Every finding on record at Ohio Living Westminster-Thurber

Based on observations, staff interview, and policy review, the facility failed to ensure food was held and served at safe and appetizing temperatures. This had the potential to affect 32 of 32 residents who receive food from the kitchen. Facility census was 32. Findings include:Observation and interview on 05/05/26 from 11:47 A.M. to 12:10 P.M., with Kitchen Manager #81 revealed the facility was serving a turkey club sandwich (cold), coleslaw (cold), gelatin (cold) and loaded potato soup (hot) for lunch. The temperatures were taken at the time the test tray was made and found the turkey club sandwich had a temperature of 53 degrees. It was placed back in the freezer to cool and a new tray was removed from the freezer to serve and sandwiches held a temperature of 43 to 45 degrees. Kitchen Manager #81 returned the tray to the freezer and reported they needed to cool a bit more prior to service. Majority of the lunch trays for the 400 hall cart were already made and placed on the cart for service and came from the sandwich tray with a holding temperature of 53 degrees. These remained on the service cart and was served to resident on the 400 hall. Additional food temperatures at time of service included soup at 167 degrees, coleslaw at 38.8 degrees, and gelatin with cream cheese topping at 39.1 degrees. The test tray left the kitchen at 12:10 P.M. and Kitchen Manager confirmed the food (sandwiches) were not held at the correct temperature. Observation on 05/05/26 from 12:10 to 12:25 P.M., with Kitchen Manager #81 revealed upon arrival to the nursing unit the trays were passed out by staff with the last tray being passed out at 12:20. At that time the test tray had temperatures checked with reading for the sandwich at 59.7 degrees, the soup had a temperature of 126.3 degrees the coleslaw had a temperature of 54.6 degrees and the gelatin had a temperature of 54.7 degrees. Upon taking temperatures Kitchen Manager #81 stated that's not good. when several items were in the mid to high 50 degree range. He stated cold foods should be held and served under 48 degrees. The Kitchen Manager also stated he was surprised the gelatin and coleslaw had such a drastic temperature changes from 38 and 39 degrees to over 54 degrees. The test tray was tasted and the sandwich, coleslaw and gelatin were not cold but tasted closer to room temperature. Review of facility policy titled Food Temperatures dated 2023, revealed temperatures should be taken periodically to ensure cold foods stay below 41 degrees during the holding and plating process until food leaves the service areas. Food should be transported quickly to maintain temperatures for delivery service. Food prep areas shall follow these methods: hold food at or below 41 degrees and food sent to the unit for distribution shall be transported and delivered to the unit maintaining temperature at or below 41 degrees. This deficiency represents non-compliance investigated under Complaint Number 2568205.

Based on review of the medical record, review of the facility investigation, review of witness statements, review of facility staff training email, review of staff training records, review of facility audits, staff interviews, resident family interviews, and review of policy, the facility failed to ensure a thorough investigation was completed and corrective action was implemented to correct an incident of neglect, when a severely cognitively impaired nonmobile resident, who was dependent on staff for all activities of daily living (ADLS), was not provided food, drink or assistance with ADLs, including incontinence care for approximately 12 hours. This affected one (#12) of three residents reviewed for potential abuse and neglect. The facility census was 32.Findings include: Review of the medical record for Resident #12 revealed an admission date of 03/23/21. Diagnoses included Alzheimer's disease, anxiety, dementia, malnutrition, muscle weakness, contracture of the right foot, and hypertension. Review of Resident #12's Minimum Data Set (MDS) assessment, dated 04/08/26, revealed the resident was rarely if ever understood and cognition was unable to be assessed for Resident #12. The assessment indicated Resident #12 was dependent on staff assistance for all mobility and transfers and was assessed to in be incontinent of bowel and bladder. Review of Resident #12's care plan, revised 04/09/26, revealed Resident #12 was noted to have bladder and bowel incontinence and was at risk for infection and skin integrity impairment with intervention to monitor bowel movements for color, amount and frequency, assess needs, routine skin assessments, encourage fluids, and give incontinence care routinely and as needed. The care plan, revised 04/23/26, revealed Resident #12 had a functional status deficit related to Alzheimer's disease, malnutrition, muscle weakness and difficulty walking with interventions to sit in her room and watch tv, sit in the dining room and look out the window or sit at the ends of the hall to look outside, the resident requires a Hoyer lift for transfers, the resident requires staff to assist in putting on resident's glasses, the resident requires use of a Broda chair and was dependent on staff for bed mobility, transfers and activities of daily living. Review of notes dated 04/12/26 to 05/05/26 revealed no other mention of care concerns or that Resident #12 was thought to be out of the facility for a period of time. The notes made no mention of the resident being thought to be missing, staff searching for and locating Resident #12 or any contacts made to the family, the Director of Nursing (DON) or the physician. Review of the intake/output report dated 04/12/26 documented Resident #12 ate 51-75% of breakfast and no lunch (marked not taken) and dinner was not documented on the form. Urine output was marked as not taken on 04/12/26 at 11:19 A.M. and 6:06 P.M. and documented as large at 11:14 P.M. Review of the food intake form included hand written amounts of food and fluid intakes. On 04/12/26, it was documented Resident #12 ate 80% of her breakfast and both lunch and dinner were marked out. Review of Resident #12's progress notes revealed a note dated 04/13/26 from Physician #166 who spoke with Resident#12 and Resident #12's daughter during a routine follow-up visit and Resident #12's daughter reported concerns about the care over the weekend and planned to see the DON (Director of Nursing). Review of the facility investigation dated 04/13/26 revealed on 04/12/26, Registered Nurse (RN) #134 was working when a Resident (#5)'s family member informed her she was taking her mom off the unit. RN #134 mistook which resident was leaving the unit and when the aide asked where Resident #12 was, RN #134 informed her she was out with family. When night shift staff arrived they reached out to family due to it getting late and requested an update on when Resident #12 would return. They were informed by family that Resident #12 was not with family and should be at the facility. The DON was contacted and facility staff were instructed to search the facility for Resident #12 who was found on the unit at the end of the hallway looking out the window. A skin assessment was completed on 04/13/26 and hospice and the Physician were notified on 04/13/26 by the DON who also discussed concerns with Resident's family. A second skin assessment was completed, staff were in-serviced, and audits began. The investigation file included a concern form, investigation summary form, intakes and output information from the electronic medical record, the staff schedule for the day under review, a blank training in-service log and information that was presented during the staff education related to verification the resident received care, the skin check assessment and shower sheet and three staff interviews from the day shift nurse (RN #134) and two day shift aides (Certified Nurse Assistant #101 and #137). The investigation did not include evidence of statements from staff working night shift when Resident #12 was found, or from the Director of Nursing. The investigation also did not determine details of when Resident #12 was last seen or at what time she was found. Review of RN #134's witness statement, dated 04/13/26, revealed on 04/12/26 she observed a resident leave the floor with family and was going outside. She reported she did not see Resident #12 the rest of her shift and thought she had been with family. Review of Certified Nurse Assistant (CNA) #137's witness statement, dated 04/13/26, revealed on 04/12/26 she provided morning care for Resident #12 and the resident had breakfast in the dining room. Around lunch time she asked RN #134 where resident was at and was informed family took her off the floor and went outside. At dinner time it was not asked where the resident was as the charge nurse stated she was with her family. Review of email dated 04/13/26 from facility staff education department to all nursing staff stated all nursing staff must complete a mandatory training located on the fifth floor along with sign in sheets. Review of the training information revealed dated 04/13/26 to 04/30/26 revealed RN #134, LPN #109, CNA #137 and #161 were educated on 04/13/26. Review of the training sign in sheets for additional nursing staff along with daily staff schedules revealed several nurses did not complete the mandatory staff training related to ensuring routine care was completed for all residents. RN #100 did not complete the training and worked 04/29/26, LPN #124 did not complete the training and worked 04/13/26, 04/14/26, 04/17/26, 04/18/26, 04/19/26, 04/23/26, 04/27/26, 04/28/26, 05/01/26, 05/02/26, and 05/03/26, LPN #129 did not complete the training and worked 04/23/26, 04/24/26, and 04/29/26, RN #111 did not complete the training and worked 04/13/26, 04/14/26, 04/17/26, 04/18/26, 04/19/26, 04/23/26, 04/27/26, 04/28/26, 04/30/26, 05/01/26, and 05/02/26, Nursing Supervisor #113 did not complete the training and worked 04/14/26, 04/15/26, 04/16/26, 04/18/26, 04/22/26, 04/23/26, 04/28/26, 04/29/26, 04/30/26, and 05/06/26, RN #135 did not complete the training and worked 04/15/26, 04/18/26, 04/19/26, 04/22/26, 04/23/26, 05/02/26, 05/03/26, and 05/06/26, LPN #152 did not complete the training and worked 04/16/26, 04/20/26, and 04/25/26, LPN #160 did not complete the training and worked 04/17/26, 04/19/26, 04/20/26, 04/24/26, 04/27/26, 05/01/26, 05/02/26, 05/03/26, and 05/05/26, and Unit Manager #139 did not complete the training and worked 04/13/26. A few CNA's signed off on the training but it was only for the facility nurses. Review of the facility audits dated 04/13/26 to 04/30/26 revealed on several dates rounding of all residents on the floor occurred within a one minute period of time. Rounding was also documented as occurring on vacant resident rooms. The form was to be signed by both CNA's and the Nurse on the unit during day shift and majority were missing signatures from with CNA's or nursing staff. Interview on 05/04/26 at 2:39 P.M., with the Director of Nursing (DON) revealed she spoke with Resident #12's daughter about concerns mentioned in the Physician progress note. Interview on 05/04/26 at 3:40 P.M., with the DON and Administrator revealed Register Nurse (RN) #134 was working on 04/12/26, the day shift, was newer to the facility and several residents had family visiting. Resident #5 and #12 both had daughters visiting in blue shirts and they believe she mixed up who the residents/family members matched. The DON and Administrator reported when Resident #5's daughter mentioned to the nurse they were going outside she thought it was for Resident #12. The DON and Administrator acknowledged if the nurse did not know which resident matched which family she should have clarified. The DON and Administrator also reported the nurse observed Resident #5 exit the facility and revealed she was aware Resident #5 had been off the unit for a period of time. The DON and Administrator confirmed no residents had signed out of the facility during this period of time. Resident #5 returned shortly later to the unit and received care as expected and ordered. When night shift staff started work, they received handoff that Resident #12 was still out with family. The evening nurse contacted family asking for an update when Resident #12 would be returning and the family informed the nurse she was not with family and should be at the facility. Staff realized family did not take her out of the facility and contacted the DON and started searching the unit for her. The DON reported she had informed staff to check by the end of the hall nook by the window overlooking the dog park and that was where the resident was located. The DON revealed Resident #12 liked to sit and watch the dog park area and her family frequently took her there. The DON and Administrator revealed Resident #12's family had come in on 04/12/26 and fed her breakfast and prior to leaving placed her at the end of the hall in a nook area with a window over looking a dog park. The DON and Administrator confirmed this nook is on an open area and not hidden behind any closed doors. The DON revealed the family was updated and a skin check was preformed with no negative findings. The DON revealed the family informed her of concerns related to Resident #12's care on 04/12/26 and they had several meetings with the family, conducting an investigation and reported the findings to the family. They revealed it was not identified as neglect or an allegation of neglect as it was not found to be intentional that resident did not receive care for an estimated 10-12 hours on 04/12/26 and was based on a communication issue. Interview on 05/04/26 at 4:25 P.M., with Certified Nurse Assistant (CNA) #137 reported she had not received any education related to the incident. Interview on 05/04/26 at 4:42 P.M., with CNA #161 reported no education had been provided since this incident occurred. Interview on 05/06/26 at 8:20 A.M., with Resident #12's family member revealed she had been at the facility on 04/12/26 from around 8:00 to 9:30 A.M. and before she left, she took her mom to the nook with the window overlook the dog park. Resident #12's family member revealed it was one of Resident #12's favorite spots. Resident #12's family member reported she left the facility around 9:30 A.M. and then around 9:30 P.M. she received a call from the facility nurse (LPN #109) asking her when she was bringing Resident #12 back. Resident #12's family member reported the nurse was informed family did not have the resident and she should still be at the facility as she never left. Resident #12's family member reported she later was informed Resident #12 had been located. Resident #12's family member reported it was concerning Resident #12 was not provided lunch or dinner or anything to drink and was not provided any incontinence care for about 12 hours.Interview on 05/06/26 at 11:50 A.M. with the Administrator and the DON confirmed the investigation only contained statements from staff working day shift on 04/12/26 and did not include any statements from the night shift staff or the DON who was contacted regarding resident's whereabouts. They also confirmed specific details on what led to the resident being left without care for 10-12 hours, time stamps for all events, and staff training were not included in the investigation. They confirmed the audits were for the staff (nurses and unit managers) to check that the aides were doing routine rounding and confirmed they appear to be prefilled out with the same time for all rounding to have occurred and also stating rounds occurred on vacant rooms. They also confirmed the educational sign-ins including a training on ensuring residents received timely care and they acknowledged several staff have worked without completing this mandatory training.Review of facility policy titled Abuse, Neglect, Misappropriation and Crime Reporting, dated 08/14/99, revealed the facility shall take measures to prevent abuse, neglect and mistreatment, caused by anyone including staff, visitors or other individuals. At any time resident abuse is suspected or alleged an immediate investigation would take place and the proper authorities would be notified. Neglect was defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish or emotional distress. All allegations of abuse shall be reported immediately and will be investigated. Investigating a claim should include ensuring resident safety, suspend the employee pending the completion of the investigation, and notify family member or legal guardian. The investigation may include interviews with the resident or victim, interviews with the alleged wrongdoer, interviews with other facility staff who may have first hand knowledge, interviews with other residents, families and visitors and written statements should be obtained.This deficiency was an incidental finding during the investigation of Complaint Number 2982137.

Based on review of the medical record, review of facility investigation, review of witness statements, staff interviews, resident family interviews, and review of policy, the facility failed to ensure a resident was free from neglect, when a severely cognitively impaired nonmobile resident, who was dependent on staff for all activities of daily living (ADLS), was not provided food, drink or assistance with ADLs, including incontinence care for approximately 12 hours. This affected one (#12) of three residents reviewed for potential abuse and neglect. The facility census was 32.Findings include: Review of the medical record for Resident #12 revealed an admission date of 03/23/21. Diagnoses included Alzheimer's disease, anxiety, dementia, malnutrition, muscle weakness, contracture of the right foot, and hypertension. Review of Resident #12's Minimum Data Set (MDS) assessment, dated 04/08/26, revealed the resident was rarely if ever understood and cognition was unable to be assessed for Resident #12. The assessment indicated Resident #12 was dependent on staff assistance for all mobility and transfers and was assessed to in be incontinent of bowel and bladder. Review of Resident #12's care plan, revised 04/09/26, revealed Resident #12 was noted to have bladder and bowel incontinence and was at risk for infection and skin integrity impairment with intervention to monitor bowel movements for color, amount and frequency, assess needs, routine skin assessments, encourage fluids, and give incontinence care routinely and as needed. The care plan, revised 04/23/26, revealed Resident #12 had a functional status deficit related to Alzheimer's disease, malnutrition, muscle weakness and difficulty walking with interventions to sit in her room and watch tv, sit in the dining room and look out the window or sit at the ends of the hall to look outside, the resident requires a Hoyer lift for transfers, the resident requires staff to assist in putting on resident's glasses, the resident requires use of a Broda chair and was dependent on staff for bed mobility, transfers and activities of daily living. Review of notes dated 04/12/26 to 05/05/26 revealed no other mention of care concerns or that Resident #12 was thought to be out of the facility for a period of time. The notes made no mention of the resident being thought to be missing, staff searching for and locating Resident #12 or any contacts made to the family, the Director of Nursing (DON) or the physician. Review of the intake/output report dated 04/12/26 documented Resident #12 ate 51-75% of breakfast and no lunch (marked not taken) and dinner was not documented on the form. Urine output was marked as not taken on 04/12/26 at 11:19 A.M. and 6:06 P.M. and documented as large at 11:14 P.M. Review of the food intake form included hand written amounts of food and fluid intakes. On 04/12/26, it was documented Resident #12 ate 80% of her breakfast and both lunch and dinner were marked out. Review of Resident #12's progress notes revealed a note dated 04/13/26 from Physician #166 who spoke with Resident#12 and Resident #12's daughter during a routine follow-up visit and Resident #12's daughter reported concerns about the care over the weekend and planned to see the DON (Director of Nursing). Review of the facility investigation dated 04/13/26 revealed on 04/12/26, Registered Nurse (RN) #134 was working when a Resident (#5)'s family member informed her she was taking her mom off the unit. RN #134 mistook which resident was leaving the unit and when the aide asked where Resident #12 was, RN #134 informed her she was out with family. When night shift staff arrived they reached out to family due to it getting late and requested an update on when Resident #12 would return. They were informed by family that Resident #12 was not with family and should be at the facility. The DON was contacted and facility staff were instructed to search the facility for Resident #12 who was found on the unit at the end of the hallway looking out the window. A skin assessment was completed on 04/13/26 and hospice and the Physician were notified on 04/13/26 by the DON who also discussed concerns with Resident's family. A second skin assessment was completed, staff were in-serviced, and audits began. The investigation file included a concern form, investigation summary form, intakes and output information from the electronic medical record, the staff schedule for the day under review, a blank training in-service log and information that was presented during the staff education related to verification the resident received care, the skin check assessment and shower sheet and three staff interviews from the day shift nurse (RN #134) and two day shift aides (Certified Nurse Assistant #101 and #137). The investigation did not include evidence of statements from staff working night shift when Resident #12 was found, or from the Director of Nursing. The investigation also did not determine details of when Resident #12 was last seen or at what time she was found. Review of RN #134's witness statement, dated 04/13/26, revealed on 04/12/26 she observed a resident leave the floor with family and was going outside. She reported she did not see Resident #12 the rest of her shift and thought she had been with family. Review of Certified Nurse Assistant (CNA) #137's witness statement, dated 04/13/26, revealed on 04/12/26 she provided morning care for Resident #12 and the resident had breakfast in the dining room. Around lunch time she asked RN #134 where resident was at and was informed family took her off the floor and went outside. At dinner time it was not asked where the resident was as the charge nurse stated she was with her family. Interview on 05/04/26 at 2:39 P.M., with the Director of Nursing (DON) revealed she spoke with Resident #12's daughter about concerns mentioned in the Physician progress note. Interview on 05/04/26 at 3:40 P.M., with the DON and Administrator revealed Register Nurse (RN) #134 was working on 04/12/26, the day shift, was newer to the facility and several residents had family visiting. Resident #5 and #12 both had daughters visiting in blue shirts and they believe she mixed up who the residents/family members matched. The DON and Administrator reported when Resident #5's daughter mentioned to the nurse they were going outside she thought it was for Resident #12. The DON and Administrator acknowledged if the nurse did not know which resident matched which family she should have clarified. The DON and Administrator also reported the nurse observed Resident #5 exit the facility and revealed she was aware Resident #5 had been off the unit for a period of time. The DON and Administrator confirmed no residents had signed out of the facility during this period of time. Resident #5 returned shortly later to the unit and received care as expected and ordered. When night shift staff started work, they received handoff that Resident #12 was still out with family. The evening nurse contacted family asking for an update when Resident #12 would be returning and the family informed the nurse she was not with family and should be at the facility. Staff realized family did not take her out of the facility and contacted the DON and started searching the unit for her. The DON reported she had informed staff to check by the end of the hall nook by the window overlooking the dog park and that was where the resident was located. The DON revealed Resident #12 liked to sit and watch the dog park area and her family frequently took her there. The DON and Administrator revealed Resident #12's family had come in on 04/12/26 and fed her breakfast and prior to leaving placed her at the end of the hall in a nook area with a window over looking a dog park. The DON and Administrator confirmed this nook is on an open area and not hidden behind any closed doors. The DON revealed the family was updated and a skin check was preformed with no negative findings. The DON revealed the family informed her of concerns related to Resident #12's care on 04/12/26 and they had several meetings with the family, conducting an investigation and reported the findings to the family. They revealed it was not identified as neglect or an allegation of neglect as it was not found to be intentional that resident did not receive care for an estimated 10-12 hours on 04/12/26 and was based on a communication issue. Interview on 05/04/26 at 4:25 P.M., with Certified Nurse Assistant (CNA) #137 revealed she was the assigned aide for Resident #12 on 04/12/26, day shift. CNA #137 reported she provided morning care for Resident #12 and she was being fed by her daughter around 9:00 A.M. She reported she was unable to find the resident around lunch time and dinner time. CNA #137 stated she asked RN #134 and was informed Resident #12's family had taken her off the unit and had not returned yet. CNA #137 reported Resident #12 was completely dependent and required staff assistance with eating drinking and incontinence care and reported resident was unable to call out or make needs known. CNA #137 reported she had not received any education related to the incident. Interview on 05/04/26 at 4:36 P.M., with CNA #101 revealed she saw her eating breakfast with her daughter around 9:00 A.M. CNA #101 reported she was not the assigned aide for the part of the hall and was not aware of Resident #12's whereabouts, but confirmed she did not see Resident #12 the rest of the shift. She reported Resident #12 was completely bound to her bed or chair and required total assist from staff and was non-verbal. Interview on 05/04/26 at 4:42 P.M., with CNA #161 revealed she came in to work at 7:00 P.M. and was informed by CNA #137 that Resident #12 was out with family and had been out all day. She reported it was not normal for resident to be out with family for an extended period of time. CNA #161 revealed she had reviewed the charting and was worried Resident #12 had not eaten lunch or dinner and she reported she informed Licensed Practical Nurse (LPN) #109 and asked her to reach out to family. LPN #109 stated she would wait another hour to see if she returns and then reach out to resident's family. When LPN #109 contacted Resident #12's family she was informed Resident #12 was never taken off the unit by family and should still be at the facility. CNA #161 reported LPN #109 then called the DON and was instructed to start searching the facility for Resident #12. CNA #161 reported she found the resident sitting in her broad chair in the nook at the end of the hall by the window over looking the dog park. CNA #161 reported resident appeared tired and was extremely soiled. CNA #161 reported she estimated Resident #12 was found around 9:30-10:00 P.M. CNA #161 reported she took Resident #12 to her room where she provided incontinence care and got her cleaned up and the nurse did an assessment. Resident #12 was provided with a snack of applesauce and pudding. CNA #161 confirmed staff did not have any access to the kitchen to get her a meal and did not have access to even make a peanut butter and jelly sandwich or something with substance and just gave her what they had on hand. CNA #161 revealed Resident #12 was heavily dependent on staff for care and was unable to call out or make her needs known. CNA #161 reported no education had been provided since this incident occurred.Interview on 05/05/26 at 8:10 A.M., with LPN #109 revealed when she came in to work night shift she was informed Resident #12 was off the unit with family. LPN #109 reported when she was about finished with the evening medication administration around 9:00-9:30 P.M., she called Resident #12's family and asked when they were planning to bring the resident back. LPN #109 revealed the family informed her Resident #12 was not taken out of the facility with family and should still be there. LPN #109 revealed she contacted the DON who told staff to start looking for the resident and mentioned the nook with the window overlooking the dog park. LPN #109 revealed Resident #12 was located and brought to her room, cleaned up and given snacks. LPN #109 confirmed Resident #12 was sitting in her Broda chair soiled. LPN #109 also reported she completed a skin check with no negative findings and administered her night medications. LPN #109 revealed she contacted Resident#12's family with an update and confirmed she did not inform the physician or the hospice team. Interview on 05/05/26 at 8:17 A.M., with RN #134 revealed she was the nurse working 04/12/26 day shift. She revealed she had passed morning medication including to Resident #12. RN #134 reported she saw Resident #12 at breakfast and revealed a family member was feeding her. RN #134 revealed a family member came up to her and said they were taking their mom to the garden and asked how to get down there. RN #134 reported she was a newer staff and was not aware of the best way and inform her to ask when she gets on the first floor and someone should be able to point her in the right direction. RN #134 reported Resident #5's daughter was also in the facility and both were wearing a blue shirts. She confirmed she mixed up Resident #5 and #12's families and thought Resident #12 had been taken off the unit. RN #134 confirmed she told CNA #137 that Resident #12 was taken off the unit and confirmed she did not see Resident #12 the remainder of the shift. Interview on 05/06/26 at 8:20 A.M., with Resident #12's family member revealed she had been at the facility on 04/12/26 from around 8:00 to 9:30 A.M. and before she left, she took her mom to the nook with the window overlook the dog park. Resident #12's family member revealed it was one of Resident #12's favorite spots. Resident #12's family member reported she left the facility around 9:30 A.M. and then around 9:30 P.M. she received a call from the facility nurse (LPN #109) asking her when she was bringing Resident #12 back. Resident #12's family member reported the nurse was informed family did not have the resident and she should still be at the facility as she never left. Resident #12's family member reported she later was informed Resident #12 had been located. Resident #12's family member reported it was concerning Resident #12 was not provided lunch or dinner or anything to drink and was not provided any incontinence care for about 12 hours.Review of facility policy titled Abuse, Neglect, Misappropriation and Crime Reporting, dated 08/14/99, revealed the facility shall take measures to prevent abuse, neglect and mistreatment, caused by anyone including staff, visitors or other individuals. Neglect was defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish or emotional distress. This deficiency demonstrates non-compliance related to Complaint Number 2982137.

Based on medical record review and staff interview, the facility failed to maintain an accurate complete medical record for medication administration of narcotics to a resident. This affected one (#34) of three residents reviewed for completeness and accuracy of the medical record. The facility census was 32.Findings include:Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis (paralysis and weakness) following cerebral infarction (stroke), non-Hodgkin's lymphoma, chronic pain, and dysphagia (difficulty swallowing) amongst other diagnoses. Further review of Resident #34's medical record revealed the resident was assessed as having severely impaired cognition upon admission.Review of physician orders for Resident #34 revealed an order for a dose of 0.5 milliliters (ml) of morphine liquid concentration at a strength of 100 milligrams (mg)/5 ml to be given each day every shift as needed for pain, with a start date of 07/04/25 and an end date of 07/04/25. Further review of physician orders contained in Resident #34's medical record revealed an order for 0.75 milliliters (ml) of morphine concentrate at the same strength of 100 milligrams (mg) per five ml to be given one time at 8:00 A.M. on 07/05/25.Review of nursing progress notes contained in Resident #34's medical record revealed a nurse's note from 07/04/25 at 10:41 P.M. that read Hospice nurse came back with new order for morphine 100 mg per 5 ml to be given as needed. Administer 0.5 ml by mouth everyday and every shift. 0.5 ml given at 10:40 P.M. today.Review of Resident #34's Medication Administration Record (MAR) for 07/04/25 revealed no documentation to show the administration of 0.5 ml of morphine concentrate 100 mg/5 ml as was mentioned in the nursing progress note from 07/04/25 at 10:41 P.M. Review of Resident #34's Medication Administration Record (MAR) for 07/05/25 revealed no documentation that 0.75 ml of morphine concentrate 100 mg/5 ml was given on 07/05/25 at 8:00 A.M. as ordered.Review of the Controlled Drug Receipt/Record/Disposition form for morphine 100 mg/5 ml for Resident #34 revealed a dose of 0.75 ml was dispensed at 8:15 A.M. on 07/05/25. Further review of this form revealed directions at the top of the page that read each dose signed for here requires charting on the medication record.Interview with the Director of Nursing (DON) on 05/06/26 at approximately 6:05 P.M. verified although both medications were documented in some other way (on the narcotics sign out sheet for the 0.75 ml dose, progress notes for 0.5 ml dose), there was no documentation as required on Resident #34's Medication Administration record (MAR) that showed administration of 0.5 ml morphine on 07/04/25 at 10:41 P.M. or 0.75 ml of morphine for the ordered 8:00 A.M. dose on 07/05/25.This deficiency represents non-compliance investigated under Complaint Number 2568205.

Based on review of the medical record, review of facility investigation and witness statements, staff interviews, resident family interviews, and review of policy, the facility failed to ensure an allegation of neglect was reported to the state agency in the required timeframes. This affected one (#12) of three residents reviewed for potential abuse and neglect. The facility census was 32. Findings include: Review of the medical record for Resident #12 revealed an admission date of 03/23/21. Diagnoses included Alzheimer's disease, anxiety, dementia, malnutrition, muscle weakness, contracture of the right foot, and hypertension. Review of Resident #12's Minimum Data Set (MDS) assessment, dated 04/08/26, revealed the resident was rarely if ever understood, was severely cognitively impaired and was unable to be assessed for Resident #12. The assessment indicated Resident #12 was dependent on staff assistance for all mobility and transfers and was assessed to in be incontinent of bowel and bladder. Review of Resident #12's care plan, revised 04/09/26, revealed the resident was noted to have bladder and bowel incontinence and was at risk for infection and skin integrity impairment with intervention to monitor bowel movements for color, amount and frequency, assess needs, routine skin assessments, encourage fluids, and give incontinence care routinely and as needed. The care plan, revised 04/23/26, revealed Resident #12 had a functional status deficit related to Alzheimer's disease, malnutrition, muscle weakness and difficulty walking with interventions to sit in her room and watch tv, sit in the dining room and look out the window or sit at the ends of the hall to look outside, resident requires a Hoyer lift for transfers, resident requires staff to assist in putting on resident's glasses, resident requires use of a Broda chair and was dependent on staff for bed mobility, transfers and activities of daily living. Review of Resident #12's progress notes revealed a note dated 04/13/26 from Physician #166 who spoke with Resident and daughter during a routine follow-up visit and Resident's daughter reported concerns about the care over the weekend and planned to see the DON (Director of Nursing). Review of the facility investigation dated 04/13/26 revealed on 04/12/26, Registered Nurse (RN) #134 was working when a Resident (#5)'s family member informed her she was taking her mom off the unit. RN #134 mistook which resident was leaving the unit and when the aide asked where Resident #12 was, RN #134 informed her she was out with family. When night shift staff arrived they reached out to family due to it getting late and requested an update on when Resident #12 would return. They were informed by family that Resident #12 was not with family and should be at the facility. The DON was contacted and facility staff were instructed to search the facility for Resident #12 who was found on the unit at the end of the hallway looking out the window. A skin assessment was completed on 04/13/26 and hospice and the Physician were notified on 04/13/26 by the DON who also discussed concerns with Resident's family. A second skin assessment was completed, staff were in-serviced, and audits began. The investigation file included a concern form, investigation summary form, intakes and output information from the electronic medical record, the staff schedule for the day under review, a blank training in-service log and information that was presented during the staff education related to verification the resident received care, the skin check assessment and shower sheet and three staff interviews from the day shift nurse (RN #134) and two day shift aides (Certified Nurse Assistant #101 and #137). The investigation did not include evidence of statements from staff working night shift when Resident #12 was found, or from the Director of Nursing. The investigation also did not determine details of when Resident #12 was last seen or at what time she was found. Review of RN #134's witness statement, dated 04/13/26, revealed on 04/12/26 she observed a resident leave the floor with family and was going outside. She reported she did not see Resident #12 the rest of her shift and thought she had been with family. Review of Certified Nurse Assistant (CNA) #137's witness statement, dated 04/13/26, revealed on 04/12/26 she provided morning care for Resident #12 and the resident had breakfast in the dining room. Around lunch time she asked RN #134 where resident was at and was informed family took her off the floor and went outside. At dinner time it was not asked where the resident was as the charge nurse stated she was with her family.Interview on 05/04/26 at 2:39 P.M. with the Director of Nursing (DON) revealed she spoke with Resident #12's daughter about concerns mentioned in the Physician progress note. She revealed she had an investigation summary completed. Interview on 05/04/26 at 3:40 P.M., with the DON and Administrator revealed Register Nurse (RN) #134 was working on 04/12/26, the day shift, was newer to the facility and several residents had family visiting. Resident #5 and #12 both had daughters visiting in blue shirts and they believe she mixed up who the residents/family members matched. The DON and Administrator reported when Resident #5's daughter mentioned to the nurse they were going outside she thought it was for Resident #12. The DON and Administrator acknowledged if the nurse did not know which resident matched which family she should have clarified. The DON and Administrator also reported the nurse observed Resident #5 exit the facility and revealed she was aware Resident #5 had been off the unit for a period of time. The DON and Administrator confirmed no residents had signed out of the facility during this period of time. Resident #5 returned shortly later to the unit and received care as expected and ordered. When night shift staff started work, they received handoff that Resident #12 was still out with family. The evening nurse contacted family asking for an update when Resident #12 would be returning and the family informed the nurse she was not with family and should be at the facility. Staff realized family did not take her out of the facility and contacted the DON and started searching the unit for her. The DON reported she had informed staff to check by the end of the hall nook by the window overlooking the dog park and that was where the resident was located. The DON revealed Resident #12 liked to sit and watch the dog park area and her family frequently took her there. The DON and Administrator revealed Resident #12's family had come in on 04/12/26 and fed her breakfast and prior to leaving placed her at the end of the hall in a nook area with a window over looking a dog park. The DON and Administrator confirmed this nook is on an open area and not hidden behind any closed doors. The DON revealed the family was updated and a skin check was preformed with no negative findings. The DON revealed the family informed her of concerns related to Resident #12's care on 04/12/26 and they had several meetings with the family, conducting an investigation and reported the findings to the family. They revealed it was not identified as neglect or an allegation of neglect as it was not found to be intentional that resident did not receive care for an estimated 10-12 hours on 04/12/26 and was based on a communication issue. Interview on 05/06/26 at 8:20 A.M., with Resident #12's family member revealed she had been at the facility on 04/12/26 from around 8:00 to 9:30 A.M. and before she left, she took her mom to the nook with the window overlook the dog park. Resident #12's family member revealed it was one of Resident #12's favorite spots. Resident #12's family member reported she left the facility around 9:30 A.M. and then around 9:30 P.M. she received a call from the facility nurse (LPN #109) asking her when she was bringing Resident #12 back. Resident #12's family member reported the nurse was informed family did not have the resident and she should still be at the facility as she never left. Resident #12's family member reported she later was informed Resident #12 had been located. Resident #12's family member reported it was concerning Resident #12 was not provided lunch or dinner or anything to drink and was not provided any incontinence care for about 12 hours.Review of facility policy titled Abuse, Neglect, Misappropriation and Crime Reporting, dated 08/14/99, revealed the facility shall take measures to prevent abuse, neglect and mistreatment, caused by anyone including staff, visitors or other individuals. At any time resident abuse is suspected or alleged an immediate investigation would take place and the proper authorities would be notified. Neglect was defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish or emotional distress. All allegations occurring at the health center involving residents shall be reported to the reported to the department of health.This deficiency was an incidental finding during the investigation of Complaint Number 2982137.

Based on medical record review, staff interview, review of the medication administration policy, the facility failed to ensure a resident was free from significant medication errors. This affected one (#34) of three residents reviewed for medication administration. The facility census was 32.Findings include: Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis (paralysis and weakness) following cerebral infarction (stroke), non-Hodgkin's lymphoma, chronic pain, and dysphagia (difficulty swallowing) amongst other diagnoses. Further review of Resident #34's medical record revealed the resident was assessed as having severely impaired cognition upon admission.Review of Resident #34's physician orders revealed an order for Oxycodone (pain medication) five milligram (mg) tablets, one tablet to be given every eight hours scheduled at 12:00 A.M., 8:00 A.M., and 4:00 P.M. with a start date of 07/02/25 and an end date of 07/04/25. Further review of physician orders found in Resident #34's medical record revealed multiple orders for different doses of morphine (pain medication) liquid solution at a strength of 100 mg per every five milliliters (ml). The medical record contained orders for morphine 100 mg/5 ml liquid solution to be given at the following doses: 0.5 ml every two hours as needed for pain (start 07/04/25, end 07/05/25), 0.5 ml every shift as needed (start and end 07/04/25), 0.75 ml give one dose at 8:00 A.M. (start and end 07/05/25, 0.75ml every two hours as needed for pain (start and end 07/05/25), and 1.0ml (20mg) every two hours as needed (start 07/05/26, end 07/06/26).Review of the Controlled Drug Receipt/Record/Disposition Form for Oxycodone 5 mg tablets for Resident #34 revealed Oxycodone 5 mg was documented as dispensed from storage and given at or after 1:22 A.M. on 07/04/25.Review of the Controlled Drug Receipt/Record Disposition Form for Morphine Concentrate 100 mg/5 ml liquid for Resident #34 revealed 0.25 ml of morphine was dispensed and given at or after 6:15 A.M. on 07/05/25.Interview on 05/06/26 at 6:00 P.M. with the Director of Nursing (DON) verified Oxycodone was administered late, outside of the ordered timeframe even with consideration to the one-hour grace period before and after the ordered administration time of 12:00 A.M., when the every eight hours scheduled Oxycodone tablet was administered to Resident #34 at 1:22 A.M. on 07/04/25. Further interview with the DON at this time revealed there was no order found in Resident #34's medical record that indicated the resident should have been administered 0.25 ml of morphine concentrate as was documented on 07/05/25 at 6:15 A.M.Review of the facility policy titled Medication Administration, effective 10/01/01 and last revised 02/06/26, revealed medication administered to residents must be ordered by a physician.This deficiency represents non-compliance investigated under Complaint Number 2568205.

Based on observation, staff interview, and policy review, the facility failed to ensure proper food handling techniques when checking food temperatures. This had the potential to affect all 29 residents in the facility. Findings include: Observation on 05/28/25 at 11:35 A.M. revealed [NAME] #36 checked the temperature of the lunch meal including the pork, beef, German potato salad, peas, ground meats, and soup, in that order. Between each food checked, [NAME] #36 wiped the thermometer on a dry rag, which was resting on the steam table counter. Interview on 05/28/25 at 11:39 A.M., [NAME] #36 verified she wiped the thermometer on a dry rag between each food. [NAME] #36 stated she normally used alcohol wipes, but could not locate them when she started checking the temperatures. Interview on 05/28/25 at 11:40 A.M., Chef #57 verified alcohol wipes should have been used to clean the thermometer in between obtaining the temperature of each food. Review of the facility policy titled, Hazard Analysis Critical Control Points and Food Safety, dated 2023, revealed staff would be aware of sources of food-borne organisms in food service including contaminated equipment, improper sanitation, and cross contamination.

Based on review of personnel files and staff interview, the facility failed to ensure one staff completed at least 12-hours of education each year. This had the potential to affect all residents residing in the facility. The facility census was 29. Findings include Review of the personnel file for Certified Nursing Assistant (CNA) #5 revealed they began employment on 04/06/20. Review of the training logs revealed CNA #5 had completed several training's in 10/29/23. Since 10/29/23, the CNA had only completed 6.25 hours of continuing education. The educations included a medicaid waiver education on 06/24/24 for 0.25 hours, understanding dementia on 02/02/25 for one hour, communication on 02/02/25 for one hour, challenging behavior on 02/02/25 for one hour, activity on 02/04/25 for one hour, dining on 02/04/25 for one hour, and personal care on 02/04/25 for one hour. Interview on 05/29/25 at 10:50 A.M. with Human Resources #19 confirmed CNA #5 had not completed 12 hours of education in the previous 19 months. She reported the facility completed education on a rolling calendar from July to June and acknowledged this could allow staff to complete training at the beginning of one year and the end of another leading to over 12 months without required training being completed. Review of the facility policy titled, Training and Staff Development dated July 2024 revealed the facility shall encourage all employees to attend and participate in applicable training. The policy revealed training shall be completed from July 1st to June 30th each year. The policy did not include details of completing 12 hours of continuing education.

Based on record review, staff interview, review of the infection control log, and review of facility policy and procedure, the facility failed to follow its antibiotic stewardship protocol by administering antibiotics without meeting established clinical criteria. This affected two (Resident #17 and Resident #32) of three residents reviewed for antibiotic use. The facility census was 29. Findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 02/21/25 with diagnoses including vascular dementia, dysphagia, cystitis, and benign prostatic hyperplasia with lower urinary tract symptoms. Review of the admission Minimum Data Set (MDS) dated [DATE] for Resident #17 showed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Resident #17 required substantial to maximal assistance with toileting hygiene and was documented as always incontinent of bowel and bladder. Review of the care plan dated 02/26/25 for Resident #17 identified bowel and bladder incontinence. Interventions included to encourage fluids, provide routine incontinence care, obtain labs and tests as ordered, and monitor for signs of infection. Review of the hospital record dated 05/01/25 for Resident #17 revealed a urinalysis showed no bacteria present in the residents urine. A diagnosis of cystitis with hematuria was documented, and antibiotics were prescribed. Review of a physician order dated 05/01/25 for Resident #17 revealed an order for Cephalexin 500 mg, to be administered twice daily for seven days for a diagnosis of urinary tract infection (UTI). Review of the facility's infection tracking log event report dated 05/01/25 for Resident #17 indicated a diagnosis of a UTI made at the hospital. The infection log stated a urine culture was performed, but results were unknown. Resident #17 was noted to have bloody urine, but did not exhibit additional symptoms required to meet McGeers' Criteria. The evaluation noted the resident completed antibiotic therapy and the Medical Director was aware McGeers' criteria was not met, but wanted to treat from hospitalization. Review of the May 2025 Medication Administration Record (MAR) for Resident #17 revealed Cephalexin was administered from 05/01/25 through 05/07/25. Interview conducted on 05/29/25 at 2:11 P.M. with the Director of Nursing (DON) confirmed Resident #17 did not meet McGeers' Criteria for treatment of a urinary tract infection. The DON stated that the physician was notified, but antibiotic therapy was continued based on the hospital diagnosis and physician decision. 2. Review of the medical record for Resident #32 revealed an admission date of 03/27/25 with diagnoses including osteopathic, obesity, constipation, diarrhea, reduced mobility, and nondirective gastroenteritis and colitis. Review of the facility's infection tracking log event report dated 03/27/25 revealed a urine culture was completed for Resident #32. Culture results were noted as have not received results-completed in the hospital. Review of the McGeers' criteria indicated the questionnaire was incomplete, with the result noted as does not meet McGeers' criteria and a manual trigger marked yes for appropriate antibiotic usage. Review of physician orders dated 03/28/25 revealed sulfamethoxazole-trimethoprim (antibiotic medication) 800-160 milligrams was ordered to be administered twice daily, starting 03/29/25 through 04/02/25. Review of the Medication Administration Record (MAR) from 03/29/25 through 04/02/25 confirmed sulfamethoxazole-trimethoprim tablets were administered as ordered. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 was cognitively intact, was dependent on staff assistance for toileting, and was always continent of bowel and bladder. Review of the care plan dated 04/07/25 revealed that Resident #32 was at risk for bowel and bladder incontinence, placing the resident at risk for infection. Interventions included to provide routine incontinence care, assess for needs as they arise, perform labs and tests as ordered, and monitor for signs and symptoms of infection. Interview conducted with the Director of Nursing (DON) on 05/29/25 at 2:11 P.M. confirmed Resident #32 continued on the prescribed antibiotic following their readmission, despite the absence of documentation indicating the presence or confirmed identification of an organism in the urine. Additionally, the DON acknowledged that comprehensive data supporting McGeers' criteria had not been documented in the facility's infection tracking log event report. Review of the Antibiotic Stewardship policy, revised 09/14/23, revealed antibiotic treatment will only be considered if the suspected infection meets McGeers' criteria and if pathology strongly suggests a bacterial origin. For urinary tract infections without a catheter, both Criteria One and Two must be met. Criteria One includes symptoms such as acute flank or supra pain, increased incontinence, urgency or frequency, and fever. In the absence of a fever, at least two of the other listed symptoms must be present. Criteria Two requires a urine culture showing at least 100,000 colony forming units per milliliter (CU/ml) of no more than two species, or 100 CU/ml of any number of organisms if collected via straight catheter.

Based on review of the medical record, staff interviews, and review of Food and Drug Administration (FDA) guidelines, the facility failed to ensure adequate behavioral monitoring to evaluate effectiveness and psychotropic medication necessity for Resident #136. This affected one resident (#136) of five reviewed for unnecessary medications. The facility census was 29. Findings include: Review of Resident #136's medical record revealed an admission date of 05/20/25 with diagnoses including Parkinson's Disease without dyskinesia, cognitive communication deficit, muscle weakness, major depressive disorder, type two diabetes mellitus without complications, age-related osteoporosis without current pathological fracture, history of falling, neurocognitive disorder with Lewy bodies, and severe dementia with agitation. Review of Resident #136's Minimum Data Set (MDS) assessment completed on 05/28/25, revealed the resident was dependent on staff for upper and lower body dressing, toileting and showering. She required substantial assistance for changing positions and she was dependent on others for moving the wheelchair 50 feet. Review of Resident #136's physician orders revealed two orders dated 05/20/25 for Seroquel (an antipsychotic medication) for dementia in other diseases, classified elsewhere, severe with agitation. One order was for Seroquel 25 milligrams (mg) to be given twice a day and the other order was for Seroquel 50 mg to be given in the evening with the 25 mg Seroquel. Neither order specified instructions regarding monitoring Resident #136's behaviors. There were no orders for Resident #136 specifying behavioral monitoring. Review of progress notes for Resident #136 from 05/20/25 through 05/29/25 revealed no progress notes regarding any negative behaviors for Resident #136. Review of Resident #136's Medication Administration Record (MAR) dated 05/20/25 through 05/28/25 revealed no documentation the resident received monitoring for effectiveness and adverse consequences for the use of the medication Seroquel. Review of Pharmacy Progress Note dated 05/26/25 revealed an Medication Regimen Review (MRR) was completed for Resident #136 and there were no recommendations. Interview on 05/28/25 at 2:21 P.M. with Licensed Practical Nurse (LPN) #14 who stated she had worked with Resident #136 in her prior memory care assisted living setting revealed Resident #136 used to be a fall risk but wasn't a fall risk now. She spoke of resident's physical decline and said Resident #136 had no recent behavioral issues. Interview on 05/28/25 at 2:39 P.M. with the Director of Nursing (DON) revealed Resident #136's medications were not new as she was a transfer from the facility's memory care unit in assisted living. She said the resident's normal body posture was to lean forward and that they had a care conference with the family regarding the need for more care due to her significant decline. She said she didn't think the resident was a risk for elopement and that they charted behaviors by exception. Observation on 05/29/25 at 8:15 A.M. in the alcove of the dining room, revealed CNA #555 greeted Resident #136, asked her to pick up her feet and then wheeled her to dining room table and locked the wheelchair. Resident #136 was leaning forward with her head over the table. Observation on 05/29/25 from 8:22 A.M. to 8:41 A.M., Resident #136 touched her nose once with the clothing protector, but otherwise had no body movement; she did not attempt to move towards or away from the breakfast in front of her and was exhibiting no negative behaviors. Interview on 05/29/25 at 8:46 A.M. with CNA #555 revealed she worked with Resident #136 at her previous assisted living setting and acknowledged Resident #136 had declined since that time. Observation on 05/29/25 at 12:20 P.M., Resident #136 was seated in her wheelchair at a table in the dining room. The resident was exhibiting no negative behaviors. Interview on 05/29/25 at 12:41 P.M. with Physician #500 revealed he was aware of the black box warning that Seroquel should not be used in patients who had dementia. He said that Resident #136 used to have significant behavioral issues. He confirmed he wrote the prescription for the Seroquel to continue with her medication regimen and not because of recent behaviors. He confirmed he did not have orders for behavioral monitoring. He said that while she was in memory care she was followed by an outside psychiatric consulting group. He said the last known visit he had with resident in which behaviors were reported to be a concern was August of 2024. He reviewed his notes from appointments since that time and confirmed that he did not have any notes regarding behavioral issues since August 2024. He also had not received any reports of significant behavioral issues from staff since that time. He was uncertain regarding the last time a gradual dose reduction (GDR) had been attempted and stated it would be appropriate to try again. He said he did not think Resident #136 had been seen by the outside psychiatric consulting group in four or five months. Review of the Food and Drug Administration (FDA) manufacture's guideline for Seroquel revealed Seroquel is an atypical antipsychotic indicated for the treatment of Schizophrenia, Bipolar I disorder manic episodes and Bipolar disorder, depressive episodes. There is a black box warning that states elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel is not approved for elderly patients with dementia related psychosis.

Based on resident interview, staff interview, record review, and review of the facility policy and procedure, the facility failed to ensure an allegation of sexual and physical abuse were reported to the State agency within the required timeframe's. This affected one resident (#1) of two reviewed for abuse. The facility census was 29. Findings include: Review of the medical record for Resident #1 revealed an admission date of 05/06/21. Diagnoses included arthritis, weakness, obesity, depression, and colostomy status. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact with a Brief Interview of Mental Status (BIMS) of 15 and required substantial/maximum assistance from staff members for toileting assistance. Interview on 05/27/25 at 10:11 A.M. with Resident #1 revealed a concern of staff giving rough care during incontinence care and also a report of sexual abuse. Resident #1 reported Certified Nursing Aide (CNA) #200 had, on one occasion, provided rough care and was asked to stop as she thought he was making her bleed. On a second occasion the same week, Resident #1 reported CNA #200 had used his finger to penetrate her in a sexual manner during incontinence care. Resident #1 reported she requested him to stop which he informed her he was cleaning her and did not stop right away upon her request. She reported these situations were physical abuse and sexual abuse. Resident reported this occurred around the March or April 2025 timeframe, but could not be certain. Review of the grievance form dated 03/03/25 revealed Resident #1's sister reported to staff that she had concerns related to rough care by a Certified Nursing Aide. The DON completed a grievance concern form. The investigation included an interview from Resident #1 and Resident #1's sister. Interview on 05/27/25 at 3:24 P.M. with Director of Nursing (DON) revealed she had received customer service concerns about staff being rough during incontinence care, but denied any concerns were brought to her attention related to penetration during care or sexual or physical abuse. The DON revealed she completed a grievance concern report and took statements from the resident and family, and they agreed for a long stick sponge to be provided for resident to be able to assist in some of her own incontinence care. The DON reported CNA #200 was terminated 03/03/25 after being found sleeping after a previous warning for sleeping while on duty. During the interview the DON was informed of Resident #1's statements and allegations of physical and sexual abuse. Review of the State reporting site on 05/28/25 at 11:50 A.M. and again at 4:45 P.M., an allegation of abuse was not reported to the State agency for Resident #1. Interview on 05/28/25 at 4:50 P.M. with DON confirmed facility had not reported the allegation of sexual/physical abuse to the state agency within the required 24 hours window after the surveyor report. The DON revealed she misunderstood and would complete the report and start investigating for the allegation. Review of the State reporting site revealed the Self Reported Incident was initiated on 05/28/25 at 5:07 P.M., for an allegation of sexual abuse related to Resident #1. Review of facility policy titled Abuse, Neglect and Misappropriation and Crime Reporting dated 01/18/23, revealed all allegations of abuse shall be reported immediately and will be investigated. The policy noted that annually, covered individuals (each individual who is an owner, operator, employee, manager, agent, or contractor of a long term care facility) will be notified of their obligation to report crime or suspicion of a crime occurring to residents and anyone receiving care in the facility, to the State agency and one or more law enforcement agencies. It noted that the covered individual shall report no later than two hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury.

Based on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure care conferences were completed as required. This affected two (#6 and #18) of two residents reviewed for care conferences. This had the potential to affect all 29 residents in the facility. Findings include: Review of the medical record of Resident #18 revealed an admission date of 04/11/24. Diagnoses included major depressive disorder with psychotic symptoms, myotonia congenita, and age-related physical debility. Review of Resident #18's care conferences revealed they were held for the resident on 04/12/24, 07/31/24, and 04/25/25. Review of Resident #18's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Interview on 05/27/25 at 9:35 A.M. with Resident #18 revealed she only recalled having a care conference about a year prior. Interview on 05/28/25 at 10:17 A.M., Director of Social Services (DSS) #38 stated care conferences were to be held quarterly and she verified Resident #18 did not have any evidence of any additional care conferences being conducted between 07/31/24 and 04/25/25. Review of the facility policy titled, Resident-Centered Care Advanced Care Planning, revealed care planning discussions were available for each resident as directed by federal and state guidelines and as requested by the resident, responsible party, and/or the interdisciplinary team. 2. Review of the medical record for Resident #6 revealed an admission date of 06/17/17. Diagnoses included psychotic disorder with delusions, muscle weakness, dementia, malnutrition, delusion disorder and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively impaired with a Brief Interview of Mental Status (BIMS) of 06, indicating impaired cognition. It noted the resident was dependent on staff assistance for bed mobility, and required total dependence of one staff for eating. Review of Resident #6's care conference dated 09/27/24 revealed a care conference was in process. Review of Resident #6's care conference dated 03/27/25 (entered on 05/28/25) revealed most sections were left blank including code status, physical enablers, nursing needs, therapy services, activities, and dietary service. The care conference included a narrative comment that discussed activities, medications, care plans, and hospice, but did not mention resident code status, dietary services, or other specific nursing needs. Interview on 05/28/25 at 10:27 A.M. with Social Services Director (DDS) #38 acknowledged the facility only had evidence of two quarterly care conferences (09/27/24 and 03/27/25) in the previous year. SSD #38 confirmed the care conference dated 09/27/24 was listed as being in progress but was not completed. SSD confirmed facility had no evidence of care conferences from the second and fourth quarters of 2024. SSD #38 also confirmed documentation was not completed thoroughly, with most sections not documented. Review of facility policy titled Resident-Centered Care Advanced Care Planning, dated 01/10/23 revealed facility shall give residents an opportunity to discuss care plans including goals and preferences. Care planning discussion be available as required by federal and state regulations. Problems, goals, interventions, advanced directives and care planning shall be documented in the medical record.

Based on observation, medical record review, and staff interviews, the facility failed to follow podiatry recommendations. This affected one resident (Resident #16) out of one resident reviewed for limited range of motion. The facility census was 29. Findings include: Review of Resident #16's medical record revealed an admission date of 06/03/15. Medical diagnoses included right foot talipes equinovarus (a club-like deformity), hemiplegia, mild cognitive impairment, muscle weakness, and marked limited ambulation. Review of the Minimum Data Set (MDS) assessment completed on 04/29/25 revealed Resident #16 had intact cognition and was independent with eating, oral hygiene, showering, and dressing. He required partial to moderate staff assistance with toileting and was dependent on a manual wheelchair for mobility due to a severe foot deformity and the inability to walk. Review of Resident #16's care plan dated 02/05/24 included a goal that the resident would receive the appropriate staff support with all functional abilities and interventions to include mobility devices as ordered. The care plan also revealed the resident was at risk for pressure areas and frequent skin tears to extremities secondary to thin, fragile skin, and history of leukemia, anemia, reduced mobility, muscle weakness, contractures to the right hand, fingers, right ankle/foot, and right foot club deformity and he preferred not to wear the splint/brace. The skin care plan (updated on 06/08/24) stated the resident was seen by the podiatrist, he was diagnosed with onychomycosis (a fungal infection) and his shoes were worn out and he needed new shoes. Interventions included to administer medications/treatments as ordered and encourage the residents not to ambulate on his right foot. Review of Resident #16's podiatry notes dated 06/07/24 stated Shoes are worn out, needs new shoes, right foot severely deformed. Interview with Resident #16 on 05/27/25 at 1:23 P.M. confirmed he would like to have a new orthopedic boot to help with positioning of his right foot. He stated his boot went bad, and that he would wear it regularly if he had a newer boot. Observation on 05/27/25 at 12:36 P.M. of Resident #16's orthopedic boot revealed the bottom area was worn down with no tread, there was a medium sized hole out of the fabric of the heel, and it was unkempt with wear and dirt. Interview with Licensed Practical Nurse #14 on 05/28/25 at 2:42 P.M. confirmed she had not seen Resident #16 wear his orthopedic boot unless he went to an outside appointment, which did not happen often. Interview with the Director of Nursing (DON) on 05/29/25 at 9:57 A.M. confirmed the Podiatrist recommended a new boot for Resident #16 at his last appointment on 06/07/24, but the facility did not follow up on the recommendations.

Based on record review, interview, and review of facility policy, the facility failed to ensure timely follow-up of pharmacy recommendations. This affected one (Resident #24) out of five residents reviewed for pharmacy recommendations. The facility census was 29. Findings include: Review of the medical record for Resident #24 revealed the resident was admitted on [DATE] with diagnoses including Parkinson's disease, dementia, atherosclerotic heart disease, bradycardia, coronary artery disease (CAD), chronic diastolic heart failure, and hyperlipidemia. Review of the care plan dated 12/31/19 revealed the resident had cardiopulmonary/circulatory/coronary conditions with interventions that included to administer medications as ordered. Review of physician orders dated 03/01/24 revealed Resident #24 was prescribed Aspirin 81 milligrams (mg) daily for CAD. Review of Resident #24's progress note dated 07/16/24 documented a monthly medication regimen review was completed with recommendations made. Review of Resident #24's medication regimen review dated 07/16/24 revealed the pharmacist recommended evaluating the resident's Aspirin use in the context of current cardiovascular disease (CVD) primary prevention guidelines and suggested discontinuation. There were two options to mark, to discontinue the Aspirin or other. The Director of Nursing (DON) selected other with a notation to continue CVD prevention and indicated the medical director was notified, and no new order was provided. The prescriber response section was left blank, and the form contained only the Director of Nursing's signature. Review of Resident #24's progress note dated 08/14/24 revealed a subsequent monthly medication regimen review was completed with no new recommendations. Review of the email dated 08/15/24 from the facility's pharmacist to the Director of Nursing revealed there was a request for response from 07/16/24 regarding Resident #24 and another resident's medication regimen review. Review of Resident #24's medication regimen review recommendations follow-up form dated 08/15/24 noted the recommendation from 07/16/24 was still pending final response. The form documented a physician acknowledgment to discontinue Aspirin, signed by the provider, but lacked a date. Review of Resident #24's physician orders revealed on 08/20/24 the residents Aspirin was discontinued. Interview on 05/28/25 at 2:26 PM with the Director of Nursing confirmed the residents medical record did not provide a rationale or date on the recommendation from 07/16/24 from the physician. Additionally, although a response was requested again on 08/15/24, the discontinuation order was not finalized until 08/20/24. Review of the facility's policy titled Medication Regimen Review, dated 08/05/24, revealed all medication regimen review findings must be documented in the resident's medical record by the attending physician, including the action taken or rationale for no change.

Based on observation, interviews, and record reviews, the facility failed to ensure sanitary practices were performed during medication administration. This affected three residents (#22, #29, and #136) out of twelve observed during medication administration. The facility census was 29. Findings include: 1. Review of the medical record for Resident #29 revealed an admission date of 12/23/24 with diagnoses including pulmonary hypertension, gastro-esophageal reflux disease with esophagitis, hypertension, cardiomegaly, and chronic systolic heart failure. Review of the care plans dated 01/02/25 and 03/10/25 revealed Resident #29 had chronic cardiopulmonary and gastrointestinal conditions, with an approach to administer medications as ordered by the physician. Review of physician orders dated 03/26/25 revealed an order for Carvedilol 6.25 milligrams (mg), one tablet, scheduled between 10:00 A.M. and 1:00 P.M. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #29 had no cognitive impairment. Review of physician orders dated 04/04/25 revealed an order for Protonix delayed-release 40 mg, one tablet, scheduled between 10:00 A.M. and 1:00 P.M. Observation on 05/28/25 at 12:05 P.M. during medication administration with Licensed Practical Nurse (LPN) #14 revealed Protonix and Carvedilol, each in a single-dose blister pod, were prepared for administration. LPN #14 used the tip of a pen retrieved from a stack of papers on the medication cart to create a U-shaped opening in the blister pod. The tablets were then removed through the opening, and the pen was returned to the paper. 2. Review of the medical record for Resident #22 revealed an admission date of 04/23/20 with diagnoses including Parkinson's disease, mild cognitive impairment, mood disorder, and ataxic gait. Review of physician orders dated 12/17/24 revealed Resident #22 was ordered Sinemet (anti-Parkinson ' s medication) 1.5 tablets, 25-100 milligrams (mg) every three hours. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 had severe cognitive impairment. Review of the care plan dated 03/02/25 revealed Resident #22 had Parkinson's disease, with an approach to administer medications/treatments as ordered. Observation on 05/28/25 at 12:15 P.M. during medication administration with Licensed Practical Nurse (LPN) #14 revealed Sinemet located in a single-dose blister pod. To open the pod, LPN #14 used the tip of a pen retrieved from a stack of papers on the medication cart to create a U-shaped opening. The tablet was removed through the opening, and the pen was returned to the paper. 3. Review of the medical record for Resident #136 revealed an admission date of 05/20/25 with diagnoses including Parkinson's disease, lack of coordination, cognitive communication deficit, difficulty walking, and history of falls. Review of physician orders dated 05/20/25 revealed Resident #136 was ordered Sinemet 25-100 milligrams (mg) one tablet three times daily at 8:00 A.M., 1:00 P.M., and 8:00 P.M. Review of Resident #136's care plan dated 05/27/25 revealed a diagnosis of Parkinson's disease, with an approach to administer medications/treatments as ordered. Observation on 05/28/25 at 12:21 P.M. during medication administration with Licensed Practical Nurse (LPN) #14 revealed Sinemet located in a single-dose blister pod. To open the pod, LPN #14 used the tip of a pen retrieved from a stack of papers on the medication cart to create a U-shaped opening. The tablet was removed through the opening, and the pen was returned to the paper. Interview on 05/28/25 at 12:31 P.M. with LPN #14 confirmed that single-dose blister pods for Residents #22, #29, and #136 were opened with the tip of a pen that was located on the nurses cart during the entire medication administration. Additionally, the pen was left unattended and had never received sanitation. LPN #14 acknowledged the potential infection risk, confirming that the pills passed through the potentially contaminated opening before being placed into the medication cup. Interview on 05/29/25 at 10:00 A.M. with the Director of Nursing confirmed the potential infection risk associated with using a contaminated pen to open single-dose blister pods. Review of medication administration policy dated January 2025 revealed medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles, and practices. Additionally, during medication administration, staff should avoid touching any of the medication unless wearing gloves.

Based on observations, medical record review, hospice record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure hospice communication/documentation was maintained by the facility. This affected one (Resident #6) of one reviewed for hospice services. The facility census was 29. Findings include Review of the medical record for Resident #6 revealed an admission date of 06/17/17. Diagnoses included psychotic disorder with delusions, muscle weakness, dementia, malnutrition, delusion disorder and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively impaired. It noted he was dependent on staff assistance for bed mobility, and required total dependence of one staff for eating. Review of physician orders for Resident #6 revealed an order dated 09/14/23 for admission to hospice services. Review of Resident #6's hospice episode detail report dated 03/27/25 revealed a summary of hospice orders. Review of Resident #6's hospice notes revealed the facility had only maintained documentation through 03/25/25. Observation, record review, and interview on 05/28/25 at 8:49 A.M. with Licensed Practical Nurse (LPN) #14 revealed a hospice binder was found at the nursing station. Within the binder included documents of a calendar for 2023, 2024 and 2025 with visits written by N, SW, HC, and CH over the date. The calendar included no details about what was occurring on those visits, what staff treated the resident, or needs/concerns addressed and/or care provided. The binder included a comprehensive assessment from hospice dated 04/03/24 and 05/15/24, and a set of orders reviewed and signed by the physician dated 05/01/24. LPN #14 confirmed the binder contained no documentation from the previous year and confirmed the binder included no notes or details of the visits. LPN #14 revealed she would have to check with social services to see if he maintained updated records. Interview on 05/28/25 at 9:07 A.M. with Liaison #30 who reported the facility maintained the hospice records in the medical record. He revealed it was under the observations section in the electronic health record and after reviewing the electronic medical record with Liaison #30, he confirmed updated hospice documentation was not found in the electronic medical record. He revealed he was uncertain where to find documentation and revealed the Director of Nursing (DON) should have it. Interview on 05/28/25 at 9:20 A.M. to 10:15 A.M. with the DON confirmed the hospice documentation should be present in the facility and confirmed she did not have the records. The DON revealed the documentation was likely in the queue to be scanned into the medical record. The DON confirmed the facility found documents in the queue and the Director of Social Services was scanning them in now. She provided evidence of progress notes from past dates up to March 2025. Interview on 05/28/25 at 10:27 A.M. with the Director of Social Services #38 confirmed the remainder of hospice documents were provided for review and the most recent date was March 2025. The facility was unable to provide evidence of hospice notes and documentation from April 2025 or May 2025. Interview on 05/28/25 at 10:35 A.M. with Hospice Registered Nurse #255 confirmed hospice completed comprehensive assessments at least quarterly and hospice sent progress notes over to the facility from nursing, social services, pastoral services and bath aide on a weekly basis in a bundle. Hospice RN #255 confirmed the facility should maintain the records that were transmitted to them and confirmed hospice kept on track with sending weekly notes and confirmed hospice tracked the timeliness of and completeness of notes to verify the facility received timely information. She denied any concerns related to a delay. Review of facility policy titled, Hospice dated 07/22/24, revealed the facility shall ensure coordination of care for all skilled nursing facility hospice patients.

Based on staff interviews and medical record review, the facility failed to regularly assess a resident's catheter routinely per the resident's plan of care. This affected one (Resident #4) of three residents reviewed for catheter care. The facility census was 30. Findings include: Review of the medical record for Resident #4 revealed a readmission on 06/04/24. Diagnoses included neurogenic bladder and retention of urine. Review of the care plan dated 06/11/24 for Resident #4 revealed the need for an indwelling urinary catheter due to urinary retention. Interventions included assessing the drainage every shift, recording the amount, type, color, and order, observing for leakage, encouraging fluid intake, and providing catheter care every shift as needed. The physician orders dated 07/31/24 revealed to change indwelling Foley catheter and keep in place. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/07/24, revealed Resident #4 was severely cognitively impaired, and required partial/moderate assistance with toileting. The urinary appliance noted was an indwelling catheter, and a diagnosis of neurogenic bladder. Review of Resident #4's medical record found no evidence of routine and consistent assessment of the indwelling catheter, including monitoring drainage, amount, type, and color of the urine output. Interview on 01/02/24 at 10:22 A.M. with Charge Nurse - Licensed Practical Nurse (LPN) #64 confirmed nursing staff were required to document catheter assessments in the progress notes every shift. This assessment includes details such as the color, amount, consistency, and odor of the urine. Interview on 01/02/24 at 11:39 A.M. with LPN #77 confirmed the staff were required to document catheter output, consistency, and color in the progress notes every shift. Interview on 01/02/24 at 12:33 P.M. with the Director of Nursing (DON) confirmed Resident #4's medical record did not contain urinary assessments every shift, which should include drainage amount, type, color, and consistency. The DON confirmed the facility should adhere to the resident's care plan. This deficiency represents non-compliance investigated under Complaint Number OH00160633.

Based on observations and interviews with staff, the facility failed to ensure that the kitchenette rodent traps were properly maintained and disposed of in a timely manner. This had the potential to affect all 16 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #19, #11, #12, #13, #14, #15 and #16) who received food from the third floor kitchenette. The facility census was 30. Findings include: Observation of third floor kitchenette on [DATE] at 9:43 A.M. revealed a deceased mouse in a sticky trap near the dishwasher. There was a large hole in the drywall beneath the sink, with a visible metal guard trim, which allowed easy access to the kitchen and the movement of rodents between floors. Subsequent observations of the third floor kitchen on [DATE] at 11:07 A.M., 12:58 P.M. and 5:02 P.M. the mice had not been identified by staff. The observation on [DATE] at 12:58 P.M. during lunch service revealed Certified Nursing Assistant (CNA) #53 and CNA #94 were serving lunches to resident. They also needed to collect ice from the kitchenette, which they frequented during meal service. The ice machine was located approximately six feet away from the deceased mouse. Interview on [DATE] at 5:04 P.M. with CNA #53 and CNA #67 confirmed they have been on this floor all day, they confirmed the mouse in the kitchen was easily visible in the trap. They confirmed they did not see it, however it should be removed immediately due to it being in the kitchen. They confirmed they frequently visited the kitchen for snacks and to gather ice for beverages. Interview on [DATE] at 5:08 P.M. with Licensed Practical Nurse (LPN) #127 confirmed the presence of the deceased mouse in the kitchen and stated she would contact maintenance for its removal. Interview on [DATE] at 5:32 A.M. with the Director of Environmental Services (DES) #90 confirmed the presence of the deceased mouse in the trap on the third-floor kitchenette. He was unaware of the situation until LPN #127 informed him. DES #90 stated the deceased mice should be promptly addressed, especially in areas like kitchens and kitchenettes where food was stored. He also stated he observed traps daily as required but had not encountered any mice that morning and did not have documentation regarding the daily rounds. Interview on [DATE] at 9:57 A.M. with Local Pest Control Technician #500 confirmed mice should be removed immediately once identified. The technician emphasized the staff should conduct daily checks in these areas and remain vigilant regarding the traps to identify catches. This deficiency represents non-compliance investigated under Complaint Number OH00160633.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, observation, review of the hospital records, staff, family, and resident interviews, review of a Self- Reported Incident (SRI), review of the facility investigation, and review of the facility's abuse policy, the facility failed to ensure a resident was free from neglect. This resulted in Actual Harm when Resident #01 went five hours lying on the floor, crying for help, vomiting several times, suffered pain, and did not receive medical attention for approximately five hours. Subsequently, Resident #01 required an emergency transfer to the hospital, an inpatient hospital stay for seven days, and treatment for multiple fractures of the clavicle, medial and lateral left elbow, and left humerus. This affected one (Resident #01) of three residents reviewed for abuse. The facility census was 32. Findings include: Clinical record review revealed Resident #01 was admitted to the facility on [DATE] from the assisted living area of the facility due to a cognitive decline. Diagnoses included Alzheimer's dementia, osteoarthritis, and heart disease. Resident #01 used a walker and gait belt for ambulation with staff supervision when admitted . Review of a progress note dated 08/04/23 revealed at 5:30 A.M., Licensed Practical Nurse (LPN) #43 was rounding and found Resident #01 on her back on the floor by her bed. The resident stated she hurt really badly all over with no deformities. Range of motion to the right arm was good but the left arm was extremely painful. A small emesis was noted on the floor next to the resident. Vital signs were stable except for an elevated blood pressure. State tested Nursing Assistant (STNA) #70 stayed with the resident while the nurse contacted the physician; she was sent out with emergency services. Resident #01 stated she did not know what happened. Review of the hospital documentation revealed Resident #01 was admitted to the hospital on 08/04/23 and discharged back to the facility on [DATE] with injuries including a fractured clavicle, fractured medial and lateral left elbow, and fractured left humerus. The resident's medications included Compazine injections and orally at five milligrams (mg) as needed every six hours for nausea, and pain medications included Acetaminophen 975 mg every eight hours and 650 mg every four hours, Oxycodone 2.5 mg every three hours as needed, and a one-time dose on 08/04/23 of Morphine two mg intravenously, and Dilaudid 0.2 mg as needed every three hours intravenously. The resident's power of attorney/daughter elected hospice services with no surgical intervention for the fractures. Review of the Self-Reported Incident (SRI) dated 08/04/23 revealed there was an allegation of neglect when LPN #43 and STNA #70 failed to complete the standard every two-hour visual check for Resident #01 following an unwitnessed fall. Interview with LPN #43 revealed he relied on STNA #70 who reported she completed every two-hour rounds. Interview with STNA #70 verified she did not do rounds every two hours because she thought Resident #01 would call for assistance if she needed help. The call light report revealed Resident #01 last pushed her call light on 08/03/23 at 5:12 P.M. The preventative maintenance report for the resident call system the past year was reviewed for completion with no negative findings. The facility substantiated the neglect. On 08/07/23, STNA #70 was terminated, and LPN #43 was provided with a final warning. Review of the facility's neglect investigation dated 08/04/23 revealed Resident #01 was found on the floor incontinent and on her back complaining of left arm pain. The resident had not used her call light or neck pendant to call for assistance which she typically did in the assisted living. Resident #01 was sent to the emergency room related to left arm pain. Resident's son reported Resident #01 laid on the floor for several hours during the night and was not checked on during the night. LPN #43 and STNA #70 were the staff working and were immediately suspended. Telephone interview with LPN #43 on 08/17/23 at 7:05 A.M. revealed he last observed Resident #1 on 08/03/23 at 8:30 P.M. when he administered medications until he found her on the floor on 08/04/23 at 5:30 A.M. He thought STNA #70 was visualizing Resident #01 at least every two hours. Interview with Resident #01 on 08/17/23 at 8:53 A.M. revealed she did not remember lying on the floor or falling in her room. Observations at that time revealed the resident was in bed with a splint on her left arm. Telephone interview with Resident #01's son on 08/17/23 at 9:45 A.M. revealed the family had a camera in the resident's room which showed staff did not enter to check on her from approximately 8:30 P.M. on 08/03/23 until 5:30 A.M. on 08/04/23 when they found her on the floor. The resident had vomited several times and was crawling on the floor calling for help after she fell approximately at 12:30 A.M. Interview with the Director of Nursing (DON) on 08/17/23 at 10:40 A.M. revealed Resident #01's son reported neglect to her when she notified him on 08/04/23 of Resident #01's fall and hospital transfer. At that time, the son reported he reviewed the camera in the resident's room showing she was not checked by the staff for hours when she was on the floor. The DON verified Resident #01 was neglected the night of 08/03/23 and the morning of 08/04/23 when LPN #43 and STNA #70 did not complete visual checks of Resident #01 from 8:30 P.M. to 5:30 A.M. Review of the policy titled Abuse, Neglect, Misappropriation, and Crime Reporting, last revised 01/18/23, revealed neglect was defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. As a result of the incident, the facility took the following actions to correct the deficient practice by 08/07/23: On 08/04/23 Resident #01's physician and responsible party were notified of the fall, and she was transferred to the hospital. On 08/04/23, STNA #70 and LPN #43 were suspended pending the investigation. On 08/04/23, a rounding/visual check sheet was created by the DON for the STNAs to document for their assigned residents each shift every two-hour visual check and the nurse signed each shift. On 08/04/23, all nursing staff training was completed regarding the staff responsibilities rounding/visual check sheet documentation by the DON and training added to the orientation program for new hires. On 08/04/23, the DON initiated audits completed five times a week for two weeks, once a week for four weeks and monthly for two months to ensure the check sheets were completed by the nursing staff appropriately. On 08/07/23, STNA #70 was terminated. LPN #43 was provided with a final warning regarding rounding responsibilities by the DON. On 08/17/23, review of the employee files for STNA #70 verified STNA #70 was terminated on 08/07/23 and LPN #43 received a final written warning on 08/07/23. On 08/17/23, interviews and observations with Residents #02, #06, #15, #20, #27, and #29 revealed no concerns regarding neglect were identified. On 08/17/23, review of the completed visual documentation sheets and audits since 08/04/23 submitted by the DON revealed there were no additional abuse concerns. On 08/17/23, review of two additional resident records (#2 and #43) revealed no concerns regarding neglect were identified. On 08/17/23, interviews with Registered Nurse (RN) #36 at 6:45 A.M., RN #52 at 8:30 A.M., STNA #40 at 6:50 A.M., STNA #41 at 7:00 A.M., and STNA #57 at 9:00 A.M. verified they were trained to visually check each resident at least every two hours and document. On 08/17/23, review of the facilities SRIs revealed there were no further concerns identified regarding neglect. This deficiency represents non-compliance investigated under Master Complaint Number OH00145289.

Based on medical record review, staff interview, review of a facility incident report, review of the facility investigation, policy review, and review of hospital records, the facility failed to ensure fall preventions were implemented. This resulted in Actual Harm on 05/08/23 when Resident #50, who was cognitively impaired and required extensive assistance from two staff for bed mobility, was left by staff laying in bed in the high position after care was provided. Subsequently, Resident #50 fell from the high positioned bed sustained multiple injuries resulting in hospitalization . This affected one Resident (#50) of three residents reviewed for falls. The facility census was 31. Findings Include: Review of the medical record revealed Resident #50 was admitted on [DATE] with diagnoses including Parkinson's disease, Alzheimer's, disorders of bone density and structure, osteoarthritis, age-related osteoporosis without current pathological fracture, history of falling and anxiety. Review of Resident #50's plan of care, last updated 02/10/23 revealed the resident was at risk for falls due to weakness, difficulty in walking, lack of coordination, pain, and dementia. Fall interventions included putting pillows to the side of bed, to assist elder to not pull self to side of bed. Two people assist with incontinence care, enabler bars per family request, and Resident #50's bed should always be in the low position. Review of Resident #50's fall risk assessment dated [DATE] revealed the resident was high risk for falls. Review of Resident #50's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident required extensive assistance of two staff for bed mobility and used a mechanical lift for transfers. Review of Resident #50's physician's orders dated 04/24/23 to 05/24/23 revealed orders for enabler bars with padding per family request, a low bed, and the use of a mechanical lift for transfers. Review of Resident #50's nursing progress notes revealed on 05/08/23 at 6:50 A.M. State tested Nursing Assistant (STNA) #130 called Licensed Practical Nurse (LPN) #120 to Resident #50's room. Upon arrival Resident #50 was on her back lying on the floor, with skin tears, abrasions and swelling to her head. STNA #130 reported he dressed Resident #50, left the room to get the mechanical lift, and when the STNA returned to the room Resident #50 was on the floor. At 7:00 A.M. the hospice nurse evaluated the resident obtained an order to send Resident #50 out to the hospital for sutures. Review of the incident report dated 05/08/23 at 5:50 A.M. revealed STNA #130 called LPN #120 to Resident #50's room after finding the resident on the floor. The family representative, the guardian and the hospice provider were notified. STNA #130 revealed he got the resident up and dressed, laid her back in the bed, left the room, helped two other residents, and came back to Resident #50's room with the mechanical lift and found the resident lying on the floor. The bed was in a high position. Review of the fall investigation initiated by the Director of Nursing (DON) revealed on 05/08/23 at 4:12 P.M. an interview with STNA #130 revealed he got Resident #50 dressed for the day; he placed the resident back in the bed in a laying position. He left the room and took care of two other residents on the unit. He came back to the room with the mechanical lift and found Resident #50 on the floor. He called for the nurse, LPN #120 who witnessed Resident #50 on the floor. Review of LPN #120's statement in the fall investigation report revealed on 05/08/23 at 6:50 A.M. STNA #130 called LPN #120 to Resident #50's room. Upon arrival the resident was laying on her back on the floor, with skin tears, abrasions and swelling on the back of her head. The area was red and moist with a small amount of sanguineous drainage noted. STNA #130 reported he dressed the resident, went to get the mechanical lift, came back to the room and Resident #50 was on the floor. Neurological checks were initiated due to the unwitnessed fall and notifications were made. Review of the hospital record dated 05/08/23 for Resident #50 revealed an [AGE] year-old female with history of dementia presented to the emergency department for evaluation status post fall with a small area of active bleeding several hours and clotting. Various bruising noted throughout the body. No midline tenderness appreciated on exam. Resident #50 was admitted to the hospital trauma unit with a closed non-displaced fracture of the seventh cervical vertebra, unspecified fracture morphology, traumatic cephalohematoma, fall, and multiple contusions. Interview on 05/24/23 at 9:30 A.M., with the DON revealed a fall investigation was implemented as soon as the fall was reported. She interviewed LPN #120 and STNA #130. The investigation determined Resident #50 was left lying in a bed (not in a low position) while STNA #130 left the room, which resulted in Resident #50 falling on the floor sustaining injuries. Telephone interview on 05/24/23 at 2:25 P.M., LPN #120 revealed on 05/08/23 he was called to the room by STNA #130 when he arrived at the room Resident #50 was on the floor. He could not recall if the pillows were placed beside the resident in the bed. He verified the bed was not in a low position. The bed was higher than a normal positioned bed. A follow-up interview on 05/24/23 at 3:00 P.M., with the DON verified per her investigation Resident #50's bed was not in a low position when she fell . Telephone interview on 05/24/23 at 4:12 P.M., with STNA #130 revealed he went into Resident #50's room and dressed her for the day. The STNA indicated it was too early to get her out of bed, so he went and helped two other residents. He came back with the mechanical lift and found Resident #50 on the floor. He noticed Resident #50 was bleeding and called for the nurse. He verified the bed was in a high position, but stated it was not the highest position. Review of the policy titled Fall Prevention and Management, dated 09/13/22 revealed fall risk screening will be completed on admission and quarterly thereafter, interventions will be put into place based on risk factors for example falls from bed require the resident to have a low bed, customized activities, etc. This deficiency represents noncompliance discovered in Complaint Number OH00142774.

Based on observation, interview, record review, and review of the facility's policy on care of pressure ulcers, the facility failed prevent the development of two avoidable unstageable pressure ulcers, resulting in harm to Resident #97. This affected one of 3 stage two residents sampled for pressure ulcers. The facility identified four residents who developed pressure ulcers in the facility. Findings Include: Review of Resident #97's "Current [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was alert and oriented, required extensive assistance of one person for transfers, limited assistance of one person for bed mobility, had impairment on both sides of his legs, was at risk of developing pressure ulcers, and had one, stage two pressure ulcer that was not present on admission. The MDS assessment dated 01/06/11 revealed the resident was alert and oriented, required extensive assistance of one person for transfers and bed mobility, was not steady during surface to surface transfers, had impairments on both sides of his legs, was at risk of developing pressure ulcers, and did not currently have a pressure ulcer. Review of the "Braden Scale" skin assessment dated [DATE] and 01/18/11 revealed the resident walked occasionally and spent majority of the time in bed or a chair and made frequent, though slight, changes in his body or position independently. The Braden scale identified the resident was at risk of developing pressure sores. A "Weekly Skin Assessment" dated 01/03/11 documented the resident's skin was intact. The resident's current plan of care for pressure ulcers was dated 01/29/11 and identified the resident was at risk for pressure ulcers related to bowel incontinence and requiring assist with mobility. Approaches listed in the plan of care included to report any signs of skin breakdown when found, use a pressure reduction mattress, elevate heels when in bed, turn and reposition him every two hours, and conduct weekly skin inspections. The plan of care did not identify the potential for the resident to develop pressure areas due to rubbing his feet together and not being able to maintain the use of heel boots. The "Skin Integrity Events" dated 01/12/11 documented a fluid filled blister to the right heel that measured four cm by five cm was identified. The form documented the blister was caused by the resident rubbing his heels on his sheets. Physician' s orders for a treatment to the resident's right heel was obtained on 01/12/11. Another physician's orders [REDACTED]. The "Weekly Skin Assessment" dated 01/16/11 and 01/24/11 documented the presence of an intact fluid filled blister to the resident's right heel. No other skin issues were identified. The "Weekly Skin Wound Tracking" dated 01/27/11 documented the resident's right heel ulcer measured five cm by four cm and appeared as a deflated blister that had eschar (think, leathery, necrotic, devitalized tissue). The "Weekly Skin Assessment" dated 02/14/11 documented the right heel ulcer measured four cm by five cm. The "Physical Assessment" dated 02/18/11 identified the resident's pressure area to the right heel measured three cm by two and two tenths cm. The "Weekly Skin Assessment" dated 02/21/11 revealed the right heel ulcer measured four cm by five cm. The "Physical Assessment" dated 02/25/11 documented the resident's pressure area to the right heel had eschar and measured one and one tenth cm by one and one tenth cm. Review of the physician's orders [REDACTED]. Review of the "Weekly Wound Tracking" dated 02/18/11 and the "Weekly Skin Assessment" dated 02/21/11 both documented the resident's left heel had hard yellow eschar that measured five and one half cm by five cm. Further review of the physician's orders [REDACTED]. The "Weekly Wound Tracking" dated 02/25/11 revealed the resident's left heel had eschar that measured five and nine tenths cm by five and eight tenths cm. The "Wound Management Progress/Procedure Note" dated 02/14/11 revealed the resident's necrotic areas to both heels were caused by shearing . The resident's MS had advanced over the past few months and he was spending more time rubbing his feet/legs together. Heel foam boots were implemented as an intervention. On 03/16/11 at 8:57 A.M., Resident #97 was observed laying on his back in bed; his right heel was elevated by a pillow and his left heel rested on the air mattress. He was not wearing heel boots or rubbing his feet on the sheets. At 9:20 A.M. both of the resident's heels were observed wrapped but he was not wearing heel boots and his heels were not elevated. At 2:41 P.M. the resident was sitting up in a wheel chair in front of a television in the lobby. Both of the resident's heels were wrapped and they were resting directly on the foot pedals of the wheel chair. At 4:00 P.M. the was still wearing the dressings to his heels but did not have any heel boots on. At 5:30 P.M. revealed the resident was in bed with both of his heels wrapped and his right heel was elevated by a pillow. He was not wearing heel boots. Interview with Registered Nurse (RN) #2 at 5:35 P.M. verified the resident did not have boots on either of his feet, but he should be wearing them when he was in bed. On 03/18/11 at 8:15 A.M. observations were made of a treatment being done to the resident's heels. The resident did not exhibit any signs of pain during the treatment. There was a necrotic area to the right heel that measured two and two tenths cm by four and one tenth cm with no depth. The necrotic area to the left heel measured five and three tenths cm by six and six tenths cm. On 03/18/11 at 8:12 A.M. State tested Nursing Assistant (STNA) #5 stated they would use whatever was available to elevate the resident's heels; either heel boots when he was in bed or prop his ankles on pillows. STNA #5 stated she assumed the resident's heels were propped on pillows before he had the order for the heel boots. However, she was not sure. Interview on 03/18/11 at 12:35 P.M. with the Director of Nursing (DON) revealed the resident does not keep the heel boots on and kicks them off. Interview on 03/18/11 at 1:06 P.M. with LPN #2 revealed the resident did not take his boots off, rub his feet together, or move his legs. At 1:07 P.M., STNA #2 also stated the resident did not take his boots off and only wore them in bed. She was not sure if he moved his legs/feet. At 1:09 P.M. STNA #1 stated the resident's legs didn't move much but he would move his legs if you asked him. STNA #1 stated he did not take his boots off and did not kick the pillow out from under his feet. Interview on 03/18/11 at 4:00 PM. with Certified Nurse Practitioner (CNP) #1 revealed resident's MS has advanced over the past few months and he spent more time rubbing his heels together. CNP #1 stated the resident's blisters were caused by rubbing. At 4:05 P.M. the DON stated the facility implemented an air mattress for the resident on 03/07/11 as he was spending more time in bed. She verified the facility did not identify the resident's behavior of rubbing his feet together in the skin assessment or the resident was unable to maintain the use of his heel boots. She also verified the plan of care was not updated to reflect the resident's behavior or wearing of the heel boots. Review of the facility's policy for the treatment/management of pressure ulcers dated 03/07 revealed an unstageable pressure ulcer is defined as full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, green, gray, or brown) and/or eschar (tan, brown, or black) in the wound bed. The skin condition should be observed and documented using the pressure ulcer risk assessment tool and the admission skin assessment. At least daily, staff would observe and report potential and actual changes in the skin. Skin condition would be observed and reported to the nurse by the nursing assistant with every bath. Weekly skin condition evaluations were to be completed. Unavoidable pressure ulcers occur when the facility has taken the following steps: 1. Evaluated the clinical condition and risk factors 2. Defined and implemented interventions 3. Monitored and evaluated the impact of the interventions 4. Revised the approaches as appropriate