Every finding on record at Otterbein Sunset House

Based on staff interview and review of facility staffing documentation, the facility failed to ensure the facility was staffed with sufficient Registered Nursing staff each day. This affected all residents residing in the facility. Facility census was 14. Findings include: Review of facility nursing schedules between 04/21/25 and 04/27/25 revealed the schedule lacked documentation indicating a Registered Nurse (RN) was scheduled to work in the facility on 04/26/25 and 04/27/25. On 04/30/25 at 1:37 P.M. interview with the Administrator and Director of Nursing (DON) during a review of the nurse staffing scheduled between 04/21/25 and 04/27/25 verified the facility was not staffed with a Registered Nurse on 04/26/25 or 04/27/25. The Administrator stated the DON was on call on 04/26/25 and 04/27/25. However, the DON did not report to the facility on either date. On 05/01/25 at 7:50 A.M. review of facility weekly staffing sheet between 04/21/25 and 04/27/25 during interview with the DON confirmed no Registered Nurse was working in the facility on 04/26/25 and 04/27/25.

Based on interview, facility documentation, and a policy for water management, the facility failed to ensure a sufficient water management program based on an accurate risk assessment. This had the potential to affect all residents. The census was 14. Findings include: Review of a document titled Legionnaire's Risk Assessment revealed the document was undated, unsigned, and did not include the name of the facility. Interview on 05/01/25 at 9:15 A.M. with Administrator and Environmental Services Director #233 confirmed the risk assessment did not include the date of the assessment, a signature, or the name of the facility. Both denied knowledge of when the risk assessment was completed and by whom. Review of policy titled, Water Management Program for Legionella Risk Reduction, dated 2017, revealed the facility shall conduct a risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread.

Based on staff interview and review of fire drill reports, corrective action plans, and a state fire marshal report, the facility failed to conduct fire drills across all shifts during the twelve-month review period preceding the survey. This had the potential to affect all residents. The census was 14. Findings include: Interview on 05/01/25 at 9:15 A.M. with the Administrator and Environmental Services Director (ESD) #233 revealed fire drills were not conducted on first or third shift in the first quarter of 2024, and no fire drill was conducted on third shift in the third quarter of 2024. Follow-up interview on 05/01/25 at 1:15 P.M. with the Administrator revealed the state fire marshal issued a violation on 07/25/24 for failure to conduct fire drills across all shifts during each quarter. Review of the Emergency and Disaster Plan, last reviewed 11/26/24, confirmed fire drills are to be conducted monthly and rotated so drills are conducted on each shift at least once per quarter. The deficient practice was corrected on 12/24/24 when the facility implemented the following corrective actions: On 08/22/24 and 08/23/24, the facility educated all staff, including maintenance staff, on fire safety. On 10/01/24, the (former) Environmental Services Director was educated by the Administrator on conducting fire drills. This employee was later terminated for continued failure to perform job duties, including those pertaining to fire drills. The facility conducted fire drills on 10/12/24 on third shift, on 11/12/24 on first and second shifts, on 12/12/24 on third shift, on 12/16/24 on first shift, and on 12/19/24 on second shift. These drills met the state fire marshal's required corrective actions. The Administrator conducted audits of fire drill documentation on 10/12/24, 11/12/24, 12/16/24, and 12/19/24 and found no further deficiencies. On 11/26/24, a representative from the [NAME] Fire Prevention Bureau and the Administrator reviewed the facility's Emergency and Disaster Plan and deemed it satisfactory. On 12/24/24, the Division of State Fire Marshal Code Enforcement Bureau conducted an onsite inspection and determined the facility had corrected the drill violation, effective 12/24/24. Since the date of correction on 12/24/24, the facility conducted fire drills on 01/17/25, 02/27/25, 03/20/25, and 04/18/25. Review of the fire drill reports for drills conducted since the 12/24/24 correction, confirmed the facility has had no further deficiencies with fire drills.

Based on observation and staff interview, the facility failed to ensure resident toilet facilities were maintained in a sanitary manner. This affected one of 14 residents (#125) reviewed for environmental and housekeeping services. Facility census was 14. Findings include: Resident #125 admitted to the facility on [DATE] with diagnoses including, nondisplaced right femur fracture, paranoid schizophrenia, type 2 diabetes mellitus, urinary tract infection, anemia, chronic kidney disease, hypertension, Alzheimer's disease, dementia, depression, coronary artery disease and heart failure. According to the functional abilities assessment dated [DATE] assessed Resident #125 to require substantial to maximal assistance with activities of daily living. On 04/26/25 skilled nursing charting assessed Resident #125 as alert and oriented to person and place, received oxygen via nasal cannula, continent of bowel and bladder, and unable to bear weight with unsteady gait. On 04/28/25 at 12:10 P.M. observation in Resident #125's private restroom located inside the resident room discovered a soiled bedpan placed on top of the toilet. The bedpan contained a yellow liquid substance pooling in the pan. The toilet had particles of brown substance clinging to the toilet bowl. Located on the floor of the restroom next to the toilet noted a brown substance on the floor tile. Interview with Housekeeper #211 on 04/29/25 at 7:58 A.M. verified the soiled restroom contained in Resident #125 room on 04/28/25. Housekeeper #211 further stated frequently following weekends the resident restrooms are discovered with soiled debris.

Based on medical record review and staff interview, the facility failed to ensure resident pharmacy medication regimen reviews were conducted monthly. This affected two of five sampled residents (#4, #1) reviewed for unnecessary medications and related pharmacy services in a facility census of 14. Findings include: 1. Resident #4 admitted to the facility on [DATE] with the diagnosis including, cerebral infarction resulting in hemiplegia and hemiparesis right side, dysphagia, abnormal posture, coronary artery disease, hypokalemia, congestive heart failure, glaucoma, atrial fibrillation, major depression, type 2 diabetes mellitus, and neuromuscular dysfunction of bladder. According to the most current Minimum Data Set (MDS) assessment dated [DATE] Resident #4 was assessed with severe cognitive impairment, no behaviors, dependent on staff for the completion of activities of daily living, incontinent of bowel and bladder, and received scheduled pain medications. Review of Resident #4's medical record noted current physician orders for 17 medications including oral, topical, eye, and inhalation. According to progress notes on 04/05/25 at 6:39 P.M. a pharmacy review was completed including the resident's medication regimen and have noted any irregularities and/or observations on a separate report to the Director of Nursing (DON) and prescriber. No documentation contained in the medical record indicated information related to the result of the medication regimen review. On 04/30/25 at 7:35 A.M. interview with the DON verified no documentation contained in the medical record was available indicating the results of the pharmacist monthly medication review or specific medication adjustments. 37452 2. Review of Resident #1's record revealed an admitted [DATE]. Diagnoses include severe dementia with behavioral and mood disturbance, anxiety disorder, heart failure, morbid obesity, hyperlipidemia, osteoarthritis, hypothyroidism, insomnia, edema, major depressive disorder, type 2 diabetes mellitus with neuropathy, and hypertension. Resident #1 was admitted to hospice 08/15/24 based on the dementia diagnosis. Review of Resident #1's quarterly MDS assessment, dated 04/03/25, indicated the resident had severe cognitive impairment and received multiple medications including antianxiety medication, antidepressant medication, antibiotic medication, opioid medication, hypoglycemic medication, and anticonvulsant medication. Review of Resident #1's physician orders revealed they included orders for 20 medications, including oral, topical, eye, sublingual (under the tongue), and subcutaneous (under the skin). Review of Resident #1's progress notes revealed they included a monthly progress notes by the consulting pharmacist. Each progress note stated the resident's medication regimen was reviewed and any irregularities and/or observations were provided on a separate report provided to the Director of Nursing (DON) and prescriber. Review of the remaining record revealed no such reports were included. Interview on 04/30/25 at 12:55 P.M. with the DON confirmed the pharmacist's monthly medication regimen review reports, were not part of Resident #1's medical record or otherwise available. Review of a policy titled, Documentation and Communication of Consultant Pharmacist Recommendations, last revised December 2019, confirmed a record of the consultant pharmacist's observations and recommendations must be made available in an easily retrievable form to nurses, prescribers, medical directors, and the care planning team. The policy further stated the findings of the monthly medication regimen review should be included in the medical record. Additionally, the policy stated recommendations shall be acted upon and documented by the staff and/or prescriber within 30 days or the DON and/or consulting pharmacist will take appropriate action, including with the medical director.

Based on medical record review, and staff interview, the facility failed to ensure psychoactive medication recommendations were implemented as directed by the physician. This affected one of five sampled residents (#4) reviewed for the provision of unnecessary medication administration in a facility census of 14. Findings include: Resident #4 admitted to the facility on [DATE] with diagnoses including, cerebral infarction resulting in hemiplegia and hemiparesis right side, dysphagia, abnormal posture, coronary artery disease, hypokalemia, congestive heart failure, glaucoma, atrial fibrillation, major depression, type 2 diabetes mellitus, and neuromuscular dysfunction of bladder. According to the most current Minimum Data Set assessment dated [DATE] Resident #4 was assessed with severe cognitive impairment, no behaviors, dependent on staff for the completion of activities of daily living, incontinent of bowel and bladder, and received pain medications. On 12/13/16 a nursing plan of care was initiated to address Resident #4 risk for side effects from psychotropic medication use for diagnosis of depression. Interventions included the following; Administer Effexor medication as ordered by doctor. Discuss with resident and family potential side effects of the drug Venlafaxine. Monitor and record resident behaviors. Observe resident for adverse side effects, document if noted, notify resident physician. The pharmacy consultant will review medication every month, and make recommendations as needed. On 05/07/24 a physician order was initiated for the administration of Venlafaxine HCl ER 37.5 milligrams (mg) to be administered related to major depressive disorder. According to pharmacy recommendation note to attending physician/prescriber dated 01/10/25 Consultant Pharmacist listed current psychiatric medication to include the administration of Effexor ER 37.5 mg QD since at least 05/07/24. The Consultant Pharmacist requested the physician consider a possible gradual dose reduction (GDR). Please complete the form indicating any change in medication (med) orders or documentation as to why you (physician) consider a GDR is not indicated at this time. Physician response dated 01/31/25 documented to involve psych (psychiatry/psychology). No documentation contained in the medical record indicated the physician response was implemented. On 04/30/25 at 7:35 A.M. interview with the Director of Nursing (DON) during a review of pharmacy the recommendation 01/31/25 confirmed the physicians response had note been implemented.

Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure medications were provided as ordered by the physician and without error. This resulted in three errors of 37 medications being administered with a 8.11% error rate. This affected one of three residents (#20) observed for medication administration in a facility census of 14. Findings include: Resident #20 admitted to the facility on [DATE] with diagnoses including, pneumonia, hypoxemia, fluid overload, type 2 diabetes mellitus, chronic obstructive pulmonary disease, long term use insulin, polyneuropathy, glaucoma, chronic kidney disease, hypertension and depression. According to the most current Minimum Data Set assessment dated [DATE] assessed Resident #20 with moderately impaired cognition, dependent on staff for the completion of activities of daily living, vision adequate with corrective lenses, and incontinent of urine. Review of physician orders noted the following; 03/18/25 Cilostazol Oral Tablet 100 milligrams (mg) (Cilostazol) Give 1 tablet by mouth every morning and at bedtime for claudication. On 03/18/25 Dorzolamide HCl Ophthalmic Solution 2 % (Dorzolamide HCl) Instill 1 drop in both eyes every morning and at bedtime for glaucoma. On 03/20/25 Brimonidine Tartrate Ophthalmic Solution 0.2 % (Brimonidine Tartrate) Instill 1 drop in left eye every 12 hours for glaucoma. Observation on 04/29/25 at 9:22 A.M. noted Registered Nurse (RN) #207 gathering medications for Resident #20. Medications included brimonidine 0.2% eye drops and dorzolamide 2% eye drops. At the time of observation RN #207 stated the medication cilostzol 100 milligrams (mg) was not available and would not be administered. RN #207 then proceeded to Resident #20's room and administered several medications mouth. At 9:31 A.M. RN #207 placed one drop of brimonidine 0.2% into Resident #30 left eye. After 30 seconds RN #207 placed one drop of dorzolamide 2% into each eye. No pause between eye drop medications was attempted. On 04/29/25 at 9:40 A.M. interview with RN #207 verified eye drops were given one after another with no pause between. In addition the medication cilostazol 100 mg was to be administered twice daily and the morning dose would be omitted due to not being available at the facility. According to medication administration procedure revised November 9, 2021. Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. Medications are administered in accordance with written orders of the attending physician or physician extender. Medications are administered within one hour before or one hour after scheduled time. According to facility medication administration procedure for eye drop administration dated May 2022. The time for optimal eye drop absorption is approximately 3 to 5 minutes. If another drop of the same or different medication is prescribed for administration in the same eye at the same time, wait 3 to 5 minutes. In the case of administering levobunolol, timolol, brinzolamide, or dorzolamide, wait 10 minutes before administering additional drops.

Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure medications were administered to prevent the occurrences of significant medication errors. This affected two of four sampled residents (#20, #125) reviewed for the administration of medications in a facility census of 14. Findings include: 1. Resident #20 admitted to the facility on [DATE] with diagnoses including, pneumonia, hypoxemia, fluid overload, type 2 diabetes mellitus, chronic obstructive pulmonary disease, long term use insulin, polyneuropathy, glaucoma, chronic kidney disease, hypertension and depression. According to the most current Minimum Data Set assessment dated [DATE] assessed Resident #20 with moderately impaired cognition, dependent on staff for the completion of activities of daily living, vision adequate with corrective lenses, and incontinent of urine. Review of physician orders noted the following; 03/18/25 Cilostazol Oral Tablet 100 milligrams (mg) (Cilostazol) Give 1 tablet by mouth every morning and at bedtime for claudication. On 03/18/25 Dorzolamide HCl Ophthalmic Solution 2 % (Dorzolamide HCl) Instill 1 drop in both eyes every morning and at bedtime for glaucoma. On 03/20/25 Brimonidine Tartrate Ophthalmic Solution 0.2 % (Brimonidine Tartrate) Instill 1 drop in left eye every 12 hours for glaucoma. Observation on 04/29/25 at 9:22 A.M. noted Registered Nurse (RN) #207 gathering medications for Resident #20. Medications included brimonidine 0.2% eye drops and dorzolamide 2% eye drops. At there time of observation RN #207 stated the medication cilostzol 100 milligrams (mg) was not available and would not be administered. RN #207 then proceeded to Resident #20 room and administered several medications mouth. At 9:31 A.M. RN #207 placed one drop of brimonidine 0.2% into Resident #30 left eye. After 30 seconds RN #207 placed one drop of dorzolamide 2% into each eye. No pause between eye drop medications was attempted. On 04/29/25 at 9:40 A.M. interview with RN #207 verified eye drops were given one after another with no pause between. In addition the medication cilostazol 100 mg was to be administered twice daily and the morning dose would be omitted due to not being available at the facility. According to facility medication administration procedure for eye drop administration dated May 2022. The time for optimal eye drop absorption is approximately 3 to 5 minutes. If another drop of the same or different medication is prescribed for administration in the same eye at the same time, wait 3 to 5 minutes. In the case of administering levobunolol, timolol, brinzolamide, or dorzolamide, wait 10 minutes before administering additional drops. 2. Resident #125 admitted to the facility on [DATE] with diagnoses including, nondisplaced right femur fracture, paranoid schizophrenia, type 2 diabetes mellitus, urinary tract infection, anemia, chronic kidney disease, hypertension, alzheimer's disease, dementia, depression, coronary artery disease and heart failure. According to the functional abilities assessment dated [DATE] assessed Resident #125 to require substantial to maximal assistance with activities of daily living. On 04/26/25 skilled nursing charting assessed Resident #125 as alert and oriented to person and place, received oxygen via nasal cannula, continent of bowel and bladder, unable to bear weight with unsteady gait, and intact skin. Review of physician orders dated 04/26/25 noted Vilazodone 20 milligrams (mg) to be administered in the morning related to depression. Review of Medication Administration Records (MAR) between 04/26/25 and 04/28/25 noted the medication documented as not administered. No further documentation contained evidence indicating the medication was administered or the physician being notified of the omission. On 05/01/25 at 9:34 A.M. interview with Director of Nursing following medical record review verified Resident #125 did not receive Vilazodone 20 mg on 04/26/25, 04/27/25, 04/28/25 due to medication not available in facility. According to medication administration procedure revised November 9, 2021, medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. Medications are administered in accordance with written orders of the attending physician or physician extender. Medications are administered within one hour before or one hour after scheduled time.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of the facility policy, staff interview, and review of the facility self-reported incident, the facility failed to prevent staff-to-resident physical abuse. This affected one (Resident #1) of four residents reviewed for abuse. The facility census was 15. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE]. Diagnoses included peripheral venous insufficiency, polyarthritis, macular degeneration right and left eye, dementia, chronic kidney disease, hemiplegia and hemiparesis following a cerebral vascular accident. An additional diagnosis of cerebral atherosclerosis was added on 10/21/24. Review of the quarterly Minimum Data Set (MDS) assessment completed on 10/09/24 Resident #1 was highly impaired visually and had severe cognitive impairment. Resident #1 was dependent on staff for toilet hygiene, bathing and bed mobility and required the physical assistance of two people for transfers using a lift device. Resident #1 was also incontinent of bowel and bladder. Review of the care plan for Resident #1 revealed an activities of daily living (ADL) deficit due to impaired cognition and hemiparesis. Interventions included for caretakers to provide assistance without rushed care, anticipate needs, allow of rest periods with care and to ensure a safe environment. Review of the skin assessment completed on 09/18/24 at 4:35 P.M. revealed Resident #1 had bruising to the right hand and wrist. The skin assessment completed on 09/19/24 at 5:30 P.M. revealed Resident #1 had bruising to bilateral forearms. Additional skin assessments completed on 09/19/24 and 09/20/24 revealed bilateral forearm bruising. The provider progress note dated 09/19/24 revealed Resident #1 had bruising to the right and left arm and wrist. The left forearm bruise was darkening, and the right wrist continued to improve. Review of the facility self-reported incident (SRI) dated 09/18/24 revealed on 09/18/24 at approximately 4:00 P.M., a family member of Resident #1 reported to the Director of Nursing that State tested Nursing Assistant (STNA) #75 was rough when providing care on the midnight shift. The facility's investigation revealed the family's video camera footage was reviewed and found STNA #75 did provide improper care and had disrespectful communication with Resident #1. Interview with the Executive Director (ED) on 10/30/24 at 11:00 A.M. stated Resident #1's family showed video footage from the video camera in Resident #1's room. The ED stated on 09/18/24, STNA #275 crossed Resident #1's across the resident's chest, pulled the resident's shirt up over the crossed arms of Resident #1 and secured the shirt over the resident's shoulders, limiting the resident's movement. Additionally, STNA #275 mocked Resident #1 when the resident was moaning during care. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/25/22 revealed residents have the right to be free of abuse, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint that is not required to treat the resident's medical symptoms. The policy defined a physical restraint as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The deficient practice was corrected on 10/11/24 when the facility implemented the following corrective actions: On 09/18/24, the Executive Director notified the Medical Director of the abuse allegation. On 09/18/24, a meeting with the family and a review of the situation, including a video the family had of the care revealed STNA #75 displayed disrespectful behavior and delivered poor resident care to Resident #1. On 09/18/24, STNA #75 was immediately placed on administrative leave pending investigation. STNA #75 never returned back to work and the facility terminated STNA #75's employment. On 09/18/24, the DON completed a head-to-toe assessment of Resident #1; no additional injuries were noted, the resident had no signs of psychosocial distress. Resident #1 at the time of the assessment was pleasant and unaware of the incident. On 09/18/24, the DON and designee completed head to toe skin assessments on all residents with no abnormal findings. On 09/19/24, an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting was held to review internal action plan for the care concern of Resident #1. On 09/19/24, Resident #1 was evaluated by Nurse Practitioner (NP) #215, with no concerns identified and no new orders given. On 09/19/24, all residents were interviewed regarding care and roughness during care. All residents interviewed stated the care received was good, with no complaints regarding care. All residents denied having received rough care. On 09/19/24, the DON and designee educated all nursing staff on duty on the abuse policy and peri care. On 09/20/24, the DON and designee educated all nursing staff on the abuse policy including, mistreatment, neglect, exploitation and misappropriation of resident property and reporting. As well staff were educated on peri care, customer service and respectful communication and restraints. On 09/20/24 and 09/21/24, the DON and designee completed skin sweeps on all residents. There were no abnormal findings. Beginning on 09/21/24, the DON or designee will observe and monitor resident care on third shift weekly for four weeks to ensure appropriate compassionate care, random audits thereafter. Review of the audits completed on 09/18/24, 09/27/24, 10/01/24 and 10/11/24 revealed no concerns. Interviews on 10/30/24 with Therapist #200, Housekeeper #220, STNAs #58 and #60, LPN #51 confirmed staff were re-educated on the facility's abuse policy and reporting procedures and each staff were knowledgeable about the facility's procedures. This deficiency represents non-compliance investigated under Complaint Number OH00158626.

Based on observation, staff interview, and review of the facility policy, the facility failed to seal and date opened food items in the freezer. This had to potential to affect all 19 residents residing in the facility. Findings include: Observation on 06/24/24 of the kitchen's freezer from 7:20 A.M. to 7:45 A.M. revealed an opened, unsealed, undated bag of Alaskan polluck, an opened, unsealed, undated bag of turkey sausage, an opened, unsealed, undated bag of seasoned beef patties. Interview on 06/24/24 at 7:25 A.M. with Dietary [NAME] #202 verified the finding. Interview on 06/24/24 at 1:26 P.M. with the Administrator stated all residents were getting food from the kitchen and there were no residents nothing by mouth. Review of the facility's Food Storage and Policy and Procedure, last revised 05/2013, revealed all food is to be stored, labeled and dated properly to assure stock rotation and prevent food illness. This deficiency represents non-compliance investigated under Complaint Number OH00154237.

Based on medical record review, review of admissions documents, staff interview, and review of facility policy, the facility failed to ensure admission agreements were provided and signed timely for newly admitted residents. This affected three (#10, #11, and #12) of three residents reviewed for admissions. The facility census was 20. Finding Include: 1. Review of Resident #10's medical record revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included sepsis, prostate cancer, type II diabetes, cognitive communication deficit, chronic kidney disease, hypertension, and acute respiratory infection. Review of Resident #10's admission agreement revealed Resident #10 was admitted to the facility on [DATE]. The admission agreement form contained the services the facility would provide, cost of services and payor sources, resident rights, bed hold notification, consent for ancillary services, and a consent to treat. Resident #10 was not provided his agreement for signature until 02/11/24, nine days after his admission to the facility. 2. Review of Resident #11's medical record revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included fracture of the right clavicle subsequent encounter, urinary tract infection, anxiety disorder, heart disease, spinal stenosis, and cognitive communication deficit. Review of Resident #11's admission agreement revealed Resident #11 was admitted to the facility on [DATE]. The admission agreement form contained the services the facility would provide, cost of services and payor sources, resident rights, bed hold notification, consent for ancillary services, and a consent to treat. Resident #11 was not provided his agreement for signature until 02/11/24, nine days after his admission to the facility and three days prior to his discharge. 3. Review of Resident #12's medical record revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included aftercare following joint replacement surgery, obesity, atrial fibrillation, ventral hernia, long term use of anticoagulants, and cognitive communication deficit. Review of Resident #12's admission agreement revealed Resident #12 was admitted to the facility on [DATE]. The admission agreement form contained the services the facility would provide, cost of services and payor sources, resident rights, bed hold notification, consent for ancillary services, and a consent to treat. Resident #11 was not provided his agreement for signature until 02/12/24, seven days after his admission to the facility and one day prior to his discharge. Interview on 04/01/24 at 10:02 A.M. with Admissions Director (AD) #237 revealed typically resident admission packets were signed within 72 hours of admission, though there was not defined timeframe for signature. AD #237 Verified Resident #10, #11, and #12 had not signed their admission agreements until seven to nine days after admission to the facility. AD #237 verified the agreements contained the consent to treat, cost of stay, services offered, photo release, Health Insurance Portability and Accountability Act (HIPAA) policy, resident rights, and consent for ancillary services. Review of the facility policy titled, Admission Policy, revised 12/06/16, revealed potential residents must sign the facility's admission agreement and agree to abide by the facility's policies and procedures. Prospective residents would be given a copy of the facility's description of services, payment options, resident rights, and all other applicable prior to the signing of the admission agreement whenever practical. On admission the facility would explain to residents the special characteristics or services limitations of the facility which were also to be identified in the admission material. This deficiency represents non-compliance investigated under Complaint Number OH00152165.

Based on record review and staff interview, the facility failed to follow physician orders to obtain daily weights to monitor for fluid overload. This affected two (#20 and #1) of three residents reviewed for daily weights. The facility census was 18. Findings include: 1. Review of the medical record for Resident #20 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnosis included congestive heart failure (CHF). Review of the physician orders for Resident #20 revealed an order for daily weight and to notify the physician of a greater than two-pound weight gain in 24 hours, or greater than five pound weight gain in one week. Review of Resident' #20's Treatment Administration Record (TAR) for 10//23 revealed no daily weights were obtained for the following days: 10/17/23, 10/18/23, 1022/23, 10/24/23, 10/25/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, and 10/31/23. Review of the TAR for the month of 11/23 revealed revealed no daily weights were obtained for th following days: 11/02/23, 11/04/23, 11/05/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23. Review of the TAR for the month of 12/23 revealed revealed no daily weights were obtained for th following days: 12/04/23, 12/07/23, 12/08/23, 12/09/23, 12/10/23, 12/11/23, and 12/17/23. 2. Review of the medical record for Resident #1 revealed an admitted [DATE] with a diagnosis of heart failure. Review of the current physician orders for Resident #1 revealed an order to obtain a daily weight and notify the physician for weight gain of greater than two pounds in 24 hours or greater than five pounds in one week. Review of the TAR for Resident #1 for 11/23 revealed revealed no daily weights were obtained for the following days: 11/02/23, 11/03/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23/11/11/23, 11/12/23, 11/15/23, 11/17/23, 11/20/23, and 11/26/23. Review of the TAR for Resident #1 for 12/23 revealed revealed no daily weights were obtained for the following days: 12/04/23, 12/09/23, 12/21/23, 12/23/23, 12/24/23, and 12/25/23. Interview on 01/22/24 at 12:45 P.M. with the Director of Nursing (DON) verified daily weights were missing for Resident #20 and Resident #1. This deficiency represents non-compliance investigated under Complaint Number OH00149536.

Based on medical record review, staff interview, and drug manufacturer indications for use, the facility failed to ensure medications were obtained and administered as prescribed in a timely fashion. This affected one (#1) of five residents reviewed for the provision of medications. The census was 14. Findings include: Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included a right humerus fracture, COVID-19, coronary artery disease, carotid artery stenosis, hypertension, hyperlipidemia, malignant neoplasm of bladder, peripheral vascular disease, and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was assessed with moderately impaired cognition and was dependent on staff for the completion of activities of daily living. Review of Resident #1's nursing progress notes on 02/16/23 at 8:12 A.M., Resident #1 tested positive for COVID-19. The Director of Nursing was notified and the resident was placed into droplet isolation. At 10:09 A.M., Resident #1's family member was notified of the positive COVID-19 test result. At 10:42 A.M., the physician was notified and no new orders were obtained. Further review of the nursing progress notes on 02/17/23 at 2:24 P.M. revealed Resident #1's family representative requested to call the physician to obtain a monoclonal (antiviral) medication to reduce COVID-19 symptoms and the nurse noted a voicemail was left for the physician. On 02/19/23 at 10:45 P.M., the nurse indicated the medication Paxlovid (150/100) oral tablet therapy pack give 150 milligrams (mg) by mouth every morning and at bedtime every five days was ordered, but the the medication was not in stock and the facility was awaiting arrival from pharmacy. The order was changed for Resident #1 to start the medication in the morning on 02/20/23. Review of a nursing progress note dated 02/20/23 at 7:54 A.M. revealed the nurse documented Resident #1's Paxlovid was not available. A nursing progress note was written on 02/20/23 at 1:47 P.M. that Resident #1's Paxlovid medication was delivered and was given after lunch. There was no further documentation contained in the medical record noted the medication was administered. Review of a a nursing progress note on 02/23/23 at 11:53 A.M. revealed the nurse noted having the Paxlovid in the computer, but it was not on the electronic medication administration record (EMAR) to allow for administration. The nurse communicated the concern with the Director of Nursing and updated the family that the medication was available; however, the medication could not be given until it was transcribed to the EMAR. Resident #1 received the medication during the evening medication administration of 02/23/23. Review of the February 2023 medication administration record (MAR) revealed Resident #1 did not receive the first dose of Paxlovid 150 milligrams (mg) until the evening of 02/20/23 and another dose was not given until 02/23/23 due to a transcription error. Interview with the Administrator and Director of Nursing(DON) on 03/03/23 at 11:35 A.M. confirmed Resident #1 did not receive the medication Paxlovid from the pharmacy in a timely manner. The physician was notified of the medication request on 02/17/23 and did not respond until 02/19/23. One dose of the medication was administered during the evening of 02/20/23 and not administered again until 02/23/23 in the evening due to a transcription error. The DON verified the primary pharmacy was unable to obtain the medication and attempted to contact a secondary pharmacy that was unable to obtain the medication. No communication from the pharmacy was provided to the facility until 02/19/23 regarding the status of the medication. Review of Paxlovid manufacturer indications for use, revised February 2023, instructed to initiate Paxlovid treatment as soon as possible after diagnosis of COVID-19 and within five days of symptom onset. This deficiency represents non-compliance investigated under Master Complaint Number OH00140774.

Based on medical record review, staff interview, and drug manufacturer indications for use, the facility failed to ensure medications were obtained and administered as prescribed by the physician. This affected one (#1) of five residents reviewed for the provision of medications. The census was 14. Findings include: Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included a right humerus fracture, COVID-19, coronary artery disease, carotid artery stenosis, hypertension, hyperlipidemia, malignant neoplasm of bladder, peripheral vascular disease, and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was assessed with moderately impaired cognition and was dependent on staff for the completion of activities of daily living. Review of Resident #1's nursing progress notes on 02/16/23 at 8:12 A.M., Resident #1 tested positive for COVID-19. The Director of Nursing was notified and the resident was placed into droplet isolation. At 10:09 A.M., Resident #1's family member was notified of the positive COVID-19 test result. At 10:42 A.M., the physician was notified and no new orders were obtained. Further review of the nursing progress notes on 02/17/23 at 2:24 P.M. revealed Resident #1's family representative requested to call the physician to obtain a monoclonal (antiviral) medication to reduce COVID-19 symptoms and the nurse noted a voicemail was left for the physician. On 02/19/23 at 10:45 P.M., the nurse indicated the medication Paxlovid (150/100) oral tablet therapy pack give 150 milligrams (mg) by mouth every morning and at bedtime every five days was ordered, but the the medication was not in stock and the facility was awaiting arrival from pharmacy. The order was changed for Resident #1 to start the medication in the morning on 02/20/23. Review of a nursing progress note dated 02/20/23 at 7:54 A.M. revealed the nurse documented Resident #1's Paxlovid was not available. A nursing progress note was written on 02/20/23 at 1:47 P.M. that Resident #1's Paxlovid medication was delivered and was given after lunch. There was no further documentation contained in the medical record noted the medication was administered. Review of a a nursing progress note on 02/23/23 at 11:53 A.M. revealed the nurse noted having the Paxlovid in the computer, but it was not on the electronic medication administration record (EMAR) to allow for administration. The nurse communicated the concern with the Director of Nursing and updated the family that the medication was available; however, the medication could not be given until it was transcribed to the EMAR. Resident #1 received the medication during the evening medication administration of 02/23/23. Review of the February 2023 medication administration record (MAR) revealed Resident #1 did not receive the first dose of Paxlovid 150 milligrams (mg) until the evening of 02/20/23 and another dose was not given until 02/23/23 due to a transcription error. Interview with the Administrator and Director of Nursing(DON) on 03/03/23 at 11:35 A.M. confirmed Resident #1 did not receive the medication Paxlovid from the pharmacy in a timely manner. The physician was notified of the medication request on 02/17/23 and did not respond until 02/19/23. One dose of the medication was administered during the evening of 02/20/23 and not administered again until 02/23/23 in the evening due to a transcription error. The DON verified the primary pharmacy was unable to obtain the medication and attempted to contact a secondary pharmacy that was unable to obtain the medication. No communication from the pharmacy was provided to the facility until 02/19/23 regarding the status of the medication. Review of Paxlovid manufacturer indications for use, revised February 2023, instructed to initiate Paxlovid treatment as soon as possible after diagnosis of COVID-19 and within five days of symptom onset. This deficiency represents non-compliance investigated under Master Complaint Number OH00140774.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure frozen food was stored in a safe and sanitary manner and ventilation ducts were kept clean. This had the potential to affect all 19 residents in the facility. The facility census was 19. Findings include: Observation on 08/22/22 at 9:33 A.M. of the walk in freezer found ice build up along the edge of the door, preventing the door from closing properly. Ice was built up on the inside of the door and covered the bars and racks on the shelving unit along with the boxes of food items on the shelves. The food items were not able to be identified due to the ice build up. Removal of some of the ice crystals from the front of the boxes found they contained breadsticks, pretzel buns, burritos, strawberry rhubarb pie, cherry pie and whipped topping. Also, boxes were found being stored on the floor containing chicken and tiramisu desserts. In addition, a large box of frozen peas was found to be open, uncovered, and unlabeled. Interview on 08/22/22 at 9:36 A.M. with Dietary Manager (DM) #419 verified the peas were not in use and were most likely left open from the day before, the boxes of chicken and tiramisu were stored on the floor and there was ice built up on the side of the door, the shelves, and food boxes. DM #419 reported the seal on the door most likely needed to be replaced again or one of the staff did not ensure it was closed tightly. Observation on 08/23/22 at 9:56 A.M. of the walk in freezer found ice build up continued to be on the inside of the door, the shelves, and breadsticks, pretzel buns, burritos, strawberry rhubarb pie, cherry pie, and whipped topping. 2. Observation on 08/22/22 at 9:27 A.M. of the ceiling ducts above the preparation area in the kitchen and dishwashing area, found dusty-brown/gray buildup, consistent with the appearance of dust, on the ventilation slats of the duct work. Interview on 08/22/22 at 9:30 A.M. with DM #419 verified there was dust build up on the ventilation duct work. DM #419 reported the local health department had completed an inspection and noted the same concern. DM #419 reported maintenance completed the cleaning of the vents and she would make a report again to have them address the dust as she did not think it had been taken care of from the previous inspection. Interview on 08/25/22 at 12:15 P.M. with the Administrator revealed the walk in freezer was last serviced on 06/30/22. The Administrator showed photographs of the ventilation ducts having been cleaned of dust. The Administrator provided documented training that was held on 06/09/22 which included a server cleaning schedule and cook duties. None of the training included cleaning of the walk in cooler/freezer or the vents. The Administrator reported they had no food borne illnesses, and no complaints from resident council regarding food. Review of the Food Inspection Report dated 04/21/22 revealed the local health department had a non-critical finding of build up on the shelving in the the walk in cooler and observed build up on fan and ceiling in the dish wash area. Review of the facility policy titled, Food Storage and Procurement, revised 06/20/17 revealed foods should be stored, prepared and distributed in accordance with professional standards for food services safety. Once a package was opened any remaining food should be placed in a sealed container or bags and marked to identify what was in the container. If the items were placed in a freezer it must be labeled with the date the product/food item was opened.

Based on medical record review, observation, staff interview, review of facility policy, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure facility staff wore proper Personal Protective Equipment (PPE) when in contact with a resident on Transmission-Based Precautions (TBP). This affected one (Resident #12) of two residents reviewed for TBP. The facility census was 19. Findings include: Medical record review revealed Resident #12 admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #12 was alert, oriented, and able to make needs known. The resident was dependent on staff for the completion of activities of daily living. Further review of the medical record revealed no documentation indicating Resident #12 was vaccinated for COVID-19. Review of Resident #12's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 08/22/22 at 3:47 P.M. noted Resident #12 in their room with a sign posted on the door noting the resident was in droplet isolation. There was a cabinet with PPE placed outside the door. Observation on 08/23/22 at 1:10 P.M. revealed Registered Nurse (RN) #429 was observed in Resident #12's room, standing at the bedside. RN #429 was wearing a face shield and N95 mask. RN #429 was not wearing any additional PPE, including gloves or a gown. The droplet isolation sign was still posted to Resident #12's door. Interview on 08/23/22 at 3:50 P.M. with RN #429 confirmed when in Resident #12's room, staff were to wear full PPE due to the resident being in droplet isolation. RN #429 stated she was unaware full PPE was required when in the residents room. Interview on 08/24/22 at 8:03 A.M. with the Director of Nursing (DON) verified RN #429 was required to wear full PPE (gown, gloves, eye protection, and N95 mask) when entering and working with Resident #12. The DON indicated due to the resident being unvaccinated for COVID-19 and going out to appointments in a healthcare setting on 08/22/22, the resident was in droplet isolation for seven days. Additional observation on 08/25/22 at 6:14 A.M. noted State tested Nurse Aide (STNA) #440 in Resident #12's room assisting the resident at the bedside. STNA #440 was wearing surgical gloves, an N95 mask, and a face shield applied. STNA #440 was not wearing a gown. Interview on 08/25/22 at 6:20 A.M. with the DON verified STNA #440 should have applied all PPE, including a gown due to Resident #12 being placed on droplet isolation. According to the facility's COVID-19 policy dated 02/07/22 revealed new residents or those that have been readmitted and are not up to date with vaccines, are required to quarantine in their private room with transmission based precautions on the appropriate unit, for 10 days or seven days with a negative test within 48 hours or longer if showing signs and symptoms. Place precaution signage on resident door. Personal Protective Equipment (PPE) required includes: Gloves, isolation gowns, facemask, respiratory protection N95 masks or equivalent are recommended, eye protection that covers both the front and sides of the face, hand hygiene using Alcohol Based Hand Sanitizer before and after all patient contact, contact with infectious material and before and after removal of PPE, including gloves if hands are soiled, washing hands with soap and water is required for at least 20 seconds. Review of CDC guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 02/02/22 revealed recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection included staff should wear an N95 mask, gown, gloves, and eye protection.

Based on medical record review, observation, and staff interview, the facility failed to ensure nail care and grooming was provided to a dependent resident. This affected one (Resident #7) of one resident reviewed for activities of daily living (ADLs). The facility census was 19. Findings include: Medical record review revealed Resident #7 admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #7 had severe cognitive impairment and was dependent on staff for the completion of ADLs. Review of the care plan dated 07/22/22 revealed Resident #7 had ADL self-care deficit and physical mobility deficit related to decrease in ability to perform ADLs, difficulty with mobility, and increase dependence for most ADLs. Interventions included the following: ensure glasses are clean, assistance with mobility as needed, check nail length, trim and clean on bath day and as necessary and report any changes to the nurse, requires total dependence of one person with bathing, totally dependent to reposition and move in bed with assistance of two persons, assist to choose simple comfortable clothing that enhances ability to dress self, totally dependent with dressing with the assistance of one person, brush teeth, rinse mouth with wash, requires total dependence with assistance of one person for toileting, and encourage to participate to the fullest extent possible with each interaction. Review of task completion documentation from 07/26/22 to 08/24/22 noted Resident #7 required full staff performance and was totally dependent upon staff for the completion of maintaining personal hygiene. Observations on 08/22/22 at 12:51 P.M. and 3:51 P.M. noted Resident #7 in bed wearing a hospital gown. The resident had matted hair to the back of her head, lips with pealing skin and oral cavity with dry mucous membranes, a dark substance under fingernails of both hands, and multiple grey hairs to her chin measuring approximately one inch. Observations on 08/23/22 at 8:55 A.M., 11:46 A.M., and 3:18 P.M. noted Resident #7 in bed a shirt with an adult brief without pants. The resident had matted hair to the back of her head, lips with pealing skin and oral cavity with dry mucous membranes, a dark substance under fingernails of both hands, multiple grey hairs to her chin measuring approximately one inch. Observations 08/24/22 at 6:10 A.M. and 9:16 A.M. noted Resident #7 in bed wearing hospital gown. The resident had matted hair to the back of her head, lips with pealing skin and oral cavity with dry mucous membranes, a dark substance under fingernails of both hands, and multiple grey hairs to her chin measuring approximately one inch. The resident had glasses on and the lenses had a film and debris to the lens surface. Interview and observation on 08/24/22 at 9:30 A.M. with State tested Nurse Aide (STNA) #431 verified Resident #7 had long hair on her face, matted hair to her head, dark substance under fingernails to both hands, dry oral cavity with dry skin clinging to the lips and debris to glasses. STNA #431 verified providing care to Resident #7 on 08/23/22 and 08/24/22. STNA #431 stated the resident was resistant to personal care, however, she did not report the resistant interactions to the nurse for further guidance. Interview on 08/24/22 at 9:20 A.M. with the Director of Nursing verified Resident #7 was dependent upon staff for the completion of ADLs and confirmed the resident was not provided sufficient care to carry out ADLs.

Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure fall interventions were in place as care planned. This affected one (Resident #10) of two residents reviewed for falls. The facility census was 19. Findings include: Review of Resident #10's medical record revealed an admitted [DATE]. Diagnoses included [CONDITION(S)], heart disease, [CONDITION(S)], depression, protein calorie malnutrition, cognitive communication deficit, and repeated falls. Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #10 was cognitively intact. Resident #10 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #10 displayed no behaviors during the review period. Resident #10 was noted to have had a fall prior to admission but none at the time of the review. Review of Resident #10's care plan revised 08/01/22 revealed supports and interventions for self-care deficit and the resident was at risk for falls. Fall interventions included anticipating needs, ensuring his call light was in reach, and ensure he had access to a working and reachable call light. Review of Resident #10's Fall Risk assessment dated [DATE] revealed Resident #10 was at high risk for falls. Observation on 08/22/22 at 10:35 A.M. of Resident #10 found him in his room alone, seated on the front edge of the seat of his wheelchair, leaning forward out of his wheelchair, reaching down toward the floor. Resident #10 was unstable and appeared close to falling. Coinciding interview with Resident #10 revealed he was trying to reach his call light. Resident #10 reported he was looking for it and when he found it, it was stuck under the recliner. Resident #10 stated he was not sure how it got there or how long it was there but he needed to have it. A sign was noted on the wall of Resident #10's room reminding Resident #10 to use his call light for assistance. Closer inspection of the call light found it was stuck in the gears of the recliner. Interview on 08/22/22 at 10:40 A.M. with Physical Therapist (PT) #454 verified Resident #10 was at risk for falls, his call light was not in reach and the call light was stuck in the gears of his recliner. PT #454 dislodged the call light chord and provided the call light to Resident #10. Review of the facility policy titled, Falls Management revised 12/03/19 revealed the facility was to institute interventions to prevent a further fall.

Based on observation, staff interview, medical record review and review of the medication administration policy, the facility failed to ensure two medications of 26 were provided within prescribed timeframe's, resulting in a medication error rate of 7.69 percent (%). This affected one (Resident #7) of four residents reviewed for medication administration. The facility census was 19. Findings include: Observation on 08/23/22 at 11:40 A.M. noted Registered Nurse (RN) #429 obtained Resident #7's medications from the medication cart to prepare them for gastrostomy tube (G-tube) administration. Medications included omeprazole suspension two milligrams (mg) per (/) one milliliter (ml) equaling 10 ml in a medication cup and [MEDICATION(S)] 0.5 mg crushed and placed into a medication cup. RN #429 proceeded to Resident #7's room and administered the medications via G-tube. Interview with with RN #429 revealed the medications were ordered twice daily by the physician and were scheduled for 10:00 A.M. However, RN #429 was running behind. Review of Resident #7's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No specified times were included. Continued review revealed an order dated 08/16/22 for [MEDICATION(S)] 0.5 mg administered two times a day for anxiety and restlessness. Scheduled times were 10:00 A.M. and 9:00 P.M. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 2:00 P.M. and [MEDICATION(S)] was scheduled for 10:00 A.M. and 9:00 P.M. Interview on 08/24/22 at 3:05 P.M. with the Director of Nursing verified Resident #7's medications were not administered within established timeframes. According to medication administration policy revised on 08/30/16, medications ordered two times daily are administered at 9:00 A.M. and 5:00 P.M. with an hour time before and after the designated times.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of facility investigation, observations, and review of facility inservices, the facility failed to ensure a resident was provided with sufficient staff supervision when positioned in bed during direct care. Actual harm occurred when Resident #1's bed was raised from the low position and staff stepped away from the bed, out of sight of the resident. Resident #1 subsequently rolled from the bed hitting her head causing a cognitive and respiratory change which resulted in a concussion. This deficient practice affected one (#1) of three residents reviewed for falls and bed mobility. The facility census was 18. Findings include: Review of the medical record revealed Resident #1 admitted to the facility on [DATE]. Diagnoses included [CONDITION(S)] and [CONDITION(S)], [CONDITION(S)] disease affecting the right side, abnormal posture, anxiety disorder, muscle weakness, [CONDITION(S)], type 2 diabetes mellitus, dementia, [CONDITION(S)], hypertension, peripheral vascular disease and [CONDITION(S)]. Review of the Minimum Data Set (MDS) assessment, dated 02/23/22, revealed Resident #1 was identified with severe cognitive impairment. The resident was dependent on two staff for the completion of activities of daily living including bed mobility and transfer. The assessment also recorded the resident with an upper extremity impairment on one side and bilateral impairments to the lower extremities. Review of the care plan initiated 12/04/16 revealed a plan of care was initiated to address the residents dependence on staff for the provision of activities of daily living. Interventions included: caretakers to wash up and dress. Revisions on 08/05/20 noted extensive assistance of one to two staff with toileting was required. Review of the nurses's notes dated 10/25/21 at 5:04 P.M. revealed State tested Nurse Aide (STNA) #202 was caring for Resident #1. The bed was up in the air to provide pericare. STNA#202 left the resident to grab a towel from the bathroom, heard a bang and returned, finding the resident on the floor lying flat on her back. STNA#202 called for help and Registered Nurse (RN) #300 responded. RN #300 found the resident flat on back on floor. Neurological exam revealed Resident #1 was unable to respond to questioning and staring blankly. Vitals signs revealed a blood pressure of 109/61 and pulse oxygen of 86-88% (90-100% is the normal). A purple area to the back of the right side of head was discovered. No other visible injuries or abnormalities noted. The resident responded ow to general pain noted to all of body. The hospice and Director of Nursing (DON) were contacted to to assist. Oxygen saturations dropped to 80% and oxygen was initiated via nasal cannula at 2 liters (L) per minute. The oxygen was later increased to 3L per minute to increase oxygen levels above 90% after 30 minutes of oxygen therapy. After an hour increase to 94%. The resident's mental status fluctuated during this period, with long periods ob being unable to answer any questions but maintained eyes open and alertness. When no longer responsive the second time assessed, Emergency Medical Services (EMS) were called. EMS completed an evaluation at bedside. Resident #1's vital signs returned to baseline with oxygen at 3 liters per minute. The resident's mental status continued to vary but improved in general. No transportation was provided to the hospital related to hospice Do Not Resuscitate Comfort Care (DNRCC) status. The only injury noted was a bruise on the back of the head and soreness all over. Review of the physician note dated 10/30/21 revealed the physician evaluated the resident related to the fall on 10/25/21 and noted the resident sustained a concussion. Further review of the medical record noted Resident #1 to have oxygen documented as administered from the time of the incident on 10/25/21 until 11/08/21 at 8:48 A.M. when nurses notes record Resident #1 oxygen saturation maintained between 96-97% on 1 L monitored over 10 minutes. Oxygen removed and continuous pulse oxygen monitoring shows oxygen saturation is maintained between 93-96% on room air, will continue to spot check with oxygen off at this time. On 11/08/21 at 9:34 A.M. the resident was noted with continuous pulse oxygen monitoring while eating. Oxygen saturations were between 90-93% on room air. No shortness of breath was noted. Review of the investigation revealed a dictated statement in which STNA #202 reported on 10/25/22 between 3:00 P.M. and 3:30 P.M., Resident #1 had a bowel movement. STNA #202 stated sometimes Resident #1 rolls a little but not much. STNA #202 stated there are no siderails on Resident #1's bed. STNA#202 went in to provide care to Resident #1. STNA #202 nwas standing on the side of the bed closest to the bathroom. While giving care, STNA #202 didn't have enough towels and needed to wet a towel to finish cleaning Resident #1. STNA #202 had turned Resident #1 towards the closet and when she realized she didn't have enough towels she put Resident #1 on her back. STNA #202 went to the bathroom and heard a thump. Resident #1 did not yell out. When coming out of the bathroom STNA #202 saw Resident #1 on her back on the floor between the bed and closet. STNA #202 checked to make sure she was breathing. Resident #1 was breathing but couldn't relax her head. STNA #202 put on the call light to get help. She used her cell phone to call Registered Nurse (RN) #300 for help. STNA #202 stated the bed was in the low position when she entered the room and she raised it up to work with Resident #1. When in the bathroom to wet the towels she left the bed for a few seconds and didn't lower it back down. Review of the investigation revealed a statement from STNA #204. STNA #204 noted on 10/25/22 she arrived to work at 2:00 P.M. She walked out of another resident's room and saw the door for Resident #1 was closed. She saw the call light was on and was going to tell STNA #202. When she opened the door, STNA #202's back was towards the wall where head of bed was. STNA #204 called for STNA #200. Resident #1 was on her back on the floor. STNA #202 was crying really hard. RN #300 came in and moved the bed more to the side. RN #300 had STNA #202 leave the room and asked STNA #200 to get a hoyer pad. STNA #204 stayed with RN #300 until she left to get Emergency Medical Services (EMS). When STNA #204 first entered the room Resident #1 seemed like she was just staring and maybe in shock. RN #1 started asking questions of the resident such as: can you raise your eyebrow; smile; name; daughter's name. RN #1 put oxygen on Resident #1 due to her oxygen level was 80% on room air. The DON brought in an oxygen concentrator and put oxygen on Resident #1 at 2L. RN #300 said Resident #1's oxygen level was at 85-86% so they increased the concentrator to 3 L and her oxygen went up to 91 %. Resident #1 was not breathing heavy breathes. She wasn't talking, wouldn't squeeze the STNA's finger, stared off, and didn't answer. RN #300 moved fingers and Resident #1 said, Ow.'' The resident seemed Very out of it. When asked if she felt pain, Resident #1 said,I hurt. The resident seemed like she was in pain all over. Review of the Administrator and DON statement dated 10/26/21 revealed the DON reported there was a small purple bruise on the back of Resident #'s1 head. The resident was not acting like herself. Usually she will carry on a simple conversation and have movement of her arms and hand. When Resident #1 was on the floor her oxygen levels were in the low 80% reange. After oxygen was applied the level rose to 95%. Staff notified the doctor and hospice. EMS completed an assessment of the resident's spine. The DON contacted the resident's daughter, RN #300 and then EMS. The daughter elected not to have her go to hospital. The nurse from hospice was going to meet Resident #1 at hospital if she went. The nurses were completing neurological checks. Review of the facility investigation revealed on 10/26/21 at 3:00 P.M. a STNA meeting revealed the root cause analysis outcome was mattress air flow, two people assist for care, bring supplies to bed before giving care, make sure call light was in reach, and lower bed before leaving side of bed. An interview by the Administrator and DON on 10/28/21 with STNA #202 revealed Resident #1 was centered in the bed. The STNA stated the air mattress sometimes shifts. Interview on 03/28/22 at 12:08 P.M., the DON and the Administrator verified STNA #202 failed to ensure the Resident #1's bed was in the low position when stepping away. The DON stated staff are to lower the bed when not at a residents bedside as standard procedure. As a result of the incident, the facility implemented the following corrective actions: · On 10/26/21 the DON conducted a medical record audit to ensure residents received appropriate supervision while in bed and updated plans of care and point of care guidance for caregivers. · On 10/26/21 the Quality Assurance Team initiated monitoring of falls related to the delivery of care. · Starting on 10/26/21 inservice training was provided by the therapy department staff to all STNAs on providing care when residents are in bed, correct positioning, and when walking away from the bed return it to the lowest position. This was completed on 10/27/21 On 10/27/21 the DON or designee completed weekly audits of any falls in the skilled nursing facility that may be related to the delivery of care. The weekly audits were completed through 12/22/21, with no concerns identified on the audits. · On 10/29/21, Resident #1's bed mattress had bilateral bolsters applied. · On 11/01/21 STNA #202 was given an employee disciplinary written warning related to a serious infraction of safety rules by leaving a resident unattended in a raised bed and the resident subsequently fell off the bed · On 03/28/22 observation and interview with STNA #200 and STNA #201, during transfer activities with three current resident, revealed appropriate supervision provided during bed mobility and transfers. This deficiency substantiated Complaint Number OH 973.