Every finding on record at Trinity Community at Fairborn

Based on observations, resident interviews, staff interviews, an interview with the pest control provider, review of pest control invoices, and review of facility policy, the facility failed to maintain an effective pest control program. This affected three (Residents #62, #70, and #71) of six residents sampled for pest control and had the potential to affect all 21 residents living on the 400-Hall. The facility census was 84.Findings include: 1.Review of the medical record revealed Resident #62 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, type II diabetes, chronic combined congestive heart failure, end stage renal disease, unspecified dementia, and unspecified anxiety. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. 2. Review of the medical record revealed Resident #70 was admitted to the facility on [DATE]. Diagnoses included hemiparesis and hemiplegia following cerebral infarction, morbid obesity, chronic combined congestive heart failure, major depressive disorder, and stage II chronic kidney disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. 3. Review of the medical record revealed Resident #71 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, unspecified anxiety disorder, unspecified depression, stage II chronic kidney disease, generalized weakness, and repeated falls. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 had severely impaired cognition, did not reject care, had occasional self-directed behaviors, and wandered occasionally. Observation on 03/31/25 at 11:04 A.M. revealed Resident #70 was seated in her wheelchair at bedside watching television (T.V.) There were two small, winged insects flying near her head. There were two bags of apples on the top shelf of a cabinet located against the wall directly in front of the resident with five large black flies swarming around the fruit. During an interview on 07/31/25 at 11:04 A.M. Resident #70 stated she had gnats and flies in her room all the time, but she never saw the facility spray for pests. During an interview on 07/31/25 at 11:06 A.M. Medication Aide #125 verified Resident #71 had multiple winged insects in her room flying near her head and near stored fruit. The aide stated Residents #70 and #71 both kept fruit in their room that attracted pests. During an interview on 07/31/25 at 11:21 A.M. Director of Environmental Services (EVS) #95 stated they deep-cleaned Resident #70's room daily and sent letters to families asking them not to bring excessive amounts of perishable foods. The director stated they had routine pest control services monthly and additionally as needed. During a telephone interview on 07/31/25 at 1:56 P.M. Pest Control Technician #150 stated the pest control company did not spray for gnats or flies as this was not allowed in skilled nursing facilities, and stated these pests indicated either a water or sanitation problem. The pest company offered blue-light devices that were hung on the walls to attract and trap/kill flying insects. The company could order these, but the facility would need an electrician to install them. During an observation on 07/31/25 at 4:10 P.M. Resident #62 was observed to lay in bed supine with eyes open. Two winged insects were observed flying around the resident's head. During the concurrent interview, Resident #62 swatted repeatedly at the flying insects. Additional observation in the room revealed a small, winged insect crawling on the toilet seat. During an interview on 07/31/25 at 4:12 P.M. Resident #62 stated there were frequently flies in his room and they drove him crazy. During an interview on 07/31/25 at 4:15 P.M. Medication Aide #125 verified Resident #62 had flying insects in his room and bathroom. Observation on 07/31/25 at 4:18 P.M. revealed greater than twenty winged insects were seen in Resident #70 and #71's shared room flying around bags of apples, and crawling on the ceiling, walls, and privacy curtain. Resident #70 was not in the room. Resident #71 was standing at bedside with walker swatting at winged insects as they neared her face. During an interview on 07/31/25 at 4:18 P.M. Resident #71 indicated there were flying insects in her room all the time. During an interview on 07/31/25 at 4:20 P.M. Certified Nursing Assistant (CNA) #120 verified there were more than 20 flying insects in Resident #70 and #71's shared room. CNA #120 stated she had made numerous complaints to management about the flies on 400-Hall, but nothing was done. CNA #120 stated at times she brought an electric flyswatter to work to kill as many as she could, but the flies and gnats were always back the next time she worked. Review of pest control invoices dated 05/01/25, 05/27/25, 06/03/25, and 07/01/25 revealed the pest control company treated the facility for mice, ants, and cockroaches. Review of policy titled Pest Control, not dated, revealed the facility maintained an on-going pest control program to ensure that the building was kept free of insects. This deficiency represents noncompliance investigated under Complaint Number 1388109.

Based on medical record review, resident interview, staff interviews, and facility policy review, the facility failed to maintain communication for dialysis services and failed to ensure post-dialysis assessments were completed. This affected Resident #62, the only resident at the facility who received dialysis services. The facility census was 84.Findings include:Review of the medical record revealed Resident #62 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, type II diabetes, chronic combined congestive heart failure, end stage renal disease, unspecified dementia, and unspecified anxiety.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander.Review of the care plan dated 07/01/24 revealed Resident #62 had renal insufficiency related to stage IV chronic kidney disease. Interventions included hemodialysis every Monday, Wednesday, and Friday at a community based dialysis center. Arrival time was 11:00 A.M. with chair time at 11:30 A.M. Pick up from dialysis was at 3:15 P.M. Resident #62's transportation was scheduled for every Monday, Wednesday, and Friday at10:37 A.M. and 3:15 P.M. each appointment time. Review of the medical record revealed Resident #62 had one communication from the dialysis center dated 03/05/25 which listed laboratory results from 02/07/25 to 03/05/25. During an interview on 07/31/25 at 12:40 P.M. the Director of Nursing (DON) stated the facility sent copies of the pre-dialysis assessment with the resident to the dialysis appointment. The papers had a section for the dialysis center to fill out and return, but they never did. The DON verified the only evidence of communication the facility had was a document regarding laboratory results dated [DATE]. During an interview on 07/31/25 at 12:52 P.M. Registered Nurse (RN) #105 verified the medical record had no documentation of nurses following up with dialysis center for treatment reports. During an interview on 07/31/25 at 4:10 P.M. Resident #62 stated the facility did not always send papers with him to dialysis and the dialysis center never sent papers back to the facility with him. The resident stated he was unaware of how the facility communicated with the dialysis center. Review of the medical record revealed Resident #62 had physician orders to complete pre- and post-dialysis evaluations under the assessment tab before and after each dialysis appointment. Review of the medical record revealed Resident #62 had no pre-dialysis or post dialysis assessments completed on 07/09/25. During an interview on 07/31/25 RN #105 verified there were no pre- or post-dialysis assessments completed on 07/09/25, and there was no nursing note regarding transportation issues that day. Review of the facility policy titled Hemodialysis dated 07/2015 revealed staff completed Hemodialysis Communication Form and sent the form with the resident to dialysis. Upon returning to the facility, nurses reviewed the notes from the dialysis service. If notes were absent upon the resident's return, the nurse called the dialysis center for report. The facility assessed weight and vital signs before treatments and assessed vital signs and access site after dialysis treatments.This deficiency represents noncompliance investigated under Compliant Number 2564248.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, resident interview, staff interview, review of facility Self-Reported Incidents (SRIs) and review of the facility policy, the facility failed to ensure residents were free were free from abuse. This affected one (Resident (#17) of three residents reviewed for abuse. The facility census was 84 residents. Findings include: Review of the medical record for Resident #17 revealed an admission date of 12/24/24 with diagnoses including chronic respiratory failure and failure to thrive. Review of the Minimum Data Set (MDS) assessment for Resident #17 dated 12/30/24 revealed the resident had intact cognition and was dependent on staff for bathing. Review of the care plan for Resident #17 dated 03/06/25 revealed the resident had an ADL (activities of daily living) deficit related to altered respiratory status, deconditioning, and decreased endurance and frequently refused showers. Interventions included permission to receive a shower at any time of choice. Review of the SRI for Resident #17 dated 03/03/25 revealed Resident #44 reported to the Director of Nursing (DON) that on nightshift on 02/28/25 Certified Nursing Assistant (CNA) #370 forced Resident #17 to take a shower. Resident #44 confirmed Resident #17 screamed in protest, but CNA #370 ignored the resident, transferred the resident into a shower chair using a Hoyer lift, and wheeled the resident to the shower room with the resident screaming as the aide pushed the resident down the hallway. Interview with Resident #17 confirmed on 02/28/25 on night shift she told CNA #370 she did not want a shower, that it was illegal for the aide to touch her against her will, but the aide forced her to take a shower. Interview with CNA #300 who was also assigned to the unit confirmed on 02/28/25 he heard yelling found Resident #17 up in the shower chair and very angry. Interview with Registered Nurse (RN) #305 confirmed she heard screaming and went to Resident #17's room and found CNA #370 attempting to get Resident #17 out of bed and into the shower chair while the resident loudly refused. RN #305 confirmed she told CNA #370 to lay the resident back down, but the aide said the resident was already up and the aide wanted to get the shower done. The facility substantiated the allegation of abuse and terminated CNA #370. Interview on 06/02/25 at 10:08 A.M. with Resident #44 confirmed her previous roommate Resident #17 was screaming at staff and refusing to take a shower a few nights ago. Resident #44 stated the aide forced Resident #17 to take a shower. Interview on 06/02/25 at 10:14 A.M. with Resident #17 confirmed CNA #370 had forced her to take a shower on 02/28/25 and she was very upset at the time and did not want to take a shower. Resident #17 further stated CNA #300 and RN #305 were present at the time, but were not listening to her, and did not stop CNA #370 from forcibly giving the shower. Interview on 06/02/25 at 12:08 PM with CNA #300 confirmed he was at the nurses' station on 02/28/25 when he heard yelling coming from Resident #17's room. CNA #300 and RN #305 went to see where the commotion was coming from and entered Resident #17's room. CNA #300 stated he saw Resident #17 in the Hoyer lift yelling at CNA #370 because she didn't want to take a shower. CNA #300 and RN #305 helped lower Resident #17 into the shower chair for safety and then left the room. CNA #300 confirmed he did not report the incident to management. Interview on 06/02/25 at 12:48 PM with RN #305 confirmed on 02/28/25 she heard yelling coming from Resident #17's room so she and CNA #300 went to the room and observed Resident #17 in the Hoyer lift yelling at CNA #370 because she did not want to take a shower. RN #305 stated did not intervene with the situation other than to help lower Resident #17 into the shower chair and then left the scene. RN #305 confirmed she did not report the incident to management. Interview on 06/02/25 at 3:05 PM with the Administrator confirmed Resident #44 notified the Assistant Director of Nursing (ADON) on 03/03/25 of an allegation of abuse towards Resident #17 per CNA #370 which had occurred on 02/28/25. The Administrator confirmed staff members should have reported the incident on 02/28/25 when it occurred. The Administrator confirmed the facility substantiated the allegation of abuse towards Resident #17 per CNA #370 and terminated the aides' employment. . Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 01/25/25 revealed residents have the right to be free from abuse. Staff should immediately report all incidents/ allegations to the Administrator who should make notifications to appropriate state reporting agency. Review of the facility's corrective action plan, completed by the Administrator, revealed the following actions were implemented and the deficiency corrected as of 04/04/25: • There had been no other allegations of abuse per staff towards residents since the SRI dated 03/03/25. • On 03/03/25 the Administrator suspended CNA #370 pending investigation. • On 03/03/25 the Administrator and the DON terminated CNA #370's employment and was terminated on 03/03/25 and the facility reported CNA #370 to the nurse aide registry (NAR.) • On 03/03/25 the DON assessed Resident #17 for injury with none noted. The DON offered emotional support via Social Services/Spiritual Care and the resident declined. • On or before 03/05/25 the Social Services Director (SSD) interviewed all interviewable residents on Resident #17's hall to identify other care concerns with no concerns identified. • On or before 03/05/25, the DON and unit managers conducted skin assessments on all non-interviewable residents on or before 03/05/25 with no abnormal findings. • On or before 03/05/25 the DON/designee educated all staff on the abuse policy, including requirements for reporting abuse. • Starting on 03/05/25 the DON designee started conducting the following audits: Interview two staff members daily for two weeks, then twice weekly for two weeks regarding resident rights/abuse Interview two residents daily for two weeks, then twice weekly for two weeks about care concerns. Observe direct care being delivered twice daily for two weeks and then twice weekly for two weeks to ensure proper delivery. This deficiency represents noncompliance investigated under Complaint Number OH00163421 and Complaint Number OH00163350.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, resident interview, staff interview, review of facility Self-Reported Incidents (SRIs) and review of the facility policy, the facility failed to ensure allegations of abuse were reported immediately to the state agency. This affected one (Resident (#17) of three residents reviewed for abuse. The facility census was 84 residents. Findings include: Review of the medical record for Resident #17 revealed an admission date of 12/24/24 with diagnoses including chronic respiratory failure and failure to thrive. Review of the Minimum Data Set (MDS) assessment for Resident #17 dated 12/30/24 revealed the resident had intact cognition and was dependent on staff for bathing. Review of the care plan for Resident #17 dated 03/06/25 revealed the resident had an ADL (activities of daily living) deficit related to altered respiratory status, deconditioning, and decreased endurance and frequently refused showers. Interventions included permission to receive a shower at any time of choice. Review of the SRI for Resident #17 dated 03/03/25 revealed Resident #44 reported to the Director of Nursing (DON) that on nightshift on 02/28/25 Certified Nursing Assistant (CNA) #370 forced Resident #17 to take a shower. Resident #44 confirmed Resident #17 screamed in protest, but CNA #370 ignored the resident, transferred the resident into a shower chair using a Hoyer lift, and wheeled the resident to the shower room with the resident screaming as the aide pushed the resident down the hallway. Interview with Resident #17 confirmed on 02/28/25 on night shift she told CNA #370 she did not want a shower, that it was illegal for the aide to touch her against her will, but the aide forced her to take a shower. Interview with CNA #300 who was also assigned to the unit confirmed on 02/28/25 he heard yelling found Resident #17 up in the shower chair and very angry. Interview with Registered Nurse (RN) #305 confirmed she heard screaming and went to Resident #17's room and found CNA #370 attempting to get Resident #17 out of bed and into the shower chair while the resident loudly refused. RN #305 confirmed she told CNA #370 to lay the resident back down, but the aide said the resident was already up and the aide wanted to get the shower done. The facility substantiated the allegation of abuse and terminated CNA #370. Interview on 06/02/25 at 10:08 A.M. with Resident #44 confirmed her previous roommate Resident #17 was screaming at staff and refusing to take a shower a few nights ago. Resident #44 stated the aide forced Resident #17 to take a shower. Interview on 06/02/25 at 10:14 A.M. with Resident #17 confirmed CNA #370 had forced her to take a shower on 02/28/25 and she was very upset at the time and did not want to take a shower. Resident #17 further stated CNA #300 and RN #305 were present at the time, but were not listening to her, and did not stop CNA #370 from forcibly giving the shower. Interview on 06/02/25 at 12:08 PM with CNA #300 confirmed he was at the nurses' station on 02/28/25 when he heard yelling coming from Resident #17's room. CNA #300 and RN #305 went to see where the commotion was coming from and entered Resident #17's room. CNA #300 stated he saw Resident #17 in the Hoyer lift yelling at CNA #370 because she didn't want to take a shower. CNA #300 and RN #305 helped lower Resident #17 into the shower chair for safety and then left the room. CNA #300 confirmed he did not report the incident to management. Interview on 06/02/25 at 12:48 PM with RN #305 confirmed on 02/28/25 she heard yelling coming from Resident #17's room so she and CNA #300 went to the room and observed Resident #17 in the Hoyer lift yelling at CNA #370 because she did not want to take a shower. RN #305 stated did not intervene with the situation other than to help lower Resident #17 into the shower chair and then left the scene. RN #305 confirmed she did not report the incident to management. Interview on 06/02/25 at 3:05 PM with the Administrator confirmed Resident #44 notified the Assistant Director of Nursing (ADON) on 03/03/25 of an allegation of abuse towards Resident #17 per CNA #370 which had occurred on 02/28/25. The Administrator confirmed staff members should have reported the incident on 02/28/25 when it occurred. The Administrator confirmed the facility substantiated the allegation of abuse towards Resident #17 per CNA #370 and terminated the aides' employment. . Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 01/25/25 revealed residents have the right to be free from abuse. Staff should immediately report all incidents/ allegations to the Administrator who should make notifications to appropriate state reporting agency. Review of the facility's corrective action plan, completed by the Administrator, revealed the following actions were implemented and the deficiency corrected as of 04/04/25: • There had been no other allegations of abuse per staff towards residents since the SRI dated 03/03/25. • On 03/03/25 the Administrator suspended CNA #370 pending investigation • On 03/03/25 the Administrator and the DON terminated CNA #370's employment and was terminated on 03/03/25 and the facility reported CNA #370 to the nurse aide registry (NAR.) • On 03/03/25 the DON assessed Resident #17 for injury with none noted. The DON offered emotional support via Social Services/Spiritual Care and the resident declined. • On or before 03/05/25 the Social Services Director (SSD) interviewed all interviewable residents on Resident #17's hall to identify other care concerns with no concerns identified. • On or before 03/05/25, the DON and unit managers conducted skin assessments on all non-interviewable residents on or before 03/05/25 with no abnormal findings. • On or before 03/05/25 the DON/designee educated all staff on the abuse policy, including requirements for reporting abuse. • Starting on 03/05/25 the DON designee started conducting the following audits: Interview two staff members daily for two weeks, then twice weekly for two weeks regarding resident rights/abuse Interview two residents daily for two weeks, then twice weekly for two weeks about care concerns. Observe direct care being delivered twice daily for two weeks and then twice weekly for two weeks to ensure proper delivery. This deficiency represents noncompliance investigated under Complaint Number OH00163421 and Complaint Number OH00163350.

Based on record review, observations, staff interviews, interview with the local Health Department staff, review of facility policies, review of the Center for Disease Control and Prevention (CDC) guidance, and review of Ohio Department of Health's (ODH) guidance for reporting infectious diseases, the facility failed to develop and implement effective infection control procedures which included when and to who potentially communicable diseases should be reported, failed to ensure the local Health Department was notified in a timely manner of a facility gastrointestinal illness (GI) outbreak and failed to track the residents and employees who developed GI related symptoms as part of their infection surveillance plan. This affected 13 Residents (#24, #22 #10, #35, #68, #66, #27, #02, #59, #07, #61, #237, #236, and #11) but had the potential to affect all residents at the facility. The facility census was 88. Findings include: Review of a list of residents with GI related symptoms provided by the Director of Nursing (DON) included the following: Resident #24 on 02/12/25, Resident #22 on 02/06/25, Resident #10 on 02/14/25, Resident #35 on 02/14/25, Resident #68 on 02/15/25, Resident #66 on 02/15/25, Resident #27 on 02/17/25, Resident #2 on 02/17/25, Resident #59 on 02/17/25, Resident #7 on 02/17/25, Resident #61 on 02/17/25, Resident #237 on 02/17/25, Resident #236 on 02/18/25, and Resident #11 on 02/14/25. Review of the staff schedules dated from 02/13/25 through 02/18/25 revealed the following 20 staff members called off related to illnesses: Licensed Practical Nurses (LPNs) #922, #535, and #500. Certified Nursing Assistants (CNAs) #573, #575, #560, #593, #546, #559, #563, #576, #509, #507, #548, #598,#524, #530, #675, and #539. Interview with Infection Control Preventionist (ICP) #549 on 02/18/25 at 2:28 P.M verified Residents #24, #22 #10, #35, #68, #66, #27, #02, #59, #07, #61, #237, #236, and #11 developed GI related symptoms starting on 02/12/25 and they were not recorded on the infection control surveillance log. ICP #549 verified 20 employees called off for illness and she was not tracking the surveillance for the GI symptoms by the employees when they called off sick. Interview with Director of Nursing (DON) on 02/18/25 at 2:30 P.M., verified Residents #24, #22 #10, #35, #68, #66, #27, #02, #59, #07, #61, #237, #236, and #11 developed GI related symptoms starting on 02/12/25 and the residents were not being tracked as part of their infection control surveillance plan. The DON stated they could not keep track of the residents who had symptoms. The DON also verified the aforementioned 20 employees called off for illness and they were not being tracked according to their infection control surveillance plan. Interview with Scheduler #660 on 02/19/25 at 11:25 A.M., revealed employees were supposed to call off every day when they were sick. Scheduler #660 stated a nurse, or manager placed the employee call-offs in the On-Call Shift Application and a description of the call off. Scheduler #660 stated the DON informed her about the employees calling off due to GI related symptoms. Interview with County Health Department Nurse #880 on 02/19/25 at 3:51 P.M., revealed their department had not received any information related to the facility of having a GI virus outbreak. Interview with Nurse Practitioner (NP) #770 on 02/19/25 at 4:40 P.M. revealed she was first notified on 02/14/25, when Resident #35 developed GI related symptoms. NP #770 stated she was notified again on Monday 02/17/25 of additional Residents #02, #07, #27, #59, and #68 with GI related symptoms. NP #770 stated she started the residents on a nausea, vomiting and diarrhea protocol on Monday 02/17/25. NP #770 stated if a resident had nausea or vomiting, the staff were to place an order for Zofran (anitiemetic) four milligrams (mg) every eight hours as needed and if a resident had diarrhea, staff were to place an order for Imodium (anti-diarrhea) to take two initial tablets, and then can take one tablet every hour, and up to six tablets in one 24 hours as needed. Interview with DON on 02/19/25 at 5:20 P.M., verified the facility didn't timely notify the local Health Department of the GI virus outbreak. The DON also noted they were notifying the resident's families of the GI virus outbreak. Review of the CDC guidance titled Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings (2011), revealed as with all outbreaks, notify appropriate local and state health departments, as required by state and local public health regulations, if an outbreak of Norovirus gastroenteritis is suspected. The guidance further stated Personnel who work with, prepare or distribute food must be excluded from duty if they develop symptoms of acute gastroenteritis. Personnel should not return to these activities until a minimum of 48 hours after the resolution of symptoms or longer as required by local health regulations. Review of ODH guidance titled, Know Your ABCs: A Quick Guide to Reportable Infectious Diseases in Ohio, effective 08/01/19 revealed under the section Class C, facilities should report an outbreak, unusual incident or epidemic of other diseases by the end of the next business day. Review of the facility policy titled Infection Surveillance Policy dated 01/13/23 revealed a system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommend infection prevention and control practices in order to reduce infections and prevent the spread of infections. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to facility's Quality Assessment and Performance Improvement (QAPI) Committee, and public health authorities when required. All residents' infection will be tracked. Separate, site-specific measures may be tracked as prioritized form the infection control risk assessment. Outbreaks will be investigated. Employee, volunteer, and contract employee infections will be tracked, as appropriate, such as influenza or gastrointestinal infection outbreaks.

Based on record review, staff interview, facility protocol, and review of facility policy, the facility failed to notify the physician or the non-physician practitioner (NPP) for residents with change in conditions. This affected three Residents (#05, #70, and #71) reviewed for changes in condition. The facility census was 88. Findings Included: 1) Review of medical record for Resident #05 revealed an admitted on 05/26/20. Diagnosis included obstructive hypertrophic cardiomyopathy, adult failure to thrive, Alzheimer's disease, chronic kidney disease stage two, orthostatic hypotension, essential hypertension, dementia, history of transient ischemic attack, and nonrheumatic aortic stenosis. Review of Resident #05's blood pressure monitoring revealed the following blood pressures documented: On 06/28/24 at 7:52 A.M., a blood pressure (B/P) reading of 185/77 (elevated) millimeters of mercury (mm/Hg) was recorded. On 06/28/24 at 7:52 A.M., a B/P 185/77 mm/Hg was recorded. On 07/15/24 at 8:41 A.M., a B/P 184/76 mm/Hg was recorded. On 09/02/24 at 8:00 A.M., a B /P 193/75 mm/Hg was recorded. On 09/08/24 at 9:48 A.M., a B/P 183/89 mm/Hg was recorded. On 09/24/24 at 7:28 A.M., a B/P 194/86 mm/Hg was recorded. On 09/29/24 at 7:17 A.M., a B/P 194/82 mm/Hg was recorded. On 09/30/24 at 7:18 A.M., a B/P 187/85 mm/Hg was recorded. On 10/11/24 at 8:30 A.M., a B/P 192/79 mm/Hg was recorded. On 10/14/24 at 7:21 A.M., a B/P 194/87 mm/Hg was recorded. Review of the nurse progress notes for Resident #05 from 06/28/24 through 10/14/24, revealed no documentation to support the physician or the NPP was notified when the resident's blood pressure was assessed to be elevated. Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #05 had a Brief Interview of Mental Status (BIMS) of 01 which indicated severely cognitively impaired. Review of the plan of care dated 01/08/25 revealed that Resident #05 had altered cardiovascular status related to obstructive hypertrophic cardiomyopathy orthostatic hypotension, hypertension, and history of transient ischemic accident (TIA). Interventions included to monitor vital signs as needed, and notify the physician of significant abnormalities. Interview on 02/25/25 at 4:00 P.M. with Regional Clinical Nurse (RCN) #622, verified that there were no notifications to the physician or NPP when Resident #05's blood pressures were assessed to be elevated for aforementioned dates. Review of the facility protocol titled Standing Order Protocol dated November 204, revealed. If systolic blood pressure was above 180, staff should assess the resident for shortness of breath, chest pain, headaches, and visual changes and notify a physician. Review of facility policy titled Notification and Reporting of Changes in Health Status, Illness, Injury and Death of a Resident dated 12/27/23 revealed that if a resident had significant changes the provider, or its designees was to be notified no later than one business day. The provider was to be notified of significant change that may affect resident's service needs or safety, including any significant change in the individual's physical, mental, or emotional status. A notation of the change in health status and any interventions shall be documented in the medical record.

Based on record review and staff interviews, the facility failed to issue an Advanced Beneficiary Notice (ABN) when a Notice of Medicare Non-Coverage (NOMNC) was issued to a resident under a Medicare stay and the resident did not discharge. This affected one Resident (#77) out of the three residents reviewed for ABN. The facility census was 88. Findings include: Review of the medical record for Resident #77 revealed an admitted [DATE] with diagnoses of acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease with acute exacerbation, and anemia. Review of the NOMNC indicated the last covered day was 01/07/25 and Resident #77 signed the NOMNC on 01/03/25. Review of the resident census information revealed Resident #77 was listed as private pay on 01/08/25 and 01/09/25. Review of the progress noted from 01/08/25 and 01/09/25 revealed no documentation that Resident #77 was notified of a last covered date (LCD) of 01/07/25 or the cost to remain in the facility. Review of the care plan for Resident #77 dated 01/13/25, revealed the resident planned to remain at the facility for long term care services and does not wish to be asked about returning to the community with every assessment. Interview on 02/24/25 at 9:03 A.M. with Business Office Manager (BOM) #592, confirmed Resident #77 received an LCD of 01/07/25 which was issued on 01/03/25 and an ABN or the cost to stay in the facility was not issued to Resident #77. BOM #592 stated the resident had initially planned to discharge home but then changed his mind. BOM #592 stated Resident #77 did end up being billed as private pay for 01/08/25 and 01/09/25 and then the resident applied for his veterans' benefits at that time. BOM #592 stated the facility does not have a policy on issuing an ABN.

Based on observation, staff interviews, record review, and review of a facility policy, the facility failed to maintain a clean and safe environment. This affected three Residents (#13, #64, and #08) out of three Residents reviewed for environment. The facility census was 88. Findings include: 1) Review of the medical record for Resident #13 revealed he was admitted to the facility on [DATE]. His diagnoses included anemia, heart failure, hypertension, ortho static hypertension, diabetes mellitus (DM), and aphasia. Review of the Minimum Data Set (MDS) assessment for Resident #13 dated 01/28/25, revealed he had impaired cognition. Resident #13 was dependent on staff for activities of daily living (ADLs). Observation of Resident #13's room on 02/18/25 at 12:05 P.M. with Certified Nursing Assistant (CNA) 598, revealed the resident's bed had soiled sheets with stains and food crumbs all over it. The center of the mattress dipped inward. CNA #598 pulled the corner of the sheet off the mattress to reveal a severely worn mattress and sunken in the middle. The light switch was broken with sharp pieces sticking out. Interview with CNA #598 at the same time, verified Resident #13's bed and the broken wall plate. Interview with Resident #13 on 02/20/25 at 2:45 P.M., revealed he needed a new mattress via communication with a wipe off board. Resident #13 motioned with his hand that he needed to be pulled up in the bed. Resident #13 stated he needed to be pulled up in the bed because he slid down in the middle of the bed. Observation of Resident #13's room on 02/20/25 at 2:50 P.M. with CNA #511 revealed the resident's bed had active gnats flying around the bed with food crumbs and the bed appeared soiled. CNA #511 verified Resident #13 was sunken in the middle of the mattress and needed to be pulled up in the bed. Observation also revealed the windowsill was dirty with an unknown brown and green sticky substance. CNA #511 verified the window seal had an unknown brown and green sticky substance. 2) Review of the medical record for Resident #64 revealed he was admitted to the facility on [DATE]. His diagnoses included dementia, schizoaffective disorder, depression, heart failure, gastro esophageal reflux disease (GERD), and essential primary hypertension. Review of the MDS assessment dated [DATE] for Resident #64 revealed he had mildly impaired cognition. Resident #64 was dependent on staff for ADLs. Observation of Resident #64's room on 02/18/25 at 10:23 A.M., revealed the bathroom floor had dust, other debris, an unknown brown chunky substance around the toilet and the floor appeared slippery. The toilet had a brown substance on/around the toilet. Interview at the same time with Resident #64, indicated he recently had a fall in his bathroom due to the floor being slick. Interview with Housekeeper (HK) 583 on 02/18/25 at 10:28 A.M., verified Resident #64's bathroom floor was dusty, soiled, slippery and had an unknown chunky brown substance around the toilet. HK #583 verified the toilet was dirty and stated she was not in the facility the previous day and could not say when it had late been cleaned. 3) Review of the medical record for Resident #08 revealed she was admitted to the facility on [DATE]. Her diagnoses included tachycardia, obstructive sleep apnea, epilepsy, impetigo, major depressive disorder, diffuse traumatic disorder, paraplegia, hereditary spastic paraplegia, anemia, chronic respiratory failure, and endometriosis. Review of MDS assessment, dated 11/01/25, revealed Resident#08 was cognitively intact and was dependent on staff for ADLs. Observation of Resident #08's room on 02/18/25 at 4:48 P.M. revealed a stick fly tray over her bed. Interview with Resident #08 at the same time revealed she asked the staff to hang the sticky fly strip on her ceiling over her bed several months ago because she had multiple large black flies swarming in her room. Interview with Licensed Practical Nurse (LPN) 564 on 02/18/25 at 5:30 P.M. verified the sticky fly strip hanging over Resident #08's with multiple large black flies stuck to it had been in place. Observation of Resident #08's room on 02/20/25 at 1:130 P.M. with Housekeeper (HK) #623 revealed the sticky flip strip with several dead large black flies remained hanging over Resident #08's bed. Interview with HK #623 verifed the stick fly trap was hanging over the residents bed. Review of the facility policy titled, Routine Housekeeping Policy, dated 06/16/20, confirmed it the policy of this community to provide routine cleaning and disinfection in order to provide a safe, sanitary environment.

Based on record review and interview, the facility failed to complete a Pre Admission Screening and Resident Review (PASRR) following a significant change in residents' condition. This affected two Residents (#10 and #41) out of two residents reviewed for a PASRR. The facility census was 88. Findings Include: 1) Review of the medical record for Resident #10 revealed she was admitted to 10/13/21. Her diagnoses included diabetes mellitus (DM), chronic obstructive pulmonary disease, hepatic failure, gastroparesis, contracture of muscle, schizophrenia, bipolar disorder, major depressive disorder, anxiety disorder, dementia, and pseudobulbar. Resident #10 was admitted to hospice care at the facility on 04/23/24. There was no correlating PASRR associated with the admission to Hospice. Review of the Minimum Data Set (MDS) dated [DATE], revealed Resident #10 is cognitively impaired. Interview with the Social Worker (SW) #523 on 02/19/24 at 3:15 P.M., verified the facility failed to complete a Significant Change PASRR on 04/23/24, when Resident #10 was admitted to Hospice. 2) Review of the medical record for Resident #41 revealed he was admitted to the facility on [DATE]. His diagnoses included, bradycardia, essential primary hypertension, atrial fibrillation, hyperlipidemia, obstructive sleep apnea, dementia, metabolic encephalopathy, and dysphagia. Resident #41 was admitted to hospice care at the facility on 11/05/24. There was no correlating PASRR associated with the admission to Hospice. Review of the MDS assessment, dated 02/05/25, revealed Resident #41 had impaired cognition. Interview with Regional Clinical Nurse (RCN) #622 on 02/20/25 at 4:47 P.M., verified the facility failed to complete a Significant Change PASRR review for Resident #41 when he was admitted to Hospice.

Based on observation, staff interviews, and record review, the facility failed to ensure residents were provided with quarterly care conferences. This affected two Residents (#08 and #64) out of the two residents reviewed for care conference. The facility census was 88. Findings include: 1) Review of the medical record for Resident #08 revealed she was admitted to the facility on [DATE]. Her diagnoses included tachycardia, obstructive sleep apnea, epilepsy, impetigo, major depressive disorder, diffuse traumatic disorder, anemia, chronic respiratory failure, and endometriosis. Review of the Inter Disciplinary Team (IDT) Care Conferences, revealed Resident #08 had care conferences on 09/13/24, and 01/21/25. The resident had no documented care conferences for the two remaining quarters of the past year. Review of Minimum Data Set (MDS) assessment, dated 11/01/25, revealed Resident #08 was cognitively intact and dependent on staff for activities of daily living (ADLs). Interview with Social Worker (SW) #523 on 02/19/25 at 2:40 P.M., verified Resident #08 did not have two of the four quarterly care conferences in the past year. 2) Review of the medical record for Resident #64 revealed he was admitted to the facility on [DATE]. His diagnoses included dementia, schizoaffective disorder, depression, heart failure, gastro esophageal reflux disease (GERD), and essential primary hypertension. Review of the IDT Care Conferences dated 09/24/24 at 1:32 P.M. and 12/20/24 at 10:31 A.M. revealed Resident #64 and/or his representative(s) did not attend the care conferences. Further review of Resident #64's chart revealed no other information documentation related to any other care conferences for the past year. Review of the MDS assessment dated [DATE] for Resident #64, revealed he had mildly impaired cognition and was dependent on staff for ADLs. Interview Resident #64 on 02/18/25 at 10:20 A.M. revealed he did not recall having any care conferences. Interview with the SW #523 on 02/19/25 at 2:40 P.M. verified Resident #64 did not have quarterly scheduled care conferences for the past year.

Based on record review, staff interview, and review of facility policy, the facility failed to ensure a resident's suprapubic urinary catheter was changed according to physician orders. This affected one Resident (#79) of the three residents review for foley catheters. The facility census was 88. Findings include: Review of medical record for Resident #79 revealed an admitted on 10/30/24. Diagnoses included dementia, hydronephrosis with renal and urethral calculous obstruction, calculus of gall bladder without obstruction, and chronic kidney failure. Review of admission Minimum Data Set (MDS) for Resident #79 dated 11/06/23, revealed he was severely cognitively impaired. Review of Resident #79's care plan dated 10/31/24, revealed Resident #79 had a suprapubic catheter related to obstructive uropathy. Interventions were to monitor for signs and symptoms of infection and change catheter as ordered and as needed. Review of a physician order dated 12/18/24, revealed Resident #79 was ordered to have the suprapubic catheter 14 French with 10 milliliter (mL) balloon changed every four weeks and as needed related to obstructive uropathy. Review of the January 2024 Treatment Administration Record (TAR) for Resident #79, revealed Resident #79 had his suprapubic urinary foley catheter changed on 01/15/25. Interview with the Director of Nursing (DON) on 02/19/25 at 2:20 P.M., revealed Resident #79's suprapubic urinary foley catheter change was due on 02/14/25; however, a new foley was not placed. The DON stated the nurse did not change the suprapubic urinary foley catheter as ordered and the nurse did not give a reason as to why she did not place a new suprapubic urinary catheter in Resident #79. The DON stated Resident #79 was prone to infections. Review of the February 2025 TAR revealed Resident #79 was due to have his suprapubic urinary foley catheter changed on Friday 02/14/25. The date was marked with a 9 which indicated other- see nurses notes. There was no corresponding progress note related to this entry on 02/14/25. Interview with Acting Administrator #799 on 02/25/25 at 5:20 P.M. revealed there was no policy on following physician's orders related to catheter care and the expectation was to follow standard nursing practices.

Based on record reviews, staff interviews, review of facility policy, and review of facility standing orders, the facility failed to ensure residents received medications as ordered. This affected one Resident (#05) of the five residents reviewed for medications. The facility census was 88. Findings include: Review of medical record for Resident #05 revealed an admitted on 05/26/20. Diagnosis included obstructive hypertrophic cardiomyopathy, adult failure to thrive, Alzheimer's disease, chronic kidney disease stage two, orthostatic hypotension, essential hypertension, dementia, history of transient ischemic attack, and nonrheumatic aortic stenosis. The resident was cognitively impaired. Review of a physician order for Resident #05 dated 09/04/24, revealed the resident was ordered Midodrine tablet five milligrams (mg) one tablet in the morning for hypotension (low blood pressure) and to hold for systolic blood pressure (B/P) above 120 millimeters of mercury (mm/Hg). The Midodrine was discontinued on 12/18/24. Review of plan of care dated 01/08/25, revealed that Resident #05 had altered cardiovascular status related to obstructive hypertrophic cardiomyopathy orthostatic hypotension, hypertension, and history of transient ischemic accident. Interventions included to administer medications as ordered, monitor vital signs as needed, and notify the physician of any significant abnormalities. Review of the April, May, June, July, August, September, October, November and December 2024 Medication Administration Records (MARs) for Resident #05 revealed the following: On 04/06/24, a B/P reading of 124/70 mm/Hg was recorded and Midodrine was administered. On 04/13/24, a B/P reading of 112/68 mm/Hg was recorded and Midodrine was held. On 04/14/24, a B/P reading of 116/68 mm/Hg was recorded and Midodrine was held. On 04/24/24, a B/P reading of 126/70 mm/Hg was recorded and Midodrine was administered. On 05/04/24, a B/P reading of 132/71 mm/Hg was recorded and Midodrine was administered. On 05/10/24, a B/P reading of 132/72 mm/Hg was recorded and Midodrine was administered. On 05/12/24, a B/P reading of 121/62 mm/Hg was recorded and Midodrine was administered. On 05/14/24, a B/P reading of 128/71 mm/Hg was recorded and Midodrine was administered. On 05/25/24, a B/P reading of 126/70 mm/Hg was recorded and Midodrine was administered. On 06/05/24, a B/P reading of 130/75 mm/Hg was recorded and Midodrine was administered. On 06/16/24, a B/P reading of 119/68 mm/Hg was recorded and Midodrine was held. On 07/13/24, a B/P reading of 153/68 mm/Hg was recorded and Midodrine was administered. On 08/01/24, a B/P reading of 118/65 mm/Hg was recorded and Midodrine was held. On 09/05/24, a B/P reading of 141/76 mm/Hg was recorded and Midodrine was administered. On 09/15/24, a B/P reading of 143/75 mm/Hg was recorded and Midodrine was administered. On 10/25/24, a B/P reading of 148/72 mm/Hg was recorded and Midodrine was administered. On 11/23/24, a B/P reading of 96/55 mm/Hg was recorded and Midodrine 5 mg was held. On 11/30/24, a B/P reading of 136/57 mm/Hg was recorded and Midodrine was administered. On 12/06/24, a B/P reading of 151/73 mm/Hg was recorded and Midodrine was administered. Interview with Regional Clinical Nurse (RCN) #622 on 02/25/25 at 3:40 P.M., verified Resident #05 did not receive Midodrine as ordered on the aforementioned dates. Review of the facility policy titled Long Term Care Facility Pharmacy Services and Procedures Manual dated 04/30/24 stated the facility staff should also refer to the facility policy regarding medication administration and should comply with applicable law and the state operations manual when administering medications. Review of the facility's standing orders titled [NAME] Community Standing Orders dated 11/24, revealed Midodrine parameters were to hold the medication if systolic B/P was above 120 mm/Hg and to be administered if the systolic B/P was below 120 mm/Hg and if consistently held, the physician was to be notified.

Based on observation, record review, and staff interview, the facility failed to ensure residents' medications were stored properly. This affected one Resident (#26) out of the three residents reviewed. The facility census was 88. Findings include: Review of the medical record for Resident #26 revealed he was admitted to the facility on [DATE]. His diagnoses included, essential primary hypertension, gastro-esophageal reflux disease, diabetes mellitus (DM), obstructive sleep apnea, chronic kidney disease, bradycardia, depression, and obesity. Review of the Minimum Data Set (MDS) assessment for Resident #26, dated 01/31/25, revealed he was cognitively impaired, and the resident was dependent on staff for medication administration. Observation of Resident #26's room on 02/18/25 at 10:51 A.M. with Licensed Practical Nurse (LPN) #680 and Certified Nursing Assistant (CNA) 598, revealed a half full bottle or over the counter (OTC) bottle Pepto Bismol on the resident's table. LPN #680 verified the bottle of Pepto Bismol and stated the resident was required to have all medications administered by facility staff and was not permitted to have any medications at his bedside. Interview with Resident #26 on 02/18/25 at 2:00 P.M., revealed he had the Pepto Bismol at his bedside because he felt nauseated on 02/17/25.

Based on observation, staff interview, record review and review of facility policy, the facility failed to maintain an effective pest control program. This affected Resident (#13) and had the potential to affect all 23 Residents living on the 200 unit. The facility census was 88. Findings include: 1) Review of the medical record for Resident #13 revealed he was admitted to the facility on [DATE]. His diagnoses included anemia, heart failure, hypertension, ortho static hypertension, diabetes mellitus (DM), and aphasia. Resident #13's room was located on the 200-hall. Review of the Minimum Data Set (MDS) assessment for Resident #13 dated 01/28/25, revealed the resident had impaired cognition. Observation of Resident #13's bed on 02/20/25 at 2:50 P.M. with Certified Nursing Assistant (CNA) #511 revealed the resident's bed had active gnats flying around the bed. Resident #13's bed had food crumbs, and the bed was soiled. Interview at the same time with CNA #511 verified the condition of Resident #13's bed. 2) Observation of the dining room on the 200-hallway on 02/18/25 at 12:00 P.M. with Licensed Practical Nurse (LPN) #564, revealed a breakfast tray sitting on the cabinet and two large juice containers in the sink and the cabinet area was soiled with food debris. The sink, faucet and cabinet area had multiple ants crawling around. Interview at the same time with LPN#564, verified the area was soiled with food debris and numerous ants crawling around the sink and cabinet area. Continued observation of dining room on the 200-hallway on 02/18/25 at 1:56 P.M., revealed the ants remained crawling on and around the sink. Observation of the dining room on the 200-hallway on 02/20/25 at 1:16 P.M. with Housekeeper (HK) #623, revealed a large amount of dead and live ants crawling on the sink, on the faucet, and on the cabinet next to the refrigerator. HK #623 stated maintenance was aware of the issue with the active ants. Interview with the Environmental Service Director (ESD) #625 on 02/20/25 02:32 P.M., revealed the facility has a pest control company that will treat the facility monthly. During the interview with ESD #625, he stated he was aware of the active ants, then laughed and exited the conference room without completing the interview. Review of the facility policy titled, Pest Control, dated 10/10, confirmed the facility will maintain an effective pest control program. Further review of the facility policy stated this facility maintained an on-going pest control program to ensure that the building was kept free of insects and rodents.

Based on observation, interview ,record review, facilities investigation review, and policy review, revealed the facility failed to implement abuse policies to report allegations of resident abuse. This affected one resident, (Resident #25) of three residents reviewed for reporting abuse . The total facility census was 86. Findings Include: Record review of alleged victim Resident #25 revealed the resident was admitted to the attached skilled living facility on 11/19/20. The resident had a legal guardian and resided on the skilled living unit. Diagnoses for Resident #25 included age related physical debility, diabetes, atrial fibrillation, morbid obesity, dementia, psychosis, communication deficit, depressive disorder, muscle weakness, intellectual disabilities, and cerebrovascular disease. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and required maximum assistance of one for transfers and mobility. Review of the State Reportable Incident, (SRI) dated 06/06/24 revealed the facility was notified on 06/06/24 of an alleged kissing encounter between Resident #36, the perpetrator, residing on the attached residential care unit, and Resident #25, the alleged victim, residing on the skilled care unit. Record review of Resident #36 revealed the resident was admitted to the Residential Care unit of the facility on 05/25/24 and discharged to the attached skilled living unit on 06/06/24. The resident was his own responsible party. Diagnoses for Resident # 36 include dementia, behavioral disturbance on 06/07/24, communication deficit, aphagia, reduced mobility, tachycardia, chronic kidney disease, depression, and transient cerebral attack. Review of MDS dated [DATE], revealed Resident #36 had severely impaired cognition rating a three scored out of 15 on the Brief Interview Mental Status, (BIMS) exam. The resident was independent for walking and required supervision for personal hygiene. Review of the facility investigation of alleged sexual encounter of Resident #36 towards Resident #25, dated 06/06/24 revealed, the Administrator was notified by State tested Nurse Aide, (STNA) #73 that STNA #60 witnessed male Resident #36 kissing female Resident #25 on 06/03/24. STNA #60 had not notified the Administrator of the incident of 06/03/24. Review of STNA #60 witness statement, dated 06/07/24, revealed on 06/03/24 at 2:30 A.M., Resident #25's roommate activated the call light. STNA #60 witnessed Resident #36 sitting on Resident #25's bed, leaning over kissing her. Review of STNA #70 statement revealed she responded after hearing STNA #60 state get off her get out of her bed. STNA #70 did not witness contact between the residents and did not hear STNA #60 report resident unwanted kissing contact to the Licensed Practical Nurses, (LPN), # 80, #90 and #50. Review of LPN #80, #90 and #50 witness statements revealed no report from STNA #60 of SR #36 contact with or kissing of Resident #25. Observation on 06/10/24 at 1:26 P.M. revealed Resident #25 on the skilled living unit in bed, in no apparent distress. Interview on 06/10/24 at 1:26 P.M. revealed Resident #25 denied having any unwanted male in her room and no male had kissed her. Observation on 06/010/24 at 2:17 P.M. revealed Resident #36 on the skilled unit in bed. Resident #36 appeared to be in no apparent distress. Interview on 06/10/24 at 2:17 P.M. with Resident #36 revealed he denied having contact with Resident #25. Interview on 06/10/24 at 2:47 P.M. STNA #60 verified she walked into Resident #25's room and witnessed Resident #36 sitting on her bed. Resident #36 was kissing Resident #25. STNA #60 revealed Resident #25 stated Resident #36 was kissing her, and the resident did not want Resident #36 in her room. STNA #60 stated she told LPN #80, #90 and #50 and STNA #70, Resident #36 was kissing Resident #25, but was not sure any staff heard her report, as there was no response from the nurses. STNA #60 stated she had received abuse reporting training, which included reporting abuse to the Administrator or Director of Nursing. STNA #60 stated she did not notify the Administrator or Director of Nursing Resident #36 was kissing Resident #25 on 06/03/24. Interview on 06/10/24 at 3:45 P.M., LPN # 50 stated on 06/03/24 at 3:00 A.M., she responded to call from STNA #60 of Resident #36 had fallen on way out of Resident #25's room. STNA #60 reported Resident #36 was previously sitting on Resident #25 bed. LPN #50 stated STNA #60 did not report physical contact between the two residents. Interview on 06/10/24 at 4:15 P.M. revealed LPN #90 responded to a call from STNA #60 of Resident #36 on floor outside of Resident #25 room. STNA #60 stated Resident #36 was trying to get into Resident #25's bed. LPN #90 interviewed Resident #25 who stated Resident #36 was pulling at her gown but denied any touching. LPN #90 denied STNA #60 reported kissing or physical contact between the residents. Interview on 06/11/24 at 1:32 P.M. the Administrator verified STNA #60 had not reported the alleged sexual abuse of Resident #36 towards Resident #25, as witnessed on 06/03/24. The Administrator verified the contact information for the Administrator and Director of Nursing was available to all staff, and the STNA #60 should have reported the incident on 06/03/24. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation, Misappropriation of Resident Property dated 10/20/22, revealed community staff should immediately report all allegations to the Executive Director/Administrator. The community policy is to investigate all alleged violations and report to the state reporting agency. This deficiency represents non-compliance investigated under Complaint Number OH00154692.

Based on observation, interviews, record review, facility investigation report, and policy review, revealed the facility failed to report allegations of abuse. This affected one resident, (Resident #25) of three residents reviewed for reporting abuse. The total facility census was 86. Findings Include: Record review of alleged victim Resident #25 revealed the resident was admitted to the attached skilled living facility on 11/19/20. The resident had a legal guardian and resided on the skilled living unit. Diagnoses for Resident #25 included age related physical debility, diabetes, atrial fibrillation, morbid obesity, dementia, psychosis, communication deficit, depressive disorder, muscle weakness, intellectual disabilities, and cerebrovascular disease. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and required maximum assistance of one for transfers and mobility. Review of the State Reportable Incident, (SRI) dated 06/06/24 revealed the facility was notified on 06/06/24 of an alleged kissing encounter between Resident #36, the perpetrator, residing on the attached residential care unit, and Resident #25, the alleged victim, residing on the skilled care unit. Record review of Resident #36 revealed the resident was admitted to the Residential Care unit of the facility on 05/25/24 and discharged to the attached skilled living unit on 06/06/24. The resident was his own responsible party. Diagnoses for Resident # 36 include dementia, behavioral disturbance on 06/07/24, communication deficit, aphagia, reduced mobility, tachycardia, chronic kidney disease, depression, and transient cerebral attack. Review of the MDS dated [DATE], revealed Resident #36 had severely impaired cognition rating a three scored out of 15 on the Brief Interview Mental Status, (BIMS) exam. The resident was independent for walking and required supervision for personal hygiene. Review of the facility investigation of alleged sexual encounter of Resident #36 towards Resident #25, dated 06/06/24 revealed, the Administrator was notified by State tested Nurse Aide, (STNA) #73 that STNA #60 witnessed male Resident #36 kissing female Resident #25 on 06/03/24. STNA #60 had not notified the Administrator of the incident of 06/03/24. Review of STNA #60 witness statement, dated 06/07/24, revealed on 06/03/24 at 2:30 A.M., Resident #25's roommate activated the call light. STNA #60 witnessed Resident #36 sitting on Resident #25's bed, leaning over kissing her. Review of STNA #70 statement revealed she responded after hearing STNA #60 state get off her get out of her bed. STNA #70 did not witness contact between the residents and did not hear STNA #60 report resident unwanted kissing contact to the Licensed Practical Nurses, (LPN), # 80, #90 and #50. Review of LPN #80, #90 and #50 witness statements revealed no report from STNA #60 of SR #36 contact with or kissing of Resident #25. Observation on 06/10/24 at 1:26 P.M. revealed Resident #25 on the skilled living unit in bed, in no apparent distress. Interview on 06/10/24 at 1:26 P.M. revealed Resident #25 denied having any unwanted male in her room and no male had kissed her. Observation on 06/010/24 at 2:17 P.M. revealed Resident #36 on the skilled unit in bed. Resident #36 appeared to be in no apparent distress. Interview on 06/10/24 at 2:17 P.M. with Resident #36 revealed he denied having contact with Resident #25. Interview on 06/10/24 at 2:47 P.M. STNA #60 verified she walked into Resident #25's room and witnessed Resident #36 sitting on her bed. Resident #36 was kissing Resident #25. STNA #60 revealed Resident #25 stated Resident #36 was kissing her, and the resident did not want Resident #36 in her room. STNA #60 stated she told LPN #80, #90 and #50 and STNA #70, Resident #36 was kissing Resident #25, but was not sure any staff heard her report, as there was no response from the nurses. STNA #60 stated she had received abuse reporting training, which included reporting abuse to the Administrator or Director of Nursing. STNA #60 stated she did not notify the Administrator or Director of Nursing Resident #36 was kissing Resident #25 on 06/03/24. Interview on 06/10/24 at 3:45 P.M., LPN # 50 stated on 06/03/24 at 3:00 A.M., she responded to call from STNA #60 of Resident #36 had fallen on way out of Resident #25's room. STNA #60 reported Resident #36 was previously sitting on Resident #25 bed. LPN #50 stated STNA #60 did not report physical contact between the two residents. Interview on 06/10/24 at 4:15 P.M. revealed LPN #90 responded to a call from STNA #60 of Resident #36 on floor outside of Resident #25 room. STNA #60 stated Resident #36 was trying to get into Resident #25's bed. LPN #90 interviewed Resident #25 who stated Resident #36 was pulling at her gown but denied any touching. LPN #90 denied STNA #60 reported kissing or physical contact between the residents. Interview on 06/11/24 at 1:32 P.M. the Administrator verified STNA #60 had not reported the alleged sexual abuse of Resident #36 towards Resident #25, as witnessed on 06/03/24. The Administrator verified the contact information for the Administrator and Director of Nursing was available to all staff, and the STNA #60 should have reported the incident on 06/03/24. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation, Misappropriation of Resident Property dated 10/20/22, revealed community staff should immediately report all allegations to the Executive Director/Administrator. The community policy is to investigate all alleged violations and report to the state reporting agency. This deficiency represents non-compliance investigated under Complaint Number OH00154692.

Based on record review, interview, and policy review, the facility failed to ensure a resident's representative was notified of medication changes. This affected one (Resident #84) of three residents reviewed for notifications. The facility census was 83. Findings include: Review of the medical record for Resident #84 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses including but not limited to lobar pneumonia, acute respiratory failure with hypoxia, dementia with behavioral disturbance, depression, and hyperlipidemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #84 had severe cognitive impairment. Resident #84 required extensive assistance for activities of daily living, supervision for ambulation, and was independent for eating. Review of physician orders revealed an order for Seroquel 25 milligrams (mg) at bedtime was decreased to seroquel 12.5 mg on 08/18/23 and Zoloft 25 mg was discontinued on 08/18/23. Review of the progress note dated 08/07/23 at 3:21 P.M. revealed a pharmacy gradual dose reduction was declined due to the resident not being appropriate at the time to decrease Seroquel. Resident #84 required one-time doses of Haldol during his stay for increased aggression and combativeness at nighttime. Review of the practitioner/physician note dated 08/17/23 revealed Resident #84 was very confused and required a lot of cues with activities of daily living. The resident required a lot of distractions to prevent the resident from falling. Resident #84 was restless and constantly wanting to be moving. On today's visit, would like to taper down Seroquel to 12.5 mg at bedtime and discontinue Zoloft since the resident is on Remeron. Left a message for the resident's wife to call to discuss code status. Further review of the progress notes revealed no documentation Resident #84's representative was notified of the decreased Seroquel or discontinuation of Zoloft. Interview on 03/04/24 at 2:05 P.M. with Director of Nursing (DON) #685 verified there was no documentation to indicate the resident's representative was notified of Zoloft being discontinued or Seroquel being decreased. Review of policy titled, Notification and reporting of changes in health status, illness, injury and death of a resident, dated 07/19/16 revealed the nursing home administrator or designee shall immediately inform the resident, consult with the resident's physician, and notify the resident's sponsor or authorized representative, with the resident's permission, and other proper authority, in accordance with state and local laws and regulations when there is a need to alter treatment significantly such as a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. This deficiency represents non-compliance investigated under Complaint Number OH00151021.

Based on record review, interview, and policy review, the facility failed to ensure the admission agreement was signed or explained to the resident or resident's representative. This affected one (Resident #84) of three residents reviewed for admission agreements. The facility census was 83. Findings include: Review of the medical record for Resident #84 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses including but not limited to lobar pneumonia, acute respiratory failure with hypoxia, dementia with behavioral disturbance, depression, and hyperlipidemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #84 had severe cognitive impairment. Resident #84 required extensive assistance for activities of daily living, supervision for ambulation, and was independent for eating. Review of the admission agreement for Resident #84 revealed the agreement was not signed by the resident or resident's representative. Interview on 03/04/24 at 12:41 P.M. with the Administrator verified Resident #84's admission agreement was not signed. The Administrator stated Admissions Coordinator (AC) #629 could not seem to get with the resident's representative to get the papers signed. Interview on 03/04/24 at 1:33 P.M. with AC #629 verified Resident #84 nor his representative did not sign the admission agreement and the admission packet was not completed. AC #629 could not remember if the resident and his representative were given the information or if the information was explained to them. Review of policy titled, Admission Policy, revised 08/17 revealed resident requirements: sign admission agreement and agree to abide by all facility policies and procedures. Admission process, the admission agreement, admission authorizations, notice of acknowledgements and other appropriate documents will be signed by the resident and, as applicable, a designated representative and uploaded by the admission coordinator into the electronic health record system. This deficiency represents non-compliance investigated under Complaint Number OH00151021.

Based on medical record review, observation, staff and local health department personnel interview, review of the facility policy, and review of guidelines from the Centers for Disease Control and Prevention (CDC), the facility failed to properly isolate residents placed in transmission-based precautions (TBP) per CDC guidelines for Coronavirus Disease 2019 (COVID-19) infections to potentially prevent the spread of COVID-19. This affected four (#74, #68, #25, and #12) of eight residents reviewed for transmission-based precautions and infection control practices. The facility census was 81. Findings include: 1. Medical record review for Resident #62 revealed admitted [DATE]. Resident #62 was fully vaccinated for COVID-19 and had received a COVID-19 booster vaccine on 11/18/21. Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had moderately impaired cognition. Review of Resident #62's medical record revealed a document titled Severe Acute Respiratory Syndrome ([CONDITION(S)]) COVID-19 by Polymerase Chain Reaction (PCR) dated 12/30/21 which revealed positive test results. Review of Resident #62's plan of care dated 12/03/21 revealed the resident required isolation precautions related to COVID-19 infection. Interventions included ensure resident stayed in room, away from other people, droplet isolation, all treatments, meals, activities, and therapy services to be given in room. Resident #62 was relocated to a room on the designated COVID-19 unit on 01/03/22. Medical record review for Resident #25 revealed admitted [DATE]. Resident #25 was fully vaccinated for COVID-19 and received a COVID-19 booster vaccine 10/13/21. Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE] revealed the resident had intact cognition. Review of Resident #25's Coronavirus Testing Result Forms dated 12/29/21 and 01/06/22 revealed BinaxNOW negative test results. Review of the plan of care dated 10/28/21 revealed the resident was at risk for Coronavirus-19 Disease illness. Interventions included encourage to practice good infection control procedures such as hand hygiene, wearing a mask, and social distancing until otherwise instructed. Resident #25 shared a semi-private room with Resident #62 until 01/03/22. 2. Medical record review for Resident #65 revealed admitted [DATE]. Resident #65 was fully vaccinated for COVID-19 and received a COVID-19 booster vaccine on 10/13/21. Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #65's quarterly MDS dated [DATE] revealed a brief interview mental status (BIMS) score of 99 indicating the resident was unable to complete the interview. Further documentation revealed impaired short-term memory and modified independence for daily decision making. Review of Resident #65's medical record revealed a document titled [CONDITION(S)] COVID-19 by PCR dated 12/30/21 which revealed a positive test result. Review of Resident #65's plan of care dated 12/09/21 revealed the resident required isolation precautions related to COVID-19 infection. Interventions included ensure resident stayed in room, away from other people, droplet isolation, all treatments, meals, activities, and therapy services to be given in room. Resident #65 was relocated to a room on the designated COVID-19 unit on 01/04/22. Medical record review for Resident #45 revealed admitted [DATE]. Resident #45 was fully vaccinated for COVID-19 and received a COVID-19 booster vaccine on 10/13/21. Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE] revealed the resident had moderately impaired cognition. Review of Coronavirus Testing Result Form Dated 12/29/21 and 01/06/22 revealed BinaxNOW negative test results. Resident #45 shared a semi-private room with Resident #65 until 01/04/22. 3. Medical record review for Resident #178 revealed admitted [DATE]. Resident #78 was fully vaccinated for COVID-19 on 12/01/21. Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #178's admission MDS assessment dated [DATE] revealed the resident had moderately impaired cognition. Review of Resident #178's medical record revealed a document titled [CONDITION(S)] COVID-19 by PCR dated 12/31/21 which revealed positive test results. Review of Resident #178's plan of care dated 12/08/21 revealed the resident required care and isolation precautions related to COVID-19 infection. Interventions included ensure the stay in my room, away from other people, droplet isolation, all treatments, meals, activities, and therapy services to be given in room. Medical record review for Resident #74 revealed admitted [DATE]. Resident #74 was fully vaccinated for COVID-19 on 05/01/21. Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had intact cognition. Review of Resident #74's Coronavirus Testing Results dated 12/30/21 and 01/06/22 revealed BinaxNOW negative test results. Review of Resident #74's plan of care dated 12/13/21 revealed the resident was at risk for COVID-19 illness. Interventions included encourage the resident to continue to practice good infection control procedures such as hand hygiene, wearing a mask, and social distancing until instructed otherwise. Resident #74 was relocated to a semi-private room on 01/03/22. Resident #178 shared a semi-private room with Resident #74 until the room change on 01/03/22. 4. Medical record review for Resident #69 revealed admitted [DATE]. Resident #69 resident was fully vaccinated for COVID-19 on 04/05/21. Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #69's admission MDS dated [DATE] revealed a BIMS score of 99 indicating the resident was unable to complete the interview. Further documentation revealed impaired short- and long-term memory problems and moderately impaired daily decision making. Review of Resident #69's medical record revealed a document titled [CONDITION(S)] COVID-19 by PCR dated 12/31/21 which revealed positive test results. Review of Resident #69's plan of care dated 12/15/21 revealed the resident required care and isolation precautions related to COVID-19 infection. Interventions included ensure resident stays in his/her room, away from other people, droplet isolation, all treatments, meals, activities, and therapy services to be given in room. Medical record review for Resident #68 revealed admitted [DATE]. Resident #68 was fully vaccinated for COVID-19 on 04/14/21. Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #68's admission MDS assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #68's Coronavirus Testing results Form dated 12/20/21 and 01/06/22 revealed BinaxNOW negative test results. Review of Resident #68's plan of care dated 12/07/21 revealed the resident was at risk for COVID-19 illness. Interventions included encourage the resident to continue to practice good infection control procedures such as hand hygiene, wearing a mask, and social distancing until instructed otherwise. Resident #68 was relocated to a semi-private room on 01/03/22. Resident #68 shared a semi-private room with Resident #69 until the room change on 01/03/22. Interview on 01/03/22 at 9:43 A.M. the Administrator and Director of Nursing (DON) revealed the facility had resident's positive for the COVID-19 infection. The Administrator stated the facility had moved Resident #75, fully vaccinated for COVID-19, to a private room in the area designated as the nest because the resident had a positive COVID-19 test and was symptomatic. The Administrator revealed Resident #179, unvaccinated, tested positive for COVID-19 test, and was asymptomatic, was also in a private room. The Administrator further stated corporate office told them to keep the exposed negative residents in the semi-private rooms with the positive residents. The Administrator stated a staff member had tested positive on 12/24/21 and the facility started outbreak testing. The Administrator stated residents on the 100 and 600 halls were tested [DATE]. The Administrator stated residents tested positive on 12/29/21 and on 12/30/21. The Administrator stated residents and families/representatives had been informed of the positive test results by use of one-call, in person conversation, and/or email. The Administrator stated the negative residents had been informed their roommates had tested positive for the virus. The Administrator stated the Green County Public Health Department liaison had been notified by email. Interview on 01/03/22 at 10:46 A.M. the Green County Public Health Department Liaison #9 stated she was not aware that the facility had negative and positive residents in the same room. Green County Public Health Department Liaison #9 stated they always discussed moving positive cases to a private room or with another positive resident. Green County Public Health Department Liaison #9 stated that had always been the practice in the past. Green County Public Health Department Liaison #9 verified the facility had notified the health department of the testing results by email. Interview on 01/03/22 at 11:11 A.M. Registered Nurse (RN) #84, Infection Control Liaison, revealed the facility did not want to move the residents around when they started having residents test positive for COVID-19, since they had already been exposed. RN #84 stated Resident #75 was moved to the designated Nest and was symptomatic. RN #84 stated the roommate had tested negative. Interview on 01/03/22 at 12:04 P.M. the [NAME] County Public Health Department Liaison #9 stated she spoke with the facility Corporate Nurse and Administration. Green County Public Health Department Liaison #9 stated she did not see the guidance as they had reviewed it. Green County Public Health Department Liaison #9 stated she had recommended that the positive residents not share a room with the negative residents. Green County Public Health Department Liaison #9 stated corporate had looked at it from the number of positive residents in the facility and the risk of exposing those with no exposure. Green County Public Health Department Liaison #9 stated the facility stated fully vaccinated and boosted residents did not need to quarantine after exposure. Green County Public Health Department Liaison #9 further stated corporate revealed they understood her interpretation and would follow up with the Administrator. Interview on 01/03/22 at 12:26 P.M. the Administrator stated the original plan from November 2020 was to designate the therapy room as the Nest. The facility soon realized the space would not accommodate enough residents. He stated six residents tested positive overnight and then three tested positive. The Administrator stated the facility made the determination, with how virulent Omicron was, the movement of residents posed a greater risk of further exposure. The Administrator stated contact tracing had the four negative residents in contact with the four positive residents with no personal protective equipment (PPE) or source control and felt it necessary to leave the residents in the room. The Administrator stated with the current guidance, boosted and vaccinated individuals did not have to be quarantined. The Administrator stated the residents were considered infected 48 hours prior to a positive test. The Administrator further stated, at the rate the residents were turning up positive and with twice weekly testing, rather than try to find open, semi-private beds, they decided to leave the residents in place. The Administrator confirmed four (#25, #45, #74 and #68) residents who were COVID-19 negative and vaccinated for COVID-19 continued residing in the same room with four (#62, #65, #178 and #69) COVID-19 positive residents. Interview on 01/03/22 at 1:00 P.M. the Administrator verified the facility did not notify the [NAME] County Health Department that the negative residents had not been moved from rooms with positive roommates. The Administrator stated he thought he had included that information, but on review, it was not included. Review of emails dated 12/24/21 though 01/03/22 verified the facility did notify the Health Department of positive test results, as well as vaccination status for staff and residents. Observation on 01/03/22 at 1:00 P.M. verified three semi-private rooms on the 100-hall identified with isolation precautions with PPE supply carts outside each of the three rooms. Two (#28 and #41) residents with COVID-19 positive test results resided in one room. The other two rooms each housed one resident with a negative and one resident with a positive COVID-19 test result. The 500-hall had two semi-private rooms with signage and PPE supply carts at the doors. Each of the rooms housed one resident with a negative and one resident with a positive COVID-19 test result. Resident #179, COVID-19 positive, unvaccinated, and asymptomatic, resided in one private room. Resident #75, COVID-19 positive, fully vaccinated, and symptomatic resided in the second private room. Observation on 01/03/22 at 6:40 P.M. staff members gathered cleaning supplies and PPE for resident room changes. Review of Centers for Disease Control and Prevention (CDC) Infection Control for Nursing Homes updated 09/10/21 recommend identifying space in the facility that could be dedicated to monitor and care for residents with confirmed severe acute respiratory syndrome Coronavirus ([CONDITION(S)]-CoV-2). The location of the COVID-19 care unit should ideally be physically separated from other rooms or units housing residents without confirmed [CONDITION(S)]-CoV-2 infection. Residents should only be placed in a COVID-19 care unit if they have confirmed [CONDITION(S)]-CoV-2 infection. Recommended infection prevention and control (ICP) practices when caring for a resident with suspected or confirmed [CONDITION(S)]-CoV-2 infection stated asymptomatic residents who have met the criteria for Transmission-Based Precautions (BBP) (quarantine) based on close contact with someone with severe acute respiratory syndrome Coronavirus ([CONDITION(S)]-CoV-2) infection should not be cohorted (the practice of isolating multiple laboratory-confirmed COVID-19 cases together as a group or quarantining close contacts of a particular case together as a group). With residents with confirmed [CONDITION(S)]-CoV-2 infection unless they are confirmed to have [CONDITION(S)]-CoV-2 infection through testing. Review of facility policy titled COVID Positive Residents: Screening and Management, revised date 07/26/21 revealed residents on the COVID Unit who are confirmed to have COVID-19 through testing should not share a room with a symptomatic resident without a positive COVID-19 test. Discontinuation of Transmission-Based Precautions/NEST Unit (Asymptomatic Resident), COVID-19 positive resident who did not have/develop symptoms may leave the COVID Unit and/or transmission-based precautions in accordance with the following: time strategy, ten days since the date of their first positive COVID-19 diagnostic test, assuming they have not subsequently developed symptoms since their positive test.

Based on medical record review, staff interview and policy review, the facility failed to notify the resident and the Ombudsman of a transfer or discharge from the facility. This affected two (#79 and #330) out of two residents reviewed for discharge notification from the facility. The facility census was 81. Findings Include: Review of medical record for Resident #79 revealed he was admitted to the facility on [DATE] and discharged to the hospital on 11/15/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the five day admission Minimum Data Set (MDS) assessment, dated 11/15/21 revealed Resident #79's cognition was not assessed. Further review of the MDS assessment for Resident #79 revealed his assistance from staff was not assessed. Review of the Resident #79's nurse's progress notes revealed resident was admitted to the facility on [DATE] and found to be pacing while naked in the hallway at 1:28 A.M. on 11/15/21. Resident #79 was noted to be confused and combative. Resident #79 was discharged to the hospital on 11/15/21 at 8:47 A.M. related to a mental status change. Further review of Resident #79's chart review revealed the facility did not notify his family in writing of his discharge on 11/15/21 and there was no documentation the facility notified the Ombudsman of the residents discharge from the facility. 2. Review of the medical record for Resident #330 revealed an admission of 01/29/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #330 was discharged to the hospital on 09/08/21. The quarterly MDS assessment dated [DATE] revealed Resident #330's cognition was not assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MDS assessment revealed Resident #330 required supervision with bed mobility, transfers, eating toilet use and personal hygiene. Review of Resident #330's nursing progress notes revealed she was discharged to the hospital for assessment due to aggressive behaviors. Further review of Resident #79's chart review revealed the facility did not notify his family in writing of his discharge on 11/15/21 and there was no documentation the facility notified the Ombudsman of the residents discharge from the facility. Interview on 01/06/22 at 09:40 A.M. with the Social Service Director (SSD) #38 revealed the facility is not notifying the Ombudsman or the resident's families of discharges from the facility. SSD #38 stated he was not aware of the need for notification for discharge to the resident's or the Ombudsman. Interview on 01/06/22 at 10:30 A.M. with the Administrator confirmed the facility did not notify residents in writing for discharges from the facility. The Administrator confirmed the facility had not notified the Ombudsman of discharges from the facility. The Administrator stated the facility had been cited during previous surveys for failing to provide this information. The Administrator confirmed the facility failed to notify the resident/resident representative or Ombudsman of Resident #79 or Resident #330's discharge to the hospital. Review of the facility policy titled, Admission/Transfer/Discharge Criteria Policy, dated 11/01/16, revealed resident and/or resident representative will be notified of transfer/discharge and the reasons for the transfer/discharge in writing when applicable. The office of the State Long-Term Care Ombudsman will also receive a copy of the notice when applicable.

Based on record review, observations, resident, facility staff, and agency staff interviews, review of the hospital records, review of the facility investigation and review of the facility policy and documents, the facility failed to ensure one resident was provided adequate supervision and assistance during transfers to prevent falls. Actual harm occurred when Resident #57, who required assistance of two persons using a Hoyer lift, was transferred with a gait belt and without using a Hoyer lift from the bed to the wheelchair by one person resulting in fractures of the right humerus (arm) and left femur (leg). In addition, Resident #71, was improperly transferred using a sit to stand lift from the bed to the wheelchair when the wheelchair lock was not secured prior to seating the resident in the wheelchair. This affected two (Resident #57 and #71) of three residents reviewed for transfers using a mechanical lift. The facility identified 29 residents who required a mechanical lift for transfers including both Hoyer and sit to stand lifts. The total facility census was 73. Findings include: 1. Review of the medical record for Resident #57 revealed an admission date of [DATE]. The resident went out to the hospital on [DATE], and returned from the hospital on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #57 had intact cognition. Resident #57 required total dependence of two persons for transfers and had impairments to both sides of lower extremities. The MDS revealed Resident #57 had no falls or other orthopedic surgeries since the prior assessment. Review of the nursing progress note written by Licensed Practical Nurse (LPN) #213 dated 03/05/21 at 2:52 P.M., revealed Agency State tested Nursing Assistant (ASTNA) #214, was working in the facility. Prior to providing care, this nurse provided ASTNA #214 with information regarding care needs and transfer information of each resident. ASTNA #214 was providing care to the resident and assisting the resident into the chair for a family visit. The resident stated ASTNA #214 needed education on the proper use of the Hoyer lift. During the visit with family, the resident stated she fell out of bed. This nurse asked the resident to explain what occurred during the transfer. At this time, the resident stated ASTNA #214, picked her up and placed her the wheel chair at which point, the resident felt a pop in right arm/shoulder and left leg/hip. It was documented ASTNA #214, stated she used a gait belt and transferred the resident to the wheelchair, although the care information indicated to use a Hoyer. This nurse assessed range of motion (ROM) for the resident, with no ROM in the left leg/hip and limited ROM in the right arm/shoulder. This nurse and another nurse assisted the resident onto the Hoyer pad while in the chair and transferred the resident into bed at this time. The physician was notified of the incident and ordered an immediate (STAT) X-ray of all areas previously mentioned. Review of the care plan dated 02/03/21, revealed Resident #57 had an activities of daily living self-care deficit related to [MEDICAL CONDITION] and was risk for falls related to [MEDICAL CONDITION] and decreased mobility. Interventions included Resident #57 required a mechanical lift for transfers with two assist. Review of the self-reported incident dated 03/06/21, revealed Resident #57 stated ASTNA #214 improperly transferred the resident resulting in the resident landing on the knees. Resident #57 has a fracture to the left femur. Facility investigation revealed Resident #57 reported ASTNA #214, was getting the resident ready for a visit with Resident #57's mother. When transferring the resident, ASTNA #214 used the incorrect technique. ASTNA #214 used a gait belt and not a Hoyer lift, which resulted in Resident #57 falling to the knees. ASTNA #214 assisted Resident #57 to the wheelchair and took the resident to the visit where the resident complained of pain in the shoulder and the leg. The mother reported this to the nurse, LPN #213, who assessed the resident's range of motion, notified the physician and obtained orders for immediate (STAT) x-rays. Resident #57 remains at the hospital at the time of the investigation and plans to return to the facility. Review of the hospital records dated 03/05/21, for imaging results at 8:42 P.M., revealed an acute comminuted humeral head/neck [MEDICAL CONDITION] arm and an acute comminuted and displaced distal femur [MEDICAL CONDITION] leg, however, neither was well delineated due to positioning. Review of the hospital orthopedic consult on 03/06/21 at 12:28 P.M., was for right arm and left leg pain. The consult indicated Resident #57 presented after falling while being transferred at the nursing facility yesterday, has a history of [MEDICAL CONDITION], was wheelchair-bound and was complaining of pain in the left leg and right arm after the fall. X-rays showed a comminuted proximal humerus [MEDICAL CONDITION] arm. X-rays of the left femur showed a malformed femur with a distal femur fracture as well as a possible proximal femur fracture. Resident #57 uses a Hoyer lift for transfers. Resident #57 has been unable to stand for transfers for over [AGE] years and has minimal function of her right arm. Resident #57 has bilateral lower extremity flaccid paralysis and right upper extremity flexion contracture's. Resident #57 was complaining of pain in the right arm. The plan was for nonoperative management of the humerus and femur fractures. At baseline, Resident #57 had no function of the left leg and minimal function of the right arm. Recommendations were for a sling for the arm and a knee immobilizer for the left leg. Non-weight bearing for the right arm. Resident #57 was non-weight bearing on the left leg at baseline. The plan was to follow up with the physician in two weeks. Review of the pain assessment upon admitted d 03/11/21, revealed Resident #57 frequently has moderate pain. Interview on 03/15/21 at 2:13 P.M. with ASTNA #214, related to the incident on 03/05/21 with Resident #57, revealed the nurse did not communicate on the paper that was provided to her on how Resident #57 was to be transferred. ASTNA #214 denied being told by Resident #57 or any other facility staff that Resident #57 required a Hoyer lift to be transferred. ASTNA #214 confirmed she used a gait belt by herself to transfer Resident #57 and not the Hoyer lift. ASTNA #214 stated there was a gait belt by the television and in the top drawer of the dresser. She stated she used the gait belt and transferred the resident to the electric wheelchair. Once situated in the chair, she put her seatbelt on. The resident stated she was in pain and that she hurt her leg and her thigh. ASTNA #214, stated she let the nurse know, as the nurse was standing right outside the door. ASTNA #214 asked if Resident #57 could have something for pain and LPN #213 said she was due for her pain medication. Interview on 03/15/21 at 4:08 P.M. with LPN #213, revealed she denied telling ASTNA #214 that Resident #57 required a Hoyer lift for transfers. She indicated around lunch time, she told ASTNA #214, that Resident #57 had to get up for a visit and did not tell ASTNA #214 about how to transfer the resident. ASTNA #214 went in to the room by herself and the nurse had intended on assisting her. LPN #213 was held up at the door to Resident #57's room assisting another resident. About ten minutes had past and ASTNA #214 opened the door of Resident #57's room after transferring Resident #57 to the wheelchair, and reported to LPN #213 that Resident #57 was in pain. LPN #213 confirmed no other staff members entered Resident #57's room and only one person transferred Resident #57. LPN #213 confirmed Resident #57 required a Hoyer lift for transfers. Interview on 03/16/21 at 11:17 A.M. with Resident #57, revealed information related to the incident on 03/05/21. Resident #57 stated an STNA dropped her when she tried to lift her to the wheelchair. The resident stated she told the STNA to use the Hoyer lift and she didn't use it. She said the STNA totally ignored her and when she picked her up, she tried to bounce me up and heard my leg making a popping sound and then tried to grab my arm. The resident indicated she had a sprained knee, a fractured shoulder and leg, her leg was in a brace and her shoulder was in a sling. 2. Review of the medical record for Resident #71 revealed an admission date of [DATE] and a readmission date of [DATE]. [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], revealed Resident #71 had intact cognition with a brief interview for mental status score of 13, indicating the resident was alert and oriented. Review of the plan of care dated 02/18/21, revealed Resident #71 was a risk for falls related to gait/balance problems, leg weakness, decreased endurance and vision deficits and an alteration in musculoskeletal status related to [MEDICAL CONDITION] disc disease. The plan of care for activities of the daily living (ADL's) revealed an intervention for a sit to stand lift for transfers. Observation on 03/11/21 at 4:21 P.M., revealed Resident #71 was transferred using a sit to stand lift (mechanical lift) from the bed to the wheelchair, by STNA's #211 and STNA #212. Observation revealed the wheelchair was not locked, prior to seating Resident #71 in the wheelchair. Concurrent interview on 03/11/21 at 4:21 P.M., revealed STNA #211 unlocked the wheelchair to readjust it and did not lock it prior to seating Resident #71 in the wheelchair. STNA #211 confirmed the wheelchair was unlocked. Communication received on 03/16/21 at 5:51 P.M. from the Administrator verified Resident #71 was a sit to stand for transfers. Review of an undated, untitled document referred to as care sheets, revealed a list of residents by room numbers and included a section for orders/notes, vitals and meal intakes. The document revealed Resident #57 was on the list indicating a Hoyer lift (mechanical lift) was required with two people for transfers. Resident #71 was indicated E-Z stand (mechanical sit to stand lift) for toileting as needed. Review of the facility policy titled, Lifting Machine, Using a Portable, updated 01/18/20, revealed to use the following procedures to help lift residents who were too heavy to lift manually, to promote comfort, and to maintain good body alignment while the resident was being transferred. The policy indicated the portable sit-to-stand lift can be used by one (1) nursing assistant if the resident can bare weight and participate in the lifting procedure. If not, two (2) nursing assistants will be required to perform the procedure using the portable mechanical lift. The policy included procedures to follow for each method. To transfer a resident from a bed to a chair using the mechanical lift, you should position the chair, if it is a wheelchair, and be sure to lock the wheels. To transfer the resident using the sit-to-stand lift, you should if transferring to wheelchair or bed, make sure the wheels were locked. Review of a facility document titled, Falls Management dated 01/14/14, revealed all residents admitted to the community were considered at risk for falls. The facility is focused on minimizing fall risk and fall related injuries, while maximizing individual dignity freedom and quality of life. The following interventions utilized in the prevention of falls included wheel chairs locked during transfers, assistance with ambulation and transfers for unsteady residents and other preventions as deemed necessary by the interdisciplinary team. The licensed nurse will complete the required electronic incident/accident report in the risk management module of point click care. This deficiency substantiates Complaint Number OH 741.

Based on medical record review, observation, staff and resident interview, review of Self-Reported Incident (SRI) and review of facility policy the facility failed to provide adequate supervision to prevent accidents for one cognitively impaired resident (Resident #10) with a known behavior of wandering into other resident rooms uninvited. This affected one of three residents reviewed for wandering behaviors. This resulted in actual harm to Resident #10 when he wandered into Resident #12's room and sustained a [MEDICAL CONDITION] when Resident #12 attempted to remove Resident #10 from his room. The facility census was 80. Findings include: Resident #12 was admitted on [DATE]. Medical [DIAGNOSES REDACTED]. Review of care plan for Resident #12 revealed he had trouble controlling impulses, so his anger could lead to starting altercations with others. The interventions were to approach in calm soothing and non-judgmental manner, audible door open signal to alert staff of other residents entering the room uninvited, a do not enter sign on the door, and to place in secured memory care neighborhood. Review of physician notes dated 11/06/18 for Resident #12 revealed he was seen for a routine evaluation. He has had repeated psychiatric hospitalization s for episodic [MEDICAL CONDITION] marked by agitation with aggressive behavior and sexually inappropriate/hyperreligious behaviors due to Schzoaffective disorder and [MEDICAL CONDITION] disorder. Since altercation with his roommate four months ago there have been no further reports of inappropriate behavior has been reported. Review of the quarterly MDS dated [DATE] revealed Resident #12 was cognitively impaired. He required supervision for bed mobility and transfers. There was nothing coded for behaviors on the MDS. Resident #10 was originally admitted on [DATE]. Resident #10 was discharged to the hospital on [DATE] and readmitted back into the facility on [DATE]. Medical [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #10 was cognitively impaired. Resident #10 was a limited assistance for bed mobility and transfers. There was nothing coded for wandering or behaviors on the MDS. Review of the care plan for Resident #10 revealed he was at risk for wandering from the facility unattended. Interventions included to allow him to wander freely within the unit but remove him from the area if annoying peers and to attempt to avoid the resident from wandering into other resident's rooms, whenever possible. Review of nursing progress note dated 10/01/18 (not timed) revealed Resident #10 had an altercation with another resident and attempted to kick the other resident. On 10/02/18 at 2:27 P.M., the resident wandered into a resident's room and on the same day he attempted to leave the unit without success. On 10/03/18 at 1:55 P.M., Resident #10 was moved to another unit. Review of nursing progress note dated 10/04/18 at 5:28 A.M., revealed Resident #10 wandered into another female's room and climbed into her bed. The female resident was naked in her bathroom and found him in her bed when she returned to her bed. Resident #10 was removed from her room and redirected back to his room. On 10/05/18 at 4:38 A.M., a female resident found Resident #10 sleeping in her bed. She went to the nurses' station for assistance and the resident was returned to his room. Review of physician visit note dated 10/16/18 revealed Resident #10 was seen for follow-up for dementia with behavioral disturbances. He required [MEDICATION NAME] intramuscularly in the past month and was moved to a behavior unit for aggression. He had a history of [REDACTED]. Review of nursing progress notes dated 11/24/18 at 11:30 A.M. revealed State tested Nursing Assistant (STNA) #87 and Licensed Practical Nurse (LPN) #83 were at the nursing station and heard Resident #10 scream, the son of a b*tch pushed me down . Resident #10 was laying on the ground next to Resident #12's room. Resident #12 was standing at the doorway and stated Resident #10 wandered into his room and he pushed him out. The staff assisted Resident #10 up off the ground, but he was unable to bear weight on his right leg. Resident #10 was placed in a wheelchair and taken to the nursing station. Resident #10 was complaining of pain in his right leg. an order for [REDACTED].#10 was grimacing and grabbing his right leg and the X-ray company had not shown up, so an order was obtained to send the resident to the emergency room . Review of SRI dated 11/24/18 revealed physical abuse was substantiated between Resident #10 and Resident #12 when Resident #12 pushed Resident #10 out of his room. Resident #10 sustained a right [MEDICAL CONDITION]. Review of Interdisciplinary Team (IDT) progress note dated 11/27/18 for Resident #12 revealed he was interviewed as a follow-up from a suspected Resident to Resident altercation. Initial report and assumptions inferred that he had maliciously pushed Resident #10 down in response to Resident #10 being in his room. At the time Resident #12 indicated he had. Director of Social Services (SW) #40 inquired in detail and learned Resident #12's perspective was he attempted to guide Resident #10 out of his room and was surprised he met resistance. Resident #12 stated later he questioned himself about pushing too hard, but when asked about intent, he was clear he only meant to assist the Resident #10 out of his room. He stated his intent was not for Resident #10 to fall. He stated he spoke to Resident #10 in a calm manner, but Resident #10 didn't understand him like the other residents did. He started he didn't know what to do. SW #40 explained he could use the call light, and someone would help him with redirecting the resident out of the room. The note further revealed Resident #12 had no intent to harm or abuse Resident #10 but was trying to get him to leave his room. Review of nurses progress note dated 11/29/18 at 4:00 P.M. revealed the resident returned to the facility. Resident had three areas noted on his right leg, one with eight staples, second one with seven staples and the third one with four staples. Resident complained of pain upon return to the facility. Interview on 12/03/18 at 11:35 A.M. with Resident #12 revealed Resident #10 had come into his room a couple of times prior to the incident. In the past he was able to tell him Resident #10 he was in the wrong room. He stated he could not remember the events completely, but Resident #10 wandered into his room. He said this aggravated him and he pushed Resident #10 on his shoulders with both of his hands. He stated he shoved Resident #10 and he fell on to the floor. He stated Resident #10 said, you hurt me. Resident #12 stated he shoved Resident #10 before to get out of his room, but Resident #10 never fell on to the floor. He stated sometimes he could not control himself. He stated he only meant to shove him away from his door, he didn't t mean to hurt him. He stated all the staff knew he didn't want Resident #10 in his room, so a stop sign was put on the door but stated the wanderers didn't pay any attention to the sign. Interview with the Director of Nursing (DON) on 12/03/18 at 2:08 P.M. revealed she received a call on 11/24/18 during the day. The nurse stated Resident #10 had fallen and there might have been an altercation between Resident #10 and Resident #12. The nurse revealed Resident #10 said Resident #12 pushed him. She stated Resident #12 originally would not respond when questioned, but then indicated he must have pushed him. Interview with Licensed Practical Nurse (LPN) #83 on 12/03/18 at 2:30 P.M. revealed she and STNA #87 were at the nursing station and they heard yelling. Resident #10 was lying on the floor in front of the Resident #12 ' s room. She stated she asked Resident #12 if he pushed Resident #10 and initially he indicated he kind of pushed him. When asked a second time, Resident #12 admitted to pushing Resident #10. She stated Resident #10 was assisted up from the floor, but he could not bear weight on his right leg, so he was placed in a wheelchair. She stated she obtained an order for [REDACTED]. Review of policy entitled Accident/Incident revised 01/10/14 revealed an incident is defined as any event, occurrence, situation or circumstance, which is unusual or inconsistent with the policies, practices and routine operation of the community. An accident which may or may not result in bodily injury and/or property damage. physical or mental mistreatment (abuse, actual or suspected) of a resident is considered an incident even when an actual injury has not occurred. This deficiency substantiated Control Number OH 406.

Based on observation, record review, staff interviews and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement physician recommended interventions for a resident at risk for the development of pressure ulcers after the resident developed a pressure ulcer. This resulted in actual harm when Resident #38 developed an avoidable stage 3 pressure ulcer to the left buttock. This affected one (#38) of four residents investigated for pressure ulcers. The facility census was 83. Findings inlude: Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of most recent Minimum Data Set (MDS) assessment dated [DATE], revealed the resident has a brief interview of mental status (BIMS) score of 4 indicating the resident has severely impaired cognition. The resident is coded as having delusions, but no other behaviors during the review period. The resident requires limited assist for eating, extensive assist for dressing and hygiene and supervision for all other daily care. The resident is frequently incontinent of bladder and always continent of bowel. Resident #38 is at risk for pressure ulcers but has no pressure ulcer, the resident has pressure reducing surface to bed and chair. Review of Resident #38's skin assessments revealed the resident had assessments completed on the following days with the measurements and descriptions included: On 03/27/18, documented the resident has an open area measures 0.5 centimeters (cm) x 0.5 cm x 0.0 cm to left buttock. On 04/03/18, documented the open area to left buttock measures 1.0 cm x 1.0 cm x 0.0 cm. On 04/07/18, documented the resident has a stage II pressure ulcer to left buttock that measures 2.5 cm x 2.0 cm x 0.1 cm. On 04/10/18, documented the resident has a stage III to left buttock that measured to 2.1 cm x 2.4 cm x 0.1 cm On 04/18/18, documented the resident has a stage II to buttock that measures 2.0 cm x 2.0 cm x<0.1 cm. Review of the physician progress notes [REDACTED]. The ulcer was described as having irregular boarders with underlying soft yellow exudate mixed with some granulation tissue and non-infected. The physician recommended a hydrogel with gauze and foam boarder daily, a low air loss mattress to the bed and a Roho cushion for off- loading pressure for this resident to increase tissue perfusion. Review of the physician progress notes [REDACTED]. The resident does not alert the staff that he is soiled and is often found in a soiled incontinence product. Observation of Resident #38 on 04/17/18 at 2:12 P.M., revealed the resident was lying on his left side on the bed. A cushion (not a Roho) was visualized in the chair and the bed was observed with no pump on it, indicating the bed is not a low air loss mattress. Observation of Resident #38 on 04/17/18 at 5:18 P.M., revealed the resident was observed in the dining area, no signs of distress noted. Observation of Resident #38 on 04/18/18 at 11:47 A.M., revealed the resident was sitting in his bedside chair with the same cushion in the chair, no signs of distress noted. Observation of Resident #38 on 04/19/19 throughout the day, revealed the resident continued to have the original cushion to his bedside chair, and no low air loss mattress to his bed. Interview with Licensed Practical Nurse #15 on 04/18/18 at 2:16 P.M., verified Resident #38's mattress was a regular mattress, and the cushion to the resident's chair was a cushion the family had brought to the facility, not a Roho cushion. Interview with the Director of Nursing (DON) on 04/18/18 at 3:45 P.M., verified Resident #38 did not have a low air low mattress nor a Roho cushion used in his care at the facility. The DON stated she was unaware of the recommendation the physician made in the physician progress notes [REDACTED]. The DON verified the resident is on a pressure reducing cushion and, if a Roho is indicated, the facility will need to order that specialty cushion. The DON additionally stated that if the physician had spoken to her regarding the low air loss mattress she would counsel against it as the resident is able to position himself and get in and out of bed, and the DON felt the low air loss mattress would place the resident at a greater risk for falling with his mobility. Review of Resident #38's progress notes revealed the notes contained no documented evidence of the physician being informed the facility had not followed the physician's recommended interventions for the low air loss mattress and the Roho cushion. Review of information from the NPUAP (www.npuap.org) revealed a stage 3 pressure injury is a full-thickness skin loss in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Further review of the NPUAP indicated a plan of care should be developed based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface. Consider the level of immobility, exposure to shear, skin moisture, perfusion, body size and weight of the individual when choosing a support surface.

Based on medical record review and staff interview, the facility failed to safely provide Occupational Therapy which resulted in harm to one resident (Resident #8) when she sustained a femur fracture and increased pain. This affected one of three residents reviewed for accidents. There were 15 residents receiving Occupational Therapy. The facility census is 86. Findings include: Resident #8 was initially admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status Score of 14 indicating Resident #8 was cognitively intact. Her nursing Plan of Care for increased risk of fractures had interventions including "take special care when positioning and transferring." She had physician orders [REDACTED]. The Occupational Therapy evaluation on 07/02/14 indicated Resident #8's functional status as total assistance with dressing, transfers, toileting, grooming, and bathing. The Occupational Therapy goal was for Resident #8 to "demonstrate symmetric upright posture with even weight distribution in the wheelchair," and to "increase left upper arm strength to increase her ability to self-feed." The evaluation indicated Resident #8 had "poor postural stability." Resident #8 received Occupational Therapy five days a week beginning on 07/02/14. On 07/16/14 Occupational Therapist #100 attempted to assist Resident #8 from a lying down position in bed, to sitting up on the side of the bed. Resident #8 began to slide off the side of the bed and was assisted by the therapist onto the floor to a sitting position with her legs to the left. Occupational Therapist #100 called for assistance using the residents call light. Facility staff responded and the nurse's note dated 07/16/14 revealed Licensed Practical Nurse #13 and three State tested Nursing Assistants assisted the resident with the use of a Hoyer lift back into her bed. The nursing note also revealed Occupational Therapist #100 was new to the facility and was "educated of importance of knowing residents capabilities and transfer abilities before initiating therapy with them." Resident #8 was assessed for injuries and new orders were received from the physician for X-rays of the arms, shoulders, pelvis, hips, and knees. Nurse's note dated 07/16/14 revealed the X-rays were negative for fractures or injuries. Nurse's note dated 07/24/14 revealed Resident #8 had swelling in her right foot with redness and warmth. The swelling became worse and Resident #8 was sent to the emergency room for an evaluation with no new diagnoses. The physician evaluated the resident on 07/25/14 and ordered further X-rays. Nurse's note dated 07/26/14 revealed the X-ray result was conclusive of a right distal femoral fracture. The resident was sent to the hospital on 07/26/14 and was readmitted to the facility on [DATE]. Staff Licensed Practical Nurse #13 was interviewed on 08/06/14 at 10:10 A.M. and stated she was the nurse on duty on 07/16/14 when Resident #8 slid off her bed onto the floor. She stated she was alerted of the incident by the State tested Nursing Assist. When she entered Resident #8's room the resident's weight was on her right hip and her legs were bent toward the left side of her body, and her back was against the bed. The X-ray showing Resident #8 had a fracture was not confirmed until 07/26/14. She felt the resident sustained [REDACTED]. The Occupational Therapist that was working with Resident #8 on 07/16/14 was not available to interview. However, on 08/06/14 at 2:30 P.M. Rehab Manager #1 was interviewed. She stated the Occupational Therapist on duty on 07/16/14 was instructed to work with Resident #8 with learning to eat independently. Resident #8's therapy plan of care identified her as a Hoyer lift for transfers, having "poor postural stability" and needing total assistance for dressing, grooming, transferring, and toileting. She confirmed that the Occupational Therapist should not have attempted to sit the resident up on the side of the bed independently. The facility provided a copy of the incident report that was last updated on 08/05/14. The facility determined that Resident #8 was taking high risk medications and had severe osteoporosis. The incident report concluded, " that with her legs having been out to her left, while sitting on her right hip, at the time she was lowered to the floor, this fracture does appear to be a result of being lowered to the floor. " A review of the past three months of medication administration records reveal Resident #8 had taken pain medication (Tylenol) only once during the 15 days (June 1,2014 to June 15, 2014) previous to the fracture. Further review revealed she had taken pain medication 19 times(07/16/14-08/06/14) since the fracture occurred on 07/16/14. Resident #8 returned from the hospital admission on 7/28/14 with new physician orders [REDACTED]. Prior to the fracture Resident #8 only used Tylenol (a non-prescription pain medication) for pain.

Based on closed record review, review of manufacture recommendations and staff interviews, the facility failed to ensure residents transferred with mechanical lifts were transferred safety and in accordance to manufacture's recommendations. This affected one (#96) of four sampled residents who sustained a fracture of the left hip and a subdural hematoma and three fractures of the thoracic spine as a result of avoidable falls during transfers with the use of two different mechanical lifts. Findings include: Review of the closed medical record of Resident #96 revealed the accumulative [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] stated the resident was alert and oriented and required extensive assistance of one staff member with transferring, dressing and hygiene tasks and was dependent on staff for bathing. The MDS also stated the resident experienced no pain during the assessment period. Review of the resident's plan of care for activities of daily living dated 12/22/10 revealed interventions that included the use of a brace on her left foot for transfers, passive range of motion to the right lower extremity, the use of side rails to assist with mobility, and the use of a sit to stand mechanical lift for transfers. Nurse's notes dated 01/10/11 at 9:30 A.M., stated state tested nurse aide (STNA) #1 alerted licensed practical nurse (LPN) #2, that Resident #96 was on the floor in the public shower room. The notes stated upon entry to the shower room, the nurse found the resident laying on her back on the floor next to the sit to stand mechanical lift. The resident was assessed and complained of pain in her left hip. At that time LPN #2 and STNA #1 used another mechanical lift (Hoyer) to transfer the resident off the floor to her bed. The physician was notified of the fall and gave orders for x-rays to be taken of the resident's left hip. Nurse's notes dated 01/10/11 at 3:30 P.M. stated the physician was notified of the x-ray results which stated the resident had an intertrochanteric fracture of the left hip. The resident was then transferred to the hospital for further treatment. The resident was readmitted to the facility from the hospital on [DATE]. Physician orders [REDACTED]. Review of a significant change MDS assessment dated [DATE], revealed the resident was now totally dependent and required two or more staff to transfer and bathe her. The MDS further stated the resident experienced moderate pain occasionally. Review of the resident's plan of care for activities of daily living, revealed it was updated on 01/17/11 with interventions to transfer the resident with the use of a Hoyer lift and to provide skilled therapy as ordered. Review of nurse's notes dated on 02/25/11 at 6:45 A.M. revealed the resident hit her head during a transfer. The notes did not document any other information regarding this incident. The physician was notified and gave orders to send the resident to the hospital for an evaluation. Review of the hospital emergency room notes revealed the resident had fallen an estimated 4.5 feet out of a Hoyer lift at the facility around 7:00 A.M. on 02/25/11. The physician documented the resident stated during interview that she was not strapped in the lift correctly. The resident was diagnosed at the hospital with a subdural hematoma and spinous process fractures of the thoracic 6, 7, and 8 areas of the spinal column. During review of the facility's investigation of the fall dated 02/28/11, revealed on 02/25/11 at 6:45 A.M., STNA's #4 and #6 were transferring Resident #96 from her bed to the wheelchair with the use of a mechanical lift (Hoyer). During the transfer, the lift strap fell off the bottom lift bar (which held the strap under the resident's left leg) and caused the resident to fall to the floor and hit her head and back. The investigation concluded the lift strap loop had been pushed down the bar during the transfer, displacing it off the hook on the lift bar. Review of manufacturer's instructions and teaching video regarding the use of the sit to stand lift, revealed the resident was to have a harness applied two to three inches below the armpits and around the waist. The safety harness strap around the waist was to be secured with a front clasp seatbelt to keep the resident secure during the lift. The resident's lower extremities were to rest in the padded shin rests with leg straps to be applied to prevent the legs from moving during the transfer. The harness then would be attached to the lift arms with either short loops or long loops depending on the resident's size and needs. At that point, the resident would be secured and ready for the transfer. During interview on 03/18/11 at 10:00 A.M., LPN #2 stated she was the nurse who was called into the shower room after the resident's fall on 01/10/11 at 9:30 A.M. LPN #2 stated the resident was laying on the floor next to the sit to stand lift. She stated the resident stated she hit her head on the wall as she fell out of the lift. LPN #2 verified the resident complained of pain in her left hip. During interview on 03/18/11 at 12:15 P.M., STNA #1 stated on the morning of 01/10/11, he was getting the resident into the shower and used a sit to stand lift to transport the resident to the shower chair. STNA #1 stated the standard harness was on the resident with the short loops used to connect the harness to the lift bar. He stated when he stood the resident up with the lift, the short loop came off the hook on the right side and caused the resident to fall out of the lift onto the floor. He stated he then went and asked LPN #2 for help. During further interview on 03/18/11 at 2:15 P.M., STNA #1 stated he had applied the harness on the resident but neglected to fasten the front clasp seatbelt as required. He stated he had used the safety straps around the resident's legs but not around her waist. STNA #1 verified he did not follow the manufacturer's instructions when he used the sit to stand lift to transfer Resident #96 on 01/10/11. During interview on 03/18/11 at 3:00 P.M., the Administrator stated STNA #1 had been re-educated on the use of the sit to stand lift on 01/12/11. She confirmed he had not used the sit to stand lift in accordance to manufacturer's instructions. This certification deficiency substantiates Complaint Control Number OH 966.