Every finding on record at Village at St Edward NRSG Care

Based on observations, interviews, and resident record reviews, the facility failed to ensure call lights were in reach. This affected two residents (#8 and #67) of three residents reviewed for call lights. The facility census was 79.Findings include: 1. Review of the medical record for Resident #8 revealed she was admitted to the facility on [DATE] with diagnoses that included respiratory syncytial virus, fall, dementia, and anxiety.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had severe cognitive impairment. Resident #8 had a history of inattention, disorganized thinking, was dependent on staff for activities of daily living (ADLs) that included, but not limited to, maximal assistance for upper body dressing and rolling left and right.Review of the care plan dated 01/14/26 revealed Resident #8 was at risk for falls and had an ADL self-care performance deficit related to dementia, impaired balance, impaired cognition and mobility with interventions that included assistance from staff for ADLs, assistance of one staff for bed mobility for turning and repositioning and ensure the call light was within reach.Review of the physician orders dated 01/14/26 revealed Resident #8 was a two person assist for transfers via mechanical lift.Observation and interview on 02/25/26 at 9:55 A.M. revealed Resident #8 was lying in the bed with her body facing towards the left wall. Resident #8's bed was positioned against the wall on the left-hand side of the room. Resident #8 call light was not visible and out of reach. Resident #8 stated she did not know where her call light was and could not reach it.Interview on 02/25/26 at 9:59 A.M. with Licensed Practical Nurse (LPN) #722 revealed Resident #8 required assistance with ADLs including bed mobility. LPN #722 stated Resident #8's call light was to always be in reach. Observation at the time of the interview upon entering Resident #8's room revealed LPN #722 was unable to locate Resident #8's call light. LPN #722 was then observed reaching under Resident #8's bed and using her hands to follow the cord which was wrapped around Resident #8's right handrail and hanging between the handrail and mattress. LPN #722 stated Resident #8 always faced the left side and that was her typical position. Continued observation revealed Resident #8 was still unable to reach the call light. LPN #722 confirmed and verified the above findings at the time of the observation.Observation and interview on 02/26/26 at 11:05 A.M. revealed Resident #8 lying in bed on her left side and facing the left side wall. Resident #8's call light was observed to be wrapped around the right-side handrail and hanging between the right handrail and mattress. Resident #8 stated she could not reach her call light, and she did not know where it was. Resident #8 was observed attempting to fold her arms backwards to try to reach and find the call light.Observation and interview on 02/26/26 at 11:07 A.M. with Registered Nurse (RN) #611 revealed RN #611 entered Resident #8's room. RN #611 was observed trying to locate Resident #8's call light by reaching under Resident #8's bed and using her hands to follow the cord which was wrapped around Resident #8's right handrail and hanging between the handrail and mattress. RN #611 stated, Oh, you can't reach that as she spoke to Resident #8. RN #611 was observed placing the call light at the top of the right handrail and asking Resident #8 if she could reach it. Resident #8 was observed attempting to reach the call light but could not. RN #611 continued to try to position the call light in a position on the right handrail that was within reach for Resident #8 but was unsuccessful. RN #611 stated Resident #8 always was on her left side and faced the left side wall. RN #611 confirmed and verified the above findings at the time of the observation.2. Review of the medical record for Resident #67 revealed she was admitted [DATE] and had diagnoses including unspecified dementia, diabetes, amnesia, edema, and degenerative disease of nervous system. Review of her MDS assessment dated [DATE] revealed she had moderate cognitive impairment and required at least setup assistance for ADLs.Observation of Resident #67 on 02/26/26 at 10:13 A.M. revealed she was in bed. Her call light was sitting on a set of drawers roughly three feet from the bed and out of her reach. She was not interviewable.Interview with Registered Nurse #611 on 02/26/26 at 10:16 A.M. confirmed the above observation. This deficiency represents noncompliance investigated under Complaint Number 2629951.

Based on observations, resident record review, resident interview, and staff interviews, the facility failed to accurately assess and document a resident's hearing status on the minimum data set (MDS) assessment. This affected one resident (#1) of four residents reviewed for assessments. The facility census was 79.Findings include:Review of the medical record for Resident #1 revealed she was admitted to the facility on [DATE] with diagnoses that included pulmonary fibrosis, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and type two diabetes.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had no cognitive impairment. Resident #1 required supervision or touching assistance with eating, and some assistance with activities of daily living (ADLs). Resident #1's ability to hear was adequate and she did not utilize hearing devices.Review of the care plan dated 01/12/26 revealed Resident #1 had an ADL self-care performance deficit with interventions that included, but not limited to, assistance with care. Review of the care plan revealed nothing related to hearing devices.Review of the physician orders revealed an order dated 01/22/26 to provide audiology services.Review of the current physician orders revealed no orders related to Resident #1 hearing devices.Review of the audiology consultation dated 05/16/23 revealed Resident #1 utilized hearing aids and/or amplifiers in both ears. A whisper test (a simple and accurate test for detecting hearing impairment) was conducted on both ears and was positive. Resident #1 could not hear the whisper test.Review of the audiology consultation dated 08/16/23 revealed Resident #1 utilized hearing aids and/or amplifiers in both ears. A whisper test was conducted on both ears and was positive. Resident #1 could not hear the whisper test and was working with audiologist regarding hearing aids echoing.Review of the hearing, speech, and vision assessment dated [DATE] revealed Resident #1 hearing was adequate and utilized no hearing devices.Review of the quarterly MDS assessments dated 04/21/25, 07/22/25, and 10/22/25, Section B for hearing, speech and vision revealed Resident #1's hearing was adequate and utilized no hearing devices.Review of the annual MDS assessments dated 03/04/25 and 01/27/26, Section B for hearing, speech and vision revealed Resident #1's hearing was adequate and utilized no hearing devices.Observation on 02/25/26 at 8:34 A.M. revealed Resident #1 seated in a recliner adjacent to the left side of her bed. Resident #1 was visibly upset and struggling to place both left and right hearing aids into her ears. Interview at the time of the observation with Resident #1 revealed no one had helped with putting in her hearing aids. Resident #1 stated it's so hard to put in my hearing aids.Interview on 02/25/26 at 8:40 A.M. with Registered Nurse (RN) #313 revealed Resident #1 preferred to get up prior to breakfast and required help from staff with hearing aids. RN #313 revealed Certified Nurse Assistant (CNA) #721 had already dressed and prepared Resident #1 for the day. The CNA's or the nurse assisted with Resident #1's hearing aid devices and she let staff know if they were placed correctly through a monitoring device on her phone.Observation and interview on 02/25/26 at 8:42 A.M. revealed RN #313 enter Resident #1 room with Resident #1 stating I been trying for ten minutes to put hearing aids in. I can't do it. RN #313 was observed assisting Resident #1 with the hearing aids. RN #313 confirmed and verified the above findings at the time of the interviews and observations.Interview on 02/26/26 at 10:31 A.M. with RN #611 confirmed Resident #1 utilized hearing aids that linked to her phone, and she required assistance with ADLs. Resident #1's phone provided instructions on how to assist with the hearing aids, which were color coordinated to determine what ear each one was placed in and if the batteries were dead. Staff were responsible for assisting with hearing aids and keeping them charged. Resident #1 required more assistance with her ADLs due to a decline in her health and care needs. RN #611 verified the hearing aid devices were not coded on the above MDS assessments. Interview on 02/26/26 at 1:57 P.M with Licensed Social Worker (LSW) #519 verified Resident #1 was admitted to the facility approximately three years prior with hearing aids for both her left and right ears.

Based on observations, resident record reviews, interviews, review of a Self-Reported Incident (SRI) and facility policy review, the facility failed to provide adequate assistance with activities of daily living (ADL) for dependent residents. This affected two residents (#1 and #86) of four residents reviewed for ADL care. The facility census was 79.Findings include:1. Review of the medical record for Resident #1 revealed she was admitted to the facility on [DATE] with diagnoses that included pulmonary fibrosis, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and type two diabetes.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had no cognitive impairment. Resident #1 required supervision or touching assistance with eating, and some assistance with activities of daily living (ADLs). Resident #1's ability to hear was adequate and she did not utilize hearing devices.Review of the care plan dated 01/12/26 revealed Resident #1 had an ADL self-care performance deficit with interventions that included, but not limited to, assistance with care. Review of the care plan revealed nothing related to hearing devices.Review of the physician orders revealed an order dated 01/22/26 to provide audiology services.Review of the current physician orders revealed no orders related to Resident #1 hearing devices.Review of the audiology consultation dated 05/16/23 revealed Resident #1 utilized hearing aids and/or amplifiers in both ears. A whisper test (a simple and accurate test for detecting hearing impairment) was conducted on both ears and was positive. Resident #1 could not hear the whisper test.Review of the audiology consultation dated 08/16/23 revealed Resident #1 utilized hearing aids and/or amplifiers in both ears. A whisper test was conducted on both ears and was positive. Resident #1 could not hear the whisper test and was working with audiologist regarding hearing aids echoing.Review of the hearing, speech, and vision assessment dated [DATE] revealed Resident #1 hearing was adequate and utilized no hearing devices.Observation on 02/25/26 at 8:34 A.M. revealed Resident #1 seated in a recliner adjacent to the left side of her bed and a bedside table with a breakfast tray, which was untouched with three sealed white containers with lids. The bed was left unmade with the covers tossed aside at the foot of the bed. Resident #1 appeared to be visibly upset and struggling to place both left and right hearing aids into her ears. Interview at the time of the observation with Resident #1 revealed the facility staff did not get her up when she requested at 7:00 A.M. She preferred to be showered, dressed and prepared for breakfast prior to her breakfast tray being placed in her room. Resident #1 stated the staff did not get her up until 7:50 A.M. Her care and shower were rushed, staff did not make her bed, and no one helped her with opening her breakfast containers or putting in her hearing aids. Resident #1 stated, It's so hard to put in my hearing aids.Interview on 02/25/26 at 8:40 A.M. with Registered Nurse (RN) #313 verified Resident #1 preferred to get up prior to breakfast and required help from staff with meal set-up and hearing aids. RN #313 stated Certified Nurse Assistant (CNA) #721 had already dressed and prepared Resident #1 for the day. The CNA's or the nurse assisted with Resident #1's hearing aid devices and she let staff know if they were placed correctly through a monitoring device on her phone.Observation and interview on 02/25/26 at 8:42 A.M. revealed RN #313 entered Resident #1's room with Resident #1 stating, I been trying for ten minutes to put hearing aids in. I can't do it. I need help with breakfast to open all this stuff. RN #313 was observed assisting Resident #1 with hearing aids and the breakfast tray. RN #313 confirmed and verified the above findings at the time of the interviews and observations.Interview on 02/25/26 at 8:45 A.M. with CNA #721 revealed she had already assisted Resident #1 with her morning care and was now assisting other residents. CNA #721 confirmed she did not assist with Resident #1 hearing aids, did not make her bed and did not assist with her breakfast tray. CNA #721 stated, I don't usually work with her. CNA #721 revealed if her assignment was changed, information on the resident care needs was available. CNA #721 confirmed and verified the above findings at the time of the interview.Interview on 02/26/26 at 10:31 A.M. with RN #611 revealed Resident #1 utilized hearing aids that linked to her phone and required assistance with ADLs. Resident #1's phone provided instructions on how to assist with the hearing aids, which were color coordinated to determine what ear each one was placed in and if the batteries were dead. Staff were responsible for assisting with hearing aids and keeping them charged. RN #611 verified Resident #1 required more assistance with her ADLs due to a decline in her health and care needs. RN #611 confirmed and verified the above findings at the time of the interview.2. Review of the medical record for Resident #86 revealed he was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, intervertebral disc displacement lumbar region and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. Resident #86 was discharged from the facility on 01/20/26.Review of the MDS assessment dated [DATE] revealed Resident #86 had no cognitive impairment. Resident #86 required assistance from staff for ADLs including, but not limited to, toileting, lower body dressing, sit-to-stand position, and toilet transfers. Resident #86 was occasionally incontinent with bladder and frequently incontinent with bowel.Review of the care plan dated 12/23/25 revealed Resident #86 had an ADL self-care performance deficit related to left hemiplegia, was at risk for falls, and had mixed bladder incontinence with interventions that included assistance from staff including toileting. Review of the physician orders dated 12/22/25 revealed Resident #86 required staff assistance of one for transfers.Review of the physician orders dated 12/23/25 revealed Resident #86 required staff assistance with ADLs due to left hemiparesis.Review of the skilled charting assessment dated [DATE] revealed Resident #86 required assistance with toilet use.Review of the occupational therapy treatment encounter notes dated 12/23/25 through 01/19/26 revealed Resident #86 was dependent on toileting, hygiene and moderate assistance with toilet transfers.Review of the progress note dated 01/03/26 at 3:21 P.M. revealed Resident #86 was found on the floor in his room holding onto the bedrail. Resident #86's visitor reported observing Resident #86's left leg give out, and he landed on the buttocks. Resident #86 was educated to ask for assistance from staff.Review of the progress note dated 01/05/26 at 2:00 A.M. revealed Resident #86 was compliant with allowing staff to assist with ADLs and transfers.Review of the progress note dated 01/05/26 at 9:37 A.M. revealed Resident #86 continued to have weakness related to post cerebrovascular accident (CVA) and/or stroke. Resident #86 was encouraged to have assistance.Review of SRI #269883 dated 01/16/26 revealed Resident #86 alleged that CNA #220 was neglectful after requesting assistance with incontinence care. Resident #86 reported after requesting assistance via the call light, CNA #220 replied why can't you wait until first shift. Resident #86 stated he requested briefs and when he was provided briefs, CNA #220 did not provide assistance. The facility unsubstantiated the SRI. Review of the progress note dated 01/18/26 at 6:45 A.M. revealed Resident #86 was found on the floor at the foot of his bed lying on his left side. Resident #86 was assisted to his wheelchair from the floor with assistance of two staff and a gait belt. Resident #86 was assessed due to concern related to landing on his affected and/or weak side and could barely move his lower left extremity. Resident #86 stated he fell attempting to clean himself up after a bowel movement and fell due to his bad leg. Resident #86 was assisted with donning a clean brief and sweatpants and was encouraged to use call light for staff assistance. Interview on 02/25/26 at 3:11 P.M. with Resident #86's friend revealed Resident #86 was treated rudely and alleged CNA #920 threw a pack of briefs at him, did not offer any help and asked him, why he couldn't wait until the next shift?Interview on 02/26/26 at 10:54 A.M. with CNA #920 revealed she provided care for Resident #86 when he was a resident in the facility. Resident #86 required assistance from staff for incontinence care but stated Resident #86 thought he was more independent than he was. She recalled the event related to SRI #269883 and gave identical details on what occurred and stated management spoke to her about the incident because she was named as an alleged perpetrator. CNA #920 revealed on the day in question, Resident #86 requested a pack of briefs for incontinence care and said he needed to go to the bathroom. She verified she provided Resident #86 with a pack of briefs and left the room without assisting him. CNA #920 stated she returned an hour later to find Resident #86 visibly upset due to having experienced a bowel incontinence episode. CNA #920 stated Resident #86 had asked her to leave his room because she did not care about his condition and did not assist him. CNA #920 confirmed she was aware Resident #86 required assistance but since he did not ask for help, she did not provide it. CNA #920 could not explain why she did not assist a resident who was dependent on staff with incontinence care.Interview on 03/02/26 at 9:19 A.M. with the Administrator and Director of Nursing (DON) revealed Resident #86's concerns related to SRI #269883 were brought forward regarding CNA #220. Resident #86 requested assistance, CNA #220 came and gave him briefs and left his room. CNA #220 said Resident #86 was able to provide his own care despite his medical record indicating assistance was needed. CNA #920 was named as an alleged perpetrator but was not listed in the SRI. They revealed that due to multiple staff members being named in the SRI, CNA #920 was not added, and no disciplinary actions were taken due to Resident #86's story changing. The Administrator and DON confirmed and verified Resident #86 required assistance and was not provided with incontinence care.Review of the facility document titled, ADL Care Policy, undated, revealed the facility had a policy in place to provide individualized and person-centered assistance with ADLs to all residents including, but not limited to, essential self-care tasks, assessments and care planning. This deficiency represents noncompliance investigated under Complaint Number 2720699.

Based on observation, interview and record review, the facility failed to provide care planned interventions to prevent resident falls. This affected one (Resident #67) of two residents reviewed for accident hazards. The total census was 79.Findings include:Review of the medical record for Resident #67 revealed she was admitted [DATE] and had diagnoses including unspecified dementia, diabetes, amnesia, edema, and degenerative disease of nervous system. Her last fall assessment dated [DATE] revealed she was at high risk for falls. Her care plan noted she was at risk for falls related to impaired cognition, poor safety awareness, and impaired mobility. One care planned intervention dated 07/19/22 revealed Resident #67 was to have Dycem (a rubber-like material designed to have high friction and prevent slipping) above and below the pressure cushion in her wheelchair.Observation on 02/25/26 at 2:03 P.M. revealed Resident #67 lying down on the floor in front of her wheelchair in the second-floor hallway by the dining room. She said she was not sure how she fell and felt she just slipped out of the chair. Observation of her wheelchair revealed a Dycem sheet beneath her seat pad, but none elsewhere on the wheelchair or on or near her person. Staff post-fall response was ongoing at the time of the observation.Interview with Registered Nurse #611 on 02/25/26 at 2:16 P.M. confirmed Resident #67 was care planned to have a Dycem sheet both above and below her wheelchair pad, and only had one located below it.

Based on observations, resident record review, resident interview, and staff interviews, the facility failed to develop and implement a comprehensive care plan to reflect a resident's hearing impairment. This affected one resident (#1) of one resident reviewed for care planning. The facility census was 79.Findings include:Review of the medical record for Resident #1 revealed she was admitted to the facility on [DATE] with diagnoses that included pulmonary fibrosis, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and type two diabetes.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had no cognitive impairment. Resident #1 required supervision or touching assistance with eating, and some assistance with activities of daily living (ADLs). Resident #1's ability to hear was adequate and she did not utilize hearing devices.Review of the care plan dated 01/12/26 revealed Resident #1 had an ADL self-care performance deficit with interventions that included, but not limited to, assistance with care. Review of the care plan revealed nothing related to hearing devices.Review of the physician orders revealed an order dated 01/22/26 to provide audiology services.Review of the current physician orders revealed no orders related to Resident #1 hearing devices.Review of the audiology consultation dated 05/16/23 revealed Resident #1 utilized hearing aids and/or amplifiers in both ears. A whisper test (a simple and accurate test for detecting hearing impairment) was conducted on both ears and was positive. Resident #1 could not hear the whisper test.Review of the audiology consultation dated 08/16/23 revealed Resident #1 utilized hearing aids and/or amplifiers in both ears. A whisper test was conducted on both ears and was positive. Resident #1 could not hear the whisper test and was working with audiologist regarding hearing aids echoing.Review of the hearing, speech, and vision assessment dated [DATE] revealed Resident #1 hearing was adequate and utilized no hearing devices.Review of the quarterly MDS assessments dated 04/21/25, 07/22/25, and 10/22/25, Section B for hearing, speech and vision revealed Resident #1's hearing was adequate and utilized no hearing devices.Review of the annual MDS assessments dated 03/04/25 and 01/27/26, Section B for hearing, speech and vision revealed Resident #1's hearing was adequate and utilized no hearing devices.Observation on 02/25/26 at 8:34 A.M. revealed Resident #1 seated in a recliner adjacent to the left side of her bed. Resident #1 was visibly upset and struggling to place both left and right hearing aids into her ears. Interview at the time of the observation with Resident #1 revealed no one had helped with putting in her hearing aids. Resident #1 stated it's so hard to put in my hearing aids.Interview on 02/25/26 at 8:40 A.M. with Registered Nurse (RN) #313 revealed Resident #1 preferred to get up prior to breakfast and required help from staff with hearing aids. RN #313 revealed Certified Nurse Assistant (CNA) #721 had already dressed and prepared Resident #1 for the day. The CNA's or the nurse assisted with Resident #1's hearing aid devices and she let staff know if they were placed correctly through a monitoring device on her phone.Observation and interview on 02/25/26 at 8:42 A.M. revealed RN #313 enter Resident #1 room with Resident #1 stating I been trying for ten minutes to put hearing aids in. I can't do it. RN #313 was observed assisting Resident #1 with the hearing aids. RN #313 confirmed and verified the above findings at the time of the interviews and observations.Interview on 02/26/26 at 10:31 A.M. with RN #611 confirmed Resident #1 utilized hearing aids that linked to her phone, and she required assistance with ADLs. Resident #1's phone provided instructions on how to assist with the hearing aids, which were color coordinated to determine what ear each one was placed in and if the batteries were dead. Staff were responsible for assisting with hearing aids and keeping them charged. Resident #1 required more assistance with her ADLs due to a decline in her health and care needs. RN #611 verified the hearing aid devices and Resident #1's hearing impairment were not included in the care plan.Interview on 02/26/26 at 1:57 P.M with Licensed Social Worker (LSW) #519 verified Resident #1 was admitted to the facility approximately three years prior with hearing aids for both her left and right ears.Review of Resident #1's care plan initiated on 03/28/23 with multiple subsequent revisions had no focus of or interventions for hearing aid use including monitoring, maintenance, or staff assistance with the application and removal of the hearing aids.

Based on observation, record review and interview, the facility failed to appropriately track and account for dispensed narcotics. This affected one (Resident #18) of three residents reviewed for narcotic tracking. The facility census was 79.Findings include:Review of the medical record for Resident #18 revealed she was admitted [DATE] and had diagnoses including major depressive disorder, pain in lower leg, and deep vein thrombosis. Her only past or current order of oxycodone tablets began 08/24/25 and was discontinued 08/27/25. Review of her October medication administration record revealed no active orders or documented administrations of oxycodone in that timeframe.Observation of the 200-hall medication cart on 03/02/26 at 9:40 A.M. revealed Resident #18 had one card of 54 oxycodone tablets which matched the medication count sheet. The most recent non-wasted removals of oxycodone tablets were dated 10/01/25, 10/12/25 and 10/31/25.Interview with the Administrator on 03/02/26 at 9:53 A.M. confirmed the above findings, including that multiple doses were removed from Resident #18's oxycodone card with no documentation of their final disposition.This deficiency represents noncompliance investigated under Complaint Number 2791137.

Based on observation, review of the medical record, review of facility policy, and interview with staff, the facility failed to provide privacy during wound care to Resident #1. This affected one resident (Resident #1) of one observed for wound care. Findings included: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, diabetes, pulmonary hypertension, atrial fibrillation, coronary atherosclerosis, flaccid neuropathic bladder, insomnia, dementia, depression, and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had moderately impaired cognition. Review of Resident #1's physician orders revealed the resident had treatment orders for a right heel wound dated 03/13/25 to cleanse the wound with normal saline, apply Santyl ointment to the wound, and cover it with a foam dressing daily and as needed. Observation of wound care on 04/09/25 at 10:00 A.M. revealed Licensed Practical Nurse (LPN) #100 provided wound care to Resident #1 with the assistance of Registered Nurse #102. During the observation, the staff failed to close the door to the residents room or pull the privacy curtain. The resident was able to be observed receiving wound care by anyone in the hallway. On 04/09/25 at 10:30 A.M. an interview with LPN #100 confirmed she did not close the door or the privacy curtain to provide privacy during wound care to Resident #1. Review of the undated facility policy titled, Privacy, revealed before performing assessments or procedures, the staff should close the doors or pull the privacy curtains to prevent others from seeing or overhearing, thereby respecting the residents privacy and dignity.

Based on observations, review of the medical record, interview with staff, and review of policy and procedure, the facility failed to maintain infection control during wound care for Resident #1's pressure ulcer. This affected one resident (Resident #1) of three reviewed for pressure ulcers. Findings included: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, diabetes, pulmonary hypertension, atrial fibrillation, coronary atherosclerosis, flaccid neuropathic bladder, insomnia, dementia, depression, and congestive heart failure. Review of the physician's order revealed Resident #1 had an order to cleanse the right heel with normal saline, apply Santyl ointment to the wound, cover with a foam dressing daily and as needed dated 03/13/25. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #1 had moderately impaired cognition and had a one unstageable pressure ulcer not present on admission. Observation of wound care on 04/09/25 at 10:00 A.M. revealed Licensed Practical Nurse (LPN) #100 provided wound care to Resident #1 with the assistance of Registered Nurse #102. LPN #100 did not sanitize the over-the-bed table prior to placing a paper towel (obtained from the paper towel dispenser in the room) onto the table, then she placed the dressing supplies on the paper towel. LPN #100 then soaked the four-by-four gauze in normal saline and laid it on the paper towel. The gauze soaked through the paper towel onto the unsanitized over-the-bed table below. She removed the old dressing from Resident #1's right heel. LPN #100 proceeded to pick up the normal saline soaked four-by-four gauze to clean the right heel wound, when the surveyor intervened. LPN #100 verified at this time the gauze had soaked through, onto the unsanitized table below, and the four-by-fours were now contaminated. On 04/09/25 at 10:30 A.M. an interview with LPN #100 confirmed she did not sanitize the over-the-bed table prior to placing her clean dressing supplies on the table. She further confirmed she placed the normal saline soaked four-by-four gauze on the paper towel and it soaked through the thin paper towel onto the unsanitized over-the-bed table below, contaminating the gauze that she had attempted to use for Resident #1's wound care. Review of the undated facility policy titled, Dressing Change, revealed the policy was to provide a clean wound covering to promote healing. All dressings, unless otherwise specified by a physician, were performed using clean rather than sterile technique. This deficiency represents non-compliance investigated under Master Complaint Number OH00161663 and Complaint Number OH00161643.

Based on record review and staff interview, the facility failed to ensure the State Ombudsman was notified of resident discharges. This affected one resident (Resident #4) of two residents reviewed for discharge and had the potential to affect all 76 residents in the facility. Findings revealed: Resident #4's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included hereditary spastic paraplegia (inherited leg weakness), osteoporosis, joint derangements, major depressive disorder, mild cognitive impairment, dysphagia, abnormal involuntary movements, secondary scoliosis, malnutrition, cerebral infarction, chronic osteomyelitis, and multiple sclerosis. Review of progress notes revealed Resident #4's cognition was impaired. Further review found the Resident had been discharged to the hospital on 06/08/24 for sepsis and urinary tract infection (UTI), 06/17/24 for UTI, 07/08/24 for UTI, and 10/22/24 for aspiration pneumonia. Review of discharge notifications to the Ombudsman revealed the facility did not send notifications for January, February, May, June, August, September, October, and November of 2024. Resident #4 was not on the list of discharge notifications sent to the Ombudsman for July 2024. Interview on 12/10/24 at 1:20 P.M. with Licensed Social Worker (LSW) #348 confirmed Resident #4 was not on the discharge list for July 2024. Interview on 12/10/24 at 1:47 P.M. with the Administrator confirmed Resident #4 was not on the discharge lists for her 6/8/24, 6/27/24, 7/8/24 and 12/22/24 discharges to the hospital. Interview on 12/10/24 at 3:04 PM with LSW #348 confirmed she only sent discharge lists to the Ombudsman for the months of March, April, and July 2024. Stated she had been with the facility since May 2023 and started doing the discharge lists in March 2024. Stated she just missed the other months. Review of facility policy titled Transfer/Discharge Notification, undated, asserted a copy of all resident discharge notices will be sent to the Office of the State Long Term Care Ombudsman that includes the reason for the transfer/discharge.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to timely notify resident representatives of significant changes in health status. This affected one (Resident #79) of three residents reviewed for falls. The facility census was 77 residents. Findings include: Review of the medical record for Resident #79 revealed an admitted [DATE] with diagnoses of vascular dementia with other behavioral disturbances, diabetes, expressive language disorder, adjustment disorder, rheumatoid arthritis and fracture of the first lumbar vertebrae with a discharge date of [DATE]. Review of the Minimum Data Set (MDS) assessment for Resident #79 dated 09/05/24 revealed the resident was severely cognitively impaired required staff assistance with activities of daily living (ADLs.). Review of the nurse progress note for Resident #79 dated 09/08/24 timed at 10:45 P.M. revealed the resident had a fall without injury and the resident's representative was notified. Review of the nurse progress note for Resident #79 dated 09/09/24 timed 1:35 P.M. revealed the resident had an unwitnessed fall in the hallway without injuries and the resident's representative was notified. Review of the communication with physician note for Resident #79 dated 09/09/24 timed 5:14 P.M. revealed the resident's representative was visiting and noticed the resident had complaints of pain to the left hand and the fifth digit appeared swollen and bruised. The nurse assessed the resident and notified the nurse practitioner who ordered an x-ray to the left hand. Review of the left-hand x-ray results for Resident #79 dated 09/09/24 timed 10:08 P.M. revealed the resident had an acute displaced fracture of the 5th digit (pinky finger) middle phalanx. Review of the nursing notes for Resident #79 dated 09/09/24 to 09/15/24 revealed the notes did not include notification to Resident #79's representative of the fracture. Interview on 11/04/24 at 12:30 P.M. with Resident #79's representative confirmed Resident #79's left finger did not look right on 09/09/24 so an x-ray was ordered. Resident #79's representative confirmed she was not notified until 09/16/24 that the resident had a fractured finger. Inteview on 11/04/24 at 12:45 P.M. with Director of Nursing (DON) confirmed the facility learned on 09/09/24 that Resident #79 had sustained a fracture to her finger. The DON confirmed the staff did not notify Resident #79's representative of the resident's fractured finger until 09/16/24. Review of the facility policy titled Notification of Condition of Change undated in the event of a clinical complication, the resident was informed of immediately and the physician thereafter. The resident's responsible party would be notified at the earliest convenience of the nurse, but within 24 hours of discovery.

Based on medical record review, staff interview, resident representative interview, and review of the facility policy, the facility failed to implement interventions to prevent falls. This affected one (Resident #79) of three residents reviewed for falls. The facility census was 77 residents. Findings include: 1. Review of the medical record for Resident #79 revealed an admitted [DATE] with diagnoses of vascular dementia with other behavioral disturbances, diabetes, expressive language disorder, adjustment disorder, rheumatoid arthritis and fracture of the first lumbar vertebrae with a discharge date of [DATE]. Review of the Minimum Data Set (MDS) assessment for Resident #79 dated 09/05/24 revealed the resident was severely cognitively impaired, required staff assistance with bed mobility and transfers and used a walker and a wheelchair for mobility. Review of the nurse progress note for Resident #79 dated 09/08/24 timed at 10:45 P.M. revealed the resident had unwitnessed fall from her wheelchair by the nurses' station Review of the physician's orders for Resident #79 revealed an order dated 09/09/24 for the resident to have every 15-minute checks starting on 09/09/24 at 7:00 A.M for three days until 09/11/23 at 11:59 P.M. Review of the safety checks form for Resident #79 dated 09/09/24 revealed the resident's every 15-minute safety checks did not begin until 09/09/24 at 1:45 P.M. Review of the fall care plan for Resident #79 updated 09/09/24 revealed the resident was at risk for falls related to gait/balance problems, impaired cognition, impaired mobility, incontinence, pain, poor communication/comprehension, poor safety awareness, psychoactive drug use, history of falls, gout, and attempts to self-transfer. Interventions included staff should anticipate and meet the resident's needs. Interview on 11/04/24 at 12:45 P.M. with the Administrator and Director of Nursing (DON) confirmed Resident #79's every 15-minutes safety checks were supposed to begin on 09/09/24 at 7:00 A.M., but the staff did not start them until 09/09/24 at 1:45 P.M. 2. Review of the nurse progress note for Resident #79 dated 09/09/24 timed 1:35 P.M. revealed the resident had an unwitnessed fall in the hallway. Resident stated that she was trying to get into bed. Staff initiated neurological checks. Review of the neurological check records for Resident #79 revealed the resident's neurological checks were only completed until 09/10/24 at 2:20 A.M. Interview on at 2:10 P.M. and 3:05 P.M. with the Administrator and DON confirmed Resident #79 should have had a full 24-hours of neurological checks following the fall which occurred on 09/09/24 around lunchtime, and the facility failed to complete neurological checks for a full 24 hours following the fall. Review of the facility policy titled Neurological Assessment policy revealed neurological assessment would be initiated per facility protocol in events of falls with known head injury and/or unwitnessed falls. Neurological assessments would be done each shift for 24 hours, or longer as indicated, in the following instances: after a fall with actual or suspected head injury. 3. Review of the nurse progress note for Resident #79 dated 10/20/24 timed 12:10 P.M. revealed the resident had an unwitnessed fall without injury in her room while self-ambulating with her walker. Further review of the note revealed every 15-minute safety checks were initiated. Review of the nurse progress note for Resident #79 dated 10/20/24 timed at 6:27 P.M. revealed resident had an unwitnessed fall in her room and sustained a small bruise below the left knee. Review of the Interdisciplinary Team (IDT) review form for Resident #79 dated 10/21/24 revealed the resident had an unwitnessed fall in her room on 10/20/24. The IDT determined the resident should be referred to therapy for evaluation and should have every 15-minute safety checks for 24 hours. Review of electronic medical record and hard chart for Resident #79 revealed they did not include every 15-minute safety checks for 10/20/24 and 10/21/24. Interview on 11/04/24 at 12:30 P.M. with Resident #79's representative confirmed the staff said the resident was on every 15-minute safety checks following the fall on 10/20/24 around lunchtime but she felt the resident wouldn't have fallen again on 10/20/24 if the staff truly completed the 15-minute safety checks. Interview on 11/04/24 at 3:05 P.M. with the Administrator and DON confirmed the facility did not complete every 15-minute safety checks for Resident #79 on 10/20/24 or 10/21/24. Review of the facility policy titled Falls/Found on Floor Protocol undated revealed with each resident fall the facility would review and revise the resident's care plan if needed and the facility would implement new interventions to prevent further falls. This deficiency represents noncompliance investigated under Complaint Number OH00159164.

Based on medical record review and interview the facility failed to provide timely written notifications to residents or residents' representatives related to the bed hold policy when residents were transferred to a hospital. This affected four residents (#20, #63, #65 and #274) of five residents reviewed for hospitalization . Findings include: 1. Review of Resident #20's medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note dated 08/13/22 at 10:15 A.M. revealed Resident #20 was unresponsive and her head and extremities were flaccid. The note indicated Resident #20's color was gray and her skin was diaphoretic (sweating profusely). Resident #20 was drooling and a blood pressure was unable to be obtained. After being assisted to bed, Resident #20 opened her eyes and was able to respond verbally. The physician was notified and Resident #20 was sent to the hospital. The note indicated Resident #20's daughter was updated. A nursing note, dated 08/13/22 at 5:25 P.M. indicated Resident #20 was admitted to the hospital with altered mental status. A nursing note, dated 08/14/22 at 4:09 P.M. indicated the hospital reported Resident #20 was evaluated for seizures and would be started on the medication, [MEDICATION(S)] (anti-convulsant). A nursing note, dated 08/15/22 at 4:15 P.M. indicated Resident #20 returned to the facility. A nursing note, dated 08/16/22 at 4:55 A.M. indicated Resident #20 was observed lying on the floor with blood smeared from the bed to the back of the resident's head. Resident #20 stated she fell off the bed. Resident #20 had a large abrasion on the back of her head that was bleeding. Resident #20 reported she was having back pain. Emergency services was contacted to transport Resident #20 to the hospital. The physician and daughter were notified of the incident. A nursing note dated 08/16/22 at 6:25 P.M. indicated Resident #20 was admitted to the hospital with a subdural hematoma (condition due to bleeding under the membrane covering the brain). Resident #20 returned to the facility on [DATE]. Review of the payor information revealed Resident #20 was paying privately for her stay prior to both hospitalization s. Review of bed hold notices, dated 08/16/22 and 08/18/22 revealed the notices were sent because Resident #20 was being admitted or was recently admitted to the hospital or would be out of the facility temporarily on therapeutic leave or vacation. The notice indicated private pay residents could choose to pay privately to hold a bed at the current room and board rates until the resident returned to the facility. The resident or responsible party was required to verify they wished to have the bed held within 24 hours of being admitted to the hospital or the bed would be relinquished. Verification of bed hold was required to be made prior to the start of vacation or therapeutic leave from the facility. Bed hold fees were payable prior to return to the facility. The notices indicated notification was made/verbal consent received from Resident #20's son on the days Resident #20 returned to the facility. On 09/14/22 at 9:25 A.M. interview with Assistant Administrator #863 verified the bed hold notice on 8/16/22 was dated after the resident returned from the hospital and the one dated 8/18/22 was on the day of return from the hospital. Assistant Administrator #863 verified it would be important for the resident/responsible party to know of the bed hold policy and cost to hold the bed in a more timely manner. 2. Review of Resident #63's medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note, dated 09/04/22 at 1:34 P.M. indicated Resident #63 would not eat lunch, was diaphoretic and had a low blood pressure of 79/44. Resident #63's pulse was 130 and oxygen saturation was 87% on room air. The power of attorney was notified and agreed he wanted Resident #63 sent to the hospital. A nursing note, dated 09/04/22 at 10:53 P.M. indicated Resident #63 was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #63 returned to the facility on [DATE]. Review of the payor source information indicated Resident #63 was receiving Medicaid at the time of discharge to the hospital. Review of the bed hold notice revealed if a resident's stay was paid by Medicaid, the bed would be held at not cost for a maximum of 30 days in a calendar year (January - December). The notice informing Resident #63's representative of the number of days used during the year and of the bed hold policy revealed the notification was made with verbal consent to hold the bed the day (09/08/22) Resident #63 returned to the facility. On 09/14/22 at 9:25 A.M. interview with Assistant Administrator #863 verified the bed hold notice was dated the day the resident returned from the hospital and verified it would be important for the resident/responsible party to know of the bed hold policy in a more timely manner. 3. Review of Resident #65's medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note, dated 07/14/22 at 12:49 P.M. indicated Resident #65 was in the hallway after breakfast and started yelling at other residents, telling them to get out of there and leaning forward in her chair to intimidate them. Resident #65 started screaming over and over stating her dog was dead and she needed a cab. Attempts to redirect and provided one on one care were unsuccessful. Resident #65 kept yelling at any one that walked by. Several staff members tried to sit with her and redirect Resident #65 who was having random thoughts one after the other, going from angry to happy. The Assistant Director of Nursing was notified and reached out to the psychiatrist services. A social worker note dated 07/14/22 at 2:15 P.M. indicated Resident #65 was discharged to a psychiatric hospital. Resident #65 returned to the facility on [DATE]. Review of payor source information revealed Resident #65's stay was paid for by Medicaid. Review of the bed hold notice revealed if a resident's stay was paid by Medicaid, the bed would be held at not cost for a maximum of 30 days in a calendar year (January - December). The notice informing Resident #65's representative of the number of days used during the year and of the bed hold policy revealed the notification was made with verbal consent to hold the bed 11 days after Resident #65 was discharged to the hospital. On 09/14/22 at 9:25 A.M. interview with Assistant Administrator #863 verified the bed hold notice was provided 11 days after discharge and that it was important to provide timely notices. 4. Review of Resident #274's medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note, dated 08/24/22 at 10:45 A.M. indicated Resident #274 was found on the floor in the hallway on the left side. When Resident #274 was assisted back to the wheelchair she was moaning of pain to the left hip/femur region. The Certified Nurse Practitioner ordered a stat x-ray. A social service note dated 08/24/22 at 4:51 P.M. indicated Resident #274 was discharged to the hospital. Resident #274 returned to the facility on [DATE]. Review of payor source information revealed Resident #274 paid privately. Review of the bed hold notice information Resident #274's responsible party revealed verbal consent was provided to hold the bed the day (08/29/22) Resident #274 returned to the facility (five days after discharge to the hospital). The notice indicated the responsible party or resident were required to verify if they wished to have the bed held within 24 hours of being admitted to the hospital or the bed would be relinquished. There was no evidence Resident #274's responsible party was notified of the bed hold rate at the time of discharge. On 09/14/22 at 9:25 A.M. interview with Assistant Administrator #863 verified the bed hold notice was dated the day Resident #274 returned from the hospital. Assistant Administrator #863 verified it would be important for a resident/responsible party to know of the bed hold policy and cost to hold the bed in a more timely manner.

Based on record review and interview the facility failed to ensure residents and/or their representatives were notified in writing when their personal fund account (PNA) reached $200.00 less than the Medicaid resource limit (of $2000.00). This affected four residents (#9, #49, #53 and #67) of six resident records reviewed for PNA accounts. Findings include: Review of the Trust Fund Balance Report dated 09/30/22 revealed the following: Resident #9, who received Medicaid benefit had a PNA balance of $3,551.33. Resident #49, who received Medicaid benefit had a PNA balance of $2,412.49. Resident #53, who received Medicaid benefit had a PNA balance of $3,415.85. Resident #67, who received Medicaid benefit had a PNA balance of $3,206.76. Record review revealed no evidence a spend down notice had been provided to any of the residents and/or the residents' representative when the resident reached $200.00 of the Medicaid resource limit of $2000.00. On 09/14/22 at 9:26 A.M. interview with Bookkeeper #893 confirmed Resident #9, #49, #53 and #67 and/or their representative had not been notified in writing when their PNA balance was within the $200.00 Medicaid resource limit.

Based on medical record review and interview the facility failed to provide written notifications to residents and residents' representatives before transfer to a hospital. This affected four residents (#20, #63, #65 and #274) of five residents reviewed for hospitalization . Findings include: 1. Review of Resident #20's medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note, dated 08/13/22 at 10:15 A.M. revealed Resident #20 was unresponsive and her head and extremities were flaccid. The note indicated Resident #20's color was gray and her skin was diaphoretic (sweating profusely). Resident #20 was drooling and a blood pressure was unable to be obtained. After being assisted to bed, Resident #20 opened her eyes and was able to respond verbally. The physician was notified and Resident #20 was sent to the hospital. The note indicated Resident #20's daughter was updated. A nursing note, dated 08/13/22 at 5:25 P.M. indicated Resident #20 was admitted to the hospital with altered mental status. A nursing note dated 08/14/22 at 4:09 P.M. indicated the hospital reported Resident #20 was evaluated for seizures and would be started on the medication, [MEDICATION(S)] (anti-convulsant). A nursing note dated 08/15/22 at 4:15 P.M. indicated Resident #20 returned to the facility. A nursing note, dated 08/16/22 at 4:55 A.M. indicated Resident #20 was observed lying on the floor with blood smeared from the bed to the back of the resident's head. Resident #20 stated she fell off the bed. Resident #20 had a large abrasion on the back of her head that was bleeding. Resident #20 reported she was having back pain. Emergency services was contacted to transport Resident #20 to the hospital. The physician and daughter were notified of the incident. A nursing note, dated 08/16/22 at 6:25 P.M. indicated Resident #20 was admitted to the hospital with a subdural hematoma ( condition due to bleeding under the membrane covering the brain). Resident #20 returned to the facility on [DATE]. Record review revealed no evidence of a written transfer notice being issued to the resident and/or resident's responsible party related to the hospital transfers. On 09/13/22 at 3:04 P.M. interview with Assistant Administrator #863 verified the facility did not provide written transfer notices when the resident was discharged to the hospital. 2. Review of Resident #63's medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note, dated 09/04/22 at 1:34 P.M. revealed Resident #63 would not eat lunch, was diaphoretic, and had a low blood pressure of 79/44. Resident #63's pulse was 130 and oxygen saturation was 87% on room air. The power of attorney was notified and agreed he wanted Resident #63 sent to the hospital. A nursing note, dated 09/04/22 at 10:53 P.M. indicated Resident #63 was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #63 returned to the facility on [DATE]. Record review revealed no evidence of a written transfer notice being issued to the resident and/or resident's responsible party related to the hospital transfer. On 09/13/22 at 3:04 P.M. interview with Assistant Administrator #863 verified the facility did not provide written transfer notices when the resident was discharged to the hospital. 3. Review of Resident #65's medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note, dated 07/14/22 at 12:49 P.M. indicated Resident #65 was in the hallway after breakfast and started yelling at other residents, telling them to get out of there and leaning forward in her chair to intimidate them. Resident #65 started screaming over and over stating her dog was dead and she needed a cab. Attempts to redirect and provided one on one care were unsuccessful. Resident #65 kept yelling at any one that walked by. Several staff members tried to sit with her and redirect Resident #65 who was having random thoughts one after the other, going from angry to happy. The Assistant Director of Nursing was notified and reached out to the psychiatrist services. A social worker note, dated 07/14/22 at 2:15 P.M. indicated Resident #65 was discharged to a psychiatric hospital. Resident #65 returned to the facility on [DATE]. Record review revealed no evidence of a written transfer notice being issued to the resident and/or resident's responsible party related to the hospital transfers. On 09/13/22 at 3:04 P.M. interview with Assistant Administrator #863 verified the facility did not provide written transfer notices when the resident was discharged to the hospital. 4. Review of Resident #274's medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note, dated 08/24/22 at 10:45 A.M. indicated Resident #274 was found on the floor in the hallway on the left side. When Resident #274 was assisted back to the wheelchair she was moaning of pain to the left hip/femur region. The Certified Nurse Practitioner ordered a stat x-ray. A social service note dated 08/24/22 at 4:51 P.M. indicated Resident #274 was discharged to the hospital. Resident #274 returned to the facility on [DATE]. Record review revealed no evidence of a written transfer notice being issued to the resident and/or resident's responsible party related to the hospital transfers. On 09/13/22 at 3:04 P.M. interview with Assistant Administrator #863 verified the facility did not provide written transfer notices when the resident was discharged to the hospital.

Based on medical record review and interview the facility failed to refer a resident with newly evident or possible serious mental disorder for a pre-admission screening and resident review (PASARR) Level II review. This affected one resident (#65) of two residents reviewed for PASARR. Findings include: Review of Resident #65's medical record revealed an original admitted [DATE] with no psychiatric/mood diagnoses identified. A Hospital Exemption from Preadmission Screening Notification, dated 04/20/22 indicated prior to hospital admission Resident #65 resided at a residential care facility. There had been no adverse preadmission screen and record review (PASARR) determination within the past 60 days. Resident #65 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The certification for hospital exemption indicated as the individual's attending physician, he certified the individual was being discharged to a nursing facility directly from a hospital after receiving acute patient care at the hospital, required nursing facility services for the condition for which she received care in the hospital and required fewer than 30 days of nursing facility services, no later than the date of discharge. The form indicated the nursing facility accepted responsibility for electronically initiating a resident review (if required) prior to the 30th day following admission from the hospital. On 04/21/22 an order was written for the antipsychotic medication, [MEDICATION(S)] 25 milligrams (mg) every 12 hours as needed for agitation for 14 days. Resident #65 was discharged [DATE] and returned 04/28/22. A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/30/22 the resident's diagnosis list included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A PASARR dated 05/05/22 indicated Resident #65 had no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review results indicated there were no indications of serious mental illness and/or developmental disability. The resident's diagnosis list was updated on 06/13/22 to include a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Between 06/28/22 and 07/13/22 orders were obtained for use of the use of the antipsychotic medication, [MEDICATION(S)] on an as needed basis due to [CONDITION(S)]/agitation. A nursing note dated 07/14/22 at 12:49 P.M. indicated Resident #65 was in the hallway after breakfast and started yelling at other residents, telling them to get out of there and leaning forward in her chair to intimidate them. Resident #65 started screaming over and over stating her dog was dead and she needed a cab. Attempts to redirect and provided one on one care were unsuccessful. Resident #65 kept yelling at any one that walked by. Several staff members tried to sit with her and redirect Resident #65 who was having random thoughts one after the other, going from angry to happy. The Assistant Director of Nursing was notified and reached out to the psychiatrist services. A social worker note, dated 07/14/22 at 2:15 P.M. indicated Resident #65 was discharged to a psychiatric hospital. Resident #65 returned to the facility on [DATE]. On 08/02/22 the resident's diagnosis list was updated to reflect diagnoses of dementia with behavioral disturbance and delusional disorders. Between 08/02/22 and 08/17/22 Resident #65 had orders for the antipsychotic medication, [MEDICATION(S)]. A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/13/22 at 3:04 P.M. interview with Assistant Administrator #863 verified a new PASARR was not completed after Resident #65 had a psychiatric hospitalization and new psychiatric diagnoses/psychiatric medications ordered. On 09/15/22 at 10:45 A.M. interview with Assistant Administrator #863 provided a PASARR dated 09/14/22 and indicated a new screen was completed. The new screen indicated Resident #65 was readmitted from a psychiatric facility/unit with admission on 08/02/22. It indicated although Resident #65 had no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The screen indicated Resident #65 did not utilize psychiatric services more than once due to the mental disorder. It indicated the resident used ongoing case management from a mental health agency once in the past two years. The inpatient psychiatric hospitalization was not recorded in determining if Resident #65 had a serious mental illness. The screen indicated in the past six months Resident #65 experienced one or more of the following functional limitations on a continuing or intermittent basis due to the mental disorder: maintaining personal hygiene, dressing herself and verbalizing needs were checked. In the past six months Resident #65 was prescribed antipsychotics and anti-anxiety medications. The screen indicated Resident #65 had indications of serious mental illness. A referral was made for a Level II evaluation.

Based on record review and interview the facility failed to ensure Resident #36 received the appropriate beneficiary notice when skilled services were discontinued. This affected one resident (#36) of three residents reviewed for beneficiary notices. Findings include: Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #36's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form revealed the resident's Medicare Part A skilled services started on 06/16/22 and her last covered day was 07/07/22. Review of Resident #36's Notice of Medicare Non-Coverage (NOMNC) form indicated skilled services would end 07/07/22. The form was verbally signed 07/05/22. The resident remained in the facility after the services ended. On 09/14/22 at 10:46 A.M. interview with Licensed Social Worker (LSW) #808 confirmed Resident #36 and/or her family did not receive the Advance Beneficiary Notice of Non-Coverage (SNFABN) form as required.

Based on observation, medical record review and interview the facility failed to ensure fall interventions were implemented as plan to decrease the risk of falls/injury for Resident #20 and Resident #274. This affected two residents (#20 and #274) of three residents reviewed for accidents. Findings include: 1. Review of Resident #20's medical record revealed diagnoses including dementia, chronic pain, [CONDITION(S)] and chronic pain. The resident's current plan of care revealed Resident #20 was at risk for falls related to gait and balance problems, impaired mobility, potential chronic pain, impaired cognition, poor to no safety awareness, impulsiveness, believing she could walk by herself at times, self-transfer attempts, removing non-skid footwear/shoes at times and history of falls. An intervention noted was to place a Dycem (non-skid surface) above and below the pressure reducing cushion in the resident's wheelchair. A fall risk assessment, dated 08/18/22 revealed Resident #20 was at high risk for falls with risk factors including history of falls, co-morbidities, impaired gait and over-estimating or forgetting limits. A significant change Minimum Data Set (MDS) 3.0 assessment, dated 08/31/22 indicated Resident #20 was able to make herself understood and was able to understand others. The assessment revealed Resident #20 had short and long term memory problems, was dependent on staff for transfers and did not walk. On 09/13/22 at 2:49 P.M. Resident #20's wheelchair was observed with no Dycem on top of the cushion. On 09/13/22 at 2:56 P.M. interview with State tested Nursing Assistant (STNA) #826 verified there was no Dycem in the wheelchair, stating the cushion in the chair was velcroed on the bottom so it did not slide. STNA #826 revealed she believed the Dycem was not needed on top of the cushion because Resident #20 no longer slid in the chair. On 09/13/22 at 3:26 P.M. interview with Licensed Practical Nurse (LPN) #937 revealed the Dycem was supposed to be placed on top of the resident's wheelchair cushion. On 09/13/22 at 4:00 P.M. interview with LPN #937 revealed she placed a Dycem on top of Resident #20's wheelchair cushion because there had been none there. 2. Review of Resident #274's medical record revealed diagnoses including Alzheimer's disease, anxiety disorder, presence of left artificial hip joint and peri-prosthetic fracture around the internal prosthetic left hip joint. A care plan initiated 07/14/22 revealed Resident #274 was at risk for falls related to deconditioning, impaired cognition, impaired mobility, incontinence, poor to no safety awareness, and attempts to transfer/ambulate unassisted at times. An intervention included to place Dycem above and below the pressure reducing cushion in the wheelchair. A fall risk assessment, dated 08/29/22 revealed Resident #274 was at high risk for falling. Risk factors included history of falls, co-morbidities, impaired gait and overestimating or forgetting limits. A Medicare five day MDS 3.0 assessment, dated 09/02/22 revealed Resident #274 rarely/never understood others, had hallucinations, required extensive (staff) assistance for transfers and did not walk. On 09/13/22 at 11:29 A.M. Resident #274 was observed in the hallway attempting to raise herself out of a specialized (Broda) chair. At 2:44 P.M. Resident #274 was observed sitting in the television lounge area occasionally leaning forward in the Broda chair. On 09/14/22 9:58 A.M. Resident #274 was observed sitting in a Broda chair in the hall by the nurse's station occasionally leaning forward then sitting back. At 11:43 A.M. STNA #826 and STNA #920 were observed transferring Resident #274 from the Broda chair to bed with a mechanical lift. There was no Dycem observed between Resident #274 and the cushion or between the cushion and the chair. At 11:57 A.M. interview with STNA #826 verified there was no Dycem on top of or below the cushion in the Broda chair. On 09/14/22 at 12:49 P.M. interview with LPN #937 revealed although Resident #274 now used a Broda chair instead of a wheelchair there should still be a Dycem above and below the cushion. LPN #937 revealed she had just reviewed that information (use of Dycem) with staff the afternoon of 09/13/22 and morning of 09/14/22.

Based on observation, record review and interview the facility failed to ensure Resident #59 was assisted with her breakfast meal in a timely manner. This affected one resident (#59) and had the potential to affect seven additional residents (#16, #26, #27, #29, #31, #47 and #53) who resided on the third floor and required staff assistance with meals. Findings include: Review of Resident #59's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #59's activities of daily living (ADL) care plan revealed an intervention dated 07/11/22 which reflected the resident was able to feed herself after set-up and needed maximum verbal cues at times to initiate and/or complete meals. Review of Resident #59's Minimum Data Set (MDS) 3.0 assessment, dated 08/11/22 revealed the resident exhibited a memory problem, required limited one person assist for meals and did not have significant weight loss. Review of Resident #59's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/12/22 at 9:20 A.M. Resident #59's breakfast meal tray was observed sitting on her over bed tray table, pushed against the wall and away from the bed. The utensils were still wrapped and the food and fluids still had the lids on them. Resident #59 was not interviewable. On 09/12/22 at 9:41 A.M. State tested Nursing Assistant (STNA) #900 was observed to enter Resident #59's room and picked up the breakfast meal tray located on the over bed table. A subsequent interview on 09/12/22 at 9:42 A.M. with STNA #900 revealed residents who required assistance with meals would normally not receive a tray until the staff were ready to assist them with the meal. The STNA revealed she would heat up Resident #59's breakfast tray because she had not had time previously to this to assist the resident with her breakfast. The STNA was unaware of how long the tray had been sitting on the over bed table and indicated she was not aware of any other staff assisting Resident #59 with the breakfast meal until this point. STNA #900 revealed Resident #59 had a decline in condition and currently required more assistance with meals. On 09/12/22 at 9:50 A.M. interview with STNA #942 revealed he had delivered Resident #59's breakfast meal tray at approximately 8:30 A.M. and set it on the over bed table for another staff member to assist the resident with the breakfast meal. STNA #942 revealed he was usually the only staff member who delivered the meal trays and he had to deliver them all. On 09/12/22 at 9:57 A.M. interview with Dining Services Supervisor #905 revealed the meal trays left the third floor servery (the floor where Resident #59 resided) at approximately 8:20 A.M. and once they were placed in the hall, the STNA staff were required to deliver the meal trays. On 09/12/22 at 11:15 A.M. during an interview with Assistant Administrator (AA) #863, the AA was made aware Resident #59's breakfast meal tray was delivered and remained on her over bed table from the time it was delivered at approximately 8:30 A.M. until 9:41 A.M. when STNA #900 entered the room. During the interview, Assistant Administrator #863 confirmed there were eight residents, Resident #16, #26, #27, #29, #31, #47, #53 and #59 who resided on the third floor who required assistance with meals. This deficiency substantiates Complaint Number OH 272.

Based on observation, interview, record review policy review and Centers for Disease Control and Prevention (CDC) guidance review, the facility failed to ensure staff changed or discarded their N95 masks and sanitized their eye protection upon exiting resident rooms suspected of COVID-19. This affected eight residents (Residents #1, #2, #3, #6, #7, #8, #9 and #10) and had the potential to affect all residents in the facility. The facility census was 65. Findings include: Resident #1 was admitted on [DATE] and diagnosed with [REDACTED]. Resident #1 resided on the COVID-19 isolation unit. Resident #2 was admitted on [DATE] and diagnosed with [REDACTED]. Resident #2 resided on the COVID-19 isolation unit. Resident #3 was admitted on [DATE] and diagnosed with [REDACTED]. Resident #3 resided on the COVID-19 isolation unit. Resident #6, Resident #7, Resident #8, Resident #9 and Resident #10 were in quarantine for suspected COVID-19 and resided on the COVID-19 isolation unit. Interview on 11/18/20 at 1:17 P.M. with Licensed Practical Nurse (LPN) #101 revealed he was working the entire 100 unit which included caring for residents on COVID-19 isolation unit and in general population. LPN #101 was wearing a N95 mask. LPN #101 revealed he did not change or discard his N95 mask when exiting suspected and confirmed COVID-19 rooms; therefore, he wore the same mask when caring for residents with and without COVID-19. LPN #101 revealed he does not sanitize his eye protection when exiting suspected or confirmed COVID-19 rooms either. Interview on 11/18/20 at 2:29 P.M. with State tested Nursing Assistant (STNA) #103 revealed she was designated to the COVID-19 unit. STNA #103 was wearing a N95 mask. STNA #103 revealed she did not change or discard her N95 mask when exiting suspected and confirmed COVID-19 rooms. STNA #103 did not sanitize eye protection upon exiting suspected of confirmed COVID-19 rooms either. Interview on 11/18/20 at 2:58 P.M. with Assistant Director of Nursing (ADON) #105 and the Director of Nursing (DON) revealed staff do not change and or discard their N95 masks upon exiting suspected or confirmed COVID-19 rooms. Review of the undated facility policy, titled Quarantine hallway and COVID positive Hallway personal protective equipment (PPE) Usage, revealed N95 masks, eye protection, gowns, and gloves were required in the resident rooms. Staff should clean eye protection if/when it becomes soiled. Staff are to change gowns as leaving COVID positive rooms and leaving the quarantine/COVID unit. Disposal of PPE included staff to remove gowns/gloves before exiting each COVID positive resident room and dispose in biohazards bins. The policy did not include the need to change or discard the N95 mask or to sanitize eye protection upon exiting a confirmed or suspected COVID. Review of the CDC guidance, updated 11/04/20, revealed PPE recommended when caring for a patient with suspected or confirmed COVID-19 includes the following: respirator or facemask and eye protection. Disposable respirators and facemasks should be removed and discarded after exiting the patient's room or care area and closing the door unless implemented extended use or reuse. If reusable respirators are used, they should be removed after exiting the patient's room or care area. They must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to re-use. Reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to re-use. Disposable eye protection should be discarded after use unless following protocols for extended use or reuse.

Based on record review and interview the facility failed to provide one resident (Resident #45) significant anticonvulsant medication as ordered. Actual Harm occurred when Resident #45's anticonvulsant medication was not administered for four consecutive doses, resulting in the resident being found unresponsive due to [MEDICAL CONDITION] activity and sent to the hospital for evaluation. This affected one of three residents reviewed for hospitalization . Findings include: Record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #45's quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed severely impaired cognition Resident #45's nurses notes dated 11/06/19 revealed the resident possibly had [MEDICAL CONDITION] activity for one minute, and as a result was sent to the hospital. Resident #45's comprehensive care plan initiated on 11/07/19. revealed the resident had a history of [REDACTED]. The resident had focal [MEDICAL CONDITION] during her hospital stay. Interventions to address [MEDICAL CONDITION] activity included medications would be given as ordered. Review of Resident #45's physician orders [REDACTED]. This order was discontinued on 11/13/19. Resident #45's physician orders [REDACTED]. Review of Resident #45's Administration Note dated 11/13/19 at 9:50 [NAME]M. revealed Resident #45's lacosamide medication was on order. Review of Resident #45's Administration Note dated 11/13/19 at 10:38 P.M. revealed the resident's lacosamide medication was not delivered by pharmacy. Resident #45's Nurses Note dated 11/14/19 at 8:00 [NAME]M. revealed the pharmacy called regarding the need for lacosamide medication for Resident #45 and the pharmacy stated they needed a prescription. The physician's office was notified and a copy of the prescription info was faxed to the the office. A message was left for the prescription to be filled and faxed. Review of Resident #45's Administration Note dated 11/14/19 at 9:23 [NAME]M. revealed lacosamide medication was not available, and the pharmacy was called. Review of Resident #45's nurses note dated 11/14/19 at 11:45 [NAME]M. revealed the resident's physician office was called again regarding the needed prescription, and a message was left. Review of Resident #45's nurses note dated 11/14/19 at 2:00 P.M. revealed the resident's physicians office called regarding the prescription and office staff stated the nurse practitioner would send the prescription for lacosamide. Review of Resident #45's nurses note dated 11/14/19 at 3:44 P.M. revealed the written prescription for lacosamide was obtained and faxed to the pharmacy. The pharmacy indicated the medication would be delivered that evening. Review of Resident #45' Administration Note dated 11/14/19 at 10:09 P.M. revealed the resident's lacosamide medication was not available. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Review of Resident #45's Nursing progress note revealed on 11/15/19 at approximately 5:00 [NAME]M., the resident was found unresponsive bleeding form the nose. The nurses responded to the residents room, and found Resident #45 sitting upright with staff assistance. Resident #45 would not respond to verbal commands, also no response from a sternal rub. While getting vital signs the resident began shaking and blood began running of of her mouth. Emergency 911 was called at 5:05 [NAME]M. and they arrived at 5:10 [NAME]M., and the resident exited the building at 5:20 [NAME]M. to the local emergency room . Resident #45 returned to the facility on [DATE] at 11:50 [NAME]M. Review of Resident #45's hospital records dated 11/15/19 revealed she was diagnosed with [REDACTED]. Review of the radiology report on 11/15/19 revealed no evidence of acute [MEDICAL CONDITION] or new abnormal intra-axial densities. The impression given based on physical exam was consistent with a [MEDICAL CONDITION] and the resident was at baseline at the time. The resident was likely postictal (altered stae of consciousness following [MEDICAL CONDITION] activity) and that is why she was unresponsive at the nursing home. Review of Resident #45's certified nurse practitioner note, dated 11/15/19, revealed in discussion with the assistant director of nursing, the resident was ordered [MEDICATION NAME] (lacosamide medication), and did not receive this medication for two days due to the facility being unaware that the medication was a schedule two narcotic medication and required a written prescription when ordered. Interview on 11/27/19 at 11:08 [NAME]M. with the Director of Nursing (DON) confirmed Resident #45 did not receive her medication as ordered. The DON revealed the lacosamide required a controlled substance written prescription, and the facility could not pull it without authorization. The DON revealed the pharmacy was waiting on the prescription. This deficiency is an incidental finding to Master Complaint Number OH 471 and Complaint Number OH 411.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on observation, resident interview, facility staff interview, medical record review, Self-Reported Incident (SRI) review and associated investigation, and Abuse policy review, the facility failed to ensure an allegation of physical and emotional abuse involving Resident #29 which was witnessed by Hospice Aide (HA) #10 was immediately reported to administrative staff and thoroughly investigated. The facility also failed to protect residents from abuse after Licensed Practical Nurse (LPN) #11 forced Resident #29 to take crushed medications against her will by allowing the LPN to continue to work for the remainder of her scheduled shift (approximately six hours) following the incident. This resulted in Immediate Jeopardy when LPN #11 was witnessed to state she was not going to play games with the resident, entered Resident #29's room, pushed the resident's legs down in bed, cradled the resident's head in her arms and then squeezed the resident's mouth open to intentionally and willfully administer crushed medication to the resident against her will. The potential for serious harm continued when Resident #29 verbalized fear of LPN #11 and the LPN continued to work and provide direct care and medication administration to residents, including Resident #29 following the incident. This affected one resident (Resident #29) and had the potential to affect 27 additional residents who resided on the unit LPN #11 was working on 04/20/17 (Resident #1, #6, #23, #28, #30, #31, #43, #44, #45, #49, #56, #65, #70, #78, #81, #86, #88, #89, #92, #95, #97, #98, #107, #108, #111, #119 and #121). The facility census on 04/20/17 was 76. On 06/02/17 at 8:38 A.M., the Administrator, Director of Nursing (DON), Director of Health Services #22, Vice President of Operations #23, Assistant Administrator #24 and Assistant Administrator in Training #25, were notified that Immediate Jeopardy began on 04/20/17 at approximately 10:00 A.M. when Hospice Aide #10 witnessed LPN #11 forcefully administer crushed medication to Resident #29 against her will. Following the observation, Resident #29 informed Hospice Aide #10 she was afraid of LPN #11 and stated the LPN was forceful in her actions. The incident, which was not immediately reported by LPN #12 to administrative staff resulted in LPN #11 working the remainder of her scheduled shift (approximately six hours) following the incident. LPN #11 continued to work and provide direct care and medication administration to residents, including Resident #29 following the incident. The Immediate Jeopardy was removed and corrected on 04/27/17 when the facility implemented the following corrective action: On 04/21/17, LPN #11 was removed from the schedule and notified she was suspended pending investigation related to an allegation of abuse. On 04/21/17, the Director of Health Services initiated in-service training to all charge nurses regarding medication administration and resident rights. Sixteen Registered Nurses (RN) and 17 LPN's were in-serviced. The in-service for all charge nurses was completed on 04/25/17. On 04/25/17, LPN #11's employment with the facility was terminated. On 04/26/17, the Director of Health Services #22 initiated random observations (audits) of medication administration to ensure medication administrations were completed in accordance with facility policy and the resident's right to refuse medications were honored in accordance with the resident's rights. Audits were completed weekly through 05/23/16 and no issues were identified related to resident right to refuse medications. On 04/27/17, in-servicing began for all nursing staff related to the following topics: (1) the facility Abuse policy, including the need to ensure all allegations were timely reported and residents were immediately protected pending the investigation; (2) how to appropriately respond to resident behaviors, including identifying when a resident was refusing care/treatment; and (3) resident rights, including the right to refuse care, treatment and medications. In-serving was completed for all staff by 05/09/17. Staff not in-serviced were identified to be on medical leave and would not be permitted to work until in-serving is completed. A facility audit, following the termination of LPN #11 revealed no other residents were at risk as being forced to take medications. On 05/30/17 and 05/31/17 interviews with Resident #6, #23, #25, #29, #38, #43, #45, #52, #62, #66, #76, #80, #82, #89, #94, #97, #123, #124, #125 were completed. Eighteen of 19 residents interviewed had no concerns, complaints or allegations of abuse. On 05/30/17 and 05/31/17 interviews with family members of Resident #77, #101 and #108 were completed. Three of three family members interviewed had no concerns, complaints or allegations of abuse. During the interview with Resident #29, the resident reported an allegation of physical abuse involving LPN #11 as noted above. On 05/31/17 and 06/01/17 interview with LPN #14, LPN #15, LPN #16, State tested Nurse Aide (STNA) #17, STNA #18, STNA #19 and STNA #20 revealed all staff interviewed were knowledgeable of the facility abuse policy and procedures, a resident's right to refuse medications or care, and how to manage resident behaviors. Findings include: Record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident received Hospice services for a [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) 3.0 assessment dated [DATE] and 04/27/17 revealed Resident #29 was alert and oriented with no cognitive impairment, capable of being understood, usually understood others and exhibited no verbal or physically aggressive behaviors. Resident #29 required extensive assistance for activities of daily living including mobility and personal hygiene care. Review of a facility Self-Reported Incident (SRI) tracking number 8, dated 04/21/17 revealed the facility reported to the State agency an allegation of neglect when a facility nurse, LPN #11, administered medications to a resident (Resident #29) who declined administration. The summary of the incident revealed Resident #29 was experiencing a Parkinsonian episode on 04/20/17 at the time routine medications were ordered. (A Parkinsonian episode is a temporary inability to move any muscles. These episodes affect strength, mobility and speech. The episode may last a few seconds to a few minutes.) Resident #29 was non-verbal and demonstrated little or no movement. The nurse administering the crushed medication assessed the resident and determined administering the medications was appropriate at that time. The administration was observed by HA #10. The nurse assessment and approach to administration was perceived by HA #10 as inappropriate. The same SRI review revealed the observation was reported and an investigation to determine neglect was initiated. The facility investigation determined the resident did not consent or decline administration at the time of the incident and the administration of the medication during the period of the episode placed the resident at increased risk for complications such as aspiration. Review of the facility investigation revealed a witness statement, dated 04/20/17 (no time was indicated on the witness statement however, it was faxed to the facility on [DATE] at 2:06 P.M. by the Hospice Agency) and authored by HA #10. The facility investigation included an undated witness statement authored by LPN #12, the charge nurse which revealed HA #10 came to her on 04/20/17 and informed her Resident #29 was afraid of LPN #11. The facility investigation also contained a statement by the DON which included information from Resident #29 and witness statement dated 04/24/17 and authored by LPN #11. Review of Resident #29's medical record, including nursing progress notes and social service progress notes revealed no written information related to the above incident. Additionally, review of the facility investigation revealed no evidence any other residents or staff were interviewed at the time of the incident related to their potential knowledge of the incident or interactions with LPN #11. On 05/30/17 at 3:21 P.M. Resident #29 was observed in her room in bed. An interview was completed at the time of the observation. During the interview the resident was asked if she had ever been physically, verbally or emotionally abused. The resident replied that yes she had been abused. Upon further interview the resident explained she had been physically abused, about a month earlier when a nurse tried forcing her to take her pain medication. The resident described the actions by the nurse as forceful and Resident #29 stated she was afraid of the nurse. On 06/01/17 at 11:16 A.M., an interview with LPN #12 was completed. The DON was present during the interview. During the interview, LPN #12 revealed she did not ask LPN #11 to leave the facility pending investigation, or immediately report the allegation to the DON because she believed the incident was resolved after meeting with Resident #29 on 04/20/17. LPN #12 revealed she did report the incident the following morning 04/21/17 because it was something the DON should be aware occurred. Review of LPN #11's time card and an interview with LPN #12 on 06/02/17 at 11:16 A.M., revealed LPN #11 remained on the nursing unit providing care and services to Resident #29 and potentially the other the 27 residents residing on the unit through the remainder of her shift on 04/20/17. LPN #11 punched out at 3:55 P.M. Review of LPN #11's personnel file revealed after leaving on 04/20/17, LPN #11 did not return to the facility. On 04/21/17 LPN #11 was notified she was suspended pending investigation and on 04/25/17 LPN #11 was terminated. On 06/02/17 at 8:30 A.M. interview with Vice President of Operations #23 verified none of the 27 residents residing on the unit where LPN #11 worked on 04/20/17 were immediately interviewed as part of the initial facility investigation. On 06/02/17 at 3:07 P.M. interview with Director of Health Service #22 verified the above incident was not reported to her until 04/21/17 which resulted in LPN #11 continuing to work and provide care and medication administration to residents, including Resident #29 on 04/20/17 for the remainder of her shift following the incident. Director of Health Service #22 also verified the initial investigation completed did not include interviews with other residents or staff who might have had knowledge or information of the incident. Review of the facility abuse policy and procedure, revised 11/2016 revealed the resident had the right to be free from abuse, neglect, coercion, and misappropriation. Under the area of prevention, the policy indicated that any employee of the facility who becomes aware through actual knowledge, suspicion, or receipt of an actual verbal or written allegation of resident abuse, neglect, or misappropriation of resident property by an authorized or unauthorized individual shall immediately report this information to their supervisor verbally. Under the area of protection, the policy indicated if a specific employee was suspected of being involved in a situation of resident abuse, neglect, and/or misappropriation of property, the employee would be suspended pending investigation as soon as it was known he/she was a suspect. On 05/30/17 and 05/31/17 interviews with Resident #6, #23, #25, #29, #38, #43, #45, #52, #62, #66, #76, #80, #82, #89, #94, #97, #123, #124, #125 were completed. Eighteen of 19 residents interviewed had no concerns, complaints or allegations of abuse. On 05/30/17 and 05/31/17 interviews with family members of Resident #77, #101 and #108 were completed. Three of three family members interviewed had no concerns, complaints or allegations of abuse. During the interview with Resident #29, the resident reported an allegation of physical abuse involving LPN #11 as noted above. On 05/31/17 and 06/01/17 interview with LPN #14, LPN #15, LPN #16, State tested Nurse Aide (STNA) #17, STNA #18, STNA #19 and STNA #20 revealed all staff interviewed were knowledgeable of the facility abuse policy and procedures, a resident's right to refuse medications or care, and how to manage resident behaviors.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on observation, resident interview, family interview, Hospice staff interview, facility staff interview, medical record review, Self-Reported Incident (SRI) review and associated investigation, and Abuse policy review, the facility failed to effectively implement their abuse policy and procedure to ensure Resident #29 was free from physical and emotional abuse which was witnessed by Hospice Aide (HA) #10. The facility failed to ensure the allegation was immediately reported and thoroughly investigated and failed to protect residents from abuse after Licensed Practical Nurse (LPN) #11 forced Resident #29 to take crushed medications against her will by allowing the LPN to continue to work for the remainder of her scheduled shift (approximately six hours) following the incident. This resulted in Immediate Jeopardy when LPN #11 was witnessed to state she was not going to play games with the resident, entered Resident #29's room, pushed the resident's legs down in bed, cradled the resident's head in her arms and then squeezed the resident's mouth open to intentionally and willfully administer crushed medication to the resident against her will. The potential for serious harm continued when Resident #29 verbalized fear of LPN #11 and the LPN continued to work and provide direct care and medication administration to residents, including Resident #29 following the incident. This affected one resident (Resident #29) and had the potential to affect 27 additional residents who resided on the unit LPN #11 was working on 04/20/17 (Resident #1, #6, #23, #28, #30, #31, #43, #44, #45, #49, #56, #65, #70, #78, #81, #86, #88, #89, #92, #95, #97, #98, #107, #108, #111, #119 and #121). The facility census on 04/20/17 was 76. On 06/02/17 at 8:38 A.M., the Administrator, Director of Nursing (DON), Director of Health Services #22, Vice President of Operations #23, Assistant Administrator #24 and Assistant Administrator in Training #25, were notified that Immediate Jeopardy began on 04/20/17 at approximately 10:00 A.M. when Hospice Aide #10 witnessed LPN #11 forcefully administer crushed medication to Resident #29 against her will. Following the observation, Resident #29 informed Hospice Aide #10 she was afraid of LPN #11 and stated the LPN was forceful in her actions. LPN #11 was observed to enter Resident #29's room pushed the resident's legs down in bed, cradle the resident's head in her arms and then squeeze the resident's mouth open to intentionally and willfully administer medications. Following the observation, Resident #29 informed Hospice Aide #10 she was afraid of LPN #11 and stated the LPN was forceful in her actions. The Immediate Jeopardy was removed and corrected on 04/27/17 when the facility implemented the following corrective action: On 04/21/17, LPN #11 was removed from the schedule and notified she was suspended pending investigation related to an allegation of abuse. On 04/21/17, the Director of Health Services initiated in-service training to all charge nurses regarding medication administration and resident rights. Sixteen Registered Nurses (RN) and 17 LPN's were in-serviced. The in-service for all charge nurses was completed on 04/25/17. On 04/25/17, LPN #11's employment with the facility was terminated. On 04/26/17, Director of Health Services #22 initiated random observations (audits) of medication administration to ensure medication administrations were completed in accordance with facility policy and the resident's right to refuse medications were honored in accordance with the resident's rights. Audits were completed weekly through 05/23/16 and no issues were identified related to resident right to refuse medications. On 04/27/17, in-servicing began for all nursing staff related to the following topics: (1) the facility Abuse policy, including the need to ensure all allegations were timely reported and residents were immediately protected pending the investigation; (2) how to appropriately respond to resident behaviors, including identifying when a resident was refusing care/treatment; and (3) resident rights, including the right to refuse care, treatment and medications. In-serving was completed for all staff by 05/09/17. Staff not in-serviced were identified to be on medical leave and would not be permitted to work until in-serving is completed. A facility audit, following the termination of LPN #11 revealed no other residents were at risk as being forced to take medications. On 05/30/17 and 05/31/17 interviews with Resident #6, #23, #25, #29, #38, #43, #45, #52, #62, #66, #76, #80, #82, #89, #94, #97, #123, #124, #125 were completed. Eighteen of 19 residents interviewed had no concerns, complaints or allegations of abuse. On 05/30/17 and 05/31/17 interviews with family members of Resident #77, #101 and #108 were completed. Three of three family members interviewed had no concerns, complaints or allegations of abuse. During the interview with Resident #29, the resident reported an allegation of physical abuse involving LPN #11 as noted above. On 05/31/17 and 06/01/17 interview with LPN #14, LPN #15, LPN #16, State tested Nurse Aide (STNA) #17, STNA #18, STNA #19 and STNA #20 revealed all staff interviewed were knowledgeable of the facility abuse policy and procedures, a resident's right to refuse medications or care, and how to manage resident behaviors. Findings include: Record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident received Hospice services for a [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) 3.0 assessment dated [DATE] and 04/27/17 revealed Resident #29 was alert and oriented with no cognitive impairment, capable of being understood, usually understood others and exhibited no verbal or physically aggressive behaviors. Resident #29 required extensive assistance for activities of daily living including mobility and personal hygiene care. Review of a facility Self-Reported Incident (SRI) tracking number 8, dated 04/21/17 revealed LPN #11, administered medications to a resident (Resident #29) who declined administration. The summary of the incident revealed Resident #29 was experiencing a Parkinsonian episode on 04/20/17 at the time routine medications were ordered. (A Parkinsonian episode is a temporary inability to move any muscles. These episodes affect strength, mobility and speech. The episode may last a few seconds to a few minutes.) Resident #29 was non-verbal and demonstrated little or no movement. The nurse administering the crushed medication assessed the resident and determined administering the medications was appropriate at that time. The administration was observed by HA #10. The nurse assessment and approach to administration was perceived by HA #10 as inappropriate. The same SRI review revealed the observation was reported and an investigation to determine neglect was initiated. The facility investigation determined the resident did not consent or decline administration at the time of the incident and the administration of the medication during the period of the episode placed the resident at increased risk for complications such as aspiration. Review of the facility investigation revealed a witness statement, dated 04/20/17 (no time was indicated on the witness statement however, it was faxed to the facility on [DATE] at 2:06 P.M. by the Hospice Agency) and authored by HA #10 revealed HA #10 had notified LPN #11 that upon arriving to Resident #29's room on 04/20/17 at approximately 10:00 A.M., the resident ignored her. LPN #11 responded by saying she was not going to play games with Resident #29. LPN #11 entered the resident's room and informed Resident #29 she had her pain medication. Resident #29 was lying in bed with her eyes closed at that time. The resident's mouth was shut and she was facing the wall. LPN #11 lowered the head and foot of the resident's bed, lifted and cradled the resident's head and pushed the top of the resident's legs downward on the bed. LPN #11 then rolled the head of the bed up and told Resident #29 she was going to take her medications. The same witness statement revealed LPN #11 forcefully gave Resident #29 medication through the right and left side of her mouth, instructed HA #10 to wash the resident from head to toe and change the resident's brief. Then, LPN #11 exited the room. After LPN #11 exited the room, HA #10 indicated Resident #29 had her eyes wide open and was staring at Hospice Aide #10. When HA #10 asked Resident #29 if she wanted a bath, the resident nodded yes. When HA #10 asked Resident #29 if she swallowed the medication, Resident #29 shook her head no. Resident #29 then asked to call her daughter. Immediately following the incident, HA #10 indicated she informed the charge nurse, LPN #12 of the incident and also told LPN #12 that Resident #29 was requesting LPN #12 be her nurse because she was afraid of LPN #11. HA #10 also notified LPN #12 the resident wanted to call her daughter. The same witness statement revealed LPN #12, LPN #11 and HA #10, then returned to the resident's room. LPN #11 apologized to Resident #29 and told the resident she would never do anything to hurt her. The same witness statement quoted Resident #29 as saying, I don't believe you and I am afraid of you and you are forceful. Resident #29 told LPN #11 if she had her mouth closed shut that meant she did not want to take her medication. Resident #29 reported the medication sometimes made her feel dizzy. On 06/01/17 at 9:11 A.M. during an interview with HA #10, the HA was asked to review her witness statement dated 04/20/17 and clarify any incorrect information or misrepresentations. At 9:13 A.M. HA #10 verified all the information was correct and accurate. Additionally, HA #10 stated that immediately following the incident she shut the resident's door and explained to Resident #29 that she needed to report the incident to the charge nurse, LPN #12. Resident #29 agreed. HA #10 stated while reporting the incident to LPN #12, LPN #11 was observed getting off the elevator. LPN #11 approached HA #10 and LPN #12. HA #10 revealed she told LPN #11 and LPN #12 that Resident #29 said she wanted LPN #12 to be her nurse because she was afraid of LPN #11. HA #10 revealed LPN #11 immediately went down the hallway toward the resident's room and there was no stopping her, indicating she was determined to return to the resident's room. HA #10 and the charge nurse, LPN #12 followed her and the three entered the resident's room. Further interview with HA #10 revealed upon returning to Resident #29's room, Resident #29's reaction was that she couldn't believe LPN #11 had returned to her room. LPN #11 was observed to kneel next to the resident's bed. LPN #11 touched the resident's hand and in a softened voice LPN #11 apologized for causing Resident #29 to be fearful and reassured Resident #29 she would never hurt her. HA #10 stated Resident #29 acted as though she was afraid to pull her hand away. HA #10 stated the three staff were in the resident's room for approximately five minutes. HA #10 completed the resident's care and left the facility about half an hour later. HA #10 stated she observed LPN #11 on the unit passing medications at the time she was leaving the facility. HA #10 stated she was aware LPN #11 had called the resident's daughter but did not know if anyone else from the facility had talked with the resident's daughter. HA #10 stated she was aware LPN #11 was terminated following the incident and believed Resident #29 was doing well and seemed much more peaceful since LPN #11 was terminated. Review of an undated witness statement authored by LPN #12, the charge nurse revealed HA #10 came to her on 04/20/17 and informed her Resident #29 was afraid of LPN #11. The statement stated that she, LPN #11 and HA #10 went to talk to Resident #29 to straighten things out. LPN #11 apologized for making Resident #29 feel afraid and LPN #12 felt Resident #29 accepted her apology. LPN #12 told Resident #29 she did the right thing by telling someone she was afraid of LPN #11. When LPN #12 left the room she felt everything was resolved. On 06/01/17 at 11:16 A.M., an interview with LPN #12, with the DON present revealed LPN #12 reviewed her written statement and verified all the information was correct and accurate. LPN #12 revealed she did not ask LPN #11 to leave the facility pending investigation, or immediately report the allegation to the DON because she believed the incident was resolved after she, LPN #11 and HA #10 met with Resident #29 on 04/20/17. LPN #12 revealed she did report the incident to the DON the following morning, on 04/21/17 because she thought it was something the DON should be aware occurred. Review of a witness statement dated 04/21/17 and authored by the DON revealed she interviewed Resident #29 regarding the incident with LPN #11. Resident #29 verified she did not speak to LPN #11 and never declined the medication but she just did not open her mouth. Resident #29 told the DON she did not want to get anyone in trouble but Resident #29 believed she was getting too much medication. The DON and Resident #29 discussed the resident's pain level and the DON encouraged Resident #29 to discuss her medication concerns with her physician. The same witness statement revealed the DON spoke to the resident's daughter. The daughter stated she wanted LPN #11 to know she should not force medications on her mother when her mother doesn't open her mouth. Review of a witness statement dated 04/24/17 and authored by LPN #11 revealed on the morning of 04/20/17 HA #10 notified her Resident #29 was having one of her days where she was not talking. The statement described this as normal behavior for Resident #29. LPN #11 entered the resident's room and told Resident #29 she had her pain medication. Resident #29 never said no or shook her head no so LPN #11 placed the crushed medication into the side of her cheek. The statement indicated LPN #11 thanked the resident and informed her she would see her at lunchtime. LPN #11 exited the room and went on a break. Upon her return, LPN #12 and HA #10 informed LPN #11 that Resident #29 was angry with her because LPN #11 made her take her medications. The statement indicated HA #10 was in the room during medication administration and told LPN #11 she did nothing wrong. Then, LPN #11, LPN #12 and HA #10 returned to the resident's room to talk to her and try to resolve her being upset. LPN #11 went to the resident's bedside, apologized if she had upset her and told Resident #29 all she had to do was tell her no and LPN #11 would respect that. The same witness statement revealed LPN #11 later returned to the resident's room with her noon medications. LPN #11's statement revealed there were no issues with the medication administration at this time. Review of Resident #29's medical record, including nursing progress notes and social service progress notes revealed no written information related to the above incident. Additionally, review of the facility investigation revealed no evidence any other residents or staff were interviewed at the time of the incident related to their potential knowledge of the incident or interactions with LPN #11. On 05/30/17 at 3:21 P.M. Resident #29 was observed in her room in bed. An interview was completed at the time of the observation. During the interview the resident was asked if she had ever been physically, verbally or emotionally abused. The resident replied that yes she had been abused. Upon further interview the resident explained she had been physically abused, about a month earlier when a nurse tried forcing her to take her pain medication. The resident described the actions by the nurse as forceful and Resident #29 stated she was afraid of the nurse. Review of LPN #11's time card and an interview with LPN #12 on 06/02/17 at 11:16 A.M., revealed LPN #11 remained on the nursing unit providing care and services to Resident #29 and potentially the other the 27 residents residing on the unit through the remainder of her shift on 04/20/17. LPN #11 punched out at 3:55 P.M. Review of LPN #11's personnel file revealed after leaving on 04/20/17, LPN #11 did not return to the facility. On 04/21/17 LPN #11 was notified she was suspended pending investigation and on 04/25/17 LPN #11 was terminated. On 06/01/17 at 4:13 P.M., a telephone interview with Resident #29's daughter revealed she lived out of state but spoke to her mother, daily. The daughter revealed LPN #11 did call her on 04/20/17 to notify her that her mother refused her pain medications. The daughter verified she was aware of what constituted a Parkinsonian episode but was not aware her mother was experiencing these episodes. In fact, the daughter asked LPN #11 if the lack of response could have been the Parkinson disease but LPN #11 revealed it was not the [MEDICAL CONDITION] and described her mother as deliberately turning her head toward the wall in an attempt to not take her medicine. The resident's daughter revealed she spoke with her mother the same day but could not recall if she called her mother or if her mother called her. However, she did recall that during the conversation her mother told her she was afraid of LPN #11. This surprised the daughter because she described her mother as not being afraid of anyone. The daughter revealed she was aware her mother did not like LPN #11 but believed it was because LPN #11 was a little rough around the edges. The complaints Resident #29 had previously were more like LPN #11 patronizing or scolding her. The resident's daughter revealed she had not previously reported these concerns to staff. During the interview, Resident #29's daughter revealed she was very concerned after her conversation with her mother but was unsure what action, if any, she should pursue. Therefore, the daughter spoke with a family member who visited her mother frequently and who was also in the health care field. The family member advised her to call the DON. The daughter spoke with the DON the following day, 04/21/17. The daughter revealed the DON could not provide much information because she was having problems getting information from the Hospice agency. The DON did call her a few days later and read the information she had regarding her mother's refusal of medication. The daughter revealed she was aware LPN #11 was no longer was employed at the facility and stated her mother had not had any other related concerns since. On 06/02/17 at 8:30 A.M. interview with Vice President of Operations #23 verified none of the 27 residents residing on the unit where LPN #11 worked on 04/20/17 were immediately interviewed as part of the initial facility investigation. On 06/02/17 at 3:07 P.M. interview with Director of Health Service #22 verified the above incident was not reported to her until 04/21/17 which resulted in LPN #11 continuing to work and provide care and medication administration to residents, including Resident #29 on 04/20/17 for the remainder of her shift following the incident. Director of Health Service #22 also verified the initial investigation completed did not include interviews with other residents or staff who might have had knowledge or information of the incident. Review of the facility administration of medication policy and procedure revised 01/2016 and 04/2017 revealed the purpose of the policy was to ensure medications were administered in a safe and sanitary manner. The procedure included prior to administering oral medications determine the resident's tolerance for administration. In the event of resident refusal provide education regarding the benefit of the medication. Review of the facility abuse policy and procedure, revised 11/2016 revealed the resident had the right to be free from abuse, neglect, coercion, and misappropriation. The policy defined abuse as the willful infliction of injury, unreasonable, confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The abuse policy included coercion, defined as the practice of persuading someone to do something by using force or threats; physical abuse, defined as holding roughly, hitting, slapping, pinching, kicking, scratching, spitting, jerking or corporal punishment; emotional/mental abuse, includes but not limited to, humiliation, harassment, being ignored, chronic ridiculing, degrading or criticizing and; physical restraint, defined as any manual method, physical or mechanical device attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Under the area of prevention, the policy indicated that any employee of the facility who becomes aware through actual knowledge, suspicion, or receipt of an actual verbal or written allegation of resident abuse, neglect, or misappropriation of resident property by an authorized or unauthorized individual shall immediately report this information to their supervisor verbally. Under the area of protection, the policy indicated if a specific employee was suspected of being involved in a situation of resident abuse, neglect, and/or misappropriation of property, the employee would be suspended pending investigation as soon as it was known he/she was a suspect. On 05/30/17 and 05/31/17 interviews with Resident #6, #23, #25, #29, #38, #43, #45, #52, #62, #66, #76, #80, #82, #89, #94, #97, #123, #124, #125 were completed. Eighteen of 19 residents interviewed had no concerns, complaints or allegations of abuse. On 05/30/17 and 05/31/17 interviews with family members of Resident #77, #101 and #108 were completed. Three of three family members interviewed had no concerns, complaints or allegations of abuse. During the interview with Resident #29, the resident reported an allegation of physical abuse involving LPN #11 as noted above. On 05/31/17 and 06/01/17 interview with LPN #14, LPN #15, LPN #16, State tested Nurse Aide (STNA) #17, STNA #18, STNA #19 and STNA #20 revealed all staff interviewed were knowledgeable of the facility abuse policy and procedures, a resident's right to refuse medications or care, and how to manage resident behaviors.

Based on record review, observation and interview, the facility failed to transfer a resident properly and safely using a mechanical lift. Actual Harm occurred when Resident #62 was transferred by one state tested nursing assistant (STNA) instead of the required two STNAs using a mechanical lift. Resident #62 fell and sustained a fracture of the distal tibia diaphysis (the lower leg). This affected one (Resident #62) of four residents reviewed for falls. The facility census was 74. Findings include: Review of the medical record for Resident #62 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the plan of care for falls revealed Resident #62 was to be transferred with the use of a mechanical lift and the assistance of two staff. This intervention was initiated on 03/12/15. Review of the fall risk assessment dated [DATE] revealed Resident #62 was a low risk for falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #62 was totally dependent with the physical assistance of two or more staff to transfer to and from a bed, chair or wheelchair. Review of the nursing progress note dated 12/14/15 at 12:34 A.M. revealed an STNA informed the nurse the mechanical lift broke and Resident #62 was on the floor. When entering the resident's room, Resident #62 was observed lying on his back with the mechanical lift laying on its side over the resident and held up by the bedside table. One of the legs of the mechanical lift was detached from the lift itself. Resident #62 was assisted to a comfortable position and the resident's vital signs were obtained. Resident #62 complained of right ankle pain. The resident was able to move both the upper and lower extremities. No bruising or swelling was noted. The physician was notified and ordered an ankle x-ray. Review of the nursing progress note dated 12/14/15 at 2:43 A.M. revealed a new order was provided by the attending physician to send the resident to the local hospital for evaluation and treatment. Emergency medical technician (EMT) staff arrived at the facility at 2:30 A.M. and departed with the resident for the local hospital at 2:40 A.M. Review of the radiology report dated 12/14/15 revealed Resident #62 sustained a spiral acute displaced fracture of the distal tibia diaphysis. Both edema and swelling were present in the overlying soft tissue of Resident #62's right leg. Review of a statement included in the facility's investigation report revealed STNA #25 attempted to transfer Resident #62 from the wheelchair to the bed using a mechanical lift at approximately 11:00 P.M. without the assistance of another STNA. During the transfer, the legs of the mechanical lift folded up and turned inward causing the lift to go down to the floor. STNA #25 did not have any help from any other nursing staff when this occurred. The report revealed STNA #25 accepted full responsibility for the consequences of his actions. STNA #25 realized he should have gotten another nursing staff member to assist with the transfer of Resident #62. Review of a facility termination-retirement notification document of 12/14/15 revealed STNA #25's employment at the facility was terminated on 12/14/15. Observation of Resident #62 at 12:00 P.M. on 01/07/16 revealed the resident seated in a wheelchair with a cast on the right leg in the day room located at the end of the hall near the resident's room. The resident's right leg was up on the wheelchair leg rest. Interview with the director of nursing (DON) and registered nurse (RN) #32 at 4:34 P.M. on 01/07/16 verified STNA #25 transferred Resident #62 alone with the use of the mechanical lift, the resident fell during the transfer and suffered a fractured lower leg. Review of the facility's undated policy for transferring residents with the use of a mechanical lift indicated two staff was needed to perform the mechanical lift transfer for a resident. Review of the manufacturer's specifications for transferring residents with the use of a Golvo (Liko) lift revealed the transfer procedure using this equipment needed to be conducted using two staff members. This deficiency substantiates Complaint Number OH 076.