Every finding on record at Seven Hills Health & Rehab Center

Based on record review, observation, policy review, and interview, the facility failed to provide evidence that enteral tube feedings were administered to prevent weight loss. This affected two residents (#57 and #60) out of three reviewed for tube feeding. The facility also failed to obtain weekly weights as ordered. This affected four residents (#11, #20, #57, and #60) out of six reviewed for nutrition. The facility also failed to provide adequate hydration to prevent dehydration. This affected one resident (#11) out of three reviewed for hydration. The facility census was 63.Actual harm occurred on 06/16/25 when Resident #60, who had severe cognitive impairment and required enteral tube feeding to meet nutritional needs, sustained a 20.6 pound weight loss (in 34 days) as a result of the facility's failure to accurately monitor and record tube feed intakes, obtain weekly weights as ordered, and adjust tube feeding rate timely to prevent further weight loss. On 05/01/25, Resident #60 weighed 207.2 pounds. On 05/07/25 and 05/13/25, Resident #60 weighed 207.0 pounds. On 05/22/25, Resident #60 weighed 197.8 pounds, which was a weight loss of 9.2 pounds (4.4%) in 9 days. On 06/16/25, Resident #60 weighed 186.4 pounds, which was a further weight loss of 11.4 pounds (5.8%) and there was no evidence that the facility had been monitoring Resident #60's weight between 05/22/25 and 06/16/25 or that adjustments had been made to the tube feeding order to prevent further weight loss. The weight loss continued and on 06/19/25 the resident was assessed to sustain an additional weight loss of 7.0 pounds (3.8%) with a recorded weight of 179.4 pounds. Resident #60 sustained a severe weight loss of 13.4% since admission (in 51 days). Findings include: 1. Review of the medical record for Resident #60 revealed an admission date of 04/30/25 with diagnoses including aspiration pneumonia, lung cancer, cerebral infarction, dysphagia, laryngeal cancer, aphasia, and dysarthria. Review of the medical nutritional therapy assessment, dated 05/02/25, revealed Resident #60 received nothing by mouth (NPO) and required a feeding tube to meet nutritional needs. The assessment indicated Resident #60 required 2184 to 2589 calories, 81 to 97 grams of protein, and 2427 to 2832 milliliters (ml) of fluid daily. The nutritional goals included no unplanned significant weight changes, tube feeding formula and flushes as ordered, and weekly weights for four weeks. Review of the nutrition care plan, initiated 05/05/25, revealed Resident #60 was at increased nutritional risk related to gastric tube use, lung and laryngeal cancer, pneumonia, cerebral infarction, dysphagia, hemiplegia, overweight, requiring enteral feedings for nutrition and hydration, and malnutrition. Interventions included but were not limited to: check tube placement prior to medication or tube feeding administration (05/05/25), monitor for complications such as diarrhea, gastric distention, aspiration, and report complications to the physician (05/05/25), monitor labs per orders (05/05/25), monitor need for increased nutritional interventions related to diagnoses, tube feeding, medications, and other listed problems (05/05/25), monitor for signs and symptoms of dehydration such as poor skin turgor, cracked lips, thirst, fever, and abnormal labs (05/05/25), monitor weight per protocol (05/05/25), provide diet as ordered (05/05/25), provide tube feeding as ordered (05/05/25), provide tube feeding and medication flushes as ordered (05/05/25), and report 5% weight loss or gain to the physician and Registered Dietitian (RD) (05/05/25). The nutrition care plan was last reviewed and revised on 05/05/25 at 2:02 P.M. by RD #83.Review of the admission Minimum Data Set (MDS) assessment, dated 05/06/25, revealed Resident #60 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 00. The assessment also indicated Resident #60 received 51% or more of daily calories from tube feeding and 501 milliliters (ml) or more of daily fluid from tube feeding.Review of the physician's orders for Resident #60 identified orders for NPO (ordered 04/30/25), weekly weights for four weeks (ordered 04/30/25, discontinued 06/03/25), bolus enteral feedings of Isosource to infuse 360ml every six hours via enteral tube, flush with 30ml of water after the bolus feed, and record amounts (ordered 04/30/25, discontinued 05/01/25), bolus enteral feedings of Isosource 1.5 to infuse 360ml every six hours via enteral tube for a total of 1440ml of formula providing 2160 calories, flush with 30ml of water after the bolus feed, and record amounts (ordered 05/01/25, discontinued 05/02/25), bolus enteral feedings of Isosource 1.5 to infuse 400ml every six hours via enteral tube for a total of 1600ml of formula providing 2400 calories, flush with 30ml of water after the bolus feed, and record amounts (ordered 05/02/25, discontinued 06/19/25), and bolus enteral feedings of Isosource 1.5 to infuse 500ml every six hours via enteral tube for a total of 2000ml of formula providing 3000 calories, flush with 30ml of water after the bolus feed, and record amounts (ordered 06/19/25). Physician's orders for routine tube feeding flushes were separate from the enteral formula orders and were as follows: free water flushing 250ml once daily via peg tube (ordered 04/30/25, discontinued 05/01/25), free water flushing 250ml every six hours via peg tube (ordered 05/01/25, discontinued 05/02/25), free water flushing 300ml every six hours via peg tube (ordered 05/02/25, discontinued 06/19/25), and free water flushing 250ml every six hours via peg tube (ordered 06/19/25). Review of the weights documented in the vitals portion of the electronic health record and on the Medication Administration Record/Treatment Administration Record (MAR/TAR) for Resident #60 revealed the following recorded weights: 207.2 pounds on 05/01/25, 207.0 pounds on 05/07/25, 207.0 pounds on 05/13/25, 197.8 pounds on 05/22/25, 186.4 pounds on 06/16/25, and 179.4 pounds on 06/19/25. There were no recorded weights between 05/22/25 and 06/16/25. Review of the MAR/TAR documentation for Resident #60 for May 2025 through June 2025 revealed the following: - On 05/14/25, 800ml of Isosource 1.5 was administered, which provided a daily total of 1200 calories (a deficit of 984 calories from the calculated nutritional needs). - On 05/15/25, 800ml of Isosource 1.5 was administered, which provided a daily total of 1200 calories (a deficit of 984 calories from the calculated nutritional needs). - On 05/16/25, 1200ml of Isosource 1.5 was administered, which provided a daily total of 1800 calories (a deficit of 384 calories from the calculated nutritional needs). - On 05/17/25, 900ml of Isosource 1.5 was administered, which provided a daily total of 1350 calories (a deficit of 834 calories from the calculated nutritional needs). It was documented that Resident #60 refused the 12:00 P.M. tube feeding formula administration. - On 05/18/25, 1200ml of Isosource 1.5 was administered, which provided a daily total of 1800 calories (a deficit of 384 calories from the calculated nutritional needs). - On 05/19/25, 1200ml of Isosource 1.5 was administered, which provided a daily total of 1800 calories (a deficit of 384 calories from the calculated nutritional needs). - On 05/20/25, 1400ml of Isosource 1.5 was administered, which provided a daily total of 2100 calories (a deficit of 84 calories from the calculated nutritional needs). - On 05/22/25, 1400ml of Isosource 1.5 was administered, which provided a daily total of 2100 calories (a deficit of 84 calories from the calculated nutritional needs). - On 05/23/25, 1200ml of Isosource 1.5 was administered, which provided a daily total of 1800 calories (a deficit of 384 calories from the calculated nutritional needs). - On 05/25/25, 1400ml of Isosource 1.5 was administered, which provided a daily total of 2100 calories (a deficit of 84 calories from the calculated nutritional needs). - On 05/26/25, 1200ml of Isosource 1.5 was administered, which provided a daily total of 1800 calories (a deficit of 384 calories from the calculated nutritional needs). - On 05/27/25, 1400ml of Isosource 1.5 was administered, which provided a daily total of 2100 calories (a deficit of 84 calories from the calculated nutritional needs). - On 05/29/25, 700ml of Isosource 1.5 was administered, which provided a daily total of 1050 calories (a deficit of 1184 calories from the calculated nutritional needs). - On 05/30/25, 1400ml of Isosource 1.5 was administered, which provided a daily total of 2100 calories (a deficit of 84 calories from the calculated nutritional needs). - On 05/31/25, 850ml of Isosource 1.5 was administered, which provided a daily total of 1275 calories (a deficit of 909 calories from the calculated nutritional needs). - On 06/01/25, 600ml of Isosource 1.5 was administered, which provided a daily total of 900 calories (a deficit of 1284 calories from the calculated nutritional needs). - On 06/02/25, 600ml of Isosource 1.5 was administered, which provided a daily total of 900 calories (a deficit of 1284 calories from the calculated nutritional needs). - On 06/03/25, 1100ml of Isosource 1.5 was administered, which provided a daily total of 1650 calories (a deficit of 534 calories from the calculated nutritional needs). - On 06/11/25, 1400ml of Isosource 1.5 was administered, which provided a daily total of 2100 calories (a deficit of 84 calories from the calculated nutritional needs). - On 06/12/25, 800ml of Isosource 1.5 was administered, which provided a daily total of 1200 calories (a deficit of 984 calories from the calculated nutritional needs). - On 06/14/25, 1400ml of Isosource 1.5 was administered, which provided a daily total of 2100 calories (a deficit of 84 calories from the calculated nutritional needs). - On 06/15/25, 930ml of Isosource 1.5 was administered, which provided a daily total of 1395 calories (a deficit of 789 calories from the calculated nutritional needs). - On 06/16/25, 1030ml of Isosource 1.5 was administered, which provided a daily total of 1545 calories (a deficit of 639 calories from the calculated nutritional needs). - On 06/20/25, 1000ml of Isosource 1.5 was administered, which provided a daily total of 1500 calories (a deficit of 684 calories from the calculated nutritional needs). - On 06/21/25, 1250ml of Isosource 1.5 was administered, which provided a daily total of 1875 calories (a deficit of 309 calories from the calculated nutritional needs). - On 06/23/25, 1000ml of Isosource 1.5 was administered, which provided a daily total of 1500 calories (a deficit of 684 calories from the calculated nutritional needs).Review of the dietary progress note dated 05/26/25 at 3:02 P.M. indicated Resident #60 had sustained a 4.5% weight loss since admission on Isosource 1.5 at 400ml every six hours with 300ml water flushes to provide 2400 calories, 109 grams (g) protein, and 2422ml free fluid. The note indicated the current tube feeding order was meeting Resident #60's nutritional needs and weight maintenance was desirable. The note indicated no changes were made to the tube feeding order and weekly weights would be continued for close monitoring.Review of the weights documented in the vitals portion of the electronic health record and on the MAR/TAR for Resident #60 revealed weekly weights were not obtained as ordered on 05/27/25 and 06/03/25. There was no progress note indicating the physician or RD were notified of the weight loss on 06/16/25.The nurses note dated 06/17/25 at 3:11 P.M. indicated Resident #60 was visited by a physician's assistant (unnamed) that day and new orders were added for Trazadone to address increased restlessness and agitation. There was no mention of weight loss.Review of the dietary progress note dated 06/19/25 at 4:37 P.M. indicated Resident #60 had sustained a significant weight loss of 15% in one month. The note indicated Resident #60 had increased nutritional needs due to a cancer diagnosis and activity levels. The tube feeding order was increased to Isosource 1.5 to infuse 500ml every six hours with 250ml water flushes to provide 3000 calories, 136g protein, and 2528ml free fluid.On 06/30/25 at 9:36 A.M., an interview with RD #83 stated when weight loss occurred, she would make any nutritional recommendations on the following Monday and the expectation was those recommendations would be addressed by Thursday each week (three days later). She also stated re-weights would be obtained to verify the weight loss. On 06/30/25 at 11:27 A.M., an interview with RD #83 stated she had not done the calculations to determine exact amounts, but a significant weight loss would require a large calorie deficit.On 06/30/25 at 3:57 P.M., an interview with Medical Director (MD) #87 stated the facility probably notified Physician's Assistant #88 of weight changes because the facility usually only notified MD #87 of bigger things. MD #87 said he would just follow the RD's recommendations for any changes because the RD was the expert with weight loss and calculating calories.On 06/30/25 at 4:45 P.M., an interview with the Director of Nursing (DON) verified the documentation on the MAR/TAR indicated Resident #60 did not receive the amount of tube feeding formula that was ordered on numerous days in May 2025 and June 2025.On 07/01/25 at 11:50 A.M., an interview with Regional RD #86 confirmed the documentation indicated the full amount of tube feeding formula was not administered for Resident #60. Regional RD #86 claimed it was just a documentation error, however, she was unable to provide any evidence that the tube feeding formula was administered as ordered. On 07/01/25 at 3:28 P.M., an interview with Regional RD #86 stated RD #83 reviewed the weight change that occurred on 05/22/25, recommended weekly weights to monitor weight trend, and Regional RD #86 confirmed those weekly weights were not obtained after 05/22/25. RD #86 confirmed no changes were made to the tube feeding formula order between 05/02/25 and 06/19/25. Regional RD #86 further stated the way their electronic health records were set up was confusing for the nurses, claiming that was why there were inconsistencies between the physician's orders and the documentation of tube feeding formula administration.On 07/01/25 at 3:53 P.M., an interview with the DON verified the weekly weights were documented as not obtained on the MAR/TAR on 05/27/25 and 06/03/25. The DON was unable to provide a reason why those weights were not obtained.An attempt to interview Physician's Assistant #88 on 07/02/25 was unsuccessful.Review of the facility's policy titled Dietary Enteral Nutrition Care, dated 06/02/20, revealed upon initiation of enteral feeding, the RD would conduct an assessment that included a calculation of the individual's energy, protein, and fluid requirements, as well as any potential medication interactions. If there was an existing enteral nutrition order, a comparison would be made between the individual's requirements and the physician ordered enteral formula and free fluid flush. The RD or designee would monitor weight, skin conditions, labs, physical symptoms, and tolerance to feeding. The nursing staff would communicate any concerns to the physician and RD regarding changes in condition such as weight loss, diarrhea, nausea, vomiting, bloating, gas, and high residual levels. Review of the facility's policy titled Resident Weight Policy, dated 12/12/23, revealed weights would be obtained routinely in order to monitor nutritional health over time. Each resident's weight would be determined upon admission to the facility, weekly for four weeks after admission, and monthly or more often if risk was identified, or as ordered. Nursing was responsible for obtaining weights. After the first four weeks, the resident review committee would determine the need for continued weekly weights. Weights would be recorded in the electronic health record. 2. Review of the medical record for Resident #57 (R #57) revealed an admission date of 01/09/25 with diagnoses of metabolic encephalopathy, moderate protein-calorie malnutrition, dysphagia, and type two diabetes mellitus.Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed R #57 was cognitively impaired, rarely or never able to make needs known, and rarely or never understood communication. The assessment indicated that she was dependent upon two staff members to move in bed, take a shower or bath, and dependent on one staff member for dressing. Review of the physician's orders revealed no pharmacological intervention for anxiety, agitation or restlessness, and no as needed medication for bowel regime. Further review of the physician's orders for June 2025 for R #57 identified orders for Diabetisource AC at 60 milliliters (ml) per hour for 22 hours to provide 1320ml formula and 1584 calories daily (ordered 03/17/25, discontinued 06/30/25), and Diabetisource AC at 65 ml per hour for 22 hours to provide 1,430ml formula and 1,716 calories daily (order dated 06/30/25).Review of medical nutritional therapy assessment, authored by Registered Dietitian (RD) #83 and dated 04/03/25, revealed R #57 received nothing by mouth (NPO) and required a feeding tube to meet nutritional needs. The assessment indicated the ordered enteral feeding would provide 1,584 calories, 79 milligrams (mg) of protein, 1,077 milliliters (ml) of free fluids plus flushes to total 1,977 ml daily. The estimated nutritional needs portion of the assessment was blank and there were no nutritional needs specified. The nutritional goals included tolerance to enteral feedings, no signs or symptoms of dehydration, and no significant weight changes. Review of lab results dated 05/08/25 revealed a basic metabolic panel (BMP) and a complete blood count (CBC) was obtained with results essentially within expected range for diagnosis and no new orders were obtained. Review of the lab results dated 06/05/25 revealed a BMP, CBC and hemoglobin A1C were obtained, and all results were within expected range and no new orders were written. There was no evidence that a Pre-Albumin level was obtained.Review of weights for R #57 revealed a weight loss of 4.8% within 30days. The documented weights were as follows: 152.0 pounds on 05/06/25, 154.2 pounds on 06/09/25, and 146.8 pounds on 06/26/25.Review of the Medication Administration Record (MAR) for R #57 for June 2025 revealed the following: On 06/09/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/11/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/12/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/14/25, 750ml of Diabetisource AC was administered, which provided a daily total of 900 calories (a deficit of 684 calories from what was ordered).On 06/15/25, 810ml of Diabetisource AC was administered, which provided a daily total of 972 calories (a deficit of 612 calories from what was ordered).On 06/16/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/17/25, 810ml of Diabetisource AC was administered, which provided a daily total of 972 calories (a deficit of 612 calories from what was ordered).On 06/18/25, 810ml of Diabetisource AC was administered, which provided a daily total of 972 calories (a deficit of 612 calories from what was ordered).On 06/19/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/21/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/22/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/23/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/24/25, 870ml of Diabetisource AC was administered, which provided a daily total of 1044 calories (a deficit of 540 calories from what was ordered).On 06/25/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/26/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/27/25, 870ml of Diabetisource AC was administered, which provided a daily total of 1044 calories (a deficit of 540 calories from what was ordered).On 06/28/25, 1260ml of Diabetisource AC was administered, which provided a daily total of 1512 calories (a deficit of 72 calories from what was ordered).On 06/29/25, 660ml of Diabetisource AC was administered, which provided a daily total of 792 calories (a deficit of 792 calories from what was ordered).Review of bowel tracking records for R #57 from 06/20/25 through 06/29/25 revealed no evidence of a bowel movement (BM) on 06/21/25, 06/22/25, 06/23/25, 06/25/25, 06/26/25, 06/27/25, 06/28/25, 06/29/25. There was no evidence of any as needed bowel interventions provided during this interval, just the routine daily dose of Miralax.Review of progress notes since admission revealed no documented evidence of anxiety or restlessness. Review of a progress note dated 06/26/25, authored by RD #83, revealed R #57 had a 4.8% weight loss since 06/09/25 (17 days). The note indicated R #57 was often restless, anxious and, per nursing staff, often rolled onto her tubing causing the infusion of formula to occlude. There were no other notes between 01/09/25 and 06/26/25 to indicate R #57 rolled onto her tubing causing the tube feed formula to stop infusing. Review of the progress note dated 07/01/25 at 8:43 P.M. indicated R #57 was transferred to an acute care hospital due to unrelieved brown emesis.An observation on 06/23/25 at 10:30 A.M. revealed that R #57 was in bed lying on her left side, the enteral feeding pump was alarming, and the formula was not infusing. A bag of Diabetisource AC was hanging on a pole and was attached to the infusion pump. The formula bag was labeled with a date of 06/23/25 without a time. Continued observation of R #57's room revealed no staff were present on the unit and no staff entered R #57's room until 12:52 P.M., approximately two hours and 22 minutes after the tube feed was first observed alarming.An observation on 06/23/25 at 12:52 PM revealed MDS nurse #11 walked into R #57 room. The enteral feeding pump ceased beeping. MDS nurse #11 verified that the pump was not infusing formula, that she restarted it and could not say how long the pump was beeping.A continuous observation on 06/24/25 from 8:00 A.M. until 1:13 P.M. revealed R #57 lying on her left side, not laying on enteral tubing. No staff members were observed entering R #57's room at any point during this observation.An observation on 06/25/25 07:41 A.M. revealed R #57 lying on her back with legs bent at the knees, not laying on enteral tubing. Further observations at 10:00 A.M., 12:30 P.M. and 4:03 P.M. revealed R #57 was in the same position.An interview on 06/24/25 at 02:43 P.M. with Certified Nursing Assistant (CNA) #58 revealed that R #57 was checked and changed about every 3 hours. CNA #58 was unable to state when she was last in the room. CNA #58 shared that they had twelve residents to care for all of which were located on the same hallway.An interview on 06/30/25 at 10:23 A.M. with the Director of Nursing (DON) revealed that when R #57's enteral feeding pump beeped then the nurses went down to the resident's room, readjusted the pump and/or tubing, and restarted the pump. The DON stated the pump would be occluded for a minimal time, not a significant amount of time. The DON indicated that she did not know how long a pump would have to be off to cause significant weight loss. The DON verified the documentation on the MAR of less than the ordered amount of enteral feeding. Regarding the lack of bowel movements, the DON stated that the MDS nurse brought a report to morning meeting and identified all residents that had no BM in three days or greater. That information was given to the nurses on the floor for follow-up. Once the information was given to the nurse, the alerts were cleared from the electronic health record system and no further information was tracked. An interview on 06/30/25 at 11:27 A.M. with RD #83 confirmed the documentation in the MAR was less than the ordered amount of tube feeding formula. RD #83 indicated that she would have to do calculations but that a significant weight loss in 30 days would require a large calorie deficit.An interview on 06/30/25 at 03:06 P.M. with Licensed Practical Nurse (LPN) #55 revealed that occasionally the tubing on R #57's feeding pump got kinked. The pump beeped but was not as loud as an IV pole and that R #57's room was two-thirds of the way down the hall away from the nurse's station, so it could not be heard at the nurse's station. LPN #55 Further shared that the second floor had two nurses assigned to split the all the residents on the second floor. Each nurse assigned to a hall also had to split another hall for medication administration and could not hear anything that occurred on the other hall. Further shared that Resident #57 used to move about and pull the whole pump and pole over when they were first admitted but doesn't do that anymore.An interview on 06/30/25 at 3:57 P.M. with Medical Director (MD) #87 stated the facility probably notified Physician's Assistant #88 of weight changes because the facility usually only notified MD #87 of bigger things. MD #87 said he would just follow the RD's recommendations for any changes because the RD was the expert with weight loss and calculating calories. MD #87 indicated that he expected lab chemistry to be monitored and to include pre-Albumin levels.Review of the facility's policy titled Dietary Enteral Nutrition Care, dated 06/02/20, revealed upon initiation of enteral feeding, the RD would conduct an assessment that included a calculation of the individual's energy, protein, and fluid requirements, as well as any potential medication interactions. If there was an existing enteral nutrition order, a comparison would be made between the individual's requirements and the physician ordered enteral formula and free fluid flush. The RD or designee would monitor weight, skin conditions, labs, physical symptoms, and tolerance to feeding. The nursing staff would communicate any concerns to the physician and RD regarding changes in condition such as weight loss, diarrhea, nausea, vomiting, bloating, gas, and high residual levels. Review of the facility's policy titled Resident Weight Policy, dated 12/12/23, revealed weights would be obtained routinely in order to monitor nutritional health over time. Each resident's weight would be determined upon admission to the facility, weekly for four weeks after admission, and monthly or more often if risk was identified, or as ordered. Nursing was responsible for obtaining weights. After the first four weeks, the resident review committee would determine the need for continued weekly weights. Weights would be recorded in the electronic health record.Review of the facility's policy titled Bowel Tracking Protocol, dated 03/12/24, revealed bowel movements were documented by nurse aides in the electronic medical record. If the resident had not had a bowel movement for 3 full days (72 hours), and in the absence of other resident-specific orders, the nurse would determine if laxatives were indicated based on the resident's bowel habits and patterns. Step 1: Milk of Magnesia 30 ml at bedtime the evening after 72 hours without a bowel movement (BM) ; Step 2: If no BM by 10:00 A.M. the following day, give bisacodyl suppository 10 mg PR; Step 3: If no BM by the next morning, contact provider for further orders.3. Review of the medical record for Resident #11 revealed an admission date of 04/17/25. Diagnoses included but were not limited to epilepsy, unspecified fracture of right and left pubis, fracture of right tibia, poly osteoarthritis, and repeated falls. Review of the 06/16/25 Minimum Data Set (MDS) for Resident #11 revealed a Brief Interview of Mental Status (BIMS) of 15 which indicated intact cognition. Resident #11 was noted to be independent for self-care, eating and dependent for toileting, bathing, dressing and wheeling 150 feet. Resident #11 was not noted to be on a therapeutic diet and was noted to have significant weight loss and was not on a physician prescribed weight loss program. Review of the 04/17/25 physician order for Resident #11 revealed an order to obtain weight upon admission and then weekly for four weeks once a day on Tuesdays.Review of the facility weight recording form from 04/14/25 revealed a weight for Resident #11 but was not dated as being another date other than 04/14/25 since resident was not at the facility on 04/14/25. Review of the admission progress note for Resident #11 revealed no listed admission weight. Review of the 04/21/25 care plan for Resident #11 revealed increased nutrition and hydration risk related to epilepsy, fracture of pubis, muscle weakness, obesity, diuretic use and potential for fluid related weight fluctuations. Interventions listed were to encourage compliance with diet guidelines, encourage resident to dine in the dining room, monitor dietary intake, monitor lab values per orders, monitor need for increased nutritional intervention related to diagnosis, medication and listed problems, monitor weight per protocol, offer alternate food is less than 50 % of meals, and encourage adequate fluid intake.Review of the facility weight recording form from 04/21/25, 04/28/25, for Resident #11 revealed no weight recorded. Review of the nursing progress note date 04/20/25 timed at 1:59 P.M. for Resident #11 revealed a burning sensation when voiding, and order for a urinalysis (UA) and a urine culture and sensitivity (C &S) test were obtained. Review of the nursing progress note dated 04/21/25 at 3:24 P.M. for Resident #11 revealed an order for Macrobid 100 milligrams (mg) by mouth twice daily for seven days for symptoms of a urinary tract infection.Review of the 04/22/25 lab results for Resident #11 revealed they were completed and a request with an order to repeat the labs on 04/29/25.Review of the facility weight recording form from 05/01/25 (monthly weights) for Resident #11 was 150.8 # and a reweight was requested but not completed. No weight was recorded in the medical record.Review of the facility weight recording form from 05/12/25 and 05/20/25 for Resident #11 revealed no weight recorded. Review of the medical record for Resident #11 revealed a weight on 04/21/25 of 173.2# and 06/16/25 of 164.4 pounds (#) and no additional weights recorded. Weight loss from 4/21/25 to 06/16/25 was 8.8# which was a 5 percent loss.Review of the labs recorded on 04/29/25 for Resident #11 revealed the physician requested no new orders. Review of the 05/12/25 nursing pro[TRUNCATED]

Based on observations, interviews, and record reviews the facility failed to follow enhanced barrier precautions as indicated during care for Resident #46, Resident #33, and #5. This affected one resident (#46) of three reviewed for pressure ulcers, one resident (#33) of three reviewed for catheter use, and one resident (#5) out of four reviewed for incontinence. The facility also failed to ensure staff performed hand hygiene during medication pass. This affected six residents (#23, #29, #48, #52, #61, and #130) out of eight observed for medication administration. The facility also failed to ensure staff followed contact precautions when entering Resident #12's room. This affected one resident (#12) of one reviewed for contact precautions. The facility census was 63.Findings include:1. Review of the medical record for R #5 admitted [DATE] with diagnosis overactive bladder, schizophrenia, and anxiety disorder. R #5 was alert and oriented without cognitive impairment. R #5 was dependent upon staff for performance of all activities of daily living (ADLs) including toileting, hygiene, bathing, dressing and bed mobilityReview of MDS for R #5 revealed that they were always incontinent of bowel and bladder and were dependent upon staff for toileting hygiene. Review of Care plan for R #5 revealed that they were to have incontinence care provided after each episode of bowel and bladder incontinence and that they preferred to have a liner insert in their brief.Review of current physicians' orders for R #5 revealed that they were checked and changed every two hours and as needed due to incontinence. An observation on 06/26/25 at 08:10 A.M. revealed LPN #47 and CNA #70 performed incontinence care for R #5. Observed LPN #47 and CNA #70 using towels, one end wet and one end dry, to clean, rinse and dry resident. After the incontinence care was completed, CAN #70 did not apply a new liner to R #5 brief and did not remove her gloves prior to touching the clean sheets, blanket, pillow, and the overbed table. An interview on 06/26/25 at 8:20 A.M. CNA #70 verified that she did not remove her gloves prior to touching clean linen and surfaces. Further CNA #70 shared that she was using towels instead of wash clothes to perform incontinence care because she only had 3 wash clothes for her entire floor. They stated that R #5 is supposed to have a liner in her brief, but she did not replace it because they didn't have any. An observation on 06/26/25 at 08:44 AM with Laundry Aide #42 revealed a supply of clean linen including wash clothes in the main supply closet adjacent to the laundry. The door was unlocked and accessible to staff. 2. Review of the medical record for R #33 admitted on [DATE] with diagnosis of diabetes mellitus type 2, and obstructive reflux uropathy. R #33 was alert and oriented without cognitive impairment and dependent upon staff for activities of daily living including care of an indwelling urinary catheter. Review of Physicians' orders revealed an order dated 09/27/24 For enhanced barrier precautions (EBP). According to CDC guidelines EBP is an approach of targeted gown and glove use during high contact resident care activities. EBP are applied (when Contact Precautions do not otherwise apply) to residents with any wounds or medical indwelling devices, regardless of infection. Review of care plan revealed R #33 had and indwelling urinary catheter due to obstructive uropathy with a goal of catheter care to manage indwelling catheter appropriately without signs and symptoms of infection or urethral trauma. There was no evidence of EBP mentioned in the care plan. An observation on 06/23/25 at 10:55 AM revealed R #33 lying in bed with an indwelling urinary catheter collection bag lying on the floor and no privacy cover on the bag. EBP posting was not visible outside R #33 rooms to alert staff to use appropriate personal protective equipment (PPE). Continued observations on 06/24/25 at 8 AM and 12:05 PM, 06/25/25 at 2:32 PM, and O6/26/25 at 10 AM revealed that posting remained absent outside R #33 room. Indwelling catheter bag was off the floor, attached to the bed frame below their bladder with privacy cover during these observations. An observation on 06/26/25 at 10:35 AM revealed CNA #70 performed AM care including shaving, changing bed linens and emptying an indwelling urinary catheter bag. CNA #70 preformed hand hygiene and donned gloves without donning a gown prior to performing care. CNA emptied the urinary drainage bag for 1450 milliliters (ml) of pale urine. An interview on 06/26/25 at 11:11 AM with CNA #70 verified that she did not wear a gown while providing care and that she did not know she was supposed to. Further verified that the urinary drainage bag was very full of urine, not able to flow freely from the bladder into the bag and was backed up into the tubing. CNA shared that the bag was over full when she came on shift and was not emptied by the previous shift. At interview on 06/26/25 at 1:06 PM with ADON/infection control preventionist #8 verified the physicians' order for EBP and that there were no visible posting for R #33 to alert staff to use EBP while giving care. Further shared that staff should be donning gowns and gloves while providing care due to the use of an indwelling urinary catheter. 3. Record review of Resident #33 (R #33) revealed an admission date of 09/24/21 with diagnoses including diabetes mellitus, Review of the physician order dated revealed Resident #33 had an order to check their blood sugar before each meal.An observation 06/25/25 08:00 AM revealed that LPN #44 exited R #33 room with a glucometer and placed it on the med cart without a barrier while she donned gloves and got bleach wipes out of the medication cart. She proceeded to pick up the glucometer and wipe it with the bleach wipe, wrap the glucometer in a bleach wipe, then place it into a disposable cupAn interview with LPN #44 revealed that she had taken a blood sugar reading for R #33 and placed the glucometer on her medication cart while they got out the supplies to disinfect the glucometer. LPN #44 further shared that they should have used a barrier beneath the glucometer before placing it on the medication cart. Review of CMS guidelines for disinfection of a multi-use glucometer revealed the guidance to use a barrier (e.g., clean paper towel) under the glucometer when testing on surfaces like overbed tables and medication carts to prevent contamination. 3. Review of the medical record for Resident #46 revealed an admission date 8/15/24 with diagnoses including lupus, congestive heart failure, venous insufficiency, type II diabetes, acute kidney failure, and systemic inflammatory response.Review of the MDS quarterly assessment dated [DATE] revealed Resident #46 had intact cognition and was dependent on staff for ADLs. The assessment identified Resident #46 had four venous ulcers. Observation on 06/24/25 at 3:04 P.M. of Resident #46's wound care with LPN #19 revealed LPN #19 gathered supplies and walked into Resident #46's room. Prior to entering the room there was a sign posted next to the door with two stop signs that stated Enhanced Barrier Precaution, everyone must wear gloves and a gown for wound care. There was a cart filled with PPE and supplies. LPN #19 proceeded to walk into the room without any gown or gloves. LPN #19 washed his hands, donned gloves, and completed Resident #46 wound dressing as ordered. LPN #19 removed his gloves, washed his hands, and walked out of the room. Interview on 06/24/24 at 3:45 P.M. with LPN #19 verified he did not don a gown and gloves prior to entering the room. LPN #19 stated Resident #46 did not have a wound infection that required him to wear a gown. Review of Center for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant organisms (MDROs) dated 04/02/24, nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRO. The use of gown and gloves for high contact resident care activities is indicated, when contact precaution do not otherwise apply, for nursing home resident with wounds and or indwelling medical devices regardless of MDRO colonization as well as for resident with MDRO infection or colonization. 4. Observation on 06/24/25 at 7:31 A.M. during medication administration revealed LPN #23 opened the locked medication cart and pulled the medication cards and bottles for Resident #23. LPN #23 then placed each prescribed medication dose into the medication cup. LPN #23 then signed off medications in the electronic medical record and proceeded directly to administer pulled medications to Resident #23. LPN #23 did not perform hand hygiene prior to accessing medications, prior to administering medications to Resident #23, or after contact with Resident #23 and the environment. Additionally, LPN #23 was subsequently observed to administer medications to Residents #48 and #130 without performing any hand hygiene between each resident's medication administrations. Interview with LPN #23 on 06/24/25 at 8:00 A.M verified she had not performed hand hygiene as required. Observation on 06/24/25 at 8:05 A.M. revealed LPN #19 did not perform hand hygiene prior to administering Residents #52, #61, and #29 their medications. LPN #19 was not observed performing hand hygiene prior to, after, or between resident medication administration. Interview with LPN #19 on 06/24/25 at 8:25 A.M. verified that he had forgotten to perform hand hygiene before, between, and after resident care as required.Interview with the Director of Nursing (DON) on 06/24/25 at 12:05 P.M verified that all staff were to follow the facility medication administration policy and complete hand hygiene before and after administering medications, and prior to next resident contact. A follow up interview with the DON at 1:35 P.M. revealed the DON provided evidence of hand hygiene re-education and competency validation provided to both LPN #19 and LPN #23 after the prior interview. Review of the facility policy titled Hand Hygiene/Handwashing Policy revised 02/28/25 revealed hand hygiene is the most important component for preventing the spread of infection. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water immediately before touching a patient and after touching a patient or the patient's immediate environment. 6. Review of the medical record for Resident #12 revealed an admission date of 09/16/20 and re-admission date of 06/19/25. Current diagnoses included chronic kidney disease, colostomy status, hypertension, resistance to specified beta lactam antibiotics, and need for assistance with personal care.Review of the care plan, revised 04/07/25, revealed Resident #12 was at-risk for infection related to positive for carbapenem-resistant Enterobacteriaceae (CRE), need for contact isolation indefinitely, and cannot have a roommate. Interventions included providing isolation precautions as ordered (initiated 04/16/24).Review of the physician's orders for Resident #12 identified an order for contact isolation precautions (ordered 06/23/25).On 06/23/25 at 12:20 P.M., an observation of Resident #12's room revealed a sign by the door indicating contact isolation precautions indicating all staff must don a gown and gloves prior to entering the room, a cart of personal protective equipment was positioned outside the room, and red isolation waste bins were just inside the door to the room. On 06/24/25 at 8:11 A.M., an interview with the Director of Nursing (DON) stated Resident #12 was on contact isolation precautions due to CRE in his urine. The DON stated Resident #12 returned from the hospital on [DATE] and the order for isolation precautions was not re-started until 06/23/25, four days after re-admission. The DON said there was a delay in reinstating the contact isolation order because she did not have a chance to review the ancillary orders until four days after he returned from the hospital. On 06/24/25 at 8:35 A.M., an observation of Resident #12's room revealed Activities Director #4 entered Resident #12's room without applying any PPE, proceeded to set up his meal tray, moved his bedside table into position, and left the room three minutes after entering the room. Activities Director #4 did not perform hand hygiene before going in the room or after leaving the room. An interview at the time Activities Director #4 left Resident #12's room confirmed she did not apply any PPE because she was unaware he was on any precautions. Activities Director #4 confirmed there was a contact isolation sign outside Resident #12's room, and she further stated she was just delivering his meal tray. Activities Director #4 verified the contact isolation sign posted outside the door did not specify that PPE was only to be applied for hands on care. On 06/24/25 at 8:46 A.M., an interview with Social Services Designee (SSD) #13, who was seated at the nurses station, stated all isolation signs were color coded and staff were supposed to read the signs prior to entering the room. She further stated all PPE indicated on the sign should be donned prior to entering the room.On 06/24/25 at 9:48 A.M., an interview with the DON stated gloves should be on the PPE cart outside Resident #12's room.On 06/24/25 at 9:49 A.M., an observation with the DON of the PPE cart outside Resident #12's room verified there were no gloves on the cart.Review of the facility's policy titled Transmission-Based Precautions and Isolation Policy, dated 05/19/25, revealed contact precautions were intended to prevent transmission of infectious agents which were spread by direct or indirect contact with the patient or the patient's environment. Personal protective equipment recommended included gloves, gowns, limiting transportation and movement of the resident outside the room, using disposable care equipment when able or resident dedicated equipment if disposable is not available, cleaning rooms daily with a focus on frequently touched surfaces, and single room placement when available.

Based on observation, interviews, review of resident council meeting minutes, review of dining council minutes, the facility failed to ensure palatable meals were being provided. This affected three residents (Resident #11, #30 and #45) and had the potential to affect 56 residents receiving food from the kitchen (except Residents # 6, #44, #51, #55, #57, #60, and #218 whom the facility identified as nothing by mouth). The facility census was 63. Findings include: Review of the food committee meeting minutes dated 01/21/25 revealed the following concerns: -an unidentified resident stated the Salisbury steak was bad -residents are asking for more juice options to be added to the juice cart at meals. Review of the food committee meeting minutes dated 02/25/25 revealed the following concerns: -rice is cooked too long and hard to chew -residents requested fresh fruit with meals -residents requested no more vegetable lasagna -residents reported getting sour milk with meals -residents reported kitchen not making enough food and are told they are not allowed to request more -Resident #50 stated on 02/22/25's lunch tray they only got spinach and bread with no meat -Residents requested if the dining room can be served first so their food is still hot when they are served Review of the 03/18/25 resident council meeting minutes revealed to see attached dining concerns, but the facility was unable to provide evidence of the food committee minutes for 03/18/25. Review of the 04/22/25 food committee meeting minutes revealed the following concerns: -the resident wanted things added to the food to make it taste better not just Stouffer's food -dietary staff need to read meal tickets better to ensure accuracy Review of the 05/20/25 food committee meeting minutes revealed the following concerns: -snacks are left at the nurses' desk, but when residents request a snack there are none left -Resident #37 reported not getting his double portions as requested Interview on 06/23/25 at 11:48 A.M. with Resident #11 revealed sometimes she gets foods she dislikes even though she has requested not to receive them. Observation on 06/25/25 at 11:40 A.M. with [NAME] #26 revealed the following temperatures: stuffed peppers 176 Fahrenheit (F), ground beef tips 170 F, pureed beef roast 183 F, beef patty 182 F, pureed cauliflower 168 F, cauliflower 185 F, mashed potatoes 175 F, gravy 185 F, burgers 185 F, chicken noodle soup 185 F, chicken breast 167 F, and noodles 180 F, and pureed bread 172 F. Lunch tray service began at 11:55 P.M. in the first floor serving station and finished at 12:18 P.M. The tray serving cart was delivered to first floor rooms starting at 12:20 P.M. The lunch tray pass finished at 12:31 P.M. The lunch test tray was completed with Regional Dietary Manager #82 and Dietitian #83 at 12:32 P.M. Temperatures of the test tray were as follows: Stuffed pepper 139 F, mashed potatoes 116 F, mixed vegetables 113 F, milk 49 F, and coffee 140 F. Interview following the temperatures with Dietitian #83 revealed the mashed potatoes and mixed vegetables were warmish but could be warmer for preference. Interview on 06/25/25 at 2:26 P.M. with Resident #30 revealed lunch was okay today but is frequently cold and has reported it previously. Interview on 06/25/25 at 2:29 P.M. with Resident #45 revealed she frequently receives cold meals and just doesn't eat them. Review of the 08/28/19 revised facility policy called; Food Temperatures Policy revealed hot foods should be palatable at the time of delivery. This deficiency represents non-compliance investigated under Complaint Number OH00165427.

Based on medical record review, review of shower documentation and interviews, the facility failed to ensure accurate and complete bathing documentation was completed as required for four residents (Residents #5, #19, #33 and #57) of four residents reviewed for activities of daily living. The facility census was 63. Findings include:1. Review of the medical record for Resident #5 revealed an admission date of 12/09/16. Diagnoses included but were not limited to schizophrenia, anxiety disorder, obsessive compulsive disorder and osteoarthritis. Review of the 03/31/25 Minimum Data Set (MDS) 3.0 for Resident #5 revealed intact cognition and was dependent upon staff for bathing. Review of Resident 5's care plan dated 02/26/24 revealed she is dependent upon staff for bathing. Review of the shower sheets from 04/03/25, 4/07/25, 04/10/25, 04/14/25, 04/17/25, 04/20/25, 04/25/25, 05/06/25, 05/09/25, 05/13/25, 05/15/25, 05/20/25, 05/23/25, 05/27/25, 06/06/25, 06/10/25, and 06/17/25 revealed no evidence the nurse reviewed the shower sheet and no signature. Shower sheets that had documented refusals on 04/07/25, 04/14/25, 04/17/25, 04/20/25, 05/06/25, 05/15/25, and 05/27/25 revealed no evidence of a nursing progress note documenting the refusal or reattempts to offer bathing.Review of the facility provided shower sheet for Resident #5 received on 6/24/25 at 4:06 P.M. dated 06/24/25 revealed a bed bath was given and no nurse signature was found. Review of the facility shower schedule revealed Resident #5's scheduled shower days were Tuesday and Friday on the day shift. Interview on 06/24/25 at 4:34 P.M. with Assistant Director of Nursing (ADON) #8 revealed there is a shower book on each unit with the shower schedule. If a resident refuses, the aide is supposed to tell the nurse, and the nurse is to go to the resident and ask the reason for the refusal and document it in the nursing progress notes. The aide is supposed to give the completed shower sheet to the nurse, and the nurse is to review and sign the shower sheet. The ADON confirmed the above shower sheets provided by the facility were not signed by the nurse and the refusals listed above were not documented in the nursing progress notes. Interview on 06/24/25 at 5:00 P.M. with Resident #5 confirmed no one had offered her a bed bath and had only provided incontinence care. Interview on 06/24/25 at 5:16 P.M. with Certified Nurse Aide (CNA) #80 revealed Resident #5 was scheduled for a shower today but had not had the chance to bathe her due to busyness. CNA #80 confirmed the shower sheets was filled out at the beginning of shift in the morning because she always completes her showers. CNA #80 confirmed she had completed a shower sheet for Resident #5 at the beginning of her shift but had not bathed her and confirmed since she had not bathed her, she was unable to accurately confirm the completed skin check questions. Review of the 09/09/22 revised facility policy called Resident Bath/Showering/Scheduling Policy revealed each resident will be asked about bathing preferences upon admission (type of bath, preferred days and times). Each resident will be scheduled to receive a minimum of two times per week. When the bath or shower is complete, the nursing assistant will document the activity on the shower sheet in the electronic record. The nurse will address any findings in the clinical record and appropriate interventions will be initiated. If the bath/shower cannot be given or the resident refuses, the nursing assistant will promptly report the refusal to the charge nurse. The nurse in charge will speak with the resident who refuses to ascertain why and determine if alternative arrangements can be made. If the resident continues to refuse, the charge nurse will document the resident's refusal in the medical record.Review of the facility form called Bath/Shower sheet revealed the licensed nurse and nursing assistant are to review the shower sheet together. Charge nurse will address the concerns before submitting the form to the Director of Nursing. 2. Review of the medical record for Resident #33 admitted on [DATE] with diagnosis of diabetes mellitus type 2, and obstructive reflux uropathy. Review of Resident #33's MDS admission assessment dated [DATE] revealed Resident #33 was alert and oriented without cognitive impairment and was dependent upon staff for ADLs. Resident #33 was noted to have an indwelling urinary catheter and was continent of bowel. Review of Resident #33's shower sheets for April 2025 through June 2025 revealed the resident received showers on 04/05/25, 04/16/25, 05/07/25, 05/24/25, 05/28/25, 05/31/25, 06/04/25. 06/14/25, 06/18/25, 06/21/25. 06/25/25, 06/27/25, and on two additional dates for which the dates are illegible on the shower sheets. No other evidence was provided of showers being given for Resident #33.An interview on 06/26/25 at 2:25 P.M. with ADON #8 revealed that the facility did not have all the documentation for Resident #33's showers for the months of April, 2025, May 2025, and June 2025. ADON #8 confirmed she had requested unnamed staff members to complete and sign shower sheets for the missing dates where there is no record of a shower being given. 3. Review of the medical record for Resident #57 revealed an admission date of 01/09/25 with diagnoses including metabolic encephalopathy, moderate protein-calorie malnutrition, dysphagia, and type two diabetes mellitus.Review of the MDS quarterly assessment dated [DATE] revealed Resident #57 was cognitively impaired, rarely or never able to make needs known, and rarely or never understood communication. The assessment indicated that she was dependent upon two staff members to move in bed, take a shower or bath, and dependent on one staff member for dressingReview of Resident #57's shower sheets provided by ADON #8 included shower sheet for the following dates 4/21/25, 4/24/25, 5/2/25, 5/6/25, 5/9/25, 5/13/25, 6/20/25 that were blank except for the nurse's signature at the bottomAn interview on 06/30/25 at 03:21 P.M. with LPN #55 verified that shower sheets provided for 4/21/25, 4/24/25, 5/2/25, 5/6/25, 5/9/25, 5/13/25, and 6/20/25 were blank except for room number, date and nurse signature. The forms contained no evidence of documentation on whether a shower or bed bath had been given or was refused on these dates. 4. Review of the medical record for Resident #19 revealed an admission date of 10/22/24 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, convulsions, hyperlipidemia, hypertension, depression, aphasia, muscle weakness, need for assistance with personal care, and difficulty in walking.Review of the MDS quarterly assessment, dated 04/18/25, revealed Resident #19 had severely impaired cognition. Review of Resident #19's shower sheets for April 2025 through June 2025 revealed 22 out of 26 shower sheets were not reviewed or signed by a licensed nurse, which the form indicated was required, and the shower sheet for 05/05/25 was completely blank.Review of the physician's orders for June 2025 identified orders for resident to be up before lunch and down after lunch as tolerated (ordered 04/02/25).Review of the Medication Administration Record/Treatment Administration Record (MAR/TAR) for 06/02/25 through 07/02/25 for Resident #19 revealed the order for getting Resident #19 out of bed before lunch and putting him back down after lunch was signed as completed daily. There were no refusals documented.On 06/23/25 at 12:45 P.M., an observation of Resident #19's room revealed he was sitting in bed feeding himself a hamburger.On 06/24/25 at 4:41 P.M., an interview with ADON #8 verified the shower sheets were not completed in their entirety and stated she had educated the nurses multiple times previously about reviewing and signing the shower sheets.On 06/30/25 at 12:31 P.M., an observation of Resident #19 revealed he was in bed feeding himself a cheeseburger. On 06/30/25 at 12:40 P.M., an interview with Licensed Practial Nurse (LPN) #55 confirmed staff did not get Resident #19 out of bed before lunch. LPN #55 further stated she's not aware of staff ever getting Resident #19 out of bed before lunch in the entire time she had worked at the facility (eight months). LPN #55 verified she signed the MAR/TAR as completed for getting him out of bed despite staff not getting him out of bed on multiple days. LPN #55 also verified there were no documented refusals for Resident #19 getting out of bed.On 07/01/25 at 12:07 P.M., an observation of Resident #19's room revealed he was in bed and Social Services Designee (SSD) #13 was delivering his lunch to him in bed. On 07/01/25 at 12:10 P.M., an interview with SSD #13 confirmed Resident #19 was eating lunch in bed.On 07/02/25 at 12:34 P.M., an observation of Resident #19's room revealed he was in bed feeding himself a cheeseburger.On 07/02/25 at 2:13 P.M., an interview with LPN #44 confirmed Resident #19 had not been out of bed all day, verified she signed the MAR/TAR as completed for getting him out of bed despite staff not getting him out of bed, and LPN #44 said she signed it off as completed because she offered it. LPN #44 claimed Resident #19 refused to get out of bed and confirmed there was no documentation of the refusal.This deficiency represents non-compliance investigated under Master Complaint Number OH00165594.

Based on record review and interview, the facility failed to ensure notice of transfer and bed hold notice was provided to the resident, and the discharge summary was completed. This affected six Residents #28, # 46, #55, #66 #118, and #119 of eight residents reviewed for hospitalization and discharge. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date 05/02/24 with diagnoses including diabetes type II, puerperal vascular disease (PVR), hypertension, anxiety, depression, and bipolar. The record revealed Resident #28 was sent out to the hospital on [DATE].Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had intact cognition and was dependent on staff for activities of daily living. Review of the Immediate Transfer/Discharge, a written discharge notice to the resident/representative dated 05/13/25 revealed that the welfare and needs of the resident cannot be met in the facility due to the urgent medical needs of the resident. There was no evidence that the resident/representative received the written discharge notice. Interview on 06/26/25 at 1:13 P.M. with Receptionist #9 stated when a resident is sent out to the hospital, the Immediate Transfer/Discharge Notice is added to the packet of information that goes with the resident to the hospital. Interview with the Administrator on 06/26/25 at 1:15 P.M. verified there was no way to ensure the residents received the written notice. The Administrator stated the facility had identified the transfer discharge notices as a part of Quality Assurance (QA) project. The Administrator stated she had instructed the receptionist to put a copy of the discharge transfer notice in with the hospital paperwork with every person who leaves 911. Interview on 06/26/25 at 1:32 P.M. with Resident #28 stated he had never seen the Immediate Transfer/Discharge form. 2. Review of the medical record for Resident #46 revealed an admission date 8/15/24 with diagnoses including chronic respiratory failure, quadriplegia, neuromuscular bladder, tracheostomy status. The record revealed Resident #46 was sent to the emergency room on [DATE], 05/16/25, and 05/24/25.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had intact cognition and was dependent on staff for activities of daily living. Review of the Immediate Transfer/Discharge, the discharge notice to the resident/representative dated 04/10/25, 05/16/25, 05/24/25 revealed the welfare and needs of the resident cannot be met in the facility due to the urgent medical needs of the resident. There was no evidence that the resident/representative received the written notice. Interview on 06/26/25 at 1:13 P.M. with Receptionist #9 stated when a resident is sent out to the hospital the Immediate Transfer/Discharge Notice is added to packet of information that goes with the resident.Interview on 06/26/25 at 4:30 P.M. with Resident # 46 stated he had never seen the Immediate Transfer/Discharge form. Interview on 06/26/25 at 1:13 P.M. with Receptionist #9 stated when a resident is sent out to the hospital, the Immediate Transfer/Discharge Notice is added to the packet of information that goes with the resident to the hospital. Interview with the Administrator on 06/26/25 at 1:15 P.M. verified there was no way to ensure the residents received the written notice. The Administrator stated the facility had identified the transfer discharge notices as a part of Quality Assurance (QA) project. The Administrator stated she had instructed the receptionist to put a copy of the discharge transfer notice in with the hospital paperwork with every person who leaves 911. 3. Review of the medical record for Resident #66 revealed an admission date 04/09/25 with diagnoses including respiratory failure, cocaine use, chronic obstructive pulmonary disease (COPD), tracheostomy status a gastrostomy. The record revealed Resident #66 was sent to the emergency room on [DATE]. Further review of the discharge documentation revealed there was no evidence of a bed hold notice or Immediate Transfer/Discharge notice, the written notice to the representative provided on 04/11/25.Interview on 07/02/25 at 1:30 PM with the Administrator verified the Resident #66 did not receive a written notice of transfer or a bed hold notice. 4.Review of the medical record for Resident #119 revealed an admission date 04/09/25 with diagnoses including paroxysmal atrial fibrillation, cancer of the colon, respiratory failure, type II diabetes and ileostomy status. The Resident was discharges on 4/17/25. Further review of the medical record revealed there was no evidence of an Immediate Transfer/Discharge form, a written notice of discharge to the resident/representative. Interview on 07/02/25 at 9:30 A.M. with the Administrator verified there was no evidence of a written discharge notice issued to Resident #119. Review of the facility policy titled Resident discharge/transfer letter policy revised 12/09/24 stated the facility will complete discharge letter appropriately and according to all federal, state and local regulation. 6. Review of the medical record for Resident #55 revealed an admission date of 02/19/25 with diagnoses including cerebral infarction, supraventricular tachycardia, hypertension, and muscle wasting and atrophy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/19/25, revealed Resident #55 had severely impaired cognition.Review of the physician's orders for Resident #55 identified an order for an appointment for magnetic resonance imaging (MRI) testing on 06/27/25 at 10:00 A.M. (ordered 06/24/25).Review of the progress notes for June 2025 revealed no notes indicating Resident #55 had been transferred or admitted to the hospital.Review of the transfer/discharge assessment, dated 06/27/25, revealed Resident #55 was transferred to the hospital for MRI testing and the bed hold and transfer notices were sent with the resident at the time of transfer. There was no indication that the bed hold and transfer notices were provided to Resident #55's representative.On 06/26/25 at 1:13 P.M., an interview with Receptionist #9 stated the process for when a resident was transferred to the hospital was the immediate transfer/discharge notice was added to the packet that was sent to the hospital with the resident. Review of the certified mail tracking information for the bed hold notice mailed for Resident #55 revealed it was mailed on 06/30/25. There was no evidence that a transfer notice was mailed with the bed hold notice.On 06/30/25 at 4:51 P.M., an interview with the Director of Nursing (DON) stated Resident #55 was sent to the hospital for testing per his sister's request and the hospital kept him for further testing. The DON confirmed there was no note indicating the transfer and said there should have been a progress note. The DON further stated the transfer and bed hold notices were always sent with the residents to the hospital. The DON confirmed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 2.0, indicating severe cognitive impairment, and his sister was notified of the transfer via phone call. On 07/02/25 at 12:49 P.M., an interview with the Administrator confirmed only a bed hold notice was mailed to Resident #55's representative and no transfer notice was provided in writing. 7. Review of medical record for Resident #118 revealed an admission date of 02/13/25 with a diagnoses including acute and subacute endocarditis, methicillin resistant staph aureus (a highly resistant organism), anxiety, obesity, obstructive sleep apnea, hypertension, congestive heart failure, pacemaker, dysphagia, and muscle weakness. Review of Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which is indicative of the resident having full cognition. Resident #118 needed partial/moderate assistance with activities of daily living (ADLs) and hygiene needs. Resident used a wheelchair for mobility and was able to self-propel. Review of baseline care plan dated 02/14/25 revealed goals of safety, nutritional status, medication and activities. Review of medical record revealed no discharge summary or discharge planning process was completed by facility as required. Interview with Administrator on 06/30/25 at 1:57 P.M. verified that Resident #118 did not have a discharge summary completed at the facility per requirement.Review of facility policy titled, Resident Discharge/Transfer Letter Policy revised 12/09/24 revealed discharge notices must have the following components: 1. Reason for discharge 2. The effective date of transfer/discharge, 3. The location to which the resident is transferred/discharge.

Based on record review, interview, policy review, and review of the employee handbook, the facility failed to ensure staff performed transfers in a safe manner per physician's orders and re-assess fall risk after a fall occurred. This affected one resident (#19) out of four reviewed for accident hazards. The facility census was 63. Findings include: Review of the medical record for Resident #19 revealed an admission date of 10/22/24 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, convulsions, hyperlipidemia, hypertension, depression, aphasia, muscle weakness, need for assistance with personal care, and difficulty in walking. Review of the physician's orders for Resident #19 identified an order for a mechanical lift for transfers (ordered 10/23/24). Review of the most recent fall risk assessment, dated 10/23/24, revealed Resident #19 had no falls within the previous six months, was completely paralyzed or completely immobilized, and had a score of 0.0 indicating low fall risk. Review of the progress note dated 12/17/24 at 1:38 P.M. revealed Resident #19's roommate notified staff that Resident #19 was on the floor. Resident #19 was found laying on his back to the side of his bed. Resident #19 had no indicators or complaints of pain, answered yes/no questions indicating he was trying to get out of bed, and denied hitting his head. The note dated 12/17/24 at 10:57 P.M. revealed Resident #19 returned to the facility. The note dated 12/19/24 at 1:45 P.M. revealed Resident #19 returned to the facility following a transfer to the emergency room after experiencing a fall on 12/17/24. There was no documentation of a new fall risk assessment after Resident #19 sustained a fall on 12/17/24. Review of a video from the in-room camera dated 01/21/25 revealed Resident #19 was laying on the floor beside his bed. After the nurse assessed Resident #19 for injury, the video showed Certified Nursing Assistant (CNA) #60 and CNA #76 getting Resident #19 off the floor by lifting him under his arms. At no point was a mechanical lift used while transferring Resident #19 back into bed. Review of the progress note dated 01/21/25 at 9:30 P.M. revealed Resident #19 had a fall in his room, was assessed with no injuries identified, and the resident had no indicators or complaints of pain. The progress note dated 01/22/25 at 10:03 A.M. revealed the interdisciplinary team (IDT) reviewed Resident #19's fall from 01/21/25. Resident #19 was found on the floor in his room, was unable to state what he was attempting to do, had been in bed prior to the fall, and did not have any injuries after the fall. New interventions included low bed, bed against wall, mat to floor on open side of bed, and perimeter mattress to bed. The progress note dated 01/22/25 at 2:29 P.M. revealed Resident #19's representative was agreeable to the placement of a perimeter mattress. Resident #19's representative stated she did not want Resident #19's bed to be placed against the wall. The progress note dated 01/24/25 at 1:24 P.M. revealed the IDT reviewed the request from Resident #19's representative that the bed not be placed against the wall. There was no documentation of a new fall risk assessment after Resident #19 sustained a fall on 01/21/25. Review of the progress note dated 02/01/25 at 4:15 A.M. revealed Resident #19 was found sitting on the floor next to his bed, there was no apparent injury, and close observation would continue. Review of the IDT note dated 02/06/25 at 11:39 A.M. revealed Resident #19's fall was reviewed, the resident was unable to state what he was doing prior to the fall, no new safety devices were recommended by IDT, and therapy would assess for appropriateness of reacher in regards to ability to use. There was no documentation of a new fall risk assessment after Resident #19 sustained a fall on 02/01/25. Review of a video from the in-room camera dated 01/25/25 revealed CNA #46 and CNA #58 transferred Resident #19 from the bed to an electronic wheelchair utilizing a gait belt. At no point was a mechanical lift used while transferring Resident #19 into his wheelchair. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/18/25, revealed Resident #19 had severely impaired cognition. The assessment indicated Resident #19 required partial or moderate assistance for eating, oral hygiene, and personal hygiene; required substantial or maximum assistance for rolling left and right, sit to lying, and lying to sitting; and was totally dependent on staff for toileting hygiene, showering or bathing self, dressing, and chair/bed to chair transfer. The assessment indicated Resident #19 had one fall with no injury since the last assessment. Review of the optional state MDS assessment, dated 04/18/25, revealed Resident #19 required extensive assistance of two staff for bed mobility, total dependence of two staff for transfers, supervision with setup assist for eating, and total dependence of two staff for toilet use. Review of the physical therapy Discharge summary dated [DATE] revealed Resident #19 required a hoyer mechanical lift for transfers and was dependent on staff for basic mobility. Resident #19 was discharged from physical therapy due to progress ceased. Review of a video from the in-room camera dated 06/15/25 showed two staff members, Certified Nursing Assistant (CNA) #55 and CNA #58, in Resident #19's room during a hoyer mechanical lift transfer. While operating the hoyer mechanical lift to lift Resident #19 out of bed, CNA #55 grabbed her cell phone, propped the phone between her shoulder and her ear, and continued operating the hoyer mechanical lift while talking on the phone. On 06/25/25 at 3:38 P.M., review of the video dated 06/15/25 with the Administrator verified CNA #55 operated the hoyer mechanical lift to transfer Resident #19 while talking on her cell phone. On 06/26/25 at 10:45 A.M., review of the videos dated 01/21/25 and 01/25/25 with the Director of Nursing (DON) verified CNAs #46, #58, #60, and #76 all transferred Resident #19 without utilizing a hoyer mechanical lift. The DON further stated the facility did not have a specific policy or protocol detailing what to do after a fall occurs. On 06/26/25 at 10:50 A.M., an interview with the Administrator stated Resident #19's wife did not want Resident #19 to be transferred via mechanical lift. The Administrator verified Resident #19's care plan indicated the resident required a mechanical lift for transfers. The Administrator also reviewed and verified the contents of the videos from 01/21/25 and 01/25/25 at that time. On 06/26/25 at 12:20 P.M., an interview with the DON stated all staff were reporting to her that Resident #19's wife was insistent that staff not utilize a hoyer mechanical lift for transfers because Resident #19's wife wanted him transferred with a gait belt. The DON confirmed therapy had not cleared Resident #19 to be transferred with anything other than a hoyer mechanical lift. On 06/30/25 at 10:22 A.M., an interview with the DON confirmed Resident #19 did not have any new fall risk assessments after experiencing falls. The DON stated after a fall occurs, the IDT reviews the fall and a fall meeting occurs with therapy. The DON further stated no new fall risk assessment was completed that would give a new fall risk score. The DON also confirmed there was no mention of increased fall risk following the falls in January 2025 and February 2025. Review of the facility's employee handbook, dated 01/01/21, revealed the nature of the business of the facility did not allow for personal telephone calls during working hours. The unauthorized use of personal cellular phones or pagers while working in the facility was strictly prohibited and they may be confiscated until the end of the employee's shift. Review of the facility's policy titled Mechanical Lift Policy, dated 01/07/22, revealed a mechanical lift may be used for transferring residents that could not be safely transferred by themselves or with staff assistance. The resident's transfer status would be assessed on admission, quarterly, and as needed with any changes in the resident's transfer ability. Two staff person assist would be required for total body lifts. Any resident who could not be elevated from the floor utilizing contact guard or minimal assist would be lifted from the floor using a mechanical lift only. Review of the facility's policy titled Fall Prevention and Management Policy, dated 08/06/24, revealed residents would be assessed for fall risk on admission, quarterly, and as needed. All falls would be reviewed by the IDT, any new interventions would be implemented, and the care plan would be updated as necessary. The IDT review should include the results of the new fall risk assessment, discussion with the resident and/or any witnessing parties and to potential causal factors, review of the environment where the fall occurred, and discussion as to any new interventions which may help prevent further falls. This deficiency represents non-compliance investigated under Master Complaint Numbers OH00165594 and Complaint Number OH00165427.

Based on record review, observation, and interview, the facility failed to honor resident preferences as ordered by the physician. This affected one resident (#19) out of two reviewed for choices. The facility census was 63. Findings include: Review of the medical record for Specified Resident #19 revealed an admission date of 10/22/24 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, convulsions, hyperlipidemia, hypertension, depression, aphasia, muscle weakness, need for assistance with personal care, and difficulty in walking. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/18/25, revealed Resident #19 had severely impaired cognition. The assessment indicated Resident #19 required partial or moderate assistance for eating, oral hygiene, and personal hygiene; required substantial or maximum assistance for rolling left and right, sit to lying, and lying to sitting; and was totally dependent on staff for toileting hygiene, showering or bathing self, dressing, and chair/bed to chair transfer. Review of the optional state MDS assessment, dated 04/18/25, revealed Resident #19 required extensive assistance of two staff for bed mobility and total dependence of two staff for transfers. Review of the physician's orders for June 2025 identified orders for crush medications and split in divided amounts with pudding or yogurt only (ordered 12/28/24) and resident to be up before lunch and down after lunch as tolerated (ordered 04/02/25). Review of the progress note dated December 2024 through June 2025 revealed multiple documented instances of Resident #19 refusing his medications. Review of the progress note dated 12/08/24 at 12:12 P.M. revealed Resident #19 refused all morning medications crushed in applesauce because yogurt was unavailable. Review of the progress note dated 12/27/24 at 6:59 P.M. revealed medications were to be crushed and administered with pudding or yogurt. Review of the progress note dated 04/02/25 at 10:28 A.M. revealed Resident #19's representative was in agreement with getting the resident up before lunch and going down after lunch as long as Resident #19 agrees. Review of the progress note dated 04/12/25 at 4:59 A.M. revealed Resident #19 refused his medications and the resident indicated he would take them if the nurse put them in yogurt. On 06/23/25 at 12:45 P.M., an observation of Resident #19's room revealed he was sitting in bed feeding himself a hamburger. On 06/26/25 at 8:51 A.M., an interview with Licensed Practical Nurse (LPN) #45 revealed Resident #19's medications had been administered with applesauce that morning because the facility was out of yogurt. LPN #45 confirmed Resident #19's preference was for medications to be administered with yogurt instead of applesauce. On 06/26/25 at 9:03 A.M., an interview with Regional Dietary Manager #82 revealed there was yogurt available. Observation at the time of interview revealed a sufficient supply of yogurt in the walk-in refrigerator in the kitchen. On 06/26/25 at 9:05 A.M., an interview with the Director of Nursing (DON) confirmed Resident #19 preferred to take his medications with yogurt instead of applesauce. On 06/26/25 at 10:35 A.M., an interview with the DON confirmed Resident #19 had a physician's order to provide medications in pudding or yogurt only. The DON further revealed there was probably no yogurt in the second floor servery and LPN #45 did not go downstairs to look in the kitchen for yogurt. On 06/30/25 at 12:31 P.M., an observation of Resident #19 revealed he was in bed feeding himself a cheeseburger. On 06/30/25 at 12:40 P.M., an interview with LPN #55 confirmed staff did not get Resident #19 out of bed before lunch. LPN #55 further stated she's not aware of staff ever getting Resident #19 out of bed before lunch in the entire time she had worked at the facility (eight months). LPN #55 verified she signed the MAR/TAR as completed for getting him out of bed despite staff not getting him out of bed on multiple days. LPN #55 also verified there were no documented refusals for Resident #19 getting out of bed. On 07/01/25 at 12:07 P.M., an observation of Resident #19's room revealed he was in bed and Social Services Designee (SSD) #13 was delivering his lunch to him in bed. On 07/01/25 at 12:10 P.M., an interview with SSD #13 confirmed Resident #19 was eating lunch in bed. On 07/02/25 at 12:34 P.M., an observation of Resident #19's room revealed he was in bed feeding himself a cheeseburger. On 07/02/25 at 2:13 P.M., an interview with LPN #44 confirmed Resident #19 had not been out of bed all day, verified she signed the MAR/TAR as completed for getting him out of bed despite staff not getting him out of bed, and LPN #44 said she signed it off as completed because she offered it. LPN #44 claimed Resident #19 refused to get out of bed and confirmed there was no documentation of the refusal. This deficiency represents non-compliance investigated under Master Complaint Number OH00165594.

3. Review of the medical record for Resident #28 revealed an admission date of 05/02/24 with diagnoses including diabetes mellitus, hypertension, anxiety, depression, bipolar disorder, and chronic kidney disease. Review of the minimum data set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact and required substantial or maximum assistance for activities of daily living (ADLs). On 06/24/25 at 3:01 P.M., an observation of Resident #28's room revealed Resident #28 was laying in bed calling for help and her call light was observed on the floor and out of reach. An interview at the time of observation with Certified Nursing Assistant (CNA) #27 verified Resident #28's call light was on the floor and out of reach. On 06/25/25 at 10:40 A.M., an observation revealed Resident #28 was lying in bed and the call light was not in reach. The call signal light on top of the door was illumined, indicating the residents in the room requested assistance. Licensed Practical Nurse (LPN) #44 entered the room and asked Resident #28 what she needed. Resident #28 replied she needed her call light and wanted to get dressed. LPN #44 retrieved the call light and put it in reach of Resident #28. Resident #28's roommate stated she needed help and had put on the call light. On 06/25/25 at 10:42 A.M., an interview with LPN #44 verified Resident #28's call light was not reach. This deficiency represents non-compliance investigated under Master Complaint Number OH00165594. Based on observation, interview, record review and facility policy, the facility failed to ensure the resident's call light was within reach. This affected three Residents (#6, #28 and #122) out of six residents reviewed for call lights. The facility census was 63. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 06/25/25 with diagnoses including acute respiratory failure, catatonic disorder, dysphagia, major depressive disorder, dependence on respiratory, multiple contractures, dependence on supplemental oxygen, and encephalopathy. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 with maximum full dependence on staff for all activities of daily living (ADLs) and hygiene needs. Resident #6 was unable to perform any self-care due to catatonic state and contractures and uses a pressure pad call light for assistance. Observation on 06/24/25 at 9:30 A.M. revealed pressure pad call light located on the floor and resident was unable to call for assistance. Interview on 06/24/25 at 9:32 A.M. with Certified Nursing Assistant (CNA) #52 verified pressure pad call light on floor. CNA #52 replaced call light next to contracted arm so resident could activate if needed. 2. Review of medical record for Resident #122 revealed an admission date of 06/19/25 with diagnoses including infection of skin and subcutaneous tissue, sepsis, staphylococcus and pseudomonas infections (highly resistant bacterial organisms which require extended antibiotics), morbid obesity, protein-calorie malnutrition, chronic kidney disease, and muscle weakness. Review of MDS dated [DATE] revealed Resident #122 was alert, oriented, appropriate and no behavioral concerns. MDS also revealed Resident #122 required maximum assistance for ADLs, mobility, and hygiene needs due to deconditioning and morbid obesity. Interview and observation on 06/25/25 at 9:11 A.M. revealed Resident #122 complained of having a wet gown and needed to be changed. Resident was unable to reach call light for assistance. Call light was observed to be wrapped around the side of the bed rail near head of bed and out of reach for resident. Interview on 06/25/25 at 9:13 A.M. with CNA #84 verified call light was out of reach for resident. Call light was repositioned and secured on bed within reach for resident. Review of facility policy titled Resident Communication and Call Light Policy revised on 02/24/2023 revealed when resident is in bed or confined to a chair, the call light will be within easy reach.

Based on record review, review of the facility's self-reported incident (SRI), and interview, the facility failed to conduct a thorough investigation of an allegation of abuse. This affected one resident (#32) out of four reviewed for abuse. Findings include: Review of the medical record for Resident #32 revealed an admission date 04/15/25 with diagnoses including osteomyelitis, clostridium difficile (c-diff), diabetes type II, peripheral vascular disease (PVR), bipolar, chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had intact cognition and was dependent on staff for activities of daily living. Review of the progress note dated 05/12/25 revealed the resident made an accusation about a staff member. Review of the Self-Reported Incident (SRI) 260268 dated 05/12/25 at 10:31 A.M. revealed an allegation of sexual abuse. The Assistant Director of Nursing (ADON) reported to administration that Resident #32 was raped on 05/11/25. The employee was suspended immediately pending investigation. The name of the alleged employee was not listed as a perpetrator. Resident #32 denied being touched inappropriately and stated she was held down gently over the bed and up against the wall. Interview with staff witnesses revealed no pertinent information discovered. Interviews with other staff on duty revealed no additional pertinent information. The SRI was completed on 05/13/25 at 6:25 P.M. The investigation included two employee witness statements completed by a Registered Nurse (RN) #54, and State Tested Nursing Assistant (STNA) #76 who was the suspected perpetrator. There were no additional staff interviews. There was no witness statement from the ADON who reported the allegation. There was an interview statement with Resident #32 conducted by the Administrator and the Director of Nursing (DON). Staff education consisted of an email written by the Business Office Manager (BOM) #3. The email was sent to 102 listed staff plus an additional 78 staff whose names were not listed. The subject line on the email read Resident abuse policy please read, very important. The attachment was a copy of the facility abuse policy. There was no evidence that staff completed the education. Interview on 07/01/25 at 11:44 A.M. with the Administrator stated she interviewed Resident #32 who denied any rape. RN #54 and STNA #76 denied any allegation of rape. The Administrator stated she suspected STNA #76 as the perpetrator because he was the only male who provided care to Resident #32 that night. STNA #76 was in Resident #32's room one time to pull her in bed with RN #54. The Administrator stated since Resident #32 denied the allegation of rape she did not further interview staff. The Administrator verified there were only two staff interviews and there was no evidence that staff completed the training on abuse. The Administrator stated the allegation could have been better investigated.

Based on record review, Resident Assessment Instrument (RAI) user manual review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate related to wounds. This affected one (Resident #46) of 21 residents reviewed for comprehensive assessments. The facility census was 63. Findings include: Review of the medical record for Resident #46 revealed an admission date 8/15/24 with diagnoses including chronic respiratory failure, quadriplegia, neuromuscular bladder, and tracheostomy status. Review of the assessment revealed Braden scale for pressure ulcer risk assessments was completed on 11/06/24 indicating Resident #46 was at high risk for pressure ulcer development. There was no evidence of the current Braden assessment. Review of the plan of care dated 05/02/25 revealed Resident #46 had a plan for neuropathic ulcer (a type of ulceration that develops due to nerve damage, commonly found in individuals with conditions like diabetes or spinal cord injuries) to the right foot with risk for complication. Review of the quarterly MDS assessment dated [DATE] revealed Resident #46 had intact cognition and was dependent on staff for activities of daily living. Under section M0150 of the assessment revealed the resident was at risk for pressure ulcers and under M1040 had no open lesions on the foot. Review of the physician's wound noted dated 05/25/25 stated the wound the right foot planter aspect was neuropathic. Review of the physician's orders dated June 2025 revealed Resident #46 had a wound dressing order to the right foot planter to cleanse and apply foam cover to the right great toes, dated 04/28/25. Interview on 06/30/24 at 10:20 A.M. with MDS Nurse #11 verified Resident #46 she did not check the box und M1040 other open lesions on the foot. MDS #11 stated she was taught to check the box only if it was related to cancer. MDS Nurse #11 stated neuropathic wounds meet the definition of an open lesion that develops as part of the disease or condition. Review of the RAI manual dated October 2024 stated M1040D Open Lesion(s) Other than Ulcers, Rashes, Cuts. Open lesions that develop as part of a disease or condition and are not coded elsewhere on the MDS, such as wounds, boils, cysts, and vesicles, should be coded in this item. Do not code rashes, abrasions, or cuts/lacerations here. Although not recorded on the MDS assessment, these skin conditions should be considered in the plan of care. Do not code pressure ulcers/injuries, venous or arterial ulcers, diabetic foot ulcers or skin tears here. These conditions are coded in other items on the MDS.

Based on record review and staff interview, the facility failed to ensure the appropriate Ohio Department of Mental Health and Addiction Services was timely notified of a significant change in a residents Pre-admission Screen (PASRR). The affected one (Resident #20) of three reviewed for PASRR status. The facility census was 63. Findings include: Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including heart failure, type II diabetes mellitus, major depressive disorder, generalized anxiety disorder and acquired absence of left leg below knee. Review of the 03/27/20 PASRR results for Resident #20 revealed no indications of serious mental illness or developmental disability. Review of the medical record for Resident #20 revealed on 06/01/24 a new diagnosis of bipolar disorder was received. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 was cognitively intact and receiving antipsychotics. Diagnoses listed included but were not limited to anxiety disorder, depression, bipolar disorder, and psychotic disorder. Review of the nursing progress note dated 05/30/25 revealed Resident #20 was sent to the hospital for a mental status change. Review of the 05/30/25 hospital admission paperwork for Resident #20 revealed he was admitted with left-sided weakness. Resident #20 was noted to have medical history of bipolar disorder. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #20 had moderate cognitive impairment. Resident #20 required extensive assistance for activities of daily living and had diagnoses including bipolar disorder, depression, and anxiety disorder. Review of the 06/11/25 PASRR Level II outcome results for Resident #206 revealed approval for nursing facility services related to a diagnosis of bipolar disorder, major depressive disorder and generalized anxiety disorder. Interview on 06/24/25 at 2:40 P.M. with Social Services Designee (SSD) #13 confirmed a PASRR review was completed prior to admission and no additional PASRR was completed until Resident #20 returned from the hospital on [DATE]. SSD #13 confirmed Resident #20 had a diagnosis of bipolar disorder added on 06/01/24, prior to the recent hospitalization, and should have had a PASRR completed as required following the diagnosis on 06/01/24.

Based on record review, interview and facility policy review, the facility failed to ensure the baseline care plan included person-centered care that included goals to properly care for the resident's specific health and safety concerns and physician orders to prevent decline for Resident #118. This affected one (Resident #118) out of eight residents reviewed for baseline care planning. The facility census was 63. Findings include: Review of the medical record for Resident #118 revealed was admitted to the facility on [DATE] with diagnoses including acute and subacute endocarditis, methicillin resistant staphylococcus aureus (a highly resistant organism), anxiety, obesity, obstructive sleep apnea, hypertension, congestive heart failure, pacemaker, dysphagia, and muscle weakness. Review of the baseline care plan dated 02/14/25 revealed it did not include infection prevention or interventions regarding maintenance and care of peripheral intravascular central catheter (PICC) or care of sternal wound post open heart surgery. Interview on 07/02/25 at 3:00 P.M. with the Director of Nursing (DON) and Minimum Data Set (MDS) Coordinator #6 verified Resident #118's baseline care plan did not include resident specific surgical sternal wound care and infection control interventions for methicillin-resistant staphylococcus aureus (MRSA) (a highly resistant bacteria) which required a six-week course of antibiotics via PICC line. Review of the facility policy titled, Interim/Baseline Care Planning Policy, revised 03/24/25, revealed the facility will develop and implement an interim/baseline care plan for each resident that includes instructions needed to provide effective and person-centered care of the resident. The baseline care plan will include the minimum information necessary to care for a resident including but not limited to: Initial goals based on admission orders, and physician orders etc.

Based on record review and interview, the facility failed to ensure medical records were accurate. This affected one (Resident #5) of 16 resident medical records reviewed. The facility census was 63.Findings include: Review of the medical record for Resident #5 revealed an admission date of 12/09/16. Diagnoses included but were not limited to schizophrenia, anxiety disorder, obsessive compulsive disorder and osteoarthritis. Review of the 03/31/25 Minimum Data Set (MDS) 3.0 for Resident #5 revealed intact cognition and was dependent upon staff for bathing. Review of Resident 5's care plan dated 02/26/24 revealed she is dependent upon staff for bathing. Review of the shower sheets from 04/03/25, 4/07/25, 04/10/25, 04/14/25, 04/17/25, 04/20/25, 04/25/25, 05/06/25, 05/09/25, 05/13/25, 05/15/25, 05/20/25, 05/23/25, 05/27/25, 06/06/25, 06/10/25, and 06/17/25 revealed no evidence the nurse reviewed the shower sheet and no signature. Shower sheets that had documented refusals on 04/07/25, 04/14/25, 04/17/25, 04/20/25, 05/06/25, 05/15/25, and 05/27/25 revealed no evidence of a nursing progress note documenting the refusal or reattempts to offer bathing.Review of the facility provided shower sheet for Resident #5 received on 6/24/25 at 4:06 P.M. dated 06/24/25 revealed a bed bath was given and no nurse signature was found. Review of the facility shower schedule revealed Resident #5's scheduled shower days were Tuesday and Friday on the day shift. Interview on 06/24/25 at 4:34 P.M. with Assistant Director of Nursing (ADON) #8 revealed there is a shower book on each unit with the shower schedule. If a resident refuses, the aide is supposed to tell the nurse, and the nurse is to go to the resident and ask the reason for the refusal and document it in the nursing progress notes. The aide is supposed to give the completed shower sheet to the nurse, and the nurse is to review and sign the shower sheet. The ADON confirmed the above shower sheets provided by the facility were not signed by the nurse and the refusals listed above were not documented in the nursing progress notes. Interview on 06/24/25 at 5:00 P.M. with Resident #5 confirmed no one had offered her a bed bath and had only provided incontinence care. Interview on 06/24/25 at 5:16 P.M. with Certified Nurse Aide (CNA) #80 revealed Resident #5 was scheduled for a shower today but had not had the chance to bathe her due to busyness. CNA #80 confirmed the shower sheets was filled out at the beginning of shift in the morning because she always completes her showers. CNA #80 confirmed she had completed a shower sheet for Resident #5 at the beginning of her shift but had not bathed her and confirmed since she had not bathed her, she was unable to accurately confirm the completed skin check questions. Review of the 09/09/22 revised facility policy called Resident Bath/Showering/Scheduling Policy revealed each resident will be asked about bathing preferences upon admission (type of bath, preferred days and times). Each resident will be scheduled to receive a minimum of two times per week. When the bath or shower is complete, the nursing assistant will document the activity on the shower sheet in the electronic record. The nurse will address any findings in the clinical record and appropriate interventions will be initiated. If the bath/shower cannot be given or the resident refuses, the nursing assistant will promptly report the refusal to the charge nurse. The nurse in charge will speak with the resident who refuses to ascertain why and determine if alternative arrangements can be made. If the resident continues to refuse, the charge nurse will document the resident's refusal in the medical record.Review of the facility form called Bath/Shower sheet revealed the licensed nurse and nursing assistant are to review the shower sheet together. Charge nurse will address the concerns before submitting the form to the Director of Nursing.

Based on record review, observations and interviews, the facility failed to provide meaningful resident-centered activities for Resident #57. This affected one (Resident #57) out of three residents reviewed for activities. The facility census was 63. Findings include: Review of the medical record for Resident #57 revealed an admission date of 01/09/25 with diagnoses of metabolic encephalopathy, moderate protein-calorie malnutrition, dysphagia, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively impaired, rarely or never able to make needs known, and rarely or never understood communication. The assessment indicated that she was dependent upon two staff members to move in bed, take a shower or bath, and dependent on one staff member for dressing. Review of the current physician's orders revealed no pharmacological intervention for anxiety, agitation, or restlessness. Review of progress notes since admission revealed no evidence of anxiety or restlessness. Review of Resident #57's care plan revealed no evidence of anxiety, agitation, or restlessness addressed. Review of the activities care plan for Resident #57 revealed that she preferred activities that identify with her prior lifestyle. The identified goal was that Resident #57 would express satisfaction with daily routine and leisure activities. The identified interventions were to allow her to express her feelings and to interact with peers that have similar interests. Review of an activity assessment dated [DATE] for Resident #57 authored by Life Enrichment Director (LED) #4 revealed that Resident #57 interacted with team members during care and received a minimum of two visits per week from friends and family resulted in an assessment score of two. Per the facilities assessment a score of two required Resident #57 to receive two one-on-one visits per week. Review of the one-on-one activities visit documentation for Resident #57 provided by LED #4 with the following findings. 04/05/25 Resident #57 made eye contact, 04/19/25 Resident #57 refused, 04/26/25 Resident #57 refused, 05/03/25 Resident #57 made eye contact and verbal sounds, 05/17/25 Resident #57 refused, 05/21/25 Resident #57 made eye contact, verbal sounds and soft music was played, 05/31/25 Resident #57 refused, 06/07/25 Resident #57 refused, 06/21/25 Resident #57 refused, 06/21/25 Resident #57 made eye contact activities held her hand and applied lotion. No other documentation was provided. Visitation records were not signed to verify who provided these activities. During an observation on 06/23/25 at 10:30 A.M. Resident #57 was in bed lying on her left side, an enteral feeding pump was alarming, and the formula was not infusing. During an observation on 06/23/25 at 12:52 P.M. MDS Nurse #11 walked into Resident #57's room. The enteral feeding pump ceased beeping. MDS Nurse #11 verified that the pump was not infusing formula, that she restarted it and could not say how long the pump was beeping. During an observation 06/24/25 from 8:00 A.M. until 1:13 P.M. revealed Resident #57 lying on her left side without positioning device or pillows to relieve pressure or provide support. No staff members were observed entering Resident #57's room during this observation. An interview on 06/24/25 at 2:43 P.M. with Certified Nursing Assistant (CNA) #58 revealed that the CNAs check and change Resident #57 about every three hours or so. CNA #58 shared that Resident #57 required a Hoyer (mechanical) lift for transfer, but Resident #57 usually wasn't gotten out of bed. CNA #58 was unable to state why they did not get Resident #57 out of bed. An observation on 06/25/25 7:41 A.M. revealed Resident #57 lying on her back with legs bent at the knees without support for legs. Continued observations at 10:00 A.M., 12:30 P.M. and 4:03 P.M. revealed Resident # 57 to be in the same position. An interview on 06/26/25 at 7:52 A.M. LED #4 shared that residents who could not come to activities due to medical reasons or that preferred to stay in their rooms received one-on-one activities in their room. Some examples of one-on-one activities were puzzles, coloring pages, books, conversation, and playing music of the resident's choice. All residents were interviewed to find out what their preferred activities were, and a one-on-one visitation needs assessment was completed for residents that required one-on-one activities. Further shared that for Resident #57 it was more difficult to assess her preferences due to their lack of cognition and meaningful verbalization. We usually do one-on-one activities two to three times a week with her. For activity, we talk to her, she could nod or say yes/no responses. Lastly, she shared that the staff interacted with her while providing care, and she received visits from her husband. On 06/26/25 at 1:49 P.M. an interview with LED #4. verified that handwritten activity assessment that LED #4 provided was not dated or signed. LED #4 was unable to verify when the assessment was completed. Further verified that the handwritten assessment did not match the one in Matrix dated 04/04/25 and that the assessment in Matrix was the most accurate assessment. LED #4 shared that Resident #57 refused activities by frowning if they did not want to participate and was often asleep when activities staff approached them. LED #4 indicated that she did not think that being asleep was the same thing as refusal of the activity but could not verify if Resident #57 was reapproached while awake. An interview on 06/30/25 at10:36 A.M. with the Director of Nursing (DON) revealed that Resident #57 is a mechanical lift for transfers. The DON shared that this information was in Matrix for the CNAs to access. The DON verified that Resident #57 was not on bed rest. It was the expectation that she be dressed in street clothes and out of bed per the resident's wishes, but Resident #57 often did not want to be bothered. The DON further shared that Resident #57 got restless and could only be up in a chair for short periods of time before she became agitated. This deficiency represents non-compliance investigated under Complaint Number OH00165427.

Based on record review, interviews, and observations, the facility failed to ensure that colostomy care was provided as ordered and per resident's preference. This affected one resident (Resident #26) out of two residents reviewed for ostomy care. Findings include: Review of medical record revealed that Resident #26 was admitted on [DATE] with diagnosis of heart failure, weakness, polyneuropathy, and major depression. Review of the annual Minimum Data Set (MDS) dated [DATE] Resident #26 was alert and oriented without cognitive impairment. They were dependent upon staff for toilet hygiene, shower and bath, as well as personal hygiene. Resident #26 was always incontinent of bladder and had a colostomy for bowel movements. Review of physician's orders reveal an order dated 01/26/25 to empty the colostomy bag every shift. Report any changes noted such as changes is color of stool, amount of stool, or consistency of stool. Document emptying contents and any changes noted. Review of the comprehensive care plan updated 05/12/25 revealed that per resident's preference empty colostomy pouch, empty all stool, rinse well with water, make sure no stool is left inside the pouch. Reapply the pouch to the wafer. If it remained unclean, replace the pouch with a new one. Review of point of care history for Certified Nursing Assistant (CNA) documentation revealed instructions to the CNA, per Resident's preference, empty colostomy pouch, empty all stool, rinse well with water (make sure no stool left inside pouch) reapply pouch to wafer. If it remained unclean place a new pouch on. The documents provided indicated that the colostomy bag was emptied as follows: 05/27/25 The colostomy pouch was emptied on day shift but not night shift 05/28/25 The colostomy pouch was emptied on both shifts 05/29/25 The colostomy pouch was emptied on both shifts 05/30/25 No evidence that the colostomy pouch was emptied 05/31/25 No evidence that the colostomy pouch was emptied 06/01/25 No evidence that the colostomy pouch was emptied 06/02/25 The colostomy pouch was emptied on day shift but not on night shift 06/03/25 The colostomy pouch was emptied on both shifts 06/04/25 The colostomy pouch was emptied on day shift but not night shift 06/05/25 The colostomy pouch was emptied on night shift but not day shift 06/06/25 The colostomy pouch was emptied on night shift but no day shift 06/07/25 The colostomy pouch was emptied on day shift but not night shift 06/10/25 The colostomy pouch was emptied on both shifts 06/11/25 The colostomy pouch was emptied on day shift but not night shift 06/12/25 The colostomy pouch was emptied on day shift but not night shift 06/13/25 The colostomy pouch was emptied on both shifts 06/14/25 through 06/16/25 There was no evidence that the colostomy pouch had been emptied 06/17/25 The colostomy pouch was emptied on night shift but not day shift 06/18/25 There was no evidence that the colostomy pouch was emptied 06/19/25 The colostomy pouch was emptied on night shift but not on day shift 06/20/25 through 06/23/25 There was no evidence that the colostomy pouch was emptied 06/24/25 The colostomy pouch was emptied on night shift but not on day shift An interview on 06/23/25 at 9:30 A.M. with Resident #26 revealed hey had a colostomy bag that didn't get emptied or cleaned the way it was supposed to. Resident #26 further shared that if the colostomy pouch was not emptied often enough the pressure from gas and fecal matter kept the stoma from draining and that they became experienced nausea. They shared that when the pouch was emptied, the pouch should be taken off the wafer, rinsed and cleaned out. They stated that the CNAs often just open the bottom of the bag and don't clean the pouch out. An interview on 06/24/25 at 02:43 PM with CNA #58 revealed that they only emptied the colostomy pouch if a nurse told them to. CNA #58 reported that they just opened the bottom pouch and emptied it into another bag. Further they shared they received the usual training from the nurse about how to empty Resident #26 colostomy pouch. An observation on 06/25/25 at 03:33 P.M. of Resident #26 revealed their colostomy pouch to be puffed up with large amount of gas and more than half full of feces. Resident #26 revealed her pouch had not been emptied on night shift or day shift this day. An interview on 06/25/25 at 03:49 PM with Assistant Director of Nursing (ADON) #8 revealed Resident #26 was alert, oriented and a reliable source of information. ADON #8 verified that there was no evidence of CNA documentation for emptying the resident's colostomy bag for multiple days and shift and could not verify that the care was provided. This deficiency represents non-compliance investigated under Complaint Number OH00165230.

Based on medical record review, interview, and facility policy review, the facility failed to ensure pain medications were administered timely to ensure effective pain management. This affected one resident (#120) out of eight residents reviewed for medication administration. The facility census was 63. Findings include: Review of medical record for Resident #120 revealed an admission date of 04/15/25 with diagnoses including pathological fractures, malignant neoplasm's of bone, malignant neoplasm of bladder, protein-calorie malnutrition, urostomy, and need for assistance with personal care. Review of Resident #120's Minimum Data Sheet (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition. Resident #120 required moderate assistance for upper body activities of daily living (ADLs) and maximum assistance for lower body and mobility needs. Resident #120 also needed maximum assistance for toileting and hygiene needs. Review of care plan dated 05/01/25 revealed Resident #120 had chronic pain related to cancer and fractures. Interventions included the administration of pain medications per physician order and evaluate the effectiveness. Review of Resident #120's physician orders dated 04/15/25 revealed Morphine Extended Release 15 milligrams was ordered to be a scheduled medication administered twice daily from 7:00 A.M. to 11:00 A.M. and from 7:00 P.M. to 11:00 P.M., not as needed. Review of Resident #120's Medication Administration Record (MAR) revealed the resident did not receive any scheduled morphine doses on 04/15/25 or 04/16/25 in the morning as required. Resident #120 received one dose of Acetaminophen 325 milligrams on 04/16/25 at 6:58 A.M. for a pain score of four and a follow-up pain assessment of four with no relief. Further review of the MAR noted Resident #120 received the first dose of scheduled Morphine on 04/16/25 during the evening between 7:00 P.M. and 11:00 P.M. Further review of Resident #120's medical record revealed no documented evidence of new interventions for pain management while Resident #120 was awaiting his Morphine ER medication and while the Acetaminophen medication was ineffective. Interview with Licensed Practical Nurse (LPN) #19 on 06/24/25 at 1:45 A.M. verified the pharmacy delivers twice daily. She stated the facility also kept a variety of frequently used medications and antibiotics in stock to use if resident medications were unavailable. Those were kept in the medication storage room. Interview with LPN #23 on 06/24/25 at 2:00 P.M. revealed if there was a stat order, the pharmacy could make an emergency drop of the medication. If something was not available, the Omnicare Pharmacist would reach out to other sites for availability or notify physician of possible replacement. Interview with LPN #23 on 06/24/25 at 2:35 P.M. verified that pharmacy dropped off medications twice daily, once at 5:00 P.M. and another during the night. Interview with the Director of Nursing (DON) on 06/30/25 at 10:20 A.M. verified the missing medication in the MAR and further verified that Resident #120 did not receive his scheduled pain medication as ordered. Review of facility policy titled, Pain Management Policy revised on 01/08/25 revealed the facility will assess for pain and/or potential for pain in order for the resident to reach and maintain his/her highest practicable level of physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Review of facility policy titled Pharmacy: Delivery and Receipt of Routine Deliveries revised on 08/01/24 revealed if an item ordered by the facility is not received, the facility staff should check for a pharmacy communication slip indicating the reason a medication was not delivered. Facility should also contact pharmacy and document any delivery discrepancies. This deficiency represents noncompliance investigated under Complaint Numbers OH00163252 and OH00165427.

Based on record review, observations and interviews the facility failed to ensure insulin was dated, labeled, and discarded properly. This affected six residents (#11, #12, #16, #30, #41 and Resident #53) of 12 residents reviewed for insulin storage. Findings include: Review of medical record for Resident #11 revealed an admitted [DATE]. Diagnosis included type two diabetes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #11 dated 08/14/24 revealed the resident had impaired cognition. Review of medical record for Resident #12 revealed an admitted [DATE]. Diagnosis included type two diabetes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #12, dated 09/26/24 revealed the resident had intact cognition. Resident #12 was ordered insulin. Review of medical record for Resident #16 revealed an admitted [DATE]. Diagnosis included type two diabetes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #16 dated 09/30/24 revealed the resident had intact cognition. Resident #16 was ordered insulin. Review of medical record for Resident #30 revealed an admitted [DATE]. Diagnoses included type two diabetes, alcoholic cirrhosis of the liver and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #30 dated 08/07/24 revealed the resident had intact cognition. Resident #30 was ordered insulin. Review of medical record for Resident #41 revealed an admitted [DATE]. Diagnosis included type two diabetes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #41 dated 07/30/24 revealed the resident had intact cognition. Resident #41 was ordered insulin. Review of medical record for Resident #53 revealed an admitted [DATE]. Diagnosis included type two diabetes and hypoglycemia unspecified. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #53 dated 08/02/24 revealed the resident had impaired cognition. Resident #53 was ordered insulin. Observation of a medication cart on 10/03/24 at 8:30 A.M. revealed insulin injector pens with no date or name documented. Observations included one injector pen with no name or date, an injector pen of Aspart for Resident #11 dated 08/18/24, two injector pens of Lispro for Resident #12 not dated, and an injector pen of Lispro for Resident #41 that was not dated. Interview during observation with Licensed Practical Nurse (LPN) #840 verified the findings and stated all insulin must be labeled with names and dates. LPN #840 revealed insulin should be discarded after 28 days of the open date. Observations of a medication cart on 10/03/24 at 8:50 A.M. revealed insulin injector pens with no date or name documented. Observations included one injector pen with no name or date, an injector pen Lispro for Resident #16 not dated, an injector pen of Lispro and B insulin for Resident #30 not dated, and an injector pen of Glargine for Resident #53 not dated. Interview during observations with LPN #836 verified the findings and stated all insulin must be labeled with names and dates when opened. Review of the facility policy titled Pharmacy Services and Procedure Manual, dated 2022 noted staff should document the date opened on the label of medications with shortened expiration dates including insulin's and irrigation solutions.

Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5% (percent). A total of 24 medications were observed with two errors for a medication error rate of 8.33%. This finding affected two (Resident #39 and #41) of three residents observed for medication administration. Findings include: 1. Review of medical record for Resident #39 revealed an admitted [DATE]. Diagnoses included type two diabetes with diabetic neuropathy, unspecified, major depressive disorder, recurrent and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of physician order dated 01/24/24 revealed orders for Novolin 70-30 via flexpen, administer 45 units one time a day. Observation on 10/03/24 8:43 A.M. revealed Licensed Practical Nurse (LPN) #836 administered 45 units of Novolin to Resident #39. LPN #836 retrieved the injector pen, sanitized the tip, twisted the injector needle and turned to the dosage dial to 45 units before injecting the insulin. LPN #836 did not prime the insulin pen. Interview during observation with LPN #836 revealed they did not know they were supposed to prime the insulin pen before administering insulin. 2. Review of medical record for Resident #41 revealed an admitted [DATE]. Diagnoses included type two diabetes with foot ulcer. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of physician order dated 09/25/24 revealed orders for insulin Glargine-yfgn, administer 14 units one time a day. Observation on 10/03/24 8:11 A.M. revealed LPN #840 administered 14 units of Glargine to Resident #41. LPN #840 retrieved the injector pen, sanitized the tip, twisted on the injector needle and turned to the dosage dial to 14 units before injecting the insulin. LPN #840 did not prime the insulin pen. Interview during observation with LPN #836 revealed they were not aware of the need to prime the insulin pen. Review of the facility policy titled, Using Insulin Pen Delivery Systems, dated 2023 indicated to attach new safety pen needle, hold upright and prime the pen to remove air bubbles and to ensure the needle is open and working properly, dial to prescribed dosage, and inject fully by depressing push button.

Based on record review, observation, interview and policy review the facility failed to maintain infection control standards when administering medications. This affected one (Resident #30) of three residents reviewed for infection control during medication administration. Findings include: Review of medical record for Resident #30 revealed an admitted [DATE]. Diagnoses included type two diabetes, alcoholic cirrhosis of the liver and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #1 dated 08/07/24 revealed the resident had intact cognition. Observations on 10/02/24 at 7:55 A.M. revealed Licensed Practical Nurse (LPN) #836 administering medications for Resident #30. LPN #836 placed nine medications into her bare hand before placing them in the medication cup. Interview during the observation with LPN #836 revealed she should not have put the medication in my hand, they should go in the cup. Review of the facility policy titled, Pharmacy Services and Procedure Manual, dated 2022 revealed staff should not touch the medication when opening a bottle or unit dose package.

Based on observation of video from camera in room and record review, the facility failed to ensure call lights were kept within reach and residents were able to use if desired. This affected Resident #152, one of three sampled residents. The census was 62. Findings include: Medical record review revealed Resident #152 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, peripheral vascular disease with bilateral lower extremities wounds, hypertension, type 2 diabetes, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease, dementia, cerebral infarction, protein-calorie malnutrition, osteomyelitis (bone infection), stage IV coccyx pressure wound and neuromuscular dysfunction of the bladder. Resident #152 was severely cognitively impaired and was totally dependent on staff for all activities of daily living including bed mobility, transfers, dressing, toileting, and personal hygiene. Review of Resident #152's care plan dated 07/27/23 revealed Resident #152 was at risk for falls characterized by history of falls, injury and/or multiple risk factors related t impaired gait and mobility. The care plan included multiple interventions to meet the goal, which was to minimize risk for falls and injuries related to falls, including maintain call bell within reach and educate resident to use call bell. Observation of a video dated 09/16/23 obtained from the surveillance camera located in Resident #152's room revealed State tested Nurse Aide (STNA) #402 walked into the Resident 152's room. STNA #402 approached Resident #152, removed the call light and set it at the top of the bed, out of Resident #152's sight and reach. STNA #402 proceeded to check Resident #152 for incontinence then exit the room. Resident #152's call light remained out of the Resident 152's sight and reach.

Based on observation, record review, facility policy review and interview the facility failed to ensure timely assessments were completed, wound care was completed as ordered and adequate interventions were implemented to prevent the development of pressure ulcers for Resident #33 and Resident #51. The facility census was 58. Actual Harm occurred on 04/03/23 when Resident #33, who required extensive to total dependence from staff for activities of daily living (ADL) including bed mobility, toileting and transfers, was found to have an unstageable (full thickness tissue loss in which the actual depth of the ulcer was obscured by slough/ dead skin) pressure ulcer to his right trochanter (hip). On 04/18/23 Resident #33 was identified with another unstageable pressure ulcer to his left trochanter. There was no evidence adequate interventions and monitoring was in place to prevent the development of these wounds or to ensure the wounds were identified prior to being unstageable. Actual Harm also occurred on 05/17/23, when Resident #51 who required extensive assistance from staff for ADL care including bed mobility, transfers, and toileting, was found to have an unstageable pressure ulcer to his right buttock/ upper posterior thigh. There was no evidence adequate interventions and monitoring was in place to prevent the development of this wound or to ensure the wound was identified prior to being unstageable. This affected two residents (#33 and #51) of three residents reviewed for pressure ulcers. Findings included: 1. Review of medical record for Resident #33 revealed an admitted [DATE] with diagnoses including acute kidney failure, hypertension, cerebral infarction, and dementia. Review of care plan dated initiated on 01/24/23 (last revised on 06/07/23) revealed Resident #33 had actual impaired skin integrity related to the coccyx, right hip, and left hip areas. Interventions included to administer medication and treatments as ordered, to assess and document status of the wounds, to complete skin checks per protocol, to monitor nutritional status,to turn and reposition as indicated, and to use pressure relieving devices as indicated to bed and wheelchair. Review of Braden Scale Pressure Ulcer Risk Assessment completed on 02/24/23 by Registered Nurse (RN) #616, revealed Resident #33 was at moderate risk for developing pressure ulcers due to the following risk factors: occasionally moist, chairfast, very limited with mobility, inadequate nutrition, and a problem with friction and shear. Review of care plan, revised 03/30/23, revealed Resident #33 had an activities of daily living (ADL) self-care deficit related to impaired cognition and mobility. Interventions included assist with ADL's including dressing, grooming, toileting, and feeding, assist with one staff with bed mobility, assist with two staff with toileting, and transfer with two staff assist with a mechanical lift. Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/30/23 revealed Resident #33 was rarely and/or never understood. He required extensive assist of two staff with bed mobility and was totally dependent of two staff with transfers. He required extensive assist of one staff with toileting and was unable to ambulate. He was at risk for pressure ulcers but had no pressure ulcers at the time of the assessment. Review of nursing notes dated from 03/01/23 to 04/03/23, for Resident #33, revealed there were no skin impairments/ pressure ulcers identified to his right trochanter area prior to 04/03/23 when the Wound Nurse Practitioner (NP) #615 found an unstageable pressure ulcer during wound rounds. Review of Wound Evaluation progress note dated 04/03/23 and completed by Wound NP #615 revealed Resident #33 had a new pressure wound to his right trochanter that was found as unstageable. The wound measured 1.8 cm in length, 1.2 cm in width and unable to determine depth due to slough. The note revealed the wound contained 100 percent slough. Review of Weekly Wound Assessment V1-V5 dated 04/04/23 and completed by Former Registered Nurse (RN) #617 revealed Resident #33 had an unstageable in house acquired pressure ulcer to his right trochanter hip. The pressure ulcer measured a length of 1.8 cm, width of 1.2 cm and unable to determine depth due to the slough. The wound was described with a small amount of serous (this watery fluid) drainage and the wound bed contained yellow slough. Review of nursing notes dated, 04/04/23 to 04/18/23, revealed no evidence Resident #33 had any skin impairments/ pressure areas to his left trochanter prior to 04/18/23 when former RN #617 documented she had found the unstageable pressure ulcer. Review of Weekly Wound Assessment V1-V5 dated 04/18/23 and completed by former RN #617 revealed Resident #33 had an unstageable in house acquired pressure ulcer to his left trochanter hip that measured 7.3 cm in length, 5.5 cm in width and had a depth of .1 cm. The wound was described as having small amount of serosanguineous (containing fluid and clear fluid) drainage and the wound bed was yellow. Review of Wound Evaluation progress note dated 04/26/23 and completed by Wound NP #615 revealed Resident #33 had a left trochanter pressure ulcer that was unstageable. The note revealed the wound measured 4 cm in length, .8 cm in width and unable to determine depth due to slough. The note revealed there was a small open area in the above measurement that was .5 cm in length, .5 cm in width and 100 percent slough with surrounding dark purple tissue. Review of Treatment Administration Record (TAR) dated May 2023 revealed Resident #33's treatment order to his right trochanter was to cleanse his wound with wound cleanser, apply Xeroform, and cover with border foam three times a week and as needed. There was no documentation the treatment order was completed on 05/16/23 or 05/23/23. The treatment record also revealed Resident #33's treatment order to his left hip that was to cleanse his left hip with wound cleanser, apply Xeroform, cover with border foam every Tuesday, Thursday and Saturday. There was no documentation the treatment was completed on 05/16/23, 05/23/23, or 05/25/23. Review of physician's orders from June 2023 revealed Resident #33 had an order dated 04/04/23 to cleanse right trochanter wound with wound cleanser, apply Xeroform, and cover with border foam three times a week and as needed; and an order dated 05/03/23 cleanse left hip with wound cleanser apply Xeroform, cover with border foam every Tuesday, Thursday and Saturday on night shift and side to side turned every two hours. Review of TAR for June 2023 revealed Resident #33's treatment to his left hip was not documented as completed on 06/01/23. Review of Wound Evaluation progress note dated 06/21/23 completed by Wound NP #615 revealed Resident #33 continued to have unstageable pressure ulcers to his right and left trochanter. The right trochanter measured a length of 1.5 cm in length and a width of 1 cm with 100 percent slough. The left trochanter pressure ulcer measured 5 cm in length and 8 cm in width with also 100 percent slough. Interview on 06/28/23 at 9:14 A.M. and at 2:22 P.M. with Licensed Practical Nurse (LPN)/Wound Nurse #614 revealed she had only been the wound nurse approximately for three weeks. She verified, after review of the documentation, that Resident #33's right trochanter was found as an unstageable pressure ulcer on 04/03/23, per the Wound NP #615 notes from the wound rounds, as that was the first the wound was documented. She also verified Resident #33's left trochanter pressure ulcer was also found as unstageable on 04/18/23. She verified Resident #33 required extensive to total dependence of staff for his bed mobility, toileting, and transfers. She verified the wounds should have been detected prior to being found unstageable. She verified the identified treatments were not documented as completed on the TAR for May 2023 and June 2023 as noted above. She verified if the treatments were not documented on the TAR, then most likely they were not done. She revealed she completed all the wounds treatments every Wednesday on the wound rounds. When she first started, she noted several times when treatments were not completed as ordered. She stated that when went to complete the treatment, the same treatment was in place that she had completed days prior. She verified the floor nurses were not doing the treatments as ordered. Observation on 06/28/23 at 11:41 A.M. of wound care completed by LPN/ Wound Nurse #614 and Wound NP #615 revealed Resident #33's right trochanter had an unstageable pressure ulcer that measured 1.5 cm in length, one cm in width and contained 100 percent slough with a small amount of serosanguineous drainage. The observation revealed Resident #33's left trochanter was an unstageable pressure ulcer that measured three cm in length, four cm in width and contained in the wound bed 100 percent slough. The treatment was completed according the the current order. Interview on 06/28/23 at 11:41 A.M. with Wound NP #615 verified, upon review of her notes, that Resident #33's pressure ulcer to his right trochanter was found on wound rounds as unstageable on 04/03/23. She revealed Resident #33's left trochanter pressure ulcer, that she evaluated on 04/26/23, was previously identified, according to the documentation on 04/18/23, as unstageable. The facility was unable to provide evidence adequate interventions had been implemented and were in place prior to the developed and failed to ensure skin monitoring was being completed to prevent the development of these wounds and to ensure the wounds were identified prior to being unstageable 2. Review of medical record for Resident #51 revealed an admitted [DATE] with diagnoses including peripheral vascular disease, failure to thrive, lymphedema, chronic kidney disease, heart failure and diabetes. Review of care plan dated 06/29/21 revealed Resident #51 had a self-care deficit. Interventions included Resident #51 required staff assistance with dressing, grooming, and toileting, bed mobility of one staff assist, toileting of two staff assist, and transfers with two staff assist. Review of care plan dated 06/29/21 (with a revision date of 08/02/22) revealed Resident #51 had a potential for skin breakdown related to impaired mobility and incontinence. The interventions included to turn and repositioned as indicated, apply pressure relieving devices as indicating including ROHO cushion and air mattress, and to complete skin assessments per protocol. Review of annual MDS 3.0 assessment, dated 03/09/23 revealed Resident #51 had intact cognition. He required extensive assist of one person with bed mobility, transfers, dressing, toileting, and personal hygiene. He was unable to ambulate. Review of Wound Evaluation progress note dated 03/29/23 and completed by Wound Nurse Practitioner (NP) #615 revealed Resident #51 had moisture associated skin damage (MASD) to his left buttock. There were no documented concerns regarding his right buttock/ posterior thigh area. Review of physician's orders from 01/01/23 to 06/28/23 revealed an order dated 05/17/23, that was discontinued on 06/14/23, to cleanse wound to right buttocks with wound cleanser, apply Xeroform, cover with bordered foam and change daily. There was another order dated 06/14/23 to apply triad to right buttocks/ upper thigh area, cover with border foam and change daily and as needed, turn and reposition every two hours, and apply pressure reducing cushion to wheelchair. There were no other wound care treatment orders prior to 05/17/23 for his right buttock/ upper posterior thigh region. Review of Wound Evaluation progress note dated 05/17/23 and completed by Wound NP #615 revealed Resident #51 had a new unstageable pressure ulcer to his right buttock/ posterior upper thigh that measured a length of five centimeter (cm), width of 2.5 cm and a depth that was unable to be determined due to slough. The note revealed the wound had serosanguinous drainage and contained 100 percent slough. Review of Weekly Wound Assessment V1-V5 dated 05/17/23 and completed by former RN #617, revealed Resident #51 had an unstageable in house acquired pressure ulcer to his right buttock that measured a length of 5 cm, width 2.5 cm and the depth was unable to be determined as there was slough. The assessment revealed the date the wound was identified was 12/07/22 but subsequent interview with Licensed Practical Nurse (LPN)/ Wound Nurse #614 verified this was inaccurate as the date should have been 05/17/23. The assessment revealed the wound had a small amount of serosanguinous drainage and the wound bed was yellow and red. Review of quarterly MDS 3.0 assessment, dated 06/09/23 revealed Resident #51 had intact cognition and required limited assist of one person with bed mobility and extensive assist of one person with transfers, toileting, and personal hygiene. He was unable to ambulate. Review of Wound Evaluation progress note dated 06/14/23 and completed by Wound NP #615 revealed on assessment Resident #51's unstageable pressure ulcer to his right buttock/ upper thigh was healed with 100 percent epithelial tissue. Review of Wound Evaluation progress note dated 06/21/23 and completed by Wound NP #615 revealed Resident #51's wound to his right buttock/ upper thigh had reopened and was classified as a Stage III (full thickness skin loss in which adipose tissue (fat) is visible in the ulcer) measuring a length of 16 cm, width of eight cm, and a depth of 0.1 cm. The note revealed he had scattered open areas and 40 percent of the scattered areas had epithelia tissue with purple discoloration. Review of Weekly Wound Assessment V1-V5 dated 6/21/23 and completed by Licensed Practical Nurse (LPN)/ Wound Nurse #614 revealed Resident #51 had an in-house acquired Stage III pressure ulcer to his right buttock/ upper posterior thigh that measured a length of 16 cm, width of eight cm, and was 0.1 cm in depth. The assessment noted the wound had moderate amount of serosanguinous drainage and the wound bed was red. Review of Review of Wound Evaluation progress note dated 06/28/23 and completed by Wound NP #615 revealed Resident #51 continued to have a Stage III pressure ulcer to his right buttock/ posterior upper thigh area that measured 11 cm in length, two cm in width and 0.1 cm in depth. The note revealed he had 100 percent granulated tissue to the scattered open areas with moderate serosanguinous drainage. Interview on 06/28/23 at 1:11 P.M. with Wound NP #615 verified Resident #51, on 05/17/23 during wound rounds was found to have an unstageable pressure ulcer to his right buttock/ posterior thigh region. She revealed she did not have in her notes that he had any skin issues to his right buttock just his left from 01/01/23 to 05/17/23. She revealed the unstageable pressure ulcer resolved on 06/14/23 but reopened and was found at a Stage III on 06/21/23. Interview on 06/28/23 at 2:22 P.M. with LPN/ Wound Nurse #614 revealed she had only been the wound nurse approximately for three weeks. She revealed upon review of the Weekly Wound Assessment V1-V5 dated 05/17/23 Resident #51's pressure ulcer to his right buttock/ posterior thigh area was found as an unstageable. She verified that the date on the assessment was dated as 12/07/22 as the date when identified but she revealed this had to be inaccurate as on review Resident #51 had not received any treatments for his right buttock/ posterior thigh region from 01/01/23 to 05/17/23 and/or that she had any documentation he had any issues. She also revealed he had a pressure ulcer to his left buttock that was identified on 12/07/22 and felt the previous nurse had mixed up the dates on the assessments. She verified that Resident #51 needed staff assistance with his activities of daily living including with toileting as he was incontinent. She verified since he required assistance most likely his pressure ulcers should have been detected at a prior stage than unstageable/ Stage III. She verified the unstageable pressure ulcer healed on 06/14/23 but then was found at a Stage III on 06/21/23. Observation on 06/29/23 at 10:28 A.M. of wound care for Resident #51 completed by LPN #607 revealed Resident #51 had a Stage III to his right buttock that was red. She applied the treatment as ordered. There was no evidence adequate interventions were in place prior to the development of the unstageable pressure ulcer. In addition, there was no evidence of ongoing monitoring to prevent the development of this wound or to ensure the wound was identified prior to being unstageable. During the onsite investigation, the facility identified 19 residents, Resident #2, #3, #4, #5, #7, #11, #14, #17, #27, #33, #34, #36, #37, #47, #48, #49, #51, #57, and #58 with pressure ulcers. Review of facility policy labeled, Skin and Wound Care Best Practices dated 06/10/22 revealed the purpose of the policy was to provide evidence based preventative skin care and wound treatment to prevent unavoidable skin complications. The policy revealed prevention included provide pressure reduction and redistribution for those at risk including reposition at a frequency determined by risk assessment. The policy revealed educating the nursing aide staff on the importance of basic care such as bathing, repositioning, toileting, skin care and nutrition. This deficiency represents non-compliance investigated under Master Complaint Number OH00143562 and Complaint Number OH00143520.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, facility policy and procedure review and interview the facility failed to prevent second degree [CONDITION(S)] to Resident #37. Actual Harm occurred on 06/01/22 when Resident #37, who had a diagnosis of dementia, impaired cognition and required set up assistance for drinking, was served hot coffee, with a temperature of 160 degrees Fahrenheit during a supervised activity program which was spilled on his inner thighs resulting in second degree [CONDITION(S)] (burn involves the first two layers of skin and may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin which required daily wound care treatments). The resident sustained increased pain from the [CONDITION(S)] requiring narcotic analgesic medication ([MEDICATION(S)]) and the [CONDITION(S)] subsequently became infected and required antibiotic treatment. This affected one resident (#37) of three residents reviewed for accident hazards. Findings include: Review of the medical record for Resident #37 revealed an admitted [DATE] with diagnoses including dementia, adult failure to thrive, repeated falls, hypertension, depression, [CONDITION(S)], muscle weakness, difficulty in walking and malignant neoplasm of prostate. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/12/22 revealed Resident #37 had impaired cognition, required extensive assistance from one staff for bed mobility, transfers, dressing, and personal hygiene and required staff set-up help only for eating and drinking. Review of Resident #37's progress note, dated 06/03/22 revealed the nurse was notified on 06/01/22 Resident #37 had spilled coffee on himself while sitting in the activities room and attempting to set his coffee on the table. The resident was assessed immediately after and the area was red and painful to the touch. A new order was implemented for ice to the inner thigh daily. Review of the physician's order, dated 06/01/22 revealed an order to apply ice to right upper thigh three times per day for 30 minutes. On 06/03/22 a nursing note revealed Licensed Practical Nurse (LPN) #216 and Nurse Practitioner (NP) #705 assessed the resident and noticed the resident's inner thigh had an open area where a blister had burst and two other intact blisters to the right and left inner thighs. New orders were implemented and the resident's family was updated. Review of additional physician's orders for Resident #37 for June 2022 following the injuries revealed orders to rinse right inner thigh with normal saline, pat dry, apply Xeroform cover with ABD and paper tape, change daily, cleanse right upper thigh with wound cleanser, apply Xeroform and [MEDICATION(S)], ABD Kerlix and ACE bandage to keep dressing in place, change daily and cleanse left upper thigh with wound cleanser, apply Xeroform then calcium alginate on top, apply ABD, Kerlix (no tape), check placement ever shift. The resident also had orders for the antibiotic, [MEDICATION(S)], 500 milligram (mg) two times per day for burn and the narcotic analgesic, [MEDICATION(S)] five mg, one tablet every four hours for pain. Review of the medication administration record revealed the resident received the [MEDICATION(S)] for pain associated with the [CONDITION(S)]: On 06/06/22 at 5:00 P.M. for a pain rated a seven out of 10 (on a scale of one to 10). On 06/07/22 at 5:00 A.M., 9:00 A.M., 1:00 P.M., 5:00 P.M., and 9:00 P.M. for pain rated a five out of 10. On 06/08/22 at 1:00 A.M., 5:00 A.M., 9:00 A.M., 1:00 P.M., 5:00 P.M., and 9:00 P.M. for pain rated a five out of 10. On 06/09/22 at 1:00 A.M., 5:00 A.M., 9:00 A.M., and 1:00 P.M. Review of Resident #37's skin assessment, dated 06/06/22, revealed [CONDITION(S)] on Resident #37's right thigh measuring 27 centimeters in length by nine centimeters width containing a small amount of drainage and left thigh area measuring 10 centimeters in length by 5 centimeters width with no drainage. Review of Resident #37's progress notes, dated 06/12/22 at 6:38 P.M. revealed Resident #37's wound had a slight odor and a wound culture was ordered and obtained. Review of Resident #37's progress notes, dated 06/16/22, revealed Resident #37's wound culture was positive for E-Coli and proteus mirabilis. The nurse practitioner and family were notified and the resident was prescribed the antibiotic, [MEDICATION(S)] 875-125 mg tablet once every 12 hours for seven days. Review of Resident #37's progress notes, dated 06/16/22 revealed Resident #37 returned from an appointment with new instructions for burn treatments. Treatments were to be completed daily and included to wash wound with warm water and soap (Dial) with a clean washcloth, try to wash off all the crusty material and drainage as it would prevent healing and could cause infection. Saturate gauze with [MEDICATION(S)]. Apply in a single layer. Cover the burn wound with ABD pad, do not leave open to air, wrap in ACE bandages. On 08/09/22 at 4:46 P.M. interview with Life Enrichment Director #700 revealed on 06/01/22 Resident #37 was attending an activity where Life Enrichment Director #700 was serving hot coffee, tea, and cocoa to residents. Resident #37 went to take a sip of his coffee. The coffee was hot so Resident #37 went to set it down but missed the table. The coffee then spilled onto Resident #37's lap, causing Resident #37 to yell out in pain. Life Enrichment Director #700 immediately took Resident #37 out to the nurse (LPN #216) so the resident could be assessed. Life Enrichment Director #700 further reported hot beverages should not be served to residents if more than 150 to 160 degrees Fahrenheit and stated the coffee served to Resident #37 on this date was 160 degrees Fahrenheit. On 08/15/22 at 9:59 A.M. attempts to reach LPN #216 for interview were unsuccessful. On 08/15/22 at 10:00 A.M. interview with Nurse Practitioner (NP) #705 revealed a nurse contacted him and sent a photo of Resident #37's thigh to him on 06/01/22 at approximately 4:00 P.M. Resident #37 had a small reddened area around his right upper thigh and the area was intact. NP #705 reported the reddened area appeared superficial and gave orders to ice the area. On 06/03/22 NP #705 went to see Resident #37 and assess the area-which he stated had developed into a second-degree burn on both the resident's inner thighs. NP #705 reported new orders were implemented and stated [CONDITION(S)] could take a couple of days to develop. On 08/15/22 at 10:05 A.M. interview with LPN #205 revealed LPN #205 was Resident #37's nurse on 06/01/22 but stated she was on break at the time of the incident. LPN #205 reported Resident #37 was immediately assessed by LPN #216. When LPN #205 returned to work, a virtual visit was completed with Nurse Practitioner (NP) #705 and Resident #37's family was contacted. LPN #205 reported she also assessed the area, which was a little red in one spot with no blistering. On 06/03/22 a State tested Nurse Aide (STNA) alerted LPN #205 of a change in Resident #37's skin and when LPN #205 assessed, the skin was off like a burn peel. The physician and family were notified. On 08/09/22 at 3:29 P.M. interview with the Director of Nursing (DON) verified Resident #37 was burned as a result of spilled coffee to his legs. The DON revealed following the incident all staff were educated the temperature of hot beverages should not exceed 135 to 155 degrees Fahrenheit. The DON also verified there was no documentation showing Resident #37 was assessed between 06/01/22 following the incident and 06/03/22 when the staff documented the presence of second degree [CONDITION(S)]. The DON revealed the expectation would be for the resident's skin to be checked at least once per shift. Review of facility policy titled Hot Beverage Service Policy, revised 10/22/18 revealed the community would provide hot beverages to residents in a manner that promotes safety and meal satisfaction. Review of the facility undated Resource for Hot Beverages revealed all hot liquids had the potential to burn residents, and hot liquids at 156 degrees for one second could cause a third-degree burn. The resource further stated hot liquids served directly to residents should be between 135 and 155 degrees Fahrenheit. The deficiency was corrected on 06/04/22 after the facility implemented the following corrective actions: a. On 06/01/22 Resident #37 was assessed, the NP and family were notified, and new orders were obtained for ice to affected area(s) three times per day. b. On 06/03/22 Resident #37's [CONDITION(S)] were reassessed, a weekly wound assessment was completed, and Resident #37 was seen by NP #705. The family was updated. c. On 06/03/22, like residents were identified and skin assessments were completed on all residents with no negative findings. d. Beginning on 06/03/22 the dietary department began providing any hot water and/or coffee to the activities department for activities. e. On 06/03/22 the Regional Director of Clinical Services provided education to the DON to ensure the 24-hour summary and order line listing would be pulled and reviewed to ensure new orders and possible reportable events would be identified. f. On 06/03/22 the Administrator/DON initiated review of incident and accident reports and progress notes daily for 14 days to ensure any resident with skin integrity issues would have a wound evaluation completed. g. On 06/03/22 in-service training was provided by the DON/designee to dietary department staff to ensure all hot liquids would be served at appropriate temperatures. h. On 06/03/22 in-service training was provided by the Administrator/designee to the dietary department to ensure any hot beverages served to activities would be tempted and would not exceed 155 degrees Fahrenheit. i. On 06/03/22 in-service training was provided by the DON/designee to all licensed staff to ensure all incidents would be documented timely and wound assessments would be initiated timely. j. On 06/03/22 the Administrator/designee began audits to ensure new orders were identified for five days per week for four weeks. The results would then be forwarded to the Quality Assurance and Performance Improvement (QAPI) committee for further review and recommendations. k. On 06/03/22 the DON/designee implemented a plan to review incident and accident reports and progress notes weekly for four weeks, followed by monthly for two months, to ensure skin integrity issues would be identified and have a weekly wound assessment in place. The results would then be forwarded to the QAPI committee for further review and recommendations. l. On 06/03/22 the Administrator/designee implemented a plan to audit temperature logs weekly for four weeks, followed by monthly for two months, to ensure hot beverages served to activities would be tempted and not exceed 155 degrees Fahrenheit. The results would then be forwarded to the QAPI committee for further review and recommendations. This deficiency substantiates Complaint Number OH 491 and Complaint Number OH 493.

Based on observation, record review and interview the facility failed to ensure fall prevention interventions were in place to prevent falls for Resident #71 and Resident #14. Actual Harm occurred on 10/12/19 when Resident #71, who had a history of [REDACTED]. The resident was assessed to have a laceration to his head which required staples. There was no evidence prior to the fall the facility had adequately assessed the resident's safety needs and implemented individualized and comprehensive fall interventions to prevent the fall from occurring. This affected two residents (#71 and #14) of five residents reviewed for falls. Findings include: 1. Review of the facility incident tracking log revealed Resident #71 sustained falls on 09/04/19, 09/06/19, 09/17/19, 09/27/19, 09/28/19, 10/04/19, 10/06/19, 10/08/19, 10/12/19 and 10/15/19. Record review for Resident #71 revealed the resident was admitted to the facility from 08/30/19 to 10/18/19, and was hospitalized from [DATE] to 09/26/19. The resident had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/06/19 revealed the resident had severe cognitive impairment and required extensive assistance from staff for transfers and locomotion. Review of the resident's plan of care revealed he was at high risk for falls with interventions including a mat at bedside, nonskid socks when out of bed, checks every two hours, and one-to-one monitoring for 24 hours (which was initiated on 09/27/19). Review of the resident's physician orders [REDACTED]. Review of the fall investigations for Resident #71 revealed the following: On 09/04/19 Resident #71 had an unwitnessed fall. The resident was found lying down on the floor. The resident stated he was trying to walk around the room. The facility intervention included removing the resident's walker from the room in order to prompt him to call for help. On 09/06/19 Resident #71 had an unwitnessed fall. The resident was found sitting on his buttocks. The facility intervention included applying nonskid socks and placing his bed in the lowest position. On 09/17/19 Resident #71 had an unwitnessed fall. The resident was found lying at the side of the bed. The resident was combative and agitated, grabbed at staff, and pulled out his tube feed pump. The resident was sent to the hospital (progress notes revealed he was admitted with acute kidney injury and [MEDICAL CONDITION]). The investigation did not note any consideration or application of new interventions to prevent similar falls in the future (however, the facility did readmit the resident to a room closer to the nursing station upon his return on 09/26/19). On 09/27/19 Resident #71 had a witnessed fall. The resident was witnessed sliding off the bed to the floor. The resident grabbed and hit staff during the event. The resident was placed on one-to-one observations for 24 hours. The investigation did not note any consideration or application of new interventions to prevent similar falls in the future. On 09/28/19 Resident #71 had an unwitnessed fall. The resident was found lying on the floor with his head resting on a bed rail. The resident grabbed and fought nursing staff during the event. The resident complained of a headache. Facility interventions included a new order for pain medications and chest x-ray (the facility also ordered a fall-mat on 09/29/19). On 10/04/19 Resident #71 had an unwitnessed fall. The resident was found lying on the floor. Interventions included assessment and assistance back to bed. The investigation did not note any consideration or application of new interventions to prevent similar falls in the future. On 10/06/19 Resident #71 had an unwitnessed fall. The resident was found lying on the floor. He said he was trying to go home. Interventions included assisting the resident to a wheelchair and placing him in a common area for supervision. The investigation did not note any consideration or application of new interventions to prevent similar falls in the future. On 10/08/19 Resident #71 had a witnessed fall. The resident stood from his wheelchair in the dining room and fell . He was confused and combative. Interventions included providing a sitter throughout the remainder of the work shift and medicating him with as-needed anxiety medication. The investigation did not note any consideration or application of new interventions to prevent similar falls in the future. On 10/12/19 Resident #71 had an unwitnessed fall. The resident was found lying on the floor with a new 1.5 centimeter-long laceration on his head. The resident resisted care by swinging his arms. He was sent to the emergency room . A progress note following this event noted he returned from the emergency room the same date with three staples applied to the wound. The investigation did not note any consideration or application of new interventions to prevent similar falls in the future. Hospital documentation from 10/12/19 revealed Resident #71 had an unwitnessed fall in the nursing home and suffered a 2 centimeter-long laceration on the back of his head. It noted the bleeding was controlled, and the resident was incoherent with words. In addition to the above falls, Resident #71's progress notes identified he had a witnessed fall on 10/13/19 when he was seen attempting to self-ambulate in the room using a bedside table, which broke under his weight. Staff caught him and assisted him to bed. The facility did not furnish an investigation for this fall. Progress notes stated this occurred when the family left him alone in the room despite him needing constant supervision. Review of Resident #71's record revealed no further documentation, plan, or orders for increased supervision aside from temporary placements on one-to-one care. On 10/15/19 Resident #71 had an unwitnessed fall. The resident was found lying on the floor. Interventions included assessing the resident and placing him back in bed. The investigation did not note any consideration or application of new interventions to prevent similar falls in the future. On 11/06/19 at 10:02 [NAME]M. interview with the Director of Nursing (DON) and Administrator revealed Resident #71 was very impulsive and cognitively impaired. During the interview the DON and Administrator verified Resident #71 sustained a fall with injury on 10/12/19. The DON and Administrator verified the facility had not investigated all of the resident's falls or completed comprehensive assessments to ensure individualized and effective interventions were implemented to prevent falls including a fall with injury. The facility interventions that were initiated were not sufficient/effective to prevent a total of 11 falls over the course of the resident's 43 days in the facility, including one that resulted in injuries that required a transfer to the hospital emergency room for staples. 2. Review of Resident #14's MDS 3.0 assessment, dated 09/03/19 revealed the resident exhibited severe cognitive impairment and required extensive assistance from staff for transfers. Record review revealed Resident #14 sustained two falls on 10/02/19. Record review revealed the resident was transferred to the hospital following the falls and returned the next day. Record review for Resident #14 revealed the resident had a current physician order, dated 10/04/19 for a perimeter mattress. There was no evidence the resident had refused the perimeter mattress or that there were any complications in its application. On 11/06/19 at 11:16 [NAME]M. an observation revealed Resident #14 did not have a perimeter mattress on her bed. On 11/06/19 at 11:42 [NAME]M. interview with the DON verified Resident #14 did not have a perimeter mattress in place as ordered. Review of the facility fall prevention policy, dated 04/2010 revealed the interdisciplinary team was to identify and document residents' risk factors for falls and address modifiable risk factors to minimize the risk factors that were not modifiable. The facility was to aggressively manage risks for falls. Staff response to each resident fall included reviewing the strategies for fall prevention, establish new interventions and place them on the fall care plan. Safety checks were to be implemented if the resident was at very high risk for another fall. This deficiency substantiates Master Complaint Number OH 979 and Complaint Number OH 967.

The following deficiency represents an incident of Past Non-Compliance that was subsequently corrected prior to this survey. Based on medical record review, interview of family, law enforcement and staff, video recording review, and facility abuse policy review, the facility failed to implement the facility policy to ensure a resident was free from physical abuse by a facility staff member during provision of care. This resulted in Immediate Jeopardy for Resident #39 when State tested Nurse Aide (STNA) #1 threw a blanket over the resident's head and face during care, left her unclothed in bed and hit her in the face with a pillow three times. This affected one of 14 residents on the second floor west unit who were cared for by STNA #1 on the night of 11/05/17, and placed the other 13 residents at risk for imminent harm. On 11/13/17 at 3:12 P.M. the Director of Nursing (DON), Regional Nurse Consultant (RNC) #7 and Corporate Vice President of Operations #8 were notified that Immediate Jeopardy began on 11/05/17 at 9:30 P.M. when STNA #1 threw a blanket over Resident #39's head and face, left her in bed unclothed and picked up a pillow and hit her in the face three times. These actions were recorded on a video camera that had been placed in the room by the family three to four weeks prior to the incident. The Immediate Jeopardy remained ongoing until 11/06/17 at 7:00 A.M. when STNA #1 left the building at the end of the working shift. STNA #1 did not return to the facility. Although the Immediate Jeopardy was removed on 11/06/17, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until the deficiency was corrected on 11/11/17 when the facility completed the following corrective actions. On 11/08/17 at approximately 1:00 P.M. the DON assessed Resident #39 who was not in distress and had no apparent signs/symptoms of abuse. On 11/08/17 at approximately 1:30 P.M. the Administrator called the local police department to notify them a crime had occurred as required. The Administrator notified the dispatcher. On 11/08/17 at 2:00 P.M. the Administrator notified the physician of Resident #39 via telephone of the occurrence. On 11/08/17 at 2:01 P.M. the Administrator initiated an investigation into the incident of alleged abuse and initiated a self-reported incident report to the state agency. On 11/08/17 at 2:15 P.M. the Administrator called the alleged perpetrator, STNA #1, and notified her of suspension pending investigation. On 11/08/17 at 2:30 P.M., the DON, Assistant DON and Nursing Manager #5 initiated education for staff that included the abuse policy, caregiver burnout and working with residents with impairment/dementia. They provided education to 101 staff members that included registered nurses (RN), licensed practical nurses (LPN), STNAs, housekeeping, activities, social workers, licensed physical and occupational therapists, physical and occupational therapy assistants, dietary, admissions, receptionists, maintenance, payroll, business office, department heads and administration. 100% of all staff education was completed on 11/09/17, either in person or via phone. On 11/08/17 from 2:45 P.M. until 4:30 P.M., 39 alert and oriented residents were interviewed by Social Worker #3 and Business Office Manager #4 in regard to concerns of abuse by STNA #1 or any other abuse/care concerns. Forty-five residents who were not able to be interviewed were assessed head to toe by the Assistant DON and Nursing Manager #5 to identify any skin concerns to include discolorations, bruises or trauma with no findings. On 11/09/17 interviews were completed by RNC#7, Corporate Vice President of Operations #8, the Administrator, the DON, the Assistant DON and Nursing Manager #5 of all 101 staff regarding knowledge of the incident on 11/05/17 involving Resident #39 . All staff indicated no knowledge or witness of the incident. Between 11/08/17 and 11/09/17, the DON and RNC #7 reviewed and revised Resident #39's care plan relative to ADL care. The DON, Minimum Data Set (MDS) Nurse #6, and the Assistant DON reviewed all other residents to identify any resident at risk to be abused due to cognitive impairment or exhibiting behaviors. Residents identified as at risk had care plans reviewed and revised by the interdisciplinary team. From 11/09/17 to 11/11/17 all 101 staff were tested by the Administrator, Social Worker #3 and Human Resources Staff #10 and given a competency quiz on resident abuse and neglect. Quizzes were administered on paper and via phone. Incorrect answers resulted in re-education. On 11/09/17 STNA #1 was terminated from employment at the facility. Findings include: Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of progress notes dated 09/15/17, 10/04/17, 11/07/17, and 11/11/17 revealed Resident #39 resisted care and had combative behaviors during care. Review of a video provided by the family on 11/13/17, clearly showed on 11/05/17 at 9:30 P.M. STNA #1 provided personal care to Resident #39. There was no audio, but it appeared that Resident #39 was yelling while STNA #1 changed her brief. STNA #1 turned and positioned Resident #39 in a hurried, rough manner. STNA #1 then attempted to put a hospital gown on Resident #39. When Resident #39 resisted, STNA #1 took a blanket and threw it over Resident #39's face and head and walked away from the bed. It was not clear if Resident #39's body was uncovered. STNA #1 returned to the bed, picked up a pillow and struck Resident #39 three times in the face/head with the pillow. In an interview on 11/13/17 at 8:52 A.M. the facility Administrator stated that on 11/08/17 at approximately 12:30 P.M. to 1:00 P.M., two family members of Resident #39 came to him with concerns about physical abuse. The family stated they witnessed the abuse on video from a camera they had placed in Resident #39's room. The Administrator stated that he saw the video and it showed that on 11/05/17 at 9:30 P.M. STNA #1 entered the room and provided care to Resident #39. The Administrator stated STNA #1 pushed and pulled Resident #39 roughly. STNA #1 attempted to put a hospital gown on Resident #39 while she was in bed, and could not get the gown on her. STNA #1 then covered Resident #39, who was in her underwear. The Administrator said that STNA #1 returned to the bed, approached Resident #39, picked up a pillow and hit Resident #39 twice with the pillow. The Administrator stated Resident #39's family members took the video to the local police department who issued a warrant for the arrest of STNA #1. In an interview on 11/15/17 at 8:25 A.M. the Administrator stated that at the time of the interview on 11/13/17 he remembered STNA #1 struck Resident #39 twice. In an interview on 11/13/17 at 9:40 A.M. RNC #7 stated the facility was notified of the allegation of abuse by the family on 11/08/17. RNC #7 stated that after notification she viewed the video of the incident which was provided by the family. RNC #7 stated that the family told her the incident occurred on 11/05/17 at 9:30 P.M. RNC #7 stated the video revealed STNA #1 provided care to Resident #39 in a rough manner. When Resident #39 refused to put on the hospital gown, STNA #1 threw a blanket over the resident's head and face and walked away. STNA #1 returned to the bed, picked up a pillow and hit Resident #39 in the face/head three times with the pillow. RNC #7 stated this was abuse. On 11/13/17 at 12:18 P.M. an interview was conducted with Detective #1 from the local police department who handled the case. Detective #1 stated the initial police visit and report were handled by a patrolman, who was not available for contact. Detective #1 stated after review of the video, the police department issued a warrant for the arrest of STNA #1. Detective #1 stated the police department was not able to locate STNA #1 and the case was given to the detective bureau to handle. Detective #1 stated a warrant was issued for the arrest of STNA #1 for assault of a functionally impaired person, a fourth degree felony. On 11/13/17 at 1:04 P.M. the surveyor met with Resident #39's two family members. Family Member (FM) #2 stated they placed the camera in Resident #39's room three to four weeks prior to the incident on 11/05/16. FM #2 showed the surveyor the video of the incident (on her phone) that occurred on 11/05/17. FM #2 stated she removed the disc from the video camera on 11/06/17 and reviewed it on 11/07/17. On 11/07/17, FM #2 and FM #3 took it to the local police department who reviewed it and told the family it showed enough to arrest STNA #1. On 11/08/17 at 12:30 P.M. the family notified the facility of the incident and showed the video to the Administrator and the DON. On 11/15/17 from 2:48 P.M. to 3:15 P.M., interviews with STNAs #20, #21, #22, #23, and #24 regarding abuse, neglect, misappropriation revealed they had all received in-service education in regard to abuse one week prior and took a quiz on the abuse education. They were not aware of any incident of abuse in the facility prior to the incident that occurred on 11/05/17. They stated they were interviewed by management and gave a statement in regard to the incident on 11/05/17. On 11/15/17 from 3:46 P.M. to 4:06 P.M., interviews with LPNs #25, #26 and #27 revealed all were knowledgeable of actions to take in regard to abuse, neglect, misappropriation, reporting, and staff burnout. They stated they were interviewed by management about STNA #1 and the incident on 11/05/17 and were not aware of it until then. LPN #25 and #26 did not know STNA #1. LPN #27 stated she met STNA #1 for the first time on 11/05/17 and did not observe STNA #1 treating any resident badly. They all stated they received in-service education on abuse and took a quiz. Review of the facility policy for Resident Abuse, last revised 03/03/17, revealed the facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also included the deprivation by an individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental and psychosocial well-being. It included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology, misappropriation of resident property, exploitation, involuntary seclusion, injuries of unknown origin source and physical and chemical restraints. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury. Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. This deficiency substantiates Complaint Number OH 517.

The following deficiency represents an incident of Past Non-Compliance that was subsequently corrected prior to this survey. Based on medical record review, interview of family, law enforcement and staff, video recording review, and facility abuse policy review, the facility failed to prevent physical abuse to one resident (Resident #39) by State tested Nurse Aide (STNA) #1. This resulted in Immediate Jeopardy for Resident #39 when STNA #1 placed the resident in imminent harm when she threw a blanket over the resident's head and face during care, left her unclothed in bed and hit her in the face with a pillow three times. This affected one of 14 residents on the second floor west unit who were cared for by STNA #1 on the night of 11/05/17, and placed the other 13 residents at risk for imminent harm. On 11/13/17 at 3:12 P.M. the Director of Nursing (DON), Regional Nurse Consultant (RNC) #7 and Corporate Vice President of Operations #8 were notified that Immediate Jeopardy began on 11/05/17 at 9:30 P.M. when STNA #1 threw a blanket over Resident #39's head and face, left her in bed unclothed and picked up a pillow and hit her in the face three times. These actions were recorded on a video camera that had been placed in the room by the family three to four weeks prior to the incident. The Immediate Jeopardy remained ongoing until 11/06/17 at 7:00 A.M. when STNA #1 left the building at the end of the working shift. STNA #1 did not return to the facility. Although the Immediate Jeopardy was removed on 11/06/17, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until the deficiency was corrected on 11/11/17 when the facility completed the following corrective actions. On 11/08/17 at approximately 1:00 P.M. the DON assessed Resident #39 who was not in distress and had no apparent signs/symptoms of abuse. On 11/08/17 at approximately 1:30 P.M. the Administrator called the local police department to notify them a crime had occurred as required. The Administrator notified the dispatcher. On 11/08/17 at 2:00 P.M. the Administrator notified the physician of the abuse incident involving Resident #39 via telephone. On 11/08/17 at 2:01 P.M. the Administrator initiated an investigation into the incident of alleged abuse and initiated a self-reported incident report to the state agency. On 11/08/17 at 2:15 P.M. the Administrator called the alleged perpetrator, STNA #1, and notified her of suspension pending investigation. On 11/08/17 at 2:30 P.M., the DON, Assistant DON and Nursing Manager #5 initiated education for staff that included the abuse policy, caregiver burnout and working with residents with impairment/dementia. They provided education to 101 staff members that included registered nurses (RN), licensed practical nurses (LPN), STNAs, housekeeping, activities, social workers, licensed physical and occupational therapists, physical and occupational therapy assistants, dietary, admissions, receptionists, maintenance, payroll, business office, department heads and administration. All staff education was completed on 11/09/17, either in person or via phone. On 11/08/17 from 2:45 P.M. until 4:30 P.M., 39 alert and oriented residents were interviewed by Social Worker #3 and Business Office Manager #4 in regard to concerns of abuse by STNA #1 or any other abuse/care concerns. Forty-five residents who were not able to be interviewed were assessed head to toe by the Assistant DON and Nursing Manager #5 to identify any skin concerns to include discolorations, bruises or trauma with no findings. On 11/09/17 interviews were completed by RNC#7, Corporate Vice President of Operations #8, the Administrator, the DON, the Assistant DON and Nursing Manager #5 of all 101 staff regarding knowledge of the incident on 11/05/17 involving Resident #39 . All staff indicated no knowledge or witness of the incident. Between 11/08/17 and 11/09/17, the DON and RNC #7 reviewed and revised Resident #39's care plan regarding ADL care. The DON, Minimum Data Set (MDS) Nurse #6, and the Assistant DON reviewed all other residents to identify any resident at risk for abuse due to cognitive impairment or exhibiting behaviors. Residents identified as at risk had care plans reviewed and revised by the interdisciplinary team. From 11/09/17 to 11/11/17 all 101 staff were tested by the Administrator, Social Worker #3 and Human Resources Staff #10 and given a competency quiz on resident abuse and neglect. Quizzes were administered on paper and via phone. Incorrect answers resulted in re-education. On 11/09/17 STNA #1 was terminated from employment at the facility. Findings include: Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of progress notes dated 09/15/17, 10/04/17, 11/07/17, and 11/11/17 revealed Resident #39 resisted care and had combative behaviors during care. A progress note dated 11/03/17 documented Resident #39 swung her arms at staff during care and Resident #39's combativeness and aggressiveness was discussed with her daughters. The daughters verbalized understanding and stated Resident #39 was at times aggressive and combative with them as well. Review of a video provided by the family on 11/13/17, clearly showed on 11/05/17 at 9:30 P.M. STNA #1 provided personal care to Resident #39. There was no audio, but it appeared that Resident #39 was yelling while STNA #1 changed her brief. STNA #1 turned and positioned Resident #39 in a hurried, rough manner. STNA #1 then attempted to put a hospital gown on Resident #39. When Resident #39 resisted, STNA #1 took a blanket and threw it over Resident #39's face and head and walked away from the bed. It was not clear if Resident #39's body was uncovered. STNA #1 returned to the bed, picked up a pillow and struck Resident #39 three times in the face/head with the pillow. In an interview on 11/13/17 at 8:52 A.M. the facility Administrator stated that on 11/08/17 at approximately 12:30 P.M. to 1:00 P.M., two family members of Resident #39 came to him with concerns about physical abuse. The family stated they witnessed the abuse on video from a camera they had placed in Resident #39's room. The Administrator stated that he saw the video and it showed that on 11/05/17 at 9:30 P.M. STNA #1 entered the room and provided care to Resident #39. The Administrator stated STNA #1 pushed and pulled Resident #39 roughly. STNA #1 attempted to put a hospital gown on Resident #39 while she was in bed, and could not get the gown on her. STNA #1 then covered Resident #39, who was in her underwear. The Administrator said STNA #1 returned to the bed, approached Resident #39, picked up a pillow and hit Resident #39 twice with the pillow. The Administrator stated Resident #39's family members took the video to the local police department who issued a warrant for the arrest of STNA #1. In an interview on 11/15/17 at 8:25 A.M. the Administrator stated that at the time of the interview on 11/13/17 he remembered STNA #1 struck Resident #39 twice. In an interview on 11/13/17 at 9:40 A.M. RNC #7 stated the facility was notified of the allegation of abuse by the family on 11/08/17. RNC #7 stated that after notification she viewed the video of the incident which was provided by the family. RNC #7 stated the family told her the incident occurred on 11/05/17 at 9:30 P.M. RNC #7 stated the video revealed STNA #1 provided care to Resident #39 in a rough manner. When Resident #39 refused to put on a hospital gown, STNA #1 threw a blanket over the resident's head and face and walked away. STNA #1 returned to the bed, picked up a pillow and hit Resident #39 in the face/head three times with the pillow. RNC #7 stated this was abuse. On 11/13/17 at 12:18 P.M. an interview was conducted with Detective #1 from the local police department who handled the case. Detective #1 stated the initial police visit and report were handled by a patrolman, who was not available for contact. Detective #1 stated after review of the video, the police department issued a warrant for the arrest of STNA #1. Detective #1 stated the police department was not able to locate STNA #1 and the case was given to the detective bureau to handle. Detective #1 stated a warrant was issued for the arrest of STNA #1 for assault of a functionally impaired person, a fourth degree felony. On 11/13/17 at 1:04 P.M. the surveyor met with Resident #39's two family members. Family Member (FM) #2 stated they placed the camera in Resident #39's room three to four weeks prior to the incident on 11/05/17. FM #2 showed the surveyor the video of the incident (on her phone) that occurred on 11/05/17. FM #2 stated she removed the disc from the video camera on 11/06/17 and viewed it on 11/07/17. On 11/07/17, FM #2 and FM #3 took it to the local police department who viewed it and told the family it showed enough to arrest STNA #1. On 11/08/17 at 12:30 P.M. the family notified the facility of the incident and showed the video to the Administrator and the DON. On 11/14/17 at 9:10 A.M. the surveyor observed Resident #39 awake and in bed. The surveyor attempted to interview Resident #39. Resident #39 stated staff took good care of her and were nice to her. Resident #39 stated she was punched. When asked who punched her she did not answer. When asked if anyone ever hit her with a pillow she stated no. The surveyor asked if she felt safe and she replied yes. Resident #39 then stopped answering. The surveyor asked if she wanted to go back to sleep and she replied yes. On 11/14/17 beginning at 2:40 P.M., interviews were conducted with Resident #30, Resident #28 and Resident #54 regarding staff treatment. All stated staff were nice, treated them respectfully and with dignity and they were not aware of anyone in the facility being mistreated. Interview on 11/15/17 at 2:30 P.M. with Resident #6, who was cared for by STNA #1 on the date of the abuse revealed she knew STNA #1 and did not like her because she had an attitude. Resident #6 stated that one time (did not remember when) STNA #1 cussed at her. Resident #6 stated she cussed right back at her and it never happened again. Resident #6 did not remember what was said but that it wasn't ladylike. Resident #6 did not report it. Resident #6 stated she did not observe STNA #1 or any other staff ever mistreat any other resident. Review of the interview of Resident #6 completed by management staff on 11/08/17 revealed she was cared for by STNA #1 while in the facility. Resident #6 stated she had no problems with STNA #1 or the care she provided. Resident #6 told management staff she never experienced any abuse or neglect while in the facility. Resident #6 stated that if that were to happen she would report it to the social worker or the facility administrator. On 11/15/17 at 2:40 P.M. interview of Resident #32, who was cared for by STNA #1 on 11/05/17, revealed she was never treated badly by anyone in the facility. Resident #32 was not able to remember STNA #1 by name, but stated she never saw any staff mistreat any resident in any way and stated staff were all very nice. On 11/15/17 from 2:48 P.M. to 3:15 P.M., interviews with STNAs #20, #21, #22, #23, and #24 regarding abuse, neglect, misappropriation revealed they had all received in-service education in regard to abuse one week prior and took a quiz on the abuse education. They were not aware of any incident of abuse in the facility prior to the incident that occurred on 11/05/17. They stated they were interviewed by management and gave a statement in regard to the incident on 11/05/17. On 11/15/17 from 3:46 P.M. to 4:06 P.M., interviews with LPNs #25, #26 and #27 revealed all were knowledgeable of actions to take in regard to abuse, neglect, misappropriation, reporting, and staff burnout. They stated they were interviewed by management about STNA #1 and the incident on 11/05/17 and were not aware of it until then. LPN #25 and #26 did not know STNA #1. LPN #27 stated she met STNA #1 for the first time on 11/05/17 and did not observe STNA #1 treating any resident badly. They all stated they received in-service education on abuse and took a quiz. Review of the facility policy for Resident Abuse, last revised 03/03/17, revealed the facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also included the deprivation by an individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental and psychosocial well-being. It included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology, misappropriation of resident property, exploitation, involuntary seclusion, injuries of unknown origin source and physical and chemical restraints. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury. Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. This deficiency substantiates Complaint Number OH 517.