Every finding on record at The Pavilion at Canal Fulton for Nursing and Rehab

Based on review of facility documentation and interview, the Quality Assurance and Performance Improvement (QAPI) committee failed to meet at least quarterly. This had the potential to affect all 44 residents residing in the facility. Findings include: Review of the facility QAPI committee sign in sheets provided by the facility revealed a single sign-in sheet for May 2025. Interview on 06/17/25 at 4:18 P.M. with the Administrator verified the QAPI committee sign-in sheet dated May 2025 was the only sign in sheet available. No additional information was provided to support additional QAPI meetings were held.

Based on observation, interview, record review, policy review, and CMS memorandum QSO-24-08-NH review, the facility failed to provide care to Residents #7, #29, and #46 in a manner to prevent the potential spread of infection. This affected Residents #7, #29 and #46 and had the potential to affect all residents residing in the facility. The facility census was 44. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 05/06/14. Diagnoses included multiple sclerosis, atrial fibrillation, and Alzheimer's disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had severe cognitive impairment, required extensive to total dependence for all activities of daily living, and was always incontinent of urine and bowel. Review of the care plan for Resident #7 dated 03/18/25 revealed the resident had pressure ulcers related to impaired mobility. Interventions included to administer treatments as ordered and monitor for effectiveness, and to monitor/document/report any changes in skin status appearance, color, wound healing, signs and symptoms of infection, wound size, and stage. Review of the physician's order dated 05/18/25 revealed an order to clean Resident #7's sacrum with normal saline solution, pat dry, apply calcium alginate (antimicrobial dressing), and cover with a boarded gauze daily and as needed. Further review of physician orders revealed there was not an order enhanced barrier precautions (EBP). Observation of wound care for Resident #7 on 06/17/25 at 2:00 P.M. with Licensed Practical Nurse (LPN) #118 and the Director of Nursing (DON) revealed the DON entered Resident #7's room and applied gloves but did not wash her hands. The DON and LPN #118 began to pull down Resident #7's pants after explaining the procedure to the resident. Resident #7 became irate and began screaming she did not want the surveyor in the room and she wanted them to stop. The surveyor exited the room and LPN #118 and the DON finished care for Resident #7. Interview on 06/17/25 at 2:45 P.M. with the DON confirmed that she did not wash her hands before applying gloves and providing care to Resident #7. The DON also confirmed that Resident #7 had wounds and should be in enhanced barrier precautions due to her compromised status. Review of the facility policy enhanced barrier precautions, revised March 2024, revealed enhanced barrier precautions were indicated for residents with wounds and/or indwelling medical devices regardless of colonization. Review of QSO-24008 NH with a posted date of 03/20/24 revealed EBP recommendations included use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. 2. Review of the medical record for Resident #29 revealed an admission date of 12/23/21. Diagnoses included unspecified dementia, major depressive disorder, and hypothyroidism. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 required extensive assistance to dependence for all activities of daily living. Review of the care plan dated 06/16/25 revealed Resident #29 was at risk for infection. Interventions included to monitor for signs and symptoms of infection and to administer medications as ordered. Review of the medical record for Resident #46 revealed an admission date of 01/27/25. Diagnoses included Alzheimer's disease, atrial fibrillation, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed Resident #46 had moderate cognitive impairment and required set-up to moderate assistance for all activities of daily living. Review of the care plan dated 06/16/25 revealed Resident #46 was at risk for infection. Interventions included to monitor for signs and symptoms of infection and to administer medications as ordered. Observation of medication administration on 06/18/25 at 8:50 A.M. with Licensed Practical Nurse (LPN) #134 revealed LPN #134 preparing medications for Resident #29 and then entering Resident #29's room to administer the medications. After administering the medications to Resident #29, LPN #134 exited the room returned to the medication cart and began preparing medications for Resident #46. LPN #134 then entered Resident #46's room and administered Resident #46's medications. LPN #134 then exited the room of Resident #46 and returned to the medication cart. No hand hygiene was performed. Interview on 06/18/25 at 9:12 A.M. with LPN #134 confirmed she did not wash her hands or use hand sanitizer after administering medications to Resident #29 and before administering medications to Resident #46. Review of the facility policy, hand hygiene, revised October 2023, revealed hand hygiene was indicated immediately before touching a resident.

Based on record review and interview, the facility failed to ensure resident assessments were accurate related to hospice services and use of tobacco. This affected seven residents (Residents #3, #12, #16, #17, #28, #42, and #43) of sixteen residents reviewed for Minimum Date Set (MDS) assessment accuracy. Facility census was 44. Findings include: 1. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and started on hospice services on 03/12/25. Diagnoses included dementia, gastro esophageal reflux disease (GERD), insomnia, anxiety, chronic pain, and Alzheimer's disease. Review of the MDS assessment dated [DATE] revealed the assessment did not indicate the provision of Hospice Services. 2. Medical record review revealed Resident #12 was admitted to the facility on [DATE] and started on hospice services on 02/04/25. Diagnoses included dementia, schizoaffective disorder, anxiety, GERD, diabetes, major depressive disorder, and tachycardia. Review of the MDS assessment dated [DATE] revealed the assessment did not indicate the provision of Hospice Services. 3. Medical record review revealed Resident #16 was admitted on [DATE] and started hospice services on 01/09/25. Diagnoses included chronic obstructive pulmonary disease (COPD), Alzheimer's disease, chronic respiratory failure, major depressive disorder, dementia, anxiety, malnutrition, and peripheral vascular disease (PVD). Review of the MDS assessment dated [DATE] revealed the assessment did not indicate the provision of Hospice Services. 4. Medical record review revealed Resident #17 was admitted on [DATE] and started hospice services on 05/11/25. Diagnoses included diabetes, dementia, anxiety, major depressive disorder, GERD, atrial fibrillation, Alzheimer's disease, sepsis, and PVD. Review of the MDS assessment dated [DATE] revealed the assessment did not indicate the provision of Hospice Services. 5. Medical record review revealed Resident #42 was admitted on [DATE] and started hospice services on 03/11/25. Diagnoses included neurocognitive disorder with Lewy bodies, depression, COPD, and diabetes. Review of the MDS assessment dated [DATE] revealed the assessment did not indicate the provision of Hospice Services. 6. Medical record review revealed Resident #43 was admitted on [DATE] and started hospice services on 02/06/25. Diagnoses included Alzheimer's disease, depression, anxiety, atrial fibrillation, heart disease, dementia, and scoliosis. Review of the MDS assessment dated [DATE] revealed the assessment did not indicate the provision of Hospice Services. Interview on 06/18/25 at 2:00 P.M. with MDS Nurse #105 confirmed Residents #3, #12, #16, #17, #42, and #43's MDS assessments did not include the provision of Hospice Services. 7. Review of the medical record for Resident #28 revealed an admission date of 03/13/25. Diagnoses included chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease, and nicotine dependence. Review of the smoking assessment dated [DATE] revealed Resident #28 smoked and required supervision. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had intact cognition and did not use tobacco. Interview on 06/17/25 at 10:54 A.M. with Resident #28 revealed she smoked at the facility and had been a smoker for 50 years. Interview on 06/17/25 at 12:57 P.M. with MDS Nurse #105 revealed she was not aware Resident #28 was a smoker when she completed the MDS assessment dated [DATE] and verified the MDS for tobacco use was marked incorrectly.

Based on observation, interview, record review, and policy review the facility failed to ensure call lights were within resident reach. This affected two (#7 and #23) of two residents reviewed for call lights. The facility census was 44. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 05/06/14. Diagnoses included multiple sclerosis, atrial fibrillation, and Alzheimer's Disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had severe cognitive impairment. required extensive to dependence for all activities of daily living, and was always incontinent of urine and bowel. Review of the care plan dated 03/18/25 revealed Resident #7 had self-care deficits for activities of daily living related to her diagnoses. Interventions included to provide bed mobility of two persons and encourage Resident #7 to use call light when assistance was needed. Observation on 06/16/25 at 9:59 A.M. revealed Resident #7 lying in bed hollering for help. Resident #7 was screaming I need someone to help me. Resident #7's call light button was hanging on the wall by the curtain approximately ten feet from her. Interview on 06/16/25 at 10:01 A.M. with Certified Nursing Assistant (CNA) #237 confirmed Resident #7's call button was not in reach. Review of the facility policy titled call system, residents, revised September 2022, revealed each resident was provided with a means to call staff directly for assistance from his/her bed and from toileting/bathing facilities. 2. Review of the medical record for Resident #23 revealed an admission date of 04/22/24. Diagnoses included chronic obstructive pulmonary disease, Parkinson's disease, and vascular dementia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had severe cognitive impairment and required extensive to dependence for all activities of daily living. Review of the care plan dated 04/17/25 revealed Resident #23 had a self-care deficit for activities of daily living related to his diagnoses. Interventions included to provide bed mobility of two persons and encourage Resident #23 to use a call light when assistance was needed. Observation on 06/16/25 at 9:56 A.M. revealed Resident #23 sitting in a wheelchair in his room. Resident #23 was approximately five feet from his bed where his call light was positioned. Interview during the observation with the Director of Nursing (DON) confirmed that Resident #23's call light button was out of his reach. Review of the facility policy titled call system, residents, revised September 2022, revealed each resident was provided with a means to call staff directly for assistance from his/her bed and from toileting/bathing facilities.

Based on record review and interview the facility failed to ensure advanced directives had the appropriate signatures. This affected one resident (#8) of 17 residents (#15, #9, #46, #37, #28, #5, #40, #11, #16, #4, #1, #42, #22, #7, #12, #8, and #3) whose advanced directives were reviewed. The facility census was 44. Findings include: Review of the medical record for Resident #8 revealed an admission date of 05/16/25. Diagnoses included urinary tract infection, dementia, and prostate cancer. Review of Resident #8's physician orders for June 2025 revealed an active order for Do Not Resuscitate Comfort Care- Arrest (DNRCC-A) dated 05/16/25. Review of Resident #8's DNRCC-A form dated 05/16/25 revealed on the line for required signature of physician, APRN [advance practiced registered nurse], or PA [physician assistant] were the signatures of Assistant Director of Nursing (ADON) #102 and Licensed Practical Nurse (LPN) #134. Written on the line required for APRN or PA: name of the supervising physician (PA) or collaborating physician (APRN) for this patient and the physician's HNPI [national provider identifier], DEA [drug enforcement administration], or state medical license number was per Physician #300. Interview on 06/16/25 at 4:17 P.M. with the Administrator verified the physician, PA, or APRN did not sign Resident #8's DNRCC-A form. The Administrator stated the two nurses (ADON #102 and LPN #134) signed the form with the physician's verbal consent.

Based on review of Notice of Medicare Non-Coverage letters and staff interview, the facility failed to inform residents of the name and phone number of the Quality Improvement Organization (QIO). This affected one resident of one resident reviewed for liability notices (Resident #2). The census was 44. Findings include: Review of Resident #2's medical record revealed the resident was re-admitted to the facility on [DATE]. Review of a Notice of Medicare Non-Coverage letter, signed by the resident/resident representative on 12/18/24, revealed services ended on 12/20/24. The letter did not provide the necessary QIO information to request a timely appeal regarding the ending of skilled services and therapies. Interview on 06/16/25 at 3:30 P.M. with Social Service Coordinator #113 confirmed the Notice of Medicare Non-Coverage letter to Resident #2 did not provide the information needed for the appeal process. Interview on 06/16/25 at 3:37 P.M. with the Director of Nursing verified the Notice of Medicare Non-Coverage provided to Resident #8 did not have the name or telephone number to appeal the discharge date .

Based on record review and interview, the facility failed to complete Significant Change in Minimum Data Set (MDS) status assessments within 14 days after hospice admission date. This affected three residents (#16, #17 and #42) of nine reviewed for hospice services. Facility census was 44. Findings include: 1. Medical record review revealed Resident #16 was admitted on [DATE] and started hospice services on 01/09/25. Diagnoses included chronic obstructive pulmonary disease (COPD), Alzheimer's disease, chronic respiratory failure, major depressive disorder, dementia, anxiety, malnutrition, and peripheral vascular disease (PVD). Review of Resident #16's assessments revealed there was no Significant Change assessment completed within 14 days of Resident #16's hospice admission. 2. Medical record review revealed Resident #17 was admitted on [DATE] and started hospice services on 05/11/25. Diagnoses included diabetes, dementia, anxiety, major depressive disorder, gastro esophageal reflux disease (GERD), atrial fibrillation, Alzheimer's disease, sepsis, and peripheral vascular disease (PVD). Review of Resident #17's assessments revealed there was no Significant Change assessment completed within 14 days of Resident #17 hospice admission. 3. Medical record review revealed Resident #42 was admitted on [DATE] and started hospice services on 03/11/25. Diagnoses included neurocognitive disorder with Lewy bodies, depression, chronic obstructive pulmonary disease (COPD), and diabetes. Review of Resident #42's assessment revealed there was no Significant Change assessment completed within 14 days of Resident #42's hospice admission. Interview on 06/17/25 at 9:35 A.M. with MDS Nurse #105 confirmed Residents #16, #17, and #42 did not have the required Significant Change assessment completed.

Based on record review and interview, the facility failed to develop a care plan for smoking for Resident #28. This affected one resident (#28) of one resident reviewed for smoking. The facility census was 44. Findings include: Review of the medical record for Resident #28 revealed an admission date of 03/13/25. Diagnoses included chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease, and nicotine dependence. Review of the smoking assessment dated [DATE] revealed Resident #28 smoked and required supervision. Review of the smoking assessment dated [DATE] revealed Resident #28 did not require supervision or any adaptive equipment for smoking. Review of Resident #28's plan of care revealed the care plan did not address smoking. Interview on 06/17/25 at 10:54 A.M. with Resident #28 revealed she smoked at the facility and had been a smoker for 50 years. Interview on 06/17/25 at 12:57 P.M. with MDS Nurse #105 revealed she was not aware Resident #28 was a smoker when she completed the MDS assessment dated [DATE] and verified a care plan for smoking was not developed. Review of the facility policy Smoking Policy-Residents, revised July 2017 revealed any smoking related privileges, restrictions, and concerns (for example, need for close monitoring) would be noted on the care plan, and all personnel caring for the resident would be alerted to the issues.

Based on record review and interview, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected one resident (#40) of five residents (#5, #40, #11, #3, and #12) reviewed for unnecessary medications. The facility census was 44. Findings include: Review of the medical record for Resident #40 revealed an admission date of 09/25/23. Diagnoses included dementia, depression, Alzheimer's disease, and hallucinations. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had impaired cognition. Review of the pharmacy recommendation dated 03/13/25 revealed Resident #40 had a medication order for fluticasone nasal spray two spray each nostril (EN) everyday (QD) which started 11/28/23. The recommendation indicated in an effort to ensure the lowest most effective does was administered please consider discontinuing fluticasone nasal spray or change the fluticasone nasal spray to one spray EN QD as needed (prn) for rhinitis. A handwritten check was marked next to change fluticasone nasal spray to one spray EN QD prn rhinitis and was signed by the physician and dated 03/25/25. Review of the physician orders for June 2025 revealed active orders for Flonase (fluticasone propionate) Allergy Relief Nasal Suspension 50 micrograms/activation two spray in both nostrils in the morning for sinuses with a start date of 11/28/23. Interview on 06/17/25 at 5:06 P.M. with Corporate Regional Nurse #231 verified that although the pharmacy recommendation regarding fluticasone nasal spray was approved by the physician on 03/25/25 the recommendation was not implemented.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on facility self-reported incident review, medical record review, staff interview, policy review and facility investigation, the facility failed to ensure staff did not misappropriate resident narcotic medication. This affected one (Resident #44) of one residents reviewed for misappropriation of property. The facility census was 46 residents. Findings include: Review of the facility Self-Reported Incident (SRI) #245379 dated 03/18/24 revealed Resident #44's Percocet (a pain medication) tablets were reported missing. Further review of the SRI revealed Percocet tablets were reported missing when staff notified the pharmacy of the need for a refill and the pharmacy indicated there should be a two-week supply left. SRI investigation completed on 03/25/24 revealed the facility was unable to verify or determine if misappropriation of medication occurred. Review of the medical record for Resident #44 revealed an admitted [DATE] with diagnoses including Alzheimer's disease with dementia and radiculopathy of the lumbar region. Review of the physician's orders for Resident #44 revealed an order dated 12/11/23 for Percocet one tablet every six hours for pain. Review of the Medication Administration Record (MAR) for Resident #44 dated March 2024 revealed Percocet was signed off as given to the resident every six hours. Interview on 07/31/24 at 11:00 A.M. with the Administrator, the Director of Nursing (DON), Assistant Director of Nursing (ADON) #79, Regional Nurse (RN) #81 and [NAME] President of Clinical (VP) #85 confirmed Licensed Practical Nurse (LPN) #88 had misappropriated Percocet from Resident #44. Further interview confirmed on 02/24/24 the pharmacy delivered 60 Percocet tablets for Resident #44 in two separate blistered medication packs. Staff indicated review of the controlled medication shift change log revealed on 03/11/24 LPN #88 removed and signed out two narcotic medications blister packs but did not complete the back of the form and indicate which narcotic medications blister packs were removed. Staff added that LPN #88 destroyed the sign out sheet therefore making the counts correct by eliminating the sign out sheets and recording the blister pack medication cards as removed. Staff indicated they had no proof medication was stolen due to the sign out sheets being destroyed, medication packs signed out LPN #88, but the pharmacy indicated they should have a two-week supply remaining based on amount sent and date medication delivered. Review of the controlled medication shift change log for the South unit revealed on 03/11/24 at 7:00 A.M. LPN #88 removed two medication count sheets and medication cards. Registered Nurse (RN) #91 co-signed as verifying and observing with LPN #88 as destroying/returning medication back to the pharmacy. The back side of the controlled medication shift change log did not indicate which medication cards and count sheets were removed as required. Review of the facility policy titled Medication Disposals and Returns dated 05/16/23 revealed staff should complete the controlled medication shift change log to indicate the disposition of any remaining doses. Two individuals (or as required by state regulations) should witness and document the destruction in the format required per applicable state regulations. Interview on 08/01/24 at 12:21 P.M. with the DON confirmed RN #91 signed the controlled medication shift change log for the South unit on 03/11/24 as the observer. Interview on 08/01/24 at 12:26 P.M. with RN #91 confirmed verified she had signed the controlled medication shift change log with LPN #88 as the verification and observer but did she did not observe LPN #88 discard the medications and return them to the pharmacy as per facility policy. Further review of the SRI including Abuse Neglect Misappropriation (ANM) investigation notes and reports revealed that LPN #44 was found with an outstanding warrant for stealing narcotics. Police questioned LPN #44 who then admitted to stealing 48 tablets of Percocet from Resident #44. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program with a revision date of April 2021 indicated residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The deficient practice was corrected on 03/19/24 when the facility implemented the following corrective actions: -On 03/18/24 the Administrator initiated an SRI. -On 03/18/24 the DON interviewed Resident #44 and completed a pain assessment. -On 03/18/24 the DON and the ADON accounted for all narcotics in facility. -On 03/18/24 the DON and the ADON obtained statements from all nursing staff. -On 03/18/24 the DON and the ADON educated the staff on the misappropriation policy -On 03/19/24 the Administrator and the DON notified the local police. -On 03/19/24 the DON and the ADON interviewed and completed pain assessments on all other residents who used narcotic medications. -On 03/19/24 the DON and ADON tested all nursing staff for drugs. LPN #88 tested positive for methadone and suboxone on 03/19/24. -On 03/19/24 the DON notified the Ohio Board of Nursing and the Ohio Board of Pharmacy of the incident. -On 03/19/24 the Human Resources Director reviewed background checks and board of nursing checks for nursing staff. -On 03/19/24 the facility held an emergency Quality Assurance Performance Improvement (QAPI) committee meeting with the Medical Director, the Administrator, the DON, the ADON, and all department heads. -On 03/25/24 the DON and the ADON initiated a narcotic audit which they completed twice weekly for 4 weeks until 04/22/24. -On 04/22/24 the QAPI committee reviewed the weekly narcotic audits.

Based on observation, interview, and review of meeting minutes, the facility failed to serve palatable food at an appetizing temperature. This affected all 51 residents in the facility. Findings include: During the initial screening, Resident's #5 and #16 on 12/04/22 beginning at 11:12 A.M. reported the food was often cold and of poor quality. Observation of the dinner meal on the South unit on 12/04/22 at 5:00 P.M. revealed multiple residents complained the meal did not look appetizing, the meat was of poor poor quality. The menu indicated the meal was a hot hamburger sandwich with brown gravy, mashed potatoes and carrots. The thin dotted hamburger patty was on top of a piece of bread and covered in brown gravy. Three residents requested the substitution after receiving their meal. The posted substitution was a fish sandwich. An aide called the kitchen requesting fish sandwiches. The aide then informed the residents the kitchen did not have the fish sandwiches and offered them a choice of chicken nuggets or grilled cheese. Several asked for the chicken nuggets. Then the residents were informed the kitchen did not have chicken nuggets. The residents verbalized they were upset with this and indicated this occurred with some frequency. On 12/06/22 at 11:35 A.M. the food temperatures of items in the steam table were above the required temperatures. The pork with peaches were 194 degrees Fahrenheit (F), mechanical soft pork 198 F, pureed pork 202 F, baked beans 201 F, vegetables 174 F, pureed vegetables 196 F and hamburger patties 165 F. A test tray was requested for the South unit. Foods were plated and covered with a thermal dome but not on a thermal bottom. Interview with State tested Nurse Aides (STNA) #506 and #507 and Licensed Practical Nurse (LPN) #505 all reported residents complained daily of the quality of the food, not receiving the food on the menu because it was not available, not following the menu, not providing the residents coffee at each meal. The biggest concern in the facility was the food service. This information was shared with the Administrator on 12/04/22 at 5:37 P.M. The food cart arrived with the test tray on 12/06/22 at 11:49 A.M. This cart was for residents who ate independently however it contained two food trays for residents who required to be fed. All trays were served and assistance provided by 12:09 P.M. when the test tray was conducted. The test tray was conducted with Registered Dietitian (RD) #501 on 12/06/22 at 12:09 P.M. RD #501 took the temperature of the pork and said it was over 140 F and pulled out the thermometer quickly. The thermometer was observed to read 110 F. She was requested to place the thermometer back into the pork. The temperature measured 105 F. The pork was tasted and it was barely luke warm but had good flavor. The vegetables were 97.2 F and were cold and not appetizing. RD #501 was asked about not using the thermal bases observed in the kitchen. She reported there were not enough for each resident. Interview with the Administrator on 12/06/22 at 4:30 P.M. verified there were not enough thermal bases for the plates and that would help to keep the food warm. Review of the concern log and resident council minutes revealed on 04/21/22 residents voiced they strongly disliked the food supplier and requested a change in supplier, 06/16/22 would like fresh fruit more often, 07/21/22 noticing coffee grounds in the coffee, 08/22/22 requesting the return of the food committee and 09/15/22 reported the meals were cold. Review of the food meeting minutes dated 09/15/22 at 1:30 P.M. residents want to see a slight change in the alternative menu, discussed with dietary manager, alternative menu: Monday-Pizza Tuesday-Hamburger/cheeseburger Wednesday-Bologna sandwich (fried or regular) Thursday-Chef salad Friday-Baked potato (cheese, sour cream, broccoli, bacon) Saturday-Egg salad Sunday-Fish sandwich Review of the food meeting minutes dated 10/20/22 at 1:30 P.M. indicated the staff in the kitchen were continuing to do the best job with making the good as good as possible for the residents. The alternative menu switched back to chicken nuggets on Wednesdays as not many residents have been ordering bologna sandwiches. Review of the food meeting minutes dated 11/22/22 at 1:30 P.M. revealed the facility was working on hiring a new dietary manager, discussed choice meal, the residents would have surprise sack bags for holidays like Christmas and thanksgiving, and wanted more homemade dessert.

Based on interview and record review, the facility failed to ensure Resident #204's personal funds were forwarded to the resident's estate within 30 days. This affected one resident (Resident #204) of one resident reviewed for personal funds after death. Findings include: Review of the medical record for Resident #204 revealed an admitted [DATE] with a diagnosis of Alzheimer's disease. She passed away on 04/17/22. Review of Resident #204's personal funds statement dated 12/05/22 revealed on 04/18/22 she had a balance of $12.25. The facility closed her account on 04/18/22. A check was made out to Resident #204 in the amount of $12.25 and was dated for 06/06/22 and cleared the facility's bank on 07/11/22. Interview on 12/06/22 at 12:20 P.M. with the Business Office Manager (BOM) #504 verified Resident #204 passed away on 04/17/22 and personal funds were not dispersed to the resident's estate until 06/06/22. She verified this was over 30 days.

Based on interview and record review, the facility failed to ensure resident assessments were completed timely. This affected three (Residents #26, #34 and #49) of three residents reviewed for resident assessments. The facility had a census of 51 residents. Findings include: 1. Review of the medical record for Resident #26 revealed an admitted [DATE] with diagnoses including hypertension and depression. Review of the Minimum Data Set (MDS) assessments for Resident #26 revealed she had quarterly assessments on 07/25/22 and 11/18/22. Interview on 12/05/22 at 1:52 P.M. with Registered Nurse (RN) #500, verified the MDS dates were not done timely and should have been completed at least every three months. 2. Review of the medical record for Resident #34 revealed an admitted [DATE] with diagnoses including diabetes mellitus and hypertension. Review of the Minimum Data Set (MDS) assessments for Resident #34 revealed he had a quarterly assessment completed on 07/19/22. The next assessment was in progress and dated 11/23/22. Interview on 12/05/22 at 1:52 P.M. with Registered Nurse (RN) #500, verified the MDS dates were not done timely and should have been completed at least every three months. 3. Review of the medical record for Resident #49 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, diabetes mellitus and congestive heart disease. Review of the Minimum Data Set (MDS) assessments for Resident #49 revealed he had a quarterly assessment on 07/07/22. The next scheduled quarterly assessment was in progress and dated 12/08/22. Interview on 12/05/22 at 1:52 P.M. with Registered Nurse (RN) #500, verified the MDS dates were not done timely and should have been completed at least every three months.

Based on interview and closed record review, the facility failed to properly address Resident #10's risk of blood clotting who had a known history of venous [CONDITION(S)], embolism, and anticoagulant medication use. This affected one resident (Resident #10) of three residents reviewed for quality of care. Findings include: Review of the medical record for Resident #10 revealed the resident was admitted on [DATE] from another skilled nursing facility, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission packet dated 03/21/22 for Resident #10, sent from his prior nursing facility, revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) 3.0 dated 04/04/22 revealed the resident was moderately cognitively impaired, with no behaviors, independent for most activities of daily living (ADL), had a urinary catheter, and received an anticoagulant for two days while at the facility. Review of Resident #10's 04/23/22 progress notes revealed Resident #10 was sent out to the emergency room (ER) for stat Doppler imaging (noninvasive test to estimate the blood flow through the blood vessels) and was admitted for leg swelling and observation. Review of Resident #10's medical record from admission on 03/29/22 to the time of discharge on 04/23/22 revealed no evidence the facility developed a plan of care with evidence of interventions to address the resident's history of blood clotting or use of anticoagulant therapy. Interview on 05/03/22 at 2:13 P.M. with Resident #10's sister revealed the resident was diagnosed with deep vein [CONDITION(S)] (blood clots in his leg) after admission to the hospital on 04/22/22. He was treated and discharged to another nursing facility. During an interview on 05/03/22 at 3:30 P.M. with Director of Nursing (DON) a request for a plan of care with evidence of interventions to address Resident #10's risk of blood clotting was made. The facility did not provide evidence of the plan or care or interventions to address the resident's risk. Review of the facility November 2018 policy titled, Anticoagulation - Clinical Protocol revealed as part of the initial assessment the physician and staff would identify individuals who are currently anticoagulated and identify situations when an individual is not anticoagulated but where anticoagulation may be indicated. This deficiency substantiates Complaint Number OH 268.

Based on record review and interview the facility failed to ensure staff timely reported potential allegations of employee to resident abuse and failed to ensure all allegations of abuse were reported to the State agency as required. This had the potential to affect 19 residents (#6, #11, #12, #16, #17, #20, #21, #22, #24, #25, #27, #30, #31, #33, #35, #37, #38, #41 and #43) of 40 residents residing in the facility. Findings include: On 09/15/20 at 5:59 A.M. interview with State tested Nursing Assistant (STNA) #130 revealed she had witnessed staff to resident abuse. Upon further interview, the STNA revealed she had observed STNA #155 being abusive to the residents on the unit where this STNA worked. STNA #130 indicated in the past month or two, STNA #155 had been rude and stated petty, hateful things to residents on the unit. The STNA indicated she thought the issue had been taken care of as STNA #155 no longer worked in the facility. Review of a facility resident roster revealed 19 residents, Resident #6, #11, #12, #16, #17, #20, #21, #22, #24, #25, #27, #30, #31, #33, #35, #37, #38, #41 and #43 resided on the unit STNA #155 worked. On 09/15/20 at 7:30 A.M., an interview with Registered Nurse (RN) #140 who worked the 6:30 P.M. to 7:00 A.M. shift on the unit where STNA #155 worked, revealed she had observed STNA #155 being rude to residents. RN #140 revealed she had reported this behavior to administrative staff. Review of the facility self reported incidents (SRI's) related to abuse revealed there had been no reported incidents to the State agency during the past month or two with STNA #155 identified as the alleged perpetrator. On 09/15/20 at 8:04 A.M. interview with the Administrator revealed she was not aware of any complaints of STNA #155 being rude or verbally abusive towards residents. The Administrator verified no SRI's had been completed or submitted to the State agency within the past two months involving STNA #155. At the time of this investigation, STNA #155 was noted to be currently suspended related to another matter. On 09/21/20 at 1:20 P.M. interview with the Director of Nursing (DON) revealed the DON denied knowledge of STNA #155 being rude or verbally abusive to residents. Review of the facility Mistreatment, Abuse, Neglect, and Misappropriation of Resident Property policy, dated September 2016 revealed verbal abuse was defined as the use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Review of the facility Reporting Abuse to Facility Management, revised November 2016 indicated any staff member or person affiliated with this facility who had witnessed or who believed a resident had been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report or cause a report to be made of, the mistreatment or offense. This deficiency is an incidental finding to Complaint Number OH 937.

Based on closed record review and interview the facility failed to ensure Resident #45's responsible party and physician were notified timely following a decline in meal intake. This affected one resident (#45) of four residents reviewed for notification of change. Findings include: Review of Resident #45's closed medical record revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's medical record identified a daughter was listed as power of attorney (POA) for health care. Resident #45 was discharged to the hospital on [DATE]. Review of the weight record revealed on 03/09/20 the resident's weight was 152 pounds. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/15/20 revealed the resident was cognitively intact and needed set up assistance and supervision at meals. The MDS revealed the resident's weight was 152 pounds which reflected no weight loss. Review of the progress note, dated 04/07/20 revealed Resident #45 had a temperature of 100 degrees Fahrenheit and a cough. The note indicated she had had the cough for a couple days. The daughter was informed, the resident was in isolation, and a COVID-19 swab test was done. Review of the laboratory test report, dated 04/09/20 revealed Resident #45 was positive for COVID-19. Review of the State tested nursing assistant documentation in Resident #45's electronic medical record from 03/26/20 through 04/25/20 revealed a lack of documentation for many of the meal intakes. What meals were documented revealed Resident #45 had a decline in meal intakes beginning around 04/12/20. Previously, the resident's meal intakes were documented 51 to 100 percent, usually 76 to 100 percent. Beginning around 04/12/20, Resident #45's meal intakes varied between 0 and 50 percent, usually 0 to 25 percent. There was no indication the resident's physician and/or nurse practitioner and the POA were notified of the decreased appetite until 04/23/20 and 04/24/20 respectively. Review of a progress note by the nurse practitioner, dated 04/23/20 indicated per staff, resident has been medically declining, decreased appetite, and needing more hands on care for activities of daily living. A progress note dated 04/24/20 by Social Service (SS) #105 revealed she updated the POA. During an interview on 09/21/20 at 9:16 A.M., Licensed Practical Nurse (LPN) #100 indicated when Resident #45 was first admitted her appetite was okay. When she had COVID-19, her appetite was poor. During an interview on 09/21/20 at 12:57 P.M., the Director of Nursing (DON) indicated he could find no documentation indicating the physician, nurse practitioner, or POA were notified in a timely manner of the decline in Resident #45's appetite. The DON stated when you have COVID-19, you do not have an appetite. This deficiency substantiates Complaint Number OH 134.

Based on observation, policy review and interview the facility failed to maintain acceptable infection control practices to prevent the spread of infection during incontinence care for Resident #38. This affected one resident (#38) of two residents observed during incontinence care. Findings include: On 09/14/20 at 11:40 A.M., Resident #38's room was noted to have an odor of feces. An attempt to interview the resident was unsuccessful due to the resident being hard of hearing and the surveyor wearing a mask. At the time of the observation, Licensed Practical Nurse (LPN) #110 reported the odor to State tested Nursing Assistant (STNA) #115. On 09/14/20 at 11:46 A.M. STNA #115 was observed providing incontinence care to Resident #38. The STNA first obtained supplies, washed her hands, applied gloves and then proceeded to provide incontinence care. Resident #38 was incontinent of a large amount of liquid stool. During the observation, STNA #115 placed the soiled washcloths, towels, and bed pad with incontinence brief directly on the floor next to the resident's bed. The STNA also had to leave the room during the process to obtain additional supplies. She removed her gloves, cleansed her hands and left room. Upon returning to room, the STNA applied new gloves and continued to provide incontinence care cleaning the resident's front peri area, again placing soiled item on the floor. STNA #115 then changed the bottom sheet, placed the top sheet and blanket back on the bed, folded the sheet at top and tucked it under the resident's arms. She then used the bed control device to adjust the resident's bed. STNA #115 did all this wearing the same gloves she used to clean the front peri area of resident. The STNA then placed the soiled linen inside two separate bags, removed her gloves and carried the bags to soiled linen room where she washed her hands. On 09/14/20 at 12:05 P.M. STNA #115 verified she placed the soiled washcloths, towels and bed linen directly on the floor next to Resident #38's bed. She indicated she usually places soiled linen inside a plastic bag not on the floor. The STNA confirmed she did not wash or cleanse her hands after providing peri care or before touching the clean bed sheets, resident, and bed controls. Review of the facility Soiled Laundry and Bedding policy, revised July 2009 revealed soiled laundry and bedding contaminated with blood or other potentially infectious materials must be handled as little as possible and with a minimum of agitation. Place contaminated laundry in a bag or container at the location where it is used. Transport contaminated laundry in bags. Review of the facility Handwashing/Hand Hygiene policy, revised August 2015 revealed all personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infection. The policy indicated to use an alcohol-based hand rub containing at least 62% alcohol or alternatively soap and water for situations including before moving from a contaminated body site to a clean body site and after contact with blood or bodily fluids. This deficiency is an incidental finding to Complaint Number OH 134.

Based on record review and interview the facility failed to timely notify Resident #37's responsible party of a positive coronavirus (COVID-19) test result. This affected one resident (#37) of three residents reviewed for COVID-19. Findings include: Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident's son was listed as her emergency contact. Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/05/20 revealed the resident was cognitively intact. Review of a progress note, dated 04/10/20 revealed the social service designee spoke with Resident #37's son to inform him of the presence of COVID-19 in the facility. She also informed him the resident had shown at least one symptom of [MEDICAL CONDITION] and was being tested for COVID-19. The social service designee indicated as soon as the facility received results, he would be notified. Review of the laboratory test to detect COVID-19 indicated a specimen was obtained on 04/10/20. The results, reported to the facility on [DATE] were positive for COVID-19. Review of the medical record revealed on 04/21/20 Social Service Designee (SSD) #105 attempted to reach Resident #37's son. The voice mailbox was full so no message was left. There was no other indication the facility attempted to notify the son of the resident's positive COVID-19 results. On 09/21/20 at 9:16 A.M. interview with Licensed Practice Nurse (LPN) #100 revealed administrative staff were completing the notification of families for residents with positive COVID-19 tests. On 09/21/20 at 12:45 P.M. interview with the Director of Nursing (DON) confirmed there was no evidence the facility attempted to notify Resident #37's son of the positive COVID-19 test until 04/21/20 (six days after the positive test results were provided) with no success. This deficiency substantiates Complaint Number OH 134 and Complaint Number OH 937.

Based on closed record review and interview the facility failed to ensure laboratory test results for Resident #45 were reported timely to the physician and/or nurse practitioner. This affected one resident (#45) of four residents reviewed for notification of change. Findings include: Review of Resident #45's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE]. Review of the progress note dated 04/07/20 indicated Resident #45 had a temperature of 100 degrees Fahrenheit and a cough. The note indicated the resident had the cough for a couple days. The daughter was informed, the resident was in isolation, and a COVID-19 swab test was done. Review of the laboratory tested reported 04/09/20 revealed Resident #45 was positive for COVID-19. The physician was notified and ordered Hydrochloroquine, [MEDICATION NAME], and laboratory testing. Review of laboratory results revealed laboratory tests were completed on 04/14/20, 04/17/20, 04/20/20 and 04/24/20. The test dated 04/17/20 indicated the resident's blood urea nitrogen (BUN) level was above the normal range and had gone up 19 milligrams (mg)/decaliters (dL) over the previous laboratory test on 04/14/20 in which it was in the normal range. The BUN/creatinine ratio had also gone from within the normal range to above the normal range, going from 22 on 04/14/20 to 35 on 04/17/20. This could indicate conditions including dehydration or [MEDICAL CONDITION]. The test dated 04/20/20 indicated the BUN had again gone up 4 more mg/dL and the BUN/creatinine ratio 4 more points. Review of the record revealed no evidence laboratory tests, including a comprehensive metabolic panel and complete blood count completed 04/17/20 and 04/20/20 were reported to the physician in a timely manner. A progress note dated 04/23/20 by the nurse practitioner indicated she reviewed the laboratory test results. There is no evidence prior to 04/23/20, the physician or nurse practitioner were notified of the resident's laboratory testing including the abnormal lab results. During an interview on 09/21/20 at 1:08 P.M., the Director of Nursing (DON) revealed he could not find evidence the physician or nurse practitioner were notified of Resident #45's 04/17/20 or 04/20/20 laboratory results. He stated he or another nurse usually take a picture with their phone and send the results to the physician. He could not find evidence anyone did that. The DON indicated he was off work during that time period due to illness. This deficiency substantiates Complaint Number OH 134.

Based on closed record review and interview the facility failed to ensure daily meal intakes were documented for Resident #45. This affected one resident (#45) of three residents reviewed for nutrition. Findings include: Review of Resident #45's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #45 was discharged to the hospital on [DATE]. Review of the State tested nursing assistant documentation in Resident #45's electronic medical record from 03/26/20 through 04/25/20 revealed a lack of documentation for many of the meal intakes. There was no documentation of meal intakes on 03/28/20, 03/29/20, 03/30/20, 04/01/20, 04/07/20, 04/09/20, 04/10/20, 04/11/20, 04/13/20, 04/15/20, 04/16/20 and and 04/17/20. In addition, only one or two meals had documented meal intakes on 03/26/20, 03/27/20, 03/31/20, 04/02/20, 04/03/20, 04/04/20, 04/05/20, 04/06/20, 04/08/20, 04/14/20, 04/18/20, 04/19/20, 04/20/20, 04/21/20, 04/22/20, 04/23/20 and 04/24/20. On 09/21/20 at 12:57 P.M. interview with the Director of Nursing (DON) verified many meals were not documented to reflect Resident #45's meal intake as noted above. This deficiency is an incidental finding to Complaint Number OH 134.

Based on record review, interview, observation, and facility protocol review, the facility failed to re-evaluate Resident #67 after a fall, and implement appropriate interventions related to falls for Residents #67, #80 and #62. Actual Harm occurred when Resident #67's cause of falls related to toileting was not identified and appropriate interventions were not put in place resulting in falls occurring on 08/05/17 and 08/28/17 that required sutures to lacerations. This affected three of five residents reviewed for accidents. Findings include: 1. Review of Resident #67's medical record revealed a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #67's care plan dated 07/26/16 revealed Resident #67 has bladder incontinence related to impaired mobility. The interventions included to establish voiding patterns. Interventions included to check the resident as needed for incontinence. Review of Resident #67's care plan dated 07/26/17 revealed Resident #67 had an actual fall. The interventions for this problem included to assure environment was free from hazards, and to determine and address causative factors of the fall. Review of Resident #67's MDS 3.0 assessment dated [DATE] revealed Resident #67 required extensive assistance for toilet use. Review of the progress note dated 06/24/17 at 8:42 A.M. revealed Resident #67 had a fall and was observed on the floor. The description of the incident revealed Resident #67 was found laying with his head against the wall in the bathroom in front of the sink. His feet were facing the bathroom door. The resident indicated he fell going to the bathroom. Review of the witness statements revealed no indication of when the resident was toileted prior to the fall. There was no evidence an intervention related to toileting was implemented following the fall. Review of the progress note dated 08/05/17 at 6:00 A.M. revealed the nurse was in the hallway passing medication and answered the resident's bathroom call light. Resident #67 was sitting upright on his buttocks, both legs extended, on the right side of the toilet in between the toilet and the wall. Resident #67's head was between the toilet and wall with the left arm holding on to the toilet and his right hand on the floor. The nurse assessed the resident and noted a bloody gash on the resident's right lower side of his face in between his beard, and a bloody gash in the middle of his bottom lip. Resident #67 stated, I hit my head when I was trying to get up. There was no evidence of an intervention of a toileting plan or review of Resident #67's toileting needs following the fall. Resident #67 required an emergency room visit and received three sutures to the right cheek and three dissolvable sutures to the bottom lip. Review of the progress note dated 08/28/17 at 12:47 P.M. revealed Resident #67 had a fall and was observed on the floor. The nurse observed a 6.0 centimeter (cm) by 1.0 cm laceration on the left eyelid and the resident stated he hit the floor. Resident #67 required an emergency room visit and received 10 sutures on the left eyelid. Review of the witness statement by Activity Aide #29 dated 08/28/17 revealed Resident #67 stated he was going to the restroom when he fell . Review of the witness statement by State tested Nurse Aide (STNA) #28 dated 08/28/17 revealed the last time the resident was toileted was between 10:00 A.M. and 10:15 A.M. Interview on 09/28/17 at 8:32 A.M. with the Director of Nursing (DON) confirmed the falls were related to Resident #67 needing to use the toilet. The DON indicated she did not identify the association between toileting and falls and indicated she focused on alarms more so than identifying the continued reason for the falls. The DON confirmed Resident #67 required one person physical assistance to toilet safely following the resident's readmission on 04/11/17. Review of the Falls Clinical Protocol, revised September 2012, revealed the staff would evaluate and document falls that occur while the individual was in the facility, including when and where they happen, any observations of the events, etc. The protocol revealed for an individual who had fallen, staff would attempt to define possible causes within 24 hours. The staff and physician would continue to collect and evaluate information until either the cause of the falling was identified, or it was determined that the cause could not be found or that finding a cause would not change the outcome or the management of falling and fall risk. If the individual continued to fall, the staff and physician would re-evaluate the situation and consider other possible reasons for the resident's falling and would re-evaluate the continued relevance of current interventions. 2. Review of the medical record revealed Resident #80 had [DIAGNOSES REDACTED]. Her care plan initiated on 07/19/17 revealed Resident #80 had impaired decision making skills requiring cues and supervision, she had impaired cognitive function and dementia or impaired thought processes, she had a self care performance deficit and was at a high risk for falls. Staff were to anticipate and meet her needs as possible. Review of her progress notes from 08/31/17 through 09/26/17 revealed she had fallen five times, all with injuries. Her physician's orders [REDACTED]. Review of the interdisciplinary care plan conference notes dated 09/25/17 revealed the team discussed wearing non-skid socks in the facility. Review of a progress note dated 09/26/17 for Resident #80 revealed she had tripped on her shoes and fell to the floor landing on her right side. It revealed Resident #80 was to only wear gripper socks and to encourage resident to use her walker. An interview on 09/27/17 at 3:22 P.M. with STNA #15 revealed Resident #80 was a fall risk and she had to have on her tennis shoes and socks. If anything would change for her, the nurse would tell the STNAs. He revealed Resident #80 did fall a lot. An observation on 09/27/17 at 3:31 P.M. of Resident #80 walking down the hallway in the locked unit revealed she wore tennis shoes with socks. This was verified by STNA #15 and Licensed Practical Nurse (LPN) #16 on 09/27/17 at 3:32 P.M. An interview on 09/27/17 at 3:33 P.M. with LPN #16 revealed Resident #80 was no longer to wear tennis shoes. An observation on 09/28/17 at 10:56 A.M. of Resident #80 walking with LPN #16 revealed the resident did not have on her hipsters and wore tennis shoes. This was confirmed by LPN #16 on 09/28/17 at 10:58 A.M. An interview on 09/28/17 at 11:03 A.M. with STNA #17 revealed that the STNAs were provided a communication clip board at the nurse's station for any changes with resident care. An observation on 09/28/17 at 11:04 A.M. of the Communication Clip Board at the nurse's station on the locked Creekside unit revealed there was no documentation of any changes in the care plan regarding falls for Resident #80. This was confirmed by STNA #17. An interview on 09/28/17 at 2:03 P.M. with Licensed Social Worker (LSW) #33 revealed they had a care plan conference for Resident #80 on 09/25/17 and they discussed with therapy to put in place to wear only non-skid socks with no shoes for Resident #80. She revealed that after the meeting the nurse would type up the minutes and put new orders or instructions on the communication clip board for aides to see. An interview on 09/28/17 at 3:05 P.M. with Physical Therapy Assistant #14 revealed and confirmed they had discussed at the care conference meeting on 09/25/17 regarding Resident #80 only wearing the non-skid socks and no shoes. The resident was tripping on her own feet and the shoes would catch and stop her in her place. The staff were to only put the socks on her with no shoes. An observation on 09/28/17 at 4:20 P.M. revealed Resident #80 asleep in a chair in the dining room with her socks and tennis shoes on. 3. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #62 resided on the secured dementia unit. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #62 was severely impaired for cognition. Review of fall investigations revealed Resident #62 had 12 falls between 07/21/17 and 09/26/17, which included one fall each on 07/21/17, 07/24/17, 07/31/17, 08/09/17, 08/15/17, 08/22/17, 08/23/17 and 09/21/17 and two falls each on 08/01/17 and 09/26/17. During the falls on 07/31/17, 08/01/17, 08/15/17, 08/23/17 and 09/26/17, Resident #62 hit his head on the floor or furniture, sustaining lacerations to his head on two occasions, once requiring sutures. A physician's orders [REDACTED].#62's head to be worn at all times, except for hygiene or family request. On 09/28/17 at 08:14 A.M., Resident #62 was observed lying in his bed with his eyes closed. Resident #62 was not wearing his soft helmet nor was the helmet observed in the surrounding area. During an interview on 09/28/17 at 8:15 A.M., Registered Nurse (RN) #14 verified Resident #62 was not wearing his soft helmet and acknowledged the physician's orders [REDACTED]. RN #14 searched Resident #62's room for the helmet, which could not be found. RN #14 left the room and returned with Resident #62' soft helmet. RN #14 revealed the helmet had been located at the nurses' station.

Based on record review, self reported incident investigation review and interview, the facility failed to use the physician ordered Hoyer lift (mechanical) transferring device for Resident #1. This affected one (Resident #1) of three residents reviewed for proper transfers. The census was 59. Harm occurred when an assistive device was used to transfer Resident #1 that was not ordered by the physician resulting in a fracture of the right femur, subsequent hospitalization and surgical repair. Findings include: Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the medical record revealed that on 08/25/15 at 1:30 A.M. State tested Nurse Aide (STNA) #22 noticed that Resident #1's leg did not look right and immediately notified Registered Nurse (RN) #10. RN #10 assessed the resident and discovered an irregularity to the right thigh of Resident #1. According to the documentation and the investigation completed by the facility, the resident did not complain of pain and was not able to provide any helpful information as to the cause of the injury. Resident #1 had cognitive impairment. His brief interview for mental status (BIMS) completed 06/29/15 revealed a score of five of a possible 15 with 15 having been no cognitive impairment and zero to seven scope indicating severe mental impairment. A review of the physician orders [REDACTED]. This device was operated by two people for safe transfers from chair to bed or bed to chair. The Minimum Data Set (MDS) for Resident #1 revealed that he needed extensive assist with all transfers and was not able to walk either with assistive devices or independently. The review of the self reported incident (SRI) initiated on 08/25/15 included witness statements and a summary of the investigation completed by the facility. This review contained a written statement from STNA #23 and STNA #24, who performed care and assistance with transferring Resident #1 on 08/24/15 during the 3:00 P.M. to 11:00 P.M. shift. The statement identified that STNA #23 admitted to using a stand and pivot transfer and not the mechanical lifting device as ordered when placing Resident #1 back into his bed. The investigation of the injury to Resident #1 also included a written statement from STNA #24, who performed care and assistance with transferring Resident #1 on 08/24/15 during the 3:00 P.M. to 11:00 P.M. shift and this statement identified that she also admitted to using a stand and pivot transfer for Resident #1 when the physician orders [REDACTED]. Both statements did not provide any indication of swelling, redness, deformity or pain when Resident #1 was placed in bed. The result of the observation and subsequent physician notification regarding the right leg of Resident #1, was to obtain an x-ray. This was completed in the facility. The x-ray revealed a fracture of the lower right femur or thigh bone and deep tissue swelling. Resident #1 was transferred to the hospital on [DATE] for surgery to repair the fractured femur bone in the right leg. Interview with the Administrator on 09/29/15 at 1:30 P.M. verified these findings regarding staff not having followed the physician orders [REDACTED].#23 and STNA #24 did not follow the physician orders [REDACTED].#1 from his chair into the bed resulting in a fracture of the right femur. This deficiency substantiates Complaint Number OH 877.