Every finding on record at Wood Glen Alzheimer's Community

Based on observation, interview and policy review, the facility failed to ensure food preparation equipment was maintained in a clean and sanitary manner and further failed to ensure foods were defrosted appropriately to prevent foodborne illness. Additionally, the facility failed to ensure foods stored in resident refrigerators were properly labeled and the refrigerator temperatures were monitored. This had the potential to affect all residents of the facility, except for one (#4) resident identified by the facility as receiving no food by mouth. The facility census was 141. Findings include:1. Observation on 04/19/26 at 8:34 A.M. of the kitchen revealed the blade of the can opener was unclean. Concurrent interview with Interim Dietary Manager (IDM) #123 verified the can open was dirty and should have been cleaned. Continued observation on 04/19/26 at 8:36 A.M. revealed a tube of frozen ground beef was defrosting in the preparation sink without the water running. Concurrent interview with IDM #123 verified the ground beef was defrosting in the preparation sink and when thawing food in the sink, cold water should be running over the food to maintain temperature. Further observation on 04/19/26 at 8:40 A.M. revealed a deli slicer with a plastic bag placed over it. Concurrent interview with IDM #123 revealed the deli slicer was clean and ready for use. Continued observation of the deli slicer, after the plastic bag was removed, revealed the slicer was unclean. IDM #123 verified there was dried food debris still on the slicer. Review of the facility policy titled, Equipment, dated September 2017, revealed all food service equipment would be clean, sanitary, and in proper working order. 2. Observation on 04/23/26 at 12:15 P.M. of the Rosewood Unit resident refrigerator revealed a fast food drink container with an unknown liquid that was not dated. A thermometer was not observed in the refrigerator and there was no temperature log for the refrigerator for the month of April 2026. Concurrent interview with Licensed Practical Nurse, (LPN) #296 verified the resident refrigerator had a fast-food drink container of fluid which did not have a date on the container and there was no thermometer in the refrigerator and no refrigerator temperature log for the month of April 2026. LPN #296 stated the resident refrigerator should have all resident foods labeled with the resident's name, date opened and the food item. Additionally, LPN #296 verified there should be a thermometer in the refrigerator to monitor the temperature daily and the temperatures recorded on a log. Observation on 04/23/26 at 12:20 P.M. of the Magnolia Unit resident refrigerator revealed five small cups of an unidentified brown substance. There was no label indicating the contents of the cups. Concurrent interview with LPN #398 verified the resident refrigerator had five small cups of an unknown brown substance that had no label to identify the contents. LPN #398 confirmed the cups should have had the food item labeled on the container. Observation on 04/23/26 at 12:30 P.M. of the [NAME] Bay Unit resident refrigerator revealed ten small cups of an unidentified brown substance. There was no label indicating the contents of the cups. Concurrent interview with Registered Nurse (RN) #283 verified the resident refrigerator had ten small cups of an unidentified brown substance. RN #283 confirmed the cups should have been labeled with the contents. Observation on 04/23/26 at 12:33 P.M. of the Spring Cove Unit resident refrigerator revealed there was no thermometer in the freezer compartment. The refrigerator temperature log was missing recorded temperatures on 04/21/26 and 04/22/26. Additionally, there were 11 unlabeled small cups of an unidentified brown and yellow substance and an open liquid coffee creamer that was unlabeled. Further observation revealed a sign on the exterior of the refrigerator stating to date and label all foods. Concurrent interview with LPN #398 verified there was no thermometer in the freezer, the refrigerator temperature log was not completed for the dates of 04/21/26 and 04/22/26 and the food items should have been labeled. Interview on 04/23/26 at 3:15 P.M. with Division Director of Risk Management (DDRM) #319 verified foods stored in the resident refrigerators on each unit should have foods dated and labeled, a thermometer in refrigerator compartment and daily refrigerator temperatures monitored and recorded on a temperature log maintained on the exterior of the refrigerator. DDRM #319 stated only resident foods should be stored in the resident refrigerators. Review of the facility policy titled, Storage of Resident Food, undated, revealed the facility would monitor refrigerated food storage daily, date the food container and foods would be stored in a labeled container.

Based on medical record review, resident representative and staff interview and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure care conferences were held with the interdisciplinary team (IDT) and further failed to ensure resident representatives had the opportunity to participate in care conferences. This affected five (#6, #69, #83, #105, and #127) of seven residents reviewed for care conferences. The facility census was 141.Findings include:1. Review of the medical record revealed Resident #6 was admitted on [DATE] with diagnoses of vascular dementia, chronic obstructive pulmonary disease, adult failure to thrive, alcohol abuse, atrial fibrillation, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was severely cognitively impaired. Further review of Resident #6's electronic medical record (EMR) revealed the last documented care conference was on 07/08/25. Interview on 04/20/26 at 11:01 A.M. with Resident #6's representative revealed she had only been invited to one care conference for the resident and it had been a while ago. She was unsure if they still had care conferences. Interview on 04/21/26 at 11:33 A.M. with Social Services Director (SSD) #395 verified that a care conference had not been conducted since 07/08/25 for Resident #6. Interview on 04/23/26 at 1:57 P.M. with Division Director of Risk Management (DDRM) #319 revealed the facility did not have a policy regarding care conferences. 2. Review of the medical record for Resident #105 revealed he was admitted to the facility on [DATE] with diagnoses including Alzheimer's, vascular dementia, major depressive disorder, violent behaviors, Type II diabetes, chronic kidney disease, and restlessness and agitation. Review of the MDS assessment dated [DATE] revealed Resident #105 was cognitively impaired. Review of the Social Services note dated 11/07/25 revealed the SSD called the resident's spouse to confirm a care conference for 11/13/25 at 1:45 P.M. via phone. Further review of the medical record revealed no documentation a care conference ever occurred. Interview on 04/19/26 at 1:54 P.M. with Resident #105's wife revealed she had not been asked to attend a care conference and she had a lot of questions about the resident's current condition. Interview on 04/22/26 at 7:41 A.M. with the Administrator verified there was no evidence of care conferences being held for Resident #105. 3. Review of the medical record for Resident #127 revealed an admission date of 03/10/26 with diagnoses including Alzheimer's disease, vascular dementia, chronic kidney disease and Type II diabetes. Review of the MDS assessment dated [DATE] revealed Resident #127 was cognitively impaired. Review of the 72-hour summary dated 03/16/26 revealed a message was left with Resident #127's Power of Attorney (POA) to schedule a care conference. Further review of the medical record revealed no documentation of a care conference occurring for Resident #127. Interview on 04/22/26 at 7:41 A.M. with Administrator verified there was no evidence of a care conference being held for Resident #127. 4. Review of the medical record for Resident #69 revealed an admission date of 02/20/25 with diagnoses including, but not limited to, Alzheimer's disease with late onset and dementia with behavioral disturbances. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #69 was severely cognitively impaired. Review of the MDS schedule revealed assessments were completed for Resident #69 on 04/02/25, 07/03/25, 10/03/25, 10/28/25, 01/12/26 and 04/14/26. Review of the care conference progress notes for Resident #69 revealed a care conference was held with family on 03/07/25, 06/17/25 and 01/13/26. Interview on 04/23/26 at 1:57 P.M. with DDRM #319 confirmed care conferences were not held quarterly with Resident #69's representative and further verified the facility did not conduct care conferences per the recommendations of the RAI Manual. 5. Review of the medical record for Resident #83 revealed an admission date of 02/27/25 with diagnoses including, but not limited to, Parkinson's disease, hypertension, peripheral vascular disease and diabetes mellitus. Review of the quarterly MDS assessment dated [DATE] revealed Resident #83 was severely cognitively impaired. Further review of the medical record revealed no evidence of a care conference being held since Resident #83's admission on [DATE]. Interview on 04/23/26 at 1:57 P.M. with DDRM #319 confirmed there was no evidence of a care conference being held for Resident #83 and further verified the facility did not conduct care conferences per the recommendations of the RAI. Review of the RAI Manual, dated October 2025, revealed the flow included assessment, decision making, identification of outcomes, care planning, implementation, and evaluation. Further review revealed care planning established a course of action with input from the resident (resident's family and/or guardian or other legally authorized representative), resident's physician and IDT that moved a resident toward resident-specific goals utilizing individual resident strengths and interdisciplinary expertise; crafting the how of resident care.

Based on record review, observation, interview, and policy review, the facility failed to treat residents with dignity while providing feeding assistance. This affected two (#66 and #134) of three residents reviewed for dignity. The facility census was 141. Findings include:1. Review of the medical record for Resident #66 revealed an admissions date of 01/05/26 with diagnoses including cerebral ischemia, vascular dementia, dementia, transient cerebral ischemic, cerebral infraction, altered mental status, and need assistance with personal care. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively impaired and required substantial or maximal assistance with eating. Review of the current care plan for Resident #66 revealed he had the potential for altered nutritional status. Interventions included providing assistance with meals as needed. Observation of the lunch service on 04/22/26 at approximately 12:45 P.M. revealed Certified Nursing Assistant (CNA) #244 was sitting at a dining table with Resident #66 and assisting with his meal. CNA #244 left the table to help another resident with personal care. Continued observation revealed at 1:00 P.M., CNA #244 returned to the table to assist Resident #66 and remained standing next to him while assisting him with eating the rest of his meal. Interview on 04/22/26 at 1:05 P.M. with CNA #244 verified she was standing up while assisting Resident #66 and that she should have been seated with the resident. 2. Review of the medical record revealed Resident #134 admitted to the facility on [DATE] with diagnoses including vascular dementia, Type II diabetes, altered mental status, adjustment disorder with depressed mood, muscle weakness, cognitive communication deficit, and dysphagia. Review of the MDS assessment dated [DATE] revealed Resident #134 was cognitively impaired and required supervision while eating. Review of the current care plan revealed Resident #143 had a Activities of Daily Living (ADLs) self-care performance deficit related to cognitive deficit, disease process, and functional deficit. Interventions included eating supervision or touching assist, helper cues, and/or touches/steadies resident. Observation on 04/19/26 at 12:46 P.M. revealed Medical Records Coordinator (MRC) #355 was standing next to Resident #134 while feeding him his meal.Interview on 04/19/26 at 12:50 P.M. with MRC #355 verified she stood over Resident #134 while assisting him with eating instead of being seated with the resident. Interview on 04/19/26 at 12:53 P.M. with Licensed Practical Nurse (LPN) #325 revealed Resident #134 had a recent decline where he would sit and stare instead of eating at meals times. LPN #325 stated staff had been feeding him at the start of meals to gain his interest and then Resident #134 would normally start to feed himself. Review of the undated facility policy titled, Resident Rights, revealed residents would be treated with respect and dignity. This deficiency represents non-compliance investigated under Complaint Numbers 2669811 and 2642807.

Based on medical record review, observations, staff interviews and review of the facility policy, the facility failed to ensure fall interventions were implemented. This affected two (#13 and #83) of eight residents reviewed for falls. The facility census was 141. Findings include:1. Review of the medical record for Resident #13 revealed an admission date of 03/04/25 with diagnoses including, but not limited to, Alzheimer's disease with late onset. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was severely cognitively intact. Resident #13 required maximum assistance from staff for bed mobility and transfers and had two or more falls without serious injury. Review of the current plan of care revealed Resident #13 was at risk for falls related to weakness, unsteady ambulation, and pain. Interventions included assessment for fall risk on admission, readmission and quarterly, encourage hipsters (shock-absorbing foam or plastic pads designed to protect the hips from fractures during side-impact falls) as resident allowed and may remove for hygiene purposes, encourage resident to be in common area while awake, ensure resident's room was free of potential visible hazards, bed locks engaged, neurological (neuro) checks if falls were unwitnessed, and perimeter mattress to bed. Observation on 04/22/26 at 4:44 P.M. revealed Resident #13 was not wearing hipsters. Concurrent interview with Licensed Practical Nurse (LPN) #292 verified Resident #13 was not wearing hipsters and should have them on as a fall intervention when she was out of bed and ambulating. Interview on 04/22/26 at 4:46 P.M. with Certified Nursing Assistant (CNA) #274 revealed Resident #13 had the hipsters on earlier today, but they were soiled and sent to the laundry. CNA #13 confirmed Resident #13 did not have hipsters on because they did not have any available to apply. Observation on 04/22/26 at 4:50 P.M. revealed Registered Nurse (RN) #401 checked the supply room and returned to advised CNA #274 that the facility did not have any additional hipsters in the stock room. 2. Review of the medical record for Resident #83 revealed an admission date of 02/27/25 with diagnoses including, but not limited to, Parkinson's disease, hypertension, peripheral vascular disease and diabetes mellitus. Review of the quarterly MDS assessment dated [DATE] revealed Resident #83 was severely cognitively impaired. Resident #83 required maximum assistance from staff with bed mobility and transfers. Review of the current plan of care for Resident #83 revealed the resident was at risk for falls related to disease process, gait and balance problems, and history of falls. Interventions included assessing risk for falls on admission, quarterly and as needed, ensure bed locks were engaged, hipsters, perimeter mattress, and neuro checks if fall was unwitnessed. Review of a post fall follow up progress assessment dated [DATE] revealed Resident #83 had a fall, and it was not known what was happening at the time of the fall. Hipsters were added as an intervention. Observation on 04/22/26 at 4:20 P.M. of Resident #83 revealed the resident did not appear to have hipsters on. Interview on 04/22/26 at 4:24 P.M. with CNA #252 verified Resident #83 did not have hipsters on. Interview on 04/22/26 at 4:31 P.M. with LPN #292 confirmed hipsters were a fall intervention for Resident #83 and further verified the resident did not have them on. Review of the facility policy titled Fall Prevention and Management, undated revealed if a resident was identified to be at risk for falls, a care plan should be initiated that included a plan to potentially diminish the risk for falls. The care plan should be reviewed and updated as needed with each change of condition. This deficiency represents non-compliance investigated under Complaint Numbers 2967069 and 2642807.

Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure personal protective equipment (PPE) was readily accessible for residents on enhanced barrier precautions (EBP). This affected two (#2 and #50) of four residents reviewed for transmission-based precautions (TBP). The facility census was 141.Findings include:1. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, Type II diabetes, and post-traumatic stress disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively impaired. Review of the physician orders revealed Resident #2 had an order dated 02/23/26 for EBP for infection control. Observation on 04/20/26 at 10:00 A.M. revealed a sign posted outside of Resident #2's room indicating the resident was on EBP. Further observation revealed no PPE was readily accessible near the resident's room. Interview on 04/20/26 at 11:09 A.M. with Registered Nurse (RN) #321 verified Resident #2 was on EBP due to a wound. RN #321 confirmed no PPE was readily accessible and there was none at the entrance of the resident's room. Observation on 04/20/26 at 11:14 A.M. revealed RN #321 began gathering PPE supplies for Resident #2. RN #321 asked staff at the nurses' station where he could find PPE and he was instructed to check central supply. Observation on 04/20/26 at 11:23 A.M. revealed there was still no PPE available at Resident #2's room. Concurrent interview with RN #321 revealed he was waiting on another nurse to bring PPE supplies. Observation on 04/20/26 at 11:30 A.M. revealed RN #321 was stocking a PPE cart outside of Resident #2's room with gowns, gloves, and hand sanitizer. 2. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including vascular dementia and end stage renal disease. Review of the MDS assessment dated [DATE] revealed Resident #50 was cognitively impaired. Review of the physician orders revealed Resident #50 had an order dated 12/17/24 for EBP related to dialysis port. Observation on 04/20/26 at 10:00 A.M. revealed a sign posted outside of Resident #50's room indicating the resident was on EBP. Further observation revealed no PPE was readily accessible near the resident's room. Interview on 04/20/26 at 11:09 A.M. with Registered Nurse (RN) #321 verified Resident #50 was on EBP due to having a dialysis port. RN #321 confirmed no PPE was readily accessible and there was none at the entrance of the resident's room. Observation on 04/20/26 at 11:14 A.M. revealed RN #321 began gathering PPE supplies for Resident #50. RN #321 asked staff at the nurses' station where he could find PPE and he was instructed to check central supply. Observation on 04/20/26 at 11:23 A.M. revealed there was still no PPE available at Resident #50's room. Concurrent interview with RN #321 revealed he was waiting on another nurse to bring PPE supplies. Observation on 04/20/26 at 11:30 A.M. revealed RN #321 was stocking a PPE cart outside of Resident #50's room with gowns, gloves, and hand sanitizer. Review of the undated facility policy titled, Enhanced Barrier Precautions, revealed gowns, gloves, and hand sanitizer should be readily accessible to staff.

Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure resident weights were obtained to monitor for weight loss. This affected one (#20) of seven residents reviewed for nutrition. The facility census was 141. Findings include: Medical record review for Resident #20 revealed an admission date of 01/20/26 with diagnoses including, but not limited to, fracture of unspecified part of right femur, acute posthemorrhagic anemia, and atrial fibrillation. Review of the significant change Minimum Data set (MDS) assessment dated [DATE] revealed Resident #20 was severely cognitively impaired. Resident #20 was coded for coughing and choking during meals or when swallowing medications and holding food in mouth or cheeks after meals. Resident #20 had no significant weight loss or gain and weighed 100 pounds. Review of the plan of care, dated 02/02/26 and without revision, revealed Resident #20 was at risk for dehydration related to cognitive or functional impairment, decreased kidney function, and protein calorie malnutrition. Interventions included administering medications as ordered, nutritional consult on admission, quarterly and as needed, obtain weights, and diet, oral care, and speech therapy as ordered or needed. Review of the recorded weights for Resident #20 revealed weights were obtained on 01/26/26, 02/05/26, 02/09/26, 02/10/26, and 02/16/26. The resident's documented weight on 01/26/26 was 100.8 pounds (lbs) and her weight on 02/16/26 was 99.8 lbs.Review of the admission nutritional assessment dated [DATE] revealed Resident #20 received a regular diet with an average intake of 50 percent (%). Assessment notes indicated intakes were likely not adequate to meet estimated energy needs and fortified pudding at lunch and house supplement two times a day would be added.Review of a progress note dated 02/24/26 revealed Resident #20 was transferred to the hospital for evaluation of a displaced fracture of the right femoral hip. Review of a progress note dated 03/04/26 revealed Resident #20 was readmitted to the facility. Review of the nursing admission note dated 03/04/26 at 7:46 P.M. revealed no documented admission weight for Resident #20. Review of the post hospital visit dated 03/05/26 and completed by the Nurse Practitioner (NP) revealed the resident was readmitted post-surgical repair of a fracture of the right femur following a fall at the facility. Further review revealed the resident's weight was automatically (auto) populated from the last documented weight in the electronic medical record (EMR) on 02/16/26, at which time the resident weighed 99.8 lbs.Review of the NP progress note dated 03/06/26 revealed a follow-up post hospitalization visit. The progress note stated no acute concerns were reported by staff. Oral intakes and vital signs remained stable. The resident's weight was auto populated from the weight obtained on 02/16/26 at 99.8 lbs.Review of the NP progress note dated 03/09/26 revealed a follow-up post hospitalization visit. The resident's weight was auto populated from the weight obtained on 02/16/26 at 99.8 lbs. Review of the NP progress note dated 03/11/26 revealed a follow-up post hospitalization visit. The progress note stated no acute concerns had been reported by staff. The resident's weight auto populated from the weight obtained on 02/16/26 at 99.8 lbs.Further review of Resident #20's weights revealed the next documented weight was on 04/02/26, at which time the resident weighed 93.8 lbs. On 04/07/26, Resident #20 weighed 93.0 lbs.Review of the NP progress note dated 04/08/26 revealed Resident #20 was seen for an acute visit for evaluation of constipation. Staff reported chronically poor intake, which remained unchanged. Physical appearance notable for temporal wasting, chronic poor oral intake and ongoing weight loss. Further review revealed the NP documented a diagnosis of cachexia and appreciation for dietary recommendations, assist with feeding, and monitor weekly weights. Additional review of Resident #20's documented weights revealed on 04/13/26, the resident weighed 93.4 lbs.Review of the dietary progress noted dated 04/14/26 at 2:38 P.M. revealed a weight change warning for Resident #20. Dietary preferences were updated per resident's family with salads being added two times a day and bananas three times a day. Review of the Nutrition at Risk (NAR) note dated 04/16/26 at 1:43 P.M. revealed Resident #20 had weight loss since 01/26/26, due to low oral intake. Observation on 04/20/26 at 12:19 P.M. revealed Resident #20 was independently ambulating throughout the unit. Resident #20 appeared very thin. Interview on 04/22/26 at 3:29 P.M. with Corporate Registered Nurse (CRN) #319 revealed weights should be obtained upon readmission. CRN #319 verified the facility did not obtain a weight upon Resident #20's readmission to the facility on [DATE] to adequately monitor the resident for weight loss. Review of the facility policy titled, Resident Height and Weight, undated, revealed on admission, the resident would be weighed within 24 hours and documented in the electronic health record. This deficiency represents non-compliance investigated under Complaint Number 2738781.

Based on interviews, review of resident funds accounts, closed medical record review and policy review, the facility failed to ensure timely distribution of personal funds account balances after discharge. This affected one (#146) of three residents reviewed for personal funds accounts. The facility census was 141. Findings include: Review of the closed medical record for Resident #146 revealed an admission date of 7/24/23 and a discharge date of 08/27/25. Diagnoses included, but not limited to, Alzheimer's disease with late onset. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #146 revealed a brief interview of mental status (BIMS) score of three, indicating severely impaired cognition. Review of the plan of care for Resident #146, dated 08/01/23 and revised on 07/01/25, revealed the resident had a communication problem related to disease condition including Alzheimer's disease, dementia with behavioral disturbances and psychotic disorder with delusions. Interventions include allowing for adequate response time, repeat as necessary, request feedback and clarification to ensure understanding and ask simple brief questions. Review of the resident fund management services ledger for Resident #146 revealed an account balance of $179.33 at the time of discharge on [DATE]. Further review revealed the account was closed on 10/03/25 (37 days after discharge) with check number 3056 being issued for 179.33 to Resident #146. Interview on 04/23/26 at 3:17 P.M. with Regional Business Office Manager (RBOM) #550 verified the account for Resident #146 was not closed and the refund issued within the required 30 days after discharge. Review of the facility policy titled, Resident Rights, undated, revealed the facility would return the resident's funds within 30 days. This deficiency represents non-compliance investigated under Complaint Number 2642807.

Based on medical record review, incident investigation documents, staff interview, and policy review, the facility failed to ensure medical records were complete and accurate. This affected two (#17 and #30) of three residents reviewed for medical record content. The facility census was 141. Findings Include: 1. Review of the medical record for Resident #17 revealed an admitted [DATE]. Diagnoses included encephalopathy, dementia, violent behavior, generalized anxiety, heart failure, malnutrition, and cellulitis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively impaired. Review of Resident #17's progress note created 01/17/25, and back dated to 01/13/25 at 3:06 P.M., titled, Post Fall Evaluation, revealed a fall occurred on 01/13/25. Review of a progress note created 01/17/25, and back dated to 01/13/25 at 3:28 P.M., titled Nurses Note, revealed a head-to-toe assessment was completed and range of motion (ROM) for all extremities were within normal limits. There was no complaints of pain and neurological checks were initiated at that time. Review of Resident #17's electronic medical record revealed no documentation of neurological checks completed related to the incident. Review of a fracture investigation file revealed a paper document titled, Neurological Assessment, dated 01/13/25 through 01/18/25. The document was signed and initialed by Licensed Practical Nurse (LPN) #203, LPN #325, and Director of Nursing (DON) #257 and was fully completed. Interview with on 03/06/25 at 9:47 A.M. with LPN #203 revealed she never completed any documentation for Resident #17's incident on 01/13/25, 01/14/25, 01/15/25, or 01/16/25. LPN #203 confirmed the signature and initials on Resident #17's document titled, Neurological Assessment, were not hers and further stated she had never seen that document before and had no knowledge of Resident #17 having had a fall on 01/13/25. Interview with on 03/06/25 at 11:42 A.M. with LPN #325 revealed she also had no knowledge of the document titled, Neurological Assessment, for Resident #17. LPN #325 revealed she was unaware of Resident #17 having had any incident on 01/13/25. 2. Review of the medical record for Resident #30 revealed an admitted [DATE]. Diagnoses included peripheral neuropathy, vascular dementia, Alzheimer's disease, dementia, cerebral atherosclerosis, and anxiety. Review of the MDS assessment dated [DATE] revealed Resident #30 was cognitively impaired. Review of Resident #30's progress notes dated 02/20/25 to 02/26/25 revealed no documentation of behavioral outbursts, the resident banging on the door, or swinging her walker. The progress notes also did not include any documentation or mention of an injury being identified, contacting the physician, or getting an order for an x-ray. Review of Resident #17's progress note dated 02/27/25 at 11:09 P.M. revealed staff reviewed an x-ray and found a fracture of the distal phalanx of the left fourth digit with a plan to continue to manage pain with medications. Review of Resident #17's fracture incident investigation revealed a questionnaire that indicated the resident reported she was in her doorway when another resident tried to go in her room, so she used her walker to block the door, and smashed her hand between the walker and the door. Interview on 03/05/25 at approximately 3:40 P.M. with Regional Director of Operations (RDO) #400 revealed she was not involved with Resident #17's investigation and did not know specific details of how the injury occurred. RDO #400 confirmed the resident's medical record did not contain any details about behavioral incidents or injuries and also did not include any information about staff identifying a change in condition. RDO #400 confirmed the only notations in the resident's medical record included the x-ray results. Review of the undated facility policy titled, Clinical Documentation Standards, revealed the facility shall maintain the integrity and quality of medical records. A complete record contains accurate and functional representation of the actual experience of the resident and must contain enough information to show the status of the resident was known. Staff shall follow basic standards of documentation including timely and accurate. This deficiency represents an incidental finding discovered during investigation under Complaint Number OH00162164.

Based on medical record review, staff interview, review of investigation documents, and review of self-reported incidents, the facility failed to report injuries of unknown origin in a timely manner. This affected two (#17 and #30) of two residents reviewed for injuries of unknown origin. The facility census was 141. Findings Include: 1. Review of the medical record for Resident #17 revealed an admitted [DATE]. Diagnoses included encephalopathy, dementia, violent behavior, generalized anxiety, heart failure, malnutrition, and cellulitis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was assessed as cognitively impaired. Review of Resident #17's progress note created 01/17/25, and back dated to 01/13/25 at 3:06 P.M., titled Post Fall Evaluation, revealed documentation that a fall occurred on 01/13/25. The Post Fall Evaluation revealed vital signs were refused by Resident #17 and no injuries were noted. Review of a progress note created 01/17/25, and back dated to 01/13/25 at 3:28 P.M., titled Nurses Note, revealed a head-to-toe assessment was completed and range of motion (ROM) for all extremities were within normal limits. There were no complaints of pain at that time and neurological checks were initiated. Review of a progress note titled Nurses Note, created and completed on 01/16/25 at 3:55 P.M., revealed Resident #17 complained of pain to the right lower extremity during care, the physician and family were notified, an x-ray was ordered and performed, and the pain medication acetaminophen was ordered and administered. Review of a Nurses Note dated 01/16/25 at 10:39 P.M. revealed Resident #17's x-ray results were obtained, and a proximal femoral fracture was reported. The physician was notified of the findings and orders were obtained to send the resident to hospital. Review of a fracture incident investigation dated 01/16/25 revealed Resident #17 had no pain and had full ROM after the fall on 01/13/25. There was no pain or discomfort reported until 01/16/25. Interview with Director of Nursing (DON) #257 on 03/06/25 at 8:55 A.M. revealed no investigation was completed as an injury of unknown origin for possible causes of Resident #17's fractured femur when it was discovered on 01/16/25. DON #257 indicated Resident #17's fractured femur to the fall on 01/13/25. Interview with Licensed Practical Nurse (LPN) #203 on 03/06/25 at 9:47 A.M. revealed the cause of Resident #17's fractured femur on 01/16/25 was unknown due to no documented incidents prior to 01/16/25. Interview on 03/06/25 at 2:00 P.M. with Regional Risk Manager #399 acknowledged an investigation for an injury of unknown origin should have been completed and reported for Resident #17 related to the fracture found on 01/16/25. 2. Review of the medical record for Resident #30 revealed an admitted [DATE]. Diagnoses included peripheral neuropathy, vascular dementia, Alzheimer's disease, dementia, cerebral atherosclerosis, and anxiety. Review of the MDS assessment dated [DATE] revealed Resident #30 was assessed as cognitively impaired. Review Resident #30's progress notes dated between 02/20/25 to 02/26/25 revealed no mention of behavioral outbursts, the resident banging on the door, or swinging her walker. Further review of the progress notes revealed no documentation of an injury being identified, contacting the physician, or getting an order for an x-ray. Review of a progress note dated 02/27/25 at 11:09 P.M. revealed review of an x-ray found a fracture of the distal phalanx of the left fourth digit with a plan to continue to manage pain with medications. Review of a fracture incident investigation related to the fracture identified on 02/27/25 revealed a questionnaire that indicated Resident #30 reported she was in her doorway when another resident tried to go in her room, so she used her walker to block the door and smashed her hand between the walker and the door. Review of a statement from Regional Director of Operations (RDO) #400 to DON #257 dated 02/27/25 revealed she met with Resident #30 and the team ordered an x-ray of the resident's finger. The statement also revealed Resident #30's ring finger had bruising. Interview on 03/05/25 at approximately 3:10 P.M. with DON #257 revealed the investigation was completed by RDO #400 and she was not familiar with the details. DON #257 revealed she was not sure if another resident was involved or not. Interview on 03/05/25 at approximately 3:40 P.M. with RDO #400 revealed she was not involved with the investigation and was unsure who completed it. RDO #400 confirmed she was not aware of any other residents being involved and just talked with Resident #30 on the day the x-ray was ordered. DON #257 confirmed a self-reported incident was not reported. Interview on 03/06/25 at 1:50 P.M. with Regional Risk Manager #399 acknowledged since Resident #30 was assessed with severely impaired cognition and had an unwitnessed injury as evidence by the fracture to the distal phalanx of the left fourth digit discovered on 02/27/25. Regional Risk Manager #399 confirmed the facility did not report the injury as a self-reported incident. Review of facility self-reported incidents between 01/01/25 and 03/05/25 revealed no reports were made to the state agency regarding Resident #30's injury on 02/27/25. Review of an undated facility policy titled, Abuse, Neglect, and Misappropriation, revealed the facility shall identify and report incidents timely and accurately. Each occurrence of a resident incident, bruise and injury of unknown origin shall be reported timely. A suspected abuse investigation (including injury of unknown origin) shall be initiated and reported to the Administrator or designee and the Executive Director shall report to the appropriate agencies. If the incident involves serious bodily injury the facility shall report within two hours (to the state agency). This deficiency represents non-compliance investigated under Complaint Number OH00162164.

Based on medical record review, staff interview, review of investigation documents, and review of self-reported incidents, the facility failed to thoroughly investigate injuries of unknown origin in a timely manner. This affected two (#17 and #30) of two residents reviewed for injuries of unknown origin. The facility census was 141. Findings Include: 1. Review of the medical record for Resident #17 revealed an admitted [DATE]. Diagnoses included encephalopathy, dementia, violent behavior, generalized anxiety, heart failure, malnutrition, and cellulitis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was assessed as cognitively impaired. Review of Resident #17's progress note created 01/17/25, and back dated to 01/13/25 at 3:06 P.M., titled Post Fall Evaluation, revealed documentation that a fall occurred on 01/13/25. The Post Fall Evaluation revealed vital signs were refused by Resident #17 and no injuries were noted. Review of a progress note created 01/17/25, and back dated to 01/13/25 at 3:28 P.M., titled Nurses Note, revealed a head-to-toe assessment was completed and range of motion (ROM) for all extremities were within normal limits. There were no complaints of pain at that time and neurological checks were initiated. Review of a progress note titled Nurses Note, created and completed on 01/16/25 at 3:55 P.M., revealed Resident #17 complained of pain to the right lower extremity during care, the physician and family were notified, an x-ray was ordered and performed, and the pain medication acetaminophen was ordered and administered. Review of a Nurses Note dated 01/16/25 at 10:39 P.M. revealed Resident #17's x-ray results were obtained, and a proximal femoral fracture was reported. The physician was notified of the findings and orders were obtained to send the resident to hospital. Review of a fracture incident investigation dated 01/16/25 revealed Resident #17 had no pain and had full ROM after the fall on 01/13/25. There was no pain or discomfort reported until 01/16/25. Interview with Director of Nursing (DON) #257 on 03/06/25 at 8:55 A.M. revealed no investigation was completed as an injury of unknown origin for possible causes of Resident #17's fractured femur when it was discovered on 01/16/25. DON #257 indicated Resident #17's fractured femur to the fall on 01/13/25. Interview with Licensed Practical Nurse (LPN) #203 on 03/06/25 at 9:47 A.M. revealed the cause of Resident #17's fractured femur on 01/16/25 was unknown due to no documented incidents prior to 01/16/25. Interview on 03/06/25 at 2:00 P.M. with Regional Risk Manager #399 acknowledged an investigation for an injury of unknown origin should have been completed and reported for Resident #17 related to the fracture found on 01/16/25. 2. Review of the medical record for Resident #30 revealed an admitted [DATE]. Diagnoses included peripheral neuropathy, vascular dementia, Alzheimer's disease, dementia, cerebral atherosclerosis, and anxiety. Review of the MDS assessment dated [DATE] revealed Resident #30 was assessed as cognitively impaired. Review Resident #30's progress notes dated between 02/20/25 to 02/26/25 revealed no mention of behavioral outbursts, the resident banging on the door, or swinging her walker. Further review of the progress notes revealed no documentation of an injury being identified, contacting the physician, or getting an order for an x-ray. Review of a progress note dated 02/27/25 at 11:09 P.M. revealed review of an x-ray found a fracture of the distal phalanx of the left fourth digit with a plan to continue to manage pain with medications. Review of a fracture incident investigation related to the fracture identified on 02/27/25 revealed a questionnaire that indicated Resident #30 reported she was in her doorway when another resident tried to go in her room, so she used her walker to block the door and smashed her hand between the walker and the door. Review of a statement from Regional Director of Operations (RDO) #400 to DON #257 dated 02/27/25 revealed she met with Resident #30 and the team ordered an x-ray of the resident's finger. The statement also revealed Resident #30's ring finger had bruising. Interview on 03/05/25 at approximately 3:10 P.M. with DON #257 revealed the investigation was completed by RDO #400 and she was not familiar with the details. DON #257 revealed she was not sure if another resident was involved or not. Interview on 03/05/25 at approximately 3:40 P.M. with RDO #400 revealed she was not involved with the investigation and was unsure who completed it. RDO #400 confirmed she was not aware of any other residents being involved and just talked with Resident #30 on the day the x-ray was ordered. DON #257 confirmed a self-reported incident was not reported. Interview on 03/06/25 at 1:50 P.M. with Regional Risk Manager #399 acknowledged since Resident #30 was assessed with severely impaired cognition and had an unwitnessed injury as evidence by the fracture to the distal phalanx of the left fourth digit discovered on 02/27/25. Regional Risk Manager #399 confirmed the facility did not report the injury as a self-reported incident. Review of facility self-reported incidents between 01/01/25 and 03/05/25 revealed no reports were made to the state agency regarding Resident #30's injury on 02/27/25. Review of an undated facility policy titled, Abuse, Neglect, and Misappropriation, revealed the facility shall identify and report incidents timely and accurately. Each occurrence of a resident incident, bruise and injury of unknown origin shall be reported timely. A suspected abuse investigation (including injury of unknown origin) shall be initiated and reported to the Administrator or designee and the Executive Director shall report to the appropriate agencies. If the incident involves serious bodily injury the facility shall report within two hours (to the state agency). This deficiency represents non-compliance investigated under Complaint Number OH00162164.

Based on medical record review, observations, staff interviews, review of facility policy, and review of facility documents, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed as being at risk for elopements did not elope from the facility. Additionally, the facility failed to ensure ordered elopement interventions were in place. This affected one (#1) of three residents reviewed for elopement. The census was 144. Findings include: Review of Resident #1's medical record revealed an admitted [DATE]. Diagnoses listed included erectile dysfunction, alcohol abuse, hypertension, dementia, anxiety, and congestive heart failure. Review of a brief interview for mental status (BIMS) assessment dated [DATE] revealed Resident #1 was severely impaired with score or three out of a possible 15. Review of a admission nursing assessment dated [DATE] revealed Resident #1 was at risk for elopement. Review of Resident #1's care plan dated 08/29/24 revealed Resident #1 was at risk for elopement due to dementia with mood disturbance. An intervention of 1:1 (one on one supervision) was added on 08/30/24. Resident #1 required a secured unit due behaviors, elopement risk, and poor cognition. Review of facility investigative documents revealed Resident #1 was unable to be located in the facility by staff the morning of 08/30/24 at 8:00 A.M. when the nurse went to administer morning medications. Resident #1 was last seen by staff on 08/30/24 at 7:20 A.M. An elopement code was called on 08/30/24 at 8:10 A.M. and staff searched the facility and surrounding areas of the facility. Resident #1 was found near a local park on 08/30/24 at 8:19 A.M. Resident #1 returned to the facility on [DATE] at 8:30 A.M. Resident #1 did not have any injuries. Review of physician orders revealed an order dated 08/30/24 for Resident to be 1:1 at all times every shift for elopement risk. Observation on 09/03/24 at 10:25 A.M. revealed Resident #1 in his room in bed. Resident #1's room door was closed and could not be seen from the hallway. There was not a staff member observed in Resident #1's room. Observation on 09/03/24 at 10:30 A.M. revealed Resident #1 in his room in bed. Resident #1's room door was closed and could not be seen from the hallway. There was not a staff member observed in Resident #1's room. Interview with State tested Nursing Assistant (STNA) #180 and STNA #190 on 09/03/24 at 10:30 A.M. confirmed Resident #1 was ordered to be 1:1 supervision. STNA #180 and STNA #190 confirmed a staff member should be with Resident #1 at all times and there was a brief time that he was not being provided with 1:1 supervision. Interview with the Administrator on 09/03/24 at 10:38 A.M. confirmed Resident #1 had eloped from the facility on 08/30/24. Resident #1 was just admitted the prior evening. Resident #1 was found near a local park. The Administrator was unsure how Resident #1 had eloped. The Administrator confirmed Resident #1 was ordered to be 1:1. The Administrator confirmed the facility conducted an investigation but was unable to determine how Resident #1 eloped so Resident #1 was placed on 1:1 supervision. Interview with the Director of Nursing (DON) on 09/03/24 at 11:24 A.M. confirmed Resident #1 eloped from the building on 08/30/24. Resident #1 was last seen by staff on 08/30/24 approximately 7:30 A.M. Resident #1 was found by Nurse Practitioner (NP) #100 near a local park and returned to the facility on [DATE] at 8:25 A.M. Resident #1 was assessed and had no injuries. The DON confirmed Resident #1 was ordered to be 1:1 and that a staff member was not in his room when observed 09/03/24 at 10:25 and 10:30 A.M. Interview with Business Office Manager (BOM) #120 on 09/03/24 at 2:00 P.M. revealed she searched for Resident #1 when he eloped on 08/30/24. BOM #120 arrived to the location where Resident #1 was located at about the same time as NP #100. BOM #120 transported Resident #1 back to the facility. Resident #1 came back the facility willingly. Phone interview with Licensed Practical Nurse (LPN) #200 on 09/03/24 at 2:24 P.M. revealed she was the dayshift nurse on 08/30/24. LPN #200 was unable to find Resident #1 when she went to his room to get medications on 08/30/24 at approximately 7:30 A.M. LPN #200 informed STNA's who helped search the unit. Resident #1 was unable to be found so an elopement code was called and staff began searching the facility and surrounding areas. Resident #1 was found outside of the facility and returned on 08/30/24 at approximately 8:30 A.M. LPN #200 assessed Resident #1 upon his return and he did not have any injuries. LPN #200 denied hearing any exit alarms, seeing any windows open, or having any family members in the unit the morning on 08/30/24. Phone interview with LPN #150 on 09/03/24 at 2:32 P.M. revealed she was the night shift nurse on 08/29/24 to 08/30/24. LPN #120 reported last seeing Resident #1 on 08/30/24 at approximately 7:00 A.M. when reporting off to the day shift nurse. Resident #1 stuck his head out of his room. Resident #1 was a little restless during the night and walked around. LPN #120 denied seeing Resident #1 push on any doors or attempt to elope. LPN #120 did not hear any exit alarms on 08/29/24 or 08/30/24. LPN #120 was informed Resident #1 was missing form the facility while at a tanning salon and questioned when the last time she had seen him. Interview with NP #100 on 09/03/24 at 2:38 P.M. revealed she found Resident #1 near a local park on 08/30/24. Resident #1 was very pleasant, but confused. NP #100 had not yet seen Resident #1 at the facility before 08/30/24 and did not know him. NP #100 identified Resident #1 by a picture that was sent out by the facility. Resident #1 did not have any injuries. Resident #1 has been assessed and some medication have been adjusted. Review of the facility's undated policy Elopement Prevention and Management Overview revealed elopement is defined as when a resident/patient leaves the premises or a safe area without authorization and/or any necessary supervision and places the resident at risk for harm or injury. Post elopement procedures included complete and document a physical assessment of the resident/patient upon return to the facility to determine if further treatment is required, notify all parties of resident's return to the facility, review and revise the interventions related to prevention of elopement/missing resident, and communicate the modification of interventions to the caregiving staff, resident and/or resident representative. This deficiency represents non-compliance investigated under Complaint Number OH00157403.

Based on observation, medical record review, staff interviews, and policy review, the facility failed to follow infection control policies. This affected one (#30) out of three residents reviewed for enteral feedings. The facility census was 140. Findings include: Review of the medical record for Resident #30 revealed an admitted [DATE] with medical diagnoses of right sided hemiplegia status post cerebral infarction, Alzheimer's disease, adult failure to thrive (AFTT), diabetes mellitus, atrial fibrillation, and dysphagia. Review of the medical record for Resident #30 revealed an admission Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #30 was severely cognitively impaired and was dependent upon staff for toilet hygiene and bathing and required substantial staff assistance with dressing, transfers, and bed mobility. The MDS indicated Resident #30 received 51% or more proportion of total calories through parenteral or tube feeding. Review of the medical record for Resident #30 revealed a physician order dated 05/07/24 for nothing by mouth status (NPO) and orders dated 06/04/24 for Nepro 1.8 to provide 200 milliliter (ml) every four hours to provide 1200 ml formula per day via gastrointestinal tube (g-tube), 100 ml of water flush to g-tube before and after each tube feeding every four hours and enhanced barrier precautions (EBP) related to enteral tube when dressing/bathing, showering/transferring in room or therapy gym, during personal hygiene, changing linen, providing hygiene, changing briefs or assisting with toileting. Observation on 07/10/24 at 8:40 A.M. revealed Registered Nurse (RN) #275 administered bolus tube feeding to Resident #30. RN #275 obtained all the supplies for the administration, performed hand hygiene, and donned gloves. RN #275 administered bolus tube feeding, and water flushes as ordered. The observation revealed an EBP sign posted on Resident #30's door but no personal protective equipment (PPE) was located outside or inside of Resident #30's room. The observation revealed RN #275 did not don a gown prior to tube feeding administration. Interview on 07/10/24 at 9:06 A.M. with RN #275 confirmed Resident #30 had an order for EBP, an EBP sign was posted on Resident #30's door, and Resident #30's room did not contain PPE for staff use. RN #275 confirmed she donned gloves but did not don a gown prior to administering bolus tube feedings to Resident #30. Interview on 07/10/24 at 9:48 A.M. with Director of Nursing (DON) confirmed staff should follow EBP during administration of tube feedings via g-tube and all residents with orders for EBP should have PPE available in the resident rooms. Review of the facility policy titled, Enhanced Barrier Precautions, revealed EBP was an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs hand hygiene, targeted gown and glove use during high contact resident care activities that include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and wound care. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation, staff interview, medical record review, and policy review, the facility failed to administer enteral feeding (tube feeding) as ordered. This affected one (#137) out of the three residents reviewed for enteral feedings. The facility census was 140. Findings include: Review of the medical record for Resident #137 revealed an admitted [DATE] with medical diagnoses of dementia, chronic kidney disease stage III, hypertensive heart disease, dysphagia. Review of the medical record for Resident #137 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #137 had severe cognitive impairment and required substantial staff assistance for eating, dressing bed mobility and transfers. Review of the MDS revealed Resident #137 received 51% or more proportion of total calories through parenteral or tube feeding. Review of the medical record for Resident #137 revealed a physician order dated 01/28/24 for enteral feed order as needed for tube patency, check for residual prior to each intermittent feeding: if greater than or equal to 100 cubic centimeters (CC), hold tube feeding and check residual again in two hours and notify physician and/or nurse practitioner when appropriate. Review of the medical record revealed an order dated 04/09/24 for nothing by mouth (NPO) status and an order dated 06/23/24 for Jevity 1.5, 55 milliliter (ml) per hour for 22 hours via pump, on at 10 P.M., off when total volume of 1,210 ml infused. Review of the medical record for Resident #137 revealed a nurse progress note dated 07/10/24 at 11:58 A.M. which stated the tube feeding was placed on temporary hold at approximately 10:15 A.M. due to approximately 50 ml of residual volume. The note stated Resident #137 did not have any discomfort, abdomen was soft and round, placement checked, no distension noted, and not signs of distress noted. The note stated the nurse practitioner was notified, ordered to follow up within two hours and notified to continue the tube feeding. Observation on 07/10/24 at 8:40 A.M. of Resident #137 revealed tube feeding was being administered via pump at 55 ml per hour. Observation on 07/10/28 at 11:40 A.M. of Resident #137 revealed the tube feeding pump was turned off and Resident #137 was not receiving any tube feeding. Interview on 07/10/24 at 11:45 A.M. with Licensed Practical Nurse (LPN) #217 stated she had checked Resident #137's tube feeding residual at 10:15 A.M. and it was between 50-60 ml so she turned off the tube feeding for a little while. LPN #217 stated Resident #137 was not in any distress or showing any signs or symptoms of aspiration. LPN #217 stated the amount of tube feeding that had been infused was about 900 ml. Review of the facility policy titled, Enteral General Nutritional (tube feeding) Guidelines, stated continuous nutritional meals will utilize an electronic programmable pump to deliver the required amount of solution over time unless the physician and/or RD determined that the specific needs for a resident would require gravity with manual control instead of automated delivery using a pump. Continuous delivery provides for short, interrupted periods when nutrition is not being delivered such as during showers or other procedures or when the physician orders a temporary delivery stop but is not considered intermittent delivery. This deficiency represents non-compliance investigated under Complaint Number OH00155361.

Based on observations, staff interview, and review of facility policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This had the potential to affect 133 residents who received meals from the facility kitchen. The facility identified one Resident (#82) as receiving no food from the kitchen. The facility census was 134. Findings include: Observation of the kitchen during the initial kitchen tour on 04/09/24 at 8:10 A.M. with the Registered Dietician (RD)#801 and the Administrator and revealed the following: a) The reach in refrigerator contained thirteen bowls of salads with no label and/or date, nine cups of pears with no label and/or date, six cups of pureed fruit with no label and/or date, and a large fast-food container with no label and/or date. b) The kitchen floor under the dishwasher was dirty with dried food particles. c) There was an unknown black substance on the walls and under the appliances. d) The ceiling had an unknown brown substance splattered on it. e) A long metal table in front of the dishwasher had a large, rusted bottom shelf and the rusted shelf had chunks of metal missing. f) The trash receptacles had dried food debris and a dried, splattered substance running down the sides. g) The light fixtures above the dishwasher contained dead bugs. Interview with RD #801 on 04/09/24 at 8:20 A.M. confirmed the findings of the kitchen. Review of the facility policy titled, Environment, dated 09/2017, revealed all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. The Dining Services Coordinator will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. Review of the facility policy titled, Food Storage: Cold Food, dated 09/2017, revealed all foods will be stored wrapped or in covered containers, labeled and dated, arranged in a manner to prevent cross contamination.

Based on observations, record review, staff interviews, and review of facility policy, the facility failed to ensure medications were properly labeled with a date after being opened. This affected one (#58) resident of the four residents observed for medication administration. The facility also failed to ensure medications were discarded after their expiration date. This affected six (#10, #16, #21, #32, #124, and #236) residents of the 37 who received medication from the medication cart. The facility also failed to ensure medications were not left unattended at residents' bedside. This affected one (#1) resident of the one resident observed. The facility census was 134. Findings include: 1) Review of the medical record for Resident #58 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, type two diabetes mellitus (DM II), and chronic kidney disease stage three. Review of the physician's order dated 08/23/23 revealed Resident #58 was ordered to receive Insulin Glargine (long-acting insulin) subcutaneous solution 100 units/ milliliter (ml), inject 15 units subcutaneously in the morning for diabetes. Review of the physician's order dated 03/20/24 revealed Resident #58 was ordered to receive Humalog (short acting insulin) KwikPen subcutaneous solution injector 100 units/milliliter (ml), inject per sliding scale before meals and at bedtime. Observation of the Heatherwood medication cart on 04/11/24 at 3:50 P.M. with Registered Nurse (RN) #54 revealed Resident #58's Humalog KwikPen and the Insulin Glargine pen was opened and not dated. Interview with RN #54 at the same time verified Resident #58's insulin pens were opened but not labeled with an open date. 2) Observation of the Magnolia medication cart on 04/12/24 at 10:43 A.M. with RN #45 revealed a bottle of over the counter (OTC) Geri-knot (laxative) 8.6 milligrams (mg) with an expiration date of March 2024. Interview with RN #45 at the same time verified the bottle of Geri-knot 8.6 mg was expired. Review of the physician's orders for the residents on the Magnolia unit, revealed Residents #10, #16, #21, #32, #124, and #236 had orders to receive Geri knot 8.6 mg. 34291 3) Review of medical record for Resident #01 revealed an admitted [DATE]. Diagnoses included Dementia, cardiorespiratory conditions, atrioventricular block first degree, heart failure, peripheral vascular disease, and renal insufficiency. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 was cognitively intact. Observation of Resident #01's room on 04/12/24 at 9:54 A.M. revealed two white pills inside a clear plastic container sitting on the resident's bedside table. Interview with the Licensed Practical Nurse (LPN) #23 on 04/12/24 at 9:58 A.M. confirmed the two white pills on Resident #01's bedside table. LPN #23 confirmed she left the medication cup with two potassium pills at Resident #1's beside. LPN #23 stated she was supposed to watch the resident take the medication. Review of the facility policy titled, Storage of Medications, dated 09/2018 revealed medications and biologicals were stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply was accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The nurse would check the expiration date of each medication before administering it. All expired medications would be removed from the active supply and destroyed in accordance facility policy, regardless of amount remaining. The nurse shall place a date opened stick on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container would be 30 days from opening unless the manufacturer recommended another date or regulations/guidelines require different dating.

Based on record review, staff and resident interviews, and review of facility policy, the facility failed to ensure care conferences were completed. This affected three (#01, #15, and #91) residents of seven residents reviewed for care planning conferences. The census was 134. Findings include: 1) Review of the medical record for Resident #01 revealed an admitted [DATE]. Diagnoses included cardiorespiratory conditions, atrioventricular block first-degree, heart failure, peripheral vascular disease (PVD), renal insufficiency with dependency on dialysis, and non-Alzheimer's Dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #01 was cognitively intact. Review of the care conferences from 07/01/23 through 04/12/24 for Resident #01, revealed the resident had one care conference on 02/07/24 and the resident was noted to be out to dialysis during the care conference. Interview with Resident #01 on 04/10/24 at 7:56 A.M. revealed she was not having care conferences every three months. Interview with the Licensed Social Worker (LSW) #123 on 04/11/24 at 8:18 A.M. revealed there were set dates for care conferences, and they were on Tuesdays and Thursdays. LSW #123 stated these days were the same days Resident #01 was out to her dialysis appointments. LSW #123 stated the facility had care conference on these days whether the residents could attend or not. LSW #123 stated the care conferences were supposed to be every three months and confirmed Resident #01 did not have a care conference every three months. 2) Review of the medical record for Resident #15 revealed the resident was admitted on [DATE]. Diagnoses included coronary artery disease, heart failure, peripheral vascular disease (PVD), renal insufficiency, diabetes, Alzheimer's disease, and dementia. Review of the MDS assessment dated [DATE], revealed Resident #15 was moderately cognitively impaired. Review of care conferences from 07/17/23 through 04/08/24 for Resident #15, revealed the resident's last care conference was dated 07/17/23. Interview with the Resident #15 on 04/09/24 at 11:51 A.M. revealed he had not received any care conferences. Interview with LSW #123 on 04/10/24 at 2:01 P.M. confirmed Resident #15's last care conference was dated 07/17/23 and stated care conferences should be held every three months. 43062 3) Review of the medical record for Resident #91 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, conversion disorder, epilepsy, borderline personality disorder, major depressive disorder, asthma, diabetes mellitus, anxiety disorder, post-traumatic stress disorder (PTSD), congestive heart failure (CHF), and gastro-esophageal reflux disease (GERD). Further review of Resident #91's record revealed no documented information related to a care conference being completed. Review of the MDS assessment dated [DATE], for Resident #91 revealed the resident had impaired cognition. Interview with LSW #123 on 04/10/24 at 4:31 P.M. revealed Resident #91 should have a had care conference scheduled in December 2023. LSW #123 confirmed the facility failed to provide a care conference for the Resident #91. Review of the facility policy titled Process for Care Plan Meetings, undated, revealed the facility's MDS coordinator and the facility's Social Worker would meet to determine when to schedule a Resident's care conference. Social Services would be responsible to ensure the care plan meeting invitation was completed and sent to the resident and the responsible part. A copy of the letter was to be placed in the resident's chart and the facility would keep a copy of the invitation families/and resident for the scheduled care conference the Resident's record. A care plan note must be created at the time of the meeting which includes the attendees and placed in the resident's electronic medical record (EMR) under progress notes.

Based on record review, staff interviews, and observations, the facility failed to ensure ancillary services were provided to residents with hearing and visual impairments. This affected one (#116) resident out of two residents reviewed for hearing and vision. The facility census was 134. Findings include: Review of the medical record for Resident #116 revealed an admitted [DATE] with a readmission of 03/21/24. Diagnoses included parkinsonism, dementia, generalized anxiety disorder, and hypertension. Review of the personal items inventory log dated 11/10/23 for Resident #116 revealed the resident was admitted to the facility with hearing aids and two boxes of batteries. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #116 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of six. This resident was assessed to require supervision with eating, toileting, dressing, and transfers, and partial assistance with bathing. Review of section B for hearing, speech, vision of the Admission MDS dated [DATE] revealed Resident #116 had hearing aids. Review of the care plan dated 03/28/24 revealed Resident #116 had a communication problem related to sensorineural bilateral hearing loss. Interventions included offer interpretation services, staff to provide reading materials, movies, newspapers, and music in preferred language, staff to provide verbal education regarding equipment, treatments, and medications as needed and staff to refer resident to audiology for hearing consult as needed. Observations during the annual survey revealed Resident #116 was not wearing hearing aids and did not have them present in his room. Interview on 04/11/24 at 2:01 P.M. with the Administrator reported she was unaware Resident #116 had hearing aids. Interview on 04/12/24 at 10:07 A.M. with the Administrator revealed Resident #116 had bilateral hearing aids noted on his inventory log. Interview on 04/12/24 at 10:34 A.M. with Social Services Director (SSD) #123 revealed she was unaware Resident #116 had hearing aids upon admission. SSD #123 confirmed no ancillary referral services had been completed for Resident #16.

Based on record review, staff interviews, review of facility policy, review of pharmacy documents, and review of online resources from Medscape, the facility failed to ensure residents' antipsychotic medications were given with adequate indications for use. This affected three (#61, #71 and #104) residents out of five residents reviewed for unnecessary medications. The facility census was 134. Findings include: 1) Review of the medical record for Resident #104's revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia unspecified severity with other behavioral disturbance, generalized anxiety disorder, major depressive disorder, insomnia, alcohol dependence with alcohol induced persisting dementia, weakness, and muscle weakness. Review of the physician's order for Resident #104 dated 02/21/24, revealed the resident was ordered quetiapine fumarate (Seroquel) (anti-psychotic) 50 milligrams (mgs) by mouth at bedtime for agitation and Alzheimer's Disease. Review of the admission Minimum Data Set (MDS) assessment for Resident #104 dated 03/12/24 revealed the resident had severe cognitive impairment. Resident #104 was assessed as receiving anti-psychotic and anti-depressant medication during the MDS review period. Review of the anti-psychotic medication care plan for Resident #104 dated 03/13/24, revealed the resident would be provided anti-psychotic medications per the physician's orders. Interview with the Director of Nursing (DON) on 04/10/24 at 4:27 P.M. verified Resident #104 was ordered Seroquel 50 mg by mouth at bedtime for agitation and Alzheimer's Disease. Review of the facility's pharmacy documents from the Seroquel manufacturer's prescribing information dated 11/29/21 revealed Serious Warning and Precautions: increased mortality in elderly patients with dementia. Review of online resources from Medscape.com (https://reference.medscape.com/drug/seroquel-xr-quetiapine-342984#5) revealed Seroquel was not approved for dementia-related psychosis and elderly patients with dementia-related psychosis who are treated with antipsychotic drugs are at increased risk of death. 2) Review of the medical record for Resident #61 revealed the resident was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, squamous cell carcinoma of skin of right lower eye lip including canthus, unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, unspecified asthma, type two diabetes mellitus without complications, chronic kidney disease stage four, hypertension, syncope and collapse, depression, personal history of malignant neoplasm of breast, and sleep disorder. Review of the physician's order for Resident #61 dated 02/09/24, revealed the resident was ordered Trazodone (anti-depressant) 50 milligrams (mgs) by mouth at bedtime for mood and mental health. Review of admission MDS assessment for Resident #61 dated 02/12/24, revealed the resident had severe cognitive impairment. Resident #61 received anti-psychotic and anti-depressant medication during the MDS review period. Review of the anti-depressant care plan for Resident #61 dated 02/20/24, revealed the resident used anti-depressant medication related to depression. Interventions included provide anti-depressant medication per medical provider's orders. Interview with the DON on 04/10/24 at 4:29 P.M. verified Resident #61 was ordered Trazodone 50 mgs at bedtime for mood and mental health. 43062 3) Review of the medical record for Resident #71 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia, chronic kidney disease, edema, anxiety disorder, dysphasia, major depressive disorder, and vitamin-d deficiency. Review of the most recent MDS assessment dated [DATE], revealed Resident #71 was cognitively impaired. Review of the physician's order dated 03/18/24 for Resident #71, revealed an order for quetiapine fumarate 12.5 mgs by mouth every morning and at bedtime for dementia behaviors. Review of the care plan for Resident #71 dated 08/01/22, revealed the resident received anti-psychotic medication related to behavior management. Interview with the DON on 04/15/24 at 8:05 A.M. confirmed Resident #71 was taking Seroquel 12.5 mgs every morning at bedtime for dementia behaviors. The DON confirmed she was aware of the medications black box warning for seniors with Dementia. Review of the facility's pharmacy documents from the Seroquel manufacturer's prescribing information dated 11/29/21 revealed Serious Warning and Precautions: increased mortality in elderly patients with dementia. Review of online resources from Medscape.com (https://reference.medscape.com/drug/seroquel-xr-quetiapine-342984#5) revealed Seroquel was not approved for dementia-related psychosis and elderly patients with dementia-related psychosis who are treated with antipsychotic drugs are at increased risk of death.

Based on record review, staff and resident interviews, and review of facility policy, the facility failed to follow-up on a cellular (cell) phone being reported missing. This affected one (#15) resident of six residents reviewed for missing personal property. The facility census was 134. Findings include: Review of the medical record for Resident #15 revealed the resident was admitted on [DATE]. Diagnoses included coronary artery disease, heart failure, peripheral vascular disease (PVD), renal insufficiency, diabetes, Alzheimer's disease, and dementia. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was moderately cognitively impaired. Review of the care conference notes for Resident #15 dated 07/17/23 held with the Veteran's Administration (VA) representative revealed Resident #15 had lost his cell phone in transition to the hospital from another facility. The VA representative indicated she would replace the cell phone for the resident. Review of the progress notes from 07/17/23 through 04/11/24 for Resident #15 revealed no documentation related to Resident #15's cell phone being lost or communication with the VA representative for follow-up. Interview with Resident #15 on 04/09/24 at 11:28 A.M. revealed his cell phone was missing when he transferred to the hospital from another facility, and he was told it would be replaced and it had not been replaced yet. Interview with the Licensed Social Worker (LSW) #123 on 04/10/24 at 2:01 P.M. revealed she knew about the missing cell phone for Resident #15, but waited to see if it was going to be replaced by the VA representative and it never got replaced. LSW #123 verified she had not reached out to the VA representative to follow-up on the missing cell phone. Review of the policy entitled Social Services dated 07/17/20 revealed the primary objective of the Social Services Department was to establish a working system designed to meet the social and psychological needs of the residents and their families. This includes intervention while the individual resides here and communication with outside agencies, upon discharge. Promoting psychosocial well-being within the nursing facility is a primary concern. This deficiency represents non-compliance investigated under Complaint Number OH00152479.

Based on record review, staff interviews and review of facility policy, the facility failed to ensure falls were reviewed and discussed by the Interdisciplinary Team (IDT) and a root cause analysis was determined. This affected two (#20 and #01) residents out of eight residents reviewed for falls. The fility census was 134. Findings include: 1) Review of the medical record for Resident #20 revealed an admitted [DATE]. Diagnoses included non-traumatic brain disorder, renal insufficiency, diabetes, dementia, and psychotic disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. The resident required supervision for activities of daily living (ADLs). Review of the care plan dated 10/18/23 revealed Resident #20 was at risk for falls related to disease process. Review of a progress note dated 12/12/23 revealed Resident #20 was found on the floor next to his bed. The resident sustained a small skin tear to the left elbow, and to the back of the head. He had no bleeding, no pain, no change in mental status and no anticoagulation. Neuro checks were started per the facility's protocol. Further review of the medical record revealed no documented evidence of an IDT meeting being held to review and discuss the resident's fall on 12/12/23 and to determine a root cause analysis. Review of a progress note for Resident #20 dated 02/19/24 at 7:29 A.M. revealed at approximately 6:10 A.M., the resident's roommate alerted the nurse Resident #20 had fallen. The resident was observed on the floor in the entrance to the bathroom and was lying on the left side in a fetal position. The resident indicated he hit his head and was sent out to the hospital for treatment, and there were no injuries. Further review of the medical record revealed no documented evidence of an IDT meeting being held to review and discuss the resident's fall on 02/19/24 and to determine a root cause analysis. Interview with Licensed Practical Nurse (LPN) #51 on 04/11/23 at 10:12 A.M. confirmed there were no IDT meetings held to review and discuss Resident #20's falls on 12/12/23 and 02/19/24 to determine a cause analysis. 2) Medical review for Resident #01 revealed an admitted [DATE]. Medical diagnoses included cardiorespiratory conditions, atrioventricular block first degree, heart failure, peripheral vascular disease, renal insufficiency, and non-Alzheimer's Dementia. Review of quarterly MDS dated [DATE] revealed Resident #01 was cognitively intact. Review of the care plan revised 01/18/24 revealed Resident #01 was at risk for falls related to disease process. Review of a progress note dated 01/20/24 revealed Resident #01 fell while ambulating in the hall using her walker. The resident stated she lost her balance and fell and hit her head on the floor. The physician was notified with no new orders and neuro checks were initiated, which were negative. Further review of the medical record revealed no documented evidence of an IDT meeting being held to review and discuss the resident's fall on 01/20/24 and to determine a root cause analysis. Interview with LPN #51 on 04/11/23 at 10:12 A.M. confirmed there was not an IDT meeting held to review and discuss Residents #01's fall on 01/20/24 to determine a root cause analysis. Review of the undated facility policy titled Fall Prevention and Management revealed the IDT should review all information for all falls at the next daily clinical meeting. The IDT should discuss the fall, potential causes of the fall, interventions put into place and if they were effective. A deep root cause investigation should be discussed. A progress note of the discussion should be placed in the resident's chart. The team should have a way to inform all care given of any new interventions placed in the care plan. This deficiency represents non-compliance investigated under Complaint Number OH00152479.

Based on medical record review, staff and resident interview, review of the facility self-reported incidents (SRIs) and investigations, and policy review, the facility failed to ensure residents were free from physical abuse by a facility resident. This resulted in Actual Physical and Psychosocial Harm, based on a reasonable person's response to fear and anxiety, for Resident #06, who had impaired cognition, when Resident #59 struck Resident #06 in the face and Resident #06 reported being fearful of Resident #59 and they remained on the same unit. This affected five (#06, #18, #44, #56, and #75) of eight residents reviewed for resident-to-resident abuse. The facility census was 91. Findings include: 1. Review of the medical record for Resident #59 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, bipolar disorder, psychotic disorder with delusions depression, and anxiety disorder. Review of the plan of care dated 04/06/23 revealed Resident #59 had behavior problems related to dementia, bipolar, psychosis with delusions which included roaming the halls, elopement risk and aggression aimed at staff and residents with interventions including one to one (1:1) care while awake for safety precautions, administer medications as ordered, approach and speak in a calm manner, and monitor behaviors to determine underlying causes. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #59 was cognitively impaired and required extensive assistance from staff for activities of daily living and supervision with eating. Review of the progress note on 05/04/23 revealed Resident #59 went into Resident #06's room and struck her in the face. Resident #59 admitted to striking Resident #06 in the face and stated he would hit her again. The note revealed the affected resident (#06) reported to staff after the incident that Resident #59 hit her in the face with a closed fist. The affected resident reported she felt fearful and said she would not feel safe while he was on the unit. Referrals were made to several psychiatric hospitals. On 05/05/23 while on 1:1 supervision, Resident #59 became aggressive and threw coffee at another resident. Review of a neurology note dated 05/08/23 revealed Resident #59 had a GeneSight study to ensure psychiatric medications were the correct choices and administration plans to ensure behaviors were appropriately monitored. Review of the medical record for Resident #06 revealed an admitted [DATE]. Diagnoses included schizoaffective disorder, chronic obstructive pulmonary disease (COPD), diabetes, anxiety, bipolar disorder, insomnia, abnormal weight loss, and heart disease. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #06 was cognitively impaired and required assistance for activities of daily living. Review of the progress notes dated 05/04/23 revealed Resident #06 was sitting in a wheelchair in her room and was struck in the face by Resident #59. The Nurse Practitioner (#127) heard the resident yelling and informed the nurse of the altercation. Resident #59, the suspected perpetrator, informed staff that he was not putting up with that and hit her. Resident #06 reported she was struck in the face with closed fists on both sides of her face. Review of the SRI dated 05/04/23 revealed Resident #06 reported Resident #59 came into her room and struck her in the face when attempting to get Resident #59 out of her bed. Staff removed Resident #59 from Resident #06's bed, assessed both residents and contacted all necessary parties. Residents were assessed with no known injuries. The investigation included statements: Nurse Practitioner (NP) #127 reported she was in her office and heard Resident #06 yell out and said Resident #59 was in her room and he had hit her. NP #127 went to Resident #06's room and found Resident #59 exiting the room. When asked what happened Resident #59 stated he hit that expletive. Resident #59 was wheeled back to his room. Interview on 05/24/23 at 12:15 P.M. with NP #127 revealed her office was across the hall from Resident #06's room. NP #127 revealed she heard Resident #06 yell he hit me. NP #127 said she arrived at Resident #06's room as Resident #59 was exiting the room and she asked Resident #59 if he hit Resident #06, and he responded, yes, he hit that expletive. She deserved it. NP #127 revealed she spoke with Resident #06 who reported Resident #59 struck her on the left side of her cheek with a closed fist and reported she could see a red mark. NP #127 stated she spoke with Resident #06 daily for a few days after the incident and reported Resident #06 stated, he doesn't belong here, and he isn't like us. NP #127 revealed she had talked with the facility staff about his history of behaviors and aggression with other residents and had discussed with staff he was not appropriate for this facility as they have not been able to manage his behaviors and revealed she thought Resident #59 had Lewy body dementia. NP #127 revealed Resident #59 was placed on 1:1 after the incident and had several medication changes including a genetic test to determine which psychiatric medications were working for him. NP #127 reported his behavior had improved in the last few weeks and stated if resident did have Lewy bodies the facility was not capable of caring for him. She revealed he had flipped a table since then and had aggression more generally and directed at staff. NP #127 revealed being unaware why the referral process ended related to his transfer discussed in 03/2023 and reported behaviors have not changed much since that time. Interview on 05/24/23 at 10:02 A.M. with the Social Services #65 and the Director of Nursing (DON) confirmed a care conference meeting was held 03/2023 and the interdisciplinary team discussed Resident #59's behaviors and it was reported that the facility was unable to manage Resident #59's behavior and aggression and he needed to transfer to another facility. Social Services #65 revealed the facility sent about three referrals to their sister facilities but revealed Resident #59 had not been accepted. Social Services #65 and the DON denied neither Residents #06 or #59 were moved off the unit or had room changes. Interview on 05/24/23 at 10:24 A.M. with Resident #06 revealed Resident #59 punched her in the face about three weeks ago. Resident #06 said she feared Resident #59 and his behavior and did not feel safe at the facility. Interview on 05/24/23 at 3:44 P.M., with the DON and Corporate Nurse #130 revealed a referral was sent to behavioral hospitals for admission and resident had a neurology appointment scheduled to review medications for appropriate effect. Resident #59 was placed on 1:1 supervision, but the DON reported 1:1 supervision was ordered on 05/08/23 to 05/18/23 and facility had no evidence of the 1:1 being in place consistently from 05/04/23 when the incident occurred until 05/08/23 when it was ordered. Corporate Nurse #130 and the DON revealed Social Services #65 would check on resident to provide support and revealed the facility had no evidence of psychosocial supports put in place after the incident on 05/04/23 except one check-in by social services asking how her day was going. 2. Review of the medical record for Resident #44 revealed an admitted [DATE]. Diagnoses included dementia with behavioral disturbances, hypertension, generalized anxiety disorder and dysphagia. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #44 was cognitively impaired and required extensive assistance for all activities of daily living and supervision with eating. Review of the progress notes dated 03/19/23 revealed Resident #44 was standing at the nurse's station when another resident came up and struck her in the chest. Resident #44 was found to have no injuries. Review of the SRI dated 03/19/23 revealed Resident #44 was struck in the chest at the nurse's station by Resident #59. No injuries were noted. The investigation included statements: Certified Nurse Aide (CNA) #87 reported Resident #59 stood up from his chair and the CNA assisted him to sit back in his wheelchair which irritated Resident #59. CNA reported Resident #59 swung at her and missed and ended up hitting Resident #44. CNA #31 reported Resident #59 was at the nursing station and hit Resident #44 in the chest for no reason. CNA #88 revealed staff attempted to get Resident #59 to sit back in his wheelchair. Resident #59 became upset and started being aggressive and swinging at staff and ended up hitting Resident #44 in the chest who was standing at the nurses' station. Interview on 05/24/23 at 2:53 P.M. with CNA #88 revealed being at the nurses' station with Resident #44 who was exit seeking and Resident #59 was in his wheelchair and was having aggression and swinging his arms in the air. Resident #44 walked by Resident #59 and was struck in the chest. CNA #88 revealed Resident #44 did not have any injuries but was crying. 3. Review of the medical record for Resident #56 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, major depressive disorder, anxiety disorder, asthma, and abnormal weight loss. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #56 was cognitively impaired and required extensive assistance for all activities of daily living. Review of the progress notes dated 04/21/23 revealed staff were at the nurses' station when they heard screams coming from the 200 hall. Staff entered Resident #56's room and saw the over bed table lying on the floor in front of Resident #59 and Resident #56 was crying and had a trash bin placed on her head. Resident #56 complained of left side forehead pain, no injuries identified. Resident #56 reported to staff that Resident #59 called her a dumbo and hit her with a rounded object (trashcan). Review of the SRI number dated 04/21/23 revealed Resident #56 was heard yelling from her room. When staff entered, they found an over bed table flipped over and Resident #56 had a trashcan on her head while she was lying in bed. The report did not include statements, but the responding staff wrote progress notes. Interview on 05/24/23 at 2:05 P.M. with Resident #56 revealed she was not afraid and did not remember being hit. Interview on 05/24/23 at 2:07 P.M. with Registered Nurse #63 revealed she did not witness the incident but went to Resident #56's room due to a scream and found Resident #59 in there and Resident #56 had a trash bin on top of her head while she was laying on her bed. The bedside table had also been knocked over onto the floor. No injuries were noted. RN #63 revealed Resident #59 gets frustrated and he would get mad and slam his wheelchair or walker into staff or walls/doors but denied seeing him get physical with another resident. Interview on 05/24/23 at 3:44 P.M. with the DON and Corporate Nurse #130 revealed Resident #59 was placed on 1:1 supervision until he transferred to the hospital for a urinary tract infection (UTI). 4. Review of the medical record for Resident #75 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia with anxiety, cerebrovascular disease and diabetes. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #75 was cognitively impaired and required supervision assistance for all activities of daily living and limited assistance with transfers. Review of the progress notes dated 05/03/23 revealed Resident #75 reported to staff that Resident #59 was in her bed and when she tried to get him out of her bed, Resident #59 kicked her in the stomach. Review of the SRI dated 05/03/23 revealed Resident #75 reported Resident #59 kicked her in the stomach when attempting to get Resident #59 out of her bed. Staff removed Resident #59 from Resident #75's bed, assessed both residents and contacted all necessary parties. Residents were assessed with no known injuries. The investigation included statements: CNA #27 reported she did not see the event but had last seen Resident #59, 20 to 25 minutes prior, when she put him in his own bed. CNA #95 reported Resident #75 informed her of the altercation CNA observed Resident #59 in Resident #75's bed CNA along with additional staff entered the room and assisted Resident #59 out of Resident #75's room. Interview on 5/24/23 at 11:45 A.M., with CNA #95 revealed Resident #59 was in his bed sleeping right before the incident. CNA #95 revealed Resident #59 got out of bed by himself and walked into Resident#75's room and laid in her bed and when she tried to get him out of it Resident #59 kicked and hit Resident #75. CNA #95 revealed Resident #59 often became physically aggressive when he was aggravated and upset and had seen him become aggressive with residents previously. CNA #95 also revealed Resident #59 would get aggravated by things such as too much noise. Interview on 05/24/23 at 1:58 P.M. with Resident #75 revealed she remembered the incident and could point out the person who hurt her in the incident. Interview on 05/24/23 at 3:44 P.M., with the DON and Corporate Nurse #130 revealed Resident #59 was not placed on 1:1 supervision after this incident due to staff believed it was due to him being in another resident's bed and that it was more situational as he thought it was his bed. Signs were placed on resident #59's door to help him find it easier. 5. Review of the medical record for Resident #18 revealed an admitted [DATE]. Diagnoses included traumatic subarachnoid hemorrhage without loss of consciousness, and dementia with agitation. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #18 was cognitively impaired and required extensive assistance for all activities of daily living. Review of the progress notes dated 05/06/23 as late entry revealed a head-to-toe assessment done and unable to recall the incident from 05/05/23. Review of the SRI dated 05/05/23 revealed Resident #59 had 1:1 supervision and was observed by staff to flip over a table and spill/throw coffee on Resident #18. The investigation included statements: Licensed Practical Nurse (LPN) #131 reported Resident #59 was in the dining room and without any trigger, Resident #59 threw coffee at Resident #18. The coffee was lukewarm and sitting on the table for sometime before the incident occurred. Resident #18 had no injuries related to the incident. Interview on 05/24/23 at 1:55 P.M. with Resident #18 revealed he did not remember anyone hitting him or hurting him. Interview on 05/24/23 at 3:44 P.M. with DON and Corporate Nurse #130 revealed while Resident #59 was on 1:1 supervision, he flipped over a table and threw coffee on Resident #18. Resident remained on 1:1 supervision until he was seen by the neurologist and had medication changes on 05/18/23. Review of facility policy titled OHIO Abuse, Neglect and Misappropriation, undated revealed it was the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. In the event the alleged abuse involves a resident-to-resident altercation, the residents would be placed in separate areas by the staff and resident safety was the priority.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, interviews with staff, interview with the police detective, review of personnel files, review of the facility's investigation, review of facility Self-Reported Incidents (SRI) and review of the facility's abuse policy and procedure, the facility failed to ensure a resident was free from staff to resident physical abuse during the provision of care. This resulted in Immediate Jeopardy and serious injury for one resident (#05), when he was struck in the face by State tested Nursing Assistant (STNA) #120 while attempting to provide care for Resident #05. Consequently, the resident sustained [REDACTED]. This affected one (#05) of three residents reviewed for abuse. The facility census was 141. On 03/14/19 at 12:18 P.M., the Administrator, Regional Director of Operations #155 and the Director of Nursing (DON) were notified Immediate Jeopardy began on 01/25/19 when Resident #05 was struck by STNA #120 while attempting to provide care to the resident. Resident #05 received care from STNA #120 on 01/25/19 at 6:30 A.M. and STNA #120 initially reported to the nurse that Resident #05 was combative during care and had a self-inflicted scratch to his right eye. The staff nurse responded to Resident #05 at 6:45 A.M., assessed the injury and Resident #05 was noted to be combative striking out at staff and self. Resident #05 was noted rubbing his eye vigorously with his hands. Blood was noted on the resident's hands, face, and eye brow area. Blood was also noted underneath Resident #05's fingernails. Resident #05 had a skin tear that measured four tenths of a centimeter (cm) in width, by four tenths of a cm in length, by one tenth of a cm in depth to his right eye brow. The Certified Nurse Practitioner (CNP) and the resident's son were notified of the incident. STNA #120 clocked out at 7:25 A.M. At 9:00 A.M, Resident #05 was noted to have bruising and moderate swelling to his right eye and the DON and unit manager were made aware. At 11:00 A.M., a bruise was noted to Resident #05's left temple and the DON and unit manager were notified. On 01/25/19 at 12:45 P.M., the Administrator was notified of the bruising and at 1:30 P.M. an SRI was submitted to the state agency for an injury of unknown origin. On 02/28/19, the detective reported to the Administrator that STNA #120 had modified her statement and had confirmed she struck Resident #05 two times in the face with a closed fist. The Immediate Jeopardy was removed on 01/26/19 when the facility suspended STNA #120 pending an investigation, Resident #05 was sent to the hospital for medical evaluation and treatment, all other residents residing on the unit were assessed, and in-service training regarding abuse, neglect and escalating behaviors, including education on the facility's abuse policy and procedure was completed with facility staff. The deficiency remained at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) until it was corrected on 03/05/19 when the facility implemented the following: · On 01/25/19 from 1:00 P.M. to 2:00 P.M., the Administrator began an investigation and obtained statements from staff to determine the origin of the bruise to Resident #05's left temple. · On 01/25/19 from 1:00 P.M. to 6:00 P.M., the DON and designee completed skin assessments on all residents who resided on the same unit as Resident #05. There were no other negative findings identified. · On 01/25/19 at 1:00 P.M., the Administrator, DON and designee began all staff in-service training regarding abuse, neglect and escalating behaviors. During the training, the abuse policy and procedures were reviewed. The education was completed on 01/25/19 at 9:00 P.M. · On 01/25/19 at 1:30 P.M., orders for STAT (immediate) facial X-Ray's for Resident #05 were obtained. · On 01/25/19 at 4:00 P.M. to 4:30 P.M., local law enforcement responded to the facility and interviewed Resident #05. · On 01/25/19 at 5:00 P.M., the Quality Assessment and Assurance (QA&A) committee held a meeting to discuss the circumstances and the on-going investigation. · On 01/25/19 at 5:45 P.M., law enforcement responded to the facility to interview STNA #120. At 6:30 P.M., STNA #120 was suspended by the Administrator pending an investigation. · On 01/25/19 at 6:30 P.M., Resident #05 was transferred to a hospital per family request. · On 02/08/19 through 03/05/19, the Administrator conducted weekly audits regarding abuse. Audits revealed staff were knowledgeable and understood the process. There were no further incidents of staff to resident physical abuse identified. · On 02/28/19, STNA #120 was terminated from employment at the facility. · On 02/28/19, the Administrator contacted the state Nurse Aide Registry to report STNA #120 had physically abused Resident #05. · The facility continues to screen all new applicants via background checks, and licensure verification. Abuse training and special population (Alzheimer's) training is conducted upon hire for all new applicants, monthly at all staff meetings, and on an as needed basis. · On 03/13/19, Licensed Practical Nurse (LPN) #160, #170, Hall Monitors #180, #190, and Housekeeper #200 verified they had received abuse training and could verbalize if abuse was witnessed the abuse needed to be stopped, to protect the resident and to report the abuse immediately. · On 03/13/19 and 03/14/19, two (#15 and #20) medical records were reviewed for abuse and injury of unknown origin. There were no concerns identified. · On 03/13/19, Residents #25, #30, #55 and #60 were interviewed and all verified they felt safe at the facility and had not been abused by the staff at the facility. Findings Include: Review of the medical record for Resident #05 revealed an admission date of [DATE] and a discharge date to the hospital on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/22/19, revealed the resident had moderately impaired cognition and the Brief Interview of Mental Status (BIMS) score was 9. The resident required extensive assistance for bed mobility, transfer, locomotion, dressing, eating, toileting and personal hygiene. Resident #05 is coded as having physical behavioral symptoms directed toward others and self. Review of the plan of care revised on 08/08/18, indicated Resident #05 had the potential to demonstrate physical behavior of being combative, hitting, punching staff in mouth, attempting to spit on staff, throwing items at staff and attempting to run over others with his wheelchair. Goals indicated Resident #05 will not harm self or others. The care plan also indicated Resident #05 was often non-compliant with care. The plan of care documented interventions that instructed staff to re-approach Resident #05 calmly from the front, do not startle the resident and if the resident becomes aggressive, staff should walk calmly away and approach later. Review of Resident #05's progress notes dated 01/25/19, revealed staff was providing direct care when the resident became very combative with care and scratched self on right eyebrow. The progress notes indicated the CNP and son (emergency contact) were both notified. Further review of Resident #05's progress notes dated 01/25/19 at 1:30 P.M., revealed a STAT X-ray of the resident's face was ordered. Additionally, the progress notes indicated Resident #05 was sent out to the local Emergency Department (ED) at 6:30 P.M. on 01/25/19 per family request. Review of an SRI dated 01/25/19 revealed that morning, Resident #05 became combative with morning care which is his norm. An STNA reported to the nurse that during morning care, Resident #05 scratched his right eyebrow. The nurse responded to the resident's room, and the resident was observed vigorously rubbing his eye, and blood was noted on hands, face, and under nails. Resident #05 was again resistant with care. The nurse returned to find the resident resting comfortably, and the nurse was able to cleanse the wound to the eye and add treatment. Resident #05 refused his morning medications and refused breakfast. At lunch time, the resident was approached to get up and dressed. Resident #05 was resistant to care. Resident #05 was turned and at this time a bruise was identified on his left temple. Resident #05 receives blood thinners daily and has a grab bar to the bed. Staff were interviewed regarding the bruise. All staff interviewed had no knowledge of the origin of the bruise. Law enforcement was contacted regarding the bruise. Law enforcement interviewed the primary caregiver at the time of the self-inflicted injury and could not substantiate the origin of the other bruise. One officer indicated this could be self-inflicted. Other residents were assessed head to toe for any injuries, bruising, or redness. None of the assessments indicated any new bruising or redness identified. The SRI documented abuse and neglect is not substantiated as it is inconclusive. Further review of an addendum to the SRI, dated 03/19/19, revealed the Administrator was contacted by local police on 02/28/19 and informed STNA #120 admitted to striking Resident #05. STNA #120 had not worked since 01/25/19, was terminated and was reported to the state Nurse Aide Registry. This would substantiate that STNA #120 physically abused Resident #120. Review of the facility's investigation timeline, dated 01/25/19 starting at 6:30 A.M., revealed STNA #120 noted Resident #05 was combative with care and caused a self-inflicted scratch to his right eye. The timeline indicated at 12:30 P.M. staff were getting the resident out of bed for lunch and bruising and swelling was observed on Resident #05's left eye. Resident #05 was noted as being combative by swinging his hands. The Administrator was notified at 12:45 P.M. and interviewed Resident #05. The timeline indicated the Administrator started obtaining statements from staff at 1:00 P.M. and the CNP ordered a STAT X-ray at 1:30 P.M. The timeline further revealed at 4:00 P.M., the local law enforcement arrived at facility to interview Resident #05 and then returned at 5:45 P.M. to interview STNA #120 who initially reported the self-inflicted wound. Resident #05 was transported to the hospital on [DATE] at 6:30 P.M. The investigation timeline indicated a detective returned to the facility to obtain further information. Review of the investigation file and witness statements which were collected from numerous staff members, revealed no concerns related to thoroughness of the investigation, timeliness of reporting or family notification. Review of the local hospital records dated 01/25/19 at 9:30 P.M., revealed Resident #05 arrived in the ED very combative and required sedation with medications including [MEDICATION NAME] ([MEDICATION NAME]), [MEDICATION NAME] (antianxiety) and [MEDICATION NAME] (antipsychotic). Initial hospital notes indicated an X-ray of the orbital areas revealed no periorbital fractures. Hospital notes also revealed Resident #05's periorbital ecchymosis (bruising) was potentially caused by the chronic Xarelto (anticoagulation) medication. The hospital also completed a Computed Tomography (CT) scan of the head; however, there were no findings and could not be read due to the resident's movements and further testing maybe indicated. Further review of hospital documentation dated 01/29/19 revealed Resident #05 had further testing performed which indicated the resident sustained [REDACTED]. During an interview with the Administrator on 03/13/19 at 9:30 A.M. it was revealed the local police department called him on 02/28/19 and informed him STNA #120 altered her initial statement. The Administrator stated STNA #120 amended her initial report to reflect on 01/25/19 when she was providing care to Resident #05, the resident was combative and struck her, scratched her eye and she hit the resident back, up to three times in the face. The Administrator confirmed STNA #120 has not worked since the incident and has been terminated from employment at the facility. On 03/13/19 at 10:49 A.M., STNA #120 was interviewed via phone and stated while providing care, Resident #05 was combative, scratched her eye and punched her. STNA #120 stated when she deflected Resident #05's punch, she accidentally hit the resident in the face. STNA #120 stated she hit him twice and it was a mistake and she was trying to deflect his arm. STNA #120 stated she didn't hit him with her fist, but her arms hit him across the face, and that she did not mean to hit him, and it was not intentional. During an interview on 03/14/19 at 12:10 P.M. with Detective #01 it was revealed STNA #120 is involved in an ongoing investigation which may result in criminal charges. Review of STNA #120's personnel file revealed a hire date of 10/30/18 and the STNA was current and in good standings with the state Nurse Aide Registry. STNA #120 had a Bureau of Criminal Investigation (BCI) background check completed prior to hire at the facility which showed no convictions. STNA #120 received abuse training at the facility on 10/30/18, 12/26/18, and on 01/23/19. The STNA clocked out of the facility on 01/25/19 at 7:25 A.M. and had not worked after that date. The personnel file contained termination papers dated 02/28/19 documenting STNA #120 was involved in an assault on a resident. There was no evidence of prior discipline regarding abuse in the file. Review of the facility policy titled OHIO Abuse, Neglect & Misappropriation, dated 10/07/14 with a revision date of 09/02/16, revealed it is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. It is the intent of this facility to prevent the abuse, mistreatment, or neglect of residents or the misappropriation of their property, corporal punishment and or involuntary seclusion and to provide guidance to direct staff, and to manage concerns or allegations of abuse neglect or misappropriation of their property. Furthermore, it is the intent of this facility to employ only properly screened persons as a part of the resident care team by the applicable requirements. Employees will receive abuse prevention and training as required as part of their orientation, as needed/indicated and annually thereafter. In the event an allegation is made, the facility will take measures to protect residents from harm during an investigation. Accurate and timely reporting of incidents, both alleged and substantiated, will be sent to officials in accordance with the state law. If the alleged violation is verified, appropriate corrective action will be taken by the facility. This deficiency substantiates Complaint Number OH 958.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a fall investigation, staff interview, review of a personnel file and Review of the POS [REDACTED]. Actual harm occurred to Resident #50 when their safety intervention was not in place resulting in a [MEDICAL CONDITION] and subsequent hospitalization . This affected one (#50) of three residents reviewed for fall safety interventions. The facility census was 141. Findings include: Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. with late onset. Review of Resident #50's physician orders [REDACTED]. The order was initiated on 01/04/19. The hipsters are signed off as in place on the night shift of 01/24/19 and on the day shift of 01/25/19 are coded as the resident is at the hospital. The treatment record indicated the resident has a treatment every shift to the right lower leg and foot and the day shift nurse had charted and signed off the record as completing the treatment on 01/25/19. Review of the Minimum Data Set (MDS) assessment, dated 02/14/19 and coded as discharge return not anticipated, revealed the resident was unable to complete a Brief Interview of Mental Status (BIMS), and had no delusions or hallucinations; however, did have physical and other behaviors one to three days of the review period, required extensive assist with all activities of daily living, and was always incontinent of both bowel and bladder. Review of Resident #50's plan of care revealed the resident is at risk for falls, is to be toileted every two hours, have on proper foot wear, activities to minimize the potential for falls while providing diversion and distraction, and hipsters as tolerated. Review of progress notes dated 01/25/19 at 7:30 A.M. revealed the day shift nurse completed the treatment to the resident's legs. Further review of resident progress notes dated 01/25/19 at 7:45 A.M. revealed the resident was witnessed to fall out of his chair in the activities room and his right leg was rotated in an outward position after the fall. Further review of the facility's investigation of the fall revealed on 01/25/19, Resident #50 did not have hipsters in place at the time of the fall as per plan of care and physician order. Resident #50 was transported to a hospital where it was determined he sustained a right [MEDICAL CONDITION] and had to undergo surgery to repair the fracture sustained during the fall. During an interview with the Director of Nursing (DON) and the Administrator on 03/14/19 at 10:00 A.M., it was confirmed Resident #50 was up in the activity room and had been in therapy earlier on the morning of 01/25/19 and had staff present with him when he attempted to stand unassisted and staff were unable to reach him when he fell sustaining a [MEDICAL CONDITION]. The Administrator and DON verified Resident #50 did not have his hipsters on at the time of the fall. The DON and Administrator stated the care plan states Resident #50's hipsters are to be on as tolerated but verified the resident does not have a care plan for refusals of care or refusals to wear the hipsters. The Administrator confirmed the Treatment Administration Record (TAR) would reflect the physician's orders [REDACTED]. Review of State tested Nursing Assistant (STNA) #120's personnel file revealed a hire date of 10/30/18. Further review of STNA #120's personnel file revealed she had assisted Resident #50 with dressing the morning of 01/25/19. STNA #120 received disciplinary action for not having Resident #50's hipsters in place as per the residents plan of care. Review of the POS [REDACTED]. As a result of the incident, the facility implemented the following corrective actions to correct the deficient practice by 02/22/19: · On 01/25/19, upon discovery of the incident, Resident #50 was assessed, and orders were obtained to send the resident to the hospital for evaluation and treatment. Resident #50 was found to have a right [MEDICAL CONDITION]. · On 01/25/19, STNA #120 who had dressed Resident #50 on 01/25/19 received disciplinary action for not having the hipsters in place as per the resident plan of care. · On 01/25/19, in-service education was provided by the DON or designee to the nursing department on the importance of maintaining fall prevention interventions per the plan of care, Kardex and physician orders. · On 01/25/19, a review of all residents who utilize hipsters as part of their care was completed to determine if the resident refuses to wear the hipsters and/or the hipsters are not effective, then they would discontinue the use. If the hipsters are discontinued, further review was completed to ensure there are other fall interventions in place. · On 01/25/19 through 02/22/19, the DON and Unit Managers performed weekly audits for four weeks to ensure residents with hipsters ordered as part of their care are having the hipsters used as ordered. There were no additional concerns identified. · On 03/14/19, medical record review and observation of two (#60 and #15) additional residents were reviewed/observed regarding the use of hipsters. There were no concerns identified. This deficiency substantiates Complaint Number OH 958.

Based on observation, review of medical record, review of self-reported incident (SRI), review of facility abuse policy, review of police report, review of incident report, review of witness statements, resident and staff interviews, the facility failed to provide supervision to two residents displaying behavior preventing a resident to resident altercation. This resulted in actual harm when Resident #38 was observed to push Resident #47 down to the floor and began to hit Resident #47 with a closed fist multiple times in the face and chest, resulting in Resident #47 receiving a fractured right hip requiring surgical intervention. This affected one (#47) of four medical records reviewed for supervision. The facility census was 127. Findings include: Review of Resident #47's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #47 as having severely impaired cognition, with verbal and wandering behaviors. Review of the behavior care plan revealed Resident #47 wanders aimlessly, has a habit of pushing his walker into doors and walls when he has delusions of working and fixing the walls, has the potential to be verbally abusive to others. Care plan interventions included: distract the resident from wandering, by offering pleasant diversions, structured activities, food, conversation, television and books and redirect resident when exhibiting inappropriate behaviors. Review of Resident #47's progress notes from 11/07/16 to 11/20/16 revealed multiple documentation's of Resident #47 displaying behaviors of wandering and pacing. Review of Resident #47's progress notes dated 11/21/16 at 8:30 P.M. revealed the resident was sent to the hospital for evaluation after an altercation with Resident #38. Resident #47 returned to the facility on [DATE] from the hospital, status [REDACTED]. Review of Resident #38's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was assessed as having severe impaired cognition, with no behaviors. Review of the behavior care plan updated on 09/02/16, revealed the resident had impaired cognitive function and impaired thought processes related to dementia and required supervision with all activities of daily living (ADL's) and was independent with hygiene and dressing. Review of the Resident #38's progress notes dated 11/19/16 at 2:25 P.M., revealed the resident was upset and angry about male peer (Resident #47) pacing down the hallway numerous times. Resident #38 began to make verbal threats to jump Resident #47 next time he came past his door. The nurse documented Tender Loving Care (TLC) and one on one given with little success. Resident #38's door was closed to prevent any disturbances. Review of the Resident #38's progress notes dated 11/20/16 at 2:04 P.M., revealed the resident continued to be anxious about male peer (Resident #47) pacing in the hallway in front of his room. Resident #38 continued to state he will take care of Resident #47, if he continues to walk in front of his room. The nurse documented TLC and one on one given with some success. Review of the facility self-reported incident (SRI), revealed on 11/21/16 at 7:10 P.M., staff observed Resident #38 push Resident #47 down to the floor and began to hit Resident #47 with a closed fist multiple times in the face and chest. Staff approached and separated the residents immediately. Resident #38 was taken to his room for assessment. Resident #38 reported Resident #47 hit him first. Resident #38 reported pain to his right ankle from kicking the walker away from the Resident #47. The SRI documented interviews with staff revealed no one observed anything prior to Resident #38 pushing down Resident #47. Resident #47 was assessed for painful right leg and sent to the hospital for evaluation. Review of the witness statement of State tested Nursing Assistant (STNA) #62 dated 11/21/16, revealed she did not see the altercation, she just observed Resident #47 lying on the floor. STNA #62 reported Resident #38 stated Resident #47 hit him first and if Resident # 47 comes back Resident #38 stated he was going to give it to him worse. Review of the witness statement of Licensed Practical Nurse (LPN) #19 dated 11/21/16, revealed she heard the STNA yell help from the 600 hall. When she looked down the hall she observed Resident #38 punching Resident #47, in the face while the he was laying on his back on the floor. Review of the witness statement of STNA #35 dated 11/21/16, revealed when she was walking up 800 hall she observed Resident #47 flying across the hallway on to the floor, hitting head against the wall. She stated she took off running and yelling for help. She observed Resident #38 started walking toward Resident #47 standing over him and hitting his face and chest, he did it approximately five or six times. STNA #35 stated she yelled stop and Resident #38 stopped hitting Resident #47. Resident #38 yelled he hit me first. Then Resident #38 returned to his room. Review of witness statement from unit coordinator (UC) #89 dated 11/30/16, revealed an interview with Resident #17 (Resident #38's roommate). Resident #17 revealed both he and Resident #38 were eating and heard Resident #47's walker coming up the hallway. Resident #38 told Resident #17 he was getting sick of this. Resident #38 hollered for Resident #47 to knock it off and Resident #38 used curse words. Resident #47 stopped at the door of the Resident #38's room and both Resident #38 and Resident #47 started hollering at each other. Resident #38 told Resident #47 not to come into the room. Resident #38 walked to the door with his arms crossed and told Resident #47 not to take one more step. Resident #47 took a step into the room and with his left arm struck Resident #38 in the jaw. Resident #17 indicated Resident #47 threw one punch per Resident #38's two punches, at that time Resident #38 got on top of Resident #47 and was punching him. Review of Resident #38's incident note date 11/21/16 at 7:44 P.M., revealed the nurse observed staff running down 600 hall when the nurse entered hallway Resident #38 was seen pushing another male resident (#47) down on the floor. Then while standing over male resident (#47), Resident #38 had a fist drawn back and began punching Resident #47 in the face over and over. When staff approached the residents, they were separated. Resident #38 returned to his room and other resident was removed from the area. The physician was notified and ordered for Resident #38 to be pink slipped out of facility. Resident #38's family notified as well. Resident #38 complained of pain to right ankle due to him kicking the walker away from other resident. Ice provided to resident for swelling. Resident was placed on one on one until the police arrive. Review of the Police Report dated 11/21/16 at 7:50 P.M., revealed upon arrival to the facility, the officer met with staff regarding an incident between two residents. The Officer was informed of the incident that occurred during shift change and that some of the staff witnesses had left for the day. Resident #38 was reported as the aggressor and staff wished for police to transport him for a 72 hour hold for his violent behavior. The Officer reported meeting with Resident #38 and roommate (Resident #17), and both reported Resident #47 hitting their door with his walker. Resident #47 struck Resident #38 once and Resident #38 struck Resident #47 twice. Photos were completed by the police, in which no obvious signs of injury were present with Resident #38. The Officer reported responding to the Hospital to interview Resident #47. Resident #47 claimed he had fallen trying to get into the medic, and had no memory of the fight. Due to the mental state of the Resident #47 and Resident #38 statement of defending himself, no charges were pursued at that time. Review of Resident #47's incident note dated 11/21/16 at 8:36 P.M. revealed during shift change, a STNA yelled that there was a fight in 600 hallway. Resident #47 was lying on back with head on wall, other resident was over top resident punching in face-chest area. Several employees ran to altercation and separated residents. Range of motion was performed, finding pain and non-movement to right upper leg area/hip. A skin tear to the right upper elbow area. Redness noted to right side of face. Two nurses lifted resident and seated in wheelchair. Resident stated he could not lift leg because it hurts too bad . The physician was called and an order to send the resident out to be evaluated. Interview with the Administrator on 12/01/16 at 8:57 A.M., revealed the Resident #38 had been discharged to the local behavioral hospital on [DATE]. Interview on 12/01/16 at 10:11 A.M. with Licensed Practical Nurse (LPN #88) revealed she/he was notified by the hospital 11/22/16, when she arrived to work, that Resident #47, had a fractured femur and was in surgery at that time. LPN #88 revealed she worked full time on the unit, where Resident #38 and Resident #47 were living on. At no time does she recall the Resident #47 entering other resident's rooms, Resident #47 only ambulated in the hallway with his walker. Observation of Resident #47 on 12/01/16 at 1:49 P.M., revealed the resident was sitting in a wheel chair in the activities room watching television. An interview at this time, revealed the resident to smile and deny pain. Resident #47 stated his right hip is sore when he moves it. Resident #47 revealed he hurt his hip when he tripped at the top of the hill, making sure all his workers were there, resident has no recollection of the incident. Review of the facility policy on titled Abuse revised 11/07/16, revealed the intent (of the facility) is to prevent in any way possible the abuse of residents, by providing a comfortable safe environment. When an alleged abuse involves a resident to resident altercation, the residents will be immediately separated. This deficiency substantiates the allegations contained in Complaint Number OH 194.

Based on record review and staff interview, the facility failed to ensure the lap buddy was in place as ordered by the physician to provide safety to one resident with a history of falls and decreased safety awareness. This resulted in actual harm to Resident #15 when it was determined State tested Nurse Aide (STNA) #10 failed to put the lap buddy in place in the wheelchair, the resident was left alone in the dining room unsupervised, stood and fell . This resulted in a fracture to his clavicle. This involved one of three sampled residents. The facility census was 142. Findings include: Review of the medical record for Resident #15 revealed [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. The latest comprehensive assessment included the resident needed extensive assist of two for bed mobility, transfers and toileting. His physician orders [REDACTED]. Nursing notes dated 07/04/14 at 10:48 P.M. documented Resident #15 was found on the floor in the common area lying on his left shoulder and back. The left side of his head was swollen and he complained of pain with range of motion. The emergency squad (911) was called and the resident was admitted to the hospital and diagnosed with [REDACTED]. Resident #15 returned to the facility on [DATE] with a sling in place to the left arm. During an interview with the Director of Nursing (DON) on 07/22/14 at 8:00 A.M. she stated that Resident #15 fell from his wheelchair on 07/04/14 at 9:00 P.M. He had been seated at the dining room table and his lap buddy was not on. STNA #10 had not applied the lap buddy. The DON said that the STNA said it was not on him when she came on at 3:00 P.M. and she did not check with the nurse or check his plan of care. Resident #15 had been previously toileted by the STNA, and according to the DON, Licensed Practical Nurse (LPN) #50 did not notice the SR's lap buddy was not on as he was seated at the table. Resident #50 was reported to have stood up and hit the table and fell backwards. He was sent out to the emergency room and admitted to the hospital with [REDACTED]. A meeting was conducted with the Administrator, the DON, and the Regional Director on 07/22/14. The investigation of the fall and witness statements were reviewed. Review of the investigation statements dated 07/08/14, and 07/09/14 by the two first shift STNA's #12, #13 documented the residents lap buddy was on when they left at 3:00 P.M. after their shift. A written statement by STNA #11 documented she was working on the unit on the 3:00 P.M. to 11:00 P.M. shift. She heard the alarm go off, it was Resident #15's. He stood up, pivoted and hit the dining room table in front of him, then the floor. She said she did not see the residents lap buddy on him earlier in the shift and reported it to his assigned STNA #10. STNA #10 told her the lap buddy had been discontinued. A written statement by LPN #50 documented the resident had been left alone in the dining room, and STNA#11 was the first to reach him. The written statement by LPN #50 dated 07/07/14 revealed she was told by STNA #11 the resident's lap buddy was not on, and was told by the STNA it had been discontinued. The written statement by STNA #10 documented the alarm was sounding, she did not witness the fall, and his lap buddy was not on him. The DON confirmed STNA #10 was terminated. On 07/22/14 at 1:45 P.M. LPN #50 was interviewed by phone. LPN #50 stated she was told after the fact by STNA #11 she had not seen the residents lap buddy in place during the shift. She said she did not notice it as her back was to the dining area during the medication pass and when the resident is up to the table the lap buddy is not visible. She said when she spoke to STNA #10 she verified the lap buddy had not been put on, she said it had been discontinued. This citation substantiates Master Complaint Number OH 458.