Traditions at Camargo

Based on observation, medical record review, and staff interview, the facility failed to provide the resident's timely incontinence care. This affected three (#69, #74 and #75) of three residents reviewed for incontinence care. The facility census was 95.

Findings include:

1) Review of the medical record revealed Resident #69 was admitted to the facility on 08/01/23. Diagnosis included Alzheimer's disease, diabetes mellitus type II, atrial fibrillation and multiple myeloma remission.

Review of the Change of Condition Assessment dated 03/26/25, revealed Resident #69 had severe cognitive impairment and was incontinent of bowel and bladder. The resident was dependent on staff for toileting, eating, dressing, grooming, bathing, and transfers.

2) Review of the medical record revealed Resident #74 was admitted to the facility on 01/26/24. Diagnosis included dementia, hypertension, atrial fibrillation and adult failure to thrive.

Review of the Change of Condition Assessment dated 08/11/25, revealed Resident #74 had moderate cognitive impairment and was incontinent of bowel and bladder. The resident required moderate to maximal assistance with toileting, dressing, grooming, bathing, and transfers.

3) Review of the medical record revealed Resident #75 was admitted to the facility on 06/24/20. Diagnosis included unspecified dementia, delusions, hypertension and generalized anxiety disorder.

Review of the Six-Month Assessment dated 02/13/25, revealed Resident #75 had moderate cognitive impairment and was incontinent of bowel and bladder. The resident was dependent on staff for toileting, eating, dressing, grooming, bathing, and transfers.

Continuous observations on the Memory Care Unit on 08/14/25 between 7:20 A.M. and 10:32 A.M., revealed Residents #69, #74 and #75 were seated in manual high-back wheelchairs in the common area in front of the television. All three residents were dependent on staff for mobility. The three residents were not checked on and provided incontinence care as needed. At 7:20 A.M. Resident #74 was noted to have a strong urine odor. At 8:47 A.M. Residents #69, #74 and #75 were wheeled to the dining room table by staff where breakfast was served and consumed. At 9:54 A.M. Residents #69, #74 and #75 were wheeled back to the common area, situated behind the couch, and in front of the television. At 10:32 A.M. Residents #69, #74 and #75 remained in the common area, behind the couch, and in front of the television with odors of urine.

Interview on 08/14/25 at 10:32 A.M. with Resident Assistant (RA) #590, verified Resident's #69, #74 and #75 were dependent on staff for toileting and verified she was the assigned caregiver for three residents. RA #590 stated the three residents were placed in the common area at approximately 7:10 A.M. and Residents #69, #75 and #75 were provided with incontinence care prior to being taken to the common area. RA #590 verified Residents #69, 74# and #75 had not been checked and/or provided incontinence care between 7:20 A.M. and 10:32 A.M. RA #590 verified residents are to be checked every two hours and provided incontinence care as needed.

Interviews on 08/14/25 at 5:17 P.M. with the Health and Wellness Director (HWD), verified the expectation was that residents would be checked every two hours and be provided with incontinence care. HWD stated the facility did not have a policy on incontinence care.

This violation represents non-compliance investigated under Complaint Number OH00167737.

Based on medical record review, review of hospital records, and staff interviews, the facility failed to administer medications as ordered by the physician. This affected one (#57) of three residents reviewed for medication administration. The facility census was 95. Findings include: Review of the medical record revealed Resident #57 was admitted to the facility on 08/23/21 with diagnoses of vascular dementia, hypertension, hypothyroidism, retention of urine and gastro-esophageal reflux disease. Review of the Health Assessment dated 05/09/25, revealed Resident #57 had severe cognitive deficits and was incontinent of bowel and bladder. The resident was dependent on staff for medication administration. Review of a physician order dated 05/15/25, revealed Resident #57 was ordered to receive levetiracetam (anti-seizure) 1,000 milligrams (mg) two times daily (6:00 A.M. and 6:00 P.M. This order remained active until discontinued on 06/20/25. Review of the hospital discharge instructions dated 06/18/25, revealed Resident #57 was to receive levetiracetam 750 milligrams (mg), take two tablets (1,500 mg) two times a day for 60 days. Review of a physician order dated 06/18/25 for Resident #57, revealed the resident was ordered to receive levetiracetam 750 mg two times a day for 60 days. This order was discontinued on 06/21/25 at 4:00 P.M. and a new order for levetiracetam 750 mg two tablets two times a day for 60 days was created. There was also an order on the same date, to draw a levetiracetam level next Friday (06/27/25) to ensure an adequate dosage of levetiracetam. Review of a progress note dated 06/21/25 at 1:43 P.M. for Resident #57 and authored by Licensed Practical Nurse (LPN) #405, revealed Resident #57's power of attorney (POA) questioned the resident's levetiracetam dosage and requested a medication list. The POA reported that the hospital discharge paperwork indicated the resident was to receive levetiracetam 750 mg two tablets (1,500 mg total) by mouth two times daily but the order in the electronic medical record (EMR) said the resident was ordered one 750 mg tablet by mouth two times daily. LPN #405 called the physician to change the order to reflect the correct dosage. The order was corrected in the EMR on 06/21/25 at 2:04 P.M. with an additional order to have a levetiracetam level drawn (a blood test completed through a laboratory) to determine an adequate dosage. Review of the June 2025 Medication Administration Record (MAR) for Resident #57 revealed the resident was administered the following: a) On 06/18/25, levetiracetam 1,000 at 6:00 P.M. b) On 06/19/25, levetiracetam 1,000 mg at 6:00 A.M. and 6:00 P.M. c) On 06/20/25, levetiracetam 750 mg at 6:00 A.M. 6:00 P.M.) On 06/21/25, levetiracetam 750 mg 6:00 A.M. and two tabs (1,500 at 6:00 P.M.). e) On 6/28/25, no levetiracetam was administered at 6:00 A.M. or 6:00 P.M. Review of the July 2025 MAR for Resident #57, revealed the resident's levetiracetam was omitted on the following dates/time: a) On 07/02/25 at 6:00 P.M., no levetiracetam was administered. b) On 07/05/25 at 6:00 P.M., no levetiracetam was administered. c) On 07/19/25 at 6:00 P.M., no levetiracetam was administered. ) On 07/22/25 at 6:00 P.M., no levetiracetam was administered. Review of the levetiracetam laboratory results dated 07/02/25 for Resident #57 provided by Regional Vice President (RVO) #900 on 08/13/25 at 3:42 P.M., revealed the resident had a levetiracetam level of 84.9 milligrams per liter (mg/L) which was flagged as being high. (The accepted reference range was between 12 to 46 mg/L and high levetiracetam levels can increase the risk of side effects, including psychiatric and neurological symptoms). Review of a progress note dated 07/29/25 at 12:15 P.M. and authored by LPN #405 revealed Resident #57 was observed not to be at her baseline. The resident had a blank expression on her face, was mumbling incoherent words, and not responding verbally to questions. The resident's blood pressure was 106/65 millimeters per mercury (mm/Hg), heart rate 140 (elevated) beats per minute, respirations 26 (elevated) per minute, oxygen saturation of 94 percent (%) on room air, and temperature 98.7 degrees Fahrenheit. Due to resident's history of stroke and previous similar episodes that preceded a seizure, emergency medical services (EMS) were called for transport to the hospital. Notifications were made to the physician and the resident's POA. Review of a progress note dated 07/29/25 at 5:54 P.M. authored by Licensed Practical Nurse #405 revealed Resident #57 was admitted to the hospital with a diagnosis of expressive aphasia. Review of hospital discharge summary dated 08/12/25 revealed Resident #57 was hospitalized from 07/29/25 to 08/12/25 and with a discharge diagnosis of seizure-like activity. Review of the medical record (EMR and paper chart) on 08/13/25 at 3:00 P.M. for Resident #57 revealed no documented evidence the levetiracetam level obtained on 07/02/25 was documented in the medical record and no documented evidence the results were relayed to the physician. Interview on 08/13/25 at 3:42 P.M. with RVO #900, verified the facility did not have a copy of Resident #57's levetiracetam level results from 07/02/25. RVO #900 stated she had to call the laboratory provider to obtain a copy of Resident #57's Levetiracetam level. RVO #900 stated she was unaware if Medical Director (MD) #910 was aware of the results. Interview via phone with MD #910's office on 08/14/25 at 1:22 P.M., revealed Office Manager #915 stated their office was not aware of the levetiracetam levels being completed and they didn't receive a copy of the levels until 08/14/25 at which time she provided a copy to MD #910. Interview on 08/14/25 at 2:50 P.M. with MD #910 stated she was never notified of Resident #57's levetiracetam level results completed on 07/02/25. Interview on 08/18/25 at 1:44 P.M. with the HWD, stated Resident #57 was discharged from the hospital on 06/18/25 with orders to receive 1,500 mg of levetiracetam twice daily and the nursing staff created an order for 750 mg twice daily. The HWD verified the facility did not administer Resident #57 levetiracetam per orders until it was brought to their attention by the resident's POA. The HWD also verified Resident #57 had two different active orders for levetiracetam upon returning from the hospital on 06/18/25. The HWD also verified Resident #57 was not administered levetiracetam 1,500 mg on 07/02/25, 07/05/25, 07/19/25 and 07/22/25 at 6:00 P.M. Additionally, the HWD verified the facility failed to obtain the laboratory results from 07/02/25 and failed to notify MD #910. Review of the policy titled, Medication AdministrationBased on medical record review, review of hospital records, and staff interviews, the facility failed to administer medications as ordered by the physician. This affected one (#57) of three residents reviewed for medication administration. The facility census was 95.

Findings include:

Review of the medical record revealed Resident #57 was admitted to the facility on 08/23/21 with diagnoses of vascular dementia, hypertension, hypothyroidism, retention of urine and gastro-esophageal reflux disease.

Review of the Health Assessment dated 05/09/25, revealed Resident #57 had severe cognitive deficits and was incontinent of bowel and bladder. The resident was dependent on staff for medication administration.

Review of a physician order dated 05/15/25, revealed Resident #57 was ordered to receive levetiracetam (anti-seizure) 1,000 milligrams (mg) two times daily (6:00 A.M. and 6:00 P.M. This order remained active until discontinued on 06/20/25.

Review of the hospital discharge instructions dated 06/18/25, revealed Resident #57 was to receive levetiracetam 750 milligrams (mg), take two tablets (1,500 mg) two times a day for 60 days.

Review of a physician order dated 06/18/25 for Resident #57, revealed the resident was ordered to receive levetiracetam 750 mg two times a day for 60 days. This order was discontinued on 06/21/25 at 4:00 P.M. and a new order for levetiracetam 750 mg two tablets two times a day for 60 days was created. There was also an order on the same date, to draw a levetiracetam level next Friday (06/27/25) to ensure an adequate dosage of levetiracetam.

Review of a progress note dated 06/21/25 at 1:43 P.M. for Resident #57 and authored by Licensed Practical Nurse (LPN) #405, revealed Resident #57's power of attorney (POA) questioned the resident's levetiracetam dosage and requested a medication list. The POA reported that the hospital discharge paperwork indicated the resident was to receive levetiracetam 750 mg two tablets (1,500 mg total) by mouth two times daily but the order in the electronic medical record (EMR) said the resident was ordered one 750 mg tablet by mouth two times daily. LPN #405 called the physician to change the order to reflect the correct dosage. The order was corrected in the EMR on 06/21/25 at 2:04 P.M. with an additional order to have a levetiracetam level drawn (a blood test completed through a laboratory) to determine an adequate dosage.

Review of the June 2025 Medication Administration Record (MAR) for Resident #57 revealed the resident was administered the following:

a) On 06/18/25, levetiracetam 1,000 at 6:00 P.M.

b) On 06/19/25, levetiracetam 1,000 mg at 6:00 A.M. and 6:00 P.M.

c) On 06/20/25, levetiracetam 750 mg at 6:00 A.M. 6:00 P.M.) On 06/21/25, levetiracetam 750 mg 6:00 A.M. and two tabs (1,500 at 6:00 P.M.).

e) On 6/28/25, no levetiracetam was administered at 6:00 A.M. or 6:00 P.M.

Review of the July 2025 MAR for Resident #57, revealed the resident's levetiracetam was omitted on the following dates/time:

a) On 07/02/25 at 6:00 P.M., no levetiracetam was administered.

b) On 07/05/25 at 6:00 P.M., no levetiracetam was administered.

c) On 07/19/25 at 6:00 P.M., no levetiracetam was administered. ) On 07/22/25 at 6:00 P.M., no levetiracetam was administered.

Review of the levetiracetam laboratory results dated 07/02/25 for Resident #57 provided by Regional Vice President (RVO) #900 on 08/13/25 at 3:42 P.M., revealed the resident had a levetiracetam level of 84.9 milligrams per liter (mg/L) which was flagged as being high. (The accepted reference range was between 12 to 46 mg/L and high levetiracetam levels can increase the risk of side effects, including psychiatric and neurological symptoms).

Review of a progress note dated 07/29/25 at 12:15 P.M. and authored by LPN #405 revealed Resident #57 was observed not to be at her baseline. The resident had a blank expression on her face, was mumbling incoherent words, and not responding verbally to questions. The resident's blood pressure was 106/65 millimeters per mercury (mm/Hg), heart rate 140 (elevated) beats per minute, respirations 26 (elevated) per minute, oxygen saturation of 94 percent (%) on room air, and temperature 98.7 degrees Fahrenheit. Due to resident's history of stroke and previous similar episodes that preceded a seizure, emergency medical services (EMS) were called for transport to the hospital. Notifications were made to the physician and the resident's POA.

Review of a progress note dated 07/29/25 at 5:54 P.M. authored by Licensed Practical Nurse #405 revealed Resident #57 was admitted to the hospital with a diagnosis of expressive aphasia.

Review of hospital discharge summary dated 08/12/25 revealed Resident #57 was hospitalized from 07/29/25 to 08/12/25 and with a discharge diagnosis of seizure-like activity.

Review of the medical record (EMR and paper chart) on 08/13/25 at 3:00 P.M. for Resident #57 revealed no documented evidence the levetiracetam level obtained on 07/02/25 was documented in the medical record and no documented evidence the results were relayed to the physician.

Interview on 08/13/25 at 3:42 P.M. with RVO #900, verified the facility did not have a copy of Resident #57's levetiracetam level results from 07/02/25. RVO #900 stated she had to call the laboratory provider to obtain a copy of Resident #57's Levetiracetam level. RVO #900 stated she was unaware if Medical Director (MD) #910 was aware of the results.

Interview via phone with MD #910's office on 08/14/25 at 1:22 P.M., revealed Office Manager #915 stated their office was not aware of the levetiracetam levels being completed and they didn't receive a copy of the levels until 08/14/25 at which time she provided a copy to MD #910.

Interview on 08/14/25 at 2:50 P.M. with MD #910 stated she was never notified of Resident #57's levetiracetam level results completed on 07/02/25.

Interview on 08/18/25 at 1:44 P.M. with the HWD, stated Resident #57 was discharged from the hospital on 06/18/25 with orders to receive 1,500 mg of levetiracetam twice daily and the nursing staff created an order for 750 mg twice daily. The HWD verified the facility did not administer Resident #57 levetiracetam per orders until it was brought to their attention by the resident's POA. The HWD also verified Resident #57 had two different active orders for levetiracetam upon returning from the hospital on 06/18/25. The HWD also verified Resident #57 was not administered levetiracetam 1,500 mg on 07/02/25, 07/05/25, 07/19/25 and 07/22/25 at 6:00 P.M. Additionally, the HWD verified the facility failed to obtain the laboratory results from 07/02/25 and failed to notify MD #910.

Review of the policy titled, Medication Administration

Based on record review, staff interviews, and review of online resources from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure a comprehensive Water Management Plan was implemented to minimize the risk of waterborne pathogens including Legionella. This had the potential to affect all residents living in the facility. The facility census was 95. Findings include: Review of the facility's Water Management Plan on 08/12/25 at 9:55 A.M. with Maintenance Director #200, revealed a form titled, Water Management Program for Prevention of Legionella GrowthBased on record review, staff interviews, and review of online resources from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure a comprehensive Water Management Plan was implemented to minimize the risk of waterborne pathogens including Legionella. This had the potential to affect all residents living in the facility. The facility census was 95.

Findings include:

Review of the facility's Water Management Plan on 08/12/25 at 9:55 A.M. with Maintenance Director #200, revealed a form titled, Water Management Program for Prevention of Legionella Growth

Based on record review and staff interviews, the facility failed to ensure the Heating, Ventilation and Air-Conditioning (HVAC) was inspected at least every two years by a heating contractor. This had the potential to affect all residents living in the facility. The facility census was 95.

Findings include:

During a review of the most recent HVAC inspection on 08/12/25 at 3:20 P.M., with Maintenance Director #200, revealed that the facility could not provide a current inspection. Interview with Maintenance Director #200 at the same time revealed no knowledge that the facility needed an inspection of the HVAC system every two years by a heating contractor and verified the facility had not had the HVAC system inspected.

Interview on 08/12/25 at 3:01 P.M. with the Executive Director (ED), verified the facility had not completed an inspection of the HVAC system by a heating contractor in the past two years.

Based on record reviews, observations, resident representative interview, staff interviews, and review of resident rights, the facility failed to maintain a clean, safe and healthy environment. This affected one (#71) of the three residents reviewed for a clean environment. The facility census was 95.

Findings include:

Review of the medical record revealed Resident #71 was admitted to the facility on 04/01/25 with diagnoses of Alzheimer's disease, alcohol abuse and anxiety disorder.

Review of the Thirty-Day Assessment dated 04/25/25, revealed Resident #71 had severe cognitive impairment and was incontinent of bowel and bladder. The resident required moderate assistance for dressing, grooming, toileting and bathing.

Observation during the initial tour on 08/11/25 between 4:02 P.M. and 4:52 P.M., revealed the Memory Care Unit (MCU) to have a pervasive and lingering odor of urine that emanated from Resident #71's room. The urine odor was easily detected and pervasive in the corridor outside of Resident #71's room. Upon entering the room, the urine odor was so pervasive, it caused the surveyors eyes to water. In the bathroom, soiled linen was observed stacked on the bathroom floor, along with more soiled linen in a linen hamper sitting outside of the resident's clothes closet.

Interview on 08/11/25 at 4:50 P.M. with Resident #71's representative, revealed the urine odor had been present since Resident #71 was admitted to the facility. She said the odor was so bad it was negatively impacting her mother and other residents in that area of the MCU. .

Interview on 08/11/25 at 5:30 P.M. with Licensed Practical Nurse (LPN) #405, verified the source of the pervasive and lingering urine odor present in the corridor as emanating from Resident #71's room.

Interview on 08/18/25 at 10:50 A.M. with the Executive Director (ED), verified Resident #71's room had a pervasive and lingering odor of urine.

Observation on 08/18/25 at 5:42 P.M. of the corridor outside of Resident #71's room had a pervasive and lingering odor of urine.

Interview on 08/18/25 at 5:42 P.M. with Resident Assistant (RA) #592 verified the source of the pervasive and lingering urine odor present in the corridor as emanating from Resident #71's room.

Review of Resident Rights revealed the resident had a right to a safe and clean-living environment.

This violation represents non-compliance investigated under Complaint Number OH00167326.

Based on observation, staff interview and review of Material Safety Data Sheets (MSDS), the facility failed to ensure the safe storage of hazardous materials. This had the ability to affect 14 (#48, #49, #50, #52, #53, #56, #58, #59, #62, #63, #66, #67, #71 and #72) residents who the facility identified as being independent with ambulation of the 29 residents residing in the Memory Care Unit (MCU). The facility census was 95.

Findings include:

Review of the medical record revealed Resident #48 was admitted to the facility on 06/24/24 with a diagnosis of dementia and was housed in the secured MCU.

Review of the Change in Condition Assessment dated 03/26/25 revealed Resident #48 had moderate cognitive impairment, ambulated independently with assistance or an assistive device, wandered with exit seeking behaviors.

Observation of the MCU kitchenette area on 08/14/25 at 7:38 A.M. revealed a nearly full spray bottle of Array germicidal bleach and disinfectant sitting on the kitchenette counter next to the sink with no staff members present. The kitchenette area was not secured and had a thigh-high swinging door that had no latch or locking mechanism.

Interview on 08/14/25 at 7:44 A.M. with Licensed Practical Nurse (LPN) #440 verified the bottle of Array cleaner sitting on the counter and stated it should not be unsecured on the counter. LPN #440 placed the bottle of cleaner in an unsecured cabinet below the sink. The cabinet did not have a latch or locking mechanism to secure the cabinet. LPN #440 exited the kitchenette area.

Continued observation of the MCU on 08/14/25 at 8:26 A.M. revealed Resident #48 opened the thigh-high door unassisted and proceeded to freely roam unsupervised in the MCU kitchenette area, picking up things off the counter, opening cabinets and looking in drawers. There were no staff members visible in the area. The resident remained in the kitchenette area for ten minutes without staff knowledge before the resident was redirected away by LPN #440.

Continued observation of the MCU on 08/14/25 at 9:10 A.M. revealed Resident #48 continued to wander around the MCU unit including attempting to enter the kitchenette area.

Interview on 08/14/25 at 9:10 A.M. with the Executive Director (ED), verified the spray bottle of Array cleaner was in the unsecured cabinet below the kitchenette's two-compartment sink. The ED stated the spray bottle should not be left unsecured and removed the bottle from the cabinet.

Review of the MSDS Array germicidal bleach and disinfectant provided by the facility, revealed Array germicidal bleach and disinfectant was considered hazardous by the 2012 Occupational Safety and Health Administration (OSHA) Hazard Communication Standard (29 CFR 1910.1200). The Hazard Statement said the product causes skin irritation and skin burns and serious eye damage. If ingested, immediate medical attention is required. If ingested, a possible perforation of stomach or esophagus should be investigated, asphyxia from glottal edema may occur and marked decreased in blood pressure may occur. The product is listed as a corrosive material.

Based on observation, medical record review, and staff interview, the facility failed to provide the resident's timely incontinence care and provide incontinence care appropriately, and failed to ensure resident's hair was clean. This affected one (#27) of three residents reviewed for incontinence care and two (#3 and #36) of three residents reviewed for hygiene care. The facility census was 94.

Findings included:

1. Medical record review for Resident #27 revealed an admission date of 07/19/21. Diagnoses included dementia and diabetes mellitus. Resident #27 had a poor memory

Review of the care plan dated 03/22/24 revealed Resident #27 required incontinence and toileting assistance two times daily after meals.

Continuous observations on 06/23/25 from 10:30 A.M. to 1:30 P.M. revealed Resident #27 resided on the memory care unit (MCU) and was not checked or changed during the three hours of observations.

Interview and observation with Resident Assistant (RA) #141 on 06/23/25 at 1:33 P.M. stated she got Resident #27 up for the day at 8:30 A.M. and had not changed her since then. RA #141 confirmed Resident #27 was incontinent and had an odor. RA #141 took Resident #27 and stood her up against the wall and removed her pants and her brief, which was saturated with odorous urine that was dark yellow. RA #141 proceeded to sit Resident #27 on the toilet and searched for wipes but couldn't find any, and then RA #141 got Resident #27 up and wiped her with toilet tissue.

Interview with RA #141 on 06/23/25 at 1:45 P.M. confirmed she couldn't find any wipes in the room so she didn't wash the resident even though she was saturated with an odorous urine.

2. Medical record review for Resident #3 revealed an admission date of 09/19/22. Diagnoses included Lewy Bodies disease, Parkinson with psychosis, and agitation and restlessness. Resident #3 had a poor memory and was incontinent.

Continuous observations on the memory care unit (MCU) on 06/23/25 from 10:30 A.M. to 1:30 P.M. revealed Resident #3's hair was greasy.

Interview with Resident Assistant (RA) #123 on 06/23/25 at 1:52 P.M. confirmed Resident #3's hair was greasy.

3. Medical record review for Resident #36 revealed an admission date of 08/01/23. Diagnoses included diabetes mellitus, dementia with agitation, and multiple myeloma remission. Resident #36 had a poor memory

Continuous observations on the MCU on 06/23/25 from 10:30 A.M. to 1:30 P.M. revealed Resident #36's hair was greasy.

Interview with Resident Assistant (RA) #123 on 06/23/25 at 1:52 P.M. confirmed Resident #36's hair was greasy.

This violation represents non-compliance investigated under Complaint Numbers OH00166778 and OH00164397.

Based on record review and staff interview, the facility failed to complete timely physicals for three Medication Aides (MA) #210, #237, and #247 out of three MAs reviewed. This had the potential to affect all residents at the facility. The facility census was 95.

Findings include,

1) Review of the personnel file MA #210, revealed a hire date of 08/19/24. MA #210's physical was completed on 12/13/24.

2) Review of the personnel file for MA #237, revealed a hire date of 06/05/24. MA #237's physical was completed on 12/23/24.

3) Review of the personnel file for MA #247, revealed a hire date of 08/27/24. MA #247's physical was completed on 10/31/24.

Interview with the Administrator on 01/09/25 at 1:38 P.M. verified the physicals for MAs #210, #237, and #247 were not completed at the time of their hire.

This violation was issued relative to incidental findings that were discovered during this complaint investigation completed on 04/08/25.

Based on medical record review, observations, interview with facility staff, review of fall investigations, review of hospital records, and review of facility policy on falls, the facility failed to adequately assess the root cause of falls, identify trends and patterns of falls, and failed to implement appropriate fall interventions to reduce and/or eliminate falls. This resulted in Real and Present Danger and actual serious-life threatening injuries, negative health outcomes and/or death for one resident when Resident #12 had multiple falls, including a fall on 12/04/24, was transferred to the hospital via 911, diagnosed with a subdural hematoma (collection of blood that accumulates between the brain and the innermost layer of the skull, known as the dura mater) with midline shift and subfalcine herniation (occurs when a portion of the brain tissue moves under a fold of dura mater [protective tissue] that separates the two hemispheres of the brain), neurosurgery was consulted and the resident underwent an emergent cerebral angiogram with embolization (a medical procedure that involves blocking or closing off a blood vessel) of parietal branch meningeal artery and a right sided craniotomy for subdural hematoma evacuation and was admitted to the Intensive Care Unit (ICU). Resident #12 continued to decline and passed away on 12/15/24. This affected one (#12) of five residents reviewed for falls. Additionally, the facility failed to adequately assess the root cause of falls, identify trends and patterns of falls, and failed to implement appropriate fall interventions to reduce and/or eliminate falls that placed three additional residents (#28, #50, and #63) at risk for potential physical harm out of the five residents reviewed for falls. The facility census was 95.

On 03/20/25 at 3:21 P.M., the Executive Director (ED) and Wellness Director (WD) were notified Real and Present Danger began on 12/04/24 at approximately 8:41 A.M., when Resident #12, who was cognitively impaired due to diagnosis of dementia and Parkinson's Disease, resided in the Memory Care Unit (MCU), was at risk for falls, had several prior unwitnessed falls, sustained an unwitnessed fall in her bathroom and was found with bruising to her forehead, above her left eye and hip. Resident #12 was transferred to the hospital via nine-one-one (911) where she was diagnosed with a subdural hematoma, underwent an emergent surgery to stop the bleeding in the resident's brain and was admitted to the ICU. The resident continued to decline from the injuries sustained from the fall on 12/04/24 and subsequently passed away on 12/15/24.

The Real and Present Danger was abated on 03/28/25 when the facility implemented the following corrective actions:

On 03/20/25, the ED in-serviced the WD and Unit Coordinator/Licensed Practical Nurse (LPN) #305 on fall investigation and management.

From 03/20/25 to 03/21/25, the WD and Unit Coordinator /LPN #305 educated 41 nursing staff (twelve 12 nurses, five Certified Medication Aides [CMAs], and 24 Resident Assistants [RA]) on the Community Fall Policy. The education was verified from signature logs from the education being led. The staff on vacation were called, and if unable to reach individuals, a voice mail was left. Verification of education to be done before a shift can be worked. Verification of the education will be completed by the WD and/or the Unit Coordinator/LPN #305 via signature logs. Education has been completed for all full time and part time Nurses, CMAs and RAs. The remaining as needed (PRN) staff not educated will be required to have education prior to being approved for their next shift. This will be completed and monitored by the WD and/or Unit Coordinator/LPN #305.

Starting on 03/21/25, all other departments will be educated on the Community Fall Policy and what to do if they encounter a fall. All other departments consist of the dietary department, housekeeping department, maintenance department, and administrative department. The education was completed on 03/25/25.

On 03/21/25, the Community Fall Policy was reviewed by Regional Clinical Support Specialist (RCSS) #501. There were no updates to the policy.

Starting on 03/21/25, the WD/designee to review evaluations to identify residents at risk for falls and ensure Service/Care plans are complete. Evaluations were completed on 03/28/25. There have been 32 residents identified for evaluation review. Service/Care plans were updated as needed.

Starting on 03/21/25, WD/designee to conduct thorough investigation of all falls of current residents that occurred 12/4/24 to present, to ensure proper interventions are in place and update Service/Care plan as necessary by 03/28/25. Review of investigations has determined in some cases more appropriate interventions. One hundred forty-four falls with 50 current residents to have thorough investigations. Service/Care Plans have been updated for 32 Residents (#80, #70, #71, #29, #07, #76, #72, #08, #09, #45, #60, #62, #48, #68, #97, #38, #57, #95, #32, #22, #40, #86, #43, #27, #82, #65, #36, #63, #100, #102, #37 and #92). Listed below are some of the patterns that were identified and corrected:

a. Resident #60 was identified to have 13 falls and nine of those falls were between 6:00 P.M. and 8:00 P.M. from bed. New interventions in place to assist to bed later.

b. Resident #36 had 12 falls and four of them, the resident did not have his walker. Interventions to have the walker within reach. Staff to monitor the resident for use of the walker and

reminders.

c. Resident #63 (resides in the MCU), interventions for falls were education. New interventions in place for the staff to encourage the resident to stay in common areas, increased safety checks, and the staff to monitor the resident to ensure she is using her walker.

d. Resident #32 had four falls and three were during self-transfers from the bed to the bedside commode. The resident's bed was too high for safe transfers. Physical Therapy is working with the resident and the resident's family was asked to remove the box springs from the bed for safer transfers.

e. Resident #52 (resides in the MCU), interventions for falls were education. New interventions are in place for the staff to ensure proper footwear, offer toileting before and after meals, and keep assistance devices within reach.

f. Resident #07 had nine falls. Several of the falls were due to improper use of rollator walker. Interventions for education to lock the wheelchair prior to sitting, encourage the resident to wear proper footwear and increase monitoring.

Starting on 03/21/25, to monitor ongoing compliance, WD/designee will complete fall audits five times weekly for four weeks then ongoing daily Monday through Friday during morning meetings which is an hour clinical meeting after the morning standup meeting. The morning meetings include all directors of the community. The Clinical Morning Review meeting includes the ED, WD and Unit Coordinator/LPN #305. The Afternoon Clinical Review meetings include the nurses, the CMAs, and RAs. The meetings are recorded in the ED daily notes.

Although the Real and Present Danger was abated on 03/28/25, the violation continues as the facility is still in the process of implementing their corrective action plan and monitoring for ongoing compliance.

Findings include:

1) Review of the medical record for Resident #12 revealed she was admitted to the facility on 09/27/24 and discharged to the hospital on 12/04/24. Her diagnoses included Parkinson's disease, and dementia.

Review of a progress note for Resident #12 dated 10/02/24 at 9:47 A.M., revealed the resident was found on the floor in her bathroom.

Review of the Incident Log revealed an entry dated 10/02/24 at 9:47 A.M. indicating Resident #12 had an unwitnessed fall.

Review of the facility document titled Incident Report dated 10/02/24 at 9:47 A.M., revealed Resident #12 was found on the floor and the nurse assessed the resident for injuries. The facility staff requested a family member to spend the night. The staff placed Resident #12 on the physician's list to be seen. The Incident Report did not have any documented interventions to reduce and/or eliminate falls.

Review of a progress note for Resident #12 dated 10/03/24 at 11:17 A.M., revealed the resident's family reported the resident was found on the floor in the bathroom.

Review of the Incident Log revealed an entry dated 10/03/24 at 11:17 A.M. indicating Resident #12 had an unwitnessed fall. There was no collaborating Incident Report and no documented interventions to reduce and/or eliminate falls.

Review of the Incident Log revealed an entry dated 10/06/24 at 7:45 A.M. indicating Resident #12 was found on the floor lying on her back with her legs extended out and the resident could not say what happened. Resident #12 was assessed by the nurse with no injuries noted. There was no collaborating Incident Report and there were no documented interventions to reduce and/or eliminate falls.

Review of a progress note for Resident #12 dated 10/06/24 at 8:36 A.M., revealed the resident was found on the floor by the nurse without a call light pendant and not wearing any non-skid socks. Resident #12 was assessed with no visible injuries.

Review of the Incident Log revealed an entry dated 10/14/24 at 5:23 P.M. indicating Resident #12 had an unwitnessed fall.

Review of the facility document titled, Incident Report dated 10/14/24 at 5:23 P.M., revealed Resident #12 fell outside while walking her dog. Resident #12 was assessed with no injuries. The Incident Report did not have any documented interventions to reduce and/or eliminate falls.

Review of a progress note for Resident #12 dated 10/14/24 at 5:42 P.M., revealed the resident reported she fell while walking her dog. The nurse noted Resident #12 did not wear her call light pendent.

Review of the Incident Log revealed an entry dated 10/25/24 at 5:58 P.M. indicating Resident #12 had an unwitnessed fall.

Review of the facility document titled, Incident Report dated 10/25/24 at 5:58 P.M., revealed Resident #12 reported she had facial pain. The Nurse assessed the resident to have a bruise on the left side of her face. The Incident Report did not have any documented interventions to reduce and/or eliminate falls.

Review of a progress note for Resident #12 dated 10/25/24 at 6:22 P.M., revealed the resident complained of facial pain. The nurse identified a bruise to the left side of Resident #12's face.

Review of the Resident Functional Assessment for Resident #12 dated 11/05/24, revealed the resident was cognitively intact, had difficulty remembering details, was independent with mobility, toilet use, and activities of daily living (ADLs). Resident #12 was assessed as a fall risk with confusion, disorientation, and impulsiveness.

Review of a progress note for Resident #12 dated 11/27/24 at 8:15 A.M., revealed the resident was found on the floor next to her television stand from an unwitnessed fall.

Review of the Incident Log revealed an entry dated 11/27/24 at 8:15 A.M. indicating Resident #12 had an unwitnessed fall.

Review of the facility document titled, Incident Report dated 11/27/24 at 8:15 A.M., revealed Resident #12 was found on the floor next to her television stand. The resident was assessed with an injury; however, nothing was documented in the Incident Report or in the resident's medical record. The Incident Report did not have any documented interventions to reduce and/or eliminate falls.

Review of a progress note for Resident #12 dated 11/28/24 at 8:59 A.M., revealed the resident had an unwitnessed fall and suffered a contusion (an injury that occurs when blunt force impacts the body, causing damage to underlying tissues) to the middle of the resident's head. Resident #12 was sent to the hospital.

Review of the Incident Log revealed an entry dated 11/28/24 at 8:59 A.M. indicating Resident #12 had an unwitnessed fall.

Review of the facility document titled, Incident Report dated 11/28/24 at 8:59 A.M., revealed Resident #12 had an unwitnessed fall and suffered a contusion to the middle of her head. Resident #12 was transferred to the hospital for evaluation and treatment. The Incident Report did not have any documented interventions to reduce and/or eliminate falls.

Review of a progress note for Resident #12 dated 12/01/24 at 8:20 A.M., revealed the resident was found on the floor by her bed. Resident #12's daughter was notified, and she requested the resident's medication for Parkinson's disease (Sinemet) be moved to 6:00 A.M. to help with the prevention of falls.

Review of the Incident Log revealed an entry dated 12/01/24 at 8:20 A.M. indicating Resident #12 had an unwitnessed fall.

Review of the facility document titled, Incident Report dated 12/01/24 at 8:20 A.M., revealed Resident #12 had an unwitnessed fall. The resident was found on the floor by her bed and the nightstand, and the resident was assessed to have no injuries. Resident #12 was helped back to the bed. The resident's family requested the nurse to change Resident #12's medication for Parkinson's disease to an earlier time to help in the prevention of morning falls.

Review of a progress note for Resident #12 dated 12/02/24 at 2:35 P.M., revealed the resident told the physical therapist she fell and hit her head a few days ago. Resident #12 was assessed to have a small bump on the right side of her forehead.

Review of a progress note for Resident #12 dated 12/04/24 at 8:41 A.M., revealed the resident had an unwitnessed fall and was observed lying on her back in her bathroom. Resident #12 was noted to have bruising to the right side of her forehead, eye, and hip. Resident #12's family requested for the resident to be transferred to the hospital for an evaluation.

Review of the Incident Log revealed an entry dated 12/04/24 at 8:41 A.M., noting Resident #12 had an unwitnessed fall.

Review of facility document titled, Incident Report dated 12/04/24 at 8:41 A.M., revealed Resident #12 was found on her back by the bathroom sink. Resident #12 had bruising to the left side of her forehead, left eye and hip. Resident #12 was transferred to the hospital.

Review of the hospital records for Resident #12 dated 12/04/24 revealed the resident sustained a fall with a head injury, bleeding, multiple bruises to the right shoulder, bilateral legs, right hip, right eye, right forehead and small abrasions to the left forearm. The resident has a history of Alzheimer's dementia and was found on the floor in her memory care facility after she was given her Sinemet at 6:00 A.M. When the staff returned, they found the resident with a depressed alertness. Prior to the fall, the resident was able to perform most daily activities. The resident received numerous radiological studies including a computerized tomography (CT) scan that showed a right subdural hemorrhage with midline shift and parafalcine herniation and neurosurgery was consulted. Resident #12 was taken to the operating room for embolization of parietal branch of middle meningeal artery and right sided craniotomy for evacuation of the blood. Following the surgery, Resident #12 was admitted to the intensive care unit and remained unresponsive until the resident was discharged to an inpatient Hospice on 12/09/25.

Interview with the WD on 01/09/25 at 11:20 A.M., verified Resident #12 had unwitnessed falls on 10/02/24, 10/06/24, 10/14/24, 10/25/24, 11/27/24, 11/28/24, 12/01/24 and 12/04/24. The WD stated Resident #12's first recorded fall was on 10/02/24 and it was not unusual to ask a family member to stay with a resident when they were new to the facility to help the resident adjust to the new environment. The WD verified the falls on 10/02/24, 10/06/24, 10/14/24, 10/25/24, 11/27/24, 11/28/24, 12/01/24 and 12/04/24 and verified the facility did not implement any interventions to reduce and/or eliminate falls. The WD verified Resident #12 was sent to the hospital on 10/25/24 to rule out a head injury from an unwitnessed fall. The WD stated the resident was sent to the hospital again on 11/28/24 for an unwitnessed fall which was the intervention for the fall. The WD noted the facility had no hospital records from the resident's recent hospital admission because the resident went home with the family after being discharged and when the family brought the resident back to the facility, they didn't bring the hospital discharge paperwork with them. The WD stated the facility had no current hospital records from the fall on 12/04/24.

Interview with Memory Care Director (MCD) #269 on 01/09/25 at 12:45 P.M., verified the Resident #12 had an unwitnessed fall on 12/01/24 and the facility implemented an intervention to place items in reach since Resident #12 fell by her bedside. MCD #269 stated there was no investigation for the fall and the facility thought Resident #12 might have been reaching for something on her nightstand. MCD #269 verified the facility failed to implement the appropriate fall interventions.

Interview with RCSS #501 and WD at 01/09/25 at 3:21 P.M., verified the facility did not complete an investigation or incident report for Resident #12's injury of unknown origin on 11/06/24 where the resident was sent to the hospital and required sutures. RCSS #501 stated the facility does not investigate injuries of unknown sources, complete an incident report or put an entry on the incident log. RCSS #501 stated the facility believed Resident #12 cut her arm on her dresser; however, they have no documentation or investigation to verify this. RCSS #501 and the WD stated Resident #12 had a fall on 11/27/24 and had no idea what injuries the resident sustained due to the fall not being recorded in the medical record or an incident report being created. Additionally, RCSS #501 verified the facility failed to implement fall interventions when Resident #12 fell on 11/27/24.

Subsequent interview with the WD on 3/19/25 at 2:52 P.M. revealed Resident#12 had a fall on 12/04/24 and sustained bruising and complained of pain. The WD verified Resident #12 was transferred to the hospital via 911 following the unwitnessed fall on 12/04/24. The WD stated Resident #12's daughter contacted the facility to inform them that Resident #12 had a brain bleed and required emergency surgery. The WD stated the daughter called again and noted Resident #12 was discharged from the hospital to an inpatient Hospice unit and then passed away on 12/15/25. The WD stated Resident #12's brain bleeding diagnosis was likely a result from the resident's fall on 12/04/24.

2) Review of the medical record for Resident #28 revealed the resident was admitted to the facility on 10/22/24. Diagnoses included Parkinson's Disease, and dementia. Resident #28 resided in the secured MCU.

Review of a progress note for Resident #28 dated 12/17/24 at 8:10 A.M., revealed the resident reported he fell when he reached for something in his closet. There were no documented interventions to reduce and/or eliminate falls.

Review of the facility document titled, Incident Report dated 12/17/24 at 8:10 A.M., revealed Resident #28 had an unwitnessed fall while reaching into his closet. The Incident Report did not have any documented interventions to reduce and/or eliminate falls.

Review of a progress note for Resident #28 dated 12/23/24 at 12:38 P.M., revealed the resident reported to the staff that his legs became weak, and he fell. Resident #28 was assessed with no injuries. There were no documented interventions to reduce and/or eliminate falls.

Review of facility document titled, Incident Report dated 12/23/24 at 12:38 P.M., revealed Resident #28 reported his legs felt weak and he fell. The Incident Report did not have any documented interventions to reduce and/or eliminate falls.

Review of the Incident Log revealed an entry dated 12/23/24 at 12:38 P.M. indicating Resident #28 had an unwitnessed fall.

Review of a progress note for Resident #28 dated 12/25/24, revealed the resident fell and was unable to report what happened. The resident had a skin tear to his right arm and did not want to go to the hospital. There was no documented Incident Report, and there were no documented interventions to reduce and/or eliminate falls.

Review of the facility document titled, Incident Report dated 12/30/24 at 8:15 A.M., revealed Resident #28 was found on the floor on his right side in a fetal position. The proper footwear was not found, the resident's wheelchair was not locked, and his call light pendant was not in reach. Resident #28 had a new injury on his right hand and scattered intact red areas on his right side and back. Resident #28 was reminded to keep the call light pendent in reach.

Review of the Incident Log, revealed an entry dated 12/30/24 at 8:15 A.M., indicating Resident #28 had an unwitnessed fall.

Review of a progress note for Resident #28 dated 12/30/24 at 11:02 A.M., revealed the resident was found kneeling, facing his bed and reported he fell trying to get into bed.

Review of a progress note for Resident #28 dated 12/31/24 at 6:24 A.M., revealed the resident was found kneeling by his bed and suffered a laceration above his right eyebrow and skin tear to right forearm and above the thumb. Resident #28 stated he wanted to stay in bed because he falls every time he is up. There were no documented interventions to reduce and/or eliminate falls.

Review of a progress note for Resident #28 dated 12/31/24 at 11:20 A.M., revealed the resident reported a fall and had to crawl back into bed. Resident #28 could not state the time of the fall. There were no documented interventions to reduce and/or eliminate falls.

Review of the facility document titled, Incident Report dated 12/31/24 at 12:24 P.M., revealed Resident #28 was found on the floor in the bedroom kneeling on both knees in a prayer style position by his bed. Resident #28 was noted to have bruising all over body from previous injuries. Resident #28 refused to go to the hospital for evaluation. The Incident Report did not have any documented interventions to reduce and/or eliminate falls.

Review of the Incident Log revealed an entry dated 12/31/24 at 12:34 P.M. indicating Resident #28 had an unwitnessed fall.

Review of the Incident Log revealed an entry dated 01/02/25 at 9:55 A.M., indicating Resident #28 had an unwitnessed fall. There was no collaborating Incident report and there were no documented interventions to reduce and/or eliminate falls.

Review of a progress note for Resident #28 dated 01/02/25 at 11:07 A.M., revealed the resident was found on the floor. Resident #28 stated he tried to reach his phone. The progress note did not have any documented interventions to reduce and/or eliminate falls.

Review of the Resident Functional Assessment for Resident #28 dated 01/10/25, revealed Resident #28 had impaired cognition and resided in the secured MCU. Resident #28 was dependent on staff for medication administration, required assistance from staff with incontinence care, required safety checks eight times per day and was considered a high fall risk related to vertigo and depression.

Interview with RCSS #501 on 01/13/25 at 1:00 P.M., verified Resident #28 had falls on 12/17/24, 12/23/24, 12/25/24, 12/30/24, 12/31/24 and 01/02/25. RCSS #501 verified there were no interventions implemented to reduce and/or eliminate falls for the falls on 12/17/24, 12/23/24, 12/25/24, 12/31/24 and 01/02/25.

Review of a progress note for Resident #28 dated 02/02/25 at 9:23 P.M., revealed the resident was found on the floor. The resident was on his bottom at the foot of the bed. The nurse reported she spoke to Resident #28 about the importance of asking for assistance.

Review of the Incident Log revealed an entry dated 02/02/25 indicating Resident #28 had an unwitnessed fall.

Review of the facility document titled, Incident Report dated 02/02/25, revealed Resident #28 had a fall on 02/02/25 at 9:08 P.M. and the intervention was listed to educated Resident #28 on the importance of assistance with bathroom use and transfers.

Review of facility document titled, Incident Report dated 02/03/25 at 2:09 A.M., revealed Resident #28 was found on the floor in his bathroom. The intervention was to initiate one-hour rounds and to assist Resident #28 with toilet use.

Review of a progress note for Resident #28 dated 02/03/25 at 2:24 A.M., revealed the resident was found on the bathroom floor.

Review of the Incident Log revealed an entry dated 02/03/25 indicating Resident #28 had an unwitnessed fall.

Review of the facility document titled, Incident Report dated 02/11/25 at 3:15 P.M., revealed Resident #28 was observed sitting on his buttocks next to the bed. The nurse provided education to Resident #28 to wear proper footwear or nonskid socks at all times.

Review of a progress note for Resident #28 dated 02/11/25 at 3:57 P.M., revealed the resident was found on the floor next to his bed and did not have proper footwear in place. The nurse educated Resident #28 to wear proper footwear or nonskid socks, and to have staff bring Resident #28 to the common area.

Review of the Incident Log revealed an entry dated 02/11/25 indicating Resident #28 had an unwitnessed fall.

Review of the facility document titled, Incident Report dated 02/21/25 at 11:40 P.M., revealed Resident #28 was observed on the floor with some blankets around him. The resident was educated on the importance of proper footwear and the importance of locking his wheelchair before any transfers.

Review of a progress note for Resident #28 dated 02/21/25 at 12:06 A.M., revealed Resident #28 was found on the floor on his back with some blankets around him. Resident #28 stated he tried to transfer from his wheelchair to his bed. Resident #28 did not have proper footwear, and the wheelchair was not locked. Resident #28 was educated on the importance of proper footwear.

Review of the Incident Log revealed an entry dated 02/21/25 indicating Resident #28 had an unwitnessed fall.

Review of a progress note for Resident #28 dated 02/25/25 at 12:53 P.M., revealed the resident was found on the floor by the housekeeper. Resident #28 did not have any footwear on. The nurse provided education to Resident #28 about proper footwear and to call for assistance.

Review of the Incident Log revealed an entry dated 02/25/25 indicating Resident #28 had a witnessed fall.

Review of the facility document titled, Incident Report dated 02/25/25, revealed Resident #28 was lowered to the floor by the housekeeper. The nurse educated Resident #28 on the importance of proper footwear and to call for assistance.

Review of the facility document titled, Incident Report dated 03/06/25 at 1:46 P.M., revealed a housekeeper found Resident #28 on the floor. Resident #28 had a small red mark on the left side of his back. The nurse educated Resident #28 on safety and to ask for assistance.

Review of a progress note for Resident #28 dated 03/06/25 at 2:57 P.M., revealed a housekeeper notified the nurse that Resident #28 was on the floor. Resident #28 had a small red mark on the left side of his back. The nurse educated Resident #28 on safety and to request assistance.

Review of the Incident Log revealed an entry dated 03/06/25 indicating Resident #28 had an unwitnessed fall.

Review of the facility document titled, Incident Report dated 03/13/25 at 3:18 P.M., revealed Resident #28 was found lying on his back with his feet out in front of him and his wheelchair to the side of him. He was noted to only have one shoe on. Resident #28 was educated on the importance of proper footwear and to ask for assistance.

Review of a progress note for Resident #28 dated 03/13/25 at 3:47 P.M., revealed the resident was found on his back with his feet in front of him and his wheelchair to the side of him. Resident #28 only had one shoe on. The staff educated Resident #28 to ask for assistance and to ensure Resident #28 had on proper footwear.

Review of the Incident Log revealed an entry dated 03/13/25 indicating Resident #28 had an unwitnessed fall.

Review of the facility document titled, Incident Report dated 03/14/25 at 8:08 P.M., revealed Resident #28 and a RA attempted to transfer from the wheelchair to the bed and they slipped and fell on the ground. The nurse observed the wheelchair was not locked and educated the resident on the importance of locking the wheelchair and calling for assistance.

Review of a progress note for Resident #28 dated 03/14/25 at 1:12 A.M., revealed the resident and an RA attempted to transfer from the wheelchair to the bed and they slipped and fell on the ground. The resident was unable to get body up without help and resident was unable to stand on two legs without assistance. The nurse observed the wheelchair was not locked and educated the resident on the importance of locking the wheelchair and calling for assistance. The resident got agitated and stated he called, but no one came.

Review of the Incident Log revealed an entry dated 03/14/25 indicating Resident #28 had a witnessed fall.

Interview with the WD on 03/19/25 at 2:52 P.M., verified Resident #28 had additional falls on 02/02/25, 02/03/25, 02/11/25, 02/21/25, 02/25/25, 03/06/25, 03/13/25, and 03/14/25. The WD stated on 02/02/25, the intervention was to educate Resident #28 to ask for assistance. The WD stated on 02/03/25, the intervention was to assist Resident # 28 with toilet use and for staff to complete one-hour rounds. The WD stated on 02/11/25, the intervention was to educate Resident #28 to wear proper footwear and for the staff to bring him to the common area. The WD stated on 02/21/25, the intervention was to educate Resident #28 on the use of non-skid socks. The WD stated on 02/25/25, the intervention was for the resident to ask for assistance and utilize non-skid socks. The WD stated on 03/06/25, the intervention was to educate Resident #28 to ask for assistance and proper footwear. The WD stated on 03/13/25, the intervention was for the resident to ask for assistance and wear proper footwear. The WD stated on 03/14/25, the intervention was to educate Resident #28 to lock his wheelchair. The WD noted the repetitive education to the resident was normally effective for residents with dementia. The WD verified the post-fall interventions weren't effective at reducing and/or eliminating further falls for Resident #28.

Interview with RCSS #501 on 03/19/25 at 3:15 P.M., verified the facility used the interventions to educate Resident #28 to wear proper footwear and ask for assistance. RCSS #501 felt these were effective interventions because Resident #28 was cognitively impaired, and repetitive education could be useful for a resident with dementia.

3) Review of the medical record for Resident #50 revealed the resident was admitted to the facility on 05/13/24. Diagnoses included dementia, anxiety disorder, major depressive disorder, and anemia. Resident #50 resided in the MCU.

Review of a progress note for Resident #50 dated 12/27/24 at 5:26 A.M., revealed Resident #50 was found on the floor in her bathroom and the resident was assessed with no injuries. There were no documented interventions to reduce and/or eliminate falls.

Review of the Incident Log revealed an entry dated 12/27/24 at 5:26 A.M. indicating Resident #50 had an unwitnessed fall. There was no collaborating Incident report and there were no documented interventions to reduce and/or eliminate falls.

Review of the Resident Functional Assessment, for Resident #50 dated 01/10/25, revealed the resident was severely cognitively impaired, resided in the memory care unit, was dependent on staff for medication administration, toileting, had a history of hallucinations and delusions, required assistance from staff with bathing and dressing and required safety checks two times per day. Resident #50 was a fall risk related to confusion and disorientation.

Interview with RCSS #501 on 01/13/25 at 1:00 P.M., verified the facility failed to implement any fall interventions to reduce and/or eliminate falls after Resident #50 fell on 12/27/24.

4) Review of the medical record for Resident #63 revealed she was admitted to the facility on 03/11/24. Diagnoses included Alzheimer's disease, hyperlipidemia, and osteopenia. Resident #63 was cognitively impaired and resided in the memory care unit.

Review of a progress note for Resident #63 dated 02/08/25 at 1:50 P.M., revealed the resident had an unwitnessed fall. A RA reported Resident #63 fell when she tried to get up from a chair in the living room. Resident #63 was found kneeling on the floor in front of the chair next to her walker. The immediate intervention listed was to lock the walker when not in use and ensure Resident #63 used her walker.

Review of the facility document titled, Incident Report dated 02/08/25 at 1:50 P.M., revealed the nurse was alerted by an RA that Resident #63 fell when the resident attempted to get up from a chair in the living room. The immediate intervention was to lock the walker when not in use and ensure Resident #63 used her walker when she needed to ambulate.

Review of the Incident Log revealed an entry dated 02/08/25 indicating Resident #63 had an unwitnessed fall.

Review of the facility document titled, Incident Report dated 02/20/25 at 8:31 A.M., revealed the nurse was notified by the RA that Resident #63 was in a fetal position in the common area on her right side. The nurse observed Resident #63's walker was not in reach. Resident #63 had a small hematoma on the right side of her scalp. The intervention was to educate the RA to ensure Resident #63 had her walker when the resident was up and walking around.

Review of a progress note for Resident #63 dated 02/20/25 at 8:54 A.M., revealed the resident was found in the common area on the floor in a fetal position and on her right side. The nurse observed Resident #63's walker was not in reach. Resident #63 had a hematoma (localized collection of clotted blood, that forms outside of blood vessels due to injury or damage to a blood vessel, often appearing as a painful, swollen, and bruised area) on the right side of her scalp. The nurse educated RA for the resident to utilize her walker when the resident was up and walking around.

Review of the Incident Log revealed an entry dated 02/20/25 indicating Resident #63 had an unwitnessed fall.

Review of the Resident Functional Assessment, for Resident #63 dated 02/25/25, revealed the resident was cognitively impaired, resided in the MCU, and had severe orientation deficits with a history of poor judgement. Resident #63 required the use of a walker, had a history of falls, required safety checks eight times per day and resided on the secured memory care unit. Resident #12 was assessed as a fall risk with confusion, disorientation, and impulsiveness.

Review of the facility document titled, Incident Report dated 03/02/25 at 6:50 A.M., revealed the nurse observed Resident #63 sitting on the floor in front of her chair in the common area.

Review of a progress note for Resident #63, dated 03/02/25 at 7:21 A.M., revealed the nurse observed Resident #63 sitting on the floor in front of the chair in the common area.

Review of the Incident Log revealed an entry dated 03/02/25 indicating Resident #63 had a witnessed fall.

Review of the facility document titled, Incident Report dated 03/08/25 at 6:05 A.M., revealed Resident #63 was found on the floor in her room. Resident #63 was to be centrally located in the middle of the bed.

Review of a progress note for Resident #63 dated 03/08/25 at 7:17 A.M., revealed the RA found Resident #63 on the floor in her room. The progress notes stated to do safety checks to ensure Resident #63 is centrally placed in the middle of the bed.

Review of the Incident Log revealed an entry dated 03/08/25 indicating Resident #63 had an unwitnessed fall.

Review of the facility document titled Incident Report dated 03/12/25 at 3:02 P.M., revealed Resident #63 was observed on her hands and knees on the floor. Resident #63 was observed by the RA to walk without her walker and the nurse educated Resident #63 about the importance of using her walker.

Review of a progress note for Resident #63 dated 03/12/25 at 3:17 P.M., revealed Resident #63 was observed on hands and knees on the floor. Resident #63 was noted to walk without her walker and fell. The nurse educated the resident about the importance of using her walker while she was ambulating.

Review of the facility document titled Incident Report dated 03/12/25 at 8:02 P.M., revealed Resident #63 was observed on the floor in the hallway sitting on her bottom with a chair to the right of her.

Review of a progress note for Resident #63 dated 03/12/25 at 8:06 P.M. revealed Resident #63 was found on the floor (a second fall) in the hallway, sitting on her bottom with a chair to the right of her.

Review of the facility document titled Incident Report dated 03/12/25 at 9:20 P.M., revealed Resident #63 was found on the bathroom floor.

Review of a progress note for Resident #63 dated 03/12/25 at 9:50 P.M., revealed the resident was found on the floor (a third fall) in the bathroom.

Review of the Incident Log revealed three separate entries dated 03/12/25 indicating Resident #63 had three unwitnessed falls.

Review of a progress note for Resident #63 dated 03/13/25 at 6:39 A.M., revealed the resident had a few falls earlier in the shift and neurological (neuro) checks were started at 8:00 P.M.; however, Resident #63 refused many of the neuro checks.

Interview with the WD on 03/19/25 at 4:23 P.M., verified Resident #63 had unwitnessed falls on 02/08/25, 02/20/25, 03/08/25, three falls on 03/12/25 and a witnessed fall on 03/02/25.

The intervention for the fall on 02/08/25 was to educate the resident and staff on the use of non-skid socks and to lock Resident #63's walker. The intervention for the fall on 02/20/25 was to educate the staff to ensure Resident #63 utilized her walker when ambulating. There was no documented intervention for the fall on 03/02/25. The intervention for the fall on 03/08/25 was

to ensure Resident #63's walker was in reach and to place Resident #63 in the middle of her bed. The intervention for the first fall on 03/12/25 at 3:02 P.M. was to educate the resident on the use of the walker. There were no documented interventions for the two other falls on 03/12/25 at 8:02 P.M. and 9:20 P.M. The WD verified the post-fall interventions weren't effective at reducing and/or eliminating falls for Resident #63.

Review of the facility policy titled, Fall Policy, dated 06/24/20, revealed the facility would ensure the residents' safety by identifying and preventing injuries related to a fall and if a resident had a fall, the facility would have an incident report completed to initiate the investigation process.

This violation represents non-compliance investigated under Master Complaint Number OH00163790 and Complaint Number OH00161309.

Based on record review, facility policy review, and staff interviews, the facility failed to administer medications as ordered by a physician. This resulted in a medication error for two Residents (#11 and 15) out of four residents reviewed. The facility census was 95.

Findings include:

1) Review of the medical record for Resident #11 revealed the resident was admitted to the facility on 08/31/21. Diagnoses included hypothyroidism, urine retention, and gastro-esophageal reflux disease (GERD).

Review of Resident #11's physical assessment, dated 12/24/24, revealed the resident had impaired cognition and was dependent on staff for medication administration.

Review of the December 2024 Medication Administration Report (MAR) for Resident #11, revealed the resident had the following medications documented as being administered on 12/31/24 at 10:22 P.M.: Atorvastatin 40 milligrams (mg) (high cholesterol) scheduled at 7:00 P.M.; Melatonin three mg (sleep aide) scheduled for 7:00 P.M.; and Metoprolol tartrate 25 mg (high blood pressure) scheduled for 7:00 P.M. The medications were signed as being administered by Medication Aide (MA) #210.

Review of a facility incident report titled, Medication Error, dated 01/02/25 with a completed date of 01/02/25, revealed Resident #11 did not receive her evening/P.M. medications. Notes indicated staff notified the power of attorney (POA), and the primary care physician. Resident #11 will be monitored for changes in condition. The intervention listed is to have increased monitoring.

2) Review of the medical record for Resident #15 revealed the resident was admitted to the facility on 11/01/23. Diagnoses included, dementia, metabolic encephalopathy, sepsis, Coronavirus 2019 (COVID-19), chronic obstructive pulmonary disease (COPD), asthma, heart disease, and pneumonia.

Review of Resident #15's physical assessment, dated 11/20/24, revealed the resident had impaired cognition, and the resident was dependent on staff for medication administration.

Review of an incident report dated 12/31/24 at 11:00 P.M., revealed Resident #15 did not receive her evening/P.M. medications.

Review of the December 2024 MAR for Resident #15 revealed on 12/31/24 at 10: 32 P.M., MA #210 documented she administered the resident the following Medications: acetaminophen (for pain) 500 mg two tablets scheduled at 7:00 P.M.; Memantine 10 mg scheduled for 7:00 P.M. for dementia, Dulera inhaler 200-5 micrograms (mcg) /13 Grams (gm) for COPD scheduled at 11:00 P.M.

Review of a facility incident report titled, Medication Error, dated 01/02/25 with a completed date of 01/09/25, revealed Resident #15 did not receive her evening/P.M. medications. Notes indicated staff notified the POA, and the primary care physician. Resident #15 will be monitored for changes in condition. The intervention listed is to have increased monitoring.

Interview with Resident #14's daughter on 01/08/24 at 10:30 A.M., revealed Resident #14 has a camera in her room. Resident #14's daughter stated the private duty nurse arrived early on 01/01/24 and found medication cups sitting on Resident #14's dining room table. Resident #14's daughter stated she shared the information with the Director of Nursing (DON) and the Administrator. Resident #14's daughter provided the video and pictures as verification of the two medication cups left on Resident #14's dining room table.

Interview with Medication Aide (MA) #210 01/08/25 at 6:13 P.M., revealed she worked at the facility on 12/31/24 and was tasked with administering medications to the residents. MA #210 stated she took three Medication cups into Resident #14's room and sat Residents #11, and #15's medication cups on Resident #14's dining room table. MA#210 stated she administered Resident #14's medication and walked out of the room and left Residents #11 and #15's medication cups on Resident #14's table. MA #210 verified she signed Resident #11 and 15's MAR because she attempted to administer their medications, but they were not in their rooms. MA #210 stated she forgot about sitting the medication cups for Residents #11 and #15 on Resident #14's dining table and left them as she walked out.

Observation of the camera footage from Resident #14's room on 01/09/25 at 4:20 P.M. with the Regional Clinical Specialist (RCS) #501 and Regional Operations Manager (ROM) #500, revealed on 12/31/24, at approximately 11:33 P.M., MA #210 entered the resident's room with a total of three medication cups in her hand. MA #210 was observed sitting two of the medication cups on the table in the front room. MA #210 entered Resident #14's bedroom to administer Resident #14's medications. The camera footage revealed MA #210 left the room and left the two medication cups on Resident #14's dining room table. ROM #500 verified the two medications left on the table belonged to Resident #11, and Resident #15.

Interview with the Director of Nursing (DON) on 01/09/25 at 11:20 A.M., verified on 12/31/24, during the evening medication administration pass, MA #210 walked into Resident #14's room with three medication cups. The DON verified MA #210 sat Residents #11 and #15's medication cups on Resident #14's dining room table, administered Resident #14's medication and left the room leaving the two medication cups for Residents #11 and #15 on the table. The DON stated MA #210 was issued a write up for the medication error incident. The DON verified Residents #11 and #15 did not receive their evening medications on 12/31/24.

Review of MA #210's personnel file revealed she was hired on 08/19/24. The personnel file indicated MA #210 did not receive any training for medication administration until 12/30/24. The personnel file contained a Disciplinary Action Form, and a Written Warning dated 01/02/25. The disciplinary action was marked, standard of Resident care/medication error.

Review of the facility policy titled, Medication Administration, undated, confirmed no medication shall be given to any resident unless ordered by a physician and ordered medications shall be administered. If a mediation is not administered, the staff member responsible for administering the medications shall be documented in the Resident's record why the medication was not administered.

This violation represents non-compliance investigated under Complaint Number OH00161309.

Based on record review, review of fall investigations, staff interviews, and policy review, the facility failed to conduct thorough investigations to determine a root cause analysis for residents' falls and failed to record the falls on the incident log. This affected three Residents (#12, #28, #50) out of three Residents reviewed for falls. The facility census was 95.

Findings include,

1) Review of the medical record for Resident #12 revealed she was admitted to the facility on 09/27/24 and discharged to the hospital on 12/04/24. Her diagnoses included, Parkinson's disease, and dementia.

Review of the Resident Functional Assessment, for Resident #12, dated 11/05/24, revealed the resident was cognitively intact, had difficulty remembering details, independent with mobility, toilet use, and activities of daily living. Resident #12 displayed agitation and anger at times, wandered and becomes aggressive when redirected. Resident #12 assessed as a fall risk with confusion, disorientation, and impulsiveness.

Review of a progress note for Resident #12 dated 10/02/24 at 9:47 A.M., revealed the resident was found on the floor in her bathroom.

Review of the Incident Log revealed an entry dated 10/02/24 at 9:47 A.M. indicating Resident #12 had an unwitnessed fall.

Review of facility document titled, Incident Report, dated 10/02/24 at 9:47 A.M., revealed Resident #12 was found on the floor and the nurse assessed the resident for injuries. The facility staff requested a family member spend the night. The staff placed Resident #12 on the physician's list to be seen. The Incident Report did not have any documented evidence of a thorough investigation being completed to determine a root cause analysis.

Review of a progress note for Resident #12 dated 10/03/24 at 11:17 A.M., revealed the resident's family reported the resident was found on the floor in the bathroom.

Review of the Incident Log revealed an entry dated 10/03/24 at 11:17 A.M. indicating Resident #12 had an unwitnessed fall. The was no collaborating incident report and no documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall.

Review of a progress note for Resident #12 dated 10/06/24 at 8:36 A.M., revealed the resident was found on the floor by the nurse without a call light pendant and not wearing any non-skid socks. Resident #12 was assessed with no visible injuries.

Review of the Incident Log revealed an entry dated 10/06/24 at 7:45 A.M. indicating Resident #12 was found on the floor lying on her back with her legs extended out and the resident could not say what happened. Resident #12 was assessed by the nurse with no injuries noted. The was no collaborating incident report and no documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall.

Review of a progress notes for Resident #12 dated 10/14/24 at 5:42 P.M., revealed the resident reported she fell while walking her dog. The nurse noted Resident #12 did not wear her call pendent.

Review of the Incident Log revealed an entry dated 10/14/24 at 5:23 P.M. indicating Resident #12 had an unwitnessed fall.

Review of facility document titled, Incident Report, dated 10/14/24 at 5:23 P.M., revealed Resident #12 fell outside while walking her dog. Resident #12 was assessed with no injuries. The Incident Report did not have any documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall.

Review of a progress note for Resident #12 dated 10/25/24 at 6:22 P.M., revealed the resident complained of facial pain. The nurse identified a bruise to the left side of Resident #12's face.

Review of the Incident Log revealed an entry dated 10/25/24 at 5:58 P.M. indicating Resident #12 had an unwitnessed fall.

Review of facility document titled, Incident Report, dated 10/25/24 at 5:58 P.M., revealed Resident #12 reported she had facial pain. The Nurse assessed the resident to have a bruise on the left side of her face. The Incident Report did not have any documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall.

Review of a progress note for Resident #12 dated 11/06/24 at 8:16 A.M., revealed the resident was found with an injury of unknown origin and required sutures in her arm. Resident #12 was transferred to the hospital.

Review of the Incident Log revealed an entry on 11/06/24 indicating Resident #12 had an injury of unknown origin and required sutures. There was no collaborating Incident Report for the resident receiving sutures and there was no documented evidence of a thorough investigation being completed to determine the resident's injury of unknown origin.

Review of a progress note for Resident #12 dated 11/27/24 at 8:15 A.M., revealed the resident was found on the floor next to her television stand from an unwitnessed fall.

Review of the Incident Log revealed an entry dated 11/27/24 indicating Resident #12 had a fall at 8:14 A.M.

Review of facility document titled, Incident Report, dated 11/27/24 at 8:15 A.M., revealed Resident #12 was found on the floor next to her television stand. The resident was assessed with an injury; however, nothing was documented in the Incident Report or in the resident's medical record regarding the injury. The Incident Report did not have any documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall.

Review of a progress note for Resident #12 dated 11/28/24 at 8:59 A.M., revealed the resident had an unwitnessed fall and suffered a contusion (an injury that occurs when blunt force impacts the body, causing damage to underlying tissues) to the middle of the resident's head. Resident #12 was sent to the hospital.

Review of the Incident Log revealed an entry dated 11/28/24 at 8:51 A.M. indicating Resident #12 had an unwitnessed fall.

Review of facility document titled, Incident Report, dated 11/28/24 at 8:51 A.M., revealed Resident #12 had a fall and suffered a contusion to the middle of her head. Resident #12 was transferred to the hospital for evaluation and treatment. The Incident Report did not have any documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall.

Review of a progress note for Resident #12 dated 12/01/24 at 8:20 A.M., revealed the resident was found on the floor by her bed. Resident #12's daughter was notified, and she requested the resident's medication for Parkinson's disease be moved to 6:00 A.M. to help with the prevention of a falls.

Review of the Incident Log revealed an entry dated 12/01/24 at 8:20 A.M. indicating Resident #12 had an unwitnessed fall.

Review of facility document titled, Incident Report, dated 12/01/24 at 8:20 A.M., revealed Resident #12 had an unwitnessed fall. The resident was found on the floor by her bed and the nightstand, and the resident was assessed to have no injuries. Resident #12 was helped back to the bed. The resident's family requested the nurse to change Resident #12's medication for Parkinson's disease to an earlier time to help in the prevention of morning falls. The Incident Report did not have any documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall.

Review of a progress note for Resident #12 dated 12/02/24 at 2:35 P.M., revealed the resident told the physical therapist she fell and hit her head a few days prior. Resident #12 was assessed to have a small bump on the right side of her forehead.

Review of a progress note for Resident #12 dated 12/04/24 at 8:41 A.M., revealed the resident had an unwitnessed fall and was observed lying on her back in her bathroom. Resident #12 was noted to have bruising to the right side of her forehead, eye, and hip. Resident # 12's family requested for Resident #12 to be transferred to the hospital for an evaluation.

Review of the Incident Log revealed an entry dated 12/04/24 at 8:41 A.M. revealed Resident #12 had an unwitnessed fall.

Review of facility document titled, Incident Report, dated 12/04/24 at 8:41 A.M., revealed Resident #12 was found on her back by the bathroom sink. Resident #12 had bruising to the left of her forehead, eye and hip. Resident #12 was discharged to the hospital. The Incident Report did not have any documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall.

Interview with the Director of Nursing (DON) on 01/09/25 at 11:20 A.M. verified Resident #12 had unwitnessed falls on 10/02/24, 10/06/24, 10/14/24, 10/25/24, 11/27/24, 11/28/24, 12/01/24 and 12/04/24. The DON stated the Resident #12's first recorded fall was on 10/02/24 and it was not unusual to ask a family member to stay with a resident when they were new to the facility to help the resident adjust to the new environment. The DON verified the falls on 10/02/24, 10/06/24, 10/14/24, 10/25/24, 11/27/24, 11/28/24, 12/01/24 and 12/04/24 were not thoroughly investigated to determine a root cause analysis for the falls. The DON verified Resident #12 was sent to the hospital on 10/25/24 to rule out a head injury from an unwitnessed fall. The DON noted the facility had no hospital records from the resident's recent hospital admission because the resident went home with the family after being discharged and when the family brought the resident back to the facility, they didn't bring the hospital discharge paperwork with them. The DON verified the resident had an injury of unknown origin on 11/06/24 and the facility did not thoroughly investigate the incident.

Interview with Memory Care Director (MCD) #269 on 01/09/25 at 12:45 P.M. verified the Resident #12 had an unwitnessed fall on 12/01/24 and there was no thorough investigation for the fall. MCD #269 thought Resident #12 might have been reaching for something on her nightstand.

Interview with the Regional Clinical Specialist (RCS) #501 and DON at 01/09/25 at 3:21 P.M. verified the facility did not complete an investigation or incident report for Resident #12's injury of unknown origin on 11/06/24 where the resident was sent to the hospital and required sutures. RCS #501 stated the facility does not investigate injuries of unknown sources, complete an incident report or put an entry on the incident log. RCS #501 stated the facility believed Resident #12 cut her arm on her dresser; however, they have no documentation or investigation to verify this. RCS #501 and the DON stated Resident #12 had a fall on 11/27/24 and had no idea what injuries the resident sustained due to the fall not being recorded in the medical record or the injury being recorded on the incident report. Additionally, RCS #501 verified the facility failed to complete a thorough investigation to determine a root cause analysis for the resident's fall on 11/27/24.

2) Review of the medical record for Resident #28 revealed the resident was admitted to the facility on 10/22/24. Diagnoses included Parkinson's Disease, and dementia.

Review of a progress note for Resident #28 dated 12/17/24 at 8:10 A.M., revealed the resident reported he fell when he reached for something in his closet.

Review of facility document titled, Incident Report, dated 12/17/24 at 8:10 A.M., revealed Resident #28 had an unwitnessed fall while reaching into his closet. The Incident Report did not have any documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall and the fall was not recorded on their incident log.

Review of a progress note for Resident #28 dated 12/23/24 at 12:38 P.M., revealed Resident #28 reported to the staff that his legs became weak, and he fell. Resident #28 was assessed with no injuries.

Review of facility document titled, Incident Report, dated 12/23/24 at 12:38 P.M., revealed Resident #28 reported his legs felt weak and he fell. The Incident Report did not have any documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall.

Review of the Incident Log, revealed an entry dated 12/23/24 at 12:38 P.M., revealed Resident #28 had an unwitnessed fall.

Review of a progress note for Resident #28 dated 12/25/24, revealed the resident fell and was unable to report what happened. The resident had a skin tear to his right arm and did not want to go to the hospital. There was no documented Incident Report, no documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall and the fall was not recorded on their incident log.

Review of a progress note for Resident #28 dated 12/30/24 at 11:02 A.M., revealed the resident was found kneeling, facing his bed and reported he fell trying to get into bed.

Review of facility document titled, Incident Report, dated 12/30/24 at 8:15 A.M., revealed Resident #28 was found on the floor on his right side in a fetal position. The proper footwear was not found, the resident's wheelchair was not locked, and his call light pendant was not in reach. Resident #28 had a new injury on his right hand and scattered intact red areas on his right side and back. Resident #28 was reminded to keep the call light pendent in reach. The Incident Report did not have any documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall.

Review of the Incident Log, revealed an entry dated 12/30/24 at 8:15 A.M., indicating Resident #28 had an unwitnessed fall.

Review of a progress note for Resident #28 dated 12/31/24 at 6:24 A.M., revealed the resident was found kneeling by his bed on 12/30/24 at 10:45 P.M. and suffered a laceration above his right eyebrow and skin tear to right forearm and above the thumb. Resident #28 stated he wanted to stay in bed because he falls every time he is up.

Review of an additional progress note for Resident #28 dated 12/31/24 at 11:20 A.M., revealed the resident reported a fall and had to crawl back into bed. Resident #28 could not state the time of the fall.

Review of facility document titled, Incident Report, dated 12/31/24 at 12:24 P.M., revealed Resident #28 was found on the floor in the bedroom kneeling on both knees in a prayer style position by his bed. Resident #28 was noted to have bruising all over body from previous injuries. Resident #28 refused to go to the hospital for evaluation. The Incident Report did not have any documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall.

Review of the Incident Log revealed an entry dated 12/31/24 at 12:34 P.M., indicating Resident #28 had an unwitnessed fall

Review of a progress note for Resident #28 dated 01/02/25 at 11:07 A.M., revealed the resident was found on the floor. Resident #28 stated he tried to reach his phone.

Review of the Incident Log revealed an entry dated 01/02/25 at 9:55 A.M., indicating Resident #28 had an unwitnessed fall. There was no collaborating Incident report and there was no documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall.

Review of the functional assessment dated 01/10/25, revealed Resident #28 had impaired cognition. Resident #28 was dependent on staff for medication administration, required assistance from staff with incontinence care, required safety checks eight times per day and was considered a high fall risk related to vertigo and depression.

Interview with Regional Clinical Specialist (RCS) #501 on 01/13/25 at 1:00 P.M. verified Resident #28 had falls on 12/17/24, 12/23/24, 12/25/24, 12/30/24, 12/31/24 and 01/02/25. RCS #501 verified there was documented evidence of a thorough investigations being completed to determine a root cause analysis for the resident's falls. RCS #501 verified the falls on 12/17/24 and 12/25/24 were not recorded on the incident log.

3) Review of the medical record for Resident #50 revealed the resident was admitted to the facility on 05/13/24. Diagnoses included dementia, anxiety disorder, major depressive disorder, and anemia.

Review of a progress note for Resident #50 dated 12/27/24 at 5:26 A.M., revealed Resident #50 was found on the floor in her bathroom. The resident was assessed with no injuries.

Review of the Incident Log revealed an entry dated 12/27/24 at 5:26 A.M. indicating Resident #50 had an unwitnessed fall. There was no collaborating Incident report and there was no documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall.

Review of Resident #50's Functional Assessment dated 01/10/25, revealed the resident was severely cognitively impaired, was dependent on staff for medication administration, toileting, had a history of hallucinations and delusions, required assistance from staff with bathing and dressing and required safety checks two times per day. Resident #50 was a fall risk related to confusion and disorientation.

Interview with RCS#501 on 01/13/25 at 1:00 P.M., verified there was no documented evidence of a thorough investigation being completed to determine a root cause analysis for the resident's fall on 12/27/24.

Review of the facility policy titled, Fall Policy, dated 06/24/20, revealed the facility would ensure the residents' safety by identifying and preventing injuries related to a fall and if a resident had a fall, the facility would have an incident report completed to initiate the investigation process.

This violation represents non-compliance investigated under Master Complaint Number OH00163790 and Complaint Number OH00161309.

Based on observation, record review, and interview the facility failed to maintain a clean, sanitary and effective pest control program for the kitchen and dining areas of the Memory Care Unit (MCU). This affected all 29 Residents (#1, #2, #3, #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and #31) who resided on the MCU. The facility census was 97.

Findings include:

Observations of the MCU dining area on 10/28/24 at 11:03 A.M. with Resident Assistant (RA) #206 revealed breakfast was completed in the MCU; however, the dining room floor was sticky, contained food crumbs, dirt and debris scattered throughout. There were black flies and gnats flying around the half door leading from the dining room into the MCU kitchen. The kitchen floor was soiled and dirty and the kitchen sink had food particles throughout. RA #206 verified the findings in the MCU kitchen and dining room.

Interview with Housekeeper (HK) #216 on 10/28/24 at 11:11 A.M. revealed the facility is short staffed with housekeepers. HK #216 stated he was told to sweep the dining room on the MCU after lunch. HK #216 stated he is not sure who sweeps the kitchen and dining areas after breakfast, dinner, and on the weekends because no one is scheduled to complete the tasks from housekeeping. HK #16 confirmed the food crumbs, dirt, and debris scattered throughout the floor.

Interview with the Maintenance Supervisor (MS) #215 on 10/28/24 at 12:30 P. M. revealed the facility does not treat the active flies or gnats in the MCU and has never had a pest control company to provide any treatment to aid in the elimination of the gnats and black flies in the MCU's dining and kitchen areas. MS #215 stated he poured bleach water down the kitchen sink to try and eliminate the black flies and gnats in the MCU dining and kitchen area.

Interview with the Administrator on 10/28/24 at 4:26 P.M. verified the MCU dining room floor was sticky and soiled. The Administrator stated a staff member utilized the wrong cleaner and ruined the surface of the floor. The Administrator stated the facility did not have a pest control policy.

This violation represents non-compliance investigated under Complaint Number OH00158811.

Based on observation, record review, and staff interview, the facility failed to maintain a clean and healthy environment. This affected three (#08, #09, and #10) residents of the three residents reviewed. The facility census was 97.

Findings include:

1) Review of medical record for Resident #10 revealed she was admitted to the facility on 03/11/22. Diagnoses included Parkinson's disease, hypothyroidism, hyperlipidemia, and osteoarthritis.

Review of Resident #10's functional assessment, dated 07/11/24, revealed the resident was cognitively impaired and dependent on staff for housekeeping.

Observation of Resident #10's room located on the Memory Care Unit (MCU) on 10/28/24 at 10:57 A.M. with Resident Assistant (RA) #206, revealed the resident's bathroom sink had multiple unknown brown scattered debris and stains, the toilet was splattered with unknown substance, the shower was soiled and stained, the bathroom walls had an unknown substance splattered on them, the floor in the living room was soiled with dirt and debris, RA #206 verified the conditions of Resident #10's living area.

2) Review of the medical record for Resident #02 revealed she was admitted to the facility on 01/25/22. Diagnoses included dementia, hyperlipidemia, and endometriosis.

Review of Resident #09's functional assessment, dated 07/11/24, revealed the resident was cognitively impaired and was dependent on staff for housework and laundry.

Observation of Resident #02 room located on the MCU on 10/28/24 at 11:03 with RA #206, revealed the bathroom floor was soiled with dirt and debris; the toilet was stained with a brown substance and the shower was soiled and dirty. RA #206 verified the conditions of the resident's room.

3) Review of the medical record for Resident #08 revealed she was admitted to the facility on 06/21/24. Diagnoses included dementia, hypertension, and stroke.

Review of Resident #08's functional assessment, dated 07/30/24, revealed the resident was cognitively impaired and was dependent on staff for housekeeping, and laundry.

Observation of Resident #08's room located on the MCU on 10/28/24 at 11:05 A.M. with RA #206, revealed the resident's floor in the bedroom and bathroom was soiled with debris, the shower was soiled, and the toilet seat was soiled with a brown substance.

Interview on 10/28/24 at 4:54 P.M. with the Administrator, revealed the facility did not have a policy related to the Resident's physical environment.

This violation represents non-compliance investigated under Complaint Number OH00158811.

Based on observation, record review, staff interview, and review of Material Data Safety Sheets (MSDS), the facility failed to store hazardous chemicals in a safe and secure manor on the Memory Care Unit (MCU). This had the potential to affect all 29 Residents (#1, #2, #3, #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and #31) who resided on the MCU.. The facility census was 97.

Findings include:

Observation of the MCU dining and kitchen on 10/28/24 at 11:03 A.M. with Resident Assistant (RA) #206 revealed a large open dining and kitchen area. An unlocked cabinet under the kitchen sink contained a spray can of Raid -Ant and Roach Killer, a spray can of Raid - Flying Insect Killer, two bottles of Purell surface cleaner and an unknown green liquid substance in an unmarked spray bottle. RA #206 verified the chemicals being stored in the unlocked cabinet within the MCU and stated she didn't know what was in the unmarked bottle. RA #206 stated the cabinet should be locked at all times.

Interview on 10/28/24 at 4:54 P.M. with the Administrator revealed the facility did not have a policy related to stored hazardous chemicals on the secured memory care unit.

Review of the MSDS sheet for Purell Surface Disinfectant, dated 08/29/17, revealed the product was highly flammable and dangerous if swallowed. Avoid contact with the skin and seek medical aid immediately if swallowed.

Review of the MSDS sheet for Raid - Flying Insect Killer, dated 02/24/15, revealed the product was considered highly flammable and dangerous if consumed. Swallowing Raid can cause severe symptoms, including nausea, headache, sore throat, inflammation, redness of the hands and feet, auditory hallucinations, convulsions, coma, and death.

Review of the MSDS for Raid- Ant and Roach Killer, dated 07/31/24, revealed the product was considered extremely flammable and dangerous if consumed. Swallowing Raid can cause severe symptoms, including nausea, headache, sore throat, inflammation, redness of the hands and feet, auditory hallucinations, convulsions, coma, and death

This violation represents non-compliance investigated under Complaint Number OH00158811.

Based on record review, staff interview, and policy review, the facility failed to ensure Resident Assistants (RA) had competency check-offs completed by a licensed nurse prior to working with residents independently. This affected three (RA #300, RA #315, and RA #325) of three RA employee files reviewed for training. This had the potential to affect all 116 residents in the facility. The facility census was 116.

Findings include:

1) Review of the employee file of RA #300 revealed a hire date of 05/07/24. Review of the employee file revealed RA #300 was an unlicensed caregiver and there was no documented evidence of a skills check-off completed by a licensed nurse.

Interview on 07/02/24 at 1:03 P.M., Interim Director of Nursing (IDON) #305 verified there was no skills check-off for RA #300. IDON #305 stated, following an incident involving a resident who fell, RA #300 stated she did not have enough training. IDON #305 stated she reviewed RA #300's employee file and discovered there had not been a skills check-off completed prior to RA #300 working independently.

2) Review of the employee file of RA #315 revealed a hire date of 05/21/24 and was an unlicensed caregiver. A skills check-off was completed on 07/02/24 by RA #330 and not by a licensed nurse.

Interview on 07/03/24 at 10:15 A.M., RA #315 revealed she was hired on 05/21/24 and reported she completed her competencies on 07/02/24 and the competency check-off was completed by RA #330.

3) Review of the employee file for RA #325 revealed a hire date of 06/18/24 and was an unlicensed caregiver. A skills check-off was completed on 06/18/24 by RA #330 and not by a licensed nurse.

Interview on 07/02/24 at 1:20 P.M., IDON #305 stated RA competency checkoffs were completed by the lead Aide (RA #330) and Memory Care Director (MCD) #335 reviewed handwashing and peri care with the new RAs.

Interview on 07/02/24 at 3:03 P.M., IDON #305 stated the competencies for RAs #315 and #325 were completed by the lead Aide (RA #330). IDON #305 affirmed RA #330 was not a licensed nurse.

Interview on 07/03/24 at 10:43 A.M., MCD #335 stated, when an RA completes their training with the lead aide, she asks the RA if they are comfortable performing all tasks. MCD #335 stated she would provide more education if the RA indicated they were uncomfortable performing any task. MDS #335 stated she would not watch the RA complete the check-off tasks unless they report they do not feel comfortable in an area.

This violation represents non-compliance investigated under Complaint Number OH00154866.

390 Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident who experienced a fall received appropriate treatment and was assessed by a licensed nurse. This affected one (#74) of three residents reviewed for falls. The facility census was 116. Findings include: Review of the medical record for Resident #74 revealed an admission date of 09/14/23. Diagnoses included Alzheimer's disease, mood disorder, depression, back pain, arthritis, myelodysplastic disorder, and chronic constipation. Review of the Nursing Evaluation, dated 09/19/23, revealed Resident #74 had difficulty recalling details. The resident was assessed as having good long-term memory and fair short-term memory. The resident had a history of falls and was assessed as a high risk for falls. Review of the Service Plan, dated 03/28/24, revealed Resident #74 required the assistance of two staff for transfers. Review of the Fall Incident Report, dated 06/12/24 at 10:25 A.M. for Resident #74, revealed Resident Assistant (RA) #300 found the resident on the floor. RA #300 attempted to transfer the resident from the floor and into a wheelchair. After multiple attempts, RA #300 was finally able to get the resident transferred to the wheelchair. RA #300 then got a sit-to-stand mechanical lift, lifted the resident in the air and then changed the resident's incontinent brief. RA #300 then transferred the resident to the bed. The facility met with the resident's family and reviewed the camera footage and discussed the plan of care. RA #300 was contacted and was suspended, pending an investigation. Head-to-toe assessments were completed on Resident #74 and other like residents on RA #300's assignment with no injuries or skin alterations noted. During the investigation, RA #300 stated she needed more training. Additional training was offered to RA #300, however, RA #300 resigned. Interview on 07/02/24 at 9:03 A.M., Executive Director (ED) #320 and Interim Director of Nursing (IDON) #305 stated Resident #74's family alerted the facility of a concern involving Resident #74 and provided the video footage of the incident. IDON #305 and ED #320 stated they watched the video footage and observed a nightshift aide (RA #300) who found Resident #74 on the floor and tried picking Resident #74 up by herself and clearly struggled. IDON #305 stated RA #300 was eventually able to get Resident #74 into the wheelchair, lifted in a sit-to-stand to change him, and then put him in the bed. IDON #305 stated an hour lapsed from the time the resident was found on the floor to the time he was put into bed. IDON stated RA #300 did not notify the nurse of the fall nor did she summon any help to assist with lifting Resident #74 off the floor. Interview on 07/02/24 at 1:13 P.M., IDON #305 verified Resident #74 required the assistance of two staff for all transfers and did not require the use of any type of mechanical lift. IDON #305 stated RA #300 took a mechanical lift from another resident's room and used it on Resident #74. Review of the facility policy titled, Fall Management390

Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident who experienced a fall received appropriate treatment and was assessed by a licensed nurse. This affected one (#74) of three residents reviewed for falls. The facility census was 116.

Findings include:

Review of the medical record for Resident #74 revealed an admission date of 09/14/23. Diagnoses included Alzheimer's disease, mood disorder, depression, back pain, arthritis, myelodysplastic disorder, and chronic constipation.

Review of the Nursing Evaluation, dated 09/19/23, revealed Resident #74 had difficulty recalling details. The resident was assessed as having good long-term memory and fair short-term memory. The resident had a history of falls and was assessed as a high risk for falls.

Review of the Service Plan, dated 03/28/24, revealed Resident #74 required the assistance of two staff for transfers.

Review of the Fall Incident Report, dated 06/12/24 at 10:25 A.M. for Resident #74, revealed Resident Assistant (RA) #300 found the resident on the floor. RA #300 attempted to transfer the resident from the floor and into a wheelchair. After multiple attempts, RA #300 was finally able to get the resident transferred to the wheelchair. RA #300 then got a sit-to-stand mechanical lift, lifted the resident in the air and then changed the resident's incontinent brief. RA #300 then transferred the resident to the bed. The facility met with the resident's family and reviewed the camera footage and discussed the plan of care. RA #300 was contacted and was suspended, pending an investigation. Head-to-toe assessments were completed on Resident #74 and other like residents on RA #300's assignment with no injuries or skin alterations noted. During the investigation, RA #300 stated she needed more training. Additional training was offered to RA #300, however, RA #300 resigned.

Interview on 07/02/24 at 9:03 A.M., Executive Director (ED) #320 and Interim Director of Nursing (IDON) #305 stated Resident #74's family alerted the facility of a concern involving Resident #74 and provided the video footage of the incident. IDON #305 and ED #320 stated they watched the video footage and observed a nightshift aide (RA #300) who found Resident #74 on the floor and tried picking Resident #74 up by herself and clearly struggled. IDON #305 stated RA #300 was eventually able to get Resident #74 into the wheelchair, lifted in a sit-to-stand to change him, and then put him in the bed. IDON #305 stated an hour lapsed from the time the resident was found on the floor to the time he was put into bed. IDON stated RA #300 did not notify the nurse of the fall nor did she summon any help to assist with lifting Resident #74 off the floor.

Interview on 07/02/24 at 1:13 P.M., IDON #305 verified Resident #74 required the assistance of two staff for all transfers and did not require the use of any type of mechanical lift. IDON #305 stated RA #300 took a mechanical lift from another resident's room and used it on Resident #74.

Review of the facility policy titled, Fall Management