Every finding on record at Otterbein at Maineville

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility Self-Reported Incidents (SRIs), staff interview, and policy review, the facility failed to provide a resident's food in the correct texture to meet individual needs per physician's orders for one (Resident #1) resident. This resulted in actual harm when Resident #1 choked on the food of incorrect texture which caused the need for cardiopulmonary Resuscitation (CPR) and hospitalization. This affected one (Resident #1) of three residents reviewed for specialized diets. The facility census was 50. Findings include: Record review revealed Resident #1 was originally admitted to the facility on [DATE] with diagnoses including type 1 diabetes, chronic obstructive pulmonary disease, dementia, personal history of transient ischemic attack, cerebral infarction, gastro-esophageal reflux disease, and anxiety disorder. Review of Resident #1's Minimum Data Set (MDS) significant change assessment, dated 12/09/25, revealed he was cognitively intact. He required supervision with eating and was dependent on activities of daily living (ADL). Review of the Care Plan for Resident #1 dated 12/09/25 revealed he was at risk for changes to nutrition due to risk of aspiration related to dysphagia. Interventions included providing his diet as ordered, monitoring for signs of aspiration and referral to speech therapy as needed. Review of the physician orders on 12/04/25 revealed Resident #1 was ordered a regular diet with minced and moist texture. Review of a nursing progress note for Resident #1 dated 12/04/25 revealed an unidentified Certified Nursing Assistant (CNA) #125 yelled from Resident #1's room that the resident was blue and not breathing. A nurse ran to assist, and no visible breathing was noted. The nurse instructed the staff to call for additional assistance and to call 911. Resident #1 was lowered to the floor and found to be choking on food. Some breath was noted while he was tongue thrusting to remove food. He was able to dislodge some food, and more was dislodged with a mouth sweep. Cardiopulmonary resuscitation (CPR) was initiated when no pulse was found and continued until emergency services personnel (EMS) arrived and took over. EMS reported Resident #1 had a pulse when they left the facility. Review of an additional progress note dated 12/04/25 revealed the nurse called the hospital for an update and was notified Resident #1 had been intubated and would be admitted . Review of the Self-Reported Incident (SRI) dated 12/05/25 revealed Resident #1 was found unresponsive in his room on 12/04/25 at approximately 6:00 P.M. CPR was immediately started and 911 was called. Food was noted in Resident #1's mouth during resuscitation measures. During the investigation it was noted Resident #1 generally ate in his room and had an order for a minced and moist diet which he was able to consume with intermittent supervision from staff. Social Worker (SW) #303, who normally would not prepare or serve meals provided a plate without checking Resident #1's diet order. She provided a regular texture meal. Approximately six minutes after receiving the wrong diet order, a CNA #125 walked into the room with a plate containing the correct diet and found Resident #1 unresponsive. CNA #125 immediately called for assistance with CPR initiated and 911 called. He was subsequently transferred to the hospital. The facility took corrective actions but did not substantiate neglect. Review of the hospital discharge paperwork for Resident #1 dated 12/09/25 revealed he was admitted from 12/04/25 through 12/09/25 with a diagnosis of cardiac arrest and pneumonitis to due inhalation of food and vomit. He was released with a diet order of a regular diet with pureed texture and moderately thick liquids. During an interview on 12/15/25 at 1:30 P.M., the Administrator and Director of Nursing (DON) confirmed all staff were trained on 11/20/25 verifying diet orders prior to serving meals in anticipation of the upcoming holiday dinner. On 12/04/25 the facility had a holiday dinner which included turkey and mashed potatoes. SW #303 heard staff state Resident #1 had not yet received a plate and she thought he would enjoy the garlic mashed potatoes, so she made him a plate and provided it without checking his diet order. About two minutes later she brought him a napkin and he was fine. About six minutes later an aide brought the correct diet to him not knowing he had been provided the wrong diet and found him unresponsive. She called for the nurse who began CPR and he was sent out to the hospital where he was on a ventilator in the intensive care unit (ICU) a couple of days and then returned to the facility with his diet downgraded to pureed. There were no other residents provided the wrong diet texture during this holiday meal on 12/04/25. During an interview on 12/15/25 at 3:38 P.M., Registered Nurse (RN) #168 stated revealed they were having a holiday dinner, and the social worker was assisting with ensuring all residents received a meal so she brought Resident #1 a plate of food without checking his diet order. A few minutes later CNA #125 brought Resident #1 a plate with the correct diet texture unaware he had already been provided a plate and found him unresponsive. CNA #125 immediately contacted RN #168 who assisted her with lowering Resident #1 to the floor. She assessed him found he was choking on food and assisted with clearing his airway. She was then not able to find a pulse and began CPR which she continued until EMS arrived. She stated EMS reported he had regained a pulse when they were leaving. During an interview on 12/15/25 at 4:02 P.M. CNA #125 stated as she was preparing a plate for Resident #1 with his correct diet, the social worker brought him a plate with a regular texture. She stated she was not aware he had been given the incorrect plate of food until she took him the food and found him unresponsive. She immediately called for the nurse and assisted with lowering him to the floor so the nurse could begin CPR while she called 911. Review of the policy titled Neighborhoods Diet, revised 12/02/21, revealed that a minced and moist diet consisted of a regular diet with textured altered for those with difficulty swallowing and/or chewing. Food can be eaten with fork or spoon, scooped or shaped onto the plate in a ball, soft and moist with no separate thin liquids, minimal chewing. Meat is finely minced or chopped. Fruit mashed or drained of excessive juice, vegetables finely minced or chopped or mashed, cereal very thick and smooth, and no regular dry bread. The deficient practice was corrected on 12/05/25 when the facility implemented the following corrective actions: - - On 12/04/25 Resident #1 was immediately assessed by RN #168 and CPR was initiated and he was sent to the hospital - - On 12/04/25 RN #151and Assistant Director of Nursing (ADON #168) conducted an audit and assessment of all residents either through interview or physical assessment with no concerns. - - -On 12/04/25 Education was sent by the Administrator to all staff via an email system and in-person training was completed by the Administrator, the Assistant Administrator (AA #181) and the DON with all staff regarding how to verify diet orders and the importance of following them. Staff not trained by 12/05/25 was not permitted to work until education was completed. - -On 12/04/25 All resident records were audited by the [NAME] President of Operations (VPoO #306) and the DON to identify anyone who currently required any type of modified diet to ensure it was correctly listed and to clarify the level of supervision needed with meals for each resident. No one else in the same house identified. - -On 12/05/25 A root cause analysis was completed by VPoO #306, AA #181 and the DON regarding the incident and statements were obtained from all staff present. The root cause analysis revealed Social Worker (SW) #303 had not reviewed the diet orders before serving the food. Staff present were RN #168, LPN #142, SW #303, and CNA #104 and #125. - - -On 12/05/25 A Quality Assurance Performance Improvement (QAPI) meeting was held with the Medical Director to discuss the incident and action plan. Members in attendance were the Medical Director, Administrator, DON, RN #168, SW #303 and the Director of Rehab/SLP #290. - -On 12/05/25, SW #303 was terminated from the facility. - -On 12/06/25, two random audits were conducted by the DON daily to ensure the diet books had the correct diet orders and residents received the correct orders and level of supervision needed. The audits consisted of two residents each day for two weeks, two residents a week for two weeks and then two residents a month for two months. This deficiency represents non-compliance investigated under Master Complaint Number 2690997 and Complaint Number 2689516.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, observation, staff and physician interview, review of hospital records, and policy review, the facility failed to ensure the residents environment remained as free from accident hazards as possible when the Heating, Ventilation, and Air Conditioning (HVAC) system malfunctioned causing the temperatures in House 150 to drop, and portable space heaters were placed in four resident rooms, which were prohibited. This resulted in Immediate Jeopardy and serious life-threatening physical harm and/or injuries when on 04/17/25, Resident #47 sustained a full thickness burn to the left outer calf from below the knee to the top of the left foot. Resident #47 was sent to the hospital to be evaluated on 04/25/25 and required hospitalization due to the severe burns that developed faecalis and Enterococcus (E.) faecium infection in the wounds. This affected one (Resident #47) of four residents reviewed for accident hazards and placed an additional three residents (#04, #49 and #51) at risk for potential serious physical harm and/or injuries who had space heaters placed in their rooms in House 150. On 05/07/25 at 3:35 P.M., the Administrator, Director of Nursing (DON), Clinical Regional Nurse (CRN) #399, Regional Administrator (RA) #477, and Maintenance Neighborhood Director (MND) #555 were notified the Immediate Jeopardy began on 04/17/25 at 3:00 P.M. when Resident #47 sustained severe burns to his left leg from below his knee outer to the top of his left foot as a result of the use of a portable space heater in the resident's room. A treatment of Silvadene (a topical antibiotic used in partial thickness and full thickness burns was used to prevent infection) was implemented on 04/18/25 when Wound Physician (WP) #449 saw and examined Resident #47. Resident #47 was seen again on 04/25/25 by WP #449 and Wound Nurse (WN) #509 who had noticed the change in the left leg, and the left foot had three black toes from the middle toe to pinkie toe. WP #449 recommend that Resident #47 go to the emergency room to be evaluated. Resident #47 was admitted to a hospital Intensive Care Step Down Unit with burns to left leg and foot, urinary tract infection, and pneumonia in both lungs. Resident #47 was started on intravenous antibiotics immediately due to infection, cellulitis, and burns. Resident #47 was discharged from the hospital to another nursing home on [DATE]. Resident #47 was currently being treated at the burn unit clinic at the hospital as an outpatient. Although the Immediate Jeopardy was removed on 04/17/25 when WN #509 removed the portable space heaters from the rooms of Residents #04, #47, #49 and #51, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 05/04/25 when the facility implemented the following corrective actions: • On 04/18/25, the Administrator began educating all employees that space heaters are not permitted in resident rooms, and if found, to notify the Administrator as soon as possible. All immediate education was given in person to employees working at the time during second shift 04/18/25, including Leadership/Interdisciplinary Team (IDT) employees with messages and/or calls going out to others. All employees were notified by the Administrator that they must complete and acknowledge education as soon as possible, but that it was mandatory before the next shift worked. • On 04/18/25, Maintenance Coordinator (MC) #404 was educated by MND #555 with regard to the prohibition of use of space heaters in nursing areas. • A Quality Assurance and Performance Improvement (QAPI) meeting was held on 04/18/25 at 4:30 P.M. The Medical Director was in attendance by telephone and was in agreement with the plan of action. The IDT was present as well or called in by telephone, including MC #404. • Beginning 04/17/25, every day/every shift/every house/every room will have twice a shift per day audits to be completed on room temperatures and to ensure no space heater is present. The nurse on duty or designee will complete the audit to verify that no space heaters are present, and room temperatures are between 71-81 degrees Fahrenheit (F) and residents are comfortable. The employee who was designated will review the audits in real time to verify accuracy and any need to make immediate corrections. Audits to be completed at this pace and interval until 04/27/25. From 04/28/25 on, the same audits will occur once daily in all rooms and all houses for two weeks and then weekly for two weeks. Audits, along with the rest of this action plan, will be reviewed by the QAPI committee and recommendations about amendments to the plan, audit scope or frequency, or other feedback will be shared. • Review of facility audits dated 04/17/15 through 05/04/25 revealed audits were performed twice a shift daily. • During interviews on 05/07/25 from 1:27 P.M. through 2:34 P.M., Licensed Practical Nurse (LPN) #313 and Certified Nursing Assistants (CNA) #314, #298, #255, #412, and #331 all stated they had received education about space heaters not being allowed at the facility, and to notify management of temperatures of resident rooms not in range of 71 degrees to 81 degrees. Staff was also educated on telling families not to bring in space heaters. Findings include: Record review revealed Resident #47 was admitted on [DATE]. Review of the hospital Discharge summary dated [DATE] revealed Resident #47 had spinal cord compression recently due to epidural hematoma and had lower extremity paralysis. Additional diagnoses included diabetes mellitus. Review of the progress note dated 04/17/25 at 7:52 P.M. revealed the DON documented LPN #205 was notified by CNA #355 that Resident #47 had increased edema with weeping fluids from both legs. During the assessment, Resident #47 was noted with weeping edema. Resident #47 stated he was not currently experiencing any pain. Resident #47's lower extremities were cleansed with normal saline and patted dry. Abdominal (ABD) pads and Kerlix were placed on his legs. Resident #47 was his own person, and his family member was visiting in the room. Review of a progress note dated 04/17/25 at 11:56 P.M. revealed the DON documented Resident #47's lower extremities were reassessed and had a superficial open area to the left lower leg. A new treatment of Xeroform gauze was initiated and put in place. Resident #47 had ABD pads on his leg. The physician was notified. Review of the initial wound evaluation and management summary dated 04/18/25 revealed WP #449 documented Resident #47 had wounds on his left lateral ankle and left lateral leg. History of the present illness was a space heater burn on left leg. The burn wound of the left lateral ankle was full thickness that measured 7 centimeters (cm) by 6 cm by 0.1 cm. Slough was 30 percent, granulation tissue was 70 percent. No signs of infection. WP #449 debrided the left ankle by removing the necrotic tissue and establishing the margins of viable tissue. The burn wound of the left lateral leg was full thickness and measured 20 cm by 10 cm by 0.2 cm that had 100 percent granulation tissue. No signs of infection. Review of the service order from the HVAC contractor, dated 04/18/25, revealed a service call was made to troubleshoot heating operations in House 150. The hot surface igniter did not come on initially. After cycling power, the hot surface igniter came on, but the gas did not ignite. As a result of intermittent issues, it was recommended to replace the control board, pressure switch and gas valve. Gas valve and pressure switch on order. Review of a service order from the HVAC contractor, dated 04/22/25, noted the faulty gas valve, control board and pressure switch were replaced in House 150. The heating unit was operational. Review of a wound evaluation dated 04/25/25 by WP #449 revealed Resident #47 had been seen today for wounds to his left lateral leg, right lower lateral leg, sacrum, and right buttocks. History of present illness stated space heater burn on the left leg. The left lateral leg was a full thickness burn and measured 19.5 cm by 7.0 cm by 0.2 cm. Exudate was light, thick adherent devitalized necrotic tissue 50 percent, slough 30 percent, granulation tissue 20 percent, and no signs of infection. A surgical excisional debridement procedure was done to remove necrotic tissue to establish the margins of viable tissue. The left distal foot was described as a full thickness venous wound measuring 3.5 cm by 7.0 cm by 0.2 cm. Exudate light serous fluid, granulation tissue 100 percent. No signs of infection. Review of the hospital Discharge summary dated [DATE] revealed that Resident #47 had admitting diagnoses of urinary tract infection with foley catheter, bilateral pneumonia, and infected left lower extremity, sacral ulcer, and atrial fibrillation (A-fib). Resident #47 had a history of A-fib, diabetes, hypertension, paraplegia secondary to cord compression (03/13/25), neurogenic bladder who presented with cellulitis of left lower extremity/burn injury. He had sustained a burn wound to his left lower extremity from a space heater that was next to his leg. Resident #47 was paraplegic with decreased sensation from his torso down. He was also found to have possible pneumonia as well as urinary tract infection. Left lower extremity cellulitis and burn had wound culture that found faecalis, and E. faecium. Resident #47 on Vancomycin (a powerful antibiotic used to treat a range of serious bacterial infections) while an inpatient. During an interview on 05/05/25 at 1:06 P.M., MC #404 stated that the facility had heating problems on 04/17/25 in House 150. Resident rooms were not heated above 71 degrees Fahrenheit (F). MC #404 stated Rooms #106 through #110 had problems with heating. MC #404 looked at the unit, and observed it was working, then not working. He called the HVAC company that came out the next day to determine the problem. On 04/18/25 there were problems with the gas valve for that side of the building. The pressure switch was not opening, and the circuit board was failing. MC #404 stated that he checked the room temperatures. He couldn ' t remember what the temperatures were and did not document them, but he knew they were below 71 degrees F. MC #404 stated he had never given space heaters to any residents. MC #404 stated the facility had no space heaters. MC #404 stated he did not know there were space heaters in the rooms at the facility or where they came from. MC #404 stated the reasons not to have a space heater were the risk of starting a fire or a resident getting burned. During an interview on 05/05/25 at 2:56 P.M., LPN #205 stated that CNA #355 had told her that Resident #47 was sitting too close to the space heater. LPN #205 stated when assessing Resident #47, he had large amounts of clear fluid draining from his left leg. LPN #205 stated she notified the management and wrapped his legs with Kerlix right away when he was lying down in his bed. During an interview on 05/05/25 at 3:11 P.M., CNA #270 stated she worked first shift on 04/17/25. When she returned to work on 04/18/25, Resident #47 had a burn on his left calf that was red with bubbles like blisters. On 04/18/25 there was a physician that came in to see Resident #47. Resident #47 had a bubble on his left ankle, and on the top of his left foot. WP #449 popped the bubble on his left ankle. Resident #47 had other bubbles on his left leg. Resident #47's skin to the left leg was also leaking fluid. CNA #270 stated that on 04/17/25, Resident #51 and Resident #49 also had space heaters. CNA #270 stated that the space heater did get hot to touch and could cause a burn. CNA #270 said the Administrator was aware, because she was the one that told them to move the space heaters into the rooms of Residents #49 and #51. CNA #270 said the heat was broken for a week and the temperature in the building was in the 70's. During an interview on 05/05/25 at 4:11 P.M., Resident #49 stated when she arrived at the facility on 04/07/25 she had complained about the heat that day. Resident #49 stated the thermostat kept reading 78 degrees F, and the room was not that warm. She stated that MC #404 had come to see her room and told her that the heater was broken. Resident #49 stated she watches the weather, and there was a frost warning that day. Resident #49 stated she had no heat for eight days. She said she received a space heater on 04/17/25 but was afraid to turn it on. Resident #49 stated that once the resident got burnt the facility then pulled the space heaters and moved residents into other rooms. During an interview on 05/05/25 at 4:24 P.M., CNA #255 stated the heat went out the week of 04/17/25. CNA #255 stated that Resident #47 was up in his wheelchair because therapy got him up. Resident #47 stated he was cold, and he was given a blanket to use in his wheelchair. MC #404 had brought a space heater to Resident #47's room. CNA #255 stated the space heater was under the television at the foot of the bed. The space heater was on and was heating his room. CNA #255 stated that she had seen pictures of the resident's leg, and it was red, blistered, and skin peeling off. CNA #255 stated the only residents she knew of that had a space heater in their room were Residents #49 and #51. During an interview on 05/05/25 at 4:26 P.M., Resident #47's family member stated when he entered the room on 04/17/25 at 6:40 P.M. he saw Resident #47 sitting less than six inches from a space heater. He pulled Resident #47's wheelchair back away from the space heater. The family member notified staff to put Resident #47 back to bed and told the staff to check his legs because he saw something. Resident #47's legs were blistering, and liquid was pouring out of them during the lift transfer to bed. After Resident #47 was laid down in bed, the bed linens were soaking up liquids from his legs. He had redness on the left leg, blisters and peeling skin. Resident #47's family member said it looked like a burn on his left leg. During an interview 05/06/25 at 9:28 A.M., WP #449 stated he talked to the nurse practitioner prior to seeing Resident #47 on 04/21/25. He and the nurse practitioner decided to call the wounds on the resident's legs venous ulcers. WP #449 stated he had seen Resident #47 and was concerned about his wounds on his left leg. WP #449 requested Resident #47 to be sent to the hospital because of the black toes on the left foot. On 04/18/25 there were no black toes and on 04/25/25, he told the Administrator and DON to send him to the hospital, to have an evaluation. WP #449 stated this was the best course of action for Resident #47 because his wounds got worse. During an interview on 05/06/25 at 9:48 A.M., Resident #47's family member stated he was currently being seen at a burn clinic for treatment. During an interview on 05/06/25 at 10:38 A.M., CNA #355 stated she had reported for work on 04/17/25 at 3:00 P.M. CNA #355 stated that when she got to work, she noticed portable space heaters in resident rooms and stated she was confused because she was told they are not allowed to have them. The portable space heaters were in resident Rooms #106, #108, and #110. She was told by another staff that the heat had gone out on 04/14/25. CNA #355 stated that around 5:00 P.M. she started cooking for the residents. At around 6:00 P.M., she went into resident room [ROOM NUMBER] and observed Resident #47 in his wheelchair about a foot away from a portable space heater. She moved Resident #47 away from the space heater to the other side of the room and advised him that it was not safe to be that close to the portable space heater due to him not having any feeling in his legs. At 6:40 P.M., CNA #355 stated that she was paged to resident room [ROOM NUMBER] and when she went to the room Resident #47 was again up too close to the portable space heater. She asked him if he wanted to come out for dinner and he replied he did not. At this time, Resident #47 asked to be placed into his bed. CNA #355 stated that as she was transferring Resident #47 at 7:00 P.M. to his bed, she noted that his leg was red and hot to the touch. She placed Resident #47 into a Hoyer lift and as he was about halfway up to the bed, his leg busted open and began spraying fluid. LPN #205 was called and came into evaluate Resident #47's injuries. LPN #205 examined his leg at 7:25 P.M. and then wrapped it. CNA #355 stated that she attempted to call the Administrator and the DON but got no answer. She then contacted Coach #444 and reported the incident to her. CNA #355 stated that she returned to the room and noted that the leg was leaking a lot of fluid and that the skin was peeling back and the area affected was on his left leg from his toes to his knee. CNA #355 stated that she received a call from both the Administrator and the DON who advised her to remove the portable space heaters and transfer residents to other rooms. Resident #47 did not want to move rooms at this time. CNA #355 stated that WN #509 removed the space heaters, and she did not know where they were placed. CNA #355 stated that she did not know the make and model of the portable space heaters, but it was not the first time the facility had used portable space heaters. During an interview on 05/06/25 at 11:00 A.M., the DON stated that Resident #47 did not have any black toes when he was at the facility. She was unaware that the wound physician was concerned about Resident #47's black toes. During an interview on 05/06/25 at 11:05 A.M., the Administrator stated that the facility had heat problems in House 150. The facility never had space heaters, and none at this time. The Administrator stated the employees at the facility had put the space heaters out in resident rooms. She did not know where the space heaters came from. She stated she was not aware that Resident #47 had a burn. There were five rooms affected by the heat that was not working. During an interview on 05/06/25 at 1:58 P.M., WN #509 stated that she was not there when Resident #47 had an incident with the space heater. She came in on second shift on 04/17/25 at 7:00 P.M. and got the nurse report, and was notified that there was concern for Resident #47's legs. WN #509 stated she removed four space heaters from resident rooms and placed them in the DON's office as directed. Review of the facility policy titled Loss of Heat, dated 10/29/2017, revealed the policy was to provide comfortable and safe temperature levels. The temperature throughout this facility shall be maintained at between 71-81 degrees to avoid potential negative impact degrees. Any temperature outside of this rage requires specific interventions to avoid potential negative impact on the residents ' well-being. Should the air conditioning or heating system fail, specific monitoring and safety measures should be activated. Environmental temperatures are monitored by staff. This deficiency represents non-compliance investigated under Complaint Numbers OH00165344 and OH00165076.

THIS IS AN INCIDENCE OF PAST NON COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interviews, observation, and policy review, the facility failed to ensure portable space heaters were not utilized in resident rooms in when the facility Heating, Ventilation, and Air Conditioning (HVAC) system malfunctioned causing the temperatures in House 150 to drop. This affected five (Rooms #106, #107, #108, #109, and #110) of 12 resident rooms in House 150. The facility has five separate houses. Findings include: During an interview on 05/06/25 at 9:04 A.M., MC #404 found that the heat malfunctioned in a section of House 150 on or about 04/17/25. MC #404 stated he was not sure when the heat malfunctioned. The affected resident rooms were Rooms #106, #107, #108, #109, and #110. MC #404 stated that he was unable to fix the heat immediately and portable space heaters were placed in resident Rooms #106, #107, #108, and #110. MC #404 stated that he did not know where the portable space heaters came from, who placed them in the resident rooms, or what happened to the space heaters. MC #404 stated that he did take temperatures of the rooms while the heat was out but did not have any documentation and that the lowest temperature, he could remember was 67 degrees F. MC #404 was not sure in which room he noted that temperature. During an interview on 05/06/25 at 9:28 A.M., MND #555 stated the heat went out on 04/16/25 resulting from a bad gas valve in House #150. MND #555 stated that the heat was fixed on 04/22/25 by the facility ' s heating contractor. Review of the facility policy titled Loss of Heat from emergency preparedness, dated 10/29/2017, revealed the policy was to provide comfortable and safe temperature levels. The temperature throughout this facility shall be maintained at between 71-81 degrees to avoid potential negative impact degrees. Any temperature outside of this rage requires specific interventions to avoid potential negative impact on the residents' well-being. Should the air conditioning or heating system fail, specific monitoring and safety measures should be activated. Environmental temperatures are monitored by staff. Review of the facility policy titled Space Heaters dated 05/05/25 revealed that life safety code by the National Fire Protection Association generally prohibits the use of portable space heaters in healthcare occupancies such as nursing homes. According to the NFPA 101 portable space heaters are not allowed in any residents' sleeping room or compartments. Portable space heaters can overload a facility's electrical system. In addition, space heaters can become a tripping hazard or be covered with combustible materials such as sheets, blankets, or pillows, which may result in a fire. The facility prohibits the use of any portable space heater in the facility. If the portable space heaters were found the employee would be subject to disciplinary action or termination. The deficient practice was corrected on 05/04/25 when the facility implemented the following corrective actions: • On 04/18/25, the Administrator began educating all employees that space heaters are not permitted in resident rooms, and if found, to notify the Administrator as soon as possible. All immediate education was given in person to employees working at the time during second shift 04/18/25, including Leadership/Interdisciplinary Team (IDT) employees with messages and/or calls going out to others. All employees were notified by the Administrator that they must complete and acknowledge education as soon as possible, but that it was mandatory before the next shift worked. • On 04/18/25, Maintenance Coordinator (MC) 404 was educated by the MND #555 with regard to the prohibition of use of space heaters in nursing areas. • A Quality Assurance and Performance Improvement (QAPI) meeting was held on 04/18/25 at 4:30 P.M. The Medical Director was in attendance by telephone and was in agreement with the plan of action. The IDT was present as well or called in by telephone, including MC #404. • Beginning 04/17/25, every day/every shift/every house/every room will have twice a shift per day have audits to be completed on room temperatures and to ensure no space heater is present. The nurse on duty or designee will complete the audit to verify that no space heaters are present, and room temperatures are between 71-81 degrees Fahrenheit (F) and residents are comfortable. The employee who was designated will review the audits in real time to verify accuracy and any need to make immediate corrections. Audits to be completed at this pace and interval until 04/27/25. From 04/28/25 on, the same audits will occur once daily in all rooms and all houses for two weeks and then weekly for two weeks. Audits, along with the rest of this action plan, will be reviewed by the QAPI committee and recommendations about amendments to the plan, audit scope or frequency, or other feedback will be shared. • Review of facility audits dated 04/17/15 through 05/04/25 revealed audits were performed twice a shift daily. • During interviews on 05/07/25 from 1:27 P.M. through 2:34 P.M., Licensed Practical Nurse (LPN) #313 and Certified Nursing Assistants (CNA) #314, #298, #255, #412, and #331 all stated they had received education about space heaters not being allowed at the facility, and to notify management of temperatures of resident rooms not in range of 71 degrees to 81 degrees. Staff was also educated on telling families not to bring in space heaters. This deficiency represents non-compliance investigated under Master Complaint Number OH0015344 and Complaint Number OH00165076.

Based on observation, staff interview, and menu review, the facility failed to have pasteurized eggs available for residents if requested over easy fried eggs. This had the potential to affect all 53 residents residing in the facility. The facility census was 53. Findings include: Observation on 03/31/25 at 11:39 A.M., with Certified Nursing Assistant (CNA) #345 revealed there was a 18 pack of eggs that were not pasteurized. Interview on 03/31/25, during observation, with CNA #345 reported that if a resident request over easy fried eggs then they will make them because it is available all the time item. Observation on 03/31/25 at 11:46 A.M., with CNA #293 revealed there was a three large trays of eggs that were not pasteurized. Interview on 03/31/25, during observation, with CNA #293 reported that if a resident request over easy fried eggs then they will make them because it is on the always available menu. Review of the Always Available Menu revealed that eggs of choice (scrambled, fried, or hard boiled) are available for breakfast.

Based on observations, medical record review, policy review, resident interview, family interview and staff interview, the facility failed to provide clean and homelike environment. This affected two (#21 and #24) of 10 resident rooms reviewed for environment. The facility census was 53. Findings include: 1. Review of Resident #21's medical record revealed an admitted [DATE], with diagnoses including: multiple sclerosis, gastro esophageal reflux disease, osteoporosis, and bipolar disease. Review of quarterly Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 14 with intact cognition. Interview on 04/01/25 at 9:36 A.M., with Resident #21's sister revealed concern about housekeeping. Revealing Resident #21's room had dirty carpet, and dirty bedside table while visiting on 03/31/35 which is a common occurrence. Sister reported that the room regularly looks unkept, with crumbs on the floor and stained bedding. Sister revealed that Resident #21's bathroom had dirty sink and toilet during her visit on 03/31/25, which is a common occurrence. Sister reported not being able to figure out what cleaning schedule staff follow to keep resident's room clean. Observation of Resident #21's room on 04/01/25 at 1:30 P.M., revealed carpet with crumbs scattered around bed and television and was dirty. The bedside table was not clean, with sticky residue. The bathroom floor was dirty as well as the sink that had stained dark residue as well as toothpaste in the bowl of the sink. Resident #21's toilet had multiple rings that appeared to be dirty. Resident #21's shower also had a residue and hair lying on the shower floor. Interview on 04/01/25 at 1:38 P.M., with Certified Nurse Assistant (CNA) #298 revealed sweeping, cleaning the bathroom, cleaning the room and laundry should be done on scheduled shower days. CNA #298 confirmed housekeeping tasks cannot always be accomplished that often, depending on the other tasks needing to be accomplished based on priority. CNA #298 confirmed the carpet was dirty and needed to be deep cleaned as well as having a lot of residual crumbs lying around. CNA #298 confirmed the bathroom floor, the sink and the toilet were all dirty; the shower had residue and hair lying on the shower floor. Interview on 04/01/25 at 3:58 P.M., with Resident #21 revealed she regularly showers herself and that room is not clean on days when she showers herself. Resident #21 confirms CNA's will assist with cleaning tasks when asked but they do not keep any regular schedule for cleaning as far as she can tell. Interview on 04/01/25 at 2:31 P.M., with CNA # 286 revealed Resident #21 frequently has dirty linens but will, at times, refuse to allow CNA to change her linens. 2. Review of Resident #24's medical record revealed an admission on 10/24/23, with diagnoses including: seizure disorder, diabetes, hypertension, and respiratory failure. Review of MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) test score of 14 indicating intact cognition. MDS also revealed Resident #24 to be dependent or needing maximum assistance for all activities of daily living and dependent for all independent activities of daily living. Observation and interview on 04/01/25 at 2:06 P.M., with Resident #24, revealed Resident #24 was lying in his bed watching television. Interview with Resident #24, at this time, revealed his room is cleaned if he requests it to be cleaned. Resident #24 admitted he does not like to be bothered and will forgo getting it cleaned. Observation of the carpet directly next to Resident #24's bed was sticky and was very dirty. Resident #24 confirmed he normally eats in his bed and does tend to drop a lot of food due to the tremors in his hands. Resident #24's bathroom was observed with a pink residue in the sink, the toilet had numerous dirt rings, as well as dirty floor. Interview on 04/01/25 at 2:27 P.M., with CNA #286 confirmed Resident #24's room should be cleaned on shower days or when dirty. Linens are normally changed on shower days, but Resident #24's linens are changed more frequently as he regularly eats in his bed. Resident #24 has hand tremors which affect his ability to always keep food on silverware or accurately get food to his mouth resulting in needing bed linens changed more frequently. CNA #286 confirmed Resident #24's room carpet was dirty, and the bathroom floor was also dirty. Resident 24s sink had a pink residue and sink top was dirty. The toilet has numerous dirt rings. CNA #268 confirmed that resident's room should have been cleaned on 04/01/25 when he was given a bed bath. CNA #268 admits getting to all resident room housekeeping tasks is challenging on most days. Review of the policy titled, Elder Room Cleaning Policy and Procedure, created July 2007 and updated May 2013, revealed the facility is to provide a clean, attractive, and safe environment for elders and their families, visitors, and partners. This deficiency represents non-compliance investigated under Complaint Number OH00161906.

Based on medical record review, staff interview, and Ombudsman notification list review, the facility failed to notify the Ombudsman of resident admissions to hospital. This affected two (#37 and #44) of four residents reviewed for hospitalization. The facility census was 53. Findings include: 1. Review of Resident #37's medical record revealed an admission date of 10/25/24, with diagnoses including depression, dementia, encephalopathy, and debility. Review of the State Optional Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had severe cognitive deficits and required extensive assistance with activities of daily living. Review of nursing note dated 12/30/24, indicated Resident #37 experienced a sudden health condition change and was transferred and admitted to the hospital. 2. Review of Resident #37's medical record revealed an admission date of 07/17/24, with diagnoses including hypertensive kidney disease, vascular dementia, mood disorder, and aortic stenosis. Review of the State Optional MDS dated [DATE] revealed Residents #44 had severe cognitive deficits and requires extensive assistance with activities of daily living. Review of nursing note dated 02/27/25 revealed Resident #44's daughter came to take resident to a doctor's appointment where it was found that she had fluid around her lungs and the doctor had sent Resident #44 to the hospital for admission. Review of the form listed as Ombudsman Notification of Discharges dated for February 2025 revealed Resident #44 was not on the list. Interview on 04/03/25 at 10:41 A.M., with the Administrator and Director of Nursing (DON) verified that they were not notifying the Ombudsman of admissions if the resident was coming back to the facility and was only notifying the ombudsman if the resident was not returning to the facility. There was no notification made for Resident #37 and #44.

Based on medical record review and staff interview, the facility failed to provided bed hold notices. This affected three (#37, #39 and #44) of four residents reviewed for hospitalization. The facility census was 53. Findings include: 1. Review of Resident #37's medical record revealed an admission date of 10/25/24, with diagnoses including depression, dementia, encephalopathy, and debility. Review of the State Optional Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had severe cognitive deficits and required extensive assistance with activities of daily living. Review of nursing note dated 12/30/24, indicated Resident #37 experienced a sudden health condition change and was transferred and admitted to the hospital. Review of the medical record revealed there was no evidence of a bed hold being offered to Resident #37. Interview on 04/03/25 at 10:09 A.M., with the Administrator verified there was no bed hold for Resident #37. 2. Review of Resident #37's medical record revealed an admission date of 07/17/24, with diagnoses including hypertensive kidney disease, vascular dementia, mood disorder, and aortic stenosis. Review of the State Optional MDS dated [DATE] revealed Residents #44 had severe cognitive deficits and requires extensive assistance with activities of daily living. Review of nursing note dated 02/27/25 revealed Resident #44's daughter came to take resident to a doctor's appointment where it was found that she had fluid around her lungs and the doctor had sent Resident #44 to the hospital for admission. Review of the medical record revealed there was no evidence of a bed hold being offered to Resident #44. Interview on 04/02/25 at 5:12 P.M., with the Administrator verified Resident #44 had not received a bed hold notice when they were admitted to the hospital. 3. Review of the closed record for Resident #39 revealed she was admitted on [DATE] and discharged on 02/28/25 to the hospital. Her diagnoses included severe protein-calorie malnutrition, anxiety disorder, hypomagnesemia, hypothyroidism, neurocognitive disorder with Lewy bodies, hyperparathyroidism, osteoarthritis, osteoporosis, and hyperlipidemia. Review of her Minimum Data Set (MDS) admission dated 02/04/25 revealed her Brief Interview of Mental Status (BIS) score was 2 indicating she was severely cognitively impaired. She required maximal assistance for eating and was dependent for her activities of daily living (ADLs). Review of a progress notes dated 02/28/25 revealed Resident #39 was sent to the hospital due to her nephrostomy tube coming out. Review of the medical record revealed there was no evidence of a bed hold being offered to Resident #39. Interview on 04/02/25 at 5:12 P.M., with the Administrator verified Residents #39 had not received a bed hold notice when they were admitted to the hospital.

Based on medical record review and staff interview, the facility failed to accurately assess the resident status in the facility. This affected one (#17) of four residents reviewed for discharge. The facility census was 53. Findings include: Review of the closed medical record for Resident #17 revealed she was admitted [DATE] and discharged [DATE]. Her diagnoses included anemia, type 2 diabetes, chronic kidney disease, chronic obstructive pulmonary disease, malignant neoplasm of lung, hypertension, osteoarthritis, glaucoma, obstructive sleep apnea, and gout. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed her Brief Interview of Mental Status (BIMS) score was 15 indicating she was cognitively intact. She required supervision for eating and maximal assistance for activities of daily living (ADLs). There was no evidence of a discharge MDS for her 10/23/25 discharge. Interview on 04/03/25 at 11:48 A.M., with the MDS Nurse (#326) confirmed there was no discharge MDS completed.

Based on record review and staff interview, the facility failed to notify the physician of stat (immediate) diagnostic imaging in a timely fashion. This affected one (#208) of one resident reviewed for radiology services. The facility census was 53. Findings include: Review of records for Resident #208 revealed an admitted [DATE] with an admitting diagnoses of chronic obstructive pulmonary disease (COPD), seizures, anxiety, and polyneuropathy. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #208 had moderate cognitive impairment and required extensive assistance of one for toileting. Review of physician's orders revealed an order dated 03/26/25 for an urgent (stat) Kidney, Ureter, and Bladder x-ray (KUB) for abdominal pain. Review of results for KUB revealed examination date of 03/26/25 at 6:05 P.M. and facility reported date of 03/26/25 at 6:21 P.M., results included There was a moderate amount of rectal stool present. Review of progress notes from 03/26/25 to 03/31/25 revealed the physician, resident, and family were notified of the stat KUB results on 03/31/25 at 3:19 P.M. by Registered Nurse (RN) #311. Interview on 04/02/25 at 9:46 A.M., with RN #311 stated she called the physician on 03/31/25 because she noticed there was no documentation in Resident #208's chart indicating the physician had been notified of the results of the stat KUB. RN #311 verified five days had passed since the results were received. RN #311 stated stat diagnostic results should have been called to the physician by which ever nurse received the notification by the imaging provider on 03/26/25.

Based on medical record review, resident interview, family interview, staff interview and policy review, the facility failed to assure dental services were provided in a timely manner to meet the needs of the resident. This affected one (#21) of three residents reviewed for dental care. The facility census was 53. Findings include: Review of Resident #21's medical record revealed an admitted [DATE], with diagnoses including: multiple sclerosis, gastro esophageal reflux disease, osteoporosis, and bipolar disease. Review of quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 with intact cognition. Review of medical record revealed on 09/25/24 Resident #21 was experiencing jaw pain. Resident #21 alerted Licensed Practical Nurse (LPN) #262, she had fallen and hit her face on her snack cabinet. Resident #21 felt the fall lead to the jaw pain. Resident revealed she had not reported the fall to the staff. LPN #262 assessed resident's face and no bruising noted. LPN #262 attempted to do neurologic checks but resident #21 refused. Record indicated that a written note was left for physician in a folder for review. Medical record review revealed on 11/26/24, Registered Nurse (RN) #306 had spoken to Social Worker #343 and a referral had been made to dentist for Resident #21's jaw pain Review of Resident #21's medical record revealed an order written on 11/26/24 for Resident #21: Refer to Dentist for jaw pain two times a day for jaw pain. Order remains in place as of 04/01/25 and there was no clarifications on what the order was actually stating. Medical record review revealed a note that Resident #21 was seen by dentist on 01/29/25. Medical record revealed she was seen for a periodic oral evaluation that made no mention of jaw pain or assessment for jaw pain. Dentist noted that dentures fit well and oral tissue was healthy. Dentist unable to get x-rays due to resident's gag reflex. Oral hygiene instructions provided to resident during visit. Dentist indicated there was no plan for treatment follow up and that resident would be seen based on payor source requirements. Review of medical record revealed a social service note dated 03/07/25 that emergency dental care request sent to 360 Care related to jaw pain. Interview on 04/01/25 at 9:36 A.M., with Resident #21's sister revealed continued concerned for resident's jaw pain as Resident #21 continues to complain to sister of jaw pain and ill fitting dentures. Sister stated she wanted Resident #21 seen by a dentist for evaluation and treatment. Sister was unaware of Resident #21 being seen previously by dentist. Interview on 04/02/25 at 3:46 P.M. with LPN #263 revealed Resident #21 is assessed for jaw pain twice daily and believed Resident #21 had been referred to dentist for follow up. LPN #263 revealed Resident #21 does not complain of jaw pain at every assessment. Interview on 04/01/25 at 10:14 A.M. and again on 04/02/25 at 3:48 P.M., with Resident #21 stated she continues to have intermittent jaw pain and ill fitting dentures. Resident #21 confirmed she was seen by dentist in the past few months, but did not feel jaw pain was addressed. Review of the undated policy titled , Ancillary Services stated: Upon admission and thereafter, the right to adequate and appropriate medical treatment and nursing care and to other ancillary services that comprise necessary and appropriate care consistent with the program for which the resident contracted. This care shall be provided without regard to considerations such as race, color, religion, national origin, age, or source of payment for care.

Based on observation, medical record review, staff interview and policy review, the facility failed to ensure incontinence care was provided correctly. This affected one (#23) of three residents reviewed for incontinence. The census was 53. Findings included: Medical record review for Resident #23 revealed an admitted [DATE]. Medical diagnoses included Alzheimer's disease and dementia. Review of the care plan dated 09/15/23 for Resident #23 revealed he had bladder incontinence related to activity intolerance and dementia. Intervention was to cleanse the perineum (peri) area after each incontinence episode. Wash, rinse, and dry perineum after each episode. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was moderately cognitively impaired. He was frequently incontinent with his bladder and always incontinent with his bowel. Observation of incontinence care on 12/17/24 at 8:50 A.M. revealed Certified Nursing Aide (CNA) #82 washed hands and placed gloves on. The resident was uncircumcised, and the resident had urinated and defecated in the brief. She tucked the brief to left side of the resident and took wipes and wiped in a downward motion on the right side, got another wipe and wiped down the left side of the resident and then got another wipe and brushed down the penis and then turned the resident over to cleanse the bottom area. Interview with the CNA #82 on 12/17/24 at 9:10 A.M. revealed she was trained in aide training to wipe the penis and the foreskin and the scrotum but when she was trained at the facility they didn't train her to do it that way. She said this wasn't her normal practice. Review of the policy entitled Perineal Care for a Male Resident revealed: a) wet the washcloth with warm water from a running spigot (or from a clean, disinfected bath basin) and apply mild soap. b) Hold the shaft of the penis in one hand. If the patient has an indwelling urinary catheter in place, use the other hand to clean the urethral meatus with the washcloth. c) Wash the penis with the washcloth, beginning at the tip and using a circular motion. Use a clean section of washcloth for each stroke. If the patient is uncircumcised, gently retract the foreskin and clean beneath it. d) Wet a clean washcloth and rinse the area thoroughly using the same circular motion.

Based on observation, medical record review and staff interviews, the facility failed to ensure gloves were used in a sanitary manner to prevent infection. This affected one (#04) of three residents reviewed for indwelling catheters. The facility identified there were four residents with catheters in the facility. The census was 55. Findings included: Review of medical record for Resident #04 revealed an admitted [DATE]. Medical diagnoses included hypertension and neurogenic bladder. Resident #04 was active with hospice services. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #04 was severely cognitively impaired and had an indwelling catheter. Review of the care plan dated 09/05/24 revealed Resident #04 had an indwelling catheter and was on enhanced barrier precautions (EBP). Interventions were for staff to wear gown and gloves for high-contact resident care. During observation of catheter care for Resident #04 on 11/06/24 at 1:36 P.M. revealed Certified Nursing Assistant (CNA) #102 came into the resident's room washed her hands, put on a blue isolation gown and placed gloves on her hands. CNA #102 got a basin and went into the bathroom and filled it with water. CNA #102 used her gloved right hand to lower the head of the bed with the remote, removed the bed covers from the resident, unfastened the resident's incontinent brief, and covered the top of the resident with a blanket. CNA #102 used both gloved hands and was pushing the urine down the drainage line into the catheter bag. CNA #102 put a washcloth into the water, added soap and washed the resident's peri area. CNA #102 finished and opened the trash can lid with her right gloved hand and placed the washcloth into it. CNA #102 used a clean towel and dried the resident, opened the trash can with her right hand and discarded the towel CNA #102 retrieved another cloth from the basin, using her contaminated gloved hands and wiped the catheter tubing near the insertion area. CNA #102 placed a blanket on top of the resident, removed her gloves and completed hand hygiene. During an interview with CNA #102 #102 on 11/06/24 at 2:00 P.M. verified she placed gloves on and proceeded to touch the numerous aforementioned items in the room before completing catheter care on Resident #04. CNA #102 verified she used her contaminated gloves to perform catheter care and did not complete any hand hygiene during the process. Review of the policy entitled Indwelling Urinary Catheter (Foley) Care and Management undated, revealed the following: a. Gather and prepare the equipment and supplies. Perform hand hygiene. b. Confirm the patient's identity and provide privacy. c. Explain the procedure. d. Make sure you have adequate lighting. e. Review the necessity of continued catheter use. Raise the bed to waist level. f. Perform hand hygiene. g. Put on gloves and necessary personal protective equipment. Inspect the catheter system for problems; replace it if necessary. h. Provide routine hygiene for meatal care. Clean the periurethral area using soap and water (or a perineal cleaner, if used in your facility) or a plain disposable wipe. i. Inspect the periurethral area for signs of inflammation and infection. Make sure that the catheter is secured properly. j. Assess the securement device daily and change it when clinically indicated. Monitor intake and output, as ordered. Monitor for changes in urine output. k. Empty the drainage bag regularly when it becomes one-half to two-thirds full. Use a separate collecting container for each patient, avoid splashing, and don't allow the drainage spigot to come in contact with the nonsterile collecting container. l. Keep the drainage tubing free from kinks and avoid dependent loops. m. Keep the drainage bag below the level of the patient's bladder but off of the floor. n. Return the bed to the lowest position. o. Discard used supplies in appropriate receptacles. p. Remove and discard your gloves and, if worn, other personal protective equipment. q. Perform hand hygiene. Document the procedure. This deficiency represents non-compliance investigated under Complaint Numbers OH00158944 and OH00158592.

Based on medical record review, policy review and staff interview the facility failed to ensure consecutive documentation of no urine output from an indwelling catheter was reported to the physician. This affected one (#01) of three reviewed for urine output. The facility identified four residents with indwelling catheters in the facility. The facility census was 55. Findings included: Review of medical record Resident #01 revealed an admitted [DATE]. Medical diagnoses included obstructive and reflux uropathy, non-Alzheimer's dementia, malnutrition, and complete uterovaginal prolapse. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 was severely cognitively impaired. Review of the physician order for Resident #01 dated 08/01/24 revealed the resident was to have the urine output measured every shift. Review of the Certified Nursing Assistant (CNA) tasks documentation for Resident #01 revealed on 08/22/24 there was no urine output recorded for first shift (7:00 A.M. to 3:00 P.M.) and second shift (3:00 P.M. to 11:00 P.M.). On 08/23/24 there was no urine output recorded for first, second or third shift (11:00 P.M. to 7:00 A.M.). On 08/24/24 and 08/25/24 there was no urine output recorded on night shift. On 08/26/24 there was nothing recorded for day shift and night shift. On 08/28/24 there was urine output recorded on day shift. Review of the nurse's progress note for Resident #01 from 08/22/24 through 08/26/24, revealed no documented evidence that the physician was notified when the resident had no recorded urine output for the days and times listed. Review of a nurse's progress note dated 08/29/24 at 7:00 A.M., revealed Registered Nurse (RN) #77 was informed by a CNA, Resident #01 did not have any urine output for Resident #01 during the last couple of nights. There was no documented evidence that the physician was notified. Review of policy entitled Notification of Change of Condition dated 11/22/21 revealed the facility will immediately inform the resident; consult with the resident's physician, nurse practitioner or clinical nurse specialist; and if known, notify the resident's representative when there is an accident involving the resident, which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility. This deficiency represents non-compliance investigated under Complaint Number OH 00158944 and OH00158592.

Based on observation, medical record review, staff interview and policy review, the facility failed to ensure residents were provided with dignity and respect. This affected one (#51) of three residents reviewed for dignity and respect. The census was 55. Findings include: Review of the medical record for Resident #51 revealed an admitted [DATE]. Diagnoses included dementia and atrial fibrillation. Review of the care plan dated 08/29/24 for Resident #51 revealed the resident displayed behaviors of feeling insecure in the environment and sometimes with care and yelling out for help. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was moderately cognitively impaired. Observations of Resident #51 on 11/05/24 from 11:00 A.M. to 11:40 A.M. revealed the resident was in her room seated in a recliner and yelling out for help. Certified Nursing Assistant (CNA) #109 was observed in the common area. During this time, CNA #109 was observed sitting at the counter by the kitchen and was getting some residents up in the common area to a wheelchair to go out for lunch and able to hear the resident. The resident continued yelling help me and hurry. At 11:40 A.M. CNA #109 went into the resident's room and told the resident she would be right back. CNA #109 went to the kitchen got a can of soda for the resident and took it to her. The resident stopped yelling out. Interview with CNA #51 on 11/05/24 at 11:51 A.M. revealed Resident #51 had behaviors of yelling out. CNA #51 verified resident was yelling out for help for 40 minutes, prior to her checking on the resident. Review of the policy entitled Resident Rights dated 01/22/20 revealed the residents have the right to be treated at all times with courtesy, respect, and full recognition of dignity and individuality. This deficiency represents non-compliance investigated under Complaint Number OH00158944 and OH00158592.

Based on medical record review, resident and staff interviews, and observation, the facility failed to ensure a resident was safely transferred using a mechanical lift (Hoyer). This resulted in Actual Harm when Resident #11 who was a paraplegic (paralysis of the legs), was transferred using the mechanical lift and the resident 's legs were not secured, subsequently hitting her right leg on the Hoyer bar sustaining a right lower leg fracture. This affected one (Resident #11) of three residents reviewed for accidents. The facility census was 50. Findings include: Review of the medical record for Resident #11 revealed an admitted [DATE]. Diagnoses included paraplegia, type two diabetes mellitus, and idiopathic peripheral autonomic neuropathy (damage of the peripheral nerves where cause cannot be determined). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was cognitively intact. Resident #11 was dependent on staff for bed mobility, toileting, dressing lower and upper body, transferring, and bathing. Review of the Activities of Daily Living (ADL) plan of care dated 06/20/22 revealed Resident #11 had an ADL self-care deficit. Interventions included Resident #11 was dependent on staff for transfers between surfaces and required a mechanical lift with two or more staff assistance with transfers. Review of the plan of care dated 06/23/22 revealed Resident #11 had paraplegia and bilateral lower extremities foot drop. Interventions included to protect the resident's feet per the ADL plan of care. Review of the weekly skin observation dated 01/16/24 revealed Resident #11's skin issues were on the right foot plantar and toe, and coccyx. No new skin issues found. Review of the facility's document titled Bath and Shower Sheet, dated 01/19/24 at 7:15 P.M., revealed Resident #11's right lower leg had a bruised large area. State tested Nurse Aide (STNA) #383 and Licensed Practical Nurse (LPN) #139 signed the document. Review of the weekly skin observation dated 01/20/24 at 12:50 A.M. by LPN #139 documented there was a right lower leg bruise on Resident #11. Review of the progress note dated 01/20/24 at 12:50 A.M. documented by LPN #139 noted the nurse was coming into Resident #11's room to complete treatment. The nurse pulled down covers to begin treatment and discovered a large yellow and purple bruise with small abrasions to the right lower leg from her knee to the bottom of her shin. Resident #11 has paralysis in both legs. The nurse asked Resident #11 if she recalled any instances where she would have hit or bumped her legs. Resident #11 stated, I cannot recall any time that may have happened. Nurse notified on-call Assisted Director of Nursing (ADON) #166. Review of the interdisciplinary team progress note dated 01/22/24 documented by the Director of Nursing (DON) noted Resident #11 was assessed and STNAs were interviewed for investigation. STNAs stated Resident #11 hit the shins on Hoyer bar during transfers. Resident #11 stated she was not able to feel when this happens because of her paraplegia. Resident #11 stated that it happens when the STNAs were not making sure her legs were pulled back enough during transfers. Resident #11 denies she was in any increased pain. The STNAs were educated on making sure the resident's legs were monitored and protected when the resident was being transferred by Hoyer lift. On 01/22/24, Resident #11 went out for an outpatient Urethroscopy appointment and was subsequently held overnight for observation. Resident #11 returned to the facility on [DATE] at 3:30 P.M. Review of the progress note dated 01/23/24 at 8:30 P.M. revealed the nurse called the on-call physician due to Resident #11's right lower extremity (RLE) showing redness, swelling, bruising, and hot to the touch. The nurse explained to the physician the continued skin area to the RLE was a concern, possible injury. The nurse received a new order for an RLE x-ray. On 01/24/24 at 1:10 A.M., Resident #11 was sent to the emergency room for trouble related to swallowing and bounding pulse (a pulse that feels as though your heart is pounding or racing). Resident #11 returned to the facility on [DATE] at 6:09 A.M. with a new order for Nexium (can treat gastroesophageal reflux disease). On 01/25/24 at 7:50 P.M., the nurse followed up with the x-ray company to find out when they were coming to obtain x-rays of Resident #11's RLE. The x-ray was scheduled for 01/26/24. Subsequently, on 01/26/24 at 7:45 P.M. Resident #11 was sent to the hospital. The nurse asked Resident #11 if she wanted to go to the hospital to address her RLE issue. Resident #11 was found to have saliva and food drooling from her mouth. Resident #11 said she was in pain but could not explain where and she was groaning. Resident #11 returned to the facility on [DATE]. Review of the hospital documentation dated 01/27/24 revealed Resident #11 had an x-ray of her right tibia and fibula of leg, that revealed transverse nondisplaced tibial metaphyseal fracture with concomitant proximal fibula. Review of the self-reported incident dated 01/27/24 revealed the facility had filed a report about Resident #11's bruise and fracture. Review of LPN #139's statement, dated 01/30/24, indicated she was on duty on night shift of 01/19/24. LPN #139 stated she found Resident #11's right lower extremity to be bruised. LPN #139 asked questions to Resident #11 and investigated why this bruise was on her right leg. LPN #139 stated she notified ADON #166 regarding Resident #11's bruise and of concerns that it was possibly due to injury from Hoyer lift transfers. LPN #139 stated she returned to work on 01/23/24 and then called the on-call physician about Resident #11's bruise and obtained an x-ray order. On 01/23/24, LPN #139 stated that she received a call back from the physician giving directions to place an order for an x-ray to be performed. Interview on 02/06/24 at 10:00 A.M. with Resident #11 stated she was injured that she can remember at the facility. Resident #11 stated that a few times, the staff bumped her legs during transfer with the Hoyer lift in the room. During an interview and observation on 02/06/24 at 10:15 A.M. with Resident #11 and Registered Nurse (RN) #215, RN #215 opened the right leg brace at the Velcro to reveal Resident #11's right leg bruise. The bruise was located below the right knee and above the right ankle and had a large, faded tan-yellow appearance. Resident #11's leg had swelling. Resident #11 stated she does not feel anything below her waist, and she had no pain. Interview on 02/06/24 at 2:11 P.M. with LPN #139 revealed she found the bruise after performing a treatment. LPN #139 stated she did sign the bath sheet dated 01/19/24 that had the right shin bruise documented. This deficiency represents non-compliance investigated under Complaint Number OH00150641.

Based on medical record review and staff interview, the facility failed to timely obtain an x-ray of a resident's right lower extremity per physician orders. This affected one (Resident #11) of three residents reviewed for accidents. The facility census was 50. Findings include: Review of the medical record for Resident #11 revealed an admitted [DATE]. Diagnoses included paraplegia and type two diabetes mellitus. Review of the progress note dated 01/20/24 at 12:50 A.M. documented by Licensed Practical Nurse (LPN) #139 stated the nurse discovered a large yellow and purple bruise with small abrasions to the right lower leg from her knee to the bottom of her shin. On 01/22/24, Resident #11 went out for an outpatient Urethroscopy appointment and was subsequently held overnight for observation. Resident #11 returned to the facility on [DATE] at 3:30 P.M. Review of the progress note dated 01/23/24 at 8:30 P.M. revealed the nurse called the on-call physician for Resident #11's right lower extremity (RLE) was showing redness, swelling, bruising, and hot to the touch. The nurse explained to the physician the continued skin area to the RLE was a concern possible injury. The nurse received a new order for an RLE x-ray. There was no physician order written in the medical record for the RLE x-ray. On 01/24/24 at 1:10 A.M., Resident #11 was sent to the emergency room . Resident #11 returned to the facility on [DATE] at 6:09 A.M. On 01/25/24 at 7:50 P.M., the nurse followed up with the x-ray company to find out when they were coming to obtain x-rays of Resident #11's RLE. The x-ray was scheduled for 01/26/24. Subsequently on 01/26/24 at 7:45 P.M. Resident #11 was sent to the hospital. There was no x-ray obtained at the facility on 01/24/24 from the time Resident #11 returned back to the facility and when she went back ou to the hospital on 01/26/24 at 7:45 P.M. Review of the hospital documentation dated 01/27/24 revealed Resident #11 had an x-ray of her right tibia and fibula of leg, that revealed transverse nondisplaced tibial metaphyseal fracture with concomitant proximal fibula. Telephone interview with the Administrator on 02/08/24 at 2:59 P.M. stated they called the diagnostic company on 02/06/24 with the state surveyor. The diagnostic company verified the nurse didn't notify them of the physician order until 01/25/24 at 5:00 A.M. This was two days after the physician ordered the x-ray results. This deficiency represents non-compliance investigated under Complaint Number OH00150641.

Based on medical record review, staff interview, review of the facility's Self-Reported Incident (SRI), and review of the facility policy, the facility failed to timely report an injury of unknown origin to the State Survey Agency, Ohio Department of Health (ODH). This affected one (Resident #11) of three residents reviewed for abuse. The facility census was 50. Findings include: Review of the medical record for Resident #11 revealed an admitted [DATE]. Diagnoses included paraplegia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was cognitively intact. Resident #11 was dependent on staff for bed mobility, toileting, dressing, lower and upper body, transferring, and bathing. Review of the weekly skin observation dated 01/16/24 revealed Resident #11's skin issues were on the right foot plantar and toe, and coccyx. No new skin issues found. Review of the facility's document titled Bath and Shower Sheet, dated 01/19/24, revealed Resident #11's right lower leg had a large bruised area. State tested Nursing Aide (STNA) #383 and Licensed Practical Nurse (LPN) #139 signed the document. Review of the weekly skin observation dated 01/20/24 at 12:50 A.M. by LPN #139 documented there was a right lower leg bruise on Resident #11. Review of the progress note dated 01/20/24 at 12:50 A.M. documented by LPN #139 stated the nurse was coming into Resident #11's room to complete treatment. The nurse pulled down covers to begin treatment and discovered a large yellow and purple bruise with small abrasions to the right lower leg from her knee to the bottom of her shin. Resident #11 has paralysis in both legs. The nurse asked Resident #11 if she recalled any instances where she would have hit or bumped her legs. Resident #11 stated, I cannot recall any time that may have happened. Nurse notified on-call Assisted Director of Nursing (ADON) #166. Review of the interdisciplinary team progress note dated 01/22/24 documented by the Director of Nursing (DON) stated Resident #11 was assessed and STNAs were interviewed for investigation. STNAs stated Resident #11 hit the shins on Hoyer bar during transfers. Resident #11 stated she was not able to feel when this happens because of her paraplegia. Resident #11 stated that it happens when the STNAs were not making sure her legs were pulled back enough during transfers. Resident #11 denies she was in any increased pain. The STNAs were educated on making sure the resident's legs were monitored and protected when the resident was being transferred by Hoyer lift. On 01/22/24, Resident #11 went out for an outpatient Urethroscopy appointment and was subsequently held overnight for observation. Review of the progress note dated 01/23/24 at 3:20 P.M. documented by Registered Nurse (RN) #215 stated Resident #11 had returned from the hospital via stretcher. Skin sweeps were completed. Review of the hospital documentation dated 01/27/24 revealed Resident #11 had an x-ray of her right tibia and fibula of leg, that revealed transverse nondisplaced tibial metaphyseal fracture with concomitant proximal fibula. Review of the facility's SRI control number 243533 dated 01/27/24 revealed the facility had filed a report to ODH about Resident #11's injury of unknown origin. The nurse on duty contacted the on call nurse on 01/20/24 identifying a new skin care concern involving bruising to Resident #11's right lower extremity. The nurse on duty interviewed Resident #11 on 01/20/24 and Resident #11 did not know how it occurred and doesn't remember running into anything. The Administrator interviewed the STNAs who had worked with Resident #11 from 01/18/24 to 01/20/24 which none of them reported any incident or transfers that would have caused an injury. Review of LPN #139's statement, dated 01/30/24, stated she was on duty on night shift of 01/19/24. LPN #139 stated she found Resident #11's right lower extremity to be bruised. LPN #139 asked questions to Resident #11 and investigated why this bruise was on her right leg. LPN #139 stated she notified ADON #166 regarding Resident #11's bruise and of concerns that was possible due to injury from Hoyer lift transfers. Interview on 02/06/24 at 10:00 A.M. with Resident #11 stated she was injured that she can remember at the facility. Resident #11 stated that a few times, possibly, that staff bumped her legs during transfer with Hoyer lift in the room. Telephone interview with the Administrator on 02/08/24 at 2:59 P.M. verified she did not report the SRI until 01/27/24. The Administrator stated the injury of unknown origin didn't qualify for an investigation and she submitted the SRI because she wanted to over-report. Review of the facility's policy titled Abuse Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated 10/25/22 revealed identification and ensuring that all partners, contractors, ad volunteers are aware that they need to report all incidents and allegations of Abuse, Neglect, Mistreatment, Exploitation and Misappropriation of resident's property, as well notifying the Administrator, DON, or supervisor immediately upon identification of any new injuries. A nurse should perform an initial assessment. The resident's attending physician should be notified if an incident had occurred requiring a physician involvement. If abuse was alleged or serious bodily injury identified, then ODH was to be notified immediately or within two hours after the allegation was made. This deficiency represents non-compliance investigated under Complaint Number OH00150641.

Based on record review, staff interview, and review of the facility policy, the facility failed to timely notify the physician of a resident's change in condition. This affected one (Resident #11) of three residents reviewed for notification of change. The facility census was 50. Findings include: Review of the medical record for Resident #11 revealed an admitted [DATE]. Diagnoses included paraplegia and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was cognitively intact. Resident #11 was dependent on staff for bed mobility, toileting, dressing, lower and upper body, transferring, and bathing. Review of the plan of care dated 06/23/22 revealed Resident #11 had paraplegia and bilateral lower extremities foot drop. Interventions included to protect the resident's feet per physician orders. Resident #11 was also at risk for nutrition related to diabetes mellitus and malnutrition diagnoses. Interventions included diet as ordered, take medications as ordered, and monitor skin and wound reports, and address negative findings. Review of the facility's document titled Bath and Shower Sheet, dated 01/19/24, revealed Resident #11's right lower leg had a large bruised area. State tested Nursing Aide (STNA) #383 and Licensed Practical Nurse (LPN) #139 signed the document. Review of the weekly skin observation dated 01/20/24 at 12:50 A.M. by LPN #139 documented there was a right lower leg bruise on Resident #11. Review of the progress note dated 01/20/24 at 12:50 A.M. documented by LPN #139 stated the nurse was coming into Resident #11's room to complete treatment. The nurse pulled down covers to begin treatment and discovered a large yellow and purple bruise with small abrasions to the right lower leg from her knee to the bottom of her shin. Resident #11 has paralysis in both legs. The nurse asked Resident #11 if she recalled any instances where she would have hit or bumped her legs. Resident #11 stated, I cannot recall any time that may have happened. Nurse notified on-call Assisted Director of Nursing (ADON) #166. Review of the interdisciplinary team progress note dated 01/22/24 documented by the Director of Nursing (DON) stated Resident #11 was assessed and STNAs were interviewed for investigation. STNAs stated Resident #11 hit the shins on Hoyer bar during transfers. Resident #11 stated she was not able to feel when this happens because of her paraplegia. Resident #11 stated that it happens when the STNAs were not making sure her legs were pulled back enough during transfers. Resident #11 denies she was in any increased pain. The STNAs were educated on making sure the resident's legs were monitored and protected when the resident was being transferred by Hoyer lift. There was no documentation in the medical record Resident #11's physician was notified of Resident #11's right lower leg bruising until 01/23/24. On 01/22/24, Resident #11 went out for an outpatient Urethroscopy appointment and was subsequently held overnight for observation. Resident #11 returned to the facility on [DATE] at 3:30 P.M. Review of the progress note dated 01/23/24 at 8:30 P.M. revealed the nurse called the on-call physician for Resident #11's right lower extremity (RLE) was showing redness, swelling, bruising, and hot to the touch. The nurse explained to the physician the continued skin area to the RLE was a concern possible injury. The nurse received a new order for an RLE x-ray. Review of the hospital documentation dated 01/27/24 revealed Resident #11 had an x-ray of her right tibia and fibula of leg, that revealed transverse nondisplaced tibial metaphyseal fracture with concomitant proximal fibula. Review of LPN #139's statement, dated 01/30/24, stated she was on duty on night shift of 01/19/24. LPN #139 stated she found Resident #11's right lower extremity to be bruised. LPN #139 asked questions to Resident #11 and investigated why this bruise was on her right leg. LPN #139 stated she notified ADON #166 regarding Resident #11's bruise and of concerns that was possible due to injury from Hoyer lift transfers. LPN #139 stated she returned to work on 01/23/24 and then called the on-call physician about Resident #11's bruise and obtained an x-ray order. On 01/23/24, LPN #139 stated that she received a call back from physician giving directions to place an order for an x-ray to be performed. LPN #139 stated she wrote a progress note in Resident #11 medical record. Interview on 02/06/24 at 1:07 P.M. with the Administrator and LPN #139 revealed the Administrator asked LPN #139 if she notified the physician on 01/20/24, instead of on 01/23/24. LPN #139 verified she did not originally call the on-call physician about Resident #11's bruise on 01/20/24. LPN #139 verified she did when she came back to work on 01/23/24. LPN #139 stated she might have said that, but it was not the truth. She was exhausted the day she was interviewed by the Administrator. Another interview on 02/06/24 at 3:34 P.M. with the Administrator and LPN #139 revealed the Administrator asked LPN #139 again if she notified the physician on 01/20/24 when the bruise was found. who was asked again if she had notified the on-call physician on 01/20/24 the day the bruise was found. LPN #139 verified she called the physician on 01/23/24 when she came back to work and did not notify the physician on 01/20/24 when the bruise was found. Review of the facility's policy titled Notification of Change of Condition dated 11/22/21 revealed the facility will immediately inform the resident; consult with the resident's physician, nurse practitioner or clinical nurse specialist when there is an accident involving the resident, which results in injury and has the potential for requiring physician intervention and a significant change in the resident's physical, mental, or psychosocial status This deficiency represents non-compliance investigated under Complaint Number OH00150641.

Based on record review, staff interviews, and review of policy, the facility failed to ensure safe transfer technique was utilized to prevent falls and/or fall-related injuries. This affected one (#18) of three residents reviewed for falls. The facility census was 55. Findings include: Review of the medical record for Resident #18 revealed an admitted [DATE], with diagnoses including cellulitis, atrial fibrillation, and dementia without behavioral disturbance. Review of the Minimum Data Set (MDS) assessment for Resident #18 dated 02/19/23, revealed resident was cognitively impaired and required extensive assistance of two staff with transfers. Review of the fall risk assessment for Resident #18 dated 02/12/23 revealed resident was at risk for falls. Review of the care plan for Resident #18 dated 02/24/23 revealed resident was at risk for falls related to antihypertension medications, confusion, deconditioning, gait/balance problems, incontinence, medication side effects, psychoactive drug use, unaware of safety needs, and hearing problems. Interventions included the following: ensure resident was wearing appropriate footwear when ambulating or mobilizing in wheelchair, anticipate and meet resident needs, be sure call light/pendant is within reach and encourage resident to use it for assistance as needed, provide a safe environment with even floors free from spills and/or clutter; adequate, glare-free light, a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach, provide activities that minimize the potential for falls while providing distraction, review information on past falls and attempt to determine cause of falls, record possible root causes, alter /remove any potential causes if possible, educate resident and caregivers as to causes of falls. Review of the care plan for Resident #18 dated 02/24/23 revealed resident had an activities of daily living (ADL) self-care performance deficit related to activity intolerance, dementia, fatigue, impaired balance, musculoskeletal impairment, and weakness. Interventions included resident was weight bearing and required staff assistance to move between surfaces. Review of the nurse progress note for Resident #18 dated 04/07/23 timed at 1:55 A.M. revealed resident was sitting in the recliner in common area. A State tested Nurse Aide (STNA) assisted the resident to stand, and the resident lost her balance. STNA grabbed the resident's right arm to steady her, but the resident continued to fall hitting her left side on the table next to the chair. Two nurses witnessed the fall and after assessing the resident, they assisted the resident into her wheelchair. Review of the nurse progress note for Resident #18 dated 04/07/23 timed at 7:44 P.M. revealed the resident was noted to have bruising to her buttocks and left side following the fall. Resident #18 was medicated with as needed Tylenol for pain with good effect. Interview on 04/11/23 at 11:06 A.M., with the Administrator and the Director of Nursing (DON) confirmed Resident #18 had a witnessed fall with minor injury on 04/07/23 on the night shift. Interview confirmed investigation showed State tested Nursing Assistant (STNA) #415 was transferring Resident #18 from a chair in the common area into her wheelchair and resident lost her balance and fell hitting her left side on the table adjacent to the chair. Interview confirmed the facility determined the root cause of the fall to be the resident losing balance during transfer. Interview confirmed the facility had not obtained a statement from the STNA and had no evidence aide used a gait belt during the transfer. Interview confirmed staff should use a gait belt when transferring Resident #18. Interview confirmed the facility interdisciplinary team (IDT) reviewed Resident #18's care plan following the fall but did not determine any updates were required to the resident's care plan. Interview further confirmed the facility had not provided any education to the staff regarding gait belt use following Resident #18's fall. Interview on 04/11/23 at 2:40 P.M., with STNA #415 confirmed she assisted Resident #18 with a transfer from chair to wheelchair on 04/07/23 and did not use a gait belt. STNA #415 further confirmed during the transfer resident became weak and had to be lowered to the floor. STNA #415 confirmed she held onto resident's right arm as she went down, and resident hit her left side on the table adjacent to the chair. Review of the policy titled Use of Gait Belt, dated January 2014, revealed it was in the interest of elder and partner safety to utilize a gait belt during elder transfer and ambulation. The gait belt is used to assist the elder in achieving maximum function and to provide assistance during transfer and ambulation. The gait belt can help prevent falls and injuries in elders. The gait belt is an essential tool for an Elder Assistant and nurse. Every Elder Assistant is required to have his/her own gait belt provided by the neighborhood during initial orientation. During orientation, therapy staff will demonstrate proper use of the gait belt to all new partners. The gait belt will be used by the Elder Assistant and/or nurse during every transfer or during ambulation of an elder that requires assistance. This deficiency represents non-compliance investigated under Complaint Numbers OH00141879 and OH00141437. This deficiency represents ongoing noncompliance from the survey dated 03/20/23.

Based on record review, observation, staff interview, and review of the policy, the facility failed to ensure skin breakdown prevention measures were in place and functioning per the resident care plan and physician order. This affected one (#41) of three residents reviewed for care and services to prevent skin breakdown. The facility census was 55. Findings include: Review of the medical record for Resident #41 revealed an admitted [DATE], with diagnoses including cerebral infarction, atrial fibrillation, hypertension, osteoarthritis, dysphagia, vascular dementia, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment for Resident #41 dated 02/20/23 revealed resident was cognitively impaired and required extensive assistance of two staff with bed mobility and transfer. Review of the care plan for Resident #41 dated 10/17/19 revealed the resident was at risk for skin breakdown related to cognition loss, limited mobility, pain, and hunched over mid to upper spine area. Interventions included the following: apply protective pad to upper back daily when out of bed for a preventative measure, apply skin prep to my bilateral heels, float heels in bed as tolerated, float my heels while in bed or recliner, pressure reduction cushion to chair, pressure reduction mattress to bed, turn and reposition resident every two hours and as needed, weekly skin screening of resident's body. Review of the care plan for Resident #41 dated 05/16/22 revealed resident had an activities of daily living (ADL) self-care and/or physical mobility performance deficit related to limited mobility, cerebral infarction history and Alzheimer's dementia. Interventions included resident was to have an air mattress to bed as per physician's order. Review of the pressure ulcer risk assessment for Resident #41 dated 04/05/23 revealed resident was at moderate risk for the development of pressure ulcers. Review of the April 2023 monthly physician orders for Resident #41 revealed an order dated 06/01/22 for resident to have a low air loss mattress to her bed. Review of the April 2023 Treatment Administration Record (TAR) for Resident #41 revealed it did not include documentation of staff checking for proper functioning and placement of physician ordered low air loss mattress. Observation on 04/10/23 at 2:40 P.M., of incontinence care for Resident #41 per State tested Nursing Assistants (STNAs) #105 and #570 revealed resident had a low air loss mattress to her bed which was not inflated and was not functioning. Surveyor questioned aides about the mattress, and they said to ask the nurse. STNAs provided incontinence care and left the resident's room with the mattress not functioning. Interview on 04/10/23 at 2:40 P.M., of STNAs #105 and #570 confirmed Resident #41's low air loss mattress was not functioning, and they were unsure how long the mattress had been this way. Interview on 04/10/23 at 2:50 P.M., of Registered Nurse (RN) #540 confirmed Resident #41 had a physician's order for a low air loss mattress due to resident's risk for skin breakdown. RN #540 confirmed Resident #41's low air loss mattress was not functioning properly due to mattress was not plugged in. RN #540 plugged in the mattress, and it began to work. RN #540 confirmed she was unsure how long the mattress had been not working and also confirmed Resident #41 would not be able to unplug the mattress per self. Resident #41 did not respond to interview questions regarding the mattress. Interview on 04/11/23 at 11:06 A.M. with the Director of Nursing (DON) confirmed Resident #41 had a physician's order for a low air loss mattress, and resident was at risk for the development of skin breakdown. DON further confirmed Resident #41's record did not include documentation of staff checking the mattress for proper functioning each shift. Review of the policy titled Skin Care Management, dated 11/17/22, revealed the facility would identify individuals at risk for development of pressure ulcers and initiate management programs which would stabilize or minimize underlying risk factors or changes in condition. The facility would implement appropriate strategies to maintain intact skin. This deficiency represents non-compliance investigated under Complaint Number OH00141879.

Based on medical record review, staff interview, review of an educational consult, review of the emergency room record, and policy review, the facility failed to ensure care was provided in a manner to prevent an avoidable fall with injury and was not initially thoroughly investigated to determine the root cause analysis to identify potential hazards to reduce and/or eliminate falls with major injury. This resulted in Actual Harm when State tested Nurse Aide (STNA) #43 transferred Resident #55 alone from the toilet to the wheelchair without the use of the required planned interventions. Subsequently, Resident #55 slid down the wheelchair and obtained a laceration to her knee. Resident #55 was sent to the hospital where it was determined the laceration needed sutures. This affected one resident (#55) out of three residents reviewed for falls. The facility census was 56. Findings include: Review of the medical record for the Resident #55 revealed an admitted [DATE]. Diagnoses included hypertension, atherosclerotic heart disease, anxiety disorder, type two diabetes mellitus, chronic kidney disease, hyperlipidemia, age related osteoporosis, insomnia, cataract, and pneumonitis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. She required extensive assistance with two persons plus for bed mobility, transfer, dressing, and total dependence with two persons physical assistance for toilet use. Resident #55 was not steady, and only able to stabilize with staff assistance and used a wheelchair. Review of the falls risk screening dated 02/18/23 revealed no falls within the last 90 days, no changes in resident's cognitive stage in the last 90 days, continue with assistance, ambulates with problem and with devices. Resident scored at high risk (22), anything higher than a score of 10 or greater indicates risk for falls. Review of the plan of care dated 09/29/22 for Activities of Daily Living (ADL) self-care and/or physical mobility performance deficit related to activity intolerance, confusion, fatigue, impaired balance, limited mobility, and weakness. Interventions included Resident #55 required a mechanical lift and was dependent on two or more staff to move between surfaces. Interventions for toilet use the resident required extensive assistance of two staff and a mechanical lift for check and change in the bed. Review of the progress note for Resident #55 dated 02/21/23 at 11:06 A.M., written by the Director of Nursing (DON) revealed Resident #55 was found in the bathroom by an Elder Assistance (EA) trying to self-transfer to the toilet. The EA stated the elder's legs went weak and she caught her to prevent her from falling and lowered her to her wheelchair. During her lowering to her wheelchair, the elder sustained an open area to her right knee. Upon assessment, open area appeared to need stitches. Medical Director was notified of the area and the assessment. The resident was sent to the emergency room (ER) for further evaluation and for potential stitches. The elder was bleeding but denied pain. Pressure was applied to the area to control bleeding and emergency medical services (EMS) was called to transport the elder to ER. Review of the local emergency attending note revealed Resident #55 had a gaping three-and-a-half-centimeter laceration noted immediately distal to the right knee joint, minimal active bleeding. Sutures were placed and the resident was discharged with follow-up orders to see her primary care physician in 10 days for suture removal. An X-ray of the right knee was obtained which showed no acute abnormalities. During an interview on 03/15/23 at 11:00 A.M., revealed State tested Nursing Aide (STNA) #91 reported Resident #55 transferred with two people and used a mechanical lift. STNA #91 reported the resident was unable to bear weight nor could she self-transfer. During a telephone interview on 03/15/23 at 11:20 A.M., revealed the Power of Attorney (POA) reported the facility called her on 02/21/23 and reported they were transferring Resident #55 with a mechanical lift, and she slipped and fell . The POA reported the resident had not been able to bear weight or stand on her own in two years and believed the resident was unable to transfer to the toilet in five years without a mechanical lift and assistance. The POA reported she could not understand and had more questions the facility could not answer. During an interview on 03/15/23 at 4:20 P.M., revealed STNA #89 reported Resident #55 could propel slowly in the wheelchair. STNA #89 reported she knew the resident had a fall early in the morning during day shift and required sutures. STNA #89 reported Resident #55 required two people and the use of a mechanical lift to transfer and for toilet use. During an interview on 03/15/23 at 4:45 P.M., revealed STNA #43 reported on 02/21/23, she was scheduled to work in the house Resident #55 lived in. The house was short a worker. STNA #43 reported she worked alone in house from 7:00 A.M., to 10:00 A.M. She called for assistance due to Resident #55 had to go to the restroom. STNA #43 reported Resident #55 did not have mechanical lift pads in her wheelchair and thought she could go to the restroom with assistance. STNA #43 denied looking in the Kardex to see how to transfer the resident. STNA #43 reported Resident #55 was propelling to the bathroom, so she left the other residents and went with the resident. STNA #43 reported Resident #55 could not lift herself on her own but was able to pivot her feet. STNA #43 said she was able to get the resident on the toilet with no problems. STNA #43 reported the wheelchair cut Resident 55's leg when she was pivoted off the toilet back into the wheelchair. STNA #43 reported she believed the mechanical lift was broken at the time and was fixed later and she had not used a gait belt during the transfer. STNA #43 had not written a report. STNA #43 was nervous and did not know what to do but wanted to tell the truth. STNA #43 reported there were no witnesses to the incident beside herself and Resident #55. She said the nurse came in to help her and the DON came shortly after. During an interview on 03/16/23 at 10:06 A.M., the Administrator reported the facility rented a mechanical lift for the one that was broken. The Administrator reported there was another STNA on the way to assist STNA #43. The Administrator reported STNA #43 asked for help but did not communicate the importance of it. It was miscommunication. She asked the MDS nurse for help and the nurse was doing something, but STNA #43 had not told her she was in the house alone and had a resident that needed to go to the restroom. Surveyor requested fall investigation and was given an educational consult. During an interview on 03/16/23 10:08 A.M., the DON reported she responds immediately to emergencies. The DON reported it was not a policy to complete a fall assessment after every fall. Fall assessments were completed upon admission and quarterly. The DON reported she was there after the fall and the STNA #43 told her Resident #55 was trying to self-transfer to the toilet and cut her knee in the process. Review of the educational consult dated 02/21/23 provided when asked for the fall investigation with a root cause analysis revealed occurrence of elder fall (post fall education). STNA #43 was educated on using gait belts with transfers, find help should you need it, and to follow the care card to the best of her ability. There was no signature of STNA #43 on educational consult form. During an interview on 03/16/23 at 11:04 A.M., revealed Licensed Practical Nurse (LPN) #49 was the nurse working house 101 and was in 201 passing morning medications on 02/21/23. LPN #49 was the charge nurse and arrived immediately after the incident but was told not to document the note in the chart because the DON would do it. LPN #49 received a text message from DON that STNA #43 needed assistance in building 101, around 9:25 A.M. LPN #49 reported the aide was by herself and was not properly trained to work the house alone. STNA #43 had her hand on Resident 55's knee to keep the pressure on it. The laceration was huge. LPN #49 called nine-one-one (911), Resident #55 was sent out to the hospital and the POA was notified. LPN #49 reported there was no gait belt used and Resident #55 had on nonslip shoes. LPN #49 said STNA #43 was transferring the resident off the toilet when the incident occurred, and the resident was not self-transferring to the bathroom alone. Review of the policy titled Fall-Care of Fallen Resident, revised December 3, 2019, defined the definition of a fall. An unintentional coming to rest on the ground, floor, or other lower level, but not as a result or an overwhelming external force. An episode where a resident lost his/her balance and would have, if not for staff intervention, is considered a fall. A fall without injury is still a fall, unless there is evidence suggesting otherwise. When a resident is observed on the floor, a fall is considered to have occurred. Fall Management Assessment Process: 1. A fall risk assessment in the electronic medical record (EMR) is completed upon admission, or re-admission, quarterly and with a significant change in condition to assess a resident's risk for fall and the need to institute interventions and or changes for safety. 2. A baseline care plan and Kardex/car card will be initiated a the time of admission instructing the staff of immediate needs to provide care. The base line car plan will be reviewed with the resident and/or resident representative within seven days. The care plan will then be reviewed at the car conference with the resident and their family. In the event occur, the nurse will: 3. The resident assessment process (RAI) and care plan will be completed within 21 days. In the event of a fall should occur, the nurse will: (a) complete a physical assessment of the resident for injury, (b) provide the immediate care to the resident as needed (c) notify the family and physician of the fall and findings following the immediate assessment (d) complete the accident and injury report in the EMR (e) determine immediately if any further interventions are needed, institute the interventions to prevent a further fall, and update the care plan and/or Kardex/care with new interventions identified as needed. 4. The documentation in the progress notes in the resident's medical record should be written to include a complete account of the events surrounding the fall, include notification of the family and physician and what interventions were instituted to prevent further falls. Remember if there is evidence of head trauma or it is an unwitnessed fall, neuro checks must be completed per protocol. 5. The interdisciplinary team will meet to review the fall to determine if further interventions are needed. The care plan will be reviewed and dated to assure it has been updated to reflect the current needs of the resident to prevent a further fall. 6. The director of nursing (DON) or designee will add the IDT summation note to the resident medical record in the progress notes following the IDT meeting held. 7. The DON will then review the accident and incident form in the medical record, add the summation of the investigation to this form and close the report in the EMR. This deficiency represents noncompliance in Master Complaint Number OH00140001 and Complaint Number OH00140646.

Based on medical record review, observation, staff and resident interview and policy review, the facility failed to ensure Resident #65's pain was properly managed during a dressing change to her coccyx and failed to medicate Resident #65 in a timely manner after the resident said she was in pain. This resulted in actual harm when nursing staff failed to ensure Resident #65 received an as needed (PRN) pain medication when the resident reported pain resulting in the resident experiencing severe pain. This affected one (#65) of one resident reviewed for pain management. The facility identified four residents on a pain management program. The facility census was 42. Findings include: Medical record review for Resident #65 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/22/19, revealed Resident #65 was cognitively intact. Her functional status was extensive assistance for bed mobility, transfers, eating and toilet use. The resident had one stage three pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed.) Review of physician orders, dated 12/26/18, for Resident #65 revealed [MEDICATION NAME]-[MEDICATION NAME] (narcotic pain medication to treat moderate to severe pain) tablet 5-325 milligrams (mg.) give one tablet by mouth every eight hours as needed for pain. Review of the care plan, dated 01/09/19, for Resident #65 revealed she was at risk for actual and potential for skin breakdown related to pressure ulcer. Interventions were to monitor for complaints of pain and provide interventions as needed. The care plan for pain, dated 01/09/19, revealed the resident had potential for acute and chronic pain related to complaints of back pain. Interventions were to administer [MEDICATION NAME] as per orders and give half an hour before treatments or care, anticipate the resident's need for pain and respond immediately to any complaint of pain. Review of the pain assessment for Resident #65, dated 01/22/19, revealed she rated her pain as moderate, frequently and daily. Her indicators of pain were vocal complaints, facial expressions, and protective body movements or postures. Pain management was for as needed medication. Review of the Medication Administration Record [REDACTED].M. Further review of the MAR, dated 03/14/19, revealed Resident #65 was not given pain medication until 03/14/19 at 11:12 A.M. The pain level documented was a score of seven (pain scale from zero indicating no pain to ten being worse pain ever.) Observation of wound care on 03/14/19 at 8:17 A.M. for Resident #65 revealed Registered Nurse (RN) #169 and Elder Assistant (EA) #176 performed the treatment. The staff washed their hands and applied gloves and provided privacy for the resident. EA #176 turned the resident towards her and the resident moaned and the EA said I know, I know. The resident said at this time the pain was in her back. The RN continued with the treatment and took the normal saline and cleansed the wound and the resident expressed signs of pain when the resident clinched her buttocks and moaned out loud. The RN then took a Q-tip and placed Santyl on it and placed on the wound and the resident moaned again and clenched her buttocks again at the touch of the Q-tip, and the EA and RN said, I know, I know and continued to place an abdominal bandage with tape to the wound. The RN did not stop wound care to treat the resident ' s signs and symptoms of pain during the observation. Interview with RN #169 on 03/14/19 at 8:23 A.M. confirmed she didn't offer any pain medication prior to treatment for [REDACTED]. She verified she should have asked the resident if she wanted to be medicated for pain prior to the treatment. Subsequent interview with RN #169 at 11:15 A.M. verified she just gave [MEDICATION NAME] pain medication to Resident #65. The RN verified she waited until almost three hours later to administer the resident her pain medication after the resident expressed she was in pain. The RN stated it has been a crazy morning. Interview and observation with Resident #169 on 03/14/19 at 11:58 A.M. revealed she was in pain and rated her pain at a seven or eight normally and said that morning it was more like a nine during the dressing change and she stated she just received her [MEDICATION NAME] pain medication and didn't get it until just a few minutes ago. She stated it hurts when they change her dressing on her coccyx and said she was still in pain. The resident was observed to be tearful when explaining about her pain. Review of the policy titled Pain Management, dated 07/16/09, revealed two lines which said pain was not a normal part of living. It is the facility's goal to identify the resident's pain and establish an individualized plan of care to reduce pain and improve quality of life. This deficiency substantiates Complaint Number OH 021.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff, resident, and family interviews, as well as interview with the technician from the Hoyer Lift company, the facility failed to ensure a resident was appropriately transferred during a Hoyer lift resulting in an avoidable fall with extensive injury. This resulted in actual harm when Elder Assistants (EAs) #18 and #89 failed to ensure the Hoyer pad was securely connected, resulting in the resident falling out of the Hoyer lift, landing on the floor, sustaining a subarachnoid hemorrhage (brain bleed), a cervical neck fracture, and a complex ear laceration. This affected one (#27) of one resident who the facility identified as having a fall from a Hoyer Lift. The facility census was 45. Findings included: Review of Resident #27's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had moderate cognitive impairment. The MDS further revealed the resident required extensive two-person physical assistance with mobility and transfers. The MDS confirmed Resident #27 required the use of a mechanical lift with two staff assist for transfers. Further review of the medical record for Resident #27 revealed on 08/24/17, the resident fell from a Hoyer lift during a transfer. The resident was transported by emergency services for evaluation and treatment. Radiological testing confirmed a level two compressed [MEDICAL CONDITION] spine and a subarachnoid hemorrhage. Additionally, the resident sustained [REDACTED]. Interview on 03/13/18 at 1:55 P.M., with Resident #27 revealed she was still a little anxious when being transferred with a Hoyer lift. She stated she had fallen from a Hoyer lift while being transferred a while back, broke her neck and ripped off her ear. Interview with the Administrator on 03/14/18 at 9:08 A.M., confirmed Resident #27 had fallen during a Hoyer lift transfer on 08/24/17. The Administrator revealed the facility had performed an internal investigation of the incident. He stated all the facility's mechanical lifts were immediately inspected by an outside company and found to be in good working order. Additionally, the staff were re-educated on the use of mechanical lifts, as well as audits completed for monitoring. Phone interview on 03/14/18 at 10:31 A.M., with Technician #90 from the Hoyer Lift company revealed service was performed on 08/28/17 of the Hoyer lift used for Resident #27. The Technician revealed there were no mechanical issues found. Technician #90 further revealed the incident had to be due to operator error. In a subsequent interview on 03/14/18 at 11:06 A.M., Resident #27 revealed she could not recall the exact date of her fall, however remembered EA #18 and #89 put the lift pad under her and lifted her up with the Hoyer lift. Resident #27 then stated the next thing she remembered was she was on the floor with blood all over her and being sent to the hospital. Phone interview on 03/14/18 at 1:34 P.M., with Resident #27's daughter, confirmed on 08/24/17 her mother had fallen during a Hoyer lift transfer, was to sent to the hospital, and was treated for [REDACTED]. She revealed a plastic surgeon had to reattach her mother's ear. Interview on 03/14/18 at 3:59 P.M., with EA #18 confirmed on 08/24/17 she had assisted EA #89 with a Hoyer lift transfer of Resident #27. EA #18 stated she and EA #89 placed the lift pad under Resident #27. EA #18 stated EA #89 started to lift Resident #27 into the air and as she moved around to the foot of the bed she heard a loud sound, looked up, and saw the back strap pop off the hook. EA #18 stated Resident #27 fell out of the Hoyer lift onto the legs of the lift, however still had one leg on the bed. EA #18 stated she moved Resident #27's leg off the bed onto the floor so she wasn't hanging. EA #18 revealed she hit the emergency pendent and the nurse immediately came into the room with the Director of Nursing (DON). EA #18 confirmed Resident #27 was bleeding and was sent to the hospital. Interview on 03/14/18 at 4:26 P.M., with EA #89 confirmed on 08/24/17 she had assisted EA #18 with a Hoyer lift transfer of Resident #27. EA #89 verified she had put the lift pad under Resident #27. EA #89 stated she was the one operating the Hoyer and had transferred her like she did every day. EA #89 stated she didn't remember how the loops were hooked onto the lift. EA #89 confirmed she started to lift the resident into the air, unlocked the Hoyer brakes, slowly moved the lift away from the bed and then pushed the lift to the left. She stated she heard the Hoyer strap snap, and Resident #27 went down, hit her head and neck on her recliner, and landed on the Hoyer legs. EA #89 confirmed Resident #27 was injured and bleeding. As a result of the incident, the facility implemented the following corrective actions to correct the deficient practice. · On 08/24/17, Resident #27 was sent to the emergency room for evaluation and treatment. · The mechanical lift and sling that were in used during the incident was removed from the floor on 08/24/17. The Hoyer Lift company was notified and did a full assessment on 08/28/17 of the mechanical lift that was in use, and all other mechanical lifts on campus to ensure resident safety. No mechanical issues were found. · On 08/24/17, the Therapy Department implemented mechanical lift in-servicing for all Elder Assistants. No Edler Assistants worked the floor until in-serviced with re-demonstration returned. The mechanical lift training was completed on 11/02/17. · A Hoyer lift transfer audit was completed daily between 08/25/17 through 08/31/17, and then two times a week between 09/01/17 through 11/02/17. The audit was completed on 11/02/17 and revealed no concerns.