Every finding on record at The Enclave at Cambridge

Based on record review, care plan review, policy review, and interview, the facility failed to ensure comprehensive care plans were in place for all residents. This affected four (#2, #4, #5, and #38) of 16 residents reviewed. The facility census was 35. Findings include:1.Record review revealed Resident #38 admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy, spondylosis, hypercalcemia, anxiety disorder, anemia, depression, and hyperlipidemia. Review of a care plan dated 11/21/25 and revised on 11/24/25 revealed Resident #38 had a nutrition risk related to adult failure to thrive, muscle wasting, hypothyroidism, hypertension, hyperparathyroidism, chronic kidney disease stage three, depression, anemia, malnutrition, and diet textures. Review of a minimum data set (MDS) dated [DATE] revealed Resident #38's cognition remained intact and care area assessments to be included in the care plan should be communication, activities of daily living functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, pressure ulcer, and psychotropic drug use. Review of a care plan dated 11/27/25 revealed Resident #38 was new to the facility and may have some feelings of sadness, anxiety and despair related to losses associated with illness. There were no additional completed care plan items for Resident #38. Interview on 12/16/25 at 3:25 P.M. with MDS Nurse #353 confirmed Resident #38 did not have a completed comprehensive care plan. MDS Nurse #353 stated she had no excuse as to why so many things were missing from the care plan. Review of a policy titled Care Planning- Interdisciplinary Team reviewed in 09/2013 revealed a comprehensive care plan for each resident is developed within seven days of the completion of the resident assessment/MDS. 2. Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of gastro-esophageal reflux disease without esophagitis, nausea, and dysphagia. Observation on 12/15/25 at 9:20 A.M., of Resident #4 revealed the resident had missing teeth on top and bottom and several decayed and broken teeth on the top. The resident reported she was supposed to see a dentist to have teeth pulled and be fitted for dentures but has not seen the dentist yet. Review of Resident #4's oral assessment dated [DATE] revealed the resident had her own teeth, some broken or missing. Oral mucous, pink, and moist. Declines dental services at this time, last dental visit was 12/09/24. No complaints voiced. Tolerates diet well. Review of Resident #4's oral assessment dated [DATE] and 11/04/25 own teeth, poor condition some broken or missing. Oral mucous, pink, and moist. Declines dental services at this time. No complaints voiced. Tolerates diet well. Review of Resident #4's current comprehensive plan of care revealed no evidence of a dental plan of care. Interview on 12/16/25 at 3:02 PM with Registered Nurse (RN) #353 confirmed Resident #4 did not have a comprehensive dental care plan and she just added one. 3. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including dementia, diabetes mellitus, depression, anxiety disorder, bi-polar disorder, and post-traumatic stress disorder (PTSD). Review of the Minimum Data Set (MDS) assessment, dated 10/13/25, revealed Resident #2 was cognitively intact and had a diagnosis of PTSD. Review of the Care Plan for Resident #2 revealed there was not a plan of care in place addressing the cause of PTSD, triggers which may cause re-traumatization, or interventions to reduce the risk of re-traumatization and provide care for PTSD. Interview on 12/17/25 at 11:03 A.M. with the Social Services Director #364 verified there had not been a plan of care implemented for Resident #2 to minimize the risk of re-traumatization. Interview on 12/18/25 at 1:26 P.M. with Registered Nurse/MDS Nurse #353 confirmed a care plan had not been implemented for Resident #2's diagnosis of PTSD. 4. Review of medical record for Resident #5 revealed admission to facility on 09/28/25 with diagnoses including stroke affecting right side, diabetes, high blood pressure, anxiety, lung disease, bipolar (mood) disorder, aphasia (difficulty speaking), left above knee amputation, and right below knee amputation. Review of the comprehensive Minimum Data Set (MDS) assessment completed on 09/08/25 revealed Resident #5 had a brief interview for mental status and scored a 6/15 indicating moderate to severe cognitive deficit. Further review of the MDS revealed Resident #5 was dependent for all care including bathing and dressing and required assistance for navigation of wheelchair. Review of the MDS comprehensive assessment section J completed on 09/08/25 revealed Resident #5 had pain rated 9/10 on pain scale and pain frequently effects sleeping and activities of daily living. Further review of section J revealed Resident #5 required routine and as needed pain medications. Review on 12/16/25 of the care plan for Resident #5 dated 09/16/25 revealed no care plan addressing pain management. Review on 12/18/25 of the care plan for Resident #5 revealed a revision completed on 12/17/25 adding a care plan for monitoring complications related to opioid pain med use and a care plan for residents requiring pain medications. Interview on 12/18/25 at 8:45 A.M. with MDS Coordinator #353 verified there had been a revision to the care plan between 12/16/25 and 12/17/25 by the corporate nurse and verified there was not a pain management care plan completed on initial care plan 09/16/25.

Based on observation, interview and record review, the facility failed to preserve resident dignity while dining by allowing full urinals to remain beside food on the resident's tray table. This affected one (#12) of one resident reviewed for dignity. The facility census was 35.Findings include:Review of the resident's medical record revealed Resident #12 was admitted on [DATE]. Diagnoses included acute respiratory failure with hypoxia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side; hyperkalemia; type two diabetes mellitus; muscle weakness and muscle wasting. Review of the Minimum Data Set (MDS) version 3.0, dated 12/12/25, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 11 on a 0-15 scale. A BIMS score of 11 would indicate the resident had moderate problems with thinking and memory. Functionally, the resident used a walker and required partial to moderate assistance for mobility, with one sided impairment of the lower extremity. He is occasionally incontinent of urine, and frequently incontinent of bowel. He was receiving scheduled pain medication, and denied having any pain. Review of a care plan report for Resident #12, updated 12/15/25, revealed a focus of care for altered health maintenance. Interventions included assisting with ADLs (activities of daily living) as needed, as well as assisting with incontinence care as needed. Review of a care plan report for Resident #12, updated 12/15/25, revealed a focus of care for risk of infection or cross contamination due to resident kept his urinal of bedside table with drinking water and other items. Interventions included education of cross contamination and encouraging to keep urinal off bedside table if possible. On 12/15/25 at 12:15 P.M., an observation revealed Resident #12 was eating lunch in his recliner. There was a urinal half full of urine on the table beside him. On 12/15/25 at 1:22 P.M., an observation of Resident #12's room revealed there were now two urinals on the bedside table, each half full. On 12/16/25 at 8:46 A.M., an observation revealed Resident #12 had two half full urinals on his table, beside which was a bowl of eggs and a bottle of Mountain Dew. This was confirmed by Registered Nurse (RN) #355. On 12/16/25 at 8:50 A.M., an interview with RN #355 confirmed two urinals containing urine were on Resident #12's bedside table beside his eggs. She agreed the urinals should not be located beside the resident's food. On 12/17/25 at 8:15 A.M., an interview with the Assistant Director of Nursing revealed she was aware Resident #12's urinals were an issue. She agreed more frequent emptying or assisting with urinals was needed if resident insisted on keeping urinals on over bed table.

Based on record review, observation and interview, the facility failed to provide necessary adaptive equipment to promote mobility of two residents. This affected two residents (#47, #33) reviewed for reasonable accommodation of needs/preferences. The facility census was 35.Findings include:1.Review of medical record revealed Resident #47 was admitted [DATE]. Diagnoses included encephalopathy, type 2 diabetes mellitus with hyperglycemia, atherosclerotic heart disease of native coronary with angina pectoris, essential hypertension, hyperlipidemia, vitamin D deficiency, convulsions, personal history of transient ischemic attack. Review of a Minimal Data Set (MDS) version 3.0, dated 12/09/25, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 on a 0-15 scale. A score of 13 would indicate the resident had intact cognitive function, or normal thinking/memory. On 12/15/25 at 11:51 A.M., an interview with Resident #47 revealed she had difficulty getting on and off of the toilet because there were no handrails installed in her bathroom. On 12/15/25 at 11:52 A.M., an observation of Resident #47's bathroom revealed there were no handrails beside or near the toilet. There was also no adaptive equipment for toilets in the bathroom. On 12/15/25 at 11:52 A.M., an interview with the Maintenance Director who was present at the time of observation confirmed there was no adaptive equipment or hand rails available in Resident #47's bathroom. Recent construction had required removal of all assistive/adaptive equipment mounted to the walls, and it had not been replaced. 2. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, limitation of activities due to disability, muscle weakness, major depressive disorder, and chronic pain. Review of the quarterly Minimal Data Set (MDS), dated [DATE], revealed the resident was cognitively intact and received physical and occupational therapies. Review of the Care Plan, dated 03/20/25, revealed the resident was at risk for falls with an intervention for 1/2 side rails as enablers. Review of the Bed Rail Assist Device Assessment, dated 12/04/25, revealed side rails were in place. Interview on 12/15/25 at 11:19 A.M. with Resident #33 revealed she was concerned with mobility. In her previous room, she did have side rails to assist her with rolling over independently in bed. The resident stated she has asked for side rails but has still not received them. She stated she does not feel safe turning in bed for fear of falling out of bed. Interview on 12/16/25 at 3:15 P.M. with the Director of Nursing (DON) confirmed Resident #33 did not have side rails until yesterday 12/15/25. The DON stated she believes the siderails were removed after the resident was assessed not to need them. The DON confirmed the resident's most recent side rail assessment on 12/04/25 indicated side rails were in use. Interview on 12/16/25 at 3:22 P.M. with Resident #33 revealed she did have side rails on her bed before moving to her current room. The resident stated she had asked for side rails to be placed on her current bed but did not receive them until yesterday. Interview on 12/16/25 at 3:25 P.M. with the Director of Maintenance #338 confirmed Resident #33 side rails were placed on her bed yesterday because he was told the resident had requested them.

Based on medical record review, policy review, and staff interview the facility failed to report new onset of pain to the medical provider after Resident #10 had a fall. This affected one (#10) of four resident records reviewed for accidents.Findings include:Review of the medical record for Resident #10 revealed admission to the facility on [DATE] with diagnoses including diabetes, bipolar (mood) disorder, atrial fibrillation (irregular heart rate), Alzheimer's Disease, heart failure, degenerative joint disease of thoracic spine, artificial heart valve with use of chronic blood thinner, morbid obesity, and chronic pain.Review of the quarterly Minimum Data Set (MDS) assessment completed on 09/03/25 revealed Resident #10 had a brief interview for mental status and scored a 13/15 indicating normal cognitive function. Further review of the MDS revealed Resident #10 was dependent for all care including bathing, toileting, dressing, and required assistance with wheelchair navigation.Review of the medication list for Resident #10 revealed she was prescribed Coumadin (blood thinning medication) for management of an artificial heart valve and required routine blood work to monitor degree of blood thinning.Review of the most recent quarterly Pain Assessment 3.0/Pain in Advanced Dementia completed on 07/01/25 revealed Resident #10 had chronic mild pain to the sacral (lower back/pelvic) region and required both scheduled and as needed pain medication.Review of nursing progress notes from 07/16/25 through 08/17/25 for Resident #10 revealed no documentation of resident reporting generalized pain.Review of the nursing progress notes dated 08/18/25 at 7:15 A.M. for Resident #10 revealed an unwitnessed fall occurred in the resident's room resulting in bruising to right lower back. Further review revealed Resident #10 denied any pain or discomfort at that time and the nurse practitioner was notified.Review of the nursing progress noted dated 08/18/25 at 9:52 P.M. revealed Resident #10 complaining of generalized pain and Bio-Freeze was applied to bilateral knees. There was no documentation of notification to the resident's medical provider of the new on-set of pain after having fell earlier in the day.Review of the medication administration record (MAR) for August 2025 for Resident #10 revealed a pain scale numerical rating was documented with routine pain medication administration but did not specify location or character of pain.Interview on 12/18/25 at 9:45 A.M. with the Assistant Director of Nursing (ADON) #306 revealed confirmation that there was no medical provider notification of pain on 08/18/25 at 9:52 P.M. The ADON reported there was not an official fall policy that the facility had and provided an undated and unsigned Fall Checklist. The ADON further stated that the Fall Checklist was available at all nurses' station beside the fall logs.

Based on review of Notice of Medicare Non-Coverage (NOMNC) forms, interview, and policy review, the facility failed to ensure residents were aware of which skilled services were being discontinued and residents were given 48 hour notice of end of skilled services. This affected two (#48 and #49) of three residents reviewed for NOMNCs. The facility census was 35. Findings include:1.Record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including other specified disorders of muscle and muscle weakness. Review of a minimum data set (MDS) dated [DATE] revealed Resident #48's cognition remained intact and he would like to discharge home. Review of a care plan dated 08/29/25 and revised on 09/09/25 revealed Resident #48's goal was to discharge home. Interventions included but were not limited to discuss with resident/family discharge planning, make referrals to community agencies as needed, and notify physician of discharge plan needs. Review of a NOMNC revealed Resident #48's medicare services would end on 09/04/25. The NOMNC did not specify what type of medicare services would be ending and the notice was signed by Resident #48 on 09/03/25. 2.Record review revealed Resident #49 admitted to the facility on [DATE] with diagnoses including unspecified convulsions and other lack of coordination. Review of an MDS dated [DATE] revealed Resident #49's cognition remained intact and his goal was to discharge home. Review of a care plan dated 09/30/25 revealed Resident #49 was admitted to the facility for short term care and would discharge home. Review of a NOMNC revealed Resident #49's last day covered for skilled services would be 11/21/25. The notice did not specify which skilled services would be ending and was signed on 11/21/25. Interview on 12/18/25 at 9:36 A.M. with Social Service Director (SSD) #400 revealed when she receives a NOMNC, she has the residents sign them that day but she was not sure what the required time frame was. SSD #400 confirmed Resident #48 and #49 were not given 48 hour notice of the end of skilled services and the NOMNCs did not specify which services were ending.

Based on closed medical record review, facility investigation review, facility policy review, and interview, the facility failed to timely report an allegation of misappropriation. This affected one (#43) of one resident reviewed for abuse. The facility census was 35. Findings include: Review of Self-Reported Incident (SRI) #261920, reported date 06/23/25, was filed with the Ohio Department of Health (ODH) related to misappropriation. Review of the SRI revealed the allegation of misappropriation was made to facility staff on 06/21/25 and an investigation initiated. Resident #43 alleged his wallet with $420.00, identification, and social security card was missing from his nightstand drawer. The resident reported that he had his wallet on Saturday morning and after waking on Saturday afternoon, his wallet was missing. A search of the resident's room was initiated on Saturday evening. Review of the closed medical record for Resident #43 revealed an admission date of 05/15/25 with diagnoses including infection of internal hip prosthesis, heart failure, anxiety disorder, and chronic pain syndrome. The Minimum Data Set (MDS) revealed the resident was moderately cognitively impaired. The resident was discharged from the facility on 07/03/25. Review of the facility investigation revealed no concerns. The allegation was unsubstantiated; law enforcement was contacted; and the resident was refunded $420.00. Interview on 12/18/25 at 12:20 P.M. with the Administrator confirmed an SRI was not filed to report Resident #43's allegation of misappropriation timely. The Administrator confirmed the allegation of misappropriation was reported to staff on 06/21/25; however, he (Abuse Coordinator) was not notified until 06/23/25. The Administrator stated as soon as he learned of the allegation of misappropriation, he filed an SRI with the state agency. The Administrator stated the staff member who failed to timely report the allegation to management was in-serviced on the facility's abuse reporting policy. Review of the facility's policy titled, Abuse and Neglect Protocol, dated 06/13/21, revealed misappropriation is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The Administrator or DON must be immediately notified of suspected abuse or incidents of abuse. When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of the time lapse since the incident occurred. If an incident of suspected abuse occurs, facility shall report immediately, but no later than two hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or no later than 24 hours if the events that cause the suspicion do not result in serious bodily injury to the designated state agency.

Based on record review and interview, the facility failed to ensure complete information of transfer or discharge of residents. This affected one (#12) of two residents reviewed for hospitalization. The facility census was 35.Findings include:Review of medical records revealed Resident #12 was admitted on [DATE]. Diagnoses included acute respiratory failure with hypoxia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side; hyperkalemia; type two diabetes mellitus; muscle weakness and muscle wasting. Review of the Minimum Data Set (MDS) version 3.0, dated 12/12/25, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 11 on a 0-15 scale. A BIMS score of 11 would indicate the resident had moderate problems with thinking and memory. Functionally, the resident used a walker and required partial to moderate assistance for mobility, with one sided impairment of the lower extremity. He is occasionally incontinent of urine, and frequently incontinent of bowel. He was receiving scheduled pain medication, and denied having any pain. Review of progress notes for Resident #12, dated 11/25/25 at 12:13 P.M., revealed the facility was called by the outpatient provider where the resident had an appointment. The provider requested to send the resident to the emergency room for evaluation, however no reason for evaluation was noted in the record. Review of progress notes for Resident #12, dated 11/25/25 at 9:20 P.M., revealed the facility received a call from the Emergency Department indicating the resident would either be admitted or transferred to another facility due to anemia and elevated cardiac enzymes. There was no further note to document what facility the resident was admitted to, or the date of the admission. Review of the medical record for Resident #12 failed to reveal transfer or discharge documentation. This was confirmed by the Assistant Director of Nursing (ADON) on 12/17/25 at 10:45 A.M. On 12/17/25 at 10:45 A.M., an interview with the ADON revealed Resident #12 was admitted to the hospital from a physician appointment. On a transfer from the facility, they would send a transfer/discharge summary to the receiving facility. If the resident went to the hospital from an appointment, the facility would never send any transfer information to the receiving facility. Review of a policy titled Transfer or Discharge Notice, dated 2001, revealed residents were to be notified of an impending transfer or discharge and the reasons for the move in writing and in language they would understand. A copy of the notice would be sent to the Ombudsman. The policy revealed in an emergency situation a transfer to an acute setting would require the Notice of Transfer would be provided to the resident and the resident representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (in a monthly list of residents that includes all notice content requirements). The facility would also provide a notice of facility bed-hold and return policies would be provided to the resident and representative withing 24 hours of emergency transfer. Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge. Review of an undated facility policy titled Transfer or Discharge Documentation, revealed should a resident be transferred or discharged for any reason, the following information would be communicated to the receiving facility or provider: the basis for the transfer or discharge (why the resident's needs could not be met at the facility; the facility's attempt to meet those needs, and the services available at the receiving facility to meet those needs); contact information for the practitioner responsible for the care of the resident; resident representative's information including contact information; Advanced Directive information; any special instructions or precautions; comprehensive care plan; and all other necessary information including a copy of the resident's discharge summary to ensure a safe and effective transition of care.

Based on record review, observation and interview, the facility failed to ensure residents nails were kept at desirable length. This affected one (#38) of two residents reviewed for activities of daily living (ADLs). The facility census was 35. Findings include:Record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy and spondylosis. Review of an order dated 11/20/25 revealed Resident #38 could have podiatry care, dental care, ophthalmology care, and audiology care as needed. Review of a minimum data set (MDS) dated [DATE] revealed Resident #38's cognition remained intact, she had no behaviors, and required substantial/maximum assistance for completing personal hygiene. Interview on 12/16/25 at 7:44 A.M. with Resident #38 revealed her toenails are bad and she had not seen a podiatrist in a while. Interview on 12/16/25 at 2:19 P.M. with Licensed Practical Nurse (LPN) #347 revealed the podiatrist had been at the facility the previous week. LPN #347 stated if a resident has long toenails but does not have a diagnosis of diabetes then any nurse should be able to trim the nails, then stated the nursing staff could only clean the nails and file them down but not actually cut them. Resident #38 was seated in the therapy gym and LPN #347 went in to look at her feet and confirmed her toenails were long. Resident #38 told the nurse her nails needed trimmed bad and was agreeable to having her nails filed down until she is able to see a podiatrist. Interview on 12/16/25 at 2:33 P.M. with Social Services Director (SSD) #400 revealed the podiatrist had been at the building on 12/10/25 and 12/11/25. SSD #400 stated if someone was admitted to the facility on [DATE], that would have been plenty of time to get them on the list to be seen (by podiatry). SSD #400 stated the admissions person would have filled out the paperwork. At 2:40 P.M., admission Staff (AS) #357 entered the office and stated she does not offer ancillary services to residents upon admission and stated SSD #400 is in charge of that. SSD #400 stated she was not in charge of ancillary services.

Based on record review, observation, interview, and policy review the facility failed to ensure skin alterations were comprehensively assessed and monitored. This affected three (#1, #8, and #35) of five residents reviewed for skin alterations. The facility census was 35. Findings include: 1.Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris, anemia, unsteadiness on feet, osteoarthritis, idiopathic, peripheral autonomic neuropathy, peripheral neuropathy, peripheral vascular disease, chronic kidney disease, acute osteomyelitis left ankle and foot, and diabetes with foot ulcer. Review of Resident #1's Wound Center (outside provider) note dated 11/21/25 revealed the resident was seen for gangrene of the left great toe as well as traumatic ulceration of the right great toe. The resident reported persistent pain in her left great toe and heel, which she describes as constant. She spends the majority of the day in a wheelchair, with limited mobility. When she was sitting in the wheelchair the back of her heel touches the footrest, this is what was causing her the pain. The left great toe measured 0.5 centimeters (cm) by 1.5 cm by 0.2 cm. The wound bed was brown, dry, full thickness with moderate serosanguineous drainage noted. The right great toe measured 1.0 cm by 1.5 cm by 0.1 cm. The wound bed was brown, dry, full thickness with moderate serosanguineous drainage noted. The plan for the gangrene of the left great toe revealed the gangrene and osteomyelitis in the big toe was showing signs of improvement. The breakdown of the big toes was likely due to external rotation of the feet, causing the toes to be vulnerable to trauma from the wheelchair. Debridement of the big toes was performed, and the ulcerations are healing. The resident was advised to wear boots to alleviate the heel issue and to avoid bumping the toes. She should keep her heels off the bed and chair to prevent further complications. A pillow should be used under the heel or calf for additional support. The resident will follow up in three weeks. Review of Resident #1's visiting Wound Nurse Practitioner (WNP) note dated 11/28/25 revealed the resident had new diabetic ulcer on right heel measuring 4.0 centimeters (cm) by 2.0 cm by 0.0 cm. New orders to cleanse area with normal saline, betadine, abdominal dressing, rolled gauze, and secure with tape. The right toe was a diabetic foot ulcer measuring 0.5 cm by 0.5 cm. The wound bed was 100% eschar. Orders to follow wound clinic orders. The left toe was a diabetic foot ulcer measuring 0.5 cm by 0.6 cm by 0.1 cm. The wound bed was 100% eschar. Orders to follow wound clinic orders. Review of Resident #1's weekly skin assessment dated [DATE] and 12/16/25 revealed to continue treatment to bilateral great toes and right heel. There was no evidence of a comprehensive assessment of the right and left great toes or right heel. Observation of Resident #1 on 12/17/25 3:37 P.M. with Licensed Practical Nurse (LPN) #347 revealed the resident had skin alteration on the right and left great toe and right heel. The LPN reported the facility's wound NP had seen the resident's buttocks today, but did not assess the feet due to the resident will see her wound doctor tomorrow. Interview on 12/17/25 at 9:00 A.M. and 3:53 P.M., with Registered Nurse (RN) #306 revealed the facility did not have a wound nurse to assess wounds weekly, however the new company had hired a WNP that visits weekly to assess skin alterations. RN #306 reported Resident #1 went to an outside wound provider every two weeks and the facility's WNP should conduct wound assessments on the weeks Resident #1 did not see the outside wound provider. RN #306 confirmed the last comprehensive assessment of Resident #1 skin alteration on the right and left great toe, and right heel was on 11/28/25. The RN confirmed she had spoken to the visiting wound NP and she confirmed she had seen the wounds on the feet however she did not measure or comprehensively assess the wound on the residents' feet in December (2025). RN #306 confirmed there was no documented evidence the right and left great toe and right heel were comprehensively assessed from 11/29/25 to 12/17/25. The resident was supposed to be seen on 12/11/25 at the wound center, however the wound center had cancelled the appointment, and staff had already changed the resident's dressing and the resident refused to let the visiting WNP remove the dressing again on 12/11/25 to assess the wounds. 2. Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including chronic pain, peripheral vascular disease, anemia, restless leg disease, heart failure, and overactive bladder. Review of Resident #8's quarterly MDS dated [DATE] revealed the resident did not have Moisture Associated Skin Damage (MASD) or other skin, pressure, wounds, or other skin alteration except for two venous and arterial ulcers. The resident was at risk for pressure ulcers and had pressure cushion and mattress. Review of Resident #8's skin impairment plan of care dated 02/06/25 and revised 12/15/25 revealed the resident had actual area of skin impairment related to non-pressure chronic venous ulcers left mid foot/ left heel and shearing bilateral buttocks. The wound nurse to follow. Intervention included initiate wound treatment. Continue treatment as ordered by the MD/NP. Observe and document character of wound weekly. Skin observation and document on bath/shower days. Charge nurse to notify the Wound Nurse, physician and family of any new areas. Review of Resident #8's current orders dated 12/2025 revealed orders for bilateral grab bars to aide in bed mobility and repositioning, healing partners to consult for skin and wound conditions/prevention, cleanse sheering area to bilateral buttocks and apply moisture barrier ointment three times a day and as needed, pressure relieving mattress, and weekly skin assessment. Review of Resident #8's treatment administration records revealed the resident had been receiving moisture barrier ointment three times daily to sheering area on bilateral buttocks since 02/14/25. Review of Resident #8's weekly skin assessment dated [DATE] revealed the resident areas remain to left foot and left heel. Preventative measures in place. Sees in house wound care notes. MASD to buttocks noted, barrier cream applied. Wound Nurse to see on rounds. Review of Resident #8's weekly healing partners skin note dated 12/11/25 revealed no evidence of MASD was addressed by the WNP. Observation on 12/16/25 at 3:40 P.M., of Resident #8 with RN #355 revealed the resident had a red blanchable area on the left buttocks the size of hand and a red blanchable area on the right-side of the buttocks half the size of the left side. The nurse confirmed the wound nurse did not assess the area on 12/11/25 and she only looked at the non-pressure areas on the resident's feet. The nurse confirmed the area on the buttocks was MASD and not pressure/shearing and he had received the same treatment since 02/14/25 to the area. The resident reported he has pain on the buttocks sometimes when he lays a certain way on the areas. Interview on 12/16/25 at 3:46 P.M. and 12/17/25 at 9:00 A.M. with RN #306 confirmed the visiting WNP should have been assessing the MASD on Resident #8's buttocks, however she could not find any documentation the WNP had assessed Resident #8's buttocks. The RN reported she had spoken to RN #355 and she had reported the MASD comes and goes on Resident #8, however there was no comprehensive assessment completed after the MASD was noted on 12/10/25 to determine if the area was improving or worsening. RN #306 reported the visiting WNP would be in on 12/17/25 and would assess Resident #8 and to ensure proper treatment was being applied. Review of skin tear-Abrasion and Minor Breaks, Care dated 2001 and revised 09/2013 revealed the following information would be recorded in the resident medical record: non-pressure form and notification of family and physician. 3.Record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease stage 3 and hypertension. Review of an order dated 09/22/25 revealed Resident #35 would receive aspirin oral tablet delayed release 81 milligrams (mg) give one tablet by mouth one time a day related to hypertension starting on 09/23/25. Review of nursing notes revealed no skin impairments. Observation on 12/15/25 at 9:40 A.M. revealed Resident #35 had multiple round, purple bruises on bilateral arms and legs. Observation on 12/16/25 at 7:47 A.M. revealed Resident #35 was sitting in bed eating breakfast, bruising was observed to bilateral arms and was purple in color. Interview on 12/18/25 at 10:28 A.M. with the Director of Nursing confirmed there was no indication on Resident #35's orders, treatment record, or skin check assessments of Resident #35 having any bruising. Observation and interview on 12/18/25 at 10:50 A.M. with DON revealed Resident #35 was seated in a dining room with her legs covered. Resident #35 was observed to have multiple round, purple scattered bruising to bilateral arms. The DON confirmed the observation.

Based on record review, policy review, and interview, the facility failed to ensure a timely comprehensive pressure ulcer assessment and treatment. This affected one (#46) of two residents reviewed for pressure ulcers. The facility identified four residents as having pressure ulcers. Findings include:Medical record review revealed Resident #46 was admitted on [DATE] with diagnoses including encounter for surgical aftercare following amputation, acquired absence of right leg above knee, chronic obstructive pulmonary disease, chronic congestive heart failure, and history of cerebral infarction. Review of the Baseline Care Plan, dated 12/09/25, revealed the resident was occasionally incontinent of urine and bowel and had pain of the coccyx and right knee. Review of the Care Plan, dated 12/09/25, revealed the resident has a pressure ulcer with interventions including to administer treatments as ordered and monitor for effectiveness; and to monitor dressing to ensure it is intact and adhering. Review of the Nursing admission Assessment-V4, dated 12/09/25 at 4:50 P.M., revealed a pressure ulcer, suspected deep tissue injury (DTI), located on the coccyx. The assessment did not include any documentation of wound measurements. The treatment listed was to pad and protect. Review of a skilled nursing progress note, dated 12/10/25 at 10:21 A.M., revealed no changes in skin integrity. Wound care to right stump with continuous dressing. There was no mention/documentation of the pressure ulcer located on the coccyx. Review of a physician order, dated 12/11/25 at 6:24 P.M., revealed the order to cleanse coccyx with wound cleanser, pat dry, apply medihoney, calcium alginate, cover with dry, clean, dressing daily and as needed. Review of wound nurse practitioner (NP) progress note, dated 12/11/25, revealed the resident was admitted to the facility with an unstageable pressure ulcer located on the coccyx. Review of Resident #46's December 2025 Treatment Administration Record (TAR) revealed the order with start date of 12/11/25, to cleanse coccyx with wound cleanser, pat dry, apply medihoney, calcium alginate, and cover with dry, clean, dressing daily and as needed. Further review of the TAR revealed the dressing change first occurred on 12/12/25. Interview on 12/16/25 at 9:38 A.M. with the Assistant Director of Nursing (ADON) confirmed there was no evidence of a physician order for a dressing change to Resident #46's coccyx until 12/11/25 and no evidence of a complete assessment including wound measurements until 12/11/25 when the resident was assessed by the wound nurse practitioner. Subsequent interview on 12/16/25 at 1:10 P.M. with the ADON revealed when interviewed by this surveyor earlier in the day she had forgotten that she had completed the initial assessment and measurements of Resident #46's pressure ulcer on 12/10/25. She apologized and stated she had written the measurements on a note and confirmed those measurements were not in the electronic medical record (EMR) or in the hard chart. The ADON stated she would provide this surveyor with a copy of her note. Interview on 12/16/25 at 2:16 P.M. the ADON provided this surveyor with a Pressure Skin Condition Record, dated 12/10/25, which indicated Resident #46 had a pressure ulcer located on the coccyx, first observed on 12/09/25, with measurements: 2 centimeters (cm) length by 1.3 cm width by 0.1 cm depth. The assessment did not provide documentation of the characteristics of the wound or of the wound bed, both sections of the form were blank. The assessment revealed the nurse practitioner was notified and ordered to continue the treatment to pad and protect the wound. Interview on 12/17/25 at 9:14 A.M. with the ADON revealed it was expectation that all wounds would be thoroughly assessed and measured within 24 hours of admission. The ADON confirmed all wound measurements and assessments should be entered into the electronic medical record and the wound measurements on paper should be used as a back up in case of an issue with the EMR or in the event of a power outage. Review of the facility's policy, Astoria Skin Protocol, revised on May 2019, revealed a pressure injury is localized damage to the skin and /or underlying soft tissue usually over a bony prominence or related to a medical or other device. Interventions include to do initial assessment, notify skin team, assess need for support surfaces, if heels are involved, keep elevated off bed surface, assess pain, render treatment as order per provider, measure and document on area at least every 7 days (nurse who discovers area must document initial measurement and then skin team will follow-up during weekly skin rounds. Notify provider and responsible party, document in nurses notes and care plan, RN to evaluate current method of treatment and evaluate effectiveness.

Based on observations of residents, review of medical records and facility policies, and interviews with residents and staff, the facility failed to provide adequate supervision during smoking sessions for residents. This affected two (#5, #47) of two residents reviewed for smoking safety. The facility census was 35.Findings include: Review of medical record for Resident #5 revealed admission to the facility on [DATE] with diagnoses including stroke affecting right side, diabetes, high blood pressure, anxiety, lung disease, bipolar (mood) disorder, aphasia (difficulty speaking), left above knee amputation, and right below knee amputation. Review of the comprehensive Minimum Data Set (MDS) assessment completed on 09/15/25 revealed Resident #5 had a brief interview for mental status and scored a 6/15 indicating moderate to severe cognitive deficit. Further review of the MDS revealed the resident was dependent for all care including bathing and dressing and required assistance for navigation of wheelchair. Review of the most recent quarterly smoking safety evaluation completed on 12/08/25 revealed Resident #5 required assistance with lighting smoking materials and supervision during smoking for safety. Further review of the smoking evaluation revealed the facility would store all smoking materials.Review of Resident #5's care plan dated 09/16/25 revealed a care plan addressing smoking with goal that Resident will not smoke without supervision through review date, and intervention to include, The resident requires supervision while smoking.Observation on 12/16/25 at 9:15 A.M. of Resident #5 revealed certified nurse aide (CNA) #328 taking two residents (Resident #5 and Resident #47) outside to smoking area. CNA #328 used lighter to light a cigarette for Resident #47 (who also required supervision during smoking session per smoking evaluation completed on 120/09/25) and then provided Resident #5 with a cigarette. Resident #5 reported to CNA #328 that those were the wrong cigarettes, and he did not want the menthol cigarettes but wanted the regular ones. CNA #328 then left Resident #5 and #47 and returned to the inside of the building to retrieve the correct cigarettes then returned to the smoking area. Residents #05 and #47 were left unsupervised while Resident #47 was actively smoking. Interview on 12/16/25 at 11:02 with CNA #328 revealed she did in fact leave the two residents alone during the smoking session while re-entering building to get different cigarettes for Resident #5Review of the facility Smoking policy, undated, revealed the following statement under number 12. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.

Based on resident observations, medical record review, and resident and staff interview the facility failed to provide timely incontinence care to a resident. This affected one (#10) of one resident reviewed for incontinence care. The facility census was 35.Findings include: Review of the medical record for Resident #10 revealed admission to facility on 05/04/22 with diagnoses including diabetes, bipolar (mood) disorder, atrial fibrillation (irregular heart rate), Alzheimer's Disease, heart failure, degenerative joint disease of thoracic spine, artificial heart valve with use of chronic blood thinner, morbid obesity, and chronic pain.Review of the quarterly Minimum Data Set (MDS) assessment completed on 09/03/25 revealed Resident #10 had a brief interview for mental status and scored a 13/15 indicating normal cognitive function. Further review of the MDS revealed the resident was dependent for all care including bathing, toileting, dressing, and required assistance with wheelchair navigation.Review of the MDS assessment also revealed Resident #10 to be incontinent of bowel and bladder and required a toileting program.Review on 12/16/25 of the active care plan initiated on 07/10/24 and revised on 06/14/25 revealed Resident #10 was to have toileting assistance and incontinence care every two hours to prevent skin breakdown related to frequent bowel and bladder incontinence.Observation and interview on 12/15/25 at 10:00 A.M. with Resident #10 revealed staff usually complete check and change her once at night. Further interview revealed that staff check her for incontinence during the day but not routinely. Resident #10 confirmed she was incontinent of urine and wears an adult incontinence brief. At this time, observation revealed a bedside commode present in her room for easier access for toileting. No odors were detected and Resident #10 pants appeared dry.Interview on 12/16/25 at 2:38 P.M. with certified nursing aide (CNA) #331 revealed the CNA's can view the Kardex in the computer to determine which residents are on a toileting program or need assistance with incontinence care and hygiene/bathing. Further interview with CNA #331 revealed aides are to round on their assigned residents every two hours and assist with toileting and check for incontinence and change adult brief if needed.Interview on 12/16/25 at 2:39 P.M. with CNA #328 revealed aides are to round every two hours and check assigned residents for incontinence and provide for toileting assistance if needed.Observation on 12/16/25 at 2:46 P.M. revealed Resident #10 in the activities room seated in wheelchair at a table with other residents. Resident #10 had a strong odor of stale urine coming from the direct vicinity of where she was sitting. Interview and observation on 12/16/25 at 2:46 P.M. with CNA #328 revealed she had not checked Resident #10 for incontinence or toileted her since she returned from her doctor's appointment after lunch. CNA #328 reported someone else may have provided care for Resident #10. CNA entered activity room and confirmed that Resident #10 did smell of urine and discreetly asked Resident #10 if she needed changed in which Resident #10 said she did not know if she had been incontinent.Observation on 12/17/25 at 9:08 A.M. revealed Resident #10 sitting in wheelchair in her room when Certified Nursing Assistant (CNA) #322 entered and assisted Resident #10 to bedside commode for toileting and incontinence check.Observation on 12/17/25 at 11:10 A.M. revealed Resident #10 in wheelchair in her room when CNA #322 entered and took Resident #10 in wheelchair down the hall to the activities room for lunch. CNA #322 did not check Resident #10 for incontinence or offer toileting assistance. Interview on 12/17/25 at 11:19 P.M. with CNA #322 revealed she thought she had just checked and changed Resident #10 at 10:00 A.M. and she would be okay until after lunch and she would toilet and check Resident #10 then. CNA #322 verified she did not check Resident #10 for incontinence or offer to toilet her prior to taking her down to lunch and lunch would start around 11:45 A.M. until 12:30 P.M.

Based on medical record review, observation, interview, and policy review the facility failed to ensure residents had orders for oxygen and a humidification bottle was filled. This affected two (#8 and #12) of four residents reviewed for respiratory care. The facility census was 35.Findings include: 1.Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, and heart failure. Review of Resident #8's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #8 received oxygen therapy. Review of Resident #8's current orders dated 12/2025 revealed Resident #8 was ordered five liters per milliliters (LPM) continuously. Review of Resident #8's oxygen plan of care dated 04/04/19 and revised 04/22/25 revealed the resident uses oxygen related to chronic obstructive pulmonary disease, congestive heart failure, and shortness of breath (SOB). Refuses to wear oxygen at times. The resident has SOB upon exertion and while lying flat with occasionally and at rest Observation on 12/15/25 at 1:43 P.M., of Resident #8 revealed the resident oxygen humidification bottle was empty. The resident's oxygen was running continuously at five LPM. Interview on 12/15/25 at 1:43 P.M., with Resident #8 confirmed his humidification bottle had been empty for a week. The resident reported he told staff the humidification bottle was empty, and the staff told him the facility was out of the special water that went into the humidification bottle. Additional observation on 12/16/25 at 7:57 A.M., with Registered Nurse (RN) #306 confirmed the humidification bottle was empty and staff had just changed the tubing his morning. 2.Review of the medical record revealed Resident #12 was admitted on [DATE]. Diagnoses included acute respiratory failure with hypoxia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side; hyperkalemia; type two diabetes mellitus; muscle weakness and muscle wasting. Review of the Minimum Data Set (MDS) version 3.0, dated 12/12/25, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 11 on a 0-15 scale. A BIMS score of 11 would indicate the resident had moderate problems with thinking and memory. Functionally, the resident used a walker and required partial to moderate assistance for mobility, with one sided impairment of the lower extremity. He is occasionally incontinent of urine, and frequently incontinent of bowel. He was receiving scheduled pain medication, and denied having any pain. Review of a care plan report for Resident #12, updated 12/15/25, revealed a focus of care for altered health maintenance. Interventions included assisting with ADLs (activities of daily living) as needed, as well as assisting with incontinence care as needed. Review of a care plan report for Resident #12, updated 12/15/25, revealed a focus of care for developing complications due to altered respiratory status. Requires oxygen. Interventions included providing oxygen as ordered. On 12/16/25 at 8:46 A.M., an observation of Resident #12's oxygen concentrator revealed a flow rate of 4 Liters (Liters) and the resident did not have on his nasal cannula. This was confirmed by Registered Nurse (RN) # 355. Review of the medical record for Resident #12 failed to reveal an active oxygen order. The previous oxygen order for Oxygen 2L via nasal cannula, written 11/17/25, was discontinued on 12/07/25. This was confirmed by RN #355. On 12/16/25 at 8:50 A.M., an interview with RN #355 revealed she could not locate an active order for Resident #12's oxygen in the medical record. She reported he had been to the hospital and the order probably had not been re-started when he returned. She further confirmed the resident was supposed to be on 2L of oxygen; however the concentrator flow rate was set to 4L. Review of history and physical, dated 12/11/25, failed to review any documentation of oxygen use for Resident #12. Review of an undated facility policy titled Place Oxygen Protocol, revealed all oxygen therapy should be administered or supplied according to physician orders.

Based on record review and interview, the facility failed to assess and implement trauma informed care for a resident. This affected one (#2) of one resident reviewed for trauma informed care. The facility census was 35. Findings Include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including dementia, diabetes mellitus, depression, anxiety disorder, bi-polar disorder, and post-traumatic stress disorder (PTSD).Review of the Minimum Data Set (MDS) assessment, dated 10/13/25, revealed Resident #2 was cognitively intact and had a diagnosis of PTSD.Review of the Care Plan for Resident #2 revealed there was not a plan of care in place addressing the cause of PTSD, triggers which may cause re-traumatization, or interventions to reduce the risk of re-traumatization and provide care for PTSD.Further record review for Resident #2 revealed no assessment had been completed to identify the cause of PTSD and to identify potential triggers which may cause re-traumatization.Interview on 12/17/25 at 11:03 A.M. with Social Services Director #364 verified an assessment of the cause of PTSD and possible triggers for Resident #2 had not been completed and additionally verified there had not been a plan of care implemented for Resident #2 to minimize the risk of re-traumatization.

Based on record review and interview, the facility failed to ensure residents were provided with dental services. This affected one (#14) of two residents reviewed for dental services. The facility census was 35. Findings include:Record review revealed Resident #14 admitted to the facility on [DATE] with diagnoses including Parkinson's disease and muscle weakness. Review of an order dated 11/18/25 revealed Resident #14 could receive podiatry care, dental care, ophthalmology care, and audiology care as needed. Review of a nursing admission assessment dated [DATE] revealed Resident #14 had upper dentures only. Interview on 12/17/25 at 1:44 P.M. with Resident #14 revealed his gums were sore from chewing and no one had offered dental services. Interview on 12/17/25 at 2:13 P.M. with Social Services Director (SSD) #400 revealed the nurses add residents to dental list. Interview on 12/17/25 at 2:20 P.M. with Director of Nursing (DON) revealed residents could be added to the dental list by emailing the in-house dental company. DON stated it is the duty of the social worker to sign residents up for services upon admission. DON stated she was not aware social worker had not been adding residents and added Resident #14 to the dental list at this time.

Based on medical record review and staff interview, the facility failed to ensure resident Preadmission Screening and Resident Review was resubmitted following a new mental health diagnosis added for a resident. This affected one resident (#2) of one resident reviewed for Preadmission Screening and Resident Review. The facility census was 31. Findings include: Review of Resident #2's medical record revealed an admitted [DATE] with diagnoses that included dementia, cerebrovascular accident and bipolar disorder. A Preadmission Screening and Resident Review (PASARR) was completed on 04/30/18. Further review of the medical diagnoses for Resident #2 revealed a new diagnosis of anxiety added on 08/06/21. No evidence of a resubmission of PASARR for a new mental health diagnosis was found. On 08/07/24 at 10:50 A.M., interview with Licensed Practical Nurse (LPN) #11 revealed she would contact the local area agency on aging to determine if a PASARR is required to be resubmitted for a new diagnosis of anxiety for Resident #2. On 08/07/24 at 11:10 A.M., follow up interview with LPN #11 verified a new PASARR should have been resubmitted for Resident #2 for the new diagnosis of anxiety.

Based on record review, observation, and interviews the facility failed to ensure therapy recommendation were implemented. This affected one resident (#5) of one resident reviewed for restorative services. Findings included: Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including heart failure, diabetes, hip pain, heart disease, and chronic pain. Further review of Resident #5's paper medical record revealed there were Physical Therapy (PT) notes dated 09/26/23 to 11/20/23 that indicated the resident received therapy services. The PT discharge note dated 11/20/23 recommended the resident have a walker with a basket/bag and ambulation program established. The resident was currently able to walk to the dining room, balance was steady, and tier was functional with a Restorative Nursing Program. The resident will be able to walk in the corridor with two assists of two and balance will be steady, by performing the following restorative nursing intervention. Allow resident to take her time, use gait belt, use walker, and provide assistance of two, follow with wheelchair for safety. Resident #5's prognosis would be good with consistent staff follow-through. Review of Resident #5's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident's cognition was intact and she used a walker and wheelchair for ambulation. The MDS indicated the resident was not receiving restorative or therapy services. Review of Resident #5's care conference note dated 12/28/23 revealed the resident was not receiving any therapy services. Review of Resident #5's altercation in mobility plan of care initiated 04/15/22 revealed the resident uses wheelchair and staff steady to transfer. On 08/06/24 the facility provided the surveyor a list of residents receiving restorative therapy that revealed no evidence Resident #5 was receiving a restorative program. Observation on 08/06/24 at 7:35 A.M., 08/07/24 at 8:45 A.M., and 08/08/24 at 8:47 A.M., revealed the resident was observed ambulating via wheelchair. There was no evidence the resident had a wheeled walker. Observation of Resident #5's room on 08/08/24 at 8:47 A.M., with Licensed Practical Nurse (LPN) #15 confirmed the resident did not have a wheeled walker and ambulated in the facility via a customized wheelchair. Interview on 08/05/24 at 10:07 A.M., with Resident #5 revealed she needed therapy again because she was unable to walk and was not in a restorative program or therapy. Interview on 08/05/24 at 2:04 P.M. with the Therapy Director (TD) #100 confirmed on 11/20/23 the PT recommended Resident #5 have a wheeled walker and a restorative ambulation program. Interview on 08/07/24 at 2:09 P.M., with Registered Nurse (RN) #8, State tested Nurse's Aide (STNA) #21 and STNA #36 revealed there were unaware Resident #5 could ambulate with a walker and the resident currently uses a lift and a specialized wheelchair for transfers and ambulation. Interview on 08/08/24 at 7:13 A.M., with RN #1 confirmed she was the head of the restorative program, and she was not able to find evidence therapy had referred Resident #5 to a restorative program or recommended a walker except for the discharge note. RN #1 reported in the past therapy would write the recommendation and a paper form and given them to her to initiate. The RN confirmed the resident did not receive a walker or an ambulation program per PT recommendation on 11/20/23. Interview on 08/08/25 at 8:50 A.M., with Resident #5 confirmed she never received a walker. The resident reported while she was in therapy she was able to walk short distances with a walker and therapy staff would walk behind with a wheelchair, but after she was discharged from PT no one worked with her and now she can't walk at all. Residents #5 reported she would like to walk again, and therapy spoke to her yesterday and might start working with her again. Interview on 08/08/24 at 9:00 A.M., with Occupational Therapist (OT) #101 confirmed PT evaluated Resident #5 yesterday (08/07/24) and was going to pick her up for services and she was going to screen her today for OT services.

Based on observation and interview the facility failed to ensure the facility was free of pest. This affected two residents (#7 and #9) of 16 residents observed. Findings included: Observation on 08/05/24 at 10:56 A.M. of Resident #9's room revealed there were three flies flying around the resident. The resident reported flies have been an issue for five years. The resident had a flyswatter lying on his bed. Observation on 08/05/24 at 11:08 A.M. of Resident #7's room revealed there was one fly sticky strip hanging behind a closet. There were two flies flying around the resident's face. The resident reported flies have been an issue and staff gave him a flyswatter to use and they just took down the fly strips because state was in the building, but they must have missed one. Observation on 08/06/24 at 1:12 P.M., of Resident #7 and #9's room with Licensed Practical Nurse (LPN) #15 confirmed there was flies and gnats flying on and around the residents. Observation on 08/06/24 at 2:00 P.M., of Resident #7's wound care with LPN #17 and #18 revealed flies and gnats were flying around and on the resident during wound care. Confirmed findings with the LPN's during the observation. Observation on 08/07/24 at 9:03 A.M., of Resident #7 and #9's room revealed there were two flies on Resident #9 and three flies and a gnat on Resident #7. Interview on 08/07/24 at 9:39 A.M., with the Director of Nursing (DON) revealed the facility was aware of the fly issue in Resident #7 and #9's room and the exterminator reported there was nothing he could due to treat the rooms and recommended staff use bleach in the rooms. The DON reported the facility may need to use the bleach more frequently.

Based on observation, dietary staffing and schedule review and staff interview, the facility failed to employ and maintain sufficient staffing in the kitchen to ensure resident meal service was provided as planned and without potential interruption. This had the potential to affect all 29 residents residing in the facility. Findings include: Review of the facility meal schedule revealed breakfast service was scheduled for 7:30 A.M. and 8:10 A.M. and lunch service was scheduled for 11:10 A.M. and 12:10 P.M. The second time noted was to finish the delivery of resident hall trays (for those residents who ate in their rooms) Upon entrance to the kitchen, on 03/15/24 at 8:30 A.M. Dietary Cook #49, State tested Nursing Assistant (STNA), STNA #50 and STNA #45 were observed in the kitchen preparing the residents morning meal. The meal service was noted to be finishing at the time of the observation. Interview with Cook #49 on 03/15/24 at 9:21 A.M. revealed the dietary aide scheduled to work in the kitchen on this date had walked out after getting her paycheck this morning and did not work the rest of her scheduled shift. Interview with STNA #50 on 03/15/24 at 9:22 A.M. revealed she was working on this date and had a resident care assignment, providing direct resident care but when she found out the kitchen was short staffed, she volunteered to go to help in the kitchen because she had prior work experience in the kitchen. Additional observation of the kitchen on 03/15/24 at 9:20 A.M. revealed Dietary Cook #49, STNA #50 and Dietary Manager (DM) #47 observed in the kitchen. STNA #45 went home after breakfast was served. On 03/15/24 at 9:20 A.M. interview with DM #47 revealed she was the DM from the corporation's sister facility and she was assisting today and completing the food order for next weeks delivery. The DM revealed she had come to the building on this date to make sure food was ordered for next week as the food order was due on Friday (03/15/24). Observation of the lunch meal on 03/15/24 at 11:45 A.M. revealed the first cart was 35 minutes late. Interview with kitchen staff at that time revealed the meal was running behind as it was only Dietary Cook #49's third day of work and STNA #50 was just filling in in the kitchen. On 03/15/24 at 12:30 P.M. telephone interview with the previous facility dietary manager (DM) revealed she had recently (on 03/14/24) resigned her position in the facility. The DM stated she quit because she had worked 45-60 days straight, (payroll) checks were no good and the company was going under. The DM voiced concerns she was losing employees in the dietary department (had recently had her cook walk out) and there were open shifts. She stated she physically was not able to cover (the open shifts) which was leaving residents at risk. The DM revealed the rest of her staff that were still currently working were ready to leave. The DM indicated based on the issues that were occurring she was not sure if meals would be prepared or prepared on time. Review of an All Staff listing with title document, provided by the facility on 03/15/24 revealed the staff listing included four total dietary employees. This list did not match the dietary staffing schedule which included seven staff names. The previous DM's name was not included on either the All Staff listing or the dietary staffing schedule. Review of the dietary staffing schedule, dated 03/15/24 through 03/24/24 revealed the schedule for these dates included multiple scheduled shift times with no employee assigned to work during the time period. For example, the schedule for 03/15/24 noted a dietary aide scheduled to start at 5:30 A.M. This dietary aide was the aide who walked out on this date after receiving her paycheck and did not work the shift. The schedule reflected three dietary staff shifts scheduled to start at 6:30 A.M. However, two of the shifts appeared to be associated with vacant positions (as there was no staff name associated with them) and only one of the shifts had a name, Dietary Cook #49. The schedule reflected two dietary employee shifts to begin at 12:30 P.M. However, only one of the two shifts included a staff name. The second 12:30 P.M. shift appeared to be for a vacant position. Interview with the Director of Nursing (DON) on 03/15/24 at 1:15 P.M. verified the dietary aide who was scheduled to work this morning with Dietary Cook #49, received her paycheck and walked out at that time, leaving only the dietary cook to work in the kitchen. Due to the lack of dietary staff at that time, two STNAs, one who was working the floor and one who came in to pick up her paycheck went to the kitchen to assist with morning meal service. This deficiency represents non-compliance investigated under Complaint Number OH00152028.

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 32 residents residing in the facility. On 03/05/24 at 5:24 P.M., the Administrator and Director of Nursing (DON) 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 terminated from 03/01/24 through 03/04/24, delinquent property taxes, therapy services, medical director services, refuse/recycling, and pest control 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 12/04/23 a complaint survey was completed which resulted in concerns related to financial solvency. An issue identified at that time was related to employee payroll. On 11/16/23 at 8:32 A.M., an interview with the Director of Nursing (DON) revealed some of the employee checks had been returned for insufficient funds but corporate (management located in Florida) had wired money to the employees the same day. Further interview revealed corporate also covered any fees that occurred at the employees' banks. 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 12/04/23 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, during a complaint survey completed on 01/31/24, the facility failed to ensure their governing body was effective in establishing and implementing policies regarding the management and operation of the facility and their Quality Assurance and Performance Improvement Program had continued evaluations to ensure ongoing compliance with all financial obligations for the delivery of care including therapy services, payment of the electricity bill and staff payroll. Interview with the Administrator on 03/04/24 at 8:39 A.M. revealed employees were being paid every other week and were receiving paper checks on payday. However, as of this date there were employee's checks that were being returned for insufficient funds (from the most recent pay date of 03/01/24). The Administrator revealed Epic Healthcare Solutions (the corporate management company) would then wire the funds to the affected employee's bank account after being notified the employee's check was not clearing at the bank. Interview during the survey with an anonymous staff member revealed she was very concerned with her payroll checks bouncing and being returned for sufficient funds. She stated she had both 02/16/24 and 03/01/24 paydays affected by this and would more than likely be terminating her employment and looking for another job. Interview on 03/04/24 at 9:00 A.M. with Registered Nurse (RN) #205 revealed her payroll check on 02/16/24 was returned due to insufficient funds. She stated she updated the DON on 02/19/24 who then updated corporate. RN #205 stated she received a wire transfer for her payroll check but not until 02/20/24. Interview on 03/04/24 at 9:21 A.M. with the Business Office Manager (BOM) #207 verified there were payroll checks that did not clear employee banks on 02/16/24 due to insufficient funds. She provided a list that revealed 41 out of 62 staff members did not get paid on the 02/16/24 payday as their checks bounced. BOM #207 revealed staff had been made aware by their bank their payroll checks were returned for insufficient funds for the 02/16/24 payday. The staff had reported this to the DON who then updated BOM #207. She stated she sent a list to the corporate management company who then wired the money directly into the employees' personal accounts. She stated employees who experienced wire fees or bounced check fees from the 02/16/24 pay issue, were also to be reimbursed these fees on the 03/01/24 payday. During the interview, BOM #207 also shared most of the facility bills were being sent directly from the vendors to the facility corporate office. Any bills or invoices received at the facility were scanned and emailed directly to Stampli (the company that processed and paid invoices). Review of the 02/16/24 list of employees who had their payroll checks returned for insufficient funds included the current Administrator, BOM #207, Maintenance #340, RN #205, RN #302, RN #303, RN #304, RN #339, Licensed Practical Nurse (LPN) #306, LPN #308, LPN #309, LPN #310, LPN #311, LPN #349, State tested Nurse Aide (STNA) #203, STNA #313, STNA #314, STNA #315, STNA #316, STNA #317, STNA #318, STNA #320, STNA #321, STNA #324, STNA #325, STNA #326, STNA #327, Dietary #328, Dietary #330, Dietary #331, Dietary #332, Dietary #333, Dietary #335, Dietary #336, Housekeeping (HK) #341, HK #342, HK #343, HK #345, HK #346, HK #348 and Hospitality Aide #347. Interview on 03/04/24 at 9:57 A.M. with the Chief Financial Officer (CFO) #600 revealed his corporation had more issues with banking since the previous two surveys on 12/04/23 and 01/31/24. He stated this 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 their human resource file to the bank and those were then 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. Additional interview on 03/05/24 at 10:36 A.M. With CFO #600 verified he had been updated that payroll checks were returned as having insufficient funds for the payroll date of 03/01/24. He stated he was unsure of what had occurred. He stated payroll accounts were separate then those accounts used to pay facility vendors and suppliers. He also stated they had separate accounts at the same bank (Bank of Oklahoma Financial) for all the facilities owned by the corporation. 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. Interview on 03/04/24 at 11:29 A.M. with the Ombudsman revealed a resident had stated to her during a visit that she was worried the facility would be closing and she would have to find another place to live. The resident stated to the Ombudsman that she had overhead staff talking about not being paid correctly and their payroll checks being returned for insufficient funds. The Ombudsman stated she had updated Administrator #351 (the previous facility Administrator) about the concern. Interview on 03/04/24 at 12:15 P.M. with an anonymous staff member revealed she was concerned every payday about her payroll checks not clearing her bank. Review of emails from the DON dated 03/05/24 at 11:31 A.M. through 03/11/24 at 9:33 A.M. revealed 45 out of 62 staff members received returned paychecks due to insufficient funds (from the 03/01/24 pay day). These staff included the Administrator, Previous Administrator #351, BOM #207, Social Services Designee (SSD) #337, RN #204, RN #205, RN #300, RN #301, RN #303, RN #304, RN #339, Maintenance #340, LPN #307, LPN #308, LPN #309, LPN #310, LPN #311, LPN #349, STNA #203, STNA #206, STNA #312, STNA #313, STNA #314, STNA #315, STNA #316, STNA #317, STNA #318, STNA #319, STNA #320, STNA #321, STNA #322, STNA #323, STNA #324, STNA #325, STNA #326, STNA #327, Dietary Director #208, Dietary #328, Dietary #333, Dietary #336, HK #341, HK #342, HK #343, HK #348 and Hospitality Aide #347. An interview on 03/07/24 at 8:40 A.M. with Activities Director #352 revealed she had been taking her check to a local grocery store to cash as she had been afraid to take it to her bank and be returned for insufficient funds. She stated she had been taking her payroll checks to the grocery store, cashing them (for which the grocery store charged a fee based on the amount of the check) and then would take the cash and deposit it into her bank account. She stated she was aware there were employee checks that had been cashed at the grocery store that had not cleared the grocery store's bank and been returned to them for insufficient funds. An attempt to reach the grocery store manager/owner on 03/07/24 at 10:56 A.M. was unsuccessful. A message was left for the owner/manager to return the call to the surveyor, but no return call was provided. On 03/07/24 at 11:21 A.M. a phone interview with CFO #600, Chief Executive Officer (CEO) #601 and Chief Nursing Officer (CNO) #602 was held. Chief Financial Officer #600 continued to report payroll was not met due to the identified positive payroll issue with the bank. Documentation of the bank's error with the positive payroll file submission was requested. As of 03/11/24 at 11:00 A.M. no documentation had been provided. On 03/11/24 at 9:05 A.M. an interview with the DON verified the last wire transfer to staff to pay from the 02/16/24 pay day was not made until 02/29/24 (almost two weeks after the pay date). The DON stated the (unidentified) staff member notified her on 02/28/24 that their check bounced, and the corporation then wired the funds directly to the staff member's account. 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. 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. b. Review of the invoice from [NAME] Recycling dated 02/13/24 revealed a total balance due of $1,531.10. This showed services due for 02/01/24 for $765.55 and 01/01/24 for $765.55. This had been received by the facility and scanned to the corporate office on 02/20/24. An interview on 03/04/24 at 11:05 A.M. with the recycling company's Accounts Receivable Clerk (AR) #213 revealed the facility was behind 60 days on their billing. c. Review of the invoice from Buckeye Pest Management dated 02/20/24 revealed a total balance due of $723.95. This showed services due for 10/05/23, 11/06/23, 12/07/23, 01/04/24 and 02/01/24. The statement was received and scanned to the corporate office on 02/28/24. Interview on 03/04/24 at 10:50 A.M. with the pest management's Accounts Receivable Clerk (AR) #133 revealed she had been in contact with the facility related to their balance of $723.95. She stated they had not received any payments from the facility since prior to October 2023. d. Interview on 03/05/24 at 11:45 A.M. with Medical Director (MD) #351 revealed he was unaware of how much the facility owed him for medical director fees. During the interview, he contacted his office and spoke to one of the staff and discovered the facility owed MD #351 for September 2023, November 2023, December 2023, January 2024 and February 2024. This totaled $15,000.00. It was noted the corporation had made payment arrangements and had kept those arrangements until January 2024. There was no payment received in the month of February 2024. e. Review of the invoice from Broad River Therapy dated 03/06/24 revealed a total balance due of $103,531.89. This was due for services from 11/02/23 to 12/02/23 for $27,251.19; 12/01/23 to 12/31/23 for $28,291.58; 01/02/24 to 02/01/24 for $22,527.73; and 02/02/24 to 03/03/24 for $25,461.39. Interview on 03/04/24 at 11:57 A.M. with Therapy Office Manager #128 revealed the facility had not paid for services since September 2023. However, she stated CFO #600 stated the corporation would be sending checks the week of 03/04/24. f. Interview on 03/05/24 at 10:16 A.M. with Clerk #350 at the [NAME] Country Treasurer's Office revealed the facility had set-up a payment plan for the balance due which included a delinquent balance, late fees and interest. She stated the facility owed a total of $101,283.27 for property taxes and had made a payment arrangement to pay $5,000 a month and made a payment on 01/12/24. However, Clerk #350 stated the facility (corporation) had failed to make a payment in February 2024. On 03/10/24 the Ombudsman conducted an onsite visit at the facility. The Ombudsman reported staff were worried about getting paid on Friday (03/15/24). This date is the next scheduled date for staff to be paid in the facility. Review of the Nursing Facility Admission Agreement, undated, 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, dated 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 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, psychiatrist services and pharmacist. This deficiency represents non-compliance investigated under Master Complaint Number OH00151629, Complaint Number OH00151626 and Complaint Number OH00151535.

Based on observation, record review including review of facility payroll records, review of facility billing/financial information, review of the [NAME] County Auditor website, 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, hospitalization , displacement due to potential interruption in staffing regarding non-payment of payroll benefits and continued 10/16/23 due to non-payment of essential bills. This had the potential to affect all 31 residents residing in the facility. On 11/20/23 at 5:08 P.M., the Director of Nursing (DON) and the Assistant Administrator 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 meet staff payroll on 10/13/23, delinquent balances owed to the facility food vendor resulting in delayed food delivery and the facility utilizing emergency food supplies, a city water disconnect notice due to non-payment and/or returned checks due to insufficient funds, outstanding balances with the electric company with potential shut off notices if payments were not received, delinquent property taxes since 02/21, non-payment for therapy services resulting in a change of therapy providers and a hold placed on the oxygen and respiratory supply account by the vendor due to non-payment of the outstanding balance causing potential interruption of services 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 11/28/23 when the facility implemented the following corrective actions: On 11/20/23 at 6:00 P.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 and there were no negative outcomes resulting from negative practice. Beginning on 11/20/23 and concluding on 11/21/23, the Administrator and/or designee re-educated, through in-person and phone communication, all facility staff 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 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 11/20/23 and concluding on 11/21/23 the DON and Assistant Director of Nursing (ADON) completed education with all clinical staff (nine Registered Nurses (RN), nine Licensed Practical Nurses (LPN), 17 State tested Nursing Assistants (STNA) & four Hospitality Aides) on communicating if there are any supply, vendor and/or food supply concerns to immediately notify the DON and the Administrator. On 11/21/23, the DON, ADON and RN Supervisor #47 completed a review of all 31 residents to verify that there were no resident condition changes related to the facility's lack of payment to vendors. Beginning on 11/21/23, the Administrator and/or designee monitors and ensures essential resident care services are provided by daily communication in the stand-up meeting with the facility leadership team by asking if there are any essential vendor concerns. Beginning on 11/21/23, the Administrator and or designee communicates needs to the management company (Compliance Officer #602, Chief Executive Officer (CEO) #601, and/or Chief Financial Officer (CFO) #600) as they arise via email communication. The Business Office Manager (BOM) was re-educated by the Administrator on 11/21/23 regarding the Stampli process. BOM and/or designee scan bills into Stampli, the online portal for the Management Company's approval and payment. On 11/21/23, Corporate Compliance Officer #602 re-educated the Administrator, the Assistant Administrator and the 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 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. On 11/27/2023, the Administrator verified with the Management Company (CEO, CFO, Corporate Compliance Officer) that the following vendors bills were made current; AEP (Electric), [NAME] (Trash), [NAME] Gas (Natural Gas), Respiratory Care Partners (Oxygen), and City of Cambridge (Water/Sewer). The Administrator also verified with the Management Company (CEO, CFO, Corporate Compliance Officer) that the following vendors were placed on a payment plan: [NAME] County Treasurer (Property Taxes), MedOne (Medical Director), Medline (Medical Supplies), and Broad River (Therapy). The facility provided a payment plan dated 11/27/23 for delinquent taxes with a balance of $79,428.51. The contract started on 11/27/23 with a down payment of $10,000 (no date) and a payment of $5,000 on 12/22/23. A payment of $4,964.28 would be made the twenty-second of each month through 02/22/25 and a final payment of $4,964.31 would be made on 04/22/25. Beginning on 11/28/23, the DON or designee will 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. On 11/28/23 Administrator provided a copy of check #1008 dated 11/28/23 to RCP in the amount of $1,897.19. On 11/28/23 the Administrator provided a copy of check #1005 dated 11/15/23 for $765.55 was submitted to [NAME] Refuse for payment in full. On 11/28/23 the Administrator provided a copy of check #1006 dated 11/17/23 to the City of Cambridge for $11,786.96, for the water bill to be paid in full. Interviews on 11/29/23 at 9:03 A.M. with BOM #46, at 10:05 A.M. with DD #48, at 10:24 A.M. with LPN #5, at 10:34 A.M. with STNA #30, at 10:40 A.M. with Housekeeper #58, at 10:42 A.M. with LPN #10, and 10:45 A.M. with Laundry/Housekeeping Supervisor #55 revealed they had received education on abuse and reporting any calls regarding outstanding bills, and any concerns with supplies not being delivered. Beginning on 11/29/23, weekly conference calls will be held on Wednesdays at 11:00 A.M. with the Administrator and/or designee with management company (Corporate Compliance Officer, CEO, or CFO) to communicate any concerns with essential resident care services weekly for 12 weeks. Beginning on 11/29/23, the Administrator and/or designee and CFO #600 of the management company and/or designee, will 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 are being paid and that no disconnect/cut off/end of service notifications were delivered within the week. Beginning on 11/29/23 Social Services #45 and/or designee will interview four residents weekly for four weeks and then randomly thereafter to ensure their needs are being met. Beginning on 11/29/23 Social Services #45 and or designee will interview four residents weekly for four weeks and then randomly thereafter to ensure their needs are being met. Beginning on 12/19/23 (the next scheduled meeting date) results of all audits and interventions will be brought to the Quality Assurance Performance Improvement (QAPI) meeting monthly for three months and as needed for review and recommendations. Although the Immediate Jeopardy was removed on 11/28/23, 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 11/16/23 at 8:32 A.M., an interview with the Director of Nursing (DON) revealed some of the employee checks had been returned for insufficient funds but corporate (management located in Florida) had wired money to the employees the same day. Further interview revealed corporate also covered any fees that occurred at the employees' banks. Interview on 11/16/23 at 8:36 A.M. with State tested Nursing Assistant (STNA) #32 revealed they had a paycheck from 10/13/23 returned due to insufficient funds. At 8:38 A.M. interview with Housekeeper #56 revealed they had a paycheck from 10/13/23 returned due to insufficient funds. At 8:40 A.M. interview with Housekeeper #58 revealed they had a paycheck from 10/13/23 returned due to insufficient funds. STNA #32, Housekeeper #56 and Housekeeper #58 stated corporate wired money to their accounts the same day the checks were returned and covered any penalties/fees that occurred due to the facility's insufficient funds to make payroll. Interview on 11/16/23 at 8:53 A.M. with Dietary Director (DD) #48 revealed some of the emergency supply of food had to be used due to food not being delivered by the food vendor ([NAME]) on 10/16/23. DD #48 stated a delivery truck arrived on 10/16/23 but did not unload any food (due to non-payment of the food bill) and left the facility. Review of the menus and substitutions revealed on 10/16/23 the dinner meal did not have cabbage available due to no truck delivery. On 10/17/23 and 10/18/23 the lunch and dinner meals were substituted with other food items due to no truck delivery on 10/16/23. DD #48 revealed a food delivery was made on 10/18/23 and 10/23/23 with the 10/23/23 delivery duplicating the items from the 10/18/23 order. Review of an invoice dated 10/18/23 and invoice dated 10/23/23 verified the duplicate orders. Review of meal substitutions revealed substitutions were made for dinner on 10/27/23, lunch and dinner on 10/28/23, and lunch and dinner on 10/29/23. DD #48 clarified the menu was followed from 10/19/23 until 10/27/23 but since there was a duplicate delivery on 10/23/23, substitutions were made on 10/27/23, 10/28/23, and 10/29/23 so residents were not served the same meals two weeks in a row. Some of the emergency food supply was used to prevent duplicate meals and some of the food on hand was used to make different meals. The facility started using [NAME] Food Service on 10/27/23 and stopped using [NAME]'s services for food delivery. Review of the invoice dated 10/31/23 revealed [NAME] Food Service delivered food on 10/31/23. Interview on 11/16/23 at 12:37 P.M. interview with Business Office Manager (BOM) #46 revealed most bills were sent directly from vendors to Epic Healthcare Solutions. All bills and invoices received at the facility were scanned and emailed directly to Stampli (company that processes and pays invoices) every Wednesday. If there were any disconnect notices or notice that services would be stopped, those bills would be emailed to the Administrator, Epic Healthcare Solutions, and Stampli immediately. On 11/16/23 at 12:42 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 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. The Administrator stated there had been a few disconnect notices, but no utilities had ever been disconnected. An additional interview on 11/16/23 at 2:28 P.M. with the Administrator revealed any disconnect notices were forwarded to Epic Healthcare Solutions. The Administrator stated he received an email (sender not identified by the Administrator) dated 09/08/23 that Arbor Rehabilitation and Healthcare Services (the previous therapy provider) would be ending their services. Another therapy department (Broad River Rehabilitation) would start providing services. The Administrator stated there was no disruption in therapy services for the residents. The Administrator also shared 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 and 20 additional employees were returned on 10/13/23 due to insufficient funds. The Administrator identified himself; RN #6, RN #66, and RN #509; Maintenance Director #20, Hospitality Aide (HA) #24, #56, #57, #58 and #59; STNA #36, STNA #41, Social Services Designee #45, BOM #46, Dietary Staff (DS) #49, #52; Marketing #61, Beautician #62, the Assistant Administrator, Activity Aide #64 and #65 that had payroll checks returned due to insufficient funds. Corporate had wired money to employees in the amount of their pay and any fees that had occurred when they were notified a check was returned for insufficient funds. The 21 staff (the Administrator, RN #6, RN #66, and RN #509; Maintenance Director #20, Hospitality Aide (HA) #24, #56, #57, #58 and #59; STNA #36, STNA #41, Social Services Designee #45, BOM #46, Dietary Staff (DS) #49, #52; Marketing #61, Beautician #62, the Assistant Administrator, Activity Aide #64 and #65) identified were verified with facility payroll records to have payroll checks dispersed and dated 10/13/23. On 11/20/23 at 9:12 A.M. Dietician #508 revealed food suppliers had been changed in October of 2023 from [NAME] to [NAME]. Dietician #508 stated she was unaware some of the emergency supply of food had been used but was aware there were several substitutions made in October and it was protocol to make substitutions if a food item was not available. Further interview verified DD #48 followed the procedure of making substitutions and identifying the reason why it was necessary. An additional interview on 11/27/23 at 11:28 A.M. with Dietician #508 revealed she was aware substitutions had been made due to delivery truck not delivering food on the correct day and then sending the same food items two weeks in a row. Dietician #508 stated she approved of the substitutions that were made. On 11/20/23 at 9:39 A.M. an additional interview with DD #48 revealed she contacted [NAME] on 10/16/23 when the food delivery was not made. An employee of [NAME] stated orders could not be placed until a payment had been made to [NAME] food distribution. The emergency food supply had to be used during this time. On 11/20/23 at 10:59 A.M. interview with RN #509 revealed she had worked at the facility for [AGE] years but had recently quit due to insufficient funds on 10/13/23 and then her bank held her next pay dated 10/27/23 until 11/07/23 since the facility had a previous issue with insufficient funds. The RN stated she resigned due to instability of the paycheck system and needing to be paid on time. RN #509 stated there had been times the trash dumpster was overflowing at the facility because the bill had not been paid and food was not delivered due to nonpayment to the supplier. Lastly, the facility had purchased t-shirts for the staff for nurse's week and the vendor was calling the facility asking for payment. On 11/20/23 at 11:07 A.M. RN #6 verified they had a paycheck return for insufficient funds. RN #6 stated a food delivery truck had arrived at the facility but left without unloading any food due to nonpayment. The trash dumpster had overflowed because the refuse company was owed money. A lot of vendors call the facility all hours of the day and night asking for payment. The staff would tell the vendors to call back when someone was in the office. Sometimes the staff left a note at the front desk about a vendor calling and wanting payment. On 11/20/23 at 1:31 P.M. CFO #600 revealed Epic Healthcare Solutions was in the process of transferring financial accounts to a different bank (from Regency Bank to the Bank of Oklahoma). There had been an issue with funds being moved from one account to another account. This had caused problems with payroll being covered. A conscious decision as an organization was made to use paper checks to help with timing and cash flow and there had been a change in banks due to Regency Bank not moving money from one account to another quick enough to meet the facility's financial needs. CFO #600 stated communication and payments were handled at the corporate office so the facility staff could focus on the residents. CFO #600 stated no services had been disconnected and stated he would have to check to see if any disconnection notices had been received. CFO #600 stated they would investigate trash service not being provided in September. When asked about the disconnect notice from the City of Cambridge, CFO #600 revealed the corporation made sure everyone got paid and residents and staff had everything they needed. CFO #600 verified there had been multiple checks that were returned for insufficient funds to the City of Cambridge and banks were being changed due to returned checks. CFO #600 stated they had made an agreement last week with the [NAME] County Auditor's Office for the delinquent property taxes and had made a payment for the first two months of a 12-month agreement. CFO #600 verified money was still owed to the two previous food vendors. A payment had been made to Avalon (a previous food vendor) not too long ago and there was communication daily with [NAME] (a previous food vendor). When asked why bills were not being paid on time, CFO #600 stated there was communication with vendors to make sure they received payments. CFO #600 stated most of the payment agreements were verbal and there were no written agreements. CFO #600 stated the therapy providers changed due to corporate wanted to try a different provider and he was unable to recall how much was owed to Arbor Rehabilitation. CFO #600 verified corporate did not always pay for services quickly but made sure the facility had the essential supplies. Payments were based off cash flow and corporate worked with vendors daily, but the CFO could not provide a reason the bills were not paid on time when he was asked. Interview on 11/24/23 at 10:04 A.M. interview with the Administrator revealed any final notices and/or disconnect notices were also sent to Epic Healthcare Solutions. The Administrator stated the only disconnect notice he could recall was from the city for water and sewage and he was aware food was not delivered one time but was not aware it was due to nonpayment. Dietary Director #48 was given money from petty cash to purchase anything that was needed for the residents. Additionally, the Administrator verified the facility did not receive a bill for the medical director and was not aware the medical director was not being paid. On 11/24/23 at 10:41 A.M. an interview with BOM #46 revealed any calls received at the facility about bills being owed were emailed to accounts payable at Epic Healthcare Solutions. BOM #46 stated the email to accounts payable included multiple people and not one specific person (the multiple people were not identified by the BOM). The following vendor/suppliers were reviewed as part of the State agency investigation: a. Review of bill from the City of Cambridge Utilities Department dated 11/02/23 revealed $11,786.96 was owed and this was a final shut off notice. If payment was not received by 11/15/23, service will be turned off on 11/16/23 without further notice. On 11/16/23 at 2:22 P.M. interview with City of Cambridge Office Manager #500 revealed the facility was sent a final shut-off notice dated 11/02/23 due to nonpayment for water and sewage in the amount of $11,786.96. If payment was not received by 11/15/23, service would be turned off without further notice on 11/16/23 and a delinquency charge would be made. City of Cambridge Office Manager #500 shared a check from Epic Healthcare Solutions had been received on 11/14/23 but Epic Healthcare Solutions had checks returned for insufficient funds in July, twice in August, and in September. An additional interview on 11/28/23 at 8:49 A.M. with City of Cambridge Office Manager #500 revealed the previous check received on 11/14/23 had been returned for insufficient funds after speaking with surveyor on 11/16/23. The City of Cambridge Office Manager #500 stated another check was received and deposited and had not been returned at the time of the interview. b. On 11/16/23 at 4:33 P.M. interview with Sales/Service #501 for [NAME] Innovative Management Partners verified Epic Healthcare Solutions owed $132,100.42. Sales/Service #500 stated there was a tentative schedule for weekly payments, but the vendor did not share what the agreed upon amount was with the facility. If Epic Healthcare Solutions was unable to adhere to the schedule, then there would be a meeting to brainstorm about payments. Review of statement from [NAME] Innovative Management Partners dated 11/18/23 revealed invoice amounts from 06/15/23 through 10/28/23 a total balance of $132,100.42 was owed. c. Review of statement from Avalon Foodservice dated 10/31/23 revealed there were outstanding charges from 12/06/22 through 10/31/23 totaling $31,106.05. On 11/20/23 at 8:31 A.M. an interview with Credit Manager #505 at Avalon Foodservice revealed the facility elected to stop services on 01/24/23. The facility still had an outstanding balance of $29,106.05 owed to Avalon Foodservice. d. Review of monthly statements from American Electric Power (AEP) revealed a payment in the amount of $8890.42 was made on 07/03/23. The check was returned on 07/07/23. A statement dated 07/13/23 revealed there was a balance of $12,614.68 including a previous balance of $8890.42. A payment of $8950.20 was made on 07/20/23 and was returned on 07/28/23. The monthly bill dated 08/11/23 revealed an outstanding balance of $16,645.91. A payment of $12672.88 was made on 08/28/23 and returned on 09/05/23. The monthly bill dated 09/12/23 revealed an outstanding balance of $20,908.49. The monthly bill dated 10/11/23 revealed a balance of $7,858.82. The monthly bill dated 11/09/23 revealed a balance of $13,260.14 with an outstanding balance of $7,907.19 and a current balance of $5,352.95. On 11/20/23 at 10:07 A.M. an interview with a representative of AEP revealed there was an outstanding balance of $5,401.32. If payment was not received by 12/14/23 the facility would be at risk for disconnection of service e. On 11/20/23 at 10:46 A.M. Chief Executive Officer (CEO) #503 for Arbor Rehabilitation and Healthcare Inc. revealed therapy services were ended due to a lack of payment. The representative supplied documentation dated 11/15/23 showing an outstanding balance of $247,604.28. CEO #503 stated Epic would not commit to a payment plan as it was too binding, and they wanted flexibility, so he was not receiving money monthly and had not received payment for a while. CEO #503 verified he speaks with the company frequently, but they are not easy to work with since they won't set a payment amount and don't send routine payments, He also stated he had to take out a line of credit due to the facility's failure to make payments on their owed debt. f. On 11/20/23 at 11:14 A.M. Representative #504 at Broad River Rehab revealed services were started on 09/18/23. The first invoice #106862 was sent on 10/03/23 for $8,897.76 and was due on 11/02/23. g. On 11/20/23 at 11:22 A.M. a representative at [NAME] Refuse company revealed the facility currently had service of trash pickup six days a week. There was an outstanding bill for $760.55 and the present bill was $766.55. Review of an invoice dated 08/01/23 revealed a balance due of $1,538.05 including a past due amount of $772.50. An invoice dated 09/01/23 revealed a balance due of $2,303.60 including a past due amount of $1,538.05. An invoice dated 11/01/23 revealed a current balance due of $760.55 and no past due amounts. h. On 11/20/23 at 12:15 P.M., an interview with Medical Director #506 revealed he was not aware of vendors not being paid. Medical Director #506 stated he had not been paid since June 2023 and payments prior to that had been sporadic. Medical Director #506 was aware there had been a change in therapy services but did not know it was due to the previous company not being paid. There was no bill or statement provided for review. i. Review of the property taxes owed at https://auditor.guernseycounty.gov revealed unpaid taxes with a total of $432.44 with $260.42 delinquent for parcel number 04-0000094.000. There were also unpaid taxes with a total of $79,428.51 with $47,626.26 delinquent for parcel number 04-0000038.000. On 11/20/23 at 12:49 P.M. interview with Representative #507 of [NAME] County Treasurers Office #507 verified the facility owed a total of property taxes in the amount of $79,860.95. The last tax payment was received on 02/18/21. j. On 11/20/23 at 4:41 P.M., an interview with Accounts Receivable Specialist #510 at Respiratory Care Partners (RCP) revealed there was an outstanding balance of $1,897.19. A hold had been put on delivery of services until a payment was received. An additional interview on 11/27/23 at 11:05 A.M. with Accounts Receivable Specialist #510 revealed a payment had been promised and the owner of RCP had lifted the hold on deliveries. However, no confirmation of the promised payment amount or payment arrangements had been shared. k. Attempts were made to contact Medline, the facility's medical supply company regarding payments and outstanding balances. Medline did not return calls and the facility did not provide billing statements from the medical supply company as requested. Review of the Nursing Facility Admission Agreement provided to all residents revealed the facility would provide routine nursing care and supplies, meals, housekeeping, social services, activities, and medical supplies. Review of the Facility assessment dated [DATE] 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 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 will assist with signing up for either direct deposit or a Pay Card. Review of the facility's 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 OH00148291.

Based on review of clinical records, observation, resident interview, and staff interview, the facility failed to provide prompt treatment to a resident for a [MEDICAL CONDITION] arm. Harm occurred to Resident #48 when the facility staff failed to accurately report an incident when a resident was lowered to her knees and failed to ensure a diagnostic test was completed timely to evaluate a fractured humerus resulting in uncontrolled pain. This affected one of four sampled residents (Resident #48). The census at the time of the survey was 60. Findings include: Review of the clinical record for Resident #48 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nursing documentation per nursing progress note dated 08/02/11 at 9:30 P.M. revealed the resident was assisted to the restroom with the assist of two assistants and when the resident turned to sit on the toilet the resident bumped her right arm on the walker with slight unsteady gait as she was turning to sit. The note described no visible injuries noted. The resident voiced discomfort to the right arm. Tylenol was given to the resident for discomfort. The note documented range of motion to right arm within normal limits and the resident was assisted to bed. Documentation on 08/03/11 at 5:00 A.M. revealed the resident was using the right arm while walking with a walker and pushing self up with the use of the right arm. The note indicated no visual or verbal complaints of pain while the right arm in use. Tylenol was given to the resident at that time. Documentation for Resident #48 on 08/03/11 at 12:30 P.M. revealed the resident was complaining of not feeling well. The resident's vital signs were taken, and the right arm assessed and noted no ecchymotic areas and no complaint of pain. Documentation on 08/03/11 at 2:00 P.M. revealed the resident was complaining of pain of the right arm scored at a 10 on a scale from 1-10 (10 being the worst of pain). The resident was again given Tylenol 650 mg for the pain. The note described the resident as screaming with pain at the touch of the right arm and stated she was unable to use the arm due to pain. Documentation on 08/03/11 at 3:00 P.M. revealed the Tylenol was ineffective to control the pain. The process of getting an x-ray was in place. Documentation on 08/03/11 at 3:30 P.M. revealed the resident voiced relief of pain after a compress was applied to the right elbow/shoulder with no bruising or [MEDICAL CONDITION] noted. Documentation on 08/03/11 at 11:45 P.M. revealed a bruise was noted to the right upper arm consistent with previous incident. The resident complained of right elbow pain, stated unable to move right arm due to pain and discomfort. The resident's physician was notified, and a new order was given for x-ray from bed side. This was 9 hours and 45 minutes after the resident began screaming in pain. Review of all documentation in the clinical record for Resident #48 revealed the nursing progress note dated 08/03/11 at 11:45 P.M. was the first documentation the physician was notified of the resident injury, complaint of pain and inability to use the right upper extremity. Documentation for Resident #48 on 08/04/11 at 7:30 A.M. revealed a call was placed to the x-ray technician, the x-ray was not yet completed, and the technician response was documented the x-ray was on the schedule. A note on 08/04/11 at 9:30 A.M. revealed Resident #48 was up in a chair with purplish bruising to right upper arm and near elbow. Tylenol was given for a complaint of pain to right upper arm. The resident was refusing to move or use the arm at this time related to pain. Documentation for Resident #48 on 08/04/11 at 1:30 P.M. revealed an x-ray was obtained of the right humerus and elbow. The x-ray was obtained 13 hours and 45 minutes after it was ordered by the resident's physician. A status change note on 08/04/11 at 5:00 P.M. revealed the bedside x-ray showed questionable cortical fracture of neck of humerus. The physician was notified and the family was notified at this time. The physician ordered the resident be sent to the local hospital for a repeat x-ray of the right humerus. The resident was transported to the hospital at 5:30 P.M. The resident returned to the facility at 8:00 P.M. with a new order for a sling to the right arm at all times due to a [MEDICAL CONDITION] humerus and follow up with an orthopedic physician. The physician was notified and a new order for [MEDICATION NAME] 50 milligrams was given to control pain every four hours as needed. Review of the facility fall investigation form titled Post-Fall Assessment Investigation Report, first dated 08/02/11 at 9:30 P.M. and changed to 08/03/11 at 9:30 P.M. revealed two State-tested nurse aides (STNAs) were assisting Resident #48 to the bathroom. The report indicated the incident was reported on 08/03/11. The report completed on 08/05/11 (72 hours after the incident occurred) revealed the original incident reported the resident bumped the right arm on a walker when turning to sit on the toilet. The nurse completed a head-to-toe assessment and noted no visible injury. Range of motion was noted as within normal limits. The resident complained of discomfort of the arm and was given Tylenol. After further investigation by the facility, it was determined the resident's knees buckled and she was lowered to her knees by two STNAs, and the resident bumped the right arm on the walker. The STNAs assisted the resident to standing position and continued to toilet the resident. The STNAs reported to the nurse the resident bumped her elbow and did not report the resident was lowered to knees. The STNAs were educated on reporting an unusual incident immediately. Review of the Physician's Progress Note for Resident #48 dated 8/05/11 revealed documentation which included: "The staff is investigating the incident where the resident apparently struck her right arm on her walker but it is hard to imagine how this would lead to this degree of injury." On 08/27/11 at 1:38 P.M., interview with Resident #48 revealed the resident could not remember what happened to her arm. The resident had a sling to her right arm. A large purple bruise was noted to the resident's right upper arm, approximately 8 centimeters by 6 centimeters in size. On 08/27/11 at 5:15 P.M., interview with the Director of Nursing verified the delay in treatment, delay in notification of the physician, and delay in obtaining an x-ray to provide treatment. This certification deficiency substantiates Complaint Number OH 942.

Based on medical record review and staff interview, the facility failed to have all interventions in place for proper positioning and falls prevention as ordered. This affected one of three residents sampled for falls and one of two residents sampled for in-house fractures of the 57 residents residing in the facility (Resident #14). Harm occurred on 02/14/11 at 5:00 A.M., when Resident #14 was positioned without her feet elevated and fell from her wheelchair and received a fractured femur requiring hospitalization . Findings include: Review of the closed medical record for Resident #14 revealed an original admission date of [DATE] and a readmission date of [DATE]. The admitting [DIAGNOSES REDACTED]. Review of the minimum data set (MDS) assessment completed 11/30/10 revealed the resident was able to answer questions appropriately. The resident was dependent on two staff for transfer and required extensive assistance of one staff for personal hygiene. Review of the physician's orders [REDACTED]. Review of the Resident Status Sheet used by the nurse aides revealed documentation for Resident #14 to have both feet up while in the wheelchair to improve proper wheelchair positioning. The Fall Risk Assessments completed on 09/27/10 and 12/15/10 revealed the resident was at risk for falls and had no falls in past three months. The Plan of Care addressed the resident's risk for falls. Review of Resident #14's nurses' notes dated 02/14/11 at 5:00 A.M. revealed Licensed Practical Nurse (LPN) #5 heard a call for help, immediately responded to the resident's room, and found her on the floor on her left side. A full-body assessment revealed a laceration to the right forehead measuring 1.0 centimeters (cm) by 0.2 cm with a moderate amount of bloody drainage. The resident's nose had a large amount of dark red drainage. The resident displayed signs and symptoms of pain. The resident's physician was notified and ordered the resident sent to the emergency room for evaluation. The resident was transferred to the hospital at 5:20 A.M. There was no further documentation in the medical record. Review of the Post-Fall Assessment/Investigation completed by Registered Nurse (RN) #1 revealed that Resident #14 had a fall with injury from her wheelchair at 5:00 A.M. on 02/14/11. The report indicated that Resident #14's feet were not elevated at the time of the fall and that staff was educated. On 02/28/11 at 2:45 P.M., an interview was conducted with the director of nursing (DON) and RN #1. The interview revealed that two State-tested nurse aides (STNAs) had used a Hoyer lift to place Resident #14 in her wheelchair at approximately 5:00 A.M. on 02/14/11. STNA #2 left the room to put the lift away, and the other STNA (STNA #3) was in the room. STNA #3 went into the bathroom to get a washcloth to wash Resident #14's face. In the time STNA #3 had her eyes off the resident, Resident #14 leaned forward and fell out of the wheelchair. The DON verified that Resident #14's legs were not elevated as ordered. The DON verified the facility was at fault for the fall and injury sustained to Resident #14. The DON verified Resident #14 was admitted to the hospital with [REDACTED]. This certification deficiency substantiates Complaint Number OH 673.