Every finding on record at Ohio Living Llanfair

Based on observation, staff interview, and policy revealed the facility failed to ensure medications are properly stored. This had the potential to affect one resident (#5) out of nine residents observed for medication storage. The facility also failed to ensure medications are labeled properly and not expired. This affected one (#3) of nine residents reviewed for medication labeling with the potential to affect all residents. The facility census was 33.1. Observation on [DATE] revealed Resident #5 was lying in bed asleep with her morning medications in a cup on the bedside table. Interview on [DATE] at 10:20 A.M with Licensed Practical Nursing (LPN) #8 confirmed medications were left on the bedside table. Review of Resident #5's Medication Administration Record (MAR) revealed in the medications in the cup there was Citalopram 20 milligrams (mg), cranberry tablet 450 mg, Eliquis 5 mg, famotidine 20 mg, Lisinopril 40 mg, Methenamine 1 gram, Senna-s 8.6 -50 mg, and acetaminophen 325 mg. 2. Observation on [DATE] at 4:37 P.M. of Rehab Medication Storage room with the Director of Nursing (DON) revealed an open tuberculin vial with no open date. Interview on [DATE] at 4:38 PM with the DON confirmed the open tuberculin vial did not have an open date and was supposed to. 3. Observation on [DATE] at 4:40 PM of the Rehab Medication Cart #2 revealed Resident #3 had Humalog U-100 insulin (insulin Lispro) solution with an open date for [DATE]. Interview on [DATE] at 4:41 P.M. with Licensed Practical Nurse (LPN) #8 confirmed Resident #3 had Humalog U-100 insulin (insulin Lispro) solution with an open date for [DATE]. Record Review for Resident #3 Medication Administration Record (MAR) revealed Resident #3 had an order, Humalog U-100 insulin (insulin Lispro) solution 100 units, dated for [DATE] - [DATE] and the same order dated [DATE] - [DATE]. The MAR also revealed the last date the Humalog U-100 insulin (insulin Lispro) solution 100 units was administered on [DATE]. Review of the facility policy titled, Medication Storage dated on [DATE] revealed all prescription medications shall be kept in locked storage areas and separate from materials that may contaminate the medicines and drugs. Review of the facility policy titled, Medication Administration dated on 01/2025 revealed Multi dose vials: Must have an open date for 28 days or per manufacturer's guidelines. The policy also stated the resident is always observed after administration to ensure that the dose was completely ingested.

Based on observation, interview, and facility policy review, the facility failed to provide a clean and sanitary kitchen in the main kitchen, failed to ensure the dishwasher properly sanitized the dishes on the Memory Care Unit, and failed to ensure the dietary staff utilize the use of hair nets. This had the potential to affect all residents who receive food from the kitchen. The facility identified all 33 residents receive food from the kitchen. The facility census was 33.1. Observation on 12/29/25 at 9:35 A.M. of Certified Nurse Assistant (CNA #178) revealed CNA #178 was hand washing the dishes in the Memory Care Unit kitchen with a regular household dish liquid and placed the dishes in the dishwasher. CNA #178 was not wearing a hair net. Continued observation of CNA #178 utilizes the dishwasher revealed neither the rinse or wash reached above 130 Fahrenheit (F) and the dishwasher was flashing add sanitizer.Interview on 12/29/25 at 9:35 A.M. with CNA #178 verified she was hand washing dishes in household detergent without a hair net. CNA #178 confirmed she does not utilize sanitizer in the sink because she utilizes the dishwasher. CNA #178 read the front of the dishwasher that confirmed the wash cycle should reach 160 degrees F and the rinse cycle should reach 180 degrees F if sanitizer is not used in the dishwasher. CNA #178 confirmed the dishwasher stated the temperature should reach 130 degrees F if sanitizer is being used. CNA #178 confirmed she ran the dishwasher a total of three times and each time the dishwasher continuously flashed add sanitizer. CNA #178 confirmed the dishwasher did not reach higher than 130 degrees F. CNA #178 confirmed the facility failed to maintain a dishwasher temperature log for the memory care unit. Interview on 12/29/25 at 11:22 A.M. with Dietary Manager (DM) #401 confirmed the dishwasher in the Memory Care Unit was flashing add sanitizer. DM #401 confirmed the facility failed to maintain a temperature log for the Memory Care Unit dishwasher. Review of the dishwasher temperature logs revealed the Memory Care kitchen did not have a dishwasher temperature log to review. 2. Observation on 12/30/25 at 11:45 A.M. with Registered Dietician (RD) #400 revealed the ceiling vents above the milk freezer near the food preparation table had dirt, and fuzzy debris hanging from it.Interview on 12/30/25 at 11:45 A.M. with RD #400 confirmed the kitchen vent had dirt, and fuzzy debris hanging from it. RD #400 confirmed the vent over milk freezer and food preparation area had dirt, fuzzy debris hanging from it.Review of the facility policy titled, Cleaning Dishes/Dish Machine, dated 2023, confirmed all flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. The dish machine will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning. Prior to use, proper temperatures and/or chemical concentrations and machine function should be verified. Confirm that soap and rinse dispensers are filled and have enough clearing products for the shift. Further review of the policy revealed the staff should check the dish machine gauges throughout the cycle to ensure proper temperatures for sanitation. Review of the facility policy titled, Employee Hygiene for Food Safety, dated 2023 confirmed the facility staff will wear hair restraints (hairnet or hat) to prevent hair from contacting exposed food. Review of the undated facility policy titled, General Sanitation of Kitchen, confirmed the cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule. Employees will be trained in how to perform cleaning tasks.

Based on interview, record review, and policy review the facility failed to maintain record of pneumococcal vaccine administration and failed to offer pneumococcal vaccines to residents. This impacted two residents (#18 and #33) of five residents reviewed for pneumococcal vaccine administration. The facility census was 33. 1. Record review for Resident #18 revealed resident was admitted on [DATE] with diagnoses including need for assistance with personal care; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; other asthma; and respiratory disorders in diseases classified elsewhere. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Resident #18 had no behaviors, required setup assistance for eating and oral hygiene, substantial assistance for toileting, bathing, and upper and lower body dressing, and supervision assistance for personal hygiene, and resident refused mobility assessment.Further record review for Resident #18 revealed no documentation indicating the resident and/or resident's representative were offered a pneumococcal vaccine since admission. Record review also revealed no documentation of pneumococcal vaccine administration prior to admission.Interview on 12/31/2025 at 8:01 A.M. with Director of Nursing (DON) revealed the resident and/or resident's representative declined a pneumococcal vaccine in 2023. The DON further reported that a pneumococcal vaccine had not been offered to the resident and/or the resident's representative since declination in 2023.2. Record review for Resident #33 revealed resident was admitted on [DATE] with diagnoses that included repeat falls; psychotic disorder with delusions due to known physiological condition; transient cerebral ischemic attack, unspecified (history of); other asthma; muscle weakness (generalized); depression, unspecified; anxiety disorder, unspecified; delusional disorders; and respiratory disorders in diseases classified elsewhere. Review of the MDS dated [DATE] revealed Resident #33 was moderately cognitively impaired, and the MDS dated [DATE] revealed the resident rejected care four to six days a week. In addition, MDS dated [DATE] revealed Resident #33 required setup assistance for eating and oral hygiene, substantial assistance with upper body dressing and personal hygiene, was dependent for toileting, bathing, lower body dressing, sit to lying, lying to sitting, sit to stand, and transfers.Further record review for Resident #33 revealed resident received pneumococcal vaccine (PCV - 13) on 05/20/2015. Documentation review revealed no additional pneumococcal vaccines were offered to the resident and/or the resident's representative since admission.Interview on 12/31/2025 at 8:01 A.M. with DON revealed that the resident and/or resident's representative was not offered a pneumococcal vaccine since admission.Review of a document titled Influenza and Pneumococcal Vaccines with a revised date of 10/05/2025 revealed that Each resident is offered .pneumococcal immunization at least once, unless immunization is medically contraindicated, or the resident has already been immunized with pneumococcal vaccine within the past five years.

Based on record review, staff interview, and policy review revealed the facility failed to ensure each resident receives adequate supervision to prevent accidents. This affected one Resident (#5) out of 5 residents reviewed for accidents. The facility also failed to document or implement immediate interventions for falls. This affected one Resident (#33) out of 5 residents reviewed for accidents. The facility census was 33.1. Medical record review for Resident #33 revealed she was admitted to the facility on [DATE]. Her diagnoses included myelodysplastic syndrome, psychotic disorder with delusions due to known physiological condition, anemia, paroxysmal atrial fibrillation, gastro-esophageal reflux disease without esophagitis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively impaired. Resident #33 was dependent on staff for medication administration, bathing, lower body dressing, putting on shoes, and toilet use. Resident #33 required set up assistance with meals, and oral hygiene. She required maximum assistance from staff with upper body dressing. Review of the fall assessment dated [DATE] for Resident #33 revealed she scored a thirteen and this made her a moderate risk for falls. Review of the progress notes for Resident #33 revealed she had a fall on 12/24/25 at 5:41 P.M. Resident #33 was found on the floor, lying sideways off the bed with legs on the floor mat. The bed was in the lowest position. Resident #33 sustained two skin tears one on hand and one on the index finger. No immediate intervention was listed. Resident #33 was found on the floor on 12/24/25 at 7:45 A.M. She was found on the her left side with her head under the bed. Resident sustained a skin tear to her right lower leg and sustained a bruise to her left back. Resident #33 also sustained a bruise to the left side of her head. No immediate intervention was listed for the fall. Resident #33 had a fall on 10/11/25 at 5:38 P.M. Resident #33 was found on the floor and sustained a skin tear on the side of her left leg. No immediate intervention was listed. Review of fall investigation summary dated 12/14/25 at 7:45 A.M. revealed Resident #33 was observed on the floor mat in her room with her head under the bed. Resident sustained a right lower leg, left side of the back and bruising to the left side of the head. No immediate intervention was identified. Review of the follow up intervention revealed hospice reinstated Residents Ativan. Review of the fall investigation dated 12/24/25 at 7:41 P.M. for Resident #33 revealed she was found with her legs on the fall mat and upper body was on the bed. Resident #33 sustained skin tears to her left hand, left shin, and left index finger. The facility failed to list an immediate intervention. The follow up intervention was listed as padding was applied to the left side of the bed. Review of the fall investigation summary dated 10/11/25 revealed Resident #33 was found on the floor. She sustained a skin tear to her left leg. No immediate intervention was listed. The follow up intervention was listed as the hospice nurse came in and assessed Resident #33 post fall. Interview with the Director of Nursing (DON) on 12/30/25 at 2:22 P.M. revealed if a resident has a fall the staff are to notify the nurse. The nurse will evaluate the resident and determine the next step. The nurse will notify the family and physician of the fall. The DON confirmed the nurse is expected to determine the immediate intervention and document the immediate intervention in the medical chart. The DON confirmed the facility failed to identify and document an immediate intervention for Resident #33's falls on 10/11/25, 12/14/25 and 12/24/25. 2. Record review for Resident #5 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: fracture of unspecified part of neck of right femur, unspecified atrial fibrillation, and chronic obstructive pulmonary disease. Review of the MDS assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require setup or cleanup assistance for eating, supervision or touching assistance for oral hygiene, substantial/maximal assistance for toileting, partial/moderate assistance for showering/bathing, partial/moderate assistance for dressing, and partial/moderate assistance for personal hygiene. Resident is frequently incontinent of bowel and bladder. Review of Resident #5's fall risk assessment dated on 10/20/25 at 5:47 P.M. revealed Resident #5 to be a high fall risk. Review of the fall investigation for Resident #5 revealed on 12/22/25 at 8:57 P.M. revealed Resident #5 stood up in the shower and slid down the wall and was found sitting on her buttocks while Certified Nurse Assistant (CNA) #194 stepped out of the bathroom. Review of CNA #194 witness statement revealed CNA #194 stepped out of the bathroom when Resident #5 fell in the shower. Review of Licensed Practical Nurse (LPN) #172 revealed CNA #194 was standing outside the bathroom with the door cracked open when Resident #5 fell. Review of the Witness statement from CNA #194 revealed CNA #194 stepped out of the bathroom when Resident #5 was in the shower and fell. Review of the witness statement from LPN #172 revealed CNA #194 stepped out of the bathroom when Resident #5 was in the shower and fell. Interview on 12/30/25 at 2:03 P.M. with DON confirmed CNA #194 should never have left Resident #5 alone in the bathroom. Interview on 12/30/25 at 3:19 P.M. with CNA #194 confirmed they stepped out of the bathroom and had a hand on the bathroom door when Resident #5 fell in the shower. CNA #194 also stated they were educated not to leave the resident alone in the shower, to always keep an eye on the resident, and if the resident is verbally abusive to get the resident out of the shower and backed in bed. Interview on 12/30/25 at 4:47 P.M. with LPN #172 confirmed CNA #194 stepped out of the bathroom and had a hand on the bathroom doorknob when Resident #5 fell in the shower. LPN #172 stated they were educated not to leave the resident alone in the shower, to always keep an eye on the resident, and if the resident is verbally abusive to get the resident out of the shower and backed in bed. Review of the education form for CNA #194 dated on 12/23/25 revealed CNA #194 stepped away from a resident while the resident was in the shower. The education form states all staff must stay within reach of residents while they are in the shower. Review of the facility policy titled, Fall Prevention and Management dated on 04/01/2003 and revised on 01/28/23 revealed at a time of a fall is the loss of an upright position that results in landing on the floor.

Based on review of Quality Assessment and Assurance (QAA) committee sign-in sheets and staff interview, the facility failed to ensure all required members of the QAA committee attended meetings at least quarterly. This had the potential to affect all 35 residents residing in the facility. The census was 35. Findings include: Review of the QAA committee meeting sign-in sheets for the last year revealed, for quarterly meetings held on 07/17/23 and 10/09/23, Medical Director (MD) #800 nor MD #800's designee attended the meetings as required. Interview on 02/22/24 at 5:13 P.M. with the Administrator and Director of Nursing (DON) verified MD #800 nor a designee attended the quarterly QAA committee meetings on 07/17/23 and 10/09/23.

Based on medical record review, review of discharge notes, review of facility documentation, review of Resident Handbook, review of the Admission Agreement, review of a letter from the facility, staff interview and policy review, the facility failed to issue an appropriate discharge related to corporate decisions to de-certify beds prior to issuing proper notification to the State Agency of plans to decrease capacity including quantity and location of certified beds to be affected and the date upon which the new capacity was to be implemented. This affected six (#20, #21, #22, #23, #55, and #60) of six residents reviewed for discharge. The facility census was 37. Findings include: 1. Review of the medical record for the Resident #20 revealed an admitted [DATE]. Diagnoses included but were not limited to hemiplegia and hemiparesis related to cerebral infarction, unspecified epilepsy, unspecified bipolar disorder, and autoimmune lymphoproliferative syndrome. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) of 99, had no behaviors, did not reject care, and did not wander. Resident #20 was a two-person physical assist and required total assistance for all Activities of Daily Living (ADL's). Review of the care plan dated 11/22/2017 revealed Resident #20 had no plan to discharge and long-term care at the facility was appropriate. Interventions included quarterly care conferences, provide one-on-one (1:1) as needed, and review discharge planning on comprehensive assessments only. Review of Discharge notice dated 11/04/2022 revealed Resident #20 was notified in writing that she was to be discharged by 12/06/2022 due to the facility ceasing to operated several of its licensed skilled beds. The notice provided information regarding three potential facilities to which the resident could transfer, information regarding the appeal process, and contact information for resident advocates. 2. Review of the medical record for the Resident #21 revealed an admitted [DATE]. Diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction, Bell's palsy, unspecified dementia, and unspecified depression. Review of the most recent MDS 3.0 assessment dated [DATE] revealed the resident had a BIMS of seven, had no behaviors, did not reject care, and did not wander. Resident #21 was a one-person physical assist and required supervision/setup assistance for all ADL's. Review of care plan dated 06/27/2022 revealed Resident #21 was appropriate for long term care at the facility. Interventions included care conferences as scheduled and provide care services as scheduled and as needed. Review of Discharge notice dated 11/04/2022 revealed Resident #21 was notified in writing that she was to be discharged by 12/06/2022 due to the facility ceasing to operated several of its licensed skilled beds. The notice provided information regarding three potential facilities to which the resident could transfer, information regarding the appeal process, and contact information for resident advocates. 3. Review of the medical record for the Resident #22, revealed an admitted [DATE]. Diagnoses included but were not limited to flaccid hemiplegia and hemiparesis to right side following cerebral infarction, obesity, unspecified recurrent major depressive disorder, unspecified anxiety disorder, unspecified epilepsy, and severe vascular dementia with behavioral disturbance. Review of the most recent MDS 3.0 assessment dated [DATE] revealed the resident had a BIMS of 99, had no behaviors, did not reject care, and did not wander. Resident #20 had no plan to discharge and long-term care at the facility was appropriate. Interventions included quarterly care conferences, provide 1:1 as needed, and review discharge planning on comprehensive assessments only. Review of Discharge notice dated 11/04/2022 revealed Resident #22 was notified in writing that she was to be discharged by 12/06/2022 due to the facility ceasing to operate several of its licensed skilled beds. The notice provided information regarding two potential facilities to which the resident could transfer, information regarding the appeal process, and contact information for resident advocates. 4. Review of the medical record for the Resident #23, specified, revealed an admitted [DATE]. Diagnoses included but were not limited to unspecified cerebral infarction, type II diabetes, unspecified convulsions, pseudobulbar effect, unspecified systolic congestive heart failure, generalized anxiety disorder, and severe recurrent major depressive disorder with psychotic symptoms. Review of the most recent MDS 3.0 assessment dated [DATE] revealed the resident had a BIMS of 11, had no behaviors, did not reject care, and did not wander. Resident # 23 was a one -person physical assist, required extensive assistance for bed mobility, dressing, toileting, and locomotion; limited assistance for transfers; and supervision for eating and personal hygiene. Review of the medical record revealed Resident #23 had no care plan for discharge. Review of progress notes revealed on 11/06/2022 Social Worker (SW) #320 hand-delivered a discharge notice to Resident #23 due to the facility ceasing to operate several skilled long-term beds. SW#320 asked Resident #23 if he had a preference for a facility to transfer to. The note indicated the discharge letter was also mailed to the resident representative. Review of Discharge notice dated 11/04/2022 revealed Resident #23 was notified in writing that he was to be discharged by 12/06/2022 due to the facility ceasing to operate several of its licensed skilled beds. The notice provided information regarding three potential facilities to which the resident could transfer, information regarding the appeal process, and contact information for resident advocates. 5. Review of the medical record for the Resident #55 revealed an admitted [DATE], and a discharge date of [DATE]. Diagnoses included but were not limited to type II diabetes, unspecified depression, hypertension, gout, and glaucoma. Review of the most recent MDS 3.0 assessment dated [DATE] revealed the resident had a BIMS of nine, had no behaviors, did not reject care, and did not wander. Resident #55 was a one-person physical assist, required extensive assistance for bed mobility, transfers, dressing, toileting, personal hygiene; supervision for eating; and locomotion did not occur. Review of the care plan dated 11/30/2021 revealed Resident #55 had no plan to discharge and long-term care at the facility was appropriate. Interventions included quarterly care conferences, provide 1:1 as needed, and review discharge planning on comprehensive assessments only. Review of Discharge notice dated 11/04/2022 revealed Resident #55 was notified in writing that she was to be discharged by 12/06/2022 due to the facility ceasing to operate several of its licensed skilled beds. The notice provided information regarding three potential facilities to which the resident could transfer, information regarding the appeal process, and contact information for resident advocates. 6. Review of the medical record for the Resident #60 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included but were not limited to moderate vascular dementia, flaccid hemiplegia following cerebral infarction affecting right dominant side, type II diabetes, unspecified epilepsy, and acute on chronic systolic congestive heart failure. Review of the most recent MDS 3.0 assessment dated [DATE] revealed the resident had a BIMS of 99, had no behaviors, did not reject care, and did not wander. Resident #60 was a one to two-person physical assist, required total assistance for transfers, extensive assistance for bed mobility, dressing, toileting, and personal hygiene, and supervision for eating. Review of the care plan dated 06/29/2020 revealed Resident #60 had no plan to discharge and long-term care at the facility was appropriate. Interventions included quarterly care conferences, provide 1:1 as needed, and review discharge planning on comprehensive assessments only. Review of Discharge notice dated 11/04/2022 revealed Resident #60 was notified in writing that she was to be discharged by 12/06/2022 due to the facility ceasing to operate several of its licensed skilled beds. The notice provided information regarding three potential facilities to which the resident could transfer, information regarding the appeal process, and contact information for resident advocates. Telephone interview on 11/29/22 at 2:13 P.M. with Chief Executive Officer (CEO) #550 revealed the facility had the intent to decertify the beds at the facility prior to 01/01/23. CEO #550 stated that he could not provide the state survey agency a date of when the facility would send the formal notification of the bed decrease or when the facility would decrease the beds because they were working strategically with the residents and families. CEO #550 stated that the facility had no intent to discharge and readmit residents and that the facility had integrity. CEO #550 reported the company spent 11 million dollars last year on agency staffing and there were concerns about the level of care for residents. The surveyor discussed that the facility's discharge notice stated the facility was ceasing to operate licensed beds and the state survey agency had no evidence that the facility had put plans in place to cease operating the beds. The surveyor again asked for the plans and dates of when the facility plans to notify the state survey agency of the capacity decrease and the date the tentative decrease would occur, but CEO #550 stated he did not have dates. During an interview on 11/29/2022 at 8:48 A.M. the Administrator stated the facility had already closed the Sunny Dale Hall and there were only four people left on [NAME] Hall. The facility was closing that unit next, so they sent out discharge letters which gave the residents 30-day notice. The organization was down-sizing and was not accepting any more short-term rehab from the community due to staffing costs and low reimbursement. Discharge letters were sent out in the beginning of November, date not specified, and gave the residents until 12/06/2022, a little over 30 days, to make other living arrangements. The facility provided names and contact information for three local facilities that had already agreed to accept the residents, and social services worked with the residents and families to make referrals as requested. During an interview on 11/30/2022 at 8:21 A.M. the Administrator stated the facility allowed residents who had started with the facility in Assisted Living or Independent Living to move to remain in the facility on the Rehab unit, but there was nothing in writing that supported this decision. The Administrator confirmed that the decrease in certified beds did not fit neatly into any of the acceptable reasons for facility-initiated discharge that were listed in the discharge policy, Resident Agreement, or Resident Handbook. The Administrator stated of the six residents who had received discharge notices (Residents #20, #21, #22, #23, #55, and #60), there were three residents (#21, #22, and #23) who remained in the facility. Resident #23 was discharging to another local facility, on 12/01/2022. Resident #22's family was looking for a facility with a four-to-five-star rating, and SW #320 was working with Resident #21's family to find placement. Review of Corporate Letter to ODH dated 11/29/2022 revealed As a result of the significant financial pressure resulting form escalating operational expenses, due to the cost prohibitive reliance of agency clinical staffing and the continued underfunding from the Medicaid program, Ohio Living Llanfair is in the process of strategically positioning the available number of skilled nursing beds on the campus. The letter gave no indication of how many skilled beds were affected or when the change to the facilities capacity would take effect. Review of Resident Handbook revealed reasons for involuntary (facility-initiated) discharge included the facility could not meet the resident's needs, the resident's health had improved/the resident no longer needed the facility's services, the resident's/other residents/staff's safety was endangered, failure to pay, the facility ceased to operate, or the facility's participation in Medicare/Medicaid was involuntarily terminated or denied. The facility was required to provide 30-day advanced notice of the transfer/discharge to the resident/representative in writing. Review of the Resident Admission Agreement revealed the facility could terminate the agreement for the following reasons: failure to pay, the resident's stay jeopardized the welfare of the resident/other residents, the facility's license/certification was revoked/renewal was denied, or the facility voluntarily closed. Review of policy titled Discharge/Transfer of the Resident last revised 10/24/2022 revealed the facility could initiate a resident's discharge for the following reasons: the resident's needs could not be met, the resident's health had improved/the resident no longer required the facility's services, the safety of other individual was endangered due to the resident's clinical/behavioral status, or the resident failed to pay. The facility was required to give 30-day advanced notice in writing to the resident/representative which included the reason for discharge, the effective date of discharge, the location to which the resident is to be discharge, a statement of the resident's right to appeal, and contact information for the Ombudsman (mail, e-mail, and telephone number). This deficiency represents non-compliance investigated under Complaint Number OH00137694, Complaint Number OH00137668, and Complaint Number OH00137666.

Based on record review, staff interview and policy review, the facility failed to notify family after a resident was transferred to the hospital. This affected one (#40) of three residents sampled for notifications. The facility census was 37. Findings include: Review of the medical record for the Resident #40 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included but were not limited fracture of the neck of the left femur, generalized anxiety disorder, urinary tract infection, unspecified dementia with behavioral disturbance, and hypertension. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a BIMS of 3, had no behaviors, did not reject care, and did not wander. Resident #40 was a two-person physical assist, required extensive assistance for bed mobility, transfers, dressing, toileting, and personal hygiene; supervision with eating; and locomotion did not occur. Review of progress notes revealed on 10/15/2022 Resident #40 had a fall with head injury and was sent out for evaluation due to anticoagulant therapy and change in mental status. Nurse found the resident hanging outside of the bed on his head. Resident #40 had a computerized tomography (CT) scan at the hospital and was sent back to the facility on [DATE]. During an interview on 11/29/2022 at 3:46 P.M. the Administrator stated Resident #40 was found in the fetal position by the bed at on 10/15/2022 at 10:36 P.M. with his legs and feet upright and head on the floor. Vital signs were taken and were within normal limits. Staff assisted Resident #40 back to bed, and the resident complained of a headache. Doctor was contacted at 11:02 P.M. with a message left requesting a return call, and wife was contacted at 11:08 P.M. Upon return call, the provider wanted Resident #40 to go to the hospital to get checked out because he was taking anticoagulants and was complaining of a headache. The order for Resident #40 to be sent to the hospital was written at 11:18 P.M. During an interview on 11/30/2022 at 9:43 A.M. the Administrator stated she spoke to Licensed Practical Nurse (LPN) #390 by telephone on 11/29/2022. The nurse stated she notified Resident #40's spouse on 10/15/2022 prior to receiving the physician order to send Resident #40 to the hospital and informed her there was a strong probability the resident would be sent out due to his current anticoagulant regimen. The Administrator verified there was no documentation which indicated Resident #40's family was notified that Resident #40 was sent to the hospital on 10/15/2022. Review of policy titled Change of Condition: Observing, Recording, and Reporting dated 04/01/2022, revealed the facility provide immediate notification to the resident's legal representative and physician for any accident resulting in injury which potentially required physician intervention, a significant change in the resident's condition, a need to significantly alter treatment, and a decision to transfer or discharge a resident from the facility. This deficiency represents non-compliance investigated under Complaint Number OH00137235.

Based on medical record review, staff interview and policy review, the facility failed to timely administer antibiotic medication to a resident with physician orders for antibiotic medication upon admission. This affected one (#40) of four residents sampled for medication administration. The facility census was 37. Findings include: Review of the medical record for the Resident #40 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included but were not limited fracture of the neck of the left femur, generalized anxiety disorder, urinary tract infection, unspecified dementia with behavioral disturbance, and hypertension. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) of three, had no behaviors, did not reject care, and did not wander. Resident #40 was a two-person physical assist, required extensive assistance for bed mobility, transfers, dressing, toileting, and personal hygiene; supervision with eating; and locomotion did not occur. Review of Hospital #9's medication list dated 10/13/2022 revealed in addition to continuing routine medications, Resident #40 was ordered to start taking cefdinir 300 mg by mouth twice daily for five days (no diagnosis provided), Heparin 5000 unit per ml injections every eight hours until Coumadin levels were therapeutic, magnesium oxide 400 mg by mouth once daily for 14 days, sennosides-docusate sodium 8.5-50 mg by mouth once daily, and tramadol 50 mg by mouth every six hours as needed for pain for five days. Review of progress notes revealed Resident #40 was started on cefdinir 300 mg by mouth twice daily for five days for diagnosis of Urinary Tract Infection (UTI) on 10/18/2022. Review of the Medication Administration Record dated October 2022 revealed Resident #40 took cefdinir 300 mg by mouth twice daily from 10/19/2022 to 10/23/2022. During an interview on 11/29/2022 at 3:05 P.M. Social Worker #320 stated it was mentioned during a care conference on 10/18/2022 with family that Resident #40 had a UTI in the hospital before he came to the facility. To his knowledge, the Social Worker #320 stated the hospital did not communicate that fact to the facility, and the antibiotic treatment was not started right away. During an interview on 11/30/2022 at 3:01 P.M. Registered Nurse (RN) #415 verified the facility had scanned the list of medications from the hospital paperwork on 10/14/2022, which included orders for Cefdinir 300 mg by mouth twice daily for five days, and the facility did not begin to administer the antibiotic until 10/19/2022. Review of policy titled Admission of Residents last revised 09/13/2022 revealed procedures for admission included to review all available transfer information and conduct interviews with resident and family accompanying resident. Review of policy titled Safe Medication Administration Practices, Long-Term Care revised 05/20/2022 revealed upon admission the facility obtained a list of medications and reviewed the list with the resident and accompanying family to verify accuracy. This deficiency represents non-compliance investigated under Complaint Number OH00137235.

Based on medical record review, staff interview, review of facility policy, and review of online resources per the National Pressure Injury Advisory Panel (NPIAP), the facility failed to complete consistent skin assessments of the resident's skin conducted by a licensed nurse. This affected three (#32, #46 and #57) out of three residents sampled for skin breakdown. The census was 54. Findings include: 1. Review of the medical record for Resident #57 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) for Resident #57 dated 06/14/21 revealed resident was cognitively intact, required extensive assistance of one to two staff with activities of daily living (ADL's), was at risk for pressure ulcers and was admitted with two unstageable pressure ulcers. Review of care plan for Resident #57 dated 06/14/21 revealed resident was at increased risk for infection related to wounds to the lower extremities. Interventions included medications and treatments as ordered, monitor for effectiveness and review with the physician, may have wound consult. Review of the monthly physician orders for Resident #57 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record for Resident #57 revealed the facility had performed two head to toe weekly skin assessments per a licensed nurse 05/31/21 and 06/21/21 during the resident's stay at the facility. 2. Review of the medical record for Resident #32 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS for Resident #32 dated 12/16/21 revealed resident was cognitively impaired, was totally dependent on staff assistance with ADL's and was at risk for the development of pressure ulcers. Review of the care plan for Resident #32 dated 05/13/21 revealed resident had denuded skin to her right lateral foot related to blister due to an [CONDITION(S)] disorder etiology and resident experienced random development of blisters due to [CONDITION(S)] disorder. Interventions included treatments as ordered, monitor skin for signs and symptoms of infection, warmth, drainage, changes in wounds, report to physician as needed, wound care nurse consult. Review of the monthly physician orders for Resident #32 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record for Resident #32 revealed the facility had performed two head to toe weekly skin assessments per a licensed nurse from September 2021 to January 2022: 09/24/21, 12/17/21. 3. Review of the medical record for Resident #46 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the MDS for Resident #46 dated 11/08//21 revealed resident was cognitively impaired, was totally dependent on staff assistance with ADL's and was at risk for the development of pressure ulcers. Review of the care plan for Resident #46 revealed resident had a stage II pressure ulcer to her right buttock related to impaired physical mobility, bowel and bladder incontinence, end stage disease process, protein caloric malnutrition, wheelchair dependent, and non-ambulatory status. Interventions included the following: offer to lay down between meals to offload from sitting up in wheelchair, use Hoyer to transfer, observe/assess healing, report to physician as needed for signs and symptoms of infection or if change in treatment indicated, pressure reducing Review of the monthly physician orders for Resident #32 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the monthly physician orders for Resident #46 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record for Resident #46 revealed the facility had not consistently performed weekly skin assessments. The facility performed only two assessments in October 2021 on 10/08/21 and 10/25/21. The facility performed only three assessments in November 2021 on 11/05/21, 11/19/21, 11/26/21. The facility performed only three assessments in December 2021 on 12/10/21, 12/17/21, 12/28/21. The facility had not completed any weekly skin assessments for Resident #46 in the month of January 2022. Interview on 01/27/22 at 12:25 P.M. with Licensed Practical Nurse (LPN) #125 and at 12:28 P.M. with LPN #150 confirmed a licensed nurse is to conduct a weekly head to toe skin assessment of each resident and documented it in resident's electronic medical record (EMR) as part of the facility's efforts to prevent skin breakdown. Interview on 01/27/22 at 6:15 P.M. with the Administrator and the DON confirmed residents should have a weekly head to toe skin assessment conducted by a licensed nurse documented in the EMR. The Administrator and DON confirmed the following: Resident #57 resided in the facility from [DATE] to 07/17/21 and had two weekly skin assessments included in his EMR; Resident #32 had two weekly skin assessments for September 2021 through January 2022; and Resident #46 had two weekly skin assessments in October 2021, three weekly skin assessments in November 2021, three weekly skin assessments in December 2021, and no weekly skin assessments in January 2022. Review of the facility policy titled Electronic Clinical Documentation: Observations dated 02/26/21 revealed the facility would conduct weekly skin assessments performed by a licensed nurse and would document the results in the resident's EMR. Review of the Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .internationalguideline.com/static/pdfs/Quick_Reference_Guide-10Mar2019.pdf on page 14 revealed nurses should consider individuals with limited mobility, limited activity and a high potential for friction and shear to be at risk of pressure injuries and should consider the potential impact of a previous pressure injury on additional pressure injury development. Further review on page 16 revealed nurses should conduct a skin assessment as indicated by the individual's degree of pressure injury risk and should frequently inspect the skin of individuals at risk of pressure injuries to identify presence of [CONDITION(S)]. This deficiency substantiates Complaint Number OH 159.

Based on observation, staff interview, review of facility policy, review of county transmission rates of COVID-19, and review of Centers for Disease Control (CDC) guidelines, the facility failed to ensure that staff working directly with residents providing care or services were wearing eye protection. This had the potential to affect all 59 residents of the facility. The census was 59. Findings include: Observation on 12/13/21 from 10:46 A.M. through 11:30 A.M. revealed no staff working on resident care units, including housekeeping staff, State tested Nurse Aide (STNAs), and Licensed Practical Nurses (LPNs) were wearing eye protection such as a face shield or goggles that covered the sides of the face. Observation and interview with LPN #89 on 12/13/21 at 10:53 A.M. revealed LPN #89 was wearing a surgical mask and was not wearing eye protection. LPN #89 affirmed that she was wearing a surgical mask with no eye protection. LPN #89 stated since there was no residents with COVID-19 infection in the facility that she was not required to wear eye protection. Observation and interview with STNA #93 on 12/13/21 at approximately 10:56 A.M. revealed STNA #93 was wearing a surgical mask and was not wearing eye protection. STNA #93 affirmed that she was wearing a surgical mask with no eye protection. STNA #93 stated she was agency and did not know if she was supposed to be wearing eye protection or not. Observation and interview with LPN #82 on 12/13/21 at 11:12 A.M. revealed LPN #82 was wearing a surgical mask and was not wearing eye protection. LPN #82 affirmed that she was wearing a surgical mask with no eye protection. LPN #82 stated since there were no residents who were positive for COVID-19 infection in the facility, eye protection was not required. Observation and interview with LPN #84 on 12/13/21 at 11:17 A.M. revealed LPN #84 was wearing a surgical mask and was not wearing eye protection. LPN #84 affirmed that she was wearing a surgical mask with no eye protection. LPN #84 stated since there were no residents who were positive for COVID-19 infection in the facility, staff were not instructed to wear eye protection. Observation and interview with STNA #91 on 12/13/21 at 11:20 A.M. revealed STNA #91 was wearing a surgical mask and was not wearing eye protection. STNA #91 affirmed that she was wearing a surgical mask with no eye protection. STNA #91 stated she did not need to wear eye protection since there were no active cases of COVID-19 in the facility, but the facility had face shields/goggles readily available if needed. Interview with Administrator on 12/13/21 at 1:58 P.M. affirmed that staff were not instructed to use eye protection at that time, since there were no active staff or resident cases of COVID-19 in the facility. The current county transmission rate of COVID-19 and CDC recommendations for health care personnel (HCP) was reviewed with the Administrator on the CDC web site. The Administrator confirmed the current CDC recommendations recommended HCP wear eye protection based on the counties transmission rate. Review of the facility policy titled Coronavirus (Covid-19) revised on 11/19/21 revealed real time updates, such as guidance for using Personal Protective Equipment (PPE), could be found by following the CDC link. The policy listed the following link: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Review of an online resource from the CDC titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated 09/10/21, found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed HCP should wear eye protection during all patient care encounters when working in facilities located in counties with substantial or high transmission of COVID-19. Review of an online resource from the CDC titled Covid Data Tracker - County View, found at covid.cdc.gov/covid-data-tracker/#county-view, revealed the county in which the facility is located had a seven day reporting as of 12/13/21 of High transmission (Red) of COVID-19 with a positivity rate of 10.73%. Review of an online resource from the Centers for Medicare and Medicaid Services (CMS) titled COVID-19 Nursing Home Data, revealed for the week ending 12/07/21, the county in which the facility resides had a 14 day COVID-19 test positivity rate of 10.2% and was classified as red indicating substantial transmission of COVID-19.

Based on record review, observation, and staff interview, the facility failed to ensure dependent residents were shaved during provision of grooming and hygiene care. This affected one (Resident #51) of 17 residents reviewed for hygiene. The facility census was 57. Findings include: Review of the medical record for Resident #51 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 04/12/21, revealed the resident was cognitively impaired and required extensive assistance of one staff with personal hygiene and grooming. Review of the care plan, dated 05/18/20, revealed the resident had a self-care deficit related to dementia and decreased physical function. The goal was for the resident to have proper hygiene and grooming daily and as needed. Interventions included monitoring for any improvement/decline in self-participation, encourage to complete tasks on their own and assist as needed. Observation of Resident #51 on 05/10/21 at 11:24 A.M. revealed the resident had long hairs (approximately one half inch) growing from her chin. Interview on 05/10/21 at 11:26 A.M. with State tested Nursing Assistant (STNA) #435 confirmed Resident #51 had long hairs growing from her chin and that shaving the resident should be done on shower days. STNA #435 further confirmed she was not sure when Resident #51 had last received a shower. Interview on 05/10/21 at 11:28 A.M. with Licensed Practical Nurse (LPN) #395 confirmed Resident #51 had long hairs growing from her chin and the resident was not able to shave herself. Interview on 05/13/21 at 11:00 A.M. with LPN #565 confirmed Resident #51's shower days were Wednesday (05/12/21) and Saturday on the evening shift and she should be shaved on those dates. LPN #565 confirmed the STNAs completed shower sheets with every shower but could not find any shower sheets for Resident #51 for the month of May 2021. This deficiency substantiates Complaint Number OH 766.

Based on record review, review of the facility's policy, and staff interview, the facility failed to prevent a significant medication error when Resident #20 was given another resident's medications. This affected one resident (#20) of resident reviewed for medication administration. The facility census was 57. Findings include: Medical record review for Resident #20 revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 03/03/21, revealed Resident #20 had moderately impaired cognition, did not wander, and did not reject care. Review of the physician orders, for May 2021, revealed Resident #20 had active orders for acetaminophen (treats minor pain), acidophilus (probiotic), [MEDICATION(S)] (treats and prevents bronchospasm), calcium 500 milligrams (mg.) plus D, [MEDICATION(S)] (treats gastroesophageal reflux disease), [MEDICATION(S)] (treats hypothyroidism), [MEDICATION(S)] (treats high blood pressure), [MEDICATION(S)] (stool softener), multivitamin with minerals, and Vitamin D3 (vitamin). Review of the progress note, dated 05/06/21 at 9:50 A.M., revealed Licensed Practical Nurse (LPN) #55 reported to Registered Nurse (RN) #65 she had administered another resident's medication to Resident #20 by mistake. Medications administered included Tylenol (treats mild pain) 650 mg, [MEDICATION(S)] (anti-anxiety medication) 10 mg., [MEDICATION(S)] (laxative) 30 mg., and Oxycodone (narcotic pain medication) 5.0 mg. RN #65 stated she notified the doctor and family. Review of the facility's Medication Error Log, no date, revealed LPN #55 committed and reported a medication error on 05/06/21. The corrective action taken included staff education about the Five Rights of Medication Administration. Interview on 05/11/21 at 03:07 P.M. revealed RN #65 stated on 05/06/21, the agency nurse (LPN #55) walked into the wrong room and gave medications to Resident #20 which belonged to another resident. The LPN #55 informed RN #65 immediately of what happened and what medications were given. The RN stated she looked at the medications given in error and made a list of potential side effects to monitor for before she explained to the doctor, in facility at the time of occurrence, what had happened. The doctor said the resident should be fine but recommended to monitor Resident #20 for diarrhea and drowsiness and hold routine medications. The agency nurse monitored Resident #20 frequently for vitals and adverse effects and passed on to continue monitoring in shift-to-shift report. Review of the facility's policy titled Medication Error Report, dated 08/15/20, revealed in case of medication error, the nurse provides emergency care as needed, notifies the supervisor, physician, and resident's responsible party, assesses vital signs and adverse effects frequently, reported follow-up care in shift report, and documented each shift until the resident was stable.

Based on medical record review, staff interview, review of the online Medscape resource, and review of the facility's policy, the facility failed to ensure antipsychotic medications were administered for appropriate clinical indications, monitored for target behavioral symptoms, and considered for gradual dosage reductions when indicated. This affected two (Residents #51 and #152) of six residents reviewed for unnecessary medications. The facility census was 57. Findings include: 1. Review of the medical record for Resident #152 revealed an admitted [DATE] with a diagnosis of Alzheimer's disease. Resident #152 had no diagnoses of [CONDITION(S)] or other specific medical conditions to justify the use of antipsychotic medications. Review of the physician's order, dated [DATE], revealed the resident had an order for the antipsychotic medication [MEDICATION(S)] 75 milligrams (mg.) to be administered routinely three times daily. Review of the resident's Medication Administration Record (MAR), dated [DATE], revealed it did not include monitoring of targeted behaviors associated with the use of [MEDICATION(S)]. The resident received [MEDICATION(S)] routinely three times daily as ordered. Review of the medical record for Resident #152 revealed it did not include a baseline care plan regarding the use of [MEDICATION(S)]. Interview on [DATE] at 12:40 P.M. with Licensed Practical Nurse (LPN) #565 confirmed Resident #152 received [MEDICATION(S)] three times daily and his record did not include targeted behaviors for the use of [MEDICATION(S)] or any kind of behavior monitoring or tracking. Interview on [DATE] at 2:08 P.M. with Registered Nurse (RN) #835 confirmed Resident #152's medical record did not include the following: a diagnosis or specific medical condition related to [MEDICATION(S)] use, a baseline care plan regarding the use of [MEDICATION(S)], or monitoring of targeted behavioral symptoms. Review of the facility's policy titled [CONDITION(S)] Medications, dated [DATE]. revealed [CONDITION(S)] medications will be administered pursuant to rule §483.45 in the Code of Federal Regulations (CFR). Review of the online resource Medscape revealed [MEDICATION(S)] included a black box warning indicating the medication placed elderly patients with dementia related [CONDITION(S)] at increased risk of mortality and medication was not approved for the treatment of patients with dementia-related [CONDITION(S)]. 2. Review of the medical record for Resident #51 revealed an admitted [DATE] with diagnoses including dementia with behavioral disturbance, depression, and anxiety disorder. Resident #51 had no diagnoses of [CONDITION(S)] or other specific medical conditions to justify the use of antipsychotic medications Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident was cognitively impaired, antipsychotics were received on seven out of seven days in the review period, no gradual dose reduction (GDR) had been attempted and the physician had not documented a GDR as clinically contraindicated. Review of the resident's care plan, dated [DATE], revealed the resident had altered behavior related to diagnoses of dementia with behaviors and resident could become agitated when attempting to locate deceased husband. Interventions included to address inappropriate behavior consistently as it occurs, consult with psychiatrist/psychologist as needed, medications as ordered, monitor for effectiveness/adverse/side effects, consult with social worker as needed, educate family on diagnosis of dementia and not to remind resident of husband's passing. Review of the physician's orders, dated [DATE], revealed an order for [MEDICATION(S)] (an antipsychotic) to be administered routinely twice per day. Review of the medical record for Resident #51 revealed it did not include an assessment of abnormal involuntary movements associated with long term antipsychotic use and it did not include monitoring of targeted behaviors associated with the use of [MEDICATION(S)]. Review of the MAR for [DATE] revealed the resident received [MEDICATION(S)] twice daily routinely. Interview on [DATE] at 12:40 P.M. with Licensed Practical Nurse (LPN) #565 confirmed Resident #51's record did not include targeted behaviors for the use of [MEDICATION(S)] nor did the record include behavior monitoring. Interview on [DATE] at 2:08 P.M. with Registered Nurse (RN) #835 confirmed Resident #51's medical record did not include the following: a diagnosis or specific medical condition related to [MEDICATION(S)] use, an assessment of abnormal involuntary movements associated with long term antipsychotic use, attempted GDR and/or documentation of medical contraindication, or monitoring of targeted behavioral symptoms. Review of the online resource Medscape revealed [MEDICATION(S)] included a black box warning indicating the medication placed elderly patients with dementia related [CONDITION(S)] at increased risk of mortality and medication was not approved for the treatment of patients with dementia-related [CONDITION(S)].

Based on record review, staff interview, and review of the facility's policy, the facility failed to administer insulin and intravenous (IV) antibiotics as ordered by the physician. This affected two (Resident #13 and #51) of six residents reviewed for unnecessary medications. The facility census was 57. Findings include: 1. Review of the medical record for Resident #13 revealed an admitted [DATE] with a diagnosis of Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment, dated 02/18/21, revealed the resident was cognitively impaired. Review of the resident's Medication Administration Record (MAR), dated April 2021, revealed an order for the IV antibiotic [MEDICATION(S)] to be administered three times daily from 04/16/21 to 05/05/21 for treatment of a urinary tract infection (UTI). Review of the April 2021 MAR revealed the following doses were not administered and the MAR did not note a refusal or rationale for not administering the medication: 04/17/21 at 7:00 A.M., 2:00 P.M., and 6:00 P.M., 04/18/21 at 7:00 A.M. and 2:00 P.M., 04/25/21 at 7:00 A.M., 04/28/21 at 7:00 A.M., 2:00 P.M., and 6:00 P.M. Review of the resident's MAR, dated May 2021, revealed the following doses were not administered and the MAR did not note a refusal or rationale for not administering the medication: 05/01/21 at 6:00 P.M., 05/05/21 at 2:00 P.M. Further review of the MAR revealed the medication was discontinued on 05/06/21. Review of the nurse progress notes for Resident #13 dated 04/16/21 through 05/05/21 revealed the notes were silent regarding physician notification of the missed doses and/or refusals or rationale for missed doses. Interview on 05/13/21 at 2:08 P.M. with Registered Nurse (RN) #835 confirmed Resident #13's medical record did not include physician notification of the missed doses and/or refusals or rationale for missed doses of IV antibiotics in April 2021 and May 2021. Review of the facility's policy titled Medication Administration, dated 11/20/20, revealed the facility would ensure staff administered medications as ordered within two hours of the prescribed times and would monitor and document medication administration and the effectiveness of all medications administered. 2. Review of the medical record for Resident #51 revealed an admitted [DATE] with a diagnosis of diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 04/12/21, revealed the resident was cognitively impaired. Review of the care plan, dated 01/20/21, revealed the resident was at risk for hypo/[CONDITION(S)]. Interventions included medications as ordered, monitor finger sticks as ordered, notify the physician of abnormal results, monitor for signs and symptoms of hypo/[CONDITION(S)] and provide routine sliding scale insulin per orders. Review of the resident's MAR, dated May 2021, revealed the resident did not receive nighttime dose of insulin on 05/01/21 and 05/02/21 or the morning dose of insulin per sliding scale on 05/11/21. There was not blood sugar recorded for the morning on 05/11/21 Interview on 05/13/21 at 2:08 P.M. with Registered Nurse (RN) #835 confirmed Resident #51's medical record did not include physician notification of the missed doses and/or refusals or rationale for missed doses of insulin in May 2021. Review of the facility's policy titled Medication Administration, dated 11/20/20, revealed the facility would ensure staff administered medications as ordered within two hours of the prescribed times and would monitor and document medication administration and the effectiveness of all medications administered

Based on record review, observation, staff interview, and review of the facility's policy, the facility failed to ensure oxygen tubing was dated to indicate the date on which the tubing was changed/initiated. This affected one (Resident #51) of one resident reviewed for respiratory care. The facility identified eight residents on oxygen therapy. The census was 57. Findings include: Review of the medical record for Resident #51 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 04/12/21, revealed the resident was cognitively impaired. Review of the physician orders, dated May 2021, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 05/10/21 at 11:17 A.M. revealed Resident #51 had oxygen in place per nasal cannula at five liters. The oxygen tubing was not dated. Interview on 05/10/21 at 11:19 A.M. with Licensed Practical Nurse (LPN) #395 confirmed the oxygen tubing for Resident #51 was not dated and she was unsure when it had last been changed. Observation on 05/12/21 at 12:31 P.M. revealed Resident #51 had oxygen in place per nasal cannula at five liters. The oxygen tubing was not dated. Interview on 05/12/21 at 12:32 P.M. with LPN # 530 confirmed the oxygen tubing for Resident #51 was not dated and further confirmed the May 2021 MAR/TAR for the resident did not include documentation of oxygen administration or changing of tubing. Review of the facility's policy titled Oxygen Administration and Handling, dated 10/10/20, revealed oxygen tubing should be dated when opened and should be changed at least weekly.

Based on observation, staff interview, and review of the facility's policy, the facility failed to ensure staff performed appropriate hand hygiene during meals. This affected three (Residents #13, #23, and #36) of 14 residents on the Grove Unit. The facility census was 57. Findings include: Observation on 05/10/21 at 12:21 P.M. revealed State tested Nursing Assistant (STNA) #455 entered the dining room after returning from a break off the floor, and did not perform hand hygiene before providing hands on assistance with eating to Residents #13, #23, and #36. STNA #455 did not sanitize her hands between assisting Residents #13, #23, and #36. Interview on 05/10/21 at 12: 40 P.M. with STNA #455 confirmed she did not wash or sanitize her hands upon returning to the floor following her break and did not wash or sanitize hands in between providing hands on assistance with eating to Residents #13, #23 and #36. Observation on 05/12/21 at 12:49 P.M. revealed STNA #455 was feeding Resident #13 her lunch and was wearing gloves. Then STNA #455 removed her gloves and discarded them, donned a pair of new gloves from her pocket and assisted Resident #36 with eating for approximately one minute. STNA then removed her gloves and discarded them, donned a new pair of gloves from her pocket and went back to provide additional hands-on assistance with feeding to Resident #13. The STNA was observed not to perform any hand hygiene between her glove changes from Resident #13 to Resident #36 and then Resident #36 to Resident #13. Interview on 05/12/21 at 12:55 P.M. with STNA #455 confirmed she did not wash or sanitize her hands between residents, and she thought changing gloves between residents eliminated the need for her to perform hand hygiene. Review of the facility's policy titled Hand Hygiene, dated 05/15/20, revealed hand hygiene should be performed before and after patient contact and glove use did not eliminate the need for hand hygiene. This deficiency substantiates Complaint Number OH 766.

Based on record review, observation, staff interview, and review of the facility's policy, the facility failed to provide dining services in a dignified manner. This affected two (Residents #13 and #36) of five residents reviewed for nutrition. The facility census was 57. Findings include: 1. Review of the medical record for Resident #13 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) assessment, dated 02/18/21, revealed the resident was cognitively impaired and required extensive assistance of one staff with feeding. Review of the care plan, last updated 05/11/21, revealed the resident was at nutritional risk due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident could feed herself using her hands to eat and required staff assistance needed to finish and eat adequately. Interventions included the following: serve pureed diet as ordered, provide assistance to eat as needed for optimal meal intakes, offer cueing to clear pocketed foods from mouth as needed, monitor for choking, pocketing food, or drooling, monitor for signs and symptoms of self-feeding difficulties, and serve meals in the dining room. Observation on 05/10/21 at 12:10 P.M. revealed Resident #13 was seated in the dining room with a plate of pureed food and utensils in front of her. Resident was using her fingers to eat the pureed food and was having difficulty feeding herself. There were no staff present in the dining room until 12:21 P.M. Further observation at 12:21 P.M. revealed State tested Nursing Assistant (STNA) #455 entered the dining room and placed a spoon in Resident #13's hand and cued the resident so she was able to feed herself the pureed food with a spoon. Interview on 05/10/21 at 12:22 P.M. with STNA #455 confirmed Resident #13 needed assistance and cueing to use a spoon when eating pureed food in order to provide a dignified dining experience. 2. Review of the medical record for Resident #36 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the MDS assessment, dated 04/10/21, revealed the resident was cognitively impaired and required supervision and set up help with eating. Review of the care plan, dated 01/13/21, revealed the resident was at nutritional risk due to dementia. Interventions included the following: serve regular diet as ordered, supplements as ordered, assistance to eat, cueing as needed for optimal intakes, monitor for chewing/swallowing problems such as coughing, choking, pocketing, or drooling, monitor for signs and symptoms of self-feeding difficulties, and serve meals in the dining room. Observation on 05/12/21 at 12:49 P.M. revealed STNA #455 was feeding Resident #13 her lunch when Resident #36 called for assistance. STNA #455 pushed Resident #13's plate out of the resident's reach and told the resident she would return soon. STNA #455 went to Resident #36 and fed her several bites of her food and remained standing over the resident as she did so. While STNA #455 was feeding/encouraging Resident #36 to eat, Resident #13 reached out for her plate of food but it was out of her reach. STNA #455 was the only staff person present in the dining room during the observation. Interview on 05/12/21 at 12:55 P.M. with STNA #455 confirmed staff should sit down and be eye level when assisting residents with feeding to provide a dignified dining experience. STNA #455 further confirmed she had moved Resident #13's food out of her reach because while she tended to Resident #36. STNA #455 confirmed Resident #13 was reaching for her food while STNA was assisting Resident #36 but she had deliberately placed the resident's food out of reach because she didn't think resident would be able to feed herself as resident's ability to self-feed was variable from day to day. Review of the facility's policy titled Dining and Meal Service, dated 2013, revealed the dining experience would be person-centered with the purpose of enhancing each individual patient's/resident's quality of life and would be supportive of each individuals' needs during dining and individuals would be assisted promptly and in a timely manner after the meal arrived.

Based on record review, staff interview, review of facility's Self-Reported Incidents (SRIs), and review of the facility's policy, the facility failed to report an allegation of physical abuse regarding a resident-to-resident altercation to the State Survey Agency, the Ohio Department of Health (ODH). This affected two (Residents #23 and #31) of two residents reviewed for abuse. The facility census was 58. Findings include: Review of the medical record for Resident #31 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress note for Resident #31, dated 04/09/20, revealed the nurse was called to the dining room due to resident being slapped by another resident. The nurse assessed the resident for injuries and none were noted. Review of the medical record for Resident #23 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress note for Resident #23, dated 04/09/20, revealed the nurse was called to the dining room due to resident being slapped by another resident. Resident #23 confirmed she was slapped by another resident, but she was not injured. Review of the facility's SRIs revealed there were no reports filed regarding Residents #23 and #31. Interview on 05/12/21 at 2:45 P.M. with Executive Director (ED) #730 confirmed the facility did not report the resident-to-resident physical altercation between Residents #23 and #31 to the ODH. Review of the facility's policy titled Abuse, Neglect Misappropriation and Crime Reporting, dated 11/04/19, revealed the facility would report all allegations of abuse including resident to resident abuse to ODH.

Based on record review, staff interview, review of the facility's Self-Reported Incidents (SRIs), and review of the facility's policy, the facility failed to thoroughly investigate a resident-to-resident physical altercation. This affected two (Residents #23 and #31) of two residents reviewed for abuse. The facility census was 58. Findings include: Review of the medical record for Resident #31 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress note for Resident #31, dated 04/09/20, revealed the nurse was called to the dining room due to resident being slapped by another resident. The nurse assessed the resident for injuries and none were noted. Review of the medical record for Resident #23 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress note for Resident #23, dated 04/09/20, revealed the nurse was called to the dining room due to resident being slapped by another resident. Resident #23 confirmed she was slapped by another resident, but she was not injured. Review of the facility's SRIs revealed there were no reports filed regarding Residents #23 and #31. Interview on 05/12/21 at 2:45 P.M. with Executive Director (ED) #730 confirmed the facility did not conduct an investigation regarding the resident to resident physical altercation between Residents #23 and #31. Review of the facility's policy titled Abuse, Neglect Misappropriation and Crime Reporting, dated 11/04/19, revealed the facility would thoroughly investigate all allegations of abuse including resident-to-resident abuse.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff and resident interview, review of the facility investigation and witness statements, review of the employee corrective action, and review of the Self-Reported Incident the facility failed to prevent an injury of unknown origin. This resulted in actual harm to Resident (#2) when State tested Nursing Assistant (STNA) #12 provided rough care which resulted in an injury requiring surgical repair of a dislocated left shoulder and fracture to the glenoid (a part of the scapula). This affected one Resident (#2) of one reviewed for injury of unknown origin. The facility identified no other injuries of unknown origin. The facility census was 59. Findings include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with a recent return on 10/07/20. [DIAGNOSES REDACTED]. Review of a nursing note dated 09/25/20 revealed Resident #2 had a large purplish/red scattered bruise on left arm and shoulder with swelling, discomfort, and immobilization to extremity. Passive range of motion was attempted and Resident #2 displayed facial grimacing when the extremity was moved. New orders were obtained for a shoulder and elbow x-ray. Further review of the note revealed x-ray results received and confirmed a dislocation of the left humeral head. The resident was transferred to the local hospital for evaluation. Review of radiology report dated 09/25/20 revealed: There was an age-indeterminate [MEDICAL CONDITION], large medial displacement of the fragment, and anterior dislocation of the left humeral head. Review of the care plan dated 09/28/20 revealed Resident #2 had self-care deficit related to recent dislocation of left shoulder with closed reduction on 09/25/20 receiving increased activities of daily living assistance during this time. Continued review revealed care plan dated 10/08/20 revealed Resident #2 has potential for pain related to left shoulder surgery and arthritis. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #2 had moderate impaired cognition, required extensive assistance with bed mobility, total dependence with transfers, dressing, toileting, and personal hygiene. Review of the Self-Reported Incident (SRI) # 9 revealed Resident #2 was noted to have a large black bruise and swelling on his left upper arm. Upon radiological examination it was determined that his left shoulder was dislocated, and his glenoid bone was fractured. The investigation further revealed the bruise was not present on the previous days and Resident #2 was able to describe a time of popping with increased pain during care provided by a specific State tested Nursing Assistant (STNA) #12. The STNA #12 that Resident #2 reported as being rough during care, did not admit to being rough or harming Resident #2 in any way, however she did use a stand-up lift with this resident. At the completion of the investigation, Resident #2 statements of rough treatment led to a decision to terminate the employment of STNA #12. Review of the facility investigative notes dated 09/30/20 revealed on Sunday 09/19/20, when STNA #12 was providing a bed bath to Resident #2, she noticed that he had a bright red area to his left shoulder. She finished providing care and used the standup lift to assist him up. STNA #12 notified Licensed Practical Nurse (LPN) #13 of the area. STNA #12 stated that when she touched the area, Resident #2 said it did not hurt. She further reported the area was not swollen. LPN #13 said it looked like a pressure mark (like he laid on it), however he does not lay on that side. LPN #13 gave pain medication to the resident due to increased pain in left shoulder. On Friday, 09/25/20, STNA #12 went in to assist Resident #2 with activities of daily living while he remained in bed. STNA #12 took off the residents shirt, Resident #2 complained of pain when his left arm had been raised to take off his shirt and reported it hurt upon movement. STNA #12 stated that the area on his left shoulder was a darker red, compared to 09/19/20. The shoulder was round and swollen. STNA #12 reported Resident #2 told her every time she touched him, he feels she is rough. Review of the witness statement dated 09/25/20 revealed STNA #12 worked on his shower night 09/19/20, however he does not take showers, so he received a bed bath when we get him up in the morning. STNA #12 further reported she had not put him to bed the night before she helped him up on the next morning on 09/20/20. When she began to bath the upper half she removed his gown and shirt was when she noticed his upper left arm was bright red and asked Resident #2 if it hurt and he said only when he moved his arm. She continued to assist the resident by using the stand lift. She reported these findings to the nurse. STNA #12 reported the next time she took care of him was on Friday 09/25/20 and when she provided care she took off his shirt off and noticed his shoulder was a darker red area and his whole arm looked swollen, she touched it and asked Resident #2 if it hurt. Resident #2 said only when he moved it. STNA #12 noticed that the left shoulder was bigger than the right and called for the nurse. Review of the witness statement dated dated 09/25/20 revealed STNA #14 had provided care for Resident #2 on 09/25/20. Resident #2 reported the girl who worked before her this morning was rough when she provided care. Resident #2 said she spoke aggressive to him and was physically aggressive and rough with his care. Resident #2 reported his shoulder hurt with every movement. Review of the witness statement dated 09/25/20 revealed STNA #15 had taken care of Resident #2 on 09/24/20 and Resident #2 had not complained about any pain. He was able to complete normal daily activities as he would always. Resident #2 was utilizing both arms without increased pain or hesitation. STNA #15 further reported upon returning to work on 09/25/20, Resident #2 responded and stated, the girl came in at 5:00 A.M. and was rough with me trying to make me put on my shirt. At this time, he was holding his arm. Resident #2 was loud and upset yelling about how rough the girl was over and over. STNA #15 asked him who he was referring to and Resident #2 stated his aide. STNA #15 reported this to LPN #10. Review of the witness statement dated 09/28/20 revealed LPN #13 had interviewed Resident #2 on 09/28/20 at 9:45 A.M. and asked him how he was feeling and if he could recall what may have happened to his arm and shoulder. He stated the lady was rough with me. When asked which lady and he stated, the dark black colored lady, she starts about 7:00 P.M. in the evening and she was always rough with me, the other girl that comes in here with her doesn't handle me rough. Resident #2 expressed he had not known her name, however he knew who it was not and named the other STNA who would come in with STNA #12. He further reported they came in to take care of him together most of the time and STNA #12 always twisted me around too much early in the morning. The resident had heard it pop and reported it did not stop hurting until she stopped handling me and assisted me in my wheelchair. Getting up with her was rough and she would throw you around. Resident #2 denied falling or trying to transfer on his own. Review of the witness statement dated 09/28/20 LPN #10 revealed Saturday night on 09/19/20 Resident #2 had received his routine medications. He was already in bed. LPN #10 asked Resident #2 about his pain for the day, he told the nurse about the pain to his legs and left arm. LPN #10 applied biofreeze to the extremities he complained about. This had been Resident #2's normal routine for him to complain his extremities being stiff at the end of the day because of arthritis. In the morning Resident #2 was given a bed bath by STNA #12, she stated he had some redness to the left arm. LPN #10 assessed, the area and there was some red indentation to the left arm consistent with him laying on that side. There was no swelling, red area was blanchable, skin was intact, with no pain. Extremity was able to be extended. On Thursday 09/24/20 Resident #2 was in bed when LPN #10 arrived to his room for medication. Resident #2 had no complaints of pain other than pain to his lower extremities. Resident #2 had not reported pain or had any staff reported he had pain. On Friday 09/25/20 STNA #12 was providing care in the morning to assist him up for the day. STNA #12 alerted LPN #10 of his arm, and upon assessment his arm was bruised at the top upper region, his shoulder was distended, and swollen at the armpit to the top of the arm. LPN #10 left the room and called the medical director immediately to get orders for an x-ray of the arm. Review of Notice of Corrective action dated 09/30/20 revealed STNA #12 reported being rough with a resident in her care. The resident too reports STNA #12 is rough with him. The resident was diagnosed with [REDACTED].#12 provided care. Improper use of the stand up lift. Interview on 10/15/20 at approximately 11:30 A.M., the Administrator revealed during the facility investigation STNA #12 was terminated based on the report from Resident #2 and not following up on proper protocol by ensuring it was safe to get Resident #2 up with a stand up lift and not ensuring the safety with the nurse. Interview on 10/15/20 at 12:12 P.M. Resident #2 reported the one aide that was rough he had not seen and was not going to say any more about it because he did not want any trouble. He verbalized he felt safe now and had no more to say. As a result of the incident, the facility took the following actions to correct the deficient practice by 10/01/20. On 09/25/20 the facility staff assessed and interviewed the residents STNA #12 provided care to. On 09/25/20 through 09/29/20 the facility held in-services on providing gentle care, and Abuse/Mistreatment Education to all employees. On 10/01/20 the facility started conducting audits on Providing Gentle care. On 10/01/20 the facility officially terminated STNA #12 after the completion of the investigation. This deficiency substantiated the allegations contained in Complaint Number OH 240.

Based on clinical record review, observation, resident and facility staff interviews, the facility failed to provide appropriate interventions to one resident (Resident #75) resulting in harm, when the resident developed an avoidable, painful, stage three pressure area, which was not present upon admission. This affected one resident out of three sampled for pressure ulcers. The facility identified five residents with pressure ulcers. The facility census was 75. Findings include: Clinical record review revealed Resident #75 was admitted to the facility on [DATE]. Review of his cumulative [DIAGNOSES REDACTED]. The clinical record further revealed the resident was sent to the hospital on [DATE] for an evaluation and treatment. He returned the facility on 03/06/13 with a [DIAGNOSES REDACTED].#75 was cognitively intact. He was alert and oriented and able to make his needs known and was his own person for health care decisions. His bed mobility was noted to be an extensive assist with one person transfer. His mode of locomotion was noted to be wheelchair, he self-propelled, for short distance. Further review of the MDS revealed the resident had no pressure ulcers upon admission. Review of Resident #75's plan of care revealed Resident #75 was a potential risk for impaired skin integrity related to decreased mobility and incontinence, use of anti-anxiety medication that can cause drowsiness. Skin was intact. Needs extensive assistance for bed mobility and transfers. The goal was noted to be to maintain skin integrity with a goal target date of 05/13/13. Approaches noted included; encourage/assist to turn and reposition every two hours, encourage/assist to change position in chair frequently, peri-care after each incontinent episode. Pressure re-distributing cushion/mattress, skin assessment weekly and as needed. Report any reddened or open areas to the nurse immediately. Treatments per physician's orders [REDACTED]. Keep linen clean and wrinkle free. Review of weekly skin assessment dated [DATE] revealed Resident #75's skin was intact. Review of Physical Restraint Evaluation and Consent dated 02/21/13 (not signed by the resident) revealed Resident #75 had four falls from his recliner and/or wheelchair. The evaluation further revealed a Geri chair (reclining chair that cannot be propelled per resident, or brought forward per self) was recommended and would allow the resident to sit in a semi-reclined position of comfort due to a loss of trunk muscular control with balance. The frequency for the use of the Geri chair would be used when out of bed. The evaluation further revealed to release and exercise every two hours. The record did not reveal any direction as to how long (hours per day, length of time) the resident would be kept in the Geri chair. Review of progress notes dated 02/28/13 revealed Resident #75 was experiencing increase in cough and shortness of breath. The physician was notified and the resident was sent to the hospital for an evaluation and treatment. Resident #75 returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. The record further revealed he was still utilizing the Geri chair while out of bed. Even though the physical restraint evaluation and consent updated on 03/12/13 revealed the resident had the ability to sit erect and was not leaning sideways or forward. It was noted he could recover to a sitting balance. The updated evaluation for the use of the restraint revealed Resident #75 had good trunk control. Review of resident's progress note dated 3/17/13 revealed he was sitting in the Geri chair, in the common area, complaining of pain and discomfort in his buttock area. As needed Tylenol (pain reliever) was administered and he remained in the Geri chair. Review of CNPWCN (wound specialist) #1's wound care details dated 03/18/13 revealed Resident #75 developed an abrasion to his left lower buttock region (in-house). The area measured 3.0 centimeters (cm) by 1.5 cm by 0 depth. The wound margin was attached. The wound bed was noted to be bright red, pink, firm granulation. Treatment was ordered for [MEDICATION NAME] followed by [MEDICATION NAME]. Review of Resident #75's progress note dated 03/18/13 at 2:29 A.M. revealed Resident #75 was up in the Geri chair for most of the evening. On 03/19/13 at 11:05 A.M. Resident #75 was noted sitting up in the Geri chair in the common area and was given Tylenol for complaints of buttock discomfort, he remained in the Geri chair. On 03/22/13 at 1:45 P.M. it was noted Resident #75 had complained of pain to his buttocks and requested Tylenol at that time, he again remained in the Geri chair. On 03/23/13 at 2:40 P.M., Resident #75 was noted up in the Geri chair complaining of buttock discomfort, Tylenol was again administered. On 03/25/13 at 7:00 P.M. progress notes reveal Resident #75 was sitting in his Geri chair with complaints of discomfort to his buttocks, repositioning was ineffective, Tylenol was administered, he remained in the Geri chair. Resident #75 reported moderate relief of discomfort to buttocks. Review of CNPWCN #1's wound care details dated 03/25/13 revealed the abrasion to his left buttock was not healed and there was no change in the wound's progression. Review of Resident #75's progress noted dated 03/26/13 at 11:15 A.M. revealed the resident was alert and oriented, up in the Geri chair complaining of pain to his buttock's area. The resident was repositioned, discomfort continued and Tylenol was given, he remained in the Geri chair. On 03/28/13 at 2:55 A.M. Resident #75 complained of discomfort to his buttocks while sitting in the Geri chair, repositioning in the chair ineffective. Tylenol was administered. At 2:27 P.M. Tylenol was requested again by the resident, he remained in the Geri chair. On 03/30/13 at 11:28 A.M., Resident #75 was given Tylenol again for pain. On 03/31/13 at 2:24 A.M. resident was noted alert and oriented times three, in the Geri chair, complaining of pain to his buttock's area. Repositioning ineffective, Tylenol was administered. At 1:58 P.M. Resident #75 was in the Geri chair and requested Tylenol again for pain. Review of CNPWCN #1's wound care details dated 04/01/13 revealed the abrasion to his buttock had deteriorated and the abrasion now was a stage three pressure ulcer. The note further revealed there was a scant amount of serous drainage noted and the wound was deteriorating. The treatment was changed to begin Santyl, cover with dry dressing, twice a day and limit time in the Geri chair. On 04/08/13 the pressure ulcer was noted improving. On 04/15/13 the pressure ulcer was still not healed but continued to improve. Review of progress notes dated 04/01/13 revealed Resident #75 was given Tylenol for complaints of pain to his buttock's area while in the Geri chair. It was noted to be somewhat effective. On 04/02/13 at 7:00 p.m. Resident #75 requested Tylenol due to discomfort to his buttocks while sitting up in the Geri chair. Observation of treatment to Resident #75's stage three pressure ulcer on 04/22/13 at 11:20 A.M. completed by CNPWCN #1 revealed the pressure ulcer was healed at this time. The area to his buttock's was noted red with no open areas noted. Interview with the CNPWCN #1 revealed she believed Resident #75 developed the stage three pressure ulcer due to being put in a Geri chair from the time he returned from the hospital on [DATE] through 04/01/13. She further revealed she had no idea why the resident was still in a Geri chair and recommended the time he spent in the chair be limited. Interview with State tested Nursing Assistant (STNA #20) on 04/23/13 at 9:05 A.M. revealed she had been assigned to the care of Resident #75 since his admission. She further revealed when the resident returned from the hospital on [DATE] he was like a different person, able to do so much more, always pleasant and cooperative. The STNA revealed he often complained of his bottom hurting while in the Geri chair. She further revealed she had no idea why he remained in the Geri chair after returning from the hospital until 04/02/13. Interview with Resident #75 on 04/23/13 at 2:00 P.M. revealed the resident in his room in a wheelchair, reading the newspaper. Resident #75 revealed the staff left him sit out in the common area day after day, in the Geri chair and he was very bored. He revealed it was very uncomfortable and painful to his bottom, as he couldn't get the chair down or propel the chair as he did in his wheelchair. He revealed the only true relief on his bottom was when he was placed in bed at night so he could lay on his side, as he could not lay on his side in the Geri chair. Resident #75 revealed he was told he was in the Geri chair for safety reasons and he was from the generation not to complain and question. He felt his independence was taken away. The resident revealed finally after much insistence and the wound nurse's recommendation they let him return to his wheelchair so he could propel himself and resume his independence.