Every finding on record at Trotwood Health & Rehab LLC

Based on review of personnel files, staff interviews, and policy review, the facility failed to ensure employees were screened for history of abuse on the Ohio Abuse Registry. This had the potential to affect all residents. The facility census was 31. Findings include: Review of personnel files revealed files for the Administrator, the former Director of Nursing (DON) #400, the Admissions #76, the Human Resources (HR) #74, Certified Nursing Assistant (CNA) #32 and #34, and Registered Nurse (RN) #104 had no evidence the facility had screened the employees through the Ohio Abuse Registry. During an interview on 06/16/26 at 10:33 A.M. HR #74 verified personnel files contained no evidence of abuse registry checks. During an interview on 06/16/2026 at 1:15 P.M. the Administrator stated the former DON left abruptly and they were unable to locate the binder with evidence that staff were checked against the Ohio Abuse Registry. Review of policy titled Abuse, Neglect, and Exploitation dated 2025 revealed the facility screened potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property and maintained documentation of proof the screening had occurred.

Based on review of personnel files, staff interviews, and policy review, the facility failed to implement the abuse policy. This had the potential to affect all residents. The facility census was 31. Findings include: Review of personnel files revealed files for the Administrator, the former Director of Nursing (DON) #400, the Admissions #76, the Human Resources (HR)# 74, Certified Nursing Assistant (CNA) #32 and #34, and Registered Nurse (RN) #104 had no evidence the facility had screened employees through the Ohio Abuse Registry. During an interview on 06/16/26 at 10:33 A.M. HR #74 verified personnel files contained no evidence of abuse registry checks. During an interview on 06/16/26 at 1:15 P.M. the Administrator stated the former DON left abruptly and they were unable to locate the binder with evidence that staff were checked against the Ohio Abuse Registry. Review of policy titled Abuse, Neglect, and Exploitation dated 2025 revealed the facility developed and implemented written policies and procedures to prohibit and prevent abuse and provided ongoing oversight and supervision to ensure policies were implemented as written.

Based on personnel file review and interview, the facility failed to ensure the activity department was operated by a qualified activity professional. This had the potential to affect all residents. The facility census was 31.Findings include:Review of the personnel file revealed the Social Services Director (SSD) #64 was hired on 02/17/25. Shortly after hire the SSD #64 was given the role of Activity Director. Further review of the personnel file revealed no documentation related to qualifications for the position of Activity Director.Interview on 06/16/26 at 1:37 P.M. with SSD #64 revealed the position of Activity Director was added to her job duties after she was hired. SSD #64 verified she did not have any of the required qualifications for the position and was in the process of taking an online course to become certified. Interview on 06/16/26 at 1:51 P.M. with Human Resources Director (HRD) #74 revealed there was no documentation related to the change in position for SSD #64, which included the addition of the role of Activity Director. HRD #74 was unable to provide information related to the individual in the position of Activity Director prior to SSD #64.

Based on record review, interview, and policy review, the facility failed to have Registered Nurse (RN) coverage as required. This had the potential to affect all residents. The facility census was 31.Findings include:Review of the Payroll Based Journal Staffing Data Report for 10/01/25 to 12/31/25 revealed the facility triggered for failure to have RN coverage on 10/11/25 and 10/12/25.Review of the timecard punches for 10/01/25 to 12/31/25 revealed no evidence of RN coverage for 10/11/25 and 10/12/25.Interview on 06/16/26 at 12:40 P.M. with the Administrator verified the facility had no RN coverage on 10/11/25 and 10/12/25.Review of the facility policy titled Nursing Services-Registered Nurse (RN), undated revealed the facility would utilize the services of an RN for at least eight consecutive hours daily, seven days per week.

Based on observation, resident and staff interview, and policy review, the facility failed to ensure food was served at the appropriate temperature. This had the potential to affect 30 of 30 residents in the facility who eat meals from the facility kitchen. The facility identified one resident (#05) who did not receive food from the kitchen. The facility census was 31. Findings include:Observation of a test tray on 06/15/26 at 8:52 A.M., after all trays had been delivered to residents, revealed the scrambled eggs were 107 degrees Fahrenheit (F) and the sausage links were 110 degrees F. Interview at the time of the observation the Dietary Manager (DM) #100 verified the temperature of the eggs was 107 degrees F and sausage was 110 degrees F. DM #100 stated the expectation was for food to be at least 130 degrees F when served to the residents. DM #100 tasted the eggs and confirmed they were not hot. Interview on 06/15/26 at 9:24 A.M., Resident #10 stated her breakfast that morning was not hot enough. Interview on 06/15/26 at 9:29 A.M., Resident #08 stated his breakfast that morning was not hot enough. Review of the facility policy titled, Record of Food Temperatures, dated 2023 revealed hot foods would be held at 135 degrees F.

Based on observation, staff interview, and policy review, the facility failed to ensure food was stored in a manner to prevent the potential spread of foodborne illness. The facility also failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 30 of 30 residents who receive food from the facility kitchen. The facility identified one resident (#05) who did not receive food from the kitchen. The facility census was 31. Findings include:1. Observation on 06/14/26 at 8:34 A.M., upon surveyor entrance into the kitchen, revealed there was a drain on the floor below the ice machine and handwashing sink that was overflowing with standing water, measuring approximately two feet by 1 foot. After surveyor washed her hands the size of the puddle grew. Observation on 06/15/26 at 8:04 A.M. revealed the standing water below the handwashing sink extended approximately six feet across the floor and became larger when the surveyor washed her hands. Interview on 06/15/26 at 8:29 A.M., the Dietary Manager (DM) #100 verified the presence of the standing water on the floor by the ice machine and below the handwashing sink. DM #100 stated it had been that way for a long time because the drain needed to be cleaned out. 2. Observation on 06/14/26 at 8:37 A.M. revealed two bags of chicken, dated 05/30/26, in a pan sitting on a counter just outside the walk-in cooler. The chicken was warm to the touch. Interview on 06/14/26 at 8:52 A.M., the Dietary Aid (DA) #60 verified the chicken was stored on the counter and warm to the touch. The DA #60 stated the chicken was on the counter when she came into work at 6:45 A.M. that morning and she was the only one in the kitchen that morning. Interview on 06/14/26 at 12:17 P.M., the DM #100 stated the chicken was still sitting on the counter when she arrived and stated the chicken must have been set out the night prior and verified meat should not be thawed in such a manner. 3. Observation on 06/14/26 at 8:53 A.M. of the walk-in cooler revealed 10 pitchers of unidentified liquids sitting on a cart. There were no labels nor dates observed on any of the pitchers. Further observation revealed a bag of tortillas which was not sealed, and a plastic cup of grapes which was open to air and not labeled. Interview at the time of the observation, DA #60 verified the pitchers were not labeled nor dated. DA #60 stated the pitchers contained cranberry juice, lemonade, and fruit punch and were in the cooler already when she arrived earlier that morning. DA #60 verified the tortillas were not sealed and the plastic cup of grapes was open to air and not labeled. 4. Observation on 06/14/26 at 8:55 A.M. of the walk-in freezer revealed two boxes of hamburgers with the plastic bag inside opened and not sealed, and a box of ground beef with the plastic inside open and not sealed.Interview at the time of the observation, DA #60 verified the hamburgers and ground beef were not sealed properly. 5. Observation on 06/14/26 at 8:59 A.M. of the dry storage area revealed a large box of Styrofoam cups was stored directly on the floor. Further observation revealed an area, measuring approximately six inches, of a dark brown dried liquid with unidentifiable brown debris on the floor below the shelf. The entire dry storage area had visible dirt and grime throughout. Interview at the same time, DA #60 verified the Styrofoam cups were stored on the floor and should be stored at least six inches above the floor, the dark area of dried brown liquid, and the dirt and grime throughout the dry storage area. 6. Observations on 06/15/26 between 7:30 A.M. and 8:15 A.M. in the kitchen revealed: 1. Vents on both sides of the ice machine were coated in a fuzzy grey substance. 2. Pipes above the tray line and prep area were coated in a fuzzy grey substance. 3. Multiple areas of brown splatter on walls near the steamer and stove. 4. The floor below the stove and steamer had dried food/debris and heavy dark brown grime. 5. The outside of the plate warmer had brown splatters and grime buildup. 6. The area between the tray line assembly area and the shelf below was coated in a brown grime-like substance. 7. There were crumbs, trash, and heavy dark brown grime throughout the kitchen around the edges of the floor. 8. There was a heavy coating of a grey fuzzy material on the grates of the juice machine. 9. There was brown buildup on the counter and wall behind the coffee maker. Interview on 06/15/26 at 8:55 A.M., DM #100 verified the ice machine and juice machine grates and vents were coated in a grey fuzzy material, the pipes above the tray line and prep area wee coated in a grey fuzzy material, there were multiple areas of brown splatter, food debris, crumbs, and grime throughout the kitchen. DM #100 verified the entire kitchen was in need of deep cleaning. 7. Observation on 06/14/26 at 12:25 P.M. revealed Certified Nursing Assistant (CNA) #44 stood at the front of the 200 hall and poured fruit punch from a pitcher into approximately 10 Styrofoam cups and placed the cups on top of a tray on top of the cart of lunch trays. CNA #44 then pushed the cart of trays to the opposite end of the hall. The cups of fruit punch on the top of the cart were not covered. Interview on 06/14/26 at 12:26 P.M., CNA #44 verified the cups of fruit punch were not covered prior to pushing the cart to the opposite end of the hallway. CNA #44 stated there were no lids available to cover the cups of fruit punch. Review of the facility policy titled, Food Safety Requirements, dated 2026, revealed thawing food at room temperature was not acceptable. Meat should be refrigerated. Food should be labeled and dated, stored in a manner to prevent the deterioration or contamination of the food and should be kept in covered or tight containers. Dry food should be stored in a dry area off the floor. All foods should be covered when traveling a distance (i.e. down a hallway). Hands should be washed between contact with residents. Equipment should be clean.

Based on record review, interview, and policy review, the facility failed to accurately submit staffing data in the Payroll Based Journal (PBJ) system. This had the potential to affect all residents. The facility census was 31.Findings include:Review of the PBJ Staffing Data Report for 10/01/25 to 12/31/25 revealed the facility triggered for failure to have licensed nursing coverage for 24 hours a day.Review of staffing data from 10/01/25 to 12/31/25 revealed the facility met the requirement for nursing coverage with the use of agency staff.Interview on 06/15/26 at 5:00 P.M. with the Administrator revealed agency hours were not submitted for the last quarter.Review of the undated facility policy titled Payroll Based Journal revealed the facility would timely submit complete and accurate direct care staffing information.

Based on record review, interview, and policy review, the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee met at least quarterly. This had the potential to affect all residents. The facility census was 31.Findings include:Review of the QAA Committee sign-in sheets for the last four quarters revealed no evidence of meetings prior to 04/29/26.Interview on 06/16/26 at 11:14 A.M. with the Director of Nursing (DON) verified there was no documentation of meetings prior to 04/29/26.Review of the undated facility policy titled Quality Assurance and Performance Improvement (QAPI) revealed the QAA Committee would meet quarterly.

Based on medical record review, review of the water management logs and plan, review of personnel files, observation, staff interview, and policy review, the facility failed to ensure appropriate hand hygiene was completed while passing meal trays and medications. The facility also failed to ensure enhanced barrier precautions were implemented as appropriate, legionella prevention measures were completed, and tuberculosis tests were administered to employees as planned. This had the potential to affect all 31 residents in the facility. Findings Included: 1. Observation on 06/14/26 at 12:28 P.M., Certified Nursing Assistant (CNA) #44 began to pass trays on the 200 hall. CNA #44 delivered trays to the rooms of Residents #20, #15, #01, and #24. CNA #44 did not perform hand hygiene at any time between passing each tray. A dispenser of hand sanitizer was observed on top of the cart of trays. On 06/14/26 at 12:29 P.M., CNA #44 delivered a tray to Resident #32, pulled him up in bed and assisted with tray setup. On 06/14/26 at 12:30 P.M., CNA #44 exited the room of Resident #32 and did not perform hand hygiene. CNA #44 then delivered trays to Residents #08 and #26. At 12:34 P.M., CNA #44 sanitized her hands for the first time during tray delivery on the 200 hall. Interview on 06/14/26 at 12:34 P.M., CNA #44 verified she had not sanitized her hands between each resident while passing trays, including after pulling Resident #32 up in bed. CNA #44 confirmed hand hygiene should be performed between each tray delivered. Continued observation on 06/14/26 at 12:37 P.M., CNA #44 delivered trays to Residents #12 and #10 and did not perform hand hygiene between passing the trays. Continued observation revealed CNA #44 began passing trays to the 300 hall residents at 12:40 P.M. CNA #44 delivered trays to Residents #04, #27, #28, #29, #06, and #25 and did not perform hand hygiene at any time during tray delivery on the 300 hall. Interview on 06/14/26 at 12:46 P.M., when queried, CNA #44 laughed and denied not performing hand hygiene while delivering the trays on the 300 hall. Interview on 06/16/26 at 11:49 A.M., the Director of Nursing (DON) stated she was unaware of the need to sanitize hands between the delivery of each tray, however verified hands should be sanitized after assisting residents with tray setup, including pulling the residents up in bed, and before passing the next tray. Review of the facility policy titled, Food Safety Requirements, dated 2026, revealed hands should be washed between contact with residents. 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included non-pressure chronic ulcer of the left foot, scute osteomyelitis of the right ankle and foot, type II diabetes, and acquired absence of the left leg below the knee. Review of the medical record revealed Resident #3 had physician orders dated 04/24/26 for Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject 13 units subcutaneously four times a day for diabetes mellitus. Observation on 06/14/2026 at 8:55 AM revealed Registered Nurse (RN) #9 carried pills, insulin pen, pen needle, and alcohol swabs to Resident #3's room. As Resident #3 swallowed his oral medications, RN #9 dialed the insulin pen to 12 units, applied the pen needle, swabbed Resident #3's left upper arm and injected 12 units of lispro insulin. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, unspecified anxiety disorder, and unspecified convulsions. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Review of the care plan dated 07/01/2016 revealed Resident #6 was at risk for heart disease and stroke. Interventions included medications, labs, and diet as ordered. Review of the medical record revealed Resident #6 had physician orders for medications scheduled for AM administration including Colace oral capsule 100 mg, levetiracetam 500 mg, lisinopril 10 mg tablet, methocarbamol 750 mg, metoprolol tartrate 25 mg, protein oral liquid 30 ml, and Trintellix 20 mg. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included unspecified Chronic Obstructive Pulmonary Disease (COPD), chronic diastolic heart failure, type II diabetes, unspecified epilepsy, malignant neoplasm of the lung, unspecified malignant neoplasm of the breast, and unspecified anxiety disorder. Review of the medical record revealed Resident #4 had physician orders for medications scheduled for AM administration including Aspirin EC Tablet Delayed Release 81 MG, Ativan Oral Tablet 1 MG, Clopidogrel Bisulfate Tablet 75 MG, Furosemide Oral Tablet 40 MG, Guaifenesin ER Oral Tablet Extended Release 12-Hour 600 MG, Levetiracetam Oral Tablet 1000 MG, Methocarbamol Oral Tablet 750 MG, Morphine Sulfate Oral Tablet 15 MG, Omeprazole Tablet Delayed Release 20 MG, Oxcarbazepine Oral Tablet 150 MG, Thiamine HCl Oral Tablet 100 MG, and Vilazodone HCl Oral Tablet 20 MG. Observation of medication pass on 06/14/26 from 8:55 A.M. to 9:32 A.M. revealed Registered Nurse (RN) #9 prepared and administered medications to three residents and did not wash hands with soap and water. Additionally, RN #9 pushed Resident #6's lisinopril 10 mg from the pill card into her bare hand and placed it in the medication cup prior to administrating the medication. During an interview on 06/14/2026 at 9:06 A.M. RN #9 verified she had taken the medication from the card with her bare hand and placed the pill in the medication cup. During an interview on 06/14/2026 at 9:33 A.M. RN #9 verified she had passed medications to three residents and had not washed her hands with soap and water. Review of policy titled Medication Administration dated 2026 revealed licensed personnel removed medication from the source, taking care not to touch medications with bare hands and performed appropriated hand hygiene as per policy. 3. Observation on 06/14/2026 at 12:39 P.M. revealed Certified Nursing Assistant (CNA) #38 was passing lunch trays to residents on the locked unit. CNA #38 poured red fluid from a pitcher into Styrofoam cups and placed the uncovered cups on a tray on top of the meal cart next to a large clear plastic bag with a mix of plastic utensils. CNA #38 reached into plastic bag and placed utensils on each tray and placed cups of red liquid on meal trays as she served trays to Resident #13, #18, and #22 who walked up to the meal cart. There was no hand sanitizer on cart, and CNA #38 did not sanitize hands between trays. CNA #38 closed the cart and pulled it down the hallway. CNA #38 placed pre-poured drinks on trays and retrieved plastic utensils out of the bag before delivering trays to Resident #23 and #7 who were in their rooms. CNA #38 did not sanitize or wash hands between residents. During an interview on 06/14/2026 at 12:44 P.M. CNA #38 verified she was responsible for pouring drinks and placing plastic utensils on the meal trays. She stated she poured a bunch of drinks and set them on the tray on top of the cart, uncovered, before she started passing the trays. She said she had not sanitized or washed her hands throughout the lunch service. She stated this was the only place she had ever worked where she had to put the utensils on the plate and stated Sometimes that bag gets sticky. 4. Review of the personnel files revealed the Administrator, the former DON #400, the Admissions #76, the Human Resources (HR) #74, and Certified Nursing Assistant (CNA) #32 had no evidence of a two-step Mantoux testing upon hire and CNA #34 had no evidence of Annual Tuberculosis (TB) screening of symptoms. During an interview on 06/16/26 at 10:24 A.M., the HR #74 verified the Administrator, the former DON #400, the Admissions #76, the Human Resources (HR) #74, and Certified Nursing Assistant (CNA) #32 had no evidence of two-step Mantoux testing upon hire and CNA #34 had no evidence of Annual Tuberculosis (TB) screening of symptoms. Review of facility TB Risk assessment dated [DATE] revealed healthcare workers received a two-step test upon hire and as needed. Test records were maintained in the employee file by Human Resources. Review of policy titled Infection Control – Tuberculosis Screening, undated revealed the facility screened all employees for TB infection after an offer was made but prior to the employee's duty assignment. The initial TB testing was a two-step test performed by injecting 5 Tuberculin units of purified protein derivative intradermally by a qualified health professional. If the reaction to the first test was negative, the facility administered a second test between seven to twenty-one days after the first test. The facility provided annual TB screening by screening all staff for symptoms. 5. Review of the medical record revealed Resident #5 was admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, hypertension, dysphagia, anemia, depressive episodes and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. Resident #5's functional assessment revealed he was dependent for all Activities of Daily Living (ADL) and dependent for bed mobility, transfers, and wheelchair mobility. Review of the Electronic Health Record (EHR) on 06/14/26 at 4:00PM revealed Resident #5 had a physician's order for enhanced barrier precautions related to gastronomy tube (G-Tube). Observation on 06/14/26 at 4:17 P.M. revealed Resident #5 had signage on his door announcing the resident was in enhanced barrier precautions (EBP). There was no cart with Personal Protective Equipment (PPE) outside the door. Observation on 06/15/26 at 9:00 A.M. revealed Registered Nurse (RN) #410 administered medications through the G-tube without wearing a gown. A cart with PPE had been placed outside of Resident #5's room at this time. Interview on 06/14/26 at 4:17 P.M. with the Director of Nursing (DON) verified no cart with PPE was present outside of Resident #5's door. Interview with RN #410 verified she administered medications through the G-tube of Resident #5 without having a gown on. Review of policy titled Enhanced Barrier Precautions, dated 2025 reveals to make gowns and gloves available immediately near or outside of resident's room. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities. High-contact resident care activities include: device care or use, including feeding tubes. 6. Review of the form Testing and Monitoring of Water Management Plan for Legionella revealed there were no logs or documentation of water flushes being completed. Interview on 06/16/26 at 12:12 P.M., the Maintenance Director #78 verified the facility does not document water flushes in unoccupied rooms for Legionella prevention. Review of policy titled Legionella Surveillance, dated 2023 reveals in the absence of Legionella infections for a period of at least one year the facility shall implement primary prevention strategies. Review of the facility's Water Management Plan revealed there were only the last two pages of the plan in the Legionella binder. The plan had been signed by Maintenance Director #78. The plan revealed that stagnant water was a risk factor and that taps should be run in unoccupied rooms weekly.

Based on medical record review, observations, staff interviews and policy review, the facility failed to ensure medications were stored in a sanitary and secure manner and failed to properly dispose of expired medications. This had the potential to affect 20 residents who reside on the 200-300 halls. The facility census was 31. Findings include:1.Observation on 06/15/26 at 8:53 A.M. at the Team One nurse's station revealed two medication cards each containing 30 Clozapine 50 mg pills for Resident #13 sitting out in an unlocked room on top of a wire rack holding hard charts. During an interview on 06/15/26 at 8:56 A.M. the Director of Nursing (DON) verified there were two pill cards for Resident #13 containing 60 Clozapine 50 mg tablets sitting on top of charts behind the nurse's station that were improperly stored and should have been locked in the medication room. 2. Observation of the Medication Cart One on 06/15/26 from 11:11 A.M. to 11:13 A.M. revealed there was one bottle of vitamin B12 100 microgram (mcg) tablets with an expiration date of 05/2026 in the top drawer. The middle drawers contained individual medication cards. Upon examination, four oblong orange tablets marked 512 (identified as empagliflozin) and one round blue tablet marked N559 (identified as L-methylfolate calcium) were observed out of the package in the bottom of the drawers underneath the medication cards. During an interview on 06/15/2026 at 11:18 A.M. Registered Nurse (RN) #11 verified the B12 tablets were expired and should have been discarded. RN #1 1 verified the four orange tablets and one round blue tablet were improperly stored and should have been discarded. 3. Observation on 06/15/26 at 11:22 A.M. in the Front medication room revealed two full bottles of B12 100 mcg 100 tablets with an expiration date of 05/2026 and two boxes Vapor action drops, 24 drops per box, with an expiration date of 03/2026. During an interview on 06/15/2026 at 11:26 A.M. RN #11 verified the throat drops and B12 tablets were expired and should have been thrown away. 4. Observation of the Medication Cart Three/Four on 06/15/26 at 11:27 A.M. revealed the top drawer contained nine ampules of Refresh Plus eye drop with an expiration date of 04/26 and one bottle of Thiamine B-1 100 mg marked as opened on 06/15/26 with an expiration dated of 02/26. The middle drawers contained individual medication cards. Upon examination, one tear-shaped, light yellow tablet marked TL and one round white tablet marked S-10n were found unpackaged in the bottom of the drawer under the medication cards. During an interview on 06/15/26 at 11:30 A.M. RN #410 verified B-1 100 mg tables were expired. RN #410 stated she had administered them this morning and had not checked the expiration date because it was labeled that it was opened 06/14/26 and she assumed it was good. RN #410 verified the two pills found in bottom of the middle drawer were not stored properly. During an interview on 06/16/26 at 11:13 AM the DON verified one resident (Resident #4) had active orders for B-1 100 mg, and two residents (Resident #5 and Resident #29) had active orders for Refresh Plus eye drops. There were no residents in the facility with active orders for B-12 100 mcg. Review of policy titled Medication Storage dated 2025 revealed all medications and biologicals were stored in locked compartments and the facility routinely inspected for discontinued and destroyed outdated medications according to policy.

Based on review of the weekly menu and diet spreadsheets, observation, staff and resident interviews, and policy review, the facility failed to provide drinks per resident preference. This affected four (Resident #4, #9, #10 and #35) out of 30 residents that received food trays. The facility census was 31. Findings Included: Review of the weekly menu week one provided upon request at entrance revealed coffee was listed as a menu item at all three meals every day. Review of the diet spreadsheets for 06/14/26 breakfast and lunch revealed coffee was listed at both meals. Observations of meal service in the kitchen on 06/14/26 between 8:25 A.M. and 8:45 A.M. and tray delivery on 06/14/26 between 12:25 P.M. and 12:45 P.M. revealed there was no coffee available to serve residents. Interview on 06/14/26 at 2:20 P.M. Resident #10 stated she liked to drink coffee with breakfast and did not have coffee with breakfast that morning. Interview on 06/14/26 at 2:21 P.M., Resident #09 stated she did not receive coffee with breakfast or lunch that day. Resident #09 stated she wanted coffee with every meal but often did not receive it as requested. Interview on 06/14/26 at 2:12 P.M., CNA #44 verified there was no coffee available at breakfast nor lunch. CNA #44 stated the coffee normally comes on top of the cart at breakfast. CNA #44 verified several residents asked for coffee and she told them it was not available. Interview on 06/14/26 at 2:26 P.M., the Dietary Manager (DM) #100 stated coffee was normally sent with breakfast trays but not with lunch and dinner. DM #100 stated coffee was served with activities at 11:00 A.M., 2:00 P.M., and 4:00 P.M., so coffee was not automatically sent with the trays, however if a resident wanted coffee, they could come to the dining room to get it. DM #100 verified the menus indicated coffee was listed as a menu item at all meals. Interview on 06/14/26 at 10:09 A.M., Resident # 4 prefers to have coffee with breakfast but had been told by staff for two weeks that there wasn't any coffee. Interview on 06/15/26 at 9:05 A.M. with Resident #35 revealed no coffee had been provided to her since she was admitted to the facility on [DATE]. Review of the facility policy titled, Food Preparation Guidelines, revealed menu items should be prepared following the facility's written menus and staff shall accommodate resident preferences. Drinks shall be provided consistent with resident needs and preferences.

Based on observation, interview, and policy review, the facility failed to ensure residents were treated with dignity and respect. This affected one (#02) out of four residents reviewed for dignity. The facility census was 31.Findings include:Review of the medical record for Resident #02 revealed an admission date of 09/04/18. Diagnoses included type two diabetes mellitus with diabetic polyneuropathy, aphasia following cerebral infarction, pseudobulbar affect, major depressive disorder, schizoaffective disorder, generalized anxiety disorder, and flaccid hemiplegia affecting right dominant side.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #02 was severely cognitively impaired. Resident #02 was assessed to require substantial/maximal assistance with eating, oral hygiene, and bed mobility, and was dependent for toileting, bathing, dressing, personal hygiene, and transfer.Observation on 06/14/26 at 9:59 A.M. revealed Resident #02 was sitting in bed with the breakfast tray on the overbed table. Certified Nurse Aide (CNA) #14 was standing up next to the overbed table and feeding Resident #02.Interview on 06/14/26 at 10:00 A.M. with CNA #14 revealed it was common practice for them to stand up while providing feeding assistance.Review of the facility policy titled Promoting/Maintaining Resident Dignity, undated revealed all staff were involved in providing care to residents to promote and maintain resident dignity. This deficiency represents non-compliance investigated under Complaint Number 3040887.

Based on medical record review, resident and staff interviews, and policy review, the facility failed to ensure residents had access to personal care products. This affected one (Resident #22) of five residents sampled for dignified care. The facility census was 31. Findings include: Review of the medical record revealed Resident #22 was admitted to the facility on [DATE]. Diagnoses included type II diabetes, chronic obstructive pulmonary disease, schizoaffective disorder - bipolar type, unspecified dementia, recurrent major depressive disorder, unspecified intellectual disabilities, human immunodeficiency virus, unspecified protein-calorie malnutrition, unspecified epilepsy, and unspecified anxiety disorder. Review of most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #22 required supervision for oral and personal hygiene. During an interview on 06/14/2026 at 11:00 A.M. Resident #22 stated he had issues getting razors and mouthwash. He stated the facility had been out of mouthwash for four days, and he had not shaved in four or five days. During an interview on 06/15/2026 at 12:10 P.M. Certified Nursing Assistant (CNA) #36 stated resident on the locked unit were not allowed to keep the mouthwash or razors in their rooms unsupervised. She stated there had never been a shortage of razors or mouthwash, but staff had to supervise residents on the men's unit while they used them. During an interview on 06/15/2026 at 12:12 P.M. CNA #34 stated Resident #22 asked for razors and mouthwash all the time. CNA #34 verified he told Resident #22 the facility didn't have any/were out of razors and mouthwash because Resident #22 drank the mouthwash, the CNA #34 did not want the resident cutting himself with a razor. CNA #34 stated as far as he knew, the facility had never had a shortage of razors or mouthwash. Review of policy titled Accommodation of Needs dated 2025 revealed the facility treated residents with dignity and respect and made reasonable accommodations for the individual needs and preferences of each resident.

Based on medical record review, document review, and staff interview, the facility failed to ensure residents with funds accounts had written authorizations in place. This affected two (#17 and #04) of four residents reviewed for funds. The facility identified 23 residents with current funds accounts. The facility census was 31. Findings include: 1. Review of the medical record of Resident #17 revealed an admission date of 02/09/24. Diagnoses included type II diabetes mellitus. Review of the Trust Account Balance list dated 06/15/26 revealed Resident #17 had an active funds account with the facility. The account balance was $4380.75. Review of requested documents revealed Resident #17 did not have a signed authorization for his funds account. Interview on 06/16/26 at 10:25 A.M., Business Office Manager (BOM) #74 verified Resident #17 did not have a signed authorization for his funds account. 2. Review of the medical record of Resident #04 revealed an admission date of 02/14/25. Diagnoses included chronic obstructive pulmonary disease. Review of the Trust Account Balance list dated 06/15/26 revealed Resident #04 had an active funds account with the facility. The account balance was $0.10. Review of the requested documents revealed Resident #04 did not have a signed authorization for his funds account. Interview on 06/16/26 at 10:25 A.M., BOM #74 verified Resident #04 did not have a signed authorization for her funds account.

Based on medical record review, document review, and staff interview, the facility failed to timely refund resident accounts. This affected one (#37) of one resident reviewed for closed funds accounts. The facility identified 23 residents with current funds accounts. The facility census was 31. Review of the medical record of Resident #37 revealed an admission date of 01/18/17. Diagnoses included paranoid schizophrenia. The resident discharged from the facility on 12/11/25. Review of the final resident trust fund check, dated 06/05/26, revealed the resident was refunded $1770.86. Interview on 06/16/26 at 10:34 A.M., Business Office Manager (BOM) #74 verified Resident #37's account was not refunded until 06/05/26. BOM #74 stated, upon starting her position, she reviewed accounts and found the account had not yet been refunded. BOM #74 verified refunds should be issued within 30 days of discharge. Review of Resident #37's Management of Personal Funds authorization form, dated 12/07/21, revealed personal funds would be returned to the appropriate source within thirty days of discharge.

Based on medical record review, staff interviews and policy review, the facility failed to ensure baseline care plans addressed resident needs identified upon admission. This affected one (Resident #32) of three residents sampled for care planning. The facility census was 31. Findings include:Review of the medical record revealed Resident #32 was admitted to the facility on [DATE]. Diagnoses included wedge compression fracture of unspecified vertebra, unspecified dementia, repeated falls, type II diabetes, and unspecified anxiety disorder. Review of the minimum data set (MDS) assessment in progress started 06/11/26 revealed Resident #32 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Review of the admission nursing assessment dated [DATE] at 4:44 P.M. revealed Resident #32 had Moisture Associated Skin Damage (MASD) to buttocks. Review of a baseline care plan dated 06/08/26 revealed Resident #32 had no care plan related to current MASD or risk for pressure injury, had no care plan related to code status or advanced directives, and the dietary care plan was incomplete and was missing the resident's specific diet orders . Review of a progress note dated 06/11/26 revealed the nurse practitioner assessed Resident #32's skin and recommended treatment for Incontinence Associated Dermatitis (IAD) to bilateral buttocks including cleanse with wound cleanser or normal saline, applying Triad paste to base of the wound, leaving open to air, and changing every shift and as needed. Review of the electronic medical record revealed Resident #32 had no physician orders related to code status or the IAD treatment. During an interview on 06/15/26 at 8:48 A.M. the Director of Nursing (DON) verified Resident #32 had no baseline care plan for MASD or pressure injury risk, the dietary care plan was incomplete, and there was no care plan for code status or advanced directives. During an interview on 06/15/26 at 9:07 A.M. Licensed Practical Nurse (LPN) #70 stated upon admission, the nursing assessment populated to the baseline care plan. She stated if the nurse's filled out the assessment correctly, the care plan would reflect it. LPN #70 verified Resident #32 had no care plan for MASD with interventions for treatment or monitoring. LPN #70 verified Resident #32's dietary care plan was not completed accurately to reflect his current diet orders. Review of policy titled Baseline Care Plan dated 2025 revealed the facility developed a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care. Interventions were initiated to address the resident's current needs including pressure injury risk and wound care.

Based on interview, record review, and policy review, the facility failed to ensure the care plan was revised for advance directives. This affected one (Resident #4) out of 16 residents reviewed for Advance Directive care planning. The facility census was 31.Findings Include:Review of the medical record revealed Resident #4 was admitted on [DATE]. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), chronic diastolic heart failure, type II Diabetes Mellitus, major depressive disorder, unspecified asthma, and generalized muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact as evidenced by Brief Interview for Mental Status score of 15. Functional abilities include set up assistance with oral hygiene and eating, moderate assistance toileting and bathing, supervision with dressing and grooming, supervision with bed mobility and transfers, and supervision with wheelchair mobility.Review of the electronic health record revealed Resident #4 had a physician's order dated 05/18/26 for Do Not Resuscitate (DNR). A hard copy of the advanced directive order form dated 05/18/26 was presented by the Director of Nursing (DON) revealed Resident #4 was Do Not Resuscitate Comfort Care (DNRCC). The plan of care completed on 05/20/26 revealed Resident #4 was care planned as a Full Code.Interview on 06/15/26 at 9:13 A.M. with the DON verified the most current care plan in the electronic health record does not match the advance directive ordered for Resident #4.Review of the Policy titled Residents' Rights Regarding Treatment and Advance Directives dated 2026 revealed during the care planning process, the facility will identify, clarify, and review with the resident or legal representative, whether they desire to make any changes related to any .Advance Directives. Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. Any decision making regarding the residents choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care.

Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure adequate activities of daily living (ADL) care was provided. This affected one (#10) of two residents reviewed for ADL care. The facility census was 31. Findings include:Review of the medical record of Resident #10 revealed an admission date of 04/11/27. Diagnoses included schizoaffective disorder, bipolar disorder, type 2 diabetes mellitus, peripheral vascular disease (PVD), and congestive heart failure (CHF). Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #10 had intact cognition. The resident required supervision with eating, bed mobility, and transfers, and partial/moderate assistance with bathing and personal hygiene. Review of the plan of care dated 06/30/25 revealed Resident #10 had an ADL self-care performance deficit related to CHF and PVD. Interventions included to provide assistance with bathing/showering. Observation on 06/14/26 at 11:01 A.M., Resident #10 had numerous hairs on her chin, measuring approximately one half inch in length. Interview at the time of the observation, Resident #10 stated she did not prefer to have chin hair. Interview on 06/14/26 at 11:02 A.M., Registered Nurse (RN) #09 verified Resident #10 had chin hair that needed shaved. Observation on 06/16/26 at 8:15 A.M., Resident #10 still had numerous chin hairs. Review of the facility policy titled Activities of Daily Living, dated 2025, revealed a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal hygiene.

Based on medical record review, observation, and resident and staff interview, the facility failed to provide the care and services to treat edema. This affected one (#10) of one resident reviewed for edema. The facility census was 31. Findings include:Review of the medical record of Resident #10 revealed an admission date of 04/11/17. Diagnoses included schizoaffective disorder, bipolar disorder, type 2 diabetes mellitus, peripheral vascular disease, and congestive heart failure. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #10 had intact cognition. The resident required supervision with eating, bed mobility, and transfers, and partial/moderate assistance with bathing and personal hygiene. Review of the plan of care dated 06/30/25 revealed Resident #10 had an ADL self-care performance deficit related to her disease process. The resident was noted to require assistance with bathing/showering. Review of the physician orders revealed an order dated 02/06/26 to apply compression stockings every day shift. Interview on 06/14/26 at 11:02 A.M., Resident #10 stated nobody was applying her compression stockings. Observation on 06/14/26 at 12:09 P.M. revealed Resident #10 had edema in both legs and feet. The resident was wearing non-skid socks and the non skid sock was rolled down below the ankle, which revealed pitting edema. The resident was not wearing compression stockings. Review of the June 2026 treatment administration record (TAR) on 06/14/26 revealed Registered Nurse (RN) #15 signed off the compression stockings. Observation on 06/14/26 at 3:15 P.M. Resident #10 was not wearing compression stockings. Interview on 06/14/26 at 3:16 P.M., RN #15 verified Resident #10 was not wearing compression stockings. RN #15 further verified she had signed the TAR to indicate the compression stockings had been applied. Review of the June 2026 TAR on 06/15/26 revealed RN #11 signed off the compression stockings. Observation on 06/15/26 at 4:00 P.M., Resident #10 was not wearing compression stockings. Interview on 06/15/26 at 4:01 P.M., RN #11 verified Resident #10 was not wearing compression stockings. RN #11 further verified she had signed the TAR to indicate the compression stockings had been applied and signing the TAR should indicate the compression stockings had been applied.

Based on medical record review, interviews, and policy review, the facility failed to implement orders for wound treatments. This affected one (Resident #32) out of one resident sampled for pressure injury prevention. The facility census was 31. Findings include: Review of the medical record revealed Resident #32 was admitted to the facility on [DATE]. Diagnoses included wedge compression fracture of unspecified vertebra, unspecified dementia, repeated falls, type II diabetes, and unspecified anxiety disorder. Review of the admission nursing assessment dated [DATE] at 4:44 PM revealed Resident #32 had Moisture Associated Skin Damage (MASD) to buttocks upon admission. Review of the care plan dated 06/08/26 revealed Resident #32 had no care plan related to current MASD or risk for pressure injury. Review of a wound assessment report dated 06/11/26 revealed Wound Nurse Practitioner (NP) #408 assessed Resident #32 for MASD wounds to the right and the left buttocks and wrote treatment orders to clean with wound cleanser, apply Triad paste, and leave open to air every shift and as needed. During an interview on 06/15/26 at 8:48 A.M. the Director of Nursing (DON) verified Resident #32 had no active treatment orders for MASD to bilateral buttocks. During a telephone interview 06/16/26 at 10:44 A.M., the Wound Nurse Practitioner (NP) #408 verified she completed wound rounds at the facility with an unidentified staff nurse on 06/11/26. Wound NP #408 stated she assessed and measured Resident #32's MASD to bilateral buttocks and provided verbal treatment orders to the nurse for the areas to be cleansed with wound cleanser, Triad paste applied to the wound bed, and left open to air every shift and as needed. Wound NP #408 stated the orders were also provided in her written wound assessment note that day. Wound NP #408 stated the expectation was that she provided verbal and written orders on the day of assessment and the facility staff entered the orders into the electronic record. Review of policy titled Pressure Injury Prevention and Management dated 2026 revealed the facility provided treatments and services to heal pressure injuries and to prevent infection and development of additional pressure injuries.

Based on record review, review of a facility self-reported incident (SRI), review of a police report, staff interview and policy review, the facility failed to ensure residents were from staff to resident physical abuse with serious injury. This resulted in Immediate Jeopardy and Actual Harm on 04/18/26 at approximately 10:40 A.M. when Dietary Aide (DA) #51 punched Resident #4 in the face. Resident #4 was admitted to the hospital with a broken jaw. This affected one (Resident #4) of three residents reviewed for abuse. The facility census was 29 residents. On 04/23/26 at 10:32 A.M., the Administrator was notified Immediate Jeopardy began on 04/18/26 at approximately 10:40 A.M. when DA #51 punched Resident #4. The Immediate Jeopardy was removed on 04/24/26 when the facility implemented the following corrective actions: On 04/18/26 at 10:40 A.M., Certified Nurse Aide (CNA) #86 separated DA #51 and Resident #4 to provide for resident safety and obtained assistance from Registered Nurse (RN) #71. On 04/18/26 at 10:42 A.M., Dietary Manager (DM) #50 escorted DA #51 off the unit. The Administrator suspended DA #51 pending investigation. On 04/18/26 at 10:43 A.M., RN #71 assessed Resident #4 for injury and administered first aid to the resident who had some bleeding from his nose and mouth. On 04/18/26 at 10:44 A.M., RN #71 notified the Director of Nursing (DON) of the incident. On 04/18/26 at 10:47 A.M. DM #50 phoned the DON to confirm DA #51 was awaiting law enforcement under the DM's supervision. On 04/18/26 at 10:47 A.M., the DON notified the Administrator. On 04/18/26 at 10:57 A.M., RN #71 called emergency services (EMS) and local law enforcement via 911. Resident #4 initially refused transport to the hospital, and EMS left. On 04/18/26 at 11:01 A.M., RN #71 contacted Resident #4's sister with notification of the incident and the resident's refusal of transfer to the hospital. Resident #4's sister was able to persuade the resident to go the hospital. RN #71 contacted EMS again, and they transported the resident to the hospital. On 04/18/26 at 10:58 A.M. the DON notified the Chief Nursing Officer (CNO) of the incident. On 04/18/26 at 11:15 A.M., DM #50 obtained a statement from DA # 51 regarding the incident. On 04/18/26 at 11:40 A.M., the Administrator initiated an SRI with the Ohio Department of Health (ODH) documenting there had been an altercation between DA #51 and Resident #4. The SRI documented the incident had no ill effects on Resident 4, and the resident remained at baseline. On 04/18/26 at 11:57 A.M., DA #51 met with law enforcement outside of the building in the facility parking lot. On 04/18/26 at 12:13 P.M., the Administrator and the DON advised DA #51 to leave the facility property and not to return but to be available by telephone to speak with the Administrator and DON to complete an investigation interview. On 04/18/26 the Administrator, the DON, the CNO, and the Chief Operating Officer (COO) completed a root cause analysis of the incident and determined the following root causes: unknown male on the unit, medication changes, decline in cognition. On 04/18/26, the DON/Designee began all staff education on abuse prevention initiated which included a follow-up post-test. Any employee not receiving all education by this date will receive prior to next scheduled shift. On 04/20/26, the DON/Designee began all staff education that employees should not enter the secured unit unless they have assigned duties in that area. All education was concluded on 04/21/26. Any employee not receiving all education by this date will receive prior to next scheduled shift. On 04/18/26, the following staff completed written witness statements regarding the incident: CNA #86, CNA #11, RN #71, DA #51. On 04/18/26, the nurse on duty conducted body audit on residents with a Brief Interview of Mental Status (BIMS) score below 12 (moderate cognitive impairment) with no evidence of abuse identified. On 04/20/26, the Social Service Director (SSD) conducted interviews with residents with a BIMS score of 12 (cognitively intact) and above with no concerns of abuse identified. On 04/20/26, the Clinical Consultant (CC) reviewed the facility grievance logs for the duration of DA #51's tenure with the facility and identified no concerns. On 04/20/26, the CC reviewed the facility incident logs for the duration of DA #51's tenure and identified no concerns. On 04/20/26, the CC reviewed DA #51's criminal background check and identified the aide had no criminal acts involving physical assault or altercations recorded. On 04/20/26 at 10:15 A.M., the facility implemented monitoring to confirm the only employees to enter the secured unit were those who were assigned to perform specific duties on the unit, and to ensure no other staff members entered the unit. Monitoring will continue two times per day for four weeks and then three times per week for two months. All concerns will be addressed at time of discovery. On 04/18/26 an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held which included the Administrator, the DON, the Chief Operating Officer (COO), the CNO, and DM #50. On 04/20/26, the Resident Assessment Coordinator (RAC) and the Medical Director (MD) were included in the ad hoc QAPI actions. On 04/21/26 at 2:04 P.M., DM #50 terminated DA #51's employment by phone due to resident abuse. On 04/23/26, the Resident Care Coordinator (RCC) began staff education on deescalation techniques titled Resident Aggression: Understanding and Managing Difficult Behaviors with education completed on 04/24/26. Any employee not receiving all education by this date will receive prior to next scheduled shift. On 04/24/26, the Administrator finalized the SRI involving DA #51 towards Resident #4. The facility substantiated DA #51 had physically abused Resident #4. Although the Immediate Jeopardy was removed on 04/24/26, the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure ongoing compliance. Findings include: Review of the medical record for Resident #4 revealed an admission date of 01/11/26 with diagnoses including anoxic brain damage, acute and chronic respiratory failure, anxiety disorder, viral hepatitis C, schizoaffective disorder, and cerebral infarction. Review of the Minimum Data Set (MDS) assessment for Resident #4 dated 01/22/26 revealed the resident was cognitively intact and required supervision of staff with activities of daily living (ADL). Review of the care plan for Resident #4 dated 01/22/26 revealed the resident had the potential for behavior problems related to noncompliance with care, treatment and medications, and at times would not adhere to safety measures. Resident #4 could be physically aggressive with staff. Interventions included the following: administer medications as ordered, allow resident to discuss feelings, approach and speak to the resident in a calm voice, attempt non-pharmacological interventions specific to the resident when behaviors are identified, encourage resident to attend activities of choice, staff to anticipate resident's needs. Review of a progress note for Resident #4 dated 04/18/26 revealed Certified Nursing Assistant (CNA) #86 observed Resident #4 hit DA #51. CNA #86 saw DA #51 strike Resident #4. DA #51 was immediately removed from the floor. Resident #4 was bleeding from his mouth. The nurse provided first aid to Resident #4 and notified the appropriate parties of the incident. Review of a witness statement per CNA #86 revealed DA #51 came onto the secured unit to see what Resident #4 wanted and Resident #4 immediately hit DA #51 in the face. Review of the witness statement from CNA #10 revealed DA #51 stated he was going back on the unit to see what Resident #4 wanted, because DA #51 saw the resident tapping on the window to the secured unit. CNA#10 instructed DA #51 to stay off the unit because Resident #4's aide could assist him. CNA #10 then heard screaming and went to check on the resident. DA #51 reported to the CNA #10 that Resident #4 had hit him in the face and as a reflex, he hit Resident #4 back. Review of the witness statement from RN #71 revealed DA #51 stated he was going on the unit to see what Resident #4 wanted as he was tapping on the window. RN #71 told him not to go on the unit, but he went anyway. RN #71 reported three seconds later she heard CNA #86 screaming she so ran onto the unit and found Resident #4 bleeding from his nose and mouth. Review of a witness statement from DA #51 dated 04/18/26 at 11:15 A.M. revealed as he was taking something back onto the secured unit, he saw Resident #4 standing by the door with money in his hand. DA #51 then asked Resident #4 if he wanted him to buy a soda for him. Resident #4 then swung at DA #51 hitting the aide in the lip. DA #51 punched Resident #4 in the lip as a reflex. Review of a nursing note for Resident #4 dated 04/18/26 revealed the resident was transported by emergency squad to the hospital. Review of the hospital records for Resident #4 dated 04/18/26 revealed the resident was admitted to the hospital after sustaining an open fracture to the right jaw. Resident #4's right lateral mandibular incisor (tooth) was loose and there was bleeding from the socket with the displaced tooth at the fracture site. All of Resident #4's remaining 11 teeth were extracted as they could not be restored. Review of the police report for Resident #4 dated 04/18/26 revealed the incident was reported on 04/18/26 at 11:57 A.M. and the police entered the facility on 12:07 P.M. for assault as a Misdemeanor 1. Assault by DA #51 against Resident #4 of 04/18/26 at 12:07 P.M. No physical arrest occurred. An officer responded to the facility for an assault that was not in progress. Staff advised police that a resident had punched a staff member and the same staff punched the resident back. Review of the termination notice for DA #51 dated 04/21/26 revealed the employee was terminated due to abuse of a resident. During an interview on 04/22/26 at 10:32 A.M., the Administrator stated DA #51 admitted to hitting Resident #4 in the face on 04/18/26 which broke the resident's jaw. The Administrator confirmed DA #51 was immediately removed from the floor following the incident, was interviewed by the police, was suspended pending investigation, and was terminated on 04/21/26 due to abuse of a resident. The Administrator stated Resident #4 was transferred to the hospital on [DATE] and had not returned to the facility. During an interview on 04/27/26 at 3:18 P.M., RN #71 stated she told DA #51 not to go back on the secured unit as Resident #4 had been agitated the previous day and was currently tapping on the window. RN #71 stated DA #51 ignored her advice and entered the unit. RN #71 stated she then heard the CNA yelling. RN #71 confirmed when she went onto the unit, she observed Resident #4 bleeding from his nose and mouth and provided assessment and treatment until she could get Resident #4 sent to the hospital. During an interview on 04/28/26 at 11:26 A.M., CNA #86 stated on 04/18/26 Resident #4 was knocking on the window of the unit when DA #51 came onto the unit with juice for another resident. CNA #86 stated Resident #4 hit DA #51 and CNA #86 immediately stepped between the two to attempt to deescalate the situation. She opened the door to call for the nurse due to Resident #4's aggression. As she closed the door from getting the nurse, she heard DA #51 tell the resident, I will hit you again CNA #86 said then she saw Resident #4 was bleeding. CNA #86 stated RN #71 then came to do an assessment on Resident #4 and DM #50 came and removed DA #51 from the unit. During an interview on 04/28/26 at 1:18 P.M., DA #51 stated on 04/18/26 he entered the secured unit to take juice to another resident. Once he entered the unit, he noticed Resident #4 had money in his hand and offered to buy him a soda. DA #51 stated Resident #4 hit him immediately. DA #51 confirmed he then hit Resident #4 back as a reflex. DA #51 stated he then left the unit as directed and waited to talk to the police. DA #51 confirmed he lost his job as a result of the incident. Review of the facility policy titled Abuse, Neglect, and Exploitation, undated, revealed abuse was defined as the willful inflection of injury, unreasonable confinement, intimidation, or punishment resulting physical harm, pain, or mental anguish. Physical abuse was defined as including but was not limited to hitting, slapping, punching, biting and kicking. Abuse also included controlling behavior through corporal punishment. This deficiency represents noncompliance investigated under Master Complaint Number 2989908 and Complaint Number 2988458 and Complaint Number 2977628 and Complaint Number 2988715.

Based on medical record review, hospital documentation review, staff interview, and review of facility policies, the facility failed to follow facility procedures for leave of absences (LOAs), failed to implement interventions and provide education to residents and family members to reduce falls and incidents while on LOAs, and failed to investigate causative factors and determine a root cause analysis of repeated fall incidents while on LOA from the facility. This resulted in actual harm when Resident #100 left the facility for LOAs with family and had repeated fall incidents and injuries during the LOAs. Resident #100 was seen in the emergency roiagnom on multiple occasions for fractures and dislocation of the left hip and fracture of the left femur which required hospitalization and surgical intervention. This affected one (#100) of two residents reviewed for falls. The census was 40. Findings include: Review of the medical record for Resident #100 revealed an admitted [DATE]. Diagnoses included alcohol abuse, weakness with unspecified symptoms and signs involving cognitive functions and awareness, major depressive disorder, aortic aneurysm, diabetes type two, hypoglycemia, diabetic neuropathy, hypertension, and cerebral infarct. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 was assessed with no cognitive impairment, no behavioral symptoms, no wandering, and no rejection of care indicated. Further review revealed the resident required limited assistance for bed mobility, transfers, walking in the room, dressing, and personal hygiene, required supervision only for eating, toilet use, and locomotion on and off the unit. Review of a nursing progress note dated 07/05/23 at 3:42 P.M. revealed Resident #100 was on a LOA with a family member when a facility staff member contacted the family member to inquire about Resident #100's whereabouts. Further review of the nursing progress note revealed the nurse educated Resident #100's family that the resident needed to be properly signed out of the facility during LOAs. Review of a nursing progress note dated 07/16/23 at 11:21 A.M. revealed Resident #100 was on a LOA until the next Monday. Review of a nursing progress note dated 07/17/23 at 3:23 P.M. revealed a facility nurse spoke to the hospital and informed the nurse Resident #100 was admitted to the hospital with a closed fracture of the left hip sustained when the resident was drunk and fell at home. Review of a nursing progress note dated 07/25/23 at 6:19 P.M. revealed Resident #100 returned to the facility. Review of a nursing progress note dated 08/10/23 revealed Resident #100 was out to an appointment with his daughter and had not returned. Review of a nursing progress note dated 08/11/23 at 3:15 A.M. revealed the facility received a telephone call from the hospital indicating Resident #100 fell from his daughter's truck approximately seven hours earlier that day and the resident's left hip was dislocated. The resident's left hip was put back into place and was on his way back to the facility. Review of a nursing progress note dated 08/11/23 at 3:40 P.M. revealed Resident #100 arrived to the facility, was alert and oriented, and had an abduction wedge (a padded device used to separate the legs) between the legs. Review of a nursing progress note dated 08/14/23 at 3:56 P.M. revealed a nurse was alerted that Resident #100 popped his hip out. Resident #100 stated he was trying to stand and sat down too hard in the chair and noticed his hip was out of place. A nurse practitioner was notified and Resident #100 was sent to the hospital for treatment. Review of a nursing progress note dated 08/22/23 at 4:12 P.M. revealed Resident #100 was picked up by a daughter for a LOA. Review of a nursing progress note dated 08/24/23 at 6:08 P.M. revealed, on 08/23/23, while on a LOA with a family member, Resident #100 experienced a closed dislocation of the left hip. Review of a nursing progress note dated 09/11/23 at 10:59 A.M. revealed a nurse at the facility received a telephone call from the hospital that Resident #100 was admitted for a closed fracture of the left hip. The hospital reported Resident #100 was drunk and fell at home and was brought to the facility by emergency medical services (EMS). Review of a fall risk assessment dated [DATE] revealed Resident #100 was assessed at high risk for falls with a history of multiple falls in the last six months. The resident was assessed to be confined to a chair and oriented, and was unable to independently come to a standing position, required hands on assistance to move from place to place, utilized an assistive device, and exhibited loss of balance while standing. Review of a nursing progress note dated 10/03/23 at 12:36 P.M. revealed the facility was not able to contact Resident #100's family regarding the resident's return to the facility. Review of hospital documentation dated 10/04/23 revealed Resident #100 was seen in the emergency room for complaints of hip pain and altered mental status. Resident #100 had a leg deformity on assessment, and per the resident's daughter, Resident #100 did not have the leg deformity the previous night. The resident was found to have a left femur fracture and per report did not remember how it occurred. A urine drug screen was tested and positive for amphetamines and benzodiazepines. Review of an x-radiation (x-ray) image of Resident #100's left femur dated 10/04/23 confirmed a displaced fracture of the proximal femur. Resident #100's hospital care plan timeline dated 10/05/23 included consideration of a left femur open reduction internal fixation (placing pieces of broken bone together using surgery often using screws, plates, sutures, or rods to put together) versus revision hip arthroplasty (total hip replacement). Review of the facility plan of care dated 04/22/22 for Resident #100 lacked documented evidence of any interventions during LOAs and did not address any safety for hip precautions from recent hip surgery or dislocation of hip. Review of Resident #100's fall plan of care dated 04/22/22 lacked documented evidence of any change to interventions for documented falls sustained on 07/17/23, 08/11/23, 08/23/23 and 10/04/23. Review of Resident #100's medical record had no documentation of any investigation for falls sustained while on LOA from the facility on 07/17/23, 08/11/23, 08/23/23 and 10/04/23. Review of Resident #100's medical record lacked any evidence of education for safety interventions during LOAs from the facility, and had no evidence for any release of responsibility forms for LOAs. Interview on 10/25/23 at 1:45 P.M. with the Director of Nursing (DON) verified the lack of documentation for Resident #100's LOA forms, verified there were no investigations completed for falls on 07/17/23, 08/11/23, 08/23/23 and 10/04/23, verified there was no documented education provided to Resident #100 or family for safety precautions while on LOAs, verified the lack of interventions implemented for Resident #100's hip fracture and dislocation, and verified there was no documentation of fall interventions implemented following Resident #100's repeated falls while on LOAs from the facility. Interview on 10/25/23 at 1:50 P.M. with Administrator #203 verified the facility leave of absence policy was not followed in accordance with the written policy for Resident #100's LOAs, and verified the lack of safety and/or oversight provided during Resident #100's LOAs with family. Review of a policy titled, Fall Response Policy and Procedure, dated 01/01/16, revealed the facility is to insure, to the best of its ability, the safety and well-being of residents who are at risk for falls and implement actions. The facility should implement an intervention to guard against another fall of the same type and initiate an investigation. Review of an undated policy titled, Change in Condition and Physician Notification, revealed the nurse will notify the physician and the resident when there is a need to alter medications or treatments or a significant change in the resident's physical, mental, or psychosocial status. Review of an undated policy titled, Leave of Absence, revealed the resident or person assuming responsibility will complete and sign the release of responsibility form prior to leaving. The nurse will document the LOA and relevant information. This deficiency represents non-compliance investigated under Complaint Number OH00147185.

Based on medical record review, staff and family interviews, and review of facility policy and procedures, the facility failed to ensure nutritional interventions were initiated and sustained to prevent unplanned weight loss for one (#52) of three residents reviewed for weight loss. This resulted in actual harm for Resident #52 who experienced a severe unplanned weight loss of 25.9 percent (%) in less than a one-month period of time. The facility census was 51 residents. Findings include: Review of the medical record for Resident #52 revealed an admitted [DATE] with diagnoses including bacteremia, cannabis abuse, cocaine abuse, pneumonia, protein calorie malnutrition, human immunodeficiency virus (HIV), and major depressive disorder. Review of the care plan for Resident #52 dated 07/11/23 revealed resident was at risk for nutrition/hydration problems related to mechanically altered diet, need for tube feed, underweight body mass index (BMI) noted, noncompliant with obtaining weights, prefers to stop and start tube feeding on own at times, non-compliant with wearing tube feed continuously and/or letting staff know when he disconnects from it. Interventions included the following: administer medications as ordered, allow resident to make choices/preference of food as able, dietary consult as needed, obtain weight as ordered, and provide diet as ordered. Review of the Minimum Data Set (MDS) assessment for Resident #52 dated 07/17/23 revealed the resident was cognitively intact and required supervision and set up help with eating. Review of the weight record for Resident #52 revealed the resident's height upon admission was 68 inches. On 07/10/23, the resident weighed 86.4 pounds. On 07/13/23, the resident weighed 87.1 pounds. On 07/28/23, the resident weighed 84.1 pounds. On 08/15/23, the resident weighed 79.8 pounds and on 08/31/23, the resident weighed 87.8 pounds. There were no weights recorded in the month of September. Review of the hospital progress notes dated 08/24/23 revealed Resident #52 weighed 85 pounds in the hospital. Review of the dietitian progress note for Resident #52 dated 08/31/23 revealed the resident's most recent weight was 87.8 pounds which represented a low BMI of 13.3. The resident consumed a mechanical soft diet by mouth for comfort and food drained into a stoma due to esophagus not attached. Resident #52 received feedings via a percutaneous endoscopic gastrostomy (PEG) tube for nutritional needs: Isosource 1.5 at 60 milliliters per hour via continuous pump. Resident #52 had been refusing tube feeding, disconnecting at times. The resident was educated and encouraged to accept tube feeding as ordered. The resident showed a slight weight gain which was desirable due to low BMI. Dietitian would continue to monitor the resident's weight. Review of the nurses progress notes for Resident #52 dated 09/01/23 to 09/16/23 revealed there were no recorded weights or refusal of weights for Resident #52 during this time. Review of nurses progress notes dated 09/03/23, 09/04/23, 09/05/23, 09/08/23, 09/10/23, 09/13/23, 09/14/23, and 09/16/23 revealed Resident #52 was found to have disconnected his continuous tube feeding himself and gone outside to smoke or to wander about the facility and staff educated the resident of the importance of allowing his tube feeding as ordered and to notify the nurses when he disconnected the tube feeding. Review of the nurse's progress note dated 09/16/23 revealed Resident #52 was sent to the hospital emergency room per ambulance due to difficulty breathing and decline in functioning. Review of the MDS for Resident #52 dated 09/16/23 revealed the resident was discharged from the facility with return not anticipated. Review of section K for Resident #52 revealed no weight was recorded and it was unknown if resident had experienced weight loss. Review of the hospital admission note for Resident #52 dated 09/16/23 revealed the resident's admitting weight to the hospital was 65 pounds. Review of the admitting physician's note revealed the resident was markedly malnourished and looked to have lost significant weight since the last time the physician saw the resident in the hospital on 08/24/23 (when resident's weight was 85 pounds). Review of nurse's progress note dated 09/17/23 revealed Resident #52's representative, Resident Representative (RR) #500, called the facility and shared the resident's weight upon admission to the hospital was 65 pounds, which was a 20-pound weight loss from his last hospital weight in August 2023. Further review of the note revealed the Mobile Director of Nursing (MDON) #365 would reach out to RR #500 to discuss her concerns. Interview by phone on 09/21/23 at 2:13 P.M. with RR #500 confirmed Resident #52 had been admitted to the hospital on 09/16/23, and the admitting doctor told her the resident weighed 65 pounds upon admission, which represented a 20 pound weight loss since his last hospital weight on 08/24/23 of 85 pounds. RR #500 confirmed no one from the facility had informed her of the resident's severe weight loss. Interview on 09/25/23 at 1:53 P.M. with MDON #365 confirmed Resident #52 was at nutritional risk due to tube feeding and noncompliance with feeding. MDON #365 verified the resident should be weighed weekly. Interview with MDON #365 confirmed Resident #52 frequently disconnected his tube feeding, which was his sole source of nutrition during the month of September 2023, and the facility did not obtain the resident's weight during the month of September. MDON #365 confirmed Resident #52 was admitted to the hospital on 09/16/23 and on 09/18/23, he spoke with RR #500 regarding her concerns about the resident's severe weight loss. MDON #365 confirmed the facility was not aware of Resident #52's weight loss until RR #500 brought the concern to the facility's attention. MDON #365 confirmed the facility learned the resident had experienced a weight loss of 22.8 pounds, representing a 25.9% weight loss from the last recorded facility weight on 08/31/23 of 87.8 pounds to the hospital admission weight on 09/16/23 of 65 pounds. MDON #365 confirmed the facility did not implement any new interventions regarding the severe weight loss for Resident #52 because they were not aware he had lost so much weight. Interview by phone on 09/26/23 at 11:28 A.M. with the Administrator confirmed neither the physician nor the Nurse Practitioner (NP) examined Resident #52 from 09/01/23 to 09/16/23. Review of the facility policy titled, Weight Change, dated 01/01/16 revealed a weight loss of five % or greater in 30 days was considered to be a significant weight loss. Review of the facility policy titled, Weight Protocol, dated 01/01/16 revealed residents at risk for unintended weight loss will be weighed weekly and nursing staff will document attempts and refusals. Weight was an important factor used in determining the nutritional status of every resident. Weight was needed to complete the nutritional assessment of the resident as well. The Physician should acknowledge non-compliance with weights in the progress notes and recommend other methods of nutritional assessment when indicated. This deficiency represents non-compliance investigated under Complaint Number OH00146569.

Based on record review, observation, staff, family, and Wound Physician (WP) #315 interviews, review of facility policy, review of wound physician notes, and review of guidelines from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to implement interventions/treatments to prevent the development of pressure ulcers and/or aid in the healing of existing pressure ulcers as ordered by the physician. This resulted in Actual Harm when Resident #35 was found to have avoidable pressure ulcers which were first identified as a stage III pressure ulcer on his right heel on 09/21/22 and an avoidable unstageable pressure ulcer in the palm of his left hand discovered at the time of the survey on 11/02/22. This affected one resident (#35) of two residents reviewed for pressure ulcers. The census was 48. Findings include: Review of the medical record for Resident #35 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) for Resident #35 dated 10/02/22 revealed the resident was cognitively impaired. Resident #35 was totally dependent on staff with all areas of activities of daily living (ADLs). Further review of the MDS assessment revealed the resident was coded as being at risk for the development of pressure ulcers and positive for the presence of a Stage III pressure ulcer on the right heel. Review of the care plan for Resident #35, revised on 10/02/22, revealed the resident was at risk for decreased skin integrity related to his weakness from left side [CONDITION(S)] and PVD diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the care plan revealed there were no specific interventions to reduce pressure to Resident #35's heels, such as elevation or floating of the heels. Review of the care plan revealed there was no care plan in place from 10/01/21 through 10/01/22 regarding the use of a carrot splint (wedge splint for contractures to keep hand open) or other pressure relieving interventions for resident's contracted left hand. Review of physician orders, dated 11/15/19, revealed Resident #35 was ordered to have weekly skin assessments to document skin integrity. Review of the Resident #35's most recent, Braden Scale for Predicting Pressure Sore Risk, dated 06/14/20, revealed resident was at low risk for developing pressures ulcers. Review of Occupational Therapy (OT) notes, dated 10/11/2021, revealed Resident #35, was totally dependent for all ADLs, had a contracture of the left hand, and would benefit from splinting of the left hand with carrot splint. Assessment summary indicated Carrot splint/orthotic device to be implemented. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the shower sheets dated 08/31/22, 09/14/22, 09/21/22, 09/27/22, and 10/25/22 revealed Resident #35 had no documented skin impairments. Review of the weekly skin assessment, dated 09/14/22, for Resident #35 revealed the resident was assessed to have no pressure areas and the resident's skin was intact. Additional review of weekly skin assessments prior to 11/02/22 revealed no documented skin assessments being completed. Review of the nurse progress notes for Resident #35, dated 09/21/22, revealed Nursing Assistant (NA) #500 identified an open wound on the right heel of Resident #35's foot. Further review of the note revealed the nurse cleaned and dressed the resident's wound. Review of Resident #35's, Skin Grid Pressure 3.0, dated 09/22/22, revealed a newly identified pressure area, on the resident's right heel, which measured 2.0 centimeters (cms) (length) by 3.3 cms (width) by 0.2 cm (depth), and categorized as a Stage III Pressure ulcer (full thickness tissue loss), with moderate drainage and notes indicated the physician was notified. Review of Skin Grid Pressure 3.0, dated 09/29/22, revealed the right heel pressure ulcer measured, 1.3 cms by 2.1 cms by 0.1 cm, was categorized as a Stage III pressure ulcer, and had a moderate amount of drainage. Review of Skin Grid Pressure 3.0, dated 10/06/22, revealed the right heel pressure ulcer measured, 1.2 cms by 2.4 cms by 0.1 cm, was categorized as a Stage III pressure ulcer, and had a moderate amount of drainage. Review of Skin Grid Pressure 3.0, dated 10/13/22, revealed the right heel pressure ulcer measured 1.4 cms by 1.1 cms by 0.1 cm, was categorized as a Stage III pressure ulcer, and had a moderate amount of drainage. Review of the WP #315 progress note for Resident #35, dated 09/22/22, revealed the physician classified the open area to the right heel as a Stage III pressure wound. Notes indicated the wound measured 2.0 cms by 3.3 cms by 0.2 cm, tissue bed at 75 percent (%) granular, 25 % slough, and a moderate amount of serous drainage was noted. Notes indicated the resident reported pain at the wound site as a three (zero indicated no pain and 10 indicated severe pain). Further review of the note revealed the wound was debrided to promote healing and prevention of infection, off-loading recommendations for resident to off-load heels from bed with pillow(s) or offloading boots, and antibiotics were ordered with fair prognosis. Review of WP #315 progress note, dated 10/27/22, revealed the resident's right heel pressure wound was healed and covered with stable wound scab. Plan noted for staff to use [MEDICATION(S)] solution to wound, then leave open to air and continue to off-load heels and resident was discharged from the wound clinic. Review of the active monthly physician orders, dated October 2022, for Resident #35 revealed there were no orders for pressure relieving heel boots, heel protection, or orders to offload resident's heels or pressure relieving interventions for resident's contracted left hand. Review of the physician orders, dated 10/27/22, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the October 2022 Treatment Administration Record (TAR) for Resident #35 revealed the treatment to Resident #35's right heel was not completed on 10/28/22, 10/29/22, 10/30/22, or 10/31/22 per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders, dated 10/27/22, revealed Resident #35 was ordered to receive [MEDICATION(S)] applied to the right heal daily and leave open to air. Interview on 10/31/22 at 11:05 A.M. with Resident #35's representative revealed they had a concern with staff not utilizing the carrot splint to resident's left contracted hand. Resident #35's representative stated the splint was not able to be located in the room. Observation on 10/31/22 at 11:25 A.M. revealed a typed sign over Resident #35's bed that read carrot splint to the left hand Further review of the medical record revealed no documented evidence a carrot splint or other palm protector intervention was being utilized on Resident 35's contracted left hand. Interview on 10/31/22 at 3:56 P.M. with Licensed Practical Nurse (LPN) #75 confirmed there was a sign hanging over Resident #35's bed, which indicated resident was to have the carrot splint in place and verified Resident #35 did not have the carrot splint in place for his left hand contracture. Observation revealed LPN#75 searched Resident #35's room and verified the carrot splint was not able to be located in the resident's room. LPN #75 verified the resident's contracture of the left hand and verified the carrot split was to be utilized to keep fingers off of his palmar area. Interview on 11/01/22 at 3:21 P.M. with LPN #75 confirmed Resident #35 was capable of sitting in his wheelchair. LPN#75 confirmed she was on duty when facility discovered Resident #35 had a wound to the right heel. LPN #75 stated Resident #35 had moon boots in place prior to identifying the Stage III wound on his right heel, however, Resident #35 would kick them off and the staff would not put them back on him once he kicked them off. Observation of wound care provided to Resident #35 by LPN #75 on 11/02/22 at 10:09 A.M. revealed LPN #75 washed her hands and donned gloves. Continued observation revealed LPN #75 removed the old dressing, cleansed her hands, applied clean gloves, cleaned the wound, applied [MEDICATION(S)] ointment, and wrapped the right heel with a dressing and placed the boot over the dressing. Interview on 11/02/02 at 11:05 A.M. with LPN #75 verified the observed wound treatment to Resident #35's right heel. LPN #75 verified the observed wound treatment was ordered on 09/27/22 and discontinued on 11/01/22. LPN #75 indicated the physician orders, dated 10/27/22, to apply [MEDICATION(S)] to right heal everyday and leave open to air, was the current ordered wound treatment and verified she should have provided this wound treatment to Resident #35's right heel. LPN #75 verified she provided the incorrect wound treatment to Resident #35's right heel. Observation on 11/02/22 at 5:15 P.M. of wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation revealed the DON pulled the resident's contracted fingers away from the resident's palm and the resident was observed with thick long fingernails and his nails appeared to be imbedded into the skin of his left palm area. Continued observation revealed Resident #35 had an open wound identified in the resident's palm area of the left hand. Interview with DON at that time verified the open wound in the left palm and indicated she was not aware of the wound. Review of nurse's progress notes, dated 11/02/22 at 10:01 P.M., revealed staff cleansed palm of right hand with soap and water, applied dry gauze, notified facility physician of changes, notified wound physician regarding long nails, and resident's wife made aware. Nurse's progress notes, dated 11/03/22 at 2:35 A.M., indicated resident's nails were cut down, normal saline was applied, and hand wrapped with kerlix. Nurse's progress notes, dated 11/03/22 at 4:37 A.M., indicated the resident's fingernails were cut, cleansed with normal saline, and then the left fingernail was wrapped with kerlix. Further review of the medical record revealed no documented assessment of the left hand wound for Resident #35. Review of physician orders, dated 11/03/22, revealed the resident was ordered to have the left hand/palm cleaned with soap and water, a dry four by four (4 x 4) applied to inside of hand each shift and as needed (PRN) every shift, and to report changes to the wound doctor. Review of 11/03/22 WP #315 progress notes for Resident #35 revealed the resident was assessed to have a healed Stage III pressure injury to right heel (Wound #1) and a new open wound to left palmar surface in webspace between the left thumb and index finger (Wound #2). Notes indicated the right heel was healed and covered with stable wound scab. Notes indicated left hand webspace wound was facility acquired, non-pressure, and classified as a skin tear with unknown date of onset, had moderate amount of serous drainage, measured 1.3 cms by 1.8 cms by 0.1 cm depth, with subcutaneous area exposed. Notes indicated wound was cleansed, flushed, and irrigated and debrided to reduce the risk of infection and improve wound healing. Plan was for nursing to institute pressure injury prevention protocol for left hand, including physical therapy for range of motion exercises across joints and prevention of limb contracture, as well as improve overall patient's personal hygiene, and residents progress was diagnosed as fair and to follow in one week. Interview on 11/03/22 at 10:49 A.M. with the facility WP #315 confirmed he was not aware of the wound on Resident #35's left palm/hand. WP #315 stated he did not have Resident #35 on his list to be seen since the Stage III pressure wound on Resident #35's right heel had been considered healed. WP #315 additionally stated he was not aware the facility had not been completing the correct order to the right heel, which was ordered on 10/27/22. WP #315 confirmed, if proper nursing procedures had been followed, the pressure ulcer on Resident #35's right heel could have been avoidable and identified prior to the wound being identified as a Stage III on 09/22/22. Interview on 11/03/22 at 11:02 A.M. with Occupational Therapist (OT) #505 revealed he was met with resistance from facility staff when he recommended for Resident #35 to utilize the carrot splint in the resident's contracted left hand as tolerated. OT #505 insisted that he wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . OT #505 stated, once he screened a resident for the need of a device, he educated the staff and then washed his hands of it. Follow up interview with WP #315 on 11/03/22 at 2:23 P.M. confirmed he assessed the wound located on the palm of the left contracted hand of Resident #35 on 11/03/22. WP #315 stated this was an avoidable, unstageable pressure wound and consisted of two separate wounds on the palm of the hand separated by an open area. The total size of the wound was 1.3 cms length by 1.8 cms width by 0.1 cm depth and considered it a trauma wound caused by pressure. WP #315 stated the right foot was very dry, however, he considered the right heel to be healed even with the scabbed area on the heel. WP #315 confirmed the importance of Resident #35 having clean skin and how it could affect the healing process. WP #315 stated a concern with the staffing at the facility, including the staff turning over and not having proper nursing care could affect the healing of Resident #35's skin. Interview on 11/03/22 at 3:08 P.M. with Nursing Assistant (NA) #500 confirmed she was the NA that discovered the wound on Resident #35's right heel on 09/21/22. NA #500 stated she was cleaning Resident #35 and identified red blood on the sheet under the right heel and NA #500 stated she told LPN #75. NA #500 stated she did not mark the shower sheet, dated 09/21/22, for a wound because it was the responsibility of the nurse on duty. Follow up interview on 11/04/22 at 8:46 A.M. with LPN #75 confirmed she could not remember notifying the physician or the resident representative of Resident #35's of the open area to his heel when it was found on 09/21/22. Attempted follow-up interview with WP #315 on 11/14/22 at 2:45 P. M to clarify 11/03/22 physician's wound notes was unsuccessful. Review of 11/01/18 facility policy Titled Wound Care indicated the facility would provide therapeutic treatments to heal wounds, treatments implemented by a nurse required a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the NPIAP guidelines, dated 2014, pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines, revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, [CONDITION(S)], and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for [CONDITION(S)] (redness of the skin) was the first component of every skin inspection. Skin redness and tissue [CONDITION(S)] resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on medical record review, review of the hospital record, staff interview, review of the facility investigation, review of the self-reported incident, and policy review, the facility failed to ensure timely care and follow-up was provided when a resident had a change in condition. This resulted in Actual Harm when Resident #15 appeared lethargic, was not eating, and an abrasion was noted on the left side of his forehead without immediate assessment, treatment, or follow-up care provided. Subsequently, approximately 24 hours later Resident #15 was found unresponsive and was sent to the Emergency Department (ED) where he was found with a subdural hematoma along the right lateral convexity. This affected one resident (#15) out of three residents reviewed for falls. The facility census was 49. Findings include: Review of the medical record revealed Resident #15 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 was discharged to the local hospital on 09/12/22. Review of the fall risk assessment dated [DATE] revealed a score of 21 which indicated Resident #15 was a high risk for falls. Review of the Discharge Return Anticipated Minimum Data Set, dated dated dated [DATE] revealed Resident #15 was cognitively impaired, independent with bed mobility and transfers, required supervision for toilet use and hygiene, and was always continent of bowel and bladder. Review of the late incident note dated 09/11/22 revealed Resident #15 was laying in his bed, he was soiled, the nurse and the State tested Nursing Assistant (STNA) cleaned the resident up, while cleaning him the nurse noticed a red area on the left front of Resident #15's forehead. The resident was sat up in a chair and he drank a Coke and was observed the rest of the shift. Review of the nurse's note dated 09/12/22 revealed during the morning medication pass Resident #15 was not himself. A set of vitals were obtained, and they were not within normal limits. The nurse practitioner and the Director of Nursing (DON) were notified, and Resident #15 was sent by Emergency Medical Services (EMS) to a local hospital. Review of the hospital record dated 09/12/22 revealed Resident #15 was found unresponsive by staff at the Extended Care Facility (ECF) this morning. It was unknown when Resident #15 was last seen normal. His blood pressure for the EMS staff was 75/45 millimeters of mercury (mmHg). He was responding to painful stimuli in the Emergency Department (ED) but not following commands. The head Computed Tomography (CT) showed mixed attenuation subdural hematoma along the right lateral convexity measuring up to 4 mm thick, which was not present on a comparison CT dated 06/07/22. Resident #15 was transferred to the Neurological Intensive Care Unit (NICU) for further evaluation and management. Review of the self-reported incident (SRI) dated 09/15/22 revealed Resident #15 was sent to the hospital on 09/12/22 after being found unresponsive. During the investigation, it was found the resident had a change in condition over the weekend reported to the Licensed Practical Nurse (LPN) #35 without any follow-up or assessment completed. Review of the facility investigation dated 09/12/22 revealed on 09/12/22 the weekend nurse LPN #35 was asked if there had been any change in Resident #15's status. LPN #35 reported he was more lethargic and tired and denied calling the physician to report this. On 09/14/22 the hospital record was available for the facility staff to review; the Director of Nursing (DON) and the Administrator reviewed the admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #35 said she had not assessed the area, notified the physician, wrote an incident report, or treated the area. Review of the written witness statement undated revealed State tested Nursing Assistant (STNA) #39 reported Resident #15 was up and down all day on Saturday 09/10/22 and she put him to bed when she left around her shift at 7:00 P.M. STNA #39 returned on 09/11/22 and was given report the resident slept on his stomach all night and was lethargic and was offered breakfast and lunch and he refused and slept all day, and this was reported to LPN #35. Review of the written witness statement undated revealed LPN #35 assisted Resident #15 up to the chair on 09/11/22, she noted a red area to the left front forehead which was not open and no bleeding. He wanted a coke to drink and was having a hard time drinking the coke, so she gave him a straw. LPN #35 asked the STNA to monitor him. Interview on 10/05/22 at 11:40 A.M., the DON and the Administrator said Resident #15 was sent out to the hospital for a change in condition. When they found his admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON and the Administrator said their investigation kept changing as they discovered new information. The Administrator said LPN #35 was terminated at the completion of the investigation due to her failure to assess, notify, and monitor Resident #15. A telephone interview on 10/05/22 at 2:50 P.M., Licensed Practical Nurse (LPN) #43 revealed she was giving medications and Resident #15 was not responding. LPN #43 reported she called the DON because Resident #15 was lethargic, and it was not his normal. The DON and the Assistant Director of Nursing (ADON) #40 came to assist and Resident #15 was assessed, and vital signs were not within normal limits, and he was sent to hospital. Review of the policy titled Change in Condition & Physician Notification Policy, revised 09/2019 revealed it is the policy of this facility to promptly identify, respond to, and report changes in resident condition to the resident's physician/NP/PA and resident/resident representative. A significant change is a major decline or improvement of the resident's status. 1. Facility staff should notify the nurse if/when a change in condition is observed. 2. When a change in condition is discovered, the nurse will evaluate the resident and notify the resident's physician/NP/PA with pertinent information to discuss care for the resident. 3. The nurse will notify the physician/NP/PA and the resident/resident representative when: An accident or incident occurs involving the resident. Discovery of injury of an unknown source. As a result of the incident, the facility took the following actions to correct the deficient practice as of 09/22/22: On 09/12/22, the DON educated/in-serviced all clinical staff to the importance of following proper assessing, notification of doctors, reporting signs and symptoms, and the importance of initiating treatment. On 09/17/22, Resident #15 returned to the facility. On 09/19/22, at the completion of the investigation, it was determined LPN #35 had not acted within the policy of the facility and best practices. On 09/20/22, the Administrator notified LPN #35 via the telephone her employment had been terminated. On 09/12/22 through 09/22/22 the Director of Nursing (DON) assessed residents for injuries and audited fall interventions for all residents ensuring they were in the care plan and implemented. On 09/12/22 through 09/22/22 the DON audited charts for risk management and evaluated high-risk progress notes to ensure the nursing staff had completed an assessment, made notifications of any changes, and documented accurately. Room to room rounding was completed daily to check for residents who may have any change of condition or any complaints and needs. This monitoring will be ongoing. This deficiency substantiated allegations in Control Number OH 122.

Based on medical record review, staff interview, and policy review, the facility failed to timely implement interventions to address one resident's (#19) significant weight loss. This resulted in actual harm when staff did not implement any interventions to address Resident #19's significant weight loss and the resident lost an additional 12.1 pounds. This affected one resident (#19) of five reviewed for weight loss. The facility census was 57. Findings Include: Review of the medical record for Resident #19 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the annual minimum data set assessment dated [DATE] revealed Resident #19 had no cognitive deficits and required extensive assistance with activities of daily living. Review of the comprehensive care plan revealed Resident #19 was at risk for alteration in nutrition and hydration with interventions including adaptive equipment as ordered such as a divided plate, built up utensils, and two handled cups. Further review of the care plan revealed additional interventions included assist with feeding as needed, administer medications as ordered by the physician, monitor for signs/symptoms of dehydration, monitor weight every month and as needed, offer meal substitutes for dislikes, provide diet counseling as needed, provide regular thin liquid diet as ordered by the physician, provide favorite foods/fluids within diet, provide supplement as ordered such as MedPass 2.0 120 milliliters (ml) three times a day, review labs as ordered, and record consumption of meals including fluid intake. Review of the weight records revealed the resident weighed 144.8 pounds (lbs) on 12/05/20, 143.8 lbs on 01/02/21, 136.1 lbs on 02/02/21, and 124 lbs on 02/18/21. Further review of the weight records for Resident #19 revealed he experienced a clinically significant weight loss of roughly 5.35 percent from 01/02/21 to 02/02/21 and roughly 13.76 percent from 01/02/21 to 02/18/21. Review of the dietary progress note dated 02/19/21 at 5:28 P.M. revealed Registered Dietitian (RD) #725 documented Resident #19 had a significant weight loss of 5.4% in one month. Further review of the dietary note revealed a reweigh was requested and obtained at 124 lbs on 02/18/21. Further review of the dietary note revealed Resident #19's skin was intact, he received a regular diet, and typically had good oral intake. The note further revealed Resident #19 received MedPass 2.0 120 ml one time per day and had been diagnosed with [REDACTED]. The note further revealed RD #725 recommended to discontinue MedPass 2.0 120 ml one time per day and start MedPass 2.0 120 ml three times per day. Review of the active current physician orders revealed an order dated 09/17/17 for a regular diet with regular textures and thin consistency. Further review of the active physician orders revealed an order dated 09/16/20 for MedPass 2.0 120 ml one time per day. Review of the physician orders revealed no evidence of MedPass 2.0 120 ml three times a day having been ordered since it was recommended by RD #725 on 02/19/21. Review of the Medication Administration Record [REDACTED].M. Review of the Recommendations Form- Facility Nutritional Assessment Recommendations dated 2021 revealed RD #725 recommended for Resident #19's MedPass 2.0 120 ml one time per day to be discontinued and to start MedPass 2.0 120 ml three times a day. Further review of the form revealed under the section titled Responsible, N was checked which indicated nursing was responsible. Interview on 02/24/21 at 9:50 A.M., the RD #725 revealed she reviewed resident weights every week. The interview further revealed Resident #19's weight of 136.1 lbs on 02/02/21 triggered for a significant weight loss. She reviewed the weight on 02/08/21 and requested a reweigh. She requested another reweigh on 02/14/21. The resident #19's re-weigh was not entered into the electronic medical record until 02/18/21. The reweigh on 02/18/21 Resident #19 was found to be 124 lbs which showed an increase in weight loss from the weight obtained on 02/02/21. Resident #19 received MedPass 120 ml one time per day and on 02/19/21 she recommended to increase the MedPass to 120 ml three times a day due to the weight loss. The interview revealed when she recommends a change in supplements, a recommendation form is provided to the Director of Nursing (DON) and the DON is responsible for notifying the physician of the recommendation and turning the recommendation into an actual physician order. RD #725 verified Resident #19 does not have an order for [REDACTED].#725 further verified no interventions have been implemented since 02/02/21 when Resident #19 was found to have experienced a significant weight loss. Interview on 02/24/21 at 11:32 A.M., the DON revealed she recently began communication with RD #725 about the resident weights and weight loss recommendations. She revealed RD #725 previously communicated with the Assistant Director of Nursing who was no longer employed at the facility. She said RD #725 requested a reweigh on 02/14/21 and Resident #19 refused to be reweighed on 02/15/21 however staff was able to obtain a reweigh on 02/17/21 during night shift and it was entered into the electronic medical record on 02/18/21. She said Resident #19's weight on 02/18/21 was accurate. She said when the dietitian makes recommendations, they are included on a recommendation form which was then provided to the physician who in turn writes the order. She verified no interventions had been implemented since Resident #19 was found to have lost a significant amount of weight on 02/02/21. Review of the facility policy titled Weight Policy, last revised 11/2019, revealed the Dietitian will be notified of significant changes in weights, insidious weight loss and other concerns related to diet and intake. Acute or chronic weight changes will be documented and recommendations will be provided by the dietitian as appropriate. The dietitian or physician may order specific nutritional interventions, supplements, or other interventions if indicated. The supplements may be provided on the residents food tray or distributed by the nursing staff. Interventions may include such things as offering residents foods of their preference, extra portions, snacks or supplements if decreased appetite or weight is noted. This deficiency substantiates Complaint Number OH 798.

Based on observations, medical record reviews, interviews with residents, families, staff and the technician employed by the Temperature Control Company, review of room temperature logs, review of technician proposals, review of resident council meeting minutes, review of the website https://www.underground.com for the past daily outside temperatures and review of the facility policy for Extreme Heat and Humidity, the facility failed to ensure comfortable and safe temperatures were maintained throughout the facility when temperatures exceeded 87 degrees Fahrenheit (F) in resident rooms and common areas on three (100, 200, and 300 Halls) of five units in the facility. Additionally, the facility failed to monitor temperatures of residents' rooms on a daily basis to include the weekend of [DATE] to [DATE] and the three day weekend of [DATE] to [DATE]. This resulted in Immediate Jeopardy for 40 (#1 - #40) residents who resided on the three halls where the Air Conditioning (AC) units were not working exposing residents to extreme temperatures for prolonged periods of time placing them at risk for life-threatening serious heat related illnesses or death. On [DATE] at 4:21 P.M., the Licensed Nursing Home Administrator (LNHA) was notified Immediate Jeopardy began on [DATE] when the facility first became aware that one of the two AC units had a broken compressor rendering it non-functional. Additionally, the facility failed to monitor the temperatures of residents' individual rooms on a daily basis. Observation on [DATE] at 8:35 A.M. revealed a digital thermostat mounted in the front dining room measured an ambient air temperature of 88 degrees F. Interview on [DATE] at 8:35 A.M. with Licensed Practical Nurse (LPN) #10 revealed it had been hot in the facility, especially over the three-day weekend ([DATE] through [DATE]). Review of the daily room temperature logs dated [DATE] to [DATE] revealed temperatures were not monitored during the weekend of [DATE] to [DATE] and during the three-day weekend of [DATE] to [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE], the LNHA and Director of Nursing (DON) educated the nurses and the STNA's on the Heat Exhaustion/Heat Policy to include how to recognize early signs of heat exhaustion. They were also educated to implement interventions of removing blankets and offering sheets instead, to pass ice and water every four hours and as needed (PRN), to offer popsicles and ice cream, to take temperatures every shift, to keep doors open and to offer to move residents to cooler areas of the facility. · On [DATE], Maintenance Supervisor (MS) #19 checked the chiller system/AC system. MS #19 contacted the Temperature Control Company and they faxed over a proposal the same day. · On [DATE], the LNHA signed the proposal to fix the air compressor for the cooling system. · On [DATE], the LNHA signed the second proposal to fix the water system that affected the chiller system. · On [DATE], the nurses began assessing the residents on the 100 Hall, 200 Hall and 300 Hall twice a day for signs of heat exhaustion and were monitoring the resident's body temperatures. · On [DATE], fans were provided daily to any resident who requested one. · On [DATE], MS #19 called the Temperature Control Company to check on the proposals and quotes. · On [DATE], MS #19 sent pictures of the voltage of the air compressor to the Temperature Control Company per their request. · On [DATE], the LNHA signed the third proposal for repair of the cooling tower. · On [DATE], the Temperature Control Company called and texted MS #19 about adding filters to a new quote. MS #19 indicated the filters should be included and the Temperature Control Company added the filters to the quote. · On [DATE], MS #19 called the Temperature Control Company three times to check on the status of the proposal to find out when the part would be custom made and done so repairs could begin. · On [DATE] beginning at 5:00 P.M. to [DATE] at 7:00 A.M., the LNHA and the DON educated the nurses on how to take temperatures of the resident's rooms. The nurses were re-educated on the Heat Exhaustion/Heat Policy and were instructed to document the residents temperatures each shift in the progress notes of each resident's medical record and to call the LNHA, the DON or MS #19 as soon as possible if any room temperature was above 81 degrees F. · On [DATE], the Temperature Control Company fixed the chiller system. · On [DATE], in addition to items being offered daily, the STNA's also offered Gatorade to the residents. · On [DATE] beginning at 6:00 P.M., the nurses began taking temperatures of the rooms on the 100 Hall, 200 Hall and 300 Hall every two hours. · On [DATE], the nurses assessed vitals on the residents on the 100 Hall, 200 Hall and 300 Hall. · On [DATE], the LNHA and MS #19 took temperatures of resident rooms on the 100 Hall, 200 Hall and 300 Hall every two hours. · On [DATE], the LNHA called the Temperature Control Company to come back out to inspect the chiller system that was supposed to be have been fixed. Some of the rooms on the 100 Hall and 200 Hall were still at 81 degrees F per the two hour temperature checks the facility was doing. On [DATE] at 9:00 P.M. the following rooms were 81 degrees F: 104, 105, 107, 108, 111, 201, 205, 207, 208, 211, 212, and 213. At 11:00 P.M. the following rooms were 81 degrees F: 104, 111, 112, 201, 205, 207, 208, 211, 212 and 213. On [DATE] at 1:00 A.M. the following rooms were 81 degrees F: 104, 107, 111, 207, 208, 212 and 213. At 3:00 A.M. the following rooms were 81 degrees F: 104, 107, 108, 111, 205, 207, 208, 211, 212, and 213. At 5:00 A.M. the following rooms were 81 degrees F: 104, 205, 207, 208, 211, and 212. At 7:00 A.M. the following rooms were 81 degrees F: 104, 208, 209 and 211. · On [DATE], the Chief Operating Officer (COO) called a rental company to rent four 1.5-ton portable AC units until the chiller system could be fixed. At 10:30 A.M. the rental company confirmed the portable AC units would be delivered by 4:00 P.M. · Beginning [DATE], MS #19 and the nurses began monitoring room temperatures on the 100 Hall, 200 Hall and 300 Hall every four hours. Monitoring will continue for four weeks. Although the Immediate Jeopardy was removed on [DATE] at 3:00 P.M. when all the rooms affected measured below 81 degrees F. The facility continued monitoring the affected rooms every two hours for 16 hours and all of the affected rooms remained below 81 degrees F. The facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: On [DATE] at 8:30 A.M. upon entrance to the facility, it was noted the front doors to the facility were propped open with boxes. The air in the facility was hot and humid. Further observation at 8:35 A.M. revealed a digital thermostat mounted in the front dining room measured the ambient air temperature at 88 degrees F. Observations of the 100 Hall, 200 Hall and 300 Hall revealed residents were lying in their beds with no covers on. Some of the residents did not have any fans in their rooms. Some residents were observed sitting in wheel chairs in front of fans. Residents were observed with water pitchers; however, some of the water pitchers were empty or did not have ice in them. Interview on [DATE] at 8:35 A.M. with LPN #10 revealed it had been hot in the facility, especially over the three-day weekend ([DATE] through [DATE]). Review of the medical record of Resident #22 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairments, and required extensive assistance of two with all care. Observation of Resident #22 on [DATE] at 8:40 A.M. revealed he was lying in his room on his back with only his incontinence brief on. The resident had a small desk fan located on his dresser, the fan was pointing directly at the residents bed. The resident had visible beads of moisture on his forehead. Interview with Resident #22 at the time of the observation revealed he was very uncomfortable and had been for days. He stated the AC had been out for weeks. Interview on [DATE] at 8:45 A.M. with State tested Nursing Assistant (STNA) #3 revealed the STNA's were trying their best to keep the residents cool and noted the facility had done nothing to fix the problem. Review of the medical record of Resident #37 revealed he was admitted on [DATE] with a [DIAGNOSES REDACTED]. No MDS had been completed as of [DATE]. The resident required extensive assist of two for all care. Observation of Resident #37 on [DATE] at 9:00 A.M. revealed the resident was in his wheel chair and was perspiring. At the time of the observation the resident stated he was hot and a family member revealed the resident was admitted to the facility from the hospital on [DATE]. The family member indicated the resident was in the intensive care unit at the hospital prior to coming to the facility. The family member also stated the resident had a recent fall and was sent to the emergency room for evaluation and the family wished he would have been admitted to the hospital because of how hot the facility had been. They also indicated Resident #37 had been miserable because of the heat. Observations on [DATE] at 9:10 A.M. with MS #19 revealed the ambient air temperature at the nurse's station between the 100 and 200 Halls measured 88 degrees F. Resident room [ROOM NUMBER] measured 82 degrees F, resident room [ROOM NUMBER] was 85 degrees F, and the dining room on the front hall was 88 degrees F. The temperatures were taken with a non-contact infrared thermometer. MS #19 stated the thermometer took surface temperatures and that was what he used to measure the temperatures in the building. Interview with MS #19 on [DATE] at 9:30 A.M. revealed the compressor on the AC unit for the front part of the facility (100 Hall, 200 Hall and 300 Hall) went out and a new one was ordered on [DATE]. MS #19 revealed the new compressor should arrive any day. He also revealed he took room temperatures daily between 7:30 A.M. and 8:00 A.M. Following the interview, random room temperatures were measured with MS #19 and the following rooms were above 81 degrees F: room [ROOM NUMBER] was 82 degrees F, room [ROOM NUMBER] was 82 degrees F, room [ROOM NUMBER] was 85 degrees F, room [ROOM NUMBER] was 83 degrees F, room [ROOM NUMBER] was 85 degrees F, room [ROOM NUMBER] was 84 degrees F, room [ROOM NUMBER] was 85 degrees F, room [ROOM NUMBER] was 85 degrees F, room [ROOM NUMBER] was 84 degrees F and room [ROOM NUMBER] was 84 degrees F. Interview with the LNHA on [DATE] at 9:45 A.M. confirmed the AC compressor quit working on [DATE] and the replacement compressor was ordered on [DATE]. Review of the medical record for Resident #32 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] revealed the resident was minimally cognitively impaired and required supervision with care. Observation of Resident #32 on [DATE] at 9:50 A.M. revealed he had no fan in his room. The resident was sitting up at the side of the bed leaning on the overbed table. The resident had no ice and only a small amount of water in his pitcher. At the time of the observation the resident was interviewed and revealed he did not sleep well last night because of how hot it was. He stated no staff had offered him a fan and he asked if the surveyor could get him one as he could not take much more of the heat. He indicated he did not know why the facility could not get the issue fixed. Room temperatures were again measured on [DATE] at 10:45 A.M. with MS #19 and revealed the following: room [ROOM NUMBER] measured 87 degrees F, room [ROOM NUMBER] was 86 degrees F, room [ROOM NUMBER] was 86 degrees F, room [ROOM NUMBER] was 85 degrees F, room [ROOM NUMBER] was 83 degrees F, room [ROOM NUMBER] was 83 degrees F, room [ROOM NUMBER] was 83 degrees F, room [ROOM NUMBER] was 83 degrees F, room [ROOM NUMBER] was 82 degrees F, room [ROOM NUMBER] was 88 degrees F, room [ROOM NUMBER] was 84 degrees F, room [ROOM NUMBER] was 85 degrees F, room [ROOM NUMBER] was 84 degrees F, room [ROOM NUMBER] was 83 degrees F, room [ROOM NUMBER] was 83 degrees F, room [ROOM NUMBER] was 85 degrees F, room [ROOM NUMBER] was 85 degrees F, room [ROOM NUMBER] was 85 degrees F, room [ROOM NUMBER] was 84 degrees F, and room [ROOM NUMBER] was 87 degrees F. Review of the medical record of Resident #28 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS assessment dated on [DATE] noted the resident had minimal cognitive impairment and required minimal assistance of one with all care. Observation of Resident #28 on [DATE] at 11:10 A.M. revealed the resident was lying in bed with oxygen on. The resident had a circular fan at the end of the bed blowing directly on him. The resident had a water pitcher with warm water in it. Interview with Resident #28 at the time of the observation revealed the resident wore oxygen due to his lung disease. The resident revealed his arms were red because he was hot and the hair around his head was wet from sweating. He stated he wanted relief from the heat. Review of the medical record of Resident #30 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS assessment dated on [DATE] revealed the resident had no cognitive impairments and required supervision only. Observation of Resident #30 on [DATE] at 11:50 A.M. revealed the resident had no fan in his room. The resident had his shirt off and he was wiping perspiration off his forehead. Interview at the time of the observation revealed he had asked for a fan several times the past week and never got one. Resident #30 asked if the surveyor could please get him a fan as he was in misery. Room temperatures were measured again on on [DATE] at 10:45 A.M. with MS #19 and revealed the following: room [ROOM NUMBER] was 82 degrees F, room [ROOM NUMBER] was 81 degrees F, room [ROOM NUMBER] was 82 degrees F, room [ROOM NUMBER] was 84 degrees F, room [ROOM NUMBER] was 83 degrees F, room [ROOM NUMBER] was 82 degrees F, room [ROOM NUMBER] was 82 degrees F, room [ROOM NUMBER] was 82 degrees F, room [ROOM NUMBER] was 82 degrees F, room [ROOM NUMBER] was 83 degrees F, room [ROOM NUMBER] was 87 degrees F, room [ROOM NUMBER] was 86 degrees F, room [ROOM NUMBER] was 86 degrees F, room [ROOM NUMBER] was 86 degrees F, room [ROOM NUMBER] was 83 degrees F, room [ROOM NUMBER] was 83 degrees F, room [ROOM NUMBER] was 85 degrees F, room [ROOM NUMBER] was 85 degrees F, room [ROOM NUMBER] was 86 degrees F, room [ROOM NUMBER] was 84 degrees F, room [ROOM NUMBER] was 87 degrees F, room [ROOM NUMBER] was 84 degrees F, room [ROOM NUMBER] was 82 degrees F, room [ROOM NUMBER] was 83 degrees F, room [ROOM NUMBER] was 84 degrees F, room [ROOM NUMBER] was 81 degrees F, room [ROOM NUMBER] was 82 degrees F, room [ROOM NUMBER] was 84 degrees F, room [ROOM NUMBER] was 84 degrees F, room [ROOM NUMBER] was 83 degrees F and room [ROOM NUMBER] was 83 degrees F. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] noted the resident had minimal cognitive impairment and required assist of one with all care. Observation of Resident #7 on [DATE] at 2:50 P.M. revealed the resident was watching television (TV) in his room. The resident was visibly perspiring. Interview with the resident at the time of the observation revealed he was hot even with his fan on. The resident resided on the locked unit and indicated he could not get off the unit to get relief from the heat. The resident noted he did not tolerate the heat well and it had been a week of elevated temperatures. Interview on [DATE] at 3:25 P.M. with the Temperature Control Company technician revealed MS #19 called for service on [DATE]. A technician was sent out on [DATE] and diagnosed the issue. A new part for the chiller was order on the same date, but the part had to be made for the unit. This was the reason they could not fix the AC unit. The technician further revealed the part arrived today ([DATE]) and the AC unit was now fixed. Room temperatures were measured on [DATE] at 4:00 P.M. with MS #19. A total of 21 rooms were assessed and only two rooms (#213 and #207) measured above 81 degrees F. Both resident's room temperatures were measured at 82 degrees F. Interview on [DATE] at 4:15 P.M. with the LNHA verified room temperatures were not monitored during the weekend of [DATE] to [DATE] and during the three-day weekend of [DATE] to [DATE]. Interview on [DATE] at 5:00 P. M. with STNA #5 revealed she had worked over the weekend ([DATE] and [DATE]) and described it as being very hot. STNA# 5 stated the nurses directed the STNAs to pass ice and water and to take the temperatures of the residents. A follow-up interview on [DATE] at 4:45 P.M. with the Temperature Control Company technician revealed the hold up in repairing the AC unit was due to a delay in getting a piece of equipment that was needed. Room temperatures were measured on [DATE] at 11:00 A.M. with MS #19. A total of 36 rooms were assessed on the 100 Hall, 200 Hall and 300 Hall. All rooms measured below 81 degrees F. Review of technician proposal dated [DATE] revealed work was to be performed on an air compressor replacement. The proposal was accepted by the LNHA on [DATE]. Review of technician proposal dated [DATE] revealed work was to be performed on the Trane chiller and flooded basement controls. During inspection it was determined the control system for the buildings cooling system was severely damaged by water. All documents, drawings and diagrams were also destroyed. Additional time was required to analyze and compile a list of components needed to complete the repairs. The second stage of the 50 Trane chiller also suffered damage and each time it tried to start, it locked out. The proposal was signed as accepted by the LNHA on [DATE]. Review of the technician's proposal dated [DATE] revealed work was to be performed on the cooling tower. The proposal was signed by the LNHA on [DATE]. Review of the daily room temperature logs dated [DATE] to [DATE] revealed temperatures were not monitored during the weekend of [DATE] to [DATE] and during the three-day weekend of [DATE] to [DATE]. Review of the website https://www.wunderground.com for the past outside temperatures revealed the high temperature on [DATE] was 85 degrees F, on [DATE] was 90 degrees F, on [DATE] was 92 degrees F, on [DATE] was 90 degrees F and on [DATE] was 84 degrees F. Review of the Resident Council Meeting minutes dated [DATE] revealed the residents expressed concern over the heat and lack of air conditioning. Review of the policy titled Extreme Heat and Humidity dated ,[DATE] revealed it was the policy to maintain the environmental temperature within a healthy range for the residents. Geriatric residents are extremely vulnerable to heat related complications and disorders. Every reasonable attempt will be made to maintain the temperature between 71 and 81 degrees F. If the temperature is outside of this range the Maintenance Director, Administrator and DON will be notified for direction. In case of circumstances beyond the facilities control, specific measures will be implemented until the desired temperature is able to be maintained: Some of the measures include maintaining the temperature between 71 and 81 degrees F. If the excessive facility temperature cannot be remedied in a timely fashion and/or residents are showing signs of heat intolerance, consider evacuating residents to an alternate facility that has an appropriate environmental temperature. This deficiency substantiates Complaint Number OH 340 and Complaint Number OH 222.

Based on medical record review, interviews with staff and the Coroner, review of the Emergency Medical Technician (EMT) run report, review of hospital documentation and review of facility policy, the facility failed to ensure one resident who sustained a fall with head trauma received care and treatment in a timely manner. This resulted in Immediate Jeopardy for Resident #21 who was not sent to the hospital for immediate treatment after a fall sustaining a head injury and subsequently died three days later of [MEDICATION NAME] force head trauma. This affected one (#21) of four residents reviewed for falls of 24 identified by the facility as being at risk for falls. The facility census was 61. On [DATE] at 4:07 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 12:20 A.M. when Resident #21 was found on the floor with a large amount of emesis. Licensed Practical Nurse (LPN) #78 found the resident on the floor, did a quick assessment, did not take vital signs and turned on the call light. LPN #78 left the room to get assistance from State tested Nursing Assistants (STNA's). They assisted the resident off the floor and the STNA's gave the resident a shower. LPN #78 took the resident's vital signs and put the resident back to bed. LPN #78 failed to recognize emesis was a sign of a head injury and failed to notify the physician of the fall with emesis. Resident #21 was unable to be aroused at 5:30 A.M. and was transferred to the nearest emergency room (ER) where she was placed on a ventilator. The resident expired at the hospital on [DATE]. The Immediate Jeopardy was removed on [DATE] at 12:30 P.M. when the facility terminated the employment of LPN #78 and implemented the following corrective actions: ? On [DATE], the facility suspended LPN #78 and terminated her on [DATE] for failure to perform within the LPN scope of practice as set forth by the Ohio Board of Nursing (OBN). ? On [DATE], the facility implemented a new neurological check policy (undated) with neurological checks to be performed as follows: every 15 minutes times four, every 30 minutes times four, every hour times four, every two hours times four, every four hours times four, every six hours times four, every 12 hours times two. The prior neurological assessment policy dated [DATE] indicated neurological checks were to be completed as follows: every hour times two, every two hours times two, every four hours times two and every shift times six. ? On [DATE], the facility implemented a new policy entitled Supervisors Role - Post Incident, which indicated effective immediately supervisors are to assess the resident immediately whenever the resident has a fall, change of condition or an injury. If there is not a supervisor in the building, the nurse responsible for the care of the resident is to notify the DON or the Assistant Director of Nursing (ADON) of assessment findings. ? On [DATE] through [DATE], the facility provided in-servicing training to all staff nurses and STNAs on falls, head injuries, neurological assessments, a change in condition, notification and documentation. The in-service training was completed on [DATE] at 10:56 A.M. ? On [DATE], the DON, ADON and Minimum Data Set (MDS) nurse assessed all residents who had experienced a fall in the previous thirty days. ? On [DATE] at 6:00 P.M., the facility completed an assessment on every resident to ensure no residents were experiencing a change in condition. No residents were found to be undergoing any unnoted changes. ? On [DATE] through [DATE], random interviews were conducted with Registered Nurse (RN) #54, LPN's #97 and #112 and STNAs #37, #84, #101, #110 and #114 regarding the new facility policies and in-servicing they received and verbalized knowledge of the facility's policies and in-service training regarding falls, head injuries, neurological assessments, change in condition, notification and documentation. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) because enough time has not elapsed for the facility to monitor the effectiveness of their new policy to ensure supervisors are assessing a resident immediately whenever the resident has a fall, change of condition, or an injury to verify on-going compliance. Findings include: Review of Resident #21's medical record revealed an admission date of [DATE] with a readmission on [DATE]. The resident had [DIAGNOSES REDACTED]. According to the resident's face sheet, she was a full code (in the event of an emergency, all life saving measures are to be implemented.) Review of the oxygen care plan dated [DATE] revealed the resident required oxygen for shortness of breath and [MEDICAL CONDITION]. Interventions included oxygen saturation levels per order and to maintain oxygen saturation levels above 90 percent. Review of the physical mobility and activities of daily living assistance care plan dated [DATE] revealed the resident had impaired physical mobility with ambulation, bed mobility, locomotion and transfers and the resident required extensive assistance related to limited mobility, weakness and cognitive deficits. Review of the care plan for cognition dated [DATE] revealed the resident had problems with short and long term memory. Review of the fall care plan dated [DATE] revealed the resident was a potential risk for falls due to unsteady gait and cognitive deficits. No goals or interventions were checked or written on the care plan. Review of the fall investigation forms revealed the resident had falls on [DATE], [DATE] and [DATE]. On [DATE] and [DATE] the falls were attributed to the resident's telephone and oxygen cord being tangled up. Review of the comprehensive assessment dated [DATE] revealed the resident was severely cognitively impaired and sometimes understands others. The resident needed extensive assistance for all activities of daily living except walking in room, corridor and locomotion on unit (all limited assistance). The resident was not steady, only able to stabilize with staff assistance for walking, moving on and off the toilet, surface to surface transfers and moving from seated to standing position. The resident was always continent of bowel and bladder. Also noted was the resident experienced shortness of breath with exertion and while lying flat. Review of an undated resident care card revealed the resident was alert but forgetful. The care card used by STNA's did not indicate the level of care needed with any activities of daily living, any fall interventions and that Resident #21 used oxygen. Nurses notes dated [DATE] at 12:20 A.M. by LPN#78 revealed Resident #21 was observed on the bathroom floor with a large amount of emesis noted on her gown and on the floor. She was assisted by two staff (STNA's #37 and #44) to her wheelchair. Upon assessment her skin was intact and range of motion was within normal limits. She denied pain and was able to ambulate to the bed without assistance. She had oxygen on at two liters via nasal cannula but was experiencing shortness of breath with an oxygen saturation level at 83 percent. Physician's Assistant (PA) #6 was notified at 1:15 A.M. of the low oxygen saturation levels and a new order was given for breathing treatments every six hours for two days as needed. Nurses notes dated [DATE] at 1:00 A.M. by RN #54 (late entry with no date/time of the actual entry) revealed she was notified by LPN #78 that the resident fell to the floor with no injuries. RN #54 instructed LPN #78 to notify her of any changes. Nursing notes dated [DATE] revealed LPN#78 gave the resident a breathing treatment at 1:30 A.M. and at 2:30 A.M., LPN #78 walked by the resident's room and she was ambulating to the bathroom by herself. LPN #78 assisted Resident #21 at that time. Nurses notes dated [DATE] at 5:30 A.M. by LPN #78 revealed the resident could not be aroused and had large green emesis on her gown. Nurses notes dated [DATE] at 5:45 A.M. by LPN #78 revealed PA #6 was notified of Resident #21 being unresponsive and an order was received to send her to the emergency room for an evaluation. Nurses notes dated [DATE] at 6:00 A.M. by RN #54 dated [DATE] (late entry with no date/time of the actual entry) revealed LPN #78 notified her that Resident #21 was not easily "aroused" upon assessment and the resident was unresponsive to verbal or physical stimuli. The resident had swelling on her scalp (right front) approximately three inches in length and one quarter of an inch in height and hard to the touch. Emesis was noted on the left side of her body. RN #54 instructed LPN #78 to call 911 and the resident's family. Review of the EMT run report dated [DATE] revealed the emergency services were notified at 6:21 A.M. They arrived at 6:28 A.M. and found Resident #21 lying in bed unresponsive to all stimuli. Facility staff reported the resident hit her head on the ground earlier and then went to sleep. The resident's pupils were checked and the right pupil was unresponsive while the left was a little sluggish. The resident had audible gurgling sounds and rapid shallow respirations. Per the facility staff the family had requested the resident be sent to a hospital farther away. The EMT's note revealed they were unable to secure an airway and were sending her to the nearest hospital. The resident was placed on the cot and given supplemental oxygen at 12 liters per nasal cannula. The resident was bagged to assist with breathing and the airway was suctioned as needed. Review of the hospital emergency department course dated [DATE] at 8:00 A.M. revealed the resident was admitted due to subdural hematoma, altered mental status and [MEDICAL CONDITION]. Review of hospital documentation nurse's notes dated [DATE] at 8:13 A.M. revealed the resident was on a ventilator and was not breathing over the vent. Nursing notes on [DATE] at 1:40 P.M. noted time of death. Review of a statement dated [DATE] by STNA #44 revealed at about 12:15 A.M. she went to assist LPN #78 with Resident #21. The resident was found in a puddle of emesis. After getting the resident off of the floor she revealed the resident was short of breath. She asked the resident if she wanted to be cleaned up in bed or in the shower and the resident requested a shower. At approximately 1:30 A.M., STNA #44 went back into the room and Resident #21 was still short of breath. LPN #78 instructed STNA#44 to check on Resident #21 because she felt nauseous and was having dry heaves. At approximately 2:45 A.M., Resident #21 was still short of breath and struggling to breathe. STNA #44 asked Resident #21 if she wanted to go to the hospital, Resident #21 responded by shaking her head up and down to indicate yes. STNA#44 indicated she notified LPN#78 of the resident's wishes. At approximately 6:00 A.M., STNA #44 was in another resident's room when LPN #78 requested her to clean Resident #21 due to emesis on the resident's gown. STNA #44 asked LPN #78 if she could clean Resident #21 so she could finish providing care to the other resident. Review of a statement by RN #54 (undated) revealed RN # 54 asked LPN #78 if the LPN had assessed Resident #21's head. LPN #78 stated she did not because the resident had rollers in her hair and the resident had asked her not to touch the rollers. It was further noted by RN #54 the resident's head was not palpated and an assessment was not done. Telephone interview on [DATE] at 3:43 P.M. with LPN #78 revealed the resident was "wobbly" when she walked and needed her oxygen with a long cord. LPN #78 stated she had reported to her supervisor that the resident trips over the cord and it had not been changed. LPN #78 revealed she received report from LPN #97 on [DATE] and during report LPN #97 indicated Resident #21 had low oxygen saturation levels for the past three days. LPN #78 indicated on [DATE] when Resident #21 was found on the floor she had her oxygen on. She indicated she did a quick assessment on Resident #21's range of motion and skin and Resident #21 was not bleeding. She stated she allowed the resident to get a shower and then afterwards she took a set of vital signs. LPN #78 stated Resident #21's oxygen saturation levels were low so she contacted the on call physician (PA #6). LPN #78 indicated she did not remember what she told PA #6. She stated after she gave Resident #21 the ordered breathing treatment the resident had no further complaints. LPN #78 stated she was not aware that emesis after a fall may indicate head trauma. LPN #78 stated she thought the resident had a stomach bug. Interview on [DATE] at 4:54 P.M. with STNA #37 revealed on [DATE] around 12:30 A.M., she and STNA #44 were summoned by LPN #78 to Resident #21's room. She stated the resident was lying on the floor with the bathroom door open and her head was resting on the door. Resident #21 had her hands on the floor and was trying to get up. STNA #37 stated STNA #44 had later shared with her that Resident #21 wanted to go to the hospital and she (STNA #44) had notified LPN #78 of Resident #21's wishes. Interview on [DATE] at 7:46 A.M. with STNA #44 revealed on [DATE], LPN #78 requested her to come to Resident #21's room after the resident had sustained a fall. She stated she typically worked with Resident #21 and she was familiar with her. She stated when she entered Resident #21's room she noticed her oxygen tubing was under the door and at times her tubing did get caught on the door. STNA#44 stated the resident's oxygen was on but she appeared short of breath because she was panting. STNA #44 further stated at approximately 2:45 A.M. she asked the resident if she wanted to go to the hospital. Resident #21 shook her head up and down to indicate yes. STNA #44 stated at that time the resident was breathing out of her mouth and she was struggling to breathe. STNA#44 stated the resident did have episodes of shortness of breath but this was different. STNA#44 stated she notified LPN#78 that the resident was struggling to breathe and wanted to go to the hospital. STNA #44 stated she did not realize LPN #78 had not sent Resident #21 out until later that morning approximately at 6:00 A.M. when LPN #78 requested her to help clean up Resident #21. Interview on [DATE] at 8:13 A.M. with RN #54 revealed LPN #78 had not reported to her that Resident #21 had any injuries or vomiting after the fall. RN #54 stated LPN #78 never notified PA #6 that the resident had a fall with emesis. RN #54 further revealed at approximately 6:00 A.M. when she was assessing the resident she instructed LPN #78 to call 911. She indicated LPN #78 had called PA #6 for an order to send Resident #21 out before she even called 911. RN #54 further stated the late entries were documented the morning of [DATE] and the times listed by LPN #78 were incorrect. Interview on [DATE] at 10:12 A.M. with PA#6 revealed she was never notified Resident #21 had a fall with a head injury and emesis. She further stated if a resident had a fall with a possible head injury (emesis) and increased shortness of breath she would have the facility send the resident out for an evaluation. Interview on [DATE] at 10:28 A.M. with STNA #84 revealed Resident #21 was experiencing episodes of shortness of breath the day before the incident on [DATE]. STNA #84 stated she reported the occurrences to LPN #97. LPN #97 stated she did witness and assist the resident when Resident #21 was short of breath and needed more assistance than usual, but she did not notify the physician or document any of the incidents. Interview on [DATE] at 10:56 A.M. with LPN #97 revealed she was notified by STNA #84 that Resident #21 was having episodes of shortness of breath on [DATE]. She stated that she observed Resident #21 having shortness of breath on [DATE] and that Resident #21 needed more assistance than usual. She stated she did not notify the physician or document the concerns related to Resident #21. Interview on [DATE] at 1:00 P.M. with the Coroner revealed the cause of death for Resident #21 was [MEDICATION NAME] force trauma as a result of a fall. Review of the facility's policy entitled "Nursing Standards of Practice: Significant Change", undated, revealed the physician will be notified of the change in the resident status where there is an accident resulting in injury and the potential for medical intervention; and a change in the resident's physical status. Review of the facility's policy entitled "Nursing Standards of Practice: Fall Management", undated, revealed the health care center will identify each resident who is at risk for falls and will plan care and implement interventions to manage falls. This deficiency substantiates Complaint Numbers OH 966 and OH 920. This deficiency represents continued non-compliance from the complaint survey completed [DATE].

Based on record review, observation and interview the facility failed to ensure the residents environment was free of accident hazards and that the residents received supervision to prevent accidents. This affected two residents (#28 and #50) of three reviewed for falls and one resident (#53) of three sampled for elopement risk. The facility failed to have a physician ordered front-releasing seat belt in place to prevent an avoidable fall out of a wheelchair for resident (#28). This resulted in harm to the resident as he was admitted to the hospital with [REDACTED]. The facility also failed to have the correct cushion in resident's (#50) wheelchair which resulted in an avoidable fall. The facility also failed to provide supervision to prevent one resident (#53) from elopement. The facility identified 17 residents who have had falls in the past three months and one resident who has eloped in the past year. Findings include: 1. Review of Resident #28's medical record indicated the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. transferring, bed mobility, locomotion on the unit, and dressing. The MDS indicated the resident was not steady and only able to stabilize with staff assistance when moving from a seated to a standing position and during a surface to surface transfer. The resident's admission fall assessment dated [DATE] stated the resident was at high risk for falls. The resident's fall care plan dated through 01/13/12 stated the resident was at risk for falls and had history of falls. Care planed interventions included the resident to wear a front releasing seat belt to remind him to wait for assistance. Review of the resident's physician order [REDACTED]. The medical record was silent to any assessment for the use of the front releasing seat belt until 10/29/12 when a restraint assessment was completed which indicated the resident was unable to demonstrate release of the seatbelt upon command. Review of an Incident/Accident Report dated 05/13/12 revealed on 05/13/12 at 10:20 A.M. the resident was found sitting on the floor between the bed and his wheelchair. The new intervention put in place to prevent additional falls was a front releasing seatbelt for the resident's wheelchair. Review of an Incident/Accident Report dated 10/06/12 revealed on 10/06/12 (the time was not noted) the resident had an observed fall. The Incident/Accident Report did not indicate how the resident fell but stated the resident did sustain a laceration and a hematoma to his head and a reddened left eye. The report indicated the resident was sent to the hospital and the new intervention to prevent additional falls was to make sure the resident's seat belt was in place and that the wheelchair was tilted back. Review of the Nurses Notes dated 10/06/12 indicated the resident fell out of his wheelchair and hit his head on the floor. The notes also indicated the resident's daughter was notified, came in to see her father and requested the resident be sent to the hospital. Review of the hospital documentation indicated the resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged back to the facility on [DATE]. During observations on 11/05/12 at 1:33 P.M., at 4:30 P.M. and at 6:25 P.M. the resident was observed seated in his wheelchair wearing a front releasing seatbelt propelling himself down the hallway. On 11/06/12 at 8:15 A.M. the resident was observed in his wheelchair in the dining room with his front releasing seatbelt on. During an interview on 11/06/12 at 10:50 A.M., Licensed Practical Nurse (LPN) #18 who assessed the resident after his fall stated the resident fell out of his wheelchair because he did not have his front releasing seat belt on. LPN #18 stated she did not witness the fall but was called to the resident's room by State tested Nursing Assistant (STNA) #70. LPN #18 further stated STNA #70 told her she was taking the resident down to the dining room for breakfast and when she turned the wheelchair the resident fell out on to the floor. STNA #70 no longer works for the facility and was unavailable for interview. 2. Resident #50 was admitted to the facility on [DATE] and discharged to a hospital on [DATE]. [DIAGNOSES REDACTED]. Record review revealed the resident was assessed at high risk for falls but did not have a history of falls. The fall report dated 09/17/12 documented the wheel chair leg rest got tangled with the resident's left leg, the wheelchair tipped forward and the resident slid out. She suffered an abrasion to the left forehead and left knee. A yellow oval shaped donut was in the seat of the wheelchair on top of the pressure relief cushion. The family provided it over the weekend and insisted it be used. The resident transferred only with a mechanical lift and the assistance of two staff members. One of her caregivers, STNA #36, was interviewed at 2:30 P.M. on 11/07/12. She stated she would not have transferred the resident to a wheelchair that had a cushion that was not ordered by the physician until after she had checked with the nurse. However, two staff did transfer her that morning to the chair and failed to remove the cushion that was on top of the pressure relief cushion. 3. Resident #53 was admitted on [DATE] and discharged to a psychiatric unit of a hospital on [DATE]. He had been admitted to a hospital three weeks prior for increased confusion and wandering from home, and the hospital referral stated the resident was "prone to wandering and looks for opportunities to escape". There was no nursing assessment, and only one nursing note found in the record, dated 04/27/12 on first shift. The nursing note documented the resident's severe memory loss and his continual pacing up and down the halls. It stated the resident frequently stated he wanted to go home. and staff intercepted him at an exit door at 9:00 A.M. The note documented at 9:15 A.M. the resident was threatening staff and staff was unable to redirect him. The physician was notified and ordered an increase in his antipsychotic medication and an injection of an antianxiety drug. Review of facility documentation and interview with staff revealed the resident "made a run for the front door" with five staff following on 05/06/12 (no time given). The staff tried to put him into a wheelchair but he grabbed the foot pedal of the wheel chair and tried to hit staff with it. The documentation stated he ran out the front door at 11:00 P.M. and was assisted back into the facility, threatening staff. He eloped again at 11:00 A.M. on 05/07/12; the police were called to help find him. The report stated he left the facility twice, once getting to a large clothing store nearby, and once getting to the trees behind the facility. There was no care plan which addressed the resident's wandering and elopement risk. There was no evidence of the use of alarms, secure care bracelet, or other devices designed to alert staff to an elopement. The citation substantiates Complaint Number OH 952, OH 859 and OH 742.