Every finding on record at Norwood Towers Post-Acute

Based on record review, observation, resident and staff interviews, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure residents with chronic wounds were placed in Enhanced Barrier Precautions (EBP). This affected four (Resident #15, #36, #76, and #89) of six residents reviewed for wound care. The facility census was 107.Findings include:1. Review of the medical record for Resident #89 revealed an admission date of 08/22/24. Diagnoses included complete traumatic amputation at level between left hip and knee and type II diabetes mellitus. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #89 was cognitively intact.Review of the Wound Physician's progress note dated 07/28/26 revealed Resident #89 had diabetic full thickness wounds to the right lateral ankle and right medial foot.Resident #89's medical record did not have active physician orders for EBP related to the two diabetic ulcers. Observation on 08/03/26 at 10:53 A.M. revealed Wound Nurse Practitioner # and Nurse # completed wound treatments to Resident #89's diabetic ulcers including debridement. Neither staff wore isolation gowns. There was no sign on the door indicating Resident #89 had EBP in place.During an interview on 08/03/26 at 11:15 A.M., Resident #89 stated he had diabetic wounds for several months and staff never wore gowns while providing wound care or other high-contact care activities.During an interview on 08/03/26 at 1:40 P.M., the Director of Nursing (DON) confirmed Resident #89 had a chronic diabetic ulcers and did not have orders for EBP before 08/03/26. 2. Review of the medical record for Resident #15 revealed an admission date of 03/30/21. Diagnoses included type II diabetes mellitus.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident had severely impaired cognition and had one stage IV pressure ulcer (Full thickness tissue lost with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed).Resident #15's medical record did not have active physician orders for EBP related to chronic stage IV pressure wound to the right buttock.Review of the wound care note dated 07/28/26 revealed Resident #15 had a stage IV pressure wound to the right buttock for a duration of greater than 255 days.During an interview on 08/03/26 at 1:40 P.M., the Director of Nursing (DON) confirmed Resident #15 had a chronic wound and did not implement EBP before 08/03/26. 3. Review of the medical record for Resident #36 revealed an admission date of 11/20/25. Diagnoses included cellulitis of left lower limb. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 was cognitively intact, and had two venous/arterial ulcers present.Resident #36's medical record did not have active physician orders for EBP related to chronic venous wounds.Review of the wound care note dated 07/28/26 revealed Resident #36 had a venous full thickness wound to the left superior calf for greater than 147 days duration; venous full thickness wound to the left shin for a duration of greater than 103 days; and a venous full thickness wound of the left inferior calf for a duration of greater than 40 days.During an interview on 08/03/26 at 1:40 P.M., the Director of Nursing (DON) confirmed Resident #36 had chronic wounds and did not implement EBP before 08/03/26. 4. Review of the medical record for Resident #76 revealed an admission date of 05/28/26. Diagnoses included hepatic encephalopathy. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76 had severely impaired cognition.Review of the wound note dated 07/28/26 revealed Resident #76 had a partial thickness stage II pressure wound (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.) to the left buttock for a duration of greater than 14 days.Resident #76's medical record did not have active physician orders for EBP related to the pressure ulcer on left buttock.During an interview on 08/03/26 at 1:40 P.M., the Director of Nursing (DON) confirmed Resident #76 had a pressure ulcer greater than 14 days and did not implement EBP before 08/03/26. In lieu of a policy, the facility provided QSO memo 24-08-NH dated 03/20/24 which stated EBP was used for any residents with chronic wounds including but not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers.Review of CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP is an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. This was an incidental finding discovered during the course of the complaint investigation.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of the facility's Self-Reported Incident (SRI), staff interviews, and policy review, the facility failed to the residents were free from staff-to-resident sexual abuse. This affected one (Resident #52) of nine residents reviewed for abuse. The facility census was 107.Findings include:Review of the medical record revealed Resident #52 was admitted to the facility on [DATE]. Diagnoses included post-traumatic stress disorder, alcohol dependence, generalized anxiety disorder, major depressive disorder, and chronic pain. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #52 was cognitively intact, had occasional physical and verbal behaviors, did not reject care, and did not wander. Resident #52 required supervision/touch assistance from staff with activities of daily living (ADLs).Review of the progress note dated 07/11/26 revealed Resident #53 reported to the Assistant Director of Nursing (ADON) #215 she had been receiving inappropriate text messages from a male housekeeper (Housekeeper #200) and was beginning to feel uncomfortable about it. Resident #53 denied any physical or sexual contact with the employee. The employee was immediately suspended pending investigation. Resident #52 was assessed by nurse and no injury was noted. Staff scheduled consults with the medical provider and psychiatry. Resident #52 reported she felt safe at the facility, declined filing a police report, and asked the facility to handle the situation.Review of the facilities SRI tracking number 276837 revealed an allegation that Housekeeper #200 abused Resident #52. Resident #52 reported she had been receiving inappropriate and sexually explicit text messages from Housekeeper #200. The content of the messages was confirmed to be sexually explicit and inappropriate in nature. The text messaging began on 06/28/26 and by 07/11/26, Resident #52 had become increasingly fearful, disclosing that she was afraid the employee would come to her room and cause her physical harm. This response is clinically consistent with the resident's documented diagnosis of Post-Traumatic Stress Disorder and her disclosed history of prior sexual trauma. The facility substantiated the allegation of abuse.During an interview on 08/03/26 at 9:19 A.M., the Director of Nursing (DON) stated Resident #52 showed staff a series of text messages between her and Housekeeper #200 that were inappropriate and suggestive that the staff member wanted to have sex with Resident #52. The facility immediately suspended Former Housekeeper #200 pending investigation, interviewed staff and residents, educated staff regarding abuse policy and professional staff: patient relationship boundaries. audited residents for abuse, completed weekly audits for professional staff-patient relationships, and reviewed findings in QAPI meetings.Review of the policy titled Abuse Prevention Program dated 08/2006 revealed the residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility is committed to protecting the residents from abuse by anyone, including facility staff.The deficiency was corrected on 07/24/26 after the facility implemented the following corrective actions:- On 07/11/26, ADON #215 physically assessed Resident #52 and found no signs of abuse. A psychiatric nurse practitioner consultation was initiated to ensure the resident's psychosocial needs were addressed, given her documented history of PTSD. The social worker completed a trauma-informed care assessment with the resident. The resident denied any emotional distress and verbalized that she felt safe in the facility.- On 07/11/26, the facility submitted a SRI and reported the incident to the Ohio Department of Health (ODH) and local law enforcement and began their investigation.- On 07/11/26 the facility held an ad hoc Quality Assurance Meeting to discuss the investigation and the facility's action plan.- On 07/11/26, the DON/Designee initiated a comprehensive facility-wide assessment to determine whether any other residents may have been affected by similar conduct or were potentially at risk. Resident interview questionnaires were administered to current residents to identify any additional instances of witnessed or experienced abuse, inappropriate staff communication, or boundary violations. There were no concerns identified.- On 07/11/26, the DON/Designee initiated staff interviews to gather any relevant information and to assess the broader culture of professional conduct within the facility. No additional incidents of inappropriate communication between staff and residents were identified through this review process. All interviews were completed 07/24/26.- On 07/11/26, the DON/Designee initiated education for all staff regarding maintaining professional relationships with residents and reviewing the facility's abuse policy.- On 07/11/26, the facility initiated corrective action for the DON/Designee to conduct weekly audits of five random residents ER week for four weeks from 07/17/26 to 08/11/26 to ensure residents were free from inappropriate communication or contact with staff, to ensure residents felt safe, and to ensure residents were aware of their right to report concerns without fear of retaliation. Results were to be reviewed during Quality Assurance meetings. Weekly audits completed.- On 07/15/26, the facility completed their investigation, substantiated that abuse had occurred, and Former Housekeeper #200's employment was terminated due to gross misconduct. The facility reported investigation results to ODH and appropriate authorities.- On 07/17/26, the DON/Designee initiated supplemental education to all current staff regarding the mandatory reporting of suspicious or unknown communications. Staff were educated on the following: All staff members have a professional and ethical obligation to report any suspicious, inappropriate, or unwanted communications they receive - regardless of whether the source of those communications is known or identifiable. Staff were not required to know the identity of the sender before reporting. Any text message, telephone call, image, or other communication that was sexual, threatening, harassing, or otherwise inappropriate must be reported to the Administrator or facility management immediately, regardless of whether the number is recognized or believed to be affiliated with the facility. This obligation applied equally to communications received on personal devices. Staff should never dismiss, delete, or disregard suspicious communications based on uncertainty about their origin. When in doubt, employees reported it. Preservation of communication - including screenshots and the associated phone number - was critical to any potential investigation. Management determined whether communication was related to a facility matter; it was not the responsibility of the receiving staff member to make that determination prior to reporting. The facility could not investigate what it did not know about, and delayed or absent reporting created gaps that could compromise the safety of both residents and staff. All staff were reminded that the facility's zero-tolerance policy for harassment, abuse, and exploitation extended to staff members as well as residents, and that prompt reporting of suspicious communications was expected and was a critical component of maintaining a safe environment for all individuals within the facility. Education was completed on 07/24/26. This deficiency represents noncompliance investigated under Control Number 3104842.

Based on medical record review, staff interview, and policy review, the facility failed to provide pressure ulcer wound treatments as physician ordered. This affected one (Resident #38) of six residents sampled for wound care. The facility census was 107.Findings include:Review of the medical record for Resident #38, revealed an admission date of .06/24/24. Diagnoses included paraplegia, osteomyelitis, chronic pain syndrome, non-pressure chronic ulcer of the ankle with necrosis of the muscle, peripheral vascular disease, and depression.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 was cognitively intact, had no behaviors, and occasionally rejected care.Review of the physician orders for wound care dated 07/23/26 to 07/28/26 revealed orders to cleanse areas to left heel, right heel, and right buttocks with Dakin's, apply Silvadene to the wound bed, cover with ABD pad, and wrap with Kerlix every shift for wound healing.Review of the progress notes dated 07/26/26 revealed the orders for wound treatments to Resident #38's right buttocks and right heel were not completed due to not enough supplies to perform wound care.Review of the Wound Physician note dated 07/28/26 revealed Resident #38 had a stage IV pressure wound (Full thickness tissue lost with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed.) on the right buttock, right plantar heel, and left heelDuring an interview on 08/04/26 at 10:18 A.M., the Director of Nursing (DON) verified Resident #28's treatment was not completed as physician ordered on 07/24/26 and the progress note indicated it was due to lack of supplies. The DON stated Resident #38 had stacks of supplies in her room and he had never known the facility to lack wound care supplies.Review of the policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 05/2024 revealed the physician ordered pertinent wound treatments and appropriate interventions to promote wound healing and wound prevention.This deficiency represents noncompliance investigated under Complaint Number 3123049.

Based on medical record review, staff interviews, and policy review, the facility failed to provide appropriate ileostomy care. This affected one (Resident #108) of one resident reviewed for ostomy care. The facility census was 107.Findings include:Review of the closed medical record for Resident #108 revealed an admission date of 06/03/23. Diagnoses included dementia, acquired absence of unspecified parts of the digestive tract. Resident #108 discharged to the hospital on [DATE].Review of the care plan dated 04/11/24 - revealed Resident #108 had an ileostomy and was at risk for complications. Interventions included keeping ostomy site covered, routinely empty pouch, providing privacy while providing care, and providing ostomy care as ordered.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident had severely impaired cognition, and had an ostomy appliance. Review of the medical record from 05/01/26 to 07/31/26 revealed Resident #108 had no physician orders for ileostomy care and no documentation of ostomy care provided. During an interview on 08/04/26 at 10:43 A.M., the Director of Nursing (DON) verified Resident #108 had no physician orders for ostomy device and maintenance and no documentation that ostomy care was provided. The DON stated Resident #108's physician orders for ostomy care were discontinued after hospitalization and were never started after readmission to the facility on [DATE].Review of policy titled Colostomy/Ileostomy Care dated 10/2010 revealed the facility will document the date and time ileostomy care was provided , the name and title of staff who provided care, how the resident tolerated the procedure, and any changes in skin integrity in the resident's medical record. This deficiency represents noncompliance investigated under Complaint Number 3123049.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were free of significant medication errors. This affected one (Resident #44) of three residents reviewed for medication administration. The facility census was 101 residents. Findings include: Review of the medical record for Resident #44 revealed an admission date of 11/24/15 with diagnoses including cerebral infarction, type two diabetes, and dementia. Review of the Minimum Data Set (MDS) assessment for Resident #44 dated 02/10/26 revealed the resident had severe cognitive impairment and was dependent on staff for activities of daily living (ADLs).Review of a progress note for Resident #44 dated 02/18/26 per Nurse Practitioner (NP) #368 revealed she was notified that nursing staff had administered the wrong medications to the resident on 02/17/26. Resident #44 received Clozapine 200 milligrams (mg), Depakote 250 mg, Niacin 250 mg, and Haldol mg. Staff notified the on-call provider when the incident occurred, and the provider gave orders for labs and to check the resident's vital signs every four hours. Staff reported on 02/18/26 that Resident #44 was lethargic and hard to rouse, was drooling, had an elevated heart rate, and had three episodes of emesis. NP #368 contacted poison control, and staff sent Resident #44 to the emergency department for further evaluation upon the recommendation of poison control. Review of nurse progress note for Resident #44 dated 02/18/26 revealed staff administered the wrong medication to Resident #44 on 2/17/26. On the morning of 02/18/26 Resident #44 presented as lethargic and difficult to rouse and had three episodes of vomiting and drooling. Staff notified NP#368 who gave an order to send Resident #44 to the hospital. Review of the hospital discharge paperwork for Resident #44 dated 02/18/26 revealed the resident was admitted to the hospital on [DATE] due to unintentional ingestion of medications not prescribed. She had a computed tomography (CT) scan that showed no acute intracranial abnormality. Her mental status improved back to baseline after 24 hours.Interview on 02/24/26 at 4:15 P.M. with Medication Technician (MT #272) confirmed when she was completing medication administration on the evening of 02/17/26 she pulled the medication for a resident. MT #272 stated she became distracted by another resident and when she saw Resident #44 by the medication cart she administered the medication she had pulled. MT #272 reported she then realized she had administered the wrong medication to Resident #44 and immediately notified the nurse who reported the incident to the on-call provider. Interview on 02/24/26 at 3:00 P.M. with Resident #44 confirmed facility staff gave her the wrong medication and she was sent to the hospital afterwards. Interviews on 02/24/26 at 5:10 P.M. with the Administrator and the Director of Nursing (DON) confirmed MT #272 administered the wrong medication to Resident #44 on 02/17/26 and the resident had to go to the hospital for evaluation on 02/18/26 and returned with no new orders. Review of the facility policy titled Administrating Medication revised April 2019 revealed the individual administering the medication should verify the residents identity before giving them medication. The individual administering the medication should check the label three times to verify the right resident, the right medication, the right dosage, the right time and the right method before administering the medication. The deficiency was corrected on 02/23/26 after the facility implemented the following corrective actions:-On 02/17/26 staff assessed Resident #44 and notified the on-call provider of the medication error. Immediate action was taken on 02/17/26 to ensure the safety of the resident. Staff implemented the order to check the resident's vital signs every four hours and to monitor the resident. -On 02/17/26 the DON, two Assistant Directors of Nursing (ADONs), and Regional Clinical Consultant conducted a root cause analysis of the medication error and determined the root cause of the incident was staff was distracted. The facility developed a plan of action by 02/18/26. -On 02/17/26 the DON re-educated MT #272 and reviewed expectations related to resident identification and verification prior to medication delivery.-On 02/18/26 staff sent Resident #44 to the emergency room for evaluation related to the medication error on 02/17/26. The resident returned with no new orders. -On 02/18/26 the DON began re-education of all nurses and MTs on the five rights of medication administration with specific emphasis on maintaining focus during medication passes, avoiding distractions and completing resident identification verification prior to each administration. Education of all nurses and MTs was completed on 02/18/26. -Starting on 02/18/26 the DON or Designee began completion of medication administration competencies for all nurses and MTs. Competencies included direct observation of resident identification practices, demonstration of the five rights of medication administration, proper use of medication administration records and safe response to interruptions during medication passes. Any staff unable to successfully demonstrate the competencies would receive one-on-one re-education and re-evaluation prior to resuming independent medication administration duties. Five competencies had been completed by 02/23/26 with competencies to continue until after nurse and MT had successfully completed the competency. -Starting 02/18/26 the DON or designee began conducting random medication administration audits on a minimum of five residents for four weeks and as needed thereafter with findings reviews at Quality Assurance Performance Improvement (QAPI) meetings.This deficiency represents noncompliance investigated under Complaint Number 2747068.

Based on review of the medical record, interviews, and policy review, the facility failed to implement their abuse policy when an allegation of abuse was reported. This affected two Residents (#65 and #111) of the four residents reviewed for abuse. The facility census was 108 1) Review of the medical record for Resident #111 revealed an admission date of 10/10/25 with a discharge date of 02/03/26. Diagnoses included malignant neoplasm of brain, hypertension, and metabolic encephalopathy.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #111 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. This resident was assessed to require partial assistance with eating, dependent on toileting, bathing, and dressing, and setup for transfers.Review of the progress note dated 12/30/25 at 8:00 A.M. revealed Resident #111 had facial trauma per the staff from a physical disturbance between him and Resident #65, and then they were separated immediately. Resident #111 was assessed with redness on his face and nose, and small hematoma on the right side of his head. Resident #111 was nonverbal but appeared comfortable. There were no other obvious injuries or deformities noted. X-rays of the skull, facial bones, and cervical spine were ordered. The staff will continue to monitor and notify provider of any worsening conditions.Review of the late entry progress note for dated 12/30/25 at 7:52 P.M. revealed Resident #111 received physical aggression from Resident #65 resulting in injuries. The staff intervened and separated both residents. Both residents were placed on a one-to-one observation. Resident #111 was assessed from head to toe, with injuries noted to the facial area. The responsible parties were notified and X-ray was ordered.Review of the late entry progress note for 12/31/25 at 9:05 A.M. revealed Resident #111 appeared to have been injured from an unwitnessed incident involving Resident #65. A full body assessment was done, and injuries were limited to facial bruising and hematoma on his forehead. Resident #111 was provided first-aid and care. An x-ray was obtained, which was unremarkable. Resident #111 displayed no signs of distress or pain.Review of the comprehensive skin evaluation dated 12/30/25 at 6:41 P.M. revealed Resident #111 had facial bruising, swelling, bloody nose, and a bump/knot on his head.2) Review of the medical record for Resident #65 revealed an admission date of 01/23/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, mood disorder, and peripheral vascular disease (PVD).Review of the Annual MDS assessment dated [DATE] revealed Resident #65 could not complete a BIMS because he was rarely/never understood. This resident was assessed to require supervision with eating, toileting, dressing, and transfers, and setup with bathing.Review of the progress note dated 12/30/25 at 7:00 P.M. revealed at time of incident, Certified Nursing Assistant (CNA) #12 came to the nurse's station and stated Resident #65 struck Resident #111 in the face. The staff intervened and separated both residents and placed Resident #65 on one-to-one supervision. Nurse Practitioner (NP) #90 gave orders to send Resident #65 to the hospital to be evaluated. A skin assessment was completed with no injuries noted.Review of the late entry progress note for 12/31/25 at 9:03 A.M. revealed Resident #65 struck Resident #111 in the face. Resident #65 appeared to be the aggressor and was placed on one-to-one supervision and then sent out to be evaluated. Resident #65 had dementia and was reactive to Resident #111 who walked around frequently and would reach out for balance with no intent to harm.Interview on 02/10/26 at 9:44 A.M. the Director of Nursing (DON) stated the incident was unwitnessed and unsure what exactly occurred. The DON reported that the facility did not feel there was intent between the two residents, so we did not feel there was a need to implement the abuse policy and report the incident to the state agency.Interview on 02/10/26 at 9:56 A.M. the Administrator stated the flow chart from the state agency site was used to decide whether to report the incident as abuse or not. The Administrator and the DON stated they did not feel the incident was warranted as abuse and therefore they didn't implement their abuse policy concerning the incident between Residents #111 and #65. Interview on 02/10/26 at 10:28 A.M. Licensed Practical Nurse (LPN) #23 stated CNA #12 reported the incident with Resident #65 and Resident #111 and intervened. LPN #23 reported Resident #111 had redness to his face and a hematoma to the right side of his forehead. LPN #23 stated both residents were assessed and placed on one-to-one supervision.Interview on 02/10/26 at 12:05 P.M. LPN #24 stated CNA #12 came into the nurse's station and reported Resident #65 struck Resident #111. Both residents were assessed and placed on a one-to-one supervision. Resident #111 had bruising/redness to the right side of his face and blood but could not recall where he was bleeding from. Resident #65 was sent out later in the evening to be evaluated.Interview on 02/10/26 at 12:35 P.M. CNA #12 stated she was walking down the hallway when she saw Resident #65 standing in the doorway of Resident #111's room and Resident #65 started swinging his arms. CNA #12 reported Resident #111's face was red and bleeding from his nose. CNA #12 asked Resident #65 why he did that, and Resident #65 said he expletive him up. CNA #12 walked Resident #111 to the nurse's station to be evaluated.Review of the facility policy titled, Abuse and Neglect - Clinical Protocol, revised March 2018 revealed the physician, and staff would help identify risk factors for abuse within the facility. The staff, with the physician's input, would investigate alleged abuse and neglect to clarify what happened and identify possible causes. The facility management and staff would institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The management and staff, with physician support, would address situations of suspected abuse or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. This deficiency represents non-compliance investigated under Complaint Number 2729914.

Based on review of the medical record, staff and resident interviews, and policy review, the facility failed to accommodate the residents who wanted showers versus bed baths. This affected one (Resident #40) of three residents reviewed for bathing. The facility census was 108. Review of the medical record for Resident #40 revealed an admission date of 08/26/25. Diagnoses included chronic kidney disease, peripheral vascular disease (PVD), and mood disorder.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of nine. This resident was assessed to require substantial assistance with toileting and dressing, bathing and transfers.Review of the documented showers for January and February 2026 for Resident #40 revealed the following:a) On 01/05/26, no shower was given. b) On 01/06/26, a bed bath was given.c) On 01/08/26, not applicable was documented.d) On 01/12/26, a bed bath was givene) On 01/26/26, no shower was given.f) On 01/27/26, a bed bath was given.g) On 01/29/26, no documentation.h) On 02/02/26, not applicable was documented. i) On 02/09/26, not applicable was documented.Interview on 02/10/26 at 2:45 P.M. Resident #40 stated he was not getting his showers as required.Interview on 02/11/26 at 9:31 A.M. Director of Nursing (DON) stated Resident #47 preferred a bed bath versus a shower.Subsequent interview on 02/11/26 at 10:03 A.M. Resident #40 stated he preferred a shower over a bed bath, but staff were not giving him the option.Review of the facility policy titled, Resident Rights, dated August 2009 revealed employees shall treat all residents with kindness, respect, and dignity. Residents were entitled to exercise their rights and privileges to the fullest extent possible.

Based on review of the medical record, staff interviews, and policy review, the facility failed to ensure physicians/providers were notified of a significant change in resident status and failed to notify the physicians/providers when a resident was moved to the secured Memory Care Unit. This affected one (Resident #47) of three residents reviewed for significant changes. The facility census was 108. Review of the medical record for Resident #47 revealed an admission date of 01/13/22. Diagnoses included chronic obstructive pulmonary disease (COPD), type I diabetes mellitus (DM I), and paranoid schizophrenia.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was assessed to require supervision with eating, toileting, dressing, and transfers, and setup with bathing.Review of the progress note dated 01/24/26 at 6:45 P.M. revealed Resident #47 was lying in bed, and her coat was at the foot of the bed smoldering due to a cigarette butt that she previously smoked. Resident #47 was evacuated from her room to a safe place as her coat was extinguished. Resident #47 was educated on the importance of not bringing previously lit cigarettes into the building.Review of the late entry progress note dated 01/24/26 at 11:19 P.M. revealed Resident #47 was moved to second floor secured unit due to Resident #47 now being a supervised smoker at all times.Interview on 01/28/26 at 3:14 P.M. Medical Director (MD) #100 stated she was not informed of the smoking incident involving Resident #47 until 01/27/26. MD #100 also stated she was not informed of the resident being moved to the secured Memory Care Unit . Interview on 01/28/26 at 4:56 P.M. Nurse Practitioner (NP) #90 stated she was not informed of the smoking incident involving Resident #47 until 01/27/26 and also stated she was not informed of the resident being moved to the secured Memory Care Unit . Interview on 01/29/26 at 10:09 A.M. Psychiatric NP #80 stated he was not informed of the smoking incident involving Resident #47 until 01/29/26. PNP #80 stated he was asked today within the last 20 minutes via phone to provide an order for the resident to be housed in the secured memory care unit. Interview on 01/29/26 at 10:35 A.M. the DON stated Resident #47 was moved to the secured Memory Care Unit on the second floor because she was now a supervised smoker and the Memory Care Unit was the only place the facility had supervised smokers. The DON wouldn't answer if the resident was appropriate for placement on the secured unit but stated Resident #47 was agreeable to be moved to the secured memory care unit. Review of the facility policy titled, Change in a Resident's Condition or Status, revised May 2017 revealed the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status.

Based on review of the medical record, staff interviews, and facility policy, the facility failed to ensure residents were free from abuse. This affected two Residents (#65 and #111) of four residents reviewed for abuse. The facility census was 108. 1) Review of the medical record for Resident #111 revealed an admission date of 10/10/25 with a discharge date of 02/03/26. Diagnoses included malignant neoplasm of brain, hypertension, and metabolic encephalopathy.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #111 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. Review of the progress note dated 12/30/25 at 8:00 A.M. revealed Resident #111 had facial trauma per the staff from a physical disturbance between him and Resident #65, and then they were separated immediately. Resident #111 was assessed with redness on his face and nose, and small hematoma on the right side of his head. Resident #111 was nonverbal but appeared comfortable. There were no other obvious injuries or deformities noted. X-rays of the skull, facial bones, and cervical spine were ordered. The staff will continue to monitor and notify provider of any worsening conditions.Review of the late entry progress note for 12/30/25 at 7:52 P.M. revealed Resident #111 received physical aggression from Resident #65 resulting in injuries. The staff intervened and separated both residents. Both residents were placed on a one-to-one. Resident #111 was assessed from head to toe, with injuries noted to the facial area. The responsible parties were notified and X-ray was ordered.Review of the late entry progress note for 12/31/25 at 9:05 A.M. revealed Resident #111 appeared to have been injured from an unwitnessed incident involving Resident #65. A full body assessment was done, and injuries were limited to facial bruising and hematoma on his forehead. Resident #111 was provided first-aid and care. An x-ray was obtained, which was unremarkable. Resident #111 displayed no signs of distress or pain.Review of the comprehensive skin evaluation dated 12/30/25 at 6:41 P.M. revealed Resident #111 had facial bruising, swelling, bloody nose, and a bump/knot on his head.2) Review of the medical record for Resident #65 revealed an admission date of 01/23/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, mood disorder, and peripheral vascular disease (PVD).Review of the Annual MDS assessment dated [DATE] revealed Resident #65 could not complete a BIMS because he was rarely/never understood. This resident was assessed to require supervision with eating, toileting, dressing, and transfers, and setup with bathing.Review of the progress note dated 12/30/25 at 7:00 P.M. revealed at time of incident, Certified Nursing Assistant (CNA) #12 came to the nurse's station and stated Resident #65 struck Resident #111 in the face. The staff intervened and separated both residents and placed Resident #65 on one-to-one supervision. Nurse practitioner (NP) #90 gave orders to send Resident #65 to the hospital to be evaluated. A skin assessment was completed with no injuries noted.Review of the late entry progress note for 12/31/25 at 9:03 A.M. revealed Resident #65 struck Resident #111 in the face. Resident #65 appeared to be the aggressor and was placed on one-to-one supervision and then sent out to be evaluated. Resident #65 had dementia and was reactive to Resident #111 who walked around frequently and would reach out for balance with no intent to harm.Interview on 02/10/26 at 9:44 A.M. the Director of Nursing (DON) stated the incident was unwitnessed and unsure what exactly occurred.Interview on 02/10/26 at 10:28 A.M. Licensed Practical Nurse (LPN) #23 stated CNA #12 reported the incident with Resident #65 and Resident #111 and intervened. LPN #23 reported Resident #111 had redness to his face and a hematoma to the right side of his forehead. LPN #23 stated both residents were assessed and placed on one-to-one supervision.Interview on 02/10/26 at 12:05 P.M. LPN #24 stated CNA #12 came into the nurse's station and reported Resident #65 struck Resident #111. Both residents were assessed and placed on a one-to-one supervision. Resident #111 had bruising/redness to the right side of his face and blood but could not recall where he was bleeding from. Resident #65 was sent out later in the evening to be evaluated.Interview on 02/10/26 at 12:35 P.M. CNA #12 stated she was walking down the hallway when she saw Resident #65 standing in the doorway of Resident #111's room and Resident #65 started swinging his arms. CNA #12 reported Resident #111's face was red and bleeding from his nose. CNA #12 asked Resident #65 why he did that, and Resident #65 said he expletive him up. CNA #12 walked Resident #111 to the nurse's station to be evaluated.Review of the facility policy titled, Abuse and Neglect - Clinical Protocol, revised March 2018 revealed the physician, and staff would help identify risk factors for abuse within the facility. The staff, with the physician's input, would investigate alleged abuse and neglect to clarify what happened and identify possible causes. The facility management and staff would institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The management and staff, with physician support, would address situations of suspected abuse or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. This deficiency represents non-compliance investigated under Complaint Number 2729914.

Based on medical record review, observations, staff and resident interviews, and policy review, the facility failed to ensure residents were free from involuntary seclusion. This affected one (Resident #47) of three resident reviewed for smoking. The facility census was 108.Review of the medical record for Resident#47 revealed an admission date of 01/13/22. Diagnoses included chronic obstructive pulmonary disease (COPD), type I diabetes mellitus (DM I), and paranoid schizophrenia.Review of the smoking observation assessment dated [DATE] revealed Resident #47 was an independent smoker with no cognitive impairment.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was assessed to require supervision with eating, toileting, dressing, and transfers, and setup with bathing. Review of the progress note dated 01/24/26 at 6:45 P.M. revealed Resident #47 was lying in bed, and her coat was at the foot of the bed smoldering due to a cigarette butt that she previously smoked. Resident #47 was evacuated from her room to a safe place as her coat was extinguished. Resident #47 was educated on the importance of not bringing previously lit cigarettes into the building.Review of the late entry progress note dated 01/24/26 at 11:19 P.M. revealed Resident #47 was moved to second floor secured Memory Care Unit due to Resident #47 now being a supervised smoker at all times.Review of the smoking observations assessment dated [DATE] revealed Resident #47 was a supervised smoker who was not cognitively impaired.Interview on 01/29/26 at 9:48 A.M. Director of Nursing (DON) stated all residents on the first and third floors were independent smokers. The DON reported all residents on the secured Memory Care Unit were supervised smokers. The DON stated the Psychiatric Nurse Practitioner (PNP) #80 gave an order on 01/24/26 for Resident #47 to be placed on secure unit.Interview on 01/29/26 at 10:09 A.M. Psychiatric NP #80 stated he was not informed of the smoking incident involving Resident #47 until 01/29/26. PNP #80 stated he was asked today within the last 20 minutes via phone to provide an order for the resident to be housed in the secured Memory Care Unit. Interview on 01/29/26 at 10:35 A.M. the DON stated Resident #47 was moved to the secured Memory Care Unit on the second floor because she was now a supervised smoker and the Memory Care Unit was the only place the facility had supervised smokers. The DON wouldn't answer if the resident was appropriate for the unit but stated Resident #47 was agreeable to be moved to the secured unit. Interview on 01/29/26 at 1:26 P.M. Resident #47 stated she was informed she was being moved to the secured Memory Care Unit but was not agreeable.Review of the physician orders for Resident #47 dated 01/29/26 revealed an order for Resident #47 to be housed in the secure Memory Care Unit. Observations throughout the survey from 01/28/26 through 02/11/26 revealed Resident #47 was housed in the secured Memory Care Unit.Review of the facility policy titled, Smoking Policy of [NAME] Towers Post-Acute dated 11/02/25 revealed supervised smokers had all smoking articles including lights, cigarettes, and electronic devices were securely stored and only accessible by facility staff. Smoking materials would be issued solely during designated smoking times under direct supervision.This deficiency represents non-compliance investigated under Complaint Number 2726142.

Based on review of the medical record, interviews, and policy review, the facility failed to report alleged abuse to the state agency. This affected two Residents (#65 and #111) of four residents reviewed for abuse. The facility census was 108. 1) Review of the medical record for Resident #111 revealed an admission date of 10/10/25 with a discharge date of 02/03/26. Diagnoses included malignant neoplasm of brain, hypertension, and metabolic encephalopathy.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #111 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. This resident was assessed to require partial assistance with eating, dependent on toileting, bathing, and dressing, and setup for transfers.Review of the progress note dated 12/30/25 at 8:00 A.M. revealed Resident #111 had facial trauma per the staff from a physical disturbance between him and Resident #65, and then they were separated immediately. Resident #111 was assessed with redness on his face and nose, and small hematoma on the right side of his head. Resident #111 was nonverbal but appeared comfortable. There were no other obvious injuries or deformities noted. X-rays of the skull, facial bones, and cervical spine were ordered. The staff will continue to monitor and notify provider of any worsening conditions.Review of the late entry progress note for dated 12/30/25 at 7:52 P.M. revealed Resident #111 received physical aggression from Resident #65 resulting in injuries. The staff intervened and separated both residents. Both residents were placed on a one-to-one observation. Resident #111 was assessed from head to toe, with injuries noted to the facial area. The responsible parties were notified and X-ray was ordered.Review of the late entry progress note for 12/31/25 at 9:05 A.M. revealed Resident #111 appeared to have been injured from an unwitnessed incident involving Resident #65. A full body assessment was done, and injuries were limited to facial bruising and hematoma on his forehead. Resident #111 was provided first-aid and care. An x-ray was obtained, which was unremarkable. Resident #111 displayed no signs of distress or pain.Review of the comprehensive skin evaluation dated 12/30/25 at 6:41 P.M. revealed Resident #111 had facial bruising, swelling, bloody nose, and a bump/knot on his head.2) Review of the medical record for Resident #65 revealed an admission date of 01/23/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, mood disorder, and peripheral vascular disease (PVD).Review of the Annual MDS assessment dated [DATE] revealed Resident #65 could not complete a BIMS because he was rarely/never understood. This resident was assessed to require supervision with eating, toileting, dressing, and transfers, and setup with bathing.Review of the progress note dated 12/30/25 at 7:00 P.M. revealed at time of incident, Certified Nursing Assistant (CNA) #12 came to the nurse's station and stated Resident #65 struck Resident #111 in the face. The staff intervened and separated both residents and placed Resident #65 on one-to-one supervision. Nurse Practitioner (NP) #90 gave orders to send Resident #65 to the hospital to be evaluated. A skin assessment was completed with no injuries noted.Review of the late entry progress note for 12/31/25 at 9:03 A.M. revealed Resident #65 struck Resident #111 in the face. Resident #65 appeared to be the aggressor and was placed on one-to-one supervision and then sent out to be evaluated. Resident #65 had dementia and was reactive to Resident #111 who walked around frequently and would reach out for balance with no intent to harm.Interview on 02/10/26 at 9:44 A.M. the Director of Nursing (DON) stated the incident was unwitnessed and unsure what exactly occurred. The DON reported that the facility did not feel there was intent between the two residents, so we did not feel they needed to report the incident between Resident #111 and #65 to the state agency.Interview on 02/10/26 at 9:56 A.M. the Administrator stated the flow chart from the state agency site was used to decide whether to report the incident as abuse or not. The Administrator and the DON stated they did not feel the incident was warranted as abuse and therefore they didn't need to report the incident between Residents #111 and #65 to the stage agency. Interview on 02/10/26 at 10:28 A.M. Licensed Practical Nurse (LPN) #23 stated CNA #12 reported the incident with Resident #65 and Resident #111 and intervened. LPN #23 reported Resident #111 had redness to his face and a hematoma to the right side of his forehead. LPN #23 stated both residents were assessed and placed on one-to-one supervision.Interview on 02/10/26 at 12:05 P.M. LPN #24 stated CNA #12 came into the nurse's station and reported Resident #65 struck Resident #111. Both residents were assessed and placed on a one-to-one supervision. Resident #111 had bruising/redness to the right side of his face and blood but could not recall where he was bleeding from. Resident #65 was sent out later in the evening to be evaluated.Interview on 02/10/26 at 12:35 P.M. CNA #12 stated she was walking down the hallway when she saw Resident #65 standing in the doorway of Resident #111's room and Resident #65 started swinging his arms. CNA #12 reported Resident #111's face was red and bleeding from his nose. CNA #12 asked Resident #65 why he did that, and Resident #65 said he expletive him up. CNA #12 walked Resident #111 to the nurse's station to be evaluated.Review of the facility policy titled, Abuse and Neglect - Clinical Protocol, revised March 2018 revealed the physician, and staff would help identify risk factors for abuse within the facility. The staff, with the physician's input, would investigate alleged abuse and neglect to clarify what happened and identify possible causes. The facility management and staff would institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The management and staff, with physician support, would address situations of suspected abuse or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. This deficiency represents non-compliance investigated under Complaint Number 2729914.

Based on review of the medical record, interviews, and facility policy, the facility failed to thoroughly investigate alleged abuse. This affected two (#65 and #111) of four residents reviewed for abuse. The facility census was 108. 1) Review of the medical record for Resident #111 revealed an admission date of 10/10/25 with a discharge date of 02/03/26. Diagnoses included malignant neoplasm of brain, hypertension, and metabolic encephalopathy.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #111 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. This resident was assessed to require partial assistance with eating, dependent on toileting, bathing, and dressing, and setup for transfers.Review of the progress note dated 12/30/25 at 8:00 A.M. revealed Resident #111 had facial trauma per the staff from a physical disturbance between him and Resident #65, and then they were separated immediately. Resident #111 was assessed with redness on his face and nose, and small hematoma on the right side of his head. Resident #111 was nonverbal but appeared comfortable. There were no other obvious injuries or deformities noted. X-rays of the skull, facial bones, and cervical spine were ordered. The staff will continue to monitor and notify provider of any worsening conditions.Review of the late entry progress note for dated 12/30/25 at 7:52 P.M. revealed Resident #111 received physical aggression from Resident #65 resulting in injuries. The staff intervened and separated both residents. Both residents were placed on a one-to-one observation. Resident #111 was assessed from head to toe, with injuries noted to the facial area. The responsible parties were notified and X-ray was ordered.Review of the late entry progress note for 12/31/25 at 9:05 A.M. revealed Resident #111 appeared to have been injured from an unwitnessed incident involving Resident #65. A full body assessment was done, and injuries were limited to facial bruising and hematoma on his forehead. Resident #111 was provided first-aid and care. An x-ray was obtained, which was unremarkable. Resident #111 displayed no signs of distress or pain.Review of the comprehensive skin evaluation dated 12/30/25 at 6:41 P.M. revealed Resident #111 had facial bruising, swelling, bloody nose, and a bump/knot on his head.2) Review of the medical record for Resident #65 revealed an admission date of 01/23/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, mood disorder, and peripheral vascular disease (PVD).Review of the Annual MDS assessment dated [DATE] revealed Resident #65 could not complete a BIMS because he was rarely/never understood. This resident was assessed to require supervision with eating, toileting, dressing, and transfers, and setup with bathing.Review of the progress note dated 12/30/25 at 7:00 P.M. revealed at time of incident, Certified Nursing Assistant (CNA) #12 came to the nurse's station and stated Resident #65 struck Resident #111 in the face. The staff intervened and separated both residents and placed Resident #65 on one-to-one supervision. Nurse Practitioner (NP) #90 gave orders to send Resident #65 to the hospital to be evaluated. A skin assessment was completed with no injuries noted.Review of the late entry progress note for 12/31/25 at 9:03 A.M. revealed Resident #65 struck Resident #111 in the face. Resident #65 appeared to be the aggressor and was placed on one-to-one supervision and then sent out to be evaluated. Resident #65 had dementia and was reactive to Resident #111 who walked around frequently and would reach out for balance with no intent to harm.Interview on 02/10/26 at 9:44 A.M. the Director of Nursing (DON) stated the incident was unwitnessed and unsure what exactly occurred. The DON reported that the facility did not feel there was intent between the two residents, so they did not feel there was a need to complete an thorough investigation related to the incident between Resident #111 and #65.Interview on 02/10/26 at 9:56 A.M. the Administrator stated the flow chart from the state agency site was used to decide whether to report the incident as abuse or not. The Administrator and the DON stated they did not feel the incident was warranted as abuse. The Administrator verified the facility did not complete a thorough investigation related to the incident between Resident #111 and #65.Interview on 02/10/26 at 10:28 A.M. Licensed Practical Nurse (LPN) #23 stated CNA #12 reported the incident with Resident #65 and Resident #111 and intervened. LPN #23 reported Resident #111 had redness to his face and a hematoma to the right side of his forehead. LPN #23 stated both residents were assessed and placed on one-to-one supervision.Interview on 02/10/26 at 12:05 P.M. LPN #24 stated CNA #12 came into the nurse's station and reported Resident #65 struck Resident #111. Both residents were assessed and placed on a one-to-one supervision. Resident #111 had bruising/redness to the right side of his face and blood but could not recall where he was bleeding from. Resident #65 was sent out later in the evening to be evaluated.Interview on 02/10/26 at 12:35 P.M. CNA #12 stated she was walking down the hallway when she saw Resident #65 standing in the doorway of Resident #111's room and Resident #65 started swinging his arms. CNA #12 reported Resident #111's face was red and bleeding from his nose. CNA #12 asked Resident #65 why he did that, and Resident #65 said he expletive him up. CNA #12 walked Resident #111 to the nurse's station to be evaluated.Review of the facility policy titled, Abuse and Neglect - Clinical Protocol, revised March 2018 revealed the physician, and staff would help identify risk factors for abuse within the facility. The staff, with the physician's input, would investigate alleged abuse and neglect to clarify what happened and identify possible causes. The facility management and staff would institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The management and staff, with physician support, would address situations of suspected abuse or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. This deficiency represents non-compliance investigated under Complaint Number 2729914.

Based on medical record review, observation, resident and staff interview, hospice staff interview, review of the hospice record, review of the controlled drug receipt/record/disposition form, review of the text message correspondence, and policy review, the facility failed to ensure a resident with chronic pain syndrome received as needed medication for breakthrough pain. This resulted in Actual Harm, when staff failed to ensure Resident #08 received as needed (PRN) pain medication when she reported severe pain. This affected one (#08) of three residents reviewed for pain. The census was 110. Findings include: Medical record review for Resident #08 revealed an admission date of 12/14/24. Diagnoses included chronic pain syndrome, malignant neoplasm of the larynx, anxiety, depression, posttraumatic stress disorder, osteomyelitis of the back, fibromyalgia, and bowel rupture with colostomy. Resident #08 was diagnosed on [DATE] with cT3NO (a cancer tumor that has spread into the outermost layer but has not spread to the lymph nodes) head and neck cancer. On 09/17/25 hospice services began. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #08 was cognitively intact. The resident was independent for most activities of daily living, including tracheal stoma and colostomy care. Review of the pain plan of care for Resident #08 revealed to administer pain medications as ordered, be aware of resident's diagnoses to ensure pain medication had been ordered and observe for pain every shift. The goal was for Resident #08 not to experience pain during stay in the facility. Review of the physician orders dated 09/30/25 revealed oxycodone (opioid medication for moderate to severe pain) hydrochloride (HCl) oral tablet 10 milligrams (mg), give two tablets by mouth every three hours as needed (PRN) for pain. Review of the Medication Administration Record (MAR) from 12/01/25 through 12/02/25 revealed the order was documented as given to the resident on 12/01/25 at 10:01 A.M., then again on 12/02/25 at 10:32 A.M., 8:53 P.M. and 11:59 P.M. Review of the progress notes dated 12/01/25 through 12/02/25 revealed the ordered oxycodone was administered at 10:01 A.M. on 12/01/25 and on 12/02/25 at 10:32 A.M, 8:53 P.M. and 11:59 P.M. There was no documentation on 12/01/25 revealing Resident #08 requested pain medication multiple times beginning at 1:30 P.M. through 9:30 A.M. on 12/02/25. Additionally, there was no documentation the hospice nurse was notified the pain medication was not available for administration. Review of the controlled drug receipt/record/disposition form dated 11/24/25 revealed on 12/01/25 at 12:00 A.M., two pills were signed as given leaving two pills remaining. On 12/01/25 at 10:00 A.M., two pills were signed as given and left a remaining count of zero oxycodone pills. On 12/02/25, 15 pills of oxycodone were checked in on the count sheet by Licensed Practical Nurse (LPN) #244, and two pills were documented as given on 12/02/25 at 10:32 A.M. Review of the hospice note dated 12/01/25 revealed Resident #08 was out of oxycodone, and it was reordered and will receive tonight. Interview and observation with Resident #08 on 12/02/25 at 9:52 A.M. revealed her pain level was not controlled. She stated she had asked the nurse for the PRN oxycodone more than once and was told it was not available. Resident #08 tearfully reported it had been almost 24 hours since her last PRN pain medication dose was administered, her pain was at level nine out of 10 on a numeric pain scale of one to 10 with 10 being the worst pain. Resident #08 was told the medication was still not available, and she was unclear if it was the fault of the hospice or the pharmacy. She stated she had pain in her neck, hip, back and wrist and had reduced ability to move and perform activities of daily living. Interview and observation on 12/03/25 at 12:26 P.M. with LPN #273 revealed it was reported to her that the facility was out of Resident #08's PRN oxycodone since the morning of 12/01/25 so some was ordered. She verified there was a bottle of oxycodone from the local pharmacy filled on 12/02/25 for 12 tablets with only 10 tablets left in the bottle and assumed it was an emergent order. A telephone interview on 12/03/25 at 2:44 P.M. with the hospice LPN #915 revealed Resident #08 texted on 12/01/25 at 1:27 P.M. to inform her the pain medication was out. The hospice LPN #915's review of the oxycodone medication revealed the active prescription still had 266 tablets available and she was uncertain why they were not there. Resident #08 texted her again on 12/02/25 at 9:13 A.M. reporting she still was in pain and had not received any administrations of oxycodone since the previous morning and was told the facility received the wrong medications from the pharmacy. The hospice LPN #915 further reported she was informed the facility was trying to rectify an automatic discontinue on this order for Resident #08. The hospice LPN #915 obtained an emergency order for twelve oxycodone tablets, called the order into the local pharmacy, picked up the medication and brought it to the facility for administration at 10:32 A.M. on 12/02/25. LPN #915 reported a note from a hospice Registered Nurse (RN) #910 dated 12/01/25 revealed the facility was out of Resident #08's oxycodone. It was standard procedure for the facility to inform the hospice if a refill was needed. A follow-up telephone interview on 12/10/25 at 1:31 P.M. with hospice LPN #915 revealed she had been notified via text message on 12/01/25 at 1:27 P.M., that Resident #08 was out of her breakthrough pain medication. She said she reviewed the orders for her oxycodone, and they were active and had remaining refills. She said the facility was having some issues with the pharmacy and keeping the medication refilled. LPN #915 said they had the same issue on 11/25/25 when Resident #08 ran out of pain medication. LPN #915 said she received another text message the morning of 12/02/25 at 9:13 A.M., that the wrong medication was sent and Resident #08 was still in pain. LPN #915 called for an emergency order for 12 tablets of oxycodone medication, picked it up from a local pharmacy, and brought it to the facility for administration at 10:32 A.M., on 12/02/25. Interview on 12/11/25 at 9:44 A.M. with LPN #244 verified she only administered one dose of Oxycodone 10 milligrams at 10:01 A.M. on 12/01/25 to Resident #08 because the resident had no more Oxycodone available. LPN #244 said she told Resident #08 she had no more Oxycodone available. When LPN #244 was asked why she didn't request access to the Omni-Fill emergency distribution system, she replied by saying the resident had not requested any more pain medication that day. LPN #244 verified the Oxycodone order refill did not arrive until 12/02/25. Review of the five screen shots of a text message correspondence between Resident #08 and the hospice LPN #915 on 12/01/25 at 1:27 P.M., revealed the facility notified Resident #08 they were out of her PRN oxycodone, and again on 12/02/25 at 9:13 A.M. Resident #08 sent a text message reported, per the facility, pharmacy received the wrong medication. The hospice LPN #915 replied she was on her way to the facility. Review of the policy titled Administering Medications dated April 2019, revealed medication administration times are determined by resident need and benefit, not staff convenience, and include enhancing optimal therapeutic effect of the medication, consistent with his or her care plan. Medication errors are documented, reported and reviewed by the QAPI (Quality Assurance and Performance Improvement) committee to inform process changes and/or the need for additional staff training. Review of the policy titled Pain Assessment and Management dated October 2022, revealed the facility is to implement medication regimen as ordered, document and communicate directly to the provider results of interventions when appropriate and ongoing communication between prescriber and staff is necessary for the optimal and judicious use of pain medications; notify the provider immediately if the resident's pain or the medication side effects are not adequately controlled. This deficiency represents non-compliance investigated under Master Complaint Number 2685204 and Complaint Number 2626999.

Based on review of the medical record, staff and resident interviews, observations, and policy review, the facility failed to ensure the residents were made aware of what they were going to be served for meals. This had the potential to affect 108 of the 111 residents in the facility who received food from the kitchen. The facility identified three residents (#9, #17 and #89) who did not receive food from the kitchen. The facility census was 111. Based on review of the medical record, staff and resident interviews, observations, and policy review, the facility failed to ensure the residents were made aware of what they were going to be served for meals. This affected three (#28, #93, and #117) out of five residents reviewed for food and nutrition. This had the potential to affect 108 out of the 111 residents in the facility who received food from the kitchen. The facility identified three residents (#9, #17 and #89) who did not receive food from the kitchen. The facility census was 111. Findings included: 1.Medical record review for Resident #28 revealed an admission date of 04/16/25. Medical diagnoses included traumatic spinal cord injury, paraplegic, peripheral vascular disease, neurogenic bladder, and viral hepatitis. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #28 was cognitively intact. Her functional status was supervision or touching assistance for eating. Interview and observation on 12/01/25 at 12:03 P.M. Resident #28 received her tray while surveyor was in the room and stated she didn't know what was being served for lunch. She revealed there wasn't anything handed out to the residents and the menu the facility posted was out of date. 2.Review of the medical record for Resident #93 revealed an admission date of 04/14/22. Medical diagnoses included cerebral palsy, cerebrovascular attack, and diabetes. Review of the quarterly MDS dated [DATE] revealed Resident #93 was moderately cognitively impaired. Her functional status was set up to clean-up assistance for eating. Interview with Resident #93 on 12/01/25 at 12:11 P.M. revealed she didn't like her meal, had no idea what was being served for meals and had not received a menu or did she know where to look for one. 3.Review of the medical record revealed Resident #117 was admitted to the facility on [DATE] with diagnoses of sepsis, alcoholic liver disease and pulmonary embolism. Review of the MDS admission assessment dated [DATE] revealed Resident #117 had intact cognition and was always continent of bowel and bladder. Section GG was not completed. Interview with Resident #117 on 12/01/25 at 12:12 P.M. revealed he didn't like the turkey he was served for lunch. He revealed he didn't know if he could get something else, didn't know where the menu was posted and didn't know what he was going to be served for lunch. Observation of the Certified Nursing Aide (CNA) #337 on 12/02/25 from 12:12 P.M. to 12:16 P.M. revealed she was not letting the residents know what was for lunch and dinner and asked if they wanted an alternate for those meals. Observation and interview at the same time on 12/01/25 at 12:16 P.M. with Certified Nursing Aide (CNA) #337 revealed the residents received a menu at the beginning of the week and activities usually passed the menus out to the residents. The CNA took the surveyor to where the menu was posted by the dining room and there were four months of menus with four weeks on each page and none of them were dated. The aide revealed if the menu wasn't dated the only way she would know what was served was on the day the meal was served, and she looked on this spreadsheet to determine what was going to be at that moment since it wasn't dated. She confirmed she didn't pass out any menus to the resident and the menus posted would be difficult for the residents to determine what was being served for their meals. She confirmed she didn't inform the residents what was for lunch and dinner since she didn't know herself with what was posted on the wall. Observation of the menu board in front of the dining room on 12/10/25 at 12:24 P.M. revealed there wasn't a menu in there for the three meals being served on 12/01/25. Interview with Dietary Manager (DM) #272 on 12/02/25 at 12:25 P.M. revealed there was a four-week cycle posted on the units for the meals. He revealed the aides were to pass out the menus and they were also placed in the admission packet for the residents as well. He reported the dietary staff encourage the aides when they take the residents their breakfast trays to let the residents know what was for lunch and dinner. He reported if someone wasn't cognitively intact or was bed bound, he didn't know what they would do about the menus. He reported menus were hanging on boards in the hallways he said residents just figure out what they are having, or they can ask a staff person. If staff person does not know what week it is, they can just call the kitchen to find out. it's not that hard. Review of the policy titled, Menus, undated, revealed menus for regular and therapeutic diets are written at least two (2) weeks in advance and are dated and posted in the kitchen every Monday for the following week and Friday for the upcoming weekend. Copies of menus are posted by Dietary Manager or on-duty cook, in at least two (2) resident areas, in positions and in print large enough for residents to read them.

Based on observation, staff interview, and policy review, the facility failed to ensure food was stored in a manner to prevent the potential spread of foodborne illness. This had the potential to affect 108 out of 111 residents in the facility who received food from the kitchen. The facility identified three residents (#9, #17 and #89) who did not receive food from the kitchen. The facility census was 111. Findings include: Initial tour of kitchen on 12/01/25 at 8:30 A.M. with Dietary Supervisor (DS) #272 revealed several issues with food storage in the dry storage area, the walk-in refrigerator, the walk-in freezer as well as the first floor, the second floor, and the third floor kitchenette refrigerators. Observation on 12/01/25 at 8:43 A.M. of dry storage area with DS #272 revealed a bag of undated and open to air flour tortillas and undated pasta. DS #272 confirmed the open to air and undated tortillas and the undated pasta. Observation on 12/01/25 at 9:02 A.M. of the walk-in refrigerator with DS #272 revealed three individual serving sized yogurts with expiration dates of 11/03/25. DS #272 confirmed, removed and threw the expired yogurts away. Observation on 12/01/25 at 9:25 A.M. of the walk-in freezer with DS #272 revealed a bag of cauliflower, a bag of hash brown patties, a box of hamburger patties and a bag of frozen chicken wings which had all been opened and were undated. DS #272 confirmed that the cauliflower, the hash brown patties, the hamburger patties and the chicken wings had been opened and were undated. DS #272 removed the identified undated food items from the freezer. Observation on 12/04/25 at 8:40 A.M. of the second floor kitchenette refrigerator with DS #272 revealed an unmarked, unidentified and undated bag of food. This was confirmed by DS #272. Observation on 12/04/25 at 8:47 A.M. of the third floor kitchenette refrigerator with DS #272 revealed two leftover containers that were unmarked, unidentified, and undated. Additionally, the refrigerator door would not close tightly due to an ice build-up in the freezer. DS #272 confirmed the two leftover containers that were unmarked, unidentified and undated as well as the ice build-up that prevented the refrigerator door from closing. Observation on 12/04/25 at 12:05 P.M. of the first-floor kitchenette refrigerator with DS #272 revealed three bags of unmarked, unidentified and undated food items along with one container of opened and undated cream cheese. DS #272 verified these items as described. Review of the policy titled, Food Receiving and Storage, revised July 2014, revealed food shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Food items and snacks kept on the nursing units in refrigerators must be labeled and dated (use by date), and all foods belonging to residents must be labeled with the resident's name, the item, and the use by date.

Based on record review, staff and resident interviews, observation, and review of facility policy, the facility failed to provide information on the grievance process and how to file a grievance. This affected three (Residents #37, #66 and #106) of three residents reviewed on how to file a grievance and had the potential to affect all residents residing in the facility. The facility census was 111. Based on record review, staff and resident interview, observation, and policy review, the facility failed to provide information on the grievance process and how to file a grievance. This affected three (Residents #37, #66 and #106) of three residents reviewed on how to file a grievance. This had the potential to affect all residents residing in the facility. The facility census was 111. Findings include: 1. Review of medical record and quarterly Minimum Data Set (MDS) dated [DATE] for Resident #37 revealed he was admitted to facility on 07/17/25 and revealed resident to be cognitively intact. Resident #37 currently serves as the presiding president of the facility's Resident Council. Interview on 12/09/25 at 4:20 P.M. with Resident #37 revealed Resident #37 was unaware of the right to file a grievance and how the process was accomplished. Resident #37 denied ever having the grievance process explained to him individually or during a resident council meeting. 2. Review of medical record and quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #66 was admitted on [DATE], with moderate cognitive impairment. Interview on 12/10/25 at 9:40 A.M. with Resident #66 revealed Resident #66 was unaware of how to lodge a grievance and admitted he was unaware of a process for filing a grievance. Resident #66 revealed he attended most resident council meetings but cannot remember anyone ever talking about the grievance process. 3. Review of medical record and quarterly MDS dated [DATE] for Resident #106 revealed he was admitted on [DATE] and is cognitively intact. Interview on 12/10/25 at 9:52 A.M. with Resident #106 revealed Resident #106 was aware of what a grievance was but was unaware the facility had a structured program for filing and resolution of grievances. Resident #66 revealed he had attended resident council meetings and had never heard anyone talk about the grievance process. Interview on 12/10/25 at 9:37 A.M. with the Administrator revealed the Administrator had not been involved in a formal grievance since coming to the facility. The Administrator was able to provide a facility policy on Grievances and the names of the three members of the grievance committee (Resident #66, Social Services Assistant #232 and Nurse Practitioner #996). Observation during a tour of the facility on 12/10/25 at 3:32 P.M. with Assistant Director of Nursing #224 revealed no posted information on the grievance process or how to file a grievance. Interview on 12/10/25 at 3:32 P.M. with Assistant Director of Nursing (ADON) #224 verified no knowledge of how the grievance process worked. Review of the policy titled, Grievances/Complaints, Filing, undated, revealed residents and their representatives have the right to file grievances either orally or in writing, to facility staff or to the agency designated to hear grievances (e.g. the State Ombudsman). Review of the policy titled, Resident Rights, revised August 2009, revealed the resident had the right to voice grievances and have the facility respond to those grievances, and the facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.

Based on observation, staff interviews, and policy review, the facility failed to provide a homelike environment. This affected seven (#114, #47, #25, #50, #17, #71, and #73) out of seven residents reviewed for the environment. In addition, the facility failed to ensure the elevator was clean and had appropriate lighting. This had the potential to affect any resident who used the elevator. Additionally, the facility failed to ensure the memory care unit (MCU) was free from odors. This had the potential to affect all residents who resided in rooms 251, 252, 253, 254, 255, 256, 257, 258, and 259. The facility census was 111.Findings included:Observation of Resident #17's room on 12/01/25 at 11:12 A.M. revealed his tube feeding pole had a dried brownish substance running down the pole. His blind on the window was broken. The privacy curtain that was in the room had brown spots on it. Interview with the certified nursing assistant (CNA) #279 on 12/01/25 at 11:19 A.M. confirmed the tube feeding pole was dirty and had not been cleaned in some time. She confirmed the blind was broken and the curtain was dirty. Observation of #73's room on 12/01/25 at 11:23 A.M. revealed his blind was broken, and his privacy curtains had brown stains on them. Interview with the Housekeeping Aide #321 on 12/01/25 at 11:26 A.M. confirmed the blind was broken and the privacy curtain had brown stains on them.Observation of Resident #71's room on 12/01/25 at 11:27 A.M. revealed her privacy curtain was broken and hanging off the hooks in the ceiling. Observation of Resident #47's room on 12/02/25 at 11:30 A.M. revealed the curtains had a brown substance on them. Observation of Resident #25's room on 12/01/25 at 11:31 A.M. revealed the curtains on her windows had a yellowish brownish tint to them. The privacy curtain was off the track and was missing hooks.Observation on 12/01/25 at 11:59 A.M. of Resident #50's room revealed his privacy curtain was hanging halfway off the track.Interview with the Housekeeping Aide #321 on 12/01/25 at 12:00 P.M. confirmed Resident #71, #47, #25, and #50's privacy curtains needed cleaned or replaced. Observation of Resident #114's room on 12/01/25 at 11:45 A.M. revealed the walls coming into the room on the right-hand side had drops of a light brown substance running down them, there was a hole the size of a softball on the right side of the wall walking into the room and another hole on the left side of the wall walking into the room. Interview with the Maintenance Supervisor (MS) #211 on 12/01/25 at 11:45 A.M. confirmed holes in the walls needed to be fixed, confirmed the splashes running down the walls. Observation of the south elevator on 12/02/25 at 11:34 A.M. revealed there were stains on the floor and dirt in the corners. The lights were dim and the panels covering the lights had bugs and a black substance in them. There was one panel that was yellow in color. Interview with the Maintenance Assistant (MA) #229 on 12/01/25 at 11:40 A.M. confirmed the elevator was dim and dirty. Observation of the MCU on 12/03/25 at 1:04 P.M. revealed there was a pungent smell of urine and feces down the hall with room numbers 251, 252, 253, 254, 255, 256, 257, 258, and 259. Observation on 12/08/2025 at 11:20 A.M. revealed there was a pungent smell of urine and feces on the MCU down the same hall and in the same rooms as above. The Licensed Practical Nurse (LPN) #278 took spray and sprayed in the rooms and the hallway. She found a trash bag in a closet that looked like a wet blanket in it. Observation on 12/08/25 at 1:00 P.M. revealed there was a pungent smell of urine and feces on the MCU affecting the same hall and rooms. Interview with LPN #278 on 12/08/25 at 1:05 P.M. confirmed she didn't know what the smell was on the hall but would have to investigate it and call housekeeping. Review of the policy titled Homelike Environment dated 02/01/21 revealed residents will be provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.Policy Interpretation and ImplementationI. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment.b. comfortable (minimum glare) yet adequate (suitable to the task) lighting.c. inviting colors and decor.d. comfortable and safe temperatures ande. comfortable sound levels.3. Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable and homelike environment. The lighting design emphasizes:a. sufficient general lighting in resident-use areas.b. task lighting as needed.c. reduction in glare (through use of light filters, no wax floors);d. even light levelsThis deficiency represents non-compliance investigated under Complaint Numbers 2661780, 2656231, 2655586, and 129629 (OH00162471).

Based on medical record review, Minimum Data Set (MDS) review, staff interview, review of the Resident Assessment Instrument (RAI) manual, and policy review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) was completed when a resident received a new diagnosis of bipolar disorder and when a resident had a severe weight loss. This affected two (Residents #3 and #24) of three residents reviewed for a significant change in condition. The facility census he was 111.Based on medical record review, staff interview, review of the Resident Assessment Instrument (RAI) manual, and policy review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) was completed when a resident received a new diagnosis of bipolar disorder and when a resident had a severe weight loss. This affected two (Residents #3 and #24) of three residents reviewed for a significant change in condition. The facility census he was 111. Findings include: 1. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Guillain Barre Syndrome, abnormalities of gait and mobility, long term drug therapy, obesity, asthma, malnutrition, respiratory failure, pulmonary edema, spinal stenosis, gastrostomy tube, depression, edema, and diabetes. A diagnosis of bipolar disorder was added 08/19/24. Review of the medical record for Resident #3 revealed Resident #3 was seen by the psychiatric services provider on 08/09/24 who diagnosed Resident #3 with bipolar disorder. Review of Minimum Data Set (MDS) assessments for Resident #3 revealed a Significant Change assessment had not been completed for Resident #3 that reflected the new diagnosis of bipolar disorder. 2. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease with late onset, aphasia and protein-calorie malnutrition. Review of the MDS admission assessment dated [DATE] revealed Resident #24 had severe cognitive impairment and was frequently incontinent of bowel and bladder. The resident required set up assistance for eating and oral hygiene, moderate assistance for toileting, bathing and transfers, maximal assistance for personal hygiene and dressing, and supervision for bed mobility. Review of the hospital documented weights for Resident #24 revealed on 02/18/25 Resident #24 weighed 151.7 pounds and on 08/08/25 Resident #24 weighed 160.5 pounds. Review of facility documented weights for Resident #24 revealed on 09/08/25 Resident #24 weighed 160.5 pounds and on 10/06/25 Resident #24 weighed 160 pounds. On 11/02/25 Resident #24 had a documented weight of 145.2 pounds and on 11/05/25 Resident #24 had a documented weight of 143.6 pounds. This represented a weight loss of 10.25% in one month, from 10/06/25 to 11/05/25. Review of the MDS assessments for Resident #24 revealed a Significant Change assessment had not been completed for Resident #24 that reflected the severe weight loss. Interview on 12/15/25 at 4:47 P.M. with the MDS Director #258 verified the MDS Significant Change of Status assessments had not been completed for Resident #3 after the new diagnosis of bipolar disorder or for Resident #24 after his severe weight loss but should have been completed within 14 days of the change of conditions for both Residents #3 and #24 Review of the facility policy titled Resident Assessments, dated October 2023, revealed residents with a significant change of status must undergo a comprehensive assessment which includes the Minimum Data Set (MDS) assessment, Care Area Assessment (CAA) process and care planning. Review of the Resident Assessment Instrument (RAI) manual revealed that once a change of status is determined to have occurred the comprehensive assessment process must be completed within fourteen (14) days.

Based on record review, staff interview, and policy review, the facility failed to notify the physician, registered dietician, and resident's representative when Resident #24 had a change of condition. This affected one resident (#24) out of three residents reviewed for change of condition. The facility census was 111.Based on record review, staff interview, and policy review, the facility failed to notify the physician, the registered dietician, and the resident's representative when Resident #24 had a change of condition. This affected one resident (#24) out of three residents reviewed for change of condition. The facility census was 111.Findings include:Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease with late onset, aphasia and protein-calorie malnutrition. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #24 had severe cognitive impairment and was frequently incontinent of bowel and bladder. The resident required set up assistance for eating and oral hygiene, moderate assistance for toileting, bathing and transfers, maximal assistance for personal hygiene and dressing, and supervision for bed mobility. Review of the hospital documented weights for Resident #24 revealed on 02/18/25 Resident #24 weighed 151.7 pounds and on 08/08/25 Resident #24 weighed 160.5 pounds. Review of facility documented weights for Resident #24 revealed on 09/08/25 Resident #24 weighed 160.5 pounds and on 10/06/25 Resident #24 weighed 160 pounds. On 11/02/25 Resident #24 had a documented weight of 145.2 pounds and on 11/05/25 Resident #24 had a documented weight of 143.6 pounds. This represented a weight loss of 10.25 percent in one month, from 10/06/25 to 11/05/25. Review of a nursing progress note for Resident #24 dated 12/03/25 at 3:16 P.M. authored by Assistant Director of Nursing (ADON) #224 revealed ADON #224 called Resident #24's representative to discuss the resident's severe weight loss. The resident's representative requested to be kept updated and asked for any recommendations or suggestions to improve the resident's nutritional status. A telephone interview on 12/03/25 at 2:24 P.M. with Registered Dietician #600 verified she was not aware of Resident #24's severe weight loss of 10.25 percent on 11/02/25 until 11/10/25 when she was in the facility reviewing weekly weights. Interview on 12/03/25 at 3:17 P.M. with ADON #224 verified Resident #24's representative was not notified of the resident's severe weight loss on 11/02/25 until 12/03/25. Interview on 12/04/25 at 11:29 A.M. with the Director of Nursing verified the delay in notification to the physician, dietician and resident representative about Resident #24's severe weight loss. A telephone interview on 12/04/25 at 1:21 P.M. with Medical Director #900 verified the facility did not make notification to her of Resident #24's 11/02/25 severe weight loss until 11/10/25. Review of the policy titled, Weight Assessment and Intervention, revised in March 2022, revealed a one-month weight loss of 5 percent is significant, and greater than 5 percent is severe.Review of the policy titled, Change in a Resident's Condition or Status, revised May 2017, revealed a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.

Based on record review, observation, staff and resident interviews and review of facility policy, the facility failed to provide privacy and dignity for three (Residents #39, #94, and #100) out of seven residents reviewed for dignity. The facility census was 111. Based on medical record review, observation, staff and resident interview and policy review, the facility failed to provide privacy and dignity for three (Residents #39, #94, and #100) out of seven residents reviewed for dignity. The facility census was 111. Findings Included: 1. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses of asthma, anorexia, major depressive disorder, and dementia. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed that Resident #39 had moderate cognitive impairment and required setup and clean-up assistance for meals, partial to moderate assistance for bathing, and was dependent for toileting, personal hygiene, dressing upper and lower body, and placing shoes on and off feet. Review of the plan of care dated 10/01/25 revealed Resident #39 had an activity of daily living (ADL) self-care performance deficit related to dementia with behaviors, seizures, gout, arthritis, anxiety, and delusion. Interventions included left side of bed against wall for environmental enhancement, check nail length and trim and clean, provide sponge bath when a full bath or shower could not be tolerated, allow sufficient time for dressing and undressing, assist the resident to choose simple comfortable clothing that enhances the resident ability to dress self, encourage the resident to use bell to call for assistance, participate to the fullest extent possible with each interaction, and discuss with resident family or power of attorney any concerns related to loss of independent decline in function. Observation and interview on 12/01/25 at 2:54 P.M. with Resident #39 revealed Resident #39 had approximately a half inch of facial hair under her chin. Resident #39 stated it was not always there, and staff had taken care of it before. Resident #39 stated she would like staff to take care of the facial hair. Interview on 12/01/25 at 2:55 P.M. with Licensed Practical Nurse (LPN) #404 verified Resident #39 had facial hair under her chin. LPN #404 stated that the facial hair on Resident #39 chin was about a half inch long and was very noticeable. 2. Review of the medical record revealed Resident #94 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, diabetes mellitus type II and major depression. Review of the MDS Quarterly assessment dated [DATE] revealed that Resident #94 had severe cognitive impairment and required set up or clean-up assistance for meals. Review of the plan of care for Resident #94 dated 09/26/25 revealed that Resident #94 was at risk for ADL self-care performance deficit related to disease process, fatigue, pain, and stroke. Interventions were to keep nails trim and clipped, avoid scrubbing and pat dry sensitive skin during bathing, allow sufficient time for dressing and undressing, the resident required assistance by one staff to dress, and resident required weekly skin inspections. Observation on 12/01/25 at 9:41 A.M. revealed Resident #94 was sitting in the lounge area watching television dressed in a hospital gown, pants, and shoes. The hospital gown was thin and Resident #94 ' s breast could be seen through the gown. There were six (Residents #62, #58, #38, #5, #68, and #71) other residents in the immediate proximity of Resident #94 watching television. Interview on 12/10/25 at 9:42 A.M. with Certified Nursing Assistant (CNA) #279 verified that Resident #94 ' s breast could be seen through the hospital gown that was worn thin. CNA #279 revealed she did not know how long Resident #94 had been sitting in the main lounge area, because she just brought the residents who smoke back in from the smoke break. CNA #279 revealed Resident #94 had no clothes available and that she would replace the current hospital gown. 3. Review of the medical record revealed Resident #100 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type II, morbid obesity due to excess calories, cord compression, conductive hearing loss unilateral, and anxiety disorder. Review of the MDS admission assessment dated [DATE] revealed Resident #100 had intact cognition and required supervision or touching assistance for oral care, toileting, and personal hygiene, and substantial maximal assistance for bathing. Review of the plan of care for Resident #100 dated 10/23/25 revealed that Resident #100 was risk for ADL self-care performance deficit related to disease process, and musculoskeletal impairment. Interventions included check nail length and trim, resident required assistance of one to two staff members for showering, resident required assistance of one to two staff members to provide personal hygiene and encourage resident to participate to the fullest extent possible with interaction. Observation on 12/03/25 at 2:38 P.M. from the corridor outside of Resident #100 ' s room revealed the resident room door was wide open and allowed direct and unobstructed view by the Surveyor of Resident #100 laying in his bed. CNA #209 was observed applying deodorant to Resident #100 under the resident ' s arms. Resident #100 had a sheet that was folded down to the middle of his chest which left his chest exposed with no hospital gown on. Interview on 12/03/25 at 2:39 P.M. with CNA #209 revealed she had just provided Resident #100 a bed bath. CNA #209 revealed she opened the door after the bed bath was done to leave and Resident #100 called her back in the room to apply the deodorant. CNA #209 verified Resident #100 was exposed with the door open and this was a privacy issue. Interview on 12/03/25 at 2:40 P.M. with Resident #100 verified he was provided privacy, until the aid tried to leave, and he called her back in to his room to apply deodorant under his arms. Resident #100 verified that the door was open when he did have his deodorant applied by CNA #209, but it was not her fault. Resident #100 verified it would be a dignity issue if a person who knew him witnessed him exposed from the hallway. Review of the facility policy titled, Resident Rights, dated August 2009, revealed employees should treat all residents with kindness, respect, and dignity. Review of facility policy titled Activities of Daily Living-Supporting, dated 04/2025, revealed that the resident is provided with care, treatment, and services to ensure their activities of daily living do not dimmish, unless the circumstances of their clinical condition (s) demonstrate diminishing activity of daily living are unavoidable. This deficiency represents non-compliance investigated under Complaint Number 1296290 (OH00162471) and 1296291 (OH00163286).

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Disease Control and Prevention (CDC) guidelines, review of the facility ' s Coronavirus (COVID-19) positivity log, review of the infection control policies, observations, staff interview, interview with the local health department (LHD), review of the clinical census, and medical record review, the facility failed to implement effective infection control practices to prevent the spread of COVID-19. This resulted in Immediate Jeopardy and the potential for serious negative health outcomes on 11/23/22 when Resident #82 tested positive for COVID-19 and exposed Resident #81. Residents #81 and #82 were cohorted together from 11/23/22 through 11/26/22, and Resident #81 tested positive for COVID-19 on 11/26/22. On 11/27/22, Resident #72 tested positive for COVID-19 and exposed Resident #71. Residents #71 and #72 were cohorted from 11/27/22 through 12/01/22, and Resident #71 tested positive for COVID-19 on 12/01/22. On 11/29/22, Resident #35 tested positive for COVID-19 and exposed Resident #36. Resident #36 tested negative for COVID-19 on 11/29/22 but remained in the same room as Resident #35. On 11/29/22, Resident #38 tested positive for COVID-19 but was cohorted with Resident #37 that tested negative for COVID-19 on 11/29/22. On 11/29/22, Resident #16 tested positive for COVID-19 but their roommate, Resident #15, tested negative for COVID-19 on 11/29/22. Residents #15 and #16 were cohorted in the same room. On 11/29/22, Resident #40 tested positive for COVID-19, but their roommate, Resident #39, tested negative on 11/29/22. Residents #39 and #40 were cohorted in the same room. No isolations signs or carts with personal protective equipment (PPE) were observed outside of the rooms of Residents #15, #16, #35, #36, #37, #38, #39, #40, #71, #72, #81, and #82. Additionally, the facility failed to ensure staff utilized appropriate PPE when entering the rooms of Residents #15, #16, and #68. The lack of effective infection control practices affected 13 residents (#15, #16, #35, #36, #37, #38, #39, #40, #68, #71, #72, #81, and #82) and placed other vulnerable residents in the facility at potential risk for further spread of COVID-19. The facility census was 83. On 12/02/22 at 10:53 A.M., the Administrator, the Director of Nursing (DON), Assistant Director of Nursing (ADON) #100, ADON #200, and Assistant Regional Director of Clinical Services #350 were notified Immediate Jeopardy began on 11/23/22 when the facility started cohorting COVID-19 positive residents with exposed COVID-19 negative residents, did not implement CDC guidance, and did not implement their policies regarding care of COVID-19 positive residents and initiation of transmission-based precautions. The Immediate Jeopardy was removed on 12/05/22 when the facility implemented the following corrective actions: Resident #82 tested positive for COVID-19 on 11/23/22. Resident #82's roommate, Resident #81, tested positive for COVID-19 on 11/26/22. Residents will remain in current room due to both being positive for COVID-19. Resident #72 tested positive for COVID-19 on 11/27/22. Resident #72's roommate, Resident #71, tested positive on 12/01/22. Resident #72 and Resident #71 were cohorted from 11/27/22 through 12/01/22. Residents will remain in current room due to both being positive for COVID-19. On 12/02/22, the DON/Designee verified PPE was readily available to staff. On 12/02/22, the DON/Designee completed a room change for Resident #15. Resident #15 and Resident #36 are in a room together. Resident #16 is in a room without a roommate. On 12/02/22, the DON/Designee reviewed room placement of Residents #37, #38, #39, and #40. Room moves occurred on 12/02/22 to accommodate COVID-19 positive residents together and COVID-19 negative residents together. On 12/02/22, the DON/Designee completed COVID-19 testing on all current residents at the facility. The facility identified no new COVID-19 positive residents. On 12/02/22, the Regional Director of Clinical Services #450 provided education to the DON and the Infection Preventionist ADON #200 regarding the following: Please make sure that personal protective equipment is readily available for all staff. PPE should be readily available for each unit where transmission-based precautions are needed to care for residents. Any resident on transmission-based precautions should also have a sign placed on their door, which indicates what transmission-based precautions should be practiced. To the extent possible, and per CDC and health department guidance, residents who are positive for COVID-19 should not be cohorted with residents who are negative for COVID-19. Please see the DON/Infection Preventionist for any questions. And-Education: Please make sure that you are donning and doffing personal protective equipment appropriately prior to entering a room when the resident is on transmission-based precautions. COVID-19 requires that gloves, gown, face shield, and a N-95 respirator or equivalent be used. This personal protective equipment should be donned appropriately as well as removed appropriately. On 12/02/22, the DON/Designee provided re-education to current facility staff via on-shift message related to the following: Education to all staff - Please make sure that personal protective equipment is readily available for all staff. PPE should be readily available for each unit where transmission-based precautions are needed to care for residents. Any resident on transmission-based precautions should also have a sign placed on their door, which indicates what transmission-based precautions should be practiced. To the extent possible, and per CDC and health department guidance, residents who are positive for COVID-19 should not be cohorted with residents who are negative for COVID-19. Please see the DON/Infection Preventionist ADON #200 for any questions. On 12/02/22, the DON/Designee provided re-education to current facility staff via on-shift message related to the following: Education - Please make sure you are donning and doffing personal protective equipment appropriately prior to entering a room when the resident is on transmission-based precautions. COVID-19 requires gloves, gown, face shield, and a N-95 respirator or equivalent be used. This personal protective equipment should be donned appropriately as well as removed appropriately. Starting on 12/02/22, the DON/Designee provided education to scheduled agency staff related to the following: Please make sure that personal protective equipment is readily available for all staff. PPE should be readily available for each unit where transmission-based precautions are needed to care for residents. Any resident on transmission-based precautions should also have a sign placed on their door, which indicates what transmission-based precautions should be practiced. To the extent possible, and per CDC and health department guidance, residents who are positive for COVID-19 should not be cohorted with residents who are negative for COVID-19. Please see the DON/Infection Preventionist ADON #200 for any questions. And - Education: Please make sure that you are donning and doffing personal protective equipment appropriately prior to entering a room when the resident is on transmission-based precautions. COVID-19 requires that gloves, gown, face shield, and a N-95 respirator or equivalent be used. This personal protective equipment should be donned appropriately as well as removed appropriately. On 12/05/22, the DON/Designee reviewed all current residents requiring transmission-based precautions and placed transmission-based precautions signage on their door. Residents #02, #04, #16, #26, #27, #32, #35, #38, #40, #71, #72, #81, and #82 had a sign placed. On 12/05/22, the DON/Designee placed a transmission-based precautions sign on the door for all residents currently in droplet precaution isolation for residents #02, #04, #16, #26, #27, #32, #35, #38, #40, #71, #72, #81, and #82. On 12/05/22, Resident #32 and Resident #04 tested positive for COVID-19, both residents were in a room alone at the time of testing. On 12/05/22, the DON/Designee completed a room change for Resident #35 to room with Resident #04. On 12/05/22, the DON/Designee reviewed all positive COVID-19 residents. Any residents who test positive for COVID-19 and have a roommate who is negative for COVID-19 will have a room change performed to ensure positive and negative COVID-19 residents are not cohorted together. On 12/05/22, the DON/Designee provided education to all agencies used regarding the following: Education to all staff - Please make sure that personal protective equipment is readily available for all staff. PPE should be readily available for each unit where transmission-based precautions are needed to care for residents. Any resident on transmission-based precautions should also have a sign placed on their door, which indicates what transmission-based precautions should be practiced. To the extent possible, and per CDC and health department guidance, residents who are positive for COVID-19 should not be cohorted with residents who are negative for COVID-19. Please see the DON/Infection Preventionist ADON #200 for any questions. And - Education: Please make sure that you are donning and doffing personal protective equipment appropriately prior to entering a room when the resident is on transmission-based precautions. COVID-19 requires that gloves, gown, face shield, and a N-95 respirator or equivalent be used. This personal protective equipment should be donned appropriately as well as removed appropriately. Starting on 12/05/22, the DON/Designee will complete daily audits on a minimum of five residents on each shift (7A-7P and 7P-7A) to ensure positive and negative COVID-19 residents are not cohorted together, all rooms requiring transmission-based precautions have signage related to precautions posted on the door, and that personal protective equipment is readily available to all staff. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: a.) Review of the medical record for Resident #82 revealed she was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, type one diabetes mellitus without complications, paranoid schizophrenia, posterior reversible encephalopathy syndrome, and COVID-19. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #82 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 07. The resident required extensive assistance for toilet use, limited assistance for dressing and personal hygiene, and was independent for bed mobility, transfer, and eating. Review of the progress note dated 11/23/22 revealed Resident #82 tested positive for COVID-19 on this date. Review of the facility ' s COVID-19 positivity log revealed Resident #82 tested positive for COVID-19 on 11/23/22. b.) Review of the medical record for Resident #81 revealed she was admitted to the facility on [DATE]. Diagnoses included aphasia following cerebral infarction, protein-calorie malnutrition, other seizures, rhabdomyolysis, disorganized schizophrenia, bipolar disorder, current episode depressed, mild or moderate severity, obstructive and reflux uropathy, chronic kidney disease, stage three, peripheral vascular disease, and hyperlipidemia. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #81 had severely impaired cognition evidenced by a BIMS score of 00. The resident required limited assistance for personal hygiene, supervision for dressing, and was independent for bed mobility, transfer, eating, and toilet use. Review of the Clinical Census for Residents #81 and #82 revealed the residents had remained in the same room since Resident #82 tested positive for COVID-19 on 11/23/22. Review of the progress note dated 11/25/22 revealed Resident #81 tested positive for COVID-19. Review of the physician order dated 11/26/22 revealed an order for droplet precautions related to COVID-19 every shift for ten days. Review of the facility ' s COVID-19 positivity log revealed Resident #81 tested positive for COVID-19 on 11/26/22. Observation on 12/01/22 at 2:31 P.M. revealed Residents #81 and #82 were cohorted in the same room with no isolation signs or carts with PPE present outside the door, which was verified by State tested Nursing Assistant (STNA) #05 during an interview at the time of the observation. a.) Review of the medical record for Resident #72 revealed she was admitted to the facility on [DATE]. Diagnoses included fibromyalgia, morbid (severe) obesity due to excess calories, rheumatoid arthritis, hyperlipidemia, depression, overactive bladder, other intervertebral disc degeneration lumbar region, COVID-19, and anxiety disorder. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #72 had intact cognition evidenced by a BIMS score of 15. The resident required limited assistance for personal hygiene, supervision for dressing, and was independent for bed mobility, transfer, eating, and toilet use. Review of the progress note dated 11/27/22 revealed Resident #72 tested positive for COVID-19. Review of the facility ' s COVID-19 positivity log revealed Resident #72 tested positive for COVID-19 on 11/27/22. Review of the physician order dated 12/01/22 revealed an order for isolation with droplet precautions due to COVID every shift for ten days. b.) Review of the medical record for Resident #71 revealed he was admitted to the facility on [DATE]. Diagnoses included chronic combined systolic (congestive) and diastolic (congestive) heart failure, cellulitis of right lower limb, varicose veins of right lower extremity with ulcer of ankle, non-pressure chronic ulcer of other part of right foot with severity, other specified disorders of veins, iron deficiency anemia, lymphedema, not elsewhere classified, unspecified protein-calorie malnutrition, morbid (severe) obesity due to excess calories, peripheral vascular disease, atrial fibrillation, anxiety disorder, COVID-19, cardiomegaly, gout, hyperlipidemia, atherosclerotic heart disease of native coronary artery without angina pectoris, and obstructive sleep apnea. Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #71 had intact cognition evidenced by a BIMS score of 15. This resident required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene as well as supervision for eating. Review of the progress notes from 11/27/22 through 12/01/22 revealed no documentation regarding offer of a room move for Resident #71 after his wife and roommate tested positive for COVID-19 on 11/27/22. Review of the Clinical Census for Residents #71 and #72 revealed the residents had remained in the same room since Resident #72 tested positive for COVID-19 on 11/27/22. On 11/29/22 at 4:41 P.M., an interview was conducted with Resident #71 in his room with Resident #72 (Resident #71 ' s wife) present regarding a complaint investigation that was not related to infection control prior to having knowledge of Resident #72 ' s positive COVID-19 status. There were no isolation signs or a cart with PPE to indicate any of the residents residing in the room were on precautions at the time of the interview with Resident #71 on 11/29/22. Review of the progress note dated 12/01/22 revealed Resident #71 tested positive for COVID-19. Review of the facility ' s COVID-19 positivity log revealed Resident #71 tested positive for COVID-19 on 12/01/22. Observation on 12/01/22 at 2:55 P.M. revealed Residents #71 and #72 were cohorted together with no isolation sign or cart with PPE posted outside their door, which was verified during an interview at the time of the observation with ADON #100. a.) Review of the medical record for Resident #35 revealed he was admitted to the facility on [DATE]. Diagnoses included COVID-19, congestive heart failure, unspecified-protein-calorie malnutrition, type two diabetes mellitus without complications, chronic obstructive pulmonary disease, depression, hyperlipidemia, atherosclerotic heart disease of native coronary artery without angina pectoris, sleep apnea, mononeuropathy, chronic kidney disease, stage two, polyneuropathy, other pulmonary embolism without acute or pulmonale, and spondylosis without myelopathy or radiculopathy, lumbosacral region. Review of the five-day MDS 3.0 assessment dated [DATE] revealed Resident #35 had intact cognition evidenced by a BIMS score of 15. The resident required limited assistance for personal hygiene and dressing, supervision for bed mobility and toilet use, and was independent for transfer and eating. Review of the progress note dated 11/29/22 revealed Resident #35 tested positive for COVID-19. Review of the physician orders dated 11/29/22 revealed an order for isolation with droplet precautions every shift related to COVID-19 until 12/08/22. Review of the facility ' s COVID-19 positivity log revealed Resident #35 tested positive for COVID-19 on 11/29/22. b.) Review of the medical record for Resident #36 revealed he was admitted to the facility on [DATE]. Diagnoses included hemiplegia, affecting left non-dominant side, dysphagia following cerebral infarction, encounter for attention to gastrostomy, chronic obstructive pulmonary disease, dysarthria and anarthria, paranoid schizophrenia, hyperlipidemia, Vitamin B deficiency, Vitamin D deficiency, peripheral vascular disease, sequelae of cerebral infarction, vascular dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, aphasia following cerebral infarction, emphysema, and congestive heart failure. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #36 had moderately impaired cognition evidenced by a BIMS score of 08. The resident required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene, and was totally dependent on staff for eating and transfer. Review of the progress note dated 11/29/22 revealed Resident #36 tested negative for COVID-19. Review of the Clinical Census for Residents #35 and #36 revealed the residents remained in the same room since Resident #35 tested positive for COVID-19 on 11/29/22. Review of the physician orders dated 12/01/22 revealed an order for isolation with droplet precautions due to COVID exposure every shift for ten days. Observation on 12/01/22 at 2:49 P.M. revealed Residents #35 and #36 were cohorted together with no isolation sign or cart with PPE outside of their door, which was verified during an interview at the time of the observation with STNA #10. a.) Review of the medical record for Resident #38 revealed she was readmitted to the facility on [DATE]. Diagnoses included COVID-19, dysphagia following cerebral infarction, protein-calorie malnutrition, type two diabetes mellitus without complications, hemiplegia and hemiparesis following cerebrovascular disease affecting side, hypertension, major depressive disorder, atherosclerotic heart disease of native coronary artery without angina pectoris, hyperlipidemia, contracture, right elbow, cerebral infarction, and hypokalemia. Review of the five-day MDS 3.0 assessment dated [DATE] revealed Resident #38 had moderately impaired cognition evidenced by a BIMS score of 12. The resident required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene as well as supervision for eating. Review of the physician orders dated 11/29/22 revealed an order for isolation with droplet precautions for ten days due to COVID positive. Review of the progress note dated 11/29/22 revealed Resident #38 tested positive for COVID-19 and isolation precautions were in place. Review of the facility ' s COVID-19 positivity log revealed Resident #38 tested positive for COVID-19 on 11/29/22. b.) Review of the medical record for Resident #37 revealed she was admitted to the facility on [DATE]. Diagnoses included quadriplegia, respiratory failure with hypoxia, asthma, type two diabetes mellitus without complications, aphasia following cerebral infarction, protein-calorie malnutrition, cerebral infarction, muscle wasting and atrophy, hyperkalemia, other pulmonary embolism without acute or pulmonale, and convulsions. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #37 had severely impaired cognition evidenced by a BIMS score of 00. The resident required total dependence on staff for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Review of the progress note dated 11/29/22 revealed Resident #37 was tested for COVID-19 on this date and the results were negative. Review of the Clinical Census for Residents #37 and #38 revealed the residents remained cohorted since 11/29/22 when Resident #38 tested positive for COVID-19. Review of the physician orders dated 12/01/22 revealed an order for isolation with droplet precautions due to COVID exposure every shift for ten days. Observation on 12/01/22 at 12:37 P.M. revealed Residents #37 and #38 were cohorted in the same room with no isolation sign or cart with PPE outside of their door. Interview on 12/01/22 at 12:38 P.M., with Licensed Practical Nurse (LPN) #15 verified Residents #37 and #38 were cohorted together and there was no isolation sign or cart with PPE outside of their door. LPN #15 inquired if Residents #37 and #38 had COVID-19 and indicated she did not know their COVID-19 status. a.) Review of the medical record for Resident #16 revealed he was admitted to the facility on [DATE]. Diagnoses included transient cerebral ischemic attack, Vitamin-D deficiency, hypertension, other seizures, Behcet ' s Disease, COVID-19, hemiplegia, and hemiparesis following cerebral infarction affecting left non-dominant side, and pseudobulbar affect. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #16 had intact cognition evidenced by a BIMS score of 14. The resident required limited assistance for transfer, dressing, toilet use, and personal hygiene as well as supervision for eating and bed mobility. Review of the progress note dated 11/29/22 revealed Resident #16 tested positive for COVID-19 and isolation put in place. Review of the physician orders dated 12/01/22 revealed an order for isolation with droplet precautions due to COVID every shift for ten days. Review of the facility ' s COVID-19 positivity log revealed Resident #16 tested positive for COVID-19 on 11/29/22. b.) Review of the medical record for Resident #15 revealed he was admitted to the facility on [DATE]. Diagnoses included cerebral infarction due to embolism, protein-calorie malnutrition, hyperlipidemia, atherosclerotic heart disease of native coronary artery with angina pectoris, old myocardial infarction, spinal stenosis, hypertension, insomnia, and major depressive disorder. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #15 had intact cognition evidenced by a BIMS score of 15. The resident required extensive assistance for personal hygiene, dressing, and transfer, limited assistance for bed mobility and toilet use, and supervision for eating. Review of the progress note dated 11/29/22 revealed Resident #15 tested negative for COVID-19. Review of the Clinical Census for Residents #15 and #16 revealed the residents were cohorted together since Resident #16 tested positive for COVID-19 on 11/29/22. Observation on 12/01/22 at 1:00 P.M. revealed STNA #10 and Certified Occupational Therapy Assistant (COTA) #30 were observed in the room of Residents #15 and #16 prior to the surveyor ' s knowledge of their COVID status. STNA #10 was observed wearing only an N95 mask, and COTA #30 was observed wearing an N95 mask and eye protection. Interview on 12/01/22 at 1:05 P.M., with STNA #10 verified she was only wearing an N95 mask and no eye protection. Observation on 12/01/22 at 2:53 P.M. revealed Residents #15 and #16 were cohorted together without an isolation sign or cart with PPE outside of the door. STNA #20 verified Residents #15 and #16 were in the same room and there was no isolation sign or cart with PPE outside of the door during an interview at the time of the observation. Interview on 12/02/22 at 2:08 P.M., with COTA #30 verified she was only wearing an N95 mask and eye protection. COTA #30 reported she was providing therapy to Resident #15 and was advised by her manager she did not have to wear a gown and gloves if she was just doing exercises. a.) Review of the medical record for Resident #40 revealed she was admitted to the facility on [DATE]. Diagnoses included Guillain-Barre Syndrome, traumatic arthropathy left hip, hypothyroidism, and COVID-19. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #40 had moderately impaired cognition evidenced by a BIMS score of 09. The resident required extensive assistance for bed mobility, personal hygiene, toilet use, and dressing, limited assistance with eating, and was totally dependent on staff for transfer. Review of the physician orders dated 11/29/22 revealed an order for isolation with droplet precautions every shift for ten days. Review of the progress note dated 11/29/22 revealed Resident #40 tested positive for COVID-19. Review of the facility ' s COVID-19 positivity log revealed Resident #40 tested positive for COVID-19 on 11/29/22. b.) Review of the medical record for Resident #39 revealed she was admitted to the facility on [DATE]. Diagnoses included schizophrenia, protein-calorie malnutrition, type one diabetes mellitus without complications, anxiety disorder, hypothyroidism, hyperlipidemia, other idiopathic peripheral autonomic neuropathy, obesity due to excess calories, and anemia. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #39 had severely impaired cognition evidenced by a BIMS score of 05. The resident required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene as well as supervision for eating. Review of the progress note dated 11/29/22 revealed Resident #39 tested negative for COVID-19. Review of the Clinical Census for Residents #39 and #40 revealed the residents remained cohorted since Resident #40 tested positive for COVID-19 on 11/29/22. Observation on 12/01/22 at 2:50 P.M. revealed Residents #39 and #40 were cohorted in the same room with no isolation sign or cart with PPE outside of the door, which was verified during an interview with STNA #10 at the time of the observation. Review of the medical record for Resident #68 revealed he was admitted to the facility on [DATE]. Diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Parkinson ' s Disease, right-bundle-branch block, supraventricular tachycardia, cerebrovascular disease, mixed hyperlipidemia, sick sinus syndrome, benign prostatic hyperplasia with lower urinary tract symptoms, hypothyroidism, bilateral primary osteoarthritis of hip, anxiety disorder, chronic kidney disease stage two, congestive heart failure, cardiac arrhythmias, COVID-19, and metabolic encephalopathy. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #68 had intact cognition evidenced by a BIMS score of 15. The resident required limited assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene as well as supervision for eating. Review of the physician orders dated 12/01/22 revealed an order for isolation with droplet precautions due to COVID every shift for ten days. Review of the progress note dated 12/01/22 revealed Resident #68 had tested positive for COVID-19. Observation on 12/02/22 at 1:36 P.M. revealed STNA #25 entered the room of Resident #68 with only an N95 mask and eye protection on. There was a sign on the door that indicated to see nurse before entering the room and a cart with PPE beside the door. Interview on 12/02/22 at 1:37 P.M. with STNA #25 verified she had entered the room with only an N95 mask and eye protection on. STNA #25 reported this was her first day at the facility. STNA #25 stated she had not noticed the sign, was not sure what the sign meant, and did not know the COVID status of the residents in the building. Interview on 12/01/22 at 3:17 P.M. with the DON revealed the facility was cohorting COVID-19 positive and negative residents due to the latest CDC guidelines and lack of available beds as most of the beds at the facility were full. The DON stated the facility was trying to limit exposure to COVID-19 by not moving residents around, and cohorted the COVID-19 negative residents with the COVID-19 positive residents as the negative residents had already been exposed to COVID-19. Telephone interview on 12/02/22 at 8:53 A.M., with the LHD ' s Director of Nursing (DON) #650 revealed the LHD had been in contact with the facility regarding their recent COVID-19 outbreak. The DON #650 stated the facility had not inquired about resident placement and were advised by the LHD to follow the guidelines the facility puts in place. The DON #650 stated it would not be recommended to cohort COVID-19 positive and negative residents together. Review of the facility policy titled Isolation - Initiating Transmission-Based Precautions, revised 08/2019 revealed when transmission-based precautions are implemented, the Infection Preventionist, or their designee determines the notification on the room entrance door for personnel and visitors to be aware of the need for and the type of precautions, and the signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. Further review of the policy revealed the Infection Preventionist, or their designee is also responsible for ensuring that PPE, including gloves, gowns, and masks are maintained outside the resident ' s room so that anyone entering the room can apply the appropriate equipment. Review of the facility policy titled Coronavirus Disease (COVID-19) - Identification and Management of Ill Residents, revised 07/2020 revealed residents with known or suspected COVID-19 are cared for using all recommended PPE, including an N95 or higher-level respirator (or facemask if respirators are not available), eye protection, gloves, and gown. Further review of the policy revealed residents who may have been exposed to someone with COVID-19 are monitored closely and not placed with unexposed residents until 10 days after exposure or until status of COVID-19 is determined. Review of the CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, revised 09/23/22, at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed under the section of recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection: Patients that met criteria for empiric Transmission-Based Precautions based on having had close contact with someone with SARS-CoV-2 infection should not be cohorted

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on record review, interview and policy review, the facility failed to ensure residents were assessed for alterations in skin integrity upon admission and weekly thereafter. This resulted in Actual Harm when Resident #110 was admitted with stage II pressure ulcers. No assessment or treatment was initiated on admission and two weeks later, the ulcers progressed to a stage III. This affected one (Resident #110) of three residents sampled for pressure ulcers. The facility census was 81. Findings include: Review of the medical record for Resident #110 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan, dated 12/25/22, revealed Resident #110 was non-compliant/resistive to care, therapy, medications, treatments, and using communications devices. Interventions included to monitor/document non-compliance, assess for root cause, find alternative methods to achieve goals, education risks versus benefits, and notify family/doctor of non-compliance. Resident #110 had a surgical wound to left foot status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included follow up with surgeon as directed, medications as ordered, monitor/report complications, pressure reducing mattress, and treatments as ordered. Resident #110 was at risk for pressure ulcers related to cardiovascular disease, debility, decreased bed mobility, fragile skin, incontinence, [CONDITION(S)], and non-compliance with care. Interventions included keep room uncluttered, labs as ordered, monitor hydration every shift, monitor skin during daily routine, treatments as ordered, encourage to turn/re-position every two hours, pressure redistribution cushion to wheelchair/mattress to bed, offer diet/supplements as ordered, and weekly skin assessment. Resident #110 was admitted to the hospital on 01/08/22. Review of the hospital wound consult note, dated 01/10/22, revealed Resident #110 had stage II pressure ulcers to the left and right buttocks with a combined measurement of 7 centimeters (cm) by 3.5 cm by 0.1 cm. Resident #110 was readmitted to the facility from the hospital on 01/22/22. Review of the facility's nursing admission assessment, dated 01/22/22, revealed Resident #110 had an area on the right buttock upon return from the hospital. There was no documentation regarding wound characteristics or measurements. Review of a progress noted dated 01/22/22 at 5:25 P.M. documented Resident #110 had a stage II pressure ulcer on her right buttock. There was no documentation regarding wound characteristics or measurements. Review of the Minimum Data Set (MDS) assessment, dated 01/27/2022, revealed the resident had severely impaired cognition, had verbal behaviors, frequently rejected care, and did not wander. Resident #110 was a two-person physical assist, required extensive assistance for bed mobility, transfers, dressing, toileting, and personal hygiene, and was dependent for eating, and locomotion. Resident #110 had no pressure wounds but was at risk for pressure injury. Resident #110 received enteral feeding from a feeding tube. Review of a progress note dated 01/29/22 revealed Resident #110 was assessed status post [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation regarding treatment and progress of the pressure ulcer noted upon admission. Review of the practitioner note dated 02/02/22 revealed Resident #110's skin was warm and dry, and left lower surgical site was clean, dry, closed and scarring as expected. There was no documentation regarding treatment and progress of the pressure ulcer noted upon admission. Review of the medical record revealed no documentation Resident #110's skin was assessed weekly from 01/22/22 to 02/11/22. There was no documentation the stage II pressure ulcer to the resident's right buttock had been measured or assessed since the initial assessment dated [DATE]. Review of the physician orders and treatment administration records for January and February 2022 revealed no treatment was ordered to the stage II pressure ulcer to Resident #110's right buttock, that was present on admission. Review of the documentation from a wound care visit on 02/11/22 by Nurse Practitioner (NP) #405 documented Resident #110 had three general Stage III pressure wounds to both buttocks. They were described as right medial (3.5 cm by 1.8 cm), left medial inferior (0.9 cm by 0.9 cm) and left medial superior (0.8 cm by 0.9 cm); right buttock (1.7 cm by 1.4 cm); and left hip (1.1 cm by 1.2 cm). Wounds had granulation tissue present with slough, no necrotic tissue noted, scant exudate, and no odor noted. Assessments and plans of care included Mepliex and Medi-honey twice daily dressings to areas noted as pressure ulcer of unspecified buttock stage III, pressure ulcer of the right buttock stage III, and pressure ulcer of the left hip stage III. Continue offloading of pressure and follow up during weekly wound rounds. Resident #110 was sent to the hospital on 02/12/22 for elevated blood sugar and rhonci in her lungs. She did not return to the facility. During an interview on 03/16/22 at 2:25 P.M., the Director of Nursing (DON) stated Resident #110 was readmitted from the hospital to the facility on [DATE] with an area on her right buttock. The admitting nurse did not pass on that information at the time. The State tested Nursing Assistant (STNA) found the open areas while providing care and on 02/11/22 the nurse practitioner assessed and initiated wound treatments. During interview on 03/16/22 at 3:42 P.M., STNA #150 stated Resident #110 had returned from the hospital in January with reddened areas on her bottom. STNA #150 stated she applied [MEDICATION(S)] to the open wounds after incontinence care. STNA #150 stated she was not the one who discovered the wounds and was not sure when they had opened. During a telephone interview on 03/17/22 at 10:30 A.M., the DON confirmed the progress note dated 01/22/22 at 5:25 P.M. stated Resident #110 had a stage II wound to right buttock, and the nursing assessment dated [DATE] stated Resident #100 had an area on her right buttock. The DON confirmed Resident #110 had no weekly skin assessments completed between 01/22/22 and 02/11/22. The DON stated the information was not passed on in report. Review of the facility policy titled Pressure Injury Risk Assessment, last revised March 2020, revealed risk assessments were completed within eight hours of admission and repeated weekly for the first four weeks or as often as indicated based on the resident's condition. Review of the facility's corrective action revealed the following actions were implemented and the deficiency corrected as of 02/28/22. · On 02/11/2022 the facility implemented interventions to complete two skin assessments for every new admission - the first by the admitting nurse, and the second by the ADON. · On 02/11/2022 all resident records were audited to ensure every resident had weekly skin assessments scheduled. · On 02/11/2022 admission and weekly skin assessments were added to the QAPI to audit all new admissions for two-step skin assessments and weekly skin assessments for four weeks through 03/04/22. · On 02/14/2022 all nurses were educated to policies for new admission/re-admission skin assessments and weekly skin assessments. · Skin audits were completed on all new admissions beginning on 02/11/22. · Interview conducted on 03/16/2022 at 11:09 A.M. LPN #106 stated she was educated last month (February 2022) to the new two-step skin assessment for all new admissions or re-admissions. This deficiency substantiates Complaint Number OH 183.

Based on medical record review, review of a Pyxis (automated medication dispensing system) Medication System Inventory Sheet, observation, interviews with facility staff, Nurse Practitioner (NP) #250 and Medical Director (MD) #170, review of the facility anticoagulant policy and review of medication information from Medscape, the facility failed to ensure residents were free from significant medication errors when one resident (#75) had not received ordered anticoagulant medication ([MEDICATION(S)]) for 29 days since his admission on 05/12/21. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm for Resident #75 who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (#75) of three residents reviewed for anticoagulant medication. Additionally, one (#49) resident was placed at potential risk for harm, that did not rise to the level of Immediate Jeopardy, when staff failed to administer an anticoagulant ([MEDICATION(S)]) as ordered resulting in a significant medication error. The facility census was 71. On 07/22/21 at 5:40 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 05/15/21 when Resident #75 had not received his ordered anticoagulant medication for 29 days since admission from the hospital. Review of the local hospital paperwork dated 05/12/21 revealed Resident #75 presented to the hospital in April 2021 with difficulty breathing. Resident #75 spent over two weeks in the local hospital before admitting to the current skilled nursing facility. The hospital discharge paperwork indicated Resident #75 was to continue [MEDICATION(S)] therapy (at the specified dosage) and [MEDICATION(S)]/International Normalized Ratio (PT/INR) (laboratory [lab] test used with [MEDICATION(S)] therapy) monitoring per facility policy. Resident #75 missed 29 doses of [MEDICATION(S)] since being admitted to the facility on [DATE]. Some doses were not given because of the facilities inability to obtain timely PT/INR's, other doses were not given because of the inability for the nursing staff to obtain the medications, and there was 20 days in June 2021 where the [MEDICATION(S)] order was discontinued and not given. The Immediate Jeopardy was removed on 07/22/21 when the facility reviewed all residents including Resident #75 who receive anticoagulant medications and reported any missed doses of anticoagulant medications to the physician. Additionally, the facility obtained access to the Pyxis medication system for all licensed nursing staff and began placing them physically in the system as well as providing education to all nursing staff regarding anticoagulant medications. The facility also implemented the following corrective actions: · On 07/22/21, Regional Director of Clinical Services (RDCS) #19/designee provided re-education to all current licensed nurses regarding ensuring all medications are to be given as ordered. Nurses are not to document medication unavailable. All efforts are to be made to obtain medications that are due immediately (STAT) from pharmacy, pull from emergency supply, etc. If a dose is missed, it is the nurse's responsibility to notify the practitioner and DON. It is also the responsibility of a prudent nurse to inform a member of the clinical management team regarding the need for access to the emergency medication supply (Pyxis). The nurse is also responsible for ensuring that INR's are obtained and reviewed by the practitioner prior to giving [MEDICATION(S)]. A [MEDICATION(S)] log has been placed in the 1st floor South narcotic binder to track dosing and INR results as a quality measure and should be reviewed and completed, if necessary, by the nurse prior to [MEDICATION(S)] dose administration. · On 07/22/21, the Administrator/designee provided re-education to the current scheduler regarding ensuring all licensed nurses, including agency nurses, have access to the Pyxis system prior to the start of their shift. They should be informed of the written instructions on the Pyxis system to access medications within it. · On 07/22/21, the DON/designee began resident medical records audits five times per week for four weeks and as needed (PRN) thereafter, to ensure that all anticoagulant medications are administered as ordered and PT/INR's are obtained and the provider is notified of the results prior to [MEDICATION(S)] administration. · On 07/22/21, the DON/designee began audits five times per week for four weeks and PRN thereafter to ensure all current facility nursing staff have access to the Pyxis system. · Results of audits completed by the facility will be reported to and reviewed by the Quality Assurance (QA) committee to determine if current interventions are adequate or additional action will need to be completed. · On 07/22/21 from 2:30 P.M. to 3:05 P.M., interviews with Licensed Practical Nurse (LPN) #71 and LPN #91 confirmed they received education regarding medication administration, ensuring medications are administered as ordered and ensuring licensed nursing staff are added in the Pyxis system. · On 07/22/21, two (#49 and #74) additional residents were reviewed regarding medication administration including the administration of anticoagulant medications. There were no additional medication errors or concerns identified. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital discharge and continuity of care form dated 05/12/21 revealed [MEDICATION(S)] 10 milligrams (mg) one time daily was ordered from the hospital to begin on 05/12/21 and the medication was last received in the hospital on 05/11/21 at 5:00 P.M. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 had intact cognition and received anticoagulant therapy. Review of the plan of care for Resident #75 revealed he was at risk for bleeding and bruising related to anticoagulant usage. Interventions included administering medications as ordered, labs as ordered and notifying the doctor of the results, and weekly nursing assessments to observe for bruising. Review of the physician orders for May 2021 revealed Resident #75 had orders for [MEDICATION(S)] 10 mg per day from 05/12/21 to 05/15/21; [MEDICATION(S)] 12 mg per day from 05/16/21 to 05/25/21; and [MEDICATION(S)] 16 mg per day from 05/26/21 to 05/31/21. Review of the physician orders for June 2021 revealed Resident #75 had orders for [MEDICATION(S)] 15 mg per day from 06/01/21 to 06/02/21; [MEDICATION(S)] was held from 06/09/21 through 06/28/21; and there was no [MEDICATION(S)] orders from 06/29/21 through 06/30/21. Review of the physician orders for July 2021 revealed Resident #75 was to receive [MEDICATION(S)] 10 mg per day. Review of the Medication Administration Records (MAR) from May 2021 through July 2021 for Resident #75 revealed 29 total days where [MEDICATION(S)] was not administered as ordered. The [MEDICATION(S)] was not administered on the following dates: 05/15/21, 05/19/21, 05/21/21, 06/09/21-06/29/21, 07/02/21, 07/08/21, 07/09/21, 07/17/21 and 07/18/21. Further review of nursing notes for Resident #75 from 05/12/21 through 07/20/21 revealed documented explanations regarding not giving the dose of [MEDICATION(S)] to the resident. Those reasons for not giving [MEDICATION(S)] included not being able to get in contact with a physician, facility not having a recent PT/INR, and the medication being unavailable or staff not being able to access the Pyxis medication system. Review of nurses notes for Resident #75 dated 05/15/21 at 7:12 P.M. revealed the [MEDICATION(S)] was not given due to writer waiting for a return call from the on call physician. Review of Electronic MAR (E-MAR) notes for Resident #75 dated 05/21/21 at 5:18 P.M. revealed the facility was unable to obtain the PT/INR after multiple attempts with lab. [MEDICATION(S)] being held and physician notified. Review of E-MAR notes for Resident #75 dated 06/29/21 at 2:57 P.M. revealed the [MEDICATION(S)] order was a new medication and the medication was unavailable. Review of the nursing notes for Resident #75 in June 2021 revealed no documentation regarding why the [MEDICATION(S)] was stopped as of 06/09/21. The review also revealed there was no documentation or notes from a physician addressing the subject. Review of the physician's orders regarding treatments from May 2021 through July 2021 for Resident #75 revealed daily PT/INR's were ordered to be completed from 05/13/21 through 07/02/21. STAT PT/INR's were ordered on 07/02/21, 07/09/21, and 07/19/21. A one-time order for a PT/INR was ordered for 07/20/21. The current order for Resident #75 was ordered on 07/05/21 and instructed staff to obtain PT/INR's twice weekly on Mondays and Thursdays. Review of lab results for Resident #75 from 05/12/21 through 07/20/21 revealed 14 PT/INR's completed with results. Ten of those results were obtained between 05/12/21 and 07/02/21 when the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Interviews on 07/20/21 from 9:45 A.M. to 12:00 P.M. with LPN #31, LPN #41, and LPN #51 confirmed all three nurses listed were not able to access the facility Pyxis medication system. All nurses interviewed agreed that if they were out of a medication for a resident, they would have to call the pharmacy and STAT it to the facility. Sometimes the medication would arrive to the facility so they could give the medication, other times, the resident would miss that dose of medication. All nurses interviewed confirmed as of 07/20/21, two current floor nurses were the only staff members employed by the facility who could access the Pyxis medication system and obtain medications. Neither nurse was in the facility when the surveyor was in the building on 07/20/21. During a telephone interview on 07/21/21 at 1:30 P.M. with MD #170 revealed he was unaware that Resident #75 was not receiving his [MEDICATION(S)] on a regular basis and that the facility was not obtaining routine PT/INR readings. MD #170 confirmed PT/INR's were ordered to be obtained twice weekly on Mondays and Thursdays. MD #170 went on to say that he restarted [MEDICATION(S)] therapy on 06/29/21 for Resident #75 because of the history of pulmonary embolism. MD #170 was unaware why Resident #75 had been taken off [MEDICATION(S)] therapy for the 20 days in June 2021. If he was aware of the difficulty the facility was having between giving the medication and obtaining routine labs, MD #170 indicated he could have tried a different approach for Resident #75. During a telephone interview on 07/21/21 at 1:45 P.M. with NP #250 confirmed she had no idea why the facility had stopped the [MEDICATION(S)] therapy for Resident #75. If the facility had called a PT/INR result to her she would have held the medication, increased/decreased the dosage, but never immediately stop the medication unless there was a major medical interaction, and she was not aware of any medical issues for the resident. Review of the Pyxis Medication System Inventory Sheet printed on 07/22/21 revealed the machine was stocked with [MEDICATION(S)] 1.0 mg, 2.5 mg, and 5.0 mg tablets. Review of the facility policy titled, Anticoagulation-Clinical Protocol dated 11/2018, revealed the physician shall monitor the PT/INR very closely while the resident is on [MEDICATION(S)] ([MEDICATION(S)]), to ensure the PT/INR stabilizes within therapeutic range. Review of medication information from Medscape revealed [MEDICATION(S)] is an anticoagulant. [MEDICATION(S)] is used to treat conditions such as venous [CONDITION(S)], deep vein [CONDITION(S)], pulmonary embolisms, prophylaxis of systemic embolic complications (e.g. stroke) associated with [CONDITION(S)], cardiac value replacement and post-[CONDITION(S)]. Dosing of [MEDICATION(S)] is based on the medical condition, PT/INR monitoring and response to treatment. It is very important to take [MEDICATION(S)] exactly as directed. Do not increase dose, take it more frequently than ordered, or stop using it unless directed by a physician. 2. Medical record review of Resident #49 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #49 had an intact cognition with a BIMS score of 14. Review of physician orders for Resident #49 in July 2021 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for Resident #49 in July 2021 revealed the resident did not receive his morning dose of [MEDICATION(S)] five mg. Observation on 07/20/21 at 10:15 A.M. of medication administration with LPN #31 for Resident #49 revealed the resident had received all medications prescribed except [MEDICATION(S)] five mg tablet. Interview on 07/20/21 at 11:30 A.M. with LPN #31 confirmed she did not given Resident #49 his [MEDICATION(S)] five mg during the medication administration observation. Furthermore, LPN #31 confirmed she called the pharmacy and had the [MEDICATION(S)] five mg STATTED to the facility. LPN #31 stated she did not have access to the Pyxis Medication System to pull the medication. Review of the Pyxis Medication System Inventory Sheet confirmed [MEDICATION(S)] five mg was in stock within the machine. Review of medication information from Medscape revealed [MEDICATION(S)] is an anticoagulant. [MEDICATION(S)] is use for stroke prophylaxis with [CONDITION(S)], postoperative prophylaxis of deep vein [CONDITION(S)] or pulmonary embolism and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficiency substantiates Complaint Number OH 861.

Based on medical record review, review of a Self-Reported Incident (SRI), staff interviews, review of employee timeclock punch reports, review of the local police report, review of witness statements, review of an employee personnel file and facility policy review, the facility failed to ensure one cognitively impaired Resident (#81) was free from physical abuse by facility staff. This resulted in Immediate Jeopardy and the potential for serious physical injuries and psychosocial harm for Resident #81 when on 12/28/20, Licensed Practical Nurse (LPN) #500 was observed striking the resident in the left side of the face, after redirecting him from the medication cart. This affected one (#81) of three residents reviewed for abuse. The facility census was 84. On 01/14/21 at 4:46 P.M., the Licensed Nursing Home Administrator (LNHA), Managing Director #66, the Director of Nursing (DON), Assistant Director of Nursing (ADON) #67 and Regional Director of Clinical Services (RDCS) #850 were notified Immediate Jeopardy began on 12/28/20 at 9:50 A.M., when LPN #500 was observed striking Resident #81 on the left side of his face after redirecting him from the medication cart. Resident #81 stumbled backwards after LPN #500 struck him in the face, but he did not fall. This was witnessed by other staff who stated they observed LPN #500 in a fighting stance with her fists up after the incident and LPN #500 stated she would hit the resident again. LPN #38 intervened and removed Resident #81 from the area. LPN #38 notified management and LPN #500 was escorted to an office. The local police were notified of the incident. The Immediate Jeopardy was removed on 01/09/21 when the facility implemented the following corrective actions: · On 12/28/20 at approximately 9:50 A.M., LPN #38 completed a head to toe assessment of Resident #81 with no abnormalities found. Neurological checks were initiated and continued for 72 hours. · On 12/28/20 at 10:00 A.M., LPN #38 notified ADON #67 that there was a staff to resident altercation. The staff member was identified as LPN #500 and the resident was identified as Resident #81. · On 12/28/20 at 10:05 A.M., LPN #500 was escorted by Human Resources (HR) staff #02 to the HR office and HR staff #02 obtained LPN #500's statement. After obtaining LPN #500's statement, LPN #500 indicated she wouldn't be back and to take her off the schedule. LPN #500 resigned at that time. LPN #500 remained with RDCS #850 until the police interviewed her. · On 12/28/20 at 10:06 A.M., the Administrator notified the local police department of the incident and they arrived at the facility at 10:08 A.M. · On 12/28/20 at 10:20 A.M., ADON #67 notified Physician #885 and Resident #81's resident representative of the incident. · On 12/28/20 at 10:20 A.M., ADON #67 implemented education to all staff on the abuse prevention program. Registered Nurse (RN) #23 assisted with the education and the education was completed on 01/09/21. Education will continue twice weekly along with the monitoring. · On 12/28/20 at 10:23 A.M., HR staff #02 escorted LPN #500 to the welcome center where she was interviewed by the local police. LPN #500 admitted verbally to the local police that she struck Resident #81 in the face. LPN #500 was escorted out of the facility after her interview with the police. · On 12/28/20, ADON #67 began to interview all staff and residents regarding abuse, there were no negative findings. The Administrator, RN #21 and LPN #23 assisted with the interviews. · On 12/28/20 at 4:48 P.M., RDCS #850 submitted an SRI to the state agency. · On 12/28/20, the facility implemented monitoring to include resident and staff interviews regarding abuse. This will occur two times per week for four weeks. The interviews will occur on Mondays and Thursdays. The audits will be completed by the Administrator, ADON #67, RN #21 and LPN #23. · On 12/29/20, LPN #38 completed head to toe skin assessments on the residents who resided on the same unit as Resident #81 with no abnormal findings. ADON #67, RN #21 and LPN #23 completed head to toe skin assessments on all the other residents. There were no negative findings. · On 01/14/21 from 9:07 A.M. to 9:20 A.M., interviews conducted with State tested Nursing Assistant (STNA) #01, STNA #73 and LPN #78 revealed they had recently received education on abuse and were knowledgeable about what abuse was, what to do if they witnessed abuse occurring, and who to report abuse allegations too. Although the Immediate Jeopardy was removed on 01/09/21, the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Medical record review revealed Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #81's mood and behavior care plan dated 08/10/20 revealed Resident #81 exhibited mood or behavior issues due to [DIAGNOSES REDACTED]. Resident #81 was reported to take off his clothes and walk in the hallway naked. Interventions included approach resident in a nonjudgmental behavior, access and attempt to identify underlying causes of agitation, attempt to identify triggers of behavioral symptoms, redirect resident to his room, divert attention with conversation, document behavioral episodes, document depression symptoms, education on outcomes of refusals of care as needed, medications as ordered, notify the physician and psychologist of any changes in mood or behavior, provide support and reassurance as indicated and to redirect the resident as indicated. Further review of Resident #81's mood and behavior care plan revealed Resident #81 was not care planned for aggressive behaviors. Review of Resident #81's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Resident #81 wandered daily but did not have any rejection of care, physical behaviors directed towards others or verbal behaviors directed towards others. Review of Resident #81's progress note dated 12/22/20 at 6:59 P.M. revealed the resident was noted pacing throughout the unit. Resident #81 approached the nurses' station periodically. When asked if the resident needed anything, the resident just stared and walked away. No aggression was noted. Review of the facility SRI dated 12/28/20 revealed on 12/28/20 at about 10:00 A.M., LPN #38 notified the Administrator and ADON #67 that Resident #81 had approached the medication cart and made contact with LPN #500's left arm. LPN #500 made contact with Resident #81's left side of his face. LPN #38 immediately ran and stepped in between the two and separated them. LPN #500 was immediately removed from the facility and promptly resigned. The local police department was notified and responded. The physician was contacted with new orders for labs and Resident #81's power of attorney (POA) was notified. There were no visible marks to Resident #81's left side of the face. A head to toe assessment was completed without abnormal findings. Resident #81 appeared calm with no signs of aggression or agitation. Resident #81 resumed his usual routine with wandering the halls and speaking with other residents and staff. No signs or symptoms of fearfulness or distress were noted. Further review of the SRI revealed the allegation of physical abuse was substantiated. The SRI was marked completed on 01/04/21. Review of LPN #38's witness statement dated 12/28/20 at 9:50 A.M. revealed LPN #38 was at her medication cart when LPN #500 was telling Resident #81 to get away from her medication cart. LPN #500 proceeded to turn the resident around and push him away from the cart. Resident #81 walked back to LPN #500 and stated, Don't touch me. LPN #500 pushed Resident #81 away and the resident came back up to LPN #500 and LPN #500 stated, Go ahead and hit me and I will knock you out. Resident #81 pushed at LPN #500 and LPN #500 then balled up her fist and struck Resident #81 in the left side of the face. Resident #81 tumbled backwards, LPN #38 went to the resident and got between LPN #500 and the resident. LPN #38 told LPN #500 that she could not do this to a resident and told her to go inside the nursing office. LPN #38 had the resident stay with another staff member and she immediately reported the incident to management. Review of STNA# 37's witness statement dated 12/28/20, not timed, revealed STNA #37 was doing exercises with the residents and she heard a loud noise. STNA #37 looked up and saw Resident #81's head go back. STNA #37 jumped up because Resident #81 was getting ready to fight and LPN #500 was hollering, If you hit me, I am going to hit you back. STNA #37 told them to stop and noted LPN #500 was very upset. Review of Housekeeper #56's witness statement dated 12/28/20, not timed, revealed Housekeeper #56 was mopping the floor and heard LPN #500 saying, Don't walk up on me and then Housekeeper #56 heard someone get hit. Housekeeper #56 turned his attention towards the situation and LPN #500 and Resident #81 both had their hands in a fighting position. Review of STNA #19's witness statement dated 12/28/20, not timed, revealed the incident happened on 12/28/20 and STNA #19 did not see the incident but heard the incident. The incident sounded like a hard slap against someone's skin and it was a very loud slap. LPN #500 was telling Resident #81 to come on like she was going to hit him again. Review of Resident #81's progress note dated 12/28/20 at 12:44 P.M. revealed Resident #81's responsible party and Resident #81's physician were notified of the incident. Resident #81 was ordered neurological checks for 72 hours and blood pressure to be taken every four hours. Resident #81 was also ordered lab work. Review of Resident #81's progress note dated 12/30/20 at 8:25 P.M. revealed Resident #81 was noted pacing. Resident #81 approached the nursing station periodically. When asked if Resident #81 needed anything, Resident #81 stared and walked away. No aggressive behaviors were noted. Review of Resident #81's progress note dated 12/31/20 at 11:19 A.M. revealed Resident #81's behavior was at his normal baseline. Review of Resident #81's progress note dated 12/31/20 at 11:59 A.M. revealed Resident #81's neurological checks were concluded this shift. No apparent delayed injury was noted. Resident #81 voiced no complaints and was resting well. Interview with LPN #38 on 01/14/20 at 8:32 A.M. revealed she witnessed the incident between Resident #81 and LPN #500 but did not remember the exact date it occurred. Resident #81 was wandering the unit and LPN #38 stated this was normal behavior for him. LPN #500 told Resident #81 to get away from her cart and then shoved him with both hands. Resident #81 appeared mad and looked at LPN #500. LPN #500 stated Don't come up on me. You want to fight? If you hit me, I'll hit you back. Resident #81 walked up and nudged LPN #500 in the chest and LPN #500 swung with her right hand and hit Resident #81 in the left side of his face. LPN #38 walked over and removed Resident #81. Resident #81 went with another staff member after the incident. LPN #38 told LPN #500 that she could not do that to these residents. LPN #500 stated If an (expletive) comes up on me then I'm going to hit an (expletive) back. LPN #38 took LPN #500 into the office and notified Administration immediately. LPN #38 stated administrative staff came to the unit and escorted LPN #500 off the unit. Interview with Housekeeper #56 on 01/14/21 at 8:44 A.M. revealed he was mopping a few weeks ago and heard someone get hit. Housekeeper #56 looked up and saw Resident #81 going at LPN #500. Housekeeper #56 stated another staff member went and removed Resident #81. Interview with STNA #37 on 01/14/21 at 8:54 A.M. revealed a few weeks ago she heard a hit and observed LPN #500 in a fighting stance with her hands up ready to punch. STNA #37 reported LPN #500 stated If he hits me, I'll hit him back. STNA #37 stated LPN #38 got in between Resident #81 and LPN #500. Interview with STNA #19 on 01/14/21 at 1:07 P.M. revealed she was in the dining room on the secured unit a few weeks ago when she heard a slap. STNA #19 reported LPN #500 stated Come on, do it again. STNA #19 stated LPN #500 was placed in the office by LPN #38 and Resident #81 was removed from the situation. Telephone interview with LPN #500 on 01/14/21 at 1:17 P.M. revealed Resident #81 had a cup of liquid in his hand and LPN #500 attempted to get the cup away from him because she did not know what the liquid was in the cup. LPN #500 stated Resident #81 lunged backwards so she could not get the cup. Resident #81 later came up to her at her medication cart and was gritting his teeth. LPN #500 stated Resident #81 then hit her in the chest and she saw him bring his arm back again, so she started to swing her hands to get him away. LPN #500 stated she also ran into the nurse's office. LPN #500 reported LPN #38 told her later that she struck Resident #81. LPN #500 stated she did not mean to hit him and that it was just a defense mechanism. LPN #500 denied stating that she was going to hit the resident again after the incident and stated Resident #81 had a history of [REDACTED]. LPN #500 was not able to provide any dates or names of others involved in any other incidents. Review of LPN #500's time punch dated 12/28/20 revealed LPN #500 clocked in at 7:12 A.M. and clocked out of the facility at 10:30 A.M. Review of the local police report dated 12/28/20 revealed on 12/28/20 at approximately 9:50 A.M., LPN #500 was working on the second floor of the facility. LPN #500 stated she was doing medication pass on the secured unit when Resident #81 made a comment to her. LPN #500 stated he used the word nigger when confronting her about a cup. LPN #500 stated Resident #81 hit her in the chest and she responded by swinging her arms like a windmill hitting Resident #81 in the left cheek. The witness, LPN #38, stated she was behind LPN #500 and saw the confrontation. LPN #38 stated both LPN #500 and Resident #81 were talking back and forth to each other in an aggressive manner and she did see LPN #500 swing and hit Resident #81 in the face. LPN #38 was not able to see if Resident #81 had hit LPN #500 in the chest from the angle she was standing. Others in the area stated they heard a confrontation but did not actually see anything. Resident #81 had numerous medical and psychiatric conditions and could not be properly interviewed. LPN #500 wrote a statement for the facility explaining what she said occurred and resigned. Review of LPN #500's personnel file revealed LPN #500 signed her abuse prohibition policy and procedure acknowledgement form on 09/17/20. Review of the facility's Abuse Prevention Program policy dated December 2016 revealed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse and physical or chemical restraint not required to treat a resident's symptoms. This deficiency substantiates Complaint Number OH 90.

Based on record review, observation and staff interviews the facility failed to ensure physician ordered fall interventions were in place at the time of a fall. This resulted in actual harm when Resident #12 fell out of her bed and sustained lacerations to her forehead and finger which required staples and sutures. This affected one resident (#12) of three sampled for falls. The facility identified 12 residents who had fallen in the facility since 09/27/18. The resident census was 76. Findings include: Resident #12 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] revealed the resident had severe cognitive impairment and she was rarely/never understood. She was totally dependent on staff with the exception of needing extensive assistance of staff with eating and toilet use. Review of a Fall Risk assessment dated [DATE] at 10:23 P.M. revealed the resident was at a high risk for falls. The resident did not have any history of falls within the past six months. Review of the fall plan of care identified an intervention to have a floor mat beside the bed. Review of a nurses note dated 11/13/18 at 5:20 A.M. revealed at 4:50 A.M. a state tested nurse aide (STNA) discovered Resident #12 on the floor. The STNA yelled for the nurse's assistance. The resident was observed lying on the floor on her right side with her head near the heater. The resident was noted with blood on her extremities, in her hair and on her face. The nurse and the STNA cleansed the blood to find where the bleeding was coming from. The nurse applied pressure to the open areas. The resident had a laceration on her forehead and on her middle finger of her left hand. With assistance from two other nurses the residents vitals were obtained. Paramedics arrived and assisted in transferring the resident back to the bed. The resident was alert but lethargic. She was able to answer simple commands such as her name being called. The resident was moaning in pain and reaching for the laceration on her forehead. Staff wrapped the lacerations with Kerlix. The paramedics transported the resident to the hospital for further evaluation. Notification was made to the Director of Nursing (DON) and to the on call physician. Staff was unable to reach the Power of Attorney (POA), several messages were left. Per the STNA, the resident was last changed at 2:00 A.M. The nurse was in the resident's room at 9:00 P.M. to administer evening medications. At the time the bed was in the lowest position and a floor mat was next to the bed. The nurse was also in the room at 11:00 P.M. for walking rounds and observed the resident in bed and the bed was in the lowest position. The nurse observed the resident at 1:00 A.M. during walking rounds. Resident #12 was a high fall risk and moved around frequently while in the bed. The nurse educated the aide on the importance of every two hour rounding, keeping the bed in the lowest position and keeping the floor mat in place at all times. Review of a nurses note dated 11/13/18 at 7:00 P.M. revealed the resident returned from the hospital at 4:45 P.M. with new orders for Keflex (antibiotic) 500 milligrams to be given by mouth four times a day. The residents son and daughter were in the facility and aware of the new orders. Review of the fall investigation dated 11/13/18 revealed the resident sustained [REDACTED]. Review of the Incident/Accident report dated 11/13/18 revealed at 4:50 A.M. the resident was found next to her bed by a STNA. The investigation documented the fall mat was not in place. The nurse and STNA were educated on facility protocol of fall interventions. The resident sustained [REDACTED]. On 11/26/18 at 3:15 P.M. an observation was made of Resident #12, she was sitting in her wheelchair in the television room. She was unable to be interviewed related to her cognitive impairment. The resident had bruises on her forehead and sutures were noted on her middle finger of her left hand. On 11/26/18 at 3:59 P.M. the DON was interviewed and said the fall mat was not in place at the time of the fall on 11/13/18. On 11/26/18 at 5:22 P.M., a telephone interview with STNA #10 was conducted. STNA #10 verified Resident #12 did not have her fall mats beside her bed when she fell on [DATE]. STNA #10 stated she changed the resident, put her in her nightgown and lowered the bed to the low position. STNA #10 stated at the time of the fall , she did not know Resident #12 was supposed to have fall mats beside her bed. This deficiency substantiates Complaint Number OH 236

Based on clinical record review and staff interview, the facility failed to ensure adequate supervision was provided to prevent actual harm to a resident who sustained an avoidable fall which resulted in a hip fracture. This involved one (Resident #8) of three residents who were reviewed for falls. The census was 84. Findings include: Review of the physician orders [REDACTED]. Review of the Minimum Data Set Assessment ((MDS) dated [DATE] revealed Resident #8 had moderate cognition impairment and required the extensive assistance of staff for transfers, ambulation, hygiene, bathing, bed mobility and toilet use. This assessment documented the resident was not steady and was only able to stabilize herself with human assistance for moving on and off the commode and moving from a seated position to a standing position. Review of the resident's care plan for fall prevention, dated 09/21/11, revealed the resident was at risk for falls due to unsteady gait and impaired standing balance and a history of falls. Interventions to prevent falls included Resident #8 was to be monitored while toileting and not left alone by staff. Review of the "Therapy Summary Form" dated 10/10/11 revealed Resident #8 was assessed to require stand by assist to contact guard assistance for standing from a seated position. Review of Nursing Notes dated 11/17/11 at 5:45 A.M. documented the State tested Nurse Aide (STNA) was toileting Resident #8 when she had stepped out of the bathroom to get clean clothes for the resident. Upon returning to the bathroom, the STNA observed Resident #8 on the floor in the doorway of the bathroom and facing the commode. She was assessed with [REDACTED]. She was able to move both arms and had reported right hip pain. Nursing notes dated 11/17/11 at 5:50 A.M. revealed 911 had been notified and had transported Resident #8 to the hospital. The nursing notes documented the physician had been notified Resident #8 was being transported to the emergency room for assessment of the large hematoma on her right forehead and the resident's complaint of right hip pain. She was diagnosed with [REDACTED]. Review of the "Incident Report-Investigation Summary" dated 11/17/11 revealed Resident #8 had attempted to ambulate in the bathroom without assistance and she was found sitting in the bathroom doorway on the floor. The Summary of Investigation stated while Resident #8 was sitting on the commode, staff had stepped out of the bathroom to obtain clothing. The resident had attempted to self ambulate and fell . On 12/06/11 at 3:05 P.M. Resident #8 was observed lying in bed. She had a large a scabbed hematoma over her right eye. Interview with Resident #8 at this time revealed she did not remember falling in the facility. She stated she had fallen at home. Director of Rehabilitation #20 stated during interview on 12/07/11 at 12:00 P.M. Resident #8 was discharged from Physical Therapy on 10/12/11 as she had reached her maximum potential. He affirmed on 10/12/11, Resident #8 was assessed to require contact guard assistance for safety and cueing. Currently Resident #8 was able to toe touch on her right lower extremity. He affirmed after the fall Resident #8 had decreased strength of her right lower extremity, had a lack of motion in right hip and a decrease in her abilities for activities of living. Nurse Aide #30, who had cared for Resident #8 prior to her fall, stated during interview on 12/07/11 at 2:20 P.M. prior to the fall and fracture, Resident #8 was able to stand and ambulate and now she was not able to bear weight. The Director of Nursing stated during interview on 12/07/11 at 2:15 P.M. Resident #8 had been left alone in the bathroom while the STNA went to retrieve clothing for the resident. She stated the plan of care for fall prevention had instructed Resident #8 was not to be left alone in the bathroom. She stated the resident had not fallen previously in the bathroom. The Administrator stated during interview on 12/08/11 at 10:52 A.M. Resident #8 had fallen without injury on 10/25/11 as she was leaving the bathroom to go to her bed. She stated the intervention implemented at that time was to not leave the resident alone in the bathroom. This was an incidental deficiency cited during the investigation of Complaint Master Number OH 503 and Complaint Number OH 418.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on record review, review of a facility self-reported incident (SRI) report, staff interviews and review of the facility's abuse policy, the facility failed to ensure staff immediately notified the Administrator of and protect residents from verbal threats and physical aggression by Resident #95 toward other residents. This resulted in Immediate Jeopardy for one resident (#83) of eight sampled residents. Thirty-nine residents including Resident #45 residing on the locked dementia unit were also placed at risk for Immediate Jeopardy as Resident #95 had access to each of the residents. On [DATE] 10:45 A.M. the Administrator, Director of Nursing (DON), and Regional Director of Clinical Services #200 were notified of the Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 5:04 P.M. when Resident #95 returned to the facility from the hospital emergency room with a [DIAGNOSES REDACTED].#95 ' s aggressive physical behaviors. On [DATE] at approximately 10:00 A.M, State tested Nurse Aide (STNA) #128 heard Resident #95 repeatedly yelling at Resident #45 to "Get away from me." STNA #45 assisted Resident #45 away from Resident #95's room. This incident was not reported to the supervisor and no action was taken to address Resident #95's behavior and protect Resident #45 and other residents wandering in the vicinity of Resident #95. At 10:40 A.M. on [DATE], Resident #83 was found lying on the floor outside the room of Resident #95. Resident #95 pushed Resident #83 out of his wheelchair causing Resident #83's head to hit the floor. Resident #83 was taken to the hospital with [MEDICATION NAME] force trauma to his head and subsequently died . The Immediate Jeopardy was removed on [DATE] at 10:45 A.M. when the local police arrested Resident #95 and the facility determined no other residents residing in the locked Dementia Unit exhibited violent behaviors and/or verbal threats towards other residents. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 until it was corrected on [DATE] when the facility implemented the following corrective actions: *On [DATE], the Regional Director of Clinical Services #200 educated the Administrator, all department heads, the DON, and all unit managers on recognizing, intervening, reporting and documenting on residents with behavioral disturbances. They educated all employees prior to allowing them to return to their work duties. *On [DATE], the Regional Director of Clinical Services #200 educated the interdisciplinary team about completing daily clinical rounds; quick response/notifications to the Administrator; Resident abuse-investigation and reporting requirements; incorporating new interventions on the plan of care after any behavioral incident; and nurse and social work documentation requirements. *On [DATE], all nurses and state tested nurse aides (STNA) were re-educated on resident-specific psychosocial intervention changes. *Between [DATE] and [DATE], 15 staff members were interviewed and revealed they were aware of the steps to take if any residents were heard making threats or attempting to physically harm other residents. * The facility's Quality Assurance Action Plan included the Interdisciplinary Team to monitor residents daily for potential behavioral disturbances and ongoing monitoring of the Behavior/Intervention Monthly flow records. Findings include: Review of Resident #95's Admission Sheet stated he was a [AGE] year old male admitted to the facility's second floor locked Dementia Unit on [DATE] with [DIAGNOSES REDACTED]. A physician's progress note dated [DATE] by Physician #178 stated Resident #95 was admitted from home for long term care. This progress note further stated the resident was forgetful, had left hand numbness, left foot and ankle pain when walking, and ataxia. Resident #95 had a behavior plan of care dated [DATE] stating the resident had ineffective individual coping and exhibited the following behaviors: verbally abusive (cusses and yells), physically abusive (hits, kicks, punches), resist care (meds), inappropriate (throws tray into hallway), wandering(wanders and forgets where he is and why). The behavior care plan interventions included do not argue with Resident #95 at any time, keep environment as calm and stress free as possible and gently but firmly discourage inappropriate behavior. Resident #95 had a plan of care dated [DATE] for alteration in mood related to persistent anger with self and others and "gets aggressive. " The interventions included: approach in calm non-threatening manner; respond to requests and needs in a timely manner; keep environment calm and free of stress; monitor for increased signs of depression, tearfulness, negative statements, anger, repetitive complaints etc; and see behavior plan of care. The quarterly MDS assessment dated [DATE] identified the resident as able to be understood and capable of understanding others; having good recall; and independent with supervision. Review of a nursing note dated [DATE] and timed 4:30 P.M. stated a new order was obtained to send Resident #95 to a local hospital emergency room for a psychiatric evaluation. The note contained no documentation why the physician was called and why the new order was obtained. A review of the hospital discharge instructions dated [DATE] at 5:04 P.M. stated Resident #95 was returned to the facility with a [DIAGNOSES REDACTED]. The clinical record had no documentation of non-pharmacological interventions to address Resident #95 ' s aggressive behaviors. On [DATE] at 2:00 P.M., Licensed Practical Nurse (LPN) #61 was interviewed regarding the [DATE] incident. She stated on [DATE] at approximately 7:00 A.M., she heard Resident #95 yelling, " I ' m tired of your (Resident #68) screaming. You ' ve been screaming for three nights. " She stated in response to the yelling, she ran out of the nursing station to the common area. As she arrived, Resident #95 had his left hand raised up in an attempt to swing at Resident #68. She stated because it was his impaired left hand, Resident #95 missed hitting Resident #68. LPN #61 stated Resident #95 was definitely attempting to hit her (Resident #68). He was sent out that day, however all the emergency room did was prescribe [MEDICATION NAME] and sent him right back. She stated she thought they were going to admit Resident #95 to the hospital and she was disappointed they did not. She stated no non-pharmacological interventions to address his aggressive behaviors were put into place after his return to the facility. Review of Resident #45 ' s medical record revealed a [DIAGNOSES REDACTED]. A review of the quarterly Interdisciplinary Progress Note dated [DATE] documented Resident #45 had no increase in behaviors, walked independently without devices, wandered throughout unit and goes into others rooms occasionally. A review of the MDS assessment dated [DATE] stated Resident #45 was rarely understood, had short and long term memory problems, required supervision and cues for decision making and supervision for ambulation. On [DATE] at 11:40 A.M., STNA #128 was interviewed. She revealed that at approximately 10:00 A.M. on [DATE], she heard Resident #95 repeatedly yelling at another resident (Resident #45) to "get away from me." She stated she ran into the corridor because she knew of Resident #95's history of not wanting other residents in the corridor outside of his room. She assisted Resident #45 back to her room to get her out of his (Resident #95 ' s) way. She stated Resident #45 told her, " He (Resident #95) does not want me by his room. " STNA #128 stated she left Resident #45 unsupervised in her room and went into a different resident's room to provide care. She did not address Resident #95 ' s behaviors nor protect Resident #45. Review of Resident #83's medical record revealed the most recent quarterly MDS assessment dated [DATE] documented active [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed his speech was not clear and he was rarely understood when communicating; he had long term and short term memory problems; he was moderately impaired for cognitive skills for daily decision making; he had daily wandering behaviors; he required the extensive assistance of two staff for bed mobility, transferring, toilet use, personal hygiene, and bathing; he required the use of a wheel chair for mobility. Review of a Self Reported Incident Report dated [DATE] revealed on [DATE] at 10:40 A.M. Resident #95 was found standing over Resident #83 and Resident #95 was heard by LPN #84 making the statement, "That's what he gets, I told him to stay away from here." Resident #83 became non-responsive. 911 were called and he was taken to local hospital where he later died as a result of [MEDICATION NAME] force trauma to the head." Review of Resident #83's nursing notes dated [DATE] at 10:40 A.M. stated the resident was noted to have been pushed from the wheel chair as he propelled it down the hallway. Resident #83 fell from the wheel chair on the right side of his body. The nursing note stated the resident struck the right side of his head, his blood pressure was ,[DATE], his pulse was 126 and he was sweating profusely. A nurse's note timed 10:45 A.M. by LPN #84 stated the resident was assessed for injuries and was noted to have a hematoma to the right side of his head, an abrasion to the right knee and outer elbow. According to the note, the resident was assisted to the wheel chair and a cold compress was applied to the back of his neck. He was transported to the nursing station. At 10:47 A.M., LPN #84 documented the resident was assessed with [REDACTED]. At 10:50 A.M., LPN #84 documented the ambulance arrived to the unit and at 10:55 A.M. the resident was taken out of the facility via ambulance. On [DATE] at 10:00 A.M., LPN #84 was interviewed. He stated on [DATE] at 10:00 A.M., he was in the nursing station with the door open when he heard a loud thump and found Resident #83 on the floor. He stated he was the first to arrive on the scene and Resident #95 was just inside the door to his room saying, "That is what you get." He stated he did not see what happened. It appeared as if Resident #95 flipped the wheel chair with Resident #83 in it. Resident #83 was on the floor, on his right side and the wheel chair was on its right side, within a foot of the resident. LPN #84 stated Resident #83 had "a knot" on the right side of his head. After assessing Resident #83, two STNAs (he could not remember names) put him in his wheelchair and he took Resident #83 to the nursing station with him. He stated about four minutes after the fall, Resident #83 left the nursing station and propelled himself down the hall. An STNA came and informed him Resident #83 was " not acting right " (seemed unconscious but with eyes open and breathing funny) and he called 911. LPN #84 affirmed he was not aware of the facility abuse policy in regard to resident to resident abuse prior to this incident. On [DATE]at 1:50 P.M., the Regional Director of Clinical Services #200, Registered Nurse (RN) Unit Manager #135 (the RN manager for the locked dementia unit) and the Administrator were interviewed. During the interview, the Administrator stated she had not been notified of the resident to resident incident that occurred on [DATE] when Resident #95 was heard repeatedly yelling at Resident #68 and then intentionally swinging at the resident in an attempt to hit her. Both the Administrator and RN Unit Manager #135 stated they were not informed on [DATE] that STNA #128 heard Resident #95 repeatedly yelling at Resident 45 to "get away from me." The Administrator stated she was not notified of the situation with Resident #45 until after the incident with Resident #83. She stated she should have been notified of both incidents in accordance with the facility in order to develop interventions to protect residents. The facility's "Resident-to-Resident Altercations" policy revised [DATE] was reviewed. According to the policy facility staff were to monitor residents for aggressive/inappropriate behavior towards other residents. The policy stated all occurrences of such incidents shall be reported to the nurse supervisor, DON, and to the Administrator. Review of the "Resident Abuse" policy revised [DATE] revealed that it also stated that anyone with knowledge of resident abuse must report it immediately to their supervisor and the supervisor or DON must notify the Administrator immediately. The policy also stated that corrective action must be taken to protect the residents. This citation substantiated Complaint Number OH 703.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on record review, review of a self-reported incident (SRI) report, review of facility's abuse policy, and staff interview, the facility failed to implement their abuse policy to ensure staff immediately notified appropriate supervisory staff and the Administrator of resident to resident abuse by Resident #95 resulting in Immediate Jeopardy for one resident (#83) of eight sampled residents. Thirty-nine residents including Resident #45 residing on the locked dementia unit were also placed at risk for Immediate Jeopardy as Resident #95 had access to each of the residents. On [DATE] 10:45 A.M. the Administrator, Director of Nursing (DON), and Regional Director of Clinical Services #200 were notified of the Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 5:04 P.M. when Resident #95 returned to the facility from the hospital emergency room with a [DIAGNOSES REDACTED].#95 ' s aggressive physical behaviors. On [DATE] at approximately 10:00 A.M, State tested Nurse Aide (STNA) #128 heard Resident #95 repeatedly yelling at Resident #45 to "Get away from me." STNA #45 assisted Resident #45 away from Resident #95's room. This incident was not reported to the supervisor and no action was taken to address Resident #95's behavior and protect Resident #45 and other residents wandering in the vicinity of Resident #95. At 10:40 A.M. on [DATE], Resident #83 was found lying on the floor outside the room of Resident #95. Resident #95 pushed Resident #83 out of his wheelchair causing Resident #83's head to hit the floor. Resident #83 was taken to the hospital with [MEDICATION NAME] force trauma to his head and subsequently died . The Immediate Jeopardy was removed on [DATE] at 10:45 A.M. when the local police arrested Resident #95 and the facility determined no other residents residing in the locked Dementia Unit exhibited violent behaviors and/or verbal threats towards other residents. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 until it was corrected on [DATE] when the facility implemented the following corrective actions: *On [DATE], the Regional Director of Clinical Services #200 educated the Administrator, all department heads, the DON, and all unit managers on recognizing, intervening, reporting and documenting on residents with behavioral disturbances. They educated all employees prior to allowing them to return to their work duties. *On [DATE], the Regional Director of Clinical Services #200 educated the interdisciplinary team about completing daily clinical rounds; quick response/notifications to the Administrator; Resident abuse-investigation and reporting requirements; incorporating new interventions on the plan of care after any behavioral incident; and nurse and social work documentation requirements. *On [DATE], all nurses and state tested nurse aides (STNA) were re-educated on resident-specific psychosocial intervention changes. *Between [DATE] and [DATE], 15 staff members were interviewed and revealed they were aware of the steps to take if any residents were heard making threats or attempting to physically harm other residents. * The facility's Quality Assurance Action Plan included the Interdisciplinary Team to monitor residents daily for potential behavioral disturbances and ongoing monitoring of the Behavior/Intervention Monthly flow records. Findings include: Review of Resident #95's Admission Sheet stated he was a [AGE] year old male admitted to the facility's second floor locked Dementia Unit on [DATE] with [DIAGNOSES REDACTED]. A physician's progress note dated [DATE] by Physician #178 stated Resident #95 was admitted from home for long term care. This progress note further stated the resident was forgetful, had left hand numbness, left foot and ankle pain when walking, and ataxia. Resident #95 had a behavior plan of care dated [DATE] stating the resident had ineffective individual coping and exhibited the following behaviors: verbally abusive (cusses and yells), physically abusive (hits, kicks, punches), resist care (meds), inappropriate (throws tray into hallway), wandering(wanders and forgets where he is and why). The behavior care plan interventions included do not argue with Resident #95 at any time, keep environment as calm and stress free as possible and gently but firmly discourage inappropriate behavior. Resident #95 had a plan of care dated [DATE] for alteration in mood related to persistent anger with self and others and "gets aggressive. " The interventions included: approach in calm non-threatening manner; respond to requests and needs in a timely manner; keep environment calm and free of stress; monitor for increased signs of depression, tearfulness, negative statements, anger, repetitive complaints etc; and see behavior plan of care. The quarterly MDS assessment dated [DATE] identified the resident as able to be understood and capable of understanding others; having good recall; and independent with supervision. Review of a nursing note dated [DATE] and timed 4:30 P.M. stated a new order was obtained to send Resident #95 to a local hospital emergency room for a psychiatric evaluation. The note contained no documentation why the physician was called and why the new order was obtained. A review of the hospital discharge instructions dated [DATE] at 5:04 P.M. stated Resident #95 was returned to the facility with a [DIAGNOSES REDACTED]. The clinical record had no documentation of non-pharmacological interventions to address Resident #95 ' s aggressive behaviors. On [DATE] at 2:00 P.M., Licensed Practical Nurse (LPN) #61 was interviewed regarding the [DATE] incident. She stated on [DATE] at approximately 7:00 A.M., she heard Resident #95 yelling, " I ' m tired of your (Resident #68) screaming. You ' ve been screaming for three nights. " She stated in response to the yelling, she ran out of the nursing station to the common area. As she arrived, Resident #95 had his left hand raised up in an attempt to swing at Resident #68. She stated because it was his impaired left hand, Resident #95 missed hitting Resident #68. LPN #61 stated Resident #95 was definitely attempting to hit her (Resident #68). He was sent out that day, however all the emergency room did was prescribe [MEDICATION NAME] and sent him right back. She stated she thought they were going to admit Resident #95 to the hospital and she was disappointed they did not. She stated no non-pharmacological interventions to address his aggressive behaviors were put into place after his return to the facility. Review of Resident #45 ' s medical record revealed a [DIAGNOSES REDACTED]. A review of the quarterly Interdisciplinary Progress Note dated [DATE] documented Resident #45 had no increase in behaviors, walked independently without devices, wandered throughout unit and goes into others rooms occasionally. A review of the MDS assessment dated [DATE] stated Resident #45 was rarely understood, had short and long term memory problems, required supervision and cues for decision making and supervision for ambulation. On [DATE] at 11:40 A.M., STNA #128 was interviewed. She revealed that at approximately 10:00 A.M. on [DATE], she heard Resident #95 repeatedly yelling at another resident (Resident #45) to "get away from me." She stated she ran into the corridor because she knew of Resident #95's history of not wanting other residents in the corridor outside of his room. She assisted Resident #45 back to her room to get her out of his (Resident #95 ' s) way. She stated Resident #45 told her, " He (Resident #95) does not want me by his room. " STNA #128 stated she left Resident #45 unsupervised in her room and went into a different resident's room to provide care. She did not address Resident #95 ' s behaviors. STNA #128 stated she was not aware of the facility's policy regarding Resident to Resident abuse prior to this incident. Review of Resident #83's medical record revealed the most recent quarterly MDS assessment dated [DATE] documented active [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed his speech was not clear and he was rarely understood when communicating; he had long term and short term memory problems; he was moderately impaired for cognitive skills for daily decision making; he had daily wandering behaviors; he required the extensive assistance of two staff for bed mobility, transferring, toilet use, personal hygiene, and bathing; he required the use of a wheel chair for mobility. Review of a Self Reported Incident Report dated [DATE] revealed on [DATE] at 10:40 A.M. Resident #95 was found standing over Resident #83 and Resident #95 was heard by LPN #84 making the statement, "That's what he gets, I told him to stay away from here." Resident #83 became non-responsive. 911 were called and he was taken to local hospital where he later died as a result of [MEDICATION NAME] force trauma to the head." Review of Resident #83's nursing notes dated [DATE] at 10:40 A.M. stated the resident was noted to have been pushed from the wheel chair as he propelled it down the hallway. Resident #83 fell from the wheel chair on the right side of his body. The nursing note stated the resident struck the right side of his head, his blood pressure was ,[DATE], his pulse was 126 and he was sweating profusely. A nurse's note timed 10:45 A.M. by LPN #84 stated the resident was assessed for injuries and was noted to have a hematoma to the right side of his head, an abrasion to the right knee and outer elbow. According to the note, the resident was assisted to the wheel chair and a cold compress was applied to the back of his neck. He was transported to the nursing station. At 10:47 A.M., LPN #84 documented the resident was assessed with [REDACTED]. At 10:50 A.M., LPN #84 documented the ambulance arrived to the unit and at 10:55 A.M. the resident was taken out of the facility via ambulance. On [DATE] at 10:00 A.M., LPN #84 was interviewed. He stated on [DATE] at 10:00 A.M., he was in the nursing station with the door open when he heard a loud thump and found Resident #83 on the floor. He stated he was the first to arrive on the scene and Resident #95 was just inside the door to his room saying, "That is what you get." He stated he did not see what happened. It appeared as if Resident #95 flipped the wheel chair with Resident #83 in it. Resident #83 was on the floor, on his right side and the wheel chair was on its right side, within a foot of the resident. LPN #84 stated Resident #83 had "a knot" on the right side of his head. After assessing Resident #83, two STNAs (he could not remember names) put him in his wheelchair and he took Resident #83 to the nursing station with him. He stated about four minutes after the fall, Resident #83 left the nursing station and propelled himself down the hall. An STNA came and informed him Resident #83 was " not acting right " (seemed unconscious but with eyes open and breathing funny) and he called 911. LPN #84 affirmed he was not aware of the facility abuse policy in regard to resident to resident abuse prior to this incident. On [DATE]at 1:50 P.M., the Regional Director of Clinical Services #200, Registered Nurse (RN) Unit Manager #135 (the RN manager for the locked dementia unit) and the Administrator were interviewed. During the interview, the Administrator stated she had not been notified of the resident to resident incident that occurred on [DATE] when Resident #95 was heard repeatedly yelling at Resident #68 and then intentionally swinging at the resident in an attempt to hit her. Both the Administrator and RN Unit Manager #135 stated they were not informed on [DATE] that STNA #128 heard Resident #95 repeatedly yelling at Resident 45 to "get away from me." The Administrator stated she was not notified of the situation with Resident #45 until after the incident with Resident #83. She stated she should have been notified of both incidents in accordance with the facility. The facility's "Resident-to-Resident Altercations" policy revised [DATE] was reviewed. According to the policy facility staff were to monitor residents for aggressive/inappropriate behavior towards other residents. The policy stated all occurrences of such incidents shall be reported to the nurse supervisor, DON, and to the Administrator. Review of the "Resident Abuse" policy revised [DATE] revealed that it also stated that anyone with knowledge of resident abuse must report it immediately to their supervisor and the supervisor or DON must notify the Administrator immediately. The policy also stated that corrective action must be taken to protect the residents. This citation substantiated Complaint Number OH 703.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on record review, observation, staff and resident interviews, review of a facility Self Reported Incident (SRI) and review of the facility abuse policy, the facility failed to prevent resident to resident abuse by Resident #95 resulting in Immediate Jeopardy for one resident (#83) of eight sampled residents. Thirty-nine residents including Resident #45 residing on the locked dementia unit were also placed at risk for Immediate Jeopardy as Resident #95 had access to each of the residents. On [DATE] 10:45 A.M. the Administrator, Director of Nursing (DON), and Regional Director of Clinical Services #200 were notified of the Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 5:04 P.M. when Resident #95 returned to the facility from the hospital emergency room with a [DIAGNOSES REDACTED].#95 ' s aggressive physical behaviors. On [DATE] at approximately 10:00 A.M, State tested Nurse Aide (STNA) #128 heard Resident #95 repeatedly yelling at Resident #45 to "Get away from me." STNA #45 assisted Resident #45 away from Resident #95's room. This incident was not reported to the supervisor and no action was taken to address Resident #95's behavior and protect Resident #45 and other residents wandering in the vicinity of Resident #95. At 10:40 A.M. on [DATE], Resident #83 was found lying on the floor outside the room of Resident #95. Resident #95 pushed Resident #83 out of his wheelchair causing Resident #83's head to hit the floor. Resident #83 was taken to the hospital with [MEDICATION NAME] force trauma to his head and subsequently died . The Immediate Jeopardy was removed on [DATE] at 10:45 A.M. when the local police arrested Resident #95 and the facility determined no other residents residing in the locked Dementia Unit exhibited violent behaviors and/or verbal threats towards other residents. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 until it was corrected on [DATE] when the facility implemented the following corrective actions: * On [DATE], registered nurse (RN) supervisors and staff nurses completed assessments on all residents for potential aggressive behavioral disturbances. No residents were identified with violent behaviors. The interdisciplinary team reviewed all of the care plans of residents with behavioral disturbances and updated them as needed. *On [DATE], the Regional Director of Clinical Services #200 educated the Administrator, all department heads, the DON, and all unit managers on recognizing, intervening, reporting and documenting on residents with behavioral disturbances. They educated all employees prior to allowing them to return to their work duties. *On [DATE], the Regional Director of Clinical Services #200 educated the interdisciplinary team about completing daily clinical rounds; quick response/notifications to the Administrator; Resident abuse-investigation and reporting requirements; incorporating new interventions on the plan of care after any behavioral incident; and nurse and social work documentation requirements. *On [DATE], all nurses and state tested nurse aides (STNA) were re-educated on resident-specific psychosocial intervention changes. *Between [DATE] and [DATE], 15 staff members were interviewed and revealed they were aware of the steps to take if any residents were heard making threats or attempting to physically harm other residents. * The facility's Quality Assurance Action Plan included the Interdisciplinary Team to monitor residents daily for potential behavioral disturbances and ongoing monitoring of the Behavior/Intervention Monthly flow records. * Observations conducted on [DATE], [DATE], [DATE] and [DATE] revealed nursing, activity, and or Administrative staff were interacting and supervising the residents. None of the residents in the facility displayed any fearful or aggressive behaviors. * From [DATE] through [DATE], interview with five residents revealed they had not been physically or verbally abused by any staff or residents and all stated they were not fearful of anyone on their unit. Findings include: Review of Resident #95's Admission Sheet stated he was a [AGE] year old male admitted to the facility's second floor locked Dementia Unit on [DATE] with [DIAGNOSES REDACTED]. A physician's progress note dated [DATE] by Physician #178 stated Resident #95 was admitted from home for long term care. This progress note further stated the resident was forgetful, had left hand numbness, left foot and ankle pain when walking, and ataxia. Resident #95 had a behavior plan of care dated [DATE] stating the resident had ineffective individual coping and exhibited the following behaviors: verbally abusive (cusses and yells), physically abusive (hits, kicks, punches), resist care (meds), inappropriate (throws tray into hallway), wandering(wanders and forgets where he is and why). The behavior care plan interventions included do not argue with Resident #95 at any time, keep environment as calm and stress free as possible and gently but firmly discourage inappropriate behavior. Resident #95 had a plan of care dated [DATE] for alteration in mood related to persistent anger with self and others and "gets aggressive. " The interventions included: approach in calm non-threatening manner; respond to requests and needs in a timely manner; keep environment calm and free of stress; monitor for increased signs of depression, tearfulness, negative statements, anger, repetitive complaints etc; and see behavior plan of care. The quarterly MDS assessment dated [DATE] identified the resident as able to be understood and capable of understanding others; having good recall; and independent with supervision. Review of a nursing note dated [DATE] and timed 4:30 P.M. stated a new order was obtained to send Resident #95 to a local hospital emergency room for a psychiatric evaluation. The note contained no documentation why the physician was called and why the new order was obtained. A review of the hospital discharge instructions dated [DATE] at 5:04 P.M. stated Resident #95 was returned to the facility with a [DIAGNOSES REDACTED]. The clinical record had no documentation of non-pharmacological interventions to address Resident #95 ' s aggressive behaviors. On [DATE] at 2:00 P.M., Licensed Practical Nurse (LPN) #61 was interviewed regarding the [DATE] incident. She stated on [DATE] at approximately 7:00 A.M., she heard Resident #95 yelling, " I ' m tired of your (Resident #68) screaming. You ' ve been screaming for three nights. " She stated in response to the yelling, she ran out of the nursing station to the common area. As she arrived, Resident #95 had his left hand raised up in an attempt to swing at Resident #68. She stated because it was his impaired left hand, Resident #95 missed hitting Resident #68. LPN #61 stated Resident #95 was definitely attempting to hit her (Resident #68). He was sent out that day, however all the emergency room did was prescribe [MEDICATION NAME] and sent him right back. She stated she thought they were going to admit Resident #95 to the hospital and she was disappointed they did not. She stated no non-pharmacological interventions to address his aggressive behaviors were put into place after his return to the facility. Review of Resident #45 ' s medical record revealed a [DIAGNOSES REDACTED]. A review of the quarterly Interdisciplinary Progress Note dated [DATE] documented Resident #45 had no increase in behaviors, walked independently without devices, wandered throughout unit and goes into others rooms occasionally. A review of the MDS assessment dated [DATE] stated Resident #45 was rarely understood, had short and long term memory problems, required supervision and cues for decision making and supervision for ambulation. On [DATE] at 11:40 A.M., STNA #128 was interviewed. She revealed that at approximately 10:00 A.M. on [DATE], she heard Resident #95 repeatedly yelling at another resident (Resident #45) to "get away from me." She stated she ran into the corridor because she knew of Resident #95's history of not wanting other residents in the corridor outside of his room. She assisted Resident #45 back to her room to get her out of his (Resident #95 ' s) way. She stated Resident #45 told her, " He (Resident #95) does not want me by his room. " STNA #128 stated she left Resident #45 unsupervised in her room and went into a different resident's room to provide care. She did not address Resident #95 ' s behaviors. On [DATE] at 7:15 A.M., Resident #45 was observed walking on the secured unit. An attempt was made to interview Resident #45 at that time but she did not answer any questions and walked off. Resident #45 smiled and was pleasant. Review of Resident #83's medical record revealed the most recent quarterly MDS assessment dated [DATE] documented active [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed his speech was not clear and he was rarely understood when communicating; he had long term and short term memory problems; he was moderately impaired for cognitive skills for daily decision making; he had daily wandering behaviors; he required the extensive assistance of two staff for bed mobility, transferring, toilet use, personal hygiene, and bathing; he required the use of a wheel chair for mobility. Review of a Self Reported Incident Report dated [DATE] revealed on [DATE] at 10:40 A.M. Resident #95 was found standing over Resident #83 and Resident #95 was heard by LPN #84 making the statement, "That's what he gets, I told him to stay away from here." Resident #83 became non-responsive. 911 were called and he was taken to local hospital where he later died as a result of [MEDICATION NAME] force trauma to the head." Review of Resident #83's nursing notes dated [DATE] at 10:40 A.M. stated the resident was noted to have been pushed from the wheel chair as he propelled it down the hallway. Resident #83 fell from the wheel chair on the right side of his body. The nursing note stated the resident struck the right side of his head, his blood pressure was ,[DATE], his pulse was 126 and he was sweating profusely. A nurse's note timed 10:45 A.M. by LPN #84 stated the resident was assessed for injuries and was noted to have a hematoma to the right side of his head, an abrasion to the right knee and outer elbow. According to the note, the resident was assisted to the wheel chair and a cold compress was applied to the back of his neck. He was transported to the nursing station. At 10:47 A.M., LPN #84 documented the resident was assessed with [REDACTED]. At 10:50 A.M., LPN #84 documented the ambulance arrived to the unit and at 10:55 A.M. the resident was taken out of the facility via ambulance. On [DATE] at 10:00 A.M., LPN #84 was interviewed. He stated on [DATE] at 10:00 A.M., he was in the nursing station with the door open when he heard a loud thump and found Resident #83 on the floor. He stated he was the first to arrive on the scene and Resident #95 was just inside the door to his room saying, "That is what you get." He stated he did not see what happened. It appeared as if Resident #95 flipped the wheel chair with Resident #83 in it. Resident #83 was on the floor, on his right side and the wheel chair was on its right side, within a foot of the resident. LPN #84 stated Resident #83 had "a knot" on the right side of his head. After assessing Resident #83, two STNAs (he could not remember names) put him in his wheelchair and he took Resident #83 to the nursing station with him. He stated about four minutes after the fall, Resident #83 left the nursing station and propelled himself down the hall. An STNA came and informed him Resident #83 was " not acting right " (seemed unconscious but with eyes open and breathing funny) and he called 911. On [DATE]at 1:50 P.M., the Regional Director of Clinical Services #200, Registered Nurse (RN) Unit Manager #135 (the RN manager for the locked dementia unit) and the Administrator were interviewed. During the interview, the Administrator stated she had not been notified of the resident to resident incident that occurred on [DATE] when Resident #95 was heard repeatedly yelling at Resident #68 and then intentionally swinging at the resident in an attempt to hit her. Both the Administrator and RN Unit Manager #135 stated they were not informed on [DATE] that STNA #128 heard Resident #95 repeatedly yelling at Resident 45 to "get away from me." The Administrator stated she was not notified of the situation with Resident #45 until after the incident with Resident #83. She stated she should have been notified of both incidents in accordance with the facility. The facility's "Resident-to-Resident Altercations" policy revised [DATE] was reviewed. According to the policy facility staff were to monitor residents for aggressive/inappropriate behavior towards other residents. The policy stated all occurrences of such incidents shall be reported to the nurse supervisor, DON, and to the Administrator. Review of the "Resident Abuse" policy revised [DATE] revealed that it also stated that anyone with knowledge of resident abuse must report it immediately to their supervisor and the supervisor or DON must notify the Administrator immediately. The policy also stated that corrective action must be taken to protect the residents. This citation substantiated Complaint Number OH 703.

Based on closed clinical record review, interviews with the physician, nurse practitioner and facility staff, and review of the American Diabetes Association guidelines, the facility failed to provide necessary care and services when staff failed to immediately address a resident ' s clinical change in condition and a critically high blood sugar level. This resulted in Immediate Jeopardy for one (Resident #63) of 12 residents reviewed for critical lab values. The facility census was 81. On [DATE] at 1:30 P.M., the Administrator and the Corporate Nurse were notified Immediate Jeopardy began on [DATE] at approximately 3:30 P.M. when Resident #63 was observed with an acute change in clinical condition. The resident was non-responsive and grimacing only to a sternal rub. Nurse Practitioner #303 was notified on [DATE] at 3:30 P.M. of the change in condition and ordered immediate (STAT) serum laboratory tests for Resident #63 including a basic metabolic panel (BMP) to assess electrolyte levels and blood sugar. On [DATE] at 9:41 P.M., Resident #63 ' s BMP result was sent by the laboratory to the facility via facsimile (fax). The BMP result indicated a critically high blood sugar level of 1035 milligrams per deciliter (mg/dL) (normal level ,[DATE] mg/dL). The abnormal laboratory results documenting the critically high blood sugar sat on the fax machine until approximately 7:00 A.M. on [DATE] when Nurse Practitioner #303 reviewed them. The resident ' s critically high blood sugar was not treated and Resident #63 expired on [DATE] at 8:30 P.M. The Immediate Jeopardy was removed and the deficiency corrected on [DATE] when the facility took the following corrective actions: - On [DATE], all residents were assessed for a change in condition by the Director of Nursing and the staff nurses. -On [DATE], 39 nurses were in-serviced by the Director of Nursing on recognizing and intervening when residents have a change in condition, timely communication and response to STAT and/or critical laboratory results. The in-service included a review of current policies entitled, " Review of the Resident Change in Condition " policy dated [DATE], Guidelines for Notifying Physicians of Clinical Problems revised 2007 and Change in Shift Report dated [DATE]. Staff training included the nurse assigned to the resident is responsible to call the lab to check on the results and then check the fax machine every 15 minutes until the results are received. - On [DATE], the Director of Nursing and designees completed assessments of all residents for outstanding lab results. -On [DATE], the Nurse Practitioner was in-serviced by the Regional Director of Clinical Services on the need to notify the collaborating physician of a critical change in condition -A Quality Assurance Plan was initiated on [DATE] by the Nursing Administration. The plan included in-servicing nursing staff, and monitoring of residents for a change in condition and outstanding laboratory results. Monitoring will be completed daily for thirty days, then three times a week for 30 days. -On [DATE], no current residents were exhibiting a change in condition or had outstanding lab results. -On [DATE], interview with four nurses, LPN #22, LPN #21, LPN #110 and LPN #84 nurses verified they had been in-serviced and were knowledgeable on recognizing and intervening for a change in condition, timely communication and response to stat and/or critical laboratory results. Findings include: Review of Resident #63 ' s closed clinical record revealed a Progress Note dated [DATE] that documented [DIAGNOSES REDACTED]. The progress note further stated the diabetes was stable with the hemoglobin A1C (a blood test used to monitor average blood sugar during a 1 -4 month period) was 5.8% (controlled range is 4.5 - 7.5%) on [DATE]. Review of the minimum data set (MDS) assessment dated [DATE] indicated the resident had short and long term memory problems and had moderately impaired cognition for daily decision making skills. Further review revealed she required extensive assistance of one person in the areas of transfer, ambulation, dressing, eating and personal hygiene. The MDS documented she did not have a condition or chronic disease that may have resulted in life expectancy of less than six months. Review of the nurse ' s notes from [DATE] to [DATE] revealed no change in her clinical condition. Nursing notes dated [DATE] at 3:30 P.M. documented Resident #63 was assessed by Licensed Practical Nurse (LPN) #52 with twitching of the face and neck, an elevated pulse of 113 beats per minute, and an elevated blood pressure of ,[DATE]. Resident #63 responded to sternal rub only with a facial grimace. Nurse Practitioner #303 was notified and ordered STAT serum labs for the resident. Nursing notes on [DATE] at 6:00 P.M. documented Resident #63 was in bed with her eyes closed. There was no further assessment documented in the nursing notes until [DATE] at 5:00 P.M. The laboratory report dated [DATE] at 8:24 P.M. documented urinalysis results of 4+ glucose with bacteria (abnormal) in the urine. The results of the BMP dated [DATE] at 9:41 P.M. stated it was the final report and documented the physician's name was verified with Unit Manager #135. The BMP results included blood glucose level was 1035 mg/dl (normal ,[DATE] mg/dl) and the sodium level was 158 mEq/L (normal 135 -145 mEq/L). There was no documentation the physician or nurse practitioner was notified of the abnormal results at that time. Nurse Practitioner #303 ' s progress notes [DATE], time unknown, stated she came to the facility, examined Resident #63 and reviewed the " critical lab " results. Nurse Practitioner #303 ordered all routine medications discontinued. Nursing notes dated ,[DATE]/ 11 at 3:00 P.M., documented Resident #63 was resting in bed with her eyes closed. Her blood pressure was ,[DATE], pulse 57 beats per minute, and respirations 21 breaths per minute. Her blood oxygen saturation was unable to be obtained. Resident #63 was non-responsive to voice or touch. Her respirations were quick and shallow. There were no further nursing notes until [DATE] at 8:30 P.M. when Resident #63 was found in her bed without a blood pressure, pulse or respirations. RN #135 confirmed the resident had expired. LPN #52, who was assigned to care for Resident #63 on [DATE] from 7:00 A.M. to 7:00 P.M., was interviewed on [DATE] at 10:27 A.M. She stated around 3:30 P.M., she noticed staff in the resident ' s room and they were having " issues " getting her up for dinner. She indicated she assessed Resident #63 ' s vital signs and noted her pulse was elevated. She notified Nurse Practitioner #303 and requested her to come in and see the resident. Nurse Practitioner #303 notified the nurse that she could not come to the facility that day and ordered STAT serum blood work. LPN #52 documented the orders and notified the lab of the STAT orders. LPN #52 stated the lab results were not received at the facility by the end of her shift at 7:00 P.M. She stated that she gave report to Night Shift Supervisor Registered Nurse (RN) #91 and also wrote the immediate labs were pending on the 24 hour shift report. The 24 Hour Report/Change of Condition Report dated [DATE] under the 7:00 A.M. - 7:00 P. M. was reviewed. The report revealed a STAT complete blood count (CBC), basic metabolic panel (BMP) and urinalysis tests were ordered. The report further documented that the resident (#63) was not feeling well and " see nurse ' s notes. " Interview with State tested Nurse Aide (STNA) #140 on [DATE] at 3:15 P.M. revealed she worked with Resident #63 on [DATE] from 3:00 P.M to 11:00 P.M. She stated around 3:30 P.M. or 4:00 P.M., she went to get Resident #63 up for supper. She stated the resident was not responding per her normal self. She stated she called for the nurse. Two nurses assessed her and stated to leave Resident #63 in bed. STNA #140 stated the resident was not able to eat or drink that evening and she normally ate her meals in the dining room. LPN #22, who was assigned to care for Resident #63 on [DATE] from 8:30 P.M. to 7:00 A.M., was interviewed on [DATE] at 3:47 P.M. The facility had called her into work on the evening of [DATE]. She stated when she arrived at the facility; Night Shift Supervisor RN #91 gave her the keys to the medication cart but did not give her report. She stated she was not aware Resident #63 was ill until she got into her room. LPN #22 stated she helped the STNAs clean Resident #63 because she had food on her. She stated Resident #63 " appeared to be dying. " LPN #22 stated she reviewed Resident #63 ' s chart and noticed she was a do not resuscitate (DNR); therefore, so she did not send her out for treatment. She stated she thought it was " pointless " to send her out because she was " obviously dying. " She stated she did not document anything in the nursing notes about Resident #63 ' s condition because she was too busy. She further stated she did not look at the 24 hour shift report. LPN #22 stated Resident #63 was unresponsive all night and she assumed management knew of Resident #63 ' s status and did not provide any interventions to treat her clinical condition. She stated she was not aware Resident #63 had pending STAT labs and did not check the facility fax machine for any lab results. Night Shift Supervisor RN #91, who worked on [DATE] from 7:00 P.M. to 7:00 A.M., was interviewed on [DATE] at 10:30 A.M. She stated she was aware lab tests had been drawn on Resident #63 but she was not aware they were STAT labs. She stated she gave report to LPN #22 around 8:00 or 8:30 P.M. and had reported to her that labs had been drawn on Resident #63. She stated the charge nurse (LPN #22) was responsible for the lab results. She had been on the unit several times throughout the night and assumed nothing was wrong because LPN #22 never reported any concerns to her. She stated she never saw the STAT lab results. RN #91 stated she had assessed the resident but did not document her assessment. The resident was very lethargic when she did assess her. She stated she did not notify the physician of the resident ' s continued lethargy because she was aware Nurse Practitioner #303 had already been notified earlier in the day. She affirmed that she did not provide any interventions to address Resident #63 ' s change in condition nor did check the facility fax machine. She stated had she been aware Resident #63 had critical lab results, she would have notified both Nurse Practitioner #303 and the physician of the results. LPN #84, who was assigned care for Resident #63 on [DATE] from 7:00 A.M. to 7:00 P.M, was interviewed on [DATE] at 11:07 A.M. He stated he did not recall who gave him report that morning but he believed it was Night Shift Supervisor RN #91. He stated Resident #63 was restless throughout the day and he had assessed her vitals. He stated that he was not able to get an oxygen saturation level because her skin was clammy. He stated her breathing was shallow and she did have a " fruity odor to her breath. " He stated he did not assess her blood sugar or notify the physician of his assessment. He stated he did not provide any interventions to address her clinical condition because the nurse practitioner was aware of the residents change in condition. He stated he was not aware STAT labs had been drawn on Resident #63 and was not aware of the results until Nurse Practitioner #303 told him the resident ' s blood sugar level was critically high. All they could do at this point was make her comfortable. He stated at the time Nurse Practitioner #303 assessed Resident #63, she was unresponsive. Unit Manager #135, who worked on [DATE] and [DATE] from 7:00 A.M. to 7:00 P.M., was interviewed on [DATE] at 12:24 P.M. She stated on [DATE] she had worked beyond her scheduled shift and around 8:40 P.M., the lab called in the results of Resident #63 ' s urinalysis and complete blood count. She stated the lab did not report any critical levels from the basic metabolic panel to her as the results from the basic metabolic panel were still pending at that time. She stated they wanted to verify the physician ' s name and indicated they would fax the remaining lab results to the facility on ce the results became available. She stated she was aware of Resident #63 ' s vital signs and that she did not feel good. She stated on the morning of [DATE], Nurse Practitioner #303 asked her if she was aware of the critical lab results. She stated the Nurse Practitioner did not want to treat the resident at that point because Resident #63 was actively dying. She stated she did not provide any interventions because the nurse practitioner had indicated the resident was actively dying. Interview with Nurse Practitioner #303on [DATE] at 12:50 P.M. revealed when she assessed Resident #63 on [DATE], she was actively dying, her pulse was over 120 beats per minute and her respirations were 36 breaths per minute. She stated she discussed her concerns with the resident ' s attending physician and the resident ' s son. She stated she believed the resident had acute [MEDICAL CONDITION] and was septic as her white blood count and her temperature were elevated. She stated no one from the facility had notified her of the resident ' s critical lab values and she did not become aware of the critically high lab results until she came to the facility on [DATE]. She stated she believed the resident was critically ill and actively dying at that time. She stated that the physician and the resident ' s son were in agreement not to treat Resident #63. Physician #178, the resident ' s attending physician, stated during a telephone interview on [DATE] at 2:55 P.M. that Nurse Practitioner #303 did not call him until after Resident #63 had expired. He stated it was a surprise that her blood glucose level was that high because her last hemoglobin A1C, a blood test for blood sugar control, showed her blood sugars had been in the normal range. He stated the resident must have had some sort of stressor or infection for her blood sugar to have been that high. He stated the course of treatment depends on the resident and on family wishes. He stated a resident could be sent to the hospital to treat the elevated blood sugar. During a follow up interview with Physician #178 on [DATE] at 2:00 P.M., he stated by the time the Nurse Practitioner had assessed Resident #63, she was " too far gone " and she was actively dying. A review of the facility Change in Resident Condition policy dated [DATE] stated the charge nurse will recognize and appropriately intervene in the event of a change in resident condition. The Physician/Family/Responsible will be notified as soon as the nurse has identified the change in condition and the resident is stable. The procedure included, all physician interventions will be immediately carried out by the charge nurse and overseen by the DON/designee manager/supervisor. The Guidelines for Notifying Physicians of Clinical Problems revised [DATE] stated the specific symptoms, signs and laboratory values require prompt immediate notification of the physician after an appropriate nursing evaluation. Immediate implies that the physician should be notified as soon as possible, either by phone or pager. These situations included: any lab report, normal or abnormal, which the physician requests on a " STAT " basis. According to the American Diabetes Association (www.diabetes.org <http://www.diabetes.org>), [MEDICAL CONDITION] exists when a person ' s blood glucose is above 240 mg/dl. If left untreated, a condition called ketoacidosis (diabetic coma) can occur. [MEDICATION NAME] are acids that build up in the blood and appear in the urine. The [MEDICATION NAME] are a warning sign that diabetes is out of control. High levels of [MEDICATION NAME] can poison the body, leading to diabetic coma and death. Signs of ketoacidosis include: shortness of breath, nausea, vomiting and breath that smells fruity. This citation substantiated Complaint Number OH 213.