Every finding on record at Parkside Nursing and Rehabilitation Center

Based on medical record review, observation, staff interview, review of the facility policy, and review of online guidelines per the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement treatment once the pressure ulcers were identified. This resulted in Actual Harm for Resident #34, who was admitted to the facility without pressure ulcers and developed pressure ulcers to her right antecubital and left antecubital space (inside of the elbows), which were not identified and treated until they had developed into stage IV ulcers with exposed tendon. This affected one (Resident #34) of five residents reviewed for pressure ulcers. The facility census was 67 residents. Findings include:Review of the medical record for Resident #34 revealed an admission date of 04/25/24 with diagnoses including chronic respiratory failure, encephalopathy, and epilepsy. Review of the pressure ulcer risk assessment for Resident #34 dated 04/25/24 revealed the resident was at high risk for the development of pressure ulcers. Review of the physician’s orders for Resident #34 revealed an order dated 04/25/24 for the resident to have weekly skin checks per a licensed nurse. Review of the care plan for Resident #34, dated 04/26/24 revealed the resident had the potential for alteration in skin integrity and required protective/preventative skin care maintenance related to bladder incontinence, bowel incontinence, decreased mobility, history of previous skin breakdown, Impaired cognition. Interventions included the following: encourage the resident to float heels as tolerated, encourage to turn and reposition every two hours and as needed as tolerated, inspect for any reddened areas during daily care, pressure reducing cushion to chair to promote comfort and prevent skin breakdown, pressure reducing mattress on bed to promote comfort and prevent skin breakdown, monitor skin prior to and after placing bilateral hand splints. Review of the care plan for Resident #34, dated 04/26/24, revealed the resident needed assistance with activities of daily living (ADL) related to cognitive impairment, hemiparesis, immobility, and due to the resident being in a persistent vegetative state. Interventions included the following: inspect skin condition daily during personal care and report any impaired areas to the charge nurse, staff to anticipate needs, staff to perform ADL as the resident was totally dependent and did not participate in any aspect of the care task Review of the progress note for Resident #34 dated 03/06/25 revealed the facility met with the resident’s family to discuss the resident’s appropriateness for palliative care services, and the family was in agreement. The resident’s provider gave an order to admit the resident to palliative care services for acute respiratory failure. Review of the Minimum Data Set (MDS) assessment for Resident #34, dated 04/30/25, revealed the resident had impaired cognition and was dependent on staff for assistance with all ADL and received 100 percent of her nutrition via tube feeding. Review of the pressure ulcer risk assessment for Resident #34 dated 05/08/25 revealed the resident was at high risk for the development of pressure ulcers. Review of the weekly skin checks for Resident #34 dated 05/06/25, 05/13/25, 05/20/25, and 05/27/25, revealed the resident had no open areas. Review of the shower sheet for Resident #34 dated 05/23/25 completed by Certified Nursing Assistant (CNA) #48 and signed by Registered Nurse (RN) #89, revealed the aide noted two open areas to the inside of the resident’s right and left elbows. Review of the medical record for Resident #34 dated 05/23/25 to 05/28/25 revealed the record did not include documentation of open areas to the resident’s right and left inner elbows. Review of the skin assessment for Resident #34 dated 05/29/25, revealed there was a pressure ulcer to the resident’s right antecubital space which measured 1.0 centimeter (cm) in length by 2.0 cm in width by 0.5 cm in depth. The wound bed had full tendon exposure with 100 percent granulation tissue (new connective tissue). The resident also had a pressure ulcer to the left antecubital space which measured 1.0 cm in length by 1.0 cm in width by 0.3 cm in depth. The wound bed had full tendon exposure with 100 percent granulation tissue. Review of the physician’s order for Resident #34, dated 05/29/25, was to cleanse bilateral inner elbows with normal saline (NS), pat dry, apply calcium alginate to the wound beds, cover with an abdominal dressing (ABD), and loosely wrap with Kerlix (gauze roll), complete every night shift. Review of the care plan for Resident #34, dated 05/29/25, revealed the resident had an actual area of skin impairment of pressure related to contractures to the bilateral arms. Interventions included the following: initiate wound treatment, continue treatment as ordered by the physician, nursing to observe the wound dressing daily to ensure that the dressing remained intact and that there were no signs or symptoms of infection or increased drainage, observe and document character of wound weekly, observe for clinical changes, such as infection and/or worsening of wound, skin observation and document on bath/shower days, charge nurse to notify the wound nurse, physician and family of any new areas Review of the wound visit note for Resident #34 dated 06/04/25, per Wound Doctor (WD) #150 revealed the resident had a stage IV pressure area to the right antecubital space which measured 0.8 cm in length by 1.3 cm in width by 0.6 cm in depth. There was a moderate amount of exudate (drainage) from the wound with exposed underlying structure and 100 percent granulation tissue within the wound bed. The resident had a stage IV pressure area to the left antecubital space which measured 0.7 cm in length by 1.1 cm in width by 0.5 cm in depth. There was a moderate amount of exudate from the wound with exposed underlying structure and100 percent granulation tissue within the wound bed. The resident was at high risk for development of wounds due to encephalopathy, generalize muscle weakness, epilepsy, persistent vegetative state, and respiratory failure with tracheostomy status. During an observation of Resident #34’s skin on 07/24/25 at 11:09 A.M., Licensed Practical Nurse (LPN) #92 revealed the resident had a nickel sized open area to the right and left antecubital spaces which appeared to be approximately 0.5 cm in depth. Both areas had red wound beds, with the peri wound area intact, and no signs of infection. The wounds were healing. During an interview on 07/24/25 at 2:31 P.M., LPN #92 stated she functioned as the unit manager and the wound nurse for the facility, and she expected staff to notify her of any changes to the resident’s skin integrity and initiate treatment for new impaired skin areas immediately. LPN #92 said she did not recall how or when she was notified of the open areas for Resident #34. LPN #92 stated CNA #48 first identified open areas to Resident #34’s bilateral antecubital spaces on 05/23/25, but the facility did not initiate treatment until 05/29/25 when the areas were assessed to be stage IV pressure ulcers. During an interview on 07/24/25 at 2:35 P.M., the Director of Nursing (DON) stated Resident #34’s clinical condition was compromised due to acute respiratory failure and worsening bilateral arm contractures. Resident #34 had recently been ordered to receive palliative care services, the facility did not obtain timely treatment for the pressure ulcers. During an interview on 07/24/25 at 2:59 P.M., CNA #48 stated she observed small red open areas to the inside of Resident #34’s right and left elbows on 05/23/25 during a shower and she notified the nurse on duty immediately. Multiple attempts to reach RN #89 for a phone interview on 07/24/25 were unsuccessful. Review of the facility policy titled “Pressure Injury Prevention and Management”, dated 03/05/25, revealed that licensed nurses would conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Assessments of pressure injuries would be performed by a licensed nurse and documented in the resident’s medical record. The staging of pressure injuries would be clearly identified to ensure correct coding on the MDS. Nursing assistants would inspect the resident’s skin during bathing and would report any concerns to the resident’s nurse immediately after the task. Review of online guidelines per the NPUAP, dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines, revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that included the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. This deficiency represents noncompliance investigated under Complaint Number OH00165854 (iQIES 1308588) and Complaint Number OH00163312 (iQIES 1308586) and Complaint Number OH163016 (iQIES 1308585.)

Based on observation, staff interview, and review of the facility policy, the facility failed to store, prepare, and serve food in a sanitary manner and the facility failed to properly store potentially hazardous cleaning agents away from food preparation areas. This had the potential to affect all residents who receive food from the kitchen. The facility identified ten (Residents #1, #5, #15, #16, #35, #38, #46, #53, #64, #84) who do not receive food from the kitchen. The facility census was 67 residents. Findings include: 1.Observation during the initial tour of the kitchen on 07/21/25 at 8:50 A.M. with the Dietary Manager (DM) #102 revealed the refrigerator contained the following unlabeled and undated items: a large open metal container of cooked hamburgers, a large container of what appeared to be cooked sweet potatoes, a large metal container of chicken noodle soup, a large metal container of mashed potatoes, a container of cooked omelets, thirteen individual fruit cups in a paper containers, several pieces of sliced cheese, a large plastic container that appeared to be cooked pot roast. The freezer contained the following unlabeled and undated items: an open bag of curly fries, a bag of fish patties. Interview on 07/21/25 at 8:53 A.M. with DM #102 confirmed the unlabeled and undated items in the facility refrigerator and freezer.Review of the facility policy titled Date Marking for Food Safety dated 03/01/25 revealed the facility would adhere to a date marking system ensure safety of the ready-to-eat temperature control for food safety. The policy stated food would be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The marking system should consist of a color-coded label, the date of opening and the date the item should be discarded. 2. Observation on 07/21/25 at 8:54 A.M. during the initial tour of the kitchen with DM #102 revealed the facility had two gallons of bleach stored under the food preparation table with the steamer and next to the gas stove. Interview on 07/21/25 at 8:54 A.M. with DM #102 confirmed the two gallons of bleach located under the food preparation table next to the gas stove. DM #102 confirmed the two gallons of bleach should be stored in a proper storage area away from the food preparation area. Observation on 07/23/25 at 8:23 A.M. with DM #102 revealed there was a gallon of bleach stored under the food preparation table located next to the gas stove. The counter also contained a spray can of stainless-steel cleaner, and a gallon of de-[NAME]. Interview on 07/23/25 at 8:23 A.M. with DM #102 confirmed the gallon of bleach, the spray can of stainless-steel cleaner, and the gallon of delimer located on the food preparation counter next to the gas stove and confirmed these items should not be stored in food preparation areas.Review of the facility policy titled Chemical Storage dated 06/16/25 revealed chemicals used by the dietary department would be kept in a secure area or in a secure storage area. 3. Observation during the initial tour on 07/21/25 at 9:00 A.M. with DM #102 revealed there was a buildup of crumbs, dirt, and food debris all over the top of the dishwasher and on the kitchen counters. The kitchen ceiling vents in the food preparation areas had a black substance hanging from them. The steamer located next to the stove had a drip pan under it which contained three heavily soiled white towels covered with brown substance that had been shoved under the tray of the steamer. Interview on 07/21/25 at 9:05 A.M. with DM #102 confirmed the dirt and debris on top of the dishwasher and the kitchen counters, the black substance hanging from the ceiling vents, and the dirty towels which had been shoved under the steamer tray because the steamer was broken. Interview on 07/24/25 at 10:45 A.M. with Registered Dietician (RD) #103 confirmed the facility had ongoing issues related to the sanitization in the kitchen. RD #103 stated she had worked with DM #102 to ensure the kitchen was clean and sanitized. RD #103 stated she emailed the facility Administrator outlining identified issues in the kitchen. RD #103 sent an email to the Administrator on 06/05/25 regarding the need for the kitchen steamer to be repaired. RD #103 stated she sent an email to the Administrator on 06/24/25 indicating areas in the kitchen that needed deep cleaning and including the lights, the steam well, and the walls in the kitchen. RD #103 had recommended the kitchen have a routine cleaning schedule.Review of the facility policy titled Sanitary Conditions undated confirmed all food would be properly stored and all food equipment would be cleaned and maintained in a sanitary fashion. 4.Observation of the dishwasher on 07/21/25 at 9:06 A.M. revealed DM #102 ran the dishwasher through two cycles and the thermometer failed to move for the wash cycle or the rinse cycle. Interview on 07/21/25 at 9:16 A.M. with DM #102 confirmed the dishwasher was a low-temperature dishwasher and it should have reached 120 degrees Fahrenheit (F) for the wash cycle and for the rinse cycle to ensure the facility dishes were properly sanitized. DM #102 confirmed the facility dishwasher had been utilized to clean the Resident breakfast dishes on 07/21/25. DM #102 stated the facility would utilize the three compartment sink until the dishwasher was repaired. Observation on 07/22/25 at 1:45 P.M. with Dietary [NAME] (DC) #99 revealed he ran the dishwasher through two cycles. During the first wash cycle the thermometer did not read anything for the wash or rinse cycle. For the second cycle, the wash cycle failed to have a reading, and the rinse cycle read 120 (F). Interview on 07/22/25 at 1:55 P.M. with DC #99 confirmed the facility dishwasher was not reaching proper temperatures. DC #99 confirmed the facility utilized the broken dishwasher during breakfast and lunch to attempt to sanitize the resident's dishes.

Based on record review, review of the facility's Legionella Water Management Plan, observation of hot water tank temperatures, staff interview, and review of the facility legionella mission statement, the facility failed to ensure implementation and maintenance of the legionella water management plan. This had the potential to affect all residents in the facility. The facility census was 67 residents.Findings include: Review of a facility document titled Legionella Water Management Plan undated revealed water entered the facility from the local public water supply and was stored in five holding tanks that were heated by natural gas and/or electricity. There was a tank in a storage room located adjacent to the kitchen that supplied hot water only to the kitchen. There were two tanks located in the dirty utility room of the 100 and 200-nursing units. One tank was designated to supply hot water to the 100-nursing unit, and one tank was designated to supply hot water to the 200-nursing unit. There were two tanks located in the dirty utility room of the 300 and 400-nursing units dirty utility room. One tank was designated to supply hot water to the 300-nursing unit, and one tank was designated to supply hot water to the 400-nursing unit. The four water heaters that supplied hot water to the 100, 200, 300, and 400-nursing units were 120-gallon capacity tanks which were to be maintained at 140 degrees Fahrenheit (F). The facility was to contact the outside contractor for assistance if unable to maintain the tank temperatures at 140 degrees F. The facility was to check the flow and return temperatures for the water heaters located on the nursing units on a weekly basis. The temperature at the outlet of the hot water tank should not be lower than 140 degrees F and if unable to maintain the desired temperature the program team should develop secondary methods to ensure the system is performing as needed.Observation on 07/28/25 between 11:10 A.M. and 11:30 A.M. of water temperatures with Maintenance Assistant (MA) #117 revealed he used a digital thermometer to measure the temperature of the water output line. The kitchen hot water tank reached 122 degrees F and the hot water tanks for 100, 200, 300 and 400-nursing units reached 118 degrees F. Interview on 07/28/25 at 11:30 A.M. with MA #117 verified the temperature of the kitchen hot water tank was 122 degrees F at the outlet line, and the temperature of the 100, 200, 300, and 400-nursing unit hot water tanks was 118 degrees F at the outlet lines. MA #117 confirmed these temperatures did not meet the 140-degree F threshold and further confirmed the facility had not completed weekly temperature monitoring for the kitchen, 100, 200, 300 and 400-nursing unit hot water tank outlet line temperatures.Interview on 07/28/25 at 11:58 A.M. with the Senior Administrator (SA) #199 verified the kitchen, 100, 200, 300 and 400-nursing unit hot water holding tanks were to be maintained at 140 degrees F or greater.Review of the facility's Legionella Water Management Plan mission statement revealed the facility promoted proactive steps to establish healthy, infection-free environments for residents, staff and visitors. When residents contracted Legionnaires' disease, it was often the result of exposure to inadequately managed building water systems, which could be prevented.

Based on review of personnel files, and staff interview, the facility failed to ensure Certified Nursing Assistants (CNAs) completed the required annual number of continuing education hours. This had the potential to affect all residents residing in the facility. The facility census was 67 residents. Findings include: 1.Review of the personnel file for CNA #8 revealed a hire date of 12/07/22 with five hours of continuing education for calendar year 2024.Interview on 07/28/25 at 10:03 A.M. with Human Resources Manager (HRM) #109 verified CNA #8 had only five hours of continuing education completed for calendar year 2024. 2. Review of the personnel file for CNA #15 revealed a hire date of 02/13/23 with five hours of continuing education for calendar year 2024.Interview on 07/28/25 at 10:05 A.M. with HRM #109 verified CNA #15 had only five hours of continuing education completed for calendar year 2024 and the requirement was 12 hours of continuing education annually for CNAs.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to maintain a clean, safe, and sanitary environment. This affected two (Residents #3 and #62) and had the potential to affect all of the residents in the facility with the exception of seven facility-identified residents (#6, #18, #41, #45, #51, #67, #68) who did not utilize the shower rooms. The facility census was 67 residents.Findings include:1.Review of the medical record for Resident #3 revealed an admission date of 04/30/24 with diagnoses including atherosclerotic heart disease and osteoarthritis. Review of the Minimum Data Set (MDS) assessment for Resident #3 dated 6/14/25 revealed the resident had impaired cognition and required staff assistance with activities of daily living (ADLs.) Review of the medical record for Resident #62 revealed an admission date of 5/29/25 with diagnoses including traumatic subdural hemorrhage, cerebral infarction, hypertension, heart failure, and spinal stenosis. Review of the MDS assessment for Resident #62 dated 7/09/25 revealed the resident was cognitively intact and required supervision with ADLs. Observation on 07/24/25 at 11:20 A.M. of the room shared by Resident #3 and #62 revealed the room had a strong urine odor and the floor was dirty and sticky. Interview on 07/24/25 at 11:20 A.M with Resident #62 confirmed he was unhappy with staff because his roommate would use the urinal, and the staff did not empty it. The urinal would become full and spill out on the floor and then would run under the curtain toward his side of the room. Interview on 11/24/25 at 11:30 A.M. with Licensed Practical Nurse (LPN) #66 on 11/24/25 at 11:30 A.M. confirmed the room shared by Residents #3 and #62 had a very strong urine odor especially in the area near Resident #3’s urinal. LPN #66 confirmed the floor was soiled and extremely sticky. Review of the facility policy titled Safe and Homelike Environment dated 06/01/24 revealed the facility would create and maintain to the extent possible a homelike environment. Housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly, and comfortable environment. The facility would minimize odors by disposing of soiled linens promptly and reporting lingering odors. 2. Observation on 07/28/25 at 11:14 A.M. of the shower room on the 300 hall revealed the toilet was missing and the pipe had been covered, and there were missing pieces of tile around the pipe. Interview on 07/28 25 with Floor Tech (FT) #117 confirmed there were missing tiles from where the broken toilet had been removed. 3.Observation on 07/28/25 at 12:20 P.M. of the shower room on the 100 hall revealed there was dark discoloration between the shower tiles. The toilet bowl was elongated, but the seat was round which left a gap between the edge of the seat and the toilet bowl. The entrance to the shower room was missing pieces of tile, which exposed rough and jagged flooring under the tile. Interview on 07/28/25 at 12:25 P.M. with Registered Nurse (RN) #90 verified the findings in the shower room. This deficiency represents noncompliance investigated under Master Complaint Number OH00167100 (IQIES 1308589) and Complaint Number OH00162770 (iQIES 1308590.)

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to hold resident care conferences on a regular basis. This affected five (Residents #4, #83, #20, #34, and #41) of five residents reviewed for care planning. The facility census was 67 residents. Findings include:1.Review of the medical record for Resident #4 revealed an admission date of 04/21/23 with diagnoses including chronic respiratory failure with hypoxia, morbid obesity, and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #4 revealed the resident had intact cognition and was dependent on staff with activities of daily living (ADLs.) Interview on 07/21/25 at 10:18 A.M. with Resident #4 confirmed no knowledge of when he or his wife last attended a care conference. Review of the care conference summary reports for Resident #4 revealed the facility did not conduct care conferences for the resident for the third quarter of 2024, the first quarter of 2025, and the second quarter of 2025. Interview on 07/23/25 at 3:39 P.M. with Social Services Director (SSD) #60 and Regional Social Services Director (RSSD) #250 verified the facility had not held care conferences with Resident #4 for the third quarter of 2024, the first quarter of 2025, and the second quarter of 2025. 2. Review of the medical record for Resident #80 revealed an admission date of 06/21/24 with diagnoses including diabetes mellitus type one, morbid obesity, chronic right heart failure, peripheral vascular disease, and obstructive sleep apnea. The resident transferred to another nursing facility on 05/15/25. Review of the MDS assessment for Resident #80 dated 04/03/25 revealed the resident had intact cognition and required staff assistance with ADLs. Review of the care conference summary reports for Resident #80 revealed the facility did not conduct care conferences in the third quarter of 2024, the fourth quarter of 2024, and the first quarter of 2025. Interview on 07/23/25 at 3:40 P.M. with SSD #60 and RSSD #250 verified care conferences were not held with Resident #80 in the third quarter of 2024, the fourth quarter of 2024, and the first quarter of 2025. 3. Review of the medical record for Resident #20 revealed an admission date of o1/12/24 with diagnoses including chronic respiratory failure and quadriplegia. Review of the MDS assessment for Resident #20 dated 06/24/25 revealed the resident had intact cognition and was dependent on staff for ADLs. Review of the care conference summary reports for Resident #20 revealed the facility did not conduct care conferences in the first quarter of 2024, the second quarter of 2024, the fourth quarter of 2024, and the first quarter of 2025. Interview on 07/23/25 at 3:41 P.M. with SSD #60 and RSSD #250 verified the facility had not held care conferences with Resident #20 for the first quarter of 2024, the second quarter of 2024, and the first quarter of 2025. 4. Review of the medical record for Resident #34 revealed an admission date of 04/25/24 with diagnoses including chronic respiratory failure, encephalopathy, and epilepsy. Review of the MDS assessment for Resident #34 dated 04/30/25 revealed the resident had impaired cognition and was dependent on staff for ADLs. Review of the care conference summary reports for Resident #34 revealed the facility did not conduct care conferences in the third quarter of 2024, the fourth quarter of 2024, the first quarter of 2025, and the second quarter of 2025. Interview on 07/23/25 at 3:42 P.M. with SSD #60 and RSSD #250 verified the facility did not hold care conferences for Resident #34 in the third quarter of 2024, the fourth quarter of 2024, the first quarter of 2025, and the second quarter of 2025. 5. Review of the medical records for Resident #41 revealed an admission date of 08/23/24 with diagnoses including acute respiratory failure with hypoxia, dependence on mechanical ventilation, and cerebral infarction. Review of the MDS assessment for Resident #41 dated 06/28/25 revealed the resident had intact cognition and was dependent on staff for ADLs. Review of the care conference summary reports for Resident #41 revealed the facility did not conduct care conferences in the fourth quarter of 2024, the first quarter of 2025, and the second quarter of 2025. Interview on 07/23/25 at 3:43 P.M. with SSD #60 and RSSD #250 verified the facility had not held care conferences for Resident #41 in the fourth quarter of 2024, the first quarter of 2025, and the second quarter of 2025. Review of the policy titled Care Planning-Resident Participation dated 06/01/24 revealed the facility supported the resident’s right to be informed of, and participate in, his or her care planning and treatment (implementation of care). The facility would discuss the care plan with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility would obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan. This deficiency represents noncompliance investigated under Complaint Number OH00164605 (iQIES 1308587)

Based on medical record review, resident interview, staff interview, resident representative interview, review of Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to honor a resident's right to refuse a haircut. This affected one (Resident #71) of four residents reviewed for resident rights. The facility census was 67 residents.Findings include:Review of the medical record for Resident #71 revealed an admission date of 09/15/22 with diagnoses including traumatic subarachnoid hemorrhage, hydrocephalus, anoxic brain damage and epilepsy. Review of the shower sheet for Resident #71 dated 05/09/25 revealed the resident had a haircut. Interview on 07/21/25 at 1:19 P.M. with Resident #71 confirmed on 05/09/25 the facility staff cut her hair without her permission. Resident #71 stated the staff put her in a chair and held her down. Resident #71 stated she did not want the haircut, but they did it anyway. Interview on 07/22/2025 at 2:50 P.M. with Resident #71's power of attorney (POA) confirmed he felt the resident needed a haircut and he gave the facility permission to cut the resident's hair. Interview on 07/23/2025 at 8:20 A.M. with Certified Nursing Assistant (CNA) #24 confirmed Resident #71's brother asked the facility to cut the resident's hair because it was matted. CNA #24 confirmed the next day she brought Resident #71 to the nurses' station and began cutting the resident' hair using clippers beginning on the right side of the resident's head. Residents #71 asked the CNA to stop half-way through the haircut. CNA #24 stated she did not stop when the resident requested her to stop. CNA #24 stated Licensed Practical Nurse (LPN) #76 and Registered Nurse (RN) #90 were present and encouraged Resident #71 to allow her to continue with the haircut since half of it was already completed. Interview on 07/23/25 at 10:33 A.M. with LPN #76 confirmed she was working the day Resident #71's haircut. LPN #76 confirmed CNA #19 began the haircut and then CNA #24 took over. LPN #76 denied talking to Resident #71 regarding the haircut. Interview on 07/28/25 10:40 A.M. with RN #90 confirmed she observed CNA #24 cutting Resident #71's hair a couple months ago. RN #90 confirmed she was not present when Resident #71 asked for the aide to stop the haircut. She denied speaking to Resident #71 and encouraging CNA #24 to continue the haircut. Interview on 07/28/25 at 10:58 A.M. with CNA #19 confirmed she was assigned to Resident #71 on the day of the haircut. She reports she assisted Resident #71 to a reclining chair and brought her to the nurses' station. She then prepared for the haircut gathering a basin, shampoo, towels and clippers. Resident #71 refused to allow CNA #19 to cut her hair stating because she was white and the resident felt the aide didn't know how to cut her kind of hair. CNA#19 then went to CNA#24 and asked her to cut Resident #71's hair. Interview on 07/28/2025 at 11:55 A.M. with CNA#24 confirmed her signature on Resident #71' shower sheet dated 05/09/25 which indicated the resident had a haircut. Review of the facility SRI for Resident #71 dated 06/09/25 revealed the facility investigated an allegation of neglect/mistreatment abuse when CNA #24 cut Resident #71's hair on 05/09/25 without the resident's permission. The outside psychiatric services provider reported the incident to the facility on 6/9/25, but the hair cut occurred on 5/9/25. Approximately halfway through the haircut, the resident did tell the staff to stop. CNA #24 stopped temporarily, but then told the resident she needed to finish the other side of her head and then completed the haircut. The facility did not substantiate abuse. Record review of facility policy titled Resident Rights revealed the resident had the right to request, refuse and/or discontinue treatment and the resident had the right to make choices about aspects of her life that are significant to the resident. This deficiency represents noncompliance investigated under Complaint Number OH00164105 (iQIES 1308587) and Complaint Number OH00163312 (iQIES 1308685)Complaint Number OH00163016 (iQIES 1308585) and Complaint Number OH00162770 (iQIES 1308590.)

Based on medical record review, staff interview, resident representative interview, and review of the facility policy, the facility failed to notify residents in writing of room moves and failed to notify resident representatives of room moves. This affected one (Resident #5) of one resident reviewed for room moves. The facility census was 67 residents. Findings include: Review of the medical record for Resident #5 revealed an admission date of 12/20/24 with diagnoses including hypoxic ischemic encephalopathy, cerebral infarction, congestive heart failure (CHF), hypertension, and schizoaffective disorder. Review of the Minimum Data Set (MDS) assessment for Resident #5 dated 04/15/25 revealed the resident had impaired cognition and was dependent on staff for assistance with medication administration, transfers, eating, and personal care. Review of the progress notes for Resident #5 dated 06/17/25 60 06/19/25 revealed the notes did not include information regarding a room change on 06/17/25 through 06/19/25. Interview on 07/22/2025 at 10:22 A.M. with Resident #5's representative confirmed the facility failed to notify her of the resident's room move. Interview on 07/22/25 at 2:41 P.M with Admissions Director (AD) #55 confirmed Resident #5 had a room move on 06/17/25 and the facility failed to notify the resident's representative of the move until after it had already occurred.Review of the facility policy titled Change of Room or Roommate dated 03/01/25 revealed the facility would notify residents and resident representatives of changes in room or roommate in writing in a language and manner the resident and resident representative would understand. The notification should include the reason (s) why the move or change was required.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to maintain privacy of the resident electronic medical record (EMR). This affected one (Resident #53) of three residents reviewed for privacy. The facility census was 67 residents.Findings include: Review of the medical record for Resident #53 revealed an admission date of 06/03/25 with diagnoses including chronic respiratory failure with hypoxia, cerebrovascular accident, and diabetes mellitus type two. Review of the Minimum Data Set (MDS) assessment for Resident #53 06/10/25 revealed the resident had severe cognitive impairment and was dependent on staff assistance with activities of daily living (ADLs.) Observation on 07/21/25 at 11:18 A.M. revealed the respiratory therapy treatment cart on the 400-nursing unit was unattended with an open computer monitor that displayed private health information from Resident #53's EMR. Interview on 07/21/25 at 11:18 A.M. with Assistant Director of Nursing (ADON) #56 verified the facility staff had failed to protect the privacy medical information for Resident #53. Review of the policy titled Health Insurance Portability and Accountability Act (HIPAA) Security Measures dated 01/01/25 revealed it was the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information and/or records that are in electronic format. Only appropriate employees would have access to electronic protected health information.

Based on medical record review and staff interview, the facility failed to ensure comprehensive assessments were conducted within 14 days of a significant change in resident status. This affected one (Resident # 41) of three residents reviewed for comprehensive assessments. The facility census was 67 residents. Findings include:Review of the medical record for Resident #41 revealed an admission date of 08/23/24 with diagnoses including acute respiratory failure with hypoxia, dependence on mechanical ventilation, tracheostomy, and cerebral infarction. Review of the quarterly Minimum Data Set (MDS) for Resident #41 dated 06/28/25 revealed the resident had intact cognition and was dependent on staff for activities of daily living (ADLs). Review of the pulmonary progress note for Resident #41 dated 07/09/25 revealed the physician gave an order to decannulate (remove the breathing tube) for the resident. Review of the progress note for Resident #41 dated 07/09/25 revealed Respiratory Therapist (RT) #108 decannulated the resident. Review of the medical record for Resident #41 revealed it did not include a comprehensive MDS assessment for the resident following the significant change of being decannulated. Interview on 07/24/25 at 3:35 PM with Regional MDS Nurse (RMN) #142 confirmed the facility had not completed a comprehensive MDS assessment within 14 days of a significant change for the resident.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure baseline care plans were completed upon admission and a summary was provided to the resident and/or resident's representative within 48 hours of admission. This affected one (Resident #83) of three residents reviewed for admission rights. The facility census was 67 residents.Findings include:Review of the medical record for Resident #83 revealed an admission date of 12/27/24 with diagnoses including anoxic brain damage, and post-traumatic seizures and a discharge date of 06/03/25.Review of the initial/admission care conference report for Resident #83 dated 12/27/24 revealed the facility did not provide a summary of the baseline care plan to the resident.Review of the Minimum Data Set (MDS) assessment for Resident #83 dated 06/03/25 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.)Phone interview on 07/24/25 at 9:16 A.M. with Resident #83 confirmed he could not remember a time when the facility ever met with him about his care.Interview on 07/24/25 at 4:19 P.M. with Social Services Director (SSD) #60 verified the facility had not provided a summary of the baseline care plan to Resident #83 within 48 hours of admission as required.Review of the facility policy titled Care Planning-Resident Participation dated 06/01/24 revealed the facility supported the resident's right to be informed of, and participate in, his or her care planning and treatment (implementation of care). The facility will discuss the care plan with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility would obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan.

Based on medical record review, observation, and staff interview, the facility failed to identify and initiate prompt treatment for non-pressure wounds. This affected one (Resident #5) of one resident reviewed for skin conditions. The facility census was 67 residents. Findings include:Review of the medical record for Resident #5 revealed an admission date of 12/20/24 with diagnoses including hypoxic ischemic encephalopathy, cerebral infarction, congestive heart failure (CHF), schizoaffective disorder, and hidradenitis suppurativa. Review of the Minimum Data Set (MDS) assessment for Resident #5 dated 04/15/25 revealed the resident had impaired cognition and was dependent on staff assistance with activities of daily living (ADLs.) Review of the progress note for Resident #5 dated 07/14/25 at 1:50 P.M. revealed the nurse identified blood on the resident pillow and an open wound behind the resident's right ear. The nurse applied A&D ointment to the area.Review of the progress notes for Resident #5 dated 07/23/25 at 11:39 A.M. revealed there was an open area behind the resident's right ear that measured 1.2 centimeter (cm) in width by 0.4 cm in length by 0.1 cm in depth with a scant serosanguineous drainage. There was no treatment ordered.Review of Treatment Administration Record (TAR) for Resident #5 dated July 2025 revealed there were no treatments ordered for the open area to the resident's right ear.Observation on 07/21/25 at 9:49 A.M. revealed Resident #5's pillow had an unknown reddish rust stain smeared all over the right side of the pillow.Interview on 07/21/25 at 11:50 A.M. with Housekeeper (HK) #118 confirmed there was a dried rust-colored stain all over the right side of Resident #5's pillow. HK #118 stated he believed the unknown substance was dried blood.Interview on 07/22/25 at 10:21 A.M. with Resident #5's representative confirmed the resident had an open wound on his right ear.Interview on 07/23/2025 at 9:15 A.M. with Certified Nurse Aide (CNA) #44 confirmed Resident #5 had an open area behind his right ear that was identified a couple of weeks ago. Observation on 07/23/25 at 11:05 P.M. of the area behind Resident #5's ear with Licensed Practical Nurse (LPN) #66 revealed there was an area which measured 1.0 cm in length by 2.0 cm in width with a small amount of bloody drainage to the area behind the area and to the resident's pillow. Interview on 07/23/25 at 11:10 A.M. with LPN #66 confirmed the facility identified the open area to Resident #5's right ear on 07/14/25 and the facility had not initiated a treatment.Interview on 07/23/25 at 12:50 P.M. with Nurse Practitioner (NP) #251 stated Resident #5 had a treatment order to apply ointment to resident's dry skin but there was no order specific to the area behind the residents' right ear. NP #251 stated she believed the area behind the right ear was a non-pressure wound related to the resident's diagnosis of hidradenitis suppurativa (a chronic skin condition featuring lumps under the skin that can be painful and tend to enlarge and drain pus.) Interview on 07/30/25 at 10:54 A.M. with Assistant Director of Nursing (ADON) #56 confirmed the facility failed to put a treatment in place for Resident #05's ear after the nurse identified the open area behind the right ear on 07/14/25. This deficiency represents noncompliance investigated under Complaint Number OH00163016 (iQIES 1308585.)

Based on medical record review, resident interview, staff interview, and review the facility policy, the failed to appropriately assess and treat resident pain. This affected one (Resident #62) of three residents reviewed for pain management. The facility census was 67 residents Findings include:Review of the medical record for Resident #62 revealed an admission date of on 5/29/25 with diagnoses including traumatic subdural hemorrhage, cerebral infarction, heart failure, and spinal stenosis. Resident #62 was transferred to the hospital on [DATE] and was readmitted to the facility on [DATE].Review of the Minimum Data Set (MDS) assessment for Resident #62 dated 7/09/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.)Review of the Medication Administration Record (MAR) for Resident #62 dated July 2025 for Resident #62 revealed there was an order for oxycodone 5 milligrams (mg) every six hours with a start date of 07/02/25 and a stop date of 07/23/25.Review of the hospital order form for Resident #62 dated 07/22/25 at the time of discharge from the hospital revealed there was no order for oxycodone.Review of the facility-controlled drug receipt disposition form for Resident #62 for Oxycodone IR Tablet 5 mg confirmed he received a dose on 07/22/25 at 7:40 P.M.Review of the readmission nursing assessment for Resident #62 dated 07/22/25 revealed the resident voiced complaints of pain and rated the pain as a three on a scale of 1 to 10 with 10 being the worst pain. Review of the facility-controlled drug receipt disposition form for Resident #62 revealed the resident received a dose of oxycodone 5 mg on 07/22/25 at 7:40 P.M.Review of the physician order summary for Resident #62 revealed an order dated 07/24/25 for oxycodone 5mg one tablet every six hours as needed for pain. Interview on 07/24/25 at 11:20 A.M with Resident #62 confirmed he returned from the hospital on [DATE] in the evening and asked for his pain medication and the nurse gave him a pain pill. Resident #62 confirmed the nurse later told him he would not be able to have any more doses of pain medications because the facility did not have an order. Resident #62 stated he did not understand, and he was in pain. Resident #62 stated he had told the nurses numerous time that he had pain and nothing was done. Interview on 07/24/24 at 11:30 A.M. with Licensed Practical Nurse (LPN) #66 confirmed the evening staff gave Resident #62 an oxycodone 5 mg tablet on 07/22/25 at 7:40 P.M. LPN #66 stated Resident #62 had an order for oxycodone as needed prior to discharge to the hospital. LPN #66 stated she assumed the evening nurse thought Resident #62 had readmitted with the same oxycodone order and administered it to him. LPN #66 confirmed Resident #66 had voiced complaints of pain, but the facility did not have an order on file for the pain medication, and she was not able to administer the medication. LPN #66 confirmed Resident #62 had not been given his as needed pain medication since the one dose he received after his return from the hospital on [DATE]. Review of the facility policy titled Pain Management dated 08/22/22 revealed the facility must ensure that pain management was provided to residents consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goal and preferences. The facility would recognize when the resident was experiencing pain and evaluate the resident for pain upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurred and should manage or prevent pain consistent with the comprehensive assessment and plan of care.

Based on medical record review, observation, staff interview, review of manufacturer's guidelines, and review of the facility policy, the facility failed to ensure insulin pens were properly labeled and stored. This affected two (Residents #15 and #65) of four residents who received insulin stored in the 200-medication cart. The facility census was 67 residents. Findings include:1. Review of the medical record for Resident #15 revealed an admission date of 1/07/24 with diagnoses of diabetes mellitus type and acute and chronic respiratory failure with hypoxia. Review of the Minimum Data Set (MDS) assessment for Resident #15 dated 05/16/25 revealed the resident had severe cognitive impairment and was dependent on staff for assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #15 revealed an order dated 07/02/25 for insulin Glargine inject seven units subcutaneously at bedtime for diabetes mellitus. Observation on 07/23/25 at 9:21 A.M. of the 200-hall medication cart with Licensed Practical Nurse #66 revealed Resident #15's insulin Glargine pen was not dated. Interview on 07/23/25 at 9:22 A.M. with LPN #66 confirmed Resident #15's insulin Glargine pen was not dated when removed from refrigerated storage and placed in the 200-hall medication cart. 2. Review of the medical record for Resident #65 revealed an admission date of 05/16/24 with diagnoses of diverticulitis, atherosclerotic heart disease, diabetes mellitus type two, and chronic obstructive pulmonary disease. Review of the MDS assessment for Resident #65 dated 05/23/25 for revealed the resident had intact cognition and required set up assistance with ADLs. Review of physician's orders for Resident #65 revealed an order dated 07/14/25 for Lantus SoloStar insulin pen inject eight unit subcutaneously at bedtime. Observation on 07/23/25 at 9:23 A.M. of the 200-hall medication cart with LPN #66 revealed Resident #65's Lantus SoloStar insulin pen was not dated. Interview on 07/23/25 at 9:24 A.M. with LPN #66 confirmed Resident #65's Lantus SoloStar insulin pen was not dated when removed from refrigerated storage and placed in the 200-hall medication cart Interview on 07/23/25 at 5:15 P.M. with the Director of Nursing and Assistant Director of Nursing #56 verified insulin is to be dated when removed from refrigerated storage and placed in the medication cart. Review of the manufacturer's guidelines for insulin products undated revealed staff should label insulin with the date when taken from refrigeration or put into the cart. Review of the facility policy titled Medication Storage reviewed/revised 03/03/25 revealed it was the policy of the facility to ensure all medications housed on the premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.

Based on medical record review, observation, resident interview, and staff interview, the facility failed to provide residents with food that was appealing and palatable. This affected Resident #26 and#62 and had the potential to affect all residents at the facility. The facility identified ten (Residents #1, #5, #15, #16, #35, #38, #46, #53, #64, #84) who did not receive food from the kitchen. The facility census was 67 residents. Findings include: 1.Review of the medical record for Resident #26 revealed an admission date of 12/18/24 with diagnoses including chronic atrial fibrillation, major depressive disorder, hypothyroidism, vascular dementia, heart failure, anorexia. Review of the Minimum Data Set (MDS) assessment for Resident #26 dated 06/27/25 revealed the resident had impaired cognition and required set up assistance from staff with her meals. Review of the physician's orders for Resident #26 revealed an order dated 01/09/25 for a regular diet, mechanical soft texture.Observation on 07/23/25 at 12:30 P.M. revealed Resident #26 was propped up in her bed and her meal was in a closed container on the bedside table. Resident #26 opened the container and there was a gnat flying around the mechanical soft meal which consisted of fish, broccoli and rice.Interview 07/23/25 at 12:31 P.M. with Resident #26 confirmed she could not eat the meal because it tasted terrible and the food was always served cold and tasted terrible.Interview on 07/23/25 at 12:33 P.M. with Licensed Practical Nurse (LPN) 66 confirmed Resident #26's meal tray did not look appealing and contained a gnat flying inside the container of the resident's lunch. 2. Review of the medical record for Resident #62 revealed an admission date of 5/29/25 with diagnoses including traumatic subdural hemorrhage, cerebral infarction, essential primary hypertension, gastro esophageal reflux disease (GERD), heart failure, and spinal stenosis. Review of the MDS assessment for Resident #62 dated 07/09/25 revealed the resident was cognitively intact and required set up assistance with meals. Interview on 07/24/25 at 11:07 A.M. with Resident #62 confirmed he was not happy with the food at the facility. Resident #62 stated the food was unappealing and never served at the correct temperature. Resident #62 stated he thought this was because the food trays sat on the carts too long before the staff passed them out. 3.Observation on 07/23/25 at 11:00 A.M. with Dietary [NAME] (DC)#95 revealed DC #95 prepared mechanical soft fish by mixing water with chicken paste and pouring it in with the fish. The fish was mixed into an unappealing white ball and returned to the pan for mechanical soft diets. DC #95 walked over to the food tray line and served the lump of mechanical soft fish and told the staff on the tray line he would not eat that as he referred to the lump of white mechanical soft fish. Interview on 07/23/25 at 11:05 A.M. with DC #95 confirmed he did not utilize a recipe when he mixed the mechanical soft and pureed food. DC #95 stated he had performed his job for so long he did not need a recipe, and he could just eyeball it. Observation on 07/23/25 at 11:20 A.M. revealed DM#102 placed three servings of steamed broccoli and added four cups of hot water. DM #102 continued to add eight heaping scoops of thickener to three servings of steamed broccoli. Interview on 07/23/25 at 11:22 A.M. confirmed he had placed three services of steamed broccoli into the mixer along with the four cups of hot water. DM #102 confirmed he added the food thickener and stated he wanted the broccoli to be the texture of mashed potatoes. Observation of the test tray on 07/23/25 revealed it left the kitchen on a cart at 12:11 P.M. and all meals were served to the residents at 12:31 P.M. The test tray contained two pieces of baked fish, steamed broccoli, broccoli and cheddar casserole, and iced vanilla cake. Observation with Dietary Manager (DM) #102 on 07/23/25 at 12:11 P.M. revealed the lunch test tray was delivered to 100 hallway. The facility delivered all the resident meals on the 100 hallway, and the test tray was obtained at 12:31 P.M. The fish was cold and did not have a pleasant taste. The broccoli was cold and chewy. The rice casserole was cold, chewy and did not have pleasant taste. The cake was very hard to cut and tasted very dry. Interview with DM #102 on 07/23/25 at 12:33 P.M. confirmed the test tray appeared unappealing. DM #102 confirmed the baked breaded fish was an odd white frozen color, he confirmed the steam broccoli and broccoli cheddar casserole were chewy, and the cake was dry and hard to cut.

Based on observation, staff interview, and review of the facility policy, the facility failed to provide privacy curtains in resident rooms. This affected four (Residents #26, #28, #59, #62) four residents reviewed for privacy. The facility census was 67 residents.Findings include: Observation on 07/24/25 at 8:42 A.M. with Assistant Director of Nursing (ADON) #56 revealed there were no privacy curtains in the rooms of Residents #26, #28, #59, and #62.Interview 07/24/25 at 8:46 A.M. with ADON #56 confirmed the facility had not provided proper privacy curtains to ensure full visual privacy in the rooms of Residents #26, #28, #59, and #62.Review of the facility policy titled Resident Rights dated 06/01/24 revealed residents had the right to be treated with dignity and respect and had a right to privacy during personal care.

Based on medical record review, observation, staff interview, resident interview, and review of the facility policy, the facility failed to provide an effective pest control program. This affected three (Residents #3, #26, #44) of three residents reviewed for pest control. The facility census was 67 residents.Findings include: 1.Review of the medical record for Resident #3 revealed an 04/30/24 with diagnoses including atherosclerotic heart disease, osteoarthritis, and asthma.Review of the Minimum Data Set (MDS) assessment for Resident #3 dated 6/14/25 revealed the resident had impaired cognition.Observation on 07/21/25 at 11:04 A.M. revealed there were multiple large black flying insects in Resident #3's room. Interview on 07/21/25 at 11:19 A.M. with Unit Manager (UM) #140 confirmed there were multiple large black flying insects in Resident # 3's room.2. Review of the medical record for Resident #26 revealed an admission date of 12/18/24 with diagnoses including chronic atrial fibrillation, major depressive disorder, vascular dementia, and anorexia. Review of the MDS assessment for Resident #26 dated 6/27/25 revealed the resident had impaired cognition and required set up assistance from staff with her meals.Observation on 07/23/25 at 12:30 P.M. revealed Resident #26 was propped up in her bed and her meal was in a closed container on her bedside table. Resident #26 opened the container and there was a gnat flying around inside her meal. Interview on 07/23/25 at 12:31 P.M. with Resident #26 confirmed there was a gnat flying around inside her meal. Interview on 07/23/25 at 12:33 P.M. with Licensed Practical Nurse (LPN) 66 confirmed the meal tray did not look appealing and contained a gnat flying inside the container of Resident #26's lunch.Interview on 07/24/25 at 9:20 A.M. with Maintenance Assistance (MA) #117 confirmed the staff had reported to him that Resident #26 had active gnats in her room. MA #117 reported when staff notified him of a pest issue, he was to contact the pest control company.3. Review of the medical record for Resident #44 revealed an admission date of 02/23/24 with diagnoses including anemia, congestive heart failure, hypertension, and diabetes mellitus. Observation on 07/23/25 at 8:33 A.M. of Resident #44 revealed multiple flies were observed on the resident's motorized wheelchair.Interview on 07/23/25 at 9:02 A.M. with LPN #66 verified the flies in the resident's room.Interview on 07/24/25 at 9:20 A.M. with MA #117 confirmed he was not aware of the issues related to flies in Resident #44's room.Review of the facility policy titled Pest Control dated April 2014 revealed it was the policy of the facility to ensure the facility was free of pest and rodents by maintaining an effective pest control program to eradicate and contain common household pests (example roach, mosquitoes, bees, flies, mice, rats).

Based on record review and staff interviews, the facility failed to ensure all residents were treated with respect and dignity. This affected one (#77) out of three residents reviewed for respect and dignity. The facility census was 69. Findings include: Review of the medical record for Resident #77 revealed he was admitted to the facility on [DATE] and discharged on [DATE]. Diagnoses included dependence on respirator, congenital malformation of brain, acute and chronic respiratory failure with hypoxia, other seizures, fusion of spine, arthropathy, acute infarction of spinal cord, disorder of central nervous system, scoliosis, vitamin d deficiency, anxiety disorder, chronic pain syndrome, and cortical blindness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/11/23, revealed Resident #77 was in a persistent vegetative state and was unable to be assessed for cognitive status. Resident #77 was dependent on staff for oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility, and transfer. Resident #77 also required the use of a feeding tube. Review of the facility investigation revealed a camera in the room of Resident #77 had recorded State tested Nursing Assistant (STNA) #800 sitting in the room on her phone with a hand in her pants. Interview on 02/07/24 at 2:02 P.M. via phone with State tested Nursing Assistant (STNA) #800 revealed she was sent into Resident #77's room by the nurse to observe his breathing treatment. STNA #800 confirmed she was on her phone while in the room, and that she was scratching herself because she had shaved recently and had an itch. Interview on 02/07/24 at 4:35 P.M. with the Administrator and Assistant Director of Nursing (ADON) #108 revealed ADON #108 advised it was not best practice for staff to have phones out in resident rooms. The Administrator reported that he had just met with a detective from the local police department today because Resident #77's family had filed a police report regarding the situation of STNA #800 being in the residents room on a phone and having her hand in her pants. The Administrator stated he had watched the video at the police station, but it was different than what he was shown by Resident #77's family. The Administrator expressed STNA #800 was sitting in a chair with a hand in her pants area and was using her phone. Interview on 02/08/24 at 11:35 A.M. with Social Services Director #55 revealed she had observed the brief video and believed STNA #800's behavior was inappropriate and disrespectful to Resident #77. This deficiency represents non-compliance investigated under Complaint Numbers OH00150922, OH00150122 and OH00150029.

Based on record review, review of facility self-reported incidents (SRI's), review of staff timesheets, staff interviews, and policy review, the facility failed to report an allegation of staff to resident abuse to the state surveying agency as required. This affected one (#77) out of three residents reviewed for abuse. The census was 69. Findings include: Review of the medical record for Resident #77 revealed he was admitted to the facility on [DATE] and discharged on [DATE]. Diagnoses included dependence on respirator, congenital malformation of brain, acute and chronic respiratory failure with hypoxia, other seizures, fusion of spine, arthropathy, acute infarction of spinal cord, disorder of central nervous system, scoliosis, vitamin d deficiency, anxiety disorder, chronic pain syndrome, and cortical blindness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/11/23, revealed Resident #77 was in a persistent vegetative state and was unable to be assessed for cognitive status. Resident #77 was dependent on staff for oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility, and transfer. Resident #77 also required the use of a feeding tube. Review of the facility investigation revealed a statement by the Director of Nursing (DON) regarding an interaction with Resident #77's family that occurred on 01/12/24. The statement indicated the family of Resident #77 showed the DON, Administrator and Social Services Director #55 a video from a camera in Resident #77's room. Per the DON's statement, the video showed a State tested Nursing Assistant (STNA), identified as STNA #800 by the facility, sitting in a chair in the room holding her cell phone in one hand with her other hand in her pants as though she was scratching her abdomen. The statement also revealed Resident #77's family alleged the STNA was pleasuring herself. Further review of the facility investigation revealed a statement from Licensed Practical Nurse (LPN) #138 that expressed on 01/12/24 around 12:30 A.M. that she had asked STNA #800 to sit in Resident #77's room to observe a breathing treatment. The statement expressed around 12:45 A.M. the nurse, identified as LPN #900, informed LPN #138 that Resident #77's guardian had called the facility and stated the STNA was in Resident #77's room and had put her hands into her pants and then sniffed them. Review of the facility investigation revealed no statement from LPN #900. Review of the timesheet for STNA #800 revealed she worked on 01/11/24 from 6:40 P.M. to 01/12/25 at 3:00 A.M. Review of the facility's SRI's from 01/12/24 through 02/07/24 revealed no SRI had been filed regarding Resident #77 and the alleged incident that occurred on 01/12/24. Interview on 02/07/24 at 12:38 P.M. via phone with LPN #900 revealed Resident #77's family member had called the facility and reported there was an STNA in the room on camera that was touching her private part. LPN #900 stated she and another staff member went to Resident #77's room and asked the STNA (#800) to leave. LPN #900 expressed she called management as she wasn't sure if the situation was considered abuse. LPN #900 reported STNA #800 stayed until the end of her shift at 3:00 A.M. because staff were unaware of what the protocol was. Interview on 02/07/24 at 4:35 P.M. with the Administrator revealed the facility did not believe the allegation warranted filing an SRI. However, the Administrator reported the facility educated staff on the abuse policy as they utilized any opportunity to provide education to staff on various topics. Interview on 02/08/24 at 12:59 P.M. with the DON revealed she had interviewed other residents about staff behavior and if they felt safe in the facility because of the accusation made by Resident #77's family on 01/12/24. Interview on 02/07/24 at 4:35 P.M. with the DON confirmed she had not obtained a statement from LPN #900 regarding the alleged incident involving STNA #800 and Resident #77. Review of the facility policy titled Abuse, Neglect and Exploitation, reviewed 10/01/22, revealed the facility would have written procedures that included reporting all alleged violations to the Administrator, state agency, and other required agencies immediately but no later than two hours after an allegation is made if the events that caused the allegation involved abuse or resulted in serious bodily injury, or no later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury. Further review of the policy revealed the written procedures for investigations included identifying and interviewing all involved persons, and providing thorough documentation of the investigation. The policy also indicated that efforts would be made to protect residents from harm as well as additional abuse during and after the investigation, which included responding immediately to protect the alleged victim as well as the integrity of the investigation, and staffing changes if needed to protect residents from the alleged perpetrator. This deficiency represents non-compliance investigated under Complaint Number OH00150122.

Based on record review, review of facility self-reported incidents (SRI's), review of staff timesheets, staff interviews, and policy review, the facility failed to conduct a thorough investigation following an allegation of staff to resident abuse. This affected one (#77) out of three residents reviewed for abuse. The census was 69. Findings include: Review of the medical record for Resident #77 revealed he was admitted to the facility on [DATE] and discharged on [DATE]. Diagnoses included dependence on respirator, congenital malformation of brain, acute and chronic respiratory failure with hypoxia, other seizures, fusion of spine, arthropathy, acute infarction of spinal cord, disorder of central nervous system, scoliosis, vitamin d deficiency, anxiety disorder, chronic pain syndrome, and cortical blindness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/11/23, revealed Resident #77 was in a persistent vegetative state and was unable to be assessed for cognitive status. Resident #77 was dependent on staff for oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility, and transfer. Resident #77 also required the use of a feeding tube. Review of the facility investigation revealed a statement by the Director of Nursing (DON) regarding an interaction with Resident #77's family that occurred on 01/12/24. The statement indicated the family of Resident #77 showed the DON, Administrator and Social Services Director #55 a video from a camera in Resident #77's room. Per the DON's statement, the video showed a State tested Nursing Assistant (STNA), identified as STNA #800 by the facility, sitting in a chair in the room holding her cell phone in one hand with her other hand in her pants as though she was scratching her abdomen. The statement also revealed Resident #77's family alleged the STNA was pleasuring herself. Further review of the facility investigation revealed a statement from Licensed Practical Nurse (LPN) #138 that expressed on 01/12/24 around 12:30 A.M. that she had asked STNA #800 to sit in Resident #77's room to observe a breathing treatment. The statement expressed around 12:45 A.M. the nurse, identified as LPN #900, informed LPN #138 that Resident #77's guardian had called the facility and stated the STNA was in Resident #77's room and had put her hands into her pants and then sniffed them. Review of the facility investigation revealed no statement from LPN #900. Review of the timesheet for STNA #800 revealed she worked on 01/11/24 from 6:40 P.M. to 01/12/25 at 3:00 A.M. Review of the facility's SRI's from 01/12/24 through 02/07/24 revealed no SRI had been filed regarding Resident #77 and the alleged incident that occurred on 01/12/24. Interview on 02/07/24 at 12:38 P.M. via phone with LPN #900 revealed Resident #77's family member had called the facility and reported there was an STNA in the room on camera that was touching her private part. LPN #900 stated she and another staff member went to Resident #77's room and asked the STNA (#800) to leave. LPN #900 expressed she called management as she wasn't sure if the situation was considered abuse. LPN #900 reported STNA #800 stayed until the end of her shift at 3:00 A.M. because staff were unaware of what the protocol was. Interview on 02/07/24 at 4:35 P.M. with the Administrator revealed the facility did not believe the allegation warranted filing an SRI. However, the Administrator reported the facility educated staff on the abuse policy as they utilized any opportunity to provide education to staff on various topics. Interview on 02/08/24 at 12:59 P.M. with the DON revealed she had interviewed other residents about staff behavior and if they felt safe in the facility because of the accusation made by Resident #77's family on 01/12/24. Interview on 02/07/24 at 4:35 P.M. with the DON confirmed she had not obtained a statement from LPN #900 regarding the alleged incident involving STNA #800 and Resident #77. Review of the facility policy titled Abuse, Neglect and Exploitation, reviewed 10/01/22, revealed the facility would have written procedures that included reporting all alleged violations to the Administrator, state agency, and other required agencies immediately but no later than two hours after an allegation is made if the events that caused the allegation involved abuse or resulted in serious bodily injury, or no later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury. Further review of the policy revealed the written procedures for investigations included identifying and interviewing all involved persons, and providing thorough documentation of the investigation. The policy also indicated that efforts would be made to protect residents from harm as well as additional abuse during and after the investigation, which included responding immediately to protect the alleged victim as well as the integrity of the investigation, and staffing changes if needed to protect residents from the alleged perpetrator. This deficiency represents non-compliance investigated under Complaint Number OH00150122.

Based on record review, observation, staff interview, review of facility policy, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess the resident's skin and failed to timely identify a resident's pressure ulcer until it reached an advanced stage which resulted in actual harm to Resident #44 who developed an unstageable pressure ulcer to the left flank which required sharp debridement. The facility also failed to develop and implement a care plan to prevent skin breakdown which placed the resident (#74) at risk for more than potential harm that was not actual harm. This affected two (Residents #44 and #74) of three residents reviewed for pressure ulcers. The facility census was 73. Findings include: 1. Review of the medical record for Resident #44 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), diffuse traumatic brain injury (TBI), chronic respiratory failure with hypoxia, and protein calorie malnutrition. Review of the nurse's weekly skin observation dated 06/02/23 for Resident #44, revealed there were no new areas of skin impairment noted. There was no documented evidence a weekly skin observation for Resident #44 was completed on 06/09/23 and 06/16/23. Review of the care plan dated 06/04/23 for Resident #44, revealed the resident had a potential for impairment to skin integrity related to decreased mobility, dependence on staff for all activities of daily living (ADLs), bowel and bladder incontinence, and receiving enteral nutrition. Interventions included the following: educate resident/family on skin breakdown risk factors and preventative measures, encourage, and assist to float heel as tolerated, encourage, and assist to turn and reposition often, evaluate resident's specific risk factors, provide low air loss mattress-setting per weight and comfort, once weekly skin assessment, pressure reducing cushion to chair, and provide assistance with hygiene, including peri care as needed. Review of the shower sheets dated 06/04/23, 06/07/23, 06/11/23, and 06/14/23 for Resident #44, revealed there were no new areas noted to the resident's skin. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #44, revealed the resident was cognitively impaired and was totally dependent on the assistance of one to two staff with activities of daily living (ADLs.) Resident #44 was assessed as not having the presence of any pressure ulcers. Review of the pressure ulcer risk assessment dated [DATE] for Resident #44, revealed the resident was at risk for the development of pressure ulcers. Review of the nurse's skin grid dated 06/17/23 for Resident #44, revealed an unstageable pressure (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough [dead, yellowish tissue] or eschar [dry, back hard necrotic tissue] and if the slough or eschar is removed, a Stage III or Stage IV will be revealed) to the resident's left flank which measured 9.0 centimeters (cm) in length by 5.0 cm in width with depth unable to be determined. The wound bed had green and yellow slough in the middle. Review of the nurse's skid grid dated 06/19/23 for Resident #44, revealed an unstageable pressure ulcer to the resident's left flank first identified on 06/17/23 which measured 3.0 cm in length by 3.7 cm in width with depth unable to be determined. The wound bed consisted of 10 percent (%) granulation tissue, 10% slough, and 80% eschar. The wound had approximated edges, a moderate amount of tan and green and yellow colored drainage. Review of the wound physician progress note dated 06/21/23 for Resident #44, revealed the resident had a newly identified unstageable pressure ulcer to the left flank first identified on 06/17/23 which measured 3.4 cm. in length by 5.2 cm. in width with depth unable to be determined. The composition of the wound bed tissue at the beginning of the visit was 50% granulation, 15% slough, and 35 % eschar. The wound physician performed a sharp debridement (surgical procedure of the wound with sharp instruments where devitalized tissue is removed) at the bedside using a curette to remove eschar and slough tissue and used benzocaine spray to control resident's pain during the procedure. Following the debridement procedure, the unstageable pressure area was recategorized as a stage III pressure ulcer (full thickness loss of skin, in which fat tissue is visible.) Observation of wound care on 08/01/23 at 9:11 A.M. for Resident #44 per Licensed Practical Nurse (LPN) #392, revealed the resident was resting on a pressure reduction mattress. Observation revealed the resident had a dime-sized healing pressure ulcer to the left flank. Interview with LPN #630 on 08/01/23 at 2:39 P.M. confirmed she participated in wound rounds with the wound physician, and she completed the skin grid for Resident #44 on 06/19/23. LPN #630 confirmed skin observations should be performed weekly by a licensed nurse, and Resident #44 had no skin observations recorded from 06/02/23 until 06/17/23 when the resident was found to have an unstageable pressure ulcer to his left flank. LPN #630 confirmed the pressure ulcer should have been identified before it had reached an advanced stage. LPN #630 confirmed she assisted the wound physician on 06/21/23 when he had to perform a sharp debridement on Resident #44 in order to remove the eschar and slough tissue from the wound. Interview with LPN #630 on 08/01/23 at 3:15 P.M. confirmed the State tested Nursing Assistants (STNAs) had showered and completed the shower sheets for Resident #44 during the time period of 06/02/23 to 06/17/23 and the STNAs did not identify any new skin areas for the resident. LPN #630 confirmed the shower sheets did not take the place of a nurse's assessment for the resident's skin. 2. Review of the closed medical record for Resident #74 revealed an admitted [DATE] with diagnoses including diabetes mellitus (DM), cerebral infarction, acute respiratory failure with hypoxia, asthma, hypertension, sleep apnea, atherosclerotic heart disease, and recent acute myocardial infarction and a discharge date of [DATE]. Review of the admission assessment/baseline care plan dated 07/07/23 for Resident #74, revealed the resident had no areas of skin impairment and there were no documented interventions for the prevention of skin breakdown for resident. Review of the pressure ulcer risk assessment dated [DATE] for Resident #74, revealed the resident was at very high risk for the development of pressure ulcers. Review of the July 2023 Treatment Administration Record (TAR) for Resident #74, revealed it included weekly skin check for resident signed off as completed on 07/09/23; however, there were no other interventions or treatments included in the TAR for prevention of skin breakdown. Review of the nurse's weekly skin observation dated 07/09/23 for Resident #74, revealed the resident had no areas of skin impairment. Review of the MDS assessment dated [DATE] for Resident #74, revealed the resident was cognitively impaired, required extensive assistance of staff with ADLs, and was assessed as having a stage II pressure ulcer (partial thickness loss of skin with exposed dermis) which was not present upon admission. Review of the comprehensive care plan dated 07/14/23 for Resident #74, created after the resident had discharged , revealed the resident had an actual area of skin impairment related to pressure ulcer. The care plan goals and interventions had not been entered at the time of resident's discharge from the facility. Review of the nurse progress note dated 07/14/23 for Resident #74, revealed the resident was noted with a new superficial open area to his right buttock. Review of the nurse's skin grid dated 07/14/23 for Resident #74, revealed the resident had a stage II pressure ulcer to his left buttock which measured 1.4 cm in length by 1.4 cm in width by 0.1 cm in depth. The pressure ulcer was described as a superficial open, reddened area without drainage. Interview with LPN #554 on 08/01/23 at 8:40 A.M. confirmed Resident #74 was assessed upon admission as being at very high risk for the development of pressure ulcers. LPN #554 confirmed the resident's admission skin assessment indicated resident had no skin breakdown, and the resident's baseline care plan had no documented interventions implemented to prevent skin breakdown. LPN #554 indicated the care plan included an update on 07/14/23 indicating the resident had developed a Stage II pressure ulcer. LPN #554 confirmed the facility had conducted a weekly skin observation for Resident #74 on 07/09/23, but also confirmed the facility conducted weekly skin observations per licensed nurses for all residents, and resident #74 had no individualized interventions put in place related to his very high risk of pressure ulcer development. Review of the facility policy titled Pressure Injury Prevention and Management dated 08/20/22 revealed the facility was committed to the prevention of avoidable pressure injuries. The facility defined avoidable as the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the intervention and revise the interventions as appropriate. Licensed nurses would conduct full body skin assessments for all residents weekly. Evidence-based interventions for prevention would be implemented for all residents who were assessed at risk or who had a pressure injury present. Review of the NPUAP guidelines dated 2014 pages 70-71 at (https://npiap.com/general/custom.asp?page=2014Guidelines) revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. This deficiency represents non-compliance investigated under Complaint Numbers OH00144957 and OH00144740.

Based on medical record review, observation, staff interview, review of hospital records, review of the Food and Drug Administration's guidelines, review of manufacturer's guidelines, and review of facility policy, the facility failed to ensure residents were assessed for appropriateness of bed rail use prior to the installation of bed rails. The facility also failed to assess bed rails for possible areas of entrapment. This resulted in actual harm for one (#14) of three residents reviewed for bed rails when the facility installed grab bars to the resident's bed without conducting an assessment for their use and failed to assess the rails for entrapment risk. The resident subsequently had a fall from bed in which his head became stuck between the mattress and the grab bar. Resident #14 sustained a one-inch laceration to his neck and was transferred to the hospital where they discovered an injury to a cervical ligament which required inpatient hospital treatment. The facility identified 38 residents with half rails or grab bars. The census was 71. Findings include: Review of the medical record for Resident #14 revealed an admitted [DATE] with diagnoses including malignant neoplasm of the prostate and bone, diabetes mellitus (DM), metabolic encephalopathy, affective mood disorder, and hypertension (HTN). Review of the comprehensive significant change Minimum Data Set (MDS) assessment for Resident #14 dated 01/26/23 revealed the resident was cognitively impaired and required extensive assistance of one staff with bed mobility. The resident was coded as negative for use of bed rails. Review of the care plan for Resident #14 dated 10/17/22 revealed the resident needed assistance with activities of daily living (ADLs) due to cognitive impairment, immobility, pain, status post fracture of the right hip, had a history of falls, a diagnosis of prostate cancer with metastasis to bone, was incontinent, and had multiple other co-morbidities. Interventions bilateral grab bars to increase independence, assist with bed mobility, transfers, turning and repositioning, and the resident required independence to extensive assistance for bed mobility. Review of physical therapy (PT) assessment for Resident #14 dated 03/13/23 revealed the resident was assessed by PT, and was determined to have a recent significant decline in functional mobility due to illness including COVID-19. Review of a PT treatment note for Resident #14 dated 03/16/23 revealed the resident's current level of functioning indicated maximum assistance of one staff was required with bed mobility including rolling side to side and using grab bars to assist with positioning. Review of a nurse progress note for Resident #14 dated 03/24/23 at 8:05 A.M. per Licensed Practical Nurse (LPN) #105 revealed a nurse aide notified the nurse of the resident's fall. Upon entry to room, Resident #14 was partially on floor and partially on the bed with his head positioned on the lateral portion of the bed with the bed's grab bar touching face and neck. Due to the resident's position, he was unable to speak. Staff repositioned Resident #14 on the floor for comfort and ease of breathing. The unit manager called 911. While awaiting emergency personnel arrival, the resident was alert, speaking, and answering questions appropriately. Resident #14's vital signs were taken and were within normal limits. Review of the March 2023 monthly physician's orders for Resident #14 revealed an order dated 03/24/23 at 1:23 P.M. for the resident to have bilateral grab bars to his bed. Review of the side rail assessment for Resident #14 dated 03/24/23 at 1:32 P.M. revealed resident had bilateral grab bars to his bed to assist with mobility. The side rail assessment was completed after Resident #14 had been transferred to the hospital due to his head becoming entrapped between the mattress and the grab bar. The assessment did not include an alternative to the use of grab bars was attempted nor did it address the risk of entrapment. Review of the hospital notes for Resident #14 dated 03/24/23 through 03/31/233 revealed the resident was admitted to the hospital on 03/24/23 with an admitting diagnosis of trauma and penetrating injury to the neck. Resident #14 presented in the emergency department from the facility after a fall in which the resident was reported to have been found between the railing of his bed after a fall. Results of magnetic resonance imaging (MRI) performed on 03/25/23 indicated Resident #14 sustained an injury to the interior longitudinal ligament at the cervical (C6-C7) disc interspace without spinal cord injury which the hospital physician believed was sustained during the fall on 03/24/23. Neurosurgery was consulted while Resident #14 was in the hospital and recommended non-operative management of the injury. Resident #14 wore a hard cervical collar which was ordered to be maintained for two weeks, and then he was to follow up with neurosurgery. While in the hospital, Resident #14 had a gastrostomy tube (a tube placed directly into the stomach) placed and was a nothing by mouth (NPO) status due to concern for esophageal injury. Review of the facility's investigation of Resident #14's fall on 03/24/23 revealed Maintenance Director (MD) #100 assessed Resident #14's bed on 03/24/23 at 9:00 A.M., and determined it was in working order with no malfunctioning of equipment noted. Further review of the investigation revealed it did not address assessment of Resident #14's beds for entrapment risk. Review of a written statement for State tested Nursing Assistant (STNA) #125 dated 03/24/22 revealed the aide entered Resident #14's room on 03/24/23 at approximately 8:00 A.M. and noted the resident's head was stuck in the side rail and his body was on the floor. Further review of statement revealed STNA #125 saw blood on Resident #14's face and he was shaking, wet, and cold, and the nurse aide called the nurse who assisted in moving the resident. Review of a written statement for STNA #385 dated 03/24/23 revealed at approximately 8:00 A.M. Resident #14's call light was sounding, and she entered the room and found the resident with his body on the ground and his head stuck in the bed rail. STNA #385 called for STNA #125 and the nurse and the nurse aides assisted with repositioning Resident #14's body on the floor while the nurse removed the resident's head from the bed. STNA #385 confirmed Resident #14 was gurgling and she was concerned about Resident #14 choking while waiting for 911 to arrive. Review of a written statement for LPN #105 dated 03/24/23 revealed the nurse aides called her to Resident #14's room on 03/24/23 at approximately 8:00 A.M., and the resident was found with his body on the floor and his head between the bed and the grab bar. Resident #14 complained of hip pain and there was a one inch laceration noted to his neck with a small amount of blood. The nurse and nurse aides assisted the resident to the floor and 911 was called. Interview on 03/31/23 at 9:31 A.M., with LPN #105 confirmed on 03/24/23 at approximately 8:00 A.M. the nurse aide told her Resident #14 was on the floor. LPN #105 entered the resident's room and found Resident #14 with his head on the grab bar on the left side of the bed and his body was on the ground. LPN #105 confirmed she lifted Resident #14's head up and placed it on a pillow on the floor while the nurse aides repositioned Resident #14's body. Resident #14 had a small laceration to the right side of his neck that was bleeding. The unit manager, LPN #150, called 911. Resident #14 complained of hip pain and his vital signs were stable. Interview on 03/31/23 at 9:40 A.M., with LPN #150 confirmed she called 911 on 03/24/23 because she was told Resident #14 got his head stuck between his side rail and the mattress. LPN #150 confirmed when she entered Resident #14's room on 03/24/23 at approximately 8:05 A.M., another nurse and two nurse aides were with him, and he was lying on the floor on his left side with his head on a pillow. LPN #150 confirmed she was unsure when the grab bars were installed on the resident's bed. LPN #150 confirmed the physician's order for grab bars and the side rail assessment for Resident #14 were completed on 03/24/23 after Resident #14 had been taken to the hospital. Interview on 03/31/23 at 10:00 A.M., with the Director of Nursing (DON) confirmed Resident #14 had a fall on 03/24/23 in which his head was wedged between the mattress and the grab bar. DON confirmed the resident was sent to the hospital on 03/24/23 via 911, and Resident #14 was admitted to the hospital. DON further confirmed she was unsure of Resident #14's admitting diagnosis or if he had sustained any injuries related to the incident. DON confirmed she heard Resident #14 planned to discharge back to the facility on [DATE]. Interview on 03/31/23 at 10:05 A.M., with MD #100 confirmed he assessed Resident #14's bed on 03/24/23 at approximately 9:00 A.M. per the Administrator's request because he heard the resident got stuck between the mattress and the grab bar of his bed. MD #100 confirmed he installed the grab bars to Resident #14's bed approximately one week prior to incident on 03/24/23. MD #100 confirmed when he inspected Resident #14's bed he determined the bed was in good working order, the grab bars were compatible with the resident's bed, and were installed properly per manufacturer's instructions. MD #100 confirmed his routine maintenance and inspection of beds did not include assessing for possible entrapment risk. Interview on 03/31/23 at 10:18 A.M., with the Administrator confirmed he was not aware if Resident #14 had sustained any injuries related to his fall on 03/24/23. Administrator further confirmed the resident was taken to the hospital via 911 and admitted on [DATE] because he got his head stuck between the bed rail and the mattress. Administrator confirmed Resident #14 was still in the hospital and he heard Resident #14 was possibly going to return to the facility on [DATE]. Interview on 03/31/23 at 10:22 A.M., with STNA #125 confirmed STNA #385 called her to Resident #14's room on 03/24/23 at approximately 8:00 A.M. STNA #125 confirmed the resident was on the floor on the left side of the bed and the mattress was slid over a bit. Resident #14 was gurgling, and he had blood on his face. Resident #14's body was on the floor on the left side of the bed tangled up in a blanket and his head was facing the floor with his head stuck between the grab bar and the mattress. Resident #14 indicated his neck was hurting. The nurse aide did not move the resident but waited for LPN #105 to assess him. The nurse aides assisted with repositioning Resident #14's body on the floor while LPN #105 lifted his head up and placed it on a pillow on the floor. Observation of Resident #14's bed on 03/31/23 at 12:03 P.M., with MD #100, revealed the bed, air mattress, and grab bars were all from the same manufacturer. The air mattress was in place and functioning and was secured to the bed frame with ties provided by the manufacturer. The grab bars were in place to the bilateral upper sides of the bed. When the mattress was pushed to the right side of the bed a three-to-three-and-a-half-inch gap between the mattress and left grab bar was measured. This was confirmed with MD #100 who used a tape measure to take the measurement. Interview on 03/31/23 at 12:03 P.M., with MD #100 confirmed Resident #14's bed had not been altered since he left for the hospital on 03/24/23. MD #100 stated the facility planned for Resident #14 to return to the same room with the same bed, air mattress, and grab bars when he was readmitted to the facility. Review of Food and Drug Administration (FDA) document titled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 03/10/06, revealed for [AGE] years, the FDA had received reports in which vulnerable patients had become entrapped in hospital beds while undergoing care and treatment in health care facilities. The term entrapment described an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or bed frame. Resident entrapments might result in deaths and serious injuries. The population most vulnerable to entrapment was elderly patients and residents, especially those who were frail, confused, restless, or who had uncontrolled body movement. Entrapments have occurred in a variety of patient care settings, including hospitals, nursing homes, and private homes, and long-term care facilities reported the majority of the entrapments. Reducing the risk of entrapment involved a multi-faceted approach that included bed design, clinical assessment and monitoring, as well as meeting the needs for vulnerable residents. Review of manufacturer's guidelines for the bed and grab bars in use for Resident #14 dated 04/01/18 revealed accurate assessment of the resident and monitoring of correct maintenance and equipment use were required to prevent entrapment. Review of the facility policy titled, Proper Use of Bed Rails, dated 10/01/22, revealed alternative approaches should be attempted prior to installing or using bed rails. If bed rails are used, the facility should ensure correct installation, use, and maintenance of the rails. The following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: medical diagnosis, conditions, symptoms, and or behavioral symptoms, size and weight, sleep habits, medication(s), acute medical or surgical interventions, underlying medical conditions, existence of delirium, ability to toilet self safely, cognition, communication, mobility in and out of bed, risk of falling. The assessment must include an evaluation of the alternatives that were attempted prior to the installation or the use of a bed rail. Examples of potential hazards included entrapment. The facility should inspect and regularly check the mattress and the bed rails for areas of possible entrapment. The facility should ensure the bed frame, bed rail, and mattress do not leave a gap wide enough to entrap a resident's head or body, regardless of mattress width, length, and/or depth. This deficiency represents non-compliance investigated under Master Complaint Number OH00141602 and Complaint Number OH00141506.

Based on medical record review, observation, resident and staff interviews, and review of pain policy the facility failed to ensure a resident with a chronic debilitating condition received as needed medication for breakthrough pain and failed to reevaluate the resident after receiving pain medication. This resulted in actual harm, when staff failed to ensure Resident #256 received as needed (PRN) pain medication when she reported pain. Staff also failed to follow up or monitor the resident to determine the effectiveness of routine pain medication when the resident reported a high level of pain. This affected one Resident (#256) of three reviewed for pain. The census was 65. Findings include: Medical record review for Resident #256 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #256 was cognitively intact. The resident was totally dependent for all activities of daily living. Resident #256 was coded for an ostomy and always incontinent for bladder. Review of care plan for pain for Resident #256 revealed to administer pain medications as ordered, be aware of resident's admitting [DIAGNOSES REDACTED]. The goal was for Resident #256 to not experience pain upon admission or during their stay in the facility Review of a pain assessment dated [DATE] revealed the resident had presence of pain frequently that was moderate in the last five days and made it hard for her to sleep. She was on a scheduled pain medication regimen and received as needed narcotic pain medication ([MEDICATION NAME]). Review of the physician orders [REDACTED]. Further review of the physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. A pain scale of one to 10, with 10 being the worst was utilized. Further review of the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED] Review of the progress notes dated 05/01/18 through 05/15/18 revealed no documentation that Resident #256 refused pain medication. Review of a form entitled Pain Assessment Monitoring Tool from 05/01/18 through 05/17/18 for revealed dayshift staff had initialed all the days, but night shift had missing documentation on (MONTH) 1, 4, 5, 6, 8, 10, 11, 13, 16 and 17 of (YEAR). Further review of the tool revealed staff had not documented the pain level. The form noted if the resident was on a routine [MEDICATION NAME] medication the nurse would be monitoring that they were effective and indicating if there was a need for use of a as needed pain medication. If an as needed pain medication was given the nurse must complete the as needed pain notes in the computer system. Interview with Resident #256 on 05/15/18 at 1:20 P.M. revealed her pain level wasn't controlled. She stated she had asked the physician for more medication, but he refused. She stated she had pain in her neck, in the contracture in her left hand and elbow, and at her pressure ulcer site. She stated she had asked for her PRN pain medication but the nurses wouldn't give it to her. She stated she only received her scheduled routine pain medication. She became tearful and stated she couldn't get out of bed due to her pain and the nursing staff would not give her the PRN pain medication to help with the pain. She stated the pain prevented her from coming out of her room on occasion. Observation and interview on 05/16/18 at 9:11 A.M. during medication administration revealed Resident #256 mouthed something to Licensed Practical Nurse (LPN) #48 and the nurse told the resident she would talk to her in a while. LPN #48 explained to the surveyor the resident had asked for her PRN pain medication. LPN #48 did not assess the residents pain level at this time. LPN #48 informed the resident she had already received her pain medication. LPN #48 informed the resident she received her pain medication at 6:00 A.M. and there wasn't another pain medication due until 12:00 P.M. Interview on 05/16/18 at 9:18 A.M. with LPN #48 revealed Resident #256 had two orders that were the same and she couldn't give the resident anything else for pain. Review of the MAR indicated [REDACTED]. LPN #48 reveled she wasn't sure if the PRN order was for breakthrough pain, but indicated she would give the PRN [MEDICATION NAME] to the resident. LPN #48 further revealed the Pain Monitoring Tool was to document if the resident had pain and staff were to sign off on the tool every shift if there wasn't a problem. She stated if the nurse gave a PRN medication then an assessment should be documented, but since there wasn't enough space to document the assessment on the tool then the nurse should document in the computer system. She said a reassessment of pain level for scheduled pain medication was not the facility policy. Interview on 05/16/18 at 10:30 A.M. with Physician #504 revealed Resident #256 needed her pain medication he had ordered, which was scheduled [MEDICATION NAME] 5/325 mg one tablet every six hours and also [MEDICATION NAME] 5/325 mg one tablet every six hours as needed. He further stated the resident has had MS for years and was in pain. Interview on 05/17/18 at 9:30 A.M. with Resident #256 revealed she was crying and stated she was in pain. The resident stated she had asked for her PRN pain medication, but the nurse hadn't brought it to her. The resident stated if she didn't receive her PRN pain medication then the pain made her feel terrible. On 05/17/18 at 9:44 A.M., the Director of Nursing was informed Resident #256 was crying in pain and had not received her PRN pain medication. The DON stated she would talk to the nurse. The DON was observed speaking to LPN #48 on 05/17/18 at 9:46 A.M. The DON asked LPN #48 to give Resident #256 her PRN [MEDICATION NAME]. LPN #48 verbalized to the DON she needed two seconds as she had two admissions coming and three lab results to report. LPN #48 then stated she assumed giving the PRN pain medication was a priority. She proceeded to medicate Resident #256 with the PRN [MEDICATION NAME]. Follow up interview with the DON on 05/17/18 at 10:00 A.M. revealed she called the physician and reported the situation about Resident #256's pain medications. The DON revealed the physician gave a new order for routine [MEDICATION NAME] 5/325 two tablets every six hours and kept the PRN [MEDICATION NAME] order. Further review of the progress notes for 05/16/18 and 05/17/18 revealed there was no pain assessment completed for Resident #256 after receiving her routine and PRN [MEDICATION NAME]. Review of the Pain Policy dated (MONTH) 2010, revealed the purpose of the policy was to ensure all residents are adequately assessed for pain levels and interventions. A pain monitoring tool will be put into place on each resident, which addresses pain daily. The tool will be utilized as an ongoing evaluation for pain management. This citation substantiates complaint #OH 739.

Based on medical record review, staff interview, review of a facility Self-Reported incident (SRI) and investigation, and review of facility Resident Confidentiality and Health Insurance Portability and Accountability Act of 1996 (HIPPA) the facility failed to ensure staff carried out activities that promoted each resident's dignity and failed to assist each resident to maintain and enhance his/her self-esteem and self-worth by taking inappropriate pictures/video of a resident and posting it on social media. This resulted in actual harm when one State tested Nursing Assistant (STNA) #612 engaged in actions meant to humiliate one Resident (#25) in a vegetative state by taking an inappropriate picture/video without permission. The video was discovered on social media on 12/10/15 and the facility was unable to determine how long the video had been posted, resulting in intentional humiliation and psychological harm of the resident. The picture identified a lower leg and bandaged contracted foot beside a puddle of loose stool on a(NAME)mattress, an air fluidized therapy bed. The loose stool was splattered all over the leg and bandaged foot and bubbled as the(NAME)mattress changed pressure and the caption was Mount Parkside Erupting. This affected one (#25) of three residents reviewed for dignity. The facility census was 72. Findings include: Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of annual minimum data set (MDS) comprehensive assessment dated [DATE] revealed Resident #25 was in a persistent vegetative state without discernible consciousness and was totally dependent with all activities of daily living. Review of facility SRI tracking number 3 dated 12/10/15 revealed facility management became aware on this date of a social media site among several facility STNA's which depicted, among other things, a resident photo. The picture was of one resident's foot. It was a closed Facebook group called Parkside Aides, and was created in July 2015, remained active, and had a total of 18 members, eight of which were currently employed at the facility. STNA #612 posted the picture and was terminated from employment as a result of the investigation and the social media site was shut down. A confidential interview on 06/21/16 at 11:07 A.M. reported staff failed to treat Resident #25 with respect and dignity as they took pictures and posted them on social media making fun of the Resident. An interview on 06/23/16 at 1:04 P.M. with the Administrator reported on 12/10/15 he was notified of a four second video posted to a social media private group page. The video caption was Mount Parkside Erupting and included Resident #25's lower extremity with an accumulation of loose stool in the seam of the(NAME)mattress. The(NAME)mattress was continually adjusting pressure and moving and the loose stool appeared to be bubbling like a volcano. Resident #25 was identified by the wound dressing to the contracted foot and by the(NAME)mattress as Resident #25 was the only resident in the facility with a(NAME)mattress. The social media cite was created in July 2015 but it was unable to be determined during the investigation the length of time this video had been posted. STNA #612 was interviewed during the investigation and admitted posting the video but did not recognize this as being inappropriate or a problem. Observation of a still shot of the video which the Administrator provided revealed a lower leg and bandaged contracted foot beside a puddle of loose stool on a(NAME)mattress. The loose stool was splattered all over the leg and bandaged foot. An additional interview with the Administrator on 06/23/16 at 4:51 P.M. reported the social media cite, called Parkside Mafia, which contained the video of Resident #25, was a closed group in which you had to be invited to become a member. It had 18 members which had been employed at the facility, nine of which were currently employed. The Administrator reported the guardian of Resident #25 was informed of the video. The Administrator reported the picture/video portrayed Resident #25 in a demeaning, undignified manner. The Administrator could not provide evidence of facility monitoring. Review of facility Resident Confidentiality and Health Insurance Portability and Accountability Act of 1996 (HIPPA) which each employee signed upon hire revealed posting any pictures or information about a resident (even if the name is not used) on a social media site was not permitted, even with permission of the resident or family.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on medical record review, staff and physician interview, the facility failed to ensure a resident was free from a significant medication error, when he was administered medications including [MEDICATION NAME] and [MEDICATION NAME] that were not prescribed for him. This resulted in harm to Resident #1, who was hospitalized and had to be given [MEDICATION NAME] due to an insulin and narcotic overdose. This effected one of five residents sampled for medication administration. The facility census was 68. Findings include: Record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment and required limited assistance of one staff for bed mobility, transfer, toilet use and personal hygiene. He required extensive assistance of one staff member for dressing and bathing. He was independent with eating. Review of the clinical record revealed a late entry nursing note written 11/15/15 at 3:07 P.M. which stated This documentation is written by Licensed Practical Nurse (LPN) #12. She indicated on the 7:00 P.M.-7:00 A.M. shift, during the 8:00 P.M. med pass, 30 units of [MEDICATION NAME] Insulin was administered in Resident #1's abdomen at 10:00 P.M. His blood sugar was checked at 4:30 P.M. and was 59 (a low blood sugar level). Another nurse, LPN #20, assisted her with Resident #1's assessment. [MEDICATION NAME] was administered and his blood sugar was elevated to normal level of 127. Close monitoring of the resident continued throughout the night. Resident #1 was stable without change of condition. During the morning med pass Resident #1 was noted with a change of condition as evidenced by him being non-verbal. His vital signs were obtained and he had a pulse 46, oxygen saturation level of 83 percent on room air, blood pressure 87/56, temperature 96.1 and respiration rate of 10. The 911 dispatcher was called and Resident #1 was transferred to the hospital. Review of the clinical record also revealed a nursing note dated 11/15/15 at 8:00 A.M. by LPN #15 indicating the night nurse, LPN #12, notified the other nurses that Resident #1 was administered Resident #4's medications at 10:00 P.M. which may have been the result of the emergency that morning. There was also a nursing note dated 11/15/15 at 12:34 P.M. by LPN #15 who indicated a call was made to Mercy Fairfield and that Resident #1 was admitted with an insulin overdose. A nursing note dated 11/16/15 at 12:09 P.M. by the Director of Nursing stated she called the hospital for an update on Resident #1's status. The nurse at the hospital was documented as stating Resident #1 was good now after everything wore off. Resident #1 was on a [MEDICATION NAME] drip for 12 hours. He received intravenous fluid overnight and he had completed the IV. A review of the clinical record revealed a continuity of care form dated admission 11/15/15 and discharge of 11/16/15 indicated the resident's [DIAGNOSES REDACTED]. An interview was conducted on 01/13/16 at 3:35 P.M. with Physician #30 who stated he remembered Resident #1 was given [MEDICATION NAME] and pain medication that he should not have received. He was notified late that night. He did not remember giving orders for the [MEDICATION NAME] and stated there would have been a physician on call at that time who would have been the one to give the order. A staff interview was conducted with the Director of Nursing, with the Administrator and Assistant Director of Nursing present, on 01/12/16 at 2:40 P.M. She stated Resident #1 was given medication that was prepared for Resident #4. The nurse had prepared Resident #4's medications and sat them on the med cart. Resident #4 said she was going out to smoke and would come back and take them later. So LPN #12 started to prepare Resident #1's medication and a resident was yelling. She turned around to address the resident that was yelling and when she turned back around she grabbed the wrong medication (Resident #4's medication) and administered it to Resident #1. As a result, the facility implemented the following actions to correct the deficiency on 11/17/15 at 7:00 P.M.: On 11/15/15 at 10:30 A.M. the DON immediately began in-servicing on medication administration beginning with all of the nurses in the facility which included four nurses. The in-service education continued with the other 17 nurses prior to their next scheduled shift. No nurse worked until they received education on medication administration to include specifically distraction during medication passes and how to prevent errors as a result. On 11/15/15 at 11:30 A.M. a medication administration competency skills check off for all licensed nurses was initiated and was completed on 11/17/15 at 7:00 P.M. On 11/15/15 the pharmacist was called and scheduled in-servicing for 11/19/15 to include the six rights of medication administration with time scheduled to provide time for questions and answers. On 11/15/2015 at 10:00 A.M. all residents that received medications from this nurse was assessed for any potential effects that may have been affected by this nurses practice during the evening (10:00 P.M.) medication pass. An observation audit was developed to include two licensed nurses each week for four weeks to ensure medication administration compliance was maintained. The immediate Quality Assurance (QA) committee meeting discussed the plan of correction and was accepted, with a plan to review the findings of the additional auditing to ensure compliance has been maintained. All findings were scheduled to be presented at the scheduled January QA meeting to discuss any further recommendations at that point. The facility implemented the procedure that all new nurses would receive oversight by the appointed nurse providing orientation as usual, however a formal medication administration competency skills check off would be included during the orientation and prior to the new nurse passing medications on their own. On 01/12/16, interviews were conducted with staff and they were able to articulate the five rights to check before giving medication. This included ensuring the right medication, at the right dosage was given by the right route to the right person at the right time. This deficiency substantiates Complaint Number OH 220.

Based on observation, record review, and interview with facility staff, the facility failed to ensure one resident who was admitted without contractures received services to prevent a decline in range of motion or prevent contractures from occurring, resulting in actual harm to the resident. This affected one (#86) of three residents reviewed for range of motion services. The facility identified a total of four residents currently being seen by physical therapy for range of motion. Findings include: Record review revealed Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission assessment dated [DATE] revealed the resident was alert, oriented and non-ambulatory. The resident was identified as totally dependent on two staff for bed mobility and bathing, totally dependent on one staff member for eating, toileting, and personal hygiene, extensively dependent on two staff for transfer, and extensively dependent on one staff member for dressing. The admission assessment identified the resident with functional limitations on both sides of both the upper and lower extremities. Upon admission to the facility, the resident received a physician's orders [REDACTED]. The resident was admitted without evidence of contractures. Review of physical therapy notes revealed on 04/17/12 Physical Therapist #87 completed Resident #86's evaluation on admission. The goals were to increase his strength, increase bed mobility, increase sitting tolerance to ten minutes without a blood pressure change, and increase sitting balance to moderate assist. The resident received physical therapy in April 2012 and had no contractures according to the therapy notes. Although the physician orders [REDACTED]. A "Statement of Concern" sheet dated 07/26/12, documented on 07/15/12 nursing had requested Physical Therapy to assess for boots and pressure relief to the ankles and the foot. Therapy assessed the boots sent from the hospital for pressure and determined them non-therapeutic for his condition of contractures, The resident's family brought in multi podus boots and therapy agreed they were more appropriate for the resident's contractures. The note stated the resident was noncompliant and refused to wear the boots. The Statement of Concern contained no documentation as to range of motion or any additional treatment planned for the resident's contractures. Resident #86 was not seen by physical therapy again until August 2012. Although the resident continued to reside in the facility with some hospitalization s, the medical record and physical therapy notes contained no documentation about the resident's range of motion status. The next physical evaluation of the resident occurred on 08/14/12. The evaluation stated that the goals were to increased range of motion, both knee increase extension by 15 degrees, increase sitting tolerance in wheelchair to one hour, and increase bed mobility to maximum assistance. The evaluation stated "Note patient presents with increased [DIAGNOSES REDACTED] and decreased range of motion in both knees. The knee contractures were 40 degree extensions in both knees (significant) and noticed increased tone (muscle is tight, hard and contracted - very difficult to extend) with [DIAGNOSES REDACTED]." The resident received physical therapy in August 2012 for the contractures. The resident was observed and interviewed on 09/12/12 at 9:01 A.M. He was in bed talking to respiratory therapy. The resident stated he had physical therapy for his legs which were observed bent at almost 90 degrees with his heels touching his buttocks. He stated he was supposed to be receiving range of motion services from the State tested Nurse Aides (STNA), but had not received anything with any consistency. He stated the STNA's had only been in one time this week to do his range of motion. STNA #40 and #16 were interviewed on 09/12/12 at 9:10 A.M. and stated they do not provide range of motion services for the resident because he is seen by physical therapy. On 09/12/12 at 9:15 A.M. Physical Therapy Assistant (PTA) #90 was interviewed regarding Resident #86's current status with therapy, his range of motion needs, and his current contractures. The course of therapy treatment and the therapy notes were reviewed with PTA #90, who stated he was the one who usually does Resident #86's treatments. PTA #90 stated that the resident's current contractures were not addressed on the first evaluation because the resident did not have contractures. The PTA stated the resident's current leg contractures "just started happening probably in the last month or so". PTA #90 stated on 08/31/12, the resident could do passive range of motion at 90 degrees, which was a gain of 50 degrees, but it should be at 0. The resident was discharged to the hospital on [DATE], and upon return on 09/10/12, the resident had the same goals as the previous evaluation, but to increase knee extension to 15%. PTA #90 stated extension was minus 90 degrees and stated the resident's knees and legs "are pretty much in his chest". PTA #90 stated he saw the resident on 09/11/12 and the resident was at 90 degrees still. When PTA #90 was asked why the resident did not get services for three months to prevent contractures from muscular wasting he stated that "nursing did not get us orders" and that's why treatment was delayed. Interview with STNA #11, who was a restorative nurse aide, was interviewed on 09/20/12 at 9:16 A.M. She stated she was doing restorative range of motion with the resident from 07/08/12 until he went into the hospital on [DATE]. Asked if she did restorative range of motion to the resident's legs, she stated she did not. She stated she did range of motion to the resident's arms only and physical therapy was responsible for the resident's legs. This deficiency substantiates Complaint Number OH 144.