Every finding on record at Otterbein Sunset Village

Based on record review, staff interview, and policy review, the facility failed to initiate prompt and appropriate care after a resident fell from a mechanical lift. This resulted in actual harm on 08/06/26 at approximately 3:00 P.M. when a mechanical lift being used to transfer Resident #78 had multiple batteries fail, requiring staff to use the mechanical lift's emergency release to lower the resident onto the floor. The facility also failed to recognize that Resident #78 suffered a fall and therefore the resident was not timely assessed, not provided a timely diagnosis and treatment resulting in the resident experiencing unnecessary pain. After Resident #78 started to verbalize lower back pain and left hip pain on 08/07/26 the facility failed to ensure timely implement interventions and failed to timely report the x-ray results of a left intertrochanteric (hip) fracture received on 08/08/26 at 3:51 P.M. to the provider which resulted in a delay of treatment. This affected one (Resident #78) of two residents reviewed for falls from a sit-to-stand mechanical lift. The facility census was 47.Findings include:Review of the medical record for Resident #78 revealed the resident was admitted on [DATE] with diagnoses including active primary progressive multiple sclerosis, pleural effusion, type two diabetes mellitus, vitamin D deficiency, hyperlipidemia, depression, hypertensive heart disease with heart failure, and history of cerebral infarction. Resident #78 was discharged on 08/08/26 at 7:40 P.M. to a local hospital.Review of the discharge return anticipated Minimum Data Set (MDS) assessment, dated 07/28/26, revealed Resident #78 was cognitively intact and did not display any behaviors or refusals of care at the time of the assessment. The resident utilized a wheelchair, was dependent for mobility and transfers and required moderate to maximal assistance with activities of daily living.Review of the care plan for Resident #78 revealed no interventions related to using a mechanical lift for transfers. Review of the aide task sheets revealed Resident #78 required a two-assist sit-to-stand mechanical lift to be used for transfers.Review of physician orders for Resident #78 revealed two orders dated 08/07/26 and timed 11:15 A.M. for an x-ray of the left hip and for Tramadol (pain medication) 25 milligrams (mg) to be administered every eight hours for pain.Review of the progress notes for Resident #78 revealed a note entered by LPN #162 on 08/07/26 at 12:36 A.M. summarizing a telehealth visit for reported pain to the resident's lower back and her condition was stable. The plan was to administer acetaminophen, 650 milligrams and apply a lidocaine patch to the affected area and follow up with the primary care provider on the following day.Review of the progress notes for Resident #78 revealed a note entered by FNP #163 on 08/07/26 at 11:11 A.M. for an acute visit due to increased pain to the left hip after being lowered to the ground for which she ordered imaging and Tramadol.Review of the progress notes for Resident #78 revealed a note entered by LPN #156 on 08/07/26 at 1:46 P.M. revealed Resident #78 was requesting stronger medication for pain management to her left hip for which FNP #163 had ordered imaging and Tramadol. Review of the progress notes for Resident #78 revealed a note entered by LPN #162 on 08/07/26 at 7:36 P.M. summarizing a telehealth visit for reported pain in the left hip indicating her condition was stable. The plan was to consider nonpharmacologic management options, administer Tramadol as ordered, and notify the clinician of any change of condition.Review of the medication administration record for Resident #78 revealed Tramadol was administered to Resident #78 on 08/08/26 at 9:39 A.M. The resident rated the pain a six on a one to ten scale. Review of the progress notes for Resident #78 revealed a note entered by Registered Nurse (RN) #161 on 08/08/26 at 6:37 P.M. documenting x-ray results revealed a left hip fracture.Review of the progress notes for Resident #78 revealed a note entered by RN #161 on 08/08/26 at 7:33 P.M. to send the resident to the emergency room.Review of the medication and treatment administration records for Resident #78 for August 2026 revealed no documentation that acetaminophen or a lidocaine patch had been administered for pain.Review of progress notes for Resident #78 revealed no documentation the resident had been lowered to the ground or documentation for post-fall assessments or interventions.During an interview on 08/12/26 at 9:45 A.M., Certified Nursing Assistant (CNA) #154 stated there must be two staff members present while utilizing a mechanical lift. Mechanical lift batteries were older and were not always charged. CNA #154 described one incident while using a mechanical lift where the battery failed with the resident raised, stating they were unable to lower the resident in the mechanical lift, requiring them to use the emergency release button to lower the resident onto her bed. During an interview on 08/12/26 at 10:35 A.M., the Director of Nursing (DON) stated she had not been aware of any concerns regarding the functionality of the mechanical lift batteries and there were no instances she was aware of regarding a failed battery or any falls occurring while a sit-to-stand mechanical lift was in use. The DON recalled one instance regarding a battery failing while using a mechanical lift with a resident where the emergency release had to be utilized and the resident was lowered onto the bed. The DON stated there were no injuries sustained by the resident.During an interview on 08/12/26 at 12:00 P.M., the Administrator stated no residents, including Resident #78, had experienced a fall from a mechanical lift during his tenure.During an interview on 08/12/26 at 1:00 P.M., Physical Therapy Assistant (PTA) #150 stated on 08/06/26 at approximately 3:00 P.M. she was called to Resident #78's room by a CNA to assist with a sit-to-stand mechanical lift that became non-functional while transferring Resident #78 from her wheelchair to the bed. PTA #150 stated Resident #78 was in the sit-to-stand mechanical lift with her arms extended upward hanging on to the handlebars and resting on the floor on her knees with her legs fully bent; Resident #78 was unable to stand. PTA #150 stated the mechanical lift batteries had failed, and they were unable to lower the mechanical lift to safely place Resident #78 back into her wheelchair. PTA #150 stated she and Physical Therapist #153 utilized a gait belt and the assistance of two other staff to raise Resident #78 to a standing position and place her back in her wheelchair.During an interview on 08/12/26 at 2:30 P.M., Licensed Practical Nurse (LPN) #156 stated she worked on 08/06/26 and was assigned to care for Resident #78. Therapy had verbally informed her at approximately 2:00 P.M. of an incident involving a sit-to-stand mechanical lift with Resident #78, the resident had been transferred to bed, and Resident #78 had not verbalized pain. LPN #156 stated she did not perform an assessment of Resident #78 at that time. She saw Resident #78 later in her shift on 08/06/26 and the resident did not verbalize pain to her for the remainder of her shift that ended at 6:30 P.M. LPN #156 stated she returned the following morning and was advised by the nurse on duty that Resident #78 had reported pain to her left hip overnight. LPN #156 stated she asked if Resident #78 had fallen and was advised no, the resident did not fall. LPN #156 said Resident #78 did not tell her she had fallen.During an interview on 08/12/26 at 2:45 P.M., CNA #160 stated she was working second shift on 08/06/26 but was not directly assigned to provide care for Resident #78. She recalled being called into Resident #78's room to assist with a sit-to-stand mechanical lift transfer because the mechanical lift had stopped working. When she arrived in Resident #78's room two therapy staff, CNA #161, and a nursing student were in the room attempting to lower the sit-to-stand mechanical lift. CNA #160 stated Resident #78 was in the mechanical lift, hanging on to the handlebar, arms extended upward, with her legs crossing over each other behind her and her knees bent resting on the ground and foot platform of the mechanical lift. She recalled Physical Therapist #153 obtained three different mechanical lift batteries on three separate occasions during this interaction and all three batteries failed. She was assigned to care for Resident #78 on second shift on 08/08/26, and Resident #78 complained of pain to her left hip while providing incontinence care which she reported to the nurse. CNA #160 stated Resident #78 had an x-ray completed and later that evening the resident was sent to a local hospital.During an interview on 08/12/26 at 3:00 P.M. with CNA #161 stated she was working second shift on 08/06/26 and was assigned to provide care for Resident #78. She recalled Resident #78 requesting to be changed and transferred to bed. While using the sit-to-stand mechanical lift with a student nurse she noticed Resident #78's knees started to fold, she attempted to lower the mechanical lift, but the mechanical lift stopped moving. Resident #78 was holding on to the handlebar attempting to stand but was unable to recover, her knees continued to fold, and Resident #78 came to rest on her knees on the floor with her arms extended upward. CNA #161 advised the student nurse to get another staff member. Physical therapy staff entered the room to assist, went to retrieve a different mechanical lift battery, and changed the battery, but the mechanical lift would not lower. CNA #161, a nursing student, and two physical therapy staff utilized a gait belt to raise Resident #78 back into her wheelchair. CNA #161 stated she and the student nurse left the room while the two PT staff then transferred Resident #78 to bed. CNA #161 indicated she returned to Resident #78's room, changed her brief, and Resident #78 was able to roll from side to side without verbalizing pain. CNA #161 stated this was the first instance she had experienced a mechanical lift failure while using a mechanical lift to transfer a resident.During an interview on 08/12/26 at 3:10 P.M., the DON stated if Resident #78's knees were folded and resting on the floor while she was in the sit-to-stand mechanical lift it should have been classified as a fall. Staff did not classify the incident as a fall therefore no post-fall assessments or investigations had been completed.During an interview on 08/12/26 at 3:15 P.M., Physical Therapist (PT) #153 stated he had assisted with the failed sit-to-stand mechanical lift incident involving Resident #78 on 08/06/26. PT #153 stated Resident #78 was in the mechanical lift, holding on to the handlebar, arms extended up, knees folded and on the floor when he arrived at the room. PT #153 stated he attempted to lower the mechanical lift, but it would not move. He obtained a different battery, but the mechanical lift would not move. He obtained another battery and while this one was working, the sling around Resident #78 was no longer placed properly and the mechanical lift could not be utilized safely. He advised a CNA to get PTA #150 for additional assistance. When PTA #150 arrived, they applied a gait belt to Resident #78's waist and lifted her, while the CNA supported the resident's legs, and assisted Resident #78 back into the wheelchair. PT #153 and PTA #150 proceeded to transfer Resident #78 from her wheelchair to her bed utilizing the sit-to-stand mechanical lift which functioned properly. PT #153 stated Resident #78 did not report pain to him.During an interview on 08/13/26 at 11:25 A.M., Family Nurse Practitioner (FNP) #163 stated she visited Resident #78 on 08/07/26 at 11:11 A.M. for reported pain to her left hip. FNP #163 stated she was not made aware of the sit-to-stand mechanical lift incident that had occurred on 08/06/26; she had been advised Resident #78 required additional assistance during a transfer and had possibly been lowered to the floor. She ordered a left hip x-ray and Tramadol at 11:15 A.M. She stated the x-ray had not been ordered STAT as she had not been told the resident sustained a fall. During an interview on 08/13/26 at 12:30 P.M., the DON stated Resident #78 did not have orders for acetaminophen nor tramadol entered, both should have been in her electronic health record, and there was no documentation to support Resident #78 received any pain medication from 08/06/26 through 08/08/26. The DON confirmed pain assessments were not completed related to documentation in the progress notes referring to Resident #78 complaints of pain. The DON also confirmed a nursing assessment should have been completed for Resident #78 on 08/06/26 by LPN #156 when she was notified by PTA #150 of the incident involving the sit-to-stand mechanical lift.During an interview on 08/13/26 at 12:45 P.M., LPN #162 stated she was on duty overnight on 08/06/26 and assigned to care for Resident #78. During her shift Resident #78 described a situation when therapy put her on a machine and stated she had been experiencing pain to her lower back and left side since the incident. LPN #162 stated the resident's range of motion was at baseline. LPN #162 contacted the on-call provider and was advised to administer acetaminophen, 650 milligrams, per the standing order. LPN #162 stated she administered the acetaminophen to Resident #78 but could not recall what Resident #78's pain rating was; the acetaminophen was not documented because it was a standing order.During an interview on 08/13/26 at 3:15 P.M., RN #161stated the time stamps of her nurse notes in the electronic health record corresponded with the timing of actual events. The provider was notified on 08/08/26 at 6:37 P.M. of the availability of Resident #78's x-ray results, and an order to send Resident #78 to the local emergency room was obtained on 08/08/26 at 7:33 P.M., and she immediately called 911 to obtain transportation to the emergency room for Resident #78.Review of facility policy titled Falls Management, dated 12/02/25, revealed a fall was defined as an unintentional change in position coming to rest on the floor or next level surface. Further review revealed the nurse would complete a physical nursing assessment and provide immediate care as needed for a resident who had sustained a fall.This deficiency represents non-compliance investigated under Complaint Number 3153594.

Based on observation, medical record review, and staff interviews the facility failed to ensure mechanical lift power sources were adequately maintained. This directly affected one (#78) of three residents reviewed for mechanical lift transfers and has the potential to affect 15 (#76, #77, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90 and #91) other residents the facility identified as requiring the use of a mechanical lift for transfers. The facility census was 47.Findings include:Review of the medical record for Resident #78 revealed she was admitted on [DATE] with diagnoses including active primary progressive multiple sclerosis, pleural effusion, type two diabetes mellitus, vitamin D deficiency, hyperlipidemia, depression, hypertensive heart disease with heart failure, and history of cerebral infarction. She was discharged on 08/08/26 at 7:40 P.M. to a local hospital.Review of the discharge return anticipated Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #78 was cognitively intact and did not display any behaviors or refusals of care at the time of the assessment. The resident utilized a wheelchair, was dependent for mobility and transfers and required moderate to maximal assistance with activities of daily living.Review of the care plan for Resident #78 revealed no interventions related to using a mechanical lift for transfers. Review of the aide task sheets revealed Resident #78 required a two-assist sit-to-stand mechanical lift use for transfers.Interview on 08/12/26 at 9:18 A.M. with Environmental Services Director (ESD) #151 revealed all lifts were battery powered, utilized the same batteries, and the chargers and batteries were housed in the two nurse stations. Regarding maintenance needs of the lifts, ESD #151 stated he is notified by word of mouth, a radio call, or when staff enter work order requests. ESD #151 indicated if a lift was not usable it remained locked in the maintenance shop.Interview on 08/12/26 at 9:45 A.M. with Certified Nursing Assistant (CNA) #154 revealed mechanical lift batteries were interchangeable, adding that the batteries were older and were not always charged. CNA #154 described one incident with Resident #79 while using a mechanical lift where the battery failed with the resident raised, stating they were unable to lower the resident in the mechanical lift, requiring them to use the emergency release button to lower the resident onto her bed.Observation and interview with CNA #154 on 08/12/26 at 9:55 A.M. of a mechanical lift battery charging station, located in a mechanical room off the nurse station on [NAME] Hall, revealed three battery chargers hanging on the wall plugged into a power strip. All chargers had batteries attached, the green power lights were all on and the orange charging indicator lights were all off. There were two additional batteries on a wire shelf to the left of the chargers without indication of needing to be charged or being fully charged. CNA #154 stated she did not know the status of the batteries on the wire shelf and revealed there was not a system in place to ensure batteries remained fully charged and ready for use.Interview and observation on 08/12/26 at 10:15 A.M. with ESD #151 of the mechanical lift charging area, located in a room off the nurse station across from the fireplace, revealed four battery chargers hanging on the wall with batteries attached to them. All had green power lights illuminated and two had blinking orange lights indicating those batteries were being charged. ESD #151 confirmed if the orange light was off, the battery was charged. There were three lift batteries on the counter to the left of the chargers and five batteries on the floor under the chargers with no indication if these batteries were charged and ready for use or needed to be charged.Interview on 08/12/26 at 10:35 A.M. with the Director of Nursing (DON) revealed there was not a system in place to ensure mechanical lift batteries remained charged after use, she was unsure of the age of the lift batteries, and she had not purchased any new lift batteries. Continued interview revealed she had not been aware of any concerns regarding the functionality of lift batteries and there were no instances she was aware of regarding a failed battery nor any falls occurring while a sit-to-stand mechanical lift was in use.Interview on 08/12/26 at 1:00 P.M. with Physical Therapy Assistant (PTA) #150 revealed on 08/06/26 at approximately 3:00 P.M. she was called to Resident #78's room by a CNA to assist with a sit-to-stand mechanical lift that became non-functional while transferring Resident #78 from her wheelchair to the bed. PTA #150 stated Resident #78 was in the sit-to-stand mechanical lift with her arms extended upward hanging on to the handlebars and resting on the floor on her knees with her legs fully bent; Resident #78 was unable to stand. PTA #150 stated the mechanical lift batteries had failed, and they were unable to lower the mechanical lift to safely place Resident #78 back into her wheelchair. PTA #150 stated she and Physical Therapist #153 utilized a gait belt and the assistance of two other staff to raise Resident #78 to a standing position and place her back in her wheelchair.Interview on 08/12/26 at 2:45 P.M. with CNA #160 revealed she was working second shift on 08/06/26 but was not directly assigned to provide care for Resident #78. She recalled being called in to Resident #78's room to assist with a sit-to-stand mechanical lift transfer because the lift had stopped working. When she arrived in Resident #78's room two therapy staff, CNA #161, and a nursing student were in the room attempting to lower the sit-to-stand mechanical lift. CNA #160 stated Resident #78 was in the lift, hanging on to the handlebar, arms extended upward, with her legs crossing over each other behind her and her knees bent resting on the ground and foot platform of the lift. CNA #160 recalled Physical Therapist #153 obtained three different lift batteries on three separate occasions during this interaction and all three batteries failed.Interview on 08/12/26 at 3:00 P.M. with CNA #161 revealed she was working second shift on 08/06/26 and was assigned to provide care for Resident #78. She recalled Resident #78 requesting to be changed and transferred to bed. While using the sit-to-stand mechanical lift with a student nurse she noticed Resident #78's knees started to fold, she attempted to lower the mechanical lift, but the lift stopped moving. Resident #78 was holding on to the handlebar attempting to stand but was unable to recover, her knees continued to fold, and Resident #78 came to rest on her knees on the floor with her arms extended upward. CNA #161 advised the student nurse to get another staff member. Physical therapy staff entered the room to assist, went to retrieve a different mechanical lift battery, and changed the battery, but the mechanical lift would not lower. CNA #161 stated this was the first instance she had experienced a mechanical failure while using a mechanical lift to transfer a resident.Interview on 08/12/26 at 3:15 P.M. with Physical Therapist (PT) #153 revealed he had assisted with the failed sit-to-stand mechanical lift incident involving Resident #78 on 08/06/26. PT #153 stated Resident #78 was in the mechanical lift, holding on to the handlebar, arms extended up, knees folded and on the floor when he arrived at the room. PT #153 stated he attempted to lower the mechanical lift, but it would not move. He obtained a different battery, but the mechanical lift would not move. He obtained another battery and while this one was working, the sling around Resident #78 was no longer placed properly and the mechanical lift could not be utilized safely. Interview on 08/13/26 at 12:30 P.M. with the DON revealed manufacturer recommendations for mechanical lift batteries indicate they should be replaced at least every five years. The DON could not report when the batteries were purchased. Interviews on 08/13/26 at 11:40 A.M. with CNA #164 and CNA #165 revealed they occasionally had mechanical lift batteries stop working while in use, stating that they had not experienced any resident injuries as a result of mechanical lift equipment failure.Interview on 08/13/26 at 2:20 P.M. with a representative from a supplier of the facility's mechanical lifts revealed manufacturer recommendations of the lift batteries indicated they should be replaced every two to three years and could remain functional up to five years.This deficiency represents non-compliance investigated under Complaint Number 3153594.

Based on medical record review and staff interviews the facility failed to timely obtain imaging and failed to timely notify the provider of imaging results. This affected one (#78) of one resident reviewed for imaging. The facility census was 47.Findings include:Review of the medical record for Resident #78 revealed she was admitted on [DATE] with diagnoses including active primary progressive multiple sclerosis, pleural effusion, type two diabetes mellitus, vitamin D deficiency, hyperlipidemia, depression, hypertensive heart disease with heart failure, and history of cerebral infarction. The resident was discharged on 08/08/26 at 7:40 P.M. to a local hospital.Review of the discharge return anticipated Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #78 was cognitively intact and did not display any behaviors or refusals of care at the time of the assessment. The resident utilized a wheelchair, was dependent for mobility and transfers and required moderate to maximal assistance with activities of daily living.Review of the progress notes for Resident #78 revealed a note entered by Family Nurse Practitioner (FNP) #163 on 08/07/26 at 11:11 A.M. for an acute visit due to increased pain to her left hip after being lowered to the ground for which she ordered imaging and tramadol.Review of physician orders for Resident #78 revealed an order dated 08/07/26, and timed 11:15 A.M., for an x-ray to her left hip due to reported pain.Review of documentation from the facility's mobile x-ray company, provided by the Administrator, revealed the x-ray company was notified on 08/08/26 at 1:49 P.M. by Licensed Practical Nurse (LPN) #156 of the need for an x-ray for Resident #78.Interview on 08/12/26 at 10:00 A.M. with LPN #157 revealed the facility utilized a mobile x-ray service and the nurse on duty was responsible for contacting the mobile service if an x-ray order was received. She indicated the mobile service would arrive within 24 hours to perform the x-ray unless the order was immediate (STAT), then the mobile service would arrive within one to two hours.Interview on 08/12/26 at 12:55 P.M. with Certified Nursing Assistant (CNA) #158 revealed she was assigned to provide care for Resident #78 on 08/08/26 during first shift. CNA #158 recalled Resident #78 remained in bed during her shift and verbalized pain to her upper left leg. CNA #158 stated they were waiting for an x-ray to be completed.Interview on 08/12/26 at 2:45 P.M. with CNA #160 revealed she was assigned to care for Resident #78 on second shift on 08/08/26. CNA #160 verified Resident #78 complained of pain to her left hip while providing incontinence care, the nurse was notified of the pain, orders were obtained for an x-ray, and the x-ray was obtained earlier in the day and then later that evening Resident #78 was sent to a local hospital.Interview on 08/13/26 at 9:25 A.M. with the Administrator revealed the facility used a mobile x-ray service and the nurse on duty was responsible for calling to schedule ordered imaging.Interview on 08/13/26 at 11:25 A.M. with FNP #163 revealed she visited Resident #78 on 08/07/26 at 11:11 A.M. for reported pain to her left hip. FNP #163 stated she was not made aware of the sit-to-stand mechanical lift incident that had occurred on 08/06/26 and was advised Resident #78 had required additional assistance during a transfer and had possibly been lowered to the floor. Continued interview revealed FNP #163 ordered a left hip x-ray and tramadol at 11:15 A.M. FNP #163 confirmed the x-ray had not been ordered STAT as she had not been told the resident sustained a fall.Interview on 08/12/26 at 3:10 P.M. with the Director of Nursing (DON) revealed because Resident #78's knees were folded and on the floor while utilizing the sit-to-stand mechanical lift on 08/06/26, the incident should have been classified as a fall.Review of x-ray results for Resident #78 dated 08/08/26 revealed the examination occurred at 3:28 P.M. and results, indicating her left hip was fractured, were available at 3:51 P.M. Review of the progress notes for Resident #78 revealed a note entered by Registered Nurse (RN) #161 on 08/08/26 at 6:37 P.M. indicating x-ray results revealed a left hip fracture.Review of the progress notes for Resident #78 revealed a note entered by RN #161 on 08/08/26 at 7:33 P.M. that the provider was notified and an order was received to send the resident to the emergency room.Interview on 08/13/26 at 3:15 P.M. with RN #161 revealed the time stamps of her nurse notes corresponded with the timing of actual events, the provider was notified on 08/08/26 at 6:37 P.M. of the availability of Resident #78's x-ray results, and an order to send Resident #78 to the local emergency room was obtained on 08/08/26 at 7:33 P.M. RN #161 stated she immediately called 911 to obtain transportation.This deficiency represents non-compliance investigated under Complaint Number 3153594.

Based on record review and staff interviews the facility failed to ensure a complete and accurate medical record. This affected one (#78) of four residents whose health records were reviewed. The facility census was 47.Findings include:Review of the medical record for Resident #78 revealed she was admitted on [DATE] with diagnoses including active primary progressive multiple sclerosis, pleural effusion, type two diabetes mellitus, vitamin D deficiency, hyperlipidemia, depression, hypertensive heart disease with heart failure, and history of cerebral infarction. The resident was discharged on 08/08/26 to a local hospital.Review of the discharge return anticipated Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #78 was cognitively intact and did not display any behaviors or refusals of care at the time of the assessment. The resident utilized a wheelchair, was dependent for mobility and transfers and required moderate to maximal assistance with activities of daily living.Review of the progress notes for Resident #78 revealed a note entered by Licensed Practical Nurse (LPN) #162 on 08/07/26 at 12:36 A.M. summarizing a telehealth visit for reported pain to Resident #78's lower back and indicating the resident's condition was stable. The plan was to administer 650 milligrams of acetaminophen and apply a 4% lidocaine patch to the affected area and follow up with the primary care provider on the following day.Review of the progress notes for Resident #78 revealed a note entered by Family Nurse Practitioner #163 on 08/07/26 at 11:11 A.M. for an acute visit due to increased pain to the left hip after being lowered to the ground. Family Nurse Practitioner #163 ordered imaging and tramadol.Review of the progress notes for Resident #78 revealed a note entered by LPN #162 on 08/07/26 at 7:36 P.M. summarizing a telehealth visit for reported pain to the left hip indicated that Resident #78's condition was stable. The plan was to consider nonpharmacologic management options, administer tramadol as ordered, and notify the clinician of any change of condition.Interview on 08/13/26 at 12:45 P.M. with LPN #162 revealed she was on duty overnight on 08/06/26 and assigned to care for Resident #78. During her shift Resident #78 described a situation when therapy put her on a machine and stated she had been experiencing pain since the incident. LPN #162 recalled Resident #78 experiencing pain to her lower back and left side and her range of motion was at baseline. LPN #162 contacted the on-call provider and was advised to administer acetaminophen per the standing order of 650 milligrams, which she gave to Resident #78. LPN #162 could not recall what Resident #78's pain rating was and indicated the acetaminophen was not documented because it was a standing order.Review of the medication and treatment administration records for Resident #78 for August 2026 revealed recorded pain ratings of zero out of ten, on a scale of one to ten with ten being the worst pain, on August fifth through seventh.Review of daily skilled charting for Resident #78 revealed an entry on 08/06/26, effective at 10:42 A.M., by Registered Nurse (RN) #166 indicated the resident's pain rating was 0/10 at 12:03 P.M. Review of daily skilled charting Resident #78 revealed an entry on 08/06/26, effective at 11:31 P.M., by LPN #162 indicated the resident's pain rating was zero out of ten at 10:26 P.M.Review of daily skilled charting Resident #78 revealed an entry on 08/07/26, effective at 11:44 A.M., by LPN #156 indicated the resident's pain rating was zero out of ten at 7:46 A.M. Review of daily skilled charting for Resident #78 revealed an entry on 08/08/26, effective at 2:21 P.M., by RN #161 indicated the resident's pain rating was six out of ten at 9:39 A.M.Review of the medication administration record for Resident #78 for August 2026 revealed tramadol was administered for a pain rating of six out of ten on 08/08/26 at 9:39 A.M.Review of the medication and treatment administration records for Resident #78 for August 2026 revealed no entries indicating acetaminophen or lidocaine had been administered.Interview on 08/12/26 at 1:00 P.M. with Physical Therapy Assistant (PTA) #150 revealed she had been involved in providing care for Resident #78 when she sustained a fall while using a sit-to-stand mechanical lift on 08/06/26 at approximately 3:00 P.M.Interview on 08/12/26 at 2:45 P.M. with Certified Nursing Assistant (CNA) #160 revealed she had been involved in providing care for Resident #78 when she sustained a fall while using a sit-to-stand mechanical lift on 08/06/26.Interview on 08/12/26 at 3:00 P.M. with CNA #161 revealed she had been involved in providing care for Resident #78 when she sustained a fall while using a sit-to-stand mechanical lift on 08/06/26.Interview on 08/12/26 at 3:15 P.M. with Physical Therapist (PT) #153 revealed he had been involved in providing care for Resident #78 when she sustained a fall while using a sit-to-stand mechanical lift on 08/06/26.Interview on 08/13/26 at 12:30 P.M. with the Director of Nursing (DON) confirmed Resident #78 did not have orders for acetaminophen nor lidocaine entered, both should have been in her electronic health record, and there was no documentation to support Resident #78 received any pain medication on 08/06/26 through 08/07/26. Additionally, the DON confirmed pain assessments were not completed related to documentation in the progress notes referring to Resident #78 complaining of pain and corresponding telehealth visits. The DON also confirmed a nursing assessment should have been completed for Resident #78 on 08/06/26 by LPN #156 when she was notified by PTA #150 of the incident involving the sit-to-stand mechanical lift.This deficiency represents non-compliance investigated under Complaint Number 3153594.

Based on observation, resident interview, medical record review, staff interview and review of facility policy, the facility failed to ensure timely incontinence care was provided. This affected one (#34) of three residents reviewed for incontinence care. The facility census was 42. Findings include:Review of the medical record revealed Resident #34 was admitted to the facility on [DATE]. Diagnoses included poly-osteoarthritis, chronic kidney disease, Type II diabetes, morbid obesity, and colostomy.Review of the most recent quarterly Minimum Data Set (MDS) assessment for Resident #34 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #34 was cognitively intact. Resident #34 required substantial/maximal (staff) assistance with toileting, hygiene and showering/bathing.Review of the revised care plan, dated 07/21/26, revealed Resident #34 had an activities of daily living (ADLs) self-care and/or physical mobility performance deficit related to orthopedic surgery, left knee reconstruction, colostomy status and morbid obesity. Interventions included extensive assistance by one staff for toileting.Interview on 07/28/26 at 2:20 P.M. with Resident #34 revealed she was waiting for staff to perform incontinence care. Resident #34 stated she placed her call-light on at 1:00 P.M. and a nurse arrived shortly after, stating she would go get the Certified Nursing Assistant (CNA). Resident #34 stated CNA #130 came to her room at approximately 1:45 P.M., prepared the bed and told Resident #34 he had to go find a second person to utilize the mechanical lift. Concurrent observation of the front area of Resident #34's pants revealed her pants were wet. Resident #34 verified the soiled area to the front and legs of her pants was urine from an oversaturated brief. Resident #34 also stated her colostomy bag had ruptured due to the colostomy bag not being emptied timely. Resident #34 stated she had a towel under her shirt to help contain the leaking stool.Interview on 07/28/26 at 2:41 P.M. with CNA #100 revealed she arrived at 2:00 P.M. for her shift. CNA #100 stated CNA #130 had left for the day and reported off to her that Resident #34 needed to be placed in bed to have incontinence care provided. CNA #100 went to find assistance to transfer Resident #34 with the mechanical lift. Continuous observation revealed CNA #100 and CNA #110 returned at 2:52 P.M. to provide incontinence care to Resident #34.Interview on 07/28/26 at 2:52 P.M. with Resident #34 revealed she last received incontinence care when she got up this morning, between 8:30 A.M and 9:30 A.M.Interview on 07/29/26 at 10:13 A.M. with CNA #130 confirmed he was assigned to care for Resident #34 on 07/28/26. CNA #130 stated he performed incontinence care for Resident #34 between 9:30 A.M. and 10:30 A.M. on 07/28/26 and he was unable to provide incontinence care a second time during his shift. CNA #130 verified he only provided incontinence care for Resident #34 one time during his eight hour shift on 07/28/26.Review of the facility policy titled, Incontinence Management, Urinary, dated 12/15/25, revealed the residents incontinence pad or adult brief should be checked at least every two hours to ensure it is dry.This deficiency represents non-compliance investigated under Complaint Number 3097539.

Based on observation, medical record review, staff interview, and review of facility medication administration policies, the facility failed to ensure medications were administered in accordance with physician orders resulting in a medication error rate greater that five percent (%). A total of two medication errors were observed out of 28 opportunities for a medication error rate of 7.14%. This affected two (#4 and #5) of three residents reviewed for medication administration in a facility census of 43.Findings include:1. Observation on 02/18/26 at 8:50 A.M. noted Registered Nurse (RN) #300 preparing Resident #4's medications for administration. RN #300 obtained medications from the medication cart and placed them into a clear medication cup. One medication included metoprolol succinate extended release (ER) tablet 25 milligrams (mg). At 8:58 A.M. RN #300 proceeded to Resident #4's room and provided the medications whole with water which Resident #4 consumed.Review of Resident #4's medical record noted a physician order dated 09/11/25 for the administration of metoprolol succinate ER tablet 25 mg one tablet by mouth once daily for hypertension related to hypertensive chronic kidney disease with instructions to hold for systolic blood pressure less than 100 millimeters of mercury (mmHg) or heart rate less than 60 beats per minute.On 02/18/26 at 9:20 A.M. interview with RN #300 verified no vital signs were obtained prior to administering Resident #4's metoprolol succinate ER.2. Observation on 02/18/26 at 9:13 A.M. noted RN #300 obtaining Resident #5's medications from the medication cart. RN #300 removed medications from the cart and placed them in a clear medication cup. One medication included an antibiotic cephalexin oral capsule 500 mg. RN #300 placed applesauce into the medication cup with the medications and proceeded to Resident #5 room. At 9:19 A.M., RN #300 provided the medications to Resident #5.Review of Resident #5's medical record revealed a physician order dated 02/10/26 for the administration of cephalexin oral capsule 500 mg one capsule by mouth four times a day for cellulitis for 10 Days. Further review revealed the prescribed administration times were designated for 8:00 A.M., 12:00 P.M., 16:00 (4:00 P.M.), and 20:00 (8:00 P.M.). On 02/18/26 at 9:20 A.M. interview with RN #300 verified Resident #5's cephalexin was administered outside of the physician prescribed timeframe.Review of the facility medication administration policy, revised 11/09/21, revealed medications are administered in accordance with written orders or the attending physician or physician extender. Medications are administered within one hour before or one hour after scheduled time.Review of the facility liberal medication administration policy, dated 11/02/22, revealed medications that must be administered with equally spaced hours of administration and are time sensitive, such as every four hours include antibiotic medications. Medication administration that require equal spaced administration times include four times daily are scheduled for administration at 8:00 A.M., 12:00 P.M., 16:00 (4:00 P.M.), and 20:00 (8:00 P.M.).This deficiency represents non-compliance investigated under Complaint Number 2732128.

Based on observation, medical record review, staff interview, and review of facility medication administration policies, the facility failed to ensure medications were administered in accordance with physician orders resulting in significant medication errors. This affected three (#1, #4, and #5) of four residents reviewed for administration of medications in a facility census of 43.Findings include:1. Review of the medical record revealed Resident #1 admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, type II diabetes mellitus, major depressive disorder, chronic peripheral venous insufficiency, epilepsy, hypertension, chronic pain, cortical blindness, myalgia, urge incontinence, transient ischemic attack, anxiety disorder, and morbid obesity. Review of Resident #1's most current Minimum Data Set assessment dated [DATE] revealed the resident was assessed with moderate difficulty hearing, severely impaired vision, and moderately impaired cognition. The resident received antidepressant, diuretic, opioid, antiplatelet, and anticonvulsant medications, and received oxygen therapy and hospice care.Review of Resident #1's medical record revealed on 11/24/25 a physician order was implemented for the administration of the narcotic pain medication morphine sulfate (concentrate) oral solution 20 milligrams per milliliter (mg/mL) with instruction to give 0.5 mL by mouth every two hours as needed for pain/shortness of breath. Further review revealed the resident had no active physician order for the administration of the narcotic pain medication Dilaudid.Review of Resident #1's medical record revealed event documentation dated 11/25/25 at 3:48 P.M. and contained documentation as follows; 11/25/25, 0932, 11/25/25, 1400. Description: include how they were found, chain of events: Sitting up in recliner watching television. Resident Account of Event:: Resident reports pain while sitting up in chair. Description of Environmental, Physiological, and Predisposing Factors: Medication not administered by six rights of medication administration.Further review revealed a resident assessment was completed and the resident's oxygen saturation was below 90 percent (%); as needed oxygen was applied and oxygen saturation returned to above 90% on 2.5 liters (L)/nasal cannula (NC). There were no injuries and the immediate intervention to reduce the risk of this happening again included education provided to the nurse (Licensed Practical Nurse (LPN) #200) on six rights of medication administration. Notification was made to the physician and Resident #1's responsible party, hospice, and Power of attorney. Resident #1 denied discomfort, but was drowsy while resting in bed comfortably. No documentation contained in the medical record indicated the content of the incident, ongoing assessment of resident's health status, physician instructions, or reason indicating why LPN #200 was educated on six rights of medication administration. Review of Resident #1's medical record lacked additional documentation until 11/29/25 when a weekly skin observation tool was completed. No additional progress notes were contained in the medical record until 12/01/25 with no mention of a medication error. On 02/19/26 at 8:26 A.M. interview with the Director of Nursing (DON) and the Administrator, during a review of Resident #1's medical record, revealed the entry dated 11/25/25. The DON stated on 11/25/25 LPN #200 reported she administered two different doses of the pain medication Dilaudid in error to Resident #1 instead of the ordered morphine. The DON was unable to indicate the resident which the Dilaudid was prescribed. There was no information in the medical record documented the medication or dose given to Resident #1. The DON verified she did not check the amount of Dilaudid suspension level prior to LPN #200's shift or the amount left in the bottle following the incident. The DON verbalized LPN #200 drew up the medication in an oral syringe was 0.5 mL of Dilaudid. The conclusion of the DON verbal interactions with LPN #200 following the incident indicated LPN #200 did not identify the appropriate medication before administering it to Resident #1.2. Observation on 02/18/26 at 8:50 A.M. noted Registered Nurse (RN) #300 preparing Resident #4's medications for administration. RN #300 obtained medications from the medication cart and placed them into a clear medication cup. One medication included metoprolol succinate extended release (ER) tablet 25 milligrams (mg). At 8:58 A.M. RN #300 proceeded to Resident #4's room and provided the medications whole with water which Resident #4 consumed.Review of Resident #4's medical record noted a physician order dated 09/11/25 for the administration of metoprolol succinate ER tablet 25 mg one tablet by mouth once daily for hypertension related to hypertensive chronic kidney disease with instructions to hold for systolic blood pressure less than 100 millimeters of mercury (mmHg) or heart rate less than 60 beats per minute.On 02/18/26 at 9:20 A.M. interview with RN #300 verified no vital signs were obtained prior to administering Resident #4's metoprolol succinate ER.3. Observation on 02/18/26 at 9:13 A.M. noted RN #300 obtaining Resident #5's medications from the medication cart. RN #300 removed medications from the cart and placed them in a clear medication cup. One medication included an antibiotic cephalexin oral capsule 500 mg. RN #300 placed applesauce into the medication cup with the medications and proceeded to Resident #5 room. At 9:19 A.M., RN #300 provided the medications to Resident #5.Review of Resident #5's medical record revealed a physician order dated 02/10/26 for the administration of cephalexin oral capsule 500 mg one capsule by mouth four times a day for cellulitis for 10 Days. Further review revealed the prescribed administration times were designated for 8:00 A.M., 12:00 P.M., 16:00 (4:00 P.M.), and 20:00 (8:00 P.M.). On 02/18/26 at 9:20 A.M. interview with RN #300 verified Resident #5's cephalexin was administered outside of the physician prescribed timeframe.Review of the facility medication administration policy, revised 11/09/21, revealed medications are administered in accordance with written orders or the attending physician or physician extender. Medications are administered within one hour before or one hour after scheduled time.Review of the facility liberal medication administration policy, dated 11/02/22, revealed medications that must be administered with equally spaced hours of administration and are time sensitive, such as every four hours include antibiotic medications. Medication administration that require equal spaced administration times include four times daily are scheduled for administration at 8:00 A.M., 12:00 P.M., 16:00 (4:00 P.M.), and 20:00 (8:00 P.M.).This deficiency represents non-compliance investigated under Complaint Number 2732128.

Based on medical record review and staff interview, the facility failed to ensure medical record documentation contained complete and accurate information to accurately represent resident experiences, response to services, and changes in condition involving a medication error. This affected one (#1) of three residents reviewed for medical record content in a facility census of 43.Findings include:Review of the medical record revealed Resident #1 admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, type II diabetes mellitus, major depressive disorder, chronic peripheral venous insufficiency, epilepsy, hypertension, chronic pain, cortical blindness, myalgia, urge incontinence, transient ischemic attack, anxiety disorder, and morbid obesity. Review of Resident #1's most current Minimum Data Set assessment dated [DATE] revealed the resident was assessed with moderate difficulty hearing, severely impaired vision, and moderately impaired cognition. The resident received antidepressant, diuretic, opioid, antiplatelet, and anticonvulsant medications, and received oxygen therapy and hospice care.Review of Resident #1's medical record revealed on 11/24/25 a physician order was implemented for the administration of the narcotic pain medication morphine sulfate (concentrate) oral solution 20 milligrams per milliliter (mg/mL) with instruction to give 0.5 mL by mouth every two hours as needed for pain/shortness of breath. Further review revealed the resident had no active physician order for the administration of the narcotic pain medication Dilaudid.Review of Resident #1's medical record revealed event documentation dated 11/25/25 at 3:48 P.M. and contained documentation as follows; 11/25/25, 0932, 11/25/25, 1400. Description: include how they were found, chain of events: Sitting up in recliner watching television. Resident Account of Event:: Resident reports pain while sitting up in chair. Description of Environmental, Physiological, and Predisposing Factors: Medication not administered by six rights of medication administration.Further review revealed a resident assessment was completed and the resident's oxygen saturation was below 90 percent (%); as needed oxygen was applied and oxygen saturation returned to above 90% on 2.5 liters (L)/nasal cannula (NC). There were no injuries and the immediate intervention to reduce the risk of this happening again included education provided to the nurse (Licensed Practical Nurse (LPN) #200) on six rights of medication administration. Notification was made to the physician and Resident #1's responsible party, hospice, and Power of attorney. Resident #1 denied discomfort, but was drowsy while resting in bed comfortably. No documentation contained in the medical record indicated the content of the incident, ongoing assessment of resident's health status, physician instructions, or reason indicating why LPN #200 was educated on six rights of medication administration. Review of Resident #1's medical record lacked additional documentation until 11/29/25 when a weekly skin observation tool was completed. No additional progress notes were contained in the medical record until 12/01/25 with no mention of a medication error, ongoing assessments, or physician recommendations following the medication error. On 02/19/26 at 8:26 A.M. interview with the Director of Nursing (DON) and the Administrator, during a review of Resident #1's medical record, revealed the entry dated 11/25/25. The DON stated on 11/25/25 LPN #200 reported she administered two different doses of the pain medication Dilaudid in error to Resident #1 instead of the ordered morphine. The DON was unable to indicate the resident which the Dilaudid was prescribed. There was no information in the medical record documented the medication or dose given to Resident #1. The DON verified she did not check the amount of Dilaudid suspension level prior to LPN #200's shift or the amount left in the bottle following the incident. The DON verbalized LPN #200 drew up the medication in an oral syringe was 0.5 mL of Dilaudid. The conclusion of the DON verbal interactions with LPN #200 following the incident indicated LPN #200 did not identify the appropriate medication before administering it to Resident #1. The DON confirmed there was no documentation contained in the medical record reflecting the details of the incident. On 02/19/26 at 12:05 P.M. interview with the Administrator revealed the facility did not have documented guidance or procedures to ensure accurate resident information and experiences were contained in the medical record, including pertinent information regarding medication errors.This deficiency represents an incidental finding discovered during investigation of Complaint Number 2732128.

Based on medical record review, observation, staff interview, and review of facility policy the facility failed to monitor a residents wound and implement wound interventions. This affected one (#30) of three residents reviewed for wounds. The facility census was 42.Findings Include:Review of the medical record revealed Resident #30 was admitted on [DATE]. Diagnoses included hemiplegia affecting right dominant side, type two diabetes mellitus with foot ulcer, non-pressure chronic ulcer of other part of unspecified foot with unspecified severity, neuromuscular dysfunction of bladder, diabetes mellitus due to underlying condition with foot ulcer, atherosclerotic heart disease of native coronary artery without angina pectoris, malignant neoplasm of head (face and neck), and cerebral infarction. Review of the Minimum Data Set (MDS) assessment, dated 08/01/25, revealed the resident was severely cognitively impaired. The resident was dependent for showering, personal hygiene, lower body dressing, and footwear. Resident #30 had a diabetic foot ulcer. Review of the care plan, dated 04/25/24, revealed Resident #30 was care planned for activities of daily living self-care and mobility performance due to diabetes with foot ulcer, Alzheimer's, and hemiplegia. Interventions included to apply boots bilaterally in the morning and remove at night and float legs with pillows. Review of the care plan, revised on 12/29/24, revealed Resident #30 had a history of non-pressure ulcers to feet due to diabetes, lack of sensation to affected area, and vascular insufficiency. Interventions include to ensure appropriate protective devices are applied to affected areas, monitor wound size, depth, margins and document progress in wound healing on an ongoing basis, and treatment documentation include measurement of each area of skin breakdown (width, length, depth, type of tissue and exudate and any other notable changes or observations). Review of physician orders, dated 01/10/25, revealed an order to apply [NAME] green boots bilaterally in the morning and remove at night and float legs with pillows two times a day left plantar foot wound. Review of weekly skin assessment tools, dated the last 12 weeks, revealed on 07/28/25, 08/13/25, and 09/03/25 Resident #30's left foot diabetic ulcer was measured but did not include characteristics or descriptions of the wound bed. Weekly skin assessments dated 06/20/25, 06/24/25, 07/02/25, 07/09/25, 08/05/25, 08/27/25, and 08/21/25, revealed no documented measurements of Resident #30's left foot diabetic ulcer. Review of hospice visit notes, dated the last year, revealed the hospice agency provided the facility with brief written notes after each visit with Resident #30. The notes do not include detailed weekly wound documentation.Interview on 09/04/25 at approximately 8:20 A.M. with the Director of Nursing (DON) verified she had obtained weekly wound record reports from the hospice agency. DON verified she had not previous reviewed the wound reports and if she had would have addressed it as the notes identified Resident #30 diabetic foot ulcer as a stage two pressure ulcer. DON verified the facility skin assessments did not include weekly wound measures and wound characteristics. Interview via telephone on 09/04/25 at 9:39 A.M. with Hospice Registered Nurse (RN) #300 verified the hospice agency completed Resident #30's weekly wound assessments and overall the wound has had improvement. Observation on 09/04/25 at 11:10 A.M. of Resident #30 revealed the resident was in bed with no boots applied. Interview on 09/04/25 at 11:23 A.M. with Certified Nursing Assistant (CNA) #170 verified Resident #30's bilateral boots were not applied and the resident's heels and legs were directly on the air mattress. CNA #170 stated she was told the boots were applied at night and taken off in the morning and would not have applied them during her shift. Review of the policy, Skin Care Management Procedure, revised 12/09/22, verified with each dressing change or at lease weekly at a minimum documentation should include the date observed, location and staging, size, depth, the presence, location, and the extent of any undermining or tunneling/sinus tract, exudates (if present the type, color, odor, and approximate amount), pain (if present the nature and frequency), wound bed (color and type of tissue/character including evidence of healing or necrosis and percentage of tissue, and description of wound edges and surrounding tissue. This deficiency represents non-compliance investigated under Complaint Number 2593574.

Based on medical record review, observation, and staff interview, the facility failed to ensure accurate resident medical records. This affected one (#30) of three residents reviewed for accurate medical records. The facility census was 42. Findings Include:Review of the medical record revealed Resident #30 was admitted on [DATE]. Diagnoses included hemiplegia affecting right dominant side, type two diabetes mellitus with foot ulcer, non-pressure chronic ulcer of other part of unspecified foot with unspecified severity, neuromuscular dysfunction of bladder, diabetes mellitus due to underlying condition with foot ulcer, atherosclerotic heart disease of native coronary artery without angina pectoris, malignant neoplasm of head (face and neck), and cerebral infarction. Review of the Minimum Data Set (MDS) assessment, dated 08/01/25, revealed the resident was severely cognitively impaired. The resident was dependent for showering, personal hygiene, lower body dressing, and footwear. Resident #30 had a diabetic foot ulcer. Review of the care plan, dated 04/25/24, revealed Resident #30 was care planned for activities of daily living self-care and mobility performance due to diabetes with foot ulcer, Alzheimer's, and hemiplegia. Interventions included to apply boots bilaterally in the morning and remove at night and float legs with pillows. Review of physician orders, dated 01/10/25, revealed an order to apply [NAME] green boots bilaterally in the morning and remove at night and float legs with pillows two times a day left plantar foot wound. Review of the Medication Administration Review (MAR), dated September 2025, revealed Resident #30's [NAME] green boots were applied in the morning. Observation on 09/04/25 at 11:10 A.M. of Resident #30 revealed the resident was in bed with no boots applied. Interview on 09/04/25 at 11:17 A.M. with Licensed Practical Nurse (LPN) #178 verified Resident #30's bilateral boots were not applied and had been marked in the MAR as applied. Interview on 09/04/25 at 11:23 A.M. with Certified Nursing Assistant (CNA) #170 verified Resident #30's bilateral boots were not applied and the resident's heels and legs were directly on the air mattress. CNA #170 stated she was told the boots were applied at night and taken off in the morning and would not have applied them during her shift.

Based on medical record review, resident family interviews, facility staff interview, hospice staff interview, and review of facility policy, the facility failed to ensure a complete and accurate medical record was maintained for Resident #30. This affected one resident (#30) of three residents reviewed to accurate medical record. The facility census was 43. Findings Include: Review of the facility electronic medical record for Resident #30 revealed an admitted [DATE] with diagnoses including hemiplegia, other signs and symptoms involving the nervous system, type two diabetes mellitus (DM2), non-pressure chronic ulcer of other part of unspecified foot, neuromuscular dysfunction of bladder, unspecified convulsions, non-pressure chronic ulcer of unspecified heel and midfoot, atherosclerotic heart disease, depression, fatigue, pure hypercholesterolemia, hypertension (HTN), pain in unspecified ankle and joints of unspecified severity, peripheral vascular disease (PVD), Charcot's joint-right ankle and foot, malignant neoplasm of head, face, and neck, neoplasm of unspecified behavior of digestive system, other signs and symptoms involving cognitive functions and awareness, myopia, bilateral astigmatism, presbyopia, combined forms of age related cataract, squamous cell carcinoma of skin of unspecified parts of face, transient ischemia attack (TIA), cerebral infarction, personal history of venous thrombosis and embolism, personal history of pulmonary embolism, benign prostatic hyperplasia (BPH), retention of urine, disorder of urinary system, nontoxic single thyroid nodule, and long-term use of insulin. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 10/29/24, revealed a Brief Interview of Mental Status (BIMS) score of 99, indicating Resident #30 was unable to complete the interview. Resident #30 required substantial/maximal assistance for all functional abilities and was dependent for transfers. Review of the Medicare 5-Day MDS assessment dated , dated 03/31/24, revealed a BIMS score of 07, indicating Resident #30 was severely cognitively impaired. An interview on 12/31/24 at 10:34 A.M. with Resident #30's daughter revealed Resident #30 had orders to have dressing on his left foot changed Monday, Wednesday, Friday, and Saturday. Concurrent interview with Resident #30's daughter revealed the facility nurse is supposed to change the dressing every Wednesday and Saturday, and the hospice nurse is supposed to change the dressing every Monday and Friday. Further interview with Resident #30's daughter revealed Resident #30's dressing was not changed on Saturday, 12/28/24 by the facility nurse. Review of Resident #30's electronic treatment administration record (eTAR) revealed Licensed Practical Nurse (LPN) #107 documented completion of Resident #30's dressing change on 12/28/24. An interview on 12/31/24 at 11:05 A.M. with the Director of Nursing (DON) revealed LPN #107 did not change Resident #30's dressing on 12/28/24, despite documentation in the facility eMAR that she did. Further interview with the DON revealed she was made aware by Hospice Registered Nurse (RN) #177 on 12/30/24 that the facility nurse had not changed Resident #30's dressing on 12/28/24. An interview on 01/02/24 at 11:07 A.M. with Hospice RN #177 revealed she changed Resident #30's left foot dressing on 12/27/24 and the dressing she placed on the resident on 12/27/24 was still in place when she provided care to the resident on 12/30/24. Hospice RN #177 states she knows the dressing she removed on 12/30/24 was the dressing she placed on 12/27/24, as the dressing had the date of 12/27/24 and her initials on it. Review of the facility policy titled, Skin Care Management Procedure, with a revision date of 12/09/22, revealed determination of the need for a dressing for an ulcer is based upon the individual practitioner's clinical judgement and facility protocols based upon current professional standards of practice. This deficiency represents non-compliance investigated under Complaint Number OH00160460.

Based on observation, staff interview, review of the Legionella (bacteria that can cause a severe type of pneumonia) Risk Assessment, review of facility policy and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure appropriate handling of linen to prevent contamination. In addition, the facility failed to have an appropriate Legionella water management program in place. This had the potential to affect all 47 residents of the facility. The facility census was 47. Findings include: 1. Observation on 10/21/24 at 2:41 P.M. revealed State tested Nursing Assistant (STNA) #437 carried two large stacks of linens, with one stack of linens in each arm and pressed against the top half of her body. STNA #437 walked through the locked double doors of the unit and to the linen closet. STNA #437 pressed the linens against the door and her body while entering the code to unlock the doors. Interview on 10/21/24 at 2:44 P.M. with STNA #437 verified she transported the clean linens uncovered and pressed against her body and the door. Observation on 10/22/24 at 1:49 P.M. of the laundry room washing machine area revealed no gowns were observed. Interview on 10/22/24 at 1:50 P.M. with Laundry Aide (LA) #489 verified gloves were worn when handling soiled linens but gowns were not worn to prevent possible cross-contamination. 2. Review of the facility's undated Legionella Risk Assessment revealed three of the fist four questions were answered Yes. Interview on 10/23/24 at approximately 3:15 P.M. with the Administrator revealed answering Yes to any of the first four questions on the facility's Legionella Risk Assessment indicated the facility was at high risk for Legionella. While the Administrator was identified as part of the water management team, he was uncertain of elements of the plan and referred the surveyor to Director of Environmental Services (DES) #508 for additional information related to the facility's Legionella plan. Interview on 10/23/24 at 4:32 P.M. with DES #508 revealed he was responsible for the facility's Legionella prevention plan. DES #508 stated he was not very familiar with Legionella and was not certain of the monitoring requirements. DES #508 stated an external company recently conducted a cooling tower water treatment report, temperatures of faucets and hot water heaters. DES #508 was unable to articulate control measures implemented on a routine basis, stated there was no regular monitoring of facility water temperatures and the faucets in empty rooms were not flushed to ensure no Legionella growth. Review of the facility policy titled Legionnaires Policy, dated 09/07/17, revealed the facility will identify and assess potential sources of Legionella bacteria, determine the correct operation of water systems and will ensure that necessary maintenance/monitoring is carried out by competent personnel. Additionally, the Quality Assurance Performance Improvement (QAPI) Committee will review the water management program elements annually and as needed, to include deciding where control measures should be applied and how to monitor them. Review of the CDC guidance titled Overview of Water Management Programs, dated 03/15/24, revealed water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Further review revealed the seven key elements of a Legionella water management program included: Establish a water management program team Describe the building water systems Identify areas where Legionella could grow and spread Decide where control measures should be applied and how to monitor them Establish ways to intervene when control limits are not met Ensure the program runs as designed and is effective Document and communicate all the activities This deficiency represents non-compliance investigated under Complaint Number OH00158467.

Based on observation and staff interview, the facility failed to ensure Resident #4's wheelchair was maintained in a clean and sanitary manner. In addition, the facility failed to ensure Resident #15's room was free from prevasive odors. This affected two (#4 and #15) of 12 residents reviewed for environment. The facility census was 47. Findings include: 1. Review of the medical record revealed Resident #4 was admitted on [DATE]. Diagnoses included unspecified dementia with other behavioral disturbance, major depressive disorder severe with psychotic symptoms, heart failure, hyperlipidemia, essential primary hypertension, hypothyroidism and dysphagia. Review of the Minimum Data Set (MDS) assessment, dated 07/22/24, revealed the resident was severely cognitively impaired with impairment on to both sides of the body and required the use of a wheelchair. Observation on 10/21/24 at 10:21 A.M. revealed Resident #4 in a wheelchair with a heavy amount of dirt and food crumbs on the wheelchair frame, including an intact pretzel. Observation on 10/22/24 at 11:00 A.M. revealed Resident #4 in a wheelchair with dirt and food crumbs on the wheelchair frame and on the visible area of the seat cushion. Interview on 10/22/24 at 11:01 A.M. with State tested Nursing Assistant (STNA) #506 revealed wheelchairs were cleaned by third shift staff on the resident's shower days and as needed. STNA #506 verified Resident #4's wheelchair was dirty with a thick layer of food and debris. 2. Observation on 10/21/24 at 9:54 A.M. of Resident #15's room revealed the resident's room was malodorous with an unidentified smell. Additional random observations on 10/22/24, 10/23/24 and 10/24/24 revealed Resident #15's room continued to have an unpleasant odor. Interview on 10/22/24 at 2:18 P.M. with STNA #437 revealed Resident #15's room always had a smell. Interview on 10/24/24 8:59 A.M. with the Director of Nursing (DON) verified Resident #15's room had an unpleasant odor. This deficiency represents non-compliance investigated under Complaint Number OH00158467. 47057 3. Observation on 10/22/24 at 10:15 A.M. revealed a chunk of breadlike substance with pink tinge and unidentifiable food crumbs on the floor underneath the table and alongside the table in the dining room. Further observation on 10/22/24 at 10:18 A.M. revealed an unknown kitchen staff sweeping the floor after breakfast and the unknown kitchen staff did not sweep under or around the table where the food was left on the floor. Interview on 10/22/24 at 10:23 A.M. with Dietary Aide (DA) #463 verified there was food on the floor under and alongside the table. DA #463 stated the food was from dinner the previous night because she did not service it during breakfast that morning.

Based on observation and staff interview, the facility failed to maintain a clean and sanitary serving kitchen. This had the potential to affect 18 residents (#3, #4, #5, #7, #8, #15, #16, #22, #23, #24, #26, #29, #32, #35, #36, #40, #46 and #98) who received food from the secured memory care unit serving kitchen. The facility census was 47. Findings include: Observation on 10/21/24 at 11:30 A.M. of the serving kitchen on the secured memory care unit revealed the floor was sticky and covered in food debris and splatters. There was a build-up of food debris in the corners and along the bottom of the cabinets and equipment. The floor was sticky enough in areas where a shoe became stuck and was pulled partially off. Continued observation revealed splatters and a build-up of dried food on the front of the lower cabinets and on the wall behind the kitchen sink and steam table. The juice machine had a build-up of a sticky substance behind the nozzles and along the wall next to the juice machine. Interview on 10/21/24 at 11:37 A.M. with Dietary Staff (DS) #342 verified there was build-up of food on floor, the floor was sticky, the juice machine needed to be cleaned, the cabinets had dried food residue and dried food was on the walls behind the steam table and kitchen sink. DS #342 stated she was not aware of the last time the serving kitchen had been cleaned. DS #342 stated she tried to clean the serving kitchen once a week when she worked dinner service. DS #342 could not recall the last time she worked the dinner shift and cleaned the kitchen. Observation on 10/23/24 at 10:32 A.M. of the secured memory care unit serving kitchen revealed the floors had been swept and mopped and the juice machine had been wiped down. However, dried food remained on the lower cupboards, the walls behind serving steam table, the wall next to the juice machine and the wall behind the sink.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure fall interventions were implemented. This affected one resident (#9) of three residents reviewed for falls. The facility census was 47. Findings include: Review of the medical record for Resident #9 revealed an admitted [DATE]. Diagnoses included osteoarthritis, dementia, anxiety and bipolar disorder. Review of the most recent quarterly Minimum Data Set (MDS) assessment revealed Resident #9 had some cognitive impairment. Review of the comprehensive fall risk assessment, dated 10/01/24, revealed Resident #9 was at risk for falls and had no falls in the past 90 days. Review of the care plan, revised October 2024, revealed Resident #9 was at risk for falls. Interventions included a fall mat. Observation on 10/21/24 at 10:23 A.M. of Resident #9 revealed she was in bed. A fall mat was leaning against the wall. Observation on 10/22/24 at 9:31 A.M. of Resident #9 revealed she was in bed. A fall mat was leaning against the wall. Interview on 10/22/24 at 10:32 A.M. with Licensed Practical Nurse (LPN) #473 revealed Resident #9 was to have a fall mat next to the bed when she was in bed. LPN #473 verified Resident #9 was in bed and the fall mat was leaning against the wall and not in place. Review of the facility policy titled Falls Management, revised December 2019, revealed the care plan will be reviewed and dated to assure it has been updated to reflect the current needs of the resident to prevent further falls.

Based on medical record review, observations, staff interview and review of facility policy, the facility failed to ensure residents were cleaned up after meals to promote dignity. This affected one resident (#33) reviewed for dignity. The facility census was 47. Findings include: Review of the medical record for Resident #33 revealed an admitted [DATE]. Diagnoses included dementia, cerebral vascular accident (CVA) (stroke) and aphasia (unable to speak). Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/31/24, revealed Resident #33 was cognitively impaired and was (staff) dependent for personal hygiene. Review of the care plan, initiated February 2024, revealed Resident #33 required total assistance for personal care and hygiene. Observation on 10/21/24 at 10:52 at A.M. revealed Resident #33 was sitting at a dining room table in her wheelchair, with her eyes closed, and no food in front of her. Resident #33 was wearing a shirt saver and had a lap blanket across her lap. Both the shirt saver and the lap blanket had food spilled on them. Continued observation revealed an unknown nursing student standing at the nurses' station, located directly in front of the breakfast table where Resident #33 was sitting with the soiled shirt saver and blanket. Further observation revealed the unknown nursing student did not provide care for Resident #33 to remove the soiled shirt saver or soiled blanket. Observation on 10/21/24 at 10:54 A.M. revealed State tested Nursing Assistant (STNA) #527 walked past Resident #33 sitting at the dining room table with food spilled on shirt saver and lap blanket and did not address the food on the shirt saver or the lap blanket. Observation on 10/21/24 at 10:55 A.M. revealed another unknown nursing student arrived to the unit, stopped at the nurses' station, spoke to the other unknown nursing student and did not address the spilled food on Resident #33's shirt saver or lap blanket. Observation on 10/21/24 at 10:55 A.M. revealed an unknown STNA arrived on the unit, went to the nursing station and did not address the spilled food on Resident #33's shirt saver or lap blanket. Observation on 10/21/24 at 10:57 A.M. revealed STNA #527 went from a resident's room to the common area, walking past Resident #33, to wash her hands and proceeded to another resident's room. STNA #527 did not address the spilled food on Resident #33's shirt saver or the lap blanket. Resident #33 continue sitting in her wheelchair at the dining table with her eyes closed. Observation on 10/21/24 at 10:57 A.M. revealed an unknown STNA left the nurses station, walking past Resident #33, and did not address the spilled food on her shirt saver or the lap blanket. Observation on 10/21/24 at 10:59 A.M. revealed the same unknown STNA returned to the nurses' station, walking past Resident #33 to and from the nurses' station, and did not address the spilled food on the resident's shirt saver or lap blanket. Observation on 10/21/24 11:00 A.M. revealed STNA #527 walked by Resident #33 and did not address the spilled food on shirt saver or lap blanket. Resident #33 remained at the dining table in her wheelchair with her eyes closed. Observation on 10/21/24 at 11:01 A.M. revealed STNA #527 removed the shirt saver and lap blanket from Resident #33. STNA #527 moved Resident #33 from the dining table to the common area in front of the television. Interview on 10/21/24 at 11:01 A.M. with STNA #527 verified Resident #33 was sitting at the dining room table with a shirt saver and lap blanket that had food spilled on it. Interview on 10/21/24 at 11:09 A.M. with Resident #33 was unsuccessful. Concurrent observation, while next to Resident #33, revealed she had a quarter sized glob of oatmeal in her hair, food on her headband and dried food on her face and right hand. Observations on 10/21/24 at 11:38 A.M. and 12:10 P.M. revealed Resident #33 was in common area, in front of the television. Resident #33 still had the quarter sized glob of oatmeal in her hair, food on her headband and dried food on her face and right hand. Observation on 10/21/24 at 12:15 P.M. revealed STNA #527 moved Resident #33 from the common area to the dining table for lunch. Resident #33 still had the quarter sized glob of oatmeal remained in her hair, food on her headband and dried food on her face and right hand. Interview on 10/21/24 at 12:21 P.M. with Licensed Practical Nurse (LPN) #473 verified Resident #33 had a quarter sized glob of oatmeal in her hair, food on her headband and dried food on her face and right hand. Review of the facility policy titled Federal and Ohio Residents Rights and Facility Responsibilities dated October 2019, revealed a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life.

Based on medical record review, observation and staff interview the facility to ensure call lights were with resident's reach. This affected one resident (#9) of one resident reviewed for call lights. The facility census was 47. Findings include: Review of the medical record for Resident #9 revealed an admitted [DATE]. Diagnoses included bipolar disorder, panic disorder, anxiety and epilepsy. Review of the care plan, revised October 2024, revealed Resident #9 was care planned for assistance with activities of daily living (ADLs) and fall risk with an identified intervention of call light in reach. Observation on 10/23/24 at 8:37 A.M. revealed Resident #9 was resting in bed and the call light was laying at the bottom of the bed, near the resident's feet, and not in reach of the resident. Interview on 10/23/24 at 8:48 A.M. with State tested Nursing Assistant (STNA) #430 verified the call light was located at the foot of the bed by Resident #9's feet not in reach of the resident. STNA #430 further stated Resident #9 was able to use the call light and make her needs known. Interview on 10/23/24 at 12:09 P.M. with the Administrator revealed the facility did not have a policy for call lights.

Based on medical record review, staff interview and review of facility policy, the facility failed to ensure the physician and responsible party were notified when medications were not administered as ordered by the physician. This affected one (#30) of one residents reviewed for notification of change of condition. The facility census was 47. Findings include: Review of Resident #30's medical record revealed an admitted [DATE]. Diagnoses included type II diabetes mellitus, non-pressure chronic ulcer of the heel and midfoot, neuromuscular dysfunction of bladder, benign prostatic hyperplasia, seizure disorder, coronary artery disease, depression, hypertension, peripheral vascular disease, malignant neoplasm of the head, face and neck, cerebral infarction, transient cerebral ischemic attack and history of venous thrombus and embolism. Review of the Minimum Data Set (MDS) assessment, dated 07/29/24, revealed Resident #30 was moderately cognitively impaired, had impaired range of motion to one upper extremity and required substantial to maximum (staff) assistance with activities of daily living (ADLs). Review of Resident #30's physician orders revealed the following orders: Hyoscyamine Sulfate Oral Tablet Disintegrating 0.125 milligrams (mg) give one tablet by mouth at bedtime for for overactive bladder may repeat one time after four hours if symptoms reappear; Lantus SoloStar Subcutaneous Solution Pen injector (Insulin Glargine) inject 10 units subcutaneously at bedtime for diabetes mellitus type II; Apixaban Oral Tablet 5 mg give one tablet by mouth two times a day for atrial fibrillation related transient cerebral ischemic attack, unspecified venous thrombosis and embolism and history of pulmonary embolism; Humalog Kwik Pen Subcutaneous Solution Pen injector (Insulin Lispro) inject as per sliding scale: if 0 - 249 = 0 units; 250 - 300 = 2 units; 301 - 350 = 4 units; 351 - 400 = 6 units; 401 - 450 = 8 units two times a day (morning and bedtime) for diabetes mellitus type II with further instructions to call Hospice for blood glucose over 450; Namenda Oral Tablet 10 mg give one tablet by mouth two times a day for Alzheimer's disease; Tamsulosin Oral Capsule 0.4 mg give one capsule by mouth two times a day for Benign Prostatic Hypertrophy; and Buspirone Oral Tablet 5 mg by mouth three times a day for depression. Review of the Medication Administration Record (MAR) for October 2024 revealed Licensed Practical Nurse (LPN) #551 documented 8 for the bedtime administration doses of Buspirone, Tamsulosin, Namenda , Humalog insulin sliding scale and Apixaban on 10/12/24, 10/13/24, 10/16/24 and 10/21/24. Additional review of the MAR revealed 8 indicated nauseated or vomiting. Further review of the medical record revealed no evidence the physician or responsible party were notified of the missed medications. Interview on 10/22/24 at 6:25 A.M. with LPN #551 revealed Resident #30 refused the bedtime doses of medications on 10/12/24, 10/13/24, 10/16/24 and 10/21/24. LPN #551 confirmed the medications refused during the identified evenings included insulin, an anticoagulant and mood disorder medications. LPN #551 also verified the physician and family were not notified of the medication refusals. Review of the facility policy titled Notification of Change of Condition, revised 11/22/21, revealed the facility will immediately inform the resident; consult with the residents physician and notify the residents representative when there is a need to alter treatment significantly (example: a need to discontinue an existing form of treatment due to adverse consequences, or commence a new form of treatment).

Based on observation, medical record review, staff interview and review of facility procedure, the facility failed to ensure medications were administered in a form as ordered by the physician, resulting in a medication error rate above five percent (%). This affected one (#37) of three residents observed during medication administration. A total of eight medication errors were observed out of 32 opportunities for a medication administration error rate of 25.00%. The facility census was 47. Findings include: Observation on 10/22/24 at 7:29 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #550 prepared medications for Resident #37. LPN #550 obtained the following medications from the medication cart: Amlodipine five milligram (mg), half tablet; Cholecalciferol 50 micrograms (mcg) tablet; Citalopram 40 mg tablet; Famotidine 20 mg tablet; Ferrous Sulfate 325 mg tablet; Magnesium Oxide 400 mg tablet; Senna-Docusate Sodium 8.6-50 mg, two tablets; and Calcium Citrate 950/200 mg, two tablets. LPN #550 proceeded to crush the tablets and placed them in applesauce, mixing them together. The Amlodipine 5 mg half tablet was crushed separate, placed into a medication cup and mixed with with applesauce. LPN #550 proceeded into Resident #37's room, with the medications, obtained vital signs and administered the medications to the resident. Review of Resident #37's physician orders revealed the following: Amlodipine 5 mg half tablet by mouth in the morning for hypertension; Citalopram 40 mg tablet by moth one time a day for depression; Cholecalciferol 50 mcg tablet one time a day; Famotidine 20 mg tablet one time a day for Gastroesophageal reflux disease (GERD); Ferrous Sulfate 325 mg tablet one time a day for anemia; Magnesium Oxide 400 mg tablet one time a day; Senna-Docusate Sodium 8.6-50 mg two tablets two times a day for constipation; Calcium Citrate 950/200 mg two tablets three times daily for GERD. Further review of the physician orders revealed no order to crush Resident #37's medications. Interview 10/22/24 at 7:58 A.M. with LPN #550 confirmed she crushed Resident #37's medications prior to administration. LPN #550 verified there was no physician order to crush the resident's medications. Review of the facility document titled Medication Administration Procedure, revised 11/09/21, revealed medications are to be administered in accordance with written orders of the attending physician or physician extender. If safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or tube-fed. Further review revealed the need for crushing medications is indicated on the resident's orders and the Medication Administration Record (MAR) so all personnel administering medications are aware of the need and the consultant pharmacist can advise on safety issues and alternatives during medication regimen reviews. This deficiency represents non-compliance investigated under Complaint Number OH00158467.

Based on observation, resident interview, staff interview and review of the Resident Council meeting minutes, the facility failed to ensure residents were provided with meals at an appetizing temperature. This affected two residents (#98 of #3) of seven residents who received food from the secured memory care unit serving kitchen but did not reside on the secured unit. The facility census was 47. Findings Include: Interview on 10/21/24 at 9:58 A.M. with Resident #98 revealed the resident was alert and aware. Resident #98 revealed she ate her meals in her room and by the time her meals got to her they were cold. Resident #98 stated the food did not taste good when it was cold. Interview on 10/21/24 at 10:06 A.M. with Resident #3 revealed the resident was alert and aware. Resident #3 revealed her only concern was the food served to residents in their rooms was always cold. Observation on 10/21/24 at 11:30 A.M. revealed the lunch meal cart was delivered to the serving kitchen on the secured memory care unit. Food temperatures were taken at 11:34 A.M. and the burger temperature was 150 degree Fahrenheit (F), the soup was 166 degrees F, the pureed green beans were 151 degrees F and the mashed potatoes were 146 degrees F. Continued observation revealed the lunch plates were removed from the overhead cupboard. The plates were not heated/warmed, and there were no insulated bases or lids to help maintain food temperatures. The plate covers were clear plastic covers, which had holes in the center. Observation on 10/21/24 at 12:02 P.M. revealed Dietary Staff (DS) #342 started plating food. An uncovered cart was observed with serving trays on it. Coinciding interview with DS #342 verified the open cart was used to transport the room trays to the seven residents who resided outside of the secured memory care unit. Observation on 10/21/24 at 12:22 P.M. of the lunch meal service revealed seven meals were plated and placed on the open cart. There were only five clear plastic covers for the seven meals. The meals remained on the open cart until 12:35 P.M., when Dietary Manager (DM) #478 returned with two additional clear plastic covers. Approximately 30 minutes after the seven meals were plated, the cart was then taken for meal delivery. Interview on 10/21/24 at 12:52 P.M. with Resident #3 revealed the burger was cold and the soup was lukewarm. Resident #3 stated the burger was not even warm enough to melt the cheese and lifted the bun to show unmelted cheese on top of the burger patty. Resident #3 stated the food was almost always cold. Interview on 10/21/24 12:54 P.M. with Resident #98 revealed the burger was terrible as it was cold and the soup was lukewarm. Observation on 10/21/24 at 1:00 P.M. of a lunch test tray revealed food items included chicken and rice soup, mashed potatoes and pureed green beans. There were no burger patties left to test. Temperatures were taken and the mashed potatoes were 113 degrees F, the pureed green beans were 100 degrees and the soup temperature was 110. The soup was flavorful, but the temperature was lukewarm. The pureed green beans were cold and bland and the mashed potatoes were slightly warm. Coinciding interview with DS #342 verified the cool food temperatures. DS #342 stated food items cooled quickly once they were taken off the steam table. Review of the Resident Council Meeting Minutes dated 05/20/24 and 06/24/24 revealed residents had concerns for the temperatures of food, hot foods were cold and cold foods were warm.

Based on observation, medical record review, facility policy review, staff and resident interview, the facility failed to ensure a resident was provided with the appropriate assistance during transfers resulting in an avoidable fall. This resulted in actual harm for one resident (#1) when staff transferred the resident without the use of a gait belt and the assistance of one staff member. Consequently, Resident #1 fell and sustained a fracture to the right ankle. Additionally, the facility failed to ensure the resident was provided the provisions of care and fall interventions per the residents care plan. This affected one (Resident #1) of three residents reviewed for transfers. The facility identified 47 residents who required assistance with transfers. The facility census was 49. Findings include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set (MDS) assessment revealed the resident had no cognitive deficits. Hallucinations were present as well as behavioral symptoms not directed towards others. The resident required extensive assistance of two staff with bed mobility, transfers, toileting, and extensive assistance of one staff for personal hygiene, dressing and locomotion. The resident was assessed as not steady and only able to stabilize with staff assistance, had falls prior to admission and since admission with no injury. Speech, Occupational and Physical therapies were being received. Review of a baseline care plan dated 02/04/19 revealed the resident required the assistance of two staff for transfers. Review of a fall assessment dated [DATE] revealed the resident was at risk for falls. Review of Resident #1's progress notes dated 02/17/19 at 4:50 A.M., revealed the nurse was called to the resident's room and found the resident laying on their right side with their knees at a 45 degree angle. The resident had socks on but no shoes. It revealed staff was attempting to get the resident out of bed to the bathroom, the resident was unable to stand up fully and was lowered to the floor per staff. Range of motion, skin and neurological assessments were completed, and the resident complained of bilateral knee pain. There were no changes in the resident's range of motion and there were no other skin issues. The resident was assisted back to bed but was lifted as the resident was unable to stand upright for the transfer and kept their knees bent. State tested Nursing Assistance (STNA) #20 was educated by the nurse on the need for the resident to be in shoes and to use a gait belt for transfers. The physician was notified via fax. Further review of Resident #1's progress notes dated 02/17/19 at 2:34 P.M., revealed the nurse was called to the resident's room by a family member to assess the resident's right ankle as it was swollen and the resident had pain to the ankle. An x-ray order was obtained for the right ankle and both knees. Progress notes dated 02/17/19 at 3:45 P.M., revealed the x-ray reports revealed a [MEDICAL CONDITION] ankle medial lateral malleolus. The physician was notified, and orders were received to transfer the resident to the hospital. The resident returned from the hospital on [DATE] at 9:45 P.M. with a soft cast, ace wrap and was non-weight bearing. Review of physician orders dated 02/26/19 revealed per orthopedics, a hinged knee brace was to be obtained for the left knee to be on during transfers only and could be off while the resident was in bed. It revealed the resident could be partial weight bearing to the right lower extremity for transfers. Review of a plan of care dated 03/06/19 revealed the resident had a hard cast placed to the right lower extremity on 02/26/19, and the hinged knee brace was delivered on 03/05/19. The hinged knee brace was to be worn on the left knee during transfers and as of 03/13/19 was able to be a two person assist for transfers or the use of a stand lift. Review of an undated Care Guide hanging on the back of the door in the room of the resident, revealed the resident required two staff for assistance with transfers. It did not include the use of a gait belt or a hinged knee brace for the left knee. Observation of Resident #1 on 03/26/19 at 11:00 AM., revealed she was being assisted with transferring from her bed to her wheelchair by STNA #11 and STNA #12. A cast was present on the right lower leg and a hinged knee brace was located on the resident's dresser. On completion of the transfer, STNA's #11 and #12 verified the hinged knee brace was to be placed on the left knee for the transfer and it had not been used. At that time, STNA #11 asked the resident if she was okay and the resident said yes, but you were supposed to use the knee brace when I transfer. The resident was observed to have partial weight bearing with the right leg. Interview with Assistant Director of Nursing (ADON) #10 on 03/26/19 at 1:00 P.M., verified Resident #1 was to have been transferred with the assistance of two staff prior to her fall on 02/17/19 and only one staff person was used assisted with the transfer. ADON #10 further verified the resident was to have her hinged knee brace on her left knee during transfers and the staff had been educated on that. Review of facility policy Falls Program dated 11/16/07 revealed high fall risk residents were to be reviewed weekly and were to have interventions in place to assist in safe practices. A Fall risk assessment was to be completed on admission and interventions were to be re-evaluated after any fall. An individualized safety intervention plan was to be incorporated into the resident's plan of care. Staff involved with the resident's care were to be made aware of safety interventions through the ADL (Activity of Daily Living) sheet which served as part of the care plan. Review of the facility policy Gait Belts dated 08/03/11 revealed gait belts should be used on all residents who are transferred or ambulated by staff unless the resident was being transferred with a mechanical hoyer lift, or with residents who had a gastrostomy tube, ostomy or when deemed inappropriate by the charge nurse. Each STNA was to be issued a gait belt during orientation and was to be worn or kept in their pockets if not in use. Review of the facility policy Ambulation dated 07/26/13 revealed residents were to have the appropriate footwear on and was to be assisted to a standing position with feet firmly on the floor and properly positioned prior to beginning to ambulate Instructions for the use of the gait belt were included for the use during transfers, with the resident being given time to get in a secure standing position before being sat down. This deficiency substantiates Complaint Number OH 204.