Every finding on record at The Enclave at Barnesville

Based on observation, medical record review, review of facility policies, and interview, the facility failed to develop and implement comprehensive, individualized and adequate pressure ulcer interventions to prevent the development of a pressure injury/ulcer for Resident #55. This affected one resident (#55) of one resident reviewed for facility acquired pressure injuries. The facility census was 52. Actual harm occurred on 03/26/26 when Resident #55, who was assessed to be dependent on staff for personal care including turning and repositioning in bed, had multiple hospitalizations placing her at high risk for development of pressure injuries, was not provided necessary and appropriate interventions to prevent the development of a pressure injury and subsequently developed an unstageable pressure injury (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) to her right buttock gluteal fold resulting in the resident experiencing increased pain during movement and pressure injury treatments. Findings Include: Review of the medical record for Resident #55 revealed admission to the facility on [DATE] with diagnoses of chronic respiratory failure, oxygen dependence, lung disease, fibromyalgia, diabetes, depression, anxiety, high blood pressure, chronic kidney disease stage 4, gastric reflux, cirrhosis of the liver. New diagnosis of a pressure ulcer injury of right buttock was added on 03/21/26 and a diagnosis of fall with brain bleed was added on 04/23/26.On 01/10/26 there was a physician order to start (on 01/11/26) the application of house barrier cream to peri-area/buttocks after each incontinence episode and as needed to prevent skin breakdown, may leave at bedside.Review of Resident #55's care plan titled Actual Skin Breakdown related to Unstageable Gluteal Fold initiated on 01/11/26 and revised on 04/13/26 revealed the following interventions: apply barrier cream after each incontinent episode and as needed, assist the resident to reposition and/or turn at frequent intervals to provide pressure relief, keep skin clean and dry, report changes to skin integrity to nurse, teach resident/family the importance of changing positions for prevention of skin breakdown and encourage small frequent position changes.Review of Resident #55's task documentation January 2026 through May 2026 (where direct care staff documented care being provided to the resident) revealed no evidence staff assisted the resident with turning and repositioning to provide pressure relief or evidence of offloading pressure, and evidence of encouragement/education of the resident for frequent position changes. Review of the Minimum Data Set (MDS) 3.0 initial comprehensive assessment completed with modifications dated 02/05/26 revealed Resident #55 had no hearing or visual impairments and the resident was able to make her needs known and understand others. Further review revealed a Brief Interview for Mental Status score of 15/15 indicating Resident #55 was cognitively intact. Review of section GG of the MDS revealed Resident #55 was dependent on staff for transfers, dressing, bathing, hygiene, bed mobility, and personal care. Resident #55 was utilizing a mechanical lift by staff for transfers and was not mobile at time of assessment. Review of section M of the MDS assessment for Resident #55 revealed she was at risk for the development of pressure injuries and on admission to the facility there were no current skin issues. Further review of section M of the MDS 3.0 revealed use of pressure relieving device to chair and bed as well as use of ointment/creams for prevention of pressure ulcers for Resident #55. Review of the Braden Scale Assessment (nationally recognized tool to evaluate pressure injury risk) completed on 02/10/26 revealed a score of 15/22 indicating Resident #55 was at moderate risk for pressure ulcer development. Per the Braden Scale Assessment, the resident required staff assistance with positioning.Review of Resident #55's physician/medical provider orders revealed no evidence of orders for pressure relieving devices for the chair or bed. Review of the Nurse Practitioner (NP) history and physical skin and wound assessment completed by NP #302 on 03/05/26 revealed Resident #55's skin was intact (no wounds noted) and the resident remained at high risk for skin breakdown due to mobility limitations and comorbid conditions (chronic medical issues).Review of the weekly skin assessment for Resident #55 dated 03/13/26 revealed no evidence of an unstageable pressure injury to the right buttock gluteal fold. A nursing progress note dated 03/19/26 revealed Resident #55 went out to the hospital on [DATE] due to critical sodium levels.The resident was admitted to the hospital for treatment and returned to the facility on [DATE]. Review of the re-entry nursing assessment for Resident #55 completed on 03/21/26 by Registered Nurse (RN) #223 revealed the presence of moisture associated skin damage (MASD) to the resident's bilateral buttocks. There was no evidence of measurements or presence of any wounds or pressure injury documented. There was no evidence of interventions in place or treatments of MASD or any interventions for pressure relief. There was no evidence the facility implemented pressure injury interventions including pressure reduction in the resident's wheelchair, offloading pressure to the resident's buttocks, and implementing frequent turning and repositioning even though the resident was at an increased risk for pressure injury development based on the recent hospitalization and the skin impairment identified as MASD by the facility.Review of the nurse progress notes revealed on 03/24/26 Resident #55 left the facility in her wheelchair to attend a physician appointment from 10:40 A.M. with a return at 1:01 P.M. Resident #55 had no pressure injury reduction measures in place in the wheelchair.Review of the Nurse Practitioner (NP) history and physical completed by NP #300 on 03/26/26 revealed the presence of an unstageable pressure injury to the right buttock gluteal fold measuring 5.0 centimeters (cm) in length (l) by 3.0 cm wide (w) by 0.3 cm depth (d) and the wound bed was covered with 100% slough (a film of dead cells and white blood cells). The NP note further recommended wound care to consist of cleansing wound with normal saline, applying medical grade honey to base of wound, and securing with a bordered foam dressing daily and as needed if soiled. However, review of the treatment administration record (TAR) for March 2026 revealed no wound care or treatment performed to the right buttocks for Resident #55 from 03/21/26 (when staff first identified the resident had MASD) until 03/29/26. Review of the nursing progress notes for Resident #55 revealed no evidence or documentation of an unstageable pressure ulcer or treatment from 03/21/26 through 03/29/26. Review of the weekly skin assessment for Resident #55 dated 03/27/26 revealed no evidence of an unstageable pressure injury to the right buttock gluteal fold (even though NP #300 had identified the ulcer on 03/26/26). A nursing progress note dated 03/29/26 at 1:32 P.M. authored by RN #208 revealed when assisting resident to the bathroom, resident stated her bottom is sore, when this nurse assessed resident's bottom, noticed an open area on right gluteal fold measuring 4.0 cm by 2.5 cm by >0.1cm, notified doctor and resident's son. The note included the resident dominates right side when lying in bed.Review of Resident #55's subsequent physician orders revealed an order obtained on 03/29/26 to assess area under right gluteal fold for signs and symptoms of infection, notify physician (MD) every shift until healed. In addition, there was an order to start on 03/30/26 to cleanse area under right gluteal fold with normal saline or wound cleanser, pat dry, apply xeroform gauze (a medicated bandage) cut to wound size and then foam dressing every day shift for wound healing until healed.Continued review of the weekly skin assessments and treatments for Resident #55's pressure ulcer wound to right gluteal fold revealed on 04/02/26 NP #300 staged the pressure ulcer as unstageable and measured at 3.5 cm (l) x 2.5 cm (w) x 0.3 cm (d) with 100 % slough present. An order was recommended to change wound care to cleanse with wound cleanser/normal saline, apply medical grade honey to base of the wound, and apply boarder foam and change daily and as needed if soiled/loose.On 04/09/26 NP #300 noted Resident #55's wound measurements were 3.5 cm (l) x 2.5 cm (w) x 0.3 cm (d) and 10% granulation and 90% slough and continue current wound care. Wound remained unstageable due to presence of slough.On 04/11/26 Resident #55 had a hospitalization for pneumonia, UTI, and subdural hematoma.On 04/23/26 Resident #55 returned to the facility from her hospital admission and a skin assessment was completed by the staff nurse. The assessment identified that the resident had no new skin impairment.On 04/28/26 Resident #55 was hospitalized again for a gastrointestinal bleed but returned to facility on 04/29/26. A skin assessment was completed by a facility staff nurse and noted no new open areas.On 04/30/26 Resident #55 was assessed by NP #300 and noted the right gluteal fold pressure ulcer was now stageable and assessed to be a Stage III pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) with measurements of 3.0 cm (l) x 1.5 cm (w) x 0.3 cm (d) and a wound bed that was 100% granulation. New wound care recommendations were made to start on 05/01/26 to include, cleanse area with normal saline/wound cleanser, apply collagen to wound bed and cover with bordered foam every day shift until healed.Observation and interview on 05/04/26 at 12:30 P.M. revealed Resident #55 sitting in bed eating lunch. At the time of the observation, Resident #55 reported she did have a sore on her buttocks but was unsure how long it had been there or how it was healing. Observation on 05/05/26 at 12:20 P.M. revealed Resident #55 sitting up in wheelchair eating lunch. There was no pressure relieving device noted in the wheelchair. Resident #55 was sitting on a pillow. Observation on 05/06/26 at 1:20 P.M. revealed Resident #55 lying in supine position in bed. There was no evidence of a pressure relieving device for the wheelchair present by the bed. At the time of the observation, interview with Certified Nursing Assistant (CNA) #263 verified there was no pressure relieving device to the resident's wheelchair. Interview on 05/06/26 at 3:10 P.M. with RN #208 revealed that when a resident was at risk for developing pressure injuries the admission nurse would be responsible for getting orders from the doctor or provider for pressure relieving device use. RN #208 verbalized on admission when a resident has a wound, staff notify the Assistant Director of Nursing (ADON) if she was available that day or the next morning during morning report so she could evaluate the resident further. RN #208 revealed pressure injury prevention would include the use of a barrier cream, turning residents every 2-3 hours, and use of special mattress and cushions. RN #208 reported she could not find an order for pressure relieving devices for Resident #55 and that yesterday, 05/05/26, when Resident #55 got up in wheelchair the resident asked for a pillow to sit on for comfort and a pillow was placed. RN #208 further reported that sometimes Resident #55 was not always compliant with turning on her sides to relieve pressure from her buttocks but was encouraged by staff to do so. (Note- there was no documentation the resident was non-compliant with turning and repositioning or offloading pressure.)On 05/06/26 at 3:34 P.M. Resident #55 was observed receiving wound care completed to the right buttock gluteal fold by RN #208. Further observation revealed a pressure injury to the right buttock gluteal fold with a moist pink wound bed that appeared to be free of infection and healing with a scant amount of brownish drainage to the old dressing. During the treatment, Resident #55 was observed to wince, making a vocal noise and pulling her right buttocks away (guarding behavior indicating pain) when RN #208 performed wound care. Resident #55 did verbalize some discomfort with wound care but reported the pain was becoming less from when she initially developed it (the pressure injury). Resident #55 reported she tried to lay on her sides but stated she didn't like lying on her left side and lays on her back or right side mostly. Interview on 05/07/26 at 12:25 P.M. with Nurse Practitioner (NP) #300 revealed she had recently started treating residents at the facility about two months prior. NP #300 reported she completed skin assessments on all newly admitted residents and the re-entry of residents who had been hospitalized (NP #300 had initially seen Resident #55 on 03/26/26 due to the resident's recent re-entry to the facility from the hospital). NP #300 reported RN #215 always rounded with her and they would verbally discuss wound care and treatments. NP #300 reported she would write wound care recommendations on her notes and tell RN #215 verbally the wound care orders, but RN #215 was responsible for entering the wound care orders into the electronic medical record. NP #300 reported there was one week in March (2026) when RN #215 was not available to round with her and was not working. NP #300 reported that on that day she just wrote up her notes with wound recommendations (03/26/26), a report would have been available for RN #215 to review to enter or change any orders. During the interview, NP #300 verbalized she saw Resident #55 for the first time on 03/26/26 as an initial skin assessment since re-entry to the facility after a hospitalization and was not consulted for any specific reason at that time. NP #300 confirmed she diagnosed Resident #55 with an unstageable pressure injury to her right buttock gluteal fold on 03/26/26 and recommended wound care. NP #300 reported she was not aware that the orders for Resident #55 were not entered into the computer or completed from 03/26/26 to 03/29/26. NP #300 reported that the pressure injury to Resident #55 could have been preventable with recommendations of turning and positioning (no evidence this was completed by the facility), use of pressure relieving devices (no pressure relieving device in the resident's wheelchair), barrier creams, and appropriate nutrition. Interview on 05/07/26 at 12:47 P.M. with the MDS Coordinator/Assistant Director of Nursing, RN #215 revealed the most recent MDS assessment from re-entry on 03/21/26 revealed Resident #55 had one unstageable pressure injury present on re-entry from facility was inaccurate. RN #215 confirmed the medical records for Resident #55 revealed the presence of moisture associated skin damage (MASD) to bilateral buttocks on 03/21/26 with no indication of pressure injuries. RN #215 proceeded to update the MDS assessment with modification to reflect no pressure injury present on 03/21/26. Further interview with RN #215 revealed she was the RN responsible in the facility for assessment of wounds weekly and that RN #208 also rounded weekly with the wound nurse practitioner. RN #215 verbalized that the staff nurses would describe the presence of a wound, describe the appearance of the wound, and measure the wound on admission but the staff nurses do not diagnosis or stage pressure injuries/wounds. RN #215 further reported she would assess the wounds the same day or next day she worked to determine if a pressure injury and the stage of the injury. RN #215 confirmed there was no documentation or evidence in the medical record for Resident #55 from 03/21/26 until 03/26/26 indicating the resident had an unstageable pressure injury. RN #215 also confirmed there was no documentation of a wound assessment completed for Resident #55 by RN #215 between 03/21/26 and 03/26/26. Further interview with RN #215 revealed she was responsible for completing and updating the resident care plans. RN #215 verified Resident #55's plan of care initiated on 01/11/26 titled Actual Skin Breakdown related to Unstageable Gluteal Fold was not accurate as Resident #55 did not have actual skin breakdown on 01/11/26 and the resident had not developed the unstageable pressure injury to her right gluteal fold until 03/26/26. RN #215 revealed there were no pressure injury prevention care plans in place for Resident #55 until the development of the unstageable pressure injury to the right buttocks gluteal fold on 03/26/26. Review of the facility policy titled, Pressure Ulcer/Injury Risk Assessment, and revised July 2017 revealed once assessments were conducted and risk factors identified, a resident-centered care plan would be developed to address the modifiable risk for pressure injuries. Further review revealed the risk assessment should be conducted as soon as possible after admission or within eight hours after admission was completed.

Based on review of facility records, observation of kitchen and meal service, and interview with staff, the facility failed to store food in a sanitary manner and the drainpipes were maintained to prevent sewage odor in the kitchen. This had potential to affect 52 residents who receive meals from the kitchen. The facility census was 52.Findings Include: 1.Observations on 05/04/26 between 8:10 A.M. and 8:34 A.M. during the initial kitchen tour revealed the dry storage pantry had a strong sewage smell coming from an open drainpipe in the floor. Dietary Manager (DM) #209 verified the odor and reported it had been that way for several months and both administration and maintenance were aware of the concern. Observation and interview on 05/05/26 at 4:20 P.M. with DM #209 revealed the odor in the dry storage area was no longer present. DM #209 reported the Maintenance Director from one of the other facilities came earlier that day and snaked the drain and poured vinegar and baking soda down the drain as well. DM #209 further shared that the drain needed water ran through it monthly to prevent odors and DM #209 was unaware this needed to be completed.2. Observation during the kitchen tour on 05/04/26 between 8:10 A.M. and 8:34 A.M. revealed the walk-in cooler temperature was 42 degrees Fahrenheit, and the walk-in cooler had only one fan working to circulate air. This was verified by DM #209 at that time of the observation. The DM reported administration and maintenance were aware of the broken fan but had not yet fixed it and it had been two weeks, or longer since the fan broke. On 05/05/26 observation of the dinner meal service revealed dietary cook (DC) #231 checked food temperatures prior to serving the dinner meal. The canned beets that were placed in the walk-in cooler at approximately 1:50 P.M. and removed at 4:55 P.M. had a temp of 53.2 degrees Fahrenheit. This was verified by DC #231. The canned fruit cocktail was placed in bowls in the walk-in cooler at approximately 2:00 P.M. and removed at 4:55 P.M. and had a holding temp of 49.0 degrees Fahrenheit. This was verified by DC #231 at the time of the observation.Interview on 05/05/26 at 5:15 P.M. with the facility Chief Executive Officer (CEO) revealed he was aware of the issue with the walk-in cooler fan not working and believed that a part had been ordered from [NAME] or [NAME] may have come and looked at the unit. The CEO reported he would look for invoices or receipts from [NAME].Review on 05/06/26 at 8:00 A.M. of an online order receipt revealed a new fan for the walk-in cooler was ordered on 05/05/26. There was no evidence of the fan being ordered or an estimate provided for repair prior to 05/05/26.Review of the facility Food Receiving and Storage, policy revised 2017 revealed refrigerated foods will be stored below 41 degrees Fahrenheit and will be stored in such a way that promotes adequate air circulation. Further review of the policy revealed foods in designated dry storage areas will be clear of sewage/waste disposal pipes and vents.Review of the United States Department of Agriculture (USDA) website for recommendations for safe handling, Danger Zone (40 F - 140 F) | Food Safety and Inspection Service, revealed cold foods should be kept at or below 40 degrees Fahrenheit, and place food on ice. Further review revealed the danger zone of foods left at temperatures between 40-140 degrees Fahrenheit for as little as 20 minutes can lead to doubling of bacterial growth leading to food borne illness.

Based on medical record review and staff interview the facility failed to ensure resident assessment data accurately reflected the residents' status. This affected four residents (Resident #8, #29, #30 and #55) of 46 resident records reviewed for accuracy of assessments. The census was 52. Findings include: 1.Review of the medical record for Resident #8 revealed an admission to the facility on [DATE] with diagnoses including urinary tract infection, Parkinson's disease, spinal stenosis, major depression, and high blood pressure. Review of the most recent minimum data set (MDS) 3.0 comprehensive initial assessment completed on 03/30/26 for Resident #8 revealed item N0350 answered 01 indicating that Resident #8 received insulin injections. Review of the physician order for Resident #8 revealed no insulin orders. Review of the medication administration records for March and April of 2026 for Resident #8 revealed no insulin injections provided. Interview on 05/06/26 at 10:41 A.M. with the MDS coordinator, Registered Nurse (RN) #215 revealed that on 05/04/26 after reviewing the Matrix document provided to the survey team at 9:04 A.M. she realized that Resident #8's MDS item N0350 was incorrectly answered as 01 indicating that Resident #8 was receiving insulin injections however after review it was found that Resident #8 did not receive insulin injections and the MDS was modified on 05/04/26 at 2:44 P.M. to reflect the correct answer for N0350 as 00 (no insulin injections received). 2.Review of the medical record for Resident #29 revealed an admission to facility on 04/09/26 with diagnoses including acute respiratory failure, depression, hyponatremia (low salt level in blood), gastrointestinal bleed, anemia, high blood pressure, and hepatic encephalopathy (water on brain leading to confusion). Review of the most recent minimum data set (MDS) 3.0 comprehensive initial assessment completed on 04/23/26 for Resident #29 revealed item N0350 answered 01 indicating that Resident #29 received insulin injections. Review of the physician orders for Resident #29 revealed no insulin orders. Review of the medication administration record for April of 2026 for Resident #29 revealed no insulin injections provided Interview on 05/06/26 at 10:41 A.M. with RN #215 revealed Resident #29 did not have a diagnosis of diabetes and was not ordered insulin or received insulin injections. RN #215 verified the MDS completed and signed by her on 04/23/26 for Resident #29 indicated item N0350 was answered 01 which indicated Resident #29 received insulin injections and that was incorrect and the answer needed modified to reflect 00 which indicated Resident #29 did not receive insulin injections. RN #215 made the modification to the MDS assessment at that time. 3.Review of the medical record for Resident #55 revealed admission to facility on 01/10/26 for diagnoses of chronic respiratory failure, oxygen dependence, lung disease, fibromyalgia (chronic pain in various nerve endings), diabetes, depression, anxiety, high blood pressure, chronic kidney disease stage 4, gastric reflux, cirrhosis (scarring ) of the liver, and new diagnoses of a pressure ulcer injury of right buttock on 03/21/26. Review of the most recent minimum data set (MDS) 3.0 quarterly assessment with assessment review date (ARD) of 04/29/26 for Resident #55 revealed item M0300 C2 was answered as 01 indicating presence of a stage three pressure ulcer present upon reentry to the facility. Review of the MDS 3.0 discharge from facility with anticipated return assessment completed on 03/19/26 revealed no current pressure injuries/ulcers. Review of the nursing assessment for Resident #55 completed on 03/21/26 after return to the facility by RN #223 revealed the presence of MASD (moisture associated skin damage) to the bilateral buttocks. There was no evidence of measurements or presence of any wounds or pressure injury documented. Review of the Nurse Practitioner (NP) history and physical completed by NP #300 on 03/26/26 revealed the presence of an unstageable pressure injury to the right buttock gluteal fold measuring 5.0 centimeters (cm) in length by 3.0 cm wide by 0.3 cm in depth and the wound bed was covered with 100% slough (a film of dead cells and white blood cells). Interview on 05/07/26 at 12:47 P.M. with RN #215 revealed the Matrix completed for Resident #55 on 05/04/26 did not have a stage three pressure ulcer/injury. After review of the medical records RN #215 verified Resident #55 did not have an unstageable pressure injury upon returning to the facility on [DATE] after a three-day hospital stay and was not noted in the medical record until 03/26/26. RN #215 modified the Matrix and the most current MDS 3.0 discharge assessment completed on 04/10/26 to reflect the correct answer of not having a pressure injury on most recent re-entry to facility. 4. Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, hypertension, and chronic kidney disease. Review of Resident #30's physician's orders revealed she was to receive Simvastatin (medication used to lower cholesterol levels in the blood) 10 milligrams (mg) po (oral) every night at bedtime for hypercholesterolemia (high cholesterol levels in the blood). The order had been in place since 06/18/24. Review of Resident #30's active care plans revealed she had a care plan in place for having hypercholesterolemia. The interventions included administering medications per physician's orders. Review of Resident #30's medication administration record (MAR) for March 2026 revealed the resident was documented as having received Simvastatin 10 mg by mouth (po) every night at bedtime as ordered. She was documented as having received the Simvastatin nightly between 03/10/26 and 03/16/26. Review of Resident #30's quarterly MDS assessment dated [DATE] revealed the assessor completing the MDS assessment was to code all active diagnoses the resident had in the past seven days. The section for metabolic diagnoses included a box to check, if the resident had the diagnosis of hyperlipidemia (e.g., hypercholesterolemia), but the box was left unchecked. On 05/07/26 at 9:25 A.M., an interview with the Director of Nursing (DON) confirmed Resident #30's quarterly MDS assessment completed on 03/16/26 was not coded accurately, as it did not identify the resident as having the diagnosis of hypercholesterolemia under her active diagnoses. He acknowledged Resident #30 had been receiving Simvastatin 10 mg po every night at bedtime for hypercholesterolemia during the seven day assessment period and her diagnoses coded on the MDS assessment should have reflected so.

Based on review of the facility dietary manual, observation, tasting of the pureed dinner items, and interview, the facility failed to ensure foods were prepared to an appropriate puree consistency. The had the potential to affect nine residents (Residents #3, #12, #17, #22, #27, #32, #56, #57, and #58) the facility identified as receiving a puree diet. The facility census was 52. Findings include:Observations on 05/05/26 between 1:12 P.M. and 1:50 P.M. of the pureed food preparation revealed dietary cook (DC) #231 had prepared beets, fruit cocktail, and grilled chicken for the dinner meal. All foods were processed in the robot coup (a specialized blender utilized to make pureed foods) for the puree process. DC #231 pureed nine premeasured servings of beets in the robot coup and then after visualizing the pureed beet consistency, began to place the beets into serving dishes for the dinner meal. The surveyor requested to taste the pureed beets to ensure were of pureed consistency. DC #231 stated she had never tasted pureed foods for consistency or taste. Tasting of the pureed beets revealed a crunchy texture in a semi thin liquid that was separated from the beets but tasted appropriate. DC #231 and Dietary Manager (DM) #209 verified the beets had a crunchy texture and not a smooth texture found with pureed food items. DC #231 returned the beets to the robot coup and pureed them several minutes longer and retasted prior to spooning into serving bowls.Review of the facility literature provided titled Pureed Diet, from Innovations Services Diet Manual published 2025 pages 37-39 revealed puree diets consist of foods that are smooth, cohesive, and require no chewing. Foods must be completely pureed to a smooth consistency to reduce the risk of chocking or aspiration. The manual further reads food characteristic for a pureed diet included: usually eaten with a spoon, cannot be drunk from a cup, cannot be slurped through a straw, does not require chewing, appears softly formed on a plate, no lumps, not sticky, liquid does not separate from solid, no biting or chewing required.

Based on observation, resident interview, staff interview, and review of the facility policy, the facility failed to accommodate Resident #26 personal preferences of having a nightstand and personal toiletries in her bathroom. This affected one (Resident #26) out of two reviewed for accommodation of need. Facility census was 52.Findings include: Review of the medical record for Resident #26 revealed an admission date of 12/03/22 with diagnoses including chronic kidney disease stage 4, hypertension, bilateral hearing loss, and arthropathy. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was cognitively intact and was independent with toileting hygiene, shower/bathing and personal hygiene. Review of the Activities of Daily Living (ADL) care plan revised 06/17/25, revealed Resident #26 requires assistance for ADL's in regard to advanced age, active wounds and requires an assistive device. Interventions included encourage and allow resident to complete self-care as able. An interview on 05/04/26 at 10:45 A.M. with Resident #26 stated she preferred to bathe herself, she used to have a stand in her bathroom with all of her toiletries and the staff removed it. Resident #26 stated she would like it back in the bathroom due to having to carry everything back and forth to the bathroom. Observation revealed Resident #26's nightstand was outside of the bathroom and her toiletry items were in her closet.There was nothing observed in the bathroom for the resident to use in place of the stand to accomodate the resident's preference. An interview on 05/07/2026 3:41 PM with the Director of Nursing (DON) verified Resident #26's nightstand and toiletry items were taken out of the bathroom and Resident #26 preferred it in there. The DON stated the stand was removed as part of a corporate survey and staff were told the stand could not be in the resident's bathroom. Review of facility policy titled, Quality of Life-Homelike Environment dated May 2017, revealed staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.

Based on record review, observation, and staff interview, the facility failed to ensure a resident's care plan was revised to reflect the preference of the resident's family for the resident to not wear any splints, braces, or other orthotics as part of the resident's contracture management. This affected one (Resident #17) of 24 residents reviewed for care plans. Findings include:Review of Resident #17's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) affecting his left non-dominant side, muscle weakness, cognitive communication deficit, unspecified dementia, and mood disorder with depressive features. Review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had adequate hearing and unclear speech. He was usually able to make himself understood and was usually able to understand others. His cognition was severely impaired and he was not known to display any behaviors or reject care. He had a functional limitation in his range of motion on one side of his upper extremities. He was not indicated to be receiving any therapy or restorative nursing services for range of motion at that time. Review of Resident #17's active care plans revealed he had a care plan in place for an alteration in his musculoskeletal status related to a left hand contracture and left hemiplegia. The care plan originated on 03/17/22. The goal was for the resident to remain free of any complications related to his left hand contracture as evidenced by no further contracture by the review date. The interventions included encouraging and assisting the resident with the use of supportive devices as ordered. The care plan was not revised to reflect any non-compliance with the use of any splints, braces, or other orthotics, as part of his contracture management for his left hand contracture. Review of Resident #17's physician's orders revealed the resident did not have any orders in place for the use of any splints, braces, or other orthotic devices, as part of his contracture management. He did have an order for active range of motion to be provided to an unspecified extremity, as part of a restorative program, that originated on 06/13/22. Review of Resident #17's progress notes for the past four months revealed there was no documentation pertaining to any refusals of the use of any splints, braces, or orthotics, as part of his contracture management program. On 05/05/26 at 10:26 A.M., an observation of Resident #17 noted him to be up in a specialty wheelchair (tilt in space wheelchair) in his room. He was reclined back and was noted to have his left arm drawn up and against his chest. He did not have any splints, braces, or other orthotic devices in place to his left hand/ wrist contracture. On 05/05/26 at 12:35 P.M., an interview with Rehab Director #301 revealed the facility had worked with getting Resident #17 splints and stuff in the past to address his contractures. They attempted to get splints for his left hand and the left knee. They had ordered all of that and received them, only to have the family decide they did not want the resident to use them, due to them causing him discomfort when wearing. They recently screened the resident again, and the occupational therapist recommended splints again. He had to inform the occupational therapist the resident's family would not allow them to use them. He indicated occupational therapy continued to work with the resident for gentle range of motion stretching, as part of his contracture management. On 05/05/26 at 2:15 P.M., an interview with the facility's Director of Nursing (DON) confirmed Resident #17's active care plans did not reflect the resident's family's wishes not to use any splints, braces, or orthotics as part of his contracture management. He acknowledged the resident's care plan for an alteration in musculoskeletal status related to his contracture of the left hand should have been revised to reflect the family's preference not to use any splints, braces, or other orthotics to manage the resident's contractures.

Based on medical record review, physical therapy records review, and interviews the facility failed to provide a timely implement a functional management program for Resident #29. This affected one (Resident #29) of one resident reviewed for restorative therapy services. The census was 52. Findings Include:Review of the medical record for Resident #29 revealed admission to the facility on [DATE] for diagnoses including acute respiratory failure, depression, hyponatremia (low salt level in blood), gastrointestinal bleed, anemia, high blood pressure, and hepatic encephalopathy (water on the brain leading to confusion).Review of the Resident #29 medical record revealed a physician's order on 04/10/26 for physical therapy treatments dated 04/10/26 through 04/25/26.Review of the most recent minimum data set (MDS) 3.0 comprehensive assessment completed on 04/13/26 revealed Resident #29 had no hearing or visual deficits and was able to communicate with and understand others. Further review of the MDS 3.0 indicated a brief interview for mental status was conducted and Resident #29 had a score of 15/15 indicating no cognitive impairments. Resident #29 required the use of a mechanical lift for transfers and was dependent on staff for toileting, bathing, and dressing.Review of Resident #29 physical therapy discharge summary completed on 04/25/26 and authored by the rehab director, physical therapist (PT) #301 revealed Resident #29 was discharged from physical therapy services due to care manager or physician order. Further review of the discharge summary revealed recommendations were made for a Functional Maintenance Program (FMP) by PT #301.Review of the (FMP) Communication form for Resident #29, dated 04/25/26 and signed by PT #301, revealed recommendations were made for a FMP after physical therapy with a discharge date of 04/25/26.Further review of the FMP form revealed the program was to begin on 05/07/26. Review of the FMP progress note indicated the same. There was no explanation as to why there was a delay between the recommendation for the FMP and the implementation of the FMP. Review of the functional maintenance care plan initiated on 05/07/26 revealed active range of motion to all extremities of 10 reps for 3-5 sets daily, 6-7 times per week.Interview on 05/07/26 at 9:50 A.M. with PT #301 revealed Resident #29's insurance would not authorize any further treatments after 04/25/26 and Resident #29 had a total of 10 physical therapy sessions. Resident #29 needed a lot of encouragement to participate in physical therapy. PT #301 reported that he recommended a FMP for Resident #29 on discharge from therapy services for nursing to continue. PT #301 reported that he filled out a communication form and gave it to Licensed Practical Nurse (LPN) #241 who was in charge of setting up the FMP with nursing. PT #301 reported he would have provided the communication form to LPN #241 on 04/25/26.Interview on 05/07/26 at 1:30 P.M. with LPN #241 revealed confirmation that Resident #29 did not receive FMP from 04/27/26 through 05/07/26. LPN #241 reported that the FMP communication form provided by physical therapy to set up FMP was misplaced in the pile of papers on her desk and she did not review it until today, 05/07/26. LPN #241 verbalized that her normal practice was to establish the FMP the same day she received the FMP communication form from the therapy department or the next day. LPN #241 reported she was the nurse responsible for making the FMP care plan and notifying the nursing staff of the resident's need for the FMP. LPN #241 reported that the program would show up under the task section in the electronic medical record for the certified nurses' aides (CNA) to complete with the residents.

Based on observation, record review, interview and policy review the facility failed to ensure residents identified at risk for elopement and resided on a secured memory care unit did not exit the facility without staff knowledge, failed to ensure interventions for residents identified at risk for elopement were timely implemented and failed to ensure fall prevention interventions were in place. This affected three residents (Resident #39, #54 and #17) of six residents reviewed for accidents. Findings include: 1.Review of the medical record for Resident #39 revealed an admission date of 10/03/25 with diagnoses including Alzheimer's disease, dementia, epilepsy, Parkinsonism, intermittent explosive disorder, frontotemporal neurocognitive disorder, and muscle weakness. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #39 had severely impaired cognition and was unable to complete the interview. Resident #39 was assessed to ambulate independently. Review of Resident #39's wandering risk assessment dated [DATE] revealed the resident has wandered before, wandering places the resident at significant risk of getting to a potentially dangerous place, the resident is cognitively impaired, the resident was not a new admission, the resident is able to ambulate independently and the wandering has increased since the last evaluation. Review of Resident #39's wandering risk assessment dated [DATE] revealed the resident has wandered before, wandering places the resident at significant risk of getting to a potentially dangerous place, the resident is cognitively impaired, the resident was not a new admission and the resident is able to ambulate independently. Review of Resident #39's plan of care last revised on 10/29/25 revealed the resident was transferred from an assisted living environment to secure memory unit due to Alzheimer's disease and history of exit seeking. Interventions included but not limited to supervision will be provided at all times while off of the unit/and secured courtyard, staff will redirect and/or attempt diversional activities if she attempts to elope/wander off unit/facility. Further review of care plan, initiated date 03/25/26 and last revised 05/06/26 revealed resident was at risk for elopement and/or wandering. Interventions included elopement book will be current with Resident #39's picture, supervision will be provided at all times while off of the unit/and secured courtyard. Review of Resident #39's progress notes dated 03/25/26 at 9:40 A.M. authored by Registered Nurse (RN) #227 revealed resident was found wandering outside building in the front lot. No injury was noted on assessment. Review of the elopement timeline for Resident #39 revealed on 03/25/26 at 9:40 A.M. the resident was last seen by RN #227 at 9:30 A.M. for medication administration. Resident was found outside by therapy director # 301 at 9:40 A.M. in the parking lot. Facility staff conducted a head count on 03/25/26 and all residents were accounted for and present in the building. The Director of Nursing (DON), Administrator, physician, family and risk group were notified on 03/25/26. A wandering risk assessment and behavior assessment was completed by the DON/designee. A head-to-toe skin assessment was completed and no injuries were found. Staff were interviewed on 03/25/26. The care plan was updated on or before 03/26/26. The maintenance Director fixed the door on 03/25/26 and a staff member was stationed at the door at all times until it was fixed. (The system was identified to not be closing correctly due to concerns with the magnetized lock). Interview on 05/06/26 at 2:50 P.M. with RN #227 revealed she had just administered Resident #39's medications right before the elopement. The Certified Nursing Assistant (CNA) # 207 was off the unit assisting another resident with a shower. The therapy director # 301 found the resident outside in the parking lot. We looked at the door, it was alarming and come to find out the magnet had slipped (the system was not closing properly). The Maintenance Supervisor # 223 fixed it immediately. Interview on 05/06/26 at 3:15 P.M. with Therapy Director #301 revealed he found Resident #39 outside in the parking lot in front of the building around 9:40 A.M. and he assisted her back inside. 2. Review of the medical record for Resident #54 revealed an admission date of 04/28/26 with diagnoses including vascular dementia with mood disturbance, unspecified mood (affective) disorder, and violent behavior Review of Resident #54's initial wandering risk assessment dated [DATE] indicated he has wandered before, his wandering placed him at significant risk of getting to a potentially dangerous place, cognitively impaired, ambulates independently and wandering is not a new behavior. Review of the care plan initiated 05/05/26 revealed Resident #54 uses a wander guard to right lower leg related to wandering episodes, no awareness of safety needs and diagnosis of vascular dementia. Interventions included evaluate wander guard use, evaluate/record continuing risks/benefits, alternatives, need for ongoing use and reason for use; he needs a safe environment with adequate, glare-free light, floors that are even and free from spills or clutter; call light, personal items in reach and monitor/document/report as needed any changes regarding effectiveness of wander guard, less restrictive device, if appropriate; any negative or adverse effects noted, including; decline in mood, and change in behavior. Review of Resident #54's wandering risk assessment dated [DATE] indicated he has wandered before, his wandering placed him at significant risk of getting to a potentially dangerous place, cognitively impaired, ambulates independently, wandering is not a new behavior, and the incidence of wandering has increased since the last evaluation. Observation on 05/06/26 at 11:28 A.M. Resident #54 exited through the front door of the facility. The alarm sounded and the Director of Nursing (DON) and Respiratory therapy Director #273 responded within one minute. Interview on 05/06/26 at 12:16 P.M. with Certified Nursing Assistant (CNA) #263 revealed Resident #54 frequently exit seeks. She stated he wandered a lot. CNA#263 stated Resident #54 has not been out of his room much today. CNA #263 was not aware Resident #54 exited through the front door. Review of the elopement binder on 05/06/26 at 12:07 P.M. with the DON verified no information was in the binder for Resident #54. Further review of the elopement binder revealed current information related to resident's at risk for elopement, including a current photograph and the binder was located at the front desk for staff to access. Interview on 05/06/26 at 3:30 PM with Resident #54's spouse revealed the facility spoke to her regarding his wandering behaviors and asked for her to refrain from taking him outside during visits to help him adjust to the transition. The spouse also stated the wander guard was not implemented until Monday 05/04/26. Review of facility policy titled Elopements, revised December 2007 revealed staff shall investigate and report all cases of missing residents. Review of facility policy titled Wandering, Unsafe Resident, revised August 2014 revealed the staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as detailed monitoring plan will be included. 3. Review of Resident #17's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included unspecified dementia, hemiplegia (paralysis) and hemiparesis (weakness) following a stroke affecting his left non-dominant side, age-related osteoporosis, cognitive communication deficit, and muscle weakness. Review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had unclear speech. He was usually able to make himself understood and was usually able to understand others. His cognition was severely impaired and he was not known to display any behaviors or reject care. He had a functional limitation of his range of motion on one side of his upper and lower extremities. Partial/ moderate assist was needed with bed mobility and he was dependent on staff for transfers. Review of Resident #17's active care plans revealed he had a care plan in place for being at risk for falls related to left hemiplegia, poor sitting balance, confusion, incontinence, medication use, seizure disorder, non-ambulatory, and having a custom tilt-in-space wheelchair. The care plan originated on 07/29/15. The goal was for the resident to have a decreased risk of a serious fall related injury through the next review. The interventions included padded bilateral half side rails to bed, bed changed with bed frames and function audit (03/14/24, recline chair when up (except for meals), and a soft touch call light kept within reach. Review of Resident #17's physician's orders revealed he had an order in place for the use of a low bed. The order had been in place since 10/29/20. He also had the use of fall mats on the floor to both sides of the bed that originated on 04/05/22. Review of Resident #17's treatment administration record (TAR) for May 2026 revealed the nurses were initialing the TAR to reflect the use of a low bed every shift. On 05/04/2026 at 1:53 P.M., an observation of Resident #17 noted him to be lying in the bed next to the window. The bed was in a raised position that was higher than the height of a normal bed. He was noted to have fall mats on the floor on each side of his bed. On 05/05/26 at 1:50 P.M., a follow up observation of Resident #17 noted him once again to be lying in bed by the window with the bed in a raised position. The height of the bed was not as high as with the previous observation, but it was still not in it's lowest position. He continued to have fall mats on the floor on each side of the bed. Findings were verified by LPN #239. On 05/05/26 at 1:51 P.M., an interview with LPN #239 revealed she considered Resident #17 to be at risk for falls, but she considered all residents to be at risk for falls. She was asked what interventions were in place for the resident to prevent falls. She stated she would have to check the resident's chart to see what fall prevention interventions were in place. She went to the computer and reviewed the resident's physician's orders and care plan to identify what fall prevention interventions were in place. She identified the resident had the use of a low bed, as one of his fall prevention interventions. She accompanied the surveyor back to the resident's room and confirmed he was not in a low bed, nor was the bed he was in in it's lowest position. The frame on the bed the resident was in was approximately 16 inches off the floor. The nurse was able to lower the bed about eight inches, so the bed was able to be lowered to the frame only being about eight to nine inches off the floor. On 05/05/26 at 2:05 P.M., an interview with the DON confirmed the resident was supposed to be in a low bed per his plan of care. He acknowledged the resident was observed yesterday, and again today, to be in bed when the bed was not in its lowest position. Review of the facility's policy on Falls- Clinical Protocol revised September 2012 revealed, as part of the initial assessment, the physician would help identify individuals with a history of falls and risk factors for subsequent falling. If interventions have been successful in preventing falling, the staff would continue with current approaches or reconsider whether those measures were still needed if the problem that required the intervention had resolved.

Based on review of medical records, review of facility investigation, observations, interviews, facility assessment review and policy review the facility failed to provide comprehensive, resident centered dementia care to prevent resident to resident physical abuse. This affected two residents (Resident #14 and #32) of two residents reviewed for abuse. The facility census was 52. Findings include:a. Review of the medical record for Resident #14 revealed admission to facility on 03/01/24 for diagnoses including Alzheimer's disease (impaired short term memory and ability to communicate), gastric reflux, Dementia (confusion and forgetfulness) with moderate behavior disturbances, post traumatic stress disorder, depression, and spinal stenosis (narrowing of canal the spinal cord is in the spinal vertebra). Further review of the medical record revealed Resident #14 resided on the locked memory care unit.Review of the most recent minimum data set (MDS) 3.0 quarterly assessment dated for Resident #14 revealed a brief interview for mental status score of 5/15 indicating severe cognitive impairment. Further review of the MDS revealed no current delusion or hallucinations. Resident #14 was independent with walking without a device and only required supervision for safety concerns.Further review of a nursing progress note dated 03/02/26 at 6:31 P.M. for Resident #14 revealed Resident #14 was inserting herself into other individual conversations and blocking staff from moving about the unit and would become angry when redirected.Review of a nursing progress note dated 03/19/26 at 9:45 P.M. revealed Resident #14 attempted to go out the back door with another resident earlier in shift then escalated her behaviors to the point she grabbed another resident's hair and tried to pull her out of bed. Resident #14 then began targeting other residents and the provider was notified and an order was given for Haldol 5 milligrams intramuscular (injection into a large muscle) x one dose.b. Review of the medical record for Resident #32 revealed admission to the facility on [DATE] for diagnoses including unspecified dementia without any behavioral disturbances, depression, diabetes, glaucoma (disease affecting eye pressure and vision), and poor circulation. Further review of the medical record indicated Resident #32 resided on the locked memory care unit.Review of the most recent MDS 3.0 quarterly assessment completed on 04/07/26 revealed Resident #32 had a brief interview for mental status score of 5/15 indicating severe cognitive impairment and the presence of inattention and disorganized thinking. Resident #32 relied on staff for assistance with bathing, dressing, toileting and personal care. Resident #32 used a wheelchair pushed by staff.Review of the care plan for Resident #32 revealed an active care plan initiated on 02/28/25 related to diagnosis of dementia and history of wandering behavior and attempted elopements requiring secured memory unit. Interventions included attempt to find out why resident is attempting to elope/wander, administer medications as ordered, allow Resident #32 to ambulate freely in secured memory unit, staff to redirect and attempt diversional activities if attempting to leave unit, and supervision will be provided at all times while Resident #32 is off of the secured memory unit or secured courtyard.Review of the facility self-reported incident investigation summary reported to the Ohio Department of Health on 03/20/26 revealed on 03/19/26 CNA #229 reported that Resident #14 had an altercation with Resident #32 in which Resident #14 followed the CNA #229 in the room of Resident #32. Resident #14 then reached around CNA #229 and pulled Resident #32 hair and tried to pull her out of bed. CNA #229 was able to redirect Resident #14 and notified the nurse on duty, LPN # 232. LPN #232 assessed Resident #32 and no injuries were noted. Further review revealed interventions were updated on the care plan to include a stop sign on the door of Resident #32. All physicians and emergency contacts were notified of incident and assessments. The summary continues to say out of an abundance of caution all facility staff was retrained on abuse prevention and abuse policy.Review of the resident post incident interviews revealed that neither Resident #14 nor Resident #32 could recall the event due to poor cognition/memory.Review of the staff statements regarding the incident revealed on 03/19/26 LPN #232 stated Resident #14 had been having behaviors without success of redirection. LPN #232 further stated that Resident #14 had been pacing the halls. LPN #232 did not witness the event and it was reported to her by CNA #229. LPN #232 called the nurse practitioner on duty and reported Resident #14 behaviors and was given a one-time order to administer an injection of Haldol (anti-psychotic medication that has a sedative effect). Resident #14 then slept the remainder of the night.Review of the staff statements further revealed CNA #229 stated that she had just put Resident #32 into bed and Resident #14 came into the room and reached around her and pulled the hair of Resident #32. CNA #229 stated Resident #14 left the room, and she made sure Resident #32 was okay and went and told the LPN #232 what happened.Review of staff statements completed by the Administrator via phone for staff members CNA #303, CNA #304 and RN #260 revealed they were not on the memory care unit at the time of the incident occurred. There was no witness statement from CNA #200 who was assigned to work the memory care unit that day.Review of the daily census/staffing sheet dated 03/19/26 revealed at the time of the incident the facility had one nurse, LPN #232 covering the north hall and the memory care unit, and one RN #260 covering the south unit. There were four CNA's working, one on north hall, CNA #303, one on memory care unit, CNA #200, and two on south hall CNA #229 and CNA #304.Observation on 05/05/26 at 12:17 P.M. revealed Resident #14 walking out of the dining room of the locked memory care unit and smiling and talking non-sensical to other residents and staff. Resident #14 quickly came up to the surveyor behind the nurse's desk and attempted to hug the surveyor. Resident #14 was able to be redirected, and the aide assisted in directing Resident #14 out of the nurse's area and to sit down in chairs in hallway. Resident #14 would only set momentarily and then would get up and begin engaging with others.Interview on 05/07/26 at 3:50 P.M. via phone with LPN #232 revealed she did not witness the incident and it was reported to her by CNA #229 that Resident #14 followed her into Resident #32 room and attempted to pull Resident #32 out of bed and pulled her hair.Further interview revealed that LPN #232 reported that Resident #14 has a history of targeting Resident #32 and they often have to be separated because Resident #14 will pick at Resident #32. Resident #14 can be more difficult to redirect, and Resident #32 knows how Resident #14 can be and will try to avoid her. LPN #232 confirmed that Resident #14 was having a lot of behaviors that day and LPN # 232 had to call the provider to get an order for Haldol because Resident #14 was not consolable with her behaviors that shift.Continued interview with LPN #232 revealed that normal staffing ratios for the 7:00 P.M. to 7:00 A.M. shift were one nurse to cover the north hall and the locked memory care unit and one CNA on the north hall and one CNA on the memory care unit. LPN #232 confirmed that there was often only one staff member (the CNA) on the memory care unit during the night shift to supervise all the residents and this is difficult especially when residents are known to have behaviors.Interview on 05/07/26 at 3:36 P.M. via phone with CNA #229 revealed at the time of the incident with Resident #14 and #32 she was the only staff member present on the memory care unit. CNA #229 confirmed that Resident #14 came into Resident #32's room while she was putting her to bed and reached around the CNA and pulled Resident #32's hair. CNA #229 confirmed the staffing ratios for the memory care unit from 7:00 P.M. to 7:00 A.M. were usually one CNA and one nurse to cover the memory care unit and the north hall making it difficult to supervise all the residents while assisting residents in their room and implementing appropriate dementia care to prevent potential behaviors.Interview on 05/06/26 at 2:35 P.M. with CNA #207 revealed that she works mostly on the memory care unit and has been employed at facility for over three years. CNA #207 reported that Resident #14 often gets into it with Resident #32 verbally and the two residents have to be separated. CNA #207 reported that Resident #32 is better about avoiding Resident #14. CNA #207 reported that the other day Resident #32 was in her wheelchair in the dining room and Resident #14 tried to get her wheelchair and pull her out of the dining room and she had to redirect Resident #14 and remind her to keep her hands to herself. CNA #207 confirmed there generally is only one CNA on the unit at night and the nurse goes back and forth from the memory care unit and the north hall. This makes it difficult to supervise the residents and assist other residents with needed care in their room or away from an area to monitor residents especially when behaviors are occurring or may occur. The CNA also verified it is difficult to implement dementia care when only one staff is available for the residents on the secured unit.Review of the facility assessment dated [DATE] revealed the facility has an Alzheimer's/Dementia Secured Specialty Unit of 20 beds. This unit includes staff that has received training for a cognitively impaired residents and Alzheimer's/Dementia residents. Staff training/education and competencies and skill sets of the following training topics: for nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.Review of the facility Abuse and Neglect Protocol, revised 06/13/21 revealed the following definitions of abuse to ensure recognition and reporting, misconduct, is improper, egregious, potentially dangerous behavior, abusive/offensive language or gestures directed toward or in front of a resident. The protocol further reveals the facility will not condone resident abuse by anyone including other residents.

Based on staff interview, record review, and review of facility policy, the facility failed to ensure physician-ordered medication parameters were followed for use of a narcotic pain medication and a heart rate was monitored as ordered prior to administration of medication. This affected two (#30 and #33) of five residents reviewed for unnecessary medications and medication review. The facility census was 52.Findings include: 1.Review of the medical record for Resident #33 revealed an admission date of 07/31/25 with diagnoses including repeated falls, low back pain, spinal stenosis, lumbar region without neurogenic claudication, and intervertebral disc degeneration, lumbar region with discogenic back pain only. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) had intact cognition. The resident was assessed to frequently have pain. Review of the plan of care last revised 08/18/25 revealed Resident #33 is at risk for developing complications secondary to is on pain medication therapy related to repeated falls, wedge compression fracture-lumbar, low back pain, spondylosis, spinal stenosis, right knee arthritis and degenerative disc disease-lumbar. Interventions included administer medication as ordered and review regularly for pain medication efficacy. Review of Resident #33's physicians orders dated 08/14/25 revealed an order for Acetaminophen (Tylenol) oral tablet 500 milligrams (mg) give one tablet by mouth every six hours as needed for pain and an order dated 09/08/25 for Percocet (narcotic pain medication) Oxycodone with Acetaminophen 5/325mg give one tablet by mouth every eight hours as needed for severe pain level 6-10 (on a pain rating scale of 1-10 with 1 representing minimal pain and 10 representing the worst pain ever felt). Review of the medication administration record (MAR) for January 2026 revealed Percocet was administered outside of parameters on January 1, 2, 7, 10, 11, 12, 14, 15, 16, 17, 18, 27, 29, and 30. Review of the medication administration record (MAR) for February 2026 revealed Percocet was administered outside of parameters on February 1, 3, 4, 9, 10, 12, 15, 16, 17, 18, 19, 20, 22, 23 and 26. Review of the medication administration record (MAR) for March 2026 revealed Percocet was administered outside of parameters on March 1, 2, 5, 6, 7, 12, 13, 15, 16, 19, 20, 21, 22, 23, 25 and 30. Review of the medication administration record (MAR) for April 2026 revealed Percocet was administered outside of parameters on April 2, 3, 4, 5, 6, 7, 10, 11, 12, 14, 15, 16, 17, 19, 20, 21, 22, 25, 26, 27 and 28 Review of the medication administration record (MAR) for May 2026 revealed Percocet was administered outside of parameters on May 4th and 5th. On 05/05/26 at 8:59 A.M. Resident #33 stated she doesn't ask for a specific pain medication. The resident stated she requests a pain pill when having pain. Interview on 05/07/26 at 11:04 A.M with Registered Nurse (RN) #215 stated when two pain medications were ordered the facility will have parameters for both pain medications. RN #215 verified Resident #33 was administered pain medications outside of the ordered parameters and not per physicians order. Review of the facility's policy on Administering Medications revised April 2019 revealed medications were to be administered in a safe and timely manner, and as prescribed. The individual administering the medication was to check the label three times to verify the right resident, the right medication, right dosage, right time, and the right method (route) of administration before giving the medication. 2. Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included hypertension and atrial fibrillation. Review of Resident #30's physician's orders revealed she had an order to receive Toprol XL Extended Release (beta-blocker used to treat high blood pressure) 50 milligrams (mg) by mouth (po) once daily in the morning related to essential hypertension. The order included parameters to hold the medication if the resident's heart rate was less than 60 beats per minute (bpm). Review of Resident #30's medication administration record (MAR) for April and May 2026 revealed the resident was receiving Toprol XL 50 mg po every morning for hypertension as ordered. The MAR included a place for the nurses to include their initials to show when the medication had been received. There was no place on the MAR for the nurse to document the resident's heart rate to show evidence they were monitoring the resident's heart rate and following the parameters included in the order for which the medication should be held. Further review of Resident #30's medical record revealed there was no documented evidence of the resident's heart rate being checked daily that coincided with the times the resident received her Toprol XL. There were some pulses recorded under the vital sign tab of the electronic medical record, but they were not being consistently obtained and recorded for the times the Toprol XL was received. On 05/07/26 at 9:25 A.M., an interview with the Director of Nursing (DON) confirmed Resident #30's order for Toprol XL that was to be administered every morning for hypertension did include parameters to hold the medication, if the resident's heart rate was less than 60 bpm. He could not find evidence of the nurses monitoring the resident's heart rate prior to the administration of that medication to show they were following the parameters included in the order.

Based on observation, record review, staff interview, and policy review, the facility failed to ensure their medication error rate did not exceed 5%. The facility had three errors out of 33 opportunities for a medication error rate of 9%. This affected two (Resident #25 and #31) of four residents reviewed during medication administration observations. Findings include: 1. On 05/06/26 at 8:10 A.M., a medication administration observation was completed for Resident #25 of medications administered by Registered Nurse (RN) #227. The nurse was observed to administer the morning medications that were scheduled for the resident on that day. The resident received six medications to include Amlodipine 5 milligrams (mg) by mouth (po) as ordered once daily, Plavix 75 mg po as ordered once daily, Isosorbide Mononitrate ER 60 mg po as ordered once daily, Multiple Vitamin with Minerals po as ordered once daily, Senna Plus 8.6 mg- 50 mg po as ordered once daily, and Metoprolol Tartrate 25 mg po as ordered twice daily. Review of Resident #25's physician's orders revealed, in addition to the above medications, the resident was also to receive Ferrous Sulfate 325 mg po once daily. The medication had been ordered since 06/20/24. Review of Resident #25's medication administration record (MAR) for May 2026 revealed the Ferrous Sulfate 325 mg tablet was scheduled to be given once daily at 8:00 A.M. The nurse that was observed to administer Resident #25 her medications signed the MAR to reflect the Ferrous Sulfate had been given despite observations indicating otherwise. On 05/06/26 at 9:28 A.M., findings were verified with RN #227 that she did not administer a Ferrous Sulfate 325 mg tablet to the resident that morning when she was observed to give Resident #25 her morning medications. She stated she must have just missed that medication and indicated it would have come from a stock bottle if she had pulled it for administration. 2. On 05/06/26 at 8:15 A.M., a medication administration observation was completed for Resident #31. The medications due during the morning medication administration pass was provided by RN #227. The resident was given eight medications that included Aspirin (ASA) Enteric Coated (EC) 81 mg tablet and a Vitamin D 10 micrograms (mcg) tablet among the eight different medications received. Both medications were pulled from a stock bottles from the medication administration cart. Review of Resident #31's active physician's orders revealed the resident was to receive ASA EC 81 mg tablets with directions to give two tablets (162 mg) by mouth once daily for heart health. The order had been in place since 07/30/24. The orders also included the need to administer Cholecalciferol (Vitamin D) 25 mcg tablets with directions to give two tablets (50 mcg) one time a day for a Vitamin D deficiency. Based on the observation and the reconciliation of the resident's medication orders, the resident received half the dose she should have been given for the EC ASA and a fifth of the ordered dose for the Vitamin D. On 05/06/26 at 9:30 A.M., an interview with RN #227 confirmed she only administered one (81 mg) tablet of EC ASA when giving Resident #31 her morning medications. She acknowledged the current physician's orders was to give the resident two (81 mg) tablets of EC ASA to equal 162 mg. She reported she had never seen an order to give a resident two EC ASA 81 mg tablets before, so she just assumed that the resident was to receive one tablet. She further confirmed she only gave the resident 10 mcg of Vitamin D when 50 mcg were ordered every morning. She reported they did have a stock bottle of Vitamin D 25 mcg tablets in the medication administration cart earlier, but she used the last tablet on one of the other two halls she was passing medications on. She acknowledged even with that, she would have still only given half the ordered dose, if she only gave one tablet of the 25 mcg Vitamin D tablets. She further acknowledged, since she gave a 10 mcg tablet of Vitamin D to the resident, she only administered one-fifth of the ordered dose. Review of the facility's policy on Administering Medications revised April 2019 revealed medications were to be administered in a safe and timely manner, and as prescribed. The individual administering the medication was to check the label three times to verify the right resident, the right medication, right dosage, right time, and the right method (route) of administration before giving the medication.

Based on observation, staff interview, and policy review, the facility failed to ensure a nurse followed appropriate hand hygiene practices after administering eye drops to one resident (Resident #31) and before preparing medications for another resident (Resident #11). The facility's census was 52. Findings include: On 05/06/26 at 8:15 A.M., a medication administration observation for Resident #31 noted her medications to be prepared and administered by Registered Nurse #227. Among the medications administered was Artificial Tears Opthalmic solution 0.2- 0.2-1%. The nurse was observed to enter the resident's room to give the resident her morning medications. She gave the resident her pills first, followed by the eye drops, administering one drop into both the resident's eyes before leaving the room. She was not observed to wash her hands with soap and water or to use hand sanitizer when leaving the room, or before returning to the medication administration cart to begin preparing Resident #11's medications for administration. On 05/06/26 at 8:24 A.M., an interview with RN #227 confirmed she did not perform any hand hygiene after she administered eye drops to Resident #31 or before she started to prepare the medications she was about to administer to Resident #11. She acknowledged she should have performed hand hygiene between the two residents' medication administrations. She stated they did not have hand sanitizer in the hallways, but usually had some on their medication administration cart. She reported she did not have any hand sanitizer on the medication administration cart that morning. She further acknowledged the potential to spread infections between residents when administering medications by failing to follow appropriate infection control policies and good hand hygiene practices. Review of the facility's policy on Administering Medications revised April 2019 revealed medications were to be administered in a safe manner. Staff were to follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves etc._ for the administration of medications, as applicable. Review of the facility's policy on Instillation of Eye Drops revised January 2014 revealed the purpose of the procedure was to provide guidelines for installation of eye drops to treat medical conditions, eye infections, and dry eyes. The general guidelines indicated should both eyes require instillation, wash and dry hands thoroughly before treating each eye. Steps in the procedure included the need to wash and dry hands thoroughly before donning gloves. They were to remove gloves and wash/ dry hands thoroughly, after the eye drops were administered.

Based on record review, staff interview, and policy review, the facility failed to ensure residents were provided appropriate notices when transferred to the hospital and the State's local Ombudsman was notified of all transfers/ discharges from the facility as required. This affected three (Resident #45, #51, and #53) of three residents reviewed for hospitalizations and/ or planned discharges. Findings include:1. Review of Resident #51's medical record revealed he was admitted to the facility on [DATE]. He was hospitalized on three separate occasions, during his stay in the facility, with the hospitalizations occurring between 02/23/26 and 03/03/26, 03/31/26 and 04/02/26, and again on 04/10/26, in which he did not return to the facility. Review of Resident #51's progress notes revealed a nurse's note dated 02/23/26 at 11:01 P.M. that indicated the resident was found in bed with his tracheostomy tube out at 9:45 P.M. 911 was called and the resident was transferred to a local hospital to have the tracheostomy tube put back in. The local hospital was not able to insert a new tracheostomy tube requiring him to be transferred to another hospital. The other hospital had him on a nasal cannula supplying him with oxygen and the resident was reportedly doing fine, but the family did not want him sent home, as the hospital planned, and wanted the tracheostomy tube put back in due to the resident's inability to clear his own secretions. He was then admitted to the hospital's surgical floor with an ENT (ears, nose, and throat) consult pending for re-insertion of the tracheostomy tube. While at the hospital, the resident was noted to have a fever, developed a lot of mucous, and found to have aspiration pneumonia. He returned to the facility on [DATE]. Review of Resident #51's progress notes revealed a nurse's progress note dated 03/31/26 at 2:20 P.M. that indicated the resident was found non-responsive with an elevated blood glucose level of 325 milligrams (mg)/ deciliter (dl). His other vital signs were relatively unremarkable with a blood pressure of 132/ 73 mm/Hg and a pulse of 96 beats per minute. His advanced level provider was contacted and a new order was received to send the resident to the emergency room for an altered mental status. Review of a physician/ nurse practitioner note for a Discharge summary dated [DATE] at 10:42 P.M. revealed the nurse practitioner (NP) was notified Resident #51's blood sugar was in the higher 400's (80-120 mg/dl being within normal limits) and the nursing staff gave him insulin coverage. The resident's blood sugar then raised to 525 mg/dl. At first the resident was asymptomatic, but he became lethargic requiring him to be transferred to the hospital. He was admitted to the hospital with lethargy and hyperglycemia (elevated blood sugar). The NP planned to change his enteral tube feedings upon his return to the facility. Review of a nurse's progress note dated 04/02/26 at 4:16 P.M. revealed Resident #51 returned from the hospital with new orders for Doxycycline and Augmentin (both antibiotics) for the treatment of a urinary tract infection and pneumonia. He was also indicated to be alert and at his baseline. Review of a nurse's progress note dated 04/10/26 at 4:15 P.M. revealed the nurse was notified by the respiratory therapist that the resident was not responding verbally. He was only able to open his eyes when spoken to and was found to be tachycardic (elevated heart rate). His family and the NP was notified and wanted the resident transferred to the local hospital for an evaluation. Review of a nurse's progress note dated 04/11/26 at 12:04 A.M. revealed the facility nurse contacted the local hospital for an update on the resident's condition. The nurse was informed Resident #51 was awaiting a transfer to another hospital with the diagnosis of sepsis (systemic blood infection), urinary tract infection (UTI), and an altered mental state. The facility was later informed on 04/14/26 at 2:34 P.M. that the resident's daughter did not want to hold a bed for the resident's future return. The family was wanting the resident to be transferred to a nursing facility that was closer to their home. Resident #51 did not return to the facility, after his transfer to the hospital on [DATE]. Further review of Resident #51's medical record revealed there was no documented evidence of the resident and his representative being provided with a transfer notice for any of the three transfers (02/23/26, 03/31/26, and 04/10/26) he had to the hospital during his stay at the facility. There was also no evidence of the State's local Ombudsman being notified of the resident's transfer to the hospital on [DATE]. The facility provided a copy of the list of transfers, discharges, and deaths that occurred during the month of March 2026 that had been sent to the local Ombudsman via email on 04/08/26 at 9:41 A.M. with the resident's name not being included despite his transfer to the hospital on [DATE]. Findings were verified by the Director of Nursing (DON). On 05/07/26 at 3:00 P.M., an interview with the DON and Regional Nurse #245 revealed the facility had no evidence of a transfer notice being provided to Resident #51 or his representative for any of the three hospital transfers the resident had during his stay at the facility. They were not aware there was a transfer notice that needed to be provided to the residents and their representatives with any transfer to the hospital that occurred during a resident's stay in the facility. They further confirmed Resident #51's transfer to the hospital on [DATE] was not included on the list of transfers, discharges, and deaths that was sent to the local Ombudsman notifying them of the transfers and discharges for the month of March 2026. Review of the facility's policy on Transfer or Discharge Notices revised 07/30/25 revealed residents and/ or representatives were to be notified of an impending transfer or discharge and the reasons for the move in writing and in a language and manner they understood. A copy of the notice was to be sent to the Office of the State Long-Term Care Ombudsman, as well. In the event of an immediate transfer being required, due to a resident's urgent medical needs, the notice of transfer was to be given as soon as practical. 2.Review of the medical record for Resident #45 revealed an admission date of 10/18/25 with a most recent hospital stay of 01/31/26 to 02/09/26 with diagnoses including chronic respiratory failure with hypoxia, anxiety disorder, chronic obstructive pulmonary disease, dependence on supplemental oxygen and hypertension. Review of physician orders dated 01/31/26 revealed an order to send the resident to the emergency room (ER) for vomiting and abdominal pain. An assessment dated [DATE] at 10:00 P.M. revealed Resident #45 had a change in condition and was sent to the emergency room for a change of condition. There was no evidence of a transfer notice or a bed hold notice was provided to the resident and/ or her family at/ or around the time of his transfer in Resident #45's medical record. Interview on 05/07/26 at 3:37 P.M. with the Administrator verified the facility did not have a transfer notice or a bed hold notice for Resident #45's transfer to the hospital on [DATE]. 3. Review of the medical record for Resident #53 revealed an admission date of 03/02/26 with a most recent hospital stay of 02/22/26 and a discharge date of 03/21/26 with diagnoses including fracture of left femur, difficulty in walking, chronic pain and chronic respiratory failure with hypoxia. Review of a progress note for Resident #53 dated 03/21/26 revealed the resident was discharged home with son. Interview on 05/07/2026 at 12:40 P.M. with the Director of Nursing (DON) revealed there was no evidence the Ombudsman was notified. Interview on 05/07/26 at 2:50 P.M. with the Office of the Long-Term Care Ombudsman verified there was no notification of Resident #53's discharge. Review of facility policy titled Transfer or Discharge Notices, revised 07/30/25 revealed residents (or resident representatives) are notified of an impending transfer or discharge and the reasons for the move in writing and in language and manner they understand. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman.

Based on record review and interview, the facility failed to submit the required staffing information for the fourth quarter of July 1st 2024 through September 20th 2024 to the payroll based journal (PBJ) data. This had the potential to affect all residents. The census was 46. Findings included: Review of Payroll Based Journal (PBJ) staffing report for the fourth quarter (July 1st 20024 through September 30th 2024) revealed the facility failed to submit data for the quarter, one star staffing rating, excessively low weekend staffing, no registered nurse (RN) hours, and failed to have licensed nursing coverage 24 hours per day. Interview on 02/13/25 at 7:55 A.M. with the Administrator revealed that corporate submits the staffing data, she has reached out to cooperates a few times this week for their proof of submitting the staffing data for the fourth quarter (July 1st 2024 through September 30th 2024). She stated corporate had not given her proof of submission. Interview with Administrator on 02/13/25 at 11:33 A.M. confirmed corporate was unable to provide evidence the facility had submitted required staffing information for the fourth quarter 7/01/24 through 9/20/24 to the PBJ data.

Based on observation and interview, the facility failed to maintain infection control practices. This had the potential to affect 26 residents (#1, #2, #3, #4, #5, #6, #7, #9, #10, #11, #12, #15, #17, #18, #19, #21, #23, #25, #26, #28, #32, #35, #36, #44, #47, and #152) of 46 residents residing in the facility. Findings include: Observation on 02/11/25 at 2:53 P.M. revealed a male resident walked up to the ice chest next to the nurses' station and helped himself to some ice, with no evidence of practicing hand hygiene. The ice scoop was left inside the ice chest. Two aides were at the nurses' station at the time of the observation. Interview on 02/11/25 at 2:56 P.M. with Certified Nursing Assistant (CNA) #128 confirmed the observation and stated residents typically do not and should not help themselves to ice, but should ask for assistance.

Based on record review, observations, and interview, the facility failed to ensure an order for non-skid strips was followed. This affected one resident (#32) of one resident reviewed for falls. The facility census was 46. Findings include: Record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including stage three chronic kidney disease, hyperlipidemia, anxiety disorder, dementia, and osteoarthritis. Review of an undated fall care plan revealed Resident #32 was at risk for falls related to confusion, gait/balance, unaware of safety needs, essential tremors, bilateral knee replacements, behaviors, medication use and a history of wandering. Interventions included but were not limited to call light in reach, ensure non-skid footwear is in use, and non-skid strips to right of bed. Review of an order dated 03/22/23 revealed Resident #32 should have non-skid strips in front of her bed. Review of a minimum data set (MDS) completed on 12/05/24 revealed Resident #32 had severely impaired cognition, no behaviors, and no falls since the last assessment. Observations on 02/10/25 at 7:26 P.M., 02/11/25 at 9:16 A.M., 1:13 P.M., and 2:51 P.M. revealed there were no non-skid strips to the front of Resident #32's bed. Interview on 02/11/25 at 2:58 P.M. with Licensed Practical Nurse (LPN) #110 confirmed Resident #32 did not have non-skid strips to the front of her bed.

Based on medical record review, interview, and policy review the facility failed to ensure Preadmission Screening and Resident Review (PASARR) were accurately completed. This affected three residents ( #3, #40, and #43) of three reviewed for PASARR. Findings include: 1. Medical record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, major depressive disorder, post-traumatic stress disorder (PTSD), and dementia with other behavioral disturbance. Review of Resident current orders dated 02/2025 revealed the resident received Quetiapine (anti-psychotic) 25 milligrams (mg) at bedtime for major depressive disorder. The target behaviors included agitation and aggression. Review of Resident #40's PASARR dated 02/23/24 revealed the resident had no mental illness. Interview on 02/11/25 at 5:18 P.M., with the Director of Nursing (DON) confirmed the resident had major depressive disorder and PTSD that were not reflected on the PASARR on 02/23/24. 2. Medical record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including dementia with psychotic disturbance, anxiety, major depressive disorder, and unspecified psychosis. Review of Resident #43's admission orders dated 06/04/24 and current orders dated 02/2025 revealed Resident #43 was on Zoloft for depression Depakote for mood stabilizer. Review of Resident #43's PASARR dated 06/03/24 revealed the resident had no mental health diagnoses and did not receive anti-depressant (Zoloft) and mood stabilizer (Depakote) in the last six months. Review of Resident #43's psych notes dated 07/02/24 and 12/03/24 revealed the resident had a diagnosis of bipolar and was on Depakote 250 mg twice daily, Zoloft 150 mg daily, Aricept 10 mg at bedtime, Abilify 7.5 mg daily. Interview on 02/11/25 at 5:24 P.M., with the DON confirmed Resident #43's diagnoses list didn't reflect the resident bipolar diagnoses and the PASARR was inaccurate to include the resident's mental health diagnoses and anti-depressant (Zoloft) and mood stabilizer (Depakote) in the last six months. Review of the facility policy titled Screen and PASRR Requirement (undated) revealed it was the policy of the facility that all individuals applying for a new admission to this facility must be screened to identify serious mental illness or mental retardation/developmental disability. 47985 3. Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including cerebral ischemia, dementia, anxiety disorder, bipolar disorder, hypertension, major depressive disorder, and alcohol dependence. Review of an admission MDS completed on 06/07/24 revealed Resident #3 did not have a PASARR level two, was cognitively intact, and had no behaviors. Review of a PASARR completed on 10/24/19 revealed Resident #3 had a mood disorder (bipolar disorder and depression) and other psychotic disorder (alcohol dependence), but did not have a panic or anxiety disorder, or another mental disorder that may lead to chronic disability (alcohol dependence). Interview on 02/11/25 at 11:53 A.M. with Social Service Director (SSD) #178 revealed she did not have a copy of Resident #3's PASARR on file because he transferred to the facility from a different skilled nursing facility who completed the transfer level of care. SSD #178 stated she would try to get a copy of the PASARR. Interview on 02/11/25 at 3:39 P.M. with SSD #178 revealed she did not review Resident #3's PASARR upon his admission or question the diagnoses. SSD #178 confirmed anxiety disorder was not listed, and other psychotic disorder was listed but without an appropriate diagnosis. SSD #178 confirmed alcohol dependence should be considered other mental health disorder and not a psychotic disorder. SSD #178 stated resident reviews are completed within a certain timeframe of a psychiatric admission, when a resident receives a new psychiatric medication or diagnosis. SSD #178 was unable to indicate the timeframes for the resident review to be completed. Review of an undated policy titled Screen and PASRR Requirements revealed it is the policy of the facility or all individuals applying for a new admission to be screened for serious mental illness or developmental disabilities. A screen is needed prior to admission to the facility, within 14 calendar days of receiving a new diagnosis for mental illness or developmental disability, within 14 days if a resident previously identified as having a mental illness or developmental disability has a significant change in physical and/or mental status. The social worker will receive the admission documents for all new admission and will review them to determine if a level two assessment is required and if so, to make sure it was obtained by the admissions department.

Based on record review and interview, the facility failed to revise a comprehensive, person-centered care plan with interventions for oxygen therapy and antipsychotic medication treatment. This affected two residents (#7, #46) of seven residents reviewed for respiratory care and unnecessary medications. The facility census was 46. Findings include: 1. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease, malignant melanoma, heart failure, and acute respiratory distress syndrome. Review of Resident #7's physician order, dated 01/18/24, revealed the order for oxygen to be administered at four liters per minute via nasal cannula continuously for low oxygen saturation. Review of Resident #7's care plan revealed it was not individualized and did not reflect the resident's treatment order for oxygen therapy. Interview on 02/11/25 at 2:01 P.M., the Registered Nurse (RN)/Minimum Data Set (MDS) #101 confirmed Resident #7's care plan was not individualized and did not indicate the resident was receiving oxygen therapy. RN #101 stated the care plan would be revised/updated. 2. Medical record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including gastrostomy, anemia, malignant neoplasm of colon, incisional hernia without obstruction or gangrene. Review of Resident #46's Medication Administration Record (MAR), dated February 2025, revealed the resident received Zyprexa five milligrams (mg) every day. Review of Resident #46's Care Plan revealed it was not individualized and did not reflect the resident's treatment order for Zyprexa, an antipsychotic medication. Interview on 02/12/25 at 10:26 A.M., the Director of Nursing (DON) confirmed Resident #46's care plan was not individualized and did not indicate the resident was receiving Zyprexa, an antipsychotic medication.

Based on record review, policy review, and interview, the facility failed to ensure Resident #33's blood glucose level reading was obtained prior to administering insulin and failed to timely identify Resident #26's edema. This affected two residents (#33, #26) of three residents reviewed for change in condition and edema. Findings include: 1. Review of the medical record for Resident #33 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia, encephalopathy, angina, and diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment, dated 11/22/24, revealed a Brief Interview for Mental Status (BIMs) score of 04, which indicated severely impaired cognition. The MDS further revealed Resident #33 required staff assistance with activities of daily living (ADLs). Review of physician order, dated 12/20/24, revealed the order for Degludec Subcutaneous Pen-Injector 100 units/milliliter (ml) inject 20 units subcutaneously one time a day for diabetes mellitus. Review of a physician order, dated 12/06/24, revealed the order to obtain a blood glucose level one time per day related to diabetes mellitus and to notify the physician if blood glucose is less than 60 or greater than 400. Review of the Medication Administration Record (MAR) dated February 2025 revealed Resident #33's blood glucose level was not obtained on 02/01/25 and 02/02/25 as ordered by the physician; and Insulin Degludec injection 100 units/milliliter (ml) 20 units subcutaneously was held and not administered on 02/01/25; however, it was administered on 02/02/25 without obtaining a blood glucose level prior to administration. Review of a nursing progress note, dated 12/20/24 at 7:32 P.M., revealed the nurse was unable to provide incontinence care/bathing and morning blood glucose check/insulin administration due to resident refusal. The resident became aggressive when approached for care, screaming to get out while drawing clenched fists back to strike at staff. All methods of de-escalation and calming techniques implemented without effect. The resident was left to rest as requested. Interview on 02/11/25 at 4:32 P.M. with the Director of Nursing (DON) confirmed Resident #33's blood glucose should have been obtained prior to his insulin injection on 02/02/25. The DON further confirmed the resident's blood glucose was not obtained on 02/02/24 and 02/02/25 as ordered by the physician. Review of the facility policy titled, Administering Medications, (dated April 2019), revealed medications are administered in accordance with prescriber orders, including any required time change. 32801 2. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with hemiplegia and hemiparesis following cerebral infarction affecting right dominate side and diabetes. Interview of Resident #26 on 02/10/25 at 8:10 P.M., revealed the resident reported his right foot pain and edema. Interview on 02/11/25 at 11:20 A.M., with Resident #26 revealed his right foot was swollen. The resident reported he would let the surveyor observe his foot after lunch. Interview and observation of Resident #26 with Certified Nursing Assistant (CNA) #128 on 02/11/25 at 3:02 P.M. revealed the resident had plus four edema to the top of right foot. There was no redness or warmth noted. The resident and CNA confirmed the resident's right foot had been swollen for three or four weeks. The CNA reported the edema was reported to the nurse. The resident reported he could not recall injuring his right foot and staff had not assessed or treated the swelling/edema. Interview on 02/11/25 at 2:51 P.M., with Licensed Practical Nurse (LPN) #110 revealed she was not aware Resident #26 had edema/swelling to his right foot. The LPN reported she would assess the resident and call the resident's medical provider. Interview on 02/11/25 at 3:06 P.M., with Director of Nursing (DON) confirmed there was no documentation regarding Resident #26's swelling/edema to the right foot. The DON reported staff would notify the provider. Review of Resident #26's orders, nursing progress notes, physician notes, assessment, and care plans dated 12/27/24 to 02/11/25 revealed no evidence the resident had swelling/edema of right foot. Review of LPN #110's assessment dated [DATE] revealed the resident had plus four edema to the lower right extremity. The resident denied pain and upon assessment there was no redness or warmth areas on leg. The nurse notified the resident physician, and new orders were received for a venous doppler ultrasound of the right lower extremity. The resident was notified and agreed. Review of the facility policy titled Resident Condition or Status (dated 05/2017) revealed our facility shall promptly notify the resident, his or her attending physician and representative of changes in the resident's medical/mental condition and/or status.

Based on record review, observations, and interview, the facility failed to ensure an order for an alternating air mattress was followed for a resident at risk for developing pressure ulcers. This affected one resident (#32) of four residents reviewed for pressure ulcers. The facility census was 46. Findings include: Record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including stage three chronic kidney disease, hyperlipidemia, anxiety disorder, dementia, and osteoarthritis. Review of a care plan last updated on 08/19/22 revealed Resident #32 had the potential for impairment to skin integrity related to dermatitis, use of Plavix, neuropathy, edema, and obesity. Interventions included keeping body free of moisture, cut fingernails, follow facility protocols for treatment of injury, monitor for bruising related to Plavix, pressure reducing mattress to bed, and provide incontinence care after each incontinence episode. Review of an order dated 05/16/24 revealed Resident #32 should have a low air-loss mattress with side bolsters to her bed, placement and function checked each shift for pressure reduction. Review of a minimum data set (MDS) completed on 12/05/24 revealed Resident #32 had severely impaired cognition, no behaviors, was at risk for developing pressure injuries, and had a pressure reducing device for her bed. Observations on 02/10/25 at 7:26 P.M., 02/11/25 at 9:16 A.M., 1:13 P.M., and 2:51 P.M. revealed there was not a low air-loss mattress with side bolsters to Resident #32's bed. Interview on 02/11/25 at 2:58 P.M. with Licensed Practical Nurse (LPN) #110 confirmed Resident #32 did not have a low air-loss mattress with side bolsters to her bed.

Based on record review including review of facility payroll records and facility billing/financial information, review of the facility assessment, review of the employee handbook, review of the facility Resident [NAME] of Rights, review of the facility Abuse/Neglect policy and procedure and interviews, the facility neglected to meet financial obligations for the delivery of care and maintenance and to operate in a manner to ensure all bills were being paid timely to prevent the potential interruption in services and to meet the total care needs of all residents admitted to and/or retained in the facility and failed to have adequate and effective systems in place to ensure staff were compensated via payroll benefits based on their hired agreement and payroll schedule. This resulted in Immediate Jeopardy beginning on 06/07/24 when the identified lack of financial solvency placed all facility residents at risk for serious harm, injury, hospital, displacement due to potential interruption in staffing regarding non-payment of payroll benefits and continued due to non-payment of essential bills including payment to the facility contracted therapy supplier. This affected eight residents, Resident #7, #23, #26, #28, #34, #36, #40 and #41 who were currently receiving therapy (physical, occupational and/or speech therapy) services and had the potential to affect all 42 residents residing in the facility. On 06/13/24 at 5:03 P.M. the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 06/07/24 when an onsite investigation determined the facility neglected to meet all financial obligations for the delivery of care and maintenance of the facility by not paying staff in a timely manner. This included but was not limited to insufficient funds to make payroll on 06/07/24, non-payment for therapy services (physical, occupational, and speech therapies) resulting in the therapy provider notifying the facility that services would be terminated by the end of the week, if a payment was not received and non-payment to a facility supply company. The Immediate Jeopardy was removed on 06/20/24 when the facility implemented the following corrective actions: On 06/07/24 at 6:00 A.M. the Administrator identified her paycheck was not available in her checking account. At 8:00 A.M. staff began to identify their pay was unavailable. 39 staff members did not receive their paychecks as scheduled for the 06/07/24 pay day. The Administrator identified herself, the Director of Nursing (DON), Administrative Assistant #20, Registered Nurse (RN) #61, #65, and #82), Licensed Practical Nurse (LPN) (#4, #23, #25, #33, #34, #57, #71, #76), Activity Director #6, Activity Staff #37, Marketing Director #3, Dietary Manager #9, Dietary Staff (#28, #29, #31, #32, #38, #46, #53, #46, #53, and #56), Housekeeping Staff (#5, #26, #30, #51, #58, #73, and #75), Hospitality Aide #36, Business Office Manager #8, Beautician #22, and Maintenance Director #2 who were not paid. On 06/10/24 by 11:27 A.M., via in person interviews and phone communication with the employees, the Administrator verified payroll had been met as of this date at 100% for the 38 employees affected. Beginning 06/13/24 at 7:00 P.M. and concluding on 06/14/24, all 68 staff received education via in-person, telephone and hand-outs from the Administrator regarding the facility abuse/neglect policy. Beginning on 06/13/24 at 7:00PM and ending on 06/17/24 at 10:00 A.M. all 42 residents and/or resident representatives were interviewed by the interdisciplinary team (the Administrator, DON, SSD, BOM, Unit Manager) to ensure care needs were being met. A roster spreadsheet was developed by the Administrator to track completion of the interview questions. The interview questions included: Do you feel that your needs are being met? Do you have any concerns? Beginning on 06/13/24 to ensure medical supplies, food, medications and staff continue to be provided, the Administrator/designee would complete daily audits. The Interdisciplinary Team (IDT) would ask staff if they have any concerns regarding not having necessary supplies or staffing levels to meet the needs of the residents. If concerns are identified, the management company will be notified immediately, via email and/or phone call. The audits will continue daily for 12 weeks and will be documented on a spreadsheet. The facility implemented a plan for R&R Management (court appointed receivership beginning 05/30/24) to fund payroll at the beginning of payroll week to ensure adequate time to correct any errors with payroll prior to pay day. Payroll ACHs would be deposited on 06/20/24 (Thursday), the day prior to payroll. An audit will be completed on 06/21/24 (Friday) of payroll by Administrator/designee to ensure that all funds have been received. Audits will be completed via spreadsheet with each employee asked if they have received their pay. If there is a delay in payment, wire transfers will be completed on 06/21/24 (Friday). Payroll will be funded early moving forward to ensure no issues arise on payday. On 06/17/24, letters to notify vendors of new receiver were sent via US mail. Vendors that were notified included food service, oxygen supply company, therapy company, pharmacy, electric, medical supplies, trash, water, payroll, dietician, and the medical director. New contracts would be obtained by the administrator in collaboration with the new management company. A Broad River payment plan was initiated on 06/18/24 at 2:45 P.M. that included 25% of outstanding balances to be paid each month beginning on 07/01/24. Additionally, the rehabilitation company would be kept current with 45-day terms. A representative from Broad River Therapy confirmed via email on 06/18/24 at 5:38 P.M. that there would be no interruption of services to therapy (based on the payment plan initiated). On 06/18/24 at 9:30 A.M., the Administrator verified staffing contracts via email with Interim Staffing at 9:35 A.M.; Premier Staffing at 9:35 A.M.; and with a third staffing representative at 9:57 A.M. Interview revealed two to three days' notice was best to fill shifts, but incentives would be offered to employees who pick up immediate/same day shifts. Managers were educated on shift pickup should the need arise via in-service. The Administrator provided education via handout on 06/13/24 to Activity Director, SSD, BOM, ADON, DON, Dietary Director, Two Unit Managers, Maintenance Director, and Housekeeping Supervisor. The facility implemented a plan for ancillary staffing (housekeeping, dietary, maintenance) should the need arise: The Administrator would delegate managers to shifts that were unfilled through shift pick up; State tested Nursing Assistant staff would be pulled into the ancillary shifts and their shifts would be back filled with agency staff. Staff would also be shared through the staff sharing agreement between other facilities managed by the company. The staffing agreement was established to provide supplemental staffing support to multiple nursing homes within the organization. Staff would be assigned to different facilities based on staffing needs, acuity levels, and skill sets. Shifts and assignments would be based on availability, skill level, and facility needs. The facility implemented a plan for the Administrator, in collaboration with the new management company, R&R Management, to complete audits of financial obligations weekly to validate obligations continue to be met to ensure the delivery of care continues as required. Special focus would be placed on essential resident care services to ensure vendors were up to date and there was no interruption in services. Essential resident care services include food service, oxygen provider, therapy provider, pharmacy, electric, medical supplies, trash, water, payroll, dietician, and medical director. Concerns identified would be shared with the new management company for resolution. Results of these audits and interventions would be brought to the Quality Assessment Performance Improvement (QAPI) meeting monthly for three months and as needed for review and recommendations. The facility implemented a plan for audits to begin on 06/19/24 via email and phone communication with the new management company. Residents (#7, #41, #40, #23, #26, #34, #36) were interviewed by SSD #10 on 06/19/24 at 10:00 A.M.; Therapy Director confirmed no interruption of services for Resident #28, who was unable to answer, on 06/19/24 at 10:30 A.M. to ensure continuity of therapy services and no identified interruptions. Although the Immediate Jeopardy was removed on 06/20/24, the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: On 06/13/24 at 10:05 A.M. an interview with the Administrator revealed on 06/07/24 there were staff members who did not receive their bi-weekly paychecks (due 06/07/24) via electronic bank deposit. The Administrator revealed the owner of the facility, Owner #1, would be able to provide further information and details and provided the owner's contact information. On 06/13/24 at 11:10 A.M. an interview with the Administrator regarding the facility finances and billing/payment process revealed the facility did not pay any of the vendors directly for services rendered at the facility, and she was unsure if Epic Healthcare Solutions was responsible for all payments. During the investigation and interview with the Administrator, it was determined the facility did not have a comprehensive and effective system in place to monitor the financial solvency of the facility, to ensure bills were being paid timely, vendors were paid the amount due and/or the facility was meeting all financial obligations. The following financial solvency concerns were identified, including but not limited to the following as a result of the complaint investigation: a. On 06/13/24 at 1:05 P.M. an interview with Licensed Practical Nurse (LPN) #34 revealed she was to be paid bi-weekly via electronic bank deposit, and on 06/07/24 she was not paid. LPN #34 revealed she was not paid until three days later, on 06/10/24. On 06/13/24 at 1:09 P.M. an interview with Licensed Practical Nurse (LPN) #4 revealed she was to be paid bi-weekly via electronic bank deposit, and on 06/07/24 she was not paid. LPN #4 revealed she was not paid until three days later, on 06/10/24. On 06/13/24 at 1:30 P.M. an interview with Social Services Director (SSD) #10 revealed she was to be paid bi-weekly via electronic bank deposit, and on 06/07/24 she was not paid. Social Services Director (SSD) #10 revealed she was not paid until three days later, on 06/10/24. On 06/13/24 at 1:36 P.M. an interview with Housekeeping Staff #75 revealed she was to be paid bi-weekly via electronic bank deposit and on 06/07/24, she was not paid. Housekeeping Staff #75 revealed she was not paid until three days later, on 06/10/24. On 06/13/24 at 2:10 P.M. an interview with Administrative Assistant #20 revealed she was to be paid bi-weekly via electronic bank deposit, and on 06/07/24 she was not paid. Administrative Assistant #20 revealed she was not paid until three days later, on 06/10/24. On 06/13/24 at 1:46 P.M. an interview with Laundry Staff #26 revealed she was to be paid bi- weekly via electronic bank deposit, and on 06/07/24 she was not paid. Laundry Staff #26 revealed she was not paid until three days later, on 06/10/24. On 06/13/24 at 1:55 P.M. an interview with Licensed Practical Nurse (LPN) #33 revealed she was to be paid bi-weekly via electronic bank deposit, and on 06/07/24 she was not paid. LPN #33 revealed she was not paid until three days later, on 06/10/24. On 06/13/24 at 2:20 P.M. an interview with Dietary Manager #9 revealed she was to be paid bi- weekly via electronic bank deposit, and on 06/07/24 she was not paid. Dietary Manager #9 revealed she was not paid until three days later, on 06/10/24. On 06/13/24 at 2:28 P.M. an interview with Dietary Staff #38 revealed she was to be paid bi- weekly via electronic bank deposit, and on 06/07/24 she was not paid. Dietary Staff #38 revealed she was not paid until three days later, on 06/10/24. On 06/13/24 at 2:32 P.M. an interview with Dietary Staff #31 revealed she was to be paid bi- weekly via electronic bank deposit, and on 06/07/24 she was not paid. Dietary Staff #31 revealed she was not paid until three days later, on 06/10/24. On 06/17/24 at 3:41 P.M. an interview with Licensed Practical Nurse (LPN) #71 revealed she was to be paid bi-weekly via electronic bank deposit, and on 06/07/24 she was not paid. LPN #71 revealed she was not paid until three days later, on 06/10/24. On 06/13/24 at 4:40 P.M. an interview with Facility Owner #1 revealed last week when he input data and ACH approval into his bank account at the Bank of Oklahoma there were sufficient funds. On Friday, 06/07/24, he was notified by the facility that a couple of staff didn't get paid. Facility Owner #1 stated he contacted his bank and worked with a nice lady throughout the day Friday on the issue of some of the checks not being released. The owner stated that all of the checks were released by 6:00 P.M. on Friday but didn't make it to the employee's bank accounts in time. The owner stated that he personally spoke with some of the staff over the weekend and offered $200.00 bonuses to help compensate for the delay in staff receiving their paychecks. During the interview, the owner further stated he had been making payments to the therapy provider according to a previous plan and indicated he was not aware of any concerns with payments to the therapy provider (Broad River Rehabilitation). On 06/14/24 at 8:20 A.M. the Administrator provided documentation of a court order for receivership for the facility effective 05/30/24. On 06/17/24 at 3:49 P.M. a follow-up interview with the Administrator revealed on 06/07/24 there were 39 staff members who did not receive their paychecks as scheduled. The Administrator identified herself, the Director of Nursing (DON), Administrative Assistant #20, Registered Nurse (RN) #61, #65, and #82), Licensed Practical Nurse (LPN) (#4, #23, #25, #33, #34, #57, #71, #76), Activity Director #6, Activity Staff #37, Marketing Director #3, Dietary Manager #9, Dietary Staff (#28, #29, #31, #32, #38, #46, #53, #46, #53, and #56), Housekeeping Staff (#5, #26, #30, #51, #58, #73, and #75), Hospitality Aide #36, Business Office Manager #8, Beautician #22, and Maintenance Director #2 who were not paid. Interview on 06/20/24 at 3:52 P.M. with Bank of Oklahoma Treasury Client Services Representative #104 revealed due to the facility's credit history all funding must be in the bank account before any funds can be processed for release. Client Services Representative #104 revealed the facility's payroll was not met on 06/07/24 due to insufficient funds per the bank's policy. He stated funds were sent to the Bank of Oklahoma via a check which required a one- day, intraday hold. The check was received on the same day the payroll was submitted on 06/07/24 and the payroll could not be processed as the funds were not available. Review of the undated facility Employee Handbook revealed employees would receive their pay reimbursement for hours worked either through Pay Card or Direct Deposit. During orientation, the human resources representative would assist with signing up for either direct deposit or a Pay Card. b. During the onsite investigation, the facility identified eight residents, Resident #7, #23, #26, #28, #34, #36, #40 and #41 who were currently receiving therapy (physical, occupational and/or speech therapy) services. Review of the statement issued by Broad River Rehabilitation, dated 01/02/24, revealed an invoice balance of $18,095.42 for service dates of 12/01/23 through 12/31/23. Review of the statement issued by Broad River Rehabilitation, dated 02/02/24, revealed an invoice balance of $17,825.06 for service dates of 01/01/24 through 01/31/24. Review of the statement issued by Broad River Rehabilitation, dated 03/01/24, revealed an invoice balance of $17,586.39 for service dates of 02/01/24 through 02/29/24. Review of the statement issued by Broad River Rehabilitation, dated 04/01/24, revealed an invoice balance of $13,078.95 for service dates of 03/01/24 through 03/31/24. Review of the statement issued by Broad River Rehabilitation, dated 05/01/24, revealed an invoice balance of $6,740.11 for service dates of 04/01/24 through 04/30/24. Review of the statement issued by Broad River Rehabilitation, dated 06/03/24, revealed an invoice balance of $11,529.63 for service dates of 05/01/24 through 05/31/24. On 06/13/24 at 10:24 A.M. an interview with Chief Executive Officer (CEO) #11 (physical, speech, and occupational therapies provider) revealed the facility's outstanding balance was $84,855.56 for services provided from December 2023 through May 2024. CEO #11 further stated a letter was sent out yesterday, on 06/12/24, notifying the facility management that services would stop by the end of the week, Saturday 06/15/24, if a large payment was not received. Chief Financial Officer (CFO) #12 who was present during the interview via conference call stated the therapy company has tried very hard to work with the facility for payments, but it has been unsuccessful. Review of an email communication from Broad River Rehabilitation CEO #11 to Facility Owner #1, dated 06/17/24 at 4:43 P.M., revealed We are not catching up in payment as we agree. I can't continue if I don't receive a large payment this week. The Department of Health is continuing to reach out to ask .I am sorry, but this is not negotiable at this time. Review of an email communication from Facility Owner #1 to Broad River Rehabilitation Chief Executive Officer #11, dated 06/17/24 at revealed, Understood. We are working with [J4] under receivership now and will be working officially now with them hand in hand to keep services going. On 06/17/24 at 10:15 A.M. an interview with Broad River Rehabilitation Staff Accountant #13 verified the facility's outstanding balance was $84,855.56 for therapy services between December 2023 through May 2024. Staff Accountant #13 revealed it was her understanding that a letter was sent to the facility last week notifying them that if a substantial payment was not received, services would be terminated by the end of the week. Staff Accountant #13 stated she was unsure why services continued past the end of last week but assumed it was because a plan was still in progress for ending services. c. On 06/13/24 at 11:06 A.M. an interview with Account Representative #19 from Medline Medical Supplies revealed the facility's current total outstanding balance was $23,298.14 and the facility current past due amount balance was $3,117.38, which was 13 days past due. Account Representative #19 revealed he could not comment on when supplies would cease due to non-payment as it was determined on a case-by-case basis. No additional information was provided by the facility during the investigation to explain why the facility had a past due balance or evidence the facility was in good standing with this vendor/supplier. Review of the undated Ohio and Federal Nursing Home Residents' [NAME] of Rights booklet, provided to the resident upon admission, revealed upon admission and thereafter, the right to adequate and appropriate medical treatment and nursing care and to other ancillary services that comprise necessary and appropriate care consistent with the program for which the resident contracted. Review of the facility assessment dated [DATE] revealed the facility provided all care and services as required in the requirements of participation including, but not limited to assistance with activities of daily living, personal care services, medication administration, pain management, infection prevention and control, nutritional services, skin care, fall and injury prevention, pharmacy, and therapy services. Additionally, the facility provided medical director, attending physicians, physician assistants, nurse practitioners, dentist, podiatrist, ophthalmologist, and psychiatrist services, and pharmacist. Review of the facility policy titled, Abuse Prevention, Identification, Investigation and Reporting Policy, revision date of 08/15/22, revealed neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. This deficiency represents non-compliance investigated under Complaint Number OH00154712.

Based on record review, including review of the facility payroll records, review of facility billing/financial information, review of email communication, review of the employee handbook, review of the facility Abuse/Neglect policy and procedure and interviews, the facility neglected to meet financial obligations for the delivery of care and maintenance and to operate in a manner to ensure all bills were being paid timely to prevent potential interruption in services and to meet the total care needs of all residents admitted to and/or retained in the facility. The facility also failed to have an effective system in place to ensure staff were compensated via payroll benefits based on their hired agreement and payroll schedule. This resulted in Immediate Jeopardy beginning on 02/16/24 when the lack of financial solvency placed all facility residents at risk for serious harm, injury, hospitalization , displacement due to potential interruption in staffing and/or outside service providers. This had the potential to affect all 41 residents residing in the facility. On 03/05/24 at 5:28 P.M., the Administrator and Director of Nursing (DON) #800 were notified Immediate Jeopardy began on 02/16/24 when the onsite investigation determined the facility neglected to meet all financial obligations for the delivery of care and maintenance of the facility by not paying staff in a timely manner and having outstanding balances with vendors and providers. This included, but was not limited to, insufficient funds to meet staff payroll on 02/16/24 and 03/01/24, delinquent balances owed to nutrition services which resulted in dietitian services being cut from 03/01/24 through 03/04/24, delinquent balances for the Medical Director and Psychiatrist, and delinquent balances for therapy services. The Immediate Jeopardy remains ongoing, as the facility failed to implement corrective measures to remove the Immediate Jeopardy situation. Findings include: Review of the facility survey history revealed on 12/18/23 a complaint survey was completed which resulted in concerns related to financial solvency. An issue identified at that time was related to employee payroll. An interview on 12/05/23 at 2:25 P.M. an interview with the Administrator revealed there were 14 employees who did not receive paychecks on 10/13/23 as their checks were returned due to insufficient funds. At the time of the survey, the Administrator did not provide any additional information as to why payroll was not met for these employees on this date. This payroll issue was in addition to the identification of other vendors/suppliers with past due balances, non-payment and shut off notices being issued to the facility. Following the 12/18/23 survey, the facility provided evidence of payments being made to various different supplies/vendors removing the likelihood of situations of neglect and the resolution of shut off notices for the facility. However, at the time of this complaint survey, the facility failed to ensure their governing body was effective in establishing and implementing policies regarding the management and operation of the facility and the Quality Assurance Performance Improvement Program provided continual monitoring, which included ongoing compliance with all financial obligations for the delivery of care regarding payroll, therapy services and electricity. On 03/04/24 at 9:10 A.M. an interview with State tested Nursing Assistant (STNA) # 227 revealed on 02/16/24 her payroll check did not clear the bank. She stated she did not receive her money until 02/26/24 because her bank placed a hold on her pay check. She stated this was not the first time her paycheck had not cleared the bank and she was charged penalties and late fees. On 03/04/24 at 9:15 A.M. an interview with STNA #100 revealed her paycheck on 02/16/24 did not clear the bank. She stated she was assessed fees and she did not get paid until 02/29/24 (13 days after her paycheck was issued). On 03/04/24 at 9:20 A.M. an interview with Laundry #110 revealed she had been employed at the facility for two years. She stated she has had her paycheck returned for insufficient funds four times since October 2023 with the most recent being 02/16/24 but she was waiting to see if her check from 03/01/24 cleared the bank. She stated her bank had placed a 10-day hold on the 03/01/24 pay check. On 03/04/24 at 9:40 A.M. an interview with Dietary Manager #122 revealed her check from 02/16/24 had not cleared the bank. She stated she had not received her payment until the following Wednesday (02/21/24). She stated she had not been reimbursed for wire fees and overdraft fees. She stated she was told it would be on this check but she did not believe it should be on a check with taxes taken out because she was losing money. She believed it should be cash. On 03/04/24 at 9:45 A.M. an interview with Cook #124 revealed her payroll check bounced the last two pay periods and she has not been paid the fees associated with the check bouncing. She stated she did not know about this week's check (for payroll on 03/01/24) as of this time. On 03/04/24 at 9:50 A.M. an interview with the Director of Nursing revealed employee payroll checks were not clearing the bank. She stated her paycheck did not clear the last two paydays. She stated she was not leaving (employment) but stated she was only staying because the previous Administrator had quit and she would not do that to the residents. On 03/04/24 at 9:57 A.M. an interview with CFO #600 revealed his corporation had more issues with banking since the previous two surveys in December 2023 and January 2024. He stated on 02/16/24 there was an error with their Positive Pay system (an automated cash-management service used by financial institutions where checks issued by companies are matched with those presented for payment). CFO #600 stated they placed the check numbers into the system and uploaded it from the Human Resource file to the bank and those were paid by the bank. He stated they covered the wire fees and bounced check fees as soon as the employee updated them on the amounts. An additional interview on 03/04/24 at 10:35 A.M. with CFO# 600 revealed, Chief Executive Officer (CEO) #601, Director of Finances (DOF) #603 and CFO #600 revealed they handled all the financial responsibilities for this facility and two sister facilities, Astoria Place of Cambridge, and Oakhill Manor. He confirmed he was aware the payroll checks from 03/01/24 were returning for insufficient funds for all three facilities. He stated they (Epic Corporation) used the same bank for all the payroll and wired transfers. He stated each facility had its own accounts to pay for payroll and to pay their suppliers. He stated on 02/16/24 there was a Positive Pay file error (they place a restricted range of check numbers in the account for the checks to be cashed to match the HR files and only those check would clear). He stated there was a mix-up with the numbers so all the checks were rejected. He confirmed he had no evidence from the bank that this was a banking error. In addition to the staff payroll issues, he stated the corporation had placed Physician #130 on a payment plan to get him caught up with monies due and had just sent Physician #130 a check for $6000.00 on this date. He stated he would stay in communication with the other providers the facility used and would never let the bills get to the point of a provider termination of service. He stated he was working with all the staff at the facility to get them paid. He was unable to answer the question as to why payment plans that either himself, Chief Executive Officer (CEO) #601 or Director of Finance #603 initiated, were not followed through with and why payments were missed. On 03/04/24 at 10:40 A.M. an interview with the Administrator revealed she had just started in the position of Administrator two weeks ago but she was previously the assistant administrator. She stated the corporate office had not given her a reason as to why the staff pay checks were returned for insufficient funds. She stated she does not know if any of the suppliers were being paid, however no suppliers had reached out to her directly in the last two weeks stating they had not been paid. Staff were to come to her about their paychecks and she was letting the corporate office know their checks did not clear the bank. She stated she was told their money would be wired within 24 hours. On 03/04/24 at 2:45 P.M. an interview with Business Office Manager (BOM) #120 revealed most of the bills were paid through the corporate office. She stated the secretary received the statements then she would give them to her, she would go through them, sort them out, and she would give the ones that needed to be paid to the Administrator and she wound send them to the corporate office to be paid. She stated Physician #130 and #131 had come to her asking about payment and she had to reached out the corporate office; however, they said they would take care of it but it never got done. She stated she also was responsible for completing employee payroll. She stated on 02/16/24 the facility had 43 staff members ( STNA #100, #103, #105, #106, #107, #116, #210, #211, #212, #215, #216, #220, #224, #225, #227, #229, #231, #232, #235, #236, LPN #109, #213, #214, #223, #226, #237, Dietary #122, #123, #124, #222, #228, #230, #233, #234, BOM #120, Social Service #217, Housekeeping #118, #119, #126, Marketing #121, Hospitality Aide #219, Maintenance #113 and #218) whose checked did not clear the bank. She stated they had all since been paid but there was a delay in payment. She stated the staff were told to bring her the documentation for the fees they received and they would also be paid. An email from the Administrator dated 03/07/24 at 3:08 P.M. revealed the facility had 23 staff (STNA #101, #102, #212, #224 #242, LPN #125, #223, #237, #240, Dietary #123, #228 , #233, Housekeeping #118, #126, #243, Maintenance #113, #121, Activity #112, #241, Administrator #500, #501, Receptionist #117 and Social Service #217) whose checks where returned for insufficient funds from the 03/01/24 payday. In addition to the facility's failure to ensure payroll obligations were met and continued to be met to ensure the ongoing effective day to day operation of the facility the following vendors/suppliers were reviewed as part of the State agency investigation with concerns identified: a. On 03/04/24 at 10:50 A.M. an interview with Pest Control Service #133 revealed the facility was behind from October 2023 through the present day in the amount of $810.00. She stated since the new company had taken over, they had not paid any invoices for service at all. b. Review of the invoices from Anova Psychiatric Services and Physician #130 revealed the facility was billed $500.00 on each month for 04/25/23, 05/25/23, 06/24/23, 07/25/23, 09/25/23 and 10/25/23 for a total of $3000.00. The Administrator did not have the most current invoices. On 03/04/24 at 10:54 A.M. an interview with Physician #130 (Anova Psychiatric Services) revealed he has not been paid for almost a year. He stated he received a paper check in November 2023; however, it was returned for insufficient funds. He stated he had called the corporate office in Florida but just gets the run-a-around. He stated although he had no plans to discontinue service as of this date, he hoped the company resolved the issue soon. Review of the check written on 03/04/24 revealed the facility sent a check to Physician #130 for $3000.00 to pay invoices from 04/25/23 through 10/25/23. c. On 03/04/24 at 11:05 A.M. an interview with Sanitation #213 revealed the facility was 30 days past due with their account. d. On 03/04/24 at 11:50 A.M. an interview with City Water Company Office Manager #134 from Barnesville water revealed the facility had a past due amount of $3345.82 with a current bill of $6420.97 which included the past due and current bill. e. On 03/04/24 at 11:57 A.M. an interview with Broad River Therapy Office Manager #128 revealed they had not received payment from the facility since September 2023; however, CFO #600 reported the facility would be sending out checks this week. Review of the email from Broad River Therapy Services dated 03/06/24 at 8:48 A.M. revealed the facility had a past due amount of $103,531.89. They had a statement from 11/02/23 with a due date of 12/02/23 which was 94 days past due for $27,252.19, a statement for 12/01/23 with a due date of 12/31/23 which was 65 days past due for $28291.58, a statement for 01/02/24 with a due dated of 02/01/24 which was 33 days past due for $22,527.73 and a statement for 02/02/24 with a due date of 03/03/24 which was two days past due for $25,461.39. f. The facility utilized a contracted service for the services of a dietitian. Review of the invoice from Nutritech Consulting Services dated 02/01/24 revealed the facility owed $1,645.00 and the due date was 02/10/24. This had been received by the facility and scanned to the corporate office on 02/02/24. Interview on 03/04/24 at 12:39 P.M. with Dietitian #135 revealed she was the owner of the nutrition services company that provided services to the facility. She stated due to previous concerns of not receiving payment, she required the facility to pre-pay for her services. Dietitian #135 stated she had terminated services on 03/01/24 as the facility was 23 days behind on their pre-pay plan. She stated CFO #600 called on 03/04/24 and paid the February 2024 balance of $1,645.00 so services would resume. The facility had until 03/10/24 to pre-pay for the March 2024 services. A follow-up interview on 03/11/24 with Dietitian #135 revealed if the facility did not make additional payment in full on this date, she would have to terminate services. g. Review of the invoices from the Medical Director (Physician #131) revealed the facility was billed $2000.00 on 12/11/23, 01/10/24, 02/01/24 and 02/28/24 for a total of $8000.00 owed. On 03/04/24 at 2:04 P.M. an interview with Medical Director Office Manager #132 revealed the facility was charged $2000.00 a month for Medical Director services and had not paid in four months. She stated they have an outstanding bill of $8000.00 as of 03/04/24. Review of the Nursing Facility Admission Agreement, provided to all residents, revealed the facility was responsible for basic services including room and board, routine nursing care and supplies for residents and such other personal services as may be necessary for the resident's health, well-being, and grooming. The facility would also provide meals, linens, housekeeping, social services and activities and other regular services required by law. Review of the Employee Handbook effective 2020 revealed employees would receive their pay reimbursement for hours worked either through Pay Card or Direct Deposition. During orientation, the human resources representative will assist with signing up for either direct deposit or a Pay Card. Review of the facility policy titled, Abuse Prevention, Identification and Reporting, revised 08/15/22, revealed the facility defined resident abuse to include neglect which was the failure of the facility, its employees or service providers, to provide goods and services to a resident which were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility assessment dated [DATE] revealed the facility provided all care and services as required in the requirements of participation including, but not limited to assistance with activities of daily living, personal care services, medication administration, pain management, infection prevention and control, nutritional services, skin care, fall and injury prevention, pharmacy, and therapy services. Additionally, the facility provided medical director, attending physicians, physician assistants, nurse practitioners, dentist, podiatrist, ophthalmologist, and psychiatrist services, and pharmacist. This deficiency represents non-compliance investigated under Complaint Number OH00151616.

Based on observation, record review including review of facility payroll records, review of facility billing/financial information, review of the [NAME] County Treasurer report, review of the facility assessment, review of the employee handbook, review of the facility admission agreement, review of the facility Abuse/Neglect policy and procedure and interviews, the facility neglected to meet financial obligations for the delivery of care and maintenance and to operate in a manner to ensure all bills were being paid timely to prevent potential interruption in services and to meet the total care needs of all residents admitted to and/or retained in the facility and failed to have adequate and effective systems in place to ensure staff were compensated via payroll benefits based on their hired agreement and payroll schedule. This resulted in Immediate Jeopardy beginning on 10/13/23 when the identified lack of financial solvency placed all facility residents at risk for serious harm, injury, hospital, displacement due to potential interruption in staffing regarding non-payment of payroll benefits and continued due to non-payment of essential bills. This had the potential to affect all 42 residents residing in the facility. On 12/12/23 at 9:01 A.M. the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 10/13/23 when an onsite investigation determined the facility neglected to meet all financial obligations for the delivery of care and maintenance of the facility by not paying vendors and staff in a timely manner. This included insufficient funds to make payroll on 10/13/23, a city water disconnect notice due to non-payment and/or returned checks due to insufficient funds, an electric company disconnect notice due to non-payment and/or returned checks due to insufficient funds, non-payment for therapy services resulting in a change of providers and non-payment for the current therapy services, delinquent property taxes since 02/2021, telephone company disconnect notice due to non-payment and/or returned checks due to insufficient funds, and the inability to meet the total care needs of the residents admitted to and/or retained in the facility. The Immediate Jeopardy was removed on 12/14/23 when the facility implemented the following corrective actions: On 11/28/23 at 10:30 A.M. the Assistant Administrator and the DON verified the residents had the needed supplies (food, oxygen, medication, medical supplies) to meet the needs of the residents. Beginning on 11/28/23 and concluding on 11/29/23, the Administrator and/or designee re-educated, through in-person and phone communication, all facility staff on the abuse policy. All staff included: five Registered Nurses (RN), 14 Licensed Practical Nurses (LPN), 26 State tested Nursing Assistants (STNA), four Hospitality Aides, two Maintenance Staff, seven Dietary Aides, one Activity Director, one Activity Aid, six Housekeepers and five Administration employees. This education included the requirement to meet financial obligations for the delivery of care and maintenance and to operate in a manner to ensure all bills were being paid in a timely manner to prevent potential interruption in services and to meet the total care needs of all the residents admitted to and/or retained in the facility. Beginning on 11/28/23 and concluding on 11/28/23 the DON and the Assistant Director of Nursing (ADON) completed education with all staff on communicating if there are any supply, vendor and/or food supply concerns to immediately notify the DON and the Administrator. All staff included five Registered Nurses (RN), 14 Licensed Practical Nurses (LPN), 26 State tested Nursing Assistants (STNA), four Hospitality Aides, two Maintenance Staff, seven Dietary Aides, one Activity Director, one Activity Aid, six Housekeepers and five Administration employees. On 11/28/23 the DON and ADON completed a review of all 43 resident records to verify there was no change of condition related to the facility's lack of payment to vendors. Beginning on 11/28/23, the Administrator and/or designee monitors and ensures essential resident care services are provided by daily (Business Days) communication in stand-up meeting with facility leadership team by asking if there are any essential vendor concerns. Beginning on 11/28/23, the Administrator and/or designee will communicate facility needs to the management company (Chief Compliance Officer #602, Chief Executive Officer #601, and/or Chief Financial Officer #600) as they arise via email communication. On 11/28/2023 at 1:00 P.M. an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review the QAPI Plan to address potential for resident abuse /neglect as it pertains to financial solvency due to issues that arose in the facility. In-person attendance included the Administrator, Assistant Administrator, Director of Nursing, Business Office Manager (BOM) #100, and Dietary Director #105. Medical Director #110, Chief Compliance Officer (CCO) #602 and Chief Financial Officer (CFO) #600 attended via phone. BOM #100 and Receptionist #200 were re-educated on 11/28/2023 by the Administrator on the Stampli process. BOM #100 and/or designee and Receptionist #200 scan bills into Stampli (online portal for the Management Company's (located in Florida) approval and payment). On 11/28/23, Corporate Compliance Officer #602 re-educated the Administrator, Assistant Administrator and DON on the abuse policy. This education included the requirement to meet financial obligations for the delivery of care and maintenance and to operate in a manner to ensure all bills were being paid timely to prevent potential interruption in services and to meet the total care needs of all the residents admitted to and/or retained in the facility. Beginning 11/28/23, Social Services #120 and/or designee will interview four residents weekly for four weeks and then randomly thereafter to ensure their needs are being met. Beginning 11/28/23, the DON or Designee would interview five clinical employees weekly for four weeks and randomly thereafter to verify that staff have adequate supplies, food and staffing to meet the needs of the residents. Beginning 11/29/23, the Administrator and/or designee and CFO #600 and/or designee would complete weekly audits for four weeks and then randomly thereafter of financial obligations to essential resident care services (food, pharmacy, oxygen, medical supplies, therapy, staff) by ensuring that invoices were being paid and that no disconnect/cut off/end of service notifications were delivered within the week. Beginning 11/29/23, weekly conference calls would be held on Wednesdays with the Administrator and/or designee with the management company (Corporate Compliance Officer, CEO, or CFO) to communicate any concerns with essential resident care services weekly for 12 weeks. Beginning 11/29/23, the Administrator and/or designee would verify with the Management Company (CEO, CFO, and/or Corporate Compliance Officer) that the following vendors bills were made current or placed on a payment plan: a. AEP (Electric) - On 12/11/23 account payments were made in the amounts of $103.82, and $7,876.51 (checks were delivered via FedEx on 12/13/23). b. [NAME] (Trash) - On 11/27/23 payment in the amount of $488.75 was posted to the account. c. Respiratory Care Partners (Oxygen) - On 12/06/23 a delinquent balance of $396.25 was paid. d. City of Barnesville Water - On 12/12/23 delinquent payment was made in the amount of $2,498.27. e. [NAME] County Treasurer (Property Taxes) Parcel 1 - Payment Plan initiated on 11/16/23 with 12 monthly payments of $6,613.50. Payments concluding on 10/16/24. Initial payment made on 11/16/23 via cashier's check in the amount of $13,612.00 (November and December payment for both parcels). f. [NAME] County Treasurer (Property Taxes) Parcel 2 - Payment Plan initiated on 11/16/23 with 12 monthly payments of $192.45. Payments concluding on 10/16/24. Initial payment made on 11/16/23 via cashier's check in the amount of $13,612.00 (November and December payment for both parcels). g. Medline (Medical Supplies) - A payment plan was initiated company wide to include a minimum payment of $15,000 each week via electronic payment. A payment of $7,135.78 was made on 11/20/23 and a payment of $3,340.01 was made on 12/11/23. h. Broad River (Therapy) - A payment plan was initiated on 12/14/23 with an electronic payment of $5,457.23 made. The facility indicated a payment plan contract was implemented to pay the oldest invoices first, starting with the September 2023 invoice (paid on 12/14/23). A conference call would be held on 12/14/23 to discuss the next payments. i. AT&T - A payment of $1,738.93 was made on 12/13/23 via phone debit transaction. j. Ohio Hills Health Services (OHHS) for the Medical Director's services - A payment plan was initiated on 12/07/23 to include paying three invoices in December 2023 and two invoices per month for the first six months in 2024 to bring the account current (the outstanding balance amount was not provided to the surveyor from the account manager at OHHS). Results of all audits and interventions were reviewed during an Ad Hoc QAPI meeting on 12/12/23 at 9:30 A.M. Attendees included the Administrator, Assistant Administrator, DON, [NAME] Date Set (MDS) Registered Nurse (RN) #8, Social Service Director (SSD) #64, Business Office Manager (BOM) #116, Therapy Director #230, Infection Preventionist (IP) Licensed Practical Nurse (LPN) #112, and Unit Manage LPN #120. The Medical Director was notified via phone. The results of all audits and interventions will be brought to the facility's monthly QAPI meeting for three months and as needed for review and recommendations. Although the Immediate Jeopardy was removed on 12/14/23, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure compliance. Findings Include: On 12/05/23 at 1:10 P.M. an interview with the Administrator revealed he was the Administrator at this facility as well as a sister facility, Astoria Place of Cambridge. The Administrator stated he was unaware of the extent of the financial issues this facility was experiencing until the complaint survey was in-progress at Astoria Place of Cambridge. The Administrator shared corrective actions from Astoria Place of Cambridge were also implemented at this facility, beginning on 11/28/23. On 12/06/23 at 2:35 P.M. an interview with Business Office Manager (BOM) #46 revealed most facility bills were sent directly from vendors to Epic Healthcare Solutions (the facility management company located in Florida). All bills and invoices received at the facility were scanned and emailed directly to Stampli (company that processes and pays invoices) every Wednesday. There was no evidence these bills were monitored to ensure they were being paid in a timely manner or to ensure payments were made as required to prevent outstanding balances or termination notices for the facility. Payroll information was sent to the corporation on a Monday and paper checks were sent overnight to the facility for payday (every other Friday). On 12/07/23 at 2:40 P.M. an interview with the Administrator regarding the facility finances and billing/payment process revealed BOM #46 would forward invoices and bills received at the facility to Stampli via email. The Administrator revealed the facility did not pay any of the vendors directly for services rendered at the facility, the payments were being made by an accounts payable department based in Florida. There was no evidence the facility had a comprehensive and effective system in place to monitor the financial solvency of the facility, to ensure bills were being paid timely, vendors were paid the amount due and/or the facility was meeting all financial obligations. The following financial solvency concerns were identified (to include but not limited to) the following as a result of the complaint investigation: a. On 12/05/23 at 2:25 P.M. an interview with the Administrator revealed there were 14 employees who did not receive paychecks on 10/13/23 as their checks were returned due to insufficient funds. The Administrator did not provide any additional information as to why payroll was not met for these employees on this date. On 12/05/23 at 1:25 P.M. an interview with Housekeeping Staff #74 revealed they had a paycheck from 10/13/23 returned due to insufficient funds. On 12/05/23 at 1:30 P.M. an interview with Laundry Staff #6 revealed they had a paycheck from 10/13/23 returned due to insufficient funds. On 12/05/23 at 1:35 P.M. an interview with Licensed Practical Nurse (LPN) #128 revealed they had a paycheck from 10/13/23 returned due to insufficient funds. On 12/07/23 at 9:51 A.M. an interview with Housekeeping Staff #80 revealed they had a paycheck from 10/13/23 returned due to insufficient funds. On 12/07/23 at 10:01 A.M. an interview with Activity Staff #56 revealed they had a paycheck from 10/13/23 returned due to insufficient funds. On 12/07/23 at 10:08 A.M. an interview with Dietary Staff #96 revealed they had a paycheck from 10/13/23 returned due to insufficient funds. On 12/07/23 at 2:40 P.M. interview with the Administrator revealed BOM #46 sent payroll information to corporate on a Monday and paper checks were sent overnight to the facility for payday (every other Friday). The Administrator stated paper checks had been used for several months but he was unsure why this was changed from direct deposit. Further interview revealed the Administrator called corporate on 10/13/23 when his check was returned for insufficient funds and again on 10/16/23 when the checks for 13 additional employees were returned on 10/16/23 due to insufficient funds. The Administrator identified himself, the Director of Nursing (DON), the Assistant Administrator, Licensed Practical Nurse (LPN) #210, Activity Director #56, Marketing Director #14, Dietary Director #98, Dietary Staff #88, #90 and #96, Housekeeping Staff #12, #74 and #218, and Maintenance Director #54 who had payroll checks returned due to insufficient funds. The 14 staff (the Administrator, DON, the Assistant Administrator, LPN #210, Activity Director #56, Marketing Director #14, Dietary Director #98, Dietary Staff #88, #90, #96, Housekeeping Staff #12, #74, #218 and Maintenance Director #54) identified were verified with facility payroll records to have payroll checks dispersed and dated 10/13/23. Review of the undated facility Employee Handbook revealed employees would receive their pay reimbursement for hours worked either through Pay Card or Direct Deposit. During orientation, the human resources representative would assist with signing up for either direct deposit or a Pay Card. b. The following vendor/suppliers were reviewed as part of the State agency investigation with financial solvency concerns including but not limited to the following: 1. Review of the statement issued by [NAME] Innovative Management Partners, dated 11/18/23, revealed the facility owed a balance of $133,353.10 with invoices dated back to June 2023. The facility owed the amount of $77,020.88 that was over 90 days past due. This vendor was the facility's previous food supply vendor. On 12/05/23 at 1:50 P.M. an interview with Dietary Director (DD) #98 revealed food service vendors were changed from [NAME] Distributors on 10/28/23 to [NAME] Food Services starting 10/29/23. DD #98 stated the previous food budget was set at $1,700.00 per week, which was a low dollar amount and made it difficult to order needed food items due to the increased food costs. DD #98 revealed she would have to borrow items from her emergency food supply to get through to the next week and then replace items with the next order. On 12/11/23 at 11:30 A.M. an interview with the Administrator revealed the facility's outstanding balance to [NAME] Distributors was $133,353.10 which included labor, food services, and supplies. 2. Review of a bill from Barnesville Water Department, dated 11/21/23, revealed the facility account was delinquent with an amount due of $2,498.27. The bill included, if payment was not received by 12/05/23, service would be terminated without further notice. Review of check #1006, from Bank of Oklahoma, dated 12/01/23 revealed payment of $2,498.27 made to the order of Barnesville Water Department. On 12/11/23 at 9:34 A.M. an interview with Barnesville Water Department Clerk #330 revealed a check payment was received on 12/05/23 for $2,298.27 and the payment was deposited on 12/05/23. However, on 12/08/23 there was a notice the payment had been returned due to an incorrect routing number on the check. Barnesville Water department Clerk #330 confirmed the recent bill dated 11/21/23 was a delinquent notice with possible termination of services if the amount was not paid by 12/05/23. Further interview with the clerk revealed concerns the facility/Epic Healthcare Solutions was always late on their payments for water services. On 12/15/23 at 11:01 A.M. an additional interview with Barnesville Water Department Clerk #330 revealed the delinquent statements are sent out to accounts which have a history of late payments. Epic Healthcare Solutions has a history of having late payments with the water department and would only send payment once the delinquent notice was received for the amount due including a 10% late fee. She also verified it is their practice to issue the shut off notice if payment is not received, and the facility was addressed in the same manner as a residence. 3. Review of an invoice from American Electric Power (AEP) Ohio, dated 11/29/23, revealed the facility had an amount due of $7,876.57, with a disconnection date of 12/08/23, if payment was not received. Review of check #1007 from Bank of Oklahoma, dated 12/01/23, revealed a payment of $7,876.51 paid to the order of AEP Ohio. On 12/12/23 at 10:20 A.M. an interview with AEP Customer Service Representative #365 revealed a check payment was received on 12/06/23 for $7,876.57. However, on 12/11/23 the payment for $7,876.57 was returned with no reason noted. An additional interview on 12/13/23 at 10:35 A.M. with AEP Customer Service Representative #377 revealed the facility had a current outstanding account balance of $10,891.71 due 12/29/23. A past due balance of $7,876.57 was due immediately. Per the representative, there were no pending payments noted to be on the account as of this date (12/13/23). 4. Review of an invoice from American Telephone and Telegraph (AT&T) dated 11/19/23 revealed a current charge of $640.27 with a past due balance of $2,182.82 resulting in total amount of $2,823.09 due in full by 12/19/23. Review of an email communication from Director of Finance #608 to the Administrator, dated 12/08/23, revealed a forwarded email, dated 12/07/23 at 5:01 P.M., from AT&T Business Payment Confirmation, showing a payment confirmation via bank debit for AT&T account. The payment amount and date of payment was not made available. On 12/13/23 at 10:43 A.M. an interview with AT&T Collections Representative #370 revealed a payment of $2,823.09 was received on 12/04/23. On 12/08/23 the same payment was returned due to an incorrect routing number. On 12/04/23 there was a credit placed on the account for $427.65 making the current amount owed $1,738.93 due immediately with the account being in jeopardy of termination. On 12/13/23 at 10:55 A.M. the Administrator and CFO #600 paid the account balance of $1,783.93 via the facility's petty cash credit card with the amount loaded onto the card by CFO #600. 5. Review of an invoice from the [NAME] County Treasurer Office dated 10/14/23 revealed two parcels of property located at the facility's address. The first parcel property tax amount of $79,362.61 with a payment noted on 11/17/23 for $13,227.10 bringing the current balance owed to $66,135.51. The second parcel property tax amount of $2,309.34 with a payment noted on 11/17/23 for $384.90 bringing the current balance owed to $1,924.44. On 12/11/23 at 9:52 A.M. an interview with [NAME] County Treasurer Clerk #373 revealed there was a payment plan contract dated 11/16/23 for monthly payments of $6,613.55 for the first parcel and $192.45 for the second parcel with each payment due on the 16th of each month. [NAME] County Treasurer Clerk #373 verified there were two separate payments on 11/16/23, one for $6,613.55 and the other for $384.90. 6. On 12/07/23 at 2:40 P.M. interview with the Administrator revealed the previous contracted therapy company (Arbor Therapy) terminated services on 09/17/23 (due to payment issues) and a new therapy company (Broad River Therapy) began services on 09/18/23. On 12/11/23 at 9:46 A.M. an interview with a Representative from Broad River Therapy #376 revealed the facility began services on 09/18/23 and the first invoice #106861 was sent on 10/03/23 for $5,457.23 with payment due on 11/02/23. On 11/02/23 a second invoice was sent for $18,688.17 due on 12/02/23. The facility had a current outstanding balance of $18,688.17 due immediately. Broad River Therapy #376 revealed the facility entered a payment plan contract, on 12/14/23 to pay the oldest invoices for the facility starting on 12/14/23 for the September invoice payment of $5,457.23 with a conference call to schedule the next set of payments (the conference call was also scheduled for 12/14/23). On 12/14/23 at 10:39 A.M. an interview with Arbor Rehabilitation and Healthcare Inc. Chief Executive Officer (CEO) #503 revealed therapy services provided by his therapy company in the facility, were ended due to lack of payment. The facility owes $187,594.25 for therapy services accrued from 01/17/22 to 09/17/23. CEO #503 stated the facility would not commit to a payment plan because it was too binding, and they wanted flexibility. CEO #503 stated monthly payments were not being made and a payment had not been made since 03/30/23. Review of an Excel Spreadsheet, created by Arbor Rehabilitation and Healthcare Inc. dated 11/15/23 and provided by CEO #503, verified the facility owed $187,594.23. 7. Review of the invoice for Medline Medical Supplies revealed an outstanding balance for Epic Healthcare Solutions of $41,659.20. The facility provided a payment plan that was corporation wide and not specific to the facility. The weekly agreed upon payments were to be between $15,000.00 to $20,000.00 entity wide. There were payments made on 11/20/23 for $7,135.78 and on 12/11/23 for $3,340.01 which were specifically for the facility. (However, the information regarding how the payments were made was not provided during the survey). Attempts were made to contact Medline regarding payments and outstanding balances. Medline did not return calls or emails. 8. On 12/11/23 at 11:45 A.M. an interview with [NAME] Credit Account Manager #245 revealed the facility had been 90 days delinquent with their invoice payments resulting in a suspension of service for the last week of October (10/29/23 - 11/04/23). The delinquent payment plus late fees totaled $1,552.00 and was paid on 11/06/23 and the facility service was restored. 9. On 12/11/23 at 10:35 A.M. an interview with Ohio Hills Health Services Office Manager #380 revealed Medical Director services had not been paid by the facility since 04/2023. Medical director service charges were $2,000.00 per month. A payment plan, dated and signed 12/14/23, revealed an electronic payment was to be paid by the 15th of each month in the amount of $6,000.00 until the account was paid current. The first payment was to be paid by electronic payment on 12/14/23 for $6,000.00. The current outstanding account balance was $16,000.00. On 12/11/23 at 2:00 P.M. during an interview with the Medical Director (MD) #225, the MD revealed he was aware the facility was not paying for his services as medical director. MD #225 revealed he had also been made aware by the Administrator related to the concerns with payroll not being met on 10/13/23. However, the MD denied knowledge of other unpaid vendors including water and electricity. On 12/12/23 at 10:33 A.M. an interview with Chief Financial Officer (CFO) #600 revealed the facility had attempted to make payments for some outstanding invoices/bills on 12/01/23; however, most were returned. CFO #600 revealed he believed the reason for the most recent vendor payments being returned was due to a new program offered through Bank of Oklahoma which required a routing number to be assigned prior to checks being sent out as payment. When the facility corporation, Epic sent out checks at the beginning of December 2023, the new program had not been implemented completely with the routing numbers which caused the checks to be returned. CFO #600 gave no explanation for the lack of payments to facility vendors resulting in high outstanding balances and shut-off notices to the water and electric and disconnect notices for the facility phone lines that was noted to be occurring prior to 12/01/23. Review of the undated Nursing Facility Admission Agreement, provided upon admission to the facility, revealed the facility would provide routine nursing care and supplies, meals, housekeeping, social services, activities, laundry, and medical supplies. Review of the Facility Assessment, dated 09/12/23, revealed the facility's residents were at a clinically complex and special high categories who oftentimes have one or more chronic or comorbid conditions including their acuity. Residents of the facility were at risk for falls, pressure ulcers, infections, incontinence, increased disability, weight loss, depression, and other potential areas of decline. Review of the facility policy titled, Abuse Prevention, Identification, Investigation and Reporting Policy revised 08/15/22 revealed, Neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. This deficiency represents non-compliance investigated under Complaint Number OH00148884.

Based on observation, record review and interview the facility failed to provide care and services to maintain Resident #16's ability to perform activities of daily living (ADL). Actual Harm occurred to Resident #16 when the resident was noted to experience functional declines in her ability to transfer, toilet, dress and complete personal hygiene without timely and adequate facility identification or interventions to prevent the decline and/or to restore the resident to her previous functional levels. This affected one (Resident #16) of three residents reviewed for ADL care. Findings include: Medical record review revealed Resident #16 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan titled At Risk for Self-Care Deficit related to weakness, dated 02/12/21 revealed the resident's goals included to demonstrate an increase in independence with self-care through the next review. Interventions included to assist with repositioning and transfers as needed, consult as needed and therapy to treat as ordered. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/07/21 revealed Resident #16 was severely impaired for daily decision-making and required extensive assist with toileting, transfers, dressing and personal hygiene. Review of the quarterly Interdisciplinary Historical Screen/Data Collection, dated 07/09/21 revealed the resident required maximum/dependent staff assistance with grooming, dressing and toileting with no change or referral for therapy. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed the resident had declined to total dependence with ADL's related to toileting, transfer, dressing and personal hygiene activities. The resident was not currently receiving restorative or therapy services. Occupational therapy had ended on 05/25/21. The resident was not screened by therapy for the functional level declines at the time of the quarterly MDS 3.0 assessment dated [DATE]. Review of the Task List dated 09/04/21 through 10/02/21 revealed Resident #16 was dependent on staff for transfers on six of six opportunities, dependent on staff for dressing 55 of 59 opportunities, dependent on staff for personal hygiene 49 of 59 opportunities and dependent on staff for toileting 51 of 57 opportunities. On 09/28/21 at 12:50 P.M. and 09/29/21 between 9:50 A.M. and 10:06 A.M. Resident #16 was observed laying in bed. Interview with the resident at the time of the observation revealed concerns that the staff did not get her out of bed, she required help from staff now to perform ADL's and she was not receiving any restorative or therapy services. Review of the resident's medical record, including a review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Kardex dated 09/30/21 revealed no evidence Resident #16 was receiving restorative or therapy services to restore previous transfer, toileting, dressing and personal hygiene functional levels. The resident was to use a bedside commode with a back for toileting; however, no bedside commode was observed in her room. On 09/30/21 at 2:38 P.M. interview with Registered Nurse #123 verified therapy did not screen Resident #16 after her decline in ADL's and no therapy or restorative nursing programs had been implemented to prevent the identified decline or promote increased function/independence for the resident. On 09/30/21 at 3:13 P.M., interview with Occupational Therapist Assistant (OTA) #900 revealed facility staff update the therapy director about changes in resident ADL status either by writing it up but mostly by catching him in the hallway and asking therapy to screen a resident who has had a decline. OTA #900 revealed if he thought a resident didn't need therapy after a therapy screen, they would not do evaluation for therapy. OTA #900 revealed she also believed the physician was involved in the process as well. OTA #900 revealed OT works with residents who decline in continence including recommendations for a toileting program with exercising strengthening for female residents. OTA #900 was not aware of a decline for Resident #16. On 09/30/21 at 3:57 P.M. interview with State tested Nursing Assistant (STNA) #144 revealed she routinely worked with Resident #16 and had noticed the resident's decline in ADL's over the last several months. Since the decline, the STNA staff no longer try to get the resident up with the sit-to-stand lift because Resident #16 tended to lean to the side, her knees drop and they do not feel safe using it so now all transfers were with a Hoyer lift. STNA #144 also revealed the resident had become dependent on staff for most of her ADL's, she was not receiving restorative that she was aware of and thought therapy had picked the resident up after she had first declined.

Based on observation, record review, facility policy and procedure review and interview the facility failed to provide care and services to maintain and/or restore bladder continence for Resident #16. Actual Harm occurred when Resident #16 was assessed to be a candidate for a scheduled toileting program that was not implemented and the resident declined from frequently to always incontinent of urine. This affected one resident (#16) of one resident reviewed for bladder incontinence. The facility identified 20 residents occasionally or frequently incontinent of bladder with five residents on urinary toileting programs. The facility census was 34. Findings include: Medical record review revealed Resident #16 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan titled [CONDITION(S)] bladder, dated 02/12/21 revealed the resident had timed voids. The resident must attempt to void every four hours and straight cath (catherization) as needed. Review of the care plan titled Functional Bladder Incontinence related to confusion and physical limitations, revised 03/08/21 revealed goals for the resident to be continent at all times through the review date and remain free from skin breakdown. Interventions included to monitor, document, report possible causes of incontinence and toilet the resident upon waking, before meals and at bedtime. Review of the Bowel and Bladder Program Screener, dated 04/25/21 revealed Resident #16 was a candidate for a scheduled toileting program. Review of the record revealed no evidence of a comprehensive bowel or bladder assessment after 04/25/21. Review of the progress note, dated 04/27/21 revealed Physician #500 was in to visit the resident and stated ok to start occupational and physical therapy mobility as tolerated. Resident #16 complained of frequent urination, burning with urination and incontinence at times. Review of the quarterly Interdisciplinary Historical Screen/Data Collection, dated 07/09/21 revealed the resident required max/dependent assistance (from staff) for toileting. No change in toileting or continence was noted and no referral for a therapy evaluation was completed. Review of the Bladder Task List dated 09/01/21 through 09/30/21 revealed Resident #16 was incontinent of bladder the entire month. There was no evidence the toileting program was completed per plan of care. On 09/30/21 at 1:55 P.M. interview with Registered Nurse #123 verified there was no comprehensive assessment of Resident #16's bowel and bladder after 04/25/21, a toileting program was not implemented as care planned and no interventions were implemented to restore bladder function for the resident who was identified to experience a decline in bladder function. On 09/30/21 at 2:38 P.M. interview with Registered Nurse (RN) #123 verified when the (scheduled toileting) intervention was added it did not include the staff discipline: therefore, the order for a scheduled toileting program did not flow over to the Kardex or administration records (MAR/TAR) to implement. Also, RN #123 verified therapy did not screen the resident after the identified decline in ADL care for transfers and toileting. On 09/30/21 at 3:03 P.M. interview with State tested Nursing Assistant (STNA) #142 and at 3:07 P.M. interview with STNA #100 revealed both STNAs indicated they were made aware of a residents' level of assist needed by verbal report and referencing the Kardex. Both STNAs indicated Resident #16 was checked every two hours for incontinence. The STNAs denied knowledge of any type of scheduled toileting program for the resident. On 09/30/21 at 3:13 P.M. interview with Occupational Therapist (OT) Assistant #900 revealed staff update the therapy director about changes in resident ADL status either by writing it up but mostly by catching him in the hallway and asking therapy to screen a resident who has had a decline. She stated if the therapist thought a resident didn't need therapy after the screen, they would not do an evaluation for therapy. She also believed the physician was involved in the process as well. She stated OT worked with residents for toileting if they go from being continent to incontinent. She stated they would do a bowel and bladder toileting program and they would do exercises to help with strengthening for females. On 09/30/21 at 3:57 P.M. interview with STNA #144 revealed she routinely works with Resident #16 and had noticed the resident was more incontinent of bladder, was not on an individualized toileting program but was checked every two hours for incontinence. Resident #16 was now unable to use the sit to stand lift and had to use the Hoyer lift for transfers. STNA #144 revealed it had been several months since the resident's decline was noted and had told the nurse. Since the decline the STNA staff no longer tried to get the resident up with the sit to stand lift because the resident tended to lean to the side, her knees drop and was not safe; therefore, the resident was now transferred with a Hoyer lift (mechanical lift). Review of the undated policy and procedure titled Bowel and Bladder Incontinence Management revealed the purpose was to identify, assess and provide appropriate treatment and services to achieve or maintain as much normal urinary function as possible to each incontinent resident without the use of an indwelling catheter unless there was a valid medical justification. The restorative nurse or designee was to complete a bowel and bladder incontinence assessment, determine appropriate interventions based on outcome of the assessment to enhance the resident's quality of life and functional status. Each resident would have an individualized care plan based on the goals, notify resident and responsible party would be involved in the development of the toileting program per the assessment. Staff were to implement care plan interventions. A bowel and bladder toileting program was to be individualized to each resident needs to promote or regain functional ability of bowel and bladder. Nursing and therapy as indicated would follow care plan interventions for toileting needs for overall improvement of urine and or bowel elimination. Evaluation of effectiveness of program was to be reviewed on a regular basis.

Based on observation, medical record review, resident incident tracking review, policy review and interview the facility failed to provide adequate supervision to residents at risk for falls to prevent falls, failed to ensure safety interventions were in place and failed to identify accident hazards. Actual harm occurred on 02/12/19 when the facility failed to supervise Resident #3, who was at a high risk for falls. The resident was found on the floor in the dining room, unable to ambulate and sustained a left greater trochanter [MEDICAL CONDITION] requiring hospitalization . Actual Harm also occurred on 03/28/19 when Resident #2, who was assessed at moderate risk for falls, was found on the floor in the dining room of the memory unit resulting in a left wrist fracture. No staff were supervising the dining room at the time of the falls for Residents #3 an #2. In addition Resident #1 sustained a fall with no injury in the dining room while being unsupervised. This affected three of four residents reviewed for falls. Findings include: 1. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed a plan of care, dated 04/18/17 which identified the resident had alteration in mobility related to [MEDICAL CONDITIONS] and weakness. Interventions included for staff to assist with mobility. The resident also had a plan of care which identified she was at risk for falls related to weakness and multiple [MEDICAL CONDITION]'s. The goal developed was for the resident to have no further falls and no further injuries. Review of the fall assessment dated [DATE] revealed Resident #3 was at high risk for falls. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/12/19 revealed the resident was assessed to be cognitively impaired and required supervision from one staff for ambulation. Review of the incident report, facility investigation and nursing progress notes revealed on 02/12/19 at 12:00 P.M. per the incident report and 12:20 P.M. per the investigation, Resident #3 was found lying on the floor in the doorway of the dining room on the memory unit. The fall was not witnessed by staff. Following the incident, Registered Nurse (RN) #203 was called back to the unit to assess the resident. Resident #3 complained of pain to the back of her head but denied any other injuries at that time. At 5:00 P.M., Resident #3 complained of increased right leg pain, was limping and was sent to a local emergency room (ER) for evaluation. At approximately 8:00 P.M., the resident returned to the facility by emergency squad and the squad personnel stated the resident did not have any fractures and the x-ray showed [MEDICAL CONDITION] and arthritis. No report was received from the ER and there was no evidence the facility called to get the report upon the resident's return. At 8:10 P.M. the resident did verbalize discomfort when rolling to her left side. Review of the local hospital Imaging: Pelvis and Bilateral Hip x-ray preliminary report dated 02/12/19 revealed a hairline acute appearing [MEDICAL CONDITION] greater trochanter (hip). On 02/13/19 at 10:40 A.M., Resident #3 would not ambulate and complained of left upper leg pain. The physician was notified, reviewed the x-ray and ordered the resident be sent to the ER where the resident was diagnosed with [REDACTED]. The resident was readmitted to the facility following the hospitalization with orders for non-weight bearing status to the left leg. Review of the staff statements obtained related to the fall revealed State tested Nursing Assistant (STNA) #106 and STNA #107 both indicated they were completing other tasks on the unit and did not witness Resident #3 fall. Review of the significant change Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident was severely impaired for daily decision-making. On 04/10/19 at 1:15 P.M., interview with the Director of Nursing (DON) verified Resident #3 was found on the floor after an unwitnessed fall in the doorway of the dining room during meal time. The DON stated she assumed Resident #3 had collided with another resident, Resident #12 resulting in the fall, but she was unsure what exactly happened as no staff had witnessed the fall. The DON stated there was not a designated nurse working on the memory care unit on 02/12/19 because a nurse had quit and the nurse assigned to work on the memory unit was re-assigned to the South hall. The DON revealed the nurse from the adjacent North hall was responsible for the memory care unit, but was not on the unit at the time of the fall. The DON revealed there was not adequate staffing to meet the supervision needs of the residents on the memory unit at the time the incident occurred. In addition, the DON verified no new fall interventions were implemented after the incident, staff had not ensured Resident #3's supervision level was maintained, and Resident #3's fall resulted in a left greater trochanter [MEDICAL CONDITION]. Review of the facility policy titled Falls and Fall Risk, Managing, revised (MONTH) (YEAR) revealed based on previous evaluations and current data, the staff were to identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #2 was severely impaired for daily decision-making and required limited assistance from staff with walking. Review of the admission fall assessment dated [DATE] revealed the resident was at moderate risk for falls. Review of the Incident Report, facility investigation, radiology report and progress notes revealed Resident #2 resided on the memory unit and on 03/28/19 at 5:30 P.M. the resident was found on the dining room floor laying on her back. No staff were in the dining room and the resident was unable to say what happened. When the nurse attempted range of motion to the left hand, Resident #2 moaned and jerked her hand away. An x-ray was obtained, the resident was sent to the ER for treatment and diagnosed with [REDACTED]. Following the incident, a new fall intervention was implemented for staff to monitor the resident in the dining room. On 04/10/19 at 1:20 P.M., interview with the DON verified Resident #2 was unsupervised and fell resulting in a left wrist fracture on 03/28/19 at 5:30 P.M. which was at dinner time. The DON stated there had been an increase in falls but she was blaming it on the full moon; otherwise, she had not identified a root cause or pattern. The DON stated the memory unit was very active and it was difficult for staff to supervise all the residents when some residents required two staff assist with care and others were wandering on the unit. The DON stated it was the expectation that staff from the North hall were to cover the memory unit when staff had to leave the unit but she was not sure if this was occurring. On 04/09/19 at 3:33 P.M. and 4:28 P.M., interview with Licensed Practical Nurse (LPN) #200 revealed she was the nurse assigned to the memory unit. LPN #200 stated many of the residents were ambulatory and there was not as much staff available during the evening meal. The LPN indicated there were not enough staff to monitor the residents. On 04/09/19 at 5:11 P.M., interview with STNA #103 revealed she was working on the memory unit at the time of Resident #2's fall. STNA #103 stated she had left the dining room for a minute to push a cart down the hall and when she returned to the dining room the resident had fallen. STNA #103 stated meal times on the memory unit were very busy with people getting up and down. 3. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed the resident was severely impaired for daily decision-making and was independent with walking. Record review revealed the resident had a current plan of care in place which reflected she was at risk for falls. Interventions included the use of non-skid footwear. Review of the facility Incident Reports revealed Resident #1 had an unwitnessed fall on 02/26/19 in the dining room of the memory unit resulting in no injuries. Staff was to be with the resident when in the dining room and due to the resident seeking out a bathroom after meals, the resident was to be toileted after meals. The resident had a witnessed fall on 03/19/19 when she went to sit down with no chair there and she slid down to the floor. Review of the physician progress notes [REDACTED]. The plan included the physician strongly advised to get fall precautions in place. Review of the plan of care titled at risk for falls, revised 04/09/19 revealed no evidence the intervention to be toileted after meals was added to the care plan until 04/09/19. On 04/09/19 at 4:22 P.M., observation revealed Resident #1 was walked from the resident's room to the dining room with STNA #102. Resident #1's black, loafer shoes were observed to be too big and the back of her foot and heel were coming out of the shoe which made a snapping noise with each step. LPN #200 verified the condition of the resident's shoes at the time of the observation. This deficiency substantiates Complaint Number OH 461.

Based on record review, resident incident tracking review, nursing staff schedule review, facility assessment review and interview the facility failed to maintain adequate staffing on the secured memory care unit to ensure the safety and supervision for residents at risk for falls. This affected two residents (Resident #2 and #3) of four residents reviewed for falls and had the potential to affect 14 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14) of 14 residents residing on the memory care unit. The facility census was 53. Actual Harm occurred to Resident #2 and Resident #3 when the facility failed to have sufficient staffing to adequately supervise the residents who sustained falls with injury. Resident #3 sustained a [MEDICAL CONDITION] and Resident #2 sustained a fractured wrist as a result of avoidable falls sustained by the residents. Findings include: 1. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed a plan of care, dated 04/18/17 which identified the resident had alteration in mobility related to [MEDICAL CONDITIONS] and weakness. Interventions included for staff to assist with mobility. The resident also had a plan of care which identified she was at risk for falls related to weakness and multiple [MEDICAL CONDITION]'s. The goal developed was for the resident to have no further falls and no further injuries. Review of the fall assessment dated [DATE] revealed Resident #3 was at high risk for falls. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/12/19 revealed the resident was assessed to be cognitively impaired and required supervision from one staff for ambulation. Review of the incident report, facility investigation and nursing progress notes revealed on 02/12/19 at 12:00 P.M. per the incident report and 12:20 P.M. per the investigation, Resident #3 was found lying on the floor in the doorway of the dining room on the memory unit. The fall was not witnessed by staff and following the incident, Registered Nurse (RN) #203 was called back to the unit to assess the resident. Resident #3 complained of pain to the back of her head but denied any other injuries at that time. At 5:00 P.M., Resident #3 complained of increased right leg pain, was limping and sent to a local emergency room (ER) for evaluation. At approximately 8:00 P.M., the resident returned to the facility by emergency squad and the squad personnel stated the resident did not have any fractures and the x-ray showed [MEDICAL CONDITION] and arthritis. No report was received from the ER and there was no evidence the facility called to get report upon the resident's return. At 8:10 P.M. the resident did verbalize discomfort when rolling to her left side. Review of the local hospital Imaging: Pelvis and Bilateral Hip x-ray preliminary report dated 02/12/19 revealed a hairline acute appearing [MEDICAL CONDITION] greater trochanter (hip). On 02/13/19 at 10:40 A.M., Resident #3 would not ambulate and complained of left upper leg pain. The physician was notified, reviewed the x-ray and ordered the resident be sent to the ER where the resident was diagnosed with [REDACTED]. The resident was readmitted to the facility following the hospitalization with orders for non-weight bearing status to the left leg. Review of the staff statements obtained related to the fall revealed State tested Nursing Assistant (STNA) #106 and STNA #107 both indicated they were completing other tasks on the unit and did not witness Resident #3 fall. On 04/10/19 at 1:15 P.M., interview with the Director of Nursing (DON) verified Resident #3 was found on the floor after an unwitnessed fall in the doorway of the dining room during meal time. The DON stated she assumed Resident #3 had collided with another resident, Resident #12 resulting in the fall, but she was unsure what exactly happened as no staff had witnessed the fall. The DON stated there was not a designated nurse working on the memory care unit on 02/12/19 because a nurse had quit and the nurse assigned to work on the memory unit was re-assigned to the South hall. The DON revealed the nurse from the adjacent North hall was responsible for the memory care unit, but was not on the unit at the time of the fall. The DON revealed there was not adequate staffing to meet the supervision needs of the residents on the memory unit at the time the incident occurred. In addition, the DON verified staff had not ensured Resident #3's supervision level was maintained and Resident #3's fall resulted in a left greater trochanter [MEDICAL CONDITION]. 2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #2 was severely impaired for daily decision-making and required limited assistance from staff with walking. Review of the admission fall assessment dated [DATE] revealed the resident was at moderate risk for falls. Review of the Incident Report, facility investigation, radiology report and progress notes revealed Resident #2 resided on the memory unit and on 03/28/19 at 5:30 P.M. the resident was found on the dining room floor laying on her back. No staff were in the dining room and the resident was unable to say what happened. When the nurse attempted range of motion to the left hand, Resident #2 moaned and jerked her hand away. An x-ray was obtained, the resident was sent to the ER for treatment and diagnosed with [REDACTED]. Following the incident, a new fall intervention was implemented for staff to monitor the resident in the dining room. On 04/10/19 at 1:20 P.M., interview with the DON verified Resident #2 was unsupervised and fell resulting in a left wrist fracture on 03/28/19 at 5:30 P.M. which was at dinner time. The DON stated there had been an increase in falls but she was blaming it on the full moon; otherwise, she had not identified a root cause or pattern. The DON stated the memory unit was very active and it was difficult for staff to supervise all the residents when some residents required two staff assist with care and others were wandering on the unit. The DON stated it was the expectation that staff from the North hall were to cover the memory unit when staff had to leave the unit but she was not sure if this was occurring. On 04/09/19 at 3:33 P.M. and 4:28 P.M., interview with Licensed Practical Nurse (LPN) #200 revealed she was the nurse assigned to the memory unit. LPN #200 stated many of the residents were ambulatory and there was not as much staff available during the evening meal. The LPN indicated there were not enough staff to monitor the residents. On 04/09/19 at 5:11 P.M., interview with STNA #103 revealed she was working on the memory unit at the time of Resident #2's fall. STNA #103 stated she had left the dining room for a minute to push a cart down the hall and when she returned to the dining room the resident had fallen. STNA #103 stated meal times on the memory unit were very busy with people getting up and down. 3. Review of the Resident Incident Tracking log dated (MONTH) 2019 through (MONTH) 2019 revealed the following: During (MONTH) 2019, three of the 13 unwitnessed falls occurred on the memory unit. During (MONTH) 2019, three of the 14 unwitnessed falls were in the dining room on the memory unit. Resident #3's unwitnessed fall in the dining room resulted in a left greater trochanter fracture. (See findings above) During (MONTH) 2019, seven of the 15 unwitnessed falls were in the dining room on the memory unit. Resident #2's unwitnessed fall in the dining room resulted in a left wrist fracture. (See findings above) A total of five incidents between 04/01/19 and 04/07/19 which included four falls, three of the falls were unwitnessed and two of those unwitnessed falls were in the dining room on the memory unit. The facility identified 14 residents, Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14 who resided on the facility secured care unit. None of the residents on the unit were identified to be interviewable. 4. Review of the Facility Assessment revised 02/11/19 revealed the assessment was based on the resident population, their needs for care and support. The facility approach to staffing was to ensure that each of the facility residents had the minimum direct care staff to meet the needs of the residents at any given time. The daily Staffing Plan included six RNs and more if needed; five to six LPNs (24-hour period) based on staff working 12-hour shifts. The facility strived to achieve staffing with 11 to 12 STNAs per day (24-hour period). Review of facility staffing schedules and posted staffing information from (MONTH) 2019 through (MONTH) 2019 revealed the facility did not have STNA staffing per the facility assessment on particular shifts. On 02/12/19 the facility only had 10 STNAs scheduled for the 24 hour period. On 04/03/19 the facility only had 10 STNAs scheduled for the 24 hour period. On 04/05/19 the facility only had 10 STNAs scheduled for the 24 hour period. Interviews on 04/09/19 at 11:28 A.M. and on 04/10/19 at 10:31 A.M., with the DON revealed the facility staffing levels were determined based on the number of residents in the building and not according to the resident acuity level. The DON stated over the last two to three months staff had quit and the facility was not utilizing any agency staff at this time but could, if needed. She stated the facility would offer STNAs additional shifts to come in to cover call-offs but if no one would come in, an STNA was pulled from one of the other units. Interviews on 04/09/19 between 2:41 P.M. and 5:29 P.M. with STNA #101, #102, #103, #104, #105, LPN #200, #201 and #202 revealed the facility did not have enough staff to adequately supervise all residents and there had been a lot of resident falls because of it. Staff stated their work eventually got done; however, there was just not enough staff on the unit to monitor all residents when providing care to others. Interview on 04/10/19 at 1:09 P.M. and 5:46 P.M. with the DON verified residents should have staff supervision when in the dining room especially the memory unit and the facility assessment in regards to staffing needs was not being met. This deficiency substantiates Complaint Number OH 461.

Based on observation, record review, policy review and interview, the facility failed to ensure appropriate nutritional interventions were implemented to prevent weight loss. Harm occurred when Resident #6 had a 15.8 % weight loss in six months. The facility incorrectly identified the resident's weight loss and did not place the resident at a high nutritional risk. This affected one (Resident #6) of three residents reviewed for nutrition. The facility census was 60. Findings include: Review of Resident #6's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. On 02/25/15, the supplement was discontinued due to refusal. Further review of the physician's orders [REDACTED]. Review of the medical nutrition therapy updates dated 02/09/15 revealed the resident refused commercial supplements and staff was allowed to discontinue the supplement if she refused it for seven days. Due to the resident's unlikelihood of acceptance, there was no recommendation to increase the resident's supplement at that time. The resident had a 15.8% weight loss in 6 months. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was not able to be understood and was dependent of one to two staff for activities of daily living and one staff member for eating. The MDS did not indicate the resident had a significant weight loss. Review of the medical nutrition therapy re-assessment dated [DATE] and completed by registered dietary technician (DTR) #103 revealed the resident was refusing to eat and consumed 50-100% of meals with refusals. A body mass index (BMI) was not indicated. Further review of the assessment revealed an October 2014 weight of 134.1 pounds, January 2015 a weight of 126 pounds, March 2015 a weight of 123 pounds and 05/07/15 a weight of 115 pounds. The assessment reflected the resident had a stage one pressure ulcer to her right hip. The DTR calculated the resident's weight loss to be 9.1 % in six months and was not a significant weight loss. The resident had been having chronic weight loss and weekly weights continue. The assessment indicated the resident refused meals and supplements and the physician and family were aware of the increased behaviors. The recommended intervention was to monitor weekly weights and encourage oral intake. Review of the resident's documented weights revealed : 10/25/15 134 pounds 11/08/14 132 pounds 12/14/14 127 pounds 01/02/15 123 pounds 02/05/15 122 pounds 03/05/15 123 pounds 04/02/15 121 pounds 04/23/15 115 pounds Further review of the medical record did not indicate documentation or assessment of the resident's food preferences. Review of the diet tally received from Dietary Manager #700 on 05/11/15 revealed Resident #6 was ordered a puree no added salt diet. The tally sheet did not indicate the resident was to receive a high protein diet. On 05/14/15 at 8:15 A.M. interview with Licensed Practical Nurse (LPN) #22 verified the nutritional assessment did not indicate the resident's body mass index and the only supplement/nutritional interventions for the resident was a high protein diet and med pass supplement ordered on [DATE]. LPN #22 confirmed the resident refused the supplement since ordered. On 05/14/15 at 8:30 A.M. State tested nursing assistant (STNA) #74 was observed to begin assisting Resident #6 with her breakfast meal. The meal contained a bowl of eggs, a bowl of oatmeal, milk and juice. The diet slip from the tray indicated a puree no added salt diet. Interview with STNA #74 confirmed the tray contained pureed scrambled eggs, oatmeal, thickened milk and juice. STNA #74 revealed the bowl of scrambled eggs was the same amount the other puree diets received on her unit. On 05/14/15 at 9:00 A.M. observation of Resident #6's breakfast tray revealed the resident consumed the meal as delivered. Interview with STNA #74 verified the resident consumed 100% of her meal without issues. On 05/14/15 at 9:15 A.M. interview with Registered Dietary Technician (DTR) #103 verified the weight loss calculation was incorrect and the assessment should have indicated a 14.8 percent weight loss in six months placing the resident at a high nutritional risk. The DTR shared the resident refused to eat and was combative with attempts to offer supplements. The DTR revealed her nutritional interventions were limited because the facility did not offer many nutritional supplements except med pass, sugar free med pass and Boost. The DTR shared the dietician evaluated residents at nutritional risk when she visited quarterly and the DTR is able to contact the dietician to discuss residents at nutritional risk. The DTR revealed the dietician had not seen the resident since her significant weight loss and was not updated on the resident's significant weight loss due to the DTR's incorrect weight loss calculation. On 05/14/15 at 10:15 A.M. interview with STNA #75 verified the diet slip indicated the resident received a pureed no added salt diet. STNA #75 verified the diet slip on the meal try alerts the staff to the resident's diet and the staff make sure the appropriate diet is on the meal tray and staff would not know a resident was to receive extra protein unless it was indicated on the meal slip and the resident would have an additional bowl for the extra protein. On 05/14/15 at 10:50 A.M. interview with DM #101 revealed the facility offered Boost, sugar free med pass, med pass and ProCel (a protein supplement) as the nutritional supplements. No other nutritional supplementation was available in the facility. Further interview confirmed the diet tally sheet did not indicate Resident #6 was on a high protein diet. DM #101 verified the diet slip send on the resident's tray did not indicate a high protein diet. The DM shared the cook was aware of the high protein diet and the bowl of eggs contained the additional protein. On 05/14/15 at 10:55 A.M. interview with Dietary Staff #32 revealed she had knowledge of the resident's high protein diet due to recollection of the order and additional eggs would have been used as the resident's high protein diet. On 05/14/15 at 11:00 A.M. interview with the Director of Nursing (DON) revealed the facility would purchase additional nutritional supplements if ordered by the physician or recommended by the dietician. The DON shared the medical record did not contain documentation of the residents food preferences. The DON revealed the nursing department uses the diet slip sent out on the meal tray to ensure the resident receives the physician's orders [REDACTED]. Review of the Nutrition policy dated 09/28/12 revealed the facility will ensure that residents receive adequate nutrition. Residents are evaluated for nutritional needs by the diet tech (DTR) and referred to the dietician as needed. The dietary department provides therapeutic and mechanically altered diets as indicated. Nutritional supplements are provided on an individual basis per residents needs per doctors order.

Based on closed medical record review, review of a verbal discipline, review of personnel files, and staff interviews, the facility failed to provide necessary care and services when staff did not implement cardiopulmonary resuscitation (CPR) for Resident #12. This resulted in Immediate Jeopardy for one of 17 residents (Resident #12) reviewed for emergency measures. The facility census was 62. On [DATE] at 3:30 P.M., the administrator and the director of nursing (DON) were notified Immediate Jeopardy began on [DATE] at 2:20 A.M. when Resident #12 was found seated in a chair in her room without respirations or pulse and CPR was not initiated. Licensed Practical Nurse (LPN) #2 called the funeral home to remove Resident #2 ' s body. Resident #12 expired at the facility. The Immediate Jeopardy was removed on [DATE] at 11:00 A.M. when the facility completed the following corrective actions: *On [DATE] at 11:00 A.M., the DON provided education to LPN #2 in regard to initiating CPR when residents were a full code status. The DON educated LPN #2 to check the face sheets, which were located in each medical record with detailed information about each resident and included the code status. *On [DATE] at 11:30 A.M., the DON provided education to LPN #5 in regard to initiating CPR when residents were a full code status. The DON educated LPN #5 to check the face sheets, which were located in each medical record with detailed information about each resident and included the code status. *On [DATE] at 12:00 P.M., the DON provided education to two Registered Nurses (RN ' s) and twelve LPN ' s in regard to initiating CPR when residents were a full code status and to check the face sheets in the residents' medical records to obtain the code status. *On [DATE] at 11:00 A.M., the DON provided education to two RN ' s and three LPN ' s in regard to initiating CPR when residents were a full code status and to check the face sheets on the resident ' s medical record to obtain the code status . Although the Immediate Jeopardy was removed when the facility completed education to all RNs and LPNs in regard to CPR and Code Status, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) because the facility failed to develop a comprehensive policy and procedure which addressed emergency response action. Findings include: Review of the closed medical record revealed Resident #12 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. The face sheet for Resident #12 dated [DATE] revealed Resident #12 was a full code status (required CPR in the event of cardiopulmonary arrest). physician's orders [REDACTED].#12 was to receive CPR if needed and was ordered continuous oxygen at five liters a minute via nasal cannula. Nurse' s progress notes dated [DATE] revealed Resident #12 was a new admission to the facility, alert and oriented, and wished to be a full code status. Nurse' s progress notes written by LPN #2 and dated [DATE] at 10:00 P.M. revealed Resident #12 requested and [MEDICATION NAME](a medication used to treat [MEDICAL CONDITION]). Nurse ' s progress notes dated [DATE] at 11:45 P.M. revealed Resident #12 complained of hurting all over and rated the pain a seven on a zero to ten pain scale. Resident #12 was repositioned without relief and requested and received [MEDICATION NAME] ,[DATE] milligrams that was ordered as an as needed medication. Resident #12 did not have her vital signs assessed. Nurse' s progress notes written by LPN #2 and dated [DATE] at 1:00 A.M. revealed Resident #12 had no further complaint of pain at that time. Nurse' s progress notes written by LPN #2 and dated [DATE] at 2:20 A.M. revealed Resident #12 was found with no pulse, no respiration, and no blood pressure. There was no documentation indicating CPR or life saving measures were initiated. Nurse ' s progress notes dated [DATE] at 2:40 A.M. revealed the physician was notified Resident #12 had expired. Nurse ' s progress notes dated [DATE] at 2:45 A.M. revealed the family and the funeral home were notified Resident #12 had expired. Nurse ' s progress notes dated [DATE] at 3:30 A.M. revealed the body of Resident #12 was released to the funeral home. A physician ' s telephone order dated [DATE] at 2:20 A.M. revealed an order to release the body of Resident #12 to the funeral home. The face sheet revealed Resident #12 ' s body was released to the funeral home on [DATE] at 3:30 A.M. On [DATE] at 3:13 P.M., interview with the DON revealed she did not know why LPN #2 had not performed CPR for Resident #12. The DON verified Resident #12 was a full code and this information was documented on the face sheet and on the physician's orders [REDACTED]. On [DATE] at 9:45 A.M., a telephone interview with LPN #2 revealed on the night of [DATE] at 2:20 A.M., state tested nurse aide (STNA) #3 and STNA #4 had approached LPN #2 and informed her Resident #12 had been found non- responsive. LPN #2 stated she went directly to the room of Resident #12 and found the resident seated in a high backed chair with her oxygen tubing draped over the arm of the chair. Resident #12 was found unresponsive and cold to touch. LPN #2 revealed she attempted to obtain vital signs and found Resident #12 without a pulse, blood pressure, or respirations. LPN #2 stated since she was a new nurse and was inexperienced, she instructed the staff to inform LPN #5 she needed help. LPN #2 stated LPN #5, STNA #3, and STNA #4 assisted her to lift Resident #12 into bed. After Resident #12 was placed into bed, LPN #2 notified the physician, the family, and the funeral home. LPN #2 was not able to provide any rationale as to why she had not checked the code status or attempted to provide CPR to Resident #12. LPN #2 stated " I did not think to do so. " LPN #2 stated the DON disciplined her over the incident and she was provided training the next morning on steps to take when finding a resident in cardiopulmonary arrest. LPN #2 stated she no longer worked at the facility. On [DATE] at 2:15 P.M., a telephone interview with LPN #5 revealed on the night of [DATE] one of the STNA ' s, (LPN #5 could not identify a name), asked him to assist LPN #2 with the assessment of Resident #12. LPN #5 stated he responded to the North hall and found Resident #12 seated in a chair, with no blood pressure, no pulse, and no respirations. LPN #5 stated he assisted LPN #2, STNA #3, and STNA #4 in transferring Resident #12 from the chair to the bed. LPN #2 stated to LPN #5 that she did not have a lot of experience with a death and asked if he could write down the steps she needed to complete. LPN #5 stated he wrote down a list of people LPN #2 was to notify of the death of Resident #12. The list included the physician to obtain an order to release the body to the funeral home, the family, and the funeral home. LPN #5 stated he returned to the South hall of the building and within 15 minutes or so LPN #2 reported Resident #12 was a full code. LPN #5 then told LPN #2 CPR probably should have been performed on Resident #12. LPN #5 stated he knew he and LPN #2 had not made the right decision and they should have provided Resident #12 with CPR. LPN #5 stated the DON had called him at his residence the next day and had provided verbal training over the phone on the steps that were to be taken upon finding a resident with no pulse, no blood pressure, and no respirations and who was a full code status. LPN #5 stated upon finding a resident who had expired he would go directly to the medical record and check the face sheet which would have documentation of the code status of the resident. If the resident had a full code status, he was to activate emergency medical response (EMS), initiate CPR, and continue CPR until EMS arrived. Review of the personnel file revealed LPN #2 was hired on [DATE] and her last day worked was [DATE]. Review of a verbal counseling verification revealed LPN #2 had not followed proper nursing procedures after a resident assessment had been completed. LPN #2 was educated on the proper procedure on resident ' s code status. Review of the personnel file revealed LPN #5 was hired on [DATE] and was still employed at the facility. On [DATE] at 3:30 P.M., interview of the DON verified that on [DATE] Resident #12 was found without a pulse, blood pressure, or respirations, and had a full code status documented on the face sheet of the medical record. The DON verified LPN #2 and LPN #5 failed to provide Resident #12 with CPR and Resident #12 expired at the facility. The DON also verified the facility did not have a policy or procedure in place for actions that were to be followed in the event of an emergency. This deficiency substantiates Complaint Number OH 255.