at the change of shift of bruising to Resident #59's right arm which was observed by the STNA on night shift that morning. Upon assessment, the bruising was purple and brown discoloration and widespread on the right forearm. When Resident #59 was questioned what happened, the response was someone grabbed her arm and caused the bruising. Review of written statement from RN #304, dated 08/13/21 revealed it was reported Resident #59 had bruising on the right forearm. Upon assessment, there was a large dark purple discoloration with separate round discolorations above it which appeared as a hand with fingerprints. When Resident #59 was questioned what happened, the response was a tall man who worked there frequently grabbed her arm and the resident made jerking motions to demonstrate how the arm was handled. Resident #59 was provided a picture of STNA #300 and positively identified the STNA as the alleged perpetrator who harmed the resident. Review of written statement from LPN #307, dated 08/14/21 revealed on 08/12/21 while working during the day shift, there was no observation of discoloration to Resident #59's right arm. Review of an undated written statement from STNA #302 revealed STNA #302 worked on 08/12/21 third shift and was assigned to Resident #59 who made no indication anything was wrong, and stated nothing was noticed until around 6:30 A.M. to 6:40 A.M., on 08/13/21, when assisting the resident to get dressed by removing a long-sleeved nightgown. At that time, bruising was observed on the right forearm. When Resident #59 was questioned, there was no response (from the resident) and the resident looked down and away. Review of written statement from STNA #300, dated 08/13/21 revealed on 08/12/21 STNA #300 provided care for Resident #59, assisted the resident to lay down and provided incontinence care at the beginning of the shift, and later in the evening brought the resident the dinner meal. At around 8:00 P.M., Resident #59 requested assistance using the call light, STNA #300 provided incontinence care and stated it was the final time the STNA entered the room. STNA #300 made an addendum to the statement and added while assisting Resident #59 to bed STNA #300 removed the resident's blouse, applied lotion to the entire upper torso and put on Resident #59's nightgown. Review of written statement from Certified Nurse Practitioner (CNP) #308, dated 08/13/21 revealed after examination of Resident #59's right forearm, there were four bruised areas to the top of the right forearm and a fifth bruised area to the underside of the right arm. CNP #308 documented the marks could be matched to what appeared to be a handprint with [CONDITION(S)] to the center area where the palm was. Resident #59 had extreme tenderness to the area with any manipulation or sensation and confirmed after radiology testing, there was an acute non-displaced fracture of the distal humerus and the radial head of the right extremity. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident also had orders for Acetaminophen 650 milligrams (mg) as needed every four hours for mild pain; Acetaminophen 650 mg twice daily for general [CONDITION(S)], [MEDICATION(S)] 5 mg-325 mg as needed every six hours for moderate pain and an order to monitor discolorations to right elbow and upper arm until healed twice daily. On 08/24/21 the resident was permitted to use the right arm as tolerated and begin passive range of motion. On 08/30/21 the resident's [MEDICATION(S)] 5 mg-325 mg was changed to one or two tablets as needed every six hours for pain. Review of the radiology test results, dated 08/13/21 revealed the right shoulder had no significant findings; the right humerus had an acute nondisplaced fracture of the distal humerus; and the right forearm had a non-displaced fracture of the radial head. Review of progress note, dated 08/13/21 revealed the resident's physician was notified of radiology test results and the resident was subsequently sent to the local hospital emergency room for evaluation and treatment. The resident's family was notified. Review of progress note dated 08/14/21 revealed the resident returned from the hospital with a right arm splint. Review of the employee personnel file for State tested Nursing Assistant (STNA) #300 revealed a hire date of 04/20/21. The file included two References of Previous Employment in the form of facsimile prepared by the employee and signed on 04/09/21. Both references checks were incomplete and there was no evidence in the employee file the facsimiles were sent to STNA #300's previous employers. Interview on 09/03/21 at 3:33 P.M. with Human Resources #301 verified STNA #300's reference checks were not completed. Additional review of employee file for STNA #300 revealed STNA #300 was suspended during the investigation which commenced on 08/13/21. On 08/17/21, the facility terminated STNA #300 for deliberate and willful misconduct, and for reported, suspected abuse. On 09/03/21 at 10:53 A.M. during an interview with Resident #59, the resident was asked if she remembered the incident on 08/12/21. The resident described the incident using verbalization of short sentences and demonstration. Resident #59 showed the surveyor how the male aide grabbed her right forearm with the aide's hand wrapped around the resident's arm while the aide was assisting the resident with dressing and other personal care. The resident revealed the aide did not let go and held onto the arm with enough force it caused increased pain. The resident revealed the aide made forceful movements of her arm during the personal care assistance. Observation of Resident #59's right forearm revealed medium-sized bruising, red and yellow in color, on the top center of the forearm. Observation of Resident #59 during interview and demonstration of the incident revealed the resident expressed facial distress and anxiousness while discussing the incident. On 09/03/21 at 1:12 P.M. interview with Director of Nursing (DON) confirmed on 08/13/21 Resident #59 identified STNA #300 as the male aide that caused her harm and had provided care for Resident #59 alone without other staff assistance. The DON indicated on 08/13/12, a large solid bruise with four extensions were observed on the top of the resident's right forearm and a thumb bruise was on the underside of the forearm. DON verified Resident #59 sustained two right extremity fractures as a result of the care provided by STNA #300 and verified the facility substantiated an allegation of physical abuse related to the incident. The DON also verified the resident experienced physical pain as a result of the incident. On 09/03/21 at 1:37 P.M. interview with STNA #313 confirmed Resident #59 has experienced increased pain since the injury caused by the incident on 08/12/21. On 09/03/21 at 1:57 P.M. interview with LPN #307 verified Resident #59 had experienced more pain than usual after the incident on 08/12/21 and required additional medication for pain management. On 09/03/21 at 3:53 P.M. interview with the Executive Director (ED) confirmed the facility substantiated the allegation of physical abuse after the facility investigation determined Resident #59 sustained injuries during care provided by STNA #300 on 08/12/21. The ED verified STNA #300 was terminated because of the findings, and indicated at the time of termination, STNA #300 did not deny those findings. Review of facility policy titled Abuse and Neglect, reviewed/revised on 01/06/17 revealed each resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included but was not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to community staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals and when abuse, neglect or exploitation was suspected, the Licensed Nurse should initiate an investigation immediately. This deficiency substantiates Control Number OH 141.