Every finding on record at Salem West Healthcare Center

Based on observations, medical record review, policy review, and interview, the facility failed to ensure a nurse implemented professional standards of practice when he failed to ensure a medication's expiration/use by date and administered the medication to a resident. This affected one resident (#8) of six residents observed during medication administration.Findings include:On 07/21/26 at 11:34 A.M., Registered Nurse (RN) #100 was observed preparing three units of insulin lispro (rapid acting insulin) 100 units per milliliter (u/ml) for administration to Resident #8. The insulin box and vial had an open date of 06/02/26. After RN #100 locked the cart and started to enter Resident #8's room with the syringe and alcohol swab, RN #100 was stopped by the surveyor. When asked when the insulin vial had been opened, RN #100 indicated that was a good question as he had not checked the information prior to preparing the insulin. RN #100 returned to the cart and verified the date marked on the vial and box was 06/02. RN #100 stated the insulin should not be used past 28 days of it being opened. RN #100 retrieved a new vial of insulin lispro from the medication room for administration. On 07/22/26 at 4:10 P.M., RN #105 verified it was a nurse's responsibility to ensure medications were not expired prior to administration. Review of the facility's Storage of Medications policy (effective September 2025) revealed certain medications or package types, such as multiple dose injectable vials, once opened, required both an opened date and an expiration date, which may be shorter than the manufacturer's expiration date to insure medication purity and potency. Drugs dispensed in the manufacturer's original container would carry the manufacturer's expiration date. Once opened, these would be good to use until the manufacturer's expiration date was reached unless the medication was in a multi-dose injectable vial, an ophthalmic medication or an item for which the manufacturer had specified a usable life after opening. When the original seal of a manufacturer's container or vial was initially broken, the nurse should label the medication with the date opened and the new date of expiration. The expiration date of the vial or container would be 30 days unless the manufacturer recommended another date or regulations/guidelines required different dates. No expired medication was to be administered to a resident. All expired medications were to be removed from the active supply and destroyed in accordance with facility policy, regardless of the amount remaining. Review of the facility's Medication Storage Best Practice Guideline (not dated) revealed all insulin vials/pens should be dated when opened once removed from the medication refrigerator. Place a Beyond-Use Date label on the bag and count forward the manufacturer's recommended days and indicate it on the label. The form indicated open vials of insulin lispro could be stored at room temperature for four weeks. Review of manufacturer information revealed once insulin lispro was opened, it should be thrown away after 28 days even if it still contained insulin. This deficiency represents non-compliance investigated under Complaint Number 3052754.

Based on observation, review of physician orders, policy review and interview, the facility failed to implement physician orders related to monitoring a feeding tube for placement and flushing the tube. This affected one resident (#23) of six residents observed during medication administration.Findings include:Review of Resident #23's physician orders revealed orders including buspar (anti-anxiety medication) 10 milligrams (mg) three times a day (start date of 07/10/26), prednisone (corticosteroid) 10 mg every day (start date 04/07/26), tizanidine (skeletal muscle relaxant) 4 mg three times a day, Jevity 1.5 five times a day (start date 12/11/25), polyethylene glycol (laxative) 17 grams every day (start date 05/07/26), flush enteral tube with at least 15 milliliters (mls) of water before and after each medication pass with 15 ml of flush given in between each medication and flush with 15 ml of water before and after tube feeding (start date 09/09/25), and verify enteral tube placement before feedings, flushes and medication passes by checking for gastric contents. Notify the physician if gastric contents were not visualized (start date 09/09/25). On 07/21/26 between 8:00 A.M. and 8:22 A.M., Licensed Practical Nurse (LPN) #110 was observed preparing Resident #23's above medications and nutritional feeding. LPN #110 reviewed orders and crushed the buspar, prednisone and tizanidine together in a medication cup. On 07/21/26 at 8:38 A.M., LPN #110 was observed initiating the medication administration. Between 5-10 ml of water had been added to the three crushed medications. LPN #110 checked for gastric contents and none was noted in the tube. LPN #110 proceeded to empty the contents of the medication cup (buspar, prednisone and tizanidine) into the feeding tube without flushing the tube. The medications would not go into the tube. The medications were poured back into the medication cup and LPN #110 stated she would have to get Registered Nurse (RN) #120 to unclog the tube. On 07/21/26 at 8:47 A.M., LPN #110 verified there had been no gastric contents observed when she was attempting to verify placement of the tube. At 8:50 A.M., RN #120 informed LPN #110 that Resident #23's feeding tube had been flushed and it was operating appropriately. On 07/21/26 between 9:00 A.M. and 9:13 A.M., LPN #110 was observed pouring the three crushed medications with water into the feeding tube followed by approximately half of the polyethylene glycol solution that had been mixed with water. LPN #110 proceeded to administer the jevity 1.5 then finished providing the remainder of the polyethylene glycol. There was no water flush after the medications were administered. On 07/21/26 at 9:15 A.M., LPN #110 verified although she had not been able to obtain gastric contents when checked, she proceeded to administer medications and nutritional formula without notifying the physician in accordance with orders. LPN #110 also verified she had not flushed the tube prior to attempting the initial medication administration and had not flushed the tube after medication administration. Review of the facility's Medication Administered by Enteral Tube policy (effective date of 04/06/26) revealed instructions to validate tube placement by aspirating 15-30 ml of stomach contents using a 60 ml catheter-tipped syringe. Replace stomach contents once placement was verified. If placement could not be verified, do not administer medications and contact the physician. Remove the plunger from the syringe and connect the syringe to clamped tubing. Place approximately 15 ml of tepid water or as directed in the syringe, unclamp the tube and flush tubing using gravity flow. Flush with a minimum of 15 ml of tepid water or as directed between each medication. After final medications, flush with 60 ml of tepid water or as directed by physician order. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 3052754.

Based on observation, review of physician orders, and interview, the facility failed to ensure medications were available for administration as ordered. This affected two residents (#23 and #26) of six residents observed for medication administration. The census was 67.Findings include:1. During observation of medication preparation and administration for Resident #23 by Licensed Practical Nurse (LPN) #110 revealed when preparation began between 8:00 A.M. and 8:22 A.M., no carafate (anti-ulcer medication) was available for administration. As lactulose (laxative) was prepared for administration less than 30 milliliters (ml) was available. The lactulose was mixed into a cup with miralax and water. When LPN #110 entered Resident #23's room to administer medication, he had left his room. LPN #110 disposed of the miralax and lactulose mixture. Resident #23 returned to his room at 8:24 A.M. LPN #110 prepared the miralax for administration but was unable to locate any lactulose. LPN #110 stated she would have to call pharmacy to see if they could deliver the lactulose. The Director of Nursing (DON) was passing and was informed by LPN #110 that she did not have lactulose or carafate available for administration. The DON offered to call the pharmacy.Review of Resident #23's medical record revealed diagnoses including gastro-esophageal reflux disease. Review of the July 2026 Medication Administration Record (MAR) and associated notes revealed orders to start lactulose 10 grams per 15 milliliters (gm/ml) on 05/08/26 with instructions to give 30 ml every day for constipation. A nursing notation dated 07/21/26 at 8:53 A.M. indicated pharmacy was to deliver the lactulose. There was no indication if the lactulose was going to be delivered with the regular delivery or a special delivery and there were no further notes of the lactulose being administered after it was received on 07/21/26. Review of the July 2026 MAR revealed an order for sucralfate 1 gm/10 ml with instructions to give 10 ml via the feeding tube before meals (start date of 04/06/26). An associated note indicated the sucralfate was not given but was supposed to be delivered by pharmacy that day. The order for the sucralfate was discontinued on 07/21/26 and a new order was written for sucralfate 1 gram to be administered every morning and at bedtime with the first dose administered documented at bedtime on 07/21/26. 2. On 07/21/26 at 9:30 A.M., LPN #110 was observed administering medication to Resident #26. LPN #110 reported she had no lactulose to administer in accordance with physician orders.Review of Resident #26's physician orders revealed an order to administer 30 ml of lactulose oral solution 10 gm/15 ml every morning and at bedtime for constipation starting on 03/25/26. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 3052754.

Based on observations, medical record review, policy review, and interview, the facility failed to ensure residents were free from significant medication errors in regard to expired insulin being used for administration. This affected one resident (#8) of six residents observed during medication administration. Findings include:On 07/21/26 at 11:34 A.M., Registered Nurse (RN) #100 was observed preparing three units of insulin lispro (rapid acting insulin) 100 units per milliliter (u/ml) for administration to Resident #8. The insulin box and vial had an open date of 06/02/26. After RN #100 locked the cart and started to enter Resident #8's room with the syringe and alcohol swab, RN #100 was stopped by the surveyor. When asked when the insulin vial had been opened, RN #100 indicated that was a good question. RN #100 returned to the cart and verified the date marked on the vial and box was 06/02. RN #100 stated the insulin should not be used past 28 days of it being opened. RN #100 retrieved a new vial of insulin lispro from the medication room for administration. Review of Resident #8's medical record revealed diagnoses included morbid obesity, type two diabetes mellitus with diabetic polyneuropathy (type of nerve damage that occurs as a complication of diabetes), type two diabetes mellitus with diabetic peripheral angiopathy (blood vessel disease caused by high glucose levels which limits blood flow to the legs and feet), and diabetic nephropathies (progressive kidney disease). Review of Resident #8's physician orders revealed orders to start Insulin lispro 100 u/ml via sliding scale for blood glucose levels between 151 and 400 before meals and at bedtime. Review of Resident #8's July 2026 Medication Administration Record (MAR) indicated insulin lispro was provided via sliding scale coverage at bedtime 14 days between 07/01/26 and 07/20/26. Insulin lispro was provided via sliding scale coverage before meals 32 times between 07/01/26 and lunchtime on 07/21/26. Review of the facility's Storage of Medications policy (effective September 2025) revealed certain medications or package types, such as multiple dose injectable vials, once opened, required both an opened date and an expiration date, which may be shorter than the manufacturer's expiration date to insure medication purity and potency. Drugs dispensed in the manufacturer's original container would carry the manufacturer's expiration date. Once opened, these would be good to use until the manufacturer's expiration date was reached unless the medication was in a multi-dose injectable vial, an ophthalmic medication or an item for which the manufacturer had specified a usable life after opening. When the original seal of a manufacturer's container or vial was initially broken, the nurse should label the medication with the date opened and the new date of expiration. The expiration date of the vial or container would be 30 days unless the manufacturer recommended another date or regulations/guidelines required different dates. No expired medication was to be administered to a resident. All expired medications were to be removed from the active supply and destroyed in accordance with facility policy, regardless of the amount remaining. Review of the facility's Medication Storage Best Practice Guideline (not dated) revealed all insulin vials/pens should be dated when opened once removed from the medication refrigerator. Place a Beyond-Use Date label on the bag and count forward the manufacturer's recommended days and indicate it on the label. The form indicated open vials of insulin lispro could be stored at room temperature for four weeks. Review of manufacturer information revealed once insulin lispro was opened, it should be thrown away after 28 days even if it still contained insulin. This deficiency represents non-compliance investigated under Complaint Number 3052754.

Based on observation, review of physician orders, policy review, and interview, the facility failed to ensure medications were administered in accordance with physician orders. This resulted in three medication errors out of 26 opportunities resulting in an 11.1% medication error rate. This affected two (Residents #5 and #36) of five residents observed for medication administration. 1.On 04/28/26 at 8:42 A.M., Licensed Practical Nurse (LPN) #110 was observed administering medication to Resident #36. While preparing Resident #36's medication, LPN #110 indicated Resident #36 did not have some medications in the medication cart. The medications not available included nifedipine (calcium channel blocker). LPN #110 checked the pyxis medication dispensing machine and indicated nifedipine was not available. LPN #110 stated she would have to contact pharmacy to let them know the nifedipine was not available for administration. Resident #36 was offered the remainder of the medication. Upon returning to the medication cart, LPN #110 documented the nifedipine was not available for administration and she would contact the pharmacy for refills. Review of Resident #36's physician orders revealed an order dated 02/13/25 for nifedipine Extended Release 60 milligrams (mg) every day. 2.On 04/28/26 at 9:32 A.M., Registered Nurse (RN) #130 was observed administering medication to Resident #5. Included in the medications that were administered was one tablet of furosemide (diuretic) 40 mg and one tablet of magnesium oxide 400 mg. Review of Resident #5's orders revealed there were no current orders for furosemide. (The most recent order for furosemide was discontinued 12/19/24). Resident #5's orders indicated instead of magnesium oxide 400 mg, Resident #5 had an order for two SlowMag Muscle/Heart delayed release 71.5 -119 mg (Magnesium chloride-calcium carbonate) tablets to be administered twice a day. On 04/28/26 at 10:08 A.M., RN #130 indicated he did not individually check the medications listed on the medication packets, each of which contained multiple medications. RN #130 stated he just scanned the bar codes on the packets then looked for any medications which was not indicated as being present in the packets. RN #130 stated he administered magnesium oxide because slow mag was not available and verified the two were not the same. On 04/28/26 at 12:25 P.M., Corporate Registered Nurse #100 stated when medication packets were scanned if a resident had a medication that had been discontinued, a warning was supposed to come up on the screen. She would have to call pharmacy and inform them that had not occurred with the administration of the furosemide. Review of the facility's Medication Administration policy (undated) revealed instructions to administer medication only as prescribed by the provider. Observe the five rights of medication administration which included ensuring the right medication and right dose was administered. The medication label was to be read three times prior to administering the medication and included comparing the label to the Medication Administration Record. This deficiency represents non-compliance investigated under Complaint Number 2978871.

Based on observation, review of the facility floor plan, and interview, the facility failed to ensure a fire pull station was visible and accessible in the event of an emergency. This had the potential to affect all 70 residents in the facility.Findings Include:Review of the facility floor plan revealed they had 14 fire pull stations in the facility. On 09/28/25 at 4:45 P.M. an interview with Resident #22 revealed he was concerned about the shelving blocking the fire pull station behind the nurse ' s station.An observation 11/03/25 at 10:45 A.M. revealed the wheeled cart of resident charts was stored/parked in front of the fire pull station. An interview with Licensed Practical Nurse #215 at this time verified the fire pull station behind the nurse ' s station was not accessible due to being obscured by the rack of resident ' s charts. This deficiency represents non-compliance investigated under Complaint Number 2606357.

Based on review of the medical record, review of the Self-Reported Incident (SRI) Investigation, interview, and review of the facility policy, the facility failed to ensure submission of SRI investigations were complete to include suspected perpetrators (SP) for tracking purposes, to ensure the facility and the State agency had the ability to identify potentially similar occurrences and allegations related to the same staff member. This affected two residents (#21 and #46) out of three reviewed for abuse and had the potential to affect all 20 residents (#4, #13, #14, #15, #20, #21, #27, #28, #34, #36, #39, #42, #43, #45, #46, #58, #59, #61, #62, and #63) who resided on the secure unit. Findings Include:1. Review of SRI 265131 revealed Licensed Practical Nurse (LPN) #122 stated Certified Nursing Assistant (CNA) #100 was attempting to have Resident #46 sit down so she could get her wheelchair and assist her to the bathroom. CNA #100 asked the resident several times and the resident started to yell at CNA #100 in Spanish. The CNA #100 got loud with Resident #46 so LPN #122 went to help and got Resident #46 to sit in the chair and calm down.Further review of SRI #265131 revealed an SP was not identified in the SRI section for tracking SP's even though the facility was aware of the staff member involved due to being named in the investigation, which was CNA #100. The facility was notified on 09/18/25 by the State agency to add the SP and they had not completed the action.Review of the police report dated 09/13/25 revealed the Officer responded to the facility for a complaint for an employee, CNA #100, who was involved in three sperate incidents at the facility. The employee was placed on administrative suspension until the investigation was concluded.Interview of 12/01/25 at 2:30 P.M. with Certified Nursing Assistant (CNA) #104 revealed CNA #100 was always getting into the resident's face and screaming at them. She stated they had reported her three times with nothing being done so she quit. She stated she was also there when she was in Resident #46's face yelling at her. She stated Resident #46 had dementia and only spoke Spanish and CNA #100 was yelling at her to speak English because she could not understand her when she spoke Spanish. 2. Review of SRI 265185 dated 09/13/25 revealed during an investigation on another SRI, it was reported by CNA #200 on 09/10/15 that she witnessed CNA #100 start yelling loudly and raised her arm at Resident #21, but did not hit her. It noted that Resident #21 had run over CNA #100's foot with the wheelchair.Further review of the SRI #265185 revealed an SP was not identified in the SRI section for tracking SP's, even though the facility was aware of the staff member involved due to being named in the investigation, which was CNA #100.Review of the police report dated 09/13/25 revealed the Officer responded to the facility for a complaint for an employee, CNA #100, who was involved in three sperate incidents at the facility. The employee was placed on administrative suspension until the investigation was concluded.On 12/03/25 at 11:45 A.M. an interview with the Director of Nursing verified CNA #100 was the SP, however she was not listed as an SP on SRI 265131 and 265185.Further review of facility SRIs revealed CNA #100 was involved in four other SRIs (#265184, #268248, #268392, and #268406) where she was named in the SRI as an SP.Review of the undated facility policy titled, Ohio Abuse, Neglect and Misappropriation, revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents. It was the intent of the facility to prevent the abuse, mistreatment or neglect of residents or the misappropriation of their property, corporal punishment and/or involuntary seclusion and to provide guidance to direct care staff to manage any concerns or allegations of abuse, neglect or misappropriation. Accurate and timely reporting of incidents, both alleged and substantiated, would be sent to officials in accordance with state law. Each occurrence of a resident incident, bruise, abrasion, or injury of unknown source; or report of alleged abuse, neglect or misappropriation would be identified and reported to the supervisor and investigated timely. The supervisor or designee would notify the Director of Nursing or Executive Director of the incident or allegation immediately and required notification of agencies, physician, and representative would be completed. The Executive Director would direct the investigation.This deficiency represents non-compliance investigated under Complaint Number 2617636.

Based on review of the medical record, review of staff time punches, review of facility self reported incidents (SRI), interviews, and review of facility policy, the facility failed to thoroughly investigate and take immediate action to protect a resident after an allegation of verbal abuse by a staff member. This affected one resident (Resident #28) of three residents reviewed for abuse and had the potential to affect all 20 residents who resided on the secure unit.Findings Include:Review of the medical record revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, diabetes, hypertension, diverticulitis, adult failure to thrive, schizoaffective disorder, anxiety disorder, and scoliosis.Review of the Significant Change Minimum Data Set assessment dated [DATE] revealed Resident #28 had moderately impaired cognition.Review of the Nursing Notes from 01/01/25 through 11/15/25 revealed no documentation of any incident of verbal abuse.Review of the hospice incident report for Resident #28 revealed on 11/10/25 at 11:14 A.M. Hospice Aide #400 called the hospice supervisor and reported the facility aide [CNA #100] was verbally loud with a resident after she turned on her call light too often. The facility aide told the resident she would take her call light away. The facility ' s nurse [indicating the nurse aide, CNA #203] asked the hospice aide to report the incident to the Assistant Director of Nursing due to her witnessing the event. The hospice aide spoke to the facility Administrator about the incident.Review of the typed signed statement from the Administrator dated 11/10/25 revealed she had spoken with the Hospice Aide [#400] concerning Resident #28 and Certified Nursing Assistant (CNA) #100. The hospice aide stated she was encouraged to say something to the Administrator. The hospice aide stated she did not have anything specific other than CNA #100 spoke more loudly than other staff members. The hospice aide stated that CNA #100 ' s voice carried and some of the other staff members thought she spoke loudly. There was no yelling directed at any specific person. A Self-Reported Incident (SRI) was not implemented because no SRI reportable was reported.Review of the time punches for CNA #100 revealed she worked on 11/10/25 from 6:05 A.M. through 6:16 P.M. and she continued working at the facility on 11/13/25, 11/14/25, 11/15/25, 11/16/25, 11/21/25, 11/22/25, 11/23/25, 11/24/25, 11/25/25, 11/26/25, 11/28/25, 11/30/25, 12/01/25, and 12/02/25.On 12/03/25 at 6:20 P.M. an interview with CNA #203 revealed on 11/10/25 the Hospice Aide [#400] heard CNA #100 yelling at Resident #28 when she came to visit her. She stated she told her to report it to the Administrator and Director of Nursing (DON) and she did. She stated they had a meeting with hospice regarding the incident, but nothing was done. She [CNA #203] also notified the Administrator herself, about the interaction the hospice aide observed with Resident #28 and CNA #100, when it happened a month ago.On 12/04/25 at 9:11 A.M. an interview with Hospice Director #410 revealed Hospice Aide #400 had gone to the facility Administrator the day of the incident and told her about it. She stated that since then the Hospice Social Worker was made aware and was in touch with the facility, and an occurrence was entered into their records on that day regarding what was heard. She stated Hospice Aide #400 had told her what had happen because she was upset about what had occurred. She stated the hospice aide had reached out to her and stated she was visiting with a resident and requested her nails be cleaned that day, so Hospice Aide #400 had left the room to find an aide to get an orange stick to clean under her fingernails. She stated the aide was on the phone, so it took her a little more time to get back to Resident #28 and the resident had turned her call light on again. She stated another aide, CNA #100 had entered the resident ' s room and Hospice Aide #400 was following her into the room. She stated Hospice Aide #400 heard CNA #100 yelling at Resident #28 telling her they were not doing this today, you need to be patient, and told her if she continued to turn her call light on she would take the call light from her. She stated Hospice Aide #400 stated CNA #100 was speaking aggressively to the resident. She stated at that point Hospice Aide #400 reported it to the Administrator and then called the office to notify them of the incident. She stated it was on 11/10/25. On 12/04/25 at 9:30 A.M. an interview with Hospice Aide #400 revealed on 11/10/25 she was at the facility to see Resident #28, and she asked her to go down the hall and find the aide because she was supposed to get her an orange stick to clean her nails. She stated she did that, but when she went out to find the aide, she was on phone so she was waiting for her to get off the phone. She stated while she was waiting for the aide to get off the phone, Resident #28 had turned her call light back on and CNA #100 went down the hall to answer it. She stated she had obtained the orange stick and was following CNA #100 into the room and she said to Resident #28 that she was not going to be doing this today, she was not going to be turning her call light on every five minutes, she needed to be patient, she was being impatient, and if she was going to do this she, was going to take the call light from her. She stated she did not like how CNA #100 spoke to Resident #28 so she reported it to the Administrator. She also called in to her office and told her supervisor. She stated CNA #100 did raise her voice and yelled at Resident #28 and the resident was very quiet after that. She stated she tried to change the mood, but you could tell the resident was upset about how the aide spoke to her. She stated she did see CNA #100 working after the incident.On 12/04/25 at 10:35 A.M. an interview with the Administrator confirmed she was aware of the incident from the hospice aide but after speaking to Resident #28 she did not believe it was reportable, so no SRI was completed.On 12/09/25 at 8:40 A.M. an interview with Resident #28 revealed CNA #100 was verbally abusive. She stated she would get hysterical and started yelling at the residents. She reported her the first time it had happened, to the DON and the ombudsman, and she stated she thought it was in May 2025, but she could not remember. She told the DON she did not want CNA #100 to take care of her. She stated that worked for a few weeks, then she was working with her again. She stated when she asked the DON about it, she stated she did not have anyone else to take care of her. She stated she was scared for a while to have her take care of her because she had reported her. She stated another incident happened in October 2025 where CNA #203 was taking care of her, but needed an orange stick to clean her nails. She stated the Hospice Aide [#400] came into the room and she told her she needed an orange stick also and she went out of the room, but she left the door open and she did not like it open. She stated she yelled out for the aide, but the hospice aide did not hear her. She stated she turned her call light on, and CNA #100 came into the room yelling at her about turning her call light on. She stated the hospice aide came back into the room as CNA #100 was yelling at her and Hospice Aide #400 was upset with the way CNA #100 was talking to her. She stated she had told the DON numerous times that CNA #100 yelled at her, but nothing had been done. She stated CNA #100 was not allowed to care for her again, but she was being punished because they had to go get someone from another hall to care for her and it took a long time, so she just told them to let her take care of her, so she did not have to wait. She stated CNA #100 tried to intimidate her to make herself feel superior. She stated she was very hateful. She stated CNA #100 also called her obsessive compulsive all the time because she liked to have her stuff in a specific way, but she really just likes her things neat in her room.On 12/09/25 at 2:15 P.M. an interview with the Administrator revealed she received a text from CNA #203 telling her she needed to speak to the Hospice Aide [#400] concerning how CNA #100 had spoken to Resident #28. She stated the hospice aide came to her, she could not remember her name, and stated she was encouraged by a facility staff member to report a situation with another staff member. She stated the hospice aide stated Resident #28 told her CNA #100 was very loud and boisterous. She stated she asked the hospice aide if Resident #28 was still comfortable with CNA #100 being her aide and she said yes. She stated Resident #28 would go through stages where she would allow CNA #100 to care for her and then she would not. She stated it was never reported to her that the aide was going to take her call light away because they would have done an SRI for that. She stated she never spoke to the Hospice Social Worker either. She verified she had not interviewed CNA #100, Resident #28, or the staff working that day about the reported incident. She also verified CNA #100 was never removed from the schedule and continued working with residents after the incident, CNA #100 was never educated regarding abuse or customer service, and also stated she never completed an investigation or started an SRI.Review of the undated facility policy titled, Ohio Abuse, Neglect and Misappropriation, revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents. It was the intent of the facility to prevent the abuse, mistreatment or neglect of residents or the misappropriation of their property, corporal punishment and/or involuntary seclusion and to provide guidance to direct care staff to manage any concerns or allegations of abuse, neglect or misappropriation. Accurate and timely reporting of incidents, both alleged and substantiated, would be sent to officials in accordance with state law. Each occurrence of a resident incident, bruise, abrasion, or injury of unknown source; or report of alleged abuse, neglect or misappropriation would be identified and reported to the supervisor and investigated timely. The supervisor or designee would notify the Director of Nursing or Executive Director of the incident or allegation immediately and required notification of agencies, physician, and representative would be completed. The Executive Director would direct the investigation and in the event an allegation is made, the facility will take measures to protect residents from harm during an investigation. Additionally, if an employee is alleged or accused of being a party to abuse, neglect, or misappropriation of property they will be immediately removed from the area(s) of resident care, interviewed by facility leadership for a written statement and not left alone. This deficiency represents non-compliance investigated under Complaint Number 2617636.

Based on review of the medical record, review of staff time punches, interviews, and review of facility policy, the facility failed to ensure Resident #28 was free from verbal abuse by a staff member. This affected one resident (Resident #28) of three residents reviewed for abuse. Findings Include:Review of the medical record revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, diabetes, hypertension, diverticulitis, adult failure to thrive, schizoaffective disorder, anxiety disorder, and scoliosis.Review of the Significant Change Minimum Data Set assessment dated [DATE] revealed Resident #28 had moderately impaired cognition.Review of the Nursing Notes from 01/01/25 through 11/15/25 revealed no documentation of any incident of verbal abuse.Review of the hospice incident report for Resident #28 revealed on 11/10/25 at 11:14 A.M. Hospice Aide #400 called the hospice supervisor and reported the facility aide [CNA #100] was verbally loud with a resident after she turned on her call light too often. The facility aide told the resident she would take her call light away. The facility ' s nurse [indicating the nurse aide, CNA #203] asked the hospice aide to report the incident to the Assistant Director of Nursing due to her witnessing the event. The hospice aide spoke to the facility Administrator about the incident.Review of the typed signed statement from the Administrator dated 11/10/25 revealed she had spoken with the Hospice Aide [#400] concerning Resident #28 and Certified Nursing Assistant (CNA) #100. The hospice aide stated she was encouraged to say something to the Administrator. The hospice aide stated she did not have anything specific other than CNA #100 spoke more loudly than other staff members. The hospice aide stated that CNA #100 ' s voice carried and some of the other staff members thought she spoke loudly. There was no yelling directed at any specific person. A Self-Reported Incident (SRI) was not implemented because no SRI reportable was reported.Review of the time punches for CNA #100 revealed she worked on 11/10/25 from 6:05 A.M. through 6:16 P.M. and she continued working at the facility on 11/13/25, 11/14/25, 11/15/25, 11/16/25, 11/21/25, 11/22/25, 11/23/25, 11/24/25, 11/25/25, 11/26/25, 11/28/25, 11/30/25, 12/01/25, and 12/02/25.On 12/03/25 at 6:20 P.M. an interview with CNA #203 revealed on 11/10/25 the Hospice Aide [#400] heard CNA #100 yelling at Resident #28 when she came to visit her. She stated she told her to report it to the Administrator and Director of Nursing (DON) and she did. She stated they had a meeting with hospice regarding the incident, but nothing was done. She [CNA #203] also notified the Administrator herself, about the interaction the hospice aide observed with Resident #28 and CNA #100, when it happened a month ago.On 12/04/25 at 9:11 A.M. an interview with Hospice Director #410 revealed Hospice Aide #400 had gone to the facility Administrator the day of the incident and told her about it. She stated that since then the Hospice Social Worker was made aware and was in touch with the facility, and an occurrence was entered into their records on that day regarding what was heard. She stated Hospice Aide #400 had told her what had happen because she was upset about what had occurred. She stated the hospice aide had reached out to her and stated she was visiting with a resident and requested her nails be cleaned that day, so Hospice Aide #400 had left the room to find an aide to get an orange stick to clean under her fingernails. She stated the aide was on the phone, so it took her a little more time to get back to Resident #28 and the resident had turned her call light on again. She stated another aide, CNA #100 had entered the resident ' s room and Hospice Aide #400 was following her into the room. She stated Hospice Aide #400 heard CNA #100 yelling at Resident #28 telling her they were not doing this today, you need to be patient, and told her if she continued to turn her call light on she would take the call light from her. She stated Hospice Aide #400 stated CNA #100 was speaking aggressively to the resident. She stated at that point Hospice Aide #400 reported it to the Administrator and then called the office to notify them of the incident. She stated it was on 11/10/25. On 12/04/25 at 9:30 A.M. an interview with Hospice Aide #400 revealed on 11/10/25 she was at the facility to see Resident #28, and she asked her to go down the hall and find the aide because she was supposed to get her an orange stick to clean her nails. She stated she did that, but when she went out to find the aide, she was on phone so she was waiting for her to get off the phone. She stated while she was waiting for the aide to get off the phone, Resident #28 had turned her call light back on and CNA #100 went down the hall to answer it. She stated she had obtained the orange stick and was following CNA #100 into the room and she said to Resident #28 that she was not going to be doing this today, she was not going to be turning her call light on every five minutes, she needed to be patient, she was being impatient, and if she was going to do this she, was going to take the call light from her. She stated she did not like how CNA #100 spoke to Resident #28 so she reported it to the Administrator. She also called in to her office and told her supervisor. She stated CNA #100 did raise her voice and yelled at Resident #28 and the resident was very quiet after that. She stated she tried to change the mood, but you could tell the resident was upset about how the aide spoke to her. She stated she did see CNA #100 working after the incident.On 12/04/25 at 10:35 A.M. an interview with the Administrator confirmed she was aware of the incident from the hospice aide but after speaking to Resident #28 she did not believe it was reportable, so no SRI was completed.On 12/09/25 at 8:40 A.M. an interview with Resident #28 revealed CNA #100 was verbally abusive. She stated she would get hysterical and started yelling at the residents. She reported her the first time it had happened, to the DON and the ombudsman, and she stated she thought it was in May 2025, but she could not remember. She told the DON she did not want CNA #100 to take care of her. She stated that worked for a few weeks, then she was working with her again. She stated when she asked the DON about it, she stated she did not have anyone else to take care of her. She stated she was scared for a while to have her take care of her because she had reported her. She stated another incident happened in October 2025 where CNA #203 was taking care of her, but needed an orange stick to clean her nails. She stated the Hospice Aide [#400] came into the room and she told her she needed an orange stick also and she went out of the room, but she left the door open and she did not like it open. She stated she yelled out for the aide, but the hospice aide did not hear her. She stated she turned her call light on, and CNA #100 came into the room yelling at her about turning her call light on. She stated the hospice aide came back into the room as CNA #100 was yelling at her and Hospice Aide #400 was upset with the way CNA #100 was talking to her. She stated she had told the DON numerous times that CNA #100 yelled at her, but nothing had been done. She stated CNA #100 was not allowed to care for her again, but she was being punished because they had to go get someone from another hall to care for her and it took a long time, so she just told them to let her take care of her, so she did not have to wait. She stated CNA #100 tried to intimidate her to make herself feel superior. She stated she was very hateful. She stated CNA #100 also called her obsessive compulsive all the time because she liked to have her stuff in a specific way, but she really just likes her things neat in her room.On 12/09/25 at 2:15 P.M. an interview with the Administrator revealed she received a text from CNA #203 telling her she needed to speak to the Hospice Aide [#400] concerning how CNA #100 had spoken to Resident #28. She stated the hospice aide came to her, she could not remember her name, and stated she was encouraged by a facility staff member to report a situation with another staff member. She stated the hospice aide stated Resident #28 told her CNA #100 was very loud and boisterous. She stated she asked the hospice aide if Resident #28 was still comfortable with CNA #100 being her aide and she said yes. She stated Resident #28 would go through stages where she would allow CNA #100 to care for her and then she would not. She stated it was never reported to her that the aide was going to take her call light away because they would have done an SRI for that. She stated she never spoke to the Hospice Social Worker either. She verified she had not interviewed CNA #100, Resident #28, or the staff working that day about the reported incident. She also verified CNA #100 was never removed from the schedule and continued working with residents after the incident, CNA #100 was never educated regarding abuse or customer service, and also stated she never completed an investigation or started an SRI.Review of the undated facility policy titled, Ohio Abuse, Neglect and Misappropriation, revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents. It was the intent of the facility to prevent the abuse, mistreatment or neglect of residents or the misappropriation of their property, corporal punishment and/or involuntary seclusion and to provide guidance to direct care staff to manage any concerns or allegations of abuse, neglect or misappropriation. Accurate and timely reporting of incidents, both alleged and substantiated, would be sent to officials in accordance with state law. Each occurrence of a resident incident, bruise, abrasion, or injury of unknown source; or report of alleged abuse, neglect or misappropriation would be identified and reported to the supervisor and investigated timely. The supervisor or designee would notify the Director of Nursing or Executive Director of the incident or allegation immediately and required notification of agencies, physician, and representative would be completed. The Executive Director would direct the investigation and in the event an allegation is made, the facility will take measures to protect residents from harm during an investigation. Additionally, if an employee is alleged or accused of being a party to abuse, neglect, or misappropriation of property they will be immediately removed from the area(s) of resident care, interviewed by facility leadership for a written statement and not left alone. This deficiency represents non-compliance investigated under Complaint Number 2617636.

Based on review of the medical record, review of staff time punches, review of facility self reported incidents (SRI), interviews, and review of facility policy, the facility failed to notify the State agency of an allegation of verbal abuse by a staff member. This affected one resident (Resident #28) of three residents reviewed for abuse. Findings Include:Review of the medical record revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, diabetes, hypertension, diverticulitis, adult failure to thrive, schizoaffective disorder, anxiety disorder, and scoliosis.Review of the Significant Change Minimum Data Set assessment dated [DATE] revealed Resident #28 had moderately impaired cognition.Review of the Nursing Notes from 01/01/25 through 11/15/25 revealed no documentation of any incident of verbal abuse.Review of the hospice incident report for Resident #28 revealed on 11/10/25 at 11:14 A.M. Hospice Aide #400 called the hospice supervisor and reported the facility aide [CNA #100] was verbally loud with a resident after she turned on her call light too often. The facility aide told the resident she would take her call light away. The facility ' s nurse [indicating the nurse aide, CNA #203] asked the hospice aide to report the incident to the Assistant Director of Nursing due to her witnessing the event. The hospice aide spoke to the facility Administrator about the incident.Review of the typed signed statement from the Administrator dated 11/10/25 revealed she had spoken with the Hospice Aide [#400] concerning Resident #28 and Certified Nursing Assistant (CNA) #100. The hospice aide stated she was encouraged to say something to the Administrator. The hospice aide stated she did not have anything specific other than CNA #100 spoke more loudly than other staff members. The hospice aide stated that CNA #100 ' s voice carried and some of the other staff members thought she spoke loudly. There was no yelling directed at any specific person. A Self-Reported Incident (SRI) was not implemented because no SRI reportable was reported.Review of the State agency notification system for abuse allegations revealed no SRI was submitted related to the 11/10/25 allegation of verbal abuse by CNA #100 towards Resident #28.Review of the time punches for CNA #100 revealed she worked on 11/10/25 from 6:05 A.M. through 6:16 P.M. and she continued working at the facility on 11/13/25, 11/14/25, 11/15/25, 11/16/25, 11/21/25, 11/22/25, 11/23/25, 11/24/25, 11/25/25, 11/26/25, 11/28/25, 11/30/25, 12/01/25, and 12/02/25.On 12/03/25 at 6:20 P.M. an interview with CNA #203 revealed on 11/10/25 the Hospice Aide [#400] heard CNA #100 yelling at Resident #28 when she came to visit her. She stated she told her to report it to the Administrator and Director of Nursing (DON) and she did. She stated they had a meeting with hospice regarding the incident, but nothing was done. She [CNA #203] also notified the Administrator herself, about the interaction the hospice aide observed with Resident #28 and CNA #100, when it happened a month ago.On 12/04/25 at 9:11 A.M. an interview with Hospice Director #410 revealed Hospice Aide #400 had gone to the facility Administrator the day of the incident and told her about it. She stated that since then the Hospice Social Worker was made aware and was in touch with the facility, and an occurrence was entered into their records on that day regarding what was heard. She stated Hospice Aide #400 had told her what had happen because she was upset about what had occurred. She stated the hospice aide had reached out to her and stated she was visiting with a resident and requested her nails be cleaned that day, so Hospice Aide #400 had left the room to find an aide to get an orange stick to clean under her fingernails. She stated the aide was on the phone, so it took her a little more time to get back to Resident #28 and the resident had turned her call light on again. She stated another aide, CNA #100 had entered the resident ' s room and Hospice Aide #400 was following her into the room. She stated Hospice Aide #400 heard CNA #100 yelling at Resident #28 telling her they were not doing this today, you need to be patient, and told her if she continued to turn her call light on she would take the call light from her. She stated Hospice Aide #400 stated CNA #100 was speaking aggressively to the resident. She stated at that point Hospice Aide #400 reported it to the Administrator and then called the office to notify them of the incident. She stated it was on 11/10/25. On 12/04/25 at 9:30 A.M. an interview with Hospice Aide #400 revealed on 11/10/25 she was at the facility to see Resident #28, and she asked her to go down the hall and find the aide because she was supposed to get her an orange stick to clean her nails. She stated she did that, but when she went out to find the aide, she was on phone so she was waiting for her to get off the phone. She stated while she was waiting for the aide to get off the phone, Resident #28 had turned her call light back on and CNA #100 went down the hall to answer it. She stated she had obtained the orange stick and was following CNA #100 into the room and she said to Resident #28 that she was not going to be doing this today, she was not going to be turning her call light on every five minutes, she needed to be patient, she was being impatient, and if she was going to do this she, was going to take the call light from her. She stated she did not like how CNA #100 spoke to Resident #28 so she reported it to the Administrator. She also called in to her office and told her supervisor. She stated CNA #100 did raise her voice and yelled at Resident #28 and the resident was very quiet after that. She stated she tried to change the mood, but you could tell the resident was upset about how the aide spoke to her. She stated she did see CNA #100 working after the incident.On 12/04/25 at 10:35 A.M. an interview with the Administrator confirmed she was aware of the incident from the hospice aide but after speaking to Resident #28 she did not believe it was reportable, so no SRI was completed.On 12/09/25 at 8:40 A.M. an interview with Resident #28 revealed CNA #100 was verbally abusive. She stated she would get hysterical and started yelling at the residents. She reported her the first time it had happened, to the DON and the ombudsman, and she stated she thought it was in May 2025, but she could not remember. She told the DON she did not want CNA #100 to take care of her. She stated that worked for a few weeks, then she was working with her again. She stated when she asked the DON about it, she stated she did not have anyone else to take care of her. She stated she was scared for a while to have her take care of her because she had reported her. She stated another incident happened in October 2025 where CNA #203 was taking care of her, but needed an orange stick to clean her nails. She stated the Hospice Aide [#400] came into the room and she told her she needed an orange stick also and she went out of the room, but she left the door open and she did not like it open. She stated she yelled out for the aide, but the hospice aide did not hear her. She stated she turned her call light on, and CNA #100 came into the room yelling at her about turning her call light on. She stated the hospice aide came back into the room as CNA #100 was yelling at her and Hospice Aide #400 was upset with the way CNA #100 was talking to her. She stated she had told the DON numerous times that CNA #100 yelled at her, but nothing had been done. She stated CNA #100 was not allowed to care for her again, but she was being punished because they had to go get someone from another hall to care for her and it took a long time, so she just told them to let her take care of her, so she did not have to wait. She stated CNA #100 tried to intimidate her to make herself feel superior. She stated she was very hateful. She stated CNA #100 also called her obsessive compulsive all the time because she liked to have her stuff in a specific way, but she really just likes her things neat in her room.On 12/09/25 at 2:15 P.M. an interview with the Administrator revealed she received a text from CNA #203 telling her she needed to speak to the Hospice Aide [#400] concerning how CNA #100 had spoken to Resident #28. She stated the hospice aide came to her, she could not remember her name, and stated she was encouraged by a facility staff member to report a situation with another staff member. She stated the hospice aide stated Resident #28 told her CNA #100 was very loud and boisterous. She stated she asked the hospice aide if Resident #28 was still comfortable with CNA #100 being her aide and she said yes. She stated Resident #28 would go through stages where she would allow CNA #100 to care for her and then she would not. She stated it was never reported to her that the aide was going to take her call light away because they would have done an SRI for that. She stated she never spoke to the Hospice Social Worker either. She verified she had not interviewed CNA #100, Resident #28, or the staff working that day about the reported incident. She also verified CNA #100 was never removed from the schedule and continued working with residents after the incident, CNA #100 was never educated regarding abuse or customer service, and also stated she never completed an investigation or started an SRI.Review of the undated facility policy titled, Ohio Abuse, Neglect and Misappropriation, revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents. It was the intent of the facility to prevent the abuse, mistreatment or neglect of residents or the misappropriation of their property, corporal punishment and/or involuntary seclusion and to provide guidance to direct care staff to manage any concerns or allegations of abuse, neglect or misappropriation. Accurate and timely reporting of incidents, both alleged and substantiated, would be sent to officials in accordance with state law. Each occurrence of a resident incident, bruise, abrasion, or injury of unknown source; or report of alleged abuse, neglect or misappropriation would be identified and reported to the supervisor and investigated timely. The supervisor or designee would notify the Director of Nursing or Executive Director of the incident or allegation immediately and required notification of agencies, physician, and representative would be completed. The Executive Director would direct the investigation and in the event an allegation is made, the facility will take measures to protect residents from harm during an investigation. Additionally, if an employee is alleged or accused of being a party to abuse, neglect, or misappropriation of property they will be immediately removed from the area(s) of resident care, interviewed by facility leadership for a written statement and not left alone. This deficiency represents non-compliance investigated under Complaint Number 2617636.

Based on medical record review, interview and policy review the facility failed to ensure complaints of new onset pain were addressed in a timely manner. This affected one (Resident #34) of three residents reviewed for injuries. The facility census was 81. Actual harm occurred beginning on 06/11/25 when Resident #34, who had a diagnosis of dementia and required assistance with care, complained of pain in the right thigh and lower extremity and demonstrated increased agitation during therapy that was not comprehensively assessed or treated. On 06/12/25, Resident #34 was unable to stand and had ongoing complaints of pain affecting therapy participation and mobility. Facility staff did not notify the resident's medical provider until 06/26/25 at 11:40 P.M. when the resident again complained of right hip pain to the day shift nurse resulting in an x-ray order and it was determined the resident had a pathological fracture to the right femur. The resident was subsequently transferred to the hospital for evaluation and returned to the facility the same day with hospice services at the request of family. Findings include: Review of Resident #34's medical record revealed diagnoses including type two diabetes mellitus with diabetic polyneuropathy, bipolar disorder, pseudobulbar affect, contractures of bilateral knees, pain in bilateral knees, dementia with behavioral disturbance, need for assistance with personal care, schizophrenia, post-traumatic stress disorder, neurosyphilis, persistent mood disorder, anxiety disorder, emotional lability and psychosis. Review of physician orders revealed on 04/17/23, an order was written to monitor for pain every shift. Review of a Physical Therapy (PT) evaluation dated 05/14/25 indicated Resident #34 was referred to PT for recent decline in function and bilateral knee flexion contractures. Resident #34 presented with decreased lower extremity strength, bilateral knee flexion contractures, decreased sitting balance requiring increased assistance with bed mobility and Hoyer lift for transfers. There was no pain at rest. PT notes dated 05/27/25, 05/30/25, 06/02/25, 06/03/25, 06/04/25, 06/05/25, and 06/06/25 revealed therapy included range of motion exercises with weights and standing exercises with no documentation of complaints of pain. A PT note dated 06/09/25 indicated Resident #34 performed bilateral lower extremity exercises seated using three-pound weights. Resident #34 complained of pain when staff assisted with knee extension due to stretch on bilateral knee flexion contractures. A PT note dated 06/11/25 indicated bed mobility with moderate to maximum assistance to roll and to reposition for increased comfort as Resident #34 had complaints of increased pain in the right lower extremity. Resident #34 appeared to demonstrate increased agitation with the therapist when cued for increased assistance with bed mobility. Resident #34 declined to get out of bed to go to the therapy room to attempt stands with the turn stand. A PT note dated 06/12/25 indicated four attempts were made to get Resident #34 to rise to a standing position from a seated position. However, Resident #34 appeared to have difficulty clearing her bottom from the chair. Resident #34 was unable to complete any stands due to complaints of increased pain in her right upper thigh area. Nursing was notified. Resident #34 required prolonged seated rests to recover with complaints of increased fatigue and increased right upper thigh pain. Review of an Occupational Therapy (OT) note dated 06/12/25 indicated Resident #34 was unable to stand to work on balance goals and reported right leg pain. The note indicated nursing and the nurse practitioner were aware. Review of additional PT notes revealed on 06/16/25 Resident #34 complained of pain when her right lower extremity range of motion exercises were completed. The complaints were reported to nursing. A PT note dated 06/17/25 indicated Resident #34 complained of increased right lower extremity pain and screamed out it hurts when range of motion was provided. Standing was not attempted related to complaints of pain. Nursing was notified. A PT note dated 06/19/25 indicated Resident #34 complained of pain when exercising her lower extremities and was unable to complete full range requiring staff to assist with her exercises. Nursing was aware of leg pain. A PT progress note dated 06/23/25 indicated sit to stands attempts were made twice at the turn stand with max assist of two. However, Resident #34 was unable to clear her bottom from the chair. Resident #34 demonstrated complaints of increased RLE pain. Nursing was notified. Resident #34 had complaints of increased right lower extremity pain with movement. Nursing was notified of Resident #34's complaints of increased right leg pain. Prolonged rests were required in between sets. A PT note dated 06/24/25 indicated Resident #34 performed active assistive bilateral lower extremities were exercised seated using 2.5-pound weights to improve her strength and increase her ability to perform bed mobility and transfers upon discharge from therapy. Resident #34 continued to complain of pain when her right lower extremity was ranged and bilateral lower extremities were edematous. Nursing was aware. A PT note dated 06/26/25 indicated Resident #34's range was limited in both legs but especially the right due to Resident #34 reporting pain when moved. Nursing was aware. Review of a progress note dated 06/26/25 at 11:40 P.M. revealed Resident #34 complained of right hip pain to the day shift nurse. An x-ray was ordered and results indicated in intertrochanteric fracture (type of hip fracture that occurs in the region between the greater and lesser trochanters (bony projections) of the thigh bone). The Director of Nursing (DON) and physician were notified of the abnormal x-ray and ordered Resident #34 be transferred to the emergency room for fracture evaluation. Resident #34's relative was notified by phone. During an interview on 08/19/25 at 10:04 A.M., Physical Therapy Assistant (PTA) #100 stated Resident #34 had been in the facility for a long time and was able to communicate pain. PTA #100 indicated she had been providing therapy services for Resident #34 and she had been able to stand with assistance at the turn stand. However, she was working with another resident one day when another PTA attempted to get Resident #34 to stand but she was unable. Resident #34 had neuropathy but the quality/severity of her pain prior to the fracture being discovered was different than her usual which was why therapy made sure nursing was made aware of the complaints. During interviews of five certified nursing assistants (dates/times not recorded due to a voiced desire to remain anonymous) who acknowledged familiarity with Resident #34, the following was revealed: One of the nursing assistants stated Resident #34 started complaining of pain every time she was rolled onto her right hip for at least a couple weeks before the x-ray was obtained. The information was shared with nursing. Some nurses would go in and feel her hip and leg but she was unaware of any action taken after that. Resident #34 did not complain of pain while at rest with the exception of a few times when she was sitting up in her chair. Another nursing assistant stated Resident #34 complained of pain for two to three weeks when turned prior to the x-ray being obtained. The nursing assistant stated moving aggravated the pain. Sometimes after transferring to the wheelchair from the bed, Resident #34's appetite would be decreased which she attributed to pain. The nursing assistant stated there was no place for nursing assistants to document information about residents. Notifications were completed verbally. One nursing assistant (third nursing assistant) stated Resident #34 complained of pain for over two weeks before the x-ray was obtained. The nursing assistant reported she had notified five nurses. The nursing assistant stated she was unaware there was an area in the aide documentation to indicate pain. The nursing assistant indicated she did not know if nurses had access to the information so all notifications of the pain were made verbally. Another nursing assistant stated Resident #34 complained of pain for about three weeks prior to the x-ray of her hip being obtained. The nursing assistant stated she reported the pain to nurses (could not recall which ones) that Resident #34 was having pain with movement. A fifth nursing assistant reported Resident #34 was complaining of pain with movement as early as mid-June. Nurses were made aware. On 08/19/25 at 11:14 A.M., the Director of Nursing (DON) was interviewed regarding the documentation from therapy notes which revealed multiple complaints of pain over multiple days without evidence of physician notification until 06/26/25. The DON stated she might have copies of facsimiles and would research. On 08/19/25 at 12:48 P.M., the DON provided documentation from nursing assistants which indicated no changes were noted in Resident #34's condition in June 2025. The DON also indicated and provided the Medication Administration Record (MAR) from June 2025 indicating Resident #34's pain was assessed every shift with multiple shifts indicating no pain. The DON verified the assessments were completed at a certain point in the shift and may have reflected pain at rest. The DON was unable to provide an explanation of therapy documenting Resident #34's pain was reported to nursing and the lack of physician notification of the ongoing complaints of pain with therapy. On 08/20/25 at 1:17 P.M., Licensed Practical Nurse (LPN) #120 stated she recalled being informed of Resident #34's pain but could not recall dates, stating complaints of pain were an ongoing occurrence. Resident #34 had behaviors and a history of yelling out making it difficult to determine if the yelling out was a behavior or related to pain. LPN #120 was unable to state action, if any, she took in relation to reports of pain. Review of the undated facility policy Pain Management and Assessment revealed acute pain refers to pain that is usually sudden in onset and time-limited with a duration of less than one month and often is caused by injury, trauma, or medical treatments such as surgery. It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety is a primary concern for our residents, staff and visitors. The purpose of this policy is to provide guidance to the clinical staff to support the intent of (the regulatory reference) that based on the comprehensive assessment of a resident, the facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management. There is no objective test that can measure pain. The clinician must accept the resident's report of pain. Clinical observations clarify information from the resident. Site of discomfort may direct the nurse to specific types of pain-relief measures. To the extent possible and in consideration of cognitive abilities, the nurse will provide a thorough assessment by observation of activities and treatment/relief for detection of pain and to attempt to identify location and any limitations imposed by the pain. Clues may include not participating in favorite activities or outings, facial grimaces during care, guarding or protecting a body limb or part, unexplained behaviors when the resident is unable to verbalize. Characteristics of pain, such as: intensity, pattern, location, frequency, duration.Impact of pain on quality of life including but not limited to sleep loss, function abilities, appetite and mood.Physical and psychosocial issues including physical examination of the site of the pain, movement, activity that causes the pain, as well as any discussion with resident about any psychological or psychosocial concerns that may be causing or exacerbating the pain. Pain Scale for Assessing Pain a. The Pain AD Scale1.Use for dementia related, cognitively impaired including but not limited to those with Alzheimer's Dementia that utilizes nurse observations such as breathing, moaning, tenseness, distracted, frightened b.The Verbal-Descriptor Scale1. Used for those residents who may be unable to comprehend numbers such as those with low education levels, English not their primary language; descriptive words (mild, moderate, severe, extreme) correlate to the 1-10 Pain scale For example, severe is a 6 on the 1-10 pain scale c. The 1-10 Pain Scale 1. For residents with intact cognition abilities who can /are willing to determine their worst pain ever ( l0) and no pain (1) range using numbers Pharmological and non-pharmological resident centered interventions for pain management are also documented. This deficiency represents non-compliance investigated under Master Complaint Number 1374425 (OH00167430) and Complaint Number 1374412 (OH00167460).

Based on medical record review and interview, the facility failed to ensure accuracy of medical records regarding bathing. This affected four (Residents #4, #5, #51 and #63) of six residents reviewed for provision of showers.Findings include: 1. Review of Resident #51's medical record revealed diagnoses including schizophrenia, bipolar disorder, depression, anxiety disorder, anxiety disorder, obsessive-compulsive disorder and dependent personality disorder. A nursing note dated 07/16/25 at 8:50 A.M. indicated Resident #51 was transferred out for a geriatric psych hospitalization. Review of nurse aide documentation in the electronic health record revealed Resident #51 was not available for showers/bathing on 07/23/25 and 07/27/25. However, shower sheet and body/skin inspection forms dated 07/23/25 and 07/27/25 indicated Resident #51 accepted showers and had skin assessments completed by nurses. Resident #51 was readmitted to the facility on [DATE]. During an interview on 08/21/25 at 11:00 A.M., it was addressed with the Director of Nursing that staff documented showers were given and skin assessments completed for Resident #51 while he was out at the hospital. No valid explanation was provided.2. Review of Resident #63's medical record revealed diagnoses including bipolar disorder, schizoaffective disorder, anxiety disorder, heart disease, congestive heart failure, and atrial fibrillation. Review of bathing records in the electronic health record revealed showers/bathing was not attempted due to medical condition or safety concerns on 07/23/25, 08/06/25 and 08/10/25. Review of shower sheets revealed inconsistencies with documentation in the electronic health record. Shower sheets on 07/23/25, 08/06/25 and 08/10/25 revealed Resident #63 refused showers instead of the shower not being attempted. There was a separate place in the electronic health record to indicate if showers were refused.On 08/18/25 at 2:03 P.M., Resident #63 stated he is told showers could not be offered at times due to staffing issues. Resident #63 denied showers were offered in accordance with the shower schedule.On 08/21/25 at 11:00 A.M. inconsistencies in documentation between the electronic health record and shower sheets were addressed with the DON who indicated she would need to educate nursing assistants on documentation.3. Review of Resident #4's medical record revealed diagnoses including chronic obstructive pulmonary disease, conduct disorder, generalized muscle weakness, contractures of multiple sites, and schizophrenia. A care plan initiated 09/27/22 indicated Resident #4 had activity of daily living (ADL) self-care performance deficit. Resident #4 required a hoyer for all transfers with two assists. Resident #4 was totally dependent on staff for all ADLs including bathing. Aide documentation in the electronic health record revealed between 07/20/25 and 08/17/25 staff documented showers were not attempted due to environmental limitations on 07/27/25 and 08/17/25. A shower was not attempted on 07/20/25 due to medical condition or safety concerns. However, a shower sheet and body/skin inspection form was provided for 07/27/25 indicating a shower was accepted.On 08/21/25 at 11:00 A.M. inconsistencies in documentation between the electronic health record and shower sheets were addressed with the DON who indicated she would need to educate nursing assistants on documentation.4. Review of Resident #5's medical record revealed diagnoses including Parkinson's disease, dementia, psychosis, type two diabetes mellitus, anxiety disorder, and post-traumatic stress disorder. A care plan regarding ADL self care performance deficit initiated 06/19/23 indicated Resident #5 was totally dependent on staff for bathing. Review of bathing records between 07/24/25 and 08/17/25 revealed documentation in the electronic health record indicated bathing was not attempted due to environmental limitations on 07/27/25 and 08/17/25. However, shower sheets were provided indicated a shower was accepted on 07/27/25.On 08/21/25 at 11:00 A.M. inconsistencies in documentation between the electronic health record and shower sheets were addressed with the DON who indicated she would need to educate nursing assistants on documentation.This deficiency is an incidental finding discovered during the complaint investigation.

Based on observation, review of the medical record, and interview with staff, the facility failed to ensure a wound treatment order was obtained and transcribed in the medical record for Resident #35. This affected one resident (Resident #35) of three residents reviewed for wounds. Findings Include:Review of the medical record revealed Resident #35 was admitted to the facility on [DATE]. Diagnoses included diabetes, dementia, bacteremia, chronic obstructive pulmonary disease, hypertension, anxiety disorder, depression, Alzheimer's disease, intermittent explosive disorder, dysphagia, and absence of part of the right foot.Review of the nurses note dated 10/16/25 at 6:45 P.M. revealed Resident #35 arrived with two emergency medical technicians (EMT) via an ambulance from the hospital. Resident #35 received a head to toe assessment upon admission and it was observed he had lost his right great toe.Review of the admission assessment dated [DATE] revealed Resident #35 had moderately impaired cognition and no open areas.Review of the nurses note dated 10/26/25 at 6:21 P.M. revealed Resident #35 was screaming in his room and saying he wanted to kill himself and he was unable to calm down and he was throwing items at staff. The resident was sent to the local hospital. Review of the nurse's note dated 10/31/25 at 5:30 P.M. revealed Resident #35 was readmitted from the hospital with a one by one (no standard unit listed) scab, dark in color with no drainage noted. The top of the right foot had a dry dressing. Review of the November 2025 physician's orders revealed Resident #35 did not have an order for a treatment to his right foot. Review of the November 2025 Treatment Administration Record revealed no documentation of a treatment being completed to the right foot of Resident #35.An observation on 11/03/25 at 1:00 P.M. revealed Resident #35 was sitting at the nurses station with a border foam dressing on the top of the right foot dated 11/01. Licensed Practical Nurse #101 stated she did not know why it was there. She checked the orders and verified there was no order for him to have a dressing to the top of his right foot. An interview on 11/04/25 at 10:35 A.M. with Regional Director of Clinical Operations (RDCO) #100 revealed the dressing to the right foot was placed for a pad and protect. She stated they notified the nurse practitioner on 11/01/25; However, the nurse did not put the order in the computer, but it was just a pad and protect, she stated the resident did not have any open areas or scabbed areas to the right foot. She stated they would have caught it when they completed his weekly skin check. Observation on 11/04/25 at 11:00 A.M. of Resident #35's right foot, with the Director of Nursing (DON) and RDCO #100, revealed the resident had a border foam dressing to the area of his right foot where his great toe used to be. The DON pulled the dressing back halfway to just expose his healed surgical incision. When the dressing was completely removed it exposed a dime sized scabbed area to the top of his foot, close to the second toes, and three pea sized scabs to the top of the second toe. The DON stated they did not have a treatment to the scabs because they were closed wounds.

Based on medical record review and interview, the facility failed to honor a resident's documented code status. This affected one (Resident #73) of two residents reviewed for advance directives.Findings include:Review of Resident #73 ' s medical record revealed diagnoses including late onset Alzheimer ' s disease, history of sudden cardiac arrest, hypertension, gastrostomy status, and cognitive communication deficit. Resident #73 had a signed Do Not Resuscitate Comfort Care - Arrest (DNR CC-A) order signed [DATE]. The form indicated a resident with a DNRCC-A would be treated as any other without a DNR order until the point of cardiac or respiratory arrest at which point all interventions would cease and the DNR Comfort Care protocol would be implemented. The form instructed if a resident had a DNR providers would not perform cardiopulmonary resuscitation (CPR).A nursing note dated [DATE] at 2:38 P.M. indicated the nurse found Resident #73 to be cyanotic with a respiratory rate of three breaths per minute. Staff went to retrieve oxygen supplies while Licensed Practical Nurse (LPN) #115 grabbed the crash cart and another nurse called 911. CPR was initiated and one round of chest compressions and respirations were provided before Resident #73 ' s pulse stopped and all breaths ceased as confirmed by two nurses. Emergency medical technicians (EMT) arrived and confirmed. The hospice nurse also arrived and was updated on Resident #73 ' s death.During an interview on [DATE] at 10:49 A.M., the Director of Nursing (DON) confirmed staff had initiated CPR on Resident #73 on [DATE] as they were confused about the DNRCC-A order. The DON stated she educated nurses regarding a resident with a DNRCC-A should not have had CPR initiated. During an interview on [DATE] at 2:10 P.M., LPN #115 stated she nor Registered Nurse (RN) #150 understood what the A at the end of the DNRCC-A meant. CPR was initiated with one set of chest compressions and one set of breaths delivered before they stopped and verified they could not detect a pulse or respirations. It was during this assessment that EMTs arrived and scanned Resident #73 ' s hospital bracelet and determined he had a DNR order and confirmed Resident #73 was absent of breaths and heart beat. CPR was discontinued.This deficiency represents noncompliance investigated under Complaint Number 1374412 (OH00167460)

Based on review of the facility assessment and staff interview, the facility failed to ensure a complete and accurate facility assessment was developed with active involvement of the required participants. This had the potential to affect all 64 residents residing in the facility. Findings include: Review of the Facility Assessment (FA), dated 04/03/25, revealed the following concerns: There were no persons named to identify required participants involved in completing the FA, as that section was left blank. The date the assessment was reviewed with the Quality Assurance Performance Improvement (QAPI) committee was blank indicating it had not been reviewed by QAPI. On page four, line four the facility resources needed to provide competent care for residents had several blank spaces intended for identification of laboratory services, x-ray services, food services, laundry services, nursing agency, electronic medical records, staff scheduling, and other contracted services. On page six, the certified bed capacity was incorrectly listed as 90 certified beds. On page 23, there were several blank spaces including the frequency of the clinical wound nurse practitioner's assessments and treatments, the frequency of the facility's designated wound nurse assessments and treatments, and specification as to who would be responsible for completing wound treatments and progression monitoring on the weekends. On page 24, there were several blank spaces including specification of observed food practices in the facility, meal times, and open dining times and days. On page 25, there were several blank spaces including specification of spiritual or religious programs offered, when and where spiritual or religious services would be held, what equipment if any would be provided for spiritual or religious services, frequency of facility activities, and whether any culturally relevant activities would be offered. On page 27, there were several blank spaces including identification of any facility staffed behavioral health specialists and availability of the behavioral health specialist. On page 28, there were several blank spaces including dates of staff trainings on behavioral health in the previous 24 months, identification of the group providing psychological or behavioral health services, frequency of behavioral health visits, whether or not services are provided for addiction services and frequency of sessions if applicable, and specification of days or times for activities provided in the dementia care unit and general residential care unit. On page 29, there are several blank spaces including whether or not dialysis services are provided on-site, the availability of respiratory staff, and specification of the company providing ancillary services such as dental, audiology, podiatry, and optometry. On page 30, there are two blank spaces intended to specify the schedule of the facility's risk nurse and the schedule of the facility's social services staff. In Part 3, section 3.1 of the FA starting on page 34, the staffing plan did not address the number of direct care staff across all shifts needed to address resident acuity/care needs, as the section addressing staffing of aides and nurses on each unit was blank and instead gave a report of the fourth quarter staffing reported in the payroll based journal. The section on Staff Survey and Individual Staff Assignments was left blank. On page 46, the assessment includes instructions to list contracts, memoranda of understanding, and other agreements with third parties, include a description of the process for overseeing those services and how those services will meet resident needs and regulatory requirements, list health information technology resources, describe how the facility will securely transfer health information to other health care providers, describe how downtime procedures are developed and implemented, describe how the facility ensures residents and their representatives can access their records upon request and obtain copies within required time-frames, describe the evaluation process of the infection prevention and control program, and provide the facility-based and community-based risk assessment utilizing an all-hazards approach for emergency preparedness. Although the instructions and prompts were listed, this information was not included in the facility assessment itself. On 04/23/25 at 12:29 P.M., an interview with the Administrator stated she had no involvement in completing the facility assessment revision and it was completed by a corporate staff member, whom she was unable to name. The Administrator verified the revision date was listed as 04/03/25, confirmed the multiple blank spaces throughout the facility assessment, and confirmed the certified bed capacity should have been listed as 80 not 90. On 04/23/25 at 12:54 P.M., an interview with the Administrator stated she personally completed the 2025 facility assessment, which contradicted her previous statement that she had no involvement. The Administrator also stated she received input from the Director of Nursing (DON) when completing the facility assessment. On 04/23/25 at 1:00 P.M., an interview with the DON stated she did not recall being involved in revising the facility assessment. The DON confirmed the revision date for the facility assessment of 04/03/25 was after she became the DON and verified the missing and incorrect information in the facility assessment.

Based on observation, record review, job description review, and interview the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This had the potential to affect all 64 residents who resided in the facility. Findings include: Review of facility document titled Position Description for position of Executive Director revealed the Administrator had signed the job description on 05/02/23. The description revealed the purpose of this position was to provide leadership to all staff to assure that care standards were met and the highest degree of quality resident care was provided at all times. The position description indicated the executive director must function as both a team member, team leader, and supervisor to ensure that work was accomplished and quality of care was delivered and had the authority, responsibility, and accountability for the overall operation of the facility. Major accountabilities and supporting actions of the position included but was not limited to: monitor operations to provide assurance of compliance with standards of practice, responsible for reviewing/evaluating and monitoring all staff on a regular basis to assure competence, achievement of goals, supervise and ensure care was provided in accordance with applicable standards of practice, state practice acts, and state and federal regulations. Review of facility document titled Position Description for position of Director of Nursing Services revealed the Director of Nursing (DON) had signed job description on 03/17/25. The description revealed the purpose of the position was to provide leadership to the nursing staff to assure that care standards were met and the highest degree of quality resident care was provided at all times. The position must function as a team member, team leader, and supervisor to ensure that work was accomplished and quality of care was delivered. Job duties and responsibilities included but were not limited to: make sure there was sufficient nursing levels to ensure delivery of quality resident care, ensure all nursing staff followed established department policies, monitor job performance to assure the staff were performing their work assignments within acceptable nursing standards, develop and maintaining a good working rapport with inter-department personnel as well as other departments to assure that the department services and activities could be maintained to meet the needs of the residents, assist in evaluating employee performance, inspect the nursing service areas and practices for compliance with current applicable regulations, assume the authority, responsibility, and accountability of directing the nursing service department, ensure all resident care would be provided in a dignified and respectful manner, supervise and may participate in the development of a written care plan and may review resident care plans for appropriate resident problems, approaches, goals, and revisions, ensure that a clean, comfortable and safe environment for residents was maintained at all times and resident needs were met, supervise and ensure care provided was in accordance with applicable standards of practice, state practice acts, and state and federal regulations During the annual and complaint survey, observations, record reviews and interviews resulted in concerns related to the overall operation of the facility including but not limited to sufficient staffing, completion of performance evaluation for nursing services, completion of the facility assessment, monitoring the function of resident call system, monitoring of safe and comfortable water temperatures, and therapeutic activities. The facility failed to provide evidence administrative staff, including the Administrator and/or DON had effective systems in place to timely identify and correct quality, care and environmental concerns as follows: A.The facility failed to ensure adequate staff to provide timely and adequate care for residents. Review of the Payroll Based Journal (PBJ) Staffing Report for Fiscal Year Quarter four (07/01/24 to 09/30/24) for the facility revealed a concern triggered for a one-star staffing rating indicating inadequate staffing hours. Review of the Facility Assessment (FA), dated 04/03/25, as provided by the Administrator revealed In Part 3, section 3.1 of the FA, the staffing plan did not address the number of direct care staff across all shifts needed to address resident acuity/care needs, as the section addressing staffing of aides and nurses on each unit was blank and instead gave a report of the fourth quarter staffing reported in the payroll based journal. The section on Staff Survey and Individual Staff Assignments was left blank. 1.Observation of incontinence care on 04/22/25 at 9:18 A.M. for Resident #23 with Certified Nursing Assistant (CNA) #543 and CNA #600 revealed Resident #23 was in a wheelchair in his room. CNA #543 stated Resident #23 had been up in his wheelchair since she had arrived to start her shift at 6:00 A.M. and stated she had not provided Resident #23 with incontinence care yet. Observation revealed CNA #543 and CNA #600 had used a hoyer lift (mechanical lift) to get Resident #23 out of his wheelchair. Resident #23's hoyer pad, pants, and shirt were observed to have been saturated with urine. Interviews with CNA #543 and CNA #600 confirmed Resident #23 was saturated with urine and neither were able to state when Resident #23 had last received incontinence care and stated residents should be checked for incontinence at least every two hours. CNA #543 stated there had not been enough staff at time to complete her assigned duties timely. Resident #23 was not interviewable. 2. Observation of incontinence care on 04/22/25 at 9:28 A.M. for Resident #42 with CNA #543 and CNA #600 revealed Resident #42 was in a wheelchair in his room. CNA # 543 stated Resident #42 had been up since she had arrived to start her shift at 6:00 A.M. and stated she had not provided Resident #42 with incontinence care yet. Observation further revealed Resident #42's incontinence brief was saturated with stale smelling dark urine. CNAs #543 and #600 confirmed the observation and stated residents should be checked for incontinence at least every two hours and both were unable to state when Resident #42 had last received incontinence care. CNA #543 stated there had not been enough staff at time to complete her assigned duties timely. Resident #42 was not interviewable. 3. Observations on 04/15/25 from 8:07 A.M. until 9:01 A.M. revealed Resident #38 was sitting in the dining room at a table by herself with food in bowls placed in front of her. There were two certified nursing assistants feeding other residents in the dining room. Resident #38 was observed making no attempt to feed herself. The resident was either watching other residents feed themselves or was dozing off. At 8:52 A.M. CNA #505 came over to assist Resident #38 with her meal. Interview on 04/15/25 at 8:55 A.M. with CNA #505 stated there were only two staff members in the dining room to feed four residents and assist a couple of residents. She confirmed residents were not being fed or assisted in a timely manner, which included Resident #38. 4. Observation on 04/23/25 at 11:06 A.M. with CNA #524 and #574 complete incontinence care for Resident #21 revealed Resident #21 was lying in bed. Resident #21 had a strong foul odor of urine. Observation revealed Resident #21's sheet and bath blanket Resident #21 was lying on was saturated with urine half way up her back and to her mid lower thighs. The brief was totally saturated and the blanket covering her was wet with urine. CNA #524 and #574 confirmed Resident #21 had a strong odor of urine and Resident #21's bedding and brief was saturated. Resident #21 revealed the last time she was checked or changed was 5:00 A.M. CNA #524 confirmed she was Resident #21's primary caregiver and confirmed this was the first time she checked or changed Resident #21 on her shift. CNA #524 confirmed she started her shift at 6:00 A.M. An interview on 04/23/25 at 11:43 A.M. with Resident #21 revealed she stated, they don't come in and change me like they should. Resident #21 revealed she never refused to be changed, when CNA #524 brought her breakfast tray in around 8:00 A.M. she asked to be changed. CNA #524 said she had to wait to get help, so she would do it after breakfast. Resident #21 revealed she ate her breakfast then fell back to sleep while waiting to be changed. Resident #21 stated, it makes me feel disgusting, it happens every day. An interview on 04/23/25 at 11:46 A.M. with CNA #524 revealed she stated, I did take her (Resident #21) breakfast tray in at 8:00 A.M., and she (Resident #21) did ask to be changed. I told her I would have to wait to get someone, we can't do her with one, it takes a while to find someone, the other aids were busy. Additional staff interviews conducted intermittently during the survey from 04/14/25 at 8:15 A.M. to 04/22/25 at 9:18 A.M. with eight direct care staff (Licensed Practical Nurse #538, #503, #541 and CNA #601, #550, #560, #570 and #543) revealed all of them voice concerns related to insufficient staffing affecting resident care regarding lack of timely resident checks, incontinence care, showers, medication pass and treatments. B.The facility failed to conduct performance evaluations for Certified Nursing Assistants (CNAs) who were due for required performance evaluations. Review of four employee files who were due for performance evaluations revealed CNAs #502, # 551, #552, and #562 had not had their performance evaluations. An interview on 04/23/25 at 11:10 A.M. with the Human Resource Manager confirmed the findings of performance evaluations absent from CNA #552, #502, #551 and #562 employee files. C. The facility failed to ensure the facility assessment was completed thoroughly and accurately. Review of the facility assessment, dated 04/03/25, revealed the following concerns: there was no indication who participated in the review and revision of the facility assessment. multiple sections of the facility assessment were incomplete as evidenced by blank spaces where information was needed to prepare a complete and thorough facility assessment. the certified bed capacity was incorrectly listed as 90 certified beds On 04/23/25 at 12:29 P.M., an interview with the Administrator stated she had no involvement in completing the facility assessment revision and it was completed by a corporate staff member, whom she was unable to name. The Administrator verified the revision date was listed as 04/03/25, confirmed the multiple blank spaces throughout the facility assessment, and confirmed the certified bed capacity should have been listed as 80 not 90. On 04/23/25 at 12:54 P.M., an interview with the Administrator stated she personally completed the 2025 facility assessment, which contradicted her previous statement that she had no involvement. The Administrator also stated she received input from the Director of Nursing (DON) when completing the facility assessment. On 04/23/25 at 1:00 P.M., an interview with the DON stated she did not recall being involved in revising the facility assessment. The DON confirmed the revision date for the facility assessment of 04/03/25 was after she became the DON and verified the missing and incorrect information in the provided facility assessment. D. The facility failed to ensure the resident's call system unit on the secured unit had an audible sound at all times so residents on the secured unit could call staff for assistance when needed. Observations during an environmental tour on 04/15/25 between 2:02 P.M. and 4:24 P.M. with Director of Plant Maintenance #516 revealed when a call light was pressed in Residents #8 and #58's room on the secure unit, the light outside the room lit up but there was no audible sound coming from the call system unit sitting on the nurse's station. Licensed Practical Nurse (LPN) #503 ,who was sitting at the nurse's station where the call system unit was sitting on the counter, confirmed the light outside the room had come on but she heard no audible sound coming from the emergency call system unit. LPN #503 stated the reason why there was no sound coming from the call system was because the volume on the unit had been turned down. Once LPN #503 turned up the volume on the call system unit, there was an audible sound coming out of the system when the call light was activated. LPN #503 verified if the volume was turned down, any of the resident call lights on the unit would not audibly notify staff the call light was activated. Interview on 04/15/25 at 2:57 P.M. with DPM #516 revealed he had noticed on other occassions the call system units had the sound turned off or way down so it could not be heard on the unit by staff. E. The facility failed to monitor water temperatures to ensure water was at safe and comfortable temperature at all times. Observation during an environmental tour of the water temperatures in residents' rooms on 04/15/25 from 2:02 P.M. to 4:18 P.M. with Director of Plant Maintenance (DPM) #516 revealed after the water had been running out of the bathroom faucet in Residents #36 and #267's room for approximately two minutes, DPM #516 took the facility's digital thermometer and temped the water at 130 degrees Fahrenheit (F). The water felt hot to touch and DPM #516 verified the water was too hot and immediately shut off the water on the 400 hallway and went to call the [NAME]. In Resident #34 and #54's room, after running the water for approximately two minutes, DPM #516 took the temperature of the water coming out of the bathroom faucet using a facility thermometer and the water reached 93.9 degrees F as the highest temperature. The water was lukewarm to the touch. In Residents #27 and #33's room, after running the water for approximately two minutes, DPM #516 took the temperature of the water coming out of the bathroom faucet using a facility thermometer and the water reached 93.9 degrees F as the highest temperature. The water was luke warm to the touch. In Residents #19 and #15's room, after running the water for approximately two minutes, DPM #516 took the temperature of the water coming out of the bathroom faucet and the water reached 95.0 degrees F as the highest temperature. The water was luke warm to the touch. In Resident #52's room, after running the water for approximately two minutes, DPM #516 took the temperature of the water coming out of the room faucet and the water reached 97.7 degrees F as the highest temperature. The water was lukewarm to the touch. Interview on 04/15/25 at 4:24 P.M. with DPM #516 stated the water temperatures should be between 105 and 120 degrees F. Review of the facility water temperature log provided by the Director of Plant Maintenance (DPM) #516 revealed a record of water temperatures between 01/01/25 and 04/14/25. The water temperatures had been checked in two different areas for each of the four hallways on 01/01/25, 01/06/25, 01/13/25, 02/17/25, and 03/10/25. On 01/13/25 the temperature recorded in Residents #34 and #54 room (on the 100 hallway) was 92 degrees Fahrenheit (F) and in Residents #42 and #46 room (on the 100 hallway) the temperature of the water was 90 degrees F. On 01/27/25 the water temperature taken of an unidentified area of the 100 hallway was 90 degrees F. There were no recorded temperatures on the log for the weeks of 01/20/25, 02/03/25, 02/10/25, 02/24/25, 03/03/25, 03/17/25, 03/24/25, or 04/07/25. This was confirmed by DPM #516 on 04/24/25 at 9:22 A.M. when he stated there was no proof water temperatures were being taken weekly with the missing weeks of recorded water temperatures because the program he used was not backing up the data. F. The facility failed to ensure all residents were provided therapeutic activities as scheduled and, in the evenings, to meet their needs and preferences. Review of the April activity calendar posted on the wall of hallway of the secure unit revealed activities scheduled on the unit for 04/16/25 included chair yoga at 9:00 A.M., chronicles /brain games at 9:30 A.M., games with friends at 10:00 A.M., guess your weight at 10:30 A.M., cards with friends at 1:30 P.M., sit and chat 2:30 P.M., socialize and snack at 3:00 P.M., and TED talk at 5:30 P.M. Observation on 04/16/25 at 10:45 A.M. revealed there was no activity being held on the secured unit. An interview on 04/16/25 at 10:51 A.M. with Certified Nursing Assistant (CNA) #563, who was working on the unit that day, verified there had not been any activities on the secure unit that morning and she was not sure why. Observation of the secure unit on 04/16/25 at 5:33 P.M. revealed there were two residents sitting in the secure unit lounge and two residents walking up and down the hallway. There was no [NAME] talk being held. At the time of the observation, Certified Nursing Assistant (CNA)#563 confirmed the activity at 5:30 P.M. was not being held. Interview on 04/21/25 with Activity Director #555 revealed the activity staff were only at the facility until 5:00 P.M., and activities held after 5:00 P.M. were the responsibility of the receptionist and the aides. She went on to state the receptionist position was currently vacant, and the facility had new aides who may not have known they were supposed to do the activities scheduled after 5:00 P.M. Activity Director #555 confirmed most of the even activities were not currently being held.

Based on observation, interview, record review, and review of the Payroll Based Journal (PBJ) and facility assessment, the facility failed to provide sufficient nursing staff to meet the total care needs of all residents for their highest practicable physical, mental and psychosocial well -being. This affected four residents (#21, #23, #38 and #42) of five residents reviewed for assistance with activity of daily living (ADL) needs and had the potential to affect all residents in the facility. The facility census was 64. Findings included: 1. Review of the Payroll Based Journal (PBJ) Staffing Report for Fiscal Year Quarter four (07/01/24 to 09/30/24) for the facility revealed a concern triggered for a one-star staffing rating indicating inadequate staffing hours. Review of the Facility Assessment (FA), dated 04/03/25, as provided by the Administrator revealed persons involved in completing the assessment were not identified by first or last name on the FA and there was no documentation to indicate if and when the FA had been reviewed by the Quality Assurance and Performance Improvement (QAPI) committee. The average census was identified as 61 residents. On page 10 was listed Physical Disabilities and the number of residents requiring staff assistance for ADLs based on current census which indicated out of a total of 61 residents 59 needed staff assistance for toileting hygiene, and 53 needed a minimum of set-up/clean-up assistance or a higher degree of assistance with eating. In Part 3, section 3.1 of the FA, the staffing plan did not address the number of direct care staff across all shifts needed to address resident acuity/care needs, as the section addressing staffing of aides and nurses on each unit was blank and instead gave a report of the fourth quarter staffing reported in the payroll based journal. The section on Staff Survey and Individual Staff Assignments was left blank. An interview on 04/14/25 at 8:21 A.M. with Licensed Practical Nurse (LPN) #538 revealed staffing was a concern because sometimes there were only two nurses in the facility and when there were only two nurses LPN #538 was unable to complete resident treatments. An interview on 04/14/25 at 8:43 A.M. with Certified Nursing Assistant (CNA) #601 revealed at times there will only be one CNA on the behavior unit and that was not enough to monitor and care for the residents. An interview on 04/14/25 at 11:10 A.M. with CNA #550 revealed there was usually one aide on the 400 hall so CNA #550 could not perform timely resident care. An interview on 04/16/25 at 7:23 A.M. with CNA #550 revealed because there are not enough staff there are days the residents who need every two hour checks for incontinence care will have to wait for three and a half hours before CNA #550 can find the time to go and change them. An interview on 04/16/25 at 7:53 A.M. with LPN #503 revealed when there are two nurses for the whole facility LPN #503 is unable to get medications passed on time to the residents. LPN #503 stated sometimes there is a third nurse to help pass medications until 10:00 A.M. but then that nurse leaves. An observation on 04/17/25 from 5:15 A.M. to 6:00 A.M. of the nursing staff in the facility compared to the posted schedule revealed there were two nurses and four CNA present in the facility. The posted schedule indicated there were three nurses consisting of one LPN from 6:00 P.M. to 10:30 P.M., one LPN from 6:00 P.M. to 6:30 A.M., one Registered Nurse (RN) from 6:00 P.M. to 6:30 A.M. and five CNA from 6:00 P.M. to 6:00 A.M. An interview on 04/17/25 at 5:18 A.M. with Registered Nurse (RN) #510 revealed there were two CNAs and one nurse for the 100/200 halls because the third CNA had left early. When asked if there was sufficient staff to meet all the resident care needs RN #510 replied we try our best. An interview on 04/17/25 at 5:21 A.M. with CNA #560 revealed there was not enough help on the 100/200 halls and more CNAs were needed because most of the residents needed a mechanical lift transfer which required at least two staff. CNA #560 stated with only two CNA on the 100/200 hall the staff can't get the residents up, can't get check and changes/incontinence care done and can't get showers completed. An interview on 04/17/25 at 6:00 A.M. with CNA #570 revealed she worked all shifts in the facility and when night shift is working short the residents have to wait for day shift to start before the care can be provided. CNA #570 stated when residents can get up and get showered was based on staff availability so showers do not get done as scheduled. An interview on 04/17/25 at 8:34 A.M. with LPN #541 revealed sometimes they are the only staff member on the 100/200 halls because the CNA are feeding residents. An interview on 04/17/25 at 8:40 A.M. with the Director of Nursing (DON) revealed staffing levels in the facility meet the minimum required 2.5 hours of direct care. The DON verified the night shift had four CNA and two nurses in the facility which did not match the daily posted schedule. An interview on 04/22/25 at 9:18 A.M. with CNA #543 revealed there were only two CNA on the 100/200 hall so there were several residents who had not been provided incontinence care yet. CNA #543 stated there needed to be three to four CNA on the 100/200 hall because there were over 30 residents who needed assistance. An interview on 04/23/25 at 12:29 P.M. with the Administrator verified the Facility Assessment was incomplete and did not have a staffing plan to address resident acuity needs. 2. Review of Resident #23's medical records revealed an admission of 11/20/19. Diagnoses included muscle weakness, need for personal care assistance and wheelchair dependent. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had no cognition score due to Resident #23 was rarely understood. Resident #23 was dependent with toileting, bathing and personal hygiene and was incontinent of bowel and bladder. Review of the care plan dated 02/28/25 revealed Resident #23 was incontinent of bowel and bladder. Interventions included provide incontinence care as needed. Observation of incontinence care on 04/22/25 at 9:18 A.M. for Resident #23 with Certified Nursing Assistant (CNA) #543 and CNA #600 revealed Resident #23 was in a wheelchair in his room. CNA #543 stated Resident #23 had been up in his wheelchair since she had arrived to start her shift at 6:00 A.M. and stated she had not provided Resident #23 with incontinence care yet. Observation revealed CNA #543 and CNA #600 had used a hoyer lift (mechanical lift) to get Resident #23 out of his wheelchair. Resident #23's hoyer pad, pants, and shirt were observed to have been saturated with urine. Interviews with CNA #543 and CNA #600 confirmed Resident #23 was saturated with urine and neither were able to state when Resident #23 had last received incontinence care and stated residents should be checked for incontinence at least every two hours. CNA #543 stated there were not enough staff to complete her assigned duties timely. Resident #23 was not interviewable. 3. Review of Resident #42's medical records revealed an admitted [DATE]. Diagnoses included muscle weakness, need for personal care assistance and dementia. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #42 had impaired cognition. Resident #42 was incontinent of bowel and bladder. Review of the care plan dated 03/31/25 revealed Resident #42 was incontinent of bowel and bladder. Interventions included provide incontinence care as needed. Observation of incontinence care on 04/22/25 at 9:28 A.M. for Resident #42 with CNA #543 and CNA #600 revealed Resident #42 was in a wheelchair in his room. CNA # 543 stated Resident #42 had been up since she had arrived to start her shift at 6:00 A.M. and stated she had not provided Resident #42 with incontinence care yet. Observation further revealed Resident #42's incontinence brief was saturated with stale smelling dark urine. CNA #543 and CNA #600 confirmed the observation and stated residents should be checked for incontinence at least every two hours and both were unable to state when Resident #42 had last received incontinence care. CNA #543 stated were not enough staff to complete her assigned duties timely. Resident #42 was not interviewable. 46195 4. Review of the medical record for Resident #38 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiplegia following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction, cognitive communication deficit, depression, and severe protein calorie malnutrition. Review of Resident #38's quarterly MDS 3.0 assessment, dated 03/14/25, revealed the resident was moderately impaired cognitively, exhibited continuous inattention behavior; required partial/moderate assistance for eating; had a significant weight loss which was not prescribed; and was on a therapeutic diet. Review of a weight change progress note dated 03/19/25 at 2:54 P.M. revealed Resident #38 current weight of 215.3 pounds triggered a significant weight loss of 14 percent weight loss over 180 days with poor intake of meals. Review of Resident #38's care plan, initiated on 07/24/24, revealed the resident had a potential for altered nutrition status/ nutrition related problems due to having a significant weight loss and being obese. Interventions included provide food in individual bowls to enhance independence in feeding ability; resident to be in the dining room for all meals; assistance with meals as needed; and provide diet and supplements per medical provider's orders. Observations on 04/15/25 from 8:07 A.M. until 9:01 A.M. revealed Resident #38 was sitting in the dining room at a table by herself with food in bowls placed in front of her. There were two certified nursing assistants feeding other residents in the dining room. Resident #38 was observed making no attempt to feed herself. The resident was either watching other residents feed themselves or was dozing off. At 8:52 A.M. Certified Nursing Assistant (CNA) #505 came over to assist Resident #38 with her meal. An interview on 04/15/25 at 8:55 A.M. with CNAs #505 revealed there were two staff members in the dining room to feed four residents and assist a couple of residents. CNA #505 confirmed residents were not being fed or assisted in a timely manner, which included Resident #38, due to not enough staff to provide assistance. 5. Record review for Resident #21 revealed an admitted [DATE]. Diagnosis included obesity, muscle weakness and the need for assistants with personal care. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #21 was cognitively intact. Resident #21 required substantial/maximal assistants for bed mobility, dependent for transfers to/from wheelchair and dependent for toileting hygiene. Resident #21 was always incontinent of urine and frequently incontinent of bowels. Record review of the care plan dated 12/05/23 revealed Resident #21 had an activity of daily living (ADL) self-care performance deficit due to immobility and morbid obesity. Interventions included for toileting hygiene, Resident #21 was totally dependent of two or more helpers who do all the effort. Observation on 04/23/25 at 11:06 A.M. with CNA #524 and #574 complete incontinent care for Resident #21 revealed Resident #21 was lying in bed. Resident #21 had a strong foul odor of urine. Observation revealed Resident #21's sheet and bath blanket Resident #21 was lying on was saturated with urine half way up her back and to her mid lower thighs. The brief was totally saturated and the blanket covering her was wet with urine. CNA #524 and #574 confirmed Resident #21 had a strong odor of urine and Resident #21's bedding and brief was saturated. Resident #21 revealed the last time she was checked or changed was 5:00 A.M. CNA #524 confirmed she was Resident #21's primary caregiver and confirmed this was the first time she checked or changed Resident #21 on her shift. CNA #524 confirmed she started her shift at 6:00 A.M. An interview on 04/23/25 at 11:27 A.M. with the Director of Nursing (DON) revealed each resident who was incontinent of the bowel or bladder would be checked every two hours to verify if they were incontinent, then changed if needed. If the resident was sleeping, they would still need to be checked. An interview on 04/23/25 at 11:43 A.M. with Resident #21 revealed she stated, they don't come in and change me like they should. Resident #21 revealed she never refused to be changed, when CNA #524 brought her breakfast tray in around 8:00 A.M. she asked to be changed. CNA #524 said she had to wait to get help, so she would do it after breakfast. Resident #21 revealed she ate her breakfast then fell back to sleep while waiting to be changed. Resident #21 stated, it makes me feel disgusting, it happens every day. An interview on 04/23/25 at 11:46 A.M. with CNA #524 revealed she stated, I did take her (Resident #21) breakfast tray in at 8:00 A.M., and she (Resident #21) did ask to be changed. I told her I would have to wait to get someone, we can't do her with one, it takes a while to find someone, the other aids were busy. Review of the facility policy titled, Routine Resident Care, undated, revealed it is the policy of the facility to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social, and spiritual needs and honor resident lifestyle preferences while in the care of the facility. This deficiency represents non-compliance investigated under Complaint Number OH00164146 and OH00162382.

Based on observation, interview, record review, review of the facility policies, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to maintain infection control practices by not adhering to proper hand hygiene during care for two residents (#21 and #22). This afffected two residents (#21 and #22) of five residents reviewed for assistance with activity of daily living. Also, the facility failed to ensure a flow diagram and a written description to describe the facility's water system was included in the facility water management program (WMP) in order to minimize the growth and transmission of the bacterium Legionella. This had the potential to affect all residents residing at the facility. The facility census was 64. 1.Record review for Resident #21 revealed an admitted [DATE] with diagnoses including obesity, muscle weakness and the need for assistance with personal care. An observation was conducted on 04/23/25 at 11:06 A.M. of Certified Nursing Assistant (CNA) #524 and #574 completing incontinence care for Resident #21. Resident #21's sheet and bath blanket underneath Resident #21 was saturated with urine and the blanket over her body was wet with urine. CNA #524 placed the saturated items in a disposable bag with her gloved hands. CNA #524 completed the incontinence care for Resident #21 and without changing her contaminated gloves or washing her hands after incontinence care picked up clean blankets and placed the blankets on Resident #21. CNA #524 proceeded to reposition Resident #21, opened the door, removed the glove on her right hand, left the room with the bag of soiled linen, walked down the hall to the soiled utility room, opened that door using her soiled hand, then disposed of the soiled linen into a container. CNA #524 then returned to Resident #21's room to wash her hands. CNA #524 confirmed she did not wash her hands or use hand sanitizer after providing incontinence care or before leaving Resident #21's room and touching the entrance door to the soiled utility room. CNA #524 confirmed the findings at the time of the observation. Interview on 04/23/25 at 11:27 A.M. with the Director of Nursing (DON) revealed each staff member should wash their hands after touching a resident or soiled items prior to leaving the residents room. Review of the facility policy titled, Standard Precautions dated 03/15/16 revealed practicing hand hygiene is a simple but effective way to prevent the spread of infections by breaking the chain of infection. Proper cleaning of hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming resistant to antibiotics. Examples of when to perform hand hygiene include before and after direct contact with a residents intact skin, after contact with inanimate objects, after hands move from a contaminated body site to a clean body site (example peri care) and after removing gloves. 44808 2. Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses including severe protein-calorie malnutrition, dementia with psychotic disturbance, adult failure to thrive, muscle wasting and atrophy, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/02/25, indicated Resident #22 had a severe cognitive impairment and required set-up or clean-up assistance for eating meals. On 04/17/25 at 8:20 A.M., an observation of the dining room revealed Certified Nursing Assistant (CNA) #551 entered the dining room, sat down beside Resident #22, and began providing feeding assistance to Resident #22. CNA #551 did not wash her hands after entering the dining room or before providing feeding assistance for Resident #22. On 04/17/25 at 8:24 A.M., an interview with CNA #551 confirmed she entered the dining room and did not wash her hands prior to providing feeding assistance for Resident #22. 46195 3. Review of the facility Water Management Program (WMP) for Legionella (the bacteria that causes Legionnaire's disease which results in a serious type of pneumonia). revealed there was no flow diagram or text description to identify the buildings water system and all locations in the water system where Legionella could potentially grow and spread . An interview on 04/15/25 at 1:39 P.M. with the Director of Plant Maintenance (DPM) #516 confirmed he had not developed a Legionella diagram assessment for the building or a text description of the facility's water system. DPM #516 stated he was flushing water fixtures which had not been used for 14 days or later to help prevent Legionnaire's disease. When asked why a flow diagram or text description had not been developed, DPM #516 stated he had been busy with everything else on the campus and hadn't had time to complete it. DPM #516 verified he had no evidence that all critical control points in the building were being monitored to prevent growth and spread of Legionella. Review of the undated facility policy titled Legionella or Legionnaire's Disease revealed Legionnaire's Disease also called Legionella Pneumonia is a rare but very serious type of pneumonia caused by the bacterium Legionella which is found naturally in fresh water environments including lakes and streams. Legionella becomes a health problem when it grows and spreads in human-made water systems including showers, faucets, unflushed eye washed stations, cooling towers for air conditioners, hot tubs, decorative fountains, hot water tanks and large plumbing systems. Surveillance for Legionella includes monitoring for appropriate levels of disinfectants in public and facility water systems. Monitoring the environment included maintenance performing routine water monitoring services, flushing eye wash stations, emergency potable water is secured and chlorination levels monitored, housekeeping maintains proper cleaning of ice machines, and reduce risk of growth by maintaining water temperatures in range. The policy did not address the need to describe the facility's water systems using flow diagrams and a text description. Review of the Centers for Disease Control and Prevention website located at https://www.cdc.gov/control-legionella/php/wmp/wmp-steps.html revealed WMPs identified hazardous conditions, and one of the steps to minimize the health impact of waterborne pathogens was describing the buildings water systems using flow diagrams and a written/text description to describe the building's water systems.

Based on observation and interview the facility failed to ensure a clean environment was maintained for Resident #56 and Resident #267 and failed to maintain comfortable water temperatures and at the required water temperature for Resident #11, #15, #19, #27, #33, #34, #52 and #54. This affected 10 residents (#11, #15, #19, #27, #33, #34, #52, #54, #56 and #54) with the potential to affect an additional 13 residents (#7, #14, #22, #23, #28, #31, #37, #42, #43, #45 #46, #60 and #114) residing on the 100 hall. The facility census was 64. Findings include: 1. Observation on 04/14/25 at 9:17 A.M. of Resident #56's room revealed Resident #56 was resting in bed and was noninterviewable due to drowsiness at the time of the observation. In Resident #56's bathroom the toilet was observed to have a large amount of black/green colored liquid stool on the toilet seat and in the toilet bowl. The observation was confirmed by Licensed Practical Nurse (LPN) #515. 2. Observation on 04/16/25 at 8:41 A.M. of Resident #267's bathroom revealed the toilet had dried stool on the toilet seat and inside the toilet bowl. The bathroom had a heavy odor of stale urine and there was a dark orange ring of residue surrounding the base of the toilet. The observation was confirmed by LPN #541. 46195 3. Review of the facility water temperature log provided by the Director of Plant Maintenance (DPM) #516 revealed a record of water temperatures between 01/01/25 and 04/14/25. The water temperatures had been checked in two different areas for each of the four hallways on 01/01/25, 01/06/25, 01/13/25, 02/17/25, and 03/10/25. On 01/13/25 the temperature recorded in Residents #34 and #54 room (on the 100 hallway) was 92 degrees Fahrenheit (F) and in Residents #42 and #46 room (on the 100 hallway) the temperature of the water was 90 degrees F. On 01/27/25 the water temperature taken of an unidentified area of the 100 hallway was 90 degrees F. There were no recorded temperatures on the log for the weeks of 01/20/25, 02/03/25, 02/10/25, 02/24/25, 03/03/25, 03/17/25, 03/24/25, or 04/07/25. Observations were conducted on 04/15/25 from 2:02 P.M. to 4:24 P.M. during an environmental tour with DPM #516 to obtain resident room water temperatures on the 100 hallway using DPM #516's facility thermometer. The following concerns were identified: In Resident #34 and #54's room, after running the water for approximately two minutes, DPM #516 took the temperature of the water coming out of the bathroom faucet using a facility thermometer and the water reached 93.9 degrees F as the highest temperature. The water was lukewarm to the touch. In Residents #27 and #33's room, after running the water for approximately two minutes, DPM #516 took the temperature of the water coming out of the bathroom faucet using a facility thermometer and the water reached 93.9 degrees F as the highest temperature. The water was luke warm to the touch. In Residents #19 and #15's room, after running the water for approximately two minutes, DPM #516 took the temperature of the water coming out of the bathroom faucet and the water reached 95.0 degrees F as the highest temperature. The water was luke warm to the touch. In Resident #52's room, after running the water for approximately two minutes, DPM #516 took the temperature of the water coming out of the room faucet and the water reached 97.7 degrees F as the highest temperature. The water was lukewarm to the touch. Interviews at the time of the observations with DPM #516 confirmed the water coming out of the bathroom sinks on the 100 hallway was not warm enough. DPM #516 stated the temperature of the water should be between 105 and 120 degrees F. DPM #516 said he attributed the lukewarm temperatures to the hot water tank not being large enough to meet all the needs of the residents on the affected unit. DPM #516 stated the facility had recently replaced the mixing valve which had helped to increase the water temperatures on the 100 hallway. Interview on 04/15/25 at 4:35 P.M. with Resident #11, who resided on the 100 hallway, revealed her showers were just warm and she would like the water temperature to be warmer because it was not at a comfortable temperature for her. Interview on 04/24/25 at 9:22 A.M. with DPM #516 confirmed the missing weeks of recorded water temperatures. DPM #516 stated he was taking water temperatures weekly except he had missed the week of 04/07/25. DPM #516 stated he thought the program he was using to record the water temperatures was backing up his data, and he had no idea why the program hadn't backed up the water temperatures he was recording. DPM #516 confirmed there was no written evidence the water temperatures were being monitored weekly for the missing weeks of recorded water temperatures. DPM #516 confirmed the water temperatures dating back to January of 2025 to present did not meet the regulatory requirement for water temperatures. Review of undated facility policy titled Resident Rights revealed it was the policy of the facility to provide residents with resident centered care that meets the psychosocial, physical, and emotional needs of the residents. This deficiency represents non-compliance investigated under Complaint Number OH00164146.

Based on observation, record review, interview and review of facility policy, the facility failed to ensure call lights were within reach for Resident #50, #56 and #60, and failed to ensure Resident #20 was reasonably accommodated to meet his shower preference. This affected four residents (#20, #50, #56 and #60) of 22 residents reviewed for accomodation of needs/preferences. The facility census was 64. Findings include: 1. Observation on 04/14/25 at 9:17 A.M. revealed Resident #56 was resting in bed with his call light draped on a light fixture above his bed not within reach. The observation was confirmed by Licensed Practical Nurse (LPN) #515 who stated call lights should be within reach of residents at all times. Resident #56 was not interviewable. Observation on 04/21/25 at 8:25 A.M. revealed Resident #56 was sleeping in bed and his call light was on the floor behind his bed. The observation was confirmed with LPN #503 and she stated call lights should be within reach of residents at all times. 2. Observation on 04/23/25 at 10:36 A.M. revealed Resident #60 was asleep in bed and the call light was pinned to a privacy curtain that was not within reach of Resident #60. Certified Nursing Assistant (CNA) #574 was present at the time of the observation and confirmed the call light was not within the resident's reach and should be in reach at all times. Review of resident council minutes for November 2024 revealed concerns related to call lights being left in inappropriate locations. 46195 3. Review of the medical record for Resident #50 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), type two diabetes, unspecified dementia, schizoaffective disorder, anxiety disorder, depression, bipolar disorder, and suicidal ideations. Review of Resident #50's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/03/25, revealed the resident was moderately impaired cognitively; exhibited behavioral symptoms not directed toward others one to three days of the assessment reference period; wandered one to three days of the assessment reference period, required supervision or touch for mobility which included walking up to 150 feet. Further review of Resident #50's medical record revealed a care plan with an initiation date of 01/24/25 which indicated the resident required a secure unit related to behaviors, elopement risk, and poor cognition. Interventions included the resident may have a long call cord light. Observation on 04/14/25 at 10:41 A.M. revealed Resident #50 was lying on her bed with no call light within reach of the resident. The call light cord was observed to be approximately two feet long and was hanging from the call system located in the middle of the right-hand wall of the room. Interview at the time of the observation with Resident #50 revealed she was unable to reach the call cord when she was lying on the bed. Interview on 04/14/25 at 10:55 A.M. with LPN #515 confirmed the call light was short and was not in reach of Resident #50. Interview on 04/15/25 at 10:16 A.M. with the Ombudsman revealed there was an open case regarding concerns with the short emergency call cords on the secure unit and the residents not being able to reach them. Interview on 04/15/25 at 1:39 P.M. with Director of Plant Maintenance (DPM) #516 stated the secured unit was recently opened and the rooms on the unit would have a long or short call cord depending on their diagnosis. Observation during an environmental tour on 04/15/25 with DPM #516 from 2:02 P.M. to 4:24 P.M. revealed there were both long and short emergency call cords in the residents rooms on the secure unit. Review of the undated facility policy titled Resident Rights revealed call light would be within reach of the resident. Review of the undated facility policy titled Secured (Locked) Unit revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical, and emotional needs and concerns of the residents. The unit would be adequately staffed to address the needs of the residents; would provide a homelike environment to the extent possible; would have secured areas for medications, cleaning supplies, treatment, and other products that might pose a potential hazard if inadvertently entered; would be quiet and away from unnecessary noise and interruptions; and would have secure areas to wander within the unit. There was nothing documented in the policy indicating the unit would have short and long emergency call cords. 4. Review of the medical record for Resident #20 revealed an admitted [DATE]. Diagnoses included morbid (severe) obesity, bipolar disorder, schizoaffective disorder, type two diabetes, and anxiety disorder. Review of Resident #20's quarterly MDS 3.0 assessment, dated 03/14/25, revealed the resident was cognitively intact, was dependent on staff to shower/bathe self, and the resident refused to transfer during the assessment reference period. Review of Resident #20's care plan, date initiated 08/29/23 and revised on 03/15/25, revealed Resident #20 had an ADL self care performance deficit related to morbid obesity. Resident #20 was dependent on staff for showering/bathing. There was no documentation in the care plan to indicate Resident #20 should not be showered and no documentation to indicate he preferred only bed baths. Further review of Resident #20's medical record revealed from 03/30/25 to 04/27/25 the resident either received a bed bath or refused to be bathed. The last weight recorded for Resident #20 was dated 04/04/25 and the weight was 711.0 pounds. Review of the product specification for MJM International PVCM1315 bariatric shower chair which the facility identified as being the bariatric shower chair located in the shower room on the unit where Resident #20 resided revealed the shower chair was made of PVC and had a weight capacity limit of 700 pounds. An interview with Resident #20 on 04/14/25 at 9:38 A.M. revealed he would love a shower, and if he received a shower, the facility staff would have a difficult time getting him out of the shower since it would feel so good. Resident #20 verified the staff did not shower him, they only gave him bed baths because he was told by the staff there was not a shower chair that would hold him. Interview on 04/16/25 at 7:23 A.M. with Certified Nursing Assistant (CNA) #550 revealed there was no way to safely shower Resident #20 in the shower room since the facility's bariatric shower chair would not be stable enough to support his weight. Observation of the facility's shower chairs and shower bed in all the shower rooms on 04/16/25 from 9:33 A.M. to 9:46 A.M. with Laundry and Housekeeping Manager (LHM) #603 revealed the largest shower chair was in the hall where Resident #20 resided and was made of white PVC (a synthetic resin made from the polymerization of vinyl chloride) pipe. There was a sticker on the chair indicating it was manufactured by MJM International but there was nothing on the bariatric chair indicating what the weight limit was for the chair, which was verified at the time of observation by LHM #603. Interview on 04/16/25 at 5:56 PM with the Director of Nursing (DON) confirmed the facility's bariatric shower chair had a weight limit of 700 pounds, and Resident #20 weighed more than the weight limit for the facility's bariatric shower chair. She went on to state she thought Resident #20 preferred bed baths, but if the resident wanted to take a shower, the facility did not have a safe way to shower the resident. Interview conducted on 04/17/25 approximately between 9:00 A.M. and 10:53 A.M. with DPM #516 revealed the facility could provide a bariatric shower chair to accommodate a resident who weighed between 700 and 900 pounds and it was made by the same manufacturer MJM International. Product specifications provided by the facility for MJM international Extra Wide PVC Bariatric Chair PVCM1315D8 revealed the chair was extra wide and reinforced at all stress related areas and had a weight capacity of 900 pounds. Review of the undated facility policy titled Resident Rights revealed it was the policy of the facility to provide resident centered care which would meet the physical needs of the residents and safety of the residents would be a top priority of care.

Based on observation, interview, medical record review, and review of facility policy, the facility failed to ensure Resident #13's pain was addressed in a timely and appropriate manner. Actual harm occurred on 08/17/24 when Resident #13, who had an open reduction and internal fixation (ORIF) surgery of a left femur fracture on 08/02/24, was admitted to the facility and the facility failed to develop and implement a comprehensive, individualized and adequate pain management program to provide effective and timely pain relief. Resident #13 displayed signs of pain on admission, during therapy evaluations on 08/19/24 with an increase in severity prior to direct care on 08/20/24 and received no pain interventions. Actual harm continued when Resident #13 was readmitted to the facility on [DATE] without an order for pain medication, exhibited acute pain on 09/01/24, and received no pain medication or interventions until the evening of 09/02/24. This affected one resident (#13) of three residents reviewed for appropriate and timely response to medical condition. The facility census was 56. Findings include: Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses including status post ORIF to the left femur, Alzheimer's disease, metabolic encephalopathy, cognitive communication deficit, severe protein-calorie malnutrition, history of falling, acute respiratory failure, dysphagia, and attention to gastrostomy. Review of the admission nurses progress note dated 08/17/24 at 4:10 P.M. revealed Resident #13 was admitted to the facility after recent ORIF of her left femur. The note further described Resident #13 as very restless and agitated with multiple skin tears to her bilateral upper extremities, three incision sites to her left hip with staples, and a large bruise down the back of her left upper leg. Review of the baseline care plan dated 08/17/24 revealed Resident #13 had complaints of acute and chronic pain or was at risk for pain. Interventions included a pain assessment on admission, re-admission, quarterly, with significant changes and as needed. Other interventions included assessing for pain every shift, following physician orders for complaints of pain, and administering non-pharmacological interventions for pain. Review of the admission physician's orders dated 08/17/24 revealed no orders for pain medications or interventions for pain control. Review of the Functional Abilities and Goals - Admission assessment completed 08/19/24 revealed Resident #13 was dependent on others for daily self-care. Review of the progress note dated 08/19/24 at 4:30 A.M. revealed Resident #13 was restless. There was no documentation of interventions related to Resident #13's restlessness in any of the progress notes. There was no documented evidence the physician was notified of Resident #13's restlessness. Review of the physical therapy (PT) notes from the initial evaluation visit dated 08/19/24 revealed Resident #13 had left hip pain at an intensity of five out of ten on the numeric pain scale, both at rest and with movement, the intensity was determined through resident verbalization, and the pain limited Resident #13's functional abilities. The evaluation also stated Resident #13 had interdisciplinary team (IDT) interventions listed including medications on a scheduled regimen and received medication as needed. (There was no scheduled pain medications ordered). There was no documented evidence that PT notified nursing of Resident #13's pain. Review of the occupational therapy (OT) initial evaluation visit note dated 08/19/24 revealed Resident #13 had pain rated at the intensity level of five out of 10 as determined by facial cues at rest and with movement. Further review of the OT evaluation revealed Resident #13's pain limited her functional abilities, and the interdisciplinary team (IDT) intervention was listed as Unknown. There was no documented evidence that PT notified nursing of Resident #13's pain. Observation on 08/20/24 at 2:05 P.M. revealed a visitor left the room of Resident #13 and informed State tested Nurse Aide (STNA) #340 that Resident #13 was acting like she was in pain. Review of the physician orders on 08/20/24 at 3:50P.M. revealed there were no orders for pain medication. Observation on 08/20/24 from 2:10 P.M. to 2:25 P.M. of incontinence care for Resident #13 performed by STNA #340 revealed Resident #13 was restless, agitated, moaning, had facial grimacing, and was pulling at her percutaneous endoscopic gastrostomy (PEG) tube and bed linens before, during, and after care. Observations further revealed Resident #13 had an increase in vocalizations/moaning and in muscle tone during the incontinence care. During the observed incontinence care, STNA #340 stated She is in severe discomfort, also noting that this behavior was uncommon for Resident #13. Observation after incontinence care on 08/20/24 revealed STNA #340 informed Licensed Practical Nurse (LPN) #322 that Resident #13 was demonstrating signs of pain. Interview on 08/20/24 at 2:30 P.M. with STNA #340 confirmed she was informed by a family member that Resident #13 was exhibiting signs of pain prior to performing incontinence care. Interview on 08/20/24 at 3:27 P.M. with Regional Director of Clinical Services (RDOCS) #335 confirmed once STNA #340 was informed by family that Resident #13 was in pain, she should have informed the nurse and made sure her pain was addressed prior to proceeding with the care. Review of the medical record revealed a primary health care provider telehealth encounter occurred at 10:29 P.M. on 08/20/24 for report of Resident #13 grimacing in pain. Further review of the note revealed the plan was to order Acetaminophen 325 milligrams (mg) (analgesic) two tablets every six hours as needed for pain. Review of the medication administration record (MAR) for August 2024 revealed the nurses documented they monitored for pain twice daily on days and nights from day turn on 08/18/24 through day turn on 08/19/24 by documenting a checkmark. There was no numerical pain scale. Review of the August 20024 MAR revealed Resident #13 received zero doses of Acetaminophen and zero non-pharmacological interventions in August 2024. No other pain medications were ordered or given for discomfort in the month of August. Review of the Nurse Practitioner (NP) progress note dated 08/21/24 at 3:17 P.M. stated, nursing notified me of abnormal labs for Resident #13. The resident was not seen today; however, after chart review, will send patient to emergency department (ED) for severe leukocytosis (high white blood cell count), hyperbilirubinemia/transaminitis (high liver enzymes). High concern for sepsis/MODS (multiple organ dysfunction syndrome). Review of the Medicare five day/Discharge with Return Not Anticipated (DRNA)/End of PPS Part A Stay Minimum Data Set (MDS) assessment completed on 08/21/24 revealed Resident #13 had severely impaired cognition and had a primary medical condition listed as fractures and other multiple traumas. Further review of the MDS revealed Resident #13 exhibited facial expressions, which could include grimaces, winces, wrinkled forehead, or furrowed brow, one to two of the days during the five-day look-back period and was on no scheduled pain regimen, received or was offered and declined any as needed pain medications, and received no non-pharmacological interventions. Review of Resident #13's clinical census revealed she returned to the facility on [DATE]. Review of the electronic medication administration record (eMAR) progress notes revealed Resident #13 received lorazepam 0.5 milligrams (mg) (antianxiety) via PEG tube for restlessness and agitation on 09/01/24 at 8:29 A.M. and that the lorazepam dose was deemed ineffective on 09/01/24 at 12:46 P.M. as evidenced by documentation of continued restlessness, agitation, and pushing the nurse's hands away during the vital sign assessment. A follow-up review of the physician orders revealed Resident #13 received a new order on 09/02/24 for Acetaminophen 325 mg, two tablets via PEG tube every six hours as needed for pain and that the previous order for Acetaminophen initiated on the evening of 08/20/24 was discontinued when Resident #13 was transferred to the hospital on 08/21/24 and not reordered upon her return to the facility on [DATE]. Interview on 09/03/24 at 11:38 A.M. with Registered Nurse (RN) #364 confirmed he contacted the provider for a telehealth visit to obtain an order for an as needed (PRN) pain medication at the direction of the Director of Nursing (DON) by telephone at approximately 10:30 P.M. on 08/20/24 (eight hours after the nurse was notified the resident was in pain) and, to his knowledge, there had been no other communications with the medical provider regarding Resident #13's pain prior to that interaction. Interview on 09/03/24 at 3:45 P.M. with the sister of Resident #13 confirmed she had visited Resident #13 on 08/20/24 and was concerned that Resident #13 was acting as if she were in severe pain due to her moaning and groaning, increased restlessness, drawing her legs up, and grabbing at her chest and abdomen. During the interview, the resident's sister verbalized Resident #13 looked and acted like she was having a great deal of pain that afternoon (08/20/24), which differed from her previous visits to Resident #13 while in the facility. Review of the September 2024 MAR revealed Resident #13's pain level was rated a 7 on night shift on 09/01/24 (time not indicated). Further review of the September MAR revealed Resident #13 did not receive Acetaminophen for discomfort, nor was there any documented evidence non-pharmacological interventions were attempted. The September MAR further revealed Resident #13 did not receive Acetaminophen until 09/02/24 at 9:44 P.M. Interview on 09/03/24 with LPN #318 confirmed Resident #13 exhibited signs of pain during her shift (night shift on 09/01/24), including kicking, throwing herself around, and moaning when touched. LPN #318 further reported Resident #13's tube feed was leaking, she had a rash all over her and seemed to hurt whenever she was touched. During the interview, LPN #318 confirmed Resident #13 had no orders for pain medication, so she administered gave her lorazepam every four hours to decrease her restlessness. LPN #318 further stated that report was then given to the day shift nurse that Resident #13 needed an order for pain medication and a possible increase in her antianxiety medication. LPN #318 confirmed she did not administer an analgesic to Resident #13 when she displayed signs of pain during her shift from 09/01/24 to 09/02/24 because she had no orders. Review of the facility policy titled Pain Management and Assessment, dated 04/16/24, revealed the nurse was to provide a thorough pain assessment and treatment for relieve of pain. The policy further revealed indicators of pain may include facial grimacing during care, guarding or protecting part of the body, unexplained behaviors, moaning, change in breathing pattern, and muscle tenseness. This deficiency represents non-compliance investigated under Complaint Number OH00156274.

Based on review of the medical record, emergency department records, resident and staff interviews, an interview with Physician #224 and review of the facility policy and procedure Dining and Food Preferences, the facility failed to ensure Resident #317 was served the appropriate diet to prevent a severe allergic food reaction. This resulted in Immediate Jeopardy when staff failed to ensure Resident #317, who was identified to be allergic to fish, was served fish for the dinner meal on 12/17/18 which resulted in an allergic reaction. Actual harm occurred when Resident #317 consumed the fish, causing a severe anaphylactic allergic reaction which required two doses of [MEDICATION NAME] intramuscularly and subsequent hospitalization for treatment of [REDACTED]. This affected one (#317) of six residents reviewed for food allergies. The facility identified six residents (Resident #317, Resident #35, Resident #22, Resident #5, Resident #14, Resident #54 with known food allergies. The facility census was 69. On 12/18/18 at 12:49 P.M. the Executive Director, Director of Nursing (DON), and Regional Nurse #206 were notified Immediate Jeopardy began on 12/17/18 at approximately 6:00 P.M. when Resident #317, who was identified to be allergic to fish and required set up assistance with meals, was served and then consumed tuna noodle casserole. The resident subsequently sustained [REDACTED]. The Immediate Jeopardy was removed on 12/18/18 when the facility implemented the following corrective action: · On 12/17/18, State tested Nursing Assistant (STNA) #200 received a verbal corrective counseling by DON to follow all policy and procedures very closely related to meal service after serving Resident #317 his dinner tray (which contained food he was allergic to) during the dinner meal on 12/17/18. · On 12/17/18, Cook #205 and Dietary Aide #201 received documented counseling for poor performance after failing to provide the correct meal to a resident (Resident #317) who had an identified food allergy to fish. Effective 12/17/18, Cook #205's employment was suspended pending outcome of the facility investigation. · On 12/17/18 from 7:00 P.M. through 12/18/18 at 1:20 P.M., the DON educated 12 Licensed Practical Nurses (LPN), three Registered Nurses (RN), 23 STNAs, one activity employee, eight housekeeping and laundry employees, and 14 department heads on meal service. The education included that it was imperative during meal times that all staff ensured each resident was served the appropriate diet. It was the responsibility of all staff to ensure each resident was receiving the appropriate diet consistency and liquid consistency. All staff must ensure residents received food they were supposed to have. Staff were to check for any possible food allergies prior to serving. Each resident's ordered diet was listed on their tray card located on their meal tray, any food allergies the resident had were also listed on the tray card. The staff must physically open each resident's food to check and ensure what they were being served matched what was written on the tray card. One STNA was not educated because the employee was absent through Family Medical Leave Act. · On 12/17/18 from 8:00 P.M. through 12/18/18 at 2:45 P.M. Dietary District Manager #202 provided 10 dietary staff (Dietary #208, Dietary #209, Dietary #210, Dietary #211, Dietary #212, Dietary #213, Dietary #214, Dietary #215, Dietary #216, Dietary #217) detailed education related to the responsibility of food service workers to provide every resident what was written on their meal ticket. Food service workers must read each ticket to identify any special request or special diets. Food service workers must ensure any special request or special diets were followed. Food service workers must ensure residents who had allergies did not get any food containing that allergy. Food service workers would highlight all allergies or special diet orders on the ticket. · On 12/18/18, Registered Dietician #203 and Dietary Manager #204 conducted an allergy audit comparing the meal tracker system and electronic medical record system to ensure all residents who had allergies have been properly identified. No concerns were identified. · On 12/18/18, Dietary Manager #204 checked all breakfast, lunch, and dinner meal trays for service accuracy. No concerns were identified. · On 12/18/18, the DON checked the breakfast, lunch, and dinner meal trays for all residents who had food allergies for service accuracy. · On 12/18/18, RN #218 reviewed six residents' medical records that were identified to have a food allergy (Resident #317, Resident #35, Resident #22, Resident #5, Resident #14, Resident #54). The current plan of care was reviewed to reflect the residents' current allergies. No concerns were identified. · On 12/18/18, Dietary Manager #204 and the DON created and posted a list in the kitchen and at each nurse station to identify residents with food allergies. Resident #317, Resident #35, Resident #22, Resident #5, Resident #14, Resident #54 were identified on the list. · Beginning 12/18/18 Dietary Manager/Designee will be on the tray line for all three meals to ensure accuracy and to ensure all residents with allergies are given the correct meal. A plan for Dietary Manger #204/Designee to check all residents who have allergies each shift for the next four weeks was implemented. · Beginning 12/23/18 weekly audits will be completed by the DON/Designee to ensure residents receive the correct meal trays, focused on the residents with food allergies. Audits will be completed for four weeks and then random thereafter. · Beginning 12/18/18, DON/Designee will audit the meal trays for residents who have a food allergy before being served to ensure accuracy every meal was implemented to be completed for one week and then randomly thereafter. · A plan for the Executive Director to monitor compliance monthly via the Quality Assurance Performance Improvement meetings for three months and then on an as needed basis. · On 12/18/18 and 12/19/18 interviews with Dietary #212, Dietary #209, Dietary #211, STNA #219, and STNA #220, STNA #221 revealed the staff interviewed were knowledgeable of the meal service requirements including the requirements for residents with food allergies. · Beginning 12/25/18 a plan for Dietary Manager #204/Designee to conduct a tray accuracy audit for 21 meals for one week and then for ten meals for an additional two weeks was implemented. The audit was planned to occur from 12/25/18 until 01/08/19. The findings from the audit will be recorded on a tray accuracy audit form. Although the Immediate Jeopardy was removed on 12/18/18 the facility remains out of compliance at Severity Level 2 (the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing and monitoring for corrective action. Findings include: Record review revealed Resident #317 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #317's Diet History/Food Preferences form, dated 11/09/18 revealed the resident was allergic to fish. Review of Resident #317's Allergy Report form, dated 11/12/18, revealed he was allergic to fish, and the severity was unknown. Review of Resident #317's physician's (MD) orders revealed an order, dated 11/15/18 for the facility to monitor diet tray for accuracy with current MD diet. The resident had an order for [REDACTED]. Review of Resident #317's Dietary-Nutritional Assessment, dated 11/16/18 revealed the resident was allergic to fish. The assessment did not contain additional information related to the severity of the allergy or how the allergy was determined Record review revealed a plan of care was initiated on 11/16/18 which indicated the resident reported he had an allergy to fish. Care plan interventions included the facility should provide the resident's diet as ordered and omit fish from his diet. Review of Resident #317's fourteen-day Minimum Data Set (MDS) 3.0 assessment, dated 11/26/18 revealed his cognition was intact and he required supervision, set up help only with eating. Review of a nursing progress note, dated 12/17/18 at 9:42 P.M. and authored by LPN #207 revealed the nurse was notified by an activities aide (STNA #200) that Resident #317 had called for help and appeared to be having trouble breathing. The resident said he had fish and had an allergy to fish. The nursing progress note, dated 12/17/18 at 9:42 P.M. indicated upon entering Resident #317's room at 6:16 P.M., the resident was noted to be sitting in his wheelchair directly inside the doorway and was visibly having trouble breathing. STNA #223 was sent to get another nurse. LPN #207 then obtained vital signs which included an elevated heart rate of 99 (beats per minute), elevated respirations of 26 (per minute) and an elevated blood pressure of 157/109. The resident's oxygen saturation was assessed to be normal at 99% on room air. Activities aide (STNA #200) was instructed to remain with the resident while LPN #207 placed a call to the physician. The phone call was placed to the physician at 6:18 P.M. and new orders were obtained to give one dose of the [MEDICATION NAME] medication, [MEDICATION NAME] (used to treat allergic reactions). LPN #222 began printing information for the resident to go to the hospital if needed. The [MEDICATION NAME] pen was pulled from the facility starter kit and was administered one time per physician orders at 6:20 P.M. Continued review of the nursing progress note (dated 12/17/18 at 9:42 P.M.) revealed on 12/17/18 at 6:29 P.M., the resident was re-assessed and determined to have no relief or improvement from the dose of [MEDICATION NAME] pen. A phone call was placed to the physician at 6:30 P.M. and an order was obtained to administer a second dose of [MEDICATION NAME]. The order indicated, if no relief to send the resident to the emergency room for evaluation. The additional dose of [MEDICATION NAME] was administered at 6:55 P.M. Resident #317 still had no relief of symptoms following the second dose of [MEDICATION NAME] pen. A phone call was placed to emergency medical transport (EMT) at 6:45 P.M. to notify them of the need to transport Resident #317 to the emergency room . The physician was notified at 6:46 P.M. the resident had no relief and was being transferred to the emergency room . LPN #207 remained with the resident while waiting for EMT to arrive. EMT arrived at the facility at 6:55 P.M. and the resident was transferred at 7:00 P.M. to the emergency room for evaluation and treatment of [REDACTED]. Review of Resident #317's physician's orders confirmed he was ordered two doses of [MEDICATION NAME] solution, auto-injector, 0.3 milligrams intramuscularly on 12/17/18. Review of the Medication Administration Record [REDACTED].M. and at 6:35 P.M. Review of the facility Follow-up Report dated 12/17/18 revealed STNA #200, who was working as an activities aide was interviewed (on 12/17/18) at 7:30 A.M. and stated she had served Resident #317 his dinner tray on 12/17/18. STNA #200 indicated the resident was sleeping, and she woke him and told him his tray was there. Resident #317 then called STNA #200 to his room, said he had fish and that he was allergic. The report indicated STNA #200 identified Resident #317 appeared to be very short of breath. STNA #200 got the nurse and the nurse had STNA #200 stay with the resident while calling the physician. Review of the facility Week at a Glance menu for 12/17/18 revealed the main entrée for dinner was tuna noodle casserole, and the alternate main menu entree was smothered steak. Review of Resident #317's dinner meal ticket for 12/17/18 identified the resident was allergic to fish and shellfish and revealed he should have been served smothered steak (the alternate meal). Review of the hospital emergency department note, dated 12/17/18 revealed Resident #317 was sent to the emergency room from a nursing facility after having a reaction to fish. The resident had abrupt onset of symptoms worsen, shortness of breath, and facial swelling. He was given subcutaneous [MEDICATION NAME] two times. The resident appeared cyanotic. The resident's symptoms included rash, itching, facial swelling, lip swelling, difficulty swallowing, difficulty breathing, shortness of breath, hoarseness and indicated the resident was exposed to food containing fish. The allergic reaction severity was identified as severe. Resident #317's medical decision- making narrative revealed he was given intramuscular [MEDICATION NAME] one time only upon arrival to the emergency room . Intravenous access was established, and the resident was administered [MEDICATION NAME] sulfate (a respiratory inhalation treatment), [MEDICATION NAME] and Sodium chloride (fluids) and [MEDICATION NAME][MEDICATION NAME] sodium (steroid) medication intravenously. Interview on 12/18/18 at 8:13 A.M. with the DON verified Resident #317 was served tuna noodle casserole and he was allergic to fish. The DON revealed the allergy was on his meal ticket, and verified the resident was sent to the hospital and was still in the hospital at the time of the interview. Interview on 12/18/18 at 9:36 A.M. with STNA #200 revealed she was passing hall trays and Resident #317 was sleeping in bed so she sat the resident's tray in his room. STNA #200 revealed she did not lift the lid off his plate because she did not want it to get cold. STNA #200 revealed she normally does look at the plate to ensure service accuracy. STNA #200 revealed 15 minutes later she came out of the dining room and went down the hall, to find Resident #317 holding his neck and stating he could not breathe. STNA #200 revealed she quickly got LPN #207. STNA #200 revealed the resident still couldn't breathe and looked purple in the face because he was trying to vomit after receiving the first [MEDICATION NAME] pen. STNA #200 revealed the resident stated it felt like someone was choking him. Interview on 12/18/18 at 9:43 A.M. with LPN #207 revealed she was in the hall (on 12/17/18) when STNA #200 reported to her that Resident #317 had eaten fish. Upon assessing the resident, LPN #207 revealed the resident was short of breath, his heart rate was high, his oxygen was 99 percent on room air, but she administered oxygen anyway to help him breathe. LPN #207 revealed the resident maybe had one bite of the tuna noodle casserole. LPN #207 revealed she confirmed on the computer the resident was allergic to fish and then obtained orders, from the physician to administer [MEDICATION NAME]. LPN #207 revealed the resident was still short of breath and voicing complaints of chest pain so she called the physician back and obtained an order to administer a second dose of [MEDICATION NAME] pen. LPN #207 revealed she obtained vital signs on Resident #317 throughout the situation, and his heart rate was almost up to 108 (beats per minute) at times. LPN #207 revealed she stayed with the resident until he was transferred to the emergency room . Interview on 12/18/18 at 9:48 A.M. with Cook #205 revealed she had plated the food for the dinner meal service on 12/17/18. Cook #205 revealed there were meal tickets on the trays and she usually looked at the ticket to see what a resident wanted. Cook #205 revealed on 12/17/18 she missed that Resident #317 had a food allergy and accidentally served him tuna noodle casserole. Cook #205 verified the allergy was listed on the resident's meal ticket but indicated she missed it. Interview on 12/18/18 at 12:02 P.M. with Resident #317, via phone call from the hospital, revealed he had told the facility he was allergic to fish. During the interview, Resident #317 reported he had been served fish at the facility a couple of times since his admission (dates unknown), but he had caught it and sent it back. Resident #317 revealed he didn't recognize the tuna during the dinner meal on 12/17/18 because it was in noodles. Resident #317 revealed he had a taste of the tuna noodle casserole and spit it out, but it was too late. Resident #317 revealed he had allergic reactions to fish in 1989 and 1994 and stopped breathing, so his physician told him to stay away from fish. Review of Resident #317's Return from Leave Observation Tool dated 12/18/18 at 3:03 P.M. revealed Resident #317 returned from the hospital after being kept overnight for observation. Resident #317's comprehensive care plan, revised 12/19/18, revealed the resident was admitted with report of allergies to fish, and the severity was identified to be respiratory distress. Resident #317's physician orders, dated 12/19/18 revealed he was ordered [MEDICATION NAME] 2-pack Solution Auto-injector 0.3 milligrams/0.3 milliliters, inject one application intramuscularly as needed for [MEDICATION NAME]. Interview on 12/19/18 at 2:02 P.M. with Resident #317's physician, Physician #224 revealed the resident's fish allergy was recorded, but the resident never mentioned the severity of the allergy. Physician #224 revealed when the nurse called her, she reported the resident's allergic response was respiratory related and shortness of breath. Physician #224 revealed she spoke to the admitting physician at the emergency room and they wanted to keep him overnight just in case. Review of the facility policy, titled Dining and Food Preferences, revised 09/2017 revealed the Diet Requisition Form would notify the Dining Services department of food allergies upon admission and prior to any meals served. The individual tray assembly ticket would identify all food items appropriate for the resident based on diet order, allergies and intolerances and preferences. Review of a facility PowerPoint presentation provided to all nursing staff upon hire, titled The Art and Science of Safe Eating, dated (MONTH) (YEAR) revealed the cook was responsible for preparing the correct meal tray based on the physician's order, every meal must match the meal ticket, and the aide was the second check to ensure the ticket matched the food on the plate. This deficiency substantiates Complaint Number OH 721.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on observation, interview, and record review the facility failed to prevent one cognitively impaired resident (Resident #89), assessed at risk for elopement and falls, from wandering away from the facility unsupervised. This resulted in Immediate Jeopardy for Resident #89 who left the facility without staff knowledge on 01/28/16 and was found by a neighbor approximately one mile from the facility. Resident #89 sustained actual harm when he received abrasions to both knees and his right shin, was incontinent of urine and his skin was cool to touch. This affected one of eight residents (Residents #65, #78, #83, #85, #89, #92, #100, and #114) assessed to be at risk for elopement. The facility census was 77 residents. On 07/13/16 at 3:55 P.M., the administrator, director of nursing (DON) and Regional Registered Nurse (RN) #112 were notified that Immediate Jeopardy began 01/28/16 at 5:30 P.M. when the facility was notified Resident #89 was found wandering in the streets near a neighbor's home in the community. Review of an accident/incident report dated 01/28/16 at 5:30 P.M. revealed Resident #89 was found wandering one mile from the facility, as verified using a global positioning system (GPS). Review of the witness statement dated 01/28/16 at 5:30 P.M. written by former DON #106, revealed Licensed Practical Nurse (LPN) #107 and Activity Assistant (AA) #108 picked up Resident #89 from a neighbor's house and returned him to the facility. The resident was cool to touch, his nose was draining clear mucus; his jeans were wet from incontinence; the knees of his pants were grass stained and his shoes had mud on them. The resident was wearing a Wanderguard (electronic) bracelet that should have caused an alarm to sound when the resident left the facility. The alarm was intact and functioning when tested upon the resident's return to the facility, however, no one heard the alarm sound when the resident left the building. There was no evidence that indicated the facility was able to determine how the resident exited the building. The Immediate Jeopardy was removed and the deficient practice was corrected on 01/28/16 at 7:00 P.M. when the facility implemented the following corrective actions: · On 01/28/16 at 5:45 P.M. Resident #89 was assigned a one to one staff member for supervision for 24 hours. · On 01/28/16 by 6:30 P.M., all 87 facility staff were inserviced on the Happy Feet program (lists all residents at risk for elopement) and the elopement policy and procedure. The department heads who conducted the inservices included the Administrator, Assistant Director of Nursing, Scheduler #120, Business Office Manager #121, Laundry Supervisor #122, Housekeeping Supervisor #123, Dietary Manager #124, Therapy Manager #125, Activity Director #116 and Maintenance Director #126. · On 01/28/16 at 7:00 P.M., stop signs were placed on the exit doors on four corridor hall doors. · Review of the facility Incident/Accident log, Self-Reported Incident records, and medical records of the residents identified at risk for elopement, along with interview with the Administrator and Regional Nurse RN #98 on 07/11/16 and 07/15/16 11:37 A.M., revealed no other elopements have occurred at the facility since 01/28/16. Findings include: Review of the medical record for Resident #89 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was assessed as a high risk for elopement since admission in October 2014 and wore a Wanderguard device since that time. The Minimum Data Set (MDS) 3.0 quarterly assessment, dated 04/12/16, revealed Resident #89 had severe cognitive deficits, required extensive assistance of one staff member for toilet use and transferring, was frequently incontinent of urine, and required supervision with ambulation as the resident was not steady when walking. The MDS also indicated the resident wandered daily. Review of the plan of care dated 01/28/16 revealed Resident #89 experienced wandering that placed him at risk of getting to potentially inappropriate places. The goals included that the resident would not go outside without supervision. The interventions from October, 2015 through 01/28/16 included monitoring the resident every 15 minutes. Review of the facility's investigative documentation dated 01/29/16 at 5:30 P.M., revealed on 01/28/16 the facility received a call from a neighbor stating she had found Resident #89 outside her house which was in the local community. The location was approximately one mile from the facility according to GPS tracking. The investigative material included a print out from the Weather Channel that stated the temperature that day was 38 degrees Fahrenheit. Witness statements from State tested Nurse Aide (STNA) #105, STNA #103, LPN #107, and STNA #108 all revealed Resident #89 was presenting exit seeking behaviors on 01/28/16. LPN #107 stated that on 01/28/16 at 1:50 P.M. the resident was seen standing by the door on the black rug near the break room and the Wanderguard alarm was not sounding. The witness statements indicated the resident was last seen in the facility on 01/28/16 at 5:20 P.M. Review of the Elopement Risk 15 Minute Checks forms revealed the last documented time the resident was checked was 5:15 P.M. Review of the witness statement dated 01/28/16 at 5:30 P.M., written by former DON #106, revealed that LPN #107 and AA #108 were sent to pick up Resident #89 from the neighbor's house and return him to the facility. The resident's condition upon return to the facility was documented as being cool to touch; his nose was draining clear mucus; his jeans were wet from incontinence; the knees of his pants were grass stained and his shoes had mud on them. He was wearing a black hooded sweatshirt. The statement read that the resident was wearing a Wanderguard (electronic bracelet that should cause an alarm to sound if the resident tried to leave the facility). The documentation indicated the alarm was intact and functioning when tested but no one heard it when Resident #89 left the building. Review of the Skin Body Assessment and the incident/accident report dated 01/28/16 revealed Resident #89 had returned with redness and abrasions to both knees and the right shin. Review of a witness statement dated 01/29/16 written by Corporate RN #101 revealed the neighbor who found Resident #89 near her home on 01/28/16 reported she found him between 3:30 P.M. and 4:00 P.M. on 01/28/16. On 07/12/16 at 5:30 P.M. during interview with Corporate RN #101, she verified there was inconsistency between the time the neighbor stated she found Resident #89 and the time staff stated he was last seen in the facility. Therefore it could not be determined how long the resident was gone from the facility. After Resident #89 returned to the facility, on 01/28/16 at 5:45 P.M., the facility assigned a staff member to the resident for constant monitoring for 24 hours. Monitoring of the resident continued in subsequent days every 15 minutes. Resident #89 was to wear an electronic bracelet called a Wanderguard to alert staff if he attempted to leave the facility and to ensure all staff was aware of the resident's elopement risk. The Elopement Risk 15 Minute Checks forms indicated the resident continued on 15 minute checks through 07/11/16. Review of the quarterly elopement assessment dated [DATE] revealed Resident #89 was physically capable of eloping outside the facility, had a history of [REDACTED]. On 07/13/16 at 1:00 P.M., interview with the Administrator revealed Resident #89's Wanderguard was on and functioning correctly on 01/28/16. He verified that he was sure the alarm sounded on 01/28/16 and someone silenced it, but they could not get anyone to admit it. The administrator verified the action to be taken when the Wanderguard alarm sounded was not included in the elopement prevention and management program dated June, 2008. This information was included in an addendum to this policy and all staff was inserviced on the addendum on 07/13/15 by 5:30 P.M. The updated policy, including the addendum, was posted at all nurses stations and in the employee break room. Review of the Elopement Prevention and Management Program, dated June 2008, revealed the facility would devise an elopement drill procedure to ensure the staff was confident about their ability to respond to an elopement incident. New employees would be instructed on the elopement drill procedure during general orientation. The policy and procedures did not address what staff should do when the Wanderguard alarm sounded. This information was added in the 07/13/15 addendum.

Based on observation, interview and record review, the facility failed to ensure interventions were initiated to prevent an avoidable pressure ulcer. This resulted in harm as evidenced by the development of an unstageable pressure ulcer on the bottom of the resident's left foot. This affected one (Resident #3) of one resident reviewed for pressure ulcers of 35 sampled residents. Findings include: Resident #3 was admitted [DATE] with [DIAGNOSES REDACTED]. An additional [DIAGNOSES REDACTED]. Review of a Minimum Data Set assessment dated [DATE] revealed Resident #3 was alert and oriented, non-ambulatory, totally dependent for bed mobility and transferring out of bed had not occurred. An interview was completed with Registered Nurse (RN) #230 on 07/11/16 at 4:07 P.M. RN #203 revealed Resident #3 had one pressure area. The area was on the right buttock and was a Stage 3 pressure ulcer. A Stage 3 pressure ulcer is defined as full thickness skin loss. Subcutaneous fat may be visible but bone tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. On 07/12/16 at 10:16 A.M., Resident #3 was observed in a bariatric bed, slightly propped on the left side and covered with a sheet. His feet were observed out of the sheet, resting directly on the surface of the bed. The resident's feet were [MEDICAL CONDITION] (swelling) with dry, flaky skin. A footboard was in place. An interview was completed at the time of the observation. Resident #3 revealed he had not been out of bed for three months because he fell while getting out of bed, fractured his left leg and required surgery. Resident #3 revealed the fracture was not completely healed. Resident #3 said the doctor ordered he remain non-weight bearing due to his size. Resident #3 was aware of the pressure wound on his buttock and allowed this surveyor to observe a dressing change. A dressing change was observed on 07/15/16 at 9:55 A.M. The observation revealed the pressure ulcer on the right buttock, as described. RN #102 and Licensed Practical Nurse (LPN) #120 completed the dressing change, as ordered. However, when RN #102 and LPN #120 positioned Resident #3 on his right side, two pressure areas were observed on the resident's left foot. One partially scabbed area was observed on the resident's left outer foot. One dark red, rough surfaced area were observed on the resident's left lateral plantar area. An interview was completed with RN #102 and LPN #120, at the time of the observation. RN #102 and LPN #120 verified the areas on the left foot had not previously been identified. RN #102 assessed the left outer foot wound as a Stage 2 pressure area. A Stage 2 pressure area is defined as partial thickness loss of dermis presenting as a shallow open ulcer or ruptured blister. RN #102 assessed the area on the bottom of the foot, at the left lateral plantar area, as an unstageable pressure area. An unstageable, suspected deep tissue injury is a purple or maroon localized area of discolored intact skin. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing layers of tissue even with optimal treatment. The plantar area measured 1.4 centimeters (cm) x 2.2 cm. An interview was completed with the Director of Nursing (DON) on 07/15/16 at 1:19 P.M. The DON revealed she discussed the area with Resident #3 following the observation of wound care of the right buttock. The DON revealed Resident #3 slides down in the bed. The side of his left foot was rubbing against the footboard. The footboard was not padded and the wound developed. The DON verified there was no evidence the areas were identified or interventions implemented to prevent pressure areas of the resident's feet. Review of the Prevention Protocol dated 06/2008 revealed a procedure to maintain skin integrity and prevent tissue breakdown. Skin inspection included; Remove socks, slippers, and support hose daily, and inspect feet for signs of pressure or skin breakdown.

Based on staff and resident interview, record review and review of the facility's smoking policy the facility failed to provide adequate supervision and interventions related to safe smoking by residents. This resulted in Immediate Jeopardy for one resident (Resident #1). Actual harm occurred when State tested Nurse Aide (STNA) #2 failed to remove the oxygen nasal cannula from Resident #1's nares while it was still connected to an oxygen tank that was in the off position. STNA #2 lit Resident #1's cigarette igniting oxygen that remained in the tubing and causing second degree burns to Resident #1's face and first degree burns to the right hand. This affected one of five residents reviewed that smoked. The facility identified 13 residents that were smokers. The facility census was 79. On 04/28/16 at 2:00 P.M., the Administrator, Director of Nursing (DON) and Regional Nurse #3 were notified that Immediate Jeopardy began on 04/24/16 at 1:00 P.M., when STNA #2 lit Resident #1's cigarette while he was wearing his oxygen nasal cannula, with the oxygen turned off. The oxygen tank was attached to the wheelchair. The oxygen remaining in the tubing ignited resulting in Resident #1 sustaining facial and hand burns, requiring emergency room evaluation and medical treatment. The Immediate Jeopardy was removed on 04/28/16 when the facility implemented the following corrective actions: · On 04/24/16 at 1:27 P.M., STNA #2 was escorted from the building and terminated. · · On 04/24/16 at 1:40 P.M., the Administrator and Maintenance Director #4 provided in-services for the 39 staff Smoking Supervisors to re-train them on the current smoking policy and smoking dangers. This training included the auditing of safe smoking practices, done 3-5 times a week by a Smoking Supervisor. · · On 04/24/16 at 1:40 P.M., the Administrator and Maintenance Director #4 in-serviced the first and second shift staff on the current smoking policy and smoking dangers. This involved 28 staff who worked the first shift and 19 staff who worked the second shift. On this date, in-services were held for the third shift staff starting at 9:00 P.M., involving 12 staff. On 4/25/16 by 5:00 P.M., the remaining first shift staff of 38 employees, were in-serviced on the current smoking policy and dangers of smoking by the Administrator and Maintenance Director #4. · · On 04/24/16 at 1:40 P.M., the Administrator placed the current smoke break schedule for the residents at the South nurse's station with a list of staff who were re-trained to be the Smoking Supervisors. · · On 04/24/16 at 2:00 P.M., all 13 residents who smoked were re-inserviced on the current smoking policy and smoking dangers. · · On 04/24/16 at 3:00 P.M., the Administrator initiated and conducted audits of the smoking supervisors to ensure adequate supervision was provided to the residents that smoke and the smoking policy was followed. The audits will continue to be completed three to five times a day for four weeks. · · On 04/24/16 at 9:24 P.M., the Administrator initiated an oxygen checklist which must be completed prior to each smoke break to ensure all oxygen, including the tubing, the tanks and the concentrators are removed from each resident that wears oxygen prior to smoking. · · On 04/24/16 by 3:00 P.M., the DON, Assistant Director of Nursing (ADON) and Regional Nurse #3 had updated all the assessments and care plans of the 13 residents who smoked. · · As of 04/28/16, 97 facility staff had been re-inserviced on the current smoking policy and dangers. This was confirmed with the Administrator on 05/02/16 at 10:00 A.M. · · On 04/28/16 at 4:00 P.M., STNA #9 was re-inserviced on the current smoking policy and dangers via telephone by the Administrator. During an interview with the Administrator, on 04/28/16, at 4:30 P.M., it was revealed that STNA #9 had not worked since 04/24/16. All 98 employees had been in-serviced by this date. Although the Immediate Jeopardy was removed as of 04/28/16 when the facility established systems to ensure adequate monitoring of residents' smoking activity, the facility remains out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was continuing to monitor and complete audits of residents that smoke and continuing to educate newly hired employees and newly admitted residents on safe smoking practices. Findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He signed a consent form to smoke on 07/27/11. Resident #1 was his own responsible party at the time. On 08/22/16, Resident #1's niece was appointed by the probate court as his guardian. Review of a Safe Smoking Assessment form dated 03/25/16, revealed Resident #1 was assessed as a safe smoker with supervision. He was aware of the designated smoking area and the smoking policy. Review of the Minimum Data Set 3.0 (MDS) assessment dated [DATE], revealed Resident #1 had a decline in cognition and ability to complete activities of daily living. Review of the nursing assessment dated [DATE] and care plan dated 04/24/16, revealed Resident #1 was alert with some confusion, wore oxygen and required assistance with activities of daily living. Review of nursing progress notes by Licensed Practical Nurse (LPN) #7 and an incident report dated 04/24/16 revealed Resident #1 requested to go outside for a supervised smoke break. Resident #1 attempted to stand and STNA #2 assisted him to the wheelchair. STNA #2 pushed Resident #1 in his wheelchair outside to smoke at 1:00 P.M. Resident #1 was seated in the wheelchair with a portable oxygen tank attached to the back of the wheelchair. STNA #2 applied smoking aprons to Resident #1 and four additional residents seated in the smoking area. STNA #2 lit each resident's cigarette, not realizing Resident #1 was still wearing his oxygen nasal cannula, although the oxygen tank was turned off. At 1:07 P.M., Activity Aide #5 entered the smoke area and replaced STNA #2, who returned inside the building. At 1:10 P.M., Activity Aide #5 heard a resident yell out saying Resident #1 was on fire. Activity Aide #5 removed the oxygen tubing from Resident #1's nose and patted down the resident's mustache with her hand. Activity Aide #5 ensured the other residents were safe and called for help. At 1:10 P.M., LPN #6 responded to the smoking area and got the assistance of LPN #7 and Registered Nurse (RN) #8 to aid in assessing Resident #1. Resident #1 was in no respiratory distress, was talkative and communicating with staff. The resident's mustache was observed singed and the facial area around his nose was blackened/charred. Resident #1's right thumb pad was blackened and he complained of pain. Resident #1 stated the pain was a 7-8 on a scale of 10, and he hurt bad. Resident #1 had been holding the cigarette with his right thumb and first finger. Cool compresses were applied to his face and right hand. LPN #7 notified the physician and Resident #1's guardian on 04/24/16 at 1:10 P.M. Resident #1 was transported to the emergency roiagnom on [DATE] at 1:40 P.M., via emergency transport. Review of the nurse's note written by LPN #10 dated 04/24/16 at 7:45 P.M., revealed Resident #1 returned to the facility with second degree burns to his face and first degree burns to his right hand. He was medicated with Norco, a narcotic pain reliever, as ordered by the physician. A pain assessment completed upon return to the facility, on 04/24/16, by LPN #10, revealed Resident #1 indicated he had no pain. On 04/27/16 at 2:00 P.M., Resident #1 was observed seated in the living area in a wheelchair with an oxygen mask in place and his nose was observed to be reddish/purplish in color. When spoken to, Resident #1 responded but was not able to answer questions appropriately. Review of the nurse's note written by RN #15, dated 04/28/16, revealed Resident #1 returned to the burn clinic for evaluation and treatment. He was receiving warm compresses and an antibiotic ointment to the burns. On 04/28/16 at 12:50 P.M., smoking materials were observed secured in two locked rooms behind the South nurse's station. The smoking shed was located just outside the door, near the nurse's station. On 04/28/16 at 1:00 P.M., five residents (Residents #2, #3, #4, #5 and #6) were observed smoking in the smoking area outside in the designated shed. Smoking Supervisors #11 and #12 were present with the residents. Residents #3, #4, #5 and #6 wore smoking aprons as assessed and Resident #2 did not, as he was assessed as a safe, independent smoker. A fire extinguisher and smoking blankets were in the immediate area. At that time, interview with Residents #2, #3, #4, #5 and #6 verified they had been re-inserviced on the current smoking policy and dangers by the Administrator and Maintenance Director #4 on 04/24/16 at 2:00 P.M. Smoking Supervisors #11 and #12 revealed they had been re-inserviced on the current smoking policy and dangers by the Administrator and Maintenance Director #4 on 04/24/16 at 1:40 P.M. During interviews with the Administrator on 04/28/16 at 4:00 P.M. and on 05/02/16 at 11:00 A.M., he indicated he had spoken with the guardian on 04/25/16 at 10:00 A.M. via teleconference with the DON present. The guardian requested a nicotine patch be ordered and revoked Resident #1's smoking privileges. The physician ordered a nicotine patch as requested by the guardian on 04/25/16. On 04/29/16 at 9:00 A.M., Residents #2, #3, #5 and #6 were observed smoking outside in the designated shed with Smoking Supervisors #11 and #13 present. All of the residents wore smoke aprons as assessed, except Resident #2, as he was assessed as a safe, independent smoker. Interview with Residents #2, #3, #5 and #6, on 04/20/16 at 9:00 A.M., verified they had been re-inserviced on the current smoking policy and dangers on 04/24/16 at 2:00 P.M., by the Administrator and Maintenance Director #4. Smoking Supervisor #13 was interviewed and verified she had been re-inserviced on the current smoking policy and dangers by the Administrator and Maintenance Director #4 on 04/24/16 at 1:40 P.M. On 05/02/16, at 1:00 P.M., Residents #3, #4 and #6 were observed smoking in the designated smoking area with Smoking Supervisors #11 and #14 present. Interview with Smoking Supervisor #14, on 05/02/16 at 1:00 P.M., verified she had been re-inserviced on the current smoking policy and dangers on 04/24/16 at 1:40 P.M., by the Administrator and Maintenance Director #4. During interviews with three residents who smoke, Residents #8, #9 and #10, on 05/02/16 at 1:30 P.M., they verified they had been re-inserviced on the current smoking policy and dangers by the Administrator and Maintenance Director #4 on 04/24/16 at 2:00 P.M. The Smoking Policy and Dangers, dated 07/20/13, addressed each resident who desired to smoke and indicated they would be assessed in regards to their cognitive and physical abilities to comprehend safe handling of smoking materials. The assessment would be done on admission, quarterly, annually and when there was a significant change in the resident ' s status. Smoking was never permitted in a resident room and all residents are prohibited from storing smoking materials. Residents with oxygen would not be permitted to smoke while wearing their oxygen near the smoking area. All smoking materials would be disposed of in the proper designated container. The smoking policy would be reviewed with any resident desiring to smoke and a consent form would be signed. The policy indicated if the resident is assessed to be a safe smoker he/she would be observed for three days to ensure safe smoking practices. Then the interdisciplinary team would make the final decision if the resident could smoke safely and unsupervised. Safe smokers would then be routinely assessed, quarterly and/or with a change in their health condition. Safe smokers may only smoke if they are not assessed as elopement risks. The policy indicated the facility administration reserved the right to relinquish independent smoking practices if safe smokers violate the safe smoking practices policy. Independent smokers are to request their smoking materials from the nurse when they desire to smoke and return the smoking materials to the nurse when finished. This deficiency substantiates Complaint Number OH 997.

Based on observation, record review and interview the facility failed to implement a physician ordered intervention related to pain for Resident #11. This affected one resident (Resident #11) of three residents reviewed for pain recognition and management. Findings include: Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 dated 12/09/13 revealed Resident #11's Brief Interview of Mental Status Score (BIMS) was 15. A BIMS score of 15 indicated Resident #11 was cognitively intact. Review of the 30 day pain assessment dated [DATE] revealed pain limited Resident #11's activities of daily living, transfers and ambulation. Current physician orders [REDACTED]. There was no written evidence on Resident #11's physical therapy notes for the certification period of 12/12/13 through 01/09/13 that moist heat therapy was completed until 01/09/13. On 01/09/14 at 1:20 P.M. interview with Resident #11 verified she had not been offered or provided any type of heat therapy prior to this date. On 01/09/14 at 1:25 P.M. interview with PT #23 verified there was no written documentation the resident had been provided heat therapy for pain management prior to 01/09/14.

Based on medical record review, emergency room intake documentation, hospital discharge summary, staff interview and review of the undated facility policy and procedure titled Care Standards and Notification of Change, the facility failed to appropriately address and seek timely medical attention for one resident (Resident # 75) with complaints of chest pain and chest pressure resulting in a [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). This resulted in Immediate Jeopardy for one of four residents (Resident #75) reviewed for a change in condition with hospitalization . The facility census was 73. On [DATE] at 2:00 P.M. the administrator and the director of nursing (DON) were notified that Immediate Jeopardy began on [DATE] at 2:50 P.M., when Resident #75 complained of chest pain and chest pressure to Registered Nurse (RN) #88. RN #88 obtained the resident ' s vital signs and pulse oxygen level and attempted to notify the physician. RN #88 continued with unsuccessful attempts to notify the physician of Resident #75 ' s ongoing chest pain until 4:45 P.M. when she received an order to transfer the resident to the emergency room . No documentation of additional assessments of Resident #75 was made. Resident #75 was transported at 5:15 P.M. to the emergency room . Intake documentation revealed she sustained a [MEDICAL CONDITION] infarction. The resident remained at the hospital until [DATE] when she expired. During interview with RN #88 on [DATE] at 8:15 A.M., she stated she was unaware of the need to contact the medical director when she was unable to reach the resident ' s attending physician. She did not feel it was an urgent situation. The Immediate Jeopardy was removed on [DATE] at 2:30 P.M. when the facility implemented the following measures: ? On [DATE] at 2:30 P.M. the facility ' s Quality Continuous Improvement Committee members met (medical director, administrator, DON, regional nurse director, therapy manager, social services and MDS nurse) and made revisions to the facility ' s Notification of Change policy and procedure to include the directive to notify the medical director or call 911 if a return call from the attending physician was not received within 15 minutes of a resident ' s complaint of chest pain. ? On [DATE] education was conducted by the DON with all licensed nursing staff regarding the Notification of Change policy and procedure revisions that included the call to 911 for a medical emergency such as [MEDICAL CONDITION] or unresolved chest pain. Three nursing staff on duty received onsite education and the remaining 15 nursing staff that were not on duty were educated by the DON by telephone calls on [DATE]. ? On [DATE] the DON and regional clinical director reviewed 73 of 73 resident records to determine residents with a [DIAGNOSES REDACTED]. ? A reminder was placed in 73 residents ' medication administration records for licensed nursing staff to call the physician and 911 for medical emergencies that included unresolved chest pain. ? The DON and regional clinical director compiled a list of all residents with a [DIAGNOSES REDACTED]. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) for verification of compliance through a newly developed auditing tool to be conducted by the DON for change of condition, nurses notes, physician orders [REDACTED]. Findings include: Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive assessment dated [DATE] indicated the resident had no cognitive impairment and required extensive assistance with two staff members for bed mobility, transfers and dressing. Resident #75 was her own responsible party. Review of the plan of care dated [DATE] revealed Resident #75 had a potential for discomfort related to a decrease in cardiac output and altered breathing. It indicated Resident #75 was instructed to report shortness of breath, weakness, dizziness and chest pain. Interventions included monitor blood pressure, jugular distention, decreased peripheral pulses, arrhythmia, fatigue, dyspnea, changes in mental status, cool clammy skin or [MEDICAL CONDITION] and to apply oxygen as ordered and report changes. Review of the facility ' s Condition Change form dated [DATE] and timed 4:45 P.M. by RN #88 revealed Resident #75 complained of chest pain and stated it felt like pressure at 2:50 P.M. Vital signs were obtained and revealed blood pressure- ,[DATE], pulse- 86, respirations- 20, temperature 98.2 degrees Fahrenheit and pulse oximetry 90 percent on room air. The form indicated the physician was paged every 15 to 30 minutes until " this time " (4:45 P.M.) when orders were obtained to transfer the resident to the hospital for evaluation and treatment. Review of the Condition Change form and nurses notes did not reveal any other assessments or interventions were completed for Resident #75. Review of nurses notes dated [DATE] and timed 5:15 P.M. by RN #88, revealed the emergency squad transported the resident to the emergency department at that time. The only remaining documentation for Resident #75 was dated [DATE] and timed 7:00 A.M by Licensed Practical Nurse (LPN) #92 that indicated the admitting [DIAGNOSES REDACTED]. Interview with RN #88 on [DATE] at 8:15 A.M. revealed she was the nurse on duty when Resident #75 voiced complaints of chest pain. She stated on [DATE] at approximately 2:50 P.M. a state tested nurse aide (STNA) reported to her that Resident #75 was complaining of chest pain. She could not recall which STNA it was. RN #88 indicated she immediately went to assess the resident. She stated the resident complained that the pain was across her chest and felt like pressure. She obtained her vital signs and stated the resident was alert and talkative and denied shortness of breath. She stated the resident ' s color was good and her skin was warm and dry. RN #88 stated she had paged the resident ' s physician and notified the resident she was waiting for a return call. RN #88 indicated she again paged the physician after 15 minutes had passed without a return call. She stated she had given Resident #75 a scheduled [MEDICATION NAME] (narcotic pain medication) at 4:00 P.M. RN #88 stated she had reassessed the resident approximately 45 minutes after the initial assessment and confirmed she had not documented her findings. She stated the resident left with emergency medical services at 5:15 P.M. RN #88 admitted that she should have notified the medical director when Resident #75 ' s attending physician did not return the call. Interview with STNA #95 on [DATE] at 8:28 A.M. revealed she had cared for Resident #75 on the previous shift and she did not notice any concerns or complaints from the resident. Interview with LPN #90 on [DATE] at 8:43 A.M. revealed she had worked the previous shift and Resident #75 had offered no complaints. Interview with STNA #96 on [DATE] at 9:05 A.M. by telephone revealed she was the nurse aide that responded to Resident #75 ' s call light. She stated she started her shift at 2:00 P.M. and Resident #75 had turned on her call light shortly after that. She stated Resident #75 was seated in her recliner chair and asked her to tell the nurse she was having chest pain. STNA #96 stated she told the nurse on duty and did not check on Resident #75 after that. Review of the hospital ' s emergency department (ED) intake report dated [DATE] revealed Resident #75 presented to the ED with an onset of left sided chest pain that began at 11:30 P.M. the previous evening. The resident stated it was sharp discomfort that radiated down the left arm and worsened with inspiration and cough. She presented with shortness of breath and a cough with blood tinged yellow phlegm. The ED final impression indicated Resident #75 had acute atypical chest pain and an acute non-ST elevation [MEDICAL CONDITION] infarction (MI). The resident left the ED and was admitted to ICU. Review of the hospital ' s Discharge Summary dated [DATE] revealed Resident #75 presented with chest pain, shortness of breath and cough and was found to have non-ST elevated MI and probable pneumonia [MEDICAL CONDITION]. The critical condition was discussed with the resident, mother-in-law (POA) and daughter and a code status of comfort care was decided upon since the resident was not surgical a candidate. A hospice referral was made on [DATE]. The resident expired on [DATE] while in the ICU. A review of the facility ' s policy and procedure titled Care Standards Notification of Change revised January, 2011 indicated any complaints of chest pain required immediate notification of the physician and responsible party. The procedure indicates in emergency situations if the physician does not call back call the emergency room and transport. In addition the procedure directed to document every attempt made to contact the physician. This deficiency substantiates complaint #OH 114.