Every finding on record at Park Health Center

Based on medical record review, policy review, facility self-investigation report review, review of police reports, resident observation, and interviews with residents and staff, the facility failed to complete a thorough investigation for an allegation of staff to resident sexual abuse. In addition, the facility failed to protect residents after an allegation of staff to resident sexual abuse when they permitted a specified perpetrator to continue to work and provide care to residents. This affected one resident (#171) of three residents reviewed for abuse, and eight residents (#102, #111, #121, #122, #124, #134, #142, and #143) who were provided care by a specified perpetrator who was the perpetrator identified in a staff to resident sexual abuse allegation and allowed to work. The facility census was 84.Findings include:Review of the medical record for the Resident #171 revealed an admission date of 02/17/24. Diagnoses included stroke, constipation, peripheral vascular disease, oxygen dependence, depression, hard of hearing, visual deficits, unspecified dementia without behavioral disturbances, lung disease, arthritis, and high blood pressure.Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/03/26, revealed the resident had severe cognitive impairment with a brief interview for mental status score of 6/15. Further review revealed Resident #171 required extensive assistance of two staff for bed mobility, transfers, and ambulation. Review of the behavior and mood MDS assessments revealed no behaviors since prior annual assessment completed in November of 2025 and severe depression present with no change since prior assessment. Review of the plan of care initiated on 02/25/22 and on-going revealed Resident #171 had alterations in mood/behaviors and occasionally exhibited delusional thinking and yelling out with interventions in place.Observation and interview on 03/19/26 at 11:43 A.M. with Resident #171 revealed she was resting in bed and calm. Resident #171 quickly appeared guarded in posture and defensive in demeanor when asked about any incident of abuse occurring on 03/10/26 or 03/12/26. Resident #171 reported that she was told by the Administrator and the two police officers that she was safe now and that man would no longer be allowed to care for her. Resident #171 further reported she was told not to discuss the incident but would not elaborate who said that. Attempts were made twice for elaboration of events by Resident #171, but she raised her voice and adamantly declined to answer any further questions related to alleged incident.Interview on 03/19/26 at 12:15 P.M. with the social worker designee (SWD) # 202 revealed she was made aware of an allegation of sexual abuse against certified nursing aide (CNA) # 340 by Resident #171 on Tuesday 03/10/26 around 7:45 A.M. by licensed practical nurse (LPN) #328. SWD #202 further reported that she asked the Human Resources Director (HRD) #224 to go with her to interview Resident #171 as the nursing administration and the facility Administrator was not at the facility yet. Further interview with the SWD #202 revealed she spoke with Resident #171 who appeared upset and was yelling about a man trying to put his thing in her mouth. SWD #202 asked Resident #171 if she knew who the man was and Resident #171 responded a man's proper name. Resident #171 was then asked if the man was still here and Resident #171 stated yes and reported he had a white sweatshirt on and dark hair. SWD #171 did confirm that CNA #340 was wearing a white sweatshirt that shift and had dark hair. She further reported that she told CNA #340 not to go into Resident #171 room anymore and to wait in the nursing office. SWD #202 further reported that Resident #171 complained of her right wrist hurting and she left the HRD #224 to get a nurse to check on Resident #171 wrists. SWD #202 reported that the facility Administrator was notified by phone call of events and spoke with CNA #340 on speaker phone in the presence of the SWD #202 and HRD #224. CNA #340 was advised by the Administrator to leave the facility and was escorted out by staff at 9:17 A.M. pending investigation.Interview on 03/19/26 at 12:45 P.M. with Human Resource Director (HRD) #224 revealed she was made aware of an allegation of sexual abuse against CNA # 340 by Resident #171 on Tuesday 03/10/26 around 7:45 A.M. when SWD #202 came to her office Tuesday morning on 03/10/26 and asked her to assist her with interviewing Resident #171. HRD #224 reports she called the Administrator while in Resident #171 and had him on her cell phone in speaker phone mode to hear the interview and reported events. HRD #224 further confirmed that the Administrator discussed the events with herself, SWD #202, and CNA #340 in her office via speaker phone and determined CNA needed to leave the facility until further investigation could be completed when the Administrator got on site. Interview on 03/19/26 at 1:00 P.M. with LPN #328 revealed she was the nurse on duty caring for Resident #171 on 03/10/26. LPN #328 reported she was approached by CNA #340 and was told that Resident #171 was being combative when CNA #340 tried to get her off the bed pan. LPN #328 then went to assess Resident #171 and found her to be very agitated, and Resident #171 was reporting he tried to put his thing in my mouth; you know that thing and gestured toward her own private area then the nurse's private area. LPN #328 reported not everything Resident #171 was saying was making sense, but she knew she should report the concern. LPN #328 then went to SWD #202 and reported concerns since administration was not at the facility yet. LPN #328 confirmed on 03/12/26 she was asked to write a statement about the Resident #171's cognitive and behavioral status only for 03/10/26 but nothing about Resident #171 statements or allegations of sexual abuse. LPN #328 did confirm there was a nothing in the medical record regarding Resident #171 having delusions and the Resident #171's son asking about a urinalysis on 03/10/26 in the medical record. LPN #328 denied any recent changes with Resident #171's cognition or mental status leading up to or since the alleged incident on 03/10/16. Review of the facility's internal investigation revealed a file folder with date 03/10/26 and provided by the assistant director of nursing (ADON) #216 to the surveyor. The file included an individual written statement authored by LPN #328 indicating the following, I have never witnessed CNA #340 be abusive or threatening to any residents at any time. There were three additional similar statements from CNA #236, CNA #350, and LPN #341. There were no witness statements from SWD #202 or HRD #224. There was no detailed statement from LPN #328 who was caring for Resident #171 or CNA #340 who had been providing care to Resident #171. There was no documentation in the medical record regarding the events.Further review of the facility's investigation for 03/10/26 revealed a summary of incident determining that Resident #171 was confused and combative with CNA #340 during personal cares but no abuse occurred. Resident #171's son was notified via phone of the incident and reported that Resident #171 gets that way when she has a urinary tract infection. Resident #171's son reported to nursing staff that he did not think an investigation was warranted and he liked the male CNA #340. Interview on 03/19/26 at 4:00 P.M. with the ADON #216 verified that there were no signed statements from CNA #340, SWD #202, or HRD #224 for the 03/10/26 investigation. The ADON #216 further verified that the signed statements of CNA #236, CNA #350, and LPN #341 did not provide details of event and were not witness statements. ADON #216 further revealed the facility did not continue into a deeper investigation on 03/10/26 or report the incident to the Ohio Department of Health due to Resident #171's son stating he did not feel an investigation was needed and his mother may have urinary infection.Review of the schedule and time punch card dated 03/10/26 revealed CNA #340 clocked out at 9:17 A.M. and did not continue to work on 03/10/26. Further review of time punch card and daily assignment sheet revealed the CNA #340 returned to work on 03/11/26 for a full shift and was assigned as the shower aide for eight residents (#102, #111, #121, #122, #124, #134, #142, and #143). Review of the nursing aide schedule for March 2026 revealed that on 03/12/26 CNA #340 was placed on administrative leave while a facility investigation was being completed for allegations of sexual abuse of Resident #171. As of 03/19/26 CNA #340 had not yet returned to the facility for assignment. This was verified by the ADON on 03/19/26 at 1:00 PM.Interviews on 03/19/26 at 1:00 P.M. with the DON and ADON verified that on 03/10/26 CNA #340 was directed by the Administrator to leave facility pending investigation for allegations of sexual abuse made by Resident #171. The DON further reported CNA #340 did computer module training from home on abuse and prevention for the remainder of the day on 03/10/26. Further interview with the ADON revealed that since the facility did not complete any further investigation after speaking with Resident #171's son that afternoon, CNA #340 was allowed to return to work on his next scheduled shift on 03/11/26. The DON verified that CNA #340 was assigned a different unit and was the shower aide on 03/11/26. The DON was able to verify there were eight residents (#102, #111, #121, #122, #124, #134, #142, and #143) who received showers from CNA #340 on 03/11/26. CNA #340 was then removed from work on 03/12/26 after a formal allegation of sexual abuse was made by Resident #171's son and another investigation was started at the facility.Review of facility policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, revealed the facility is to report any allegations or suspicion of all types of abuse to the state agency prior to investigation of the allegation.This deficiency represents non-compliance investigated under Complaint Number 2806392.

Based on medical record review, facility policy review, facility investigation file review, police report review, resident observation, and resident and staff interview, the facility failed to report an allegation of staff to resident sexual abuse. This affected one resident (#171) of three residents reviewed for abuse. The facility census was 84. Findings include:Review of the medical record for the Resident #171 revealed an admission date of 02/17/24. Diagnoses included stroke, constipation, peripheral vascular disease, oxygen dependence, depression, hard of hearing, visual deficits, unspecified dementia without behavioral disturbances, lung disease, arthritis, and high blood pressure.Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/03/26, revealed the resident had severe cognitive impairment with a brief interview for mental status score of 6/15. Further review revealed Resident #171 required extensive assistance of two staff for bed mobility, transfers, and ambulation. Review of the behavior and mood MDS assessments revealed no behaviors since prior annual assessment completed in November of 2025 and severe depression present with no change since prior assessment. Review of the plan of care initiated on 02/25/22 and on-going revealed Resident #171 had alterations in mood/behaviors and occasionally exhibits delusional thinking and yelling out with interventions in place.Observation and interview on 03/19/26 at 11:43 A.M. with Resident #171 revealed the resident was resting in bed and calm. Resident #171 quickly appeared guarded in posture and defensive in demeanor when asked about any incident of abuse occurring on 03/10/26 or 03/12/26. Resident #171 reported that she was told by the Administrator and the two police officers that she was safe now and that man would no longer be allowed to care for her. Resident #171 further reported she was told not to discuss the incident but would not elaborate who said that. Attempts were made twice for elaboration of events by Resident #171, but she raised her voice and adamantly declined to answer any further questions related to alleged incident.Interview on 03/19/26 at 12:15 P.M. with the social worker designee (SWD) # 202 revealed she was made aware of an allegation of sexual abuse against certified nurse aide (CNA) #340 by Resident #171 on Tuesday 03/10/26 around 7:45 A.M. SWD #202 was notified by licensed practical nurse (LPN) #328 about Resident #171's allegation against CNA #340. SWD #202 further reported that she asked the Human Resources Director (HRD) #224 to go with her to interview Resident #171 as the nursing administration and the facility Administrator was not at the facility yet. Further interview with SWD #202 revealed she spoke with Resident #171 who appeared upset and was yelling about a man trying to put his thing in her mouth. SWD #202 asked Resident #171 if she knew who the man was and Resident #171 responded a man's proper name. Resident #171 was then asked if the man was still here and Resident #171 stated yes and reported he had a white sweatshirt on and dark hair. SWD #171 did confirm that CNA #340 was wearing a white sweatshirt that shift and had dark hair. She further reported that she told CNA #340 not to go into Resident #171 room anymore and to wait in the nursing office. SWD #202 further reported that Resident #171 complained of her right wrist hurting and she left the HRD #224 to get a nurse to check on Resident #171's wrist. SWD #202 reported that the facility Administrator was notified by phone call of the events and spoke with CNA #340 on speaker phone in the presence of the SWD #202 and HRD #224. CNA #340 was advised by the Administrator to leave the facility and was escorted out by staff at 9:17 A.M. pending investigation.Interview on 03/19/26 at 12:45 P.M. with Human Resource Director (HRD) #224 revealed she was made aware of an allegation of sexual abuse against CNA # 340 by Resident #171 on Tuesday 03/10/26 around 7:45 A.M. when SWD #202 came to her office Tuesday morning on 03/10/26 and asked her to assist her with interviewing Resident #171. HRD #224 reported she called the Administrator while in Resident #171's room and had the Administrator on her cell phone in speaker phone mode to hear the interview and reported events. HRD #224 further confirmed that the Administrator discussed the events with herself, SWD #202, and CNA #340 in her office via speaker phone and determined CNA #340 needed to leave the facility until further investigation could be completed when the Administrator got on site. Review of the facility's internal investigation revealed a file folder with date 03/10/26 and provided by the assistant director of nursing (ADON) #216. The file included an individual written statement authored by LPN #328 indicating the following, I have never witnessed CNA #340 be abusive or threatening to any residents at any time. There were three additional similar statements from CNA #236, CNA #350, and LPN #341. There were no witness statements from SWD #202 or HRD #224. There was no detailed statement from LPN #328 who was caring for Resident #171 or CNA #340 had been providing care to Resident #171. There was no documentation in Resident #171's medical record regarding the events.Further review of the facility's investigation for 03/10/26 revealed a summary of incident determining that Resident #171 was confused and combative with CNA #340 during personal care but no abuse occurred. Resident #171's son was notified via phone of incident and reported that Resident #171 gets that way when she has a urinary tract infection. Resident #171's son reported to nursing staff that he did not think an investigation was warranted and he liked the male CNA #340. Review on 03/18/26 at 4:30 P.M. of the Ohio Department of Health Gateway reporting abuse allegation reporting software revealed no Self-Reported Incidents (SRI) entered for 03/10/26 for the facility. Further review revealed a SRI was reported on 03/12/16 for allegation of physical abuse of Resident #171 by CNA #340. There was no allegation of sexual abuse listed. Interview on 03/19/26 at 1:20 PM with registered nurse (RN) #365 confirmed the initial SRI entered into the system on 03/12/26 was entered as physical abuse and not sexual abuse. RN #356 further reported she was unclear why the Administrator selected physical abuse and not sexual abuse but speculated that at the time of the entry prior to full investigation it was unclear if the allegations were physical abuse due to resident stating she was hit in the face or if allegations were sexual abuse and the allegation of sexual abuse was not determined until full investigation was completed.Interview on 03/19/26 at 4:00 P.M. with the ADON #216 verified there were no signed statements from CNA #340, SWD #202, or HRD #224 for the 03/10/26 investigation. The ADON #216 further verified that the signed statements of CNA #236, CNA #350, and LPN #341 did not provide details of event and were not witness statements. ADON #216 confirmed that the Administrator was aware on 03/10/26 of the alleged incident. ADON #216 further revealed the facility did not continue into a deeper investigation on 03/10/26 or report the allegation of staff to resident sexual abuse to the Ohio Department of Health due to Resident #171's son stating he did not feel an investigation was needed and his mother may have an urinary infection.Review on 03/23/26 of Police Report # CL-26-0454 filed on 03/12/26 indicated the police responded to a report of abuse sexual in nature. Further review of the police report revealed that the Administrator reported to police that the incident occurred on Tuesday 03/10/26 but the facility was not made aware of the allegation until SR #171 after the son reported concerns on 03/12/26. (Please note the Administrator's statement to the police on 03/12/26 was not accurate as the Administrator was aware of the allegation on 03/10/26).Review of facility policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, revealed the facility was to report any allegations or suspicion of all types of abuse to the state agency prior to investigation of the allegation.This deficiency represents non-compliance investigated under Complaint Number 2806392.

Based on medical record review, review of the social services job description, and resident and staff interviews, the facility failed to provide medically related social services for a resident who had a change in her psychosocial status. This affected one resident (#171) of three residents reviewed for abuse. Findings include:Review of the medical record for Resident #171 revealed an admission date of 02/17/24. Diagnoses included stroke, constipation, peripheral vascular disease, oxygen dependence, depression, hard of hearing, visual deficits, unspecified dementia without behavioral disturbances, lung disease, arthritis, and high blood pressure.Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/03/26, revealed the resident had severe cognitive impairment with a brief interview for mental status score of 6/15. Further review revealed Resident #171 required extensive assistance of two staff for bed mobility, transfers, and ambulation. Review of the behavior and mood MDS assessments revealed no behaviors since prior annual assessment completed in November of 2025 and severe depression present with no change since prior assessment. Review of the plan of care initiated on 02/25/22 and on-going revealed Resident #171 had alterations in mood/behaviors and occasionally exhibits delusional thinking and yelling out with interventions in place.Review of the medical record for Resident #171 revealed no evidence of an incident where the resident alleged staff to resident sexual abuse documented in the resident's medical record. There were no social services notes or psychosocial assessments by social services entered in the medical record on 03/10/26 through 03/19/26. Observation and interview on 03/19/26 at 11:43 A.M. with Resident #171 revealed she was resting in bed and calm. Resident #171 quickly appeared guarded in posture and defensive in demeanor when asked about any incident of abuse occurring on 03/10/26 or 03/12/26. Resident #171 reported that she was told by the Administrator and the two police officers that she was safe now and that man would no longer be allowed to care for her. Resident #171 further reported she was told not to discuss the incident but would not elaborate who said that. Attempts were made twice for elaboration of events by Resident #171, but she raised her voice and adamantly declined to answer any further questions related to alleged incident.Interview on 03/19/26 at 12:15 P.M. with the social worker designee (SWD) # 202 revealed she was made aware of an allegation of sexual abuse against certified nurse aide (CNA) # 340 by Resident #171 on Tuesday 03/10/26 around 7:45 A.M. by licensed practical nurse (LPN) #328. SWD #202 further reported that she asked the Human Resources Director (HRD) #224 to go with her to interview Resident #171 as the nursing administration and the facility Administrator was not at the facility yet. Further interview with the SWD #202 revealed she spoke with Resident #171 who appeared upset and was yelling about a man trying to put his thing in her mouth. SWD #202 asked Resident #171 if she knew who the man was and Resident #171 responded with a man's proper name. Resident #171 was then asked if the man was still here and Resident #171 stated yes and reported he had a white sweatshirt on and dark hair. SWD #202 did confirm that CNA #340 was wearing a white sweatshirt that shift and had dark hair. She further reported that she told CNA #340 not to go into Resident #171's room anymore and to wait in the nursing office. SWD #202 further reported that Resident #171 complained of her right wrist hurting and she left the HRD #224 to get a nurse to check on Resident #171's wrist. SWD #202 reported the facility Administrator was notified by phone call of events and spoke with CNA #340 on speaker phone in the presence of the SWD #202 and HRD #224.Continued Interview with SWD #202 revealed she had met with Resident #171 several times since the alleged incident to follow up on her emotional and cognitive status and frequently checked in with her just to chat. SWD #202 verified there she did not document the behaviors or allegations of Resident #171 on 03/10/26 in the medical record. SWD #202 further verified she had not documented any follow visits with Resident #171 or any updated assessments of her psychosocial status since the alleged event. Review of the job description for the Social Worker Designee dated and signed by SWD #202 on 05/06/24 revealed job responsibilities to included: providing guidance on various emotional, mental, environmental and/or physical concerns or limitations and accurately document psychosocial needs, interaction s and follow up actions with residents and families.This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2806392

Based on review of medical records, review of facility investigations, review of police reports, facility policy reviews, observations, and interviews with residents and staff the facility failed to provide effective administration when the facility's Administrator knowingly failed to report an allegation of staff to resident sexual abuse of Resident #171 and the Administrator knowingly provided false information to investigating police officers. This affected one resident (#171) of three residents reviewed for abuse. The facility census was 84. Findings include:Review of the medical record for the Resident #171 revealed an admission date of 02/17/24. Diagnoses included stroke, constipation, peripheral vascular disease, oxygen dependence, depression, hard of hearing, visual deficits, unspecified dementia without behavioral disturbances, lung disease, arthritis, and high blood pressure.Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/03/26, revealed the resident had severe cognitive impairment with a brief interview for mental status score of 6/15. Further review revealed Resident #171 required extensive assistance of two staff for bed mobility, transfers, and ambulation. Review of the behavior and mood MDS assessments revealed no behaviors since prior annual assessment completed in November of 20256 and severe depression present with no change since prior assessment. Review of the plan of care initiated on 02/25/22 and on-going revealed Resident #171 had alterations in mood/behaviors and occasionally exhibits delusional thinking and yelling out with interventions in place.Observation and interview made on 03/19/26 at 11:43 A.M. with Resident #171 revealed she was resting in bed and calm. Resident #171 quickly appeared guarded in posture and defensive in demeanor when asked about any incident of abuse occurring on 03/10/26 or 03/12/26. Resident #171 reported that she was told by the administrator and the two police officers that she was safe now and that man would no longer be allowed to care for her. Resident #171 further reported she was told not to discuss the incident but would not elaborate who said that. Attempts were made twice for elaboration of events by Resident #171, but she raised her voice and adamantly declined to answer any further questions related to alleged incident.Interview on 03/19/26 at 12:15 P.M. with the social worker designee (SWD) # 202 revealed she was made aware of an allegation of sexual abuse against CNA # 340 by Resident #171 on Tuesday 03/10/26 around 7:45 A.M. by licensed practical nurse (LPN) #328. SWD #202 further reported that she asked the Human Resources Director (HRD) #224 to go with her to interview Resident #171 as the nursing administration and the facility Administrator was not at the facility yet. Further interview with the SWD #202 revealed she spoke with Resident #171 who appeared upset and was yelling about a man trying to put his thing in her mouth. SWD #202 asked Resident #171 if she knew who the man was and Resident #171 responded a man's proper name. Resident #171 was then asked if the man was still here and Resident #171 stated yes and reported he had a white sweatshirt on and dark hair. SWD #171 did confirm that CNA #340 was wearing a white sweatshirt that shift and had dark hair. She further reported that she told CNA #340 not to go into Resident #171 room anymore and to wait in the nursing office. SWD #202 further reported that Resident #171 complained of her right wrist hurting and she left the HRD #224 to get a nurse to check on Resident #171 wrist. SWD #202 reported that the facility Administrator was notified by phone call of events and spoke with CNA #340 on speaker phone in the presence of the SWD #202 and HRD #224. CNA #340 was advised by the Administrator to leave the facility and was escorted out by staff at 9:17 A.M. pending investigation.Interview on 03/19/26 at 12:45 P.M. with Human Resource Director (HRD) #224 revealed she was made aware of an allegation of sexual abuse against CNA # 340 by Resident #171 on Tuesday 03/10/26 around 7:45 A.M. when SWD #202 came to her office Tuesday morning on 03/10/26 and asked her to assist her with interviewing Resident #171. HRD #224 reports she called the Administrator while in Resident #171 and had him on her cell phone in speaker phone mode to hear the interview and reported events. HRD #224 further confirmed that the Administrator discussed the events with herself, SWD #202, and CNA #340 in her office via speaker phone and determined CNA needed to leave the facility until further investigation could be completed when the Administrator got on site. Interview on 03/19/26 at 1:00 P.M. with LPN #328 revealed she was the nurse on duty caring for Resident #171 on 03/10/26. LPN #328 reported she was approached by CNA #340 and was told that Resident #171 was being combative when CNA #340 when he tried to get her off the bed pan. LPN #328 then went to assess Resident #171 and found her to be very agitated and reporting he tried to put his thing in my mouth; you know that thing and gestured toward her own private area then the nurse's private area. LPN #328 reported not everything Resident #171 way saying was making sense, but she knew she should report the concerns. LPN #328 then went and reported concerns to SWD #202 since administration was not at the facility yet. LPN #328 confirmed she was not asked to write a witness statement about events on 03/10/26 and was asked on 03/12/26 to write a statement about the residents cognitive and behavioral status for 03/10/26. LPN #328 did confirm there was a note in the medical record regarding the resident having delusions and the son asking about a urinalysis on 03/10/26 but no reference to the alleged incident or Resident #171 statements. LPN #328 denied any recent changes with Resident #171 cognition or mental status leading up to or since the alleged incident on 03/10/16. Review on 03/18/26 at 4:30 P.M. of the Ohio Department of Health Gateway abuse neglect and misappropriation reporting software revealed no Self-Reported Incidents (SRI) for allegation of sexual abuse entered for 03/10/26. Further review revealed a SRI reported on 03/12/26 by the facility Administrator for an allegation of physical abuse. Interview on 03/19/26 at 1:20 PM with registered nurse (RN) #365 confirmed the initial SRI entered into the system on 03/12/26 was entered as physical abuse and not sexual abuse. RN #356 further reported she was unclear why the Administrator selected physical abuse and not sexual abuse but speculated that at the time of the entry prior to full investigation it was unclear on if the allegations were physical abuse due to resident stating she was hit in the face or if allegations were sexual abuse and the allegation of sexual abuse was not determined until full investigation was completed.Interview on 03/19/26 at 4:00 P.M. with the ADON #216 confirmed that the Administrator was aware on 03/10/26 of the alleged incident of staff to resident sexual abuse. ADON #216 further revealed the facility did not continue into a deeper investigation on 03/10/26 or report incident to the Ohio Department of Health due to Resident #171's son stating he did not feel an investigation was needed and his mother may have urinary infection.Review of Police Report # CL-26-0454 filed on 03/12/26 revealed the police responded to a sex offense report. Further review of the police report revealed that the Administrator reported to police that the incident occurred on Tuesday 03/10/26 but the facility was not made aware of the allegation until Resident #171's son reported concerns on 03/12/26.However, interviews with SWD #202, HRD #240, and ADON #216 all confirmed the Administrator was immediately made aware on 03/10/26 of the alleged incident.Review of facility policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, revealed the facility was to report all allegations or suspicion of any types of abuse to the state agency prior to investigation of the allegation.This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2806392.

Based on medical record review and staff interview the facility failed to maintain an accurate and complete medical record. This affected one resident (#171) of three residents reviewed for abuse. The facility census was 84. Findings include:Review of the medical record for Resident #171 revealed an admission date of 02/17/24. Diagnoses included stroke, constipation, peripheral vascular disease, oxygen dependence, depression, hard of hearing, visual deficits, unspecified dementia without behavioral disturbances, lung disease, arthritis, and high blood pressure.Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/03/26, revealed the resident had severe cognitive impairment with a brief interview for mental status score of 6/15. Further review revealed Resident #171 required extensive assistance of two staff for bed mobility, transfers, and ambulation. Review of the behavior and mood MDS assessments revealed no behaviors since prior annual assessment completed in November of 20256 and severe depression present with no change since prior assessment. Review of the plan of care initiated on 02/25/22 and on-going revealed Resident #171 had alterations in mood/behaviors and occasionally exhibits delusional thinking and yelling out with interventions in place.Review of medical record for Resident #171 revealed there was no documentation of the events on 03/10/26 related to the allegations of staff to resident sexual abuse. Observation and interview made on 03/19/26 at 11:43 A.M. with Resident #171 revealed she was resting in bed and calm. Resident #171 quickly appeared guarded in posture and defensive in demeanor when asked about any incident of abuse occurring on 03/10/26 or 03/12/26. Resident #171 reported that she was told by the Administrator and the two police officers that she was safe now and that man would no longer be allowed to care for her. Resident #171 further reported she was told not to discuss the incident but would not elaborate who said that. Attempts were made twice for elaboration of events by Resident #171, but she raised voice and adamantly declined to answer any further questions related to alleged incident.Interview on 03/19/26 at 12:15 P.M. with the social worker designee (SWD) # 202 revealed she was made aware of an allegation of sexual abuse against CNA # 340 by Resident #171 on Tuesday 03/10/26 around 7:45 A.M. by licensed practical nurse (LPN) #328. SWD #202 further reported that she asked the Human Resources Director (HRD) #224 to go with her to interview Resident #171 as the nursing administration and the facility Administrator was not at the facility yet. Further interview with the SWD #202 revealed she spoke with Resident #171 who appeared upset and was yelling about a man trying to put his thing in her mouth. SWD #202 asked Resident #171 if she knew who the man was and Resident #171 responded a man's proper name. Resident #171 was then asked if the man was still here and Resident #171 stated yes and reported he had a white sweatshirt on and dark hair. SWD #171 did confirm that CNA #340 was wearing a white sweatshirt that shift and had dark hair. She further reported that she told CNA #340 not to go into Resident #171 room anymore and to wait in the nursing office. SWD #202 further reported that Resident #171 complained of her right wrist hurting and she left to get a nurse to check on Resident #171 wrist. SWD #202 reported that the facility Administrator was notified by phone call of events and spoke with CNA #340 on speaker phone in the presence of the SWD #202 and HRD #224.Continued Interview with SWD #202 revealed she had met with Resident #171 several times since the alleged incident to follow up on her emotional and cognitive status and frequently checked in with her just to chat. SWD #202 verified there she did not document the behaviors or allegations of Resident #171 on 03/10/26 in the medical record. SWD #202 further verified she had not documented any follow-up visits with Resident #171 or any updated assessments of her psychosocial status since the alleged event. Interview on 03/19/26 at 1:00 P.M. with LPN #328 revealed she was the nurse on duty caring for Resident #171 on 03/10/26. LPN #328 reported she was approached by CNA #340 and was told that Resident #171 was being combative when CNA #340 tried to get her off the bed pan. LPN #328 then went to assess Resident #171 and found her/him to be very agitated, and Resident #171 was reporting he tried to put his thing in my mouth; you know that thing and gestured toward her own private area then the nurse's private area. LPN #328 reported not everything Resident #171 was saying was making sense, but she knew she should report the concern. LPN #328 then went to SWD #202 and reported concerns since administration was not at the facility yet. LPN #328 did confirm she entered a note on 03/10/26 at 4:12 P.M in the medical record of Resident #171 noting she was having increased delusions and false beliefs. States she has some discomfort to left wrist after becoming combative. Son updated and stated she gets like this when she has a UTI. LPN #328 confirmed she did not record the statements, gestures, or emotional status of Resident #171 from the interview and assessment she observed earlier that morning. Interview on 03/19/26 at 4:00 P.M. with the ADON #216 verified that there was no documentation of the incident that occurred on 03/10/26 in the medical record and reported that the nurse noted resident was having increased delusions and complaints of left wrist pain but there was no detailed explanation of the what the delusions were or what led to the resident becoming combative. ADON #216 also confirmed that there was no entry made in the medical record for Resident #171 by social services department on 03/10/26 through 03/19/26.This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2806392.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, hospital documentation review, review of a facility investigation, review of video footage, policy review and interviews, the facility failed to timely and comprehensively assess, notify a physician, and provide timely and necessary care and services to Resident #22 after she complained of hip pain as a result of a dislocated right hip. This resulted in Immediate Jeopardy and Actual Harm beginning on 07/21/25 at 1:10 A.M. when Resident #22 voiced complaints of pain and staff continued to provide personal care, assisting the resident into her bathroom and transferred the resident to bed without first assessing the resident. Licensed Practical Nurse (LPN) #113 administered a dose of as needed narcotic pain medication but failed to comprehensively assess the resident related to the pain. On 07/21/25 at 2:01 A.M. review of video footage revealed staff entered Resident #22's room to attempt to place a hip abductor wedge at which time the resident yelled out in pain upon movement of her leg. Staff exited the room and per video footage they did not return until 5:05 A.M. Video footage revealed Resident #22 was yelling out and at 5:11 A.M., Certified Nursing Assistant (CNA) #168 removed blankets from Resident #22, who had a visibly severe internal rotation to her leg, and began to undress the resident as the resident was screaming in pain. CNA #168 did not stop undressing Resident #22 and proceeded to re-dress her as Resident #22 was observed on video screaming in pain. At 5:18 A.M., CNA #169 and LPN #113 entered Resident #22's room and assisted CNA #168 to stand-pivot Resident #22 to her wheelchair as the resident was screaming. Resident #22 remained out of her room in the wheelchair until 10:56 A.M., when CNA #145, Physical Therapist (PT) #260, and Certified Occupational Therapy Assistant (COTA) #250 transferred Resident #22 from her wheelchair into her bed using a gait belt and attempted a stand/pivot transfer. Resident #22 was briefly seated at the edge of bed while crying out. An x-ray was subsequently ordered. On 07/21/25 at 1:51 P.M. Radiology Technician (RT) #400 expressed concern about the image captured (noting the dislocation of the resident's hip). Emergency Medical Transportation (EMT) was called and arrived at 2:58 P.M. Resident #22 left the facility at 3:16 P.M. to be taken to the hospital where she was diagnosed with a dislocated right hip requiring surgical intervention. This affected one resident (#22) of four residents reviewed for falls. The facility census was 86. On 08/19/25 at 3:03 P.M., the Administrator, Director of Nursing (DON) #141 and #185, Regional Clinician (RC) #300 were notified Immediate Jeopardy began on 07/21/25 at 1:10 A.M. when Resident #22 voiced complaints of hip pain that was not comprehensively or adequately assessed and treated. Between 1:10 A.M. and 10:56 A.M. Resident #22 continued to complain of severe pain to the hip area captured on video footage of the resident screaming and crying out due to the pain while staff proceeded to manipulate/move the leg providing routine care. An x-ray was not obtained until 1:51 P.M. which confirmed the hip dislocation. The resident was not transferred to the hospital until 07/21/25 at 3:16 P.M. The Immediate Jeopardy was removed on 07/21/25 and the deficiency subsequently corrected on 07/26/25 when the facility implemented the following corrective actions. On 07/21/25 at 2:40 P.M., preliminary results of Resident #22's x-ray were reported to Physician #230 by Registered Nurse (RN) #127. Physician #230 ordered Resident #22 to be transferred to the hospital for evaluation and treatment. Physician #225 was updated by RN # 127. The resident was transferred to the hospital on [DATE] at 3:16 P.M. and did not return to the facility following the hospitalization. On 07/21/25 at 2:40 P.M. Resident #22's family/responsible party was notified by RN #127. On 07/22/25 at 4:00 P.M. CNA #168 was immediately re-educated by the Administrator and DON #141 regarding performing activity of daily living (ADL) care to residents with increased pain or signs of distress ensuring stopping ADL care and notifying nursing staff with s/s of pain, distress or changes in functioning. On 07/22/25 at 4:30 P.M. (via phone) LPN #113 was immediately re-educated by the Administrator and DON #141 regarding conducting timely and thorough assessments with change in condition and notification to physician. On 07/22/25 at 6:00 P.M. (via phone) CNA #169 was immediately re-educated by the Administrator and DON #141 regarding performing ADL care to residents with increased pain or signs of distress ensuring stopping ADL care and notifying nursing staff with s/s of pain, distress or changes in functioning. On 07/22/25 at 10:00 P.M. a skin sweep was completed by DON #185 and facility wound nurse for possible injuries and changes in condition for current residents unable to be interviewed and all other current residents were interviewed for potential changes in condition warranting interventions. 82 residents were assessed. On 07/22/25 the facility Change in Condition Policy was reviewed by the Administrator, DON #185, and DON #141. No changes were made to the policy. By 7/25/25, 18 RN's, 13 LPN's and 40 CNAs were re-educated by the DON and Administrator on ensuring proper identification and assessment (e.g. vital signs, ROM, visual alignment and or deformity, palpation of joint/area and verbal interview, etc.) of residents with any changes in condition following injuries, complaints of severe pain, or suspected fractures/dislocations; on ensuring notification to physician of findings and prompt notification to responsible party; and on following the proper chain of command if a nurse fails to respond promptly, staff will escalate notifications to the DON/Administrator. On 07/22/25, the Administrator, DON#185, and DON #141 reviewed the Pain Management Policy. No changes were made to the policy. By 7/25/25, 18 RN's, 13 LPN's and 40 CNAs were re-educated by DON #141, DON #225 and the Administrator on ensuring nursing staff were assessing pain as needed and assessing for possible causes; on providing non-pharmacological pain remedies and pain medications and monitoring for effectiveness; and on ensuring new complaints or worsening complaints of pain are reported to physician and updating family. On 07/23/25 at 1:00 P.M. DON #141 reviewed current residents with an orthopedic surgical intervention or injury within last 14 days who were at risk for complications, ensuring orders were in place for assessing area every shift for two weeks or as directed by the physician. One (1) resident was identified, and an order was put in place for monitoring on 07/23/25 to monitor right hip/femur surgical site for signs and symptoms (s/s) of infection, proper alignment, or s/s of displacement and notify physician with any abnormalities. On 07/24/25 at 2:00 P.M. an Ad hoc quality assurance (QA) committee meeting was held to review investigation and findings of initial audits, as well as, the ongoing audit plan and education action plan. Meeting consisted of Administrator, DON # 185, DON # 141, RN # 204, RN # 170, HR # 153 and Physician #153. By 07/25/25, 18 RNs, 13 LPNs and 40 CNAs were re-educated by DON #141, DON # 185, and the Administrator on ensuring direct care staff stop ADL care and notify nursing staff when a resident was showing signs of discomfort, distress or increased pain (e.g., yelling out, crying, grimacing guarding, restlessness, decreased ROM or functioning etc.); ensuring nursing staff perform an assessment to identify cause of pain (e.g., vital signs, ROM, interview, palpation of site, and visualize location of pain identified ) before proceeding with care; and ensuring notification of the physician and the responsible parties as indicated. By 0/25/25, 18 RNs, 13 LPNs and 40 CNAs were re-educated by DON #141, DON # 185, and the Administrator on expectations for monitoring new surgical sites. This re-education included that nursing would assess for signs/symptoms of dislocation, increased pain, deformity, and/or misalignment and notify the physician of relative abnormalities; and that a resident with suspected fracture/dislocation must be assessed immediately by a nurse and physician notified without delay. Beginning on 07/26/25, five (5) residents were reviewed weekly for two (2) weeks by DON #141 and or LPN #132, on ensuring proper identification and assessment (e.g. vital signs, ROM, verbal interview, etc.) of residents with any changes in condition following injuries, complaints of severe pain, or suspected fractures/dislocations; on ensuring notification to physician of findings and prompt notification to responsible party; and on following the proper chain of command if a nurse failed to respond promptly. No irregularities were noted and the results were reported to the QA committee for review and recommendations on 8/13/25. QA committee recommended to continue with monthly random interviews, ongoing, until further direction from the committee and ongoing education for new hires of facility policy on change in condition and proper identification and assessment of the change in condition. Beginning on 07/26/25, five (5) residents were interviewed weekly for two (2) weeks by DON # 141 and or LPN # 132, to ensure pain is being controlled and interventions are in place to manage pain levels. No irregularities were noted and the results were reported to the QA committee for review and recommendations on 08/13/25. QA committee recommended to continue with ongoing education to new hires ensuring understanding of facility policy for pain management and intervening with signs of increased pain, and to continue monthly random interviews, until further direction from the committee. Beginning on 07/26/25, three (3) CNAs were interviewed weekly for two (2) weeks by DON #141 and or LPN #132 to ensure verbal understanding of stopping ADL care and notify nursing staff when resident is showing signs of discomfort, distress or increased pain (e.g., yelling out, crying, guarding, etc.). No irregularities were noted and the results were reported to the QA committee for review and recommendations on 8/13/25. QA committee recommended to continue with ongoing education with new hires on ensuring understanding of stopping ADL care and notifying nursing staff with s/s of pain, and continuing ongoing monthly interviews, until further direction from the committee. Beginning on 07/26/25, audits were conducted weekly for two (2) weeks by DON #141 and or DON # 185, on process for assessing new orthopedic surgical procedures ensuring order to monitor site q shift is in place and that the nurse assessed for s/s of dislocation, increased pain, deformity, and or misalignment and that relative abnormalities were reported to the physician. No irregularities were noted, and the results were reported to the QA committee for review and recommendations on 8/13/25. QA committee recommended to continue with ongoing education of new nursing hires ensuring understanding for new facility process for assessing new orthopedic surgical procedures and continuing monthly audits, until further direction from the committee. DON #185 was identified as being responsible for implementation and monitoring of this plan. Nurse Managers RN # 204 and LPN #132 were responsible to ensure staff adherence on their units. Findings include:Closed record review revealed Resident #22 originally was admitted to the facility on [DATE] and was re-admitted to the facility on [DATE] with diagnoses including unspecified intracapsular fracture of right femur, muscle wasting and atrophy, and need for assistance with personal care. Review of a care plan dated 05/07/25 revealed Resident #22 was at risk for alteration in comfort related to disease process, generalized pain, impaired mobility, diagnosis of osteoarthritis, low back pain, and fracture with surgical intervention. The goal was to decrease Resident #22's pain to an acceptable level for the resident which would allow for participate in activities of daily living (ADLs), activities, therapy, treatment, and etcetera. Interventions included administer medications as ordered, maintain proper body alignment, monitor for effectiveness of interventions, notify physician for review or for change in pain medications if needed, pain assessment per facility policy, and therapy referral as needed. Review of an order by Medical Director/Physician (MD) #225 dated 06/06/25 revealed Resident #22 was on hip precautions each shift. Review of an order by MD #225 dated 06/11/25 revealed Resident #22 was to have an abductor pillow between legs which could be removed for care and transfers. Skin integrity to be checked each shift and physician to be notified of any decline every shift for hip precautions. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had impaired cognition, no behaviors, was dependent on staff for transfers, and had occasional pain of five. Review of an order by MD #225 dated 06/30/25 revealed Resident #22 was to receive cyclobenzaprine oral tablet give milligrams (mg) one tablet by mouth every 12 hours as needed (PRN) for muscle spasms. The resident also had an order on this date for tramadol 50 mg one tablet by mouth every 12 hours as needed (PRN) for pain level of four to six (on a scale of one to 10). Review of an occupational therapy note dated 07/18/25 at 1:35 P.M. by Certified Occupational Therapy Assistant (COTA) #250 revealed Resident #22 completed dynamic stand balance activities with reaching and bending forward while engaging core, maintaining forward flexion attention to task and safety cues with fair balance until resident became fatigued. Functional sit to stand with hand placement upright posture completed with an engaged core, maintained balance with minimum assist and multimodal cues to perform the task. Resident #22 tolerated well and required minimum assistance to perform. Resident #22 was able to stand and pivot to and from the toilet utilizing a walker with minimum assistance and multimodal cues to complete the task. Review of a physical therapy note dated 07/18/25 at 2:22 P.M. by Physical Therapy Assistant (PTA) #240 revealed Resident #22 performed sit to stand transfers with verbal and tactile cues given on hand placement, done for seven reps to increase in bilateral lower extremity strength and activity tolerance, done with minimum assistance for safety, pivot transfers with minimum assistance with cues given on walker placement with understanding demonstrated, ambulation done for 35 feet two times to increase mobility and activity tolerance, and postural cues given to keep center of gravity over base of support with understanding demonstrated. Once fatigued, posterior lean noted. Review of a nursing note dated 07/21/25 at 12:25 A.M. by LPN #113 revealed Resident #22 had no cognitive impairment, a skin assessment was completed with no changes noted, and observation of neuro musculoskeletal status was completed with no new changes. Review of video footage provided by Resident #22's family revealed the following on 07/21/25:- 1:10 A.M. to 1:12 A.M.: Resident #22 was brought into her room in a standard wheelchair by CNA #168 and CNA #169. Resident #22 began to cry in pain and staff asked where it hurt at. CNAs #168 and #169 then took Resident #22 into the bathroom and LPN #113 entered to assist. (There was no evidence Resident #22 was assessed in regard to her complaints of pain). - 1:18 A.M. to 1:23 A.M.: Resident #22 was taken out of her bathroom while still in a standard wheelchair by CNA #168 and CNA #169. LPN #113 entered the room again and CNA #169 stated, she keeps saying it hurts. LPN #113 went to speak with Resident #22 who requested as needed pain medication. LPN #113 exited the room to retrieve the medication. CNAs #168 and #169 stand/pivot assisted Resident #22 into bed while she was observed whimpering in pain. CNA #168 attempted to place a hip abductor wedge between Resident #22's legs and she began to cry out in pain. CNAs #168 and #169 asked Resident #22 where she was hurting but Resident #22 provided no clear answer. Resident #22 was in bed with a pillow propping her up in a seated position with her legs out in front of her; her left leg was bent at the knee with her foot flat on the bed and her right leg was flat on the bed with an inward rotation. Resident #22 repeatedly stated, Oh it hurts. LPN #113 entered the room to administer medication. (There was no evidence Resident #22 was assessed in regard to her continued complaints of pain). - 1:25 A.M.: LPN #113 had administered medication and was talking to Resident #22 while CNAs #168 and #169 were still present in the room. LPN #113 attempted to have Resident #22 describe where the pain was located by instructing her to place her hand where she was hurting. Resident #22 was noted to be grabbing the back of her right leg. CNA #168 approached the bed to place covers over Resident #22 as resident was repeatedly stating, don't. CNA #168 reassured Resident #22 they weren't going to touch her and she could go to sleep. CNA #168 adjusted the bed position and Resident #22 cried stating, Oh it's burning. CNA #168 stated Resident #22 had been grabbing her hip but hadn't really been paying attention to how the hip looked. CNA #168 could be heard stating, I wanted to check that hip but she started whining that it was hurting. Resident #22 was trying to go to sleep so staff exited the room and turned off the lights. (There was no evidence Resident #22 was assessed in regard to her continued complaints of pain). - 2:00 A.M.: CNA #168 entered the room and attempted to place a hip abductor wedge between Resident #22's legs after asking if she felt better. When CNA #168 went to separate the resident's left leg from her right, Resident #22 stated, Oh, no, no, no. CNA #168 covered Resident #22 back up and left the room. (There was no evidence Resident #22 was assessed in regard to her continued complaints of pain). - 5:05 A.M.: CNA #169 was observed on video footage standing next to Resident #22's bed, Resident #22's blanket was slightly removed from her right side. Resident #22 stated, go away, go away, go away now, I can't, I can't, no, no, no. CNA #169 left the room. - 5:11 A.M. to 5:13 A.M.: CNA #168 entered the room to change Resident #22. Resident #22 was still crying and stated something undecipherable. CNA #168 got Resident #22's clothing ready and began to lift the bed for care. Resident #22 stated, Oh my God, and CNA #168 replied, what? - 5:14 A.M. to 5:18 P.M.: CNA #168 removed bolsters from the right side of the bed. Resident #22 was visibly leaning away from the right side, grabbing her right hip and sobbing. Resident #22 had a pained facial expression, appeared to be in pain and was visibly crying. CNA #168 proceeded to remove the covers from Resident #22 revealing her left leg was bent at the knee and her right leg had a severe inward rotation, bent at the knee and tucked under the left leg. CNA #168 removed Resident #22's brief from her while the resident continued to cry in pain. Resident #22's right leg was still bent at the knee and tucked under her left leg to the point where her right knee was touching the bed. Resident #22 was laying on her back with a pillow tucked under her and leaning to the left slightly. CNA #168 grabbed Resident #22's knees and pulled them apart to try to separate her legs while Resident #22 screamed in pain. CNA #168 attempted to separate the resident's legs multiple times to apply a new brief, but Resident #22 kept pulling her legs back together while screaming out in pain, with her head thrown back and visibly in pain. CNA #168 proceeded with care and applied a new brief and pants as Resident #22 continued crying out. Once Resident #22's pants were up to the top of her legs below her buttocks, CNA #168 used a walkie talkie to request assistance to transfer Resident #22 from her bed into her wheelchair. CNA #168 attempted again to pull Resident #22's right leg from below her left leg to place her knees together for better alignment. Resident #22 screamed in pain. CNA #169 walked into the room while Resident #22 was still crying and stated, I told you she's complaining of pain in here, while gesturing to her own inner right thigh because that's where she was grabbing a minute ago. LPN #113 entered the room and CNA #169 asked Resident #22 multiple times where she was hurting, Resident #22 stated everywhere, and CNA #169 stated, where does your leg hurt at? (There was no evidence the LPN assessed the resident in regard to her continued complaints of pain). - 5:19 A.M. to 5:27 A.M.: Resident #22 was observed on video still lying in bed grabbing her right hip while CNAs #168 and #169 and LPN #113 stood in the room to prepare to transfer her from bed to her wheelchair. LPN #113 stated, do you think if I braced her hips and then we sat her up that would help? LPN #113 applied gloves than approached Resident #22 stating, (insert name), I'm going to grab right here, and we are going to sit you up. (There was no evidence Resident #22 was assessed in regard to her continued complaints of pain or prior to attempting to move her). - 5:28 A.M. to 5:34 A.M.: LPN 113 had a hold of Resident #22's hips while CNAs #168 and #169 worked on sitting her up in bed. Resident #22 immediately began screaming. Staff got the resident seated at the edge of the bed while the resident was screaming, then proceeded to stand her to finish pulling up her pants. Resident #22 was unable to bear weight so CNA #168 and LPN #113 lifted her off the ground while CNA #169 moved the wheelchair into place. While in the air, Resident #22's legs were turned in at abnormal angles. Once seated in wheelchair, Resident #22 stopped crying. CNA #168 took Resident #22's shirt off to help her finish getting ready and redressed her. (There was no evidence Resident #22 was assessed in regard to her continued complaints of pain). Review of a Medication Administration Record (MAR) for July 2025 revealed Resident #22 received a dose of as needed tramadol 50 mg at 1:22 A.M. on 07/21/25 which was documented as effective. However, there was no evidence a comprehensive assessment of the resident's pain to include location, quality, intensity, onset, duration, aggravating/alleviating factor was completed related to the use of the as needed narcotic pain medication was completed at that time. Review of an Occupational Therapy note dated 07/21/25 at 10:44 A.M. by COTA #250 revealed nursing reported Resident #22 had complaints of right hip pain, therapy staff attempted to stand Resident #22 three times with resistance and complaints of hip pain with pulling hip up and holding up and they were unable to get her to stand completely upright. Resident #22 completed motor activities with strengthening tasks to improve ADLs and balance with bilateral upper extremity strengthening and core strengthening. CNA staff asked for help to lay Resident #22 down, transfer completed with max pain, Resident #22 laid in bed and nurse was aware of the pain. (There was no evidence Resident #22 was assessed in regard to her continued complaints of pain). Review of a nursing note dated 07/21/25 at 10:44 A.M. by RN #127 revealed Resident #22 was yelling out complaining of pain to right hip. Resident #22 was refusing to stand and having difficulties with transfers due to increased pain. Medical Director (MD) #225 was notified and new orders were received. Review of a video on 07/21/25 revealed from 10:56 A.M. to 11:01 A.M. CNA #145, PT #260 and COTA #250 were in Resident #22's room to transfer her from her wheelchair to the bed. Resident #22 can be heard repeatedly saying, oh my land. PT #260 and COTA #250 used a gait belt to stand/pivot transfer Resident #22 into bed, as the resident was crying out. Resident #22 was seated at the edge of bed and crying in pain. The staff moved the resident to a position laying down and CNA #145 attempted to place a pillow between Resident #22's legs which did cause her to cry in pain, however once she was no longer moving, was not crying out in pain. Resident #22 was saying oh my goodness. Review of physician orders revealed an order dated 07/21/25 for Resident #22 to receive a right hip x-ray with two views stat for right hip pain, previous fracture. The x-ray was to be portable due to physical limitations. Review of a MAR for July 2025 revealed Resident #22 received a dose of as needed tramadol 50 mg at 11:00 A.M. on 07/21/25 which was documented to be effective. However, there was no evidence a comprehensive assessment of the resident's pain to include location, quality, intensity, onset, duration, aggravating/alleviating factor was completed related to the use of the as needed narcotic pain medication was completed at that time. Review of continued video footage from 07/21/25 between 11:03 A.M. and 11:04 A.M. revealed Resident #22 was resting in her bed repeatedly stating, I don't wanna die. Review of video dated 07/21/25 at 11:08 A.M. revealed RN #127 entered Resident #22's room and attempted to lay down the head of the resident's bed. Resident #22 stated, oh, no, no, no, don't do that. Resident #22 indicated she wanted the head of the bed back up and RN #127 placed the bed in a more comfortable position for Resident #22. (There was no evidence Resident #22 was assessed in regard to her continued complaints of pain at this time). Review of a physical therapy note dated 07/21/25 at 12:54 P.M. by Physical Therapy Assistant (PTA) #240 revealed Resident #22 completed sit to stand transfers with maximum assistance of two staff and moderate cueing for correct sequencing and attention to task. Resident #22 performed standing at walker with maximum assistance of one to two staff and maximum cueing up to one minute with poor balance with posterior and lateral loss of balance (LOB). Patient performed lower extremity exercises seated in a chair including marching, hip adduction, hip abduction, ankle pumps, heels raises, and glute sets 15 reps each with maximum cueing for correct sequencing and attention to task. Resident #22 complained of right hip pain and discomfort during session, reported to nursing, nursing stated Resident #22 had complained of pain since midnight and had gotten medication several times. (However, there was no evidence Resident #22 was actually assessed in regard to her continued complaints of pain). Review of video footage dated 07/21/25 from 1:51 P.M. to 1:56 P.M. revealed Radiology Technician (RT) #401 entered the resident's room to perform x-rays. RT #401 gently slid an x-ray plate under Resident #22 between her pelvis and the bed. Resident #22 was heard saying, they hurt like the dickens. Resident #22 was positioned on her back with a tilt to the left, her left leg was bent at the knee with her foot resting flat on the bed and her right leg was also bent at the knee, completely rotated inward and tucked under her left leg with her right knee touching the bed. RT #401 requested an aide to help reposition the bed once she took one x-ray, she stated she would not be moving the resident to get other views. RT #401 showed RN #127 the image of the first x-ray. CNA #145 was in the room with RT #401 and stated Resident #22 had not allowed them to put a pillow between her knees and RT #401 responded she wanted her right leg tucked under her left leg because it made it feel better. CNA #145 then stated, when I got here this morning, she was in her chair. RT #401 bewildered, responded, How? and CNA #145 stated, I have no idea. Review of a nursing note dated 07/21/25 at 2:40 P.M. by RN #127 revealed Orthopedic Surgeon (OS) #230's office was notified of Resident #22's severe pain and possible displacement of right hip. OS #230 recommended Resident #22 be transferred to the emergency department. MD #225 was notified and gave new orders to transfer Resident #22 to the emergency department for evaluation and treatment. Resident #22 and her family were made aware. Review of an order dated 07/21/25 revealed it was medically necessary to send Resident #22 to the emergency room. Review of a nursing note dated 07/21/25 at 2:55 P.M. by RN #127 revealed 911 had been called to transport Resident #22 to the emergency department. A follow-up note at 3:16 P.M. revealed Resident #22 had left the facility via stretcher enroute to the emergency department. Resident #22's family was made aware. Review of video footage dated 07/21/25 from 2:58 P.M. to 3:03 P.M. revealed EMTs arrived to take Resident #22 to the emergency department. RN #127 told the EMTs Resident #22 had been in severe pain all day. When Resident #22 was uncovered and her legs were visible, one EMT says a surprised, Oh! Once loaded on the cot, Resident #22 left the building. Review of an x-ray dated 07/21/25 at 4:28 P.M. revealed Resident #22 had a single view of the pelvis with legs crossed. The right hip arthroplasty was dislocated; the femoral head component was projecting six to seven centimeters superolateral to the acetabular component. Review of a nursing note dated 07/21/25 at 9:15 P.M. by RN #127 revealed Resident #22 was admitted to the hospital. Review of a Brief Operative Note dated 07/22/25 by OS #130 revealed Resident #22 had a right hip dislocation status post total hip arthroplasty and would require a closed reduction under anesthesia. The note included the closed reduction was completed with some difficulty. Interview on 08/14/25 at 12:05 P.M. with Resident #22's responsible party (RP) revealed she had concerns about the complete disregard of Resident #22's pain while the resident could be observed on video screaming and her leg was bent at an odd angle. RP brought footage from a camera located in Resident #22's room to show the incident. RP had a hard time listening to the footage and would not look at the camera (due to the pain the resident was in and demonstrated). RP stated her mother was screaming in pain and felt staff neglected her. RP stated she spoke with OS #230 who stated it would have taken a lot of effort to dislocate the hip. Interview on 08/15/25 at 12:44 P.M. with OS #230 revealed Resident #22 already had a broken hip with a partial, then full replacement. OS #230 stated he was not sure of the mechanism that would've caused the dislocation. OS #230 stated it was fairly hard to dislocate a hip because you had to really twist the leg around somehow to get it to come out. OS #230 stated Resident #22 does have dementia, so she could've had an unwitnessed event which was the cause of the dislocation (however, the exact circumstance of how the dislocation had occurred could not be determined). OS #230 stated people with dementia express their pain in different ways or sometimes can't at all, but it would be a painful injury for most people to have. Interview on 08/18/25 at 1:20 P.M. with RN #127 revealed she worked with Resident #22 often during the resident's stay in the facility. Resident #22's baseline was confused and did not have a lot of behaviors. RN #127 stated she recalled 07/21/25 and when she came in that morning, nightshift staff were reporting the resident had yelled out in pain all night and pain medication had been administered but did not seem to be effective. RN #127 stated she asked about the right hip and the nurse (LPN #113) had stated she thought it looked aligned to her, but it had taken three staff to get her out of bed (which was not the resident's normal). RN #127 inquired about how therapy went and was told Resident #22 would scream and had to be sat down. RN #127 stated while Resident #22 was sitting in her wheelchair, she was fine and did not have signs of distress. The only time Resident #22 was transferred during RN #127's shift was to lay her down for the x-ray. RN #127 stated she called the resident's RP and let her know Resident #22 was having pain and did not do well in therapy. RN #127 stated when the x-ray tech was present, she asked her to come to Resident #22's room to see the picture and they were able to tell the right hip was out. RN #127 stated she obtained orders to send Resident #22 to the emergency [TRUNCATED]

Based on record review, policy review, review of video footage, and interview the facility failed to ensure a resident was treated with respect and dignity. This affected one resident (#22) of four residents reviewed for change in condition. The facility census was 86.Findings include:Record review revealed Resident #22 was re-admitted to the facility on [DATE] with diagnoses including unspecified intracapsular fracture of right femur, muscle wasting and atrophy, and need for assistance with personal care. Review of a minimum data set (MDS) dated [DATE] revealed Resident #22 had impaired cognition, no behaviors, was dependent on staff for transfers, and had occasional pain of five.Review of an Authorization for Electronic Monitoring in Resident Room form dated 05/12/25 revealed Resident #22's power of attorney installed a fixed position video camera with recording in her room.Review of a video provided by Resident #22's family dated 07/04/25 at 10:51 A.M. revealed Registered Nurse (RN) #162 exiting Resident #22's bathroom, raise her hand to block her face from the camera, walk over to the camera and stand in front of it, obscuring the view of Resident #22 when she was brought out of the bathroom. The camera was motion activated and due to being blocked, had stopped recording.Review of an education training document dated 07/11/25 revealed RN #162 received education on Electronic Monitoring policy and stated I put my hand up because the light turns color when it starts recording and it was a reaction to that because I hate cameras.Interview on 08/19/25 at 10:15 A.M. with Director of Nursing (DON) #141 confirmed the video of RN #162 blocking Resident #22's camera. Review of a policy titled Electronic Monitoring in Resident Rooms dated 03/23/22 revealed the facility will not intentionally obstruct, tamper with, or destroy any electronic monitoring device or any recording made by an electronic monitoring device.This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2583102.

Based on record review, policy review, review of video footage, and interview, the facility failed to ensure a resident was provided the opportunity for urination in the bathroom versus being told to urinate in her incontinence brief. This affected one resident (#22) of four residents reviewed for change in condition. The facility census was 86.Findings include:Closed record review revealed Resident #22 re-admitted to the facility on [DATE] with diagnoses including unspecified intracapsular fracture of right femur, muscle wasting and atrophy, and need for assistance with personal care. Review of a minimum data set (MDS) assessment dated [DATE] revealed Resident #22 had impaired cognition, no behaviors, required moderate assistance for transfers, and was frequently incontinent of bladder and bowel.Review of a care plan dated 04/28/25 revealed Resident #22 had an alteration in elimination related to hip fracture and revision, back pain, dementia, stroke, diabetes, overall decline in mobility, falls, and bowel and bladder incontinence. The goal was for Resident #22 to be clean, dry and odor free. Interventions included but were not limited to toileting program, monitor and provide hydration as needed, monitor and record bowel movements every shift, provide incontinence care as needed, and monitor for signs and symptoms of a urinary tract infection.Review of video footage (provided by Resident #22's family and shared with the Administrator and Director of Nursing) dated 06/18/25 at 9:38 P.M. revealed Resident #22 was in her room and asked Certified Nursing Assistant (CNA) #189 if she could go to the bathroom. CNA #189 responded, we'll get you cleaned up. Resident #22 was then being transferred to her bed and stated, I need to go to the bathroom. CNA #189 stated, it's hard to go on the toilet when your leg's been busted up. CNA #189 did not assist Resident #22 to the bathroom.Interview on 08/20/25 at 3:40 P.M. with CNA #189 revealed he had received education on incontinence care recently. CNA #189 stated Resident #22 was forgetful and he did not redirect the resident appropriately, instead opting to instruct her to go (urinate) in her (incontinence) brief because he was about to change her anyway and would get her cleaned up. Interview on 08/20/25 at 4:00 P.M. with the Administrator revealed he personally educated CNA #189 about incontinence care after being made aware of the footage of him declining to take Resident #22 to the bathroom. This deficiency represents non-compliance investigated under Complaint Number 2583102.

Based on observation, policy and interview, the facility failed to ensure food was stored, and prepared under sanitary conditions. This affected all the resident's in the facility except Residents #8, #63, #133, #183, #185 and #189 who do not receive nutrition from the kitchen. The facility census was 83. Findings include: Initial tour of the kitchen [DATE] at 08:10 A.M. with [NAME] #18 revealed: - The walk in freezer had a bag of mixed vegetables and Charbroil burgers that had been entered and not resealed exposing the contents to the freezing air. - The walk in refrigerator had 58 individual cartons of [NAME] whole milk with a sell by date of [DATE]. - There was leftover chili in the walk in refrigerator not dated. - The walk in refrigerator had a five pound carton of [NAME] Choice sour cream that expired [DATE]. - The scoop was on the lid of a thickener container not contained in a case or bag. - There was dust on all four pipes over the stove cooktop on the ansel system. - The shelf over the cooktop was dusty and greasy Interview [DATE] at 8:32 A.M. with [NAME] #18 verified the outdated, unsealed, undated food as well as the scoup not contained in a sanitary manner and dusty shelf and ansel system. Review of the Food Storage-Labeling and Dating policy revised [DATE] included all food must have a date that includes the month, day and year on the package indicating the date in which it entered the facility. Items must be dated after opening with a open date and a use by date. The use by date will be seven days unless the original manufacturer expiration date is before seven days. Leftovers can be held for seven days.

Based on medical record review, policy review and interview, the facility failed to ensure advanced directives were accurate. This affected one resident (#2) of 24 residents reviewed for advanced directives. The census was 85. Findings include: Review of Resident #2's medical record revealed an admitted [DATE] with diagnoses including epilepsy, atherosclerotic heart disease, cerebrovascular disease, hyperlipidemia, chronic obstructive pulmonary disease, schizoaffective disorder, angina, Parkinson's disease, and adult failure to thrive. Review of the electronic medical record revealed on admission, the resident had Do Not Resuscitate Comfort Care Arrest (DNRCCA) orders (this status means that while full medical care is provided before a cardiac or respiratory arrest, cardiopulmonary resuscitation and advanced life support measures are not initiated upon arrest. Instead the focus shifts to comfort measures). On 03/03/25 the physician orders included an order for the code status to be changed to a Do Not Resuscitate Comfort Care (DNRCC) (only comfort measures will be provided). Review of the paper chart revealed advance directives were the first document when opening the record. Resident #2's paper chart contained a signed DNRCCA form. Interview 03/25/25 at 11:53 A.M. with Registered Nurse (RN) #40 verified there was a discrepancy between the electronic record and paper chart. RN #40 verified the advance directives did not match. Review of the facility's Resident Rights, Treatment and Advance Directive policy dated 11/22/26 included copies of Advance Directives will be placed on the chart.

Based on record review, interview and review of a self-reported incident the facility failed to protect a resident from misappropriation and ensure the resident was reimbursed the monies. This affected one (Resident #10) of one residents reviewed for misappropriation. The facility census was 85. Findings include: Review of Resident #10's medical record revealed an admitted [DATE] with diagnoses that included chronic atrial fibrillation, congestive heart failure and peripheral vascular disease. Further review of the medical record including the Minimum Data Set (MDS) 3.0 quarterly assessment with a reference date of 03/12/25 indicated Resident #10 had an intact cognition level. Review of the facility self-reported incident (SRI) #25534 revealed on 12/21/24 at 10:30 A.M. Licensed Practical Nurse (LPN) #55 notified the Administrator of Resident #10's concern of missing money. LPN #55 contacted Resident #10's representative to gain information on the money. The representative indicated she had cashed a check for $545.00 for Resident #10 on 12/18/24. Approximately $45.00 of that was used, leaving $500.00 in a banker's envelope. Further review of the facility investigation revealed Resident #10 kept the money in her purse and had last seen the money on 12/20/24. The resident indicated she did not leave her purse unattended, taking her purse with her if she left her room. The concern of missing money was reported to the police per the request of Resident #10. A local police officer arrived to the facility on [DATE] at 11:15 A.M. and took a report including interviewing Resident #10. Interviews with staff and residents found no concerns of additional missing items, including cash. Further review of the facility SRI investigation revealed the allegation of misappropriation of resident money was unsubstantiated due to finding no evidence of any staff member taking the money and did not indicate the missing $500.00 was reimbursed to Resident #10. Interview with Resident #10 on 03/24/25 revealed approximately $500.00 in cash was taken from her purse, which was in her resident room, prior to Christmas. Resident #10 indicated the cash had not been reimbursed by the facility. Interview with the Ombudsman on 03/24/25 at 3:40 P.M. also indicated Resident #10 had approximately $500 in cash misappropriated from a purse in her room and the facility did not reimburse the resident. Interview with Certified Nurse Aide (CNA) #23 on 03/26/25 at 4:05 P.M. revealed she was providing Resident #10 a shower in the facility shower room. When returning to the resident room, Resident #10 requested CNA #23 to check her nightstand for her purse. CNA #23 provided the purse to Resident #10 who indicated her money was missing. CNA #23 indicated she notified Licensed Practical Nurse (LPN) #55 of the missing money concern and assisted LPN #55 with searching Resident #10's room for the missing money but nothing was found. Interview with LPN #55 on 03/26/25 at 4:10 P.M. revealed she was notified by CNA #23 of Resident #10's concern of missing money. LPN #55 indicated she and CNA #23 searched Resident #10's room, but did not find the missing cash. At this time LPN #55 notified the facility Administrator. On 03/27/25 at 8:00 A.M. interview with the facility administrator verified the facility did not reimburse Resident #10 any money after the allegation of missing cash due to finding no evidence the cash was misappropriated by a staff member.

Based on observation, record review and interview, the facility failed to develop a comprehensive plan of care for the use of psychotropic medication. This affected one (Resident #2) of five residents reviewed for unnecessary medication use Findings include: Review of Resident #2's medical record revealed an admitted [DATE] with diagnoses including epilepsy, anxiety disorder, Parkinson's disease and adult failure to thrive. Review of the 03/04/25 modification of the admission Minimum Data Set Assessment (MDS) revealed the resident was moderately impaired for daily decision making and received antipsychotic and antianxiety medications. Physician orders included lorazepam (antianxiety medication) 0.5 milligrams (mg) three times a day and three times a day as needed for three months for generalized anxiety disorder, Seroquel (antipsychotic medication) 50 milligrams (oral tablet) at bedtime for schizoaffective disorder and Seroquel (oral tablet) 25 mg two times a day for schizoaffective disorder. Review of the plans of care revealed a comprehensive, measurable psychotropic plan of care was not developed. There were no behaviors identified to be monitored for the use of an antipsychotic medication. Interview 03/26/25 at 2:30 P.M. with Registered Nurse #37 verified there was not a plan of care developed for the use of psychotropic mediations. Further interview revealed there were no targeted behaviors identified to monitor the effectiveness of the antipsychotic drugs. The facility did not have a policy regarding psychotropic medications.

Based on record review, observation and interview, the facility failed to ensure plans of care were updated to reflect the residents' preferences and medical needs. This affected two Residents (#26 and #133) of 22 residents reviewed. The census was 85 Findings include: 1. Review of Resident #26's medical record revealed an admitted [DATE] and readmitted [DATE] with diagnoses including morbid severe obesity. chronic atrial fibrillation, dependence on renal dialysis, type 2 diabetes with diabetic neuropathy, chronic peripheral insufficiency, acquired absence of right great toe and other right toes. osteoporosis, hypothyroidism, gastro esophageal reflux disease. lymphedema, anemia, hyperlipidemia, insomnia, absence of other left toes, chronic kidney disease Stage 4 (severe), angina pectoris, hypoxemia, glaucoma and hypertension. Review of the resident's dialysis plan of care initiated 01/18/24 revealed the care plan not individualized and did not identify the resident having a fistula (a surgically created connection between an artery and a vein, typically in the arm, to facilitate hemodialysis by providing a large accessible blood vessel for needle access). Review of the 03/06/25 Annual Minimum Data Set Assessment (MDS) included the resident was independent for daily decision making, with no behaviors, no weight gain or loss, and received dialysis. Interview 03/24/25 at 6:56 P.M. with Resident #26 included he had a fistula in his right arm for dialysis. Interview 03/26/25 at 3:32 P.M. with Registered Nurse (RN) #64 verified the plan of care was not updated to reflect the resident had a fistula. RN #64 verified the dialysis plan of care did not include the specific type of dialysis access the resident had and was not specific to what services the resident would need. 2. Review of Resident #133 revealed an admitted [DATE] and readmitted [DATE] with diagnoses including metabolic encephalopathy, anemia, type 2 diabetes and rheumatoid arthritis. Care Plans initiated on 12/16/21 included resident does not engage in group activities. Resident preferred doing activities their room including watching TV and socializing on the phone with family and staff and resident preferences for daily life and person-centered care that are important or somewhat important include: Choosing own bedtime , Choosing what clothes to wear. Having family or significant other involved in care discussions. Neither plan of care was revised between 12/16/21 and 03/25/25 to reflect the residents significant changes or preferences. Review of the 12/24/24 Significant Change MDS included the resident was moderately impaired for daily decision making, found little interest or pleasure in doing things and feeling tired or having little energy. There were no delusions. The resident had verbal behaviors four to six days of the look back period. It was somewhat important to him to take care of his personal belongings or things, very important to choose bath type, bed time, very important to have family and close friends involved in care, very important to listen to music, enjoy favorite activity, go outside when the weather is good and very important to participate in religious activities. The resident was readmitted from the hospital 03/22/25 on continuous tube feeding. Observations 03/24/25 at 11:03 A.M. Resident #133 refused to be turned was screaming and the aide went to tell the nurse of refusal. On 03/25/25 at 11:53 A.M. Certified Nurse Aide #88 said he refused his catheter care. On 03/25/25 at 11:54 A.M. Licensed Practical Nurse #12 said he would not let her flush his gastrostomy tube. On 03/26/25 at 08:39 A.M. the resident was in bed sleeping. Interview 03/26/25 at 9:18 A.M. with CNA #90 revealed the resident usually refuses the carrots to contractured hands and was ongoing her. There were no observations of music, television, family, activities or clergy in the room. There were no observations of the resident out of bed. interview 03/25/25 03:06 P.M. with Activities #100 revealed the resident was a religious person. He use to get in the wheelchair and go to activities. He has not done much since he came back from the hospital. He had declined and doesn't seem to hold a conversation with them. Activities verified religion was important to the resident but had not been added to the resident's care plan until 03/25/25. Further interview revealed the care plan was not updated to reflect the resident was not getting out of bed and going to activities was not occurring.

Based on observations, interview, and medical record review the facility failed to ensure residents were assisted with routine nail care and showers. This affected two (Resident #9 and #70) of three residents reviewed for Activities of Daily Living. The facility census was 85. Findings include: 1. Review of Resident #9's medical record revealed an admitted [DATE] with diagnoses that includes chronic obstructive pulmonary disease, hypertension and diabetes mellitus. Further review of Resident #9's medical record including the Minimum Data Set (MDS) 3.0 quarterly assessment with a reference date of 12/19/24 revealed Resident #9 had a moderately impaired cognition level, was dependent for bathing and set up assistance with personal hygiene. Review of the Certified Nurse Aide (CNA) Activities of Daily Living (ADL) Tasks revealed Resident #9 was provided a shower and nail care on 02/24/25, 03/01/25, 03/03/25, 03/06/25, 03/08/25, 03/13/25, 03/15/25, 03/19/25, 03/24/25 and 03/25/25. Review of Resident #9's plan of care revealed the resident required assistance with ADLs. Observation of Resident #9 on 03/24/25 at 9:28 A.M. revealed long, dirty and untrimmed fingernails. Interview with Resident #9 on 03/24/25 at 3:17 P.M. revealed staff do not cut or clean her fingernails. Additional observations of Resident #9's fingernails on 03/25/25 10:02 A.M. again revealed long, untrimmed and unclean fingernails. Interview with Resident #9 on 03/25/25 at 10:02 A.M. revealed it had been awhile since she last had any nail care completed. On 03/25/25 at 10:05 A.M. interview and observation of Resident #9's fingernails with CNA #80 verified the fingernails were long, untrimmed and unclean. CNA #80 indicated fingernails are to be trimmed and clean with each resident shower. 26706 2. Review of Resident #70 revealed a 07/29/25 admission with diagnoses including Parkinson's disease, psychotic disorder with delusions, vitamin D deficiency, type 2 diabetes, and anxiety disorder. The admission shower preference sheet dated 07/29/24 indicated a preference for three to four showers a week. Review of the 01/27/25 Quarterly MDS revealed the resident was severely impaired for daily decision making, had hallucinations, delusions, rejection of care, physical and verbal behaviors, He had upper and lower functional impairment on both sides and dependent for bathing. Interview 03/24/25 at 11:47 A.M. with Resident #70's wife revealed the facility was not brushing his teeth, showering and completing dressing changes. He was supposed to be getting showers three times a week and he sometimes doesn't get two a week. They have been better since she brought it to their attention but still doesn't get enough. Review of the shower schedule revealed the resident was a Sunday, Wednesday, and Friday dayshift shower. Review of the Certified Nurse Aide TASK in the electronic record revealed for the last 30 days there was no evidence of the resident receiving a shower between 03/16/25 and 03/23/25 or on 03/12/25. The facility brought a baths for the day sheet from 03/21/25 that indicated the resident received a bed bath on 03/21/25 not a shower as preferred. There was no explanation as he received a bed bath instead of a shower as preferred. Interview 03/26/25 at 8:59 A.M. with Certified Nurse Aide #80 revealed they leave it up to his wife to say if she wants him to be showered. Interview 03/27/25 at 12:19 P.M. with Registered Nurse #37 verified the resident did not receive a shower three times a week as preferred. This deficiency represents non-compliance investigated under Complaint Number OH00164054.

Based on medical record review and interview the facility failed to ensure an anticoagulant (Eliquis) medication was administered per orders after the resident received a new diagnoses of pulmonary embolism (blockage of the main artery to the lung or one of its branches). This affected one (Resident #76) of six reviewed for unnecessary medication review. Findings included: Medical record review revealed Resident #76 was admitted to the facility on [DATE] with diagnoses including chronic atrial fibrillation, heart failure, cerebrovascular disease, and chronic obstructive pulmonary disease. On 03/18/25 pulmonary embolism was added to the diagnosis list. Review of Resident #76's progress note dated 03/16/25 revealed the nurse at the emergency room reported the resident was being admitted for a diagnosis of pulmonary embolism. Review of Resident #76's hospital record dated 03/16/25 revealed the cardiologist was called due to the resident having bilateral pulmonary embolism and potential right heart strain for consideration of thrombectomy. The resident and family decided not to further procedure with aggressive measures and wished to attempt conservative management. At this time recommended Eliquis if tolerated due to resident had significant hematuria on Eliquis in the past. Review of Resident #76's progress note dated 03/17/25 revealed the resident had returned to the facility via stretcher. Review of Resident #76 orders/Medication Administration Record dated 03/17/25 revealed Eliquis 5 milligrams (mg) one tablet two times daily (upon rise and bedtime). The bedtime dose was marked 9 (see nursing note). Review of Resident #76's medication administration progress note revealed on 03/17/25 at 10:44 P.M., Eliquis was not administered due to the medication was not available and on the way from pharmacy. Interview on 03/27/25 at 12:16 P.M., with Director of Nursing (DON) #70 confirmed Eliquis was not administer at bedtime on 03/17/24 and was available in the facility's contingency medication box, however the nurse never pulled the medication. The DON confirmed the resident was recently diagnosed on [DATE] with a pulmonary embolism.

Based on medical record review, review of operational manual, review of policy, review of statement, observation and interview the facility failed to ensure low air loss mattress was functioning properly. This affected one (Resident #240) of four residents reviewed for pressure ulcers. Findings include: Medical record review revealed Resident #240 was admitted to the facility on [DATE] with diagnoses including pressure ulcers, peripheral vascular disease (PVD), metabolic encephalopathy, muscle weakness, anemia, and spondylolisthesis of lumbar region. Review of Resident #240's five-day Minimum Date Set (MDS) dated [DATE] revealed the resident was at risk for pressure and currently had two stage I pressure ulcers (skin intact with non-blanchable erythema) . The resident was substantial/maximal assist with rolling left to right, sit to lying and lying to sitting. Review of Resident #240's pressure ulcer assessment dated [DATE] revealed the resident was at high risk for pressure due to PVD and currently had pressure ulcers and moderate risk related to non-compliance, fracture, renal disease, edema, anemia, infection, low hemoglobin, head of bed elevated the majority of the time. Review of Resident #240 at risk for alteration in skin integrity related to edema, fragile skin, anemia, history of skin impairment, incontinence, mobility impairment, fracture, bruise, brain bleed, colon cancer, peripheral vascular disease, and history of redness under breast dated 03/13/25 revealed the intervention was a low air loss mattress with perimeters. Set according to weight, alternating pressure. Check functions every shift. Review of Resident #240's orders dated 03/13/25 revealed low air loss mattress with perimeters. Set according to weight, alternating pressure. Check functions every shift. Review of Resident #240's treatment administration record (TAR) dated 03/2025 revealed on 03/24/25 and 03/25/25 staff had signed off that the low air loss mattress was functioning. Observation on 03/24/25 at 10:17 A.M., and 12:46 P.M., revealed the residents low air loss mattress panel was blinking red indicating low pressure. The alarm was muted. The resident was lying in bed. Further observation at 12:46 P.M., revealed the facility's Wound Nurse #21 and visiting wound Nurse Practitioner #500 had entered the resident's room. Review of Resident #240's progress note dated 03/24/25 revealed the wound nurse practitioner was in house and assessed Resident #240. The was a new skin tear partial thickness wound to right arm. Wound care completed with autolytic debridement. Resident reported she must have bumped arm. Additional observation on 03/25/25 at 12:54 P.M. and 3:18 P.M., revealed Resident #240 was lying in bed. The panel was till flashing low pressure and the alarm was muted. Interview and observation of Resident #240's mattress on 03/25/25 at 3:18 P.M., with Registered Nurse (RN) #35 reported she was not aware of any concerns with Resident #240 mattress. The RN confirmed the resident panel was blinking low pressure and the alarm had been silenced. The RN unmuted the alarm and the alarm started sounding. The RN reported she would have Medical Record #60 look at the mattress because he was the one that responsible for the mattress. The mattress was covered in a blue zipped cover and the resident was in bed therefore the RN nor the surveyor was not able to be visualized the cells to ensure all the cells were inflated or if there were any leaks in the mattress. The RN and Surveyor pressed on the mattress to ensure there was some air in the mattress. Interview on 03/25/25 at 3:39 P.M., with Medical Record #60 confirmed he was not aware Resident #240 low air low mattress was not functioning properly until now. MR #60 reported he just ordered a new mattress and it should be here tomorrow or Thursday. Interview on 03/25/25 at 3:57 P.M., with Wound Nurse (Licensed Practical Nurse (LPN)) #21 confirmed she had rounded with the Wound Nurse Practitioner yesterday 03/24/25 and didn't notice the low-pressure light was activated. The Wound Nurse confirmed the bed was not alarming. The resident had stage one pressure ulcers on her heels that were resolved yesterday. Interview on 03/25/25 at 4:27 P.M., with Director of Nursing (DON) #37 revealed the Administrator checked the mattress and changed out the malfunctioning pump. The DON reported the mattress did have some air in it and the new pump was working properly. Interview on 03/25/25 at 4:33 P.M., with the Administrator revealed he had switched out the pump and the resident reported she was not uncomfortable. Review of statement undated signed by the Wound Nurse Practitioner #500 confirmed she had evaluated the resident on 03/24/25 and did not detect the resident bottoming out in bed and the air mattress was inflated and the resident immersed properly. There was no evidence the Wound NP had noted the pump flashing/malfunctioning. Review of the Med Aire Plus 8 alternating pressure and low air loss mattress operator's manual undated revealed the mattress was designed to redistribute pressure, these systems offer a solution for the prevention and treatment of pressure ulcers and offers an optimal solution for pressure redistribution and microclimate control. The mattress redistribution mattress provided includes cell-on-cell design constructed of a base and air inflation cells. The air cells are eight inches in height and a static four inches air cell base. 10-inch-deep static perimeters surround the length of the mattress. The cover provided is a four-way stretch, low shear, vapor permeable, quilted cover easily zipped for removal and cleaning. The low-pressure indicator flickers when the pressure is below the pre-defined level. The audible/visible alarms turn on either when the pressure is low or the system fails to alternate. Press the mute button to mute the audible alarm. The alarm indicator will continue flickering. Re-press the Mute button to re-activate the audible alarm and to extinguish the Mute indicator. If low pressure examine if there is air leakage between the control unit and the mattress connection or from the air mattress tubes. Check the valves. Check the air-connecting tubes. Be sure no single cell was broken. DO NOT use any other control unit with this mattress system than the one provided by Drive. DO NOT change any components by yourself. If there was need for replacement or repair, always contact your authorized Drive dealer or service center. Review of the facility's policy titled Skin assessment dated [DATE] and revised on 03/15/24 revealed the resident's response to preventative efforts and treatment interventions shall be monitored and approaches revised as appropriate.

Based on medical record review, review of the infection control log, and interview the facility failed to ensure antibiotics were administered as ordered to treat urinary tract infection. This affected one (Resident #236) of two reviewed for urinary tract infection. Findings included: Medical record review revealed Resident #236 was admitted to the facility on [DATE] at 2:22 P.M., with diagnoses including urinary tract infection, low back pain, muscle weakness, dementia, and depression. Review of Resident #236's five-day Mimumin Data Set (MDS) dated [DATE] revealed the resident was frequently incontinent of urine. Review of Resident #236's admission orders dated 03/08/25 revealed the resident was ordered Cefpodoxime (antibiotic) 200 milligrams (mg) two tablets by mouth twice daily for three days for a urinary tract infection. Review of Resident #236' Medication Administration records revealed no evidence Cefpodoxime was administered on 03/08/24 at bedtime. On 03/09/25 the rise dose was marked as administered, however the Director of Nursing (DON) #70 confirmed on 03/27/25 at 10:22 A.M., the Cefpodoxime was not administered uprise on 03/09/25 due to the medication was not available. The bedtime dose was not administered on 03/09/25. On 03/10/25 the rise and bedtime dose was not administered. The resident received the first dose on 03/11/25 and completed the three-day order on 03/13/25. Review of Resident #236 progress notes dated 03/08/25 to 03/11/25 revealed on 03/08/25 the physician was notified the Cefpodoxime was not available and ordered from pharmacy. There was no documented evidence the physician was notified the medication was not available on 03/09/25 or 03/10/24. On 03/10/25 at 7:30 A.M., the resident had went unresponsive while therapy had the resident on the toilet. Resident laid down and vitals were obtained. Temperature was 98.0, pulse 60, respirations were 16, and blood pressure was 98/59. The family was updated and doesn't want the resident sent out. Resident regained consciousness. The physician was updated and will continue to monitor. At 9:15 A.M., resident returned to her normal. Review of Resident #236's infection note dated 03/11/25 revealed the resident was started on Cefpodoxime for urinary tract infection this morning. Review of the infection control log dated 03/2025 revealed Resident #236 was admitted on [DATE] from the hospital with an UTI. A urine culture was collected 03/05/25 that grew Klebsiella pneumonia (bacteria). The resident was ordered Cefpodoxime 400 mg twice daily. Interview on 03/27/25 at 9:01 A.M., with DON #70 originally reported she didn't know why the Cefpodoxime was not administered from 03/08/25 till 03/11/25. The surveyor requested evidence when the pharmacy sent the Cefpodoxime. The DON confirmed the Cefpodoxime was not in the facility's contingency medication box. Additional interview on 03/27/25 at 10:22 A.M., with DON #70 confirmed pharmacy did not send the Cefpodoxime until night of 03/10/25 and staff started the medication on 03/11/25. The DON confirmed the resident had missed one dose of Cefpodoxime on 03/08/25 and two doses on 03/09/25 and 03/10/25. The DON confirmed there was not documented evidence the physican was notified on 03/09/25 or 03/10/25 the antibotic was not available or administered.

Based on record review, and interview, the facility failed to ensure care was appropriate for a resident receiving dialysis services. This affected one (Resident #26) of one resident reviewed for dialysis. Findings include: Review of Resident #26 revealed a 06/29/23 admission and readmission 05/02/24 with diagnoses including morbid severe obesity. chronic atrial fibrillation, dependence on renal dialysis, type 2 diabetes with diabetic neuropathy, chronic peripheral insufficiency, acquired absence of right great toe and other right toes. osteoporosis, hypothyroidism, gastro esophageal reflux disease. lymphedema, anemia, hyperlipidemia, insomnia, absence of other left toes, chronic kidney disease Stage 4 (severe), angina pectoris, hypoxemia, glaucoma and hypertension. Review of the resident's dialysis plan of care initiated 01/18/24 revealed the care plan was generic and did not identify the resident having a fistula. Review of the physician orders included 02/11/25 1200 milliliter (ml) fluid restriction dietary 550 ml and nursing 650 ml, enhanced barrier precautions every shift for vascath, keep dressing to right arm from fistula clean and dry. change every 12 hours as needed for wound care AND every shift for wound care, Dialysis every Monday-Wednesday-Friday at 5:15 A.M. Review of the physician orders revealed there were no orders to check right arm fistula for bruit and thrill and not to take blood pressures in the right arm. The resident did not have a vascath. Review of the 03/06/25 Annual Minimum Data Set Assessment (MDS) included the resident was independent for daily decision making, with no behaviors, no weight gain or loss, and received dialysis. Review of the March treatment record revealed staff were signing daily a dressing to right arm fistula. Interview 03/24/25 at 6:56 P.M. with Resident #26 included he had a fistula in his right arm for dialysis. There was not a dressing covering the fistula. He revealed the nurses do not check the site. Interview 03/26/25 at 3:32 P.M. with Registered Nurse (RN) #64 verified the plan of care was not updated to reflect the resident had a fistula. RN #64 verified the dialysis plan of care indicated a vas cath/or fistula and was not specific to what services the resident would need. Observation 03/25/25 at 06:15 P.M. revealed the resident did not have a dressing over the fistula in his right arm. The resident said he takes the dressing off the morning after dialysis. Interview 03/26/25 at 04:12 P.M. with Registered Nurse #37 verified the standard dialysis orders to check thrill and bruise and not to take blood pressure in right arm should have been ordered when the fistula was inserted in March 2024. Interview 03/26/25 04:16 P.M. with Registered Nurse #25 verified there was not an order to check thrill and bruise or for the blood pressure not to be taken on affected arm, She said she takes the dressing off the day after dialysis and verified they are signing off on the treatment sheet the dressing is always on.

Based on medical record review, observation, interview, and policy review the pharmacy failed to ensure medication were available timely for administration. This affected one (Resident #64) of three observed for medication administration, one (Resident #236) of two reviewed for urinary tract infections, and one (Resident #238) of one reviewed for respiratory infection. Findings included: 1. Medical record review revealed Resident #64 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus and chronic kidney disease. Review of Resident #64's current orders revealed Ozempic subcutaneous solution pen-injector two milligrams (mg)/1.5 milliliters (ml) subcutaneously one time a day every Wednesday for diabetes. Observation on 03/26/25 at 7:38 A.M., of Resident #64 medication administration with Registered Nurse (RN) #92 revealed the resident Ozempic was not available to administer. The RN confirmed the Ozempic was only administered once a week on Wednesday and the medication should have been re-ordered last week and should have been available to administered today. Review of Resident #64's progress note dated 03/26/25 revealed pharmacy stated the Ozempic was re-ordered on 03/19/25 was too early to fill and did not send it. The physician was notified the scheduled dose today was unavailable and okay to give when available without ill effect. The pharmacy will ship stat today. Interview on 03/26/25 at 10:25 A.M., via email with the Director of Nursing (DON) #70 revealed there was an error with pharmacy stating it was too soon to fill when the nurse re-ordered it on 03/19/25. The DON reported she had spoken with the pharmacist who clarified that it was not too early to send and it would be sent stat today. The physician was notified and it was okay to administer when it arrives. 2. Medical record review revealed Resident #238 was admitted to the facility on [DATE] with diagnoses including obesity, diabetes, heart disease, and overactive bladder. Review of Resident #238's pneumococcal vaccine informed consent form dated 03/11/25 revealed the resident had consented for Prevnar 20. Review of Resident #238's medical record dated 03/11/25 to 03/27/25 revealed no evidence Resident had received the Prevnar 20. Review of Resident #238's orders and Medication Administration Record (MAR) dated 03/17/25, 03/22/25, 02/24/25, 03/25/26, and 03/26/25 revealed new orders were entered for Prevnar 20; however, it was never received from the pharmacy for administration. Interview on 03/26/25 at 10:31 A.M. with Director of Nursing (DON) #37 and #70 revealed the resident had tested positive for the flu, however finished treatment on 03/15/25. The DON's reported they were not aware why the resident had not received the Prevnar 20 yet and would have to look into it. Interview on 03/26/25 at 2:21 P.M., with DON #37 confirmed the Prevnar 20 had not been administered yet due to there was an issue with pharmacy, however pharmacy was to send tonight. Review of Resident #238's progress note dated 03/26/25 revealed DON #37 spoke to pharmacy and they would send Prevnar 20 in tonight's delivery. Review of Resident #238's progress note dated 03/27/25 revealed pharmacy did not send Prevnar 20. Pharmacy notified and would send stat today. Interview on 03/27/25 at 8:27 A.M., with DON #37 revealed she would spoke to pharmacy and the Prevnar was supposed to be delivered last night. She would have to follow up to see why it was not delivered last night. Review of the facility's policy titled Immunization for Pneumonia, Influenza, and COVID-19 dated 07/03/23 revealed each resident would be offered the pneumococcal immunization. 3. Medical record review revealed Resident #236 was admitted to the facility on [DATE] at 2:22 P.M., with diagnoses including urinary tract infection, low back pain, muscle weakness, dementia, and depression. Review of Resident #236's admission orders dated 03/08/25 revealed the resident was ordered Cefpodoxime (antibiotic) 200 milligrams (mg) two tablets by mouth twice daily for three days for a urinary tract infection. Review of Resident #236' Medication Administration records revealed no evidence Cefpodoxime was administered on 03/08/24 at bedtime. On 03/09/25 the rise dose was marked as administered, however the Director of Nursing (DON) #70 confirmed on 03/27/25 at 10:22 A.M., the Cefpodoxime was not administered uprise on 03/09/25 due to the medication was not available. The bedtime dose was not administered on 03/09/25. On 03/10/25 the rise and bedtime dose was not administered. The resident received the first dose on 03/11/25 and completed the three-day order on 03/13/25. Review of Resident #236 progress notes dated 03/08/25 revealed the physician was notified the Cefpodoxime was not available and ordered from pharmacy. There was no documented evidence the physician was notified the medication was not available on 03/09/25 or 03/10/24. Review of Resident #236's infection note dated 03/11/25 revealed the resident was started on Cefpodoxime for urinary tract infection this morning. Interview on 03/27/25 at 9:01 A.M., with DON #70 originally reported she didn't know why the Cefpodoxime was not administered from 03/08/25 till 03/11/25. The surveyor requested evidence when the pharmacy sent the Cefpodoxime. The DON confirmed the Cefpodoxime was not in the facility's contingency medication box. Additional interview on 03/27/25 at 10:22 A.M., with DON #70 confirmed pharmacy did not send the Cefpodoxime until night of 03/10/25 and staff started the medication on 03/11/25. The DON confirmed the resident had missed one dose of Cefpodoxime on 03/08/25 and two doses on 03/09/25 and 03/10/25. The DON confirmed there was not documented evidence the physician was notified on 03/09/25 or 03/10/25 the antibiotic was not available or administered.

Based on medical record review and interview the facility failed to ensure medication were administered per parameters. This affected one (Resident #76) of six reviewed for unnecessary medication review. Findings included: Medical record review revealed Resident #76 was admitted to the facility on [DATE] with diagnoses including chronic atrial fibrillation, heart failure, cerebrovascular disease, and chronic obstructive pulmonary disease. On 03/18/25 pulmonary embolism was added to the diagnosis list. Review of Resident #76's cardiac plan of care dated 11/19/24 revealed to administer medication as ordered. Review of Resident #76's orders dated 03/2025 revealed the resident was ordered Midodrine 10 milligrams (mg) three times daily (rise, lunch, and bedtime) for hypotension. If the systolic greater than 110 do not give. Review of Resident #76's Medication Administration Record (MAR) dated 03/2025 revealed nurse had administered Midodrine on 03/02/25 at lunch and bedtime when the resident blood pressure was 114/70. On 03/03/25 the nurse had administered Midodrine upon rise when the resident blood pressure was 112/62 and lunch and bedtime when the residents blood pressure was 114/78 for both doses. On 03/04/25 staff administered Midodrine at lunch and bedtime when the residents blood pressure was 120/68 for both doses. On 03/23/25 the resident received rise, lunch, and bedtime dose of Midodrine when the resident blood pressure was 120/84 for all three doses. Interview on 03/27/25 at 12:16 P.M., with the Director of Nursing (DON) #70 confirmed the Midodrine was administered outside the parameters (systolic greater than 110) on 03/02/25 twice, 03/03/25 three times, 03/04/25 twice, and 03/23/25 three times. The DON confirmed she had reached out to the nurse and she had reported that she must have administered the medication if she had signed it off as administered.

Based on record review, interview, observation, and review of the fall prevention program policy and procedure, the facility failed to ensure thorough investigations, proper assessments and interventions were in place to prevent falls for three (Residents #84, #29, and #75) of four residents reviewed for falls. Actual Harm occurred when Resident #84's care planned interventions were not in working order resulting in a fall in which the resident sustained [REDACTED]. Findings include: 1. Review of Resident #84's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED].#84's bed. Review of Resident #84's care plan cover sheet, created on 01/23/17, revealed interventions including a pad alarm to bed. Review of the physician orders [REDACTED]. Review of the physician orders [REDACTED].#84's wheelchair. Review of the fall risk assessment dated [DATE] revealed Resident #84 was at high risk for falls. Review of Resident #84's progress notes revealed on 05/14/17 at 7:21 A.M., the resident was in bed and crawled onto the mat and floor. The note revealed Resident #84 stated she wanted to leave. Review of the note revealed no evidence of a review of the incident including evaluation of the cause of the incident and interventions that were in place or evidence of interventions to be implemented following the incident. Review of the progress note dated 07/11/17 at 6:38 A.M. revealed 911 was called. Review of the progress note dated 07/11/17 at 6:46 A.M. revealed the emergency medical technicians (EMT) arrived and Resident #84 was assessed. The note revealed a pressure dressing was applied to Resident #84's head by the EMT. Review of the progress note dated 07/11/17 at 1:15 P.M. revealed Resident #84 returned from the emergency room at 1:15 P.M. with five intact staples to the back of the head on right side. Review of the skin assessment dated [DATE] at 2:36 P.M. revealed Resident #84 has five staples to the back of the right side of the head with a laceration measuring five centimeters (cm) ong by less than 0.1 wide cm and a 1.5 cm long by 1.5 cm wide abrasion to the right side of the head with a ecchymotic bump surrounding the area. Review of Resident #84's progress notes dated 07/18/17 at 3:38 P.M. revealed the summary of the review of fall from 7/11/17. The note revealed Resident #84 had been assisted up to the chair by the state tested nurse aide (STNA) and the STNA placed a seatbelt on Resident #84. The note revealed approximately 15 minutes or less after getting up, the resident was laying on the floor in her room on her left side with some blood under her head. The note revealed the nurse placed a towel under the resident's head to control the bleeding from the laceration. The note revealed 911 was called for transport to the hospital for evaluation. Resident #84 was kept in position until the EMT arrived and the pressure dressing was applied to the head. Staff was unable to do full assessment prior to discharge due to the emergency situation. The resident remained alert and responsive between the fall and transport to the hospital. The note revealed neuro checks were initiated at the time of the fall and completed upon return from the emergency room . The note revealed 15 minute checks were initiated upon return from the emergency room and continued until 07/17/17. The note revealed a new seatbelt was ordered on [DATE] and obtained on 07/14/17 and placed on the wheelchair. Review of the note revealed staff stated the alarm did not sound at the time of the fall. Review of Resident #84's physician orders [REDACTED]. There was no evidence of physical therapy evaluation of the wheelchair or need of a new wheelchair. Review of the physician orders [REDACTED]. Review of the progress note dated 09/13/17 at 3:14 P.M. revealed Resident #84 was changed to a pediatric size wheelchair with a gel cushion. The seat belt was intact and functioning. Review of Resident #84's progress notes dated 09/15/17 at 4:20 P.M. revealed Resident #84 was in the hallway and observed sliding out of her wheelchair from underneath the seatbelt. Resident #84's right arm was still over the seatbelt. The note revealed the seatbelt was still attached and no injuries were noted from the fall. Interview on 09/21/17 at 2:41 P.M. with the Director of Nursing (DON) confirmed on 05/14/17, Resident #84 crawled from the bed to the mattress to the floor per the nursing progress notes on 05/14/17. The DON indicated the progress note was vague and confirmed the bed was a few inches higher than the mattress. The DON confirmed the note did not indicate if the bed alarm was functioning at that time or if anyone saw the resident crawling off the bed. The DON indicated she did not thoroughly evaluate this incident and there was no evidence of further interventions in place following this incident. The DON confirmed the resident sustained [REDACTED]. The DON confirmed the resident received five staples for the head laceration. The DON indicated STNA #10 disconnected the wheelchair cord from the alarm box during the night because it was making sounds and the resident was in bed at the time. The DON revealed STNA #10 then assisted Resident #84 out of bed on 07/11/17 in the morning and did not reconnect the cord to the alarm box. The DON confirmed this was the reason the alarm did not sound when Resident #84 released the seat belt resulting in the fall. The DON confirmed on 09/13/17 Resident #84's wheelchair was changed to a pediatric wheelchair resulting in discontinuation of the pommel cushion and the lateral support. The DON indicated the resident was small in stature and the wheelchair arms appeared too high and decided to change the resident's wheelchair to a smaller one. The DON confirmed there was no evaluation by therapy of proper positioning in the new wheelchair until after the resident slid out of the wheelchair on 09/15/17. The DON revealed through her review of the fall she concluded the seatbelt was properly positioned on Resident #84 prior to her sliding out of the wheelchair. The DON revealed Resident #84 had a gel cushion on the chair and slid due to her small stature underneath the seatbelt in vision of facility staff. The DON confirmed the fall was not able to be prevented and the resident's arm was over the seatbelt and the seatbelt continued to be fastened until staff was able to reach the resident and release the seat belt. The DON confirmed there were no injuries sustained from the 09/15/17 fall. Review of the falls prevention program policy revealed all residents will be assessed for risks of falls using the Fall Risk Assessment. The resident will be assessed upon admission, quarterly, annually, with significant change, and as needed as deemed by the Nurse Manager. The policy revealed if the resident scores higher than 10 on the fall risk assessment, he/she will have appropriate fall prevention interventions put into place. 2. Review of Resident #29's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED].#29's fall risk assessment dated [DATE] revealed Resident #29 was at risk for falls. Review of Resident #29's MDS 3.0 assessment dated [DATE] revealed Resident #29 had a short and long term memory problem, was severely cognitively impaired for daily decision making, and required extensive assistance of two persons for transfers. Review of Resident #29's current care plan revised on 01/24/17 revealed Resident #29 was at risk for falls and included to assist the resident with activities of daily living as needed. Observation on 09/21/17 at 1:15 P.M. revealed STNA #11 and STNA #12 assisted Resident #29 to transfer from the wheelchair to the bed. The STNA's placed a gait belt on the resident prior to assisting the resident and the wheelchair was positioned next to and parallel to the bed. While both STNAs were assisting the resident from sitting to standing, the wheelchair was observed to be unlocked and slightly rolled back. After the resident was standing, STNA #12 pushed the wheelchair back further toward Resident #29's roommate's side of the room. Interview on 09/21/17 at 1:19 P.M. with STNA #11 confirmed the wheelchair was not locked when they assisted Resident #29 from a seated position in the wheelchair to a standing position. STNA #11 confirmed the wheelchair should be locked when assisting the resident from a seated position in the wheelchair to a standing position. 3. Review of the medical record revealed Resident #75 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of a physician order [REDACTED].#75 to ask for assistance with transfers to reduce the risk for falls. Review of Fall Risk Assessments dated 08/28/17, 09/07/17 and 09/15/17 revealed Resident #75 was at a high risk for falls. Review of a physician order [REDACTED].#75 to ask for assistance with transfers to reduce the risk for falls. Review of a nurses note dated 08/09/17 and Falls Investigation Health Summary dated 08/20/17, revealed Resident #75 was found on the floor in front of his wheelchair on 08/09/17. A small scratch was found on the resident's right upper arm. The investigation revealed no alarm was sounding. Resident #75 was observed awake in bed on 09/21/17 at 1:29 P.M. The resident's wheelchair was at the foot of the bed. A sensor alarm was observed on the resident's wheelchair. However, no sensor alarm was observed on the resident's bed. An interview with Licensed Practical Nurse (LPN) #16 at the time of the observation verified a bed sensor pad was under the resident's bottom sheet, but the cord was not attached to a box battery alarming unit. An interview with the Director of Nursing (DON) on 09/21/17 at 4:02 P.M. regarding the resident's fall on 08/09/17. The DON revealed Resident #75 had been transferred from his bed to his wheelchair but the sensor alarm remained on the bed. The DON verified Resident #75 was sitting in his wheelchair and a safety alarm was not on the chair. This deficiency substantiates Complaint Number OH 392.