Every finding on record at Southbrook Healthcare Center

Based on observation, interview, record review, and facility policy review, the facility failed to maintain a clean and sanitary kitchen. This affected all residents who receive food from the kitchen. The facility identified three residents (#20, #24, #45) who received nothing by mouth (NPO). The facility census was 72. Findings include: Observation during the initial tour of the facility kitchen on 08/03/26 at 10:01 A.M. with Dietary Manager (DM) #200 revealed the walk-in refrigerator contained a large container of twelve individual cartons of chocolate milk for residents that were outdated with a use by date of 08/02/26. Observation of the walk-in freezer revealed a large box of opened to air hamburger patties with no label or date, a large container of unsealed hot dogs with no label or date, a large box of Salisbury steak opened with no label or date, a large box of frozen hamburger patties unsealed with no label or date. The walk-in freezer also contained two large five-gallon bags of French fries with no label or date and a five-gallon bag of frozen hash browns no label or date. Interview with DM#200 on 08/03/26 at 10:10 A.M. confirmed the findings related the expired chocolate milk. DM #200 confirmed the open boxes of food identified in the walk-in freezer. The kitchen tour continued on 08/03/26 at 10:20 A.M. and an observation of heavily soiled floor with dirt, grime, food debris under the three-compartment sink, under the stove, under the kitchen shelves the floor was heavily soiled with a black grease substance, food crumbs, and dried splatter. The walls in the dishwasher room were heavily soiled with dried food splatter running down the walls. The trash cans in the kitchen were heavily soiled with food splatter running down the sides. The lights were soiled with fuzzy substance on them. The ceiling was heavily soiled throughout the kitchen with flood splatter all over it. The spice shelf over the food prep area was heavily soiled with crumbs. The wall behind the coffee pot and behind the counter of the coffee pot was heavily soiled with dried food splatter. The shelves by the stove were heavily soiled with crumbs, dried food splatter. A hole was seen to the right of the kitchen door on the wall and an exposed wire was not connected to anything and hanging from the wall over the kitchen door. Observed a hole in the wall under the three compartment sink. Observed a hole in the wall next to the chemical closet inside the kitchen. Interview with Dietary Manager (DM)#200 at 10:20 A.M. verified the above observations. Numerous flying gnats were observed flying in the dish machine area. DM # 200 confirmed the kitchen has an ongoing issue with gnats in the drain. Review of the most recent, Food Inspection Report, dated 04/29/26 revealed the facility failed to correct a damaged wall near the chemical closet. In order to reduce the risk of pests, ensure that this damaged wall is repaired the wall is smooth and easily cleanable. Review of the policy titled, Environment, dated 06/2025 confirmed all food preparations area and dining areas will be maintained in a clean and sanitary condition. The Dining Services Director will ensure the facility kitchen is maintained in a clean and sanitary manner, including floor, walls, ceilings, lightings, and ventilation. All food contact surfaces will be cleaned and sanitized after each use. DSD will ensure that a routine cleaning schedule is in place for all cooking equipment, flood storage areas, and surfaces.Review of the facility policy titled, Food Storage: Cold Foods, date 02/2026 confirmed all food will be stored wrapped or in covered containers, labeled, and dated. This deficiency represents non-compliance investigated under Complaint Number 3013121.

Based on observation, resident interview, staff interview, record review, and policy review, the facility failed to provide appropriate window screens in the residents' bedroom window. This affected four (Residents #02, #58, #59, and #61) of four residents reviewed for homelike environment. This had the potential to affect 32 residents (#02, #03,#05, #07, #12, #14, #16,#17, #22, #23, #26, #27, #29, #31, #32, #36, #37, #39,#45, #47, #54, #56, #58, #59, #61, #62, #64, #66, #68, #71, #72, #73) identified by the facility has not having screens in their window. The facility census was 72. Findings include: 1.Medical record review for Resident #59 revealed she was admitted to the facility on [DATE]. Her diagnoses included respiratory failure, chronic obstructive pulmonary disease (COPD), anxiety disorder, and hernia. Review of the Minimum Data Set (MDS) assessment, dated 07/31/26, revealed Resident #59 revealed she was cognitively intact. Interview with Resident #59 on 08/04/26 at 10:52 A.M. revealed she felt her room is stuffy and warm. Resident #59 revealed there have been times she has wanted to open her window but could not open it related to no screen in the window. 2. Medical record review for Resident #02 revealed she was admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis, chronic hepatitis , thrombocytopenia, major depressive disorder, anxiety disorder, bipolar disorder, epilepsy, essential primary hypertension, gastroesophageal reflux disease (GERD), and vascular dementia. Review of the MDS assessment, dated 07/02/26, revealed Resident #02 was cognitively impaired. Interview with Resident #02 on 08/04/26 at 11:00 A.M. revealed her room is hot at times. Resident #02 revealed she has wanted to open her window, however, she is unable to because her room does not have a screen in the window. 3. Medical record review for Resident #58 revealed she was admitted to the facility on [DATE]. Her diagnoses included goiter, hypertensive chronic kidney disease, chronic obstructive pulmonary disease (COPD), mixed hyperlipidemia, hypothyroidism, adult failure to thrive, post traumatic stress disorder, insomnia, anxiety disorder, major depressive disorder, insomnia, dementia, and anemia. Review of the MDS assessment, dated 07/24/26, revealed Resident #58 was cognitively intact. Interview with Resident #58 on 08/04/26 at 11:10 A.M. revealed Resident #58 stated she is a country girl and loves the outside. Resident #58 voiced a concern of not having a screen in her window and she is unable to open it because of the not having a screen. 4.Medical record review for Resident #61 revealed she was admitted to the facility on [DATE]. Her diagnoses included, cerebral edema, essential primary hypertension, aphasia, GERD, hyperlipidemia, insomnia, anxiety disorder, major depressive disorder, and acute kidney failure. Review of the MDS assessment for resident #61, dated 06/20/26, revealed she was cognitively impaired. Interview with Resident #61 on 08/04/26 at 12:06 P.M. revealed Resident #61 revealed she is not able to open her window related to not having a screen in her resident room window. Observation on 08/04/26 at 10:35 A.M. with the Maintenance Supervisor (MS)#390 revealed not all windows in the residents' rooms have screens in them. Interview with MS#290 on 08/04/26 at 10:50 A.M. confirmed not all of the residents' windows have screens available. MS #290 confirmed the older rooms on the 100 hallway and some of the windows on the 200 and 300 hallways do not have screens available. MS #290 provided a list of twenty eight residents' rooms that do not have a window screen in place. Interview on 08/04/26 at 11:54 A.M. with the Administrator confirmed the facility has a identified a total of twenty eight residents' rooms that do not have screens in the window. The Administrator revealed he was not aware of a regulation that required a screen in the resident windows. The Administrator confirmed the residents do have the right to open their window Review of the facility policy titled, Resident Rights, undated, confirmed it is the policy of the facility to provide person centered care. Residents have a choice and a voice on how they will be treated. This deficiency represents non-compliance investigated under Complaint Number 3013121.

Based on observation, staff interview, repair company interview, repair bills, and record review, the facility failed to maintain working equipment for the facility kitchen. This affected all residents who receive food from the kitchen. The facility identified three residents (#20, #24, #45) who receive nothing by mouth (NPO). The facility census was 72. Findings Include: Observation during the tour of the kitchen on 08/03/26 at 10:20 A.M. with Dietary Manager (DM) #200 revealed the facility stove light was on with food cooking in the right side of the oven because the left side was not operable. Interview with DM #200 on 08/03/26 at 10:20 A.M. revealed the griddle on the top of the stove was not operable. DM #200 revealed the left lower oven was not operable. Review of the repair bill dated 07/23/26 revealed ,found oven unit has two power supply and the right service disconnect supply's the griddle, right oven, and two range burners, the right half is functioning. The left side is supplied from 100A breaker in the hall. The left supply feeds the left oven, and four range burners. None of the left burners are heating. The supply power to this oven must be repaired before any oven repair can be done. Found 1 wire burned off terminal in left entrance box, likely supplying left oven. Interview on 08/04/26 with the Manager (#500) of the oven repair company confirmed Repairman #501 arrived at the facility on 07/23/26 and informed the dietary staff that the oven was unable to be repaired that day. This deficiency represents non-compliance investigated under Complaint Number 3013121.

THE FOLLOWING SURVEY FINDINGS PERTAIN TO INCIDENCE OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of facility Self-Reported Incidents (SRIs), staff interview, and policy review, the facility failed to provide adequate supervision and monitoring for residents. This resulted in Actual Harm on 03/06/26 when Resident #12 rolled out of bed onto the floor during incontinence care, resulting in a fracture to his clavicle. This affected one (Resident #12) of three residents reviewed for accidents. The facility census was 89 residents. Findings include: Review of the medical record for Resident #12 revealed an admission date of 01/29/26 with diagnoses including end stage renal disease, cerebral infarction, and type two diabetes. Review of the Minimum Data Set (MDS) assessment for Resident #12 dated 03/13/26 revealed the resident had moderate cognitive impairment and was dependent on staff assistance for activities of daily living (ADL). Review of the care plan for Resident #12 dated 01/29/26 revealed the resident required the assistance of one staff with personal hygiene and toileting and the assistance of two for rolling left to right in bed. The resident was at risk of falls with interventions including staff to ensure the wheels to the bed were locked. Review of a nurse progress note for Resident #12 dated 03/06/26 revealed the aide called the nurse to Resident #12's room and the resident was sitting on his buttocks on the right side of the bed on the floor. The nurse assessed the resident with no complaints of pain or visible injuries. Review of a physician progress note for Resident #12 dated 03/07/26 revealed Resident #12 had complaints of left shoulder pain following the fall out of bed on 03/06/26. An X-ray revealed the resident had a distal left clavicle fracture. Review of an SRI for Resident #12 dated 03/09/26 revealed the facility initiated an investigation of possible neglect for Resident #12 based upon allegations from the resident's family member related to the fall on 03/06/26. The facility did not substantiate neglect or abuse but did determine Resident #12 fell out of bed while Certified Nursing Assistant (CNA) #24 was providing incontinent care to Resident #12 and the bed moved away causing the resident to roll out of bed. Resident #12 was a one-person assist for incontinence care but required a two-person assist for rolling side to side in bed. Review of the employee corrective action form for CNA #24 dated 03/09/26 revealed the aide received a written warning for a performance violation specifically for failing to use the Kardex to ensure the resident was properly cared for, failing to provide two-person assistance when it was called for, and was also educated on ensuring bed brakes were properly locked prior to providing resident care. During an interview on 04/17/26 at 3:18 P.M., the Administrator and the Director of Nursing (DON) stated on 03/06/26 CNA #24 was providing incontinent care by herself and she rolled Resident #12, causing him to fall out of bed sustaining a clavicle fracture. During their interview with CNA #24, the aide stated she thought she had locked the brakes on the bed, but the bed had moved as she was rolling the resident, causing him to fall with injury. Review of the facility policy titled Fall Prevention and Management undated revealed if a resident was determined to be at risk for falls the facility would implement a care plan with specific interventions to diminish the risk of falls with interventions to address environment factors, level of care needs, and risk factors resulting from mental or medical diagnoses. The deficiency was corrected on 04/03/26 when the facility implemented the following corrective actions:On 03/09/26, a new bed, a new mattress with bed bolsters and floor mats to both sides of the bed were provided to Resident #12.On 03/09/26 all residents' needs were reviewed to determine their level of assistance when providing care.Starting on 03/09/26, all staff were re-trained on the level of care and asking for assistance as required, correct use of bed brakes and the fall prevention policy. All staff were trained by 04/03/26.Starting on 03/10/26, staff were randomly observed providing resident care to ensure safety interventions were maintained.On 03/12/26, all residents were reviewed to ensure their bed brakes were operational and they had the proper mattress for care and transfers.Audits and observations to continue for six months and then randomly thereafter with results reported to the Quality Assurance Performance Improvement (QAPI) Committee. This deficiency represents noncompliance investigated under Complaint Number 2979798 and Incident Number 2806190.

Based on medical record review, staff interview, review of the facility policy, and review of online guidelines per the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess resident skin and failed to identify pressure ulcers until they had reached an advanced stage. This resulted in Actual Harm for Resident #54 who was admitted to the facility with a pressure ulcer to his sacrum, left scapula, and right scapula and developed an additional pressure ulcer to his right gluteal fold which was not identified until it had developed into an unstageable ulcer with slough (nonviable tissue which could impede wound healing) and necrotic (dead) tissue. This affected one (Resident # 54) of two residents reviewed for pressure ulcers. The facility census was 90 residents. Findings include: Review of the medical record for Resident #54 revealed an admission date of 04/22/25 with diagnoses including schizoaffective disorder, Alzheimer's Disease, and generalized anxiety disorder. Review of the pressure ulcer risk assessment for Resident #54 dated 04/22/25 revealed the resident was at high risk for the development of pressure ulcers. Review of the physician's orders for Resident #54 revealed an order dated 04/22/25 for daily skin sweeps at bedtime. Review of the care plan for Resident #54 initiated 04/22/25 and revised 05/05/25 revealed the resident had impaired skin integrity related to pressure ulcers on his sacrum, right scapula and right gluteal fold. Interventions included the following: air mattress with bolsters to bed frame, daily skin sweeps at bedtime, turn and reposition as tolerated every morning and at bedtime, float heels as tolerated, complete skin at risk assessment upon admission/readmission, quarterly, and as needed, encourage the resident to turn and reposition or assist as needed as resident allows, evaluate existing wound daily for changes (redness, edema, drainage, pain, foul odor), provide appropriate off-loading mattress and off-loading cushion. Review of the admission Minimum Data Set (MDS) assessment for Resident #54 dated 04/29/25 revealed the resident was severely cognitively impaired and required extensive staff assistance with bed mobility and other activities of daily living (ADLs). Review of the wound assessment for Resident #54 dated 04/24/25 revealed the resident was admitted to the facility with a stage I pressure ulcer on his left scapula, a stage III pressure ulcer on his right scapula, a stage I pressure ulcer on his left gluteal fold, and an unstageable pressure ulcer on his sacrum. Review of the weekly skin assessment for Resident #54 dated 04/29/25 per the Director of Nursing (DON) revealed the resident had no new skin issues. Review of the weekly skin assessment for Resident #54 dated 05/06/25 completed by Licensed Practical Nurse (LPN) #165 revealed the resident had new skin issues. Review of the Treatment Administration Records (TAR) for April 2025 and May 2025 revealed daily skin sweeps at bedtime were signed off as completed from 04/22/25 through 05/04/25. Review of the progress note for Resident #54 dated 05/05/25 per Wound Nurse Practitioner (WNP) #250 revealed the resident had an unstageable pressure area to the right gluteal fold which measured 2.5 centimeters (cm) in length by 2.0 cm in width by 0.2 cm in depth. The wound bed was 40 percent (%) epithelial tissue, 30% slough tissue, and 30% eschar (dead) tissue. Interview on 05/20/25 at 11:12 A.M. with the DON confirmed WNP #250 found the unstageable pressure ulcer on Resident #54's right gluteal fold on 05/05/25. The DON further confirmed Resident #54 had a physician's order for a daily skin sweep which the staff had signed off as completed daily from 04/022/25 to 05/04/25. The DON confirmed Resident #54's right gluteal fold pressure ulcer was not identified until 05/05/25 when it had reached an advanced stage, and staff should have identified the pressure ulcer sooner. Review of the facility policy titled Skin Care and Wound Management undated revealed the facility staff would identify residents at risk for the development of pressure ulcers, provide daily monitoring of existing wounds, and implement prevention strategies to decrease the potential for developing pressure ulcers. Review of the NPUAP guidelines dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that included the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment.

Based on personnel record review and staff interview, the facility failed to ensure annual evaluations were completed for staff. This had the potential to affect all of the residents who resided in the facility. The facility census was 90 residents. Findings include: Review of the personnel file for Certified Nursing Assistant (CNA) #120 revealed a hire date of 10/27/22 with no annual evaluation. Review of the personnel file for CNA #128 revealed a hire date of 08/15/23 with no annual evaluation. Review of the personnel file for CNA #117 revealed a hire date of 07/19/22 with no annual evaluation. Interview on 05/21/25 at 10:09 A.M. with Human Resource Manager (HRM) #153 confirmed annual evaluations were not completed for CNAs #120, #128, and #117.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure food was stored in a safe and sanitary manner. This had the potential to affect all of the residents residing in the facility excluding Resident #52 and #62 who did not eat food from the kitchen. The facility census was 90 residents. Findings include: Observation on 05/18/25 from 08:22 A.M. to 8:52 A.M. with Dietary Manager (DM) #201 revealed the following findings in the kitchen: -The dry storage area contained eleven undated cereal bowls, one container of breadcrumbs open to air, four clear plastic containers of cereal with cloudy sides and residue buildup, one clear plastic container of sugar with cloudy sides, one clear plastic container of flour with cloudy sides, one clear plastic container of brown sugar with cloudy sides, one unrefrigerated sheet cake, an uncovered trash can filled with waste. -The walk-in refrigerator contained two undated packages of salami, 20 undated individually wrapped dinner rolls, seven undated premade salads, 15 undated bowls of coleslaw, one undated and uncovered package of butter. -The walk-in freezer contained two pitchers of ice open to air, one box of beef patties open to air, and one box of sausage patties open to air. Interview on 05/18/25 at 8:53 A.M. with Dietary Manager (DM) #201 confirmed the concerns in the dry storage area, the walk-in refrigerator, and the walk-in freezer. Review of the facility policy titled Food Storage: Dry Goods dated February 2023 revealed all packaged and canned food items should be kept clean, dry, and properly sealed. Storage areas would be neat, arranged for easy identification, and date marked as appropriate. Review of the facility policy titled Food Storage: Cold Foods dated February 2023 revealed all foods should be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.

Based on medical record review, financial record review, staff interview, and review of the facility policy, the facility failed to obtain appropriate written authorization to manage residents' personal funds. This affected two (Residents #23 and #24) of five residents reviewed for personal funds. The facility census was 90 residents. Findings include: 1.Review of the medical record for Resident #23 revealed an admission date of 05/16/24 with diagnoses including cerebral infarction, hypotension and anxiety disorder. Review of the authorization form for the facility to manage resident funds for Resident #23 dated 05/30/24 revealed the resident's representative had signed to authorize the facility to manage the resident's funds, but the signature was not witnessed. 2. Review of the medical record for Resident #84 revealed an admission date of 04/23/25 with diagnoses including cerebral vascular accident, transient ischemic attack, dementia and anxiety disorder. Review of the authorization form for the facility to manage resident funds for Resident #84 dated 05/04/25 revealed the resident's representative had signed to authorize the facility to manage the resident's funds, but the signature was not witnessed. Interview on 05/21/25 at 2:00 P.M. with the Administrator confirmed the facility had not obtained proper written authorization to manage Resident #23 and Resident #84's funds. The resident representatives for Resident #23 and #84 had signed consent forms for the facility to manage the funds but neither of the representative signatures had been witnessed. The form had a space for two witnesses, but the spaces were blank on Resident #23 and #84's fund authorization forms. Review of facility policy titled Resident Rights undated revealed when the facility accepted the responsibility for the resident's financial affairs, the resident or resident representative should designate in writing, the transfer of responsibility.

Based on medical record review, observation, resident interview, staff interview, and review the facility policy, the facility failed to ensure comfortable resident room temperatures. This affected one (Resident #48) of one resident reviewed for room temperatures. The facility census was 90 residents. Findings include: Review of the medical record for Resident #48 revealed an admission date of 03/02/21 with diagnoses including epilepsy, depression, and a cerebral infarction. Review of the Minimum Data Set (MDS) assessment for Resident #48 dated 04/02/25 revealed the resident was moderately cognitively impaired and required staff assistance with activities of daily living (ADLs.) Observation on 05/18/25 at 11:06 A.M. of Resident #48 revealed the resident was in bed in her room and was covered with a thick blanket. Interview on 05/18/25 at 11:07 A.M. of Resident #48 confirmed the temperature in her room was too cold. Observation on 05/19/25 at 3:01 P.M. of the temperature in Resident #48's room with Maintenance Director (MD) #201 revealed the temperature of the resident's room was 68 degrees Fahrenheit (F.) Interview on 05/19/25 at 3:02 P.M. confirmed the temperature in Resident #48's room was 68 degrees Observation on 05/20/25 at 10:00 A.M. of Resident #48 revealed the resident was in bed in her room and was covered with a thick blanket. Interview on 05/20/25 at 10:01 A.M. of Resident #48 confirmed the temperature in her room was too cold. Observation on 05/20/25 at 10:15 A.M. with MD #201 revealed the temperature in Resident #48's room with Maintenance Director (MD) #201 revealed the temperature of the resident's room was 70.2 degrees F. Interview on 05/20/25 at 10:16 A.M. confirmed the temperature in Resident #48's room was 70.2 degrees. Review of the facility policy titled Extreme Cold Temperature Protocol undated revealed the facility would provide a safe, clean, comfortable and homelike environment including a comfortable and safe regulated temperature range of 71 to 81 degrees F. This ambient air temperature range minimized resident susceptibility to loss of body heat and risk of hypothermia or hyperthermia and provided a comfortable homelike setting.

Based on medical record review, staff interview, resident interview, review of the facility Self-Reported Incidents (SRIs) and review of the facility policy, the facility failed to ensure residents were free from verbal abuse. This affected three (Residents #15, # 59, and #69) of eight residents reviewed for abuse. The facility census was 90 residents. Findings include: 1.Review of the medical record for Resident #15 revealed an admission date of 04/12/23 with diagnoses of schizophrenia, congestive heart failure (CHF), and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #15 dated 03/18/25 revealed the resident was cognitively intact and required set up assistance and supervision with activities of daily living (ADLs.) Review of the care plan for Resident #15 dated 03/25/25 revealed the resident had a focus on psychosocial well-being with a goal for the resident to feel safe, comfortable, and well cared for through next review date. Interview on 05/18/25 at 1:08 P.M. with Licensed Practical Nurse (LPN) #162 confirmed she witnessed Resident #63 call Resident #15 a bitch sometime in the last couple of weeks LPN #162 confirmed she did not report the abuse because the nurse believed the leadership team wouldn't do anything about Resident #63's behaviors and she was afraid to report it because she believed Resident #63 was always getting employees suspended or fired. Interview on 05/19/25 at 9:13 A.M. with Resident #15 confirmed Resident #63 always yelled at him and called him and his mom profane names. Resident #15 confirmed he was a religious man, and he was offended by the way Resident #63 spoke to him. Resident #15 confirmed the verbal abuse had occurred within the last few weeks. 2. Review of the medical record for Resident #59 revealed an admission date of 11/16/22 with diagnoses of cerebral infarction, major depressive disorder, and hypertension. Review of the MDS assessment for Resident #59 dated 05/05/25 revealed the resident was cognitively intact and required staff assistance with ADLs. Review of the care plan for Resident #59 dated 11/28/22 revealed the resident had a focus of a behavior problem due to loss of independence with an intervention to approach and speak to the resident in calm manner. Interview on 05/19/25 at 8:56 A.M. with Certified Nursing Assistant (CNA) #112 confirmed Resident #63 was always yelling, cussing, and chasing residents and staff with his wheelchair. CNA #112 confirmed he witnessed Resident #63 cussing at Resident #59 and the nurse earlier in the day on 05/19/25. Interview on 05/19/25 at 9:00 A.M. with LPN #166 confirmed she witnessed Resident #63 refer to Resident #59 ugly and also call the resident a profane name. LPN #166 confirmed she did not report this to the Administrator because of fear of retaliation and concern that Resident #63 got staff suspended or fired. 3. Review of the medical record for Resident #69 revealed an admission date of 07/28/23 with diagnoses of chronic obstructive pulmonary disease (COPD), alcohol-induced psychotic disorder, and chronic hepatitis. Review of the MDS assessment for Resident #69 dated 04/11/25 revealed the resident had moderate cognitive impairment and was independent with ADLs. Review of the care plan for Resident #69 dated 05/01/25 revealed the resident had a focus of behavior problem with an intervention to approach and speak to the resident in a calm manner. Interview on 05/18/25 at 1:08 P.M. with LPN #161 confirmed she recently observed Resident #63 call Resident #69 an ugly bitch and a mortician, but she couldn't remember the exact date. Interview on 05/19/25 at 8:52 A.M. with Resident #69 confirmed Resident #63 had called her all kinds of names and she was embarrassed to repeat some of them because they were profane. Resident #63 confirmed she told LPN #161, but nothing was done about the verbal abuse. Review of the medical record for Resident #63 revealed an admission date of 08/08/23 with diagnoses of COPD, type two diabetes mellitus, and CHF. Review of the care plan for Resident #63 dated 01/06/25 revealed the resident had a behavior problem which included yelling and screaming, throwing objects, and using inappropriate language towards staff and residents with interventions for staff to intervene as necessary to protect the rights and safety of others, to monitor behavioral episodes, and to attempt to determine underlying causes. Review of the physician's orders for Resident #63 revealed an order dated 04/01/25 for staff to monitor the resident for false allegations, inappropriate language toward staff or residents, and yelling/screaming. Review of the MDS assessment for Resident #63 dated 05/08/25 revealed resident was cognitively intact and required set up and supervision with ADLs. Interview on 05/19/25 at 11:50 A.M. of Resident #63 confirmed he was not always mean to other residents and that he was only mean when people didn't do what he said they should do. Interview on 05/19/25 at 1:17 P.M. with Director of Plant Maintenance (DPM) #152 confirmed he had observed Resident #63 call other residents profane names on multiple occasions. DPM #152 confirmed he had not reported the abuse to management. Interview on 05/19/25 at 4:38 P.M. with the Administrator confirmed she was not aware of recent allegations of verbal abuse per Resident #63 towards Resident #15, #59, and #69 and the facility had not filed any SRIs related to the same, nor had the facility investigated any recent allegations of verbal abuse per Resident #63. Review of the facility SRIs dated 05/01/25 to 05/19/25 revealed there were no SRIs filed for verbal abuse per Resident #63 towards Residents #15, #59, #69. Review of the facility policy titled Ohio Abuse, Neglect, and Misappropriation undated revealed the facility would prevent abuse including resident to resident abuse and including verbal abuse which included any use of oral, written, or gestured language that willfully included disparaging or derogatory terms to residents and their families or within their hearing distance, to describe residents regardless of their age, disability, or ability to comprehend.

Based on medical record review, staff interview, resident interview, review of the facility Self-Reported Incidents (SRIs) and review of the facility policy, the facility failed to report allegations of resident to resident verbal abuse to the Ohio Department of Health (ODH). This affected three (Residents #15, # 59, and #69) of eight residents reviewed for abuse. The facility census was 90 residents. Findings include: 1.Review of the medical record for Resident #15 revealed an admission date of 04/12/23 with diagnoses of schizophrenia, congestive heart failure (CHF), and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #15 dated 03/18/25 revealed the resident was cognitively intact and required set up assistance and supervision with activities of daily living (ADLs.) Review of the care plan for Resident #15 dated 03/25/25 revealed the resident had a focus on psychosocial well-being with a goal for the resident to feel safe, comfortable, and well cared for through next review date. Interview on 05/18/25 at 1:08 P.M. with Licensed Practical Nurse (LPN) #162 confirmed she witnessed Resident #63 call Resident #15 a bitch sometime in the last couple of weeks LPN #162 confirmed she did not report the abuse because the nurse believed the leadership team wouldn't do anything about Resident #63's behaviors and she was afraid to report it because she believed Resident #63 was always getting employees suspended or fired. Interview on 05/19/25 at 9:13 A.M. with Resident #15 confirmed Resident #63 always yelled at him and called him and his mom profane names. Resident #15 confirmed he was a religious man, and he was offended by the way Resident #63 spoke to him. Resident #15 confirmed the verbal abuse had occurred within the last few weeks. 2. Review of the medical record for Resident #59 revealed an admission date of 11/16/22 with diagnoses of cerebral infarction, major depressive disorder, and hypertension. Review of the MDS assessment for Resident #59 dated 05/05/25 revealed the resident was cognitively intact and required staff assistance with ADLs. Review of the care plan for Resident #59 dated 11/28/22 revealed the resident had a focus of a behavior problem due to loss of independence with an intervention to approach and speak to the resident in calm manner. Interview on 05/19/25 at 8:56 A.M. with Certified Nursing Assistant (CNA) #112 confirmed Resident #63 was always yelling, cussing, and chasing residents and staff with his wheelchair. CNA #112 confirmed he witnessed Resident #63 cussing at Resident #59 and the nurse earlier in the day on 05/19/25. Interview on 05/19/25 at 9:00 A.M. with LPN #166 confirmed she witnessed Resident #63 refer to Resident #59 ugly and also call the resident a profane name. LPN #166 confirmed she did not report this to the Administrator because of fear of retaliation and concern that Resident #63 got staff suspended or fired. 3. Review of the medical record for Resident #69 revealed an admission date of 07/28/23 with diagnoses of chronic obstructive pulmonary disease (COPD), alcohol-induced psychotic disorder, and chronic hepatitis. Review of the MDS assessment for Resident #69 dated 04/11/25 revealed the resident had moderate cognitive impairment and was independent with ADLs. Review of the care plan for Resident #69 dated 05/01/25 revealed the resident had a focus of behavior problem with an intervention to approach and speak to the resident in a calm manner. Interview on 05/18/25 at 1:08 P.M. with LPN #161 confirmed she recently observed Resident #63 call Resident #69 an ugly bitch and a mortician, but she couldn't remember the exact date. Interview on 05/19/25 at 8:52 A.M. with Resident #69 confirmed Resident #63 had called her all kinds of names and she was embarrassed to repeat some of them because they were profane. Resident #63 confirmed she told LPN #161, but nothing was done about the verbal abuse. Review of the medical record for Resident #63 revealed an admission date of 08/08/23 with diagnoses of COPD, type two diabetes mellitus, and CHF. Review of the care plan for Resident #63 dated 01/06/25 revealed the resident had a behavior problem which included yelling and screaming, throwing objects, and using inappropriate language towards staff and residents with interventions for staff to intervene as necessary to protect the rights and safety of others, to monitor behavioral episodes, and to attempt to determine underlying causes. Review of the physician's orders for Resident #63 revealed an order dated 04/01/25 for staff to monitor the resident for false allegations, inappropriate language toward staff or residents, and yelling/screaming. Review of the MDS assessment for Resident #63 dated 05/08/25 revealed resident was cognitively intact and required set up and supervision with ADLs. Interview on 05/19/25 at 11:50 A.M. of Resident #63 confirmed he was not always mean to other residents and that he was only mean when people didn't do what he said they should do. Interview on 05/19/25 at 1:17 P.M. with Director of Plant Maintenance (DPM) #152 confirmed he had observed Resident #63 call other residents profane names on multiple occasions. DPM #152 confirmed he had not reported the abuse to management. Interview on 05/19/25 at 4:38 P.M. with the Administrator confirmed she was not aware of recent allegations of verbal abuse per Resident #63 towards Resident #15, #59, and #69 and the facility had not filed any SRIs related to the same, nor had the facility investigated any recent allegations of verbal abuse per Resident #63. Review of the facility SRIs dated 05/01/25 to 05/19/25 revealed there were no SRIs filed for verbal abuse per Resident #63 towards Residents #15, #59, #69. Review of the facility policy titled Ohio Abuse, Neglect, & Misappropriation undated revealed the facility should report allegations of resident abuse to the state agency in accordance with state law.

Based on medical record review, staff interview, resident interview, review of the facility Self-Reported Incidents (SRIs) and review of the facility policy, the facility failed to investigate allegations of abuse. This affected three (Residents #15, # 59, and #69) of eight residents reviewed for abuse. The facility census was 90 residents. Findings include: 1.Review of the medical record for Resident #15 revealed an admission date of 04/12/23 with diagnoses of schizophrenia, congestive heart failure (CHF), and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #15 dated 03/18/25 revealed the resident was cognitively intact and required set up assistance and supervision with activities of daily living (ADLs.) Review of the care plan for Resident #15 dated 03/25/25 revealed the resident had a focus on psychosocial well-being with a goal for the resident to feel safe, comfortable, and well cared for through next review date. Interview on 05/18/25 at 1:08 P.M. with Licensed Practical Nurse (LPN) #162 confirmed she witnessed Resident #63 call Resident #15 a bitch sometime in the last couple of weeks LPN #162 confirmed she did not report the abuse because the nurse believed the leadership team wouldn't do anything about Resident #63's behaviors and she was afraid to report it because she believed Resident #63 was always getting employees suspended or fired. Interview on 05/19/25 at 9:13 A.M. with Resident #15 confirmed Resident #63 always yelled at him and called him and his mom profane names. Resident #15 confirmed he was a religious man, and he was offended by the way Resident #63 spoke to him. Resident #15 confirmed the verbal abuse had occurred within the last few weeks. 2. Review of the medical record for Resident #59 revealed an admission date of 11/16/22 with diagnoses of cerebral infarction, major depressive disorder, and hypertension. Review of the MDS assessment for Resident #59 dated 05/05/25 revealed the resident was cognitively intact and required staff assistance with ADLs. Review of the care plan for Resident #59 dated 11/28/22 revealed the resident had a focus of a behavior problem due to loss of independence with an intervention to approach and speak to the resident in calm manner. Interview on 05/19/25 at 8:56 A.M. with Certified Nursing Assistant (CNA) #112 confirmed Resident #63 was always yelling, cussing, and chasing residents and staff with his wheelchair. CNA #112 confirmed he witnessed Resident #63 cussing at Resident #59 and the nurse earlier in the day on 05/19/25. Interview on 05/19/25 at 9:00 A.M. with LPN #166 confirmed she witnessed Resident #63 refer to Resident #59 ugly and also call the resident a profane name. LPN #166 confirmed she did not report this to the Administrator because of fear of retaliation and concern that Resident #63 got staff suspended or fired. 3. Review of the medical record for Resident #69 revealed an admission date of 07/28/23 with diagnoses of chronic obstructive pulmonary disease (COPD), alcohol-induced psychotic disorder, and chronic hepatitis. Review of the MDS assessment for Resident #69 dated 04/11/25 revealed the resident had moderate cognitive impairment and was independent with ADLs. Review of the care plan for Resident #69 dated 05/01/25 revealed the resident had a focus of behavior problem with an intervention to approach and speak to the resident in a calm manner. Interview on 05/18/25 at 1:08 P.M. with LPN #161 confirmed she recently observed Resident #63 call Resident #69 an ugly bitch and a mortician, but she couldn't remember the exact date. Interview on 05/19/25 at 8:52 A.M. with Resident #69 confirmed Resident #63 had called her all kinds of names and she was embarrassed to repeat some of them because they were profane. Resident #63 confirmed she told LPN #161, but nothing was done about the verbal abuse. Review of the medical record for Resident #63 revealed an admission date of 08/08/23 with diagnoses of COPD, type two diabetes mellitus, and CHF. Review of the care plan for Resident #63 dated 01/06/25 revealed the resident had a behavior problem which included yelling and screaming, throwing objects, and using inappropriate language towards staff and residents with interventions for staff to intervene as necessary to protect the rights and safety of others, to monitor behavioral episodes, and to attempt to determine underlying causes. Review of the physician's orders for Resident #63 revealed an order dated 04/01/25 for staff to monitor the resident for false allegations, inappropriate language toward staff or residents, and yelling/screaming. Review of the MDS assessment for Resident #63 dated 05/08/25 revealed resident was cognitively intact and required set up and supervision with ADLs. Interview on 05/19/25 at 11:50 A.M. of Resident #63 confirmed he was not always mean to other residents and that he was only mean when people didn't do what he said they should do. Interview on 05/19/25 at 1:17 P.M. with Director of Plant Maintenance (DPM) #152 confirmed he had observed Resident #63 call other residents profane names on multiple occasions. DPM #152 confirmed he had not reported the abuse to management. Interview on 05/19/25 at 4:38 P.M. with the Administrator confirmed she was not aware of recent allegations of verbal abuse per Resident #63 towards Resident #15, #59, and #69 and the facility had not filed any SRIs related to the same, nor had the facility investigated any recent allegations of verbal abuse per Resident #63. Review of the facility SRIs dated 05/01/25 to 05/19/25 revealed there were no SRIs filed for verbal abuse per Resident #63 towards Residents #15, #59, #69. Review of the facility policy titled Ohio Abuse, Neglect, and Misappropriation policy undated revealed the facility should investigate all allegations of resident abuse.

Based on medical record review, resident interview, staff interview, observation, and review of the facility policy, the facility failed to ensure staff provided timely resident incontinence care and failed to ensure staff provided resident nail care. This affected two (Residents #38 and #139) of four residents reviewed for activities of daily living (ADLs). The facility census was 90 residents Findings include: 1.Review of the medical record for Resident #38 revealed an admission date of 08/24/18 with medical diagnoses including multiple sclerosis and glaucoma. Review of the care plan for Resident #38 dated 04/01/25 revealed the resident was at risk for impaired skin integrity related to incontinence. Interventions included to provide incontinence care as needed for the resident. Review of the Minimum Data Set (MDS) assessment for Resident #38 dated 04/15/25 revealed the resident was cognitively intact, was always incontinent of bowel and bladder, and was dependent on staff assistance for incontinence care. Review of the task documentation for Resident #38 dated 05/16/25 revealed there was no toileting documented for the resident that day. Review of the staffing schedule for 05/16/25 revealed there were three aides on the unit where Resident #38 resided. Interview on 05/18/25 at 11:47 A.M. with Resident #38 confirmed she asked to be changed throughout the day on 05/16/25, but she didn't get changed and had to sit up for 16 hours in her wheelchair. Resident #38 confirmed Certified Nursing Aide (CNA) #131 told her they were short staffed and unable to provide incontinence care. Interview on 05/20/25 at 9:14 A.M with CNA #131 confirmed 05/16/25 was a hectic day because the facility was providing a cookout for the residents and they were short staffed. CNA #131 confirmed she was unable to provide incontinence care for Resident #38 on 05/16/25. Review of the facility policy titled Perineal Care Male/Female undated revealed the staff should provide incontinence care to dependent residents to promote a sense of well-being and meet hygiene standards of care. 2. Review of the medical record for Resident #139 revealed an admission date of 05/01/25 with diagnoses including hypothyroidism, epilepsy, and post-traumatic stress disorder. Review of the care plan for Resident #139 dated 05/01/25 revealed the resident had an ADL self-care deficit and required moderate staff assistance with bathing. Review of MDS assessment for Resident #139 dated 05/08/25 revealed the resident was cognitively intact and she required staff assistance with hygiene and grooming. Observation on 05/19/25 at 9:05 A.M., 11:21 A.M., and 2:18 P.M. of Resident #139 revealed the resident's fingernails were long, and had a dark substance under them, and her toenails were long and dirty. Interview on 05/19/25 at 2:18 P.M. with Resident #139 confirmed the aides didn't trim and clean her fingernails or toenails. Interview on 05/19/25 at 2:30 P.M with CNA #134 confirmed Resident #139's fingernails and toenails were long and dirty, and staff should provide nail care to include cleaning and trimming the resident's nails on bath day. Review of the facility policy titled Routine Resident Care undated revealed the aide should provide routine daily care which included assistance with bathing and grooming.

Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure range of motion devices were in place. This affected one (Resident #48) of two residents reviewed for positioning and mobility. The facility census was 90 residents. Findings include: Review of the medical record for Resident #48 revealed an admission date of 03/02/21 with diagnoses including epilepsy, depression, and cerebral infarction. Review of the care plan for Resident #48 dated 03/22/25 for revealed the resident had an activities of daily living (ADL) self-care deficit related to hemiplegia and hemiparesis following a cerebral infarction affecting the resident's right side with an intervention to place a rolled cloth in the resident's right hand as tolerated. Review of the Minimum Data Set (MDS) assessment for Resident #48 dated 04/02/25 revealed the resident was moderately cognitively impaired and was dependent on staff assistance with ADLs. Observations on 05/18/25 at 11:07 A.M. and on 05/20/25 at 8:24 A.M. and 11:30 A.M. of Resident #48 revealed the resident's right hand had limited range of motion (ROM) and the resident did not have a cloth placed in her right hand. Interview on 05/20/25 at 11:31 A.M. with Resident #48 confirmed she had sustained a stroke, and the staff used to place a carrot in her right hand, but someone threw it away and she hadn't received another one. Interview on 05/20/25 at 11:30 A.M. with Registered Nurse (RN) #180 confirmed the Resident #48 didn't have a rolled cloth in her right hand and she should have had one. Interview on 05/20/25 at 2:51 P.M with Therapy Manager (TM) #200 confirmed therapy had recommended staff place a cloth carrot in Resident #48's right hand as tolerated. TM #200 reported she wasn't aware the cloth carrot had been lost.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents received the appropriate level of supervision during transfer to prevent falls with injury. This affected one (Resident #61) of six residents reviewed for accidents. The facility census was 90 residents. Findings include: Review of the medical record for Resident #61 revealed an admission date of 12/23/22 with diagnoses including cerebral infarction, vascular dementia, and anxiety disorder. Review of the care plan for Resident #61 dated of 07/15/24 revealed the resident had an ADL self-care performance deficit and required assistance with ADLs with an intervention of two or more staff to assist the resident with bed mobility. Review of the Minimum Data Set (MDS) assessment for Resident #61 dated 02/19/25 revealed the resident had severe cognitive impairment and was dependent on staff assistance for all activities of daily living (ADLs) including bed mobility. Review of the fall risk assessment for Resident #61 dated 04/09/25 revealed the resident was at risk for falls. Review of the progress note for Resident #61 dated 04/29/25 timed at 12:38 A.M. revealed an incident occurred during peri-care where staff rolled the resident onto the floor. Review of the fall investigation for Resident #61 dated 04/29/25 revealed Certified Nursing Assistant (CNA) #136 was providing peri-care to Resident #61 and the aide rolled the resident onto his right side causing the resident to roll out of bed and onto the floor. Resident #61 sustained a skin tear to his right elbow and bruising to his forehead and was sent to the hospital for an evaluation and returned to the facility with no new orders. Interview on 05/21/25 at 2:01 P.M. with the Administrator confirmed Resident #61 required the assistance of two staff with peri-care. The Administrator further confirmed CNA #136 was performing peri-care on Resident #61 without additional helpers, and the aide rolled the resident out of bed and onto the floor. Review of the facility policy titled Fall Prevention and Management undated revealed it was the policy of the facility to provide physical care to meet the needs of the resident. The care plan was to include interventions that addressed resident ADL needs.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure staff followed safe hand hygiene practices during medication administration and handling of resident food. This affected two (Residents #32 and #55) of 26 sampled residents. The facility census was 90 residents. Findings include: 1. Observation on 05/18/25 at 8:56 A.M. of Licensed Practical Nurse (LPN) #154 revealed the nurse was preparing medications to administer to Resident #32. LPN #154 removed medication from Resident #32's medication dose pack and placed the medication in her ungloved hand before placing the medication into a medication cup. Interview on 05/18/25 at 8:57 A.M. with LPN #154 confirmed she touched Resident #32's medications with her ungloved hands. Review of facility policy titled Medication Administration dated 2013 revealed nurses should not touch medications with ungloved hands. 2. Observation on 05/19/25 at 12:06 P.M. of main dining room revealed Certified Nurse Aide (CNA) #110 served Resident #55 a turkey club sandwich with a packet of mayonnaise, a slice of lettuce, two slices of tomato, and at least three slices of onion on the side. CNA #110 asked Resident #55 if she wanted mayonnaise, lettuce, tomato, or onion on her sandwich. CNA #110 removed the top piece bread from Resident #55's sandwich with her ungloved hands, opened the packet of mayonnaise and applied mayonnaise, lettuce, tomato, and onion to Resident #55's sandwich without gloves on. Interview on 05/19/25 at 12:09 P.M. with CNA #110 confirmed she touched Resident #55's turkey club sandwich, lettuce, tomato, and onion with ungloved hands and she should not have done so.

Based on observation, staff interview, review of medical record, review of manufacturer insert, and review of facility reference guide the facility failed to ensure residents were free of significant medication errors when staff failed to prime insulin pens prior to administration. This affected one (Resident #82) of four residents reviewed for medication administration. The facility census was 81. Findings include: Record review of Resident #82 revealed and admitted [DATE] with pertinent diagnoses of multiple sclerosis, asthma, major depressive disorder, anxiety disorder, type two diabetes mellitus, cognitive communication deficit, anemia, convulsions, and chronic ischemic heart disease. Review of Resident #82's Physician Order dated 01/04/25 revealed Insulin Aspart FlexPen 100 units/milliliter solution pen-injector. Inject as per sliding scale: if 61 - 150 = 0 units no insulin; 151 - 200 = 3 units; 201 - 250 = 6 units; 251 -300 = 9 units; 301 - 350 = 12 units; 351 - 400 = 15 units; 401 - 500 = 20 units, subcutaneously before meals and at bedtime for diabetes mellitus type two. Review of Resident #82's Physician Order dated 01/04/25 revealed Insulin Aspart FlexPen subcutaneous solution pen-injector 100 units/milliliter. Inject 15 units subcutaneously two times a day for diabetic. Review of Resident #82's Physician Order dated 01/23/25 revealed Insulin Glargine 100 unit/milliliter solution pen-injector inject 10 units subcutaneously in the morning for diabetes mellitus. Observation on 02/13/25 at 9:10 A.M. revealed Licensed Practical Nurse (LPN) #130 completed an accucheck blood sugar check for Resident #82. Resident #82's blood sugar reading was 292 milligrams per deciliter (mg/dL) which required coverage of 9 units of Insulin Aspart added to the scheduled 15 units for a total of 24 units of Insulin Aspart. Observation on 02/13/25 at 9:12 A.M. revealed LPN #130 dialed Insulin Aspart flexpen to 24 units and did not prime the pen before dialing the 24 units. Observation on 02/13/25 at 9:13 A.M. revealed LPN #130 dialed Insulin Glargine pen-injector up to 10 units and did not prime the pen before dialing up the 10 units. Interview with LPN #130 on 02/13/25 at 9:16 A.M. verified she did not prime the insulin pens prior to administration to Resident #82. Review of the Insulin Glargine insert dated 08/01/22 revealed to perform a safety test: Dial a test dose of two units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test two more times. If there is still no insulin coming out, use a new needle and do the safety test again. Always perform the safety test before each injection. Review of Insulin Aspart insert dated 02/01/23 revealed giving the airshot before each injection: Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: Turn the dose selector to select two units hold the pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push-button all the way in, the dose selector returns to zero. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times. If you do not see a drop of insulin after six times, do not use the pen. Review of the facility insulin reference guide updated 02/01/24 revealed Insulin Glargine pen and Insulin Aspart flexpen has a pen priming requirement of two units. This deficiency represents non-compliance investigated under Complaint Number OH00161835.

Based on observation, record review, policy review, and staff interview the facility failed to maintain an infection prevention and control program to help prevent the transmission of infections when they failed to use proper hand hygiene during a dressing change, and failed to follow enhanced barrier precautions. This affected one (Resident #74) of three Residents reviewed for wounds. The facility census was 81. Findings include: Record review of Resident #74 revealed an admitted [DATE] with pertinent diagnoses of Alzheimer's disease, encounter for gastrostomy, convulsions, anxiety disorder, major depressive disorder, dementia, hypertension, atrial fibrillation, and cognitive communication deficit. Review of the 01/04/25 five day Minimum Data Set (MDS) assessment revealed the Resident was severely cognitively impaired. Review of a Physicians Order dated 01/20/25 revealed left heel-cleanse with normal saline, pat dry, apply medical grade honey, cover with silicone bordered super-absorbent dressing every night shift for wound care and as needed. Review of a Physicians Order dated 01/22/25 revealed enhanced barrier precautions related to Percutaneous Endoscopic Gastrostomy (PEG) tube, wound dressing. Review of a Physicians Order dated 02/13/25 revealed sacrum-cleanse with Dakins (debriding and wound cleanser) half strength, pat dry, skin prep periwound, apply Dakins fluffed gauze, cover with silicone bordered super-absorbent dressing every shift for wound care and as needed. Observation on 02/13/25 at 10:37 A.M. revealed Certified Nurse Aide (CNA) #112 and Licensed Practical Nurse (LPN) #122 completing incontience care for Resident #74. There was a sign on the door stating the Resident was on enhanced barrier precautions. Neither CNA #112 or LPN #122 put on gowns while providing incontience care or wound care for the resident. Observation of LPN #122 providing wound care on 02/13/25 at 10:46 A.M. revealed she gathered supplies, border silicone dressing, medihoney, normal saline, and Dakins 1/2 strength. LPN #122 washed hands, donned glove started wound dressing on the left heel/foot. She removed the old dressing, and she did not remove her soiled gloves. LPN #122 was then observed to used normal saline and gauze to clean the wound and then apply medihoney on the clean dressing and place the dressing on the left heel wound and dated the wound dressing. LPN #122 removed her gloves and donned clean gloves without completing hand hygiene. LPN #122 was then observed to remove the coccyx wound dressing, then LPN #122 removed and donned one glove without completing hand hygiene, and was then observed to cleaned the coccyx wound with gauze and Dakins solution. LPN #122 then applied Dakins soaked gauze to wound and covered the gauze with a bandage. The wound dressing was completed at 10:54 A.M. Interview with LPN #122 on 02/13/25 at 10:57 A.M. verified she and CNA #112 did not wear gowns while providing care to Resident #74 who is on enhanced barrier precautions. LPN #122 verified she did not change gloves after removing a soiled dressing and did not wash her hands or use alcohol based hand rub after removing soiled gloves multiple times during wound care. Review of the 04/01/24 facility Enhanced Barrier Precautions policy revealed enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs hand hygiene, targeted gown and glove use during high contact resident care activities that include: providing hygiene, and wound care. Review of the 02/25/22 facility Personal Protective Equipment Gloves policy revealed gloves are worn when there is potential contact with blood, body fluid, tissue from mucus membranes, non-intact skin or contaminated surfaces or equipment is anticipated. Perform hand hygiene before donning and after doffing gloves. Perform hand hygiene before and after the use of non-sterile gloves.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to follow infection control precautions when providing wound care to a resident. This affected one (#2) of three residents reviewed for infection control. The census was 81. Findings include: Review of Resident #2's medical record revealed an admitted [DATE]. Diagnoses listed included atherosclerotic heart disease, chronic kidney disease, peripheral vascular disease, osteoarthritis, depression, scoliosis, and and dysphagia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact. Observation of left leg wound care on 09/19/14 at 10:36 A.M. revealed Registered Nurse (RN) #100 removed a gauze dressing around Resident #2's left leg by cutting it with bandage scissors. RN #100 then laid bandage scissors on a bedside table. RN #100 then used the bandage scissors to cut a Xeroform (non-adherent wound dressing) to size before applying it to Resident #2's left leg wound. RN #100 did not sanitize the bandage scissors after using them to cut off Resident #2's gauze dressing or before using them to cut the Xeroform to size. RN #100 also did not wash or sanitize hands between gloves changes or after removing Resident #2's old wound dressing and applying the new wound dressing. During an interview on 09/19/24 at 11:31 A.M. RN #100 confirmed she had not sanitized the bandage scissors after cutting Resident #2's gauze dressing or before cutting the Xeroform to size. RN #100 also confirmed she did not wash or sanitize her hands between glove changes. Review of the facility's policy titled Standard Precautions dated revised 04/01/17 revealed staff should change gloves after contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings, when hands move from a contaminated body site to a clean body site during patient care, and after glove removal. This deficiency represents non-compliance investigated under Complaint Number OH00157421.

Based on medical record review, resident and staff interviews, review of self-reported incidents, and policy review, the facility failed to report an allegation of abuse to the State Survey Agency in a timely manner. This affected one (#79) of three residents reviewed for abuse. The facility census was 84. Findings include: Review of the medical record for Resident #79 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease and acute and chronic respiratory failure. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/26/24, revealed Resident #79 was cognitively intact. Interview on 05/09/24 at 10:15 A.M. with Resident #79 revealed he reported an allegation of abuse on 04/11/24 to the Administrator related to Licensed Practical Nurse (LPN) #203 sticking her finger in his face. Interview on 05/09/24 at 2:10 P.M. with LPN #203 verified Resident #79 did report to the Administrator an allegation of abuse, but stated the allegation was not true. Interview on 05/09/24 at 3:30 P.M. with the Administrator verified Resident #79 reported an allegation of abuse on 04/11/24 for LPN #203 sticking her finger in his face. The Administrator stated the facility chose not to report the incident to the State Survey Agency because they felt the incident did not occur. The Administrator stated witness statements were collected and the incident was investigated. Review of the facility's self-reported incidents (SRIs) reported to the State Survey Agency in 2024 revealed no reports were submitted regarding the allegation made by Resident #79 on 04/11/24. Interview on 05/09/24 at 4:50 P.M. with the Administrator confirmed it was the facility's policy with any allegation or suspicion of abuse to investigate the allegation and report it to the State Survey Agency. Review of the undated facility abuse policy revealed it is the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. In the event an allegation is made, the facility will take measures to protect residents from harm during the investigation. Accurate and timely reporting of incidents, both alleged and substantiated, will be sent to officials in accordance with state law. This deficiency represents non-compliance investigated under Complaint Number OH00153219.

Based on medical record review, review of hospital records, review of fall investigations, staff interviews, guardian interview, and review of facility policy for falls and nurse aide rounds, the facility failed to assess the root cause of falls, failed to identify trends and patterns of falls, failed to assess the appropriateness of added fall interventions, failed to care plan fall interventions, and failed to provide adequate supervision to prevent falls. This resulted in Immediate Jeopardy when Resident #02 had eight falls in six weeks which resulted in a fractured pelvis on 06/17/22, fractured ribs on 06/24/22, and a fall on 07/21/22 where she was found face down on the floor bleeding, was sent to the local hospital where she was subsequently transferred to a level one trauma hospital Intensive Care Unit (ICU) and found to have an [CONDITION(S)] and right-sided facial fractures. This affected one resident (#02) of six residents (#01, #02, #08, #11, #38, and #59) reviewed for falls. The facility census was 71. On 09/19/22 at 3:03 P.M., the Administrator, Interim Director of Nursing (DON), Regional Director of Operations (RDO) #157, and Regional Director of Clinical Services (RDCS) #158 were notified Immediate Jeopardy began on 06/18/22 at 4:50 A.M. after Resident #02 returned from the emergency room (ER) with a fracture of the right superior and inferior pubic rami (pelvis) following a fall. The resident had seven additional falls through 07/21/22 without the facility evaluating the root cause of the falls, implementing appropriate interventions, updating the care plan, and increasing the supervision of the resident. These falls included a fall on 06/24/22 which resulted in fractured ribs and a fall on 07/21/22 which resulted in [CONDITION(S)] as well as right-sided facial fractures requiring the resident to be transferred to the ICU of a level one trauma hospital. The Immediate Jeopardy was removed on 09/20/22 when the facility implemented the following corrective actions: On 09/19/22, all nursing staff were re-educated on the fall prevention policy by the DON. On 09/19/22, the DON/Designee began ongoing audits of staff knowledge of fall management. This will be completed with three staff members, three times per week for four weeks to ensure education is effective. On 09/19/20, the nurse management staff were re-educated on the fall protocol by RDCS #158. Education occurred again on 9/20/22 by the Administrator. Education of nurse managers reviewed the process to ensure a thorough investigation of each fall, identify patterns, and the appropriateness of the intervention for each fall. Nurse management will ensure revision of care plan and/or facility practices are updated as needed to reduce the likelihood of another fall. On 09/20/22, the clinical team of the DON, Registered Nurse (RN) #153, Licensed Practical Nurse (LPN) #74, RN #123 and RDCS #158 completed a new fall assessment on all residents and revised care plans as needed with new interventions. This clinical team updated orders, the Kardex, and plans of care to reflect resident's current fall assessment. No additional residents were identified with multiple falls. On 09/20/22, the Administrator held a Quality Assurance and Performance Improvement (QAPI) meeting with the DON, RN #153, LPN #74, RN #123, RDCS #158, and the RDO #157. In the meeting a new fall audit tool was implemented to include review of fall investigations, statements to determine root cause, identification of any patterns, appropriateness of interventions, revision of care plans, and updating the Kardex for staff. Facility will report all findings from the audits to their monthly QAPI meeting. On 09/20/22, the DON/Designee began completing an ongoing falls audit tool to include review of investigation statements to determine root cause, identification of any patterns, appropriateness of interventions, revision of care plans, visual inspection of fall prevention devices in place, and updating Kardex for staff. This will be completed for proper assessment, documentation and fall follow-up during clinical morning meeting five times a week for four weeks to ensure education is effective. The medical records for Resident #01, Resident #08, Resident #11, Resident #38, and Resident #59 were reviewed for falls, appropriate fall follow up, appropriate fall interventions, and appropriate supervision with no identified concerns. Random interviews on 09/20/22 with RN #123, RN #153, and LPN #74 verified they had been in serviced on the fall policy. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record review for Resident #02 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, non-traumatic [CONDITION(S)], depression, anxiety, unsteadiness on feet, bi-polar disorder, and repeated falls. Review of quarterly Minimum Data Set (MDS) assessment, dated 05/06/22, revealed Resident #02 was severely cognitively impaired. The resident was assessed as independent for bed mobility, walking in the room, and locomotion on the unit. The resident required supervision for transfers, walking in the corridor, locomotion off the unit, and toilet use. Review of the fall risk observation tool, dated 05/24/22, revealed Resident #02 was at risk for falls. Review of the care plan dated 11/04/21 identified Resident #02 to be at risk for falls due to impaired cognition, and safety awareness. The goal revised 05/02/22 was for Resident #02 to not sustain major injury due to a fall. Interventions dated 11/04/21 included: Complete bowel and bladder tracking to determine toileting patterns, toilet and continence programs or a timed voiding schedule as needed, ensure bed locks are engaged, call bell in reach and remind to call for assistance, and provide activities that minimize potential for falls while meeting other needs and preferences. Ensure the resident has proper footwear on was added on 05/24/22. On 06/09/09 an intervention was added to ensure the resident is wearing appropriate non-skid footwear. Review of progress note dated 06/14/22 at 7:27 A.M. revealed Resident #02's nurse was notified the resident was sitting on the floor. There were no injuries and neurological checks were initiated. The slippers were removed, and non-skid socks were placed on the resident's feet. The resident's guardian and physician were notified. Review of the fall investigation, dated 06/14/22, revealed no documentation of any analysis or staff interviews to determine where the resident was prior to the fall or if the bed was locked. The care plan was updated to include a physical therapy evaluation and treatment. Review of the progress note dated 06/17/22 at 12:30 P.M. revealed a (unidentified) State tested Nursing Aide (STNA), found Resident #02 on the bathroom floor and the resident said she fell . The resident was alert and oriented to name and birthdate and seemed to be at baseline cognitively. There was bump with an abrasion on the resident's right upper forehead/scalp line and a skin tear on the right upper arm. The resident was assisted back to bed. Oxygen saturations were 80 percent (%) on room air. New orders for treatments to the head and the skin tear were obtained. Oxygen was applied but the resident had periods when she removed it. Nurse Practitioner (NP) #800 and the resident's guardian were notified. Review of the progress note dated 06/17/22 at 4:08 P.M. revealed Resident #02's family was concerned about the head injury and wanted the resident to be sent to the hospital. An order was received to send the resident to the hospital with non-life-threatening transport. At 7:17 P.M., the resident was sent to the hospital. She returned to the facility on [DATE] at 4:50 A.M. and the Emergency Medical Technician (EMT) stated she had a fracture of the pelvis. Review of hospital records revealed a Computed Tomography (CT) scan, dated 06/17/22, showed the presence of remote fractures of the right superior and inferior pubic rami. Review of the fall investigation, dated 06/17/22, revealed Resident #02 was found on the bathroom floor. The resident stated she was going to the bathroom. The cause of the fall listed the non-skid socks were ineffective, and shoes were placed on the resident. Her oxygen saturation was 80% and oxygen was applied but she removed her oxygen at times. Neurological checks were supposed to be completed although there wasn't any record of them. It was unknown when the resident was toileted last, if anyone took her into the bathroom and left her alone, or if the resident took herself to the bathroom. The investigation listed the care plan was updated to reflect shoes were placed on the resident and to rearrange the room. Review of the care plan revealed the care plan was updated on 06/17/22 with the intervention to provide adequate lighting at night. The interventions identified in the fall investigation of shoes were placed on the resident and to rearrange the room were not added to the care plan. Review of the late entry progress note dated 06/21/22 at 11:30 A.M. revealed Resident #02 was found on the floor behind the nursing station lying on her left side. No injury was found but the resident complained about right hip pain. NP #800 was notified with an order for an X-ray to be obtained. The result of the pelvis X-ray on 06/22/22 at 6:34 P.M. revealed no acute traumatic osseous abnormality and the physician was notified. Review of fall investigation, dated 06/21/22, revealed there was a discussion with the family due to the progression of Alzheimer's and increased agitation. Further review of the investigation revealed laboratory tests were ordered. There were no interviews regarding the last time the resident was seen and what she was doing. No cause analysis was completed for this fall. Neurological checks were identified to have been initiated but there was no evidence of them being completed. The care plan had no new interventions following this fall. There was no assessment of the resident's current supervision level being appropriate. Review of the progress note dated 06/22/22 at 12:20 P.M. revealed it was reported Resident #02 was in the restroom sitting on her buttocks with her brief around her ankles. Stool was noted on the floor and the toilet seat. The resident was unable to explain what happened due to her cognitive status. It appeared the resident was trying to get off the toilet and slipped on the soiled floor. The resident did not have non-skid socks on. There were no visible injuries. The resident's oxygen saturation was 86%. The resident's guardian and the physician were notified, and neuro checks were initiated. The non-skin socks were applied, oxygen was applied, and the resident was brought to the nurses' station for further observation. Review of the fall investigation for Resident #02, dated 06/22/22, revealed the cause of the fall was the resident did not have her non-skid footwear on and stool was on the floor. She was taken to the nurses' station for close monitoring. New intervention was to offer/attempt resident with toileting every two hours. The investigation did not identify if the resident was wearing her shoes at the time of the fall, if staff assisted the resident into the bathroom and left her unattended, if the resident took herself to the bathroom, the last time the resident had been toileted, and where the resident was prior to the fall. Additionally, there no assessment of the resident's supervision needs. Review of the fall care plan revealed the intervention put into place on 06/22/22 was to rearrange the resident's room with personal items in reach. The intervention to toilet the resident every two hours was not added to the fall care plan. Review of the progress note dated 06/23/22 revealed a Comprehensive Metabolic Panel (CMP) was obtained and showed Resident #02's fasting blood glucose was low at 30 milligrams per deciliter (mg/dL). The normal measurement for fasting blood glucose is between 70-99 mg/dL. Review of a progress note dated 06/24/22 at 1:45 P.M. revealed a loud noise was heard coming from Resident #02's room. RN #129 and an unidentified STNA entered the room and found the resident sitting on her buttocks on the floor beside the bed. The resident complained of right hip pain, rib pain, and the right leg was notably shorter than the left leg. The resident was unable to say what happened due to cognition. The resident was assisted back to bed with assistance of four staff members. The physician ordered the resident sent to the hospital and the resident's guardian was notified. At 6:40 P.M., the resident returned to the facility. An X-ray of right ribs revealed there were acute nondisplaced fractures of the fourth and fifth ribs. Review of the fall investigation, dated 06/24/22, revealed the root cause of the fall was the resident attempting to transfer self. A new intervention was to add anti-rollback bars to the wheelchair, which was added to the care plan. The investigation did not identify what the resident was doing prior to the fall and the last time she had been toileted. It did not identify if she had been sitting in a wheelchair, sitting in a regular chair, or in the bed. It also did not identify if the resident had her shoes on, or any type of non-skid footwear. There was no assessment of the adequacy of Resident #02's supervision levels. The investigation did not identify this was the fourth fall the resident had in seven days between 11:30 A.M. and 1:45 P.M. Review of quarterly MDS assessment, dated 06/26/22, revealed Resident #02 was severely cognitively impaired. Her functional status had declined from last assessment, and she now required extensive assistance with one-person physical assistance for bed mobility, transfers, and locomotion on and off the unit. She required limited assistance with one-person physical assistance with walking in the room and in the corridor. She required extensive assistance with two-person physical assistance for toileting. No new fall risk assessment had been completed. Review of the Occupational Therapy discharge summary dated 06/30/22 revealed a recommendation for Resident #02 to use a wheelchair. Review of the Physical Therapy discharge summary dated 06/30/22 revealed education was provided to staff to assist Resident #02 to the wheelchair daily. Review of the record revealed on 07/01/22 Resident #02 began receiving services with Hospice. Review of a progress note dated 07/08/22 at 8:42 P.M. revealed another resident alerted the nurse Resident #02 was on the floor behind the nursing station. Resident #02 was very agitated and was sitting on her buttocks in front of a computer chair. The resident stated, The chair moved and that was it. The nurse assessed the resident and there were no apparent injuries. The resident was assisted to a locked wheelchair. The physician and the resident's guardian were notified, and education was provided to the resident. Review of the fall investigation, dated 07/08/22, revealed the resident was noted on the floor behind the nursing station and the resident said the chair moved. A new intervention was for hipsters to provide safety. The investigation did not have any interviews to find out how the resident got behind the nursing station, when the last time she had been toileted, and if she had any shoes or non-skid footwear on. Review of progress note dated 07/13/22 at 4:30 P.M. revealed RN #129 observed Resident #02 sitting on the edge of her wheelchair in the lounge area attempting to stand up. The nurse was unable to get to the resident in time to stop the fall. The resident fell forward onto the floor, landing on her right side. Resident #02 was unable to say why she was getting up unassisted. There were no visible injuries noted. The resident was assisted up with the use of a gait belt and two staff members and placed into her wheelchair. Anti-tippers were placed on the wheelchair and the resident was brought to the nursing station for further observation. The physician and the resident's guardian were notified. Review of the fall investigation, dated 07/13/22, revealed the root cause of the fall was wandering. It was indicated the anti-tippers were an appropriate intervention as the wheelchair was tipping forward. A medication review would also be conducted. The investigation did not identify the last time the resident was toileted and if she had shoes or non-skid footwear in place. Review of the fall care plan revealed an update on 07/13/22 to include a medication review. The use of the anti-tippers on the wheelchair were not added to the fall care plan. Review of the progress note dated 07/16/22 at 8:15 P.M. revealed Resident #02 was observed walking across the hall into another resident's room. LPN #120 followed the resident into the room and upon entering the room observed Resident #02 lose her balance and fall to the floor. Neuro-checks were initiated. A skin assessment was performed and a skin tear to the left posterior arm was discovered. The nurse palpated a lump to the back of resident head, it was unknown if the area existed prior to the incident. Resident #02 was assisted off the floor, walked back across the hall, and put in bed by the nurse. NP #800 and the resident's guardian were notified of the fall. Review of the fall investigation for 07/16/22 revealed neuro checks were initiated, but there was no evidence this was completed. The investigation did not identify the last time Resident #02 had been checked on or toileted and if the resident was wearing shoes or non-skid footwear. The investigation identified the resident had been wandering due to restlessness. No assessment of the resident's supervision needs had been completed. A new intervention was to provide busy mats for diversionary activity when the resident was restless. Review of the fall care plan revealed the busy mats were added as an intervention on 07/16/22. Also added as an intervention on 07/16/22 was to ensure Resident 02's room was free of accident hazards. Review of progress note dated 07/21/22 at 7:35 P.M. revealed LPN #120 heard muffled moans and started down the hall to investigate where the sounds were coming from. Upon doing so, Resident #02 was found face down on the floor with a significant amount of blood pooling around the head area. The nurse called for another unidentified nurse to come to apply pressure to the head to stop the bleeding. Nine-one-one (911) was called, and the resident was transported to the hospital. The resident's guardian and the residents' daughter were both notified of the incident. There was no evidence of documentation the facility called the physician or NP #800. Review of the hospital records dated 07/21/22, revealed Resident #02 was brought to the ER after a fall in the nursing home. She was noted with a laceration to her head and brought to the ER for treatment. A CT scan was completed with findings consistent with multiple areas of punctate hemorrhage intracranial as well as right-sided facial fractures. The resident was transferred to another emergency department for further trauma work up. Review of the progress note dated 07/22/22 at 7:14 A.M., revealed a nurse from the hospital reported the resident was in ICU and it was reported the resident had a hemorrhage to the left zygomatic fracture and fracture to the maxillary sinus. Review of the fall investigation, dated 07/21/22, revealed the resident was found face down on the floor in her room. They were unable to determine the cause of the fall. The interventions were to re-evaluate when the resident returned to the facility. The investigation did not identify if the resident had been sitting in the wheelchair, sitting in a regular chair, or in the bed; the last time the resident had been observed; the last time the resident had been toileted; and if the resident had shoes or non-skid footwear in place. The investigation did not identify this was the third fall the resident had in 13 days between 7:35 P.M. and 8:42 P.M. Interview with LPN #76 on 09/10/22 at 12:00 P.M. revealed she provided care to Resident #02. LPN #76 stated the staff did checks on Resident #02 but didn't document them in the record. She stated there weren't any orders for any increased supervision for the resident. Interview with STNA #98 on 09/10/22 at 12:51 P.M. revealed she took care of Resident #02 on multiple occasions. She revealed the resident didn't have an order for increased supervision from the normal routine checks. Interview with the DON on 09/10/22 at 1:01 P.M. revealed the facility had not implemented any increased supervision for Resident #02. She stated there should have been increased supervision for Resident #02. Additional interview with the DON on 09/19/22 at 12:05 P.M., verified it was unknown if the neuro checks were completed following the fall on 06/14/22. She confirmed for the fall on 06/17/22 it was unknown if the neuro checks were completed and unknown when the last time the resident was toileted before the fall. The DON confirmed following the fall on 06/21/22 there was no root cause analysis completed. It was unknown if neuro checks were completed. She confirmed following the fall for 06/22/22, the care plan wasn't updated to reflect the toileting every two hours. The DON stated on 06/22/22 even though the resident was found on the bathroom floor, they added an intervention to rearrange the room because the team thought if the resident had her shoes in her room where she could see them, she would place them on her feet. However, Resident #02 couldn't remember to do this. She confirmed the fall on 06/24/22 was not a complete investigation. She stated the fall was not witnessed and the DON didn't know if the resident was in the wheelchair or the bed. The DON stated she didn't have a description of the room at the time of the fall to identify where the wheelchair was located when they found the resident. She said the intervention for the anti-rollback bars for the wheelchair was implemented in case she was in her wheelchair prior to the fall. The DON revealed on 07/08/22, Resident #02 was at the nurses' station with staff but didn't know if the staff were sitting directly with her or if they were within eyesight of the resident. The DON confirmed the investigation for the fall on 07/13/22 was not thorough. The DON stated on 07/16/22 the intervention to ensure the room was free of accident hazards was to ensure the resident didn't fall over anything in her way and was a safety measure even though the resident didn't fall in her room. She stated she did an investigation following this fall but didn't have any evidence of the investigation. The DON confirmed the fall on 07/21/22 was not fully investigated. She stated the fall would have been investigated when the resident returned from the hospital. The DON verified after investigating all of these falls, she didn't recognize any trends regarding the times Resident #02 was experiencing falls. Interview with Guardian #159 on 09/20/22 at 10:33 A.M. revealed Resident #02 was declining while in the nursing home the last few weeks of her stay. She said there were several falls and the facility contacted her to talk about the falls. She said following the fall on 07/21/22, the resident was sent out to the hospital and the facility contacted her. She had to call the hospital to see how the resident was doing and discovered she had been taken by helicopter to a nearby trauma center for her injuries. The resident had a neurological consultation, and it was decided to send her to inpatient hospice care. Review of the facility policy titled Nurse Aide Rounds, dated 02/14/22, revealed the STNAs provide patient centered care by monitoring patient care needs and safety on a routine basis throughout the day per the facility and individual needs. Review of the facility policy titled Fall Prevention and Management, dated 06/01/22, revealed a fall risk assessment should be completed quarterly and with each change of condition. If at risk for falls a care plan should be initiated. The care plan should be reviewed and updated as needed. After a fall, a fall investigation should begin. Interview any witnesses and the resident. Attempt to identify why the resident fell and put an immediate intervention in place. The interdisciplinary team (IDT) should review all information for all falls at the next Daily Clinical Meeting. The team should discuss the fall, potential causes of the fall, interventions put into place and if they are effective. A deep root cause investigation should be discussed. The care plan should be reviewed to identify if interventions are appropriate or if new interventions should be added. The team should have a way to inform all care givers of new interventions placed in the care plan. This deficiency substantiates Complaint Number OH 359.

Based on medical record review and staff interviews the facility failed to ensure Resident #8 received adequate assistance with bathing to prevent the resident from falling. This caused actual physical harm to Resident #8 when she fell off the bed during her bed bath and onto the floor, sustaining a broken hip. This affected one (Resident #8) of three residents reviewed for falls. The facility census was 89. Findings include: Review of Resident #8's closed record revealed she was admitted to the facility on [DATE] and was discharged on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the annual minimum data set (MDS) 3.0 assessment dated [DATE] identified the resident as being rarely/never understood, being severely cognitively impaired with decision making, The resident was total dependence with two person assist with bathing. Review of the hospital notes dated 09/05/17 revealed the hospital identified Resident #8 as being a functional [MEDICAL CONDITION] (complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the brain or spinal cord). The physical exam revealed the resident has spontaneous movements of all extremities. Review of the Resident #8's care plan revealed the resident is at risk for falls related to advanced [MEDICAL CONDITION], dependent/total care and has no recovery ability if should began to fall. Review of Resident #8's activity of daily living (ADL) care plan revealed the resident has ADL self-care performance deficit related to advanced Alzheimer's, dependent/total care for all aspects of care. Interventions revealed the resident was dependent with bathing and dressing. Review of the State tested Nurse Aide (STNA) 'Bedside Kardex Report' identified Resident #8 as being dependent with bathing, bed mobility, dressing, personal hygiene, toileting and transferring using a mechanical lift. Review of the nurses note on 12/13/17 at 11:22 P.M. revealed STNA #94 called for the nurse and the resident was laying on the floor at bedside. The STNA stated she was giving a bed bath and the resident was soapy and slid off the edge of the bed to the floor. The resident was assessed for injury and there was none noted. The resident was lifted from the floor to the bed and reassessed for injury and none noted, the resident's eyes were open and remains non-responsive as usual and there were no signs or symptoms of pain and neuro checks were initiated. It revealed the doctor was notified and there were no new orders. Review of the nurses note on 12/14/17 at 3:54 A.M. revealed the STNA reported the resident was having facial grimacing and moaning with repositioning, especially when moving left hip. It indicated the nurse assessed and there was no noted shortening of the left leg, no redness, no bruising noted; grimacing and moaning during range of motion of left hip and the physician was notified with new orders for x-ray of left hip and as needed Tylenol given for signs and symptoms of pain. Review of the nurses note on 12/14/17 at 2:50 P.M. revealed the x-ray results returned and a left intertrochanteric fracture was identified. The physician was notified of the results and new orders to send to the emergency department for evaluation and treatment. Review of the facility's Initial Post-Episode Documentation/Investigation dated 12/15/17 at 8:53 A.M. revealed the episode happened on 12/13/17 at 10:59 P.M. It indicated the STNA called for the nurse and the resident was laying on the floor at the bedside. The STNA stated that she was giving a bed bath and the resident was soapy and slid off the edge of the bed to the floor. Interview with the Director of Nursing (DON) on 01/03/18 at 8:51 A.M. revealed the STNA was providing care to Resident #8 and the resident had rolled out of bed when she was on her side during a bed bath. She voiced initially there was no injury observed. However, then staff noticed grimacing and moaning and an x-ray was obtained that noted a positive [MEDICAL CONDITION] and she was sent to the hospital. Interview with the DON on 01/03/18 at 12:31 P.M. confirmed STNA #94 was the only STNA in the room. Interview with MDS Nurse #112 on 01/03/18 at 12:24 P.M. revealed Resident #8 required two-person assist with bed mobility and bathing and was totally dependent on staff for her ADLs including bathing. MDS Nurse #112 confirmed there should have been two people bathing the resident. Interview with STNA #92 on 01/03/18 on 2:22 P.M. revealed she could turn Resident #8 by herself, however she was a bigger lady, so sometimes turning her could be difficult. STNA #92 voiced she would be able to complete the resident's bed bath by herself. However, there would be times when the resident would be 'jerky' with all her extremities and she would then go get assistance. Interview with Licensed Practical Nurse (LPN) #50 on 01/03/18 at 2:25 P.M. revealed Resident #8 was a total dependent with assist of one or two people with turning and with bathing. LPN #50 voiced the resident would occasionally have spontaneous movement and jerks. This deficiency substantiates Complaint Number OH 290 and OH 237.

Based on record review, interview and observation the facility failed to monitor and evaluate the impact of weight management interventions to prevent a significant, avoidable weight loss for one (#83) resident. Seven residents were reviewed for weight loss and the facility identified three residents who has suffered a significant weight loss in the past six months. Findings include: Review of Resident #83's physician order [REDACTED]. The resident's admission weight was 162.8 pounds. The resident's admission Nutritional assessment dated [DATE] indicated the resident was at high nutritional risk, was to receive a regular low simple sugar diet and the facility would monitor for the need for nutritional interventions. A dietary progress note dated 03/07/11 stated Resident #83 was consuming 25 to 50 percent of her meals, was having increased agitation and was hard to feed. A Dietary Progress Note dated 03/16/11 stated Resident #83 was having difficulty chewing due to ill-fitting dentures and the diet consistency had been decreased to ground meat and then further decreased to puree on 03/14/11. The note indicated the resident was consuming 25 percent of meals and silent to any referral made to the a dentist or to speech therapy in reference to the ill-fitting dentures and chewing problems. A Dietary Progress Note dated 03/16/11 stated the residents intakes continued to be low and the facility was going to offer sugar-free health shakes with breakfast, lunch and diner and a nutritional supplement with medication pass and the resident remained on weekly weights. A Dietary Progress Note dated 03/31/11 indicated the resident's [MEDICATION NAME] was less than 5 milligrams per dL, which indicated severe protein depletion. Registered Dietitian #50 recommended an appetite stimulant and on 04/01/11 the resident was started on [MEDICATION NAME] 15 milligrams daily for low appetite. The medical record contained no documentation any additional protein supplement was offered to the resident to aide in increasing her protein levels. The resident's April 2011 weight was 161.2 pounds and on 05/13/11, her weight was 156.3 pounds, which indicated a three percent weight loss in one month. A Dietary Progress Note dated 05/30/11 noted the resident's weight loss, but contained no documentation of any additional interventions to help slow or stop the weight loss, did not indicate how well the resident was accepting the nutritional supplements and did not recommend any request for another [MEDICATION NAME] level to measure the resident's protein level. The note did state the resident continued to have variable intakes of 25-75 percent of meals. The resident's weight on 06/07/11 was 138.7 pounds; the resident was weighed again on 06/13/11 which indicated the resident's weight was 144 pounds. This indicated a 7.9 percent weight loss in one month. A Dietary Progress Note dated 06/23/11 documented the resident's significant weight loss, reviewed the resident's current nutritional interventions and stated some of the resident's weight loss was due to fluid fluctuation. No new nutrition interventions were put into place. The note did not document how well the resident was accepting the current supplements and did not recommend any request for another [MEDICATION NAME] level to measure the resident's protein level. The resident's weight on 07/05/11 was 137 pounds which indicated a significant weight loss of 12 percent in two months. A Dietary Progress Note dated 07/19/11 documented the resident's significant weight loss, reviewed the resident's current nutritional interventions and revealed the resident had developed a pressure sore. The note recommend the resident be started on a protein supplement to promote wound healing. The note did not indicate how well the resident was accepting the current supplements. On 07/20/11 at 8:15 A.M. Resident #83 was observed in bed and State tested Nursing Assistant (STNA) # 80 was feeding the resident breakfast. The resident's breakfast consisted of pureed eggs, fat free milk, four ounces of orange juice, light yogurt and hot cereal. The resident took only bites of the food items, drank all her orange juice and took a couple sips of milk. The resident did not receive the ordered nutritional shake at breakfast. When interviewed on 07/20/11 at 8: 21 A.M. STNA # 80 stated the resident intakes of meals varies but she usually drinks well. STNA #80 stated the resident did not get a nutritional shake with her meal, but stated she was going to tell the nurse the resident did not eat well and ask if she could get a supplement for her. During interview on 07/21/11 at 11:50 A.M. Dietetic Technician (DTR) #71 stated on 03/14/11 Resident #83's diet was downgraded to a mechanical soft diet, then to a pureed diet because of ill fitting dentures and chewing problems. DTR #71 stated she had not recommended the resident be evaluated by a dentist or by a speech therapist. DTR #71 stated she normally would refer the resident to the appropriate discipline, but did not remember why she had not done so for Resident #83. DTR #71 stated she would have liked Resident #83 to be on weekly weights after the resident started to lose weight and did not know why weekly weights had never been implemented. DTR #71 stated she had not started the resident on additional supplements because she was already on some and confirmed she had no way to track the acceptance of the health shake supplements which the resident received at lunch and dinner. DTR #71 stated the health shakes were never ordered by the physician and they were not transcribed to the treatment record or the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] During interview on 07/21/11 at 12:20 P.M. Registered Dietitian (RD) # 50 stated she had asked for the appetite stimulate on 03/31/11 in response to the resident's low [MEDICATION NAME] because the resident's meal intakes were poor. RD #50 stated she did not recommend any additional protein supplement at that time because she did not believe the [MEDICATION NAME] was a good indicator of the resident's protein stores because the resident had some impaired kidney function. RD #50 stated the resident's new skin breakdown was an indication that the resident's protein levels were low, so the facility had recommended a protein supplement on 07/19/11 to help with wound healing.