Ohio Veterans Home

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, review of a Self-Reported Incident (SRI), review of a facility investigation, review of staff witness statements, staff interview, and policy review, the facility failed to implement their abuse policy to provide timely interventions and further failed to provide notification to the appropriate medical and support staff for follow-up services. This affected one (#193) of eight residents reviewed for abuse and had the potential to affect all 25 residents on the Unit 3 South. The facility census was 242.Findings include:Review of the medical record for Resident #193 revealed an admission date of 08/29/24. Diagnoses included Alzheimer's disease, dementia, anxiety, hypertension, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of a facility Self-Reported Incident (SRI) dated 01/27/26 revealed staff reported an allegation of staff to resident verbal abuse for Resident #193. Review of a follow-up investigation report revealed staff witnessed Certified Nursing Assistant (CNA) #400 speaking inappropriately to Resident #193. CNA #400 was removed from duty and placed on administrative leave. The facility substantiated the allegation of verbal abuse. Also, the facility implemented an intervention for psychiatric services but there was no documentation the facility had timely contacted psychiatric services for resident care follow-up.Review of a nurse's note dated 01/27/26 at 5:45 P.M. revealed Resident #193's family was notified of a verbal abuse allegation. Further review of the nurse's notes from 01/27/26 through 01/30/26 revealed no documentation of notification to the physician, and no follow-up with the social worker. Further review of the progress notes from 01/27/26 through 02/04/26 revealed no documentation psychiatric services was notified and no documentation the resident was seen by psychiatric services after the alleged abuse. Interview on 02/04/26 at 1:46 P.M., the Director of Nursing (DON) revealed staff should have followed up with necessary notifications and assessments for the residents with allegations of abuse.Interview on 02/05/26 at 8:16 A.M., Licensed Social Worker (LSW) #312 revealed she was not made aware of the allegation of verbal abuse toward Resident #97 until yesterday. LSW #312 revealed the facility was supposed to notify her of allegations of abuse. LSW #312 also revealed psychiatric services should be notified quickly to follow up with residents with allegations of abuse.Interview on 02/05/26 at 9:30 A.M., the Assistant Director of Nursing (ADON) #370 revealed whoever was covering the unit at the time of the allegation should have notified social services, the physician, and the psychiatric services provider. ADON #370 verified the psychiatric services provider was not notified until several days later.Review of the facility policy Reporting Allegation of Abuse/Neglect/Exploitation, dated 03/25/25 revealed the facility the facility would provide complete and thorough documentation of the investigation. Further review of the policy revealed the facility would respond to the residents' needs and protect from further incidents. The facility would notify the physician and resident's family/legal representative. Also, the facility would monitor and document the resident's condition, including response to medical treatment or nursing interventions and document actions taken in the medical record. Review of the facility policy Abuse, Neglect, Exploitation, dated 03/25/25 revealed the facility would immediately protect the alleged victim and integrity of the investigation. The facility would examine the alleged victim for any sign of injury, including a physician examination or psychosocial assessment if needed, provide emotional support and counseling to the resident during and after the investigation as needed. This deficiency represents non-compliance investigated under Complaint Number 2731992.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, review of staff statements, staff interview, and policy review, the facility failed to ensure food items were provided per physician orders. This affected one (#93) of three residents reviewed for dietary services and had the potential to affect 14 residents identified by the facility with physician orders for mechanically altered diet textures. The facility census was 242.Findings include:Review of the medical record for Resident #93 revealed an admission date of 09/05/18. Diagnoses included hemiplegia and hemiparesis, dementia, type two diabetes mellitus, and dysphagia.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for feeding assistance. Review of the care plan last revised 02/03/26 revealed the resident was at risk for aspiration due to a history of dysphagia. Interventions included to monitor for choking and for signs/symptoms of aspiration and notify physician as needed. Review of the nutritional care plan last revised 12/03/24 revealed the resident was at nutritional risk due to dementia, diabetes mellitus, chronic kidney disease, and dysphagia. Interventions included a high protein diet, pureed texture, nectar consistency via nosey cup with three to four pumps thickener. Additional interventions included to monitor for chewing/swallowing problems or choking. Also for direct one to one supervision with small bite sizes, slowed rate of consumption, and alternation of foods/drinks every two to three bites.Review of the physician orders dated 12/22/25 revealed Resident #93 was ordered a high protein, pureed texture diet with nectar consistency. Further review of physician orders dated 08/14/25 revealed the resident required direct one to one supervision with implementation of small bites, slowed rate of consumption, and alternation of foods/drinks every two to three bites. Review of an undated witness statement by Dietary Staff (DS) #367 revealed on 01/27/26 Certified Nursing Assistant (CNA) #400 was always telling her to do things other than what was on the meal tickets for the residents. Review of a witness statement dated 01/28/26 by Speech Therapist (ST) #324 revealed on 01/27/26 he had been informed by a nursing assistant that CNA #400 had provided Resident #93 with a banana during snack time despite the resident being on a pureed diet and without his direct presence on the unit. ST #324 revealed the resident had an order for direct one to one assistance/supervision due to an extensive history of suspected aspiration/penetration episodes during intake. Review of a witness statement dated 01/29/26 by CNA #400 revealed CNA #400 was asked if she had given residents food or requested items not listed on the meal ticket. CNA #400 responded yes. CNA #400 was asked if she had given resident food items that had not followed their diet order such as giving a resident a banana who had a pureed diet order. CNA #400 responded yes and noted she had approval from ST #324 as long as the resident was awake and alert. Further review of the medical record, assessments, and nurse's notes dated 01/29/26 revealed no documentation Resident #93 had a respiratory assessment after receiving food with the incorrect texture per dietary orders. Interview on 02/03/26 at 1:36 P.M., ST #324 revealed CNA #350 had reported CNA #400 gave Resident #93 a whole banana despite prior education on following dietary orders. ST #324 revealed the resident was on a pureed diet and he had never okayed the resident getting a banana without his direct supervision. ST #324 revealed the resident was at risk for aspiration. ST #324 revealed he had not assessed the resident after he was notified the resident was given the banana. ST #324 revealed he reported the incident to a nursing supervisor. Interview on 02/03/26 at 3:12 P.M., CNA #350 revealed CNA #400 would serve residents the incorrect diet textures. CNA #350 revealed Resident #93 required a pureed diet but CNA #400 gave the resident a whole banana for breakfast on 01/27/26. Interview on 02/04/26 at 9:54 A.M., Registered Nurse (RN) #342 revealed ST #324 reported CNA #400 gave a resident the wrong food and had also done this in the past with the behavior continuing.Interview on 02/024/26 at 1:46 P.M., the Director of Nursing (DON) verified there was no documentation Resident #93 had a respiratory assessment completed on 01/27/26 after being given the wrong textured food item. Review of the facility policy Dysphagia, dated 08/19/24, revealed the food service manager would follow any written orders for diet and fluid consistency and educate staff and supervise preparation of altered consistency diets. The nursing staff would follow any written physician orders. This deficiency represents non-compliance investigated under Complaint Number 2731992.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, review of a Self-Reported Incident (SRI), review of a facility investigation, review of staff witness statements, staff interview, and policy review, the facility failed to thoroughly investigate allegations of staff to resident abuse. This affected six (#244, #93, #243, #129, #193, #6) of eight residents reviewed for abuse and had the potential to affect all 25 residents on the Unit 3 South. The facility census was 242. Findings include:1. Review of the medical record for Resident #193 revealed an admission date of 08/29/24. Diagnoses included Alzheimer's disease, dementia, anxiety, hypertension, and dysphagia.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of a facility Self-Reported Incident (SRI) dated 01/27/26 revealed staff reported an allegation of staff to resident verbal abuse for Resident #193. Review of a follow-up investigation report revealed staff witnessed Certified Nursing Assistant (CNA) #400 speaking inappropriately to Resident #193. CNA #400 was removed from duty and placed on administrative leave. The facility substantiated the allegation of verbal abuse. Further review of the investigation report revealed the facility had not interviewed all staff present in the dining room during lunch at the time of the allegation of verbal abuse. Further review of the staff witness statements revealed staff had reported additional allegations of resident abuse against CNA #400 with no documentation of an investigation and no Self-Reported Incidents submitted to the state agency regarding the allegations. Review of a nurse's note dated 01/27/26 at 5:45 P.M. revealed Resident #193's family was notified of a verbal abuse allegation. Further review of the nurse's notes from 01/17/26 through 01/30/26 revealed no documentation of notification to the physician, and no follow-up with the social worker. Also, the facility implemented an intervention for a psychiatric consult but there was no documentation the facility had contacted psychiatric services for resident follow-up.2. Review of the closed medical record for Resident #244 revealed an admission date of 04/16/25 and a discharge date of 01/23/26. Diagnoses included dementia, type two diabetes mellitus, and aphasia. Review of the quarterly MDS dated [DATE] revealed the resident required substantial/maximal assistance for eating.Review of the nurse's notes dated 01/01/26 through 02/03/26 for Resident #244 revealed no documentation of the allegation of abuse.Review of the facility SRIs also revealed no reported allegations of physical abuse by staff for Resident #244.3. Review of the closed medical record for Resident #243 revealed an admission date of 08/01/23 and a discharge date of 01/27/26. Diagnoses include Alzheimer's disease, Parkinson's disease, dementia, aphasia, and dysphagia oral phase.Review of the significant change MDS dated [DATE] revealed Resident #243 had severe cognitive impairment. The resident was dependent on staff for meal assistance. Review of the nurse's notes dated 01/01/26 through 02/03/26 for Resident #243 revealed no documentation of alleged staff to resident abuse. Review of the facility SRIs revealed no reported allegations of abuse by staff for Resident #243. 4. Review of the medical record for Resident #93 revealed an admission date of 09/05/18. Diagnoses included hemiplegia and hemiparesis, dementia, type two diabetes mellitus, and dysphagia.Review of the quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for feeding assistance. Review of the nurse's notes from 01/01/26 through 02/03/26 for Resident #93 revealed no documentation of allegations of abuse. Review of the facility SRIs revealed no allegations of staff to resident abuse had been submitted for Resident #93. 5. Review of the medical record for Resident #129 revealed an admission date of 04/07/25. Diagnoses include Alzheimer's disease, dementia, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed the resident required set-up assistance for meals. Review of the nurse's notes dated 01/01/26 through 02/03/26 for Resident #129 revealed no documentation of an abuse allegation. Review of the facility SRIs revealed no SRIs submitted for staff to resident abuse for Resident #129.6. Review of the medical record for Resident #6 revealed an admission date of 12/04/12. Diagnoses included Alzheimer's disease, dementia, osteoarthritis, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed Resident #6 had severe cognitive impairment. Review of the nurse's notes dated 01/01/26 through 02/03/26 for Resident #6 revealed no documentation of allegations of abuse.Review of the facility SRIs also revealed no reported allegations of staff to resident abuse for Resident #6. Review of a witness statement dated 01/28/26 by CNA #350 revealed on 01/27/26 Resident #193 was sleeping during lunch and CNA #400 went up to him and was yelling in his ear to keep waking him up to eat. CNA #350 noted CNA #400 was cursing in the dining room, and yelling at the residents to wake up and eat. CNA #350 noted CNA #400 was not compliant with the resident's diet orders and it was not unusual for her to force feed the residents. There was no documentation CNA #350 was further questioned regarding the allegation of CNA #400 force feeding residents. Review of a witness statement dated 01/28/26 by CNA #374 revealed he responded yes when asked if he had witnessed any resident being mistreated or abused. CNA #374 revealed CNA #400 had yelled at Resident #6 and had force fed Resident #243. CNA #374 revealed the incidents were reported to the Assistant Director of Nursing (ADON) #370 and the Director of Nursing (DON). There was no documentation CNA #374 was further interviewed regarding the additional abuse allegations. Review of an undated witness statement by Dietary Staff (DS) #367 revealed on 01/27/26 CNA #400 was cursing at lunch and cursed at Resident #193 who was sleeping to wake up and eat. DS #367 revealed this had been going on for weeks/months. DS #367 revealed she had made reports of her yelling at the residents. DS #367 noted CNA #400 was mean to the residents. There was no documentation DS #367 was asked additional questions regarding her previous reports of CNA #400's treatment of residents. Review of a witness statement dated 01/28/26 by Speech Therapist (ST) #324 revealed at the lunch meal on 01/27/26 CNA #400 was opening swearing at other staff members regarding personal frustration or for being suggested to follow specific diet orders/recommendations. Review of a witness statement dated 01/29/26 by CNA #400 revealed she had denied verbally abusing Resident #193. There was no documentation CNA #400 was questioned regarding the additional allegations of abuse for Resident #243, Resident #244, Resident #93, Resident #193 and Resident #6. Further review of the witness statements revealed no documentation of a witness statement by Registered Dietitian (RD) #318. Observation on 02/03/26 at 11:27 A.M. with the DON and Police Chief (PC) #648 of video surveillance dated 01/27/26 during the lunch meal on Unit 3 South from 12:20 P.M. through 1:08 P.M. revealed residents were in the dining room with staff serving and assisting the residents with meals. Staff present during the meal service in the dining room identified by PC #648 and the DON included CNA #400, CNA #350, CNA #330, Licensed Practical Nurse (LPN) #302, ST #324, RD #318, CNA #308, and DS #367. The DON verified RD #318 had not been interviewed regarding the incident. Further observations of the video surveillance revealed CNA #400 sat down briefly by Resident #193 during the meal. The surveillance video contained no audio and it could not be determined if CNA #400 was cursing or yelling at Resident #193. Interview on 02/03/26 at 10:07 A.M., LPN #488 revealed he had not witnessed resident abuse and had no reports of resident abuse from staff.Interview on 02/03/26 at 3:12 P.M., CNA #350 revealed CNA #400 was cursing in the dining room. CNA #350 revealed CNA #400 would yell at residents to eat, and had force fed Resident #129 and Resident #193. CNA #350 revealed CNA #400 would put a spoon to Resident #193's mouth and the resident shook his head no. CNA #350 revealed CNA #400 then forced the spoon inside the resident's mouth. CNA #350 also revealed CNA #400 had forced a spoon into the mouth of Resident #129. CNA #350 also reported CNA #400 would awaken former Resident #244 and Resident #93 during meal service with sternal rubs. CNA #350 revealed she told CNA #400 to stop her actions but it went in one ear and out the other. CNA #350 revealed the incidents were reported to LPN #488 and LPN #402. Interview on 02/03/26 at 3:31 P.M., CNA #374 revealed he had witnessed CNA #400 and Resident #6 yelling at each other outside the dining room. CNA #374 also revealed he saw CNA #400 force fed former Resident #243 by literally forcing the food in the resident's mouth. CNA #374 revealed he had reported the incidents to LPN #302 who then reported the incident to ADON #370.Interview on 02/03/26 at 3:50 P.M., LPN #302 revealed CNA #374 had never reported CNA #400 force feeding a resident or yelling at a resident. LPN #302 revealed she had not witnessed any resident abuse during the lunch meal on 01/27/26. LPN #302 revealed force feeding a resident was abusive and she would have immediately reported the abuse. Interview on 02/04/26 at 8:15 A.M., LPN #402 revealed he had never witnessed CNA #400 force feeding residents or performing sternal rubs on a resident. LPN #402 also revealed no staff had reported these allegations of abuse as they would have been immediately reported to a supervisor. Interview on 02/04/26 at 9:28 A.M., Supervisor RN #340 revealed anything significant from interviews conducted during an abuse investigation would be added to the summary report. RN #340 revealed the investigations were a team effort ultimately reviewed by the DON and the Administrator. RN #340 revealed he had interviewed CNA #374. RN #340 revealed CNA #374 had a meeting with the DON and had reported his concerns to her. RN #340 revealed the DON called me and told me to interview additional staff. RN #340 was not aware of any Self-Reported Incident or investigation for CNA #374's allegations. RN #340 revealed force feeding would be considered abusive. RN #340 revealed he could not recall staff reporting a nursing assistant completing a sternal rub. RN #340 revealed he had limited involvement in the investigation and was not familiar with CNA #400 or the involved residents. Interview on 02/04/26 at 9:54 A.M., Registered Nurse (RN) #342 revealed DS #367 had reported CNA #400 was at the meal service window cursing and had done so frequently. RN #342 revealed she asked ST #324 and CNA #400 to write statements. RN #342 revealed she notified the Director of Nursing and the Administrator. RN #342 revealed she was instructed to remove CNA #400 from the floor and begin an investigation. RN #342 revealed she spoke with Resident #193 who could not recall the incident. RN #342 revealed the residents on the unit were interviewed and skin sweeps were completed on the residents who could not be interviewed. RN #342 revealed the staff working the unit were asked to write statements. RN #342 revealed she was unaware the dietician was present on the unit during the meal service. RN #342 revealed the information for the investigation was gathered and the Administrator and DON completed the final review. RN #342 revealed force feeding a resident would be considered abuse and should be reported. RN #342 revealed she was not made aware of an allegation of CNA #400 waking up residents with a sternal rub which should not be completed by a nursing assistant. Interview on 02/04/26 at 11:05 A.M., DS #367 revealed on 01/27/26 as staff were serving the lunch meal, CNA #400 was cursing at other staff and then went up Resident #193 and cursed at him to wake up. DS #367 revealed ST #324 told her they needed to do something about this and ST #324 needed her to back him up on this. DS #367 revealed the incident was reported to the head nurse. DS #367 revealed a couple months earlier CNA #400 had yelled at a resident to sit down and shut up, and had also yelled at another resident to get their head off of the table. DS #367 revealed she had reported the incidents to the nursing supervisor RN #602. DS #367 revealed she had discussed one incident in person with RN #602 and another incident over the phone with RN #602. DS #367 revealed she had not been asked to write a statement regarding the prior incidents.Interview on 02/04/26 at 1:46 P.M., the DON revealed the Administrator and the DON should be notified when additional allegations of abuse were discovered during an abuse investigation. The DON revealed the nursing supervisors should be reviewing witness statements and additional allegations should be reported and additional investigations added. The DON revealed she had not reviewed the staff witness statements. The DON revealed she had not been notified of staff force feeding a resident. The DON verified the facility had not completed Self-Reported Incidents (SRI) for the additional allegations brought forward during the investigation of verbal abuse on 01/27/26. The DON revealed CNA #374 had talked to her on 01/30/26 and had never mentioned any abuse concerns during the two times she spoke with him. The DON also revealed staff should have followed up with necessary notifications and assessments for the residents with allegations of abuse. Interview on 02/04/26 at 2:39 P.M., RN #602 revealed he was aware of the allegation of CNA #400 force feeding residents. RN #602 revealed he had not reported the allegation as CNA #400 was already off from work on administrative leave. RN #602 revealed he should have reported the allegation as force feeding would be considered abusive. RN #602 revealed he could not recall if DS #367 had reported allegations of resident mistreatment by CNA #400 in the past. Interview on 02/04/26 at 4:15 P.M., Dietary Supervisor (DS) #610 revealed DS #367 had concerns regarding how a nursing assistant was treating the residents. DS #610 revealed he dialed RN #602's number for DS #367 to speak with RN #602. DS #610 revealed he heard DS #367 reporting to RN #602 about a nursing assistant being mean to the residents. Interview on 02/05/26 at 8:16 A.M., Licensed Social Worker (LSW) #312 revealed she was not made aware of the allegation of verbal abuse toward Resident #97 until yesterday. LSW #312 revealed the facility was supposed to notify her of allegations of abuse. LSW #312 also revealed psychiatric services should be notified quickly to follow up with residents with allegations of abuse. Interview on 02/05/26 at 9:30 A.M., the ADON #370 revealed whoever was covering the unit at the time of the allegation should have notified social services, the physician, and the psychiatric services provider. ADON #370 verified the psychiatric services provider was not notified until several days later. Further interview with ADON #370 revealed she was aware of an allegation of former Resident #243 being force fed but she had talked to the resident's wife who said the resident had not been force fed. ADON #370 verified the allegation was not reported or further investigated. Review of the facility policy Reporting Allegation of Abuse/Neglect/Exploitation, dated 03/25/25 revealed the facility would investigate all allegation of alleged violations by identifying and interviewing all involved person, including the alleged victim, alleged perpetrator, witnessed, and others who might have knowledge of the allegations. The facility would provide complete and thorough documentation of the investigation. Further review of the policy revealed the facility would respond to the residents' needs and protect from further incidents, remove the accused, notify the Administrator, notify the facility police department, notify the physician and resident's family/legal representative. Also, the facility would monitor and document the resident's condition, including response to medical treatment or nursing interventions and document actions taken in the medical record. Review of the facility policy Abuse, Neglect, Exploitation, dated 03/25/25 revealed all alleged violations of any form of abuse would be reported immediately, but no later than two hours after the allegation was made if the events cause the involve abuse or serious bodily injury. The Administrator would report allegations or suspected abuse to the state survey agency and other officials in accordance with state law. Only the Administrator in consultation with the Superintendent and Chief Compliance Office can determine if abuse occurred. The facility would immediately protect the alleged victim and integrity of the investigation. The facility would examine the alleged victim for any sign of injury, including a physician examination or psychosocial assessment if needed, provide emotional support and counseling to the resident during and after the investigation as needed. This deficiency represents non-compliance investigated under Complaint Number 2731992.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, review of a Self-Reported Incident (SRI), review of a facility investigation, review of staff witness statements, staff interview, and policy review, the facility failed to report allegations of staff to resident abuse. This affected six (#244, #93, #243, #129, #193, #6) of eight residents reviewed for abuse and had the potential to affect all 25 residents on the Unit 3 South. The facility census was 242. Findings include:1. Review of the medical record for Resident #193 revealed an admission date of 08/29/24. Diagnoses included Alzheimer's disease, dementia, anxiety, hypertension, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of a facility Self-Reported Incident (SRI) dated 01/27/26 revealed staff reported an allegation of staff to resident verbal abuse for Resident #193. Review of a follow-up investigation report revealed staff witnessed Certified Nursing Assistant (CNA) #400 speaking inappropriately to Resident #193. CNA #400 was removed from duty and placed on administrative leave. The facility substantiated the allegation of verbal abuse. Further review of the investigation report revealed the facility had not interviewed all staff present in the dining room during lunch at the time of the allegation of verbal abuse. Further review of the staff witness statements revealed staff had reported additional allegations of resident abuse against CNA #400 with no documentation of an investigation and no Self-Reported Incidents submitted to the state agency regarding the allegations. Review of a nurse's note dated 01/27/26 at 5:45 P.M. revealed Resident #193's family was notified of a verbal abuse allegation. Further review of the nurses' notes from 01/17/26 through 01/30/26 revealed no documentation of notification to the physician, and no follow-up with the social worker. Also, the facility implemented an intervention for a psychiatric consult but there was no documentation the facility had contacted psychiatric services for resident follow-up.2. Review of the closed medical record for Resident #244 revealed an admission date of 04/16/25 and a discharge date of 01/23/26. Diagnoses included dementia, type two diabetes mellitus, and aphasia.Review of the quarterly MDS dated [DATE] revealed the resident required substantial/maximal assistance for eating. Review of the nurse's notes dated 01/01/26 through 02/03/26 for Resident #244 revealed no documentation of the allegation of abuse. Review of the facility SRIs also revealed no reported allegations of physical abuse by staff for Resident #244.3. Review of the closed medical record for Resident #243 revealed an admission date of 08/01/23 and a discharge date of 01/27/26. Diagnoses include Alzheimer's disease, Parkinson's disease, dementia, aphasia, and dysphagia oral phase.Review of the significant change MDS dated [DATE] revealed Resident #243 had severe cognitive impairment. The resident was dependent on staff for meal assistance. Review of the nurse's notes dated 01/01/26 through 02/03/26 for Resident #243 revealed no documentation of alleged staff to resident abuse. Review of the facility SRIs revealed no reported allegations of abuse by staff for Resident #243. 4. Review of the medical record for Resident #93 revealed an admission date of 09/05/18. Diagnoses included hemiplegia and hemiparesis, dementia, type two diabetes mellitus, and dysphagia.Review of the quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for feeding assistance. Review of the nurse's notes from 01/01/26 through 02/03/26 for Resident #93 revealed no documentation of allegations of abuse. Review of the facility SRIs revealed no allegations of staff to resident abuse had been submitted for Resident #93. 5. Review of the medical record for Resident #129 revealed an admission date of 04/07/25. Diagnoses include Alzheimer's disease, dementia, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed the resident required set-up assistance for meals.Review of the nurse's notes dated 01/01/26 through 02/03/26 for Resident #129 revealed no documentation of an abuse allegation. Review of the facility SRIs revealed no SRIs submitted for staff to resident abuse for Resident #129.6. Review of the medical record for Resident #6 revealed an admission date of 12/04/12. Diagnoses included Alzheimer's disease, dementia, osteoarthritis, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed Resident #6 had severe cognitive impairment. Review of the nurse's notes dated 01/01/26 through 02/03/26 for Resident #6 revealed no documentation of allegations of abuse. Review of the facility SRIs also revealed no reported allegations of staff to resident abuse for Resident #6. Review of a witness statement dated 01/28/26 by CNA #350 revealed on 01/27/26 Resident #193 was sleeping during lunch and CNA #400 went up to him and was yelling in his ear to keep waking him up to eat. CNA #350 noted CNA #400 was cursing in the dining room and yelling at the residents to wake up and eat. CNA #350 noted CNA #400 was not compliant with the resident's diet orders and it was not unusual for her to force feed the residents. There was no documentation CNA #350 was further questioned regarding the allegation of CNA #400 force feeding residents. Review of a witness statement dated 01/28/26 by CNA #374 revealed he responded yes when asked if he had witnessed any resident being mistreated or abused. CNA #374 revealed CNA #400 had yelled at Resident #6 and had force fed Resident #243. CNA #374 revealed the incidents were reported to the Assistant Director of Nursing (ADON) #370 and the Director of Nursing (DON). There was no documentation CNA #374 was further interviewed regarding the additional abuse allegations. Review of an undated witness statement by Dietary Staff (DS) #367 revealed on 01/27/26 CNA #400 was cursing at lunch and cursed at Resident #193 who was sleeping to wake up and eat. DS #367 revealed this had been going on for weeks/months. DS #367 revealed she had made reports of her yelling at the residents. DS #367 noted CNA #400 was mean to the residents. There was no documentation DS #367 was asked additional questions regarding her previous reports of CNA #400's treatment of residents. Review of a witness statement dated 01/28/26 by Speech Therapist (ST) #324 revealed at the lunch meal on 01/27/26 CNA #400 was opening swearing at other staff members regarding personal frustration or for being suggested to follow specific diet orders/recommendations. Review of a witness statement dated 01/29/26 by CNA #400 revealed she had denied verbally abusing Resident #193. There was no documentation CNA #400 was questioned regarding the additional allegations of abuse for Resident #243, Resident #244, Resident #93, Resident #193 and Resident #6. Interview on 02/03/26 at 10:07 A.M., LPN #488 revealed he had not witnessed resident abuse and had no reports of resident abuse from staff.Interview on 02/03/26 at 3:12 P.M., Certified Nursing Assistant (CNA) #350 revealed CNA #400 was cursing in the dining room. CNA #350 revealed CNA #400 would yell at residents to eat, and had force fed Resident #129 and Resident #193. CNA #350 revealed CNA #400 would put a spoon to Resident #193's mouth and the resident shook his head no. CNA #350 revealed CNA #400 then forced the spoon inside the resident's mouth. CNA #350 also revealed CNA #400 had forced a spoon into the mouth of Resident #129. CNA #350 also reported CNA #400 would awaken former Resident #244 and Resident #93 during meal service with sternal rubs. CNA #350 revealed she told CNA #400 to stop her actions but it went in one ear and out the other. CNA #350 revealed the incidents were reported to LPN #488 and LPN #402. Interview on 02/03/26 at 3:31 P.M., CNA #374 revealed he had witnessed CNA #400 and Resident #6 yelling at each other outside the dining room. CNA #374 also revealed he saw CNA #400 force fed former Resident #243 by literally forcing the food in the resident's mouth. CNA #374 revealed he had reported the incidents to LPN #302 who then reported the incident to ADON #370.Interview on 02/03/26 at 3:50 P.M., LPN #302 revealed CNA #374 had never reported CNA #400 force feeding a resident or yelling at a resident. LPN #302 revealed she had not witnessed any resident abuse during the lunch meal on 01/27/26. LPN #302 revealed force feeding a resident was abusive and she would have immediately reported the abuse. Interview on 02/04/26 at 8:15 A.M., LPN #402 revealed he had never witnessed CNA #400 force feeding residents or performing sternal rubs on a resident. LPN #402 also revealed no staff had reported these allegations of abuse as they would have been immediately reported to a supervisor. Interview on 02/04/26 at 9:28 A.M., Supervisor RN #340 revealed anything significant from interviews conducted during an abuse investigation would be added to the summary report. RN #340 revealed the investigations were a team effort ultimately reviewed by the DON and the Administrator. RN #340 revealed he had interviewed CNA #374. RN #340 revealed CNA #374 had a meeting with the DON and had reported his concerns to her. RN #340 revealed the DON called me and told me to interview additional staff. RN #340 was not aware of any Self-Reported Incident or investigation for CNA #374's allegations. RN #340 revealed force feeding would be considered abusive. RN #340 revealed he could not recall staff reporting a nursing assistant completing a sternal rub. RN #340 revealed he had limited involvement in the investigation and was not familiar with CNA #400 or the involved residents. Interview on 02/04/26 at 9:54 A.M., Registered Nurse (RN) #342 revealed DS #367 had reported CNA #400 was at the meal service window cursing and had done so frequently. RN #342 revealed she asked ST #324 and CNA #400 to write statements. RN #342 revealed she notified the Director of Nursing and the Administrator. RN #342 revealed she was instructed to remove CNA #400 from the floor and begin an investigation. RN #342 revealed she spoke with Resident #193 who could not recall the incident. RN #342 revealed the residents on the unit were interviewed and skin sweeps were completed on the residents who could not be interviewed. RN #342 revealed the staff working the unit were asked to write statements. RN #342 revealed she was unaware the dietician was present on the unit during the meal service. RN #342 revealed the information for the investigation was gathered and the Administrator and DON completed the final review. RN #342 revealed force feeding a resident would be considered abuse and should be reported. RN #342 revealed she was not made aware of an allegation of CNA #400 waking up residents with a sternal rub which should not be completed by a nursing assistant. Interview on 02/04/26 at 11:05 A.M., Dietary Staff (DS) #367 revealed on 01/27/26 as staff were serving the lunch meal, CNA #400 was cursing at other staff and then went up Resident #193 and cursed at him to wake up. DS #367 revealed ST #324 told her they needed to do something about this and ST #324 needed her to back him up on this. DS #367 revealed the incident was reported to the head nurse. DS #367 revealed a couple months earlier that CNA #400 had yelled at a resident to sit down and shut up and had also yelled at another resident to get their head off of the table. DS #367 revealed she had reported the incidents to the nursing supervisor RN #602. DS #367 revealed she had discussed one incident in person with RN #602 and another incident over the phone with RN #602. DS #367 revealed she had not been asked to write a statement regarding the prior incidents.Interview on 02/04/26 at 1:46 P.M., the DON revealed the Administrator, and the DON should be notified when additional allegations of abuse were discovered during an abuse investigation. The DON revealed the nursing supervisors should be reviewing witness statements and additional allegations should be reported and additional investigations added. The DON revealed she had not reviewed the staff witness statements. The DON revealed she had not been notified of staff force feeding a resident. The DON verified the facility had not completed Self-Reported Incidents (SRI) for the additional allegations brought forward during the investigation of verbal abuse on 01/27/26. The DON revealed CNA #374 had talked to her on 01/30/26 and had never mentioned any abuse concerns during the two times she spoke with him. The DON also revealed staff should have followed up with necessary notifications and assessments for the residents with allegations of abuse. Interview on 02/04/26 at 2:39 P.M., RN #602 revealed he was aware of the allegation of CNA #400 force feeding residents. RN #602 revealed he had not reported the allegation as CNA #400 was already off from work on administrative leave. RN #602 revealed he should have reported the allegation as force feeding would be considered abusive. RN #602 revealed he could not recall if DS #367 had reported allegations of resident mistreatment by CNA #400 in the past. Interview on 02/04/26 at 4:15 P.M., Dietary Supervisor (DS) #610 revealed DS #367 had concerns regarding how a nursing assistant was treating the residents. DS #610 revealed he dialed RN #602's number for DS #367 to speak with RN #602. DS #610 revealed he heard DS #367 reporting to RN #602 about a nursing assistant being mean to the residents. Interview on 02/05/26 at 8:16 A.M., Licensed Social Worker (LSW) #312 revealed she was not made aware of the allegation of verbal abuse toward Resident #97 until yesterday. LSW #312 revealed the facility was supposed to notify her of allegations of abuse. LSW #312 also revealed psychiatric services should be notified quickly to follow up with residents with allegations of abuse. Interview on 02/05/26 at 9:30 A.M., the Assistant Director of Nursing (ADON) #370 revealed whoever was covering the unit at the time of the allegation should have notified social services, the physician, and the psychiatric services provider. ADON #370 verified the psychiatric services provider was not notified until several days later. Further interview with ADON #370 revealed she was aware of an allegation of former Resident #243 being force fed but she had talked to the resident's wife who said the resident had not been force fed. ADON #370 verified the allegation was not reported or further investigated. Review of the facility policy Reporting Allegation of Abuse/Neglect/Exploitation, dated 03/25/25 revealed the facility would investigate all allegation of alleged violations by identifying and interviewing all involved person, including the alleged victim, alleged perpetrator, witnessed, and others who might have knowledge of the allegations. The facility would provide complete thorough documentation of the investigation. Further review of the policy revealed the facility would respond to the residents' needs and protect from further incidents, remove the accused, notify the Administrator, notify the facility police department, notify the physician and resident's family/legal representative. Also, the facility would monitor and document the resident's condition, including response to medical treatment or nursing interventions and document actions taken in the medical record. Review of the facility policy Abuse, Neglect, Exploitation, dated 03/25/25 revealed all alleged violations of any form of abuse would be reported immediately, but no later than two hours after the allegation was made if the events cause the involve abuse or serious bodily injury. The Administrator would report allegations or suspected abuse to the state survey agency and other officials in accordance with state law. Only the Administrator in consultation with the Superintendent and Chief Compliance Office can determine if abuse occurred. The facility would immediately protect the alleged victim and integrity of the investigation. The facility would examine the alleged victim for any sign of injury, including a physician examination or psychosocial assessment if needed, provide emotional support and counseling to the resident during and after the investigation as needed. This deficiency represents non-compliance investigated under Complaint Number 2731992.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on review of the medical record, review of a facility Self-Reported Incident (SRI), review of an SRI investigation, review of staff statements, review of the staffing schedule, review of employee time records, review of a police report, review of video surveillance, review of an incident report, staff interviews, resident interview, family interview, and review of facility policy, the facility staff failed to ensure Resident #241 was free from staff to resident verbal and physical abuse. This resulted in Immediate Jeopardy when Resident #241 was thrown from his wheelchair on 09/16/25 at approximately 7:50 P.M. by Licensed Practical Nurse (LPN) #602 placing the resident at risk for potential serious life-threatening harm, injuries, and/or negative health outcomes. Additionally, the facility failed to protect the resident from further abuse and failed to immediately report resident abuse to the administrator placing 26 additional residents who resided on the Memory Care Unit at risk for abuse. On 09/16/25 beginning at approximately 7:50 P.M., Certified Nursing Assistant (CNA) #400 witnessed LPN #602 aggressively pushing Resident #241 out of his room and swearing at the resident while the resident was trying to stop the wheelchair by reaching out his arms, placing his feet on the ground and yelling no. LPN #602 then continued to push Resident #241 toward the nurses' station where LPN #602 hit the resident's arm and pulled on the back of the resident's shirt to keep the resident in the wheelchair. LPN #602 then aggressively pushed Resident #241 in his wheelchair into a recliner causing the resident to fly forward hitting the recliner and then landing on the floor. While Resident #241 was on the floor, LPN #602 tried to pick the resident up by the back of his pants. Resident #241 then rolled onto his buttocks. LPN #602 sat in the resident's wheelchair next to the resident on the floor and later kicked the back of the resident's right leg. CNA #400 failed to intervene to protect the resident and failed to call for additional help. LPN #614 arrived on the unit and LPN #602 reported the resident had fallen. Registered Nurse (RN) Supervisor #700 then arrived on the unit to assess Resident #241 all while LPN #602 remained working on the Memory Care Unit until CNA #400 reported the abuse to RN Supervisor #700 at approximately 9:15 P.M. This resulted in serious psychosocial harm as Resident #241 was agitated and upset attempting to get away from LPN #602. Resident #241 also sustained three skin tears to the bilateral upper extremities. Furthermore, all residents on the Memory Care Unit were placed at potential risk for serious injury and/or harm when LPN #602 continued to work on the unit until 9:15 P.M. This affected one (#241) of four residents reviewed for abuse and had the potential to affect 26 additional residents (#02, #08, #30, #33, #35, #49, #59, #87, #90, #91, #95, #99, #103, #109, #117, #121, #123, #152, #154, #165, #174, #188, #190, #209, #216, and #220) residing on the Memory Care unit. The facility census was 241. On 10/20/25 at 4:52 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 09/16/25 at 7:50 P.M., when Resident #241 was thrown from his wheelchair by LPN #602 placing the resident at risk for serious life-threatening harm, injuries, and/or negative health outcomes. Additionally, the facility failed to protect the resident from further abuse and failed to immediately report resident abuse to the administrator placing 26 additional residents who resided on the Memory Care Unit at risk for abuse. On 09/16/25 beginning at approximately 7:50 P.M., CNA #400 witnessed LPN #602 aggressively pushing Resident #241 out of his room and swearing at the resident while the resident was trying to stop the wheelchair by reaching out his arms, placing his feet on the ground and yelling no. LPN #602 then continued to push Resident #241 toward the nurses' station where LPN #602 hit the resident's arm and pulled on the back of the resident's shirt to keep the resident in the wheelchair. LPN #602 then aggressively pushed Resident #241 in his wheelchair into a recliner causing the resident to fly forward hitting the recliner and then landing on the floor. While Resident #241 was on the floor, LPN #602 tried to pick the resident up by the back of his pants. Resident #241 then rolled onto his buttocks. LPN #602 sat in the resident's wheelchair next to the resident on the floor and later kicked the back of the resident's right leg. CNA #400 failed to intervene to protect the resident and failed to call for additional help. LPN #614 arrived on the unit and LPN #602 reported the resident had fallen. RN Supervisor #700 then arrived on the unit to assess Resident #241 all while LPN #602 remained working on the Memory Care Unit until CNA #400 reported the abuse to RN Supervisor #700 at approximately 9:15 P.M. This resulted in serious psychosocial harm as Resident #241 was agitated and upset attempting to get away from LPN #602. Resident #241 also sustained three skin tears to the bilateral upper extremities. Furthermore, all residents on the Memory Care unit were placed at potential risk for serious injury and/or harm when LPN #602 continued to work on the unit 9:15 P.M. Although the Immediate Jeopardy was removed on 09/19/25, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until the deficient practice was corrected on 09/25/25 when the facility implemented the following corrective actions: On 09/16/25 at 9:15 P.M., CNA #400 reported an allegation of abuse against LPN #602 to RN Supervisor #700. On 09/16/25 at 9:16 P.M., off duty RN Supervisor #772 called to report the allegation of abuse to the police department. On 09/16/25 at 9:18 P.M., RN Supervisor #700 removed LPN #602 from the floor to the nursing supervisor's office on the first floor. On 09/16/25 at 9:22 P.M., Assistant Director of Nursing (ADON) #549 notified the Administrator of the allegation of abuse. On 09/16/25 at 9:23 P.M., ADON #549 notified the DON of the allegation of abuse. On 09/16/25 at 9:28 P.M., RN Supervisor #700 began getting statements from the nursing staff on duty at the time of the allegation of abuse. On 09/16/25 at 9:29 P.M., RN #740 and LPN #614 began head-to-toe assessments of the residents on the unit. On 09/16/25 at 9:29 P.M., RN Supervisor #700 and RN #748 began education of the facility Abuse policy with nursing staff. Education was completed on 09/18/25. On 09/16/25 at 9:29 P.M., Police Officer #541 reported to the Nursing Supervisor's office to interview LPN #602 and CNA #400. On 09/16/25 at 10:09 P.M., the DON notified RN Supervisor #700 to inform LPN #602 he was on administrative leave effective immediately. LPN #602 was also informed to report on 9/17/25 at 3:00 P.M. to the Police Department for questioning and interviewing. On 09/16/25 at 11:45 P.M., RN #740 completed a head-to-toe assessment for Resident #241 with no new findings since previous assessment at 7:55 P.M. On 09/17/25 at 12:28 A.M., RN #740 emailed a request for psychiatric services to evaluate Resident #241. On 09/17/25 at 6:00 A.M., ADON #549 reported for duty and started the Resident Safety interviews of the residents on the unit. On 09/17/25 at 6:00 A.M., LPN #901 and LPN #637 completed head-to-toe assessments of residents on the unit who refused the night before. On 09/17/25 at 6:00 A.M., RN Supervisor #780 and RN Supervisor #588 continued nursing staff education on the facility's Abuse policy with first shift nursing staff. On 09/17/25 at 7:52 A.M., ADON #549 notified Resident #241's guardian of the allegation of abuse. On 09/17/25 at 8:37 A.M., ADON #549 notified Nurse Practitioner (NP) #439 of the allegation of abuse for Resident #241. On 09/17/25 at 9:00 A.M., the Administrator and the DON reviewed the video of the allegation of abuse with Lieutenant #457. On 09/17/25 at 11:12 A.M., psychiatric services responded to an email indicating they would evaluate Resident #241 on 09/17/25; however, the evaluation was rescheduled as Resident #241 was in the emergency room for evaluation of hematuria and urinary retention. On 09/17/25 at 11:17 A.M., ADON #634 sent the facility Abuse policy to the staffing agencies for staff re-education. On 09/17/25 at 3:00 P.M., LPN #602 reported to the police department and was interviewed by Lieutenant #457. On 09/17/25 at 3:15 P.M., the Administrator, ADON #549 and the DON interviewed LPN #602. At the conclusion of this interview, LPN #602 was arrested by Lieutenant #457 and transported to the county jail and was booked on charges of assault and abuse. On 09/18/25, Licensed Social Worker (LSW) #473 completed a Brief Interview for Mental Status (BIMS) for Resident #241. Resident #241's BIMS score was six out 15 indicating severe cognitive impairment. On 09/18/25, resident safety monitoring was put into place. The DON or designee would conduct random monitoring of five random residents with a (BIMS) of 8 or above two times a week for four weeks, then one time a week for four weeks. Skin assessments are done weekly on all residents on the unit on one of the resident's shower days (including those with a BIMS below 8) by the LPN assigned to the unit. Findings of the monitoring and skin assessments will be discussed with the Quality Assurance and Performance Improvement (QAPI) Committee to determine if further monitoring will be required. Subsequent document review revealed resident weekly skin assessments were completed 09/16/25 through 10/09/25. Resident Safety Monitoring was completed for five residents on 09/18/25, 09/19/25, 09/22/25, 09/24/25, 09/26/25, 09/29/25, 10/01/25, 10/03/25, 10/07/25, and 10/09/25. On 09/18/25, education for all staff was put into place on the Relias (electronic education platform) system. Topic was de-escalation techniques and verbal de-escalation strategies. This education was completed by 09/25/25. On 09/19/25 at 9:00 A.M., the QAPI Committee (Superintendent #990, Administrator, DON, Social Services #433, ADON #464, ADON #634, Infection Preventionist #671, Chief Compliance Officer #994, Police Chief #409, Lieutenant #457, Medical Director #688, Pharmacy Staff #453, Activities Staff #570, Support Services #632, ADON #721, MDSRN #472, and Rehabilitation Staff #995 met via TEAMS to discuss this allegation of abuse and the mitigation items put into place. On 09/19/25 at 4:30 P.M., psychiatric services evaluated Resident #241 with no new recommendations. On 10/01/25 at 9:30 A.M., the Administrator attended the Resident Council meeting and educated the residents who attended on the facility Abuse and Reporting policy. On 10/15/25 and 10/16/25, interviews with 15 staff (RN #700, LPN #614, LPN #960, LPN #911, LPN #901, LPN #637, CNA #400, CNA #293, CNA #770, CNA #663, CNA #296, CNA #292, CNA #725, CNA #714, and CNA #684) verified recent training on the abuse policy and on de-escalation strategies with appropriate knowledge. Review of the medical record for Resident #241 revealed an admission date of 06/10/24. Diagnoses included Alzheimer's disease, dementia, hypertension, bilateral primary osteoarthritis of the knee, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was frequently incontinent of bowel and bladder. The resident required substantial/maximal assistance with toileting and partial/moderate assistance with transfers. Review of Resident #241's plan of care for non-compliant behaviors initiated 10/09/24 and last revised 03/21/25 revealed the resident had the potential to be non-compliant with refusing his medications, treatments, and peri-care at times. Interventions included acknowledging the resident's right to refuse or choose against recommended treatment. Staff should offer education and reassurance to resident as needed. Staff would review non-compliance with the physician and other members of the Interdisciplinary Team (IDT) as needed. Further review of the care plan revealed the resident had anxiety at times. Interventions included attempting to find cause of anxiety, encouraging resident to voice needs and allowing resident time to do so and attempting to divert attention. Also, to maintain a calm manner while interacting with the resident and reduce sensory stimulation by maintaining a quiet environment. Staff were to monitor behaviors and notify the registered nurse and social worker as needed. Review of the resident's communication plan of care revealed the resident had difficulty finding words or finishing thoughts at times related to Alzheimer's disease. Interventions included explaining all procedures prior to beginning them, giving the resident simple one to two step commands while providing instructions. Also, for staff to monitor for non-verbal forms of communication such as smiling, facial grimaces, agitation, guarding, and pointing. Staff were to gain attention and eye contact before speaking to resident and ask simple questions that require yes or no answers, allowing time for response. Repeat or rephrase questions as needed to assure resident's understanding. Continued review of the care plan revealed the resident required placement in the Memory Care Unit due to cognitive impairment and dementia diagnoses and the resident could be resistive to care. Interventions included when the resident was upset, it would be helpful for him to feel better when someone listened to his concerns. Additionally, staff could show care/respect by being nice/friendly. Review of a skin observation report dated 09/15/25 revealed Resident #241 had bruising to the front right thigh, a scar to the front left lower leg, bruising to the left forearm, and skin tear to the right forearm measuring 3.8 centimeters (cm) in length by 0.3 centimeters in width. Review of video surveillance footage dated 09/16/25 beginning at approximately 7:50 P.M., revealed LPN #602 entered Resident #241's room. LPN #602 remained in the room for approximately 20 seconds then LPN #602 aggressively wheeled Resident #241 out of his room while the resident was attempting to stop the wheelchair by putting his feet down and grabbing the door. CNA #400 could be seen walking toward Resident #241 and LPN #602 as the incident occurred. LPN #602 continued to wheel the resident up to the nurse's station. LPN #602 can be seen hitting the resident's right arm and grabbing and pulling the back of the resident's shirt as he was attempting to move away from the nurse while the nurse continued to hold the wheelchair in place. LPN #602 can be seen moving his mouth and pointing and appeared to be speaking to the resident. Approximately a minute later, CNA #400 approached LPN #602 at the nurse's station while carrying a white packet which LPN #602 opened and handed back to her. CNA #400 then returned to the hallway. Resident #241 appeared agitated and in distress. Approximately 30 seconds later, LPN #602 then aggressively pushed Resident #241 in his wheelchair forcefully and directly slamming the resident's legs into the front of the recliner causing the resident to fly forward hitting the recliner then landing on the floor with CNA #400 present and witnessing the incident. LPN #602 attempted to pick Resident #241 up by the back of his pants. Resident #241 then rolled onto his buttocks. LPN #602 remained standing over the resident while he was on the floor. LPN #602 glanced at the camera several times then removed his name badge. Less than a minute after slamming the resident into the recliner, LPN #602 moved the resident's wheelchair back and then sat in the resident's wheelchair next to the resident on the floor. Approximately 25 seconds after sitting in the resident's chair as LPN #614 was walking down the hall looking toward the resident on the floor, LPN #602 lifted his left leg and kicked the back of the resident's lower right leg as LPN #614 arrived at her medication cart near the nurse's station. LPN #614 remained at the medication cart for over a minute looking at her computer screen while CNA #400 approached Resident #241 and LPN #602 as LPN #602 appeared to be speaking. CNA #400 stood there for one minute before leaving toward the hallway behind the nurse's station. LPN #614 was then seen at the desk using the phone about five minutes after the incident began. CNA #400 returned to the resident's hallway and continued cleaning up water from the floor in the hallway. CNA #400 was not seen intervening between the resident and the nurse to protect the resident and CNA #400 was not seen attempting to call for additional help. As LPN #614 was on the phone, about one minute later RN Supervisor #700 arrived on the unit and then began addressing Resident #241. Continued review of the video surveillance revealed on 09/16/25 at 8:09 P.M. and 8:13 P.M., LPN #602 was seen continuing to work on the unit. Review of an incident report dated effective 09/16/25 at 7:55 P.M. revealed RN Supervisor #700 received a statement of alleged physical and verbal abuse from CNA #400 towards Resident #241. Resident #241 was unable to give a description. ADON #549 was notified, the staff member was removed from the floor immediately, and the resident was assessed. Psychiatric services and social services were notified. No injuries observed at the time of the incident. The physician was notified on 09/17/25 at 8:37 A.M. and the resident's guardian notified on 09/17/25 at 7:52 A.M. Review of a late entry nurses note by RN #740 effective for 9/16/25 at 7:55 P.M. with the document created on 09/16/25 at 11:14 P.M revealed a skin assessment had been completed for Resident #241 and three skin tears were added to the skin editor. Review of a nurses note by LPN #614 dated effective for 9/16/25 at 7:58 P.M. with the documentation not created until 09/16/25 at 9:08 P.M., revealed Resident #241 stated he needed to go the bathroom. CNA #400 attempted to assist the resident who then refused care while cussing and yelling at the CNA. When leaving the room, Resident #241 then attempted to enter another resident's room causing that resident to yell at Resident #241. Resident #241 yelled this is my room. Resident #241 was redirected to his room with his name on it and the resident then stated, I know they invited me over there. Resident #241 then wheeled himself to the sink and started to brush his teeth. Review of a nurses note by LPN #614 with an effective date of 9/16/25 at 8:09 P.M. with the document not created until 09/16/25 at 9:21 P.M., revealed a nursing assistant observed water throughout the hallway and a few resident rooms with water on floors. The nurse noted Resident #241 was observed coming out of his bathroom from his room with a urinal he had just filled from the hopper on the back of the toilet. Resident #241 was then observed raising the urinal and throwing water all over the hallway floors and his room floor. Review of a nurses note dated 9/16/25 at 8:32 P.M., LPN #602 documented assisting Resident #241 to a stationary chair in the common area. Resident #241 attempted to stand up from the wheelchair and landed on the floor on his knees. Resident noted clothed and wearing shoes in good condition. Resident denied pain. The floor was dry and free of debris. Range of motion times four and resident assessed. LPN #602 noted no injuries to the resident's knees. Staff assisted resident to the stationary chair. Interventions included a bladder scan and toileting assistance. LPN #602 initiated an incident report on 09/16/25 at 8:00 P.M. noting the resident had no injuries. LPN #602 notified the guardian on 09/16/25 at 8:12 P.M. and the physician at 8:32 P.M. Review of a facility Self-Reported Incident (SRI) dated 09/16/25 at 9:47 P.M. and review of the subsequent investigation reports revealed on 09/16/25 at approximately 9:15 P.M., the facility became aware of an allegation of staff to resident abuse on the Memory Care Unit. The facility noted the incident affected the resident causing agitation. The police were notified on 09/16/25 at 9:20 P.M. Resident #241 sustained skin injuries from fall occurring during the incident. The resident representative was notified on 09/17/25 at 7:52 A.M. Resident #241 was unable to provide useful information. Further review of the SRI investigation revealed CNA #400 informed the facility that LPN #602 was pushing Resident #241 in his wheelchair and yelling at the resident. The resident's knees struck the front of the recliner, causing him to fall forward out of the wheelchair and onto the floor because of LPN #602 pushing the resident aggressively in the wheelchair and during transfer the resident fell onto the floor. LPN #602 admitted to using inappropriate language while assisting the resident and spoke loudly due to the resident being hard of hearing. LPN #602 admitted to using excessive force when transferring the resident into the recliner by grabbing the resident's waistband and shorts. A head-to-toe assessment of Resident #241 was completed by RN #740 revealing skin injuries including an abrasion. During RN #740's assessment the resident had stated the nurse had hit him. Further review of the facility SRI investigation revealed the resident had one skin tear to the left upper arm, one skin tear to the left upper forearm, and one skin tear to the left upper arm above elbow and it was unknown if the injuries were caused by LPN #602. The resident displayed expressions of anger while in the presence of LPN #602. Review of a description of the incident revealed LPN #602 was removed from the resident care area and escorted out of the facility. Further review of the follow-up SRI investigation report noted upon further review and confirmation by video surveillance, LPN #602 was arrested by the police department and transported to the county jail awaiting further court proceedings at this time related to pending charges of patient abuse and assault. The facility completed skin sweeps for all residents on the Memory Care Unit and requested a psychiatric evaluation for the resident. Review of the SRI facility conclusion revealed the allegation of abuse was substantiated and verified by evidence. Review of CNA #400's statement dated 09/16/25 at 9:15 P.M. revealed Resident #241 was filling the urinal with water and throwing water around the floor. CNA #400 revealed when she noticed the water she grabbed a spill kit/mop to attempt to get the water up per the nurse request. When returning, LPN #602 was pushing Resident #241 through the door very aggressively while calling the resident expletive names (vulgar or profane words used to express strong emotion). CNA #400 revealed she tried to take over and get Resident #241 to the common area, but LPN #602 kept pushing him in the wheelchair very aggressively while yelling at the resident. CNA #400 noted she believed the resident was not in his right mind, his sentences were not making sense, and he was scared. CNA #400 revealed when LPN #602 got the resident to the recliner in the common area he slammed his knees in the chair and body, and the resident fell. CNA #400 revealed LPN #602 had not carefully transferred the resident like we were instructed to do. CNA #400 revealed during report she was told Resident #241 was a stand lift, so when she saw how LPN #602 manhandled him, she was very scared. CNA #400 revealed she walked over to try and help get the resident up, but LPN #602 told her to keep cleaning the spill. CNA #400 revealed she had not wanted to leave Resident #241 as she was scared for him. CNA #400 revealed he had two bloody sores on his right and left arm. CNA #400 stated Resident #241 was stating how he thought LPN #602 was his friend and CNA #400 revealed that just broke my heart. CNA #400 revealed yes the resident was throwing water, but she had removed the urinal, it did not have to go that way. CNA #400 revealed LPN #602 stated Resident #241 climbed out of the chair to the other nursing assistant which was not true. Further review of CNA #400's interview dated and initialed 09/16/25 revealed CNA #400 indicated she had been educated on the abuse policy, had worked on the Memory Care Unit on 09/16/25 on second shift, had witnessed Resident #241 throw water on the floor, and had witnessed staff use inappropriate language and excessive force while assisting Resident #241. CNA #400 also documented when assisting Resident #241 to bed, the resident stated, that nurse hit me. Review of staff statements for four additional staff (LPN #614, CNA #997, CNA #998, and CNA #999) working on the unit at the time of the alleged abuse revealed the four employees were not present in the common area during the incident and had not witnessed the fall or abusive mistreatment of the resident. Review of LPN #602's employee timecard dated 09/16/25 revealed the nurse began their work shift at 2:43 P.M. and then punched out at 10:16 P.M. after being placed on administrative leave. Review of a nurses note by LPN #614 effective for 09/16/25 at 10:59 P.M. with the documentation not created until 09/16/25 at 11:43 P.M. revealed LPN #614 had observed Resident #241 coming out of the bathroom from his room in his wheelchair holding a urinal filled with water that was filled using the hopper from the toilet. The resident was asked what he was doing when he raised the urinal and started to throw water on the floor in the hallways and his room. LPN #614 documented the resident had three skin tears with skin flaps observed. One to the right upper arm measuring one centimeter (cm) in length by one cm in width; a second skin tear to the left back of upper arm measuring three cm in length by five cm in width; and a third skin tear to the left lower arm measuring two cm in length by three cm in width. The resident denied pain or discomfort with range of motion within normal limits to the bilateral upper extremities. LPN #614 noted the skin tears were cleansed with normal saline and a dressing was applied to all three skin tears with skin flap. A new intervention was initiated for padding for the pole behind the toilet. Review of a late entry nurses note by RN #740 effective for 09/16/25 at 11:45 P.M. with the documentation created on 09/18/25 at 11:16 A.M. revealed Resident #241 had a head-to-toe skin assessment completed with no new findings since previous assessment at 7:55 P.M. Review of a police report dated 09/16/25 through 09/24/25 revealed after reviewing witness statements and video surveillance there was overwhelming evidence beyond a reasonable doubt that LPN #602's actions warranted criminal charges. On 09/17/25, LPN #602 was charged with assault and patient abuse and taken to the county jail. On 09/24/25 the police department was notified LPN #602 had resigned his position from the facility. Further review of the police report revealed photographs of Resident #241 showing two wound treatment dressings to the right upper arm above the elbow dated 09/16/25 3-11 shift, and one wound dressing to the right upper forearm dated 09/16/25 7-3 shift. On the resident's left posterior upper arm above the elbow was a wound dressing dated 09/16/25 3-11 shift and a second wound dressing to the left lower arm dated 09/16/25 3-11 shift visible. The resident had multiple bruised areas from a previous fall. Review of the staffing schedule dated 09/16/25 for the Memory Care Unit revealed there were two nurses (LPN #602 and LPN #614) and four CNA's assigned to the unit on the 3:00 P.M. to 11:30 P.M. shift. CNA #400 was assigned to Resident #241. Review of a skin observation report dated 09/17/25 revealed the resident had a skin tear to the right upper arm measuring 1 cm in length by one cm in width by 0.1 cm in depth. A second skin tear to the left lower arm measuring two cm in length by three cm in width by 0.1 cm in depth. A third skin tear to the left posterior upper arm measuring three cm in length, five cm in width, with a depth of 0.1 cm. Review of a notification letter dated 09/17/25 revealed LPN #602 was informed and acknowledged placement on administrative leave. Review of an interdisciplinary progress note by ADON #549 revealed she had been called on 09/16/25 at 9:18 P.M. about a statement received by a nursing supervisor of a nursing assistant alleging physical and verbal abuse towards Resident #241 by his nurse. ADON #549 instructed the supervisor to remove the charge nurse from the floor immediately, and requested an RN assessment of the resident, skin sweeps on all residents on the unit and for psychiatric services to be notified. Review of a progress note by ADON #549 dated 09/17/25 at 7:58 A.M. revealed the social worker and herself spoke with the resident's representative about the incident of alleged abuse. Review of a medical provider progress note dated 09/17/25 at 10:21 A.M. revealed the resident was assessed with new orders to send to the emergency room for an acute urology evaluation due to urinary urgency, retention, and hematuria. Further review of the progress notes revealed Resident #241 was sent to the emergency room (ER) and treated for a urinary tract infection and ordered antibiotic treatment. The resident returned to the facility on [DATE] at 6:00 P.M. Subsequent review of the ER laboratory final urinalysis results revealed the resident had no urinary tract infection. Review of a progress note by LSW #473 dated 09/17/25 at 10:49 A.M. revealed Resident #241 was in good spirits and recognized the social worker. The social worker inquired how the resident was doing after the incident from the previous evening and the resident stated everything was fine yesterday and he felt good. Review of an IDT progress note by ADON #549 dated 09/17/25 at 12:09 P.M. and 12:14 P.M. revealed the IDT team met to discuss the resident's skin injury from 09/16/25 and to discuss the alleged incident between the resident and staff member. Interventions were noted as in place and the care plan was reviewed and revised. Review of a documented interview dated 09/17/25 with LPN #602 revealed LPN #602 stated and initialed yes he had been educated on the policy related to abuse, neglect, and misappropriation. LPN #602 documented yes and initialed he had worked on the Memory Care Unit on 09/16/25 on second shift. LPN #602 documented and initialed no he had not witnessed Resident #241 throwing water on the floor in his room. LPN #602 documented and initialed yes he had used inappropriate language while assisting Resident #241, additionally noted was spoke loud because resident hard of hearing. LPN #602 documented and initialed yes to using excessive force that could be viewed as aggressive while assisting Resident #241 and noted grabbed waist band of shorts to help transfer. LPN #602 documented and initialed yes to attempting to assist Resident #241 in/out of the common area recliners during the shift. LPN #602 documented and initialed yes Resident #241 had skin injuries prior to the fall and noted there were two skin injuries and LPN #614 had stated there were three total. LPN #602 documented and initialed no to kicking Resident #241 while he was on the floor. LPN #602's interview statement was signed and dated by him on 09/17/25. Review of a statement dated 09/18/25 at 12:23 P.M. by RN Supervisor #700 revealed he had not witnessed the fall or any abuse. RN Supervisor #700 revealed he arrived on the unit shortly after the incident and was not aware of any allegations of abuse until CNA #400 came to his office to report concerns. RN Supervisor #700 revealed he had entered the Memory Care Unit to complete rounds. LPN #614 requested help as RN Supervisor #700 observed Resident #241 on the floor with LPN #602 standing nearby. RN Supervisor #700 stated LPN #614 and LPN #602 reported the resident was throwing water from a urinal in the hallway. LPN #602 stated Resident #241 had climbed out of his wheelchair and sustained multiple skin tears in his room when he was throwing water. RN Supervisor #700 approached Resident #241 and LPN #[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Based on medical record review, review of facility self-reported incidents (SRI) and related investigation documents, staff and resident interview, review of local new reports, and review of a facility policy, the facility failed to ensure residents were free from misappropriation. This affected one (#1) of five residents reviewed for misappropriation. The facility census was 223.
Findings Include:
Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included type two diabetes, chronic kidney disease, and gout.
Review of the most recent Minimum Data Set (MDS) 3.0 assessment revealed Resident #1 was cognitively intact and required hands on assistance from one staff person for completing his activities of daily living (ADLs).
Review of an SRI and corresponding investigation documentation dated 03/31/25 revealed the facility was made aware of a claim that Resident #1 was missing between $1000 and $1500. Resident #1 alleged that theft was done by an African American staffing agency nurse aide. An investigation was immediately initiated which included resident interviews, staff interviews of all staff on-site at the time of the alleged theft, and medical record reviews. During an interview with the facility's police force, Certified Nurse Aide (CNA) #100 confessed to the theft of Resident #1's money from the wallet that was hanging on Resident #1's wheelchair while CNA #100 was in the room. The facility's police force obtained consent to search CNA #100's vehicle and a bag with $1050 was noted in the middle console of CNA #100's vehicle in dominations of $20 bills and $50 bills. Review of a statement completed by Lieutenant #300 with the facility's police department dated 04/03/25 revealed CNA #100 was questioned about Resident #1's money and confessed to take $1050 out of the resident's bag/wallet hanging over his chair while she was in his room.
Review of a local news report dated 04/30/25 revealed CNA #100 was booked into the local county jail on 04/04/25 and charged with theft from the elderly which was classified as a fourth-degree felony and carried at minimum a six-month jail sentence to a maximum of 18 months.
Interview with the Administrator on 06/06/25 at 10:00 A.M. verified the facility was made aware of an allegation of misappropriation of Resident #1's funds and immediately began an investigation. The Administrator stated through investigation it was determined CNA #100 was responsible for stealing Resident #1's money.
Interview with Resident #1 on 06/06/25 at 10:30 A.M. stated he had money taken from his room and it was reported to the facility. Resident #1 stated the facility conducted and investigation and caught the person that stole it.
Review of the policy titled, Abuse, Neglect, and Exploitation, dated 03/25/25, revealed the facility will prohibit and prevent abuse, neglect, exploitation or mistreatment, including injuries of of unknown origin and misappropriation of resident property.
As a result of the incident, the facility took the following actions to correct the deficient practice by 04/08/25:
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On 03/31/25, all staff working at the time of the alleged incident were interviewed and questioned by both facility clinical staff and the police department.
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On 03/31/25, CNA #100 was escorted off the property upon confession of the theft.
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On 03/31/25, CNA #100's employer was contacted and CNA #100 was put on the do not return list for the facility.
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On 03/31/25, CNA #100 was reported to the Nurse Aide Registry.
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On 03/31/25, all residents with a Brief Interview for Mental Status (BIMS) score of eight (indicating moderate cognitive impairment) or higher were interviewed regarding concerns with CNA #100 or any other staff related to misappropriation with no negative findings. All residents with BIMS scores indicating they were cognitively impaired had their medical records reviewed for concerns of misappropriation with no issues identified. The interviews and medical record reviews were completed by 04/01/25.
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On 04/03/25, Resident #1's stolen funds were returned to the resident after processing for the criminal investigation into CNA #100's actions.
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Immediately after the incident, all staff were assigned an online education regarding abuse, neglect, and misappropriation with all staff completing the in-service as of 04/08/25.
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Review of facility SRIs on 06/06/25, completed between 04/01/25 and 05/19/25, revealed no further confirmed allegations of misappropriation and no trends or patterns were identified.
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On 06/06/25, review of four (#2, #3, #4, and #5) additional resident medical records revealed no concerns related to misappropriation.
This deficiency represents non-compliance investigated under Complaint Number OH00164401.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility self-reported incidents (SRIs) and investigation documents, staff and resident interview, and review a facility policy, the facility failed to ensure residents were free from verbal and physical abuse. This affected three (#3, #4, and #5) of five residents reviewed for abuse. The facility census was 223.
Findings Include:
1. Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, high blood pressure, and depression.
Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was severely cognitively impaired and required extensive assistance of two staff persons for completing his activities of daily living (ADLs).
Review of an SRI and corresponding investigation documents dated 03/20/25 revealed, on 02/06/25, staff witnesses reported that Certified Nurse Aide (CNA) #102 was deliberately agitating Resident #3 while other staff were providing Resident #3 a shower. Resident #3 was noticeably upset because of CNA #102's deliberate attempts at agitation and spit in CNA #102's face to which CNA #102 threw a towel at Resident #3, striking him in the face and head area. Upon investigation by facility administrative staff that included resident interviews, staff interviews, and record reviews, the allegation of abuse by CNA #102 to Resident #3 was substantiated. CNA #102's employment was terminated on 03/20/25.
2. Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, high blood pressure, and major depressive disorder.
Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #4 was severely cognitively impaired and required hand on assistance of two staff persons for completing his ADLs.
Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety disorder, and wandering diseases.
Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #5 was severely cognitively impaired and required hand on assistance of two staff persons for completing his ADLs.
Review of an SRI and corresponding investigation documentation dated 03/21/25 revealed CNA #103 informed administrative staff that between the dates of 03/05/25 and 03/10/25, at around 11:30 P.M., he and CNA #102 were putting Resident #5 to bed and while changing Resident #5's incontinence care products, CNA #102 took an inhalation off his nicotine vaping pen and exhaled the vapor into Resident #5's face. Further review revealed while continuing care for Resident #5, Resident #4 was heard in the hallway shouting, I do not know where to go. Upon hearing Resident #4, CNA #102 left the room and told Resident #4 to, go find a bridge to jump off of. CNA #103 confronted CNA #102 about his actions toward Resident #4 and Resident #5 and was ignored. CNA #102 was already on suspension from a previous SRI investigation and his employment was terminated subsequent to the two incidents reported on 03/20/25 and 03/21/25.
Interview with Lieutenant #300 from the facility's police department on 06/06/25 at 2:00 P.M. verified both incidents of CNA #102 being verbally and physically abusive toward Resident #3, exhaling vapor into Resident #5's face during incontinence care, and being verbally abuse to Resident #4. Lieutenant #300 described CNA #102 as someone who thought they could do whatever he wanted to.
Review of the policy titled, Abuse, Neglect, and Exploitation, dated 03/25/25, revealed the facility will prohibit and prevent abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property.
This deficiency represents non-compliance investigated under Complaint Number OH00163793.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a self-reported incident (SRI) and related investigation documents, staff interview, and review of a facility policy, the facility failed to timely report an allegation of abuse to the State Survey Agency in a timely manner. This affected one (#3) of five residents reviewed for abuse. The facility census was 223.
Findings Include:
Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, high blood pressure, and depression.
Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was severely cognitively impaired and required extensive assistance of two staff persons for completing his activities of daily living (ADLs).
Review of an SRI and corresponding investigation documents dated 03/20/25 revealed, on 02/06/25, staff witnesses reported Certified Nurse Aide (CNA) #102 was deliberately agitating Resident #3 while other staff were providing Resident #3 his shower. Resident #3 was noticeably upset and spit in CNA #102's face, to which CNA #102 threw a towel at the resident striking Resident #3's in the face and head area. Further review revealed the alleged incident was reported to the State Survey Agency more than a month after it occurred.
Interview with the current Administrator on 06/06/25 at 3:45 P.M. verified the previous Administrator did not report the allegation which occurred on 02/06/25 involving Resident #3 and CNA #102 to the State Survey Agency in a timely manner.
Review of the policy titled, Abuse, Neglect, and Exploitation, dated 03/25/25, revealed the nursing home administrator shall be designated the Abuse Prevention Coordinator at the facility. This employee is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. The facility will report to the Administrator immediately but no later than two (2) hours after the allegation was made, if the events of the allegation involved abuse or resulted in serious bodily injury or not later than 24 hours if the events that caused the allegation do not involve abuse and do not results in serious bodily injury. The facility will also report to the state agency, adult protective services, law enforcement, and to all other required agencies, as applicable.
This deficiency represents non-compliance investigated under Master Complaint Number OH00165363.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a self-reported incident (SRI) and related investigation documents, review of a hospital record, review of an employee skills checklist, and policy review, the facility failed to complete resident transfers using a mechanical lift with appropriate assistance as care planned and as ordered. Actual Harm occurred on 04/29/25 when Resident #2, who was care planned for two-person assistance with all personal care and had a physician order to always be transferred using two people, was transferred in her room by one staff member using a mechanical lift without assistance. Resident #2 sustained a right femur fracture as a result of the improper transfer. This affected one (#2) of three residents reviewed for accidents. The facility census was 223.
Findings Include:
Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, peripheral vascular disease, and constipation.
Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was severely cognitively impaired and required extensive assistance of two staff persons for completing her activities of daily living (ADLs) including transfers.
Review of the care plan for Resident #2 dated 08/04/21 revealed Resident #2 required two staff persons for all personal care.
Review of Resident #2's physician orders revealed an order dated 03/17/23 for Resident #2 to always be transferred by two persons.
Review of an SRI and related investigation documentation dated 04/29/25 revealed on 04/29/25 Resident #2 was observed at dinner at approximately 7:45 P.M. and was noted to be not be acting right. Registered Nurse Clinical Care Coordinator (RNCCC) #200 documented noticeable painful facial grimacing and bruising to Resident #2's left leg and left facial abrasions, which RNCCC #200 felt was consistent with Resident #2 bumping her leg on the wall and rubbing her face with her hand as she often did. Upon further assessment, RNCCC #200 observed a deformity to Resident #2's right knee. Resident #2 was unable to verbalize to staff how she obtained the injuries. RNCCC #200 placed a call to Resident #2's primary care physician (PCP) and received orders to obtain x-rays of Resident #2's right knee and right hip. The facility was informed by the x-ray company that Resident #2 had a fracture to her right femur and new orders were obtained to send Resident #2 to a local hospital for evaluation.
Further review of the SRI investigation dated 04/29/25 revealed common area video camera footage was reviewed by the facility's police department, the Administrator, and nursing administration. On the video, Certified Nurse Aide (CNA) #101 was seen entering Resident #2's room by herself around 5:10 P.M., bringing in a non-weight bearing lift inside the room. Approximately two minutes later, CNA #101 was seen exiting Resident #2's room with the non-weight bearing lift and placing the lift by the wall. CNA #101 then proceeded to interact with an unknown visitor. Once the interaction between the two was complete, video camera footage showed CNA #101 entered Resident #2's room by herself again, bringing the non-weight bearing lift with her. Approximately twelve (12) minutes later, CNA #101 was seen exiting the room, pushing Resident #2 in the cradle chair, and leaving the room with the non-weight bearing lift. The facility concluded after conducting interviews and statements from nursing staff and other interviews conducted by the facility police department that video footage and other investigation findings revealed CNA #101 failed to follow Resident #2's plan of care and physician orders, and failed to follow the facility policy and procedure for two staff members for all transfers with non-weight bearing residents. CNA #101 was escorted out of the building and the facility notified her staffing agency that she was placed on the do not return list.
Review of the hospital x-ray evaluation dated 04/29/25 revealed Resident #2 had a supracondylar femur fracture (a fracture of the thigh bone just above the knee) with minimal comminution (a type of bone fracture where the bone breaks into three or more pieces, but the fragments are relatively small and relatively stable) and posterior displacement.
Review of the document titled, Skills Checklist for State Tested Nurse Aide (STNA)/CNA, for CNA #101 dated 01/17/25, revealed CNA #101 was deemed capable to perform resident transfers.
Interview with Lieutenant #300 from the facility's police department on 06/06/25 at 2:00 P.M. verified the events of the SRI dated 04/29/25 and CNA #101's failure to follow Resident #2's plan of care and physician order related to transferring the resident with resulting in the fracture of Resident #2's right femur.
Interview with the Director of Nursing (DON) on 06/06/25 at 3:00 P.M. revealed, as a result of the incident when CNA #101 transferred Resident #2 by herself using a mechanical lift resulting in a fractured right femur on 04/29/25, the facility was engaging staff with re-education of the proper techniques of how to mechanical (Hoyer) lift transfer and the facility had not completed all staff education as of 06/06/25.
Interview with the Assistant Director of Nursing (ADON) on 06/06/25 at 3:30 P.M. revealed she was the primary clinical investigator and during interview with CNA #101 and confirmed CNA #101 stated Resident #2's injury occurred during the transfer on 04/29/25. The ADON further stated CNA #101 did not identify she had any assistance transferring Resident #2 on 04/29/25.
Review of the policy titled, Full Body Mechanical Lift Bed to Chair Transfer Work Instructions, dated 04/01/25, revealed all transfers involving the use of full body mechanical lift require two-assist for transfer.
This deficiency represents non-compliance investigated under Master Complaint Number OH00165363.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, review of a police report, review of an incident report, observation, staff interview, and policy review, the facility failed to ensure a resident was adequately assessed for unsupervised smoking and failed to follow the smoking policy. This affected one (#84) of three residents reviewed for smoking safety. The facility identified 38 residents who smoked. The facility census was 223.
Findings include:
Review of the medical record revealed Resident #84 had an admission date of 12/30/13 and a readmission date of 10/20/23. Diagnoses included paranoid schizophrenia, type two diabetes mellitus, osteoarthritis, anxiety disorder, depression, unspecified psychosis, insomnia, and polyneuropathy.
Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident required supervision for walking and was independent in wheelchair.
Review of the care plan initiated 10/29/23 for Resident #84 revealed the resident had schizophrenia with potential for delusions and hallucinations. Interventions included administering medications as ordered and monitoring for adverse effects and effectiveness of medications, to monitor and record episodes of hallucinations or delusions, and psychiatric consults as ordered. Further review of the care plan revealed Resident #84 had episodes of agitation raising voice and yelling at staff. Interventions included to immediately intervene if altercation with another resident, notify physician as needed, one to one visits as needed, find cause of agitation and rectify, encourage resident to vent feelings.
Review of a physician order dated 01/31/24 revealed an order for oxygen two liters per minute per nasal cannula, if using oxygen mask adjust flow meter to at least five liters per minute for pulse oximeter of less than 88 percent as needed for shortness of breath. Review of a physician order dated 10/24/24 revealed the resident had order for quetiapine 25 milligrams (mg), one tablet by mouth in evening for insomnia and schizophrenia.
Review of psychiatric progress notes dated 11/21/24 revealed the resident had been taken off most of his psychiatric medications due to a physical illness. The resident had recovered physically and had more mental health signs and symptoms. The nursing staff stated the resident had become more paranoid and agitated. The resident was started on quetiapine 25 milligrams (mg) daily after last visit. The resident denied hallucinations and paranoid beliefs at the time of the visit.
Review of a nurses note dated 12/31/24 at 7:55 A.M. revealed Resident #84 had hallucinations. The resident's antipsychotic medication quetiapine was increased to 50 mg at bedtime.
Review of a psychiatric progress note dated 01/09/25 revealed nursing had reported increased paranoia and agitation in the resident. The resident denied paranoia and hallucinations at the time of the visit. The resident was noted as more stable on quetiapine and to continue current medications.
Review of social service progress note dated 01/15/25 revealed the resident requested a carton of cigarettes. The social worker asked the resident what made him decide to smoke and the resident replied he used to smoke and missed it.
Review of a nurses note dated 01/16/25 at 7:16 A.M. revealed the resident pulled out his indwelling urinary catheter and yelled at nurse it was not needed and refused to have it replaced.
Review of a physician order dated 01/16/25 at 11:35 A.M. revealed Resident #84 was an unsupervised smoker.
Review of a smoking assessment dated [DATE] at 11:36 A.M., revealed the resident smoked in the designated smoking area and displayed safe smoking. Further review of the smoking assessment revealed the assessment evaluated the functional ability to smoke. The smoking assessment form had not indicated if other pertinent safety factors were evaluated including medical conditions (i.e. oxygen use), mental health symptoms, and cognition level before determining if a resident required supervision or no supervision while smoking.
Review of a police report dated 01/16/25 at 1:15 P.M. revealed Housekeeper #250 reported a fire in an auditorium on the second floor. Staff #260 reported exiting his office and noticing a small flame in the auditorium as Resident #84 was exiting the room. Housekeeper #250 grabbed a fire extinguisher while Staff #260 grabbed the bin with flames and carried to the open area in the room. Staff #260 stated the fire was put out using the fire extinguisher. Video footage was later observed and confirmed Resident #84 entered the auditorium at 1:07 P.M. in his wheelchair. Resident #84 proceeded to a table with tissues and blew his nose. Resident #84 then removed five tissues from the box then wheeled to the pool table and scattered the balls on the table. Resident #84 then went to the north corner of the room touching items on the shelf with his back to the camera. At 1:11 P.M. Resident #84 turns and looks around the room. At 1:12 P.M. a small fire flames/illuminating light appeared near the area the resident was located. Resident #84 placed a tissue that was lit on fire into the bin. Smoke was observed in the air. Resident #84 placed what was believed to be tissues on the shelf where the flame was located. At 1:13 P.M. Staff #260 entered the auditorium noticed the flames, requested a fire extinguisher from Housekeeper #250 who was walking by. Staff #260 confronted Resident #84 who threw his hands in the air saying he does not know what happened as he exited the room. Staff #260 picked up and carried the bin with flames to an open area. Housekeeper #250 brought a fire extinguisher and Staff #260 used the extinguisher to put the fire out. The police were called and the fire department was notified. There was very little property damage. The police asked Resident #84 for his cigarettes and lighter and the resident provided them. Resident #84 was interviewed and denied starting the fire even after watching the video and stated it was not me. The Administrator stated the resident would be placed on one-on-one staff supervision until he could be evaluated at the hospital. It was noted in the police report the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 showing cognitive impairment. The resident's St. Louis University Mental Status (SLUMS) score was 16 out of 30 showing signs of dementia. The resident was also diagnosed with paranoid schizophrenia.
Review of an incident report dated 01/16/25 at 1:29 P.M. revealed Resident #84 was not burned and had no injuries. The resident was burning items and witnessed by the police department on video surveillance. The resident's smoking materials were brought to the nurse by the police department. The resident was placed on one-one-supervision. Notifications were made to the physician, nurse practitioner, social worker, Administrator, Director of Nursing, and family.
Review of a nurses note dated 01/16/25 at 1:29 P.M., revealed the police department was on the unit looking for Resident #84 for starting a fire in the auditorium with cards. Nurse took possession of the resident's cigarettes and lighter.
Review of a progress note dated 01/16/25 at 1:55 P.M. revealed the resident set a fire and would now be a supervised smoker.
Review of a progress note dated 01/16/25 at 2:25 P.M., revealed a BIMS was completed and the resident scored 11 out of 15 indicating cognitive impairment.
Review of a social service note dated 01/16/25 at 2:47 P.M. revealed the social worker met with the resident. The resident denied starting a fire and stated he was playing pool. Resident continued to deny starting the fire even after he was told the incident was on camera. The social worker completed a slums assessment with the resident scoring a 16 out of 30 noting the resident had an eight grade education.
Review of a progress note dated 01/16/25 at 3:06 P.M. revealed the physician approved of the resident on one-on-one supervision.
Review of a social service note dated 01/16/25 at 5:12 P.M. revealed the resident agreed to go to the hospital for an evaluation for a psychiatric evaluation.
Observation on 01/27/25 at 8:46 A.M. revealed there was a camera in the auditorium on the second floor. There were tables in the room and a pool table. Along the back wall there were shelves with books and activities like cards and puzzles. Further observation revealed no signs of fire, smoke or fire damage. Later observation of the grey plastic bin the fire was started in revealed the bin was melted on one end. Inside the bin were partially burned playing cards.
Interview on 01/27/25 at 9:37 A.M., with the Administrator and Director of Nursing (DON) revealed after the fire incident on 01/16/25, the facility reviewed the smoking policy and smoking assessment with no changes made. Prior to the incident unsupervised/independent smokers could keep their lighters and cigarettes in their possession. The Administrator revealed staff were reeducated on the fire policy and smoking policy with new instructions to assess cognitive function using BIMS and SLUMS. Those with low scores were evaluated for supervised smoking. The Administrator revealed all smoking residents were reevaluated and all were now supervised while smoking. The DON revealed Resident #84 last used the as needed oxygen on 12/31/24. Further interview with the DON on 01/27/25 at 12:35 P.M. revealed she could not determine if Resident #84 had an oxygen concentrator in place for use on 01/16/24 when he was determined to be an unsupervised smoker in possessions of his cigarettes and lighter. The DON revealed the resident should not have had an oxygen concentrator in his room when he was allowed to have a lighter and cigarettes.
Observation on 01/27/25 beginning at 10:40 A.M. in the designated smoking area outside the building revealed there were two extinguished cigarettes on the ground in the resident smoking area. Further observations revealed Resident #129 and Resident #40 were supervised by video surveillance while smoking. Licensed Practical Nurse (LPN) #300 had also been present in the smoking area. Registered Nurse (RN) #302 provided the residents with cigarettes and lit the resident's cigarettes.
Interviews on 01/27/25 at 10:40 A.M., LPN #300 and at 10:43 A.M. with RN #302 each verified an extinguished cigarette was on the ground and had not been properly disposed of in the ash container.
Further observation on 01/27/25 at 12:54 P.M., in Resident #84's room revealed there was an oxygen in use no smoking sign on the resident's door to the room. Resident #84 had no oxygen concentrator on his side of the shared room. Resident #84's roommate (Resident #12) had an oxygen concentrator on his side of the room and was ordered four liters of oxygen per nasal cannula continuous.
Interview on 01/27/25 at 12:54 P.M., Certified Nursing Assistant (CNA) #200 verified Resident #84's roommate had an oxygen concentrator in the room and required continuous oxygen use.
Interview on 01/28/25 at 6:55 A.M., the DON revealed supervision for smoking was determined by the smoking assessment. The DON verified the smoking assessment form does not instruct the nurse to evaluate medical condition (i.e. oxygen use), mental health symptoms or cognition when determining if a resident was considered a supervised or unsupervised smoker. The DON revealed there was nowhere to document those things on the form. The DON revealed supervised smokers were not allowed to keep their cigarettes and lighter. Unsupervised smokers could always keep their own cigarettes and lighters with them. The DON revealed some residents just need supervision to get to and from the smoking area and were observed from a distance. Other residents required staff to be present with them. The DON revealed RN #490 had completed Resident #84's smoking assessment how the nurses were told to do it and the resident demonstrated safe smoking. The DON revealed RN #490 should have evaluated the resident's order for oxygen and discontinued the order if the resident was not using the oxygen. The DON revealed the resident was not on the radar for behavioral concerns. The DON revealed staff thought it was odd that Resident #84 wanted to start smoking and provided education to the resident about smoking. The DON verified the facility was not evaluating the residents' cognition at the time of the smoking assessment as stated in the smoking policy. The DON also revealed prior to the fire they had not been considering current medical conditions and a in determining supervision level.
Interview on 01/28/25 at 7:08 A.M., RN #490 revealed completing the smoking assessment for Resident #84 on 01/16/25. RN #490 revealed a resident's supervision level was determined by the smoking assessment form and nothing else. RN #490 revealed Resident #84 had an order for oxygen but was not using it. RN #490 revealed the resident smoked safely, and knew where to go to smoke so he was an unsupervised smoker and was allowed to keep his cigarettes and lighter. RN #490 was not having any hallucinations at the time of the smoking assessment.
Interview on 01/28/25 at 7:47 A.M. RN #492 revealed for a smoking assessment the resident was taken outside to smoke and observed for hand dexterity, not dropping ashes and distinguishing the cigarette in the bin. RN #492 revealed health conditions and mental health conditions were not considered when evaluating the resident's level of supervision needed. RN #492 revealed the smoking policy stated nothing in regard to medical conditions.
Interview on 01/28/25 at 7:53 A.M., RN #494 revealed a function smoking assessment along with a resident's diagnoses, medical conditions, mental health issues and cognition were evaluated to determine if a resident was a supervised or unsupervised smoker. RN #494 revealed residents on oxygen could not have smoking materials. RN #494 revealed residents with hallucinations would need to be supervised especially if they are going through an adjustment period with medications. RN #494 revealed everyday something changes regarding smoking. RN #494 revealed the policy should be clearer and more direct with more training. RN #494 revealed the facility had not been proactive just reactive when something happens.
Interview on 01/28/25 at 8:19 A.M., RN #496 revealed the smoking assessment form was used to determine if a resident needed supervision while smoking. RN #496 revealed we check if the resident can hold and dispose of the cigarette. RN #496 revealed some need direct one on one assistance and some were just watched through a camera but we should be a little closer. RN #496 revealed if a resident or the resident's roommate was on oxygen then the resident should not have a lighter. RN #496 revealed if a resident had an increase in delusions or hallucinations then they should not have a lighter or smoke unsupervised. RN #496 revealed the smoking policy was confusing and does not clearly state things.
Interview on 01/28/25 at 8:33 A.M., Registered Nurse (RN) #498 revealed smoking assessments were completed upon admission, readmission, and quarterly. RN #498 revealed they would observe the resident smoke. RN #498 revealed if the resident knew where to smoke, could hold, light, and ash the cigarette and where to extinguish the cigarette and not put on the ground then the resident was an independent smoker. RN #498 revealed she was not sure if a resident experiencing increases in mental health symptoms like delusions or hallucinations should be supervised or independent or have a lighter. RN #498 revealed previously she had not allowed one resident to keep his lighter because both his roommate and next door neighbor were on oxygen. RN #498 revealed the policy had some grey areas. RN #498 revealed after the fire the residents were now monitored more closely.
Interview on 01/28/25 at 9:06 A.M., the Administrator revealed the facility was still in the process of evaluating the smoking policy and the smoking assessment forms as part of their performance improvement plan.
Interview on 01/28/25 at 9:15 A.M., Licensed Social Worker (LSW) #600 revealed on 01/14/25 Resident #84 asked for cigarettes. LSW #600 revealed the resident was not a current smoker. LSW #600 revealed the resident stated he had smoked in the past and wanted a cigarette to smoke. LSW #600 revealed the cigarettes were purchased on 01/15/25 and given to the nurses on 01/16/25. LSW #600 revealed the resident had no alarming behaviors and she had not witnessed the resident having delusions or hallucinations. LSW #600 revealed after the fire she had evaluated the resident's cognition which was low which could be due to the resident's eighth grade education. LSW #600 further revealed Resident #94 denied starting the fire.
Review of the policy Smoking, dated 02/02/24, revealed the provision of ashtrays but no direction to ensure cigarettes were extinguished in the provided ashtrays. No smoking signs would be maintained where oxygen was used. Resident who smoke would be assessed to determine if it was safe to smoke unsupervised using the assessment form. Smoking materials of supervised smoking resident would be maintained by the nursing staff. Unsupervised smokers could maintain smoking materials if stored safely and only used in designated smoking areas. All resident's on oxygen would be supervised smokers. If a resident who smokes experiences any decline in condition or cognition, they would be reassessed for ability to smoke and/or evaluate whether any additional safety measures were required. Documentation/information to support decision making of the assessment would be included in the medical record including assessment of relevant functional and cognitive factors affecting ability to smoke safely. Further review of the policy revealed no guidelines if an unsupervised smoker was allowed to maintain smoking materials if there roommate was on oxygen.
Review of the policy Oxygen Safety, revised 03/18/24, revealed No Smoking signs would be used to identify oxygen in use and would remain in place until oxygen administration had been discontinued. No smoking rules would be strictly enforced while oxygen was in use including the removal of smoking materials from resident receiving oxygen.
This deficiency represents non-compliance investigated under Complaint Number OH00161827.

Based on observations, medical record review and staff interviews, the facility failed to provide the resident with a table of appropriate height to ensure proper eating for one (#139) of 40 sampled residents. The facility census was 186.
Finding include:
Review of Resident #139's medical record identified admission to the facility occurred on 05/18/23. Diagnoses included Parkinson's disease, dementia, major depression, diabetes and prostate cancer.
Review of Resident #139's record identified on 06/01/23 his weight was 161 pounds and on 01/02/24 his weight was 141 pounds, which was a 12.4% loss.
Review of Resident #139's plan of care for nutritional concerns identified Resident #139's goal was to ensure adequate intake to prevent weight loss. The plan included interventions for dining which included to ensure the resident was in an upright posture for oral intake and alternating solids and liquids with each bite.
Observation of Resident #139 on 01/10/24 at 8:29 A.M., revealed the resident was in the dining room. The dining room was observed with tables of varying heights. Resident #139 was observed at a table that was higher than others located in the room. Resident #139 was observed with his neck area at the same height as the top of the table. Resident #139 was observed to be reaching up to attempt to eat foods in front of him.
Interview with Registered Nurse (RN) #436 on 01/10/24 at 8:29 A.M. confirmed Resident #139's chair was too low to the ground to comfortably eat. The interview confirmed Resident #139's wheelchair had a lowered seat, therefore when in front of a table he was positioned to low.
Observation of Resident #139 on 01/11/24 at 9:04 A.M. revealed the resident was in his wheelchair at the dining table. Resident #139 had to reach up to get to his food and was poorly positioned.
Interview with Therapeutic Program Worker (TPW) #710 on 01/11/24 at 9:04 A.M. confirmed Resident #139 was positioned poorly to the table in the dining room. TPW #710 confirmed since his wheelchair was so low when he was sitting up to the table he had to reach up to try and eat.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, the facility failed to ensure residents receive proper treatment and assistive devices to maintain their hearing abilities. This affected one (#79) of one resident identified with hearing issues. The facility census was 186.
Findings include:
Review of Resident #79's medical records revealed he was admitted on [DATE]. Diagnoses included dementia, psychotic disturbance, mood disturbance, and anxiety.
Review of the Minimum Data Set assessment dated [DATE] revealed Resident #79 had moderate cognitive impairment and hearing difficulties.
Observation on 01/10/24 at 9:48 A.M. revealed Therapeutic Program Worker (TPW) #460 pushing Resident #79 in a wheelchair. TPW #460 was leaning close towards his ear saying Can you hear me? Resident #79 did not respond.
During an interview with Resident #79 on 01/08/24 at 11:46 A.M., Resident #79 was observed at that time with no hearing aides and his television was very loud. Resident #79 stated he has a hard time hearing sometimes and he doesn't have any hearing aides.
Interview with Licensed Practical Nurse (LPN) #418 on 01/10/24 at 8:21 A.M. identified she has never known Resident #79 not to be able to hear that well. LPN #418 confirmed Resident #79 has had no audiology exams since his admission oo 06/06/19.

Based on review of medical records, resident and staff interviews, the facility failed to ensure residents were included in their care plan meetings. This affected two (#17 and #95) of 40 sampled residents. The facility census was 186.
Findings include:
1. Review of Resident #17's medical record identified admission to the facility occurred on 05/24/19. Diagnoses included major depression, diabetes, obesity and anxiety. The records identified Resident #17 with intact cognition.
Review of care meeting notes dated 07/27/23 at 11:54 A.M. identified no participation including Resident #17 in his care plan choices.
Review of Resident #17's most recent care meeting notes dated 11/09/23 at 12:15 P.M. identified the meeting was held on a phone conference; however, the conference did not include the resident.
Interview with Resident #17 on 01/08/24 at 11:51 A.M. revealed he has not attended any care plan meetings, but would like to.
Interview with Licensed Social Worker (LSW) #700 on 01/11/24 at 10:04 A.M. revealed residents were not being invited to their care meetings because I share an office with another LSW. LSW #700 confirmed she never thought about going to Resident #17's private room to do the meeting.
2. Review of Resident #95's medical record identified admission to the facility occurred on 01/22/19. Diagnoses included dementia, diabetes, high blood pressure and depression.
Review of the Minimum Data Set (MDS) assessment, dated 10/13/23, revealed Resident #95 had moderately impaired cognition.
Review of Resident #95's social services notes dated 10/25/23 at 11:48 A.M. identified his care conference was held. The notes identified Resident #95 was out of the building attending a facility activity at the time the meeting was held.
Review of social services notes dated 07/26/23 at 11:29 A.M. identified a care meeting was held and Resident #95 was out of the facility at a baseball game.
Interview on 01/08/24 at 10:40 A.M., Resident #95 stated he has not participated in any meetings about his care and would like to.
Interview with LSW #560 on 01/10/24 at 1:49 P.M. confirmed the facility has not been working to ensure care meetings are being held at a time convenient for residents and they were not working around planned activities. The interview confirmed Resident #95 has not been able to participate in his last two meetings because they were scheduled when he was on facility initiated activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, review of facility policy, and resident and staff interviews, the facility failed to provide adequate pain management which resulted in actual harm to Resident #111 who continued to have uncontrolled pain at a level of 8 out of 10 (with 10 being the highest level). This affected one (#111) of two residents reviewed for pain management. The facility census was 186.
Findings include:
Review of Resident #111's medical record revealed an admission date of 08/22/23. Diagnoses included chronic pain, chronic obstructive pulmonary disease (COPD), anxiety, depression, and mental and behavioral disorders.
Review of Resident #111's quarterly pain assessment, dated 11/16/23, revealed pain over the last five days making it hard to sleep at night, which is frequently limiting his day to day activities. Resident has indicated his pain was moderate and rated as an eight out of 10. The care planning interventions included for the physician to check mark which interventions to utilize in helping the resident's pain revealed no pain interventions were checked and were left blank.
Review of Resident #111's Medication Administration Record (MAR) for January 2024 revealed an order for ibuprofen 200 milligrams (mg) twice a day for pain. Nothing was ordered for pain to be given as needed (PRN).
Review of the Physician-Patient Encounter Note dated 11/29/2023 revealed the resident was assessed by Physician #553 for an evaluation. Review of the physician's encounter note revealed question number nine on this form asked for the resident's most recent pain level, pain scale and date. All those questions were left blank. The note revealed the resident complained of new onset left hand pain. He reported the pain had been going on for a couple weeks. The pain was more severe in his third digit at the metacarpophalangeal (MCP) joint. The resident also complained of bilateral knee pain. The resident was offered a topical treatment and an occupational therapy evaluation, which he refused. The note revealed to continue current treatment with no changes in medications.
Observation of Resident #111 on 01/08/24 at 11:26 A.M. revealed resident sitting in his recliner chair appearing irritated and anxious.
Interview on 01/08/24 at 11:26 A.M. with Resident #111 revealed he was angry as he has been in frequent and uncontrolled pain since he admitted and the facility staff have done nothing to address it. He further stated he has notified multiple staff, including Physician #553. Upon his admission Physician #553 decreased his ibuprofen and this dosage is ineffective in relieving his pain. Resident #111 stated he wants his ibuprofen dosage back to what he was originally taking before coming to this facility, which consisted of ibuprofen 400 mg three times a day. Resident #111 stated he was currently receiving ibuprofen 200 mg twice a day and he has been in pain since the dosage decrease. He further stated Physician #553, along with all the other facility staff, were aware of how he has been feeling regarding his pain and they are well aware of how he feels about the decrease in this pain medication. He stated he has been offered Tylenol and has told the nursing staff, along with Physician #553, that Tylenol upsets his stomach and he cannot take it.
Interview on 01/10/24 at 1:00 P.M. with Registered Nurse (RN) #436 confirmed Resident #111's quarterly pain assessment dated [DATE] was accurate. RN #436 confirmed the resident was not receiving any PRN pain medications.
Interview with Licensed Practical Nurse (LPN) #396 on 01/10/24 at 08:40 A.M. revealed the medical team has discussed with Resident #111 other options. The medical team reviewed his labs and only wanted to put him on one ibuprofen due to his labs indicating there was a decline in his kidney function. Resident #111 wants his medications given his way and not the way the physician has ordered. LPN #396 stated Resident #111 currently has an order for ibuprofen 200 mg to be given in the morning and at bedtime. LPN #396 stated this is the only pain medication Resident #111 can have at this time.
Interview on 01/10/24 at 11:11 A.M., LPN #396 stated she called Physician #553 and notified her Resident #111 wanted to be seen today regarding his pain and to increase his ibuprofen. LPN #396 stated Physician #553 said Resident #111's pain was all well documented regarding his ibuprofen order and complaints of his pain. Physician #553 stated she would try to see Resident #111 today, but if she was not able to see Resident #111 today, she would see him when she became available.
Additional review of the medical record revealed a progress note dated 01/10/2024 revealed Nurse Practitioner (NP) #551 was asked to see this resident for multiple complaints. Resident #111's first complaint was pain in his hands and knees which he rated as a six out of 10 on the pain scale, stating this pain was an ache. The resident stated that he was diagnosed with arthritis and had been taking ibuprofen 400 mg three times a day, which provided relief. Resident #111 stated he was upset that when he was admitted into this this facility, the ibuprofen was decreased to 200 mg twice a day. Further review of this note reveals he did not want any arthritis cream or muscle rub, no K-Pad, or any acetaminophen. Resident #111 was adamant he had tried all of these things in the past and they were ineffective. Resident #111 insisted the ibuprofen at 400 mg three times a day was all that would work. He had been taking it that way for over twenty years without any problems and it reduced his pain down to a two or three, which was tolerable. Resident #111 stated to NP #551 he was left-handed and opening and doing things etc., was difficult for him. NP #551 thanked the resident for his time, and stated the ibuprofen would be looked at. NP #551 documented after evaluating Resident #111's laboratory (lab) results for his basic metabolic panel from December 2023, as well as his lab results for his comprehensive metabolic panel from August 2023, his kidney function was good on those two occasions. NP #551 increased the ibuprofen to 400 mg three times a day.
Review of the January 2024 MAR revealed ibuprofen 400 mg three times a day was ordered on 01/10/24.
Review of the facility policy titled Pain Management Work Instructions,dated 05/13/08, revealed a pain assessment and treatment program is used to evaluate the resident's pain consistently and accurately. For 4-6 (moderate pain) give Tylenol 650 mg and reassess. If unrelieved in one hour but minimized, attempt diversional activities. If pain persists beyond 48 hours and/or the condition worsens, notify physician for standing orders. Further review of this policy reveals if the pain is a 7-10 (severe pain) give Tylenol 650 mg per standing order or specific ordered pain medication for severe pain. Reassess and if unrelieved notify physician.
The policy further reveals the process of treating acute or chronic unrelieved pain is to notify the physician with consideration of a referral to neurologist, pain clinic, or other. Unit Supervisor to evaluate use of PRN pain medication and refer to physician if needed when the PRN medication is used routinely. For moderate to severe pain that occurs every day, formulate a pain management program with specific interventions that address the resident's individual needs.

Based on observation, resident interview, staff interview, and policy review, the facility failed to ensure safe smoking. This affected two residents (#43 and #171) of two residents reviewed for smoking. The facility census was 186.
Findings include:
1. Review of the medical record for Resident #171 revealed an admission date of 11/03/22. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and chronic respiratory failure with hypercapnia.
Review of the Minimum Data Set (MDS) assessment, dated 11/03/23, revealed Resident #171 had cognition impairment. Review of the MDS assessment revealed Resident #171 utilized oxygen.
Review of the care plan, dated 11/16/23, revealed Resident #171 was a smoker and smoked unsupervised. Interventions included following smoking policy and procedure, smoking only in designated areas, storing cigarettes and lighter in medication room, and may keep one or two cigarettes on his person. Further review of the care plan revealed Resident #171 had a history of chronic respiratory failure with hypoxia and hypercapnia with interventions in place to apply two liters of oxygen via nasal cannula when going to bed and remove in the morning.
Review of the physician orders dated 12/30/22 revealed Resident #171 had an order in place for two liters oxygen via nasal cannula every evening and night shift when resident goes to bed and remove in the morning.
Review of the physician orders dated 07/18/23 revealed Resident #171 had an order in place to be an unsupervised smoker, have cigarettes and lighter stored in medication room, and may have one or two cigarettes at a time.
Review of the quarterly Smoking Safety Evaluation dated 10/29/23 revealed Resident #171 was a smoker and did not require supervision.
Observation and interview on 01/08/24 at 10:34 A.M. revealed Resident #171 was a smoker and went to the designated smoking area multiple times a day. Resident #171 revealed he kept his smoking paraphernalia in his pockets. Observation revealed multiple cigarettes and a lighter located in his coat pocket. An oxygen concentrator was located adjacent to the bed.
Interview on 01/08/24 at 12:14 P.M. with Licensed Practical Nurse (LPN) #424 revealed cigarettes and lighter were to be kept locked in the medication room per the smoking policy. LPN #424 revealed Resident #171 kept his lighter on him and asked for two cigarettes at a time when going to smoke. LPN #424 revealed Resident #171 had a history of being caught smoking in his room and he utilized oxygen.
Interview on 01/10/24 at 9:06 A.M. with LPN #422 revealed Resident #171 utilized oxygen only at night. He was an independent smoker but his cigarettes and lighter were locked in the medication room.
Observation on 01/10/24 at 10:04 A.M. revealed Resident #171 exited his room and exited the facility to the designated smoking area without stopping at the nursing station. Resident #171 was observed retrieving his cigarette and lighter from his coat pocket, lit the cigarette, and started smoking.
Observation and interview on 01/10/24 at 10:15 A.M. with LPN #422 revealed Resident #171 entered the facility placing cigarettes and lighter in his pocket and returned to his room. LPN #422 confirmed Resident #171 had a smoke break without retrieving any cigarettes and lighter from her or the medication room. LPN #422 also verified he kept his cigarettes and lighter on his person after entering the building.
2. Review of the medical record for Resident #43 revealed an admission date of 07/13/18. Diagnoses included chronic obstructive pulmonary disease (COPD), bilateral age-related cataracts, and nicotine dependence.
Review of the MDS quarterly assessment, dated 12/22/23, revealed Resident #43 had intact cognition.
Review of a physician's order, dated 04/21/23, identified Resident #43 as an independent, unsupervised smoker with use of a protective smoke apron.
Review of Resident #43's care plan, revised 07/08/23, revealed Resident #43 was able to smoke independently and unsupervised with the use of a smoke apron.
Review of Resident #43's Smoking Safety Evaluation, dated 12/16/23, revealed Resident #43 had no burns to his skin or clothing and did not drop ashes on himself.
Observation on 01/09/24 at 10:12 A.M. revealed Resident #43 seated in his motorized wheelchair. Cigarette ashes were noted on his lap. He had his smoking supplies, a pack of cigarettes and a lighter, in the left breast pocket of his jacket. There were multiple circular burns observed in his clothing.
Observation on 01/10/24 at 9:27 A.M. revealed Resident #43 mobilized himself in his motorized wheelchair down the elevator and out the main entrance to the designated smoking area. He did not have on a smoke apron. Resident #43 retrieved his smoking supplies out of his left breast pocket and proceeded to smoke.
Interview on 01/10/24 at 9:35 A.M. with Housekeeper #351, stationed near the main entrance, verified Resident #43 was not wearing a smoke apron. Housekeeper #351 stated he never wore a smoke apron.
Observation and interview on 01/10/24 at 9:53 A.M. with Resident #43 revealed he mobilized himself back up to the nursing unit. Resident #43 was observed with ashes on his lap and no smoke apron on. Resident #43 verified he never wore a smoke apron when he went outside to smoke. Resident #43 stated the smoke apron was overkill and he did not need it, nor did he wear it. Resident #43 stated he only dropped a few ashes here and there.
Interview on 01/10/24 at 9:57 A.M. with Therapeutic Program Worker (TPW) #461 verified Resident #43 had ashes on his lap. TPW #461 stated she believed he had a smoking apron but he did not routinely wear it.
Interview on 01/10/24 at 9:53 A.M. with LPN #407 revealed Resident #43 had a smoke apron in his room but refused to wear it. LPN #407 stated the staff occasionally reminded him to wear it. LPN #407 verified he was still able to go out to smoke independently whether he wore the smoke apron or not.
Interview on 01/11/24 at 9:19 A.M. with Registered Nurse Clinical Care Coordinator (RNCCC) #433 verified Resident #43 had holes in his clothing from cigarette burns but believed them to be old holes. RNCCC #433 stated his family recently sent him new clothing and the staff are monitoring the new clothing for new holes. RNCCC #433 verified Resident #43's care plan and physician's orders identified the need for a smoke apron while out smoking independently but he did not consistently wear it.
Review of the facility policy titled Smoking, dated 04/26/23, revealed all residents who smoke will be assessed to determine if the resident is safe to smoke unsupervised. Any resident deemed safe to smoke using the assessment form will be allowed to smoke in designated smoking areas, at designated times, and in accordance with their care plan with supervision as per facility policy. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers responsible for supervising residents while smoking. If a resident does not abide by the policy or their care plan, including refusal to wear protective gear, the resident's care plan may be revised to include additional measures such as prohibited smoking or even discharge. The interdisciplinary team, with guidance from the physician, will help to support the resident's right to make an informed decision regarding smoking by developing a safe smoking plan. Documentation to support decision making will be included in the medical record, including resident's wishes, assessment of relevant functional and cognitive factors affecting ability to smoke safely, response to smoking cessation intervention and compliance with the smoking policy.

Based on observation, staff interview and review of a 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 all residents who resided in the facility except Resident #150 who was identified by the facility to not receive meals from the kitchen. The facility census was 390.
Findings include:
Observation of food storage on 10/23/19 at 8:56 A.M., revealed a plastic scoop was stored inside of a cardboard box of a powdered thickening agent (a substance which can increase the viscosity of a liquid).
Interview on 10/23/19 at 9:21 A.M., [NAME] #165 verified a plastic scoop was stored inside the cardboard box of a powdered thickening agent.
Observation on 10/23/19 at 10:07 A.M., revealed a plastic scoop was stored inside of a plastic bin of brown sugar.
Interview on 10/23/19 at 10:08 A.M., Food Services Supervisor #550 verified a plastic scoop was stored inside the plastic bin of brown sugar.
Review of a facility policy titled, Dry Storage, most recent revision date 07/11/18, revealed container with tight fitting covers were to be used for storing sugars, cereal, grain products and broken lots of bulk food. Further review revealed scoops were not to be stored directly in the product in the storage bins.

Based on observation and staff interview, the facility failed to provide staff recipes for pureed diets. This directly affected 14 residents (#3, 21, 89, 114, 164, 200, 232, 250, 300, 364, 377, 381, 383 and 384) who the food was prepared for. The facility identified 19 residents who received a pureed diet. The facility census was 390.
Findings include:
Observation on 10/23/19 at 8:29 A.M., revealed [NAME] #165 placed eight slices of bread in a food processor with roast beef and gravy. After pureeing the mixture, [NAME] #165 divided the mixture into seven separate containers, covered the containers with plastic wrap and marked each container with a specific unit (unit A, D1 and D2, 2 North, B, C, D and 1 North) to be served to the residents on each unit who were ordered a pureed diet.
Interview on 10/23/19 at 9:21 A.M., [NAME] #165 revealed she was not sure how may slices of bread she was supposed to use per serving for each pureed open face roast beef sandwich. [NAME] #165 further revealed she did not have a recipe to follow so she put in what she felt was adequate. [NAME] #16 confirmed she pureed 21 servings of open face roast beef sandwiches for 14 residents (#3, 21, 89, 114, 164, 200, 232, 250, 300, 364, 377, 381, 383 and 384) who resided on unit A, D1 and D2, 2 North, B, C, D and 1 North. [NAME] #165 further confirmed she used a total of eight pieces of bread for the 21 servings of pureed open face roast beef sandwiches.
Interview on 10/23/19 at 9:23 A.M., Food Services Supervisor #550 confirmed each serving of open faced roast beef sandwiches should have had one slice of bread for each serving.
Interview on 10/24/19 at 2:19 P.M., Director of Food Services (DFS) #560 confirmed each serving of open faced roast beef sandwiches should have had one slice of bread for each serving. DFS #560 further confirmed the facility could not find a recipe for open faced roast beef sandwiches for pureed diets.
The facility was unable to provide a policy directly related to preparing pureed diets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure residents' dignity was respected during the dining experience. This affected one (Resident #26) of two residents reviewed for dignity. The facility census was 390.
Finding Include:
Review of Resident #26's medical record revealed an admission date of 02/03/10. Diagnoses included dementia with behavioral disturbance, major depressive disorder, Alzheimer's disease, osteoarthritis, peripheral vascular disease, hypertension, diverticulitis, anemia, heart failure and chronic kidney disease.
Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was moderately cognitively impaired. Resident #26 required supervision for bed mobility, transfer, walking and eating. Resident #26 required extensive assistance with with dressing, toilet use, and personal hygiene. Resident #26 displayed verbal behavioral symptoms directed toward others, behavioral symptoms not directed toward others and rejection of care daily during the review period.
Review of Resident #26's care plan revised 10/15/19 revealed supports and interventions for self-care deficit, toileting schedule, risk for falls, risk for skin breakdown, risk for weight loss, pain, asthma, depression, potential drug related side effects, and agitation.
Observation on 10/21/19 at 11:38 A.M. of the 300 South dining room revealed Resident #26 was seated in a wheelchair at a dining room table. Resident #26 was wearing a loosely tied hospital gown exposing most of Resident #26's back. Resident #26 also had an empty urinal hooked to the seat on the back of his wheelchair.
Interview on 10/21/19 at 11:44 A.M. with Resident #26 revealed Resident #26 required staff assistance with dressing and urinal use. Resident #26 stated he would want his gown tied better when he was in the dining room but he could not reach it himself. Resident #26 also stated he did not want his urinal hanging on the back of his wheelchair.
Interview on 10/21/19 at 11:57 A.M. with State Tested Nursing Assistant (STNA) #510 verified Resident #26 was in the dining room with his back exposed because his gown was loosely tied. STNA #510 verified the urinal was hooked to the back of the residents wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview, the facility failed to ensure residents were properly positioning with positioning devices while in wheelchairs. This affected two (Residents #239 and #354) of three residents reviewed for positioning. The facility census was 390.
Findings Include:
1. Review of Resident #239's medical record revealed an admission date of 07/08/19. Diagnoses included mood disorder, anxiety disorder, depressive disorder, dementia, history of falling, and peripheral vascular disease.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. The assessment listed the resident as requiring extensive to total assistance for locomotion on and off the unit.
Review of Resident #239's care plan dated 08/15/19 revealed the resident utilized a tilt in space wheelchair.
Observation on 10/22/19 at 2:41 P.M. of Resident #239 revealed the resident sitting up in tilt in space wheelchair with no head support on the wheelchair. There was no device for the resident to lay his head on.
Observation on 10/23/19 at 9:12 A.M. revealed the resident sitting in tilt in space wheelchair with no head support on the wheelchair.
Interview on 10/23/19 at 10:12 A.M. with Occupational Therapist (OT) #104 verified Resident #239 did not have a head rest in place on his tilt in space wheelchair. OT #104 stated when the resident was discharged from OT services the tilt in space wheelchair did have a head rest. At the time of the interview, OT #104 observed the tilt in space wheelchair and she noted the bracket for the head rest had been removed.
Observation on 10/24/19 at 9:56 A.M. revealed the resident sitting in tilt in space wheelchair with no head support on wheelchair.
2. Review of Resident #354's medical record revealed an admission date of 04/08/11. Diagnoses included schizophrenia, peripheral vascular disease, diabetes, hypertension, history of falls, dysphagia, and chronic kidney disease.
Review of the MDS assessment dated [DATE] revealed the resident had moderately impaired cognition. The assessment listed the resident as being totally dependent on staff for locomotion on the unit.
Review of Resident #354's care plan dated 05/03/19 revealed the resident utilized a tilt in space wheelchair with elevating leg rests.
Review of Resident #354's physician order dated 05/03/19 revealed an order for tilt in space wheelchair with elevated leg rests.
Observation on 10/22/19 at 9:13 A.M. of Resident #354 revealed the resident reclined in tilt in space wheelchair with no foot rests in place and legs dangling.
Observation on 10/23/19 at 10:13 A.M. of the resident revealed the resident sitting in tilt in space wheelchair with no leg rests and legs dangling. Interview at the time of the observation with OT #104 verified Resident #354 did not have leg rests in place on his tilt in space wheelchair.
Observation on 10/24/19 at 10:00 A.M. of the resident revealed the resident sitting in tilt in space wheelchair with no leg rests and legs dangling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, review of hospital documentation, review of mechanical lift manufacturer instructions, review of facility mechanical lift policy, and review of facility incident investigation documentation, the facility failed to ensure residents were provided with appropriate supervision during a transfer using a mechanical lift. This resulted in actual harm when Resident #433 sustained a 5.0 centimeter (cm) laceration to the right anterior shin which required suturing. The resident was being transferred with a mechanical lift with only one staff person. This affected one (Resident #433) of three residents reviewed for use of mechanical lift for transferring. Facility census was 390.
Findings include;
Review of the medical record revealed Resident #433 was admitted to the facility on [DATE]. Diagnoses included myasthenia gravis, type II diabetes mellitus, dementia, major depression, chronic obstructive pulmonary disease, post traumatic stress disorder, chronic kidney disease, atrial fibrillation, anxiety disorder, chronic respiratory failure, and congestive heart failure.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #433 was alert, oriented, and able to make needs known. The resident was dependent on staff for the completion of activities of daily living (ADL), and required extensive physical assistance of two staff for bed mobility, transfer, and personal hygiene. The resident utilized a wheelchair for mobility.
Review of a a physician order dated 04/27/17 revealed the resident required a non-weight bearing (Hoyer) lift to be used at all times for all transfers.
Review of a nursing plan of care dated 07/24/19 was initiated to address fall risk. Interventions included the resident was an assist up in manual wheelchair daily. Additionally, a plan of care was developed on 07/24/19 to address the residents need for assistance with ADLs. Interventions included two staff assist with ADLs. There was no documentation on the care plans that indicated the number of staff to support the resident during a mechanical Hoyer lift for transfer.
Review of an evaluation report for skin injury form, located in the medical record, revealed on 10/03/19 at 6:30 P.M. the resident was alert and oriented times two. The nurse was attempting to transfer Resident #433 with the mechanical Hoyer lift. The lift got stuck and the residents leg was stuck between the bed and the lift (Hoyer). The nurse attempted to remove the residents leg and the corner of the box on the Hoyer lift sliced the residents leg open, resulting in a laceration to the lateral right lower extremity. The lift indicated the battery was full but the lift would not go up.
Review of nursing notes dated 10/03/19 at 7:16 P.M. revealed Resident #433's right anterior shin had an open area measuring 5.0 cm in length with adipose tissue exposure. Non-weight bearing Hoyer lift malfunctioned while licensed practical nurse (LPN) #400 was assisting the resident to bed. The resident sustained a large laceration with a large amount of bleeding. Pressure was placed to the laceration for over five minutes until bleeding stopped. The resident was subsequently sent to the emergency room for treatment. Review of nursing notes dated 10/03/19 at 7:25 P.M. noted the resident was being transferred to bed by LPN #400 when his leg hit on part of the Hoyer. State Tested Nurse Aide (STNA) #300 reported the Hoyer was not working properly. The maintenance staff were informed and removed the lift from service.
Review of hospital documentation dated 10/03/19 noted the resident was treated for a laceration of the leg. The resident was placed on an antibiotic Keflex 500 milligrams (mg) every six hours for seven days and had six sutures placed to close the injury.
On 10/24/19 at 8:15 A.M. interview with STNA#302 revealed residents were transferred either using one assist or two assist depending on their functional status and ability to comply with instructions while using the lift. Some residents were transferred using one staff member.
On 10/24/19 at 9:10 A.M. interview with the Director of Nursing (DON) during a review of the facility full body mechanical lift instructions (policy) updated 04/04/19 noted in red print indicating all transfers involving the use of full body mechanical lift require two assist for transfer. The DON was unaware the mechanical lift policy required two staff to be utilized during a mechanical (Hoyer) lift transfer.
On 10/24/19 at 11:04 A.M. interview with Resident #433, in his room, revealed when he sustained the laceration to his leg only one staff member performed the mechanical lift. Since that incident single staff members have provided transfers using the Hoyer lift from bed to chair and chair to bed.
On 10/24/19 at 11:15 A.M. interview with LPN #401 and LPN #402 revealed they would use one person for transferring residents during a Hoyer lift transfer. The LPN's were unaware the facility policy indicated two staff were required. Further interview during a review of nursing and STNA care plans identified no documentation to direct staff on a specific number of staff to assist with Hoyer lift transfers.
On 10/24/19 at 11:44 A.M. interview with STNA #301 during a review of STNA care plan intervention verified no directive was listed for Resident #433 referring to the number of staff to be present during a Hoyer lift transfer.
On 10/24/19 at 1:43 P.M. interview with Assistant DON #101 verified she was unaware the Hoyer lift policy indicated two staff were to be utilized with mechanical lift transfers.
According to the skin injury status post Hoyer lift malfunction investigation undated verified LPN #400 was transferring Resident #433 using the full body mechanical lift. LPN#400 was alone when the lift malfunctioned causing Resident #433's leg to become stuck between the bed frame and the lift. When LPN#400 attempted to remove Resident #433's leg from between the bed and lift, Resident #433's leg struck the corner of the Hoyer lift box and caused a laceration to his leg. The laceration resulted in Resident #433 being transported to the hospital emergency room to have six sutures put into place to close the wound. As a result of the incident corrective action was noted to remove the broken Hoyer lift from service. No documentation included staff utilized the appropriate number of staff when transferring residents while using the full body mechanical lift or the timely reporting of malfunctioning equipment.
Review of manufacturer instructions for EZ Way Smart Lift (mechanical lift) revised 06/13/11 revealed the lift was designed to be operated safely by one caregiver. However, depending on the situation, facility policy, and the patients condition, two caregivers may be necessary.
Review of facility policy entitled Full Body Mechanical Lift Bed To Chair Transfer Work Instructions with a revised date of 04/04/19 revealed all transfers involving the use of full body mechanical lift require two assist for transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #352 was admitted to the facility on [DATE] with diagnosis including cerebral vascular disease, depression, anemia, cognitive communication deficit, chronic kidney disease, anxiety, coronary artery disease, dementia. Review of the most current MDS assessment dated [DATE] identified the resident with moderately impaired cognition, dependent on staff for the completion of ADL and rejection of care.
Review of a nursing plan of care dated 11/13/17 revealed the residents need for assistance with ADL's. Interventions included to allow the resident time to complete task as able, monitor the need for clothing or personal care items and assist with purchasing, two staff assist with all care. Additionally on 11/21/17 a plan of care was developed due to the resident's behavior of resistance to care. Interventions included explain procedures prior to beginning, use two care givers with care, when episodes of refusing care are noted approach with calm manner, explain all care, attempt to address any concerns related to care, notify social worker or Registered Nurse for follow up.
Surveyor observations on 09/10/18 at 11:10 A.M., 1:00 P.M., 2:20 P.M. and on 09/11/18 at 11:08 A.M., 1:09 P.M. and 2:55 P.M. noted the resident was in bed wearing a hospital house gown. The resident had a wardrobe closet with approximately five shirts and one pair of pants.
On 09/11/18 at 2:58 P.M., interview with State Tested Nurse Aide (STNA) #101 revealed no attempts were made to get the resident dressed due to behavioral concerns and resistance to care. STNA #101 also noted the resident lacked adequate clothing.
On 09/11/18 at 3:01 P.M., interview with Licensed Practical Nurse (LPN) #200 confirmed the resident was resistive to care and was not dressed or out of bed on 09/10/18 or 09/11/18.
Review of the medical record for 09/10/18 and 09/11/18 revealed no documentation indicating the resident was resistive to care on those dates.
Based on medial record review, observation, and review of facility policy the facility failed to ensure residents with indwelling catheters had their catheters managed in a dignified manner. This affected one Resident (#147) of four reviewed for activity of daily living (ADL) care. The facility identified 41 residents as having indwelling catheters. In addition, the facility failed to ensure dependent residents were dressed on a daily basis. This affected one Resident (#352) of four reviewed for ADL care. The facility identified 24 residents as being dependent for dressing. The facility census was 392.
Findings Include:
1. Review of Resident #147's medical record revealed an admission date of 12/04/16. Diagnoses included hyperlipidemia, chronic atrial fibrillation, hypertension, major depressive disorder, hemiplegia, dysphagia, and anxiety disorder.
Review of Resident #147's Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Resident #147 required extensive assistance with transfer, dressing, and personal hygiene. Resident #147 was totally dependent on staff for toilet use. Resident #147 had an indwelling catheter.
Review of Resident #147's care plan updated 07/10/18 revealed supports and interventions for ADL assistance, risk for falls, pain, indwelling catheter, risk for aspiration, risk for dehydration, risk for malnutrition, limited range of motion, and refusal of care.
Observation on 09/10/18 at 11:48 A.M. found Resident #147 in bed with a full, uncovered, catheter bag hanging on the side of the bed. Resident #147 emitted a strong smell of body odor and urine. At the time of the observation Resident #147 was interviewed but the resident refused to comment on his hygiene or catheter bag.
Interview on 09/10/18 at 11:49 A.M. with Licensed Practical Nurse (LPN) #410 verified Resident #147's catheter bag was full, uncovered, and visible from the hallway. LPN #410 lifted the full catheter bag and placed it in the catheter bag cover.
Review of facility policy titled, Urinary Catheterization Work Instructions, dated 05/16/11 revealed the collection bag was to be emptied on each shift and as needed. Drainage bags should be placed in cloth/vinyl bag for aseptic purposes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and facility work instructions, the facility failed to ensure indwelling urinary catheter care was provided accordingly. This affected one Resident (#17) of three reviewed for indwelling urinary catheter use. The facility identified 42 current residents with indwelling urinary catheters in a facility census of 392.
Findings include:
Resident #17 was admitted to the facility on [DATE] with diagnosis including, dementia, hypertension, benign prostatic hyperplasia, urethral stricture, urinary retention, coronary artery disease, neuromuscular dysfunction of the urinary bladder, and congestive heart failure. According to the most current minimum data set (MDS) assessment dated [DATE] the resident was identified with severe cognitive impairment, dependent on staff for the completion of activities of daily living (ADL's) and utilized an indwelling urinary catheter.
According to the medical record on 10/06/16 a physician order for the placement of an indwelling (foley) urinary catheter was initiated due to the diagnosis of neurogenic urinary bladder. Catheter care was to be performed by cleansing the urinary meatus with soap and water and monitor output every shift. On 10/27/17 a nursing plan of care was initiated to address the use of the urinary indwelling catheter. Interventions included to monitor for signs and symptoms of urinary tract infection, catheter care as ordered, irrigate catheter as ordered, empty catheter drainage bag every shift, change catheter as ordered, cleanse urinary meatus with soap and water and monitor output each shift.
On 09/07/18 the resident was noted to have a positive urine culture result indicating two organisms present in the urine. The organisms were identified as citrobacter fraundii and proteus mirabilis. The physician subsequently started the resident on antibiotic therapy for the treatment of a urinary tract infection.
Review of the medical record lacked documentation indicating catheter care was being completed each shift.
Surveyor observation on 09/12/18 at 9:20 A.M. revealed state tested nurse aide (STNA) #100 was observed at Resident #17's bedside. STNA#100 washed hands and donned non-sterile gloves. STNA#100 proceeded to expose Resident #17's perineum and obtained a disposable incontinence wipe. STNA#100 then cleansed the insertion site of the catheter, wiped the tubing and cleansed the residents scrotal area and with the same portion of incontinence wipe cleansed the insertion site and tubing. Resulting in cross contamination. Interview with STNA #100 on 09/12/18 at 9:27 A.M. verified the cross contamination during the indwelling urinary catheter care.
On 09/12/18 at 11:47 A.M. interview with Assistant Director of Nursing(ADON) #1 verified the medical record did not contain documentation regarding the provision of indwelling catheter care each shift.
Review of the facility catheter care work instructions updated on 06/01/17 noted the procedure to clean the catheter from the meatus down the catheter. Clean downward, away from the meatus with one stroke.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and review of facility policy the facility failed to ensure residents who required staff assistance with activities of daily living (ADL), received adequate care. This affected one Resident (#147) of four residents reviewed for ADLs. The facility census was 392.
Findings Include:
Review of Resident #147's medical record revealed an admission date of 12/04/16. Diagnoses included hyperlipidemia, chronic atrial fibrillation, hypertension, major depressive disorder, hemiplegia, dysphagia, and anxiety disorder.
Review of Resident #147's Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Resident #147 required extensive assistance with transfer, dressing, and personal hygiene. Resident #147 was totally dependent on staff for toilet use and required supervision, set up only, for eating. Resident #147 displayed the behavior of rejecting care one to three days out of the review period.
Review of Resident #147's care plan updated 07/18/18 revealed supports and interventions for risk for falls, pain, indwelling catheter, risk for aspiration, risk for dehydration, risk for malnutrition, limited range of motion, refusal of care, and activities of daily living assistance. Resident #147 disliked changing clothes, bathing, shaving (trimming beard) and haircuts. A specific care plan goal revealed Resident #147 would receive appropriate level of support to adequately and safely complete ADLs while maintaining maximum level of independence. Resident #147 would be clean, dressed, and well groomed each day through the review. Interventions for episodes of refusal of care were to redirect as needed, speak softly, listen to complaint, and reproach at a later time in a calm manner Inappropriate behaviors were to be monitored and document.
Review of Resident #147's ADL Exception Comments form revealed Resident #147 refused a brief change on 08/14/18 and refused breakfast on 09/12/18. No other refusals were documented.
Review of Resident #147's behavior log revealed tracking was completed for the behavior of refusing of showers. Resident #147 refused showers on 08/04/18, 09/05/18, 09/08/18 and 09/12/18. Showers were listed as being provided on 08/01/18, 08/08/18, 08/11/18, 08/15/18, 08/22/18, 08/26/18, 08/29/18 and 09/01/18. Resident #147's behavior log was silent to refusal of dressing, or other ADL care.
Observation on 09/10/18 at 11:48 A.M. revealed Resident #147 was in bed with a full, uncovered, catheter bag hanging on the side of the bed. Resident #147 emitted a strong smell of body odor and urine. At the time of the observation, Resident #147 was interviewed and refused to comment on his hygiene or catheter bag.
Interview on on 09/10/18 at 11:49 A.M. with Licensed Practical Nurse (LPN) #410 verified Resident #147 had a strong smell of urine and body odor. LPN #410 reported an oxidizer had been placed in Resident #147's room to help with the smell. LPN #410 reported Resident #147's odor had been an ongoing issue. LPN #410 also verified Resident #147's catheter bag was full and uncovered. LPN #410 lifted the full catheter bag and placed it in the catheter bag cover.
Observation on 09/11/18 at 10:31 A.M. of Resident #147 revealed a strong smell of body odor and urine noted. An oxidizer was running in Resident #147's room. Resident #147's catheter bag was covered and appeared half full of urine. Resident #147 refused to answer questions. Resident #147 was found to be wearing the same clothes as the day before.
Interview on 09/11/18 at 10:47 A.M. with LPN #420 revealed Resident #147 refused to drink anything but Dr. Pepper. Resident #147's urine was darker in color and had a stronger odor due to this. LPN #420 reported Resident #147 refused to shower and there was an odor from that as well.
Interview on 09/11/18 at 11:00 A.M. with LPN #430 revealed Resident #147 refused to have his sheets changed and would refuse to get out of bed. LPN #430 reported the only time Resident #147 would get out of bed was to shower. LPN #430 reported Resident #147 would throw food if anything was brought to him after he declined to eat and he would hit at staff if they attempted to provide care after he refused. LPN #430 reported some of Resident #147's medications were adjusted for depression and they observed improvements with his cooperation. LPN #430 verified Resident #147 was wearing the same clothes as the day before.
Interview on 09/11/18 at 4:19 P.M. with State Tested Nursing Assistant (STNA) #500 revealed Resident #147 would throw food at staff and swing at staff if they provided him food he didn't want or if they tried to provide care he didn't want. STNA #500 stated Resident #147 often refused to get dressed or cleaned up.
Interview on 09/11/18 at 4:20 P.M. with LPN #440 found no refusals of care noted for Resident #147. LPN #440 verified Resident #147 was wearing the same clothes as yesterday.
Interview on 09/11/18 at 4:25 P.M. with Resident #147 revealed he refused to eat breakfast and dinner. Resident #147 reported he ate all of his lunch and had been eating the snacks he had in his room. Resident #147 smelled unclean and was wearing the same clothes as yesterday (09/10/18). Resident #147 denied refusing to be changed or cleaned up.
Interview on 09/12/18 at 10:30 A.M. with STNA #510 revealed Resident #147 was not cooperative with care and required total care for personal hygiene. STNA #510 reported she documented Resident #147's refusals as they were trained. STNA #510 reported Resident #147 had not refused care when STNA #510 worked with Resident #147. STNA #510 reported she would give Resident #147 time and Resident #147 would cooperate if re-approached with a calm tone and demeanor.
Observation on 09/12/18 at 10:37 A.M. revealed Resident #147 watching television in his room. Resident #147's catheter bag was covered but was full and bulging. Resident #147 was dressed in a different shirt. Resident #147 still had a strong smell of body odor and urine. Resident #147 refused to be interviewed.
Review of facility policy titled, Urinary Catheterization Work Instructions, dated 05/16/11 revealed the collection bag was to be emptied on each shift and as needed. Drainage bags should be placed in cloth/vinyl bag for aseptic purposes.
Review of the facility policy titled, Dressing Resident Work Instructions, dated 05/13/17 revealed the policy was silent to the frequency residents should be dressed or have their clothing changed.