Every finding on record at Walnut Creek Nursing Center

Based on record review, observation, staff interview and policy review, the facility failed to ensure medications were given as ordered. This affected one (#19) of four residents observed for medication administration. The facility census was 110. Findings include: Review of medical record for Resident #19 revealed admission date of 1/9/26. The resident was admitted with diagnoses including Parkinson's disease, right femur fracture and hypertension. The resident remained in the facility. The admission Minimum Data Set (MDS) dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of seven indicating impaired cognition. He was independent with eating, required supervision for bed mobility, moderate assistance for transfers and maximum assistance toileting hygiene. Review of the physician orders revealed an order for two Senna Plus (laxative/stool softner) tablets with a start date of 01/10/26. Observation on 01/24/26 at 9:34 A.M. of medication administration for Resident #18 by Licensed Practical Nurse (LPN) #111 revealed she administered an 81 milligram (mg) chewable aspirin, Miralax (laxative) 17 grams, Ropinirole (Parkinson's) one mg, cabidopa/levodopa (Parkinson's) 25 mg/100 mg, Vitamin D (supplement) 25 micrograms (mcg), Amlodipine (high blood pressure) and two Senna (laxative) 8.6 milligram tablets. Interview on 01/10/26 on10:18 A.M. with LPN #111 verified she had given Senna tablets instead of the prescribed Senna Plus tablets. Review of the facility policy titled , Administering Medications dated 04/28/25 documented medications must be administered in accordance with orders. This deficiency represents non-compliance investigated under Complaint Number 2735702.

Based on record review, staff interviews and policy review, the facility failed to provide skin assessments, wound treatments and wound measurements were completed in a timely manner. This affected two (#13 and #15) of three residents reviewed for pressure ulcer. The facility census was 110. Findings include: 1.Review of medical record for Resident #13 revealed an admission date of 11/11/25. The resident was admitted with diagnoses including Alzheimer's disease, Diabetes Mellitus, anxiety, atherosclerotic heart disease and hypertension. The resident remained in the facility. The admission Minimum Data Set (MDS) dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of five indicating impaired cognition. He required set up for eating, maximum assistance with bed mobility, transfers and was dependent upon staff for toileting hygiene. No pressure ulcers were documented. A care plan initiated 11/18/25 documented a risk for skin alteration related to impaired mobility with interventions which included to inform family, resident and physician of ant new skin breakdown, pressure reducing mattress and weekly skin checks. A behavioral care plan initiated 11/18/25 documented he would put himself on the floor for comfort measures interventions were to offer diversional activities and offer support and reassurance as needed. A Braden Scale (for predicting pressure ulcer risk) completed on 11/11/26 revealed he a score of 16 indicating he was at risk. Record review revealed no skin assessments were documented after the admission assessment until 01/07/26. The 01/07/26 skin assessment documented a right heel pressure area. No measurements were documented. The comment section documented Resident #13 was added to the wound round list for further assessment and treatments. Record review of the 01/07/26 wound documentation revealed a right heel Unstageable Deep Tissue injury (DTI) with intact skin. Measurements were documented as 2.0 centimeters (CM) by (x) 2.0 cm x not measurable. Treatment was to apply betadine daily and as needed. Review of the physician orders revealed an order to cleanse the right heel, pat dry and paint with betadine every night shift and as needed with a start date of 01/14/26. An order for moon boots bilaterally while in bed as tolerated with a start date of 01/14/26. Review of the 01/14/26 wound documentation revealed the wound measurements were 2.0 cm x 2.0 cm x not measurable. The wound progress was documented as improved as evidenced by decreased pain. Record review of the January Treatment Record (TAR) revealed the moon boots bilaterally while in bed as tolerated was documented as completed as expected from 01/14/26. The right heel wound treatment was documented as completed as expected with a start date of 01/15/26. Interview on 01/25/26 at 1:15 P.M. with the Director of Nursing (DON) verified skin assessments had not been completed weekly as care planned for Resident #13 and the treatment orders for the right heel DTI ordered on 01/07/26 had not been placed and initiated until 01/15/26. 2. Review of medical record for Resident #15 revealed an admission date of 12/12/25. The resident was admitted with diagnoses including Diabetes Mellitus Type Two, gout, Congestive Heart Failure (CHF) and depression. The resident remained in the facility. The 5-day Minimum Data Set (MDS) dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 14 indicating intact cognition. He required moderate assistance with meals, and was dependent upon staff for toileting hygiene, bed mobility and transfers were not attempted. One stage two and one DTI which were documented as present on admission. The readmission skin assessment dated [DATE] revealed a left heel blister no measurements were documented. Review of the physician orders revealed an order to cleanse the left heel with wound cleanser, apply foam border dressing one time a day with a start date of 01/12/26. Review of the January TAR revealed the right heel wound treatment was documented as completed as expected starting on 01/12/26. Review of the 01/14/26 rounding wound documentation revealed the visit had to be rescheduled. Record review of the 01/20/26 progress note revealed the large blister on the left heel began to pop and seep fluids. Resident #15 complained of pain and requested to be sent out for further evaluation. Interview on 01/25/26 at 1:15 P.M. with the DON verified no measurements were taken of the large left heel blister upon Resident #15's readmission to the facility on [DATE] through 01/20/26 when he was sent to the hospital for further evaluation. Review of the facility policy titled, Pressure Injury Risk Assessment dated 08/24 revealed skin would be observed routinely throughout the residents stay and preventative care plans would be implemented. This deficiency represents non-compliance investigated under Complaint Number 2726113.

Based on record review, staff interviews, and policy review, the facility failed to accurately monitor and track infections in the facility. This had the potential to affect all 107 residents in the facility. The facility census was 107.Findings include:Review of the Infection Control tracking Logs for June 2025, July 2025, and August 2025 revealed infections were monitored and there was no Coronavirus (COVID-19) or Tuberculosis (TB) in the facility. There were no Infection Control Logs for September 2025, October 2025, November 2025, December 2025 and January 2026.Review of the COVID-19 positive residents dated 11/26/25, revealed there were four residents who tested positive for COVID-19 in November 2025. Interview on 01/08/26 at 9:26 A.M., the Assistant Director of Nursing (ADON) / Infection Preventionist #311 confirmed there were no Infection Control tracking logs or Infection Location surveillance/maps for September 2025, October 2025, November 2025, December 2025, and January 2026. Interview also confirmed that the facility had COVID-19 in late November 2025 and December 2025 and there were no infection control logs available for November or December of 2025 to show the positive cases, and there was no surveillance and contact tracing (facility map) for the COVID-19 positive residents. Interview also confirmed there was no staff education on COVID-19 done at the time of the COVID-19 positive cases. Interview also confirmed there are currently six residents in isolation for wound infections and there is no infection control tracking log for the types of infection.Interview on 01/08/26 at 9:44 A.M. the Director of Nursing (DON) stated when the first case of COVID-19 was detected on 11/23/25, and all staff were notified via what's app and Paycom staff communication system. The DON stated that all the residents were notified in person and all families were notified by phone. Interview also confirmed there is no documentation available for the notifications to staff, residents or families. The DON stated the facility did not have a specific COVID-19 policy, and they followed their COVID-19 Quality Assurance Performance Improvement (QAPI) Plan which indicated the date someone was positive was considered day zero, and that all residents and staff will be tested on days one, three, and five. The DON stated the first positive COVID-19 case was on 11/23/25. The DON stated no additional staff or residents were tested on day one per their QAPI plan. All residents were documented as being tested on days two, four and nine. The DON stated the COVID-19 QAPI Plan indicated if there were additional positive residents between days one and five, then testing would be expanded to twice weekly until no new positives for 14 days. The DON verified the facility's COVID-19 QAPI Plan was not followed and verified there was no documented evidence of the staff being tested for COVID-19. The DON stated the only documentation the facility had of the COVID-19 positive residents was a log that was emailed to the local health department. Review of the COVID-19 QAPI Plan, undated revealed the facility would notify all staff, residents, and families. All staff would have COVID-19 education at the time of a positive case. All residents and staff would be tested on days one, three, and five, and the initial positive test date is day zero. If there were additional positive residents between days one and five of testing, then the testing expanded to twice weekly until no new positives for 14 days.This deficiency represents non-compliance investigated under Complaint Number 2677474.

Based on observation, staff interviews, and policy review, the facility failed to ensure the refrigerators were clean and free from expired foods. This had the potential to affect 106 residents with exception of Resident #42 who the facility identified as being nothing by mouth (NPO). The facility census was 107.Findings include: Observation on 01/08/26 at 2:37 P.M. with the Director of Nursing (DON) revealed the resident refrigerator on the 100-Hall, Skilled Hall and 200-Hall was dirty, with a moist hand towel lying inside the refrigerator on the top shelf, with brown stains scattered throughout the towel. There were four personal containers of various food items, unlabeled and undated. There were multiple bottles of opened, iced coffee in the refrigerator without names or dates noted on the bottles, there was no expiration date present on the bottles. The attached freezer was noted with a frozen red substance on the floor of the freezer. The thermometer was laying upside down, on the floor of the freezer, and was stuck and unable to move. There were two cups of Dairy Queen ice cream in the freezer, with straws sticking out of the top of the lids, undated and unlabeled. There were two personal containers of food in the freezer, undated and unlabeled. There was no temperature or cleaning log present on or around the refrigerator /freezer. Interview on 01/08/26 at 2:37 P.M. at the time of observation with the DON confirmed the findings in the 100-hall, Skilled Hall and 200-hall. Interview also confirmed that the refrigerator / freezer should be cleaned and temperature checked daily. Interview confirmed the cleaning and temperature logs were missing. The DON stated there was no policy on cleaning the residents' refrigerators.This deficiency represents non-compliance investigated under Complaint Number 2677474.

Based on record review, staff interviews, and policy review the facility failed to ensure comprehensive care plans were developed and accurate. This affected two (Residents #14 and #63) out of three residents reviewed for care plans. The facility census was 107.Findings include:Review of the medical record for Resident #14 revealed an admission date of 12/12/25, Diagnoses included abscess of lung without pneumonia, acute respiratory failure with hypoxia, and unspecified severe protein-calorie malnutrition.Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #14 was cognitively intact. Resident #14 was independent with eating and lost more than five percent (%) weight in the last month and 10 % in the last six months and was not on prescribed weight loss regimen. There were no nutritional approaches.Review of the physician orders for Resident #14 dated 12/12/25 revealed the resident was ordered to receive a regular diet, regular texture, thin consistency diet.Review of Resident #14's weights since admission revealed resident weighed 109.4 pounds (lbs.) on 12/12/25, 109.4 lbs. on 12/16/25, and 96.0 lbs. on 12/30/25.Review of the weight change progress note for Resident #14 dated 01/13/26, revealed the resident's weight continued with a downward trend. Interview on 01/13/26 at 11:31 A.M., Registered Nurse (RN) #291 confirmed Resident #14 was assessed for being at risk for nutrition and did not have a care plan in place. RN #291 stated the resident should have a care plan in place that addresses the nutritional risk.Review of the active care plans for Resident #14 revealed there was no documented care plan for the resident being at nutritional risk.Review of the medical record for Resident #63 revealed an admission date of 02/02/24. Diagnoses included traumatic brain injury (TBI), sequela, dysphagia, and unspecified severe protein-calorie malnutrition.Review of the Quarterly MDS dated [DATE] revealed Resident #63 had moderate cognitive impairment, required set-up assistance with eating. Resident did not have a swallowing disorder or weight loss and was on a mechanically altered diet.Interview on 01/14/26 at 8:26 A.M., RN #421 confirmed Resident #63 was assessed as a nutritional risk. RN #421 stated the resident's dietary are plan was discontinued on 07/29/25 when the facility had a system change over and the resident did not have a new dietary care plan implemented but should have had one.Interview on 01/14/26 at 3:06 P.M., Regional Director of Clinical Operations (RDCO) #500 stated the facility did not have a policy on care plans.Review of the active care plans for Resident #63 revealed there was no documented care plan for the resident being at nutritional risk.This deficiency represents non-compliance investigated under Complaint Number 2708144.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure neurological (neuro) assessments were completed for residents following unwitnessed falls. This affected one (Resident #110) out of four residents reviewed for assessments. The facility also failed to ensure a resident was properly assessed for a change in condition prior to a hospital transfer. This affected one (Resident #07) out of the four residents reviewed for change in condition. The facility census was 107.Findings include:Review of the medical record for Resident #110 revealed an admission date of 09/11/24. Diagnoses included Diabetes Mellitus Type II, Vascular Dementia, and Hypertension. Resident #110 was discharged from the facility on 11/08/25.Review of the medical record dated 08/01/25, revealed Resident #110 experienced an unwitnessed fall. Review of the Post-Fall Evaluation for Resident #110 dated 08/01/25 revealed the resident sustained a hematoma (collection or pool of blood that gathers outside of blood vessels, usually forming a lump or swelling due to a broken vessel) on her forehead. Review of nursing documentation and the post-fall monitoring records for Resident #110 revealed no documented evidence of neuro assessments being completed after the unwitnessed fall on 08/01/25.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 had a Brief Interview for Mental Status (BIMS) score of five indicating cognitive impairment.Interview on 01/13/26 at 4:30 P.M., the Director of Nursing (DON) stated neuro assessments were expected to be done following any unwitnessed fall. The DON verified there were no documented neuro assessments completed after Resident #110 had an unwitnessed fall on 08/01/25.Review of the facility policy titled Falls and Fall Risk Managing, dated 08/2021 and reviewed 08/2024, revealed that following an unwitnessed fall or a resident hit their head, nursing staff are to ensure neurological (neuro) checks are initiated. Review of the medical record for Resident #07 revealed and admission date of 12/24/25. Diagnoses included Diverticulitis, Hydronephrosis, and Hypertension. Resident #07 was discharged from the facility on 01/06/26. Review of the care plan dated 12/30/25 revealed Resident #07 was identified as having renal insufficiency related to hydronephrosis (swelling of one or both kidneys caused by a backup of urine, occurring when urine cannot properly drain from the kidney to the bladder due to a blockage, obstruction, or functional issue) and an indwelling catheter, putting her at risk for complications such as but not limited to infection, sepsis, and skin decline. Interventions included to monitor changes in mental status, monitor vital signs as ordered and as needed, and monitor, record, report to medical provider signs and symptoms of urinary tract infection (UTI) including altered mental status and change in behavior.Review of the admission MDS dated [DATE] revealed Resident #07 had a BIMS score of five indicating cognitive impairment. Review of the medical record revealed the last documented nursing assessment for Resident #07 occurred on 01/05/26 at 11:32 P.M. and indicated the resident was alert and oriented, with no acute complaints noted.Review of the medical record for Resident #07 on 01/14/26 at 11:30 A.M. revealed a transfer form was completed on 01/06/26 when Resident #07 experienced a change in condition and was transferred to the hospital transfer. There was no documented evidence of a nursing assessment, recognition or evaluation of a change in condition being completed. Interview on 01/14/26 at 11:43 A.M. the Director of Nursing (DON) confirmed a transfer form for Resident #07 was available for review, which did not contain any clinical data for the resident pertaining to the change in condition. The DON verified no other documentation regarding an assessment on 01/06/26 was available for review. During the interview, the DON confirmed nurses are expected to complete and document an assessment when a resident experiences a significant change in condition.Review of the facility policy titled Transfer and Discharge (Including Against Medical Advice [AMA]), dated 04/28/25, revealed that during emergency transfers to acute care staff will document assessment findings and other relevant information regarding the transfer in the medical record.This deficiency represents non-compliance investigated under Complaint Numbers 2647463 and 2710220.

Based on record review, staff interviews, review of video footage, review of personnel files, review of Self- Reported Incidents (SRI), and policy review, the facility failed to ensure timely required checks were completed on residents throughout the shift, failed to ensure residents were assessed following an unwitnessed fall and prior to moving the resident off of the floor and placing her back in the bed, failed to ensure the staff appropriately transferred residents following an unwitnessed fall and failed to ensure a post-fall assessment was completed following an unwitnessed fall. This affected one (Resident #01) out of three reviewed for falls. The facility census was 107.Findings include:Review of the medical record for Resident #01 revealed an admission date of 02/26/25 with diagnoses of cerebral atherosclerosis, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, encephalopathy, unspecified, dysphagia, oropharyngeal phase, and essential hypertension.Review of the Care Plan dated 07/17/25 revealed Resident #01 was at risk for falls related to weakness, incontinence, use of psychotropic medication, and dementia. Interventions included assistance from staff with transfers, having the call light within reach, right side of bed against wall and frequent checks by the staff.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #01 had severe cognitive impairment. Resident #01 required substantial assistance bed mobility and transfers.Review of the Fall Risk Evaluation for Resident #01 date 11/14/25 at 8:57 A.M. revealed the resident was at risk for falls.Review of the video footage provided to the facility revealed on 12/23/25 at 11:40:07 P.M. Resident #01 fell out of the left side of the bed, onto her knees, on fall mat and between her bed and the dresser. At 11:40:53, Resident #01 turned herself around and sat on her buttocks with her right leg crossed under her left leg and moaned several times. On 12/24/25 at 5:08:05 A.M. Resident #01 was observed laying directly on the floor, with a pillow under her left side of her body and a couple blankets behind her back, and the resident was laying on her left side. At 5:08:40, Registered Nurse (RN) #386 entered the room, did not say anything to the resident, positioned himself behind her, placed his hands under her arm pits, picked her up and placed her on the bed as the resident moaned. RN #386 got her situated in the bed then RN #386 giggled. RN #386 asked the resident what happened and the resident stated she fell and she had been down there for a while. RN #386 told Resident #01 if she wanted to walk, to walk with a walker, while he picked up the blankets and pillow and placed them onto the bed. RN #386 asked Resident #01 if she had any injuries and RN #386 didn't give the resident a chance to answer before he said no. RN #386 told the resident to use her walker and the resident said she couldn't walk right now. RN #386 picked up the pillows and blankets from the floor, placed the walker in front of her, and administered Resident #01's medication using a spoon RN #386 was talking to the resident, but the words were unintelligible and the resident just stared at RN #386. Review of the Health Status Notes for Resident #01 from 12/23/25 to 12/24/25, revealed no documentation regarding the fall which occurred on 12/23/25 at 11:40 P.M. There was documented evidence of the resident having a post-fall assessment and no documented evidence the physician was notified. Review of the SRI created on 12/24/25 at 5:32 P.M. for an allegation of neglect/mistreatment, revealed Resident #01's family reported the resident had a fall and the nurse did not report the incident. On 12/24/25 at 7:15 P.M., the Administrator was contacted by the facility staff who stated Resident #01's family contacted the facility after they monitored the camera footage from inside the resident's room and reported the resident fell on [DATE]. On 12/24/25 at 5:00 A.M., RN #386 went into the resident's room to administer the morning medication and observed the resident was on the side of the bed lying on the floor. RN #386 set the medication cup and water down and assisted the resident up from the floor. RM #386 administered the medications and left the room. Review of clinical chart on 12/24/25 at 7:40 P.M. revealed no nurse's note or risk was done for the resident's fall. RN #386 was contacted and concluded that since the resident was care planned for a fall mat, he didn't consider this incident a fall. RN #386 and CNA #385 were suspended until a full investigation was performed. The Administrator watched the video on 12/26/25 which confirmed the incident. RN #386 transferred the resident from the floor to the bed. RN #386 asked if the resident was ok and she thanked him for getting her up.Review of the Health Status Note for Resident #01 dated 12/24/25 at 6:05 P.M. by LPN #327, revealed this nurse was informed by the family that the resident had a fall on the night shift. Video footage was provided to LPN #327 to clarify that there was a fall. Nurse Practitioner (NP) was notified of the fall, and new orders were received to obtain a two view Xray of the left shoulder. Review of the Health Status Note for Resident #01 dated 12/25/25 at 4:26 P.M. revealed the left shoulder x-ray was negative for a fracture or dislocation.Review of the Post Fall Investigation for Resident #01 revealed the facility watched the video provided by the family on 12/26/25 and the staff did not go into the resident's room to check on the resident throughout the night shift. On 12/23/25 at 11:40 P.M. the resident fell out of bed and wasn't discovered on the floor until 12/24/25 at 5:08 A.M., when RN #386 went into the room to administer medications and found Resident #01 on the floor. RN #386 asked the resident if she was okay, then picked the resident up and put back in the bed. The investigation revealed RN #386 did not complete any post-fall assessments, did not document the fall and did not report the fall to anyone. The facility suspended RN #386 and CNA #385 and subsequently terminated both due to incident. Interview on 01/07/25 at 9:06 A.M. Director of Nursing (DON) stated RN #386 and CNA #385 were on duty on 12/23/25 through 12/24/25 and were responsible for the care of Resident #01. The DON stated the two were suspended on 12/24/25 after being notified by Resident #01's family and the lack of checks by the staff. The DON stated that after the investigation was completed both RN #386 and CNA #385 were fired. The DON stated when the facility staff watched the video, no staff entered the resident's room on 12/23/25 through 12/24/25 throughout the shift to check on the resident. The DON stated expectations of staff were to check on residents frequently throughout a shift. The DON verified RN #386 did not complete an assessment on the resident prior to picking her up and putting her in the bed and did not complete a post-fall assessment. The DON verified there was no documentation of the resident's fall and RN #386 did not report the fall to anyone including the physician.Review of the Employee Personnel File for Former CNA #385 revealed a hire date of 09/03/25. Abuse/Neglect training was completed on 09/29/25. CNA #385 was terminated on 01/05/25 due to admitting she failed to frequently check on Resident #01 during the night shift on 12/23/25 through 12/24/25 due to not feeling well. Review of the Employee Personnel File for Former RN #386 revealed a hire date of 10/21/25. Abuse/Neglect training was completed on 11/15/25. RN #386 was terminated on 01/05/25 due to not following policy and procedures with resident falls. RN #386 picked up Resident #01 from the floor and placed the resident back in bed without completing any assessments and failed to document the fall. RN #386 admitted he failed to do a fall assessment on Resident #01.Review of the Falls and Fall Risk, Managing policy dated 08/2021 revealed unwitnessed falls or if resident hit their head will have neurological checks initiated, ensure fall follow up documentation, fall risk evaluation, skin and pain assessments are completed after a fall.This deficiency represents non-compliance investigated under Complaint Number 2703602, 2648250, 2647463, and 2601225.

Based on observations, resident and staff interviews, the facility failed to ensure the common dining environment was conducive for residents eating in the dining room. This affected two (Residents #24, and #63) out of the six reviewed for dining. This had the potential to affect all 16 residents who ate in the main dining room. The facility census was 107.Findings include:Review of the medical record for Resident #24 revealed an admission date of 09/29/25. Diagnoses included major depressive disorder, permanent atrial fibrillation, adjustment disorder with anxiety, and essential hypertension.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was cognitively intact, required set-up assistance for meals and was on a mechanically altered diet.Review of the medical record for Resident #63 revealed an admission date of 02/02/24 with diagnoses of diffuse traumatic brain injury with loss of consciousness status unknown, sequela, dysphagia, oral phase, dysphagia, pharyngeal phase, dysphagia, pharyngoesophageal phase, personal history of traumatic brain injury and unspecified severe protein-calorie malnutrition.Review of the Quarterly MDS dated [DATE] revealed Resident #63 had moderate cognitive impairment, required set-up assistance with eating and was on a mechanically altered diet.Review of the medical record for Resident #84 revealed an admission date of 07/23/22 with diagnoses of type 2 diabetes mellitus with diabetic chronic kidney disease, major depressive disorder, anxiety, and Alzheimer's disease with early onset.Review of the Quarterly MDS for Resident #84 dated 11/17/25 revealed the resident had severe cognitive impairment. Resident #84 had physical behavioral symptoms directed towards others, and verbal behavioral symptoms directed towards others.Observation of dining on 01/05/26 at 12:40 P.M. revealed Resident #84 yelled out non-stop while she was eating lunch. Resident #84 did not appear to be in any distress. Residents (#63 and #24) were seated in the dining room and near Resident #84.Observation of dining on 01/06/26 at 12:05 P.M. revealed Resident #84 yelling non-stop while she was eating lunch. Resident #84 did not appear to be in any distress. Residents (#63 and #24) were seated near Resident #84. Interview on 01/06/26 at 12:07 P.M., Resident #63 stated he was tired of coming to the dining room every day and having to listen to Resident #84 yell out. The resident stated he did not feel like it was fair that all the residents in the dining room had to deal with this behavior every day while they tried to eat. The resident stated he had expressed his concerns to staff and management multiple times.Interview on 01/06/26 at 12:10 P.M., Certified Nursing Assistant (CNA) #268 verified Resident #84 yells out constantly at every meal while seated in the dining room with other residents. CNA #268 stated there were multiple residents seated in the dining room who complained about every meal, but the management team wouldn't remove Resident #84 due to not having enough staff to feed Resident #84 in her room. Interview on 01/06/26 at 12:14 P.M., Resident #24 stated Resident #84 yells at every meal in the dining room. Resident #24 stated she has expressed her concerns to the staff in the dining room, but nothing has ever changed.Interview on 01/06/26 at 12:19 P.M., Licensed Practical Nurse (LPN) #283 confirmed Resident #84 yells continuously while in the dining room and while other residents are dining. LPN #283 stated Resident #84's yelling has become louder and more frequent recently LPN #283 stated Resident #84 was brought to the dining room because there were not enough staff available on the hall to feed the resident in her room. LPN #283 stated there was only one CNA on the hall to assist all other residents during meals.

Based on observation, record review, staff interviews, and policy review, the facility failed to ensure medications were administered per physician orders and that medication errors were below five percent (%). This affected three (Residents #11, #47, and #112) out of four residents reviewed for medication administration. The facility census was 107.Findings include: Review of the medical record for Resident #11 revealed an admission date of 07/31/25 with diagnoses of cerebral palsy, gastro-esophageal reflux disease without esophagitis, and major depressive disorder. The resident was dependent on staff for medication administration. Review of the physician orders for Resident #11 dated 07/31/25 revealed the resident was ordered to receive 30 milliliters (mL) of Mylanta (heartburn and indigestion) maximum strength oral suspension (400 milligrams (mg) aluminum hydroxide, 400 mg magnesium and 40 mg simethicone) per five mL. twice daily.Review of the medical record for Resident #47 revealed an admission date of 11/11/25 with diagnoses of anemia, cyst of pancreas, gastritis, unspecified without bleeding, vitamin d deficiency, cerebral infarction without residual deficits, essential hypertension, metabolic encephalopathy, other specified diseases of pancreas, and vascular dementia. Review of the physician orders for Resident #47 dated 01/11/25 revealed the resident was ordered to receive 30 mL of lactulose (chronic constipation and to manage high ammonia levels) oral solution 20 grams (gm) per 30 mL. Review of the medical record for Resident #112 revealed an admission date of 01/05/26 with diagnoses of hematuria, chronic diastolic (congestive) heart failure, obstructive sleep apnea, chronic obstructive pulmonary disease, cardiac murmur, anxiety disorder, essential hypertension, single subsegmental thrombotic pulmonary embolism without acute cor pulmonale. Review of the physician orders for Resident #112 dated 01/05/26 revealed the resident was ordered to receive cyanocobalamin (synthetic supplement vitamin B-12) one mg daily. A physician order dated 01/08/26 revealed the resident was ordered to receive apixaban (anticoagulant) five mg twice daily for clotting.Observation of medication administration on 01/12/26 at 8:19 A.M. with Licensed Practical Nurse (LPN) #327 revealed Resident #112 was administered one tablet of vitamin D2 1.25 mg (50,000 international units [IU]). Continued observation of medication administration on 01/12/26 at 8:41 A.M. with LPN #327 revealed Resident #11 was administered 30 ml of Milk of Magnesia (saline laxative) 1200 mg per 15 ml. Continued observation of medication administration on 01/12/26 at 8:50 A.M. with LPN #327 revealed Resident #47 was administered potassium 20 milliequivalent (meq). Interview on 01/12/26 at 9:42 A.M., LPN #327 confirmed Resident #11 was administered 30 ml of Milk of Magnesia LPN #327 stated she did not administer 30 ml of Mylanta maximum strength oral suspension 400-400-40 mg per five 5 mL because she thought Milk of Magnesia was the same as Mylanta. LPN #327 confirmed Resident #47 was not administered his 30 ml of lactulose oral Solution 20 gm per 30 mL. Interview also confirmed Resident #112 was administered vitamin D2 1.25 mg (50,000 IU) without an order. LPN #327 confirmed Resident #112 was not administered cyanocobalamin one mg 1 and Apixaban five mg. Review of the Administering Medications policy dated 08/2021, revealed medications shall be administered in a safe and timely manner, and as prescribed.This deficiency represents non-compliance investigated under Complaint Number 2575203.

Based on observation, staff interviews, and review of the facility policy, the facility failed to ensure residents were served food to meet their needs. This affected one (Resident #104) out of three residents reviewed for proper diets. The facility census was 107.Findings include:Review of the medical record for Resident #104 revealed an admission date of 05/17/22 with diagnoses of vascular dementia, moderate, with other behavioral disturbance, chronic obstructive pulmonary disease, unspecified, essential (primary) hypertension, and adult failure to thrive. Review of the physician order dated 01/13/25 revealed Resident #104 was ordered to receive a regular diet, mechanical soft texture, regular consistency with regular texture food / snacks as desired with supervision. Review of the Care Plan dated 06/09/25 revealed Resident #104 was at risk for malnutrition/alteration in nutritional status related to dementia with behaviors, history of failure to thrive, depression/anxiety, diabetes, chronic obstructive pulmonary disease (COPD), and cerebrovascular accident. The resident received mechanically altered diet and snacks with supervision. Review of the Annual Minimum Data Set (MDS) assessment for Resident #104 dated 12/04/25 revealed the resident had severe cognitive impairment. Observation of meal service on 01/06/26 at 12:24 P.M. revealed Resident #104 received mechanically altered meatballs, unaltered green beans, and whole grapes. The resident was eating the grapes whole and there was no staff present in the room while the resident was eating. Interview on 01/06/26 at 12:25 P.M., Licensed Practical Nurse (LPN) #283 verified Resident #104 was ordered to receive a mechanically altered meal. LPN #283 confirmed Resident #104 was served whole grapes on her meal tray. LPN #283 verified the resident was alone in her room eating whole grapes and whole grapes were not considered a mechanically altered diet. Interview on 01/06/25 at 12:40 P.M., [NAME] #309 confirmed Resident #104 was ordered to receive a mechanically altered diet and whole grapes should not have been served to any resident on a mechanically altered diet due to whole grapes being a choke risk. Review of the Policy and Procedure of Texture and Consistency-Modified Diets dated 2021 revealed a physician order is needed for a modified diet and the food and nutrition services department will be responsible for preparing and serving the correct consistency of food as ordered. This deficiency represents non-compliance investigated under Complaint Number 2708144 and 2644953

Based on record review, staff interviews, and policy review, the facility failed to ensure a thorough investigation was completed when a resident eloped from the facility. This affected one (Resident #89) out of one resident reviewed for elopement. The facility census was 107.Findings include:Review of the medical record for Resident #89 revealed an admission date of 09/12/25. Diagnoses included cardiac arrhythmia, cerebral infarction (stroke), essential hypertension, schizoaffective disorder, bipolar type, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.Review of the Elopement Evaluation for Resident #89 completed on 09/12/25 revealed the resident was at risk of elopement.Review of the care plan for Resident #89 dated 09/22/25 revealed the resident had impaired cognition as evidenced by deficits in memory, judgement, decision making related to Dementia and was at risk for elopement and resided on a secured Memory Care Unit (MCU). Interventions included to monitor, document and report to the medical provider any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, elopement assessments, provide visual aids to locate room, toilet, and redirection as needed.Review of the Behavior Note for Resident #89 dated 10/10/25 at 1:17 P.M. revealed the resident was setting off the alarms and attempting to exit the MCU. The staff redirected each time and secured the unit doors.Review of the Incident Note for Resident #89 dated 10/10/25 at 4:30 P.M. revealed the resident was not in the facility. A missing resident (Code Brown) was called, and the staff began a search for the resident. The Unit Manager located the resident. The resident was brought back to MCU, a complete skin assessment was done, and the resident was placed on one on one (1:1) observation for 72 hours per physician order.Review of the Incident Form dated 10/10/25, provided by the Director of Nursing (DON), revealed an incident was classified as other and the incident location was off the property. Licensed Practical Nurse (LPN) #296 returned from lunch and Resident #89 was not in the MCU. Staff called a code to inform all staff of resident not being located. Unit Manager alerted nurse resident was found. Skin assessment completed, resident placed on one-on-one (1:1), physician was notified, and 1:1 continued for 72 hours.Review of the physician order for Resident #89 dated 10/14/25 revealed the resident met the criteria for placement on the Memory Care Unit (MCU) and would benefit from the structure and activity-based care philosophy. Review of the Modification of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed Resident #89 had severe cognitive impairment, with behavioral symptoms not directed towards others, rejection of care, and wandering behaviors that did not place the resident at significant risk of getting to a potentially dangerous place outside of the facility. The resident required supervision assistance with ambulation.Interview on 01/12/26 at 12:02 P.M., Registered Nurse (RN) #33 confirmed on 10/10/25 around 4:15 P.M., she received a call from LPN #296 stating Resident #89 was not in the facility and she was unsure how he eloped, but no alarms sounded. RN #33 stated she located Resident #89 on [NAME] Bell Road which was 0.75 miles from the facility. RN #33 stated she got the resident into her car, along with the Administrator who was walking towards the resident when she located the resident. RN #33 stated she drove the resident and the Administrator back to the facility.Interview on 01/12/26 at 12:14 P.M., the Administrator confirmed on 10/10/25 around 4:00 P.M., he was notified Resident #89 eloped from the facility. The Administrator stated Resident #89 was found just down the road and he talked the resident into walking back to the facility by offering him some food. The Administrator was made aware of the differing reports of how the resident was found and brought back to the facility and had no additional statements. Interview on 01/12/26 at 1:53 P.M., LPN #296 stated she was the nurse caring for Resident #89 on 10/10/25 when he eloped from the MCU. LPN #296 stated the facility staff checked all the rooms and bathrooms on and off the MCU once they realized the resident was missing. LPN #296 stated she called the Unit Manager and the Administrator when Resident #89 was not located in the facility. LPN #296 stated Resident #89 was located and brought back to the facility by the Unit Manager.Interview on 01/12/26 at 2:15 P.M., the DON confirmed there was no documented evidence of a thorough investigation being completed when Resident #89 eloped. There was no documentation as to when the resident was last seen, how the resident eloped, and the steps taken to prevent another elopement. The DON stated the immediate intervention was 1:1 for 72 hours. The DON verified the facility did not educate all staff members on elopement risks.Review of the Wandering and Elopement Policy dated 08/2021 revealed that residents will be assessed for wandering risk. If identified as a risk for wandering or elopement, orders will include strategies and interventions to maintain safety. If the resident does elope, the facility will initiate a search. Once found the DON, physician, resident and resident's representative will review the situation and possible need for transfer.This deficiency represents non-compliance investigated under Complaint Number 2677474.

Based on record review, review of facility's Self-Reported Incidents (SRI) and investigation, resident interviews, review of personnel file, and staff interviews, the facility failed to ensure the residents were treated with respect and dignity. This affected two (#34 and #40) of five residents reviewed for abuse and dignity. Findings include: Review of the medical record for Resident #34 revealed an admission to 08/30/24 with medical diagnoses of Parkinson's disease, chronic obstructive pulmonary disease (COPD), and depression. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact and was dependent upon staff for toilet hygiene, bathing, bed mobility, and transfers. Resident #34 was always incontinent with bladder and bowel. Review of the facility's SRI number 265729, dated 09/26/25 at 5:08 P.M., revealed on 09/25/25 at 7:30 P.M., Resident #34 stated Certified Nursing Assistant (CNA) #210 failed to provide cares/services for Resident #34 as requested. Resident #34 stated he felt he had been mistreated. Resident #34 reported CNA #210 had been very aggressive when putting him into bed via mechanical lift. Resident #34's stated once in bed, CNA #210 told Resident #34 to turn to his left side which Resident #34 was unable to do independently. Per Resident #34's statement, CNA #210 then informed Resident #34 Well I 'ain't' helping you and left the room with the mechanical lift pad still under Resident #34 and never returned. Per the Employee Reporting form, CNA #210 had been implicated in other situations and received verbal warnings. Review of the personnel file revealed CNA #210 was hired on 06/10/25. On 09/25/25, CNA #210 received disciplinary action, and it was her final written warning. The disciplinary action was for misconduct, lack of professionalism, unsatisfactory work performance, and negligent conduct involving a resident. On 09/25/25, a resident had a concern of terrible customer service. There were several concerns of misconduct involving the resident. CNA #210 refused to sign the disciplinary form. Interview on 10/21/25 at 8:50 A.M. with CNA #201 stated many residents complain that CNA #210 was rude with resident cares/services. Interview on 10/21/25 at 9:11 A.M. with Resident #34 stated a CNA (#210) with blue hair, had changed his clothes, assisted him back to bed via mechanical list, and had changed his incontinence brief. Resident #34 stated CNA #210 then told him to roll to his left side which Resident #34 stated he was unable to do independently. Resident #34 stated CNA #210 got mad at him because he couldn't roll and then CNA #210 left the room with Resident #34 in the bed with his incontinence brief open and mechanical lift pad underneath his body. Resident #34 stated he had to call out to get someone else to help him. Interview on 10/21/25 at 10:46 A.M. with Registered Nurse (RN) #215 confirmed the residents described CNA #210, the aide with the blue hair. Interview 10/27/25 at 8:15 A.M. with Licensed Practical Nurse (LPN) #209 stated many residents complain that CNA #210 was rude with resident cares/services. Interview on 10/27/25 at 10:50 A.M. with Resident #40 stated the night shift aide with blue hair (CNA #210) was not very nice and asked that CNA #210 no longer take care of her. SR #40 stated the DON was aware of her concerns. This deficiency represents non-compliance investigated under Complaint Number 2643951.

Based on medical record reviews, resident and staff interviews, review of facility Self-Reported Incidents (SRIs) and investigation, and policy review, the facility failed to ensure staff immediately reported allegations of abuse to administration and failed to complete a thorough investigations into allegations of abuse. This affected two (#34 and #105) of five residents reviewed for abuse. The facility census was 103.Findings include: Review of the medical record for Resident #34 revealed an admission to 08/30/24 with medical diagnoses of Parkinson's disease, chronic obstructive pulmonary disease (COPD), and depression. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact and was dependent upon staff for toilet hygiene, bathing, bed mobility, and transfers. Resident #34 was always incontinent with bladder and bowel. Review of the facility's SRI number 265729 and investigation, dated 09/26/25 at 5:08 P.M., revealed on 09/25/25 at 7:30 P.M., Resident #34 stated Certified Nursing Assistant (CNA) #210 failed to provide cares/services for Resident #34 as requested. Resident #34 stated he felt he had been mistreated. Review of an Employee Reporting Form, completed by Registered Nurse (RN) #215, revealed a statement by Resident #34 reported CNA #210 had been very aggressive when putting him into bed via mechanical lift. Resident #34's stated once in bed, CNA #210 told Resident #34 to turn to his left side which Resident #34 was unable to do independently. Per Resident #34's statement, CNA #210 then informed Resident #34 Well I 'ain't' helping you and left the room with the mechanical lift pad still under Resident #34 and never returned. Per the Employee Reporting form, CNA #210 had been implicated in other situations and received verbal warnings. The statement from CNA #210 that was obtained via text message which stated CNA #210 and a coworker (unidentified) had put Resident #34 back to bed via mechanical lift and CNA #210 had to go back to the memory care unit for the next 12 hours. No other information was noted in CNA #210's statement about the allegation. The facility's investigation did not include Resident #34's roommate (#33) statement to see if he witnessed the incident and did not include other residents who may have witnessed it and/or have concerns with CNA #210. The investigation did not include any staff statements from other staff who worked the same shift on 09/25/25. The investigation did not have a witness statement from the coworker who CNA #210 stated assisted with the transfer of Resident #34. Interview on 10/21/25 at 9:11 A.M. with Resident #34 stated a CNA (#210) with blue hair, had changed his clothes, assisted him back to bed via mechanical list, and had changed his incontinence brief. Resident #34 stated CNA #210 then told him to roll to his left side which Resident #34 stated he was unable to do independently. Resident #34 stated CNA #210 got mad at him because he couldn't roll and then CNA #210 left the room with Resident #34 in the bed with his incontinence brief open and mechanical lift pad underneath his body. Resident #34 stated he had to call out to get someone else to help him. Interview on 10/21/25 at 10:46 A.M. with RN #215 stated she was informed on 09/26/25 during morning report that a CNA (unidentified) on 09/25/25 had made an allegation of neglect against another aide (CNA #210). RN #34 confirmed the residents described CNA #210, the aide with the blue hair. RN #215 confirmed the allegation of neglect was not immediately reported to Administrator or supervisor on 09/25/25. RN #215 stated she obtained a statement from Resident #34 on 09/26/25 who stated the incident occurred on 09/25/25. Interview on 10/21/25 at 10:56 A.M. with the Administrator confirmed investigation into the allegation of abuse for Resident #34 did not contain any witness interviews and the staff had not immediately reported the allegation of abuse on 09/25/25 until 09/26/25. Interview on 10/27/25 at 10:18 A.M. with the Director of Nursing (DON) confirmed SRI number 265729's investigation did not contain documentation to support witness statements were obtained. The DON also confirmed the allegation of abuse was not reported immediately to Administrator or supervisor as per facility policy. 2. Review of the medical record for Resident #105 revealed an admission date of 09/23/25 with diagnoses including anemia, heart failure, chronic kidney disease stage III, atrial fibrillation, and myelodysplastic syndrome. Resident #105 was discharged on 10/10/25. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #105 was cognitively intact and required partial/moderate staff assistance with bathing, toilet hygiene, bed mobility, and transfers. Review of the facility's SRI number 265724 dated 09/26/25 at 4:34 P.M. stated on 09/25/25 at 9:00 P.M., Resident #105 was being assisted by CNA #211 and Licensed Practical Nurse (LPN) #220 and Resident #105 felt he was rushed with the mechanical lift transfer process and neither staff members were polite. Review of the SRI investigation revealed an Employee Reporting form, that was not dated, did not indicate who obtained Resident #105's statement, was not signed, and did not have any questions on the form answered. The form did contain documentation of a statement but did not indicate whose statement it was that said I was going to bed, I called and asked for help. I asked her to raise the bed, they tossed me in the bed and left me on the side of the bed, laying she didn't give me my call button, so I called out to see if anyone was in the hall. She came in and yelled. (It was unspecified which staff member and what exactly was yelled at to Resident #105), The facility's investigation did not include CNA #211 and LPN #220's witness statements. The investigation did not include any staff statements who worked the shift on 09/25/25. The facility's investigation did not include Resident #105's roommate statement and/or other residents to see if they witnessed the incident and/or have concerns with CNA #211 and/or LPN #220. Interview on 10/27/25 at 10:18 A.M. with the Director of Nursing (DON) confirmed SRI number 265724's investigation did not contain documentation to support witness statements were obtained. The DON also confirmed the allegation of abuse was not reported immediately to Administrator or supervisor as per facility policy. The DON also confirmed that the Employee Reporting form for SRI number 265724 did not contain the date/time, the name of the person who completed the form, the name of the person who provided the statement, or had any of the questions answered that were on the form. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property revealed the staff were to report all incidents/allegations of abuse immediately to the Administrator or designee. Once the Administrator and State Agency are notified, an investigation of the allegation violation will be conducted and completed within five working days. The investigation protocol included interviewing the resident, the accused, and all witnesses. The witnesses generally, including anyone who witnessed or heard of the incident, came in close contact with the resident the day of the incident (including other residents, family members) and employees who worked closely with the accused employee(s) and/or alleged victim the day of the incident. This deficiency represents non-compliance investigated under Complaint Number 2643951.

Based on observations, staff interviews, and review of facility policy, the facility failed to ensure staff had there hair contained in food preparation areas and failed to ensure food was stored properly. This had the potential to 98 out of 98 residents who receive their meals/food from the kitchen, the facility identified one resident (#30) that did not receive food from the kitchen. The census was 99. Findings include: Observations of the kitchen on 05/21/25 at 2:14 P.M. revealed Dietary Aide (DA) #150 preparing meals trays and DA #160 arranging drink cups and preparing drinks. Neither DA #150 or DA #160 had were wearing hairnets or had their hair contained. Interview with DA #150 on 05/21/25 at 2:19 P.M. confirmed she was not wearing a hairnet. DA #150 stated her hairnet must have fell off. Interview with Dietary Director (DD) #170 on 05/21/25 at 2:29 P.M. confirmed DA #150 and DA #170 were not wearing hairnets and did not have their hair contained in the food preparation area. DD #170 stated hairnets were required at all times in the kitchen. Further observation on 05/21/25 at 2:25 P.M. revealed an unlabeled and undated plastic container of apple pie filling and an open and undated package of cheese slices in the refrigerator. A box of hamburger patties, a plastic bag containing rolls, and a box containing a turkey were being stored directly on the floor of the freezer. Interview with DD #170 on 05/21/25 at 2:33 P.M. confirmed the above findings. DD #170 confirmed that food should be dated and labeled. DD #170 confirmed food items should not be stored directly on the floor of the freezer. During an interview on 05/28/25 at 1:43 P.M. the Director of Nursing (DON) identified Resident #30 as being nothing by mouth (NPO) and not receiving food from the kitchen. The DON stated all other 98 residents residing in the facility receive their meals/food from the kitchen. Review of the facility's policy titled, Food Storage dated 2021 revealed sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Food items will be stored on shelves, with heavier and bulkier items stored on lower shelves. Food should be stored a minimum of six inches above the floor, 18 inches from the ceiling and two inches from the wall with adequate space on all sides of stored items to permit ventilation. Racks and other storage surfaces should be clean and protected from splashes, overhead pipes, or other contamination (ceiling sprinklers, sewer/waste disposal pipes, vents, etc.). Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within seven days or discarded as per the 2017 Federal Food Code. Review of the facility's policy titled, Employee Sanitary Practices dated 2021 revealed all food and nutrition services employees will practice good personal hygiene and safe food handling procedures. All employees will wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. This deficiency represents non-compliance investigated under Complaint Number OH00165822.

Based on medical record review, staff interview, physician interview, review of the National Pressure Injury Advisory Panel (NPIAP) website, the facility failed to adequately assess residents' skin, failed to identify a pressure ulcer (a pressure ulcer is a localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), and/or aid in the healing of existing pressure ulcers. This resulted in Actual Harm to one resident (#17) who was at risk for developing pressure ulcers, was readmitted to the facility without a pressure ulcer, and subsequently developed an avoidable, in-house acquired pressure ulcer on 01/31/25 which was first identified as a stage III (full-thickness skin loss in which adipose [fat] is visible) pressure ulcer to the sacrum. The affected one (#17) of four residents reviewed for pressure ulcers. The census was 95 . Findings include: Review of Resident #17's medical record revealed an admitted [DATE]. Diagnoses included malnutrition, cerebral palsy, chronic kidney disease stage three, dysphagia, and atherosclerotic heart disease. Resident #17 was discharged to a local hospital on 12/30/24 and readmitted to the facility on [DATE]. Review of a care plan for Resident #17 revised 05/23/23, revealed the resident had a potential for impaired skin integrity and/or development of pressure related ulcers and/or skin breakdown related to impaired mobility, muscle weakness, cerebral palsy, incontinence, stage three chronic kidney disease, and coronary artery disease. Interventions included to assess skin with routine care, provide routine skin care with morning and evening care, keep skin clean and dry, apply lotion and refer to the weekly Skin Check Sheet and or the Treatment Administration Record (TAR) for treatment plan for actual impaired skin integrity problems. Review of the medical record for Resident #17 from 01/06/25 through 01/30/25, revealed no documented evidence of skin assessments or pressure ulcer risk assessments being completed until 01/31/25, when the resident was found with a stage III pressure ulcer on buttock. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #17 was cognitively intact, had no pressure ulcers and received Hospice services. Review of a progress note for Resident #17 dated 01/31/25 at 3:37 P.M., revealed when a Hospice aide and a nurse gave the resident a bath, two small areas covered in slough were noted to the resident's right buttock. A new order was obtained for wound treatment from the Hospice provider. Review of a Weekly Skin Assessment for Resident #17 dated 01/31/25, revealed the resident was documented as having two pressure ulcers to the right buttocks. One pressure ulcer measured 2.0 centimeters (cm) in width by 2.0 cm in length by 0.1 cm in depth and the second one measured 1.0 cm in width by 1.0 cm in length by 0.1 cm in depth. There were no other documented weekly skin assessments from the time the resident was readmitted on [DATE] until this assessment was completed. Review of a physician order for Resident #17 dated 02/01/25, revealed the resident was ordered to have sacrum cleansed with normal saline (NS), patted dry, a small amount of Medi-honey (wound treatment gel) applied, covered with calcium alginate (absorbent wound dressing) and a foam dressing every three days and as needed (PRN). Review of a Wound Nurse Practitioner (WNP) note for Resident #17 dated 02/06/25 and authored by WNP #602, revealed the resident was assessed for a new traumatic wound to her sacrum. Resident #17 was documented as having an in-house acquired stage III pressure ulcer to the sacrum that measured 1.0 cm in width by 1.0 cm in length by 0.1 in depth with 60 percent (%) slough (non-viable [dead] tissue that separates from the wound bed), 40 % granulation (healing skin), and a small amount of serosanguinous exudate (drainage). The resident was ordered to have Medi-honey (wound treatment gel) applied, covered with calcium alginate (absorbent wound dressing) and a bordered foam dressing three times a week and PRN (as needed). Review of the February and March 2025 Treatment Administration Records (TARs) revealed Resident #17's sacrum area wound treatment was not documented as being completed on 02/10/25, 02/16/25, 02/25/25, 03/01/25, and 03/11/25. Interview with Regional Director of Clinical Operations (RDCO) #600 on 03/19/25 at 11:01 A.M., confirmed weekly skin assessments and a pressure injury risk assessment were not completed for Resident #17 upon re-admission to the facility on [DATE]. RDCO #600 confirmed weekly skin assessments, and a pressure ulcer risk assessment were not completed until 01/31/25 when Resident #17 was discovered with a stage III pressure ulcer on her sacrum. RDCO #600 confirmed Resident #17's skin should have been assessed upon re-admission and weekly. RDCO #600 also confirmed pressure ulcer treatments were not completed as ordered. Interview with WNP #602 on 03/20/25 at 9:12 A.M. and immediately after providing wound treatment to Resident #17, confirmed the resident had a stage III pressure ulcer that measured 1.0 cm in width x 0.5 cm in length x 0.1 cm in depth. Resident #17's stage III pressure ulcer currently had no slough and was pink in color. WNP #602 confirmed Resident #17's stage III pressure ulcer was in-house acquired. Review of the facility's policy Pressure Injury Risk Assessment revised August 2024, revealed the facility will complete a standardized risk assessment which will be initiated upon admission and continue throughout the resident's stay in our facility. The purpose is to maintain an on-going process of assessing a resident's risk for pressure injury development in order to create and implement a person-centered plan of care. All residents will have a risk assessment completed by a licensed nurse upon admission, quarterly, and with a significant change in condition. All residents will have a complete head-to-toe skin check by a licensed nurse upon admission. Review of the NPIAP website (https://npiap.com/page/PressureInjuryStages), revealed skin and soft tissue assessment is the basis of pressure injury prevention and treatment. Skin and tissue assessment is an essential component of any pressure injury risk assessment and should be conducted as soon as possible after admission and as a component of a full risk assessment. Each time the individual's clinical condition changes, a comprehensive skin and tissue assessment should be conducted to identify any alterations to skin characteristics or integrity, and to identify any new pressure injury risk factors. A comprehensive skin and soft tissue assessment consists of a head-to-toe assessment with particular focus on skin overlying bony prominence's including the sacrum, ischial tuberosities, greater trochanters and heels. In addition to comprehensive skin assessment, a brief skin assessment of the pressure points should be undertaken during repositioning. A stage III pressure injury involved full-thickness skin loss. Full-thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury, which is a full-thickness pressure injury. This deficiency represents non-compliance investigated under Complaint Number OH00161918.

Based on medical record review, observation, staff interview, review of online resources from Centers for Disease Control and Prevention (CDC), and review of facility policy, the facility failed to timely implement Enhanced Barrier Precautions (EBP). This affected three (#14, #17, and #46) residents of five reviewed for Transmission-Based Precautions (TBP). The census was 95. Findings include: 1. Review of Resident #17's medical record revealed an admitted [DATE]. Diagnoses listed included malnutrition, cerebral palsy, chronic kidney disease stage 3, dysphagia, and atherosclerotic heart disease. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #17 was cognitively intact, was receiving Hospice services and did not have any pressure ulcers. Further review of Resident #17's medical record, revealed a stage III (full-thickness skin loss in which adipose [fat] is visible) pressure ulcer to the resident's sacrum was identified on 01/31/25 and treatments were started. Review of the physician orders, revealed EBP were not ordered for Resident #17 until 03/17/25. Observation on 03/19/25 at 10:05 A.M., revealed no personal protective equipment (PPE) supplies or any signs posted at Resident #17's room entrance informing staff that Resident #17 was in EBP. Interview with Assistant Director of Nursing (ADON) #160, confirmed EBP should have been ordered for Resident #17 prior to 03/17/25. ADON #160 confirmed wound care had been provided prior to 03/17/25. ADON #160 confirmed no current EBP signs or PPE at Resident #17's room entrance. 2. Review of Resident #46's medical record, revealed an admitted [DATE]. Diagnoses listed included rheumatoid arthritis, acute kidney failure, sepsis, altered mental status, iron deficiency anemia, and malnutrition. Review of a significant change MDS dated [DATE], revealed Resident #46 was rarely understood by staff, had a feeding tube, and received Hospice care. Further review of Resident #46's medical record, revealed she had received nutrition per feeding tube since 01/24/25. Test results were received on 03/12/25 from the hospital reporting Resident #46 was positive for Candida Auris a multi-drug-resistant organism (MDRO). Review of a hospital acquired laboratory results dated [DATE], revealed Resident #46 was positive for Candida Auris. Interview with ADON #160 and Regional Director of Clinical Operations (RDCO) #160 on 03/18/25, confirmed Resident #46 should have been ordered and placed in EBP prior to 03/17/25 due to having a feeding tube and being identified positive for Candida Auris on 03/12/25. 3. Review of Resident #14's medical record revealed an admitted [DATE]. Diagnoses listed included congestive heart failure, dementia, and anxiety Review of the most current annual MDS assessment dated [DATE], revealed Resident #14 was severely cognitively impaired and was dependent on staff for all care. Further review of Resident #14's medical record revealed she had a Stage II pressure ulcer (partial-thickness skin loss, appearing as a shallow open sore or an intact or ruptured blister, with a red or pink wound) on her left calf . Observations of Resident #14 on 03/17/25, 03/18/25 and 03/19/25, revealed the resident was not in EBP's. Observations of the dressing change on 03/19/25 at 11:00 A.M. revealed the residents bandage to her leg had active drainage. Interview with ADON #160 and RDCO #600 on 03/19/25, confirmed that Resident #14 should have been ordered EBP prior to 03/19/25 due to having a pressure ulcer. Review of CDC guidance, revealed candida Auris is a MDRO and transmission-based precautions should be implemented. Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with [NAME] infection or colonization. Review of the facility's policy Enhanced Barrier Precautions date 04/01/24, revealed Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of MDROs that employs targeted gown and glove use during high contact resident care activities. EBP's are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Place EBP signage on resident's room door, have PPE (gowns and gloves available and face protection may also be needed if performing activity with risk of splash or spray) available. Require gowns, and gloves only for high-contact resident care activities (face protection may also be needed if performing activity with risk of splash or spray). Examples of MDROS targeted by CDC include Candida Auris.

Based on observations, interviews, and facility policy, the facility failed to ensure the proper storage of medications when outdated and expired medications were being stored in the medication carts. This affected two (#47 and #70) residents of the five residents reviewed for medications. The facility census was 95. Findings Include: Review of medical record for Resident #70 revealed an admitted [DATE]. Diagnoses included depression, type two diabetes, anemia, and hypertension. Review of record for Resident #47, revealed an admitted [DATE]. Diagnoses included heart failure, depression and atrial fibrillation. Observation of the 100-hall medication cart on 03/19/25 at 10:55 A.M. with Licensed Practical Nurse (LPN) #117, revealed an Insulin Aspart (fast acting insulin) 100 units per milliliter belonging to Resident #70 with an open date of 02/06/25. Interview with LPN #117 at the same time verified Resident #70's insulin was opened 02/06/25. Observation of the 200-hall medication cart on 03/19/25 at 11:24 A.M. with LPN #32, revealed a container Potassium Chloride 10 milliequivalents (mEq) per 7.5 milliliters belonging to Resident #47 with no open date and expired 01/24/25. Interview with LPN #32 at the same time verified Resident #47's bottle of Potassium Chloride expired on 01/24/25. Interview on 03/19/25 at 11:55 A.M. with Director of Nursing (DON), stated insulin Aspart was fast acting and should be discarded 28 days after opening. The DON stated no medication should be expired in medication carts and/or medication rooms. Review of facility policy titled Medication Storage undated, revealed medications will be stored in a manner that maintains the integrity of the product, ensures the safety of the residents and was in accordance with Ohio Department of Health guidelines. Review of the facility policy titled 7.0 Insulin Pen Labeling and Packaging undated, revealed insulin pens are to be individually labeled and placed in a closable plastic bag to control the spread of infections. Insulin was refrigerator until opened, keep insulin in bag with sticker, and a yellow sticker that had date and expiration date.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure abnormal involuntary movement scale (AIMS) assessments were completed as ordered. This affected two (#69 and #76) of the five residents reviewed for unnecessary medications. The facility also failed to ensure an ordered stop date for an as needed (PRN) antianxiety medication was implemented. This affected one (#69) of the five residents reviewed for unnecessary mediations. The census was 95. Findings include: 1. Review of Resident #69's medical record revealed an admission date of 11/05/24. Diagnoses listed included psychotic disorder, cognitive disorder with Lewy bodies, anxiety disorder, depressive disorder, and muscle weakness. Review of a monthly medication review (MMR) dated 11/26/24, revealed Resident #69 was currently receiving the antipsychotic medication Risperdal and recommended an AIMS assessment be completed due to this antipsychotic therapy requiring an AIMS assessment. The MMR was signed by facility physician on 12/04/24 with a hand-written order to obtain an AIMS assessment. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #69 was assessed by staff as being severely cognitively impaired, was rarely understood and was receiving Hospice services. Review of physician orders, revealed an order dated 01/26/25 for Ativan 0.5 milligrams (mg) every four hours PRN for anxiety. The order did not have a stop date. Review of an MMR dated 01/28/25, revealed Resident #69 was currently receiving the antipsychotic medication Risperdal and recommended an AIMS assessment be completed due to this antipsychotic therapy requiring an AIMS assessment. The MMR was signed by facility physician on 02/19/25 with hand-written order to obtain an AIMS assessment. The MMR also noted Resident #69 was currently receiving the antianxiety medication Ativan 0.5 milligram (mg) every four hours PRN. A stop date order of 03/05/25 was signed by physician 02/19/25. Review of March 2025 Treatment Administration Record (TAR), revealed Resident #69 was administered Ativan 0.5 mg PRN on 03/06/25, 03/17/25, and 03/20/25. Further review of Resident #69's medical record, revealed no documentation of an AIMS assessment being completed Interview with Regional Director of Clinical Operations (RDCO) #600 on 03/19/25 at 11:01 A.M., verified an AIMS assessment was not completed as ordered for Resident #69. RDCO #600 also confirmed Resident #69's Ativan 0.5 mg PRN did not have a stop date. 2. Review of medical records revealed that Resident #76 admitted [DATE]. Diagnoses dementia, cognitive communication deficit, hypertension, type two diabetes, anxiety disorder, sleep disorder, and major depressive disorder. Review of Quarterly MDS assessment dated [DATE],revealed Resident #76 was severely cognitively impaired. Review of the plan of care dated 02/12/25, revealed that Resident #76 used psychotropic medications related to disease process and psychotic disorder. Interventions included administering psychotropic medications as ordered, consulting with pharmacy and physicians to consider a dose reduction, discuss with physician and family on ongoing need for use of medications, review behaviors, and alternative therapies. Review of physician orders for Resident #76 dated 09/18/24, revealed the resident was ordered Galantamine Hydrobromide (used to treat mild to moderate dementia) 4 mg twice a day. Review of physician orders for Resident #76 dated 10/09/24, revealed the resident was ordered Risperdal 0.5 mg at bedtime related to psychotic disorder, and delusions. Review of a Gradual Drug Reduction (GDR) dated 10/25/24, revealed Resident #76 had a recommendation by pharmacy to complete an AIMS assessment. Review of medical record for Resident #76, revealed an AIMS assessment wasn't completed until 02/28/25. Interview on 03/20/25 at 1:13 P.M. with Director of Nursing (DON), verified Resident #76 didn't have a timely AIMS test completed when the pharmacy recommended the assessment on 10/25/24. Review of the facility's undated policy Psychotropic Drug Use revealed the assessment of side effects for customers receiving antipsychotic therapy includes the following adverse effects: tardive dyskinesia, postural or orthostatic hypotension, cognitive and/or behavior impairment, akathisia and parkinsonism. The AIMS test or Dyskinesia Identification System: Condensed User Scale (DISCUS) are methods that may be used for monitoring tardive dyskinesia.

Based on record review, staff interview, and facility policy review, the facility failed to ensure medications were administered per physician's order. This affected one (#71) resident out of the five residents reviewed for medications. The facility census was 95. Findings Include: Review of medical record for Resident #71 revealed an admitted [DATE]. Diagnoses included acute respiratory failure, obstructive and reflux uropathy, acute and chronic respiratory failure, pleural effusion, chronic obstructive pulmonary disease, morbid obesity, and sleep apnea. Review of a physician order for Resident #71 dated 12/04/24 and discontinued on 01/24/25, revealed the resident had an order for Midodrine five milligrams (mg) by mouth every eight hours as needed (PRN) for hypotension related to systolic blood pressure less than 100 millimeters or mercury (mm/Hg), and do not give the medication four hours before bedtime. Review of a physician order for Resident #71 dated 01/01/25, revealed the resident was ordered to have a blood pressure taken twice daily (morning and night) and check blood pressure two hours before therapy, and if systolic blood pressure is less than 100 mm/Hg systolic, administer Midodrine. Review of blood pressures for Resident #71 revealed the following: a) On 01/24/25, a blood pressure reading of 97/52 mm/Hg was recorded. Review of the correlating Medication Administration Records (MAR) revealed Midodrine 2.5 mg was administered. b) On 01/31/25, a blood pressure reading of 95/60 mm/Hg was recorded. Review of the MAR revealed no documented evidence Midodrine was administered. c) On 02/04/25 at 6:59 A.M., a blood pressure reading of 95/47 mm/Hg was recorded. Review of the MAR revealed no documented evidence Midodrine was administered. d) On 02/08/25, a blood pressure reading of 98/57 mm/Hg was recorded. Review of the MAR revealed no documented evidence Midodrine was administered. e) On 02/10/25, a blood pressure of 94/56 mm/Hg was recorded. Review of the MAR revealed no documented evidence Midodrine was administered. f) On 02/17/25 at 9:48 A.M., a blood pressure of 98/60 mm/Hg was recorded. Review of the MAR revealed no documented evidence Midodrine was administered. g) On 03/01/25 at 9:10 A.M., a blood pressure of 94/59 mm/Hg was recorded. Review of the MAR revealed no documented evidence Midodrine was administered. h) On 03/03/25 at 8:44 A.M., a blood pressure of 99/51 mm/Hg was recorded Review of the MAR, revealed no documented evidence Midodrine was administered. i) On 03/09/25 at day shift, a blood pressure of 97/47 mm/Hg was recorded. Review of the MAR revealed no documented evidence Midodrine was administered. Review of Minimum Data Set (MDS) for Resident #71 dated 02/12/25, revealed the resident who had a Brief Interview of Mental Status (BIMS) of 15 which indicated she was cognitively intact. Resident #71 required set up and clean up for meals. Interview on 03/20/25 at 2:00 P.M. with Director of Nursing (DON). verified Resident #71 didn't receive Midodrine when her blood pressure met the parameters for the medication to be given. Review of facility policy titled Administering Medications revised April 2019, revealed medications will be administered in safe and timely manner and as prescribed.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure fall interventions were in place for a resident who was at risk for falls and had recent falls. This affected one (#69) of the three residents reviewed for accidents. The census was 95. Findings include: Review of Resident #69's medical record revealed an admitted [DATE]. Diagnoses listed included psychotic disorder, cognitive disorder with Lewy bodies, anxiety disorder, depressive disorder, and muscle weakness. Review of a care plan for Resident #69 dated 11/18/24, revealed the resident was at risk for falls and potential injury related to dementia, impaired balance, impaired cognition, medications, poor decision-making skills, unsteady gait, history of falls, and keeps eyes closed when walking. An intervention of anti-rollbacks to the resident's wheelchair was implemented on 02/03/25. Review of a significant change Minimum Data Set (MDS) assessment for Resident #69 dated 01/03/25, revealed Resident #69 was assessed by staff as being severely cognitively impaired and rarely understood and received Hospice services. Review of an incident note for Resident #69 dated 02/01/25 at 1:00 P.M., revealed the resident was sitting in a wheelchair at the dining room table, stood up and attempted to sit back down in wheelchair. Resident #69 missed the wheelchair and fell on the floor, landing on buttocks with back against wheelchair. The nurse obtained vital signs and assessed range of motion within normal limits. The nurse and caregiver assisted Resident #69 back to the wheelchair. The nurse took the resident to the bedroom, laid the resident down in bed and completed a skin assessment. No injuries were noted. Neurological (neuro) checks were initiated. Resident #69's physician, the Director of Nursing (DON), and power of attorney (POA) were notified. Review of an Interdisciplinary Team (IDT) note for Resident #69 dated 02/03/25 at 11:48 A.M., revealed the resident fell on [DATE]. Resident #69 was witnessed sitting in a wheelchair at the dining room table, stood up and attempted to sit down in wheelchair, missed the wheelchair and fell on the floor. Resident #69 landed on the buttock with back against wheelchair. No injury or pain was noted. Risk factors for falls were dementia, depression, anxiety, neurocognitive disorder with Lewy bodies. Intervention of anti-rollbacks to the resident's wheelchair were added. Review of a health status note for Resident #69 dated 02/13/25 at 11:40 A.M., revealed the resident was found lying on the floor in the room with a laceration to right side of forehead. Review of an IDT note for Resident #69 dated 02/13/25 at 12:12 P.M., revealed the resident fell on [DATE]. Resident #69 was noted on floor with a laceration to right side of the forehead. An intervention of medication review with Hospice was added. Risk factors for fall included neurocognitive disorder with Lewy bodies, abnormality of gait and mobility, dementia, anxiety, major depression disorder. The responsible party and physician were made aware. Observation of Resident #69 in the memory care unit dining room on 03/18/25 at 10:19 A.M., revealed the resident was sitting in a high back wheelchair. The wheelchair did not have any anti-rollback device affixed to the wheelchair. Resident #69 kept standing up and sitting back down in the wheelchair while in front of a dining table. No facility staff were present. Observation of Resident #69 in the memory care unit dining room on 03/19/25 at 10:12 A.M., revealed the resident was sitting in a high back wheelchair. The wheelchair did not have any anti-roll back device affixed to the wheelchair. Interview with Certified Nurse Aide (CNA) #133 and CNA #603 on 03/19/25 at 10:13 A.M., confirmed Resident #69's did not have an anti-rollback device affixed to the wheelchair. Both CNA #133 and CNA #603 sated Resident #69 may be in the wrong wheelchair. Review of the facility's policy Falls and Fall Risk Managing revised August 2024, revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's risk and causes to try to prevent the resident form falling and try to minimize complications from falling.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of hospital records, review of facility investigation, staff interview, policy review, and review of facility corrective action, the facility failed to ensure staff used the appropriate number of staff and safely repositioned a resident when providing care in bed. This resulted in actual harm when Resident #83 was being provided care from one staff member instead of two, was holding onto the bedside chair for support when turned onto her side, and rolled out of the bed onto the floor obtaining fractures to her left ankle and toes. This affected one (Resident#83) of three residents reviewed for falls. Findings include: Review of the medical record for Resident #83 revealed an admitted [DATE]. Diagnoses included chronic respiratory failure with hypoxia, unspecified fracture of right toes, type II diabetes, and morbid obesity. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. Resident #83 had received extensive, two-person assistance with bed mobility, toileting, and transfers during the assessment period. Review of the care plan dated 03/23/2023 revealed Resident #83's minimal level of assistance for safe transfers and bed mobility was two staff. Interventions included reposition in bed using a friction-reducing device and two to three staff. Review of progress notes revealed on 05/29/2023 at 3:15 P.M. revealed an unidentified State tested Nurse Aide (STNA) notified the nurse the resident had fallen out bed while the STNA was giving incontinence care. Upon entering the room the nurse observed the resident laying on floor on her right side in between her bed and roommate's bed. Resident #83 stated I just couldn't hold on. Head to toe assessment was completed with bruising noted to right arm. Resident #83 complained of pain to right arm and right leg. The physician was notified with new order to send out to the emergency room for evaluation. The care plan was updated to include the use of bed bolsters. Review of the progress notes on 05/29/23 at 11:45 P.M. revealed Resident #83 returned to the facility. The resident was identified with a broken ankle and three broken toes. Review of the progress notes on 05/31/2023 at 7:56 A.M. revealed the social worker interview Resident #83. The resident stated there was only one State tested Nurse Aide (STNA) in the room to assist her. She had tried to use the chair beside the bed for support and fell . Review of emergency room documentation, dated 05/29/2023, revealed Resident #83 arrived by medic after a three-foot witnessed fall at the facility. The resident was complaining of pain in her right arm, hip, and leg. X-rays revealed Resident #83 had a closed left foot fracture and a closed nondisplaced fracture of the phalanx to the toe. Review of the facility investigation revealed a witness statements dated 05/29/2023 with STNA #156. STNA #156 stated he/she was assisting Resident #83 with incontinence care. The resident lay on her left side in bed and lost her hold on the headboard while the aide was washing her. STNA #156 stated she tried to grab the resident but could not stop her from rolling off the bed and falling onto the floor. The investigation revealed Licensed Practical Nurse (LPN) #124 verified Resident #83 required two-person assistance and STNA #156 had not asked for help to assist with care before Resident #83 rolled out of the bed. During an interview on 07/03/2023 at 10:35 A.M. the Administrator stated Resident #83 was holding onto an armchair at bedside while STNA #156 provided incontinence care in the bed. The chair moved causing the resident to roll out of the bed and onto the floor resulting in fractures to her ankle and toes. The Administrator confirmed Resident #83 required two-person assistance and there was only one staff member providing care at the time of the fall. During an interview on 07/03/2023 at 4:01 P.M., LPN #124 stated she was on duty when Resident #83 rolled out of bed. LPN #124 verified the resident required two-person assistance and STNA #156 attempted to complete incontinence care by herself. Review of policy titled Falls Program Policy and Procedure, dated 01/2020, revealed all residents were assessed for fall risk upon admission, were identified for fall risk in the care plan, and had interventions for fall prevention noted on the Kardex. Review of the facility's corrective action revealed the following actions were implemented and the deficiency corrected as of 06/23/2023: 1. On 05/30/2023 all residents on the 400-Unit were interviewed regarding safe care. 2. On 06/01/2023 audits for the appropriate amount of staff assistance used for bed mobility were completed for a random sample of residents who required assistance with bed mobility per the care plan. These audits involved a random sample of three to seven residents, three times per week, for four weeks through 06/23/2023. The audits were added to the facility Quality Assurance Performance Improvement (QAPI). 3. On 06/02/2023 education was completed for all staff by the Director of Nursing or designees, regarding the abuse policy, level of care, and safe transfers including a quiz. 4. On 06/08/2023 the facility installed transfer poles to bilateral sides of Resident #83's bed and updated the resident's care plan to assist in safe bed mobility and transfers. This deficiency substantiates Complaint Number OH00143597.

Based on medical record review, review of the hospital record, review of the fall investigation, staff interview, and policy review, the facility failed to ensure incontinence care was provided in a manner to prevent an avoidable fall with injury. This resulted in Actual Harm when State tested Nursing Assistant (STNA) #200 provided incontinence care alone, rolled the resident and then turned away from the resident to obtain supplies. Subsequently, Resident #01 fell off the bed onto the floor and sustained a closed fracture of the right humeral head requiring an emergency room visit. This affected one resident (#01) of three residents reviewed for falls. The facility census was 87. Findings include: Review of the medical record for Resident #01 revealed an admitted [DATE]. Diagnoses included altered mental status, encephalopathy, heart failure, obstructive and reflux uropathy, myocardial infarction, hemiplegia affecting left nondominant side, diabetes type II, malignant neoplasm of the prostate, dementia, depression, and anxiety. Resident #01 was discharged from the facility on 01/25/23 to the local hospital. Review of the fall risk assessment dated [DATE] revealed Resident #01 was at moderate risk for falls. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 had impaired cognition. The resident required extensive assistance of one staff for toilet use, and extensive assistance of two staff for bed mobility, transfers, and ambulation. The MDS revealed Resident #01 was always incontinent of urine and bowel. Review of the plan of care dated 11/29/22 revealed Resident #01 was at risk for falls related to impaired mobility, incontinence, and the use of psychotropic medications. Resident #01 has an activities of daily living (ADL) self-care performance deficit related to impaired mobility, incontinence, muscle weakness, hyperlipidemia, hemiplegia, hypothyroidism, and self-performance varies. Interventions included bedside fall mats to both sides of bed and bolstered pressure reduction mattress. The resident required extensive assistance by two staff to turn and reposition in bed and the use of a mechanical lift by two staff for transfers. Review of the physician orders dated 01/2023 identified orders for pressure reducing mattress with gel overlay. The order was changed on 01/24/23 to a bolstered scoop mattress to bed to define the bed parameters. Review of the nurse's note dated 01/20/23 at 1:30 P.M., revealed an agency State tested Nurse Aide (STNA) #200 notified Nurse #100 while providing care to Resident #01 he rolled out of the bed onto floor. Nurse #100 observed the resident lying on the right side between the bed and the recliner. Resident #01 stated he rolled out of the bed. A head to toe assessment was completed with a skin tear noted to the top right foot measured 0.4 centimeters (cm) by 0.4 cm with treatment in place to cleanse the area with triple antibiotic ointment (TAO) and cover with dry dressing. An area noted to the right knee measured 2.0 cm by 0.6 cm and an area to the right shoulder measured 3.0 cm. STNA #200 stated Resident #01 had not hit his head. Resident #01 complained of right shoulder pain and was unable to perform range of motion and routine pain medication was given as ordered. Resident #01 was assisted into bed by four staff members. The physician was notified with new orders for an x-ray of the right shoulder and elbow. The son, the Administrator and the Director of Nursing (DON) were notified. Review of the fall investigation dated 01/20/23 at 1:30 P.M. revealed a head to toe assessment was completed with a skin tear noted to the top right foot measuring 0.4 cm by 0.4 cm with a treatment in place. An area noted to the right knee measuring 2.0 cm by 0.6 cm and an area to the right shoulder measuring 3.0 cm. STNA #200 stated Resident #01 had not hit his head. Resident #01 complained of right shoulder pain and was unable to perform range of motion and routine pain medication was given as ordered. Resident #01 was assisted into bed by four staff members. The physician was notified with new orders for an x-ray to the right shoulder and elbow. The son and the Administrator were made aware. STNA #200's statement was I rolled the resident over to change him. I turned to get the washcloth and saw him slide out of the bed. I immediately got my nurse to assess him for injuries. Intervention added was a bolstered mattress. The root cause of the fall was improper positioning/rolling. Review of the hospital records dated 01/20/23 at 8:17 P.M. revealed Resident #01 was brought in by squad from the nursing facility. The patient was rolled over in bed by staff and he fell out of the bed. Complaints of pain in the right shoulder and bruising to the left hand. The patient stated he hit his head without loss of consciousness. Final impressions were a right humeral head closed fracture. Interview on 03/22/23 at 12:08 P.M., with Nurse #100 revealed agency STNA #200 came out of Resident #01's room and stated, Resident #01 fell out of bed. I rolled him over and he fell out of bed. He was lying between the bed and the recliner. She revealed Resident #01 was usually a one person assist for changes. Nurse #100 revealed she assessed him and he stated his shoulder hurt. She revealed she called the physician and received an order for an x-ray. Nurse #100 revealed the x-ray company never came and when she called for an estimated time, the x-ray company revealed it could be tomorrow. After waiting six hours the nurse sent him out to the hospital around 7:00 P.M. Interview with the DON on 03/22/23 at 1:00 P.M., verified Resident #01 should have had two staff assistance for bed turning and positioning. Attempted telephone interview on 03/22/23 at 12:34 P.M., with agency STNA #200 revealed she was not available and no return call was received. Review of the facility policy titled, Falls dated 04/2021 revealed it is the policy of this facility to identify residents at risk of falls and to implement a fall prevention approach to reduce the risk of falls and possible injury. This deficiency represents noncompliance discovered during the investigation of Master Complaint Number OH00141024 and Complaint Number OH00140874.

Based on record review, observation and resident and staff interview, the facility failed to monitor Resident #64 ' s meal intakes, provide the recommended adaptive equipment, ensure the resident received nutritional interventions implemented by the registered dietitian, and failed to attempt new nutrition interventions for a resident with severe weight loss. Actual harm occurred to Resident #64 when the resident experienced an avoidable 6.6 percent weight loss in two months and a severe weight loss of 18.3 percent over six months. This affected one (#64) of five residents reviewed for nutrition. The facility identified five residents with significant weight loss. The facility census was 122. Findings include: Review of Resident #64's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 01/02/19, indicated the resident had severe cognitive impairment and the resident was independent with eating with set up from staff. Review of the resident's weight log indicated the following weights: 07/15/18-177 pounds (lbs.), 08/15/18-175 lbs., 09/27/18-170 lbs., 10/27/18-163 lbs., 11/27/18-150 lbs., 12/04/18-152 lbs., 01/07/19-146 lbs., 02/06/19-143 lbs. and 02/11/19-142 lbs. Review of meal intake records for the last 30 days from 01/15/19 to 02/13/19 indicated the facility had only record of three meals. One indicated the resident ate 0-25 percent (%), one indicated the resident ate 25%-50% and one indicated the resident ate 75%-100%. Review of the resident's undated care plan revealed the resident was at a potential risk for decline in nutrition and hydration status due to [MEDICAL CONDITION], resistance with staff assistance with meals, poor oral intake and history of weight loss. One of the goals for the resident included was to not have significant weight loss. Interventions included to monitor weights, provide adaptive equipment as needed, feed/assist with meals as needed/as tolerated, supplements as ordered and honor food preferences. Review of a dietary progress note, dated 11/15/18, indicated the resident's weight was 150 lbs. which represented a significant weight loss of 13 lbs. (an eight % loss) in 30 days, 25 lbs. (a 14.3 % loss ) in 90 days and 25 lbs. (a 14.3 % loss) in 180 days. The current interventions at this time included a mechanical soft diet, an eight ounce (oz.) house supplement (high calorie nutritional supplement) three times per day, double meats portions at meals and grilled cheese sandwich and tomato soup at each meal. The facility increased the house supplement to 16 oz. three times per day with meals and recommended to the physician starting [MEDICATION NAME] (may increase appetite) with meals. The facility also spoke with the resident about a tube feeding and resident declined. The note also indicated the resident refused help with meals and can be shaky at times due to [MEDICAL CONDITION]. Review of physician orders [REDACTED]. Review of a dietary progress note, dated 12/12/18, indicated the resident's current weight was 152 lbs., which was 92% of the resident's ideal body weight (IBW). Interventions included continuing with the [MEDICATION NAME], mechanical soft diet, the 16 oz. house supplement three times per day, and the grilled cheese and soup at lunch and dinner but discontinuing the double meats and starting half portions. This was the last nutritional intervention attempt to prevent further weight loss for Resident #64. Review of a quarterly Nutrition Assessment, dated 01/03/19, indicated the resident's current weight was 152 lbs., he utilized handled cups due to [MEDICAL CONDITION] and usually consumed 100% of the 16 oz. house supplement three times per day. Review of a dietary progress note, dated 01/24/19, indicated the resident's current weight was 146 lbs., which was 88% of the resident's IBW. Interventions included continuing with the [MEDICATION NAME], the mechanical soft diet half portions, the 16 oz. house supplement three times per day, and with the grilled cheese and soup at lunch and dinner. No new nutritional interventions were attempted and no recommendations were made to the physician, despite the resident lost another six lbs from the previous weight in 12/2018, and losing 17 lbs. in three months (10.4% significant weight loss) and 31 lbs. in six months (17.5% significant weight loss). Review of a dietary progress note, dated 02/12/19, indicated the resident's current weight was 143 lbs., which was 86% of the resident's IBW. Interventions included continuing with the [MEDICATION NAME], the mechanical soft diet half portions, the 16 oz. house supplement three times per day, and with the grilled cheese and soup at lunch and dinner. No new nutritional interventions were attempted and no recommendations were made to the physician, despite the resident lost another three lbs. from the previous weight in 01/2019 and losing 32 lbs in six months (18.3% significant weight loss). Interview and observation on 02/12/19 at 8:10 A.M. with Resident #64 revealed he was observed in his room. Staff had just dropped off the resident's breakfast tray. Resident #64 had started to eat. The resident stated he did not really want to eat, but fed himself a bite of ground meat. The resident's hand was noted to be shaking. The resident had also has two glasses of chocolate drinks. His drinks were not in handled cups. When asked if he usually drinks the chocolate drinks, the resident replied 'yes' and said they were his favorite. Interview and observation on 02/12/19 at 11:55 P.M. with Resident #64 revealed he was in his room with a lunch tray which included the entree, soup and cupped beverages in handled cups. The resident had no grilled cheese sandwich or empty plate indicating he had eaten the sandwich. Resident #64 did not know if he had received a grilled cheese. At 12:09 P.M., Dietary Manager (DM) #73 verified the resident did not have grilled cheese sandwich or a plate indicating the resident had received the sandwich. DM #73 stated she would get the resident a grilled cheese sandwich. Interview on 02/12/19 at 12:11 P.M. with State tested Nursing Assistant (STNA) #75 stated she served the resident his lunch tray and verified the resident did not have a grilled cheese sandwich with the meal. At 12:16 P.M., Resident #64 was observed in his room eating a grilled cheese sandwich. Interview and observation on 02/13/19 at 8:18 A.M. revealed Resident #64 was observed alone in his room with a breakfast tray. The resident had handled cups on top of his tray, however the handled cups were empty and his beverages were in regular glasses. At 8:18 A.M., STNA #143 verified the resident's beverages had not been poured into the handle cups and further stated the resident does not pour the beverages himself but that staff should completed it when they dropped off the tray. On 02/13/19 at 8:22 A.M., Resident #64 was observed in his room, drinking a health shake, in a handled cup with a lid and straw. Interview on 02/13/19 at 9:48 A.M. with Registered Dietitian (RD) #500 verified Resident #64 had significant weight in 11/2018 and confirmed the facility had not initiated any new nutritional interventions for Resident #64 since 12/2018, despite the resident continued to lose weight. RD # 500 further verified the resident should have been provided a grilled cheese sandwich with all lunch and dinner meals and that his beverages should of be served to him in handled cups to assist the resident to self fed. The RD verified the resident's meal intakes were only recorded three times in the last 30 days and verified staff should be recording meal intakes after each meal.