Every finding on record at Presidential Post-Acute

Number of residents sampled: Number of residents cited: Based on medical record review, observations, staff interviews, review of the mechanical lift manufacturer's instructions, review of the Hoyer sling owner's manual, review of the facility's investigation including witness statements, review of the Emergency Medical Services (EMS) report, review of hospital documentation, review of the death certificate, and review of the facility policies, the facility failed to ensure Resident #96 was transferred safely with a mechanical lift. This resulted in Immediate Jeopardy when Resident #96 suffered serious life-threatening injuries on [DATE] when Resident #96 was transferred using a mechanical lift and the top two straps supporting Resident #96's upper body simultaneously broke. Resident #96 fell approximately five feet from the mechanical lift sling and landed on the back of her head and neck area resulting in a fracture of the second cervical spine (C2), an epidural hematoma, age indeterminate fractures of the first, second, sixth, tenth, and twelfth thoracic spine (T1, T2, T6, T10, T12), and a two centimeter laceration to the posterior scalp that required five staples. These injuries subsequently lead to Resident #96's death on [DATE]. This affected one (#96) of three residents reviewed for utilization of a mechanical lift for transfers. The facility identified a total of 26 current residents (#4, #6, #8, #10, #11, #17, #18, #19, #22, #25, #29, #33, #41, #54, #56, #58, #60, #61, #75, #76, #78, #83, #93, #106, #107, and #108) residing in the facility as requiring the use of a mechanical lift for transfers. The facility census was 89. On [DATE] at 4:30 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at approximately 10:00 A.M., when Certified Nursing Assistant (CNA) #181 and CNA #269 began to transfer Resident #96 from her bed using a mechanical lift and a mesh sling that no longer had a tag attached to it (the tag provides critical safety data required by OSHA [Occupational safety and Health Administration] and ASME [American Society of Mechanical Engineers] B30.9, including the manufacturer's name, rated capacity [load limits] for various hitches [vertical, choker, basket], individual serial number for tracking, and the sling's width, length, and material grade. If missing or illegible, the sling must be removed from service). CNA #269 utilized the blue-colored sling loops on the top two straps near the resident's head and shoulders and the purple-colored sling loops on the bottom two straps near the resident's legs and feet. CNA #269 raised Resident #96 into the air, approximately five feet from the ground. While in the air, the top two blue-colored sling loops broke simultaneously, and Resident #96 fell out of the sling backwards and headfirst. Resident #96 landed on her head/neck sustaining major injuries. Resident #96 was sent to Hospital #1 via EMS where she was diagnosed with a C2 fracture. Resident #96 was transferred to Hospital #2 due to trauma and for a neurosurgery evaluation. On [DATE], Resident #96's advanced directives were changed from Do Not Resuscitate - Comfort Care Arrest (DNR-CCA) to Do Not Resuscitate - Comfort Care (DNR-CC) and Resident #96 was admitted to hospice. On [DATE], Resident #96 died with the immediate cause of death on her death certificate to be complications of blunt impact of injury to head. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: -On [DATE], Resident #96 was discharged to Hospital #1. -On [DATE], the facility obtained written witness statements from the two CNAs (#181 and #269) and Registered Nurse (RN) #213 involved in the incident. -On [DATE], [NAME] Clerk (WC) #127 obtained a photo of the broken sling straps. -On [DATE], WC #127 immediately removed the sling from use by the facility staff. -On [DATE], WC #127 reviewed all slings in the facility and removed one additional sling due to concerns. -On [DATE], WC #127 labeled all slings in the building to identify what sling was used during the incident with Resident #96. -On [DATE], WC #127 ordered six new slings. -On [DATE], the DON implemented a replacement schedule based on manufactures lifespan guidelines and initiated a replacement schedule. -On [DATE], the Administrator and DON developed a policy titled, Mechanical Lift Equipment Safety Policy. The policy was reviewed and approved by the Administrator, DON, Medical Director (MD), and Quality Assurance and Performance Improvement (QAPI) team on [DATE]. -On [DATE] through [DATE], the DON initiated in-service training to all staff on lift equipment integrity checks, sling/pad inspection criteria, failure risk indicators, proper equipment reporting, and emergency response protocols. -On [DATE], the DON in-serviced all staff on lift equipment integrity checks, sling/pad inspection criteria, failure risk indicators, proper equipment reporting, and emergency response protocols. -On [DATE], the DON conducted a root cause analysis. -Starting on [DATE], the DON or designee would conduct weekly random audits of ten slings/pads to ensure each pad is appropriately labeled, inspections have been conducted, and replacement schedule has been reviewed for four weeks and then monthly for two months. -On [DATE] through [DATE], the DON and/or WC #127 completed annual competency validations for mechanical lift use and equipment safety assessments on all CNAs. -On [DATE], WC #127 purchased 81 new slings for the facility and they were delivered on [DATE]. -On [DATE], the facility held an ad-hoc meeting at approximately 9:30 A.M. with the Administrator, DON, Medical Director (MD), RN Unit Manager #161, Minimum Data Set (MDS) RN #141, Social Services Assistant (SSA) #148, Housekeeping Supervisor (HS) #144, RN Unit Manager #261, Maintenance Director #163, WC #127, and Staffing Coordinator (SC) #220 to discuss the incident, the plan for ordering new slings, reviewed new policy, and discussed staff education. -On [DATE], WC #127 removed all old slings from use in the facility. New slings were labeled and put into use for the facility. -On [DATE], all systemic changes will be reviewed monthly for three months by the QAPI team. -On [DATE], the DON in-serviced all therapy staff, CNAs, and nurses on the policy/procedure and/or protocol related to not moving/dragging a resident after a fall, which could contribute to further injuries. -On [DATE], the DON reassessed all residents that were currently utilizing mechanical lift devices to ensure the proper lift was being utilized and/or necessary and the appropriate number of staff needed for assistance were identified. Care plans were updated to reflect resident needs. Residents #4, #6, #8, #10, #11, #17, #18, #19, #22, #25, #29, #33, #41, #54, #56, #58, #60, #61, #75, #76, #78, #83, #93, #106, #107, and #108's physicians orders were updated to reflect the use of a mechanical lift which required two person assistance. The task section in the medical charts of Residents #4, #6, #8, #10, #11, #17, #18, #19, #22, #25, #29, #33, #41, #54, #56, #58, #60, #61, #75, #76, #78, #83, #93, #106, #107, and #108 was updated to reflect the use of a mechanical lift which required two-person assistance. The care plans of Residents #4, #6, #8, #10, #11, #17, #18, #19, #22, #25, #29, #33, #41, #54, #56, #58, #60, #61, #75, #76, #78, #83, #93, #106, #107, and #108's were also updated to reflect the use of a mechanical lift which required two-person assistance. -Starting on [DATE], the DON or designee will conduct random visual observations of mechanical lift transfers on ten random residents weekly, to ensure proper personnel in place, proper mechanics and proper sling usage for four weeks and then ten random observations monthly for two months. -The DON or designee will report monitoring plan results to the QAPI committee monthly. The QAPI committee will monitor on an ongoing basis until sustained compliance is achieved, with quarterly reviews to assess effectiveness and make necessary adjustments to the monitoring plan frequency based on demonstrated compliance rates. -Observation on [DATE] at 9:48 A.M. of a mechanical lift transfer for Resident #78 completed by CNA #209 and CNA #226 revealed no concerns regarding a safe mechanical lift transfer. -Review of two additional medical records for Residents #08 and #22, reviewed for Hoyer lift transfers, revealed no concerns. -On [DATE], interviews with CNA #226, CNA #209, RN #213, CNA #269, and CNA #181, revealed they received education on Hoyer lift transfers, equipment, and falls. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level two (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #96's medical record revealed an initial admission date of [DATE] and a re-entry date of [DATE]. Diagnoses included hypertensive heart disease without heart failure, unspecified dementia, muscle weakness, unspecified protein calorie malnutrition, unspecified osteoarthritis, and stiffness of the right and left knees. Review of Resident #96's annual MDS assessment dated [DATE] revealed Resident #96 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of two. Furthermore, Resident #96 was dependent upon staff for bed to chair and chair to bed transfers, toileting hygiene, shower and bathing, and personal hygiene. Review of Resident #96's physician orders with a start date of [DATE] revealed an order for a Hoyer lift for all transfers with instructions for every shift. Review of Resident #96's care plan with a revision date of [DATE] revealed Resident #96 required assistance with Activities of Daily Living related to weakness, acute illnesses, functional decline, or generally not feeling well with interventions that included a Hoyer lift for all transfers and requiring the assistance of two people for dressing, personal hygiene, and bathing. Review of Resident #96's Medication and Treatment Administration Records (MAR and TAR) for the month of [DATE] revealed an order for Hoyer lift for transfers every shift and they had been signed by the nurse each shift except for one shift on [DATE]. Review of the witnessed fall incident report dated [DATE] at 10:00 A.M. revealed Resident #96 was being transferred from her bed to her wheelchair via mechanical lift. CNA #181 and CNA #269 were present in the room for the transfer. While the lift was being moved from the bed to the wheelchair, the top two blue sling loops ripped, and Resident #96 fell to the floor on her left side. The nurse was immediately notified and 911 was called. Resident #96 had an approximately two centimeters by one centimeter laceration to the back of her head. Resident #96's head was laying on the mechanical lift leg, so staff stabilized her head and removed the mechanical lift. Pressure was applied to the bleeding area on the back of her head until EMS arrived. Review of the EMS run report dated [DATE] revealed EMS arrived at Resident #96 at 10:31 A.M. Resident #96 was lying on her left side with a staff member holding gauze on the left side of her head. The laceration on her head was not able to be seen due to the resident's hair. The nurse stated she was in the mechanical lift, and the straps broke, resulting in Resident #96 falling about five feet and hitting her head on the legs of the lift. Resident #96 was complaining of chest and head pain. A C-collar was placed, and Resident #96 was transported to Hospital #1 with no lights or sirens. Review of Resident #96's Hospital #1's Emergency Department (ED) documentation dated [DATE] revealed Resident #96 presented to Hospital #1 for a fall to the ground, landing on her back and hitting her head on the mechanical lift after the mechanical lift strap broke. Resident #96 was found to have a C2 fracture, multiple thoracic compression fractures - age indeterminate on Computed Tomography (CT) scan, acute hypoxic respiratory failure - CT of chest with extensive mucous plugging and a concern for aspiration or pneumonia, a pulmonary embolism - moderate nonocclusive thrombus of the right main artery, an epidural hematoma, and a scalp laceration. Resident #96 was transported to Hospital #2 due concerns related to trauma. Review of Resident #96's Hospital #2's documentation dated [DATE] through [DATE] revealed a C2 fracture, high attenuation along the dorsum of the [NAME] measuring two millimeters in thickness and could represent epidural hematoma versus venous engorgement, age indeterminate fractures of the first, second, sixth, tenth, and twelfth thoracic spine (T1, T2, T6, T10, T12), a pulmonary embolism that was incidentally found on CT scan, acute respiratory failure, and a scalp laceration that required five staples. On [DATE], Resident #96's advanced directives were changed from Do Not Resuscitate - Comfort Care Arrest (DNR-CCA) to Do Not Resuscitate - Comfort Care (DNR-CC) and Resident #96 was admitted to hospice. Resident #96 discharged from the hospital to another Nursing Facility for hospice/palliative care. Review of Resident #96's death certificate revealed a date of death of [DATE] with the immediate cause of death to be complications of blunt impact of injury to the head with underlying causes including atherosclerotic heart disease, dementia, and atrial fibrillation. Review of the witness statement dated [DATE], written by CNA #269, revealed prior to lifting Resident #96 in the mechanical lift sling, he inspected the sling per company protocol. There were two CNAs present in the room and during the transfer, the mechanical lift sling unexpectedly snapped, causing Resident #96 to fall to the floor. The other CNA ran to get a nurse while CNA #269 stayed with the resident until the charge nurse arrived. Review of the witness statement dated [DATE], written by CNA #181, revealed a co-worker already had Resident #96 in the mechanical lift sling and hooked up to the mechanical lift when she was asked to assist with the transfer. CNA #181 was behind the wheelchair while her co-worker operated the lift. Resident #96 was turned towards the chair and as the mechanical lift was turned, both top straps broke and Resident #96 fell. Review of the witness statement dated [DATE], written by RN #213, revealed she was called by the CNAs and found Resident #96 on the floor in between the mechanical lift legs. The CNAs explained what happened. Vitals were taken and an assessment was completed. Bleeding was noted from the back of Resident #96's head. Resident #96 was complaining of shoulder and neck pain. Resident #96's head was supported, and the mechanical lift was removed. Resident #96 was then slid out into the hallway for better access for the EMS. Family was updated and EMS arrived and placed a C-collar on Resident #96. Interview on [DATE] at 1:25 P.M. with the Administrator and the DON revealed the Administrator was notified Resident #96 had fallen from the mechanical lift on [DATE] at 10:30 A.M. Immediately, corrective action was put into place to ensure the safety of all other residents in the facility who required the use of mechanical lifts. The Administrator and DON verified no other residents have had injuries related to mechanical lifts since the incident occurred. Interview on [DATE] at 2:06 P.M. with CNA #269 revealed on [DATE] around 10:00 A.M. he had given Resident #96 a bed bath and gotten her dressed. CNA #269 stated he placed the mechanical lift sling underneath Resident #96 and hooked the sling up to the mechanical lift. CNA #269 stated he saw CNA #181 walking in the hallway and asked if she would assist him in transferring Resident #96. CNA #181 stood behind the wheelchair while CNA #269 stood behind the mechanical lift. CNA #269 stated he did not see anything concerning about the sling that he could remember prior to using the sling for Resident #96. CNA #269 raised Resident #96 into the air and began to push the mechanical lift toward the wheelchair. CNA #269 stated they were close to the wheelchair when both blue straps on the sling broke and Resident #96 fell out of the sling backwards, headfirst, and hit her head/neck area on the mechanical lift leg. Immediately, CNA #269 yelled for the nurse and for help. CNA #269 stated RN #213 came into the room and assessed the resident as someone else had been directed by RN #213 to call 911. CNA #269 stated himself, RN #213, and CNA #181 pulled the resident into the hallway so EMS could get to the resident easier. CNA #269 stated Resident #96 was stating her chest hurt. EMS arrived shortly and took her to the hospital. Interview on [DATE] at 2:16 P.M. with CNA #181 revealed she was walking down the hall when CNA #269 asked her to assist in a mechanical lift transfer for Resident #96. CNA #181 stated CNA #269 had already been bathed and dressed and just needed a second person to assist in the transfer. CNA #181 stated she stood behind the wheelchair to assist in pulling her up once she got to the wheelchair. CNA #269 raised Resident #96 into the air and began the transfer when both blue straps on the sling broke, and Resident #96 fell to the floor hitting her head/neck area on the mechanical lift's legs. CNA #181 noted CNA #269 applied pressure to the back of Resident #96's head as she was bleeding from somewhere on the back of her head. RN #213 was immediately in the room after yelling for someone to call 911 and assessed the resident. RN #213 stated they needed to move her out of the room, so CNA #269 stabilized Resident #96's head and shoulders and RN #213 and CNA #181 grabbed the resident under her body and moved her from the bedroom into the hallway. The EMS were there shortly after and applied a C-collar to transport her to the hospital. Interview on [DATE] at 9:40 A.M. with RN #213 revealed she was in another resident's room when she heard yelling. She made sure the resident she was with was safe and went running to find what the yelling was about. RN #213 stated she got to Resident #96's room and saw her lying in the fetal position with no obvious injuries at that moment. She ran to grab supplies to take vital signs. RN #213 noted the resident had blood coming from the back of her head and had CNA #269 hold pressure on the wound with an ABD pad. Following assessment of Resident #96, RN #213 told another staff member to call 911. Due to Resident #96's head laying on the mechanical lift, they stabilized her head and removed the mechanical lift. Due to concerns about room for EMS, RN #213 told the staff to assist in moving her to the hallway. RN #213 stated she was concerned Resident #96 had a head/neck/spine injury and you would not normally move a resident with a potential head/neck/spine injury. RN #213 stated she wanted to move her so EMS would be able to get to the resident when they arrived. RN #213 stated four to six people assisted in dragging Resident #96 out into the hallway. RN #213 stated EMS was not going to put a C-collar on Resident #96 prior to transfer, but she told them to put one on and they did. Resident #96 was then transported to Hospital #1. Observation on [DATE] at 9:48 A.M. of a mechanical lift transfer for Resident #78 completed by CNA #209 and CNA #226 revealed no concerns regarding a safe mechanical lift transfer. Observation on [DATE] at 10:43 A.M. revealed all mechanical lift slings in the laundry room and throughout the facility revealed no holes, fraying, or concerns regarding the integrity of the slings that were currently in use at the facility. Observation on [DATE] at 9:28 A.M. of the sling used to transfer Resident #96 revealed the sling was very worn. There was no tag present on the sling, and it was undated. The green band that goes all the way around the sling was worn so much it was missing small parts of the green band in a couple places. Review of the undated Joerns Hoyer User Instruction Manual revealed prior to use, examine slings for fraying or other damage. Do not use any sling if damaged or if the sling shows signs of wear. Review of the undated Invacare Reliant 450 lift manufacturers guidelines revealed to check for wear, damage, and secure locking. Review of the Drive User Instruction Manual revealed to never use a sling which is frayed or damaged. Review of the Direct Supply Panacea Slings Owner's Manual revealed anticipated usable product life is based on normal use with proper maintenance, cleaning, and storage. Slings should be inspected, monitored, and cared for as described in the owner's manual as the product may need to be replaced sooner than anticipated in particular situations. Direct supply anticipated usable product life was six months. Review of the facility policy with a last revision date of [DATE] titled, Lifting Machine, Using a Mechanical, revealed staff should ensure all necessary equipment including slings are on hand and in good condition. Review of the facility policy with a last revision date of [DATE] titled, Assessing Falls and their Causes, revealed if there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure a homelike environment. This affected four (#53, #4, #8, and #90) residents reviewed for physical environment and had the potential to affect all residents. The facility census was 89.Observation on 03/09/26 at 9:37 A.M. of Resident #53's bedroom revealed behind the bed a large, discolored area behind the bed frame with chipped paint. Further observation of Resident #4's bedroom revealed a wall with pealing wallpaper and chipped paint. Additional observation of Resident #8's bedroom revealed a large area on the wall with dry wall chipped and missing paint. Additional observation of Resident #90's bedroom revealed two holes in the wall behind the bed with visible paint chipping.Observation on 03/09/26 at 10:00 A.M. revealed throughout the facility there were areas in the hallways with chipped paint.Interview on 03/12/26 at 9:07 A.M. with the Maintenance Director (MD) #163 revealed currently the facility was not fixing issues in the resident rooms. MD #163 confirmed that Resident #53's bedroom had a large, discolored area behind the bedframe with chipped paint, Resident #4's bedroom wall had pealing wallpaper and chipped paint, Resident #8's bedroom had a large area on the wall with dry wall chipped and missing paint. DM #163 further confirmed the areas throughout the hallways missing paint were previously repaired but never painted. When asked when bedrooms in the facility have cosmetic repairs DM #163 stated he waited till residents were discharged to fix any areas of concern.Review of the facility policy titled, Resident Environmental Quality dated 2024, revealed preventative maintenance schedules, for the maintenance for the building should be followed.

Based on interview and medical record review, the facility failed to ensure vision and hearing services were arranged for Resident #49. This affected one resident (#49) of one resident reviewed for communication and sensory. The facility census was 89.Findings include:Review of Resident #49 revealed an admission date of 10/13/25 with diagnoses including encounter for attention to colostomy, dysphagia, hypertension, anxiety disorder, spinal stenosis, depression, diaphragmatic and umbilical hernia, and overactive bladder. Review of Resident #49's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #49's medical record revealed no evidence she had been asked to sign a consent for ancillary services or had seen an audiologist or optometrist. Interview on 03/09/26 at 10:43 A.M. with Resident #49 revealed she wanted to see the audiologist about hearing aids. Additionally, she reported in the past she had surgery to her right eye and it was causing problems again and she wanted to see the doctor about it.Interview on 03/10/26 at 10:48 A.M. with Activities Director #142 revealed residents should be given consent for ancillary services once they become long term care residents. She verified Resident #49 was a long term care resident and she had not spoken to her about receiving ancillary services.

Based on medical record review, staff interview, review of the witnessed fall investigation, and policy review, the facility failed to report an incident of potential neglect to the state agency. This affected one resident (#96) of three residents reviewed for Self-Reported Incidents (SRI). The facility census was 89. Findings include:Review of Resident #96's medical record revealed an initial admission date of 10/15/21 and a re-entry date of 12/24/22. Diagnoses included hypertensive heart disease without heart failure, unspecified dementia, muscle weakness, unspecified protein calorie malnutrition, unspecified osteoarthritis, and stiffness of the right and left knees. Review of Resident #96's annual MDS assessment dated [DATE] revealed Resident #96 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of two. Furthermore, Resident #96 was dependent for bed to chair and chair to bed transfers, toileting hygiene, shower and bathing, and personal hygiene. Review of Resident #96's physician orders with a start date of 05/07/24 revealed an order for a Hoyer lift for all transfers with instructions for every shift. Review of Resident #96's care plan with a revision date of 02/13/26 revealed Resident #96 required assistance with Activities of Daily Living related to weakness, acute illnesses, functional decline, or generally not feeling well with interventions that included a Hoyer lift for all transfers and requiring the assistance of two people for dressing, personal hygiene, and bathing. Review of the witnessed fall incident report dated 02/08/26 at 10:00 A.M. revealed Resident #96 was being transferred from her bed to her wheelchair via mechanical lift. CNA #181 and CNA #269 were present in the room for the transfer. While the lift was being moved from the bed to the wheelchair, the top two blue sling loops ripped and Resident #96 fell to the floor on her left side. The nurse was immediately notified and 911 was called. Resident #96 had approximately two centimeter by one centimeter laceration to the back of her head. Resident #96's head was laying on the mechanical lift leg, so staff stabilized her head and removed the mechanical lift. Pressure was applied to the bleeding area on the back of her head until EMS arrived. Review of the facility's SRIs revealed no SRI was initiated. Interview on 03/12/26 at 9:28 A.M. with the Director of Nursing and the Administrator verified they did not submit an SRI because they did not feel abuse, neglect, or misappropriation occurred. Review of the facility policy with a last revised date of September 2022 titled, Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating revealed if abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source is suspected, the administrator immediately reports his or her suspicion to the state licensing/certification agency responsible for surveying/licensing the facility.

Based on record review, resident interviews, staff interviews, and policy review the facility failed to ensure residents understood arbitration agreements prior to signing them. This affected four (#7, #55, #62, and #68) of six residents reviewed for arbitration agreements. The facility census was 89.Findings include:1.Review of medical record for Resident #55 revealed an admission date of 01/22/26 with diagnoses including but not limited to dementia.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment.Review of Arbitration Agreement revealed the agreement was signed by the resident on 01/23/26.Interview on 03/11/26 at 1:57 P.M. with Resident #55 revealed the resident did not know what an arbitration agreement was. Resident #55 could not remember if she ate lunch today or what was for lunch. Resident #55 could not answer questions.2.Review of medical record for Resident #68 revealed an admission date of 01/08/26 with diagnoses including but not limited to contusion and laceration of cerebrum without loss of consciousness, encephalopathy, cognitive communication deficit, and nonrheumatic mitral valve insufficiency.Review of the MDS assessment dated [DATE] revealed a BIMS score of zero which indicated severe cognitive impairment.Review of the Arbitration Agreement revealed the agreement was signed by the resident on 02/23/26 during a readmission to the facility.Interview on 03/11/26 at 3:35 P.M. with admission Assistant (AA #144) revealed the arbitration agreement is signed on admission. AA #144 stated all admission paperwork is done electronically and is on an iPad that the resident initials and signs each page. AA #144 stated she informs the residents' the arbitration agreement is voluntary and if they have a dispute with the facility, it would be heard through arbitration and not a judge and jury. AA #144 stated she looked at the BIMS scores completed by Speech Therapy to determine the cognitive status of residents prior to having them sign admission paperwork including the arbitration agreement. AA #144 stated she also looked to see if a resident had a guardian, responsible party, or POA. AA #144 stated the admission paperwork could be emailed to the guardian, responsible party, or POA to be signed if they could not come to the facility.Interview on 03/12/26 at 9:37 A.M. with AA #144 verified Resident #68 had a BIMS of zero and signed her own arbitration agreement. AA #144 also verified Resident #55 had a BIMS of three and signed her own arbitration agreement. AA #144 verified that both residents should not have signed their own arbitration agreements.Review of policy titled, Binding Arbitration Agreements, dated November 2023 revealed the terms and conditions of a binding arbitration agreement are explained to the resident in a form and manner that he or she understands, taking into consideration the resident's language, literacy and stated preference for learning. After the terms and conditions of the agreement are explained, the resident or representative must acknowledge that he or she understands the agreement before being asked to sign the document. A signature alone is not sufficient acknowledgement of understanding. The resident or representative must verbally acknowledge understanding, and the verbal acknowledgement documented by the staff member who explains the agreement.

Based on record review, observation, interview, and policy review, the facility failed to ensure medications were not inappropriately crushed per physician order. This affected one (#110) resident of five residents observed for medication administration. The facility census was 89.Findings include:Review of medical record for Resident #110 revealed an admission date of 03/09/26 with diagnoses including but not limited to acute embolism and thrombosis of left axillary vein, dementia, atrial fibrillation, and hypertensive heart disease with heart failure. Review of physician orders revealed metoprolol succinate extended release (ER) 25 milligram (mg) (atrial fibrillation) give one tablet by mouth one time a day (may split- do not crush). Observation on 03/10/26 at 8:40 A.M. of medication pass revealed Licensed Practical Nurse (LPN #132) placed the medications for Resident #110 into a med cup and then into a crush pouch and crushed the medications. Medications included amiodarone 200 mg, escitalopram 10 mg, metoprolol succinate ER 25 mg, pantoprazole 40 mg, furosemide 20 mg, and spironolactone 25 mg. Interview on 03/10/26 at 9:56 A.M with LPN #132 verified that she crushed the metoprolol succinate ER and should not have crushed the medication due to it being extended-release tablet. LPN #132 stated she did not crush the pantoprazole. Review of policy titled, Administering Medications, dated April 2019 revealed medications are administered in accordance with prescriber orders, including required time frame. This deficiency represents non-compliance investigated under Complaint Number 2707817.

Based on interview and record review, the facility failed to provide colostomy care as ordered for Resident #49. This affected one resident (#49) of one resident reviewed for constipation and diarrhea. The facility census was 89.Findings include: Review of Resident #49's medical record revealed an admission date of 10/13/25 with diagnoses including encounter for attention to colostomy, dysphagia, hypertension, anxiety disorder, spinal stenosis, depression, diaphragmatic and umbilical hernia, and overactive bladder. Review of Resident #49's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #49's plan of care dated 11/20/25 revealed the resident had a colostomy and was at risk for complications related to skin integrity. Interventions included keeping the ostomy site covered, encouraging the resident to express feelings and concerns, keeping the pouch emptied routinely, maintaining privacy while providing care, observing for signs and symptoms of complications related to colostomy and notifying physician of abnormal findings, providing ostomy care as ordered, and education and emotional support as needed.Review of Resident #49's physician order from 10/18/25 to 01/20/26 revealed an order to change colostomy appliance as needed for leakage change and at least every three days.Review of Resident #49's Medication Administration Record (MAR) from 11/01/25 to 11/30/25 revealed her colostomy appliance was only changed on 11/15/25 and 11/29/25. Review of the MAR from 12/01/25 to 12/31/25 revealed it was only completed on 12/08/25.Review of Resident #49's physician order dated 02/11/26 revealed an order to change colostomy appliance every three days on night shift.Review of Resident #49's MAR for February 2026 revealed it was not completed as scheduled for 02/11/26.Review of Resident #49's progress notes from 10/18/25 to 02/11/26 revealed no documented reason for not replacing her colostomy appliance.Interview on 03/09/26 at 10:43 A.M. with Resident #49 revealed she was not always receiving colostomy care on schedule.Interview on 03/11/26 at 1:18 P.M. with Registered Nurse (RN) #161 verified there was no evidence Resident #49's colostomy appliance was changed as ordered for the above dates. A policy for colostomy's was requested and not received.

Based on resident record review, interview, and policy review, the facility failed to ensure care plans were person-centered and reflected the residents' current status. This affected three residents (#01, #23, and #49) of 25 residents reviewed for care planning. The facility census was 89.Findings include: 1. Review of the medical record for Resident #01 revealed a re-admission date of 02/09/26 and diagnosis of Post Traumatic Stress Disorder (PTSD) Review of Resident #01's care plan dated 02/06/26 revealed a focus for trauma informed care identifying the resident as being at risk for decreased psychosocial well-being, adjustment issues, emotional distress and ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual wellbeing related to PTSD. Review of the interventions and goals associated with the focus revealed no mention of Resident #01's history related to the PTSD diagnosis nor any triggers the resident has. Interview on 03/11/26 at 1:55 P.M. with the Director of Nursing (DON) revealed residents with a PTSD diagnosis should have information related to their triggers and trauma history included in their care plans. The DON further confirmed Resident #01 did not have their triggers or trauma history included in their care plan. 2. Review of the medical record for Resident #23 revealed a re-admission date of 03/03/26 and diagnoses of schizoaffective disorder and bipolar disorder. Review of Resident #23's orders revealed an order beginning 03/03/26 for behavior monitoring every shift. Review of Resident #23's care plan revealed no goals or interventions related to the resident's mental health diagnoses. Interview on 03/11/26 at 1:55 P.M. with the DON revealed a resident's mental health diagnoses should be included in their care plan. The DON further confirmed Resident #23's care plan did not address his mental health diagnoses. 3. Review of Resident #49's medical record revealed an admission date of 10/13/25 with diagnoses including encounter for attention to colostomy, dysphagia, hypertension, anxiety disorder, spinal stenosis, depression, diaphragmatic and umbilical hernia, and overactive bladder. Review of Resident #49's plan of care on 03/11/26 revealed it did not comprehensively address her activity of daily living (ADL) needs. It did not address her assistance needs for bed mobility, toileting, eating, ambulation, dressing, grooming, bathing, and personal hygiene. Interview 03/11/26 at 1:33 P.M. with MDS Coordinator #141 revealed staff of different specialties enter in information to the care plan. MDS Coordinator #141 confirmed activities of daily living (ADL) goals should always be in the care plan. MDS Coordinator #141 confirmed the ADL goals were not in Resident #49's care plan. Interview 03/11/26 at 1:40 P.M. with Registered Nurse (RN) Manager #261 revealed upon admission a residents' code status, pain, ADLs, and skin issues are triggered for the care plan. RN Manager #261 confirmed ADLs for Resident #49 were not in their care plan. Interview 03/11/26 at 1:55 P.M. with the DON revealed the admitting nurse is responsible for putting a residents' ADLs into the care plan and any further needs are added to the care plan as they arise. The DON reported the admitting nurse is not the same individual for all admissions. The DON confirmed Resident #49 did not have ADL needs documented in their care plan. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed the comprehensive, person-centered care plan should describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review of the facility policy also revealed care plan interventions are chosen with consideration between the resident's problem areas and their causes.

Based on observation, interview, and medical record review, the facility failed to ensure Resident #49's dignity was maintained when her exposed body could be observed from the hallway during colostomy care. This affected one resident (#49) of one resident reviewed for dignity. The facility census was 89.Findings include:Review of Resident #49's medical record revealed an admission date of 10/13/25 with diagnoses including encounter for attention to colostomy, dysphagia, hypertension, anxiety disorder, spinal stenosis, depression, diaphragmatic and umbilical hernia, and overactive bladder. Review of Resident #49's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #49's plan of care dated 11/20/25 revealed the resident had a colostomy and was at risk for complications related to skin integrity. Interventions included maintaining privacy while providing care.Observation on 03/09/26 at 9:36 A.M. revealed Resident #49 could be observed from the hallway. She was laying in her bed with her stomach, brief, and legs exposed, the curtain had been pulled enough that Resident #49's head, arms, and chest could not be seen. Certified Nursing Assistant (CNA) #114 could be observed providing colostomy care. Interview on 03/09/26 at 9:42 A.M. with CNA #114 revealed she did not realize Resident #49 had been exposed. She thought she had pulled the curtain far enough to provide her with privacy. CNA #114 verified the curtain should have been pulled far enough to hide Resident #49 from view.Interview on 03/09/26 at 10:43 A.M. with Resident #49 revealed she was very self-conscious of her ostomy. She expected staff to close the curtain during care and did not want to be seen during care.Review of facility policy, 'Dignity,' dated 2001 revealed, staff were to promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on record review, interview, and facility policy review, the facility failed to follow physician orders regarding insulin administration. This affected one resident (Resident #23) reviewed for insulin. The facility census was 89. Findings include: Review of the medical record for Resident #23 revealed a re-admission date of 03/03/26 and diagnosis of type two diabetes. Review of Resident #23's entry Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Review of Resident #23's orders on 03/09/26 revealed an order for Insulin Lispro Injection Solution 100 Unit/Milliliters (ML) beginning 03/03/26, to inject 23 units subcutaneously before meals for diabetes. Further review of the order revealed direction to hold the insulin if the blood sugar (BS) is less than 150. Review of Resident #23's Medication Administration Record (MAR) revealed insulin was given 03/05/26 at 11:30 A.M. for a BS of 107, given 03/06/26 at 6:30 A.M. for a BS of 127, given 03/06/26 at 4:30 PM for a BS of 97, and given 03/07/26 at 6:30 A.M. for a BS of 114. Review of Resident #23's blood sugar summary confirmed the blood sugar levels documented in the MAR. Review of Resident #23's progress notes revealed no documentation of physician notification and order to administer the medication outside of parameters. Interview on 03/11/26 at 9:47 A.M. with Licensed Practical Nurse (LPN) #180 confirmed Resident #23 was given insulin outside of physician ordered parameters. LPN #180 confirmed the insulin should have been held when the resident's BS was below 150 unless ordered by the doctor to still administer the medication, which would have been documented in the progress notes. Review of the facility policy titled, Administering Medications, revised April 2019, revealed medication is administered in accordance with prescriber orders. Further review revealed if a dosage was believed to be inappropriate or excessive for the resident's physician or facility's medical director should be contacted to discuss the concerns. This deficiency represents non-compliance investigated under Complaint Number 2707817.

Based on review of a self-reported incident (SRI), record review, facility investigation, policy review, and resident and staff interviews, and radiologist interview, the facility failed to ensure Resident #7 received proper assistance during transfers to prevent accidents. Actual Harm occurred on 07/11/25 when Resident #7 sustained a left rib fracture following an improper transfer by facility staff. This affected one (#7) of six residents reviewed for accidents. The facility census was 91.Findings include: Review of Resident #7's medical record revealed an admission date of 04/08/25. Diagnoses included chronic obstructive pulmonary disease, weakness, spinal stenosis of the lumbar region with neurogenic claudication, and adult failure to thrive. Review of Resident #7's care plan dated 04/08/25 revealed Resident #7 was at risk for falls related to functional decline, weakness, and bedbound status. Interventions included to assist with two staff members for transfers (implemented 04/09/25), and assistance with locomotion on and off the unit (implemented 04/09/25). The care plan was updated on 10/16/25 for staff education to lock wheelchair brakes. The nursing note dated 07/11/25 at 8:41 A.M. revealed Resident #7 complained of left rib pain and requested an X-ray due to pain with inhalation, exhalation, and movement. The nurse notified the nurse practitioner, and an order for an X-ray was obtained. Review of the X-Ray results dated 07/11/25 at 10:07 P.M. revealed the findings included a new acute nondisclosed left tenth rib fracture. The results were reported on 07/12/25 at 7:53 A.M. from mobilex after being reviewed by Radiologist #700. A progress note dated 07/12/25 revealed the nurse practitioner was updated on X-ray results. Review of the facility's SRI Control Number 262699, dated 07/12/25, revealed a report of Resident #7 sustaining a left rib fracture during a transfer. Licensed Practical Nurse (LPN) #494's written statement revealed on 07/11/25, Resident #7 reported left rib pain during morning care. The nurse performed a head-to-to-toe assessment. Resident #7 stated, I think the aide squeezed me too hard and broke my rib, but was unable to recall the name of the staff member or the exact date the incident. Resident #7 stated it may have been a couple of days ago. LPN #494 notified the provider and obtained an order for a chest X-ray. The X-ray, completed on 07/12/25, revealed a new acute nondisplaced left tenth rib fracture. The physician was notified of the results. Administration completed additional training to the facility staff regarding pivot transfers to ensure appropriate transfer technique was provided to the residents. A progress note dated 07/13/25 revealed a new order for a lidocaine patch to the left rib as needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, indicating her cognition remained intact and continued to be dependent on staff for transfers. The nursing note dated 10/13/25 at 10:55 A.M. revealed a certified nursing assistant (CNA) reported she had to lower Resident #7 to the floor during a transfer from bed to chair because one of the wheelchair brakes was not locked, causing the wheelchair to move. The nurse was immediately notified, and a head-to-toe assessment was completed. The resident denied pain, and no injuries were noted at that time. The progress note dated 10/13/25 at 12:14 P.M. revealed Resident #7 complained of left hip pain following another transfer. An X-ray was ordered for her left knee, hip, and elbow. The X-Ray results dated 10/14/25 revealed Resident #7's left elbow, knee, and hip had no acute osseous findings, and the left hip is in alignment with mild osteoarthritis of the left hip with no fracture or dislocation seen. Interviews conducted on 10/16/25 at 11:18 A.M. with Resident #7 revealed she could not recall the name of the CNA who transferred her in July but stated the CNA performed the transfer alone. Resident #7 stated the aide squeezed too tight, and she immediately felt pain, telling the CNA, I think you broke my rib. Resident #7 stated she informed the nurse of her pain, but she could not recall the nurse's name. She stated she was crying in pain, and the transfer that caused the rib fracture occurred the same day she reported the injury. At 12:20 P.M., Resident #7 stated for the transfer in July, only one CNA performed the transfer. She reported that a mechanical lift (Hoyer lift) had not been used for some time but could not recall when it was last used. Resident #7 also stated only one CNA performed the transfer on 10/13/25 and she had to be lowered to the ground. An interview conducted on 10/16/25 at 1:10 P.M. with LPN #466 identified CNA #353 reported having to lower Resident #7 to the floor due to the wheelchair not being locked. LPN #466 stated she believed CNA #353 was working alone during the transfer, but this was never confirmed. An interview conducted on 10/16/25 at 1:45 P.M. with Director of Nursing (DON) revealed CNA #353 involved in the October transfer was verbally educated on ensuring wheelchair brakes were locked prior to transfer. The DON stated there was no documentation of written education or retraining for the aide following either incident. An interview conducted on 10/16/25 at 2:12 P.M. with the Administrator confirmed that the facility's investigation determined the resident sustained a rib fracture during a transfer. The Administrator stated the facility was unable to identify the staff member who performed the transfer in July. An interview conducted on 10/16/25 at 3:15 P.M. with the DON revealed that when discussing the July X-ray findings with the physician, the physician was informed of a prior report of rib pain related to an incident before admission in which the resident's spouse reportedly squeezed her ribs. The DON stated the physician advised that the July fracture might be related to that incident. A follow-up interview conducted on 10/16/25 at 3:20 P.M. with Nurse Practitioner (NP) #701 revealed she was unaware of the July or October incident and had not reviewed the findings of the physician's assessment, but her name was on the X-ray orders as the ordered provider for both the July and October X-Rays. An interview was conducted on 10/16/25 at 3:30 P.M. with Radiologist #700 from MobileX. Radiologist #700 stated Resident #7's left tenth rib fracture was definitely a new injury. Radiologist #700 explained that, when determining the acuity of a fracture, he looks for specific radiologic indicators such as visible lines or fluffy areas, which suggest whether a fracture is healing or has already healed. Radiologist #700 reported he observed some early signs of healing on the July X-ray but clarified that it remained consistent with an acute fracture rather than an old or chronic one. Radiologist #700 further explained that if the fracture had been older, the X-ray would show greater density or whitening in the area from callus formation, and in some cases, older fractures may even show edges that rub against one another as they heal. He stated that comparison of the 07/11/25 X-ray with previous images from May 2025 confirmed the July fracture was not healed and appeared acute. Radiologist #700 emphasized that, based on his comparison, the July X-ray did not demonstrate the characteristics of an older fracture and confirmed that the injury was definitely not older than eight weeks. In his medical opinion, the findings were consistent with a new injury that had occurred ranging from the day of the transfer to within a few weeks prior to the 07/11/25 X-ray. Review of the facility policy titled Activities of Daily Living (ADL), Supporting dated 2001 revealed the following key points regarding assistance with ADLs: Residents unable to carry out daily living activities independently will receive necessary services. Residents will be provided with care, treatment, and services to ensure their ADLs do not diminish unless unavoidable due to clinical conditions, with a decline only justified by a resident's medical record or functional decline. Appropriate care and services are provided with resident consent and in accordance with the plan of care, covering hygiene, mobility, elimination, dining, and communication, with efforts to prevent or minimize functional decline through pain management and depression treatment.This deficiency represents non-compliance investigated under Complaint Number OH00165095 (1373756).

Based on observation, interview, medical record review, review of Centers for Disease Control and Prevention (CDC) guidance, and facility policy review, the facility failed to implement enhanced barrier precautions (EBP) as physician ordered during wound care for Resident #67. This affected one (#67) of three residents reviewed for wounds. The facility identified 13 residents who had EBP in place. The facility census was 91. Findings include:Review of Resident #67's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, chronic kidney disease, diabetes mellitus, and morbid obesity. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #67 had impaired cognition and required assistance from staff with transfers, bed mobility, and bathing. Review of Resident #67's care plan dated 05/07/24 revealed a care plan focus of EBP. Resident #67 required EBP during high-contact resident care activities due to the presence of wounds. Interventions included to utilize personal protective equipment (PPE) (gown and gloves, face-shield as indicated) during high contact resident care activities (e.g. Brief changes, toileting assistance, device care and wound care). Review of Resident #67's physicians orders dated 10/01/25 revealed orders to assist for EBP during high contact resident care every shift and a wound care treatment order to the sacrum/right buttocks every shift. Observation of wound care on 10/16/25 at 9:45 A.M. revealed Nurse #494 and Wound Nurse #474 provided wound care to Resident #67's sacrum/right buttocks and they did not wear gowns during the wound care. Interview on 10/16/25 at 10:05 A.M. with Wound Nurse #474 confirmed Resident #67 was on EBP for the wounds and confirmed Nurse #494 and Wound Nurse #474 did not wear a gown during wound care. Wound Nurse #474 confirmed a gown should have been worn by the nurse during wound care. Review of the facility's EBP policy dated March 2024 revealed EBP involves the use of gowns and gloves during high-contact resident care activities, in addition to standard precaution and staff should don appropriate PPE before engaging in high-contact resident care activities. Review of the CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP is an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. This deficiency represents non-compliance investigated under Complaint Number OH00166290 (1373764).

Based on staff interviews, review of facility policy, and medical record review, the facility failed to ensure the resident's weight loss was timely addressed and recommendations were timely followed through with. This affected one (#100) of three residents reviewed for weight loss. The facility census was 97. Findings include: Review of the medical record for Resident #100 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included metabolic encephalopathy, Alzheimer's disease, dementia, dysphasia, chronic obstructive pulmonary disease, and mild protein calorie malnutrition. Review of the plan of care dated 08/07/24 revealed Resident #100 was at risk of malnutrition with related diagnosis of underweight, significant weight loss and a need for mechanically altered diet. Interventions included providing adequate time for meal consumption as the resident was a slow eater, assist with meals and fluids as needed, cueing at meals to encourage consumption, food in bowls of finger foods with meals to promote increased oral intake, monitor meal intake, monitor weight per protocol, and provide diet and supplements per physician order. Resident #100 was hospitalized from 09/07/24 to 09/11/24 due to altered mental status and increased sodium levels. Review of Resident #100's weight dated 09/12/24 revealed upon readmission to the facility, Resident #100 weighed 92.0 lbs. This indicated Resident #100 had a weight loss of 9.8 percent (%) weight loss in one month and 8.9% in one week. Review of Registered Dietitian (RD) #80's progress note dated 09/12/24 revealed she spoke with the resident's family regarding Resident #100's food preferences. Resident #100 pocketed foods and would not always allow someone to help her with meals. The weight change found an 8.9% weight loss within one week with a request for a reweight pending. The resident's diet changed to moist and minced from puree. Will resume mighty shake (high calorie nutritional supplement with meals and medication pass 2 .0 (high calorie nutritional supplement) and add a blue plate to promote increased intake for dementia. Meal intakes ranged 25-75% and will monitor re-weights. The facility had no documentation of Resident #100 being re-weighed per RD recommendations dated 09/12/24. Review of the physician orders revealed Resident #100 had dietary supplements including medication pass 2.0 ordered once daily for underweight dated 09/11/24 and a house supplement with meals (three times daily) for inconsistent intakes dated 09/12/24 and Mirtazapine tablet (Remeron) (can increase appetite) 7.5 milligrams (mg) for one tablet at bedtime dated 09/11/24. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 was cognitively impaired and was independent with eating. Review of Nutritional Risk assessment dated [DATE] revealed a goal weight to maintain/gain without significant changes. Resident #100 accepted medication pass well and had other nutritional supplements (ONS) in the room (the family provided) for ad lib consumption. The RD progress note dated 09/23/24 revealed Resident #100 had been started on mirtazapine with increased oral intake to 50-75%. Resident #100's weight on 09/30/24 dropped to 90.0 for a weight loss of 6.25% in one week and 10.71% weight loss in about one month. On 10/15/24, there was a physician order to start an electrolyte drink to provide once daily for hydration needs. The next documentation from RD #80 was 17 days later on 10/17/24. The progress dated 10/17/24 revealed Resident #100 had additional weight loss. Resident #100 had a recent COVID diagnosis with interventions for an electrolyte drink and a new recommendation to increase medication pass 2.0 from once daily to twice daily. This was 17 days after significant weight loss was identified. Interviews on 12/17/24 at 4:30 P.M. with RD #80 stated she was present at the facility twice weekly. She stated she monitored intakes and weights that would be flagged for any significant weight loss to review for supplements and interventions and for re-weights. RD #80 confirmed the facility did not have evidence of re-weight for Resident #100 from when she recommended it on 09/12/24. RD #80 confirmed the facility had no documentation or evidence of follow up after Resident #100 had a significant weight loss on 09/30/24 and the weight loss was not addressed until over two weeks later. Interview on 12/18/24 at 11:30 A.M. with the Administrator revealed the facility had access to notify RD #80 of any resident's weight loss/ The Administrator verified any issues of weight loss such as interventions or assessments should be followed up with immediately. Review of the facility policy titled, Weight Assessment and Intervention, dated 03/2022 revealed resident weights shall be monitored for undesirable or unintended weight loss of gain. Any weight change of 5% or more since the last weight assessment shall be retaken the next day for confirmation and notify the RD immediately in writing. The weight loss threshold was a loss of 5% in under one month, 7.5% in three months and 10% in six months. Resident weight changes shall be evaluated by the treatment team. Review of facility policy titled, Dietician, dated 11/2022 revealed facility shall have a qualified Dietician to oversee the food and nutrition services in the facility. They shall oversee the food and nutrition services provided to residents. The Dietician was responsible for assessing nutritional needs, developing and evaluating therapeutic diets, developing person centered programs involving food and nutrition services, and food preparation service and storage. This deficiency represents non-compliance investigated under Complaint Number OH00160137.

Based on medical record review, policy review, review of manufacturer instructions, observation, and staff interview, the facility failed to ensure appropriate needles were used during intramuscular medication administration. This affected one (Resident #81) of two residents observed for injectable medications. The facility census was 97. Findings include: Review of the medical record for Resident #81 revealed an admitted [DATE]. Resident #81 had a new diagnoses added on 11/25/24 of urinary tract infection (UTI) and moderate protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #81 was moderately cognitively impaired. Review of the care plan dated 11/17/24 revealed Resident #81 had a UTI. Interventions included to administer antibiotic therapy as ordered and monitor/document for side effects and effectiveness. Review of the physician orders dated 12/12/24 for Resident #81 revealed Ertapenem Sodium intramuscular injection solution reconstituted (antibiotic) one gram every 24 hours for infection for 10 days Observation of medication administration on 12/16/24 at 2:03 P.M. revealed Registered Nurse (RN) #104 was preparing to administer the antibiotic to Resident #81. RN #104 grabbed a BD blunt fill needle-filter to draw up the lidocaine solution and place it into Ertapenem sodium injection powder. The appropriate amount of lidocaine was placed into the Ertapenem injection powder, the blunt needle was removed, and the nurse discarded it in the trash. After a thorough mixing, RN #104 opened up the cart looking for another needle. He was unable to find one, so he went to the storage room and grabbed four more BD blunt fill needle-filters. He said he wanted to use a fresh needle because the previous one would be dull. The nurse then placed a new blunt fill needle-filter onto the syringe and drew up the medication with a five milliliter (ml) syringe, taking 3.2 ml of the solution. The nurse capped off the needle, grabbed an alcohol pad to clean the resident's skin, and locked the cart. RN #104 walked into Resident #81's room where the nurse introduced himself and informed Resident #81 that he would be administering the antibiotic. RN #104 walked up to Resident #81 with the syringe in hand, and was approaching the resident to administer the medication. At that point, surveyor intervened prior to administration of the medication. RN #104 confirmed he was going to administer the antibiotic with a BD blunt needle-filter, and explained this was the needle he used for injections. RN #104 was unable to answer what type of needle was used for intramuscular injections. RN #104 proceeded to go through the cart for additional needles and found a 22 gauge, one-inch beveled end needle. This appropriate needle was then used to administer the medication in Resident #81's left deltoid. Interview on 12/16/24 at 2:31 P.M. with the Director of Nursing confirmed when administering intramuscular injections, a blunt fill needle - filter should not be used. The facility does not have any medications currently that would require the usage of a filter needed. He confirmed an 19-23 gauge 1.0 to 1.5 inch should be used. Review of BD blunt fill needle with filter manufactures guidance revealed the BD blunt filter needle includes a five micron filter to remove foreign matter such as glass particles from ampoules, the needle decreases the risk of needle stick due to 10 times higher skin penetration force required. The needle is packaged in a red shield to alter users it is a blunt need. The BD blunt fill needle should not be used for skin injections. Review of Intramuscular Injection Policy dated 04/2011 revealed required supplies are three ml syringe, needle (19 to 23 gauge, 1.0 to 1.5 inch), alcohol swabs, prescribed medication, medication administration record, sharps container and personal protective equipment is required for administration. This was an incidental finding discovered during the course of the complaint investigation.

Based on observation, interviews, and policy review, the facility failed to properly store chemicals in the kitchen to prevent cross contamination. This had the potential to affect 74 of 76 residents who received food from the kitchen. The facility identified two residents (Resident #7 and Resident #42) who did not receive food from the kitchen. The facility census was 76. Findings include: Observation on 05/05/24 at 8:49 A.M. with Cook #293 revealed comet bleach powder and dawn dish detergent were stored on the kitchen preparation sink. Interview on 05/05/24 at 08:49 A.M. with Cook #293 revealed the sink is used to prepare food such as dicing up peppers, onions, slicing tomatoes, and cleaning lettuce. Cook #293 verified the comet bleach powder and dawn dish detergent were stored on the sink and reported she does not know why the chemicals are there. Observation on 05/06/24 at 11:01 A.M. with Dietary Director #312 revealed dawn dish detergent was stored on the kitchen preparation sink again. Interview on 05/06/24 at 11:01 A.M. with Dietary Director #312 revealed kitchen chemicals are stored in the chemical supply closet. Review of the, Chemical Storage Policy for Nursing Home Kitchen, dated March 2019 stated, 1. Proper Storage: Chemicals must be stored in a designated area separate from food preparation, storage, and serving areas to prevent contamination.

Based on observation, interview, and policy review, the facility failed to maintain a replacement tracheostomy tube at the bedside of one resident reviewed for tracheostomy care. This affected one of one resident (Resident #7) reviewed for tracheostomy care. The facility census was 76. Findings include: Review of the medical record for Resident #7 revealed she had an admitted [DATE]. Her diagnoses included diffuse traumatic brain injury with loss of consciousness of unspecified duration, quadriplegia, aphasia, hydrocephalus, encounter for attention to tracheostomy, other mechanical complication of ventricular intracranial (communicating) shunt, and acute and chronic respiratory failure with hypoxia. Review of Resident #7's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 requires dependent care for all activities of daily living. Review of Resident #7's care plan revealed the resident exhibits alteration in respiratory status related to trach. Interventions included to keep a spare trach/obturator/trach kit at bedside. Observation on 05/05/24 at 5:00 P.M. with Registered Nurse (RN) Manager #410 revealed Resident #7 had a tracheostomy and a replacement tracheostomy was not found in the room of Resident #7. Interview on 05/05/24 at 5:00 P.M. with RN Manager #410 confirmed the room did not have a replacement tracheostomy. RN Manager #410 went to the nurse's station to get the floor nurse to see if it is in Resident #7's room. Interview on 05/05/24 at 05:03 P.M. with RN #449 confirmed Resident #7's room did not have a replacement tracheostomy. Review of the policy titled, Tracheostomy Care, dated October 2023 revealed a replacement tracheostomy tube must be available at the bedside at all times.

Based on observation, record review, facility staff interview, and policy review, the facility failed to maintain proper position of a urinary catheter drainage bag for one (Resident #23) of one reviewed for urinary catheters. The facility census was 76. Findings include: Review of Resident #23's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, retention of urine, dementia, benign neoplasm of pituitary gland, obstructive reflux uropathy, and testicular hypofunction. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired and had no behaviors. Resident #23 was coded to have an indwelling urinary catheter and required partial moderate assistance with toileting. Observation on 05/05/24 at 2:06 P.M. revealed Resident #23 was observed lying in the bed and his urinary catheter drainage bag was observed lying uncovered directly on the floor. Observation on 05/06/24 at 8:17 A.M. revealed Resident #23 was observed lying in the bed and his urinary catheter drainage bag was observed lying uncovered directly on the floor. Interview and observation of Resident #23 with State tested Nursing Assistant (STNA) #264 on 05/06/24 at 8:18 A.M. verified Resident #23's urinary catheter drainage bag was uncovered lying directly on the floor and the STNA stated the bag should not to be the floor. Review of policy titled Catheter Care, Urinary, revised August 2022 revealed catheter tubing and drainage bags should be kept off the floor for infection control purposes.

Based on observation, staff interview, and policy review, the facility failed to ensure resident medications were prepared at the time of administration. This affected 21 residents (#05, #07, #12, #13, #16, #18, #19, #28, #32, #36, #40, #41, #43, #45, #47, #54, #56, #57, #59, #71 and #77) who receive medication on the unit. The facility census was 77. Findings include: Observation on 01/12/23 at 7:32 A.M. revealed Licensed Practical Nurse (LPN) #302 was standing next to her medication cart with multiple plastic medication cups stacked upon one another. The cups had multiple loose pills located in each cup and initials written on the cups. Interview on 01/12/23 at 7:32 A , the LPN #302 verified she had pre-poured or prepared multiple residents medications prior to the start of her medication pass. The LPN #302 said she was aware this was not the proper procedure to follow when administering medications. The LPN #302 verified she should, gather each residents medications individually, due to the risk of potential medication errors. Review of the policy titled Medication Administration, dated April 2019 was identified the individual administering the medications checks the label three times to verify the right resident, medication, dosage, time and route of administration before giving the medication.

Based on medical record review, staff interview, review of facility policy, review of incident/accident logs, review of a concern form, and review of the state agency system for Self-Reported Incidents (SRI), the facility failed to complete a full and thorough investigation of resident to resident abuse. This affected two (Resident #1 and #5) out of three residents reviewed for abuse. The census was 72. Findings include: 1. Review of the medical record for Resident #5 revealed an admitted [DATE]. Resident #5 discharged from the facility on 05/27/22 against medical advice (AMA). diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission nursing assessment dated [DATE] revealed Resident #5 was transferred to the facility for a urinary tract infection, had intact cognition, and was alert and oriented to person, place, time and situation. The assessment stated Resident #5 was calm and cooperative, and ambulated with a walker. Review of the nurse progress notes dated 05/31/22 at 2:19 P.M. revealed an Interdisciplinary Team (IDT) noted which stated the IDT met to review the incident on 05/27/22. All aspects of the plan of care were in place at the time of incident. Resident #5 stated another resident (Resident #1) came in her room and grabbed the back of her wheelchair and started shaking her chair. Resident #5 had a can of sprite and poured it onto the resident (Resident #1) and on the floor. Staff were close by, immediately separated the residents, and completed a head to toe assessment with no injuries noted. Fifteen-minute checks were put in place for 24 hours to prevent further occurrences. The physician and responsible party were aware. Review of the plan of care dated 05/24/22 revealed Resident #5 used anti-anxiety medications related to anxiety disorder with interventions to administer the medications as ordered, document adverse reactions, and on 05/27/22 the resident was placed on 15 minute checked for 24 hours. Review of the Resident Concern Form, undated, revealed Resident #5 had a concern with dementia residents coming into her room. The form stated the staff involved was Licensed Practical Nurse (LPN) #102. The form also stated the staff interviewed included LPN #102 and the resident interviewed included Resident #6. The notes stated Resident #6 was present in the room during the time of Resident #5's concern. Resident #6 stated a confused resident (Resident #1) came into the room and grabbed her roommates chair. Resident #5 started yelling at the other person (Resident #1) and staff came in and removed the other resident (Resident #1). Resident #6 was asked if everyone was okay and she stated everything was fine. 2. Review of the medical record for Resident #1 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's care plan dated 08/03/20 revealed Resident #1 had impaired cognitive function with interventions to administer medications as ordered and monitor/document/report changes in cognition. The care plan also revealed Resident #1 had a mood problem related to her admission with interventions to administer medications as ordered, monitor/record/report changes in mood to the physician as needed, and on 05/27/22 she was placed on 15 minute checks for 24 hours. Review of the quarterly Minimum Data Set assessment dated [DATE], revealed Resident #1 had impaired cognition, had delusions and hallucinations but no behaviors other than wandering. Resident #1 required extensive assistance of one staff for locomotion on and off the unit. Review of Resident #1's nurses notes dated 05/27/22 at 6:07 P.M. revealed the nurse was notified by another nurse that Resident #1 was in another residents (Resident #5) room shaking her wheelchair aggressively. The other resident (Resident #5) began throwing sprite over her shoulder to get Resident #1 to stop shaking her wheelchair. The residents were separated immediately, their skin was assessed, and 15-minute checks were in place for the next 24 hours. The Director of Nursing (DON) and responsible parties were aware and okay with the plan. Review of Resident #1's nurse's notes dated 05/31/22 at 2:13 P.M. revealed an IDT note which stated the IDT met to review the incident on 05/27/22. All aspects of the plan of care were in place at the time of incident. Resident #1 was with known confusion and was unable to give credible information. The staff interviewed indicated Resident #1 went into another resident's (Resident #5) room and grabbed the back of the other residents (Resident #5) wheelchair. She (Resident #1) began shaking the chair and the other resident (Resident #5) poured her sprite on Resident #1. Staff were close by and immediately separated the residents and preformed head to toe assessments on each resident. No injuries were noted. The residents were placed on 15-minute checks for 24 hours to prevent further occurrences. The physician and responsible parties were aware. Review of the incident/accident logs from March 2022 through May 2022 revealed on 05/27/22 Resident #1 physically initiated the incident and Resident #5 physically received the incident. Review of the state agency website for facility reporting of abuse, revealed the facility had no documented evidence of an SRI having been reported for the incident on 05/27/22 with Resident #1 and #5. There was also no investigation completed related to the incident. The only form provided related to an investigation was the Resident Concern Form. Interview on 06/17/22 at 10:05 A.M. with LPN #102 revealed she was the nurse on 05/27/22. On 05/27/22, she heard yelling as she was coming down the hall and Resident #1 was shaking the back of Resident #5's wheelchair. Resident #5 had sprite in her hand and was throwing it over her shoulder at Resident #1 in order to get Resident #1 to stop shaking the wheelchair. She stated she didn't witness any contact and when she asked Resident #6 (roommate/witness), Resident #6 stated there was no physical contact. LPN #102 was the staff who instantly separated the two residents and took Resident #1 back to her hall. She stated Resident #1 had not been aggressive or had any behaviors that day but she had dementia and could flip easily. She stated Resident #1 had been going through the facility that day which was normal for her. She revealed after the incident, she assessed the residents and there were no injuries. The physicians and families were notified/aware and Resident #5 was on the phone with a friend who encouraged her to call the police. She stated she heard Resident #5's conversation and she was really making it seem like she got beat up which was not the case, but her friend was encouraging her, so the police showed up. The Sheriff attempted to interview Resident #1 who wanted to speak to him about the [MEDICATION(S)]. LPN #102 stated she was the staff who notified the DON, but she never completed any witness statement regarding the incident. Interview on 06/17/22 at 10:25 A.M. with the DON confirmed there was not a full facility investigation regarding the resident to resident abuse situation for Resident #1 and #5. Review of facility policy titled Abuse Prevention Policy, dated 02/20/20, revealed any witnesses to abuse will tell the abuser to stop immediately, report the incident to their supervisor, the supervisor will notify the Administrator or designee, if the abuse is resident to resident, the patient who has threatened or attacked another will be removed from the setting or situation, the family and physician will be notified, room changes and alternative placement will be provided based on the situation if warranted. The policy also stated if a resident incident is reported, an investigation will be initiated within 24 hours of the allegation. The investigation shall include interviews of employees, residents, family and visitors who may have knowledge of the alleged incident. The policy stated the Administrator shall report all alleged or suspected violations to the appropriate state agencies immediately or within two hours to the Ohio Department of health, and all findings of all completed investigations will be reported to the Ohio Department of Health within five working days.

Based on medical record review, staff interview, review of facility policy, review of incident/accident logs, review of a concern form, and review of the state agency system for Self-Reported Incidents (SRI), the facility failed to ensure resident to resident abuse allegations were reported to the state agency. This affected two (Resident #1 and #5) out of three residents reviewed for abuse. The census was 72. Findings include: 1. Review of the medical record for Resident #5 revealed an admitted [DATE]. Resident #5 discharged from the facility on 05/27/22 against medical advice (AMA). diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission nursing assessment dated [DATE] revealed Resident #5 was transferred to the facility for a urinary tract infection, had intact cognition, and was alert and oriented to person, place, time and situation. The assessment stated Resident #5 was calm and cooperative, and ambulated with a walker. Review of the nurse progress notes dated 05/31/22 at 2:19 P.M. revealed an Interdisciplinary Team (IDT) noted which stated the IDT met to review the incident on 05/27/22. All aspects of the plan of care were in place at the time of incident. Resident #5 stated another resident (Resident #1) came in her room and grabbed the back of her wheelchair and started shaking her chair. Resident #5 had a can of sprite and poured it onto the resident (Resident #1) and on the floor. Staff were close by, immediately separated the residents, and completed a head to toe assessment with no injuries noted. Fifteen-minute checks were put in place for 24 hours to prevent further occurrences. The physician and responsible party were aware. Review of the plan of care dated 05/24/22 revealed Resident #5 used anti-anxiety medications related to anxiety disorder with interventions to administer the medications as ordered, document adverse reactions, and on 05/27/22 the resident was placed on 15 minute checked for 24 hours. Review of the Resident Concern Form, undated, revealed Resident #5 had a concern with dementia residents coming into her room. The form stated the staff involved was Licensed Practical Nurse (LPN) #102. The form also stated the staff interviewed included LPN #102 and the resident interviewed included Resident #6. The notes stated Resident #6 was present in the room during the time of Resident #5's concern. Resident #6 stated a confused resident (Resident #1) came into the room and grabbed her roommates chair. Resident #5 started yelling at the other person (Resident #1) and staff came in and removed the other resident (Resident #1). Resident #6 was asked if everyone was okay and she stated everything was fine. 2. Review of the medical record for Resident #1 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's care plan dated 08/03/20 revealed Resident #1 had impaired cognitive function with interventions to administer medications as ordered and monitor/document/report changes in cognition. The care plan also revealed Resident #1 had a mood problem related to her admission with interventions to administer medications as ordered, monitor/record/report changes in mood to the physician as needed, and on 05/27/22 she was placed on 15 minute checks for 24 hours. Review of the quarterly Minimum Data Set assessment dated [DATE], revealed Resident #1 had impaired cognition, had delusions and hallucinations but no behaviors other than wandering. Resident #1 required extensive assistance of one staff for locomotion on and off the unit. Review of Resident #1's nurses notes dated 05/27/22 at 6:07 P.M. revealed the nurse was notified by another nurse that Resident #1 was in another residents (Resident #5) room shaking her wheelchair aggressively. The other resident (Resident #5) began throwing sprite over her shoulder to get Resident #1 to stop shaking her wheelchair. The residents were separated immediately, their skin was assessed, and 15-minute checks were in place for the next 24 hours. The Director of Nursing (DON) and responsible parties were aware and okay with the plan. Review of Resident #1's nurse's notes dated 05/31/22 at 2:13 P.M. revealed an IDT note which stated the IDT met to review the incident on 05/27/22. All aspects of the plan of care were in place at the time of incident. Resident #1 was with known confusion and was unable to give credible information. The staff interviewed indicated Resident #1 went into another resident's (Resident #5) room and grabbed the back of the other residents (Resident #5) wheelchair. She (Resident #1) began shaking the chair and the other resident (Resident #5) poured her sprite on Resident #1. Staff were close by and immediately separated the residents and preformed head to toe assessments on each resident. No injuries were noted. The residents were placed on 15-minute checks for 24 hours to prevent further occurrences. The physician and responsible parties were aware. Review of the incident/accident logs from March 2022 through May 2022 revealed on 05/27/22 Resident #1 physically initiated the incident and Resident #5 physically received the incident. Review of the state agency website for facility reporting of abuse, revealed the facility had no documented evidence of an SRI having been reported for the incident on 05/27/22 with Resident #1 and Resident #5. Interview on 06/17/22 at 10:05 A.M. with LPN #102 revealed she was the nurse on 05/27/22. On 05/27/22, she heard yelling as she was coming down the hall and Resident #1 was shaking the back of Resident #5's wheelchair. Resident #5 had sprite in her hand and was throwing it over her shoulder at Resident #1 in order to get Resident #1 to stop shaking the wheelchair. She stated she didn't witness any contact and when she asked Resident #6 (roommate/witness), Resident #6 stated there was no physical contact. LPN #102 was the staff who instantly separated the two residents and took Resident #1 back to her hall. She stated Resident #1 had not been aggressive or had any behaviors that day but she had dementia and could flip easily. She stated Resident #1 had been going through the facility that day which was normal for her. She revealed after the incident, she assessed the residents and there were no injuries. The physicians and families were notified/aware and Resident #5 was on the phone with a friend who encouraged her to call the police. She stated she heard Resident #5's conversation and she was really making it seem like she got beat up which was not the case, but her friend was encouraging her, so the police showed up. The Sheriff attempted to interview Resident #1 who wanted to speak to him about the [MEDICATION(S)]. LPN #102 stated she was the staff who notified the DON, but she never completed any witness statement regarding the incident. Interview on 06/17/22 at 10:25 A.M. with the DON confirmed the state agency was not notified of the resident to resident abuse situation with Resident #1 and Resident #5 which occurred on 05/27/22. Review of facility policy titled Abuse Prevention Policy, dated 02/20/20, revealed any witnesses to abuse will tell the abuser to stop immediately, report the incident to their supervisor, the supervisor will notify the Administrator or designee, if the abuse is resident to resident, the patient who has threatened or attacked another will be removed from the setting or situation, the family and physician will be notified, room changes and alternative placement will be provided based on the situation if warranted. The policy also stated if a resident incident is reported, an investigation will be initiated within 24 hours of the allegation. The investigation shall include interviews of employees, residents, family and visitors who may have knowledge of the alleged incident. The policy stated the Administrator shall report all alleged or suspected violations to the appropriate state agencies immediately or within two hours to the Ohio Department of health, and all findings of all completed investigations will be reported to the Ohio Department of Health within five working days.

Based on medical record review, observation, staff and resident interview and review of facility policy, it was determined the facility failed to ensure one resident's pain medication was available to administer when needed for pain management. This resulted in actual harm for Resident #63 who experienced pain for three hours before being medicated with the physician ordered narcotic pain medication. The facility identified five residents currently on an active pain management program. The total census was 96. Findings include: Review of Resident #63's medical record revealed an admission date of [DATE] following a hospital stay for surgical repair of a left [MEDICAL CONDITION]. The resident was admitted to the rehabilitation unit for therapy. Other [DIAGNOSES REDACTED]. Further review of the record revealed the resident had a long time condition of chronic back pain. The resident had a portable electric nerve stimulator (TENS unit) to use as needed for her back pain, along with pain medication. Review of the nursing admission assessment completed 11/20/11 documented Resident #63 had active surgical pain of the left hip along with chronic back pain. The nursing assessment documented the occurrence of pain for this resident as "daily for years". Review of the care plan for Resident #63 revealed a plan for pain with interventions to include monitoring the presence of pain, administration of pain medication and to note the effectiveness of the medication. The interdisciplinary progress note dated 11/23/11 revealed the documented use of [MEDICATION NAME] (narcotic pain medication) as needed for pain. Further review of the Care Meeting note revealed the resident was started on an active pain management program upon admission to the facility. Review of the physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. On 11/28/11 at 8:00 A.M., Resident #63 was observed slowly coming out of her room with the use of a walker. The resident was dressed in bedclothes. The resident was noted to be tearful and upon seeing the nurse in the hallway stated, "Haven't you got my pain medicine yet? I just about can't take anymore. I've been waiting for hours". Licensed Practical Nurse (LPN) #1 quickly approached her and Resident #63 slowly turned and stepped back into her room. The resident sat back down on the chair in her room and attempted to stifle tears as she pleaded with LPN #1 to get her something for pain. LPN #1 explained that the dose of medication she received at midnight had been the last dose available to give the resident until the pharmacy sent more. LPN #1 told the resident that the pharmacy had not yet replied to the night shift nurse's request for the medication. LPN #1 also reminded the resident that the night shift nurse had offered her Tylenol ([MEDICATION NAME]) while she was waiting, but the resident had refused. Resident #63 replied the [MEDICATION NAME] also had Tylenol in it and that she had to watch the amount she took due to her liver. LPN #1 attempted to comfort the resident. The LPN then told the resident she would see what she could do and left the room. LPN #1 was aware of the surveyor's presence and excused herself to go to the nurses' station. Interview with Resident #63, identified as alert and oriented, on 11/28/11 at 8:00 A.M., following the nurse leaving the room, revealed the resident was still tearful. The resident informed the surveyor she had requested her pain medication at 5:00 A.M. She said the night shift nurse told her she would have to call the pharmacy to get more, but it would be no more than an hour. Resident #63 described her back pain as a "10" on a scale of 1-10 (ten being the most painful). She reported the pain had been a "10" since 5:00 A.M., saying she normally took the pain medication every four hours at home, although she would try to sleep longer during the night. Resident #63 went on to report that the pain also involved her left hip. As she sobbed she stated, "I feel like an addict when I have to keep asking for it". The resident further explained the day before had been extremely difficult as she had had muscle spasms which had intensified the pain all day. Interview with LPN #1 on 11/28/11 at 8:10 A.M. revealed Resident #63's personal supply of [MEDICATION NAME] was depleted when the midnight dose was given. However, the nurse revealed the facility had a supply in their emergency box, but they were waiting for authorization from the pharmacy to use a dose from the supply available to them. LPN #1 further verified during the interview that the night shift nurse had told her that Resident #63 had requested pain medication. LPN #1 also reported she (the night shift nurse) had offered the resident Tylenol since her supply of [MEDICATION NAME] needed refilled. During the interview, LPN #1 verified the resident had not had any pain medication since 12:00 A.M. on 11/28/11 and was due for another dose of [MEDICATION NAME] at 4:00 A.M. Review of the Medication Administration Sheet on 11/28/11 at 8:15 A.M. revealed the last dose of pain medication was given at 12:00 A.M. Further review of the pain evaluation and treatment sheet documentation revealed Resident #63 consistently rated her pain at a level of "8-10". Review of the seven days of her stay at the facility revealed the resident had required [MEDICATION NAME] every four to six hours. The pain rating for cognitively intact residents described the level of "8" as severe/horrible pain. Furthermore, the pain rating for the level of "9-10" was described as excruciating pain. Observation on 11/28/11 at 8:35 A.M. revealed LPN #1 administered [MEDICATION NAME] two tabs to Resident #63. The nurse then assisted the resident from the chair into her bed to rest. The resident was grimacing, openly crying and in obvious pain when transferring to the bed. Staff interview with LPN Unit Manager #3 on 11/28/11 at 1:40 P.M. revealed the facility procedure for use of medications from the emergency box was to send a fax request to the pharmacy and to follow up with a phone call if necessary to get timely pharmacy response. As soon as the pharmacy faxed the approval, the nurse would retrieve the medication from the facility emergency box. During the interview, LPN Unit Manager #3 verified the delay in getting medication for Resident #63 was not due to needing a new prescription to refill the narcotic, as the resident had a current prescription and only required availability of the medication. Review of the facility's policy entitled "Medication Shortages/Unavailable Medications" with a revision date of 05/01/10, revealed the procedure for a medication shortage discovered after normal pharmacy hours is the licensed facility nurse should obtain the ordered medication from the Emergency Medication Supply. If the ordered medication is not available in the Emergency Medication Supply, the licensed facility nurse should call the pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. The policy notes that action may include: emergency delivery or the use of an emergency (back-up) third party pharmacy. Also, if an emergency delivery is unavailable, the facility nurse should contact the attending physician to obtain orders or directions. If the medication is unavailable from pharmacy or a third party pharmacy, and cannot be supplied from the manufacturer, the facility should obtain alternate physician/prescriber orders, as necessary. Lastly, if the facility nurse is unable to obtain a response from the attending physician/prescriber in a timely manner, the facility nurse should notify the nursing supervisor and contact the facility's medical director for orders/direction. The facility policy was verified during interview with the Director of Nursing on 11/28/11 at 2:00 P.M. "This is an incidental deficiency found during the investigation of Complaint Number OH 756."