**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, staff interview, review of self-reported incidents (SRI), review of witness statements, review of personnel files, review of X-ray results, and review of facility policy, the facility failed to ensure Resident #32 was transferred per physician orders and in a manner consistent with her plan of care. This resulted in Actual Harm on 06/22/25 at 4:01 P.M. when Certified Nursing Assistant (CNA) #168 attempted to transfer Resident #32 from the bed to a wheelchair by carrying her without additional staff and without the use of a mechanical Hoyer lift. CNA #168 tripped and fell with Resident #32 and the resident sustained an acute fracture of the right humerus, with mild displacement, and soft tissue swelling. This affected one (Resident #32) of the three residents reviewed for falls. The facility identified 11 additional residents who were dependent on a mechanical lift for transfers. The facility census was 58.Findings include::Review of the medical record for Resident #32 revealed the resident was admitted on [DATE]. Diagnoses included atherosclerotic heart disease, diabetes mellitus (DM), dementia, major depressive disorder, anxiety disorder, essential primary hypertension, and hypoglycemia.Review of a physician order dated 09/03/22 for Resident #32, revealed the resident was ordered to be transferred via mechanical Hoyer lift for all transfers. Review of the Care Plan revised on 02/02/24 for Resident #32, revealed the resident required a mechanical lift for all transfers which required two staff members. The Care Plan was revised on 06/23/35 to include a fall with major injury. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #32, revealed the resident had impaired cognition. Resident #32 was dependent on staff for all activities of daily living (ADLs) including transfers.Review of comprehensive Fall Risk Screening dated 05/15/25 for Resident #32, revealed the resident was at a high risk for falls. Review of the accident/incident log revealed Resident #32 had a witnessed fall on 06/22/25 at 4:00 P.M. Review of a progress note dated 06/22/25 at 4:01 P.M. for Resident #32, revealed CNA #168 transferred Resident #32 to a wheelchair and tripped during the transfer and Resident #32 fell. Resident #32 was lying flat on her back in front of the dresser with her legs outstretched and her wheelchair next to the bed. Resident #32 complained of right arm pain and had an abrasion to her right elbow which measured approximately three centimeters (cm) by 2 cm. Resident #32 guarded her right arm and cried when the nurse attempted to assess the arm. Review of the facility's SRI (261893) created on 06/22/25 at 5:13 P.M. for allegation of neglect/mistreatment, revealed CNA #168 improperly transferred Resident #32 who required assistance of two staff, and the resident was assessed with a minor abrasion. Registered Nurse (RN) #170 was called to the resident's room where the resident was discovered on the floor of her room. CNA #168 reported she was transferring the resident to a wheelchair by carrying her when CNA #168 tripped during the transfer resulting in the resident falling. The resident was assessed by RN #170 with a small abrasion to the right elbow and wound treatment was initiated. The resident complained of generalized right arm pain but unable to be specific about the pain or a pain level. The resident was contracted at baseline and the resident's range of motion (ROM) in the right arm was not within normal limits. The provider was notified of incident and provided new orders for a stat (immediate) X-ray of the right shoulder and right elbow. The X-ray results were received on 06/23/24 at 12:05 A.M. and Resident #32 had an acute right mildly displaced humeral head fracture. The resident was assessed by the Nurse Practitioner (NP) on 06/23/25 and spoke with family regarding treatment options. A sling was ordered for the resident and no further orthopedic follow up was needed. The resident's pain was managed with Tylenol and ibuprofen, and the family was in in agreement with the treatment plan. CNA #168 indicated she was aware Resident #32 required a two-person transfer via mechanical Hoyer lift and transferred the resident by herself. The facility's investigation was unsubstantiated for abuse/neglect related to the incident not meeting definitions of neglect in the regulations. CNA #168 was terminated on 06/27/25 for violations of company policy regarding delivery of patient care. The SRI was completed on 06/27/25 at 12:34 A.M. and unsubstantiated due to evidence indicating abuse, neglect or misappropriation did not occur.Review of the X-ray report dated 06/22/25 at 11:02 P.M. for Resident #32, revealed an acute fracture involving the neck of the right humerus with mild displacement. Review of a witness statement dated 06/22/25 and authored by Registered Nurse (RN) #170, revealed CNA #112 and #168 stated Resident #32 had a fall. CNA #168 reported she attempted to transfer Resident #32 to a wheelchair but tripped and fell with Resident #32. RN #170 reported she observed Resident #32 on the floor on her back in front of the dresser. RN #170 reported she assessed Resident #32 and identified an abrasion on her right arm approximately three centimeters (cm) by two (cm). RN #170 reported Resident #32 complained of right arm pain. RN #170 report she obtained an order for a stat (immediate) X-ray of the right arm and shoulder. Review of a NP #500 progress note dated 06/23/25 at 1:00 A.M. for Resident #32, revealed the resident was seen for an acute /follow-up visit. The chief complaint was a right arm injury related to a fall and right arm fracture. On 06/22/25 at 4:00 P.M., the resident had a fall related to an improper transfer and the imaging showed an acute mildly displaced humeral head fracture, The resident was placed in a shoulder sling and recommended for a follow-up X-ray in six weeks. The resident's family requested no opioids be ordered due to the resident's tolerance level. Review of an Interdisciplinary Team (IDT) note dated 06/23/25 at 3:32 P.M., revealed RN #170 was alerted by CNA #168 on 06/22/25 at 4:00 P.M. that she tripped as she attempted to transfer Resident #32 to her wheelchair when the resident fell. Resident #32 was lying flat on her back in front of her dresser with her legs outstretched. Resident #32 was assisted off the ground using a Hoyer lift with three staff members. An abrasion was noted to Resident #32's right elbow that measured approximately three cm by two cm. Resident #32 complained of right arm pain, guarded her right arm and cried when the nurse attempted to move and assess the right arm. An X-ray was completed which revealed Resident #32 had an acute right humeral neck fracture. Review of a witness statement dated 06/23/25 and authored by CNA #168, revealed on 06/22/25 around 3:45 P.M., she began her rounds and Resident #32 was in her bed. CNA #168 stated she checked and changed the resident's incontinent brief. CNA #168 indicated that since it was close to dinner time, she attempted to transfer Resident #32 then tripped and fell. CNA #168 sated she fell on her left side and Resident #32 fell on her right side. CNA #168 stated she went to the kitchen and called the nurse to tell her about the fall. Review of a witness statement dated 06/23/25 and authored by CNA #112, revealed on 06/22/25 around 4:00 P.M., she observed CNA #168 go into Resident #32's room then came out and stated Resident #32 was on the floor. CNA #112 called RN #170 to report the resident was on the floor. During an interview on 08/07/25 at 11:07 A.M., the Administrator stated on 06/22/25, CNA #168 completed an improper transfer on Resident #32 by transferring the resident without a Hoyer and without additional staff. Administrator reported CNA #168 tripped and fell with the resident during the transfer and Resident #32 sustained a fractured right arm. The Administrator verified Resident #32 was ordered to be transferred via mechanical Hoyer lift with two staff members for all transfers. The Administrator stated CNA #168 picked up Resident #32 with one arm under her shoulders and one arm under her knees and they both fell. The Administrator stated CNA #168 was terminated for an improper transfer of a Resident #32.Review of the personnel file for CNA #168 revealed a hire date of 05/21/25. CNA #168 had an active and unrestricted license. CNA #168 was terminated on 06/27/25 for an incident that occurred on 06/22/25 when CNA #168 failed to ensure the safety of self and others when she provided care inconsistent with Resident #32's care plan. Resident #32 required a Hoyer mechanical lift with two staff, and CNA #168 transferred Resident #32 without the assistance of another and without a mechanical Hoyer lift. CNA #168 was signed off on competency skills for Hoyer transfers during orientation. Subsequent interview with the Administrator on 08/07/25 at 4:19 P.M., revealed he did not report CNA #168 to the abuse registry because he reported her on the SRI. The Administrator stated he unsubstantiated the allegation of neglect because he felt the facility provided CNA #168 with the appropriate tools to provide the care for Resident #32 and CNA #168 chose not to utilize the tools. The Administrator stated he did not feel this met the definition of neglect, so the SRI investigation was unsubstantiated. During an interview on 08/11/25 at 9:36 A.M., RN #170 stated she was the charge nurse on 06/22/25 when she got the call from CNA #112 who stated Resident #32 had a fall. RN #170 stated there were small houses on the campus where the residents reside. RN #170 stated when she arrived in Resident's #32 house, she learned CNA #168 was the only CNA in the house. RN #170 stated CNA #168 picked up Resident #32 with her arms around her and attempted to pivot her to a wheelchair when both fell to the ground. CNA #168 stated CNA #112 was not in the house at the time of the fall. RN #170 stated Resident #32 had an abrasion on her right elbow and complained of pain in her right arm. RN #170 stated she obtained an order for a stat X-ray and provided pain medication to Resident #32.Review of the undated Kardex form (a quick reference guide for caregivers, providing a snapshot of a resident's status and care plan) for Resident #32, revealed the resident required a mechanical lift with two staff members using a red sling for transfers.Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property-Ohio only dated 10/25/22, revealed the definition of neglect is the failure of the facility or its staff to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility policy titled Falls Management dated 12/03/19, revealed the facility would have procedures in place to prevent and/or reduce falls. The definition of a fall is an unintentional coming to rest on the ground, floor, or other lower level. When a Resident is observed on the floor, a fall is considered to have occurred.The deficient practice was corrected on 07/03/25 when the facility implemented the following corrective actions: On 06/22/25 at 5:23 P.M., immediate education was sent out to all employees via a facility application installed on all the employees' phones. The education consisted of ensuring staff followed the residents' care plans, Kardex, physician orders, ensuring all staff utilized a mechanical lift if required and transferring resident with two staff members if required. The Administration was able to verify all employees received the education via a read message returned to the facility. Starting on 06/23/25 and completed on 07/03/25, the DON initiated education for all nursing staff which included nurses and CNA on providing care as documented in the residents' care plan, the importance of utilizing two staff members with resident care when required, safe transfers, utilizing mechanical lifts if required and providing care per physician orders. A return demonstration on resident transfers via Hoyer lift was completed with all nursing staff. A post-education quiz was utilized with all staff to verify the staff's knowledge related to proper transfers, abuse, neglect, and how to access the Kardex or Care Plan. On 06/23/25 and 06/24/25, the DON completed an audit for all current residents who used a Hoyer lift for transfers. The facility identified 11 (#01, #02, #13, #20, #28, #37, #38, #40, #45, #53 and #60) additional residents required the use of a Hoyer lift for transfers and/or to obtain ordered weights. There were no adverse findings.Beginning on 06/23/25, the DON/designee conducted randomized observational audits of mechanical Hoyer lift transfers on at least five residents weekly for four weeks. The results were reported to the Administrator and Quality Assurance and Performance Improvement (QAPI) committee for any modification of intervention or adjustments as needed. On 06/23/25, The DON completed an audit on all current residents to ensure physician orders, Care Plans, and Kardexs were current and up to date and current per physician orders. No additional concerns were identified.On 6/23/25, an ad hoc QAPI meeting was held by the IDT with the medical director in attendance to discuss the incident and review the audits completed of all elder records to ensure physician orders, care plans, and Kardexs were accurate. Additional QAPI meetings were held weekly for four weeks to ensure audits were completed and to review them to determine if any modification of intervention or adjustments were needed.On 06/23/25, the previous physician order dated 09/03/22 related to Resident #32 being transferred via Hoyer, was discontinued and a new order was placed so the physician order would transfer over to the treatment administration record (TAR) which required the nurses to sign off when the transfer was completed via Hoyer. This same order was also completed for the 11 additional residents identified as utilizing a Hoyer for transfers. On 06/25/25, skin assessments were completed for all residents who could not be interviewed. No issues were identified. On 06/27/25, CNA #168 was terminated for an improper transfer related to the transfer with Resident #32.This deficiency represents non-compliance investigated under Complaint Number OH00167463.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to verify a resident's (Resident #55) identity prior to medication administration, resulting in Resident #55 being given another resident's medication. This resulted in actual harm when Resident #55 had a subsequent episode of vomiting and lethargy, leading to the resident being transferred to the emergency room. Additionally, the facility failed to administer pain medication in a timely manner and as ordered by the physician for Resident #107. This affected two (Residents #55 and #107) of six residents reviewed for medication administration. The facility census was 58. Findings included: Medical record review for Resident #55 revealed the resident admitted to the facility on [DATE] with diagnoses including vascular disorder of intestine, chronic kidney disease, essential hypertension, other iron deficiency anemias, unspecified asthma, dyspnea, nonrheumatic mitral valve stenosis, aphasia, asthma, and arthropathy. Review of Resident #55's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. Resident #55 required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the facility's undated incident submission summary revealed on 05/29/22, Resident #55 was administered the wrong medication by agency staff. The agency staff member was going in order of rooms and failed to verify Resident #55's name and room number with staff. At approximately 10:30 A.M., Resident #55 was given aspirin, calcium, Aricept, doxycycline, iron, gabapentin, lisinopril, Namenda, Protonix, multivitamin, Profenone, zinc and vitamin D. After the wrong medication was administered, Resident #55 presented with vomiting. The agency nurse contacted the physician who gave orders to send the resident to the emergency room. The nurse also contacted Resident #55's representative and Resident #55 left the facility for the hospital at 11:30 A.M. On 05/29/22 at approximately 12:21 P.M., the facility contacted the emergency room, and the emergency room nurse returned the call and reported Resident #55 was fine and lethargic. Resident #55 also still had episodes of vomiting but was stable. Resident #55 returned from the hospital on [DATE] at 8:10 P.M. Review of the progress note dated 05/29/22 revealed Resident #55 was out to the hospital and should be closely monitored and charted on every shift for three days. Per the hospital, the resident was in stable condition. Review of the late entry progress note dated 05/31/22 revealed Resident #55 was administered the wrong medication. The nurse was educated on medication administration and asking facility staff for proper resident identification if unable to determine. The physician and family were notified. Resident #55 returned from the emergency room at 8:10 P.M. with vital signs within normal limits and lungs clear with a moist cough noted. Resident #55 continued on coronavirus quarantine until asymptomatic. Resident #55 denied pain or discomfort. No further emesis noted. All parties were aware. Telephone interview on 08/04/22 at 1:30 P.M. with the Director of Nursing (DON) revealed she received a call from the previous Administrator on 05/29/22. The Administrator informed the DON Resident #55 was administered another resident's medications. Resident #55 received Aspirin 81 milligrams (mg), calcium plus vitamin D 600mg, Aricept 10 mg, doxycycline 100mg, iron 325 mg, vitamin D 25 micrograms (mcg), gabapentin 300 mg, lisinopril 5 mg, Namenda 10 mg, Protonix 40 mg, multivitamin and zinc 50 mg that were not prescribed to her. The DON stated the nurse who administered the wrong medications was an agency nurse, but she could not recall her name. The DON stated the agency nurse was going room to room passing medications and did not realize she was in the wrong room. The DON stated Resident #55 had episodes of vomiting after receiving the wrong medication and was sent to the emergency room. The DON reported Resident #55's representatives were contacted. The DON reported she started medication administration audits after the incident and educated the facility's staff. The DON also reported she notified the agency where the agency nurse was employed, of the incident. The DON educated the nurse that made the medication error but did not put in place, any education for other agency nurses or staff that worked in the facility stating, It's the agencies job to educate their staff. Attempted interview on 08/09/22 at 2:05 P.M. with Staffing Agency #801 was unsuccessful. Review of the facility's medication administration procedure revised 11/09/21 revealed residents are identified before medications are administered. Methods of identification include checking the photograph attached to the medical record, ask the resident to say or spell his or her name, and verify the resident's identification with other community personnel if necessary. 2. Review of Resident #107's medical record revealed an admission date of 07/17/22. Diagnoses included pneumonia, hypertension, osteoarthritis, cardiomegaly, gout, presence of unspecified artificial knee, chronic pain, atrial fibrillation, and diabetes. Review of Resident #107's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS revealed the resident required extensive two-person assistance for bed mobility, transfers, and dressing. The resident was totally dependent with two-person assist for toileting and personal hygiene. The resident required supervision with set-up for eating. Review of Resident #107's plan of care dated 07/17/22 revealed the resident had a self-care deficit related to multiple diagnoses. The plan of care identified the resident was at risk for skin breakdown. Interventions included turn and repositioned frequently. The plan of care revealed the resident was at risk for pain with interventions to administer medications as ordered. Review of Resident #107's physician order dated 07/22/22 revealed an order for Lyrica 75mg to be administered three times daily (8:00 A.M., 5:00 P.M. and 9:00 P.M.) for pain. Observation on 08/01/22 at 11:59 A.M. revealed Resident #107 was administered the Lyrica 75mg, which was ordered to be administered at 8:00 A.M. Interview on 08/01/22 at 12:10 P.M. Resident #107 reported she did not receive her morning medications until almost noon. Interview on 08/01/22 at 12:34 P.M. with Licensed Practical Nurse (LPN) #92 confirmed the resident's Lyrica was ordered to be administered at 8:00 A.M. LPN #92 confirmed she did not administer the medication timely. LPN #92 revealed she had an admission earlier in the morning which made her medication administration times late. Interview on 08/01/22 at 1:05 P.M. with the Certified Nurse Practitioner (CNP) #325 revealed she was at the facility every Monday and Thursday. The CNP #325 revealed late medication administration was a, common occurrence. Interview on 08/02/22 at 10:44 A.M. with the Director of Nursing confirmed it was the facility's expectation to administer resident's medications within one hour prior or one hour after the scheduled medication ordered time. Review of the facility policy titled, Medication Administration Procedures, revised 11/09/21 revealed medications are administered within one hour before or one hour after scheduled times.