Every finding on record at Xenia Health and Rehab

Based on medical record review, observation, and staff interview, the facility failed to ensure medications were administered as ordered resulting in two medication errors of 33 medication opportunities which resulted in a 6.06 percent (%) error rate. This affected one (Resident #15) of three residents reviewed for medication administration. The facility census was 27 residents. Findings include: Review of the medical record for Resident # 15 revealed admission date of 01/01/21 with diagnoses including dementia, chronic obstructive pulmonary disease, diabetes mellitus, and depression.Review of the Minimum Data Set (MDS) assessment for Resident #15 dated 03/10/26 revealed the resident was cognitively impaired and was dependent upon staff assistance with activities of daily living.Review of the physician's orders for Resident #15 revealed orders dated 02/06/26 for Singulair 10 milligrams (mg) daily and calcium/vitamin D3 500mg/5 microgram (mcg) tablet every morning and at bedtime.Observation on 04/28/26 at 8:24 A.M. of medication administration for Resident #15 per Registered Nurse (RN) #105 revealed the nurse did not administer Singulair or calcium/vitamin D3 as neither medication was available for administration.Interview on 04/28/26 at 8:34 A.M. with RN #105 verified neither Singulair nor calcium/vitamin D3 were available for administration to Resident #15 as ordered.This deficiency represents noncompliance investigated under Complaint Number 2687604.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) received 90-day and annual performance evaluations and CNAs received at least twelve hours of in-services annually. This affected three (CNA #32, CNA #36 and CNA #45) of the three CNAs reviewed for performance evaluations and annual in-services. The facility census was 34.1) Review of CNA #32's personnel file revealed CNA #32 was hired at the facility on 05/22/24. Further review of CNA #32's personnel file revealed CNA #32 did not have an annual performance evaluation from 05/22/24 to 07/30/25 and CNA #32 did not have any documented in-service education from 05/22/24 to 07/30/25. Interview with Regional Support #804 on 07/31/25 at 7:31 A.M. verified CNA #32 did not have an annual performance evaluation from 05/22/24 to 07/30/25 and CNA #32 did not have any documented in service education from 05/22/24 to 07/30/25. 2) Review of CNA #36's personnel file revealed CNA #36 was hired at the facility on 01/22/25. Further review of CNA #36's personnel file revealed CNA #36 did not have a 90-day performance evaluation completed from 01/22/25 to 07/30/25. Interview with Regional Support #804 on 07/31/25 at 7:33 A.M. verified CNA #36 did not have a 90-day performance evaluation completed from 01/22/25 to 07/30/25. 3) Review of CNA #45's personnel file revealed CNA #45 was hired at the facility on 09/12/23. Further review of CNA #45's personnel file revealed CNA #45 did not have any documented in service education from 09/12/24 to 07/30/25. Interview with Regional Support #804 on 07/31/25 at 7:35 A.M. verified CNA #45 did not have any documented in-service education from 09/12/24 to 07/30/25. Review of the facility's performance evaluations policy dated September 2020 revealed the job performance of each employee shall be reviewed and evaluated at least annually. A performance evaluation will also be completed on each employee at the conclusion of their 90-day probationary period. Review of the facility's undated all staff in service training revealed all staff are required to participate in regular in service education.

Based on observation, interview and record review, the facility failed to ensure food temperatures were maintained in a manner to prevent foodborne illness. This affected all 34 residents residing in the facility as the facility indicated all residents receive food from the kitchen. The facility census was 34. Observation of the facility's kitchen on 07/29/25 at 7:30 A.M. revealed [NAME] #43 was serving food from the stove and placing the made plates on the food cart that was not insulated. [NAME] #43 took the temperature of the food items on the stove and again while on the food cart. The gravy was 128.3 degrees Fahrenheit, the boiled eggs were 73.4 degrees Fahrenheit, and the scrambled eggs were 87 degrees Fahrenheit. The gravy, boiled eggs and scrambled eggs were located on the stove. The pureed scrambled eggs were 102.4 degrees Fahrenheit, the pureed oatmeal was 127.1 degrees Fahrenheit, and the pureed biscuits and gravy were 94.8 degrees Fahrenheit. The pureed scrambled eggs, the pureed oatmeal and the pureed biscuits and gravy were located on the food cart. [NAME] #43 continued to plate meals after taking the food temperatures. Interview with [NAME] #43 on 07/29/25 at 7:30 A.M. verified the gravy on the stove was 128.3 degrees Fahrenheit, the boiled eggs were 73.4 degrees Fahrenheit, and the scrambled eggs were 87 degrees Fahrenheit. [NAME] #43 also verified the pureed scrambled eggs on the food cart were 102.4 degrees Fahrenheit, the pureed oatmeal was 127.1 degrees Fahrenheit, and the pureed biscuits and gravy were 94.8 degrees Fahrenheit. [NAME] #43 stated the facility did not have a steam table to maintain the temperature of the food items.

Based on interview and record review, the facility failed to ensure the Medical Director or his or her designee attended quarterly Quality Assessment and Assurance (QAA) committee meetings. This affected 34 out of 34 residents residing in the facility. The facility census was 34. Review of the facility's QAA meeting sign in sheets from 09/18/24 to 02/18/25 revealed the Medical Director or their designee did not attend the QAA meetings held from 09/19/24 to 02/17/25. Interview with the Administrator on 07/31/25 at 1:38 P.M. verified the Medical Director or their designee did not attend the QAA meetings held from 09/19/24 to 02/17/25.

Based on interview and record review, the facility failed to implement their tuberculosis control plan for tuberculosis testing of newly hired employees. This affected four (The Administrator, Licensed Practical Nurse (LPN) #30, Certified Nursing Assistant (CNA) #36 and CNA #41) out of eight newly hired employees reviewed for tuberculosis testing. This also affected 34 out of 34 residents residing in the facility. The facility census was 34. 1) Review of the Administrator's personnel file revealed the Administrator was hired at the facility on 03/06/25. Further review of the Administrator's personnel file revealed the Administrator did not have a tuberculin skin test or other test to rule out TB completed upon hire. Interview with Regional Support #804 on 07/31/25 at 7:31 A.M. verified the facility had no documentation that the Administrator received a TB test or interferon gamma release assay test upon hire. 2) Review of the LPN #30's personnel file revealed LPN #30 was hired at the facility on 05/08/24. Further review of LPN #30's personnel file revealed LPN #30 did not have a tuberculin skin test or other test to rule out TB completed upon hire. Interview with Regional Support #804 on 07/31/25 at 7:33 A.M. verified the facility had no documentation that LPN #30 received a TB test or interferon gamma release assay test upon hire. 3) Review of CNA #36's personnel file revealed CNA #36 was hired at the facility on 01/22/25. Further review of CNA #36's personnel file revealed CNA #36 did not have a tuberculin skin test or other test to rule out TB completed upon hire. Interview with Regional Support #804 on 07/31/25 at 7:35 A.M. verified the facility had no documentation that CNA #36 received a TB test or interferon gamma release assay test upon hire. 4) Review of CNA #41's personnel file revealed CNA #41 was hired at the facility on 02/19/25. Further review of CNA #41's personnel file revealed CNA #41 did not have a tuberculin skin test or other test to rule out TB completed upon hire. Interview with Regional Support #804 on 07/31/25 at 7:36 A.M. verified the facility had no documentation that CNA #41 received a TB test or interferon gamma release assay test upon hire. Review of the facility's employee screening for tuberculosis policy dated March 2021 revealed each newly hired employee is screened for latent tuberculosis infection and active tuberculosis infection after an employment offer has been made but prior to the employee's duty assignment. Screening includes a baseline test for latent tuberculosis infection either using a tuberculosis skin test or interferon gamma release assay, an individual assessment and a symptom evaluation. If the baseline test is negative and the individual risk assessment indicates no risk factors for acquiring TB, then no additional screening is indicated. If the baseline testing is positive, but the individual risk assessment is negative and the individual is asymptomatic, a second test with either a tuberculosis skin test or interferon gamma release assay is conducted.

Based on review of the medical record, interviews, observations, and policy review, the facility failed to ensure residents, who were unable to carry out activities of daily living (ADLs) were provided grooming for facial hair. This affected one (#38) resident of three reviewed for ADLs. The facility census was 34.Review of the medical record for Resident #38 revealed an admission date of 01/02/25. Diagnoses included type II diabetes mellitus (DM II), altered mental status, and schizophrenia. Review of the care plan dated 01/08/25 revealed Resident #38 had an ADL self-care performance deficit related to weakness, history of being a victim of physical abuse by a family member, and trauma. Interventions included assistance with bathing/showering, setup with bed mobility, dressing, and eating, encouraged to use call light for assistance, and used walker to maximize independence with transferring.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of six. This resident was assessed to require setup with eating, toileting, dressing, and transfers, and substantial assistance with bathing.Observation on 07/28/25 at 3:44 P.M. revealed Resident #38 was noted to have approximately six chin hairs noted on face that were about a half an inch in length.Observation on 07/30/25 at 3:32 P.M. revealed Resident #38 was noted to have approximately six chin hairs noted on face that were about a half an inch in length.Interview on 07/30/25 at 3:35 P.M. with Resident #38 reported that her chin hairs bothered her and would like them to be groomed. Resident #38 reported no staff had offered to shave them on shower days.Interview on 07/30/25 at 3:40 P.M. with Licensed Practical Nurse (LPN) #803 verified Resident #38 had chin hairs noted. LPN #803 stated she would take care of chin hairs for Resident #38 per request.Review of the facility policy titled, Activities of Daily Living, Supporting, dated 2001 revealed residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who were unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming, personal, and oral hygiene.

Based on interview and record review, the facility failed to ensure a cognitively impaired resident was explained or understood an Arbitration Agreement prior to signing the agreement. This affected one (#38) of the three residents reviewed for arbitration agreements. The facility census was 34. Review of Resident #38's chart revealed Resident #38 was admitted to the facility on [DATE] with adult physical abuse confirmed subsequent encounter, rectal prolapse, hypertension, schizophrenia, and altered mental status.Review of Resident #38's Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #38 had a BIMS score of a one indicating Resident #38 was severely cognitively impaired. Review of Resident #38's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Resident #38's undated arbitration agreement revealed Resident #38 signed the arbitration agreement that stated she was agreeing to arbitration and waving her right to a trial by jury and the possibility of an appeal. Interview with Social Services (SS) #43 on 07/29/25 at 1:34 P.M. revealed Resident #38 signed an Arbitration Agreement on 03/28/25 with her admission packet. SS #43 stated that she explained the arbitration agreement to the resident but reported the resident was cognitively impaired. SS #43 verified Resident #38 had a BIMS of a one on 04/14/25 indicating she was severely cognitively impaired at the time the agreement was signed, and Resident #38 was not able to understand an Arbitration Agreement. SS #43 stated Resident #38 did not have a guardian or power of attorney (POA). Interview with Resident #38 on 07/30/25 at 3:35 P.M. revealed Resident #38 did not recall signing an Arbitration Agreement. Resident #38 was not aware of the meaning of an arbitration agreement. Review of the facility's Binding Arbitration Agreements policy dated November 2023 revealed the terms and conditions of binding arbitration agreements are explained to the resident or representative in a way that ensures his or her understanding of the agreement including that the resident may be giving up his or her right to have a dispute decided in a court proceeding. Interview with Resident #38 on 07/30/25 at 3:35 P.M. revealed Resident #38 did not recall signing an Arbitration Agreement. Resident #38 was not aware of the meaning of an arbitration agreement. Review of the facility's Binding Arbitration Agreements policy dated November 2023 revealed the terms and conditions of binding arbitration agreements are explained to the resident or representative in a way that ensures his or her understanding of the agreement including that the resident may be giving up his or her right to have a dispute decided in a court proceeding.

Based on interview and record review, the facility failed to ensure Resident Funds Authorizations were signed and witnessed for residents that had deposited funds in resident funds accounts at the facility. This affected three (#03, #10 and #34) out of the five residents reviewed for resident funds accounts. The facility census was 34. 1) Review of the medical record for Resident #34 revealed an admission date of 10/19/19. Diagnoses included chronic obstructive pulmonary disease (COPD), dementia, and type II diabetes mellitus (DM II). Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14. Review of the facility's Resident Funds Accounts Balance Sheet dated 07/30/25 revealed Resident #34 had $1552.74 dollars in her resident funds account. Review of Resident 34's record revealed Resident #34 did not have a Resident Funds Authorization on file at the facility. Interview with Regional Support #804 on 07/31/25 at 7:31 A.M. verified Resident #34 did not have a Resident Funds Authorization on file at the facility. 2) Review of Resident #03's chart revealed Resident #03 admitted to the facility on [DATE] with sepsis, type two diabetes mellitus with diabetic neuropathy, heart failure, type two diabetes mellitus with hypoglycemia without coma, sleep apnea, muscle weakness and progressive supranuclear ophthalmoplegia. Review of Resident #03's quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of the facility's Resident Funds Accounts Balance Sheet dated 07/30/25 revealed Resident #03 had $50.00 dollars in her resident funds account. Review of Resident #03's Resident Funds Authorization dated 07/16/25 revealed Resident #03 signed the Resident Funds Authorization. Further review of Resident #03's Resident Funds Authorization revealed Resident #03's Resident Funds Authorization was not witnessed. Interview with Regional Support #804 on 07/31/25 at 7:31 A.M. verified Resident #03's Resident Funds Authorization was not witnessed. 3) Review of the medical record for Resident #10 revealed an admission date of 08/22/22. Diagnoses included cerebral infarction, chronic obstructive pulmonary disease (COPD), and major depressive disorder. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #10 had moderate cognitive impairment as evidenced by a BIMS score of 10. Review of the facility's Resident Funds Accounts Balance Sheet dated 07/30/25 revealed Resident #10 had $3,475.54 in her resident funds account. Review of Resident #10's Resident Funds Authorization dated 06/11/25 revealed Resident #10 signed the Resident Funds Authorization. Further review of Resident #10's Resident Funds Authorization revealed Resident #10's Resident Funds Authorization was not witnessed. Interview with Regional Support #804 on 07/31/25 at 7:31 A.M. verified Resident #10's Resident Funds Authorization was not witnessed.

Based on staff interview and record review, the facility failed to ensure a resident on Medicaid was notified when their account reached $200.00 dollars less than that supplemental security income (SSI) resource limit for one person and the facility failed to ensure a resident's personal funds held in a resident's funds account were conveyed within 30 days of discharge. This affected two (#31 and #48) out of the five residents reviewed for resident funds accounts. The facility census was 34. 1)Review of the medical record for Resident #31 revealed an admission date of 07/30/24. Diagnoses included cerebral infarction, hepatitis B, type II diabetes mellitus (DM II), and depression. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. This resident was assessed to require setup with eating, dependent with toileting, bathing, dressing, and transfers. Review of Resident #31's census information dated 07/31/25 revealed Resident #31's payer source was Medicaid. Review of Resident #31's Resident Funds Statement dated 07/31/25 revealed Resident #31 had $2,901.50 in his resident funds account. Further review of Resident #31's resident funds account revealed no documentation that Resident #31 was notified that his account reached $200.00 dollars less than the supplemental security income (SSI) resource limit for one person. Interview with Regional Support #804 on 07/31/25 at 7:31 A.M. verified there was no documentation that Resident #31 was notified that his account reached $200.00 dollars less than the SSI resource limit for one person. 2)Review of the medical record for Resident #48 revealed an admission date of 11/21/22 with a discharge date of 11/21/24. Diagnoses included cerebral infarction, hepatitis B, type II diabetes mellitus (DM II), and depression. Review of the Annual MDS assessment dated [DATE] revealed Resident #48 had intact cognition as evidenced by a BIMS score of 15. This resident was assessed to require setup with eating, toileting, bathing, dressing, and transfers. Review of the facility's check to the Attorney General's office dated 06/11/25 revealed Resident #48's account balance of $1,218.14 was paid to the Attorney General's office on 06/11/25. Interview with the Administrator on 07/31/25 at 1:38 P.M. verified Resident #48's account balance of $1,218.14 was not conveyed to the Attorney General's office until 06/11/25. The Administrator verified Resident #48 discharged from the facility on 11/21/24.

Based on interview and record review, the facility failed to ensure a resident's code status matched in the separate paper chart and a resident's Do Not Resuscitate (DNR) order form was signed by the physician in the paper chart. This affected one (#03) of the 16 residents reviewed for code status. The facility census was 34. Review of Resident #03's chart revealed Resident #03 was admitted to the facility on [DATE] with sepsis, type two diabetes mellitus with diabetic neuropathy, heart failure, type two diabetes mellitus with hypoglycemia without coma, sleep apnea, muscle weakness and progressive supranuclear ophthalmoplegia. Review of Resident #03's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #03's paper chart revealed Resident #03 did not have a DNR order form signed by a physician in the paper chart. Review of Resident #03's Code Status Consent Form located in the paper chart dated 10/30/24 revealed Resident #03 signed a consent indicating that Resident #03 consented to a Do Not Resuscitate Comfort Care Arrest (DNRCCA) code status. The form was not signed by Resident #03's physician. Review of Resident #03's Advanced Directive Discussion Form located in the paper chart dated 02/05/24 revealed Resident #03 was a Full Code. The Advanced Directive Discussion Form was located behind Resident #03's Code Status Consent in the paper chart. There was also a paper that stated Full Code in large letters located behind the Advanced Directive Discussion Form in the paper chart. Review of Resident #03's electronic medical record (EMR) revealed a physician order dated 02/05/25 which indicated Resident #03's code status was a DNRCCA. The order was electronically signed by Physician #802 on 02/06/25. Interview with Licensed Practical Nurse (LPN) #30 on 07/28/25 at 2:09 P.M. verified Resident #03 did not have a DNR order form signed by a physician in the paper chart indicating that Resident #03's code status was changed to a DNRCCA after Resident #03 consented to changing her code status on 10/30/24. LPN #30 stated that the facility should have a DNR order form signed by the physician on file in the paper chart, but the facility could not find a DNR order form indicating Resident #03 was a DNRCCA. LPN #30 also confirmed Resident #03 had Advanced Directive Discussion Form and a sign that stated Full Code in large letters in the paper chart behind Resident #03's Code Status Consent Form. LPN #30 verified the Code Status Consent Form was not signed by the physician. Review of the facility's advanced directives policy dated September 2022 revealed the resident had the right to formulate an advanced directive.

Based on interview and record review, the facility failed to ensure residents received beneficiary notices to inform them of the right to an expedited review or about the potential non-coverage and the option to continue services with the beneficiary accepting financial liability for the services. This affected two (#46 and #47) of the three residents reviewed for beneficiary notices. The facility census was 34. 1) Review of Resident #46's chart revealed Resident #46 was admitted to the facility on [DATE] with cellulitis, other asthma, acute embolism and thrombosis of right femoral vein, rheumatoid arthritis, unspecified macular degeneration, Parkinson's disease with dyskinesia, and other intervertebral disc displacement lumbar region.Review of Resident #46's census information from 02/26/25 to 04/03/25 revealed Resident #46's payer source was Medicare Part-A from 02/26/25 to 04/03/25. Resident #46 discharged from the facility on 04/03/25.Review of Resident #46's progress notes from 02/26/25 to 04/03/25 revealed no documentation that Resident #46 received a Notice of Medicare Non Coverage (NOMNC) to inform Resident #46 of the right to an expedited review upon Resident #46's discharged from Medicare Part-A services on 04/03/25. Review of Resident #46's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired. Interview with Regional Support #804 on 07/31/25 at 7:31 A.M. verified Resident #46 did not receive a NOMNC upon discharge from Medicare Part-A services on 04/03/25. 2) Review of Resident #47's chart revealed Resident #47 admitted to the facility on [DATE] with cardiac arrest, chronic obstructive pulmonary disease, maxillary fracture right side subsequent encounter for fracture with routine healing, presence of cardiac pacemaker, hypothyroidism and hyperlipidemia. Review of Resident #47's discharge MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #47's census information from 11/01/24 to 01/01/25 revealed Resident #47's payer source was Medicare Part- A from 11/01/24 to 12/17/24. Resident #47's payer source changed to private pay on 12/18/24. Resident #47's payer source remained private pay from 12/18/24 to 01/01/25. Review of Resident #47's progress notes from 11/01/24 to 01/01/25 revealed no documentation that Resident #47 received a NOMNC to inform Resident #47 of the right to an expedited review or a Skilled Nursing Facility Advanced Beneficiary Notice of Non Coverage (SNFABN) to inform Resident #47 about the potential non-coverage and the option to continue services with the beneficiary accepting financial liability for the services upon Resident #47's discharged from Medicare Part-A services on 12/17/24. Interview with Regional Support #804 on 07/31/25 at 7:31 A.M. verified Resident #47 did not receive a NOMNC or SNFABN upon discharge from Medicare Part A services on 12/17/24. This deficiency represents non-compliance investigated under Complaint Number OH001374492.

Based on interview and record review, the facility failed to ensure a resident received bed hold notices for transfers to the hospital. The facility also failed to notify the Ombudsman of a resident's transfer to the hospital. This affected one (#03) of the one resident reviewed for hospitalization. The facility census was 34. Review of Resident #03's chart revealed Resident #03 was admitted to the facility on [DATE] with sepsis, type two diabetes mellitus with diabetic neuropathy, heart failure, type two diabetes mellitus with hypoglycemia without coma, sleep apnea, muscle weakness and progressive supranuclear ophthalmoplegia. Review of Resident #03's chart from 02/02/24 to 07/30/25 revealed there was no documentation that Resident #03 received a bed hold notice for her 03/25/25 and 05/17/25 discharges to the hospital. Further review of Resident #03's chart revealed no documentation that the Ombudsman was notified of Resident #03's discharge to the hospital on [DATE]. Review of Resident #03's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #03 required set up assistance with eating, oral hygiene, and personal hygiene. Resident #03 was dependent with toileting, showering, upper body dressing, lower body dressing, putting on and taking off footwear, rolling left and right, chair transfers, and tub transfers. Review of Resident #03's progress note dated 03/25/25 at 3:51 P.M. revealed Resident #03 was noted with a red rash on chest neck, and abdomen. Resident #03 was slurring her words and was confused. The Nurse Practitioner (NP) was notified, and Resident #03 was sent to the emergency room (ER) for evaluation for a possible allergic reaction. Resident #03's brother was notified. Review of Resident #03's progress note dated 03/31/25 at 11:32 P.M. revealed Resident #03 returned from the hospital. Review of Resident #03's progress note dated 05/17/25 at 5:45 P.M. revealed Resident #03 was noted with a temporal temperature of 105.0 degrees Fahrenheit and a temperature of 104.3 degrees Fahrenheit upon recheck. The nurse administered Tylenol per order and rechecked Resident #03's temperature which was 103.9 degrees Fahrenheit. The nurse contacted the on call physician regarding Resident #03's change in condition. The on call physician ordered multiple diagnostic studies, laboratory (lab) studies, and imaging. The nurse discussed the new orders with Resident #03 and Resident #03 stated she wanted to go to the hospital. The nurse contacted the on call physician to update them and the on call physician gave an order to send Resident #03 out to the ER. Resident #03 and Resident #03's family was updated. The nurse called Emergency Medical Services (EMS). Review of Resident #03's census information dated 05/23/25 revealed Resident #03 returned from the hospital on [DATE]. Interview with the Administrator on 7/31/25 at 9:14 A.M. revealed Resident #03 was not given a bed hold notice for her 03/25/25 and 05/17/25 discharges to the hospital. The Administrator also verified that the Ombudsman was not notified of Resident #03's discharge to the hospital on [DATE].

Based on interview and record review, the facility failed to ensure a significant change Minimum Data Set (MDSs) assessment was completed for a resident that admitted to hospice. This affected one (#43) of 15 residents reviewed for MDS accuracy. The facility census was 34. Review of Resident #43's chart revealed Resident #43 was admitted to the facility on [DATE] with malignant neoplasm of bladder, unspecified protein calorie malnutrition, chronic obstructive pulmonary disease, anemia, atrial fibrillation, hyperlipidemia, history of falling, muscle weakness, hypokalemia, retention of urine, hydroureter and sepsis. Resident #43 was discharged from the facility on 07/05/25. Review of Resident #43's MDS assessments from 06/16/25 to 07/05/25 revealed Resident #43 did not have a significant change MDS assessment transmitted or completed upon Resident #43's admission to hospice services on 06/19/25. Review of Resident #43's quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired. Review of Resident #43's Hospice Election Form dated 06/18/25 revealed Resident #43 signed the consent to be admitted to Hospice services. Review of Resident #43's physician order dated 06/19/25 revealed Resident #43 was admitted to Hospice #800 on 06/19/25 with a diagnosis of Atherosclerosis. Interview with the Administrator on 7/30/25 at 11:54 A.M. verified Resident #43 did not have a significant change MDS assessment transmitted or completed upon Resident #43's admission to Hospice services on 06/19/25.

Based on record review and staff interview, the facility failed to ensure a significant change in status Pre-admission Screening and Resident Review (PASARR) was completed for a resident with a new mental health diagnosis. This affected one (#23) of the two residents reviewed for PASARRs. The facility census was 34. Review of Resident #23's medical record revealed that he was admitted to the facility on [DATE] with diagnoses that included cerebral vascular accident, dysphagia, diabetes mellitus type 2, blindness in the right eye, congestive heart failure, bipolar disorder, anxiety, depression, malnutrition and dementia. Review of Resident #23's facility assessments from March 2025 to July 2025 revealed Resident #23 did not have a significant change PASARR completed for diagnosis of bipolar disorder. Review of Resident #23's quarterly Minimum Data Set (MDS) assessment, dated 04/30/25, revealed the resident had cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of three. Review of Resident #23's diagnosis list dated 05/07/25, revealed Resident #23 had a diagnosis of bipolar disorder, added on 12/17/23.Review of Resident #23's PASARR, dated 07/29/25, revealed that the only indication marked under serious mental illness was other psychotic disorder(s). Further review of Resident #23's medical record revealed that there was no updated PASARR completed when diagnoses for a bipolar disorder was added on 12/17/23. Interview on 07/31/25 at 11:12 A.M. with Director of Nursing (DON) revealed that the facilities process for completing PASARRs was to complete them on admission and with any significant changes. The DON stated examples for significant change would be if the resident has a hospital stay for mental health or if the resident got a new psychological diagnosis added. The DON also verified that Resident #23's PASARR dated 07/29/25 did not have mood disorder, depression or anxiety as an indication marked under serious mental illness.

Based on observations, interviews, and policy review, the facility failed to ensure medications were within expiration date in the medication cart. This had the potential to affect three (#02, #06, and #15) of the three residents who were administered Pro-Stat. The facility census was 34. Observation on [DATE] at 3:11 P.M. with Licensed Practical Nurse (LPN) #803, revealed the [NAME] Hall medication cart had a Pro-Stat (albuterol) inhaler opened and was expired. The manufacturer's expiration date was marked as [DATE]. Interview with LPN #803 at the same time, verified the Pro-Stat inhaler had expired and needed to be discarded.Observation on [DATE] at 3:23 P.M. with LPN #30, revealed the Emerald Hall medication cart had a Pro-Stat inhaler that was opened and expired. The manufacturer's expiration date was marked as [DATE]. Interview with LPN #30 at the same time, verified the Pro-Stat inhaler had expired and needed to be discarded.Review of the facility policy titled, Medication Storage and Labeling, dated February 2017 revealed all medications were in order and an account of all controlled medications were maintained and periodically reconciled. Medications were in accordance with currently accepted professional principles and include appropriate accessory and cautionary instructions and expiration date.

Based on medical record review, observations, and staff interviews, the facility failed to ensure a resident room was free from holes in wall, free from broken drywall, and free from black debris on the wall. This affected one (#16) out of the three residents reviewed for cleanliness of rooms. Additionally, the facility also failed to ensure the shower rooms were free from black substance along the flooring near the walls. This had the potential to affect 19 (#17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, and #35) residents who use the shower room on the Emerald and [NAME] Halls. The facility census was 35. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 12/12/23 with medical diagnoses of diabetes mellitus, chronic obstructive pulmonary disease, Intellectual Disabilities, and hypertension. Review of the medical record for Resident #16 revealed a quarterly Minimum Data Set (MDS) assessment, dated 03/14/25, which indicated Resident #16 had severely impaired cognition and required set-up assistance for eating and was dependent upon staff for bed mobility, toileting, and bathing. Observation on 05/23/25 at 8:35 A.M. of Resident #16's room revealed a large (around 12 inch) circular hole in the wall behind Resident #16's bedside dresser. The observation revealed the drywall behind the bedside dresser was broken and crumbling and an electrical outlet was located next to the hole in the wall. The observation also revealed broken drywall behind Resident #16's bed with several large cracks noted to the drywall and black debris noted to be scattered on the wall underneath the window. Interviews on 05/23/25 at 8:37 A.M. with Certified Nursing Assistant (CNA) #100 and Licensed Practical Nurse (LPN) #101 confirmed Resident #16's room had a large hole in the drywall near an electrical outlet behind the bedside dresser, broken drywall behind Resident #16's bed, and black debris noted to be scattered on Resident #16's wall underneath her window. Interview with CNA #100 stated the hole in Resident #16's wall had been there for quite some time. 2. Observation with interview on 05/23/25 at 9:03 A.M. with CNA #102 of the Emerald Hall shower room revealed black substance scattered on the flooring by the walls. CNA #102 confirmed the shower room revealed black substance on the flooring by the walls. Observation with interview on 05/23/25 at 10:40 A.M. with Housekeeper #115 of the [NAME] Hall shower room revealed a black substance scattered on the flooring by the walls. Housekeeper #115 confirmed the shower room revealed black substance on the flooring by the walls. The facility confirmed there are 19 (#17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, and #35) residents who use the shower room on the Emerald and [NAME] Halls This deficiency represents non-compliance investigated under Complaint Number OH00163998.

Based on review of Legionella Water Management Plan, review of Water Management Evaluation Tool, interviews, and policy review, the facility failed to follow public health authority recommendations to revise the Water Management Plan in a timely manner and failed to monitor pH levels of water sources. This had the potential to affect all residents. The facility census was 40: Findings include: Review of Legionella Water Management Plan dated [DATE] revealed the facility identified members of the Water Management Team with the exception of naming the Maintenance Director; described the buildings water systems including circulation of water, number of mixing valves and hot water tanks, absence of holding tanks, points of recirculation, and location of tees; and listed the verification process including weekly checks and documentation of pH levels and water temperatures and flushing unused sinks and showers. There were no parameters listed for how long unused sinks and showers were flushed and no parameters for pH and temperature levels. Review of Water Management Evaluation Tool dated [DATE] revealed Bureau of Infections Disease (BID) Specialist #50 assessed the facility's Water Management Program (WMP) and provided 37 comments with recommendations for improvements: It was unclear whether the facility had recirculation loops or circulatory pumps. It was unclear what types of water system components/devices were present (shower wands, hoses, bathtubs, drinking fountains). The WMP did not identify which team members were responsible for implementing the WMP and direct corrective action as needed; maintaining working knowledge of the facility water system(s); identifying system control locations and control limits; and monitoring and documenting program performance. The WMP did not provide any information regarding description of the type of piping material, age, cold water storage; the number and location of cold-water outlets in the facility; or identification of any flow restrictors, aerators, showerheads, wand attachments, drinking fountains, etc. The WMP did not provide any information which indicated if hot water was recirculated nor was there a description of the type of piping material, age; type and extent of any insulation used to help maintain temperature; the number of hot water outlets and location of any thermal mixing valves within the facility. Water conditioning equipment is not identified. The WMP mentions that sinks and showers could have stagnation but does not mention why (vacancies) or identify any of the other items mentioned including dead legs in water piping; wings or rooms that are vacant temporarily unused or have been repurposed, and/or areas with variable temperature; or disinfectant level indicating increased water age. The WMP did not identify areas with consistently low or no residual disinfectant. The WMP did not specify control point locations; parameter to be measured (e.g., temperature, pH, disinfectant level); and acceptable level or range of each parameter. The WMP did not specify control limits (quantitative or qualitative) for each control location The WMP did not contain information about legionella monitoring including frequency of tests; indicate what events, in addition to routine testing, trigger additional testing (e.g., water service disruptions, before returning unoccupied areas to service, associated cases of legionellosis); or contain context for interpreting results both from the percentage of positive samples found, location(s) of Legionella detection, the quantified number of Legionella in each sample, the trends over time, and the type of Legionella detected. The WMP is not embodied in a written document that provides all the key elements of the program in a clear and concise manner so that it can be communicated and followed by WMP team. Review of weekly monitoring sheets titled, Logbook Documentation: Testing and Monitoring of Water Management Plan for Legionella, dated [DATE] to [DATE] revealed the facility did not document pH levels of water samples. During an interview on [DATE] at 12:16 P.M. Maintenance Director #51 state the facility's Water Management Plan included weekly monitoring of water pH levels and verified there was no documentation of pH levels from weekly monitoring. During an interview on [DATE] at 2:43 P.M. the Administrator stated she received an email [DATE] from the local health department with attachments. The Administrator acknowledged one of the attachments included the Water Management Evaluation Tool from the Bureau of Infectious Diseases dated [DATE] recommending changes; however, she did not open the attachment and was unaware of the recommendations. The Administrator stated she was unaware the recommendations were requirements and not merely suggestions for improvement and stated she believed since the local health department had lifted water restrictions in [DATE], there was no urgency to revise the plan. This deficiency represents non-compliance investigated under Complaint Number OH00162813.

Based on record review, interview, and review of policy, the facility failed to assess residents identified prior to admission as a fall risk and failed to thoroughly investigate a fall. This affected two (Residents #38 and #43) of three residents reviewed for falls. The facility census was 42. Findings include: 1. Record review for Resident #38 revealed he was admitted to the facility on [DATE]. His diagnoses included hypertensive crisis, essential primary hypertension, hemiplegia, gout, spinal stenosis, and syncope. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was cognitively impaired. Resident #38 was dependent on staff for medication administration, bathing, and toileting. He required assistance from staff with eating, oral hygiene, and personal hygiene. Review of Resident #38's hospital referral prior to entering the facility stated Resident #38 was a high fall risk. Review of Resident #38's assessment titled, Fall Risk Assessment, dated 06/12/24 revealed the facility failed to complete the fall risk assessment. Interview on 07/18/24 at 4:45 P.M. with Regional Nurse (RN) #500 confirmed Resident #38 should have been marked a fall risk related to his hospital paperwork and the fall assessment was not completed. 2. Record review for Resident #43 revealed he was admitted to the facility on [DATE]. He discharged to the hospital on 06/28/24 related to a fall with head injury. His diagnoses included, hemiplegia, hemiparesis, schizoaffective disorder, acute respiratory failure with hypoxia, dysphagia, essential primary hypertension, sepsis, pneumonia, major depressive disorder, anxiety disorder, gastro-esophageal reflux disease (GERD), hyperlipidemia, heart failure, and insomnia. Review of Resident #43's most recent MDS assessment dated [DATE] revealed he was severely cognitively impaired. Further review of the MDS assessment revealed he was dependent on staff for medication administration, bathing, transfers, lower body dressing, walking, and taking/off shoes. Resident #43 required maximum assistance from staff with eating, oral hygiene, upper body dressing, sit to lying, and sit to standing, Resident #43 needed partial assistance from staff to roll back and forth. Record review for Resident#43's preadmission hospital stay revealed he was admitted to the hospital on 06/09/24 with dizziness and frequent falls for the previous five days. Resident #43's hospital record revealed a diagnosis of acute infarct in the left frontal lobe. Review of Resident #43's nurse progress notes revealed on a late entry dated 06/27/24 for 06/26/24 revealed Resident #43 was found on the floor next to the bed at 8:30 P.M. on 06/26/24. The resident was agitated and tried to get himself off the floor. The nurse assessed Resident#43's skin and took his vitals. Resident #43 was assisted by the nurse and two nurse aides back into bed. Further review of the nursing progress notes revealed Resident #43 had a fall on 06/28/24 at 11:56 P.M. in the dining room and the fall was witnessed by staff and residents. The progress notes stated Resident #43 slid out of his wheelchair. The nurse notified a family member of the fall with laceration to Resident #43's side of his head. Resident was sent to the hospital for evaluation and was admitted to the hospital. Review of the facility report titled, Neurological Assessment Flow Sheet, with a start date of 06/26/24 at 8:30 P.M. for Resident #43 revealed the last neurological assessment was completed on 06/17/24 at 2:20 P.M. Further review of the Neurological Assessment form confirmed the instructions included neurological check every 16 minutes for the first hour, every hour for the next four hours, and every four hours for the next 19 hours. Review of Resident #43's assessment titled, Fall Risk Assessment, dated 06/24/24, revealed the assessment was started upon entry to the facility, however, it was not completed and signed. Further review of the initial Fall Risk Assessment revealed the facility staff marked Resident #43 had no falls in the past three months and was alert and oriented to person, place, and time. Review of the facility report titled, Incident and Accident Log, for the past ninety days, revealed Resident #43 had a fall incorrectly dated for 06/27/24 (should have read 06/26/24) and nothing listed related to Resident #43's fall on 06/28/24. Review of Resident #43's fall investigation dated 06/27/24, revealed Resident #43 was found on the floor next to his bed on 06/26/24 at 8:30 P.M. Resident #43 was agitated and tried to get himself off the floor. Review of Resident #43's fall investigation dated 06/28/24, revealed the facility failed to complete a fall investigation and did not gather any investigative information related to the fall. However, the facility did provide a report taken at the initial time of the fall. The report was titled, Fall Triage, dated 06/28/24, confirmed Resident #43 fell in the dining room on 06/28/24. Further review of the Fall Triage reported for Resident #43 revealed there were no witnesses to the fall in the dining room before lunch. Resident #43 was lifted from the floor by three members with a gait belt and sent to the emergency room . An interview on 07/18/24 at 3:27 P.M. with the RN #500 confirmed Resident #43's admission hospital paperwork confirmed Resident #43 was a fall risk. RN #500 confirmed the facility failed to accurately fill out and complete Resident #43's fall risk assessment. A subsequent interview on 07/22/24 at 10:48 A.M. with RN #500 confirmed the facility failed to provide a thorough investigation related to Resident #43's fall on 06/28/24. RN #500 confirmed the Triage Report, and the Nursing Fall report gave conflicting information related to witnesses to the fall. RN #50 confirmed the facility failed to provide statements or a complete investigation related to Resident #43's fall. Review of the facility policy titled, Fall Prevention Program, dated 09/22/22, confirmed the facility will utilize a standardized risk assessment to determine the resident's fall risk. Further review of the policy revealed the Fall Risk Assessment will be completed upon admission to determine the level of fall risk. Review of the facility policy titled, Maintenance of Medical Records, dated 2023, confirmed the facility will maintain medical records for each resident in accordance with acceptable standard of practice. The policy stated, a complete and accurate medical record will be maintained. This deficiency represents non-compliance investigated under Complaint Number OH00155726.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, staff interview, review of the fall investigation, review of witness statements, and review of the hospital records, the facility failed to ensure residents were safely transferred in a manner to prevent an avoidable major injury as care planned and per facility policy. This resulted in Actual Harm on 02/27/24 when State tested Nurse Aide (STNA) #500 transferred Resident #28 from the bed to the wheelchair without assistance as required by Resident #28's plan of care resulting in Resident #28 sliding down in the front of the wheelchair and her left shoulder making contact with the wheelchair. Subsequently, Resident #28 was sent to the local hospital where she was diagnosed with a closed fracture of the left shoulder. This affected one (#28) of three residents reviewed for accident hazards. The facility identified one( #28) resident who required a mechanical lift for transfers. The facility census was 36. Findings include: Review of the Resident #28's medical record revealed an admitted [DATE]. Diagnoses included fracture of left shoulder girdle part subsequent encounter for fracture with routine healing, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic atrial fibrillation, hypokalemia, muscle weakness, hypertension, pain in right shoulder, difficulty in walking, and gout. Review of Resident #28's activities of daily living (ADL) care plan revised 10/11/22 revealed Resident #28 had a physical functioning deficit related to mobility impairment, self-care impairment and fluctuating ADLs. Interventions included Resident #28 was totally dependent on two staff members with mechanical lift transfers. Review of Resident #28's annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact, and Resident #28 was dependent on two-person physical assistance of staff for bed mobility, and all transfers. No prior falls in the last three months were listed on the MDS. Review of Resident #28's physical therapy discharge note dated 02/21/24, revealed Resident #28 required maximal assistance with bed to chair transfers. Review of Resident #28's progress note dated 02/27/24 at 11:29 A.M., revealed Resident #28 complained of left shoulder pain of a 10 (a pain scale where zero is no pain and 10 is severe pain). Licensed Practical Nurse (LPN) #35 obtained an order from the Nurse Practitioner (NP) for a left shoulder stat (immediate) Xray. The order was placed, and Resident #28's daughter was made aware. The Director of Nursing (DON) was made aware. Review of Resident #28's progress note dated 02/27/24 at 4:07 P.M., revealed Resident #28's family requested Resident #28 be sent to the emergency room (ER) for evaluation and treatment of the shoulder. Emergency medical services (EMS) were called, and the appropriate paperwork was sent with the resident. Resident #28 was resting comfortably in her room while waiting for mobile Xray. Resident #28 was given Tylenol for pain and an order was obtained for as needed (PRN) pain medication. Review of Resident #28's progress note dated 02/27/24 at 10:35 P.M., revealed Resident #28 returned from the hospital with a diagnosis of closed fracture of the left shoulder. A sling was placed. The physician and DON were notified. Resident #28 denied pain and was resting. Review of Resident #28's hospital after visit summary dated 02/27/24, revealed Resident #28 was seen for a shoulder injury and had a diagnosis of closed fracture of left shoulder initial encounter. Further review of Resident #28's after visit summary, revealed Resident #28 complained of left shoulder pain after ambulating with an STNA at the facility. Resident #28 was getting up and the STNA assisted under her arm and Resident #28 felt a pop and pain. Resident #28 was administered Fentanyl citrate (narcotic pain medication) injectable syringe 50 micrograms (mcg) on 02/27/24 at 4:49 P.M. and Norco 5-325 milligrams (mgs) at 6:21 P.M. at the hospital. Review of STNA #500's investigation witness statement dated 02/28/24, revealed STNA #500 was assisting Resident #28 with getting out of bed for the day and to her wheelchair at approximately 10:30 A.M. STNA #500 was transferring Resident #28 out of bed by herself using a gait belt to stand and pivot her to her wheelchair. Resident #28's wheelchair was to the right side of the bed and the wheelchair locks were in the back of the wheelchair. When STNA #500 went to put the break down it must not have been all the way locked. When STNA #500 went to transfer Resident #28, the wheelchair slid backwards, and the resident started to slide down. STNA #500's gait belt slid upwards, and Resident #28 had her arms over STNA #500's arms. Due to the Resident #28's left sided weakness; the resident did not have much control over her left side. Resident #28's shoulder made contact with her wheelchair, and Resident #28 complained of pain in her left shoulder. After the resident was securely in her wheelchair, STNA #500 went to notify her nurse of the resident's complaint of pain. STNA #500 saw Physical Therapist (PT) #900 who was standing at the nurse's station and asked him to come see Resident #28. PT #900 came to look at her and evaluated her arm. PT #900 moved her arm in which she had some mild complaints of pain but not tearful, grimacing, or displaying any other symptoms of pain with movement. STNA #500 then took Resident #28 out to the nurse's station and notified LPN #35 who also evaluated Resident #28's arm. At no point was Resident #28 on the floor and STNA #500 would not have been able to get her off the floor by herself if she had fallen. STNA #500 would not have transferred her off the floor if she did fall and she would have immediately notified the nurse prior to moving her. Upon the nurse completing Resident #28's evaluation, the resident went to the dining room and ate lunch and stayed and played bingo. The interview was signed by STNA #500. Review of Resident #28's February 2024 Medication Administration Record (MAR) dated 02/28/24, revealed Resident #28 was ordered Norco oral tablet 5-325 mgs give on tablet by mouth every six hours PRN (as needed) for left shoulder pain for five days. Resident #28 received her PRN Norco oral tablet 5-325 mgs on 02/28/24 at 4:15 A.M. with a pain level of a five, on 02/28/24 at 12:21 P.M. with a pain level of a four, and on 02/29/24 at 8:20 P.M. with a pain level of a seven. There was no documentation on the MAR indicating that Resident #28 was administered Tylenol 325 mg on 02/27/24. Review of the facility's February 2024 incident and accident log revealed Resident #28 fell on [DATE]. Review of Resident #28's March 2024 Medication Administration Record (MAR) revealed Resident #28 received her PRN Norco oral tablet 5-325 mgs on 03/01/24 at 5:55 P.M. with a pain level of a five, and on 03/03/24 at 5:30 P.M. with a pain level of a five. Further review of the MAR dated 02/27/24, revealed Resident #28 was ordered Tramadol oral tablet 50 mg every six hours PRN for left shoulder pain. Resident #28 received her Tramadol 50 mgs on 03/06/24 at 10:13 P.M. with a pain level of an eight. Interview with LPN #35 on 03/07/24 at 8:50 A.M., revealed she was at the facility passing medications in the morning on 02/27/24 when STNA #500 came up to her medication cart with Resident #28. LPN #35 reported STNA #500 informed her that she was getting Resident #28 dressed when she heard her shoulder pop. LPN #35 stated Resident #28 had pain in her shoulder and LPN #35 informed the physician and got an order for pain medication and an Xray. LPN #35 reported Resident #28 was sent out to the hospital because the Xray company did not come to the facility by 3:00 P.M. LPN #35 stated Resident #28 was up in her wheelchair and went to activities prior to going out to the hospital and the Tylenol that was given seemed to help Resident #28 with her pain. LPN #35 stated Resident #28 informed her after she returned from the hospital, that STNA #500 dropped her while transferring her without any assistance. LPN #35 also reported Resident #28 informed her that STNA #500 was not using a required Hoyer lift or gait belt at the time of the fall. LPN #35 stated Resident #28 required a Hoyer or mechanical lift and two-person assistance for transfers at the time of the incident. Interview with Resident #28 on 03/07/24 at 9:06 A.M., revealed she broke her left shoulder when a nurse dropped her on the floor. Resident #28 stated she could not remember the nurse's name but stated the incident occurred approximately four weeks ago around 10:00 A.M. Resident #28 stated the nurse was trying to transfer her from the bed to the wheelchair when she was dropped to the floor. Resident #28 stated the nurse was not using a Hoyer lift or gait belt and there were not any additional staff members present with the nurse at the time of the incident. Resident #28 reported the nurse tried to lift her again after the fall and she fell again, hitting her head. Resident #28 stated that she had terrible pain in her left shoulder after the incident and she was sent out to the hospital that night. Resident #28 reported she had always used a Hoyer lift with two-person assistance for transfers. Interview with the Administrator and Regional Registered Nurse (RN) #950 on 03/07/24 at 11:03 A.M., revealed Resident #28 fractured her left shoulder after STNA #500 transferred Resident #28 using one person assistance on 02/27/24. Regional RN #950 verified Resident #28 required a Hoyer lift with two-person assistance for transfers. Regional RN #950 also confirmed she was care planned to use a Hoyer lift with two-person assistance on 02/27/24. Attempted to call STNA #500 on 03/07/24 at 11:27 A.M. with no response. Interview with Regional RN #950 on 03/07/24 at 11:58 A.M. revealed she was not able to locate STNA #500's initial education on transfers provided upon hire. Interview with [NAME] President of Clinical Services (VPCS) #700 on 03/07/24 at 12:14 P.M. revealed VPCS #700 interviewed STNA #500 regarding the incident on 02/28/24. STNA #500 stated she went into Resident #28's room and was getting Resident #28 up for lunch. VPCS #700 reported STNA #500 told her she used a gait belt and went to transfer Resident #28 into her wheelchair when the wheelchair moved backwards. VPCS #700 stated STNA #500 informed her that she pulled upon Resident #28 to put her into the wheelchair and Resident #28's left shoulder made contact with the wheelchair and she heard a pop. VPCS #700 reported Resident #28 stated she had pain after the transfer and STNA #500 asked PT #900 to come into the room to assess Resident #28. After PT #900 assessed Resident #28, STNA #500 told LPN #35 about the incident. VPCS #700 also stated she interviewed Resident #28 on 02/28/24 and Resident #28 stated that she was dropped on 02/27/24. Resident #28 stated an STNA with red hair which matched the description of STNA #500 who was transferring her from the bed to the wheelchair when she fell on the ground. VPCS #700 stated she asked Resident #28 how she got up and she stated STNA #500 used all her strength to get her up and in the wheelchair but then she later stated that someone with long blonde hair with white pants helped her get up. VPCS #700 reported Resident #28 stated she felt her arm crack at the time of the incident but later stated she heard a pop. Resident #28 told VPCS #700 that she did not receive any pain medication but later stated she was given Tylenol. VPCS #700 stated Resident #28 told her that she went to dining room for lunch but did not stay for activities because she was in too much pain, but activities staff told VPCS #700 that Resident #28 stayed for activities and did not appear in pain, but she was talking about the incident. VPCS #700 confirmed Resident #28's Tylenol received on 02/27/24 was not marked as given on the MAR. Telephone interview with PT #900 on 03/07/24 at 12:23 P.M., revealed he was at the nurse's station on 02/27/24 when STNA #500 stuck her head out of Resident #28's room and stated she needed PT #900 to come to Resident #28's room immediately. PT #900 stated STNA #500 told her that she was doing a transfer with Resident #28 when her shoulder popped, and the resident was complaining of a lot of pain. PT #900 reported Resident #28 was in her wheelchair when he entered the room. PT #900 stated he left the room and went back to the nurse's station and STNA #500 took Resident #28 out to the nurse's station and again stated Resident #28 was in a lot of pain. PT #900 stated Resident #28 had a lot of pain in her left arm and she reported her pain level was a nine out of ten which was not Resident #28's baseline. PT #900 reported LPN #35 offered Resident #28 Tylenol and PT #900 placed a blanket under the resident's elbow to assist with relieving Resident #28's pain. PT #900 stated Resident #28 was taken down to the dining room by staff and LPN #35 called the physician and an Xray was ordered. PT #900 reported he had not worked with Resident #28 in two months, and he was not sure what level of assistance she required on her care plan for transfers. Review of STNA #500's personnel file revealed STNA #500 was hired by the facility on 11/11/23. Further review of STNA #500's personnel file revealed no documentation that STNA #500 was educated on resident transfers upon hire. Review of the undated facility's safe resident handling and transfers policy revealed the facility will ensure that residents are handled and transferred safely to prevent or minimize risks for injury. The policy also stated resident lifting and transferring will be performed according to the resident's individual plan of care. As a result of the incident, the facility took the following actions to correct the deficient practice as of 03/01/24: On 02/28/24, STNA #500 was educated on referring to the Kardex (care plan) to verify the appropriate method and number of staff required to transfer a resident prior to transferring a resident and the safe handling and transfers policy by the DON. On 02/28/24, all STNAs were educated on referring to the Kardex to verify the appropriate method and number of staff required to transfer a resident prior to transferring a resident and the safe handling and transfers policy by the DON. On 02/28/24, the VPCS #700 completed a care plan transfer audit of all residents and their transfer status. No issues were discovered. On 02/28/24, the facility-initiated audits on the appropriate number of staff used for transfers and the appropriate transfer method. The audits were to occur daily for 14 days and then three days per week for 14 days. Audits were completed 02/28/24, 02/29/24, 03/04/24 and 03/06/24 with no issues discovered. On 02/28/23, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held regarding direct care staff not following the plan of care for transfers. The Administrator, Regional Director of Operations (RDO) #600, VPCS #700, the DON and Medical Director #860 were present at the meeting. On 03/01/24, all nurses were educated on referring to the Kardex to verify the appropriate method and number of staff required to transfer a resident prior to transferring a resident and the safe handling and transfers policy by VPCS #700. On 03/07/24, a review of the Inservice records revealed all staff members were in-serviced referring to the Kardex to verify the appropriate method and number of staff required to transfer a resident prior to transferring a resident and the safe handling and transfers policy. A review of the audits of resident transfers completed on 02/28/24, 02/29/24, 03/04/24 and 03/06/24, revealed all transfers were completed using the appropriate level of assistance with no resident injuries noted. There were no other residents who sustained injuries from transfers. This deficiency represents non-compliance investigated under Complaint Number OH00151717.

Based on observations, staff interview, and facility policy review, the facility failed to properly store food in the dry storage area. This had the potential to affect all 37 residents who received food from the kitchen. The facility census was 37. Findings include: Observations of the kitchen on [DATE] at 9:40 A.M. with Kitchen Staff #320 revealed the dry storage area had seven unopened 12-ounce (oz) cans of carnation evaporated milk with the manufacturer's use by date of [DATE]. One unopened 32-oz box of buttermilk pancake mix with manufactures use by date of [DATE]. There were four one-gallon jugs of honey mustard with facility received date marked ,d+[DATE]/no year. Upon opening on of the lids of the honey mustard revealed an unsealed manufacturer's top leaking onto the plastic lid causing it to ooze onto the side of the jar. Interview with Kitchen Staff #320 on [DATE] at 9:45 A.M. verified the seven cans of evaporated milk, pancake mix, and honey mustard were expired and all of it needed to be disposed of. Interview on [DATE] at 9:55 A.M. with the Administrator stated all residents eat from the facility kitchen and there were no residents who were nothing by mouth. Review of the facility's undated policy titled Dry Storage and Supplies revealed dry goods shall be stored for a period that does not exceed one year or past the manufacturers recommended used by date. This deficiency represents non-compliance investigated under Complaint Number OH00147840.

Based on medical record review, hospital medical record review, facility investigation review, self-reported incident review, staff list review, resident and staff interviews, the facility failed to ensure a resident was provided with supervision during incontinence care to prevent the resident from falling from the bed. This resulted in actual harm when Resident #5 was receiving incontinence care and was rolled to the side of the bed and subsequently fell to the floor. Resident #5 sustained a hematoma to the head, a laceration requiring 11 stitches, a skin tear, and multiple contusions including to the face, shoulder and to the bilateral knees. This affected one (#5) of three residents reviewed for safety with bed mobility. The facility census was 35. Findings include: Review of Resident #5'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 is cognitively intact and required extensive assistance of two people for bed mobility, and transfer. The resident required extensive assistance of one person for locomotion on and off unit and personal hygiene. The resident required total dependence on one person for toilet use and uses a wheelchair to aid in mobility. She is frequently incontinent of both bowel and bladder and uses a wheelchair to aid in mobility. Review of the care plan for falls dated 06/07/18, revealed the resident is at risk for falls and has a physical functioning deficit related to mobility impairment and required bed mobility assistance of 1-2 caregivers. The care plan was revised on 07/16/18 for bed mobility assistance of two persons. Review of the nurse's notes dated 07/09/18 at 7:40 A.M., documented the nurse called to resident room at 5:50 A.M. State tested Nurse Aide (STNA) performing care on resident and while turning resident, she rolled out of bed onto the floor. Resident noted to have 3 inch laceration and hematoma on forehead, 1 inch skin tear on right wrist, and bruising on bilateral knee caps. Resident was alert and oriented to person, place and time. Sent to the emergency room (ER) for treatment. Review of hospital records dated 07/09/18 revealed Resident #5 had a fall with head injury, a [MEDICAL CONDITION], contusion of the left shoulder, contusion of the knees, contusions of the face and a skin tear to the right wrist. Review of the Computed Tomography (CT) scan (combination of X-rays taken from different angles to see inside the area without cutting) revealed an acute frontal cephalohematoma (bleeding between the skull and the membrane underneath the skin of the head). Review of nurse's note dated 07/09/18 at 11:15 A.M., documented the resident returned from the ER by stretcher at 10:10 A.M. Resident is alert and oriented to person, place, time and situation. All CT scans and x-rays performed were normal. Eleven stitches noted to right side of forehead and skin tear to right wrist. Review of the facility in-service dated 07/09/18, revealed the in-servicing on repositioning a resident while performing one on one care was completed. The staff was to turn resident towards person providing care, perform care needed, then roll resident to back, staff to move self to opposite side of bed and repeat procedure. This training was signed by STNA #33 and seven other STNAs. The facility provided staff list indicated the facility employees sixteen STNA. Review of a facility self-reported incident (SRI) dated 07/10/18 revealed Resident #5 was rolled out of bed during care and is now stating she feels the staff member pushed her out of bed intentionally. The facility filed the SRI under abuse and unsubstantiated the report. The facility stated as a result of the investigation the nursing staff was educated on proper positioning while providing one on one care. Review of fall investigation dated 07/10/18 documented the proper number of assists needed was provided and the proper technique was used. The fall committee review documented to increase bed mobility to two person, add grab assist bars on bed and a therapy screen. Review of the Activities of Daily Living (ADL) record dated from 05/01/18 to 07/30/18, revealed the resident's bed mobility was documented as needing a total dependence with 30 times for two person assist and 20 times for one person assist in (MONTH) (YEAR). (MONTH) (YEAR) documents as total dependence every time for bed mobility and with assistance coded as 21 two person assist and 26 one person assist. In (MONTH) (YEAR), the bed mobility on night shift the following: 07/01/18 of extensive assist of one person, 07/02/18 of extensive assist of one person, 07/03/18 total dependence of one person, 07/16/18 total dependence of one person, 07/23/18 extensive assist of one person and on 07/24/18 extensive assist of one person. Interview on 07/30/18 at 10:10 A.M., with Resident #5 revealed she was doing good at the facility until she fell out of bed, and ended up in the hospital with her head stitched and a whole bunch of bruises. Resident #5 stated STNA #33 was changing the resident's incontinence brief and she rolled the resident over, there was no side rails to grab and she fell out of bed. The STNA was changing the resident by herself and usually they have two staff to change her. Interview on 07/30/18 at 10:55 A.M., with STNA #18 revealed she work with Resident #5 on a routine basis and she get two people to change and reposition the resident. Resident #5 can roll but she has her good and bad days. STNA #18 stated she always uses two people since they took the bed rails down, the resident complained that she did not feel secure. Resident #5 would help roll when she has the side rails. Interview on 07/30/18 at 3:15 P.M. with STNA #33 revealed she is familiar with Resident #5's care and that she always used just one person to provide incontinence care and reposition her. STNA #33 verified on 07/09/18, she was cleaning the resident and the bed was at her waist level. She rolled the Resident away from her and the resident rolled right out of bed. STNA #33 verified she told the nurse immediately and Resident #5 was sent out to the hospital. STNA #33 stated the bed did not have side rails or grab bars. Interview with the Director of Nursing (DON) on 07/30/18 at 4:00 P.M., stated she was new at the faciliy and was not at the facility when the incident occurred. The DON stated the resident's side rails were removed from Resident #5 bed in (MONTH) of (YEAR). The DON stated the facility's expectation was for staff to pull the resident towards them self, provide care then roll to back, then switch sides and repeat the procedure. The DON verified the staff were documenting they were only utilizing one staff for bed mobility not as the care plan had been updated to reflect. The DON stated the facility did not have a policy on addressing bed mobility/repositioning This is an example of an incidental deficiency discovered during the investigation of Complaint Number OH 071.