Every finding on record at Village Green Rehabilitation and Healthcare Center

Based on observation, staff interview, and review of facility policies, the facility failed to properly store and serve food in a manner to prevent contamination and spoilage. This had the potential to affect 49 residents that receive food from the kitchen. The facility identified one resident (#47) that did not eat food form the kitchen. The census was 50. Findings include: 1. Observations on 07/06/26 from 8:16 A.M. to 8:19 A.M. of the walk-in freezer revealed a plastic storage bag of pepperoni slices that were not sealed, a plastic storage bag of shredded cheese with no label or date, a plastic storage bag of an unknown meat with no label or date, and a plastic storage bag of onion rings with no date. Interview with Dietary Aide (DA) #161 at the time of the observations verified the findings. Observations on 07/06/26 from 8:21 A.M. to 8:24 A.M. of the walk-in refrigerator revealed a container of shredded cheese with no label or date, plastic storage containers of tomato juice and tomato paste with no labels or dates, a plastic storage bag of bratwurst with a use by date of 06/26/26, and a container of a yellow-colored liquid with no label or date. Interview with DA #161 at the time of the observations verified the findings. Observation on 07/06/26 at 8:25 A.M. of a tall free-standing cooler revealed multiple bottles of a thickened dairy drink with expiration dates of 02/17/26 and 05/01/26, which was verified by DA #161 at the time of the observation. Observation on 07/06/26 at 8:28 A.M. of a small refrigerator revealed a block of cheese slices wrapped in plastic with no label or date, which was verified by DA #161 at the time of the observation. Observation on 07/06/26 at 8:29 A.M. of the dry storage room revealed plastic bags of elbow macaroni, spiral noodles, and shell pasta with no labels or dates, which were verified by DA #161 at the time of the observation. Review of the facility policy titled, Food Storage, revised 11/2025, revealed date marking should be visible on all high-risk food to indicate the date by which a read-to-eat, time/temperature control for safety food should be consumed or discarded. 2. Observation of the lunch meal service on 07/07/26 at 11:19 A.M. in the memory care unit revealed platters with shredded turkey, peas, mashed potatoes, and a container of gravy were taken from a heated cart and place on a wheeled cart in the hallway. Certified Nurse Aide (CNA) #108 was preparing meal plates and handing plates to two other CNAs to pass to residents in the dining room. CNA #108 did not check any food temperatures and was not wearing a hairnet. Interview with CNA #108 on 07/07/2026 at 11:58 A.M. confirmed no food temperatures were taken and food platters were placed directly on the wheeled cart with no way to maintain food temperatures. CNA #108 confirmed she was not wearing a hairnet while serving food and stated she had never been told to take food temperatures or wear a hairnet while serving food. Observation of the memory care unit lunch meal service on 07/08/26 at 11:55 A.M. revealed plates of beef, cubed potatoes, cooked sliced carrots, and a container of gravy were uncovered on a wheeled cart in the hallway. The food containers were placed directly on the wheeled cart with no way of maintaining food temperatures. No staff members were near the cart. Interview with Dietary Director (DD) #115 on 07/08/26 at 11:58 A.M. confirmed food items were uncovered on the wheeled cart in the memory care hallway and food temperatures should be maintained during food service and staff serving food should wear hairnets. The facility identified 12 residents (#6, #9, #10, #12, #17, #27, #35, #41, #45, #48, #54, and #64) who are served meals in the memory care unit. Review of a facility policy titled, Food Handling, dated November 2025, revealed food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. Potentially hazardous foods will be cooked to the appropriate internal temperatures and held at those temperatures for the appropriate length of time to destroy pathogenic microorganisms. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure staff followed proper infection control practices for residents on contact precautions. This affected one (#63) of three residents reviewed for transmission-based precautions. The facility census was 50. Findings include:Review of the medical record for Resident #63 revealed an admission date of 06/19/26. Diagnoses included rhabdomyolysis, type two diabetes mellitus with other specified complication, unspecified protein-calorie malnutrition, and hypertension.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had moderately impaired cognition. Resident #63 was assessed to require setup assistance for eating, partial/moderate assistance for oral and personal hygiene, and substantial/maximal assistance for toileting, bathing, dressing, bed mobility, and transfer.Review of Resident #63's active physician orders revealed an order dated 06/28/26 for contact precautions related to methicillin-resistant Staphylococcus aureus (MRSA).Observation on 07/06/26 at 12:10 P.M. revealed Housekeeping Aide (HA) #197 was cleaning Resident #63's room without wearing a gown or gloves. There was a sign outside the door that indicated Resident #63 was on contact precautions.Interview on 07/06/26 at 12:12 P.M. with HA #197 verified she was not wearing a gown or gloves while cleaning Resident #63's room. HA #197 stated she they did not normally wear a gown and gloves when cleaning rooms of residents on precautions.Interview on 07/09/26 at 1:40 P.M. with Infection Control Preventionist (ICP) #112 verified housekeeping staff should wear a gown and gloves when cleaning rooms of residents on contact precautions.Review of the facility policy titled, Isolation Room - Cleaning, revised 11/2025, revealed staff would wear appropriate personal protective equipment.

Based on interviews, record reviews and policy review, the facility failed to administer medications as ordered. This affected two (#51 and #52) of four residents reviewed for medication administration. The facility census was 49. Findings include:1. Medical record review for Resident #51 revealed an admission date of 12/26/25 and a discharge date of 01/02/26. Diagnoses included, but not limited to, cerebrovascular disease, Type II diabetes with kidney disease, moderate dementia with psychotic disturbances, major depressive disorder, anxiety disorder and hypertension. Review of the discharge Minimum Data Set (MDS) assessment, dated 01/02/26, revealed Resident #51 had severely impaired cognition. Resident #51 required supervision for eating, toileting, bed mobility and transfers. Review of the plan of care dated 12/26/25 revealed Resident #51 took psychotropic medication. Interventions included to administer medications as ordered, monitor and report adverse effects of medication and review with responsible party the risks verses benefits of medication. Review of the physicians orders dated 12/16/25 revealed Resident #51 had the following medications ordered: fexofenadine tablet 180 milligrams (mg), give one tablet by mouth for allergies; losartan-potassium hydrochlorothiazide 100-12.5 mg, give one tablet a day for hypertension; olanzapine (antipsychotic medication) tablet 7.5 mg, one tablet by mouth at bedtime for Alzheimer's; potassium citrate oral capsule 99 mg, one capsule by mouth daily; Zyprexa (name brand for olanzapine) oral tablet five mg, one tablet daily for dementia; and sertraline tablet 50 mg, one tablet two times a day for depression.Review of the Medication Administration Record (MAR) for the month of December 2025 revealed fexofenadine tablet, losartan-potassium hydrochlorothiazide, olanzapine tablet, potassium citrate capsule, Zyprexa and sertraline were signed by facility staff as not available and Resident #51 was not administered these medications on 12/27/25 and 12/28/25. 2. Medical record review for Resident #52 revealed an admission date of 12/26/25 and a discharge date of 01/02/26. Diagnoses included, but not limited to, cerebral infarction, Type II diabetes, moderate dementia, major depressive disorder, anxiety disorder and essential hypertension. Review of the discharge MDS assessment, dated 01/02/26, revealed Resident #52 had impaired cognition. Resident #52 required supervision for eating, toileting, bed mobility and transfers. Review of the plan of care dated 12/26/25 revealed Resident #52 had impaired neurological status. Interventions included assisting with normal daily tasks, engage resident in simple/structured activities, monitor and report to physician significant change in neurological status and administer medications as ordered. Review of the physicians orders dated 12/26/25 revealed Resident #52 had the following medications ordered: amlodipine besylate oral tablet five mg, give one tablet by mouth daily; losartan-potassium oral tablet 100-12.5 mg, one tablet daily; levothyroxine sodium oral tablet 88 microgram (mcg), give one tablet daily; carvedilol tablet 6.25 mg, give one tablet by mouth two times a day; and glycopyrrolate oral tablet, give one tablet three times a day. Review of the MAR for December 2025 revealed amlodipine besylate oral tablet, losartan-potassium oral tablet, levothyroxine sodium oral tablet and carvedilol tablet were signed by facility staff as not available and not administered to Resident #52 on 12/27/25 and 12/28/25. Additionally, the MAR revealed glycopyrrolate oral tablet was signed by facility staff as not available on 12/26/25, 12/27/25, 12/28/25, 12/29/25, 12/30/25 and 12/31/25. Interview on 02/02/26 at 11:12 A.M. with Pharmacist #90 revealed Resident #51 and Resident #52's medications were ordered and delivered to the facility on [DATE]. Pharmacist #90 stated Resident #51 and Resident #52's medications were returned to the pharmacy for credit on 12/28/25. Interview on 04/02/26 at 11:58 A.M. with the Director of Nursing (DON) confirmed Resident #51 and Resident #52's medications were brought in by family and were available for administration. The DON verified Resident #51 and Resident #52 were not administered medications as ordered. Review of the facility policy titled, Administering Medications, dated November 2025, revealed medications should be administered in a safe and timely manner and as prescribed. This deficiency represents non-compliance investigated under Complaint Number 2742618.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview and policy review, the facility failed to ensure medications were administered as ordered. This affected four (#50, #11, #29 and #19) out of four residents reviewed for medication administration. The facility census was 49. Findings include: 1. Review of Resident #50 closed medical record revealed an admission on [DATE] with diagnoses including atrial fibrillation, heart failure, kidney failure and hypothyroidism. Review of Resident #50 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed intact cognition. Resident #50 required extensive assistance for bed mobility, transfers, and toileting. Review of the hospital discharge record dated 03/31/25 Resident #50 was prescribed Levothyroxine 125 micrograms (mcg) one tablet by mouth daily to start on 04/01/25. Review of the physicians' orders for Resident #50 for the month of March 2025 was silent for administration of levothyroxine. Review of the physicians' orders for Resident #50 for the month of April 2025 was silent for administration of levothyroxine. Review of the medication administration record (MAR) for Resident #50 was silent for any documentation of levothyroxine 125 mcg being administered. Review of the progress notes for Resident #50 dated 04/30/25 at 09:44 P.M. revealed the resident appeared to have blood in his stool and was not at baseline. The physician was notified, and resident was transferred to the emergency room (ER). Review of the progress note for Resident #50 dated 05/01/25 revealed levothyroxine 125 mcg one tablet by mouth was omitted during order entry of hospital discharge orders on 03/31/25 to begin on 04/01/25 and medication was not received. Resident #50 was transferred to the ER due to low blood pressure and blood in his stool. Resident #50 was admitted with hypothermia and hypothyroidism. Resident #50's physician and resident representative were notified. Review of the facility medication error report for Resident #50 dated 05/01/25 revealed levothyroxine 125 mcg should have been initiated on 04/01/25 and was not. Immediate corrective action revealed that new admission discharge orders will be brought to the morning meeting daily to ensure medication orders were entered into the electronic medical record correctly. In addition, the facility conducted a whole facility audit for all residents with thyroid diagnoses was conducted with emphasis on thyroid laboratory results being current and medication correctly being administered. This included seventeen residents in the facility. Interview on 07/02/25 at 12:00 P.M. with Director of Nursing (DON) verified the levothyroxine was not entered into the computer on readmission on [DATE] and should have been. DON stated a medication error report was completed on 05/01/25 and the family was notified of the error. 2. Review of current Resident #11's medical record revealed an admission on [DATE] with diagnoses including vascular dementia, atrial fibrillation, and myocardial infarction. Review of the quarterly MDS assessment dated [DATE] for Resident #11 revealed an impaired cognition. Resident #11 required extensive assistance for toileting, bed mobility and transfers. Resident #11 was coded as supervision for eating. Resident #11 was coded as receiving an anticoagulant during the assessment period. Review of the plan of care for Resident #11 dated 03/26/25 revealed resident is at risk for abnormal bleeding or hemorrhage related to anticoagulant therapy. Interventions include administering medications as prescribed, avoid activities that could cause injury, monitor for signs and symptoms of bleeding, obtain and monitor laboratory results, and review medications for adverse interactions. Review of the active physician orders for Resident #11 revealed an order for Xarelto 20 milligrams (mg) one tablet daily for left atrial thrombus dated 03/24/25. Review of the MAR for the month of March 2025 for Resident #11 revealed resident received Xarelto as ordered beginning on 03/24/25. Review of the Medication Error Report dated 03/24/25 for Resident #11 revealed Xarelto 20 mg was not entered into the electronic medical record during the transition to the new software effective on 03/01/25. Immediate corrective actions included notification of the physician to restart orders and obtain an echocardiogram. Further review of the medication error report revealed the resident representative was notified. Interview on 07/02/25 at 12:00 P.M. with DON verified the medication error occurred and the physician and Resident #11's representative was notified. DON verified the echocardiogram was completed without any negative findings. 3. Review of current Resident #19 revealed an admission date of 03/28/25 with diagnoses including chronic obstructive pulmonary disease, dementia, kidney disease, and type two diabetes with polyneuropathy. Review of the comprehensive MDS assessment dated [DATE] for Resident #19 revealed an intact cognition. Resident #19 required set up assistance for meals, supervision for bed mobility and transfers and moderate assistance for toileting. Review of the plan of care for Resident #19 dated 04/15/25 revealed resident has actual and potential for pain related to arthritis, disc disease, obesity and type two diabetes with polyneuropathy. Interventions include administering medications as ordered, encourage the resident to request pain medication as needed, monitoring changes in mood and usual activities and effectiveness of pain medication. Review of the active physicians orders for Resident #19 revealed an order dated 04/05/25 for hydrocodone-acetaminophen tablet 5-325 mg give one tablet three times a day and pregabalin 50 mg one tablet two times a day for pain. Review of the MAR for the month of April 2025 for Resident #19 revealed hydrocodone-acetaminophen tablet 5-325 mg give one tablet three times a day and pregabalin 50 mg one tablet two times a day for pain were signed off by nursing staff as administered on 04/19/25 at 6:00 P.M. Further review of the individual patient-controlled substance administration record for Resident #19's pregabalin and hydrocodone-acetaminophen revealed they were not signed out as administered on 04/19/25. Review of the medication error report dated 04/28/25 for Resident #19 revealed on 04/19/25 at 6:00 P.M. the resident did not receive the pregabalin and hydrocodone-acetaminophen as ordered. Further review of the report revealed the Nurse Practitioner (NP) and the residents' power of attorney were notified of the error on 04/21/25. Interview on 07/02/25 at 12:00 P.M. with the DON verified Resident #19 did not receive prescribed medication (pregabalin and hydrocodone-acetaminophen) as ordered on 04/19/25 at 6:00 P.M. 4. Review of current Resident #29 medical record revealed an admission date of 04/01/24 with diagnoses including anoxic brain damage, hypertensive heart disease, heart failure and peripheral autonomic neuropathy. Review of the quarterly MDS assessment dated [DATE] for Resident #29 revealed an intact cognition. Resident #29 was coded as dependent for eating and toileting assistance. Resident #29 required maximum assistance with bed mobility and transfers. Resident was coded as having pain during the assessment period. Review of the plan of care for Resident #29 dated 04/21/25 revealed resident has potential for pain related to inconsistent bowel pattern, contractures, head trauma, headaches, immobility, and verbal complaints of pain. Interventions include administer medication as ordered, encourage the resident to request pain medication as needed, monitoring changes in mood and usual activities and effectiveness of pain medication. Review of the active physician orders for Resident #29 revealed an order for Pregabalin give 25 mg by mouth three times a day related to idiopathic peripheral autonomic neuropathy dated 02/18/2025. Review of the MAR for Resident #19 for the month of April 2025 revealed the Pregabalin was signed as administered on 04/19/25 at 6:00 P.M., by the nurse. Review of the medication error report dated 04/28/25 for Resident #29 revealed the medication Pregabalin give 25 mg tabled was not administered as ordered. Interview with resident denied any complaints of pain related to the incident. Further review of the document revealed the physician and the resident representative were notified. Interview on 07/02/25 at 12:00 P.M. with DON verified Resident #29's Pregabalin was not signed off on the individual patient-controlled substance administration record indicating it was not administered on 04/28/25. DON stated with the recent sale of the facility and the move to the new electronic health record the controlled substance record was unable to be located at the time of the survey. Review of the facility policy titled Medication Errors dated 09/2021, stated the medication error report should be completed in the electronic health record with each error. Medication errors are to be reported to the physician and the director of nursing. The deficient practice was corrected on 05/18/25 when the facility implemented the following corrective actions: Review of the Episodic Event/Past Non-Compliance document revealed the date of the event was 03/01/25. The form was documented as completed on 05/18/25. Facility documented medication errors occurred from transcription at the time of change over to the new medical record software due to the sale of the facility. Nurses were manually inputting all orders into the new system when some of the errors occurred. As a result of the errors all medication records of residents in the facility at the time of the change of owners were audited. No further medication errors were noted. On 05/01/25 a medication audit was completed for all residents receiving levothyroxine in the facility. All medication orders were confirmed correct and laboratory results for thyroid levels were confirmed or ordered to ensure levels were within normal limits. On 05/05/25 all new admissions for the last 30 days will have medication and treatment audits to ensure medications are entered into the electronic health record accurately. Fifteen resident records were identified as new admissions. Each record was reviewed by two separate nurses and documented on the new admission order check verification form. No further concerns were identified regarding medication administration. On 05/13/25, audits for residents identified as receiving thyroid medications were completed without any additional negative findings. On 05/18/25, audits for all new admissions in the last thirty days were completed and no further concerns were identified regarding medication administration. Review of the facility's new admission order check verification documentation dated 05/07/25 through 06/24/25 revealed no new medication errors. By 05/18/25, the DON or designee completed in-service training with all nurses regarding medication administration policies and procedures. This deficiency represents non-compliance investigated under the Complaint Number OH00165552 (1377615).

Based on medical record reviews, staff and resident interviews and review of facility incident/event reports, the facility failed to provide adequate care and services during transfers to prevent incidents (i.e. skin tears). This affected two (#13 and #38) out of three residents reviewed for accidents. The facility census was 45. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 03/19/25 with medical diagnoses of atrial fibrillation, malignant neoplasm of prostate, congestive heart failure, anxiety, chronic obstructive pulmonary disease, and hypertension. Review of the medical record for Resident #13 revealed an admission Minimum Data Set (MDS) assessment, dated 03/24/25, which indicated Resident #13 was cognitively intact and was dependent upon staff for toilet hygiene, transfers, and showers and required substantial/maximum staff assistance with bed mobility. The MDS did not indicate Resident #13 had any skin issues. Review of facility Incident Report, dated 04/09/25, stated a State Tested Nursing Assistant (STNA) reported to nurse that Resident #13 had bumped his right forearm causing a skin tear. The report stated two STNA's were taking Resident #13 to the bathroom per sit to stand lift when the incident occurred. Interview on 04/23/25 at 8:12 A.M. with Resident #13 stated he received a skin tear a few weeks ago to right forearm/wrist area after staff wheeled him into the bathroom and bumped his arm in the bathroom doorframe. Interview on 04/23/25 at 11:29 A.M. with Director of Nursing (DON) confirmed Resident #13 sustained a skin tear to right forearm/wrist area on 04/09/25 after staff were pushing Resident #13 in his wheelchair into the bathroom and Resident #13's arm bumped into the bathroom doorframe causing a skin tear. DON confirmed the STNA's immediately reported the incident to nurse who measured the skin tear and initiated a treatment. 2. Review of the medical record for Resident #38 revealed an admission date 11/20/23 with medical diagnoses of hypertensive heart disease with heart failure, congestive heart failure, cardiomyopathy, and diabetes mellitus. Review of the medical record for Resident #38 revealed a quarterly MDS assessment, dated 03/24/25, which indicated Resident #38 had moderate cognitive impairment and required substantial/maximum staff assistance with toilet hygiene, bathing, bed mobility, and transfers. No skin issues were noted on the MDS. Review of the medical record for Resident #38 revealed a nurse's note, dated 02/23/25 at 3:13 A.M. with stated Resident #38 received a skin tear to left elbow while transferring. The note stated education provided to staff and the resident. The skin tear measured 1.5 cm by 0.7 cm, partial wound bed exposed, and able to replace skin flap. The note stated the skin tear was cleaned, steri strips applied and covered with an island dressing. Review of an Interdisciplinary Team (IDT) note, dated 02/24/25 at 2:45 P.M., stated Resident #38 obtained a skin tear to her left elbow during transfers and the area cleansed with wound cleanser and covered with island dressing. Review of a facility Event Report, dated 02/23/25, stated Resident #38 received a skin tear to her left elbow while transferring. The report stated resident representative and physician was notified. Interview on 04/23/25 at 10:21 A.M. with Resident #38 stated she sustained a skin tear to her left arm after staff were rushing to transfer her from the bathroom. Resident #38 stated the incident caused pain to her left arm, but the skin tear has since healed and pain subsided. Interview on 04/24/25 at 9:40 A.M. with DON confirmed Resident #38 sustained a skin tear to her left during a transfer with staff on 02/23/25. This deficiency represents non-compliance investigated under Complaint Number OH00164925.

Based on medical record review, staff interviews, review of staff statement, and policy review, the facility failed to ensure a nurse observed a resident consume medications at the time of administration. Additionally, the facility failed to ensure the individual who removed medications from medication cart was the same individual who administered the medications to the resident. This affected one (#24) out of the three residents reviewed for medical administration. The facility census was 45. Findings include: Review of the medical record for Resident #24 revealed an admission date of 09/17/24 with medical diagnoses of chronic obstructive pulmonary disease, arthritis, hypertensive chronic kidney disease, hypothyroidism, and arteriosclerotic heart disease. Review of the medical record for Resident #24 revealed a quarterly Minimum Data Set (MDS) assessment, dated 02/13/25, which indicated Resident #24 was cognitively intact and required partial/moderate staff assistance with bathing and transfers, supervision with toilet hygiene, and set-up with eating. Review of the medical record for Resident #24 revealed a Medication Administration Record (MAR) which had documentation to support Licensed Practical Nurse (LPN) #100 signed the MAR on 12/20/24, 12/23/24, 12/24/24, 12/27/24, 12/28/24, 12/29/24, and 12/30/24 that she administered Resident #24's medications. Review of the medical record for Resident #24 revealed an Episodic event note, dated 12/14/24, which stated Resident #24's daughter accused LPN #100 of hitting the daughter in the arm. The root cause analysis stated Resident #24's daughter was attempting to stop LPN #100 from leaving Resident #24's room. Review of a statement by LPN #100, dated 12/15/24, stated the incident occurred on 12/14/24 at 6:00 P.M. after she observed Resident #24 had not taken the medications that LPN #100 had brought into the room at approximately 4:00-5:00 P.M. LPN #100 stated when she originally brought the medications into the room, Resident #24 was in the bathroom so the LPN #100 left the medications in Resident #24's room and trusted she would take them. Interview on 04/23/25 at 12:25 P.M. with LPN #100 confirmed she left medications in Resident #24's room unattended on 12/14/24 because Resident #24 was in the bathroom as per her statement dated 12/15/24. LPN #100 stated she returned to Resident #24's room about one hour after leaving the medications in Resident #24's room to discover Resident #24 had not taken the medications. LPN #100 stated she was removed from Resident #24's care for a few months after the incident with Resident #24's daughter on 12/14/24 but stated she continued to pull Resident #24's medications from the medication cart and another nurse would administer the medications to Resident #24. LPN #100 confirmed she was the nurse who signed off on the medication administration on the MAR in December 2024 even though she did not observe Resident #24 consume the medications. Interview with Director of Nursing (DON) on 04/23/25 at 1:46 P.M. confirmed Resident #24 was removed from LPN #100 assignment after December 14, 2024, for a short period of time after an incident between Resident #24's daughter and LPN #100. DON confirmed that after the incident, LPN #100 would pull Resident #24's medications from the medication cart and another nurse would administer the medications to Resident #24. DON also confirmed Resident #24's December 2024 MAR had documentation to support LPN #100 administered medications on 12/20/24, 12/23/24, 12/24/24, 12/27/24, 12/28/24, 12/29/24, and 12/30/24. Review of the facility policy titled, Administering Medications, stated medications shall be administered in a safe and timely manner and as prescribed. The policy stated the individual administering medications must check the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. The individual administering the medication must initial the resident's MAR after giving the mediation. The policy stated for residents not in their room or otherwise unavailable to receive mediation on the pass, the MAR may be flagged and after completing the medication pass, the nurse would return to the missed resident to administer the medication. This deficiency represents non-compliance investigated under Complaint Number OH00161707.

Based on record review, staff interview, and review of medscape, the facility failed to ensure residents were not prescribed unnecessary antibiotic medications. This affected one (Resident #12) out of five residents reviewed for unnecessary medications. The current census is 44. Findings include: Record review for Resident #12 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #12 include Alzheimer's, dementia with behaviors, chronic kidney disease, and schizophrenia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and was receiving antibiotics. Per the assessment the resident had not been diagnosed with a urinary tract infection in the past 30 days. Review of Resident #12's care plans dated 12/27/21 revealed the resident was at for risk of chronic urinary tract infections. Interventions include administer medication per order, monitor for signs and symptoms of infections, avoid irritants, avoid tight pants, and assist with incontinence. Review of Resident #12's physician orders revealed on 04/25/23 the resident was ordered to receive Macrodantin oral antibiotic 50 milligrams (mg) 1 capsule daily for prophylaxis of urinary tract infections (UTI). Per the orders the Macrodantin antibiotic was re-ordered on 11/07/23 to continue for prophylaxis antibiotics for UTI. Review of Resident #12's Medication Administration Record (MAR) dated from 01/2022 to 11/2023 revealed the resident had received the oral antibiotic per physician order. Review of Resident #12's urinalysis and culture and sensitivity tests dated 11/11/22 and 09/16/23 revealed the resident's urine did not contain bacteria causing urinary tract infections. Interview on 12/28/23 at 11:00 A.M. with the Infection Control Prevention nurse (ICP) Licensed Practical Nurse (LPN) #87, verified Resident #12 did not have any signs or symptoms of a urinary tract infection which would require an antibiotic treatment. LPN #87 verified the facility's medical director continued to prescribe the oral antibiotic for Resident #12 against the facility followed antibiotic stewardship protocols. Per the LPN #87, the medical director had stated Resident #12 will continue to receive the antibiotic in order to prevent future UTIs. Interview on 12/28/23 at 1:52 P.M. with the Medical Director revealed the physician prescribed the oral antibiotic for Resident #12 despite her not having any signs or symptoms of infection. The physician verified the resident did not have an active diagnosis for an urinary tract infection. The physician stated he felt the antibiotic was to be used prophylacticly to prevent the resident from getting an UTI and becoming sepsis. The physician verified the use of prophylactic antibiotics did not follow the facility's protocols for antibiotics. Interview on 12/28/23 at 3:00 P.M. with the Director of Nursing (DON) #67 verified there was no facility policy regarding the unnecessary medication. Review of medication information from Medscape at https://reference.medscape.com/drug/macrobid-macrodantin-nitrofurantoin-342567 revealed Macrodantin is an antibiotic used to treat UTI's. Further review of the information revealed you should avoid using Macrodantin for long-term UTI suppression. Long-term use in the elderly may increase risk for pulmonary toxicity. Additionally, bacterial superinfections may occur with prolonged treatment.

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of hospital records, review of staff statements, interviews with facility staff, Nurse Practitioner (NP) #511, the Medical Director (MD) #800, Orthopedic Physician #524 and a family member, and review of facility policy, the facility failed to ensure Resident #50 was free from neglect, when staff failed to provide appropriate care and services to ensure the resident received timely care and/or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #50 developed bruising and swelling to the left knee which was not timely assessed and/or treated. Consequently, Resident #50 suffered a comminuted distal femoral fracture of the left leg, the resident was not seen by an orthopedic physician for seven days following the confirmation of the fracture and ultimately had to have an above the knee amputation of the left leg. This affected one (#50) out of three residents reviewed for neglect. The facility's census was 41. On 02/24/22 at 11:24 A.M., Clinical Support Registered Nurse (RN) #900, Assistant Vice President (AVP) of Clinical Support #915 and Divisional Vice President (DVP) of Operations #920 were notified Immediate Jeopardy began on 02/03/22 when STNA #700 rolled Resident #50 out of bed, onto the floor during incontinence care. STNA #700 placed Resident #50 back into bed and proceeded to not be truthful about the events that occurred, leading to untimely discovery and treatment to the residents' injuries. Bruising and swelling to Resident #50's left knee was noticed by multiple STNA's as early as 02/04/22, but a full body assessment was not completed by a nurse until 02/07/22, where it was noted that Resident #50 had severe bruising and swelling to her left knee, and she was in noticeable pain. An x-[CONDITION(S)] (x-ray) was ordered on 02/07/22, but not completed until 02/09/22 where it was found Resident #50 suffered from a comminuted distal femoral fracture of the left leg. Resident #50 was referred to an orthopedic physician with an appointment set for 02/16/22. On 02/16/22, Resident #50 went to the orthopedic physician appointment and the physician recommended the resident be sent to the hospital immediately. On 02/17/22, Resident #50 ultimately had to have her left leg amputated above the knee. Although the Immediate Jeopardy was removed on 02/18/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until the deficiency was corrected on 02/22/22 when the facility implemented the following corrective actions: · On 02/16/22, Resident #50 was transported to an orthopedic appointment and was then transferred to the hospital for emergency care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] · On 02/17/22, STNA #700 was suspended pending investigation. · On 02/17/22, like residents were identified and assessed for signs and symptoms of abuse and neglect by the Director of Nursing (DON). No additional abuse or neglect concerns were identified. · On 02/18/22, the Administrator, DON or designee began all facility staff education on the facility's Abuse and Neglect policy procedure, including prevention, identification and timely and accurate notifications of incidents and accidents. The education was completed on 02/18/22. · To assure ongoing compliance, the DON completed random interviews with direct care staff to ensure they were knowledgeable of Abuse and Neglect procedures and reporting incidents and accidents timely and accurately. The DON would continue to complete five interviews weekly with random direct care staff, and any deficiencies in knowledge regarding the Abuse and Neglect procedures will be addressed immediately with additional education. In addition, the DON will assess five random residents weekly for signs or symptoms of Abuse/Neglect for four weeks then randomly thereafter. · On 02/18/22, a Quality Assurance and Performance Improvement (QAPI) meeting was held where audits/assessments, education, and ongoing interventions were reviewed. QAPI meetings would be held weekly for four weeks, then monthly. · On 02/18/22, the DON or designee completed abuse audits with staff to determine staff knowledge of the facilities abuse policy. No concerns were identified. · On 02/18/22, 02/19/22, 02/20/22, 02/21/22 and 02/22/22, the DON or designee completed resident abuse and neglect audits. No further concerns were identified regarding abuse or neglect. · On 03/01/22 between 9:04 A.M. and 9:38 A.M., LPN #505, STNA #506, and STNA #507 verified they received recent training regarding abuse and neglect. Staff verified training included reporting incidents. · Medical record review for one (#51) additional closed record and three (#17, #28 and #32) open records revealed there were no incidents or potential concerns regarding abuse or neglect. Findings include: Medical record review for Resident #50 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #50's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was severely cognitively impaired. Resident #50 required extensive assistance of two staff or was totally dependent upon two staff for Activities of Daily Living (ADL's) including, bed mobility, transfers, toileting, and maintaining hygiene. Review of Resident #50's MDS dated [DATE] also indicated Resident #50 required extensive assistance of two staff or was totally dependent upon two staff for ADL's including, bed mobility, transfers, toileting, and maintaining hygiene. Review of Resident #50's care plan revealed Resident #50 was at risk for falls and staff were to be mindful of Resident #50's placement in bed. Resident #50 required a Hoyer lift operated by two staff for transfers and required staff assistance with ADL's. Resident #50 was non-verbal. The care plan did not reflect Resident #50's need for two staff assistance for bed mobility. Review of Resident #50's progress notes for February 2022 revealed the following: · On 02/03/22 at 5:00 P.M. during a transfer, Resident #50 was hit in the forehead with the arm of a Hoyer lift causing a laceration and bruised area with swelling. · There was no further documentation in Resident #50's progress notes until 02/07/22 at 2:21 A.M., which noted the resident was assessed for severe swelling to the left knee with significant dark purple bruising. The left knee was hot to the touch and Resident #50 had noticeable discomfort. Per aides, the area was noted since Thursday (02/03/22). An x-ray of Resident #50's left knee was ordered. · On 02/09/22 at 2:54 A.M., the x-ray was completed with findings of a comminute distal femoral fracture of the left leg. An order was received for Resident #50 to be referred to an orthopedic physician. An appointment was set up for 02/16/22. · On 02/13/22 at 7:30 A.M., Resident #50's family requested Resident #50 be sent to the hospital to have head examined due to the incident on 02/03/22. Resident #50 had a head CT (Computed Tomography) scan and returned to the facility on the same day around 12:00 P.M. · On 02/16/22 at 12:10 P.M., Resident #50 went to her orthopedic appointment. She returned around 1:40 P.M. and the physician wanted her transferred to the hospital immediately. Family was discussing options for surgery or hospice. · Late entry on 02/17/22 at 6:49 P.M. revealed on 02/10/22, STNA #700 reported to Licensed Practical Nurse (LPN) #500 that Resident #50 was rolled out of bed on 02/03/22 while he was providing care. Further medical record review for Resident #50 revealed there were no additional notes regarding communication with Resident #50's doctor about a delay in the x-ray being completed, delay in the orthopedic appointment, or pain during examination. Review of Resident #50's x-ray dated 02/09/22 revealed a comminuted separated fracture of the distal left femoral diaphyseal metaphyseal junction of the left leg. The left femorotibial joint space was disrupted. The adjacent soft tissues appeared swollen with joint effusion. Review of Resident #50's orthopedic surgery consult dated 02/16/22 revealed Resident #50 had an x-ray with findings of a comminuted intra-articular distal femur fracture of the left leg with 100 percent (%) displacement and four centimeters of shortening. The physician felt the best option for Resident #50 was to have surgery to complete an above-knee amputation of the left lower extremity. During an interview on 02/23/22 at 10:27 A.M. with LPN #500 she reported on 02/03/22, STNA #700 came to her and LPN #588 and reported Resident #50 had a laceration on her head due to him hitting her in the head with a Hoyer lift during a transfer. Resident #50's head injury was assessed, and neurological checks were completed. LPN #500 stated days later, Resident #50 had swelling and bruising to her left knee. STNA #700 came to her office crying and reported he had not told the truth about what happened to Resident #50 on 02/03/22. STNA #700 reported he had been providing incontinence care to Resident #50 when he rolled the resident out of bed onto the floor. STNA #700 was afraid to tell the truth at the time of the incident and lied about Resident #50 hitting her head on the Hoyer lift. An x-ray was completed and found Resident #50 had a fracture. Resident #50 went to an orthopedic appointment and was sent to the hospital for surgery where she had her leg amputated. LPN #500 reported it was to her understanding the amputation was done because the physician was worried about placing screws and rods resulting in infection. Interview on 02/23/22 at 10:40 A.M., NP #511 verified facility staff notified her of Resident #50's fracture on 02/09/22. NP #511 stated nursing staff reported Resident #50 had no pain or vascular compromise, so NP #511 ordered for Resident #50 to be referred to an orthopedic physician. NP #511 reported she had not seen Resident #50 for an examination from the time she was notified of the fracture to the time Resident #50 went to the hospital on 02/16/22. Interview on 02/23/22 at 12:00 P.M., Resident #50's family member verified Resident #50 had a fracture of the left femur due to STNA #700 rolling her out of bed during care. Resident #50's family member reported they were upset the facility nurses did not notice anything was wrong with Resident #50's leg sooner and upset the STNA (#700) who rolled her out of bed initially lied about the situation, leading to a delay in care. Resident #50's family member stated Resident #50 went to an orthopedic physician appointment on 02/16/22 and Physician #524, who was the orthopedic surgeon, felt it was in the best interest of Resident #50 to have her left leg amputated. Resident #50's family member stated Physician #524 was worried about infection and a second surgery if he tried to repair the break with hardware and was also worried about recalcification. Resident #50's family member reported amputation of Resident #50's leg was a hard decision for them to make, but ultimately agreed with Physician #524 and allowed for the amputation of the residents left leg. Resident #50's family member stated Resident #50 had her left leg amputated on 02/17/22. Resident #50's family member stated after Resident #50's surgery, Physician #524 reported he was happy the family agreed with the amputation due to recalcification of the residents' bones. Resident #50's family member stated Physician #524 reported to the family that Resident #50's injury was about two to three weeks old by the time they did the surgery. Resident #50's family member felt due to the delay in services in getting the fracture treated, Resident #50 had to have her leg amputated. Resident #50's family member was emotional when discussing the decision making and result of Resident #50's amputation. Resident #50's family member stated Resident #50 was still in the hospital and was admitted to inpatient hospice but would be discharging to a different nursing home on 02/23/22. Interview on 02/23/22 at 1:06 P.M. Registered Nurse (RN) #522 reported she notified NP #511 of Resident #50's x-ray results and severe bruising and swelling on 02/09/22. RN #522 reported she assessed Resident #50 on 02/09/22 and she did not appear to be in pain. RN #522 verified Resident #50 was non-verbal. RN #522 reported no new orders were received for pain medication or to splint the leg until the orthopedic appointment. RN #522 reported she was told Resident #50 should remain in bed (review of the medical record revealed no documentation regarding any additional orders put in place, including for Resident #50 to stay in bed). Interview on 02/23/22 at 1:48 P.M. RN #533 verified STNA #544 and STNA #555 reported they noticed Resident #50 had bruising and swelling to the residents left knee starting on 02/03/22. Interview on 02/23/22 at 2:07 P.M., STNA #700 verified on 02/03/22 he was providing routine incontinence care to Resident #50, and he was alone while providing the care. STNA #700 rolled Resident #50 in bed away from him, when she rolled out of bed and hit the floor. STNA #700 stated Resident #50's bed was in a medium to high position. STNA #700 reported Resident #50 did not call out and did not hit any furniture, so he thought she was okay and picked her up and returned her to bed, on his own. Resident #50 was bleeding from her head, and he was scared, so he lied to both LPN #500 and LPN #588 stating he accidentally hit Resident #50 with the arm of the Hoyer lift. STNA #700 reported he told the truth about the incident involving Resident #50 on 02/10/22. STNA #700 reported Resident #50 required two staff to assist her with transfers, but he was unsure at the time of the incident if Resident #50 required two staff assistance with bed mobility. STNA #700 admitted he made a mistake and should have had a second staff member helping and he should not have lied about the incident. Interview on 02/23/22 at 3:29 P.M., the Administrator reported she was unsure why there was a delay in Resident #50 receiving an x-ray. The Administrator confirmed the physician ordered Resident #50 to have an x-ray of the left knee on 02/07/22, but it was not completed until 02/09/22. The Administrator reported she was looking into the delay. Interview on 02/23/22 at 3:43 P.M. Clinical Support RN #900 reported on occasion the x-ray company the facility used could be slow to respond. Clinical Support RN #900 reported Medical Director (MD) #800 was aware of the delay in Resident #50 receiving an x-ray of the left knee and stated it was fine to wait for the x-ray. Clinical Support RN #900 reported communication with MD #800 should be documented in Resident #50's medical record; however, further review of the medical record revealed there was no documentation of correspondences with MD #800 regarding a delay in Resident #50 receiving the x-ray. Interview on 02/23/22 at 4:20 P.M., LPN #588 reported she was working on 02/03/22 when STNA #700 reported to her and LPN #500 he hit Resident #50 with the Hoyer lift and she was bleeding from her head. LPN #588 verified she assessed Resident #50 for a head injury only and did not conduct a full body examination. LPN #588 verified Resident #50 required assistance from two staff for ADL's. Interview on 02/23/22 at 4:25 P.M., STNA #555 reported on 02/05/22 another STNA (STNA #577) told her Resident #50 had bruising and swelling to her knee, which she observed. STNA #555 did not report the bruising or swelling to the nurse because she was under the impression the nurses were already aware. Interview on 02/23/22 at 4:30 P.M., STNA #577 reported he noticed bruising and swelling to Resident #50's knee on 02/04/22 and reported his concerns to LPN #599. STNA #577 verified Resident #50 required assistance from two staff for care. Interview on 02/23/22 at 4:39 P.M., the Administrator reported she did not feel STNA #700 intentionally hurt Resident #50 and truly felt it was an accident but stated he should have told the truth so Resident #50 could have been properly assessed timely. Interview on 02/24/22 at 11:02 A.M., LPN #599 reported she did not remember if STNA #577 told her Resident #50 had bruising to her knee. Interview on 02/24/22 at 10:45 A.M. and again at 11:13 A.M. with MD #800 verified he was Resident #50's physician. MD #800 reported he had been notified and reviewed the incident involving Resident #50 with the facility within the last week. MD #800 reported he was unaware of any delay in Resident #50 receiving an x-ray. MD #800 reported if there was a delay in x-rays involving Resident #50, it was dependent on the case, if the resident had pain, they would be sent to the hospital for an evaluation. MD #800 reported he reviewed his faxes and documents and the only notification he received from the facility regarding the incident involving Resident #50 was on 02/13/22, when Resident #50 went to the hospital to have her head examined. During the survey attempts to interview Orthopedic Physician #524 revealed he could not be reached for an interview to discuss the care and services provided to Resident #50 on 02/16/22 and 02/17/22 regarding the residents' left femur fracture. Interview on 03/08/22 at 1:04 P.M. Orthopedic Physician #524 verified he saw Resident #50 on 02/16/22 in his office for a femoral fracture and the resident was transferred to the hospital for surgical intervention. Orthopedic Physician #524 described the fracture as a Bad fracture, where the femur bone broke and slid up behind Resident #50 ' s thigh bone. Orthopedic Physician #524 reported due to Resident #50 being contracted, he felt amputating the leg was the best treatment plan due to potential wound complications with placing hardware to repair the fracture. Orthopedic Physician #524 stated the fracture had been present for more than a week, but he could not determine an exact time period. Orthopedic Physician #524 reported Resident #50's fracture site was calcified and starting to heal, indicating the fracture was present for some time. Orthopedic Physician #524 reported Resident #50 was non-verbal, but the average person would be in pain from this type of fracture. Review of STNA #700's statement dated 02/10/22, revealed on 02/03/22 around 3:30 P.M., STNA #700 entered Resident #50's room for routine, Check and Change. When he was providing care, she rolled out of bed. STNA #700 was located on the window side of the bed, and he rolled Resident #50 away from him. STNA #700 lost his grip and Resident #50 fell to the floor. STNA #700 did not believe Resident #50 hit any furniture and the resident did not call out. STNA #700 was scared and picked Resident #50 up on his own and returned her back to bed. STNA #700 reported to LPN #588, Resident #50 was bleeding and he accidentally bumped Resident #50's head with the Hoyer lift. LPN #588 completed neurological checks. Resident #50 went to dinner the same evening and appeared to be okay. STNA #700 did not tell anyone the truth about the incident until 02/10/22, when he reported to LPN #500. Review of LPN #500's statement dated 02/18/22 revealed on 02/03/22, she was assisting LPN #588 at the nurse's station when STNA #700 approached them to report he hit Resident #50 accidentally with the Hoyer lift arm and she was bleeding. When LPN #500 entered Resident #50's room, the Hoyer lift was by the TV and Resident #50 was lying in bed. There was a moderate amount of bleeding coming from Resident #50's forehead. Resident #50 was provided care and neurological checks were completed. STNA #700 was educated that he should not use a Hoyer lift alone. On 02/10/22, STNA #700 came to her office crying and reported he, Had not actually hit Resident #50 with the Hoyer lift. STNA #700 explained he accidentally rolled Resident #50 out of bed on 02/03/22 while providing care and he panicked, so he picked her up and put her back to bed. Review of LPN #588's statement dated 02/10/22 revealed on 02/03/22, STNA #700 reported Resident #50 was bleeding and needed assistance. LPN #588 gathered supplies and entered the room to see Resident #50 lying in bed and the Hoyer lift by the TV. STNA #700 reported he hit Resident #50 in the head with the Hoyer lift. LPN #588 completed neurological checks and opened a neurological event in the electronic medical record. Resident #50 was taken to dinner as normal and did not appear to be in distress. On 02/07/22, bruising to Resident #50's knee was reported, and an x-ray was ordered. The results of the x-ray were received on 02/09/22 and revealed a femoral fracture of the left leg and Resident #50 would be referred for an orthopedic consult. Review of MD #800's interview/statement dated 02/18/22 revealed MD #800 felt Resident #50's femoral fracture resulted from a fall from bed. The fall was not reported initially and was a matter of days until it was investigated due to clinical signs of swelling and bruising developing. Resident #50 was not sent to the hospital because she was not showing clinical signs of distress or ischemia distal. Review of the DON statement dated 02/22/22 revealed she was notified on 02/07/22 of Resident #50 having bruising to the left knee. The DON completed an assessment of Resident #50's knee and felt the bruising was consistent with the incident involving the Hoyer lift on 02/03/22. Review of facility policy titled, Abuse, Neglect and Exploitation Procedural Guidelines, revised 08/29/19 revealed the facility would strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. Neglect was defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Incidents of abuse and neglect would be investigated and reported. This deficiency substantiates Complaint Number OH 334.

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of hospital records, review of staff statements, review of facility Certified Resident Care Assistant (CRCA) sheet, interviews with facility staff, Nurse Practitioner (NP) #511, Medical Director (MD) #800, Orthopedic Physician #524 and a family member, and review of facility policy, the facility failed to provide Resident #50 with necessary and appropriate assistance with bed mobility during incontinence care resulting in the resident falling out of bed. This resulted in Immediate Jeopardy and serious life-threatening injuries when Resident #50 experienced an avoidable fall from bed when State tested Nurse Aide (STNA) #700 was providing incontinence care to the resident by himself. Resident #50 required assistance from two staff with bed mobility and STNA #700 rolled the resident away from himself during the care, resulting in Resident #50 rolling out of bed onto the floor. Consequently, Resident #50 suffered a comminuted distal femoral fracture of the left leg and ultimately had to have an above the knee amputation of the left leg. This affected one (#50) out of three residents reviewed for accidents/hazards. The facility's census was 41. On 02/24/22 at 11:24 A.M., Clinical Support Registered Nurse (RN) #900, Assistant Vice President (AVP) of Clinical Support #915 and Divisional Vice President (DVP) of Operations #920 were notified Immediate Jeopardy began on 02/03/22 when STNA #700 rolled Resident #50 out of bed, onto the floor during incontinence care. STNA #700 placed Resident #50 back into bed and proceeded to not be truthful about the events that occurred, leading to untimely discovery and treatment to the residents' injuries. Bruising and swelling to Resident #50's left knee was noticed by multiple STNA's as early as 02/04/22, but a full body assessment was not completed by a nurse until 02/07/22, where it was noted, Resident #50 had severe bruising and swelling to her left knee, and she was in noticeable pain. An x-[CONDITION(S)] (x-ray) was ordered on 02/07/22, but not completed until 02/09/22 where it was found Resident #50 suffered from a comminuted distal femoral fracture of the left leg. Resident #50 was referred to an orthopedic physician with an appointment set for 02/16/22. On 02/16/22, Resident #50 went to the orthopedic appointment and the physician recommended the resident be sent to the hospital immediately. On 02/17/22, Resident #50 ultimately had to have her left leg amputated above the knee. Although the Immediate Jeopardy was removed on 02/18/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until the deficiency was corrected on 02/22/22 when the facility implemented the following corrective actions: · On 02/16/22, Resident #50 was transported to an orthopedic appointment and was then transferred to the hospital for emergency care and treatment for her left distal femoral fracture. · On 02/17/22, STNA #700 was suspended pending investigation. · On 02/18/22, the DON audited resident's incident and accidents over the last 30 days to ensure any injuries were noted in the medical record and treated appropriately. No additional investigation was required, and no concerns were noted regarding accidents/hazards. · On 02/18/22, the DON audited new admissions and residents with recent change in condition to ensure Activities of Daily Living (ADL) assistance levels had not declined per baseline and they were accurately reflected in the residents' plan of care. No additional concerns were noted regarding accidents/hazards. · On 02/18/22, the DON audited all residents CRCA sheets which reflected ADL assistance required and to ensure the CRCA sheets were updated. · On 02/18/22, the Administrator, DON or designee began all facility staff education regarding incidents and accidents including where to locate the level of ADL assistance each resident required, notification of change in condition including addressing changes in condition immediately, appropriate ways to safely assist with bed mobility, as well as safe and appropriate use of mechanical lifts. The education was completed on 02/18/22. · On 02/18/22, the DON or designee will begin auditing residents CRCA sheets daily to ensure the correct level of ADL assistance required is accurate. · On 02/18/22, a Quality Assurance and Performance Improvement (QAPI) meeting was held where initial audits/assessments, education, and ongoing interventions were reviewed. QAPI meetings would be held weekly for four weeks, then monthly. · On 02/18/22, 02/19/22, 02/20/22, 02/21/22 and 02/22/22, the DON or designee completed audits of like residents regarding situations involving accidents/hazards. No further concerns were identified regarding accidents/hazards. · On 03/01/22 between 9:04 A.M. and 9:38 A.M., LPN #505, STNA #506, and STNA #507 verified they received education on how to verify what care a resident required and the number of staff needed for care. Aides reported if they were unsure of the number of staff required to provide care, they could find the information on their assignment sheets (CRCA Sheets), which were updated. · Medical record review for one (#51) additional closed record and three (#17, #28 and #32) open records revealed the residents had updated information reflected on their CRCA sheets. Additional review revealed there were no incidents of accidental injuries and no concerns regarding accidents/hazards. Findings include: Medical record review for Resident #50 revealed an admitted [DATE]. Diagnoses include dementia, major depressive disorder, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], dysphagia, ankle contracture, and muscle weakness. Review of Resident #50's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was severely cognitively impaired. Resident #50 required extensive assistance of two staff or was totally dependent upon two staff for Activities of Daily Living (ADL) including, bed mobility, transfers, toileting, and maintaining hygiene. Review of Resident #50's MDS dated [DATE] also indicated Resident #50 required extensive assistance of two staff or was totally dependent upon two staff for ADL's including, bed mobility, transfers, toileting, and maintaining hygiene. Review of Resident #50's care plan revealed Resident #50 was at risk for falls and staff were to be mindful of Resident #50's placement in bed. Resident #50 required a Hoyer lift operated by two staff for transfers and required staff assistance with ADL's. Resident #50 was non-verbal. The care plan did not reflect Resident #50's need for two staff assistance for bed mobility. Review of Resident #50's progress notes for February 2022 revealed the following: · On 02/03/22 at 5:00 P.M. during a transfer, Resident #50 was hit in the forehead with the arm of a Hoyer lift causing a laceration and bruised area with swelling. · There was no further documentation in Resident #50's progress notes until 02/07/22 at 2:21 A.M., which noted the resident was assessed for severe swelling to the left knee with significant dark purple bruising. The left knee was hot to the touch and Resident #50 had noticeable discomfort. Per aides, the area was noted since Thursday (02/03/22). An x-ray of Resident #50's left knee was ordered. · On 02/09/22 at 2:54 A.M., the x-ray was completed with findings of a comminuted distal femoral fracture of the left leg. An order was received for Resident #50 to be referred to an orthopedic physician. An appointment was set up for 02/16/22. · On 02/13/22 at 7:30 A.M., Resident #50's family requested Resident #50 be sent to the hospital to have head examined due to the incident on 02/03/22. Resident #50 had a head CT (Computed Tomography) scan and returned to the facility on the same day around 12:00 P.M. · On 02/16/22 at 12:10 P.M., Resident #50 went to her orthopedic appointment. She returned around 1:40 P.M. and the physician wanted her transferred to the hospital immediately. Family was discussing options for surgery or hospice. · Late entry on 02/17/22 at 6:49 P.M. revealed on 02/10/22, STNA #700 reported to Licensed Practical Nurse (LPN) #500 that Resident #50 was rolled out of bed on 02/03/22 while he was providing care. Further medical record review for Resident #50 revealed there were no additional notes regarding communication with Resident #50's doctor about a delay in the x-ray being completed, delay in the orthopedic appointment, or pain during examination. Review of Resident #50's x-ray dated 02/09/22 revealed a comminuted separated fracture of the distal left femoral diaphyseal metaphyseal junction of the left leg. The left femorotibial joint space was disrupted. The adjacent soft tissues appeared swollen with joint effusion. Review of Resident #50's orthopedic surgery consult dated 02/16/22 revealed Resident #50 had an x-ray with findings of a comminuted intra-articular distal femur fracture of the left leg with 100 percent (%) displacement and four centimeters of shortening. The physician felt the best option for Resident #50 was to have surgery to complete an above-knee amputation of the left lower extremity. Review of facility CRCA sheet updated 02/17/22 revealed Resident #50 required assistance from two staff. The facility was unable to locate a CRCA sheet from prior to 02/03/22 due to the document being updated on a regular basis and prior versions not saved. During an interview on 02/23/22 at 10:27 A.M. with LPN #500, she reported on 02/03/22, STNA #700 came to her and LPN #588 and reported Resident #50 had a laceration on her head due to him hitting her in the head with a Hoyer lift during a transfer. Resident #50's head injury was assessed, and neurological checks were completed. LPN #500 stated days later, Resident #50 had swelling and bruising to her left knee. STNA #700 came to her office crying and reported he had not told the truth about what happened to Resident #50 on 02/03/22. STNA #700 reported he had been providing incontinence care to Resident #50 when he rolled the resident out of bed onto the floor. STNA #700 was afraid to tell the truth at the time of the incident and lied about Resident #50 hitting her head on the Hoyer lift. An x-ray was completed and found Resident #50 had a fracture. Resident #50 went to an orthopedic appointment and was sent to the hospital for surgery where she had her leg amputated. LPN #500 reported it was her understanding the amputation was done because the physician was worried about placing screws and rods resulting in infection. Interview on 02/23/22 at 10:40 A.M., NP #511 verified facility staff notified her of Resident #50's fracture on 02/09/22. NP #511 stated nursing staff reported Resident #50 had no pain or vascular compromise, so NP #511 ordered for Resident #50 to be referred to an orthopedic physician. NP #511 reported she had not seen Resident #50 for an examination from the time she was notified of the fracture to the time Resident #50 went to the hospital on 02/16/22. Interview on 02/23/22 at 12:00 P.M., Resident #50's family member verified Resident #50 had a fracture of the left femur due to STNA #700 rolling the resident out of bed during care. Resident #50's family member reported the family was initially told Resident #50 had a head injury due to STNA #700 hitting the residents' head with a Hoyer lift, but days later were notified STNA #700 lied about the incident and that STNA #700 told the truth that he rolled the resident out of bed onto the floor. Interview on 02/23/22 at 2:29 P.M., STNA #566 reported she provided care to Resident #50 on a regular basis. STNA #566 verified Resident #50 required assistance from two staff for all care, including transfers, bed mobility, and incontinence care. Interview on 02/23/22 at 1:06 P.M., Registered Nurse (RN) #522 reported she notified NP #511 of Resident #50's x-ray results and severe bruising and swelling on 02/09/22. RN #522 reported she assessed Resident #50 on 02/09/22 and she did not appear to be in pain. RN #522 verified Resident #50 was non-verbal. RN #522 reported no new orders were received for pain medication or to splint the leg until the orthopedic appointment. RN #522 reported she was told Resident #50 should remain in bed (review of the medical record revealed no documentation regarding any additional orders put in place, including for Resident #50 to stay in bed). Interview on 02/23/22 at 1:48 P.M., RN #533 verified STNA #544 and STNA #555 reported they noticed Resident #50 had bruising and swelling to the residents left knee starting on 02/03/22. Interview on 02/23/22 at 2:07 P.M., STNA #700 verified on 02/03/22 he was providing routine incontinence care to Resident #50, and he was alone while providing the care. STNA #700 rolled Resident #50 in bed away from him, when she rolled out of bed and hit the floor. STNA #700 stated Resident #50's bed was in a medium to high position. STNA #700 reported Resident #50 did not call out and did not hit any furniture, so he thought she was okay and picked her up and returned her to bed, on his own. Resident #50 was bleeding from her head, and he was scared, so he lied to both LPN #500 and LPN #588 stating he accidentally hit Resident #50 with the arm of the Hoyer lift. STNA #700 reported he told the truth about the incident involving Resident #50 on 02/10/22. STNA #700 reported Resident #50 required two staff to assist her with transfers, but he was unsure at the time of the incident if Resident #50 required two staff assistance with bed mobility. STNA #700 admitted he made a mistake and should have had a second staff member helping and he should not have lied about the incident. Interview on 02/23/22 at 3:29 P.M., the Administrator reported she was unsure why there was a delay in Resident #50 receiving an x-ray. The Administrator confirmed the physician ordered Resident #50 to have an x-ray of the left knee on 02/07/22, but it was not completed until 02/09/22. The Administrator reported she was looking into the delay. Interview on 02/23/22 at 3:43 P.M., Clinical Support RN #900 reported on occasion the x-ray company the facility used could be slow to respond. Clinical Support RN #900 reported Medical Director (MD) #800 was aware of the delay in Resident #50 receiving an x-ray of the left knee and stated it was fine to wait for the x-ray. Clinical Support RN #900 reported communication with MD #800 should be documented in Resident #50's medical record; however, further review of the medical record revealed there was no documentation of correspondences with MD #800 regarding a delay in Resident #50 receiving the x-ray. Interview on 02/23/22 at 4:20 P.M., LPN #588 reported she was working on 02/03/22 when STNA #700 reported to her and LPN #500 he hit Resident #50 with the Hoyer lift and she was bleeding from her head. LPN #588 verified she assessed Resident #50 for a head injury only and did not conduct a full body examination. LPN #588 verified Resident #50 required assistance from two staff for ADL's. Interview on 02/23/22 at 4:25 P.M., STNA #555 reported on 02/05/22 another STNA (STNA #577) told her Resident #50 had bruising and swelling to her knee, which she observed. STNA #555 did not report the bruising or swelling to the nurse because she was under the impression the nurses were already aware. Interview on 02/23/22 at 4:30 P.M., STNA #577 reported he noticed bruising and swelling to Resident #50's knee on 02/04/22 and reported his concerns to LPN #599. STNA #577 verified Resident #50 required assistance from two staff for care. Interview on 02/23/22 at 4:39 P.M., the Administrator reported she did not feel STNA #700 intentionally hurt Resident #50 and truly felt it was an accident but stated he should have told the truth so Resident #50 could have been properly assessed timely. The Administrator reported STNA #700 should have had a second staff person assisting him with caring for Resident #50. Interview on 02/24/22 at 11:02 A.M. LPN #599 reported she did not remember if STNA #577 told her Resident #50 had bruising to her knee. Interview on 02/24/22 at 10:45 A.M. and again at 11:13 A.M. with MD #800 verified he was Resident #50's physician. MD #800 reported he had been notified and reviewed the incident involving Resident #50 with the facility within the last week. MD #800 reported he was unaware of any delay in Resident #50 receiving an x-ray. MD #800 reported if there was a delay in x-rays involving Resident #50, it was dependent on the case, if the resident had pain, they would be sent to the hospital for an evaluation. MD #800 reported he reviewed his faxes and documents and the only notification he received from the facility regarding the incident involving Resident #50 was on 02/13/22, when Resident #50 went to the hospital to have her head examined. Interview on 03/08/22 at 1:04 P.M. Orthopedic Physician #524 verified he saw Resident #50 on 02/16/22 in his office for a femoral fracture and the resident was transferred to the hospital for surgical intervention. Orthopedic Physician #524 described the fracture as a Bad fracture, where the femur bone broke and slid up behind Resident #50 ' s thigh bone. Orthopedic Physician #524 reported due to Resident #50 being contracted, he felt amputating the leg was the best treatment plan due to potential wound complications with placing hardware to repair the fracture. Orthopedic Physician #524 stated the fracture had been present for more than a week, but he could not determine an exact time period. Orthopedic Physician #524 reported Resident #50's fracture site was calcified and starting to heal, indicating the fracture was present for some time. Orthopedic Physician #524 reported Resident #50 was non-verbal, but the average person would be in pain from this type of fracture. Review of STNA #700's statement dated 02/10/22, revealed on 02/03/22 around 3:30 P.M., STNA #700 entered Resident #50's room for routine, Check and Change. When he was providing care, she rolled out of bed. STNA #700 was located on the window side of the bed, and he rolled Resident #50 away from him. STNA #700 lost his grip and Resident #50 fell to the floor. STNA #700 did not believe Resident #50 hit any furniture and the resident did not call out. STNA #700 was scared and picked Resident #50 up on his own and returned her back to bed. STNA #700 reported to LPN #588, Resident #50 was bleeding and he accidentally bumped Resident #50's head with the Hoyer lift. LPN #588 completed neurological checks. Resident #50 went to dinner the same evening and appeared to be okay. STNA #700 did not tell anyone the truth about the incident until 02/10/22, when he reported to LPN #500. Review of LPN #500's statement dated 02/18/22 revealed on 02/03/22, she was assisting LPN #588 at the nurse's station when STNA #700 approached them to report he hit Resident #50 accidentally with the Hoyer lift arm and she was bleeding. When LPN #500 entered Resident #50's room, the Hoyer lift was by the TV and Resident #50 was lying in bed. There was a moderate amount of bleeding coming from Resident #50's forehead. Resident #50 was provided care and neurological checks were completed. STNA #700 was educated that he should not use a Hoyer lift alone. On 02/10/22, STNA #700 came to her office crying and reported he, Had not actually hit Resident #50 with the Hoyer lift. STNA #700 explained he accidentally rolled Resident #50 out of bed on 02/03/22 while providing care and he panicked, so he picked her up and put her back to bed. Review of LPN #588's statement dated 02/10/22 revealed on 02/03/22, STNA #700 reported Resident #50 was bleeding and needed assistance. LPN #588 gathered supplies and entered the room to see Resident #50 lying in bed and the Hoyer lift by the TV. STNA #700 reported he hit Resident #50 in the head with the Hoyer lift. LPN #588 completed neurological checks and opened a neurological event in the electronic medical record. Resident #50 was taken to dinner as normal and did not appear to be in distress. On 02/07/22, bruising to Resident #50's knee was reported, and an x-ray was ordered. The results of the x-ray were received on 02/09/22 and revealed a femoral fracture of the left leg and Resident #50 would be referred for an orthopedic consult. Review of MD #800's interview/statement dated 02/18/22 revealed MD #800 felt Resident #50's femoral fracture resulted from a fall from bed. The fall was not reported initially and was a matter of days until it was investigated due to clinical signs of swelling and bruising developing. Resident #50 was not sent to the hospital because she was not showing clinical signs of distress or ischemia distal. Review of the DON statement dated 02/22/22 revealed she was notified on 02/07/22 of Resident #50 having bruising to the left knee. The DON completed an assessment of Resident #50's knee and felt the bruising was consistent with the incident involving the Hoyer lift on 02/03/22. Review of facility policy titled, Guidelines for Resident Transfers, dated 05/10/17 revealed the facility would ensure safety of residents and staff when performing mobility/transfer tasks. Review of facility policy titled, Turning and Repositioning, revised 05/11/16 revealed if a resident required assistance with repositioning, proper turning techniques and body mechanizes should be utilized to prevent injury to the resident and caregiver. This deficiency substantiates Complaint Number OH 334.

Based on medical record review, review of facility self-reported incidents (SRI's), interview with facility staff, and review of facility policy, the facility failed to report an incident of resident neglect and injury of unknown origin to the Ohio Department of Health. This affected one (#50) out of four residents reviewed for neglect. The facility's census was 41. Findings included: Medical record review for Resident #50 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #50's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had a Brief Interview for Mental Status (BIMS) score of 99, indicating Resident #50 was severely cognitively impaired. Resident #50 required extensive assistance of two staff or was totally dependent upon two staff for Activities of Daily Living (ADL's) including, bed mobility, transfers, toileting, and maintaining hygiene. Review of Resident #50's MDS dated [DATE] also indicated Resident #50 required extensive assistance of two staff or was totally dependent upon two staff for ADL's including, bed mobility, transfers, toileting, and maintaining hygiene. Review of Resident #50's care plan revealed Resident #50 was at risk for falls and staff were to be mindful of Resident #50's placement in bed. Resident #50 required a Hoyer lift operated by two staff for transfers and required staff assistance with ADL's. Resident #50 was non-verbal. The care plan did not reflect Resident #50's need for two staff assistance for bed mobility. Review of Resident #50's progress notes for February 2022 revealed the following: · On 02/03/22 at 5:00 P.M. during a transfer, Resident #50 was hit in the forehead with the arm of a Hoyer lift causing a laceration and bruised area with swelling. · There was no further documentation in Resident #50's progress notes until on 02/07/22 at 2:21 A.M., which noted the resident was assessed for severe swelling to the left knee with significant dark purple bruising. The left knee was hot to the touch and Resident #50 had noticeable discomfort. Per aides, the area was noted since Thursday (02/03/22). An x-ray of Resident #50's left knee was ordered. · On 02/09/22 at 2:54 A.M., the x-ray was completed with findings of a comminute distal femoral fracture of the left leg. An order was received for Resident #50 to be referred to an orthopedic physician. An appointment was set up for 02/16/22. · On 02/13/22 at 7:30 A.M., Resident #50's family requested Resident #50 be sent to the hospital to have head examined due to the incident on 02/03/22. Resident #50 had a head CT scan and returned to the facility on the same day around 12:00 P.M. · On 02/16/22 at 12:10 P.M., Resident #50 went to her orthopedic appointment. She returned around 1:40 P.M. and the physician wanted her transferred to the hospital immediately. Family was discussing options for surgery or hospice. · Late entry on 02/17/22 at 6:49 P.M. revealed on 02/10/22, STNA #700 reported to Licensed Practical Nurse (LPN) #500 that Resident #50 was rolled out of bed on 02/03/22 while he was providing care. Further medical record review for Resident #50 revealed there were no additional notes regarding communication with Resident #50's doctor about a delay in the x-ray being completed, delay in orthopedic appointment, or pain during exam. Review of Resident #50's x-ray dated 02/09/22 revealed an x-ray was obtained of the residents left knee due to an injury of unknown origin, swelling bruising discomfort and contusion of the knee. The x-ray report documented a comminuted separated fracture of the distal left femoral diaphyseal metaphyseal junction of the left leg. The left femorotibial joint space was disrupted. The adjacent soft tissues appeared swollen with joint effusion. Review of Resident #50's orthopedic surgery consult dated 02/16/22 revealed Resident #50 had an x-ray with findings of a comminuted intra-articular distal femur fracture of the left leg with 100 percent (%) displacement and four centimeters of shortening. The physician felt the best option for Resident #50 was to have surgery to complete an above-knee amputation of the left lower extremity. Interview on 02/23/22 at 10:27 A.M. LPN #500 reported on 02/03/22, STNA #700 came to her and LPN #588 and reported Resident #50 had a laceration on her head due to him hitting her in the head with a Hoyer lift during a transfer. Resident #50's head injury was assessed, and neuro checks were completed. LPN #500 stated days later, Resident #50 had swelling and bruising to her left knee. STNA #700 came to her office crying and reported he had not told the truth about what happened to Resident #50 on 02/03/22. STNA #700 reported he had been providing incontinence care to Resident #50 when she rolled the resident out of bed onto the floor. STNA #700 was afraid to tell the truth at the time of the incident and lied about Resident #50 hitting her head on the Hoyer lift. An x-ray was completed and found Resident #50 had a fracture. Resident #50 went to an orthopedic appointment and was sent to the hospital for surgery where she had her leg amputated. LPN #500 reported it was to her understanding the amputation was done because the physician was worried about placing screws and rods resulting in infection. Interview on 02/23/22 at 2:07 P.M. STNA #700 verified on 02/03/22 he was providing routine incontinence care to Resident #50, and he was alone while providing the care. STNA #700 rolled Resident #50 in bed away from him, when she rolled out of bed and hit the floor. STNA #700 stated Resident #50's bed was in a medium to high position. STNA #700 reported Resident #50 did not call out and did not hit any furniture, so he thought she was OK and picked her up and returned her to bed, on his own. Resident #50 was bleeding from her head, and he was scared, so he lied to the LPN #588 stating he accidentally hit Resident #50 with the arm of the Hoyer lift. STNA #700 reported he told the truth about the incident involving Resident #50 on 02/10/22. STNA #700 reported Resident #50 required two staff to assist her with transfers, but he was unsure at the time of the incident if Resident #50 required two staff assistance with bed mobility. STNA #700 admitted he made a mistake and should have had a second staff member helping and he should not have lied about the incident. Interview on 02/23/22 at 4:39 P.M. the Administrator reported she did not feel STNA #700 intentionally hurt Resident #50 and truly felt it was an accident but stated he should have told the truth so Resident #50 could have been properly assessed timely. Review of STNA #700 statement dated 02/10/22, revealed on 02/03/22 around 3:30 P.M., STNA #700 entered Resident #50's room for routine, Check and change. When he was providing care, she rolled out of bed. STNA #700 was located on the window side of the bed and she he rolled Resident #50, he rolled her away from him. STNA #700 lost his grip and Resident #50 fell to the floor. STNA #700 did not believe Resident #50 hit any furniture and the resident did not call out. STNA #700 was scared and picked Resident #50 up on his own and returned her back to bed. STNA #700 reported to LPN #588, Resident #50 was bleeding and he accidentally bumped Resident #50's head with the Hoyer lift. LPN #588 completed neuro checks. Resident #50 went to the dinner the same evening and appeared to be OK. STNA #700 did not tell anyone the truth about the incident until 02/10/22, when he reported to LPN #500. Review of LPN #500's statement dated 02/18/22 revealed on 02/03/22, she was assisting LPN #588 at the nurse's station when STNA #700 approached them to report he hit Resident #50 accidentally with the Hoyer lift arm and she was bleeding. When LPN #500 entered Resident #50's room, the Hoyer lift was by the TV and Resident #50 was lying in bed. There was a moderate amount of bleeding coming from Resident #50's forehead. Resident #50 was provided care and neuro checks were completed. STNA #700 was educated that he should not use a Hoyer lift alone. On 02/10/22, STNA #700 came to her office crying and reported he, Had not actually hit Resident #50 with the Hoyer lift. STNA #700 explained he accidentally rolled Resident #50 out of bed on 02/03/22 while providing care and he panicked, so he picked her up and put her back to bed. Review of LPN #588's statement dated 02/10/22 revealed on 02/03/22, STNA #700 reported Resident #50 was bleeding and needed assistance. LPN #588 gathered supplies and entered the room to see Resident #50 lying in bed and the Hoyer lift by the TV. STNA #700 reported he hit Resident #50 in the head with the Hoyer lift. LPN #588 completed neuro checks and opened a neurological event in the electronic medical record. Resident #50 was taken to dinner as normal and did not appear to be in distress. On 02/07/22, bruising to Resident #50's knee was reported, and an x-ray was ordered. The results of the x-ray were received on 02/09/22 and revealed a femoral fracture of the left leg and Resident #50 would be referred for an orthopedic consult. Review of MD #800's interview/statement dated 02/18/22 revealed MD #800 felt Resident #50's femoral fracture resulted from a fall from bed. The fall was not reported initially and was a matter of days until it was investigated due to clinical signs of swelling and bruising developing. Resident #50 was not sent to the hospital because she was not showing clinical signs of distress or ischemia distal. Review of the DON statement dated 02/22/22 revealed she was notified on 02/07/22 of Resident #50 having bruising to the left knee. The DON completed an assessment of Resident #50's knee and felt the bruising was consistent with the incident involving the Hoyer lift on 02/03/22. Review of facility's SRI revealed there were no SRI's completed for the year of 2022 and/or the situation involving Resident #50. E-mail received from Assistance Vice President of Clinical Support #915 on 02/28/22 revealed the facility had not completed an SRI for the incident on 02/03/22. Review of facility policy titled, Abuse, Neglect and Exploitation Procedural Guidelines, revised 08/29/19 revealed incidents of abuse and neglect would be investigated and reported. This deficiency substantiates Complaint Number OH 334.

Based on medical record review, observation and staff interview, the facility failed to ensure medications and/or treatments were properly labeled and stored. This affected one (#27) of one reviewed for medication storage. The facility census was 30. Findings included: Medical record review for Resident #27 revealed an admission on 03/28/17 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had impaired cognition. Resident #27 was coded as having behaviors not directed at others such as self-scratching, rummaging, verbal or vocal symptoms and disruptive sounds. Resident requires extensive assist with bed mobility by two staff members for bed mobility, transfers, eating and toileting. Further review of Resident #27's medical record revealed there were no medication and/or treatment orders for any ointments. Observation on 04/12/21 at 1:03 P.M. of Resident #27 awake and resting in his bed. Further observation revealed there was a yellow colored ointment in a covered specimen container without label, name or date located within range of the resident reach on side table. Interview on 04/12/21 at 5:45 P.M. with Registered Nurse #27 stated she did not know what the medication and/or treatment was in the specimen cup, but stated no medication was to be left in residents' rooms. Interview on 04/15/21 with Health Services Director verified medications and/or treatments are not to be left in residents' rooms.

Based on medical record review, resident and staff interview and review of facility policy, the facility failed to ensure residents were notified in writing when transfers to the hospital occurred. This affected two (#18 and #31) residents of two reviewed for transfers. The facility census was 30. Findings included: 1. Medical record review for Resident #18 revealed an admitted [DATE] with a discharge on 02/22/20 and readmission on 02/26/20. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of most recent quarterly Minimum Data Set (MDS) assessment for Resident #18 dated 02/12/21 revealed the resident had intact cognition. Resident requires extensive assist from two staff members for bed mobility, transfers, and toileting. Eating is independent. Resident is dependent with bathing from one staff member. Resident #18 in frequently incontinent of bladder and bowel. Resident weighs 325 pounds. No skin issues was coded. Review of plan of care date dated 04/06/2019 for Resident #18 revealed resident requires extensive to total staff assistance to complete activities of daily living (ADL) tasks completely and safely due to history of [CONDITION(S)] disease, history of [CONDITION(S)] with shunt placement, congestive heart failure chronic kidney disease, arthritis, sleep apnea. ADL participation varies related to mood and fatigue. Participation in ADL's may vary from shift to shift/ day to day related to mood and fatigue. Interventions use sit to stand lift with two assist for transfers as needed, resident feeds self independently, mobility bars as enablers assist with bed mobility, allow resident sufficient time to complete all or parts of task, encourage resident to do as much as possible, monitor for complications from shunt placement, observe for deterioration in ADL, provide adequate rest periods between activities, and therapy eval as needed. Further review of Resident #18's medical record revealed the resident was transferred to the hospital on 02/22/20 for a change of condition. The record review revealed Resident #18 was not provided with a notice of transfer. Interview on 04/13/21 at 10:04 A.M. with Resident #18 stated she was not given any paper from the facility as to why she was being transferred to the hospital. Interview on 04/19/21 at 3:05 P.M. with the Administrator verified no transfer documents were given to Resident #18 upon transfer to the hospital. 2. Review of the medical record for Resident #31 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) for Resident #31 dated 02/24/21 revealed the resident had impaired cognition. Resident requires extensive assist of one for bed mobility, transfers, and toileting. Review of the Nurses Notes dated on 03/05/21 revealed Resident #31 had a change in condition and required a transfer to the hospital. The record did not contain evidence that the facility provided the required paper work prior to discharge. The record also did not contain evidence of the required discharge paper work being sent to the responsible party. Interview with the Administrator on 04/14/21 at 3:05 P.M. revealed no paper work was given to the resident or his family when he was discharged /transferred to the hospital. Review of facility policy titled Guidelines for Transfer and Discharge, dated 05/23/18, revealed the facility failed to implemented the policy as written. Number one, letter a, stated the facility will notify the resident in writing for reason for transfer.

Based on medical record review, observation, staff interview and facility policy review the facility failed to follow fall care plan interventions. This affected one (Resident #27) of three residents reviewed for falls. The facility census was 41. Findings include: Review of the medical record for Resident #27 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #27 was cognitively intact and required extensive assistance of one staff for toilet use. Review of the care plan for Resident #27 last updated 12/02/19 revealed Resident #27 was not to be left alone in the bathroom. Observation on 01/29/20 at 2:10 P.M. revealed Resident #27 seated on the toilet in his room with the call light activated. There were no staff members present. Upon this surveyor exiting Resident #27's room, State tested Nursing Assistant (STNA) #413 was entering. STNA #413 indicated Resident #27 was not to be left alone on the toilet and the STNA denied assisted him to the toilet. STNA #413 denied knowledge of who assisted Resident #27 to the toilet. The Director of Nursing (DON) was approaching the room and was informed of the findings. STNA #403 indicated that therapy might have assisted the resident to the toilet. Interview on 01/29/20 at 2:13 P.M. with Physical Therapist (PT) #505 revealed she had assisted Resident #27 onto the toilet and left him there. PT #505 was unaware of the intervention to not leave him unattended on the toilet. PT #505 did state she could see the care plan in the electronic record. PT #505 stated the resident normally turns on his call light when he is finished. Review of the facility policy titled Fall Management Program Guidelines dated 05/22/18 revealed care plan interventions should be implemented addressing resident's risk factors. This deficiency substantiates Complaint Number OH 745.

Based on medical record review, review of facility event reports and teachable moment documents and staff interviews, the facility failed to ensure a resident was provided with the necessary assistance to prevent an avoidable fall from a bed, resulting in an injury. This resulted in actual physical harm to Resident #03 when a staff member turned the resident in bed without assistance and the resident fell from the bed, suffering a fracture of her right leg. This affected one (#03) of three residents reviewed for accidents. The census was 39. Findings include: Review of Resident #03's closed medical record revealed an admitted [DATE]. [DIAGNOSES REDACTED]. Resident #03 had been receiving Hospice services since admission and expired in the facility on [DATE]. Review of a comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #03 required extensive assistance of two staff members with bed mobility and dressing. Resident #03 was severely cognitively impaired. Review of Resident #03's care plan dated [DATE] revealed she was at risk for falls related to poor standing and sitting balance, weakness, incontinence, pain, medication use, use of a Hoyer (mechanical) lift and dementia. Review of a nurses note dated [DATE] at 3:56 P.M. revealed staff reported to nurse that Resident #03 was on the floor. Resident #03 was found on the floor lying on her back on the left side of the bed. Resident #03's right knee and lower leg were bruised with an unknown protrusion underneath skin. Staff member reported turning resident in bed to pull pants up. Resident #03 rolled over farther than expected and fell on to the floor. The physician was notified. An X-ray of the right leg was ordered as soon as possible (STAT) and pain medication was ordered. Hospice was notified. Review of the facility's Event Report dated [DATE] revealed Resident #03 fell on to the floor during care from a staff member on [DATE]. The fall resulted in a fracture. Staff member was re-educated on proper transfer of residents. Review of Resident #03's right knee X-ray results dated [DATE] revealed acute displaced tibia-fibula fractures. Review of physician orders [REDACTED].#03's right lower extremity. Interview on [DATE] at 11:08 [NAME]M. with Licensed Practical Nurse (LPN) #40, revealed she was called to Resident #03's room on [DATE] by State tested Nursing Assistant (STNA) #60. LPN #40 stated Resident #03 was found on the floor beside the left side of her bed. LPN #40 stated that Resident #03 was moaning and groaning and a divot could be seen in her skin on her right leg. LPN #40 stated Resident #03 should have been repositioned with the assistance of two staff members and was a Hoyer for transfers. Interview on [DATE] at 3:15 P.M. with STNA #60 revealed she was getting Resident #03 ready for supper on [DATE]. STNA #60 stated Resident #03 was in bed and she rolled her away from herself to pull up Resident #03's pants. STNA #60 stated Resident #03 rolled to far and fell off the bed onto the floor. STNA #60 stated Resident #03 fell on to the floor with her legs underneath her. STNA #60 stated Resident #03 was crying in obvious pain. STNA #60 stated she was re-educated on repositioning residents by the Director of Nursing (DON) on [DATE]. Review of a facility document titled Teachable Moment dated [DATE] revealed STNA #60 was re-educated on how to transfer and reposition residents safely by the DON. This deficiency substantiates Complaint Number OH 631.

Based on medical record review, staff interview, review of the facility's abuse policy, review of self-reported incidents (SRIs), the facility failed to timely report an allegation of sexual abuse between two residents to the state survey agency. This affected two Residents (#8 and #20) of two reviewed for abuse and one SRI of three reviewed. The facility census was 43. Findings include: Review of Resident #8's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #8 was assessed as being moderately cognitively impaired in a quarterly Minimum Data Set (MDS) assessment dated [DATE]. Review of progress notes dated 01/05/19 at 3:15 A.M., revealed Resident #8's call light was sounding and when staff entered her room a male resident, who she had a long term relationship with, was found in her room standing over her bed with genitals exposed. The male resident left the room when staff entered. Resident #8's incontinence brief was intact . Resident #8 was assessed for injuries and none were found. Review of progress notes dated 01/05/19 at 3:25 A.M., revealed that the Director of Nursing (DON) was notified of the incident. Review of Resident #20's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #20 was assessed as being cognitively intact in a quarterly MDS assessment dated [DATE]. Review of progress notes dated 01/05/19 at 3:15 A.M., revealed that Resident #20 was found in a female resident's room, who he had a long term relationship with. Resident #20 was standing over the female resident with his genitals exposed. Resident #20 went back to his room when staff entered the female resident's room. Review of a interdisciplinary team (IDT) note dated 01/07/19 at 10:03 A.M. revealed that Resident #20 was found in a female resident's room, who he has a long term relationship with. Resident #20 was standing over a female resident with his genitals exposed. Resident #20 went back to his room when staff entered the female resident's room. Resident #20 had showed no such behaviors since incident. Resident #20 was continued to be monitored. Review of SRI # 3 dated 01/11/19 at 7:01 P.M., revealed Resident #20 was found in Resident #8's on 01/05/19 at 3:00 A.M. engaged in a sexual activity. Resident #8 and Resident #20 were both were assessed. Resident #8 was sent to a local ER for evaluation and local law enforcement was called and they completed an investigation. Both Resident #8 and Resident #20 were place on every 15 minutes checks. Similar residents were interviewed and staff training on abuse was completed 01/11/19 through 01/16/19. Further review revealed that the incident between Resident #8 and Resident #20 was first reported to the state agency on 01/11/19 at 7:01 P.M. Interview on 01/23/19 at 2:01 P.M., with the Administrator confirmed that state agency was not notified of alleged sexual abuse that occurred on 01/05/19 between Resident #8 and Resident #20 until 01/11/19. The Administrator stated that the DON had started the submission to ODH, but may have not completed the process of submitting. The Administrator stated that Resident #8 and Resident #20 were long time acquaintances and that their families encouraged them to be at the same facility and were not concerned with their relationship. Review of the facility's policy titled Abuse, Neglect, and Exploitation Procedural Guidelines dated 10/10/18 revealed that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than two hours after the allegations are made, if the events that cause the allegation involve abuse or involve serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Sexual abuse was defined as any non-consensual sexual contact of any type with a resident.

Based on medical record review, staff interview, review of the facility's abuse policy and review of self-reported incidents (SRIs), the facility failed to follow their policy and timely report an allegation of sexual abuse between two residents to the state survey agency. This affected two Residents (#8 and #20) of two reviewed for abuse and one SRI of three reviewed. The facility census was 43. Findings include: Review of Resident #8's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #8 was assessed as being moderately cognitively impaired in a quarterly Minimum Data Set (MDS) assessment dated [DATE]. Review of progress notes dated 01/05/19 at 3:15 A.M., revealed Resident #8's call light was sounding and when staff entered her room a male resident, who she had a long term relationship with, was found in her room standing over her bed with genitals exposed. The male resident left the room when staff entered. Resident #8's incontinence brief was intact . Resident #8 was assessed for injuries and none were found. Review of progress notes dated 01/05/19 at 3:25 A.M., revealed that the Director of Nursing (DON) was notified of the incident. Review of Resident #20's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #20 was assessed as being cognitively intact in a quarterly MDS assessment dated [DATE]. Review of progress notes dated 01/05/19 at 3:15 A.M., revealed that Resident #20 was found in a female resident's room, who he had a long term relationship with. Resident #20 was standing over the female resident with his genitals exposed. Resident #20 went back to his room when staff entered the female resident's room. Review of a interdisciplinary team (IDT) note dated 01/07/19 at 10:03 A.M. revealed that Resident #20 was found in a female resident's room, who he has a long term relationship with. Resident #20 was standing over a female resident with his genitals exposed. Resident #20 went back to his room when staff entered the female resident's room. Resident #20 had showed no such behaviors since incident. Resident #20 was continued to be monitored. Review of SRI # 3 dated 01/11/19 at 7:01 P.M., revealed Resident #20 was found in Resident #8's on 01/05/19 at 3:00 A.M. engaged in a sexual activity. Resident #8 and Resident #20 were both were assessed. Resident #8 was sent to a local ER for evaluation and local law enforcement was called and they completed an investigation. Both Resident #8 and Resident #20 were place on every 15 minutes checks. Similar residents were interviewed and staff training on abuse was completed 01/11/19 through 01/16/19. Further review revealed that the incident between Resident #8 and Resident #20 was first reported to the state agency on 01/11/19 at 7:01 P.M. Interview on 01/23/19 at 2:01 P.M., with the Administrator confirmed that state agency was not notified of alleged sexual abuse that occurred on 01/05/19 between Resident #8 and Resident #20 until 01/11/19. The Administrator stated that the DON had started the submission to ODH, but may have not completed the process of submitting. The Administrator stated that Resident #8 and Resident #20 were long time acquaintances and that their families encouraged them to be at the same facility and were not concerned with their relationship. Review of the facility's policy titled Abuse, Neglect, and Exploitation Procedural Guidelines dated 10/10/18 revealed that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than two hours after the allegations are made, if the events that cause the allegation involve abuse or involve serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Sexual abuse was defined as any non-consensual sexual contact of any type with a resident.

Based on medical record review, staff interview and review of Self Reported Incidents (SRI), review of personnel files and review of facility policy the facility failed to implement their policy to report suspected abuse to administration in a timely manner. This affected two Residents (#1 and #3) of three reviewed for abuse. The facility census was 47. Findings include: 1. Review of the closed medical record for Resident #1 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) 3.0 dated 04/24/18 revealed the resident was able to understand and to be understood. The resident had moderate cognitive deficits, no behaviors or rejection of care. The resident required extensive assistance for bed mobility, dressing, toileting, and was totally dependent on staff for transfers, locomotion, hygiene, bathing and supervision for eating and had functional impairments of bilateral upper and lower extremities. The resident was occasionally incontinent of urine, always incontinent of bowel and had frequent pain. The resident did have a fall with a fracture in the last two to six months prior to the admission or reentry and none since the prior assessment. The MDS revealed the resident was at risk for development of pressure ulcers and currently had one stage two pressure ulcer that was present on admission and had pressure reduction devices in place. The resident received opioids and antidepressants. Review of a SRI dated 06/13/18 revealed the facility was informed of an employee discussing wanting to do pillow therapy to a resident to another employee on 05/16/18. The employee in question was suspended on 05/16/18 pending investigation, was written up on 05/21/18 for unprofessional conduct and in further investigation, the statement was considered verbal abuse. The SRI further revealed State tested Nursing Assistant (STNA) #135 admitted to making the comment but stated she was only joking and would not actually do this. It was also reported Registered Nurse (RN) #60 was also involved in the conversation. RN #60 was not part of the conversation but did hear STNA #135 make the comment and RN #60 acknowledged she should have reported this regardless of the scenario. The SRI revealed STNA #135 was terminated and RN #60 was provided re-education on reporting abuse. Interview with Executive Director #1 and corporate staff #125 on 07/18/18 at 11:45 A.M. verified they were not informed of STNA's statement of wanting to do pillow therapy at the time it was made. They verified staff was to notify them immediately if there were any allegations of abuse. Corporate staff #125 stated all staff were interviewed, but only a couple stated they actually heard STNA #135 make the comment, other staff members heard it second and third hand. Corporate staff #125 stated no resident was thought to be in danger at the time the statement was made and no resident was harmed. He stated RN #60 was interviewed and she denied being part of the conversation with STNA #135. RN #60 admitted being in the vicinity and only heard STNA #135 make the statement. RN #60 indicated she knew the STNA was very tired as she had been very busy. RN #60 sent her off the unit for a break and then thought everything was okay. He stated RN #60 was given re-education on the importance of reporting any statements that could be abusive. Interview with RN #60 on 07/17/18 at 12:57 P.M. revealed she was working when STNA #135 and STNA #140 were talking and STNA #135 made the statement she wanted to do pillow therapy on Resident #1. RN #60 stated it had been a very stressful shift. She sent the STNA's on a break and when they came back they were fine. She stated she did not report this right away and did not consider this abuse. She stated she went home and thought about it. She sent former Director of Health Services #1 a text to inform her the next morning. She stated STNA #140 also was talking about another resident and called the resident crazy in front of another resident's daughter. RN #60 stated she did write up STNA #140 for that. RN #60 stated she should have reported it to the administration right away. 2. Review of the medical record for Resident #3 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a quarterly MDS 3.0 assessment dated [DATE] revealed the resident had significant cognitive deficits but was able to understand and usually able to be understood. The resident had no behaviors or rejection of care. The resident required extensive assistance for bed mobility, transfers, walking, locomotion, dressing, toileting and hygiene and limited assistance with eating. The resident was frequently incontinent of bowel and bladder. Review of a facility's SRI dated 05/09/18 revealed STNA #100 submitted a letter to former Director of Health Services #1 on 05/12/18. STNA #100 overheard STNA #140 using inappropriate language and tone to Resident #6. Profanities were used by STNA #140 and then STNA #140 walked away when the resident asked for help. STNA #100 apologized to the resident and assisted the resident to the bathroom. STNA #100 then wrote she asked STNA #140 for assistance later in the night and STNA #140 was very forceful to Resident #3. STNA #140 pushed against the resident as the resident was attempting to push STNA #140 away. STNA #140 yanked on the resident's arm. The SRI further revealed the facility reported the allegation to the state agency timely after being informed of the allegation. Resident #3 was not able to be interviewed due to cognitive status but did not have continued arm pain. STNA #140 revealed she had only assisted with transfers and did not provide care to Resident #3 on the day in questions. Interview with STNA #100 on 07/17/18 at 3:33 P.M. revealed she had asked STNA #140 for assistance with Resident #3. She stated STNA #140 was forceful with Resident #3 and yanked on the resident's arm. She stated Resident #3 complained of a sore arm the next day. She stated this happened about two or three months ago, but she did not report it right away. She stated she went home and thought about it and then provided a written statement to management. She verified she should have reported this immediately. Interview with Executive Director #1 on 07/17/18 at 3:00 P.M. verified STNA #135 did not report the observations to the facility immediately and should have done so according to facility policy. She further stated the allegation was not substantiated as Resident #3 was not interviewable and they had no evidence of abuse. There were no other witnesses. She stated the facility started an investigation as soon as they were notified. Review of employee files for RN #60, STNA #135 and STNA #140 revealed no issues concerning pre-screening of employees and all employees had current credentials. RN #60 had received counseling on 06/15/18 for not reporting a scenario that was questioned as abuse. STNA #135 had counseling on 05/15/18 for refusing to go in a resident's room to answer a call light, on 05/21/18 a written warning for unprofessional conduct, and a termination notice on 06/13/18. STNA #140 received a written warning on 05/21/18 for unprofessional conduct and was terminated on 07/06/18 for not performing to facility standards. Review of facility policy Abuse and Neglect Procedural guidelines dated 10/10/17 revealed any person with knowledge or suspicion of suspected violations of abuse, neglect exploitation, were to report it immediately to the shift supervisor who was to immediately notify the Executive Director or designee. Upon identification of suspected abuse or neglect the safety of the resident was to be provided. All alleged violations were to reported to the state survey agency within 24 hours, or within two hours if serious bodily injury had occurred. This is an incidental finding discovered during the course of the investigation of Complaint Numbers OH 986, OH 001 and OH 053.

Based on medical record review, staff interview and review of Self Reported Incidents (SRI), review of personnel files and review of facility policy the facility failed to report suspected abuse to administration in a timely manner. This affected two Residents (#1 and #3) of three reviewed for abuse. The facility census was 47. Findings include: 1. Review of the closed medical record for Resident #1 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) 3.0 dated 04/24/18 revealed the resident was able to understand and to be understood. The resident had moderate cognitive deficits, no behaviors or rejection of care. The resident required extensive assistance for bed mobility, dressing, toileting, and was totally dependent on staff for transfers, locomotion, hygiene, bathing and supervision for eating and had functional impairments of bilateral upper and lower extremities. The resident was occasionally incontinent of urine, always incontinent of bowel and had frequent pain. The resident did have a fall with a fracture in the last two to six months prior to the admission or reentry and none since the prior assessment. The MDS revealed the resident was at risk for development of pressure ulcers and currently had one stage two pressure ulcer that was present on admission and had pressure reduction devices in place. The resident received opioids and antidepressants. Review of a SRI dated 06/13/18 revealed the facility was informed of an employee discussing wanting to do pillow therapy to a resident to another employee on 05/16/18. The employee in question was suspended on 05/16/18 pending investigation, was written up on 05/21/18 for unprofessional conduct and in further investigation, the statement was considered verbal abuse. The SRI further revealed State tested Nursing Assistant (STNA) #135 admitted to making the comment but stated she was only joking and would not actually do this. It was also reported Registered Nurse (RN) #60 was also involved in the conversation. RN #60 was not part of the conversation but did hear STNA #135 make the comment and RN #60 acknowledged she should have reported this regardless of the scenario. The SRI revealed STNA #135 was terminated and RN #60 was provided re-education on reporting abuse. Interview with Executive Director #1 and corporate staff #125 on 07/18/18 at 11:45 A.M. verified they were not informed of STNA's statement of wanting to do pillow therapy at the time it was made. They verified staff was to notify them immediately if there were any allegations of abuse. Corporate staff #125 stated all staff were interviewed, but only a couple stated they actually heard STNA #135 make the comment, other staff members heard it second and third hand. Corporate staff #125 stated no resident was thought to be in danger at the time the statement was made and no resident was harmed. He stated RN #60 was interviewed and she denied being part of the conversation with STNA #135. RN #60 admitted being in the vicinity and only heard STNA #135 make the statement. RN #60 indicated she knew the STNA was very tired as she had been very busy. RN #60 sent her off the unit for a break and then thought everything was okay. He stated RN #60 was given re-education on the importance of reporting any statements that could be abusive. Interview with RN #60 on 07/17/18 at 12:57 P.M. revealed she was working when STNA #135 and STNA #140 were talking and STNA #135 made the statement she wanted to do pillow therapy on Resident #1. RN #60 stated it had been a very stressful shift. She sent the STNA's on a break and when they came back they were fine. She stated she did not report this right away and did not consider this abuse. She stated she went home and thought about it. She sent former Director of Health Services #1 a text to inform her the next morning. She stated STNA #140 also was talking about another resident and called the resident crazy in front of another resident's daughter. RN #60 stated she did write up STNA #140 for that. RN #60 stated she should have reported it to the administration right away. 2. Review of the medical record for Resident #3 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a quarterly MDS 3.0 assessment dated [DATE] revealed the resident had significant cognitive deficits but was able to understand and usually able to be understood. The resident had no behaviors or rejection of care. The resident required extensive assistance for bed mobility, transfers, walking, locomotion, dressing, toileting and hygiene and limited assistance with eating. The resident was frequently incontinent of bowel and bladder. Review of a facility's SRI dated 05/09/18 revealed STNA #100 submitted a letter to former Director of Health Services #1 on 05/12/18. STNA #100 overheard STNA #140 using inappropriate language and tone to Resident #6. Profanities were used by STNA #140 and then STNA #140 walked away when the resident asked for help. STNA #100 apologized to the resident and assisted the resident to the bathroom. STNA #100 then wrote she asked STNA #140 for assistance later in the night and STNA #140 was very forceful to Resident #3. STNA #140 pushed against the resident as the resident was attempting to push STNA #140 away. STNA #140 yanked on the resident's arm. The SRI further revealed the facility reported the allegation to the state agency timely after being informed of the allegation. Resident #3 was not able to be interviewed due to cognitive status but did not have continued arm pain. STNA #140 revealed she had only assisted with transfers and did not provide care to Resident #3 on the day in questions. Interview with STNA #100 on 07/17/18 at 3:33 P.M. revealed she had asked STNA #140 for assistance with Resident #3. She stated STNA #140 was forceful with Resident #3 and yanked on the resident's arm. She stated Resident #3 complained of a sore arm the next day. She stated this happened about two or three months ago, but she did not report it right away. She stated she went home and thought about it and then provided a written statement to management. She verified she should have reported this immediately. Interview with Executive Director #1 on 07/17/18 at 3:00 P.M. verified STNA #135 did not report the observations to the facility immediately and should have done so according to facility policy. She further stated the allegation was not substantiated as Resident #3 was not interviewable and they had no evidence of abuse. There were no other witnesses. She stated the facility started an investigation as soon as they were notified. Review of employee files for RN #60, STNA #135 and STNA #140 revealed no issues concerning pre-screening of employees and all employees had current credentials. RN #60 had received counseling on 06/15/18 for not reporting a scenario that was questioned as abuse. STNA #135 had counseling on 05/15/18 for refusing to go in a resident's room to answer a call light, on 05/21/18 a written warning for unprofessional conduct, and a termination notice on 06/13/18. STNA #140 received a written warning on 05/21/18 for unprofessional conduct and was terminated on 07/06/18 for not performing to facility standards. Review of facility policy Abuse and Neglect Procedural guidelines dated 10/10/17 revealed any person with knowledge or suspicion of suspected violations of abuse, neglect exploitation, were to report it immediately to the shift supervisor who was to immediately notify the Executive Director or designee. Upon identification of suspected abuse or neglect the safety of the resident was to be provided. All alleged violations were to reported to the state survey agency within 24 hours, or within two hours if serious bodily injury had occurred. This is an incidental finding discovered during the course of the investigation of Complaint Numbers OH 986, OH 001 and OH 053.

Based on closed medical record review, staff interview and review of facility policy the facility failed to provide the resident and/or resident representative with a notice of transfer upon transfer to the hospital. This affected two Residents (#1 and #4) of three reviewed for transfers. The facility identified 23 residents who were transferred to the hospital in the last 60 days. The facility census was 47. Findings include: 1. Review of the closed medical record for the Resident #1 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) 3.0 dated 04/24/18 revealed the resident was able to understand and to be understood. The resident had moderate cognitive deficits, no behaviors or rejection of care. The resident required extensive assistance for bed mobility, dressing, toileting, and was totally dependent on staff for transfers, locomotion, hygiene, bathing and supervision for eating and had functional impairments of bilateral upper and lower extremities. The resident was occasionally incontinent of urine, always incontinent of bowel and had frequent pain. The resident did have a fall with a fracture in the last two to six months prior to the admission or reentry and none since the prior assessment. The MDS revealed the resident was at risk for development of pressure ulcers and currently had one stage two pressure ulcer that was present on admission and had pressure reduction devices in place. The resident received opioids and antidepressants. Review of progress notes for dated 01/13/18 revealed the resident was transferred to the hospital. Further review of progress notes revealed the resident was also transferred to the hospital on [DATE]. 2. Review of the closed medical record for Resident #4 revealed the resident was admitted to the facility on [DATE] and was discharged on [DATE]. [DIAGNOSES REDACTED]. Review of a quarterly MDS 3.0 assessment dated [DATE] revealed the resident was usually understood and usually was able to understand but had significant cognitive deficits. The resident required extensive assistance with bed mobility, dressing, eating, toileting and personal hygiene and was totally dependent for transfers, locomotion and bathing. The resident had functional limitations of bilateral upper extremities. The resident was always incontinent of bowel and bladder, was on a scheduled pain regimen and did not have a terminal diagnosis. There were no signs and symptoms of swallowing issues and the resident was on a mechanical diet. The resident did have a stage II pressure ulcer that developed in house on 12/11/17 and the resident did receive pressure ulcer treatment. Review of progress notes for Resident #4 dated 04/20/18 revealed the resident was transferred to the hospital. Interview with Division Vice President #125 on 07/19/18 at 11:00 A.M. verified there was no Notice of Transfer provided for Resident #1 or Resident #4. He stated the facility had not implemented providing the notice of transfers to the resident and/or resident representative and only sent the list to the Ombudsman. Review of the facility policy Social-Service Transfer/discharge date d 11/08/17 revealed the facility must send a copy of the notice of transfer or discharge to a representative of the Office of the state long term care Ombudsman, including voluntary and involuntary discharges or transfers. This is an incidental finding discovered during the course of the investigation of Complaint Numbers OH 986, OH 027 and OH 053.

Based on closed medical record review, staff interview and review of facility policy the facility failed to provide the resident and/or resident representative with written notice of the bed-hold policy upon transfer from the facility. This affected one Resident #4 of three reviewed for transfers. The facility identified 23 residents transferred from the facility in the last 60 days. The facility census was 47. Findings include: Review of the closed medical record for Resident #4 revealed the resident was admitted to the facility on [DATE] and was discharged on [DATE]. [DIAGNOSES REDACTED]. Review of a quarterly MDS 3.0 assessment dated [DATE] revealed the resident was usually understood and usually was able to understand but had significant cognitive deficits. The resident required extensive assistance with bed mobility, dressing, eating, toileting and personal hygiene and was totally dependent for transfers, locomotion and bathing. The resident had functional limitations of bilateral upper extremities. The resident was always incontinent of bowel and bladder, was on a scheduled pain regimen and did not have a terminal diagnosis. There were no signs and symptoms of swallowing issues and the resident was on a mechanical diet. The resident did have a stage II pressure ulcer that developed in house on 12/11/17 and the resident did receive pressure ulcer treatment. Review of progress notes for Resident #4 dated 04/20/18 revealed the resident was transferred to the hospital. Interview with Business Office Manager #40 on 07/19/18 at 3:00 P.M. verified Resident #4 did not receive a bed hold authorization form or bed hold policy upon discharge. She stated the resident passed away at the hospital on [DATE] and she had not sent the notice out prior to that date. Review of facility policy Re-admission: Bed hold policy on page five of the Resident Move-In agreement dated 08/28/17 revealed if the resident was eligible for or receiving Medicaid assistance and the resident left the facility for hospitalization of therapeutic leave, the resident's bed would be reserved for the applicable days paid for a reserved bed under the Medicaid program. If the period of hospitalization or therapeutic leave exceeded the maximum time for reservation under the Medicaid program, the resident would be entitled to the first available accommodation suitable for the resident's level of care if the resident required the facility's services. Prior to the lapse of the bed reservation period covered by the Medicaid program, the resident may reserve his/her bed by providing written notice to the facility and paying the Medicaid per diem rate. This is an incidental finding discovered during the course of the investigation of Complaint Numbers OH 986, OH 027 and OH 053

Based on record review and staff interview, the facility failed to ensure one (#12) of three sampled residents was ensured the right to be free of involuntary seclusion and abuse when she was confined to her room for three days (10/01/10 through 10/04/10) and deprived of her usual snacks of chips, popcorn, and diet soda for nine days. Findings include 1. Review of Resident #12's admission record revealed [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] stated the cognitively impaired resident was able to transfer, ambulate, and eat independently and required extensive assistance with dressing and hygiene. The resident was continent of bowel due to a [MEDICAL CONDITION] and associated appliance usage and was totally incontinent of bladder. The MDS also stated the resident made negative statements, asked repetitive questions, made repetitive verbalizations, displayed anger and self depreciation, and displayed fears that something terrible was about to happen. The MDS stated she had behaviors of verbal abuse, socially inappropriate behaviors, and resisted care. The resident had a behavior care plan that identified behavior problems of changing outfits multiple times throughout the day, telling staff what she would or would not do, manipulative behaviors, setting her own schedule rather than following the facility's routine, playing staff against others, wanting immediate gratification and acting out when she does not get her way. The care plan also identified the SR was usually able to find the "weak link" who wasn't consistent with the physician's and guardian's orders, was disruptive to the normal facility routine, was attention seeking and did not have any difficulty harming others, was troublesome, and mischievous. Care planned interventions included limiting the resident to two outfits per shift to teach the resident clothing management, telling the resident it was time for medications, meals, bathing, etc., not giving the resident options or making deals with her, not rewarding the resident for negative behavior (as this only taught her negative behaviors equaled an award). The resident was not to have any food or fluids without approval through nursing as her food/fluid consumption was being tracked. Staff were not to undermine behavior modification attempts and were to be consistent and unwavering. When Resident #12 demonstrated negative behaviors, staff were to instruct the resident to stop immediately. If the negative behaviors did not stop, staff were to escort the resident back to her room and inform her when she felt able to conduct herself appropriately, she could return to her usual routine. If the negative behaviors resumed, Resident #12 should be escorted back to her room and informed she will be alone for ten minutes. This should be repeated until her behavior ceased. The care plan stated this approach would teach the resident consistency. The resident also had a care plan in place for incontinence that identified the Resident #12 had a [MEDICAL CONDITION] and would remove the [MEDICAL CONDITION] bag and soil her room, hallway, and other units of the facility when acting out. Interventions included reminding the resident not to remove her [MEDICAL CONDITION] bag without staff assistance, assist the resident with incontinence care, and encourage the resident to toilet every two hours and as needed. On 09/28/10 the social service designee (SSD), who is also a licensed practical nurse (LPN) #1 sent a memorandum/directive (memo) to all staff regarding behavioral interventions for staff to follow regarding Resident #12. The memo stated the resident had removed her [MEDICAL CONDITION] bag and wafer. As a result, Resident #12's special snacks such as candy bars, chips and soda should be restricted until the following Monday (10/04/10). The restriction included anything that did not come off the snack cart. The SSD/LPN #1 reminded staff that everyone needed to be consistent and follow the guidelines so the resident learned her boundaries and knew what was expected of her. This would decrease her behavior of always seeking out the "weak link" to get what she wanted. On 09/30/10 time unknown, another memo/directive was released by SSD/LPN #1 that stated the resident's snack restriction was to continue through 10/06/10 and could be resumed on 10/07/10. The memo stated Resident #12 was allowed an item off the snack cart that would go along with her diabetic diet and was allowed one cup of coffee after breakfast. The resident was not to "hang out" in the dining room between meals as this was too tempting with the snack tray and other food and drink items in the dining room fridge. On 09/30/10 at 8:00 P.M., a third memo/directive was given to the staff by the SSD/LPN #1. This memo stated Resident #12's special snacks were suspended until further notice and this included popcorn on Friday (10/01/10) and early morning coffee after breakfast. The memo stated the resident had removed her [MEDICAL CONDITION] bag and wafter and had bowel movement everywhere in her room, on herself, in the bathroom, and on the floor. The SSD/LPN #1 documented the Resident #12 acknowledged this behavior, knew it spread germs everywhere and that she did not care. The memo stated they would "regroup" on 10/04/10 and SSD/LPN #1 should be contacted with any concerns or questions. At the bottom of the memo written in red letters, a directive was written the resident should be confined to her room until 10/04/10 per the orders of the owner of the facility. The SSD/LPN #1's notes dated 09/30/10 at 8:00 P.M. stated the resident took her [MEDICAL CONDITION] bag/wafer off and smeared bowel movement throughout her room, bathroom, and on herself. The resident inquired if she could have popcorn the next day. SSD/LPN #1 documented she counseled the resident on appropriate behaviors and told the resident when she could conduct herself appropriately she would be permitted to have her snacks back in limited quantities. The note stated the resident wished to leave the facility and stated she was not happy. The resident was informed the SSD/LPN #1 would discuss those options on 10/04/10 as the facility obviously was not able to provide adequate care and the resident may be more content in a structured environment. Review of the nursing notes from 09/28/10 through 10/08/10 did not reveal any documentation of the resident removing her [MEDICAL CONDITION] bag and wafer or having a behavior of smearing stool throughout her environment or on herself. On 09/30/10 at 11:00 A.M., nursing notes documented the resident refused to take her morning medications and was very hateful and angry, cursing up and down the hallways. At 12:00 P.M. the notes documented the resident was counseled by SSD/LPN #1 and the resident's family member who was employed by the facility. On 10/08/10 between 8:30 A.M. and 9:00 A.M., the following interviews with staff were conducted: A. Activity staff (AS) #2 stated the resident was not allowed snacks until yesterday (10/07/10) due to removing her [MEDICAL CONDITION]. She stated the SSD/LPN #1 gave directives the SR was to be kept in her room all weekend. B. State tested nurse aide (STNA) #4 stated the SR was made to stay in her room all weekend and the nurse aides were not allowed to give her any snacks until yesterday (10/07/10). C. STNA #5 stated the SR stayed in her room all weekend and stated when the SR asked for snacks she was not allowed to have them until yesterday at 3:00 P.M. (10/07/10). STNA #5 stated she did not know what the SR did to receive this punishment. D. STNA #6 stated the SR was confined to her room all weekend and staff could not give her any coffee in the morning or snacks until yesterday (10/07/10). E. Cooks #7 and #8 stated they were told they could not give the SR her early morning coffee or any of her Crystal Light drinks, juices, or anything. F. Housekeeper #9 stated under the SSD/LPN #1's orders the resident was to stay in her room until Monday (10/04/10). We also were not allowed to give her any snacks or coffee. G. LPN #14 stated the SR was kept in her room all weekend and was not to receive any snacks. LPN #14 stated SSD/LPN #1 initiated the directives but she was not a "fan of it". On 10/08/10 at 9:15 A.M. the Administrator was interviewed. He stated the SR had behaviors but it was completely appropriate addressing them by confining the SR to her room and taking away her snacks. The Administrator stated the SR never stays in her room that long and always gets her snacks. No staff follows the plan consistently. On 10/08/10 at 10:45 A.M. SSD/LPN #1 was interviewed over the telephone and verified she gave orders to confine the SR to her room over the weekend. She also stated the SR was not allowed any special snacks until 10/07/10. She stated the SR had behaviors of removing her [MEDICAL CONDITION] bag which was an infection control risk. She stated this had been discussed with the Medical Director in the Quality Assurance meetings and with the SR's family. On 10/08/10 at 12:15 P.M., the Director of Nursing (DON) also confirmed the SSD/LPN #1 was confined to her room over the weekend and was refused special snacks until 10/07/10. On 10/08/10 at 1:00 P.M. the SR was interviewed in her room. The SR had a private room with an attached private bathroom. She was neatly dressed and seated in a chair. The SR stated she was told by SSD/LPN #1 that she was bad and she had to go back to her room and stay there. When asked how this made the resident feel, she stated "sad" and then began to cry. She stated she could not have any potato chips, no popcorn,and no pop. She stated SSD/LPN #1 didn't like her. On 10/08/10 between 3:00 P.M. and 3:15 P.M. the following staff interviews were conducted: STNA #10 stated she tried to get the resident some peanut butter crackers and diet pop over the weekend and was told the resident was not allowed the snacks. She stated staff told her she was being punished for removing her [MEDICAL CONDITION] bag. She also had to eat her meals in her room this past weekend. STNA #11 stated the resident was kept in her room all weekend and was not allowed any of her usual snacks of coffee, pop, and chips. STNA #12 stated the resident was not allowed to eat her meals in the dining room over the weekend. The STNA stated the resident cried when told she had to eat in her room. LPN #13 stated she was aware of the SSD/LPN #1's directive. She stated she worked over the weekend and confirmed the resident ate her supper meal in her room.