Bath Manor Special Care Centre

Based on medical record review, interview, and review of the facility policy, the facility failed to ensure timely notification of death of the legal guardian for Resident #119. This affected one resident (#119) of three residents who were reviewed for notification of significant incidents or changes in condition. The facility census was 118.

Findings include:

Review of the closed medical record for Resident #119 revealed an admission date of 05/03/24 with diagnoses including acute and chronic respiratory failure, extended spectrum beta lactamase (ESBL) resistance, hypothyroidism, major depressive disorder, end stage renal disease, thrombocytopenia, severe protein-calorie malnutrition, dysphagia, myxedema coma, dysphagia, and abnormalities of gait and mobility. Further review of the medical record revealed a discharge date of 07/24/24 after expiring in the facility.

Review of the significant change Minimum Data Set (MDS) assessment completed on 06/17/24 revealed Resident #119's cognitive function was severely impaired, and she was receiving Hospice care.

Review of the face sheet revealed Resident #119 had a legal guardian. Further review of the face sheet revealed the legal guardian was the responsible party, and the face sheet listed the name, address, telephone number, and email address for the legal guardian. The face sheet also listed a spouse as an emergency contact.

Review of the admission documents revealed a court document which appointed guardianship of Resident #119's person and estate to the listed legal guardian on the face sheet as of 02/14/22. The court document specified the appointed legal guardian had the power to perform all duties of a guardian, indefinitely.

Review of the progress notes revealed a progress note date 07/24/24 timed 9:06 P.M. indicating Resident #119 passed away at 8:45 P.M., the Director of Nursing (DON) was notified at 8:53 P.M., the Hospice provider was notified at 8:55 P.M., and the listed emergency contact was notified at 9:20 P.M. The note did not indicate the legal guardian was contacted. An additional progress note, dated and timed for 07/24/24 at 9:21 P.M. revealed the spouse of Resident #119 was notified of her death and told the facility which funeral home he wished to use.

A progress note dated 07/25/24 at 12:28 A.M. revealed the Hospice nurse arrived at the facility at 9:51 P.M. and notified the physician that Resident #119 had expired at 8:45 P.M. There were no documented evidence indicating Resident #119's legal guardian was notified of her death on the evening or night she expired.

Review of the social services progress note dated 07/25/24 at 10:46 A.M. revealed the legal guardian of Resident #119 called and left a message requesting the time of death and funeral home information from the facility, and Social Worker #509 returned the call and provided the requested information at that time.

Telephone interview on 09/17/24 at 2:48 P.M. with Licensed Practical Nurse (LPN) #504 confirmed once she and LPN #633 verified the absence of vital signs, she notified Hospice and a man she referred to as either the resident's boyfriend, fiancée, or spouse., that Resident #119 had expired. When asked if the legal guardian was contacted, said she was trying to figure out who she was supposed to notify so she called the person listed as an emergency contact, who was also listed as the spouse. During the interview, LPN #504 confirmed she did not know that Resident #119 had a legal guardian or that the daughter was involved in Resident #119's care and should have been listed as the family contact.

Interview on 09/17/24 at 3:44 P.M. with the legal guardian for Resident #119 confirmed the facility did not notify her of Resident #119's passing on the date of her death. During the interview, the legal guardian confirmed she was responsible for all medical and financial decisions and was to be informed of any changes, including death. The legal guardian further confirmed she should have been called, regardless of whether it was after what was normal business hours, and that her answering service would have taken the message and forwarded it to her so she could have informed the resident's family. At the time of the interview, the legal guardian stated Resident #119, and her spouse had been estranged for quite some time, since before she was admitted to the facility, and that it was the resident's daughter who remained involved in Resident #119's care and with whom she communicated. The legal guardian further confirmed Resident #119's daughter visited her mother in the facility frequently and was devastated she was not afforded the opportunity to come to the facility before her mother's body was released to the funeral home (because the legal guardian was not informed timely), despite Resident #119's passing away during what the legal guardian referred to as normal waking hours.

Review of the facility policy titled Resident Change in Condition Policy

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, interview, review of drug information on triamcinolone 0.1% cream (a topical corticosteroid) on Drugs.com, and review of the facility policy the facility failed to ensure ongoing care and services remained appropriate and failed to address repeated concerns voiced by state tested nurse aides (STNAs) regarding a black discoloration in Resident #82's percutaneous endoscopic gastrostomy (PEG) tube (a surgically placed feeding tube into the stomach) resulting in the resident being transferred to the hospital related to a clogged PEG tube with maggots noted in the tube. This affected one resident (#82) of three residents reviewed for tube feedings and had the potential to affect twelve residents (#67, #68, #70, #71, #72, #73, #74, #75, #76, #77, #81, and #82) whom the facility indicated were receiving nutrition via an enteral feeding tube. The facility census was 118. Findings include: Review of the medical record for Resident #82 revealed an admission date of 02/03/22. Resident #82 was sent out to the hospital on 08/22/24 and returned to the facility on 08/31/24. Diagnoses included acute respiratory failure, type two diabetes mellitus, aphasia, cognitive communication deficit, cerebral aneurysm, and obesity. Review of wound progress note dated 03/13/24 for Resident #82 revealed the moisture associated skin damage (MASD) to the open area around the PEG tube site was healed and that the treatment of triamcinolone 0.1% cream with calcium alginate (dressing for heavily draining wounds) and split gauze was to be continued each shift as a preventative measure. Review of physician order dated 04/08/24 for Resident #82 revealed an order to check enteral tube placement each shift. Further review of the orders revealed a physician order dated 04/04/24 for PEG tube site care as follows: cleanse the PEG tube site with wound cleanser, pat dry, apply triamcinolone 0.1%, and cover with calcium alginate and split gauze dressing each shift and as needed. Review of the care plan revealed Resident #82 was noted on 04/25/24 to be at risk for skin breakdown related to incontinence, diabetes mellitus, picking at skin, and extensive assistance for bed mobility. Additionally, the care plan revealed Resident #82 had a potential for altered nutritional status secondary to dysphagia and nothing by mouth status. Intervention dated 05/08/24 included the administration of tube feeding and flushes and provision of tube site care per physician orders and facility policy. Review of the care plan revealed Resident #82 required staff assistance for ADL. Further review of the care plan dated 05/17/24 revealed Resident #82 was non-compliant with care at times, including showers, refusal of tube feeding at times, and picking at her PEG tube site. On 09/16/24, an additional care plan problem was added to reflect Resident #82 declined to have her PEG tube replaced (there was no date of occurrence related to PEG replacement refusal). Interventions included education related to complications of non-compliance and physician notification. Review of Nurse Practitioner (NP) communication notes with the facility dated 06/07/24 revealed Resident #82's PEG tube was malfunctioning, and attempt was made for exchange. The communication notes also indicated Resident #82 refused PEG tube replacement multiple times, and the tube feeding was infusing with no further issues. Review of progress notes from 05/01/24 to 08/21/24 revealed no indications of redness or other signs of infection to Resident #82's PEG tube site and revealed no documented evidence of attempts to schedule a PEG tube replacement. Review of weekly skin check dated 08/21/24 for Resident #82 completed by Licensed Practical Nurse (LPN) #528 revealed no indication abdominal redness and no documented evidence of concerns related to the stoma. Review of nursing progress note dated 08/22/24 timed at 2:16 A.M. revealed Resident #82 complained of itching on her stomach while nurse was hanging a new tube feed set up. Resident #82's PEG site was noted to be red with purulent drainage. A hole was found on the tube near the bumper (which rests on the edge of the skin) that was leaking enteral feed. The on-call NP was notified, and Resident #82 was sent to the emergency room. Review of witness statement dated 08/22/24 from LPN #640 revealed she went to change the tube feeding bag and Resident #82 stated she was having pain and itching at the dressing site. LPN #640 went to look at the dressing site and noticed maggots around the site. LPN #640 alerted Registered Nurse (RN) #624 to come assist cleaning the site. Both nurses observed a hole in the side near the PEG bumper, and Resident #82 was sent to the hospital. Review of the witness statement dated 08/22/24 from RN #624 revealed she was called down by another nurse to observe Resident #82's PEG site and after lifting the PEG bumper she observed maggots. Dakin fluid (a cleaning solution) was used to kill them, and no more maggots reappeared. Resident #82's PEG tube was noted to have a hole in the side near the bumper and tube feed was leaking out of the tube. The on-call NP was notified, and Resident #82 was sent out for evaluation. Review of hospital admission note dated 08/22/24 timed at 2:51 P.M. revealed Resident #82 presented to the hospital with a PEG tube issue and abdominal pain with stercoral colitis and possible cystitis. The hospital admission notes further revealed Resident #82 was transferred from the nursing home to the hospital due to a clogged PEG tube with maggots noted in PEG tube. Review of the discharge Minimum Data Set (MDS) 3.0 assessment dated 08/22/24 revealed Resident #82 had severely impaired cognition. Resident #82 was dependent on staff for activities of daily living (ADL), received nothing by mouth, and received nutrition though enteral tube feedings. Review of nursing progress note dated 08/25/24 timed at 6:28 P.M. revealed Resident #82 returned from the hospital following treatment and a PEG tube replacement. Interview on 09/16/24 at 8:50 A.M. with Unit Manager #518 stated she was unaware of any concerns related to resident feeding tubes and denied knowledge of black discoloration in feeding tubes or the presence of maggots. She denied being informed by STNA's of black discoloration in the PEG tube. Interview on 09/16/24 at 9:58 A.M. with the Director of Nursing (DON) confirmed Resident #82 was sent to the hospital on 08/22/24 for drainage coming out of her PEG tube insertion site and maggots found near the tube insertion site. The DON further confirmed Resident #82 had a blockage in the tube and while at the hospital the tube was replaced. During the interview the DON stated PEG site treatment had been completed the night before and no concerns were noted. Interview on 09/16/24 at 10:51 A.M. with NP #654 confirmed she noticed some leaking from the PEG tube site back in May 2024 and tried to get her an appointment for a consult for replacement, but no return phone call was received despite trying several times. NP #654 also confirmed Resident #82's PEG tube did not appear to be leaking as of 06/28/24, and Resident #82 declined a follow up appointment for the PEG tube. NP #654 also stated she discussed PEG tube replacement with Resident #82 again on 07/31/24, but she declined, stating it was not leaking and stated was experiencing no pain. On 08/22/24 the on-call NP was called at 1:30 A.M. and was informed Resident #82's PEG site was reddened with purulent drainage and itching at the site. It was also reported the PEG tube portion where the piston went attached had a blackened area and what the facility nurse reported to look like maggots around the bumper. Resident #82 was sent to the emergency room (ER) for treatment. NP #654 revealed Resident #82's history of picking at her skin and pulling at the PEG tube dressing may have made her more susceptible to infection. NP #654 confirmed she was unable to determine how long the blackened portion of the PEG tube was there as it had not been there when she last saw Resident #82 on 07/31/24 and was not aware of the blackening until 08/22/24 when Resident #82 was sent to the ER for evaluation and treatment. Interview on 09/16/24 at 12:06 P.M. with LPN #582 confirmed Resident #82 picked at her skin and pulled at her PEG tube. LPN #582 further confirmed Resident #82's PEG tube was to be cleansed twice a day and covered with a split gauze around it for skin protection. Ther was no mention of triamcinolone 0.1% or calcium alginate. During the interview, LPN #582 confirmed she was aware of moisture around the PEG insertion site, and the NP's recommendation for PEG replacement but denied knowledge of skin redness or the PEG tube appearing black in color. Interview on 09/16/24 at 1:35 P.M. with State Tested Nurse Aide (STNA) #591 revealed she had noticed tube feeding formula leaking from Resident #82's PEG tube and had also reported the PEG tube was discolored and had black on the inside to nursing at least ten times. STNA #591 further stated Resident #82's PEG tube did not look like other residents' feeding tubes and had been discolored for several months. STNA #591 stated when giving a bed bath to Resident #82, she would clean around the dressing and would ask the nurse to replace the dressing. During the interview, STNA #591 stated she never noticed redness, swelling, or drainage coming from the PEG site, but had reported tube feeding product leaking from the PEG tube. Phone interview on 09/16/24 at 5:17 P.M. with STNA #523 revealed she had reported Resident #82's PEG tube leaking to a nurse who no longer worked at the facility and had told Unit Manager #518 about Resident #82's PEG tube having black inside back in May of 2024. Phone interview on 09/16/24 at 5:25 P.M. with RN #624 confirmed she was aware the reddened area around Resident #82's PEG tube for about a month prior to being sent to the hospital but she thought it was getting better. RN #624 also stated she noticed the PEG tube had a black color that appeared to be mold about a week prior to the incident and had reported it to LPN #630 at the end of her shift. (Review of the progress notes revealed no documentation of the assessment findings or report of the findings). RN #624 further confirmed the night Resident #82 was sent out, and aide had reported the tube feeding was leaking in her bed, and Resident #82 was complaining of itching of her entire abdomen. During the interview, RN #624 confirmed when she examined the PEG tube, she noticed a hole in the peg tube and noticed clear mucous-like drainage around the tube site bumper with approximately ten maggots under it. A follow up phone interview on 09/16/24 at 5:45 P.M. with LPN #630 (who previously had stated she was unaware of any concerns related to tube feeding or maggots) revealed Resident #82's PEG tube was discolored from medications but denied noticing any black discoloration that appeared to be mold. LPN #630 further stated the area around Resident #82's PEG tube was reddened, and a treatment of calcium alginate had been in place. Phone interview on 09/16/24 at 5:56 P.M. with STNA #549 revealed she had reported Resident #82's PEG tube being black inside for several months. STNA #549 stated she had reported it more than once to Unit Manager #518 over the past three of four months and stated she knew the nurses saw the color of the PEG tube because they are the ones who administer her tube feeding each day. STNA #549 also confirmed the area around the PEG tube was reddened, and the nurse was doing a treatment for it. Interview on 09/17/24 at 1:05 P.M. with NP #654 revealed she would not order calcium alginate to be applied to healed skin because it could cause skin irritation, especially with prolonged use, but she also confirmed calcium alginate could be used if there was chronic drainage, then she deferred any further questions to the wound nurse. Interview on 09/1/24 at 2:10 P.M. with LPN #528 revealed she completed a head-to-toe assessment for Resident #82 on 08/21/24 and found no concerns, such as redness or drainage, related to her PEG tube site. Review of the drug information on triamcinolone cream on Drugs.com (https://www.drugs.com/triamcinolone-acetonide-cream.html , an online pharmaceutical encyclopedia) revealed the medication was not indicate for prolonged use and could increase the risk of skin irritation, including redness, itching, burning, and irritation, as well as atrophy of the epidermis. Further review of the triamcinolone cream drug information page revealed, when applicable, a recommendation to hold application of the cream until an infection can be controlled. Review of the facility policy titled Enteral Feeding Tube(s) PolicyTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.

Based on medical record review, interview, review of drug information on triamcinolone 0.1% cream (a topical corticosteroid) on Drugs.com, and review of the facility policy the facility failed to ensure ongoing care and services remained appropriate and failed to address repeated concerns voiced by state tested nurse aides (STNAs) regarding a black discoloration in Resident #82's percutaneous endoscopic gastrostomy (PEG) tube (a surgically placed feeding tube into the stomach) resulting in the resident being transferred to the hospital related to a clogged PEG tube with maggots noted in the tube. This affected one resident (#82) of three residents reviewed for tube feedings and had the potential to affect twelve residents (#67, #68, #70, #71, #72, #73, #74, #75, #76, #77, #81, and #82) whom the facility indicated were receiving nutrition via an enteral feeding tube. The facility census was 118.

Findings include:

Review of the medical record for Resident #82 revealed an admission date of 02/03/22. Resident #82 was sent out to the hospital on 08/22/24 and returned to the facility on 08/31/24. Diagnoses included acute respiratory failure, type two diabetes mellitus, aphasia, cognitive communication deficit, cerebral aneurysm, and obesity.

Review of wound progress note dated 03/13/24 for Resident #82 revealed the moisture associated skin damage (MASD) to the open area around the PEG tube site was healed and that the treatment of triamcinolone 0.1% cream with calcium alginate (dressing for heavily draining wounds) and split gauze was to be continued each shift as a preventative measure.

Review of physician order dated 04/08/24 for Resident #82 revealed an order to check enteral tube placement each shift. Further review of the orders revealed a physician order dated 04/04/24 for PEG tube site care as follows: cleanse the PEG tube site with wound cleanser, pat dry, apply triamcinolone 0.1%, and cover with calcium alginate and split gauze dressing each shift and as needed.

Review of the care plan revealed Resident #82 was noted on 04/25/24 to be at risk for skin breakdown related to incontinence, diabetes mellitus, picking at skin, and extensive assistance for bed mobility. Additionally, the care plan revealed Resident #82 had a potential for altered nutritional status secondary to dysphagia and nothing by mouth status. Intervention dated 05/08/24 included the administration of tube feeding and flushes and provision of tube site care per physician orders and facility policy.

Review of the care plan revealed Resident #82 required staff assistance for ADL. Further review of the care plan dated 05/17/24 revealed Resident #82 was non-compliant with care at times, including showers, refusal of tube feeding at times, and picking at her PEG tube site. On 09/16/24, an additional care plan problem was added to reflect Resident #82 declined to have her PEG tube replaced (there was no date of occurrence related to PEG replacement refusal). Interventions included education related to complications of non-compliance and physician notification.

Review of Nurse Practitioner (NP) communication notes with the facility dated 06/07/24 revealed Resident #82's PEG tube was malfunctioning, and attempt was made for exchange. The communication notes also indicated Resident #82 refused PEG tube replacement multiple times, and the tube feeding was infusing with no further issues.

Review of progress notes from 05/01/24 to 08/21/24 revealed no indications of redness or other signs of infection to Resident #82's PEG tube site and revealed no documented evidence of attempts to schedule a PEG tube replacement.

Review of weekly skin check dated 08/21/24 for Resident #82 completed by Licensed Practical Nurse (LPN) #528 revealed no indication abdominal redness and no documented evidence of concerns related to the stoma.

Review of nursing progress note dated 08/22/24 timed at 2:16 A.M. revealed Resident #82 complained of itching on her stomach while nurse was hanging a new tube feed set up. Resident #82's PEG site was noted to be red with purulent drainage. A hole was found on the tube near the bumper (which rests on the edge of the skin) that was leaking enteral feed. The on-call NP was notified, and Resident #82 was sent to the emergency room.

Review of witness statement dated 08/22/24 from LPN #640 revealed she went to change the tube feeding bag and Resident #82 stated she was having pain and itching at the dressing site. LPN #640 went to look at the dressing site and noticed maggots around the site. LPN #640 alerted Registered Nurse (RN) #624 to come assist cleaning the site. Both nurses observed a hole in the side near the PEG bumper, and Resident #82 was sent to the hospital.

Review of the witness statement dated 08/22/24 from RN #624 revealed she was called down by another nurse to observe Resident #82's PEG site and after lifting the PEG bumper she observed maggots. Dakin fluid (a cleaning solution) was used to kill them, and no more maggots reappeared. Resident #82's PEG tube was noted to have a hole in the side near the bumper and tube feed was leaking out of the tube. The on-call NP was notified, and Resident #82 was sent out for evaluation.

Review of hospital admission note dated 08/22/24 timed at 2:51 P.M. revealed Resident #82 presented to the hospital with a PEG tube issue and abdominal pain with stercoral colitis and possible cystitis. The hospital admission notes further revealed Resident #82 was transferred from the nursing home to the hospital due to a clogged PEG tube with maggots noted in PEG tube.

Review of the discharge Minimum Data Set (MDS) 3.0 assessment dated 08/22/24 revealed Resident #82 had severely impaired cognition. Resident #82 was dependent on staff for activities of daily living (ADL), received nothing by mouth, and received nutrition though enteral tube feedings.

Review of nursing progress note dated 08/25/24 timed at 6:28 P.M. revealed Resident #82 returned from the hospital following treatment and a PEG tube replacement.

Interview on 09/16/24 at 8:50 A.M. with Unit Manager #518 stated she was unaware of any concerns related to resident feeding tubes and denied knowledge of black discoloration in feeding tubes or the presence of maggots. She denied being informed by STNA's of black discoloration in the PEG tube.

Interview on 09/16/24 at 9:58 A.M. with the Director of Nursing (DON) confirmed Resident #82 was sent to the hospital on 08/22/24 for drainage coming out of her PEG tube insertion site and maggots found near the tube insertion site. The DON further confirmed Resident #82 had a blockage in the tube and while at the hospital the tube was replaced. During the interview the DON stated PEG site treatment had been completed the night before and no concerns were noted.

Interview on 09/16/24 at 10:51 A.M. with NP #654 confirmed she noticed some leaking from the PEG tube site back in May 2024 and tried to get her an appointment for a consult for replacement, but no return phone call was received despite trying several times. NP #654 also confirmed Resident #82's PEG tube did not appear to be leaking as of 06/28/24, and Resident #82 declined a follow up appointment for the PEG tube. NP #654 also stated she discussed PEG tube replacement with Resident #82 again on 07/31/24, but she declined, stating it was not leaking and stated was experiencing no pain. On 08/22/24 the on-call NP was called at 1:30 A.M. and was informed Resident #82's PEG site was reddened with purulent drainage and itching at the site. It was also reported the PEG tube portion where the piston went attached had a blackened area and what the facility nurse reported to look like maggots around the bumper. Resident #82 was sent to the emergency room (ER) for treatment. NP #654 revealed Resident #82's history of picking at her skin and pulling at the PEG tube dressing may have made her more susceptible to infection. NP #654 confirmed she was unable to determine how long the blackened portion of the PEG tube was there as it had not been there when she last saw Resident #82 on 07/31/24 and was not aware of the blackening until 08/22/24 when Resident #82 was sent to the ER for evaluation and treatment.

Interview on 09/16/24 at 12:06 P.M. with LPN #582 confirmed Resident #82 picked at her skin and pulled at her PEG tube. LPN #582 further confirmed Resident #82's PEG tube was to be cleansed twice a day and covered with a split gauze around it for skin protection. Ther was no mention of triamcinolone 0.1% or calcium alginate. During the interview, LPN #582 confirmed she was aware of moisture around the PEG insertion site, and the NP's recommendation for PEG replacement but denied knowledge of skin redness or the PEG tube appearing black in color.

Interview on 09/16/24 at 1:35 P.M. with State Tested Nurse Aide (STNA) #591 revealed she had noticed tube feeding formula leaking from Resident #82's PEG tube and had also reported the PEG tube was discolored and had black on the inside to nursing at least ten times. STNA #591 further stated Resident #82's PEG tube did not look like other residents' feeding tubes and had been discolored for several months. STNA #591 stated when giving a bed bath to Resident #82, she would clean around the dressing and would ask the nurse to replace the dressing. During the interview, STNA #591 stated she never noticed redness, swelling, or drainage coming from the PEG site, but had reported tube feeding product leaking from the PEG tube.

Phone interview on 09/16/24 at 5:17 P.M. with STNA #523 revealed she had reported Resident #82's PEG tube leaking to a nurse who no longer worked at the facility and had told Unit Manager #518 about Resident #82's PEG tube having black inside back in May of 2024.

Phone interview on 09/16/24 at 5:25 P.M. with RN #624 confirmed she was aware the reddened area around Resident #82's PEG tube for about a month prior to being sent to the hospital but she thought it was getting better. RN #624 also stated she noticed the PEG tube had a black color that appeared to be mold about a week prior to the incident and had reported it to LPN #630 at the end of her shift. (Review of the progress notes revealed no documentation of the assessment findings or report of the findings). RN #624 further confirmed the night Resident #82 was sent out, and aide had reported the tube feeding was leaking in her bed, and Resident #82 was complaining of itching of her entire abdomen. During the interview, RN #624 confirmed when she examined the PEG tube, she noticed a hole in the peg tube and noticed clear mucous-like drainage around the tube site bumper with approximately ten maggots under it.

A follow up phone interview on 09/16/24 at 5:45 P.M. with LPN #630 (who previously had stated she was unaware of any concerns related to tube feeding or maggots) revealed Resident #82's PEG tube was discolored from medications but denied noticing any black discoloration that appeared to be mold. LPN #630 further stated the area around Resident #82's PEG tube was reddened, and a treatment of calcium alginate had been in place.

Phone interview on 09/16/24 at 5:56 P.M. with STNA #549 revealed she had reported Resident #82's PEG tube being black inside for several months. STNA #549 stated she had reported it more than once to Unit Manager #518 over the past three of four months and stated she knew the nurses saw the color of the PEG tube because they are the ones who administer her tube feeding each day. STNA #549 also confirmed the area around the PEG tube was reddened, and the nurse was doing a treatment for it.

Interview on 09/17/24 at 1:05 P.M. with NP #654 revealed she would not order calcium alginate to be applied to healed skin because it could cause skin irritation, especially with prolonged use, but she also confirmed calcium alginate could be used if there was chronic drainage, then she deferred any further questions to the wound nurse.

Interview on 09/1/24 at 2:10 P.M. with LPN #528 revealed she completed a head-to-toe assessment for Resident #82 on 08/21/24 and found no concerns, such as redness or drainage, related to her PEG tube site.

Review of the drug information on triamcinolone cream on Drugs.com (https://www.drugs.com/triamcinolone-acetonide-cream.html , an online pharmaceutical encyclopedia) revealed the medication was not indicate for prolonged use and could increase the risk of skin irritation, including redness, itching, burning, and irritation, as well as atrophy of the epidermis. Further review of the triamcinolone cream drug information page revealed, when applicable, a recommendation to hold application of the cream until an infection can be controlled.

Review of the facility policy titled Enteral Feeding Tube(s) Policy

Based on observation, interview, record review and review of the facility policy the facility failed to ensure and allegation of verbal abuse towards Resident #23 was thoroughly investigated. This affected one resident (Resident #23) out of three residents reviewed for abuse. The facility census was 122.

Findings include:

Review of Resident #23's medical record revealed an admission date of 04/30/15 and a readmission date of 11/14/23. Resident #23's diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following nontraumatic subarachnoid hemorrhage affecting left dominant side, repeated falls, and need for assistance with personal care.

Review of Resident #23's Self-Reported Incident (SRI) tracking number 246669 dated 04/23/24 included the category of allegation, suspicion was neglect by facility staff. The initial source of the allegation, suspicion was a visitor, family member. Resident #23 provided meaningful information when interviewed. The Administrator received an allegation Resident #23 was being mistreated by a staff member during a shower. The accused staff member was suspended pending investigation. Resident #23 was interviewed and stated abuse did not occur. Resident #23 was cognitively intact. Resident #23 remained at facility at baseline and was annoyed by the accusation. The allegation was made by another residents family member who heard a conversation through the walls. The family member had a history of accusations and did not care for many staff members. Resident #23 received a skin check and denied abuse occurred. Interviewable residents were interviewed with no concerns. Non-interviewable residents received skin checks with no concerns. Staff were inserviced on abuse, neglect and misappropriation. Based on the facility investigation the allegation, suspicion was unsubstantiated.

Review of Resident #23 Witness Statement dated 04/23/24 and written by Family Member (FM) #340 included FM #340 overheard a young lady (STNA #281) say to Resident #23 why would I do that, I would not bring you out exposed. FM #340 stated she heard STNA #281 say omg these people are getting on my nerves, I can't wait to go home and Resident #23 stated don't take me out, why are you talking to me like that. FM #340 stated STNA #281 rolled Resident #23 into the shower room and the water was hot, Resident #23 said the water was hot, and STNA #281 stated the water was not hot and was that warmer. FM #340 stated STNA #281 left Resident #23 in the shower room alone and was taking selfies before going back in the shower room. FM #340 heard STNA #281 speak in a mean way to Resident #23 while both of them were in the shower room. FM #340 found an unidentified aide to listen outside the door and had the aide get her supervisor to quickly come and hear how STNA #281 was talking to Resident #23. The aide told Licensed Practical Nurse (LPN) #236 to come and listen, but LPN #236 who was assigned to the section did not come to address the concern. FM #340 had LPN #292 come to the shower room because LPN #236 was still sitting at the desk doing nothing. FM #340 stated she told LPN #236 if she did not get up and address the concern she was going to report her. LPN #236 then got up from her chair, went to the shower room and told STNA #281 that FM #340 reported her doing something to Resident #23. STNA #281 was still in the shower room with Resident #23 and stated people need to mind their business and worry about their family, and STNA #281 walked by Resident #65's room where FM #340 was inside the room repeatedly, and made comments about the incident each time. LPN #236 entered Resident #23's room, interviewed her, but seemed like she was directing Resident #23 in her answers.

Review of Resident #23's Witness Statements dated 04/23/24 written by Assistant Director of Nursing (ADON) #328 included she spoke with Resident #23 concerning an incident this morning that happened during her shower. Resident #23 stated the water temperature was comfortable, and she was satisfied with the care she received. Resident #23 stated she had customer service concerns with STNA #281, although Resident #23 felt cared for despite the concerns.

Review of Resident #23's Witness Statements dated 04/23/24 written by STNA #281 included STNA #281 stated while she was assisting a resident with their shower at 5:00 A.M. that LPN #236 came in the shower room to see if everything was okay, and STNA #281 told her everything was okay. STNA #281 stated Resident #23 did not share any complaints while LPN #236 was in the shower room, and LPN #236 told STNA #281 she was accused of scolding Resident #23 while she assisted Resident #23 with her shower. STNA #281 stated Resident #23 was able to do most of her bathing including washing her hair while she stood by. STNA #281 stated she would never scold a resident and was very upset with the accusation. STNA #281 stated she heard the visitor (FM #340) was walking in the hall with another visitor looking in the resident rooms, did not think it was appropriate, and STNA #281 mentioned it to a coworker and she thinks the visitor (FM #340) heard her.

Review of SRI #246669 dated 04/23/24 did not reveal any other Witness Statements from staff who were working and involved in the incident including LPN #236, LPN #292 and other STNA's.

Review of Resident #23's progress notes dated 04/23/24 through 04/28/24 did not reveal documentation regarding the incident in the shower room with STNA #281 and the allegation she was mistreating Resident #23.

Review of Resident #23's Quarterly Minimum Data Set (MDS) 3.0 assessment dated 05/01/24 revealed Resident #23 was cognitively intact. Resident #23 required supervision or touching assistance for bathing.

Review of Resident #23's care plan dated 05/10/23 included Resident #23 was at risk for self-care deficit due to left sided weakness related to CVA (cerebrovascular accident) and impaired mobility. Resident #23 would have ADL needs met daily through the next review. Interventions included bathing and hygiene with assist of one as needed.

Interview on 05/28/24 at 3:11 P.M. of FM #340 revealed weeks ago she witnessed a situation where Resident #23 did not want to come out of her room because she felt too naked and STNA #281 told her to be quiet and come on. FM #340 stated she heard STNA #281 say she was so sick of ya'll and I want to go home while she wheeled Resident #23 into the shower room. FM #340 heard Resident #23 say the water was too hot and STNA #281 said she did not do it on purpose in a not very nice way. FM #340 stated during the shower STNA #281 was verbally not nice to Resident #23. FM #340 stated she reported the event immediately and had LPN #231 come to the room to listen to the conversation. FM #340 stated she told LPN #231 to have LPN #236 come to the shower room because she was assigned to the nursing unit. FM #340 stated LPN #236 did not come and she had to threaten to report her to get her to come. When LPN #236 arrived to the shower room she told STNA #281 that FM #340 reported that she was being mean to Resident #23. FM #340 stated LPN #236 should not have told STNA #281 she was the one who reported her because STNA #281 lashed out at her. FM #340 indicated STNA #281 was mean to Resident #23 because she was tired and sleepy. FM #340 stated she spoke with ADON #328 about the situation and STNA #281 being mean to Resident #23.

Interview on 05/30/24 at 5:25 A.M. of STNA #281 revealed she was giving Resident #23 a shower and when she finished a nurse told her she needed to write a statement because she was accused of being verbally abusive to Resident #23. STNA #281 stated a nurse told her a family member wanted the nurse to listen outside the shower door because STNA #281 was being verbally abusive to Resident #23. STNA #281 stated it was frustrating to her because she did not like being accused of abusing Resident #23. STNA #281 stated she had a strong voice and in the shower room it probably echoed. STNA #281 stated Resident #23 was alert and oriented times three (time, place, person), Resident #23 adjusted the water temperature herself and she just stood by and assisted Resident #23 as needed. STNA #281 stated a nurse did not come to the shower room (even though her witness statement indicated a nurse came into the shower room with her and Resident #23) and she did not know about the allegation until she finished assisting Resident #23 with her shower and went to the nurse's station, and was told a lady was saying she was verbally abusive to Resident #23.

Interview on 05/30/24 at 5:49 A.M. of LPN #236 revealed she was told by FM #340 that STNA #281 was being mean to and hollering at Resident #23 in the shower room. LPN #236 stated she went into the shower room to make sure Resident #23 was okay, and Resident #23 told her she was alright and the water was not to hot. LPN #236 stated when she went into the shower room with Resident #23, STNA #281 was in the shower room assisting Resident #23 with her shower. LPN #236 stated she told STNA #281 that someone in the hall said she was yelling at and mistreating Resident #23. LPN #236 stated she did not report the verbal abuse allegation because Resident #23 stated nothing was wrong, and there was nothing to report.

Interview on 05/30/24 at 8:26 A.M. of LPN #231 revealed on 04/23/24 about 5:00 A.M. FM #340 told her STNA #281 was aggressive towards Resident #23. LPN #231 stated she stood for a short time at the door, but did not hear STNA #231 talking aggressively towards Resident 23. LPN #231 stated she told both STNA #281 and FM #340 to write statements about the situation, and once the statements were completed she made copies and slid the statements under the managers door. LPN #231 stated she informed ADON #328 about the situation. LPN #231 stated LPN #236 told STNA #281 that FM #340 brought it to her attention that she was being aggressive to Resident #23.

Interview on 05/30/24 at 8:49 A.M. of ADON #328 revealed she found out in a round about way about the incident between STNA #281 and Resident #23. ADON #328 stated FM #340 told her STNA #281 was being mean to Resident #23 and ADON #328 went to talk to Resident #23 in the morning. ADON #328 stated Resident #23 told her STNA #281 was not mean, the water was not hot, and ADON #328 further stated STNA #281 was talking loudly because Resident #23 wears hearing aides and she had to speak loudly. ADON #328 stated Resident #23's customer service concerns were she did not think STNA #281 was yelling but was talking loudly. ADON #328 stated she reported the situation to the DON between 7:00 A.M. and 9:00 A.M. and only saw witness statements from FM #340 and STNA #281.

Interview on 06/02/24 at 2:45 P.M. of LPN #292 revealed she was working on 04/23/24 when STNA #281 was giving Resident #23 a shower. LPN #292 stated she was not assigned to Resident #23, but FM #340 came to get her, and said she wanted me to listen at the shower door because STNA #281 was speaking inappropriately to Resident #23. LPN #292 stated she listened at the shower room door, but did not hear any inappropriate language from STNA #281. LPN #292 stated she heard LPN #236 tell STNA #281 that FM #340 could hear her screaming at Resident #23 and reported it. LPN #292 stated she did not report it because LPN #236 was assigned to Resident #23 and was supposed to be taking care of it. LPN #292 stated she was not asked to write a statement, and did not write a statement concerning the incident.

Interview on 06/03/24 at 9:50 A.M. of the Administrator and Regional Director of Clinical Services (RDCS) #342 revealed the Administrator stated she spoke with Resident #23 and anyone with involvement and determined straight away that nothing happened. RDCS #342 confirmed the questions residents were asked pertaining to the investigation did not include questions specific for abuse.

Observation on 06/03/24 at 4:09 P.M. of Resident #116 revealed she was lying in bed watching television.

Interview on 06/03/24 at 4:09 P.M. of Resident #116 revealed she was Resident #23's roommate and when Resident #23 returned from her shower with STNA #281 she was almost in tears. Resident #116 stated STNA #281 did not want to give Resident #23 her shower. Resident #116 stated STNA #281 stated she was not supposed to give showers and both Resident's #23 and #116 put their call light on to damned much and STNA #281 slammed the door on her way out of their room. Resident #116 indicated after STNA #281 left the room Resident #23 was in tears and stated she would never let STNA #281 give her a shower again. Resident #116 indicated Resident #23 told her STNA #281 would not let her wash herself, and washed her real quick and was hollering and screaming. Resident #116 stated Resident #23 was really sad. Resident #116 stated she felt STNA #281 was verbally abusive to her.

Observation on 06/03/24 at 4:15 P.M. of Resident #23 revealed she was in her wheelchair in the common area and was heading back to her room.

Interview on 06/03/24 at 4:15 P.M. of Resident #23 revealed when STNA #281 gave her a shower she was mean to her, speaking in a nasty voice and was yelling continually and saying things like she did not have to be there and she was ready to leave. Resident #23 asked STNA #281 why she was yelling at her and STNA #281 said she was not yelling, that the way she was talking was her regular voice, but Resident #23 said she knew that was not her regular voice because she was yelling. Resident #23 stated she was so upset when she was in the shower room with STNA #281 because she didn't want to be in the shower room with her, she was very uncomfortable, and could not wait for the shower to be over. Resident #23 stated she told STNA #281 she could wash her own hair, but STNA #281 would not let her, and continued to wash it herself. Resident #23 stated she felt STNA #281 was verbally abusive to her.

Review of Resident #23's SRI dated 04/23/24 revealed the questions residents were asked were not specific to abuse. The questions were Do staff assist you with your needs?; Do staff members assist you with incontinence care?; Do you receive your medications?; Are you assisted when you need help with something?; and Do you have anything else you would like to tell me?.

Review of the facility policy titled Ohio Resident Abuse Policy revised 03/03/17 included the facility would not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. It was the facility policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown source. Facility must immediately report all such allegations to the Administrator or Abuse Coordinator, and the Administrator or Abuse Coordinator would immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in the policy. Residents, interested family members, or other persons might contact any member of the administration, or the facilities nursing staff at any time with concerns relating to abuse, mistreatment, neglect, involuntary seclusion, the misappropriation of a resident's property, or concerns about a resident's injury. Verbal abuse was defined as the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. Documentation in the nurses' notes should include the results of the resident's ROM, body assessment, vital signs, the notification of the physician and the responsible party and treatment provided. All allegations of Abuse, Neglect, Involuntary Seclusion, Injuries of unknown source, and misappropriation of resident property must be reported immediately to the Administrator, Director of Nursing and to the applicable State Agency. If the event that caused the allegation involved an allegation of abuse or serious bodily injury, it should be reported to eh DOH (Department of Health) immediately, but no later than two hours after the allegation was made. The person investigating the incident should interview the resident, the accused, and all witnesses. Witnesses generally include anyone who witnessed or heard the incident, came in close contact with the resident the day of the incident, and employees who worked closely with the accused employee and or alleged victim the day of the incident.

This deficiency represents non-compliance investigated under Complaint Number OH00153519.

Based on observation, interview, record review, facility Self-Reported Incident review, hospital record review, and review of the facility policy the facility failed to ensure a comprehensive fall risk assessment with individualized interventions was in place for Resident #83 and failed to timely assess and properly treat the resident after a fall.

Actual harm occurred on 04/29/24 when Resident #83, who was at risk for falls did not have individualized interventions in place to address the risk, fell in her room and was not thoroughly assessed before being returned to bed. This resulted in the resident experiencing severe pain to her leg and a delay in immediate treatment. The resident was subsequently transferred to the emergency room for treatment of a femur fracture requiring surgical repair. This affected one resident (#83) of three residents reviewed for falls. The facility census was 122.

Findings include:

Review of Resident #83's medical record revealed an admission date of 04/10/24 and a readmission date of 05/08/24. Resident #83's diagnoses included displaced intertrochanteric fracture of the right femur, type two diabetes mellitus without complications, rhabdomyolysis and bipolar disorder, current episode depressed, mild or moderate severity.

Review of Resident #83's handwritten Preadmission Fall Review dated 04/10/24 included yes was checked for mental status, but the document did not specify as indicated if Resident #83 was confused, had delirium, had altered level of consciousness, disorganized thinking, memory or cognitive impairment, or poor safety awareness. Mobility was checked, but the document did not specify as indicated if Resident #83 had ataxia, unsteady, shuffling gait, ambulated with assistance of one person, had balance impairment or was unable to transfer, ambulate. The Preadmission Fall Review further included if yes was checked for either category of mental status or mobility the resident was considered high risk and appropriate interventions should be implemented. A preliminary review of pre-admission medical information revealed factors that might place the resident at a greater risk for falls. Please note the following interventions made by therapy and nursing in an attempt to decrease the risk of falls. The area stating what the risk factors were was not completed. Immediate Fall Prevention Interventions circled were bed in lowest position.

Review of Resident #83's handwritten Therapy-to-Nursing Communication Form dated 04/12/24 revealed the front of the form was not completed, and the back of the form had a Desmond Fall Risk Questionnaire which was completed, but unsigned. The Questionnaire included Resident #83 had a fall or near fall in the past year. Resident #83 felt uneasy or unsteady when walking down the aisle of a supermarket or in an area congested with other people. Resident #83 took medication for depression, anxiety, nerves, sleep or pain.

Review of Resident #83's Admission Minimum Data Set (MDS) 3.0 assessment dated 04/17/24 revealed Resident #83 was cognitively intact. The assessment also noted Resident #83 had a fall within the last month of her admission to the facility.

Review of Resident #83's care plan (initiated 04/10/24) included Resident #83 was at risk for falls related to impaired balance, muscle weakness, med use, debility, and impaired mobility. Resident #83 would minimize risk for falls and minimize injuries related to falls with a target date of 12/01/24. However, there were not fall interventions identified to address the fall risk. On 04/23/24 an intervention stated a fall risk evaluation would be completed to identify and minimize initial risk factors for falls and injury. There was no evidence individualized interventions were implemented including bed in lowest position until 04/29/24 (the date of Resident #83's injury of unknown origin). Interventions documented on 04/29/24 included encourage Resident #83 to keep bed in low position; fall risk assessment per routine and as needed; maintain call light within reach; reinforce need to call for assistance. When attempt was made to click on each intervention on 04/29/24 to review the history of the intervention, there were no historical interventions identified to review.

Review of Resident #83's progress notes and care plan dated 04/10/24 through 04/29/24 did not reveal evidence Resident #83's bed was in the lowest position.

Review of Resident #83's medical record including progress notes from 04/10/24 through 04/29/24 did not reveal a fall risk evaluation was completed.

Review of Resident #83's care plan dated 04/23/24 included Resident #83 was at risk for deterioration in ADLs due to immobility, fall risk, diagnosis process, medications, and incontinence. The goal indicated Resident #83 would not deteriorate in ADLs as evidenced by maintaining ability to eat after set up. Interventions included to provide assistance for all ADLs.

Review of Resident #83's progress notes dated 04/29/24 at 8:00 A.M. revealed Resident #83 was complaining of right lower extremity (RLE) pain. New order obtained from Certified Nurse Practitioner (CNP), and responsible party notified. There was no documentation describing what was causing the pain or the appearance of Resident #83's right lower extremity at this time.

Review of Resident #83's physician's orders dated 04/29/24 at 9:26 A.M. revealed an order for a stat x-ray right femur 1-2 view, and stat x-ray right hip 1-2 view.

Review of Resident #83's Physical Therapy Missed Visit Details dated 04/29/24 revealed nursing hold due to Resident #83 had complaints of hip pain after possible fall. X-rays ordered.

Review of Resident #83's progress notes dated 04/29/24 at 3:15 P.M. revealed Resident #83 was noted to have pain in the right lower extremity, and was painful to touch. Resident #83's Nurse Practitioner (NP), NP #339, was notified and x-rays were ordered. Resulted with comminuted mild displaced femoral fracture. NP gave order to transfer Resident #83 to the local hospital orthopedic department for further evaluation. Responsible party notified.

Review of an Event Report initiated 04/29/24 at 3:10 P.M. and completed 05/21/24 at 4:56 P.M. included Resident #83 had a fracture of the right femur and the location where the event occurred was unknown. Resident #83 complained of pain in right lower extremity, painful to touch, Resident #83's Nurse Practitioner (NP), NP #339, was notified and gave orders for an x-ray. Resident #83's x-ray results were comminuted (fracture producing multiple bone splinters) mild displaced femoral fracture. When Resident #83 was asked what happened she stated she fell at home. Resident #83 was transported to the hospital emergency room. The report indicated Resident #83 was oriented to person, and was ambulatory with assistance. The event was not witnessed. Further review of the Event Report included the facility completed a thorough investigation and was not able to determine the cause of the fracture. Resident #83 was alert and oriented times two with confusion. Resident #83 stated she had a fall at her apartment prior to coming to the facility. Resident #83 had a history of noncompliance with ambulating without assistance and fall prior to admission at home and also in hospital. After interviewing all staff and residents no abuse or fall was suspected. Resident #83 had the ability to self-transfer, ambulate and get herself off the floor. Resident #83 was receiving therapy services (PT, OT, and ST) and was ambulating in therapy up to 100 feet.

Review of a facility self-reported incident (SRI), tracking number 246928, dated 04/29/24 revealed the facility reported Resident #83 had an injury of unknown source. The SRI included Resident #83 did not provide meaningful information when interviewed. The Administrator was notified Resident #83 had a fracture of unknown origin. Resident #83 complained of RLE pain and when interviewed she stated she fell at home. The facility obtained an x-ray which showed a fracture. The nurse practitioner (NP) gave orders to transport Resident #83 to the emergency room for further evaluation from orthopedics. The facility was obtaining hospital notes prior to nursing home admission to see if Resident #83's fracture was prior and RLE complaint of pain was present. Resident #83 had an extensive social history, APS involvement, unsafe and unsanitary living conditions. Resident #83 had a Brief Interview for Mental Status of 14 (cognitively intact), and stated she fell at home but the facility was not aware of fracture prior to admission. Resident #83 received surgery to repair the fracture and would return to the facility. The SRI revealed all nurses and State Tested Nursing Assistants (STNAs) assigned to care for Resident #83 were interviewed and all staff denied Resident #83 fell as well as any other events taking place. The facility believed the incident happened at home (prior to the 04/10/24 admission) as Resident #83 described or while at the hospital prior to admission to the facility.

Review of the staffing schedule revealed on 04/28/24 at 10:00 P.M. through 04/29/24 at 6:00 A.M. there were nine STNA staff, including four male STNA's. STNA #257 was assigned to care for Resident #83.

Review of Licensed Practical Nurse (LPN) #341's Witness Statement dated 05/29/24 (meant 04/29/24) revealed after report and counting (medications) an unidentified aide asked her to come to Resident #83's room and look at her related to complaints of pain while the aide was dressing her. LPN #341 stated upon assessment she observed internal rotation to the right foot and Resident #83 complained of RLE pain. LPN #341 contacted the on call and obtained orders for an x-ray.

Review of a Witness Statement written by the Director of Nursing (DON) included on the morning of 04/29/24 an unidentified floor nurse noted Resident #83 voiced complaints of pain in the lower back and right hip. Upon assessment Resident #83's right hip was painful to touch. When asked what happened Resident #83 stated she had a fall at home prior to coming to the facility. The DON asked if she had a fall at the facility at any time Resident #83 stated no. The NP was notified, and orders were given to get an x-ray due to pain.

Review of Resident #83's Ortho Consult at the hospital on 04/29/24 at 9:35 P.M. included Resident #83 presented with right hip pain after a fall from standing at her facility (contradictory account of the accident from the facility injury of unknown origin report and investigation). Resident #83 was unable to get up and had to call for help. Resident #83 denied new significant pain other than right hip. Resident #83 denied head trauma and loss of consciousness. Resident #83 was awake and oriented times three (person, place, time), and her mood and affect were calm and appropriate to the situation. Resident #83 was in bed and unable to ambulate secondary to known injury. Resident #83's right lower extremity was shortened and externally rotated. Resident #83's x-ray of the right hip dated 04/29/24 revealed she had a four part intertrochanteric femur fracture. No other acute fracture or dislocation. X-ray results of the right femur were pending. Plan for surgery (OR) for right hip cephalomedullary nailing (CMN) on 04/30/24.

Review of Resident #83's progress notes dated 04/30/24 at 12:01 P.M. included Resident #83 was admitted to the local hospital and was scheduled for surgery this morning per NP #339.

Review of Resident #83's Discharge Summary for her hospital admission dated 04/29/24 through 05/08/24 included Resident #83 had a right intertrochanteric femur fracture, status post (s/p) CMN on 04/30/24.

Review of Resident #83's physician progress note dated 05/13/24 written by NP #339 included on 04/29/24 Resident #83 was sent to the emergency room after a fall with RLE pain, an x-ray showed right intertrochanteric femur fracture. Resident #83 underwent CMN on 04/30/24. Resident #83 returned to the facility for rehab.

Observation on 05/29/24 at 5:04 P.M. revealed Resident #83 was lying in bed, the lights were dim and observation of her window blinds revealed a couple slats were broken and large pieces of the blinds were missing.

During an interview with Resident #83 on 05/29/24 at 5:04 P.M. the resident revealed she fractured her hip. Resident #83 stated (on 04/29/24) she got out of bed, she was standing and went to hang her clothing on a chair and fell down. Resident #83 stated she broke her blinds when she fell. The resident stated she laid on the floor and knew she broke something when she fell. Resident #83 stated a guy came into her room, picked her up, was not gentle, put her in bed and he really hurt her as he was putting her in bed. Resident #83 stated her fall happened between 12:00 A.M. and 1:00 A.M. Resident #83 stated she did not remember anyone coming in her room after that, her call button was not in her reach and she could not activate it to call for help. Resident #83 indicated she did not know how long she laid on the floor before the guy came in and put her to bed. Resident #83 stated later in the day the paramedics were called and she was taken to the hospital.

During a follow-up interview with Resident #83 on 05/30/24 at 9:54 A.M., the resident revealed she had told the staff about her fall at the facility (on 04/29/24), how she was standing in her room, turned around and fell, and the aide picked her up and roughly put her in bed. Resident #83 stated she did not tell the staff she fell at home. Resident #83 again stated after the aide put her back in bed no one came in to see how she was, and that surprised her because she thought a nurse would come in to see if she was okay. Resident #83 stated she was in a lot of pain and her hip hurt so bad. Resident #83 indicated she was trying to remember what the male aides name was, but she could not remember.

An interview with STNA #257 on 05/30/24 at 3:30 P.M. revealed she was assigned to care for Resident #83 on 04/29/24 but she could not recall an incident with Resident #83 on 04/29/24 and did not know anything about Resident #83's injury.

Interview on 06/03/24 at 11:55 A.M. with Minimum Data Set (MDS) Nurse #237 revealed the facility recently changed companies for Residents Electronic Health Records (EHR), and the date of the change was 04/08/24. MDS Nurse #237 revealed Resident #83 was admitted two days after the facility changed companies. MDS #237 confirmed she edited Resident #83's care plan on 04/29/24, but stated she could not remember the details surrounding the edit. MDS Nurse #237 stated some of the problems and interventions were copied and pasted from the old EHR company to the care plans of the new EHR during the transition. The MDS Nurse stated she could not remember if she copied and pasted the problem and intervention for falls into Resident #83's care plan on 04/29/24, but said it was likely because when the interventions were clicked on in the care plan a history could not be seen.

Interview on 06/03/24 at 2:39 P.M. with LPN #341 revealed on 04/29/24 she worked day shift and arrived for work at 7:00 A.M. LPN #341 stated she got report, counted and was preparing for the med pass when an unidentified aide yelled for her to go to Resident #83's room because she was having pain. LPN #341 stated Resident #83 was having pain and it was obvious her leg did not look normal, it was turned in and did not look right. LPN #341 indicated she barely touched Resident #83 leg and the touch caused severe pain. LPN #341 stated she called the nurse who worked night shift, but the nurse had no knowledge of any incident regarding Resident #83, and said nothing was reported to her. LPN #341 stated she told NP #339 there was definitely something wrong with Resident #83's leg and obtained an order for an x-ray. LPN #341 stated she asked Resident #83 what happened and Resident #83 said at around 2:00 A.M. she fell and was on the floor and a guy that helped everyone helped her up, but she did not know his name. LPN #341 stated she told Unit Manager (UM) #200 that Resident #83 fell, was on the floor and a male aide helped her off the floor and put her back to bed. When asked why she did not include Resident #83 had a fall, was found on the floor and helped back to bed by a male aide in her witness statement regarding the incident, LPN #341 stated she was told to write a statement of what she found when she got to Resident #83's room, so she only put that and not what Resident #83 told her. LPN #341 stated that was why she did not write anything else about Resident #83's fall and assistance back to bed by a male aide.

Interview on 06/03/24 at 2:44 P.M. with Unit Manager (UM) #200 revealed UM #200 stated from her understanding Resident #83 was in bed and said her leg was hurting. UM #200 indicated a couple STNAs were asked what happened but they could not say. UM #200 stated Resident #83 was reaching for her pants, she heard Resident #83 was on the floor and an aide helped her up. UM #200 stated she did not interview Resident #83, only observed her leg. UM #200 stated Resident #83 required extensive assistance and could not ambulate safely by self.

Interview on 06/03/24 at 2:55 P.M. with STNA #203 and #228 revealed they took care of Resident #83 and were familiar with her. STNA #228 stated Resident #83 liked to stay up until around 1:00 A.M. then she would put her call light on for them to assist her into bed. STNA #228 stated Resident #83 had to be reminded to use the call light and she would try to get up on her own if she did not have the call light close by. STNA #228 stated before Resident #83's incident on 04/29/24 Resident #83's leg was not painful to touch or turned in. STNA #228 stated he wrote a witness statement stating he had no knowledge of Resident #83's incident. STNA #203 stated he was not asked about the incident or told to write a witness statement because Resident #83 was not his resident.

Interview on 06/03/24 at 3:00 P.M. with STNA #228 revealed he was not usually assigned to care for Resident #83, but the STNA's on the nursing unit worked together as a team and would help each other out with the assignments. STNA #228 stated he knew Resident #83 well and often went in her room to assist with her needs. STNA #228 stated he could not recall an incident on 04/29/24 and had no knowledge of a fall.

Interview on 06/03/24 at 3:36 P.M. with the DON revealed on 04/29/24 she was driving to the facility and she was called by UM #200 regarding Resident #83 and UM #200 was going to assess her. The DON stated NP #339 was in the facility, saw Resident #83 and ordered x-rays. The DON indicated the x-rays showed Resident #83 had a fracture and NP #339 gave orders for Resident #83 to be transported to the hospital for evaluation. The DON stated the facility started an investigation for injury of unknown origin, and stated she interviewed Resident #83 multiple times. The DON indicated Resident #83 stated she fell at her apartment, not at the facility. The DON stated no one told her Resident #83 fell at the facility or that Resident #83 said she fell and a male helped her back to bed. The DON indicated Resident #83 had a history of falls before she was admitted to the facility.

Interview on 06/03/24 at 4:41 P.M. with NP #339 revealed she received a call on 04/29/24 at around 8:00 A.M. by a nurse who just came on shift. NP #339 stated the nurse told her Resident #83 had fallen overnight, was having a lot of pain, and her leg did not look right. NP #339 stated she requested an x-ray and the x-ray showed Resident #83 had a fracture. NP #339 indicated she did not talk to Resident #83 about her fall because she not in the facility that day. NP #339 stated Resident #83's fall was around 3:00 A.M., somebody picked her up and put her back to bed, the facility did an investigation about that but she was not sure of the outcome. NP #339 stated Resident #83 had frequent falls at home, but she did not recall having any information about a fracture at home before she was admitted to the facility. NP #339 stated in her previous visits with Resident #83 before the fall on 04/29/24 she did not remember her leg being internally rotated or painful to the touch. NP #339 stated she read the hospital records and Resident #83's assessment when she arrived to the ED, and the assessment was not what Resident #83 had prior to her fall. NP #339 stated her leg did not look like that prior to the fall on 04/29/24.

Interview on 06/04/24 at 9:35 A.M. with Regional Director of Clinical Services (RDCS) #342 revealed the RDCS did not believe the facility had evidence Resident #83 fell and hurt her hip. RDCS #342 stated Resident #83 had pain, the DON called her, and a self-reported incident was opened for an Injury of Unknown Origin. RDCS #342 stated the DON said she did not know how Resident #83 fell, an investigation was conducted, everyone was interviewed, and no one admitted to picking Resident #83 off the floor and putting her back to bed. RDCS #342 stated she did not know how Resident #83 fell and got herself back to bed. When Resident #83 returned to the facility they made sure all interventions were in place and the facility ruled out abuse. RDCS #342 indicated she talked to the therapy department staff and was told Resident #83 was ambulatory and could walk 100 feet. RDCS #342 stated she did not know what truly happened. RDCS #342 confirmed Resident #83 did not have a fall risk evaluation completed when she was admitted to the facility. RDCS #342 indicated the handwritten Preadmission Assessment was completed by therapy and was usually completed by nursing or therapy or both.

Review of the facility policy titled Fall Prevention and Management, references were State Operations Manual 2017 and included residents would be assessed for fall risks on admission, quarterly, after any fall and as needed. If risks were identified, preventative measures would be put in place and care planned. All falls would be reviewed and investigated. Providers would be consulted regarding risks and interventions, feedback, and any further approaches.

This deficiency represents non-compliance investigated under Complaint Number OH00154506, OH00153567, and OH00154128.

Based on record review and interview, the facility failed to timely ensure a comprehensive treatment plan was in place to properly drain, monitor, and dress Resident #125's chest tube. This affected one resident (Resident #125) of three residents reviewed for quality of care.

Findings include:

Review of the closed medical record for Resident #125 revealed an admission date of 03/14/24 and a discharge to the hospital on 04/01/24. Diagnoses included acute and chronic diastolic heart failure, end stage renal disease and cardiomyopathy.

Review of the hospital discharge orders dated 03/15/24 revealed the orders did not identify how to care for the chest tube or how often it should be drained and how often the dressing should be changed.

Review of an email dated 03/15/24 from the Admission Director to the facility care team revealed the facility was aware Resident #125 had a chest tube upon admission.

Review of the care plan initiated on 03/17/24 revealed a goal to manage Resident #125's diagnosis of congestive heart failure. The interventions for CHF did not identify any care or monitoring of the resident's chest tube. Resident #125's medical record did not indicate why the resident had a chest tube.

Review of Resident #125's physician orders and medical record revealed no evidence of orders to drain, monitor, or care for chest tube until 03/18/24.

Review of the physician orders and Treatment Administration Records (TAR) for March 2024 revealed an order dated 03/18/24 for the chest tube to be drained every three days and as needed. The chest tube was initially drained on 03/19/24 then subsequently drained on 03/20/24, 3/22/24, 03/25/24, 03/26/24, 03/27/24, 03/28/24, 03/29/24, 03/30/24 and 03/31/24. On 03/19/24 orders to drain the chest tube three times a week and record volume was put in place.

Further review of the medical record and TAR revealed the facility did not order a dressing change to Resident #125's chest tube until 03/26/24 that included drain daily and as needed, access site and drain using sterile technique. Replace dressing using sterile technique and record volume. The order did not specify the type of dressing required.

Interview on 04/16/24 at 9:30 A.M. with Director of Nursing in review of hospital paperwork showed Resident #125's chest tube was last drained on 03/15/24 before admission and the facility was aware of the chest tube prior to admission without specific care orders.

Interview on 04/16/24 at 9:30 A.M. with Certified Nurse Practitioner (CNP) #900 revealed she addressed the admission orders and acknowledged the resident had a chest tube upon admission. She confirmed there were not orders to care for the chest tube upon admission. A subsequent interview at 10:10 A.M. with the CNP #900 revealed the hospital did not know the proper diagnoses for the chest tube. She stated they used it because of fluid build-up. It was meant to be temporary.

This deficiency represents non-compliance investigated under Complaint Number OH00152477.

Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #121's incontinence care was completed timely. This affected one resident (Resident #121) out of three residents reviewed for incontinence care. The facility census was

Findings include:

Review of Resident #121's medical record revealed an admission date of 04/13/23 and diagnoses included altered mental status, unspecified dementia, unspecified severity with agitation, type two diabetes mellitus with diabetic chronic kidney disease.

Review of Resident #121's care plan dated 04/14/23 included Resident #121 was incontinent of bladder and bowel. Resident #121 would receive assistance with toileting, maintained comfortable, clean and dry, and free from skin breakdown. Interventions included to provide incontinence care as needed, and monitor peri-area for redness, irritation, skin excoriation and breakdown. Resident #121 had noncompliance related to history of noncompliance at home with not taking medications and refusing care. Resident #121 would not have any negative outcomes related to noncompliance through the next review. Interventions included to explain procedures prior to starting them and the benefits of the procedure, and to notify Resident #121's physician of noncompliance per routine and as needed.

Review of Resident #121's Annual Minimum Data Set (MDS) 3.0 assessment dated 04/05/24 revealed Resident #121's Brief Interview for Mental Status was not assessed. Resident #121 was always incontinent of urine and bowel. Resident #121 had no impairment of the upper or lower extremities. Resident #121 required substantial to maximal assistance with toileting and personal hygiene.

Review of the facility Daily Staffing assignments revealed State Tested Nursing Assistant (STNA) #700 was assigned to care for Resident #121 on 04/18/24 from 6:00 A.M. until 2:00 P.M. STNA #701 was assigned to care for Resident #121 on 04/18/24 from 2:00 P.M. until 5:00 P.M.

Review of Resident #121's progress notes on 04/18/24 from 6:00 A.M. through 4:00 P.M. did not reveal evidence Resident #121 refused to have her incontience brief changed or she had redness to her buttocks, abdomen, crease of right thigh, perineal area, and posterior thighs.

Observation on 04/18/24 at 4:02 P.M. of STNA #701 revealed she walked into Resident 121's room, Resident #121 was sitting in a wheelchair in her room near her bed, and a large puddle of liquid was observed underneath the wheelchair. STNA #701 found a dry towel and soaked up the large puddle of liquid, and wiped the floor dry with the towel. Observation of the towel revealed it was wet with a large amount of dirt on the towel and it was hard to determine if the puddle under Resident #121's wheelchair was urine. STNA #701 left the room and returned with Licensed Practical Nurse (LPN) #702, and the two of them assisted Resident #121 to stand up, and sit on the edge of the bed. Observation revealed when Resident #121 stood up her pants were drenched with urine and the seat of the wheelchair was extremely wet with urine. Before assisting Resident #121 to sit on the side of the bed STNA #701 slid Resident #121's pants down and observation of her incontinence brief revealed it was saturated with urine and hanging down and away from her body. LPN #702 and STNA #701 helped Resident #121 into a lying position and proceeded to provide incontinence care. When Resident #121's brief was removed along with being saturated with urine a moderate to large greenish-brown semi-formed bowel movement could be seen in the brief. Resident #121's buttocks, inner buttocks, upper posterior thighs and perineal area were reddened, and Resident #121 cried out in pain when STNA #701 was cleansing her buttocks and perineal area. Observation of Resident #121's anterior upper thigh, crease of her right leg, and abdomen near the crease of her right leg revealed a large, reddened, irritated area of skin. LPN #702 and STNA #701 confirmed Resident #121's buttocks, inner buttocks, upper posterior thighs and perineal area were reddened, and Resident #121 had a large reddened, irritated area in her right leg crease, right thigh and abdomen. STNA #701 left the room to find Wound Nurse (WN) #703. WN #703 arrived and confirmed the large red area to Resident #121's right leg crease and abdomen and said she would need to call Resident #121's Nurse Practitioner to discuss the treatment.

Interview on 04/18/24 at 4:02 P.M. with STNA #701 revealed Resident #121's incontinence brief looked like it had not been changed for awhile and it was not on her and it was not her who was responsible because she just took over the care of Resident #121 at 2:00 P.M. STNA #701 stated STNA #700 took care of her from 6:00 A.M. until 2:00 P.M. and STNA #700 did not say anything about Resident #121's incontinence brief needing changed before she left.

Interview on 04/18/24 at 4:02 P.M. with LPN #702 revealed she was not aware and no STNA had reported to her Resident #121 had a large reddened, irritated area on the crease of her right thigh and abdomen and she was not aware Resident #121 had redness on her buttocks, inner buttocks, and perineal area.

Review of Resident #121's progress notes dated 04/18/24 at 5:00 P.M. included Resident #121's Nurse Practitioner was contacted and informed Resident #121 had redness in lower abdomen, groin and side fold areas. Resident #121's Nurse Practitioner gave instructions to wash the area with mild soap, pat dry and apply nystatin powder (treats fungal or yeast infections) twice a day for fourteen days.

This deficiency represents non-compliance investigated under Master Complaint Number OH00152597 and Complaint Number OH00152477.

Based on observation, record review and interview, the facility failed to ensure Resident #470's call light was available and accessible for the resident's use. This affected one (Resident #470) of 18 residents (Residents #4, #10, #11, #48, #50, #52, #53, #54, #63, #85, #107, #112, #118, #470, #471, #472, #475 and #570) who were observed for call lights within reach. The facility census was 123.

Findings include:

Review of Resident #470's medical record revealed the resident was initially admitted on 10/24/23 and readmitted on 12/02/23 with diagnoses including acute respiratory failure with hypoxia, shortness of breath and acquired clubfoot. Review of Resident #470's Minimum Data Set (MDS) 3.0 assessment dated 11/09/23 indicated Resident #470 exhibited intact cognition.

Observation on 12/04/23 at 8:30 A.M. revealed Resident #470's call light was not plugged into the wall for Resident #470 to call the nursing staff for assistance. Interview on 12/04/23 at 8:30 A.M. with Resident #470 revealed they had not had a call light since admission on 12/02/23.

Interview on 12/04/23 at 3:46 P.M. with Licensed Practical Nurse (LPN) #873 verified Resident #470 did not have a call light and there was no call light plugged into the wall. A search of the room revealed the unplugged call system in the bed of Resident #470's roommate. The call system was plugged in and tested by LPN #873.

Residents #4, #10, #11, #48, #50, #52, #53, #54, #63, #85, #107, #112, #118, #470, #471, #472, #475 and #570 were alert and oriented and capable of using a call light to request staff assistance.

Review of the policy titled: Resident Communication and Call Light Policy dated 02/24/23 revealed it was the policy of the facility to provide residents with a means of communicating with staff. A call system was to be installed in each resident room and toilet/bath areas.

Based on observation and interview, the facility failed to ensure Residents #82's and #470's bathrooms were maintained at a comfortable ambient temperature. This affected two (Residents #82 and #470) of nine residents (Residents #10, #54, #55, #78, #82, #116, #470, #471 and #473) whose bathroom temperatures were checked. The census was 123.

Findings include:

Interview on 12/04/23 at 9:00 A.M. with Resident #82 revealed the resident's bathroom was cold. Resident #82 was observed in bed across from the bathroom with three blankets on and was wearing a stocking cap. Resident #82 stated cold air blew on them from the bathroom. Upon entering the bathroom it felt cold.

Interview on 12/04/23 at 9:15 A.M. with Resident #470 revealed the resident's bathroom was cold.

Interview and observation on 12/06/23 at 8:10 A.M. with Maintenance Director (MD) #856 revealed the ambient temperature on the 300 hall was 73.9 degrees Fahrenheit (F). The temperature in resident rooms was controlled by the thermostat in Room 319. Resident rooms did not have individual thermostats to control the temperatures in their rooms. Resident #82's room temperature was 75.3 degrees F and the temperature in the bathroom was 61.5 degrees F. The ambient temperature in Resident #470's bathroom was 62.2 degrees F. All temperatures were taken and verified by MD #856.

A review of the policy titled; Temperature dated January 2016 revealed a comfortable temperature would be maintained in all resident areas within the home. The temperature range was to be maintained between 71 and 81 degrees F.

Based on record review and interview, the facility failed to ensure assessments were accurately completed. This affected four (Residents #4, #52, #93 and #112) of four residents reviewed for Minimum Data Set (MDS) 3.0 assessments. The facility census was 123.

Findings include:

1. Review of the medical record for Resident #4 revealed an admission date of 09/03/21 with diagnoses including chronic respiratory failure, depression and adult failure to thrive.

Review of the physician's orders for November 2023 revealed Resident #4 had an order for a regular diet dated 08/11/23.

Review of the quarterly MDS 3.0 assessment dated 11/16/23 for Resident #4 revealed under section K0520 that she did not have a feeding tube or parenteral/intravenous feedings. However, section K0710 was documented as receiving 25% or less total calories through parenteral or tube feeding as well as 500 cubic centimeters (cc)/day or less fluid intake per day by IV or tube feeding. Section K0710 stated to complete K0710 only if checked in section K0520 for intake by artificial route.

Interview on 12/05/23 at 2:25 P.M. with Dietitian #817 verified she had completed this section incorrectly.

2. Review of the medical record for Resident #52 revealed an admission date of 02/21/22 with diagnoses including dementia, hypertension (high blood pressure) and Parkinson's Disease.

Review of the physician's orders for November 2023 revealed Resident #52 had an order for a regular diet with mechanical soft texture dated 10/03/23.

Review of the quarterly MDS 3.0 assessment dated 10/18/23 for Resident #52 revealed under section K0520 that he did not have a feeding tube or parenteral/intravenous feedings. However, section K0710 was documented as receiving 25% or less total calories through parenteral or tube feeding as well as 500 cc/day or less fluid intake per day by IV or tube feeding. Section K0710 stated to complete K0710 only if checked in section K0520 for intake by artificial route.

Interview on 12/05/23 at 2:25 P.M. with Dietitian #817 verified she had completed this section incorrectly.

3. Review of the medical record for Resident #93 revealed an admission date of 10/13/21 with diagnoses including diabetes mellitus, chronic kidney disease and anxiety.

Review of the physician's orders for November 2023 revealed Resident #93 had an order for a regular diet with pureed texture dated 10/03/23.

Review of the annual MDS 3.0 assessment dated 10/20/23 for Resident #93 revealed under section K0520 that she did not have a feeding tube or parenteral/intravenous feedings. However, section K0710 was documented as receiving 25% or less total calories through parenteral or tube feeding as well as 500 cc/day or less fluid intake per day by IV or tube feeding. Section K0710 stated to complete K0710 only if checked in section K0520 for intake by artificial route.

Interview on 12/05/23 at 2:25 P.M. with Dietitian #817 verified she had completed this section incorrectly.

4. Review of the medical record for Resident #112 revealed an admission date of 09/07/23 with diagnoses including chronic kidney disease, anxiety, depression and hypertension.

Review of the physician's orders for November 2023 revealed Resident #112 had an order for a regular diet with regular texture dated 09/28/23.

Review of the admission MDS 3.0 assessment dated 10/04/23 for Resident #112 revealed under section K0520 that she did not have a feeding tube or parenteral/intravenous feedings. However, section K0710 was documented as receiving 25% or less total calories through parenteral or tube feeding as well as 500 cc/day or less fluid intake per day by IV or tube feeding. Section K0710 stated to complete K0710 only if checked in section K0520 for intake by artificial route.

Interview on 12/05/23 at 2:25 P.M. with Dietitian #817 verified she had completed this section incorrectly.

Based on observation, interview and record review, the facility failed to provide timely incontinence care for residents. This affected one (Resident #4) of one resident reviewed for incontinence care. The facility census was 123.

Findings include:

Review of the medical record for Resident #4 revealed an admission date of 09/03/21 with diagnoses including adult failure to thrive, need for assistance with personal care, and muscle weakness.

Review of the care plan for Resident #4 dated 05/11/23 revealed she was incontinent of bladder. Staff were to provide incontinence care as needed.

Review of the physician's orders for December 2023 revealed Resident #4 had an order for staff to check and change Resident #4 every two to three hours and as needed dated 08/11/23.

Review the Treatment Administration Record (TAR) for October 2023 revealed staff had not documented that they had checked and changed Resident #4 every two to three hours on 10/05/23 and 10/15/23 for the 7:00 P.M. shift.

Review of the TAR for November 2023 revealed staff had not documented that they had checked and changed Resident #4 every two to three hours on 11/07/23, 11/17/23 and 11/28/23 on the 7:00 P.M. shift as well as on 11/11/23 and 11/24/23 on the 7:00 A.M. shift.

Review of the quarterly Minimum Data Set (MDS) 3.0 Assessment dated 11/16/23 revealed Resident #4 had no behaviors, did not refuse care and had an intact cognition. She was dependent on staff for toileting and was always incontinent of urine.

Observation and interview on 12/04/23 at 9:02 A.M. of Resident #4 revealed she was in bed and eating breakfast. Resident #4 stated the staff did not provide incontinence care timely and she had not had incontinence care this morning.

Observation and interview on 12/07/23 at 8:35 A.M. of Resident #4 revealed she was still in bed. She stated staff had not provided incontinence care for her today and care was never timely.

Observation and interview on 12/07/23 at 10:25 A.M. of Resident #4 revealed she was in her wheelchair and dressed for the day. State Tested Nurse Aide (STNA) #951 was present in the room and finishing morning care. The bed was unmade and the draw sheet was wet and had a yellow circled area on it. When STNA #951 removed the draw sheet, the bed pad underneath was also wet and had yellow coloring on it. The room had an odor of urine. Resident #4 stated she had not been provided incontinence care since she went to bed the night before. STNA #951 stated she arrived at the facility at 6:00 A.M. and had not been able to provide care to Resident #4 because she had been taking care of other residents.

Interview on 12/07/23 at 11:08 A.M. with Licensed Practical Nurse (LPN) #876 revealed Resident #4 had put on her call light at 8:30 A.M. and stated she was ready to get up, get cleaned up and dressed for the day. LPN #876 stated she checked Resident #4's colostomy. LPN #876 stated she updated STNA #951 that Resident #4 was ready to get out of bed.

Review of the policy titled, Morning Care/AM Care

Based on observation, record review and interview, the facility failed to ensure Resident #107's tube feeding was infused per the physician's orders. This affected one resident (Resident #107) of one resident reviewed for tube feedings. The facility census was 123.

Findings include:

Review of Resident #107's medical record revealed the resident was admitted on 07/29/23 with diagnoses including hemiplegia and hemiparesis, gastrostomy status and cognitive communication deficit.

Review of Resident #107's physician orders revealed an order dated 08/01/23 for Isosource 1.5 at 60 cubic centimeters (cc) via a percutaneous endoscopic gastrostomy tube (PEG) for 20 hours per day. Turn off the tube feed solution at 12:00 P.M. and turn back on at 4:00 P.M.

Review of Resident #107's Minimum Data Set (MDS) 3.0 assessment dated 11/03/23 revealed the resident exhibited moderate cognitive impairment.

Observation on 12/07/23 at 9:45 A.M. revealed Resident #117 in bed. The tube feeding pump was turned off. The end of the tube was hanging over the tube feeding pole and not connected to the resident.

Interview on 12/07/23 at 9:50 A.M. with Licensed Practical Nurse (LPN) #607 verified the tube feeding was disconnected and not running. LPN #607 stated medications were administered via the PEG tube at 8:15 A.M. and the tube feed was reconnected at that time. LPN #607 was unaware how or when the feeding for Resident #117 became disconnected/turned off.

Interview on 12/07/23 at 3:15 P.M. with the Director of Nursing (DON) revealed the feeding was disconnected by her at approximately 9:15 A.M. due to Resident #117 complaining of abdominal pain. The DON confirmed there was no documentation as to why it was turned off and the DON did not notify anyone about the disconnection of the feeding or the abdominal pain.

A review of the policy titled; Enteral Feeding Tube Policy dated 09/29/21 revealed the feeding tube should not be used if there was any doubt as to placement. The physician or provider should be contacted for guidance.

Based on record review and interview, the facility failed to ensure medications were obtained timely from the pharmacy and were administered as ordered. This affected one (Resident #48) of three residents reviewed for pain medications being administered as ordered. The facility census was 123.

Findings include:

Review of the medical record for Resident #48 revealed an admission date of 06/28/23 with diagnoses including anxiety disorder, epilepsy, restlessness/agitation, polyneuropathy, and diffuse traumatic brain injury (TBI) with loss of consciousness.

Review of the physician's order dated 06/29/23 revealed an order for hospice services related to TBI with loss of consciousness.

Review of the plan of care dated 06/29/23 revealed Resident #48 had chronic pain related to TBI and polyneuropathy. Interventions included to administer pharmacological interventions as ordered.

Review of the physician's order dated 06/30/23 revealed an order for Hydromorphone Hydrochloride (HCl) eight milligrams (mg) every four hours for pain.

Review of the plan of care dated 07/02/23 revealed Resident #48 required hospice services. Interventions included to maintain Resident #48's comfort level.

Review of the Medication Administration Record (MAR) for July 2023 revealed Resident #48's order for Hydromorphone HCl eight mg was reduced from every four hours to every six hours on 07/07/23. There was no evidence of administration of Hydromorphone HCl eight mg on 07/01/23 at 9:00 P.M., 07/02/23 at 1:00 A.M., 07/02/23 at 5:00 A.M., 07/02/23 at 9:00 A.M., 07/02/23 at 1:00 P.M., 07/02/23 9:00 P.M., 07/03/23 at 1:00 A.M., 07/04/23 at 9:00 A.M., 07/22/23 at 6:00 A.M., 07/29/23 at 6:00 A.M.

Review of Medication Administration Note dated 07/02/23 at 8:47 A.M. revealed Hydromorphone HCl was unavailable.

Review of Medication Administration Note dated 07/02/23 at 10:12 P.M. revealed the facility was awaiting Hydromorphone HCl from pharmacy.

Review of Medication Administration Note dated 07/03/23 at 5:45 A.M. revealed the facility was awaiting Hydromorphone HCl from pharmacy.

Review of the physician's order dated 07/07/23 revealed an order for Hydromorphone Hydrochloride (HCl) eight milligrams (mg) every six hours for pain.

Review of the MAR for September 2023 revealed there was no evidence of administration of Hydromorphone HCl eight mg on 09/29/23 at 12:00 P.M.

Review of Medication Administration Note dated 09/29/23 at 1:38 P.M. revealed Hydromorphone HCl was unavailable and pending delivery from pharmacy.

Review of Nursing Note dated 09/29/23 at 3:29 P.M. revealed Resident #48 was very tearful and emotional. Resident #48 expressed feelings towards dying and hospice was contacted.

Review of Medication Administration Note dated 09/29/23 at 5:27 P.M. revealed Hydromorphone HCl was not available and pending delivery from pharmacy.

Review of Medication Administration Note dated 09/29/23 at 6:13 P.M. revealed Resident #48 was administered Alprazolam for displaying signs and symptoms of anxiety and agitation.

Review of Nursing Note dated 09/29/23 at 6:33 P.M. revealed Hospice services nurse visited Resident #48 and assured him comfort medications were available and prescriptions were up to date.

Review of the MAR for October 2023 revealed there was no evidence of administration of Hydromorphone HCL eight mg on 10/27/23 at 6:00 P.M.

Review of the MAR for November 2023 revealed there was no evidence of administration of Hydromorphone HCL eight mg on 11/04/23 at 12:00 A.M., 11/11/23 at 12:00 P.M., and 11/11/23 at 6:00 P.M.

Review of Medication Administration Note dated 11/04/23 at 5:48 A.M. revealed Hydromorphone HCl was unavailable and pharmacy was notified for drop shipment.

Review of Medication Administration Note dated 11/11/23 at 2:03 P.M. revealed Hydromorphone HCl was on order.

Review of Medication Administration Note dated 11/11/23 at 6:00 P.M. revealed Hydromorphone HCl was unavailable and awaiting delivery from pharmacy.

Interview on 12/04/23 at 11:54 A.M. with Resident #48 and his wife revealed he frequently ran out of medications including pain medication Hydromorphone HCl. Resident #48 indicated he was told by hospice the order was standing and he should not have trouble getting refills on medications.

Attempts on 12/07/23 at 1:28 P.M. and 12/07/23 2:49 P.M. to review missing medication administration with the Director of Nursing (DON) were unsuccessful. The DON indicated she needed more time to obtain documentation. Attempts to obtain documentation were made on 12/06/23 at 4:39 P.M., 12/07/23 at 10:00 A.M., 10:50 A.M., and 11:39 A.M. The DON indicated there were concerns with pharmacy and reported plans to change pharmacy services to another company. The DON indicated there was a limited amount of medications in the emergency/starter kit for use and with the size of the facility they needed a better starter kit.

Interview on 12/07/23 at 4:00 P.M. with the Administrator, Regional Nurse, and DON revealed no additional evidence related to missing Hydromorphone HCl administrations on MARs was provided.

Based on observation, interview and record review, the facility failed to dispose of medications when they expired. This affected two (Residents #30 and #69) of four residents reviewed for medication storage. The facility census was 123.

Findings include:

1. Review of the medical record for Resident #30 revealed an admission date of 05/14/21 with diagnoses including stroke, diabetes mellitus and depression.

Review of the physician's orders for December 2023 revealed Resident #30 had an order for Humalog KwikPen 100 units/milliliter (mL), inject six units with meals for diabetes dated 11/06/23.

Review of the Medication Administration Record (MAR) for December 2023 revealed Resident #30 had received Humalog medication at meals on 12/01/23, 12/02/23, 12/03/23, 12/04/23 and 12/05/23.

Observation and interview on 12/05/23 at 11:10 A.M. with Licensed Practical Nurse (LPN) #919 of the medication cart for the 200 hall revealed Resident #30's Humalog Kwik Pen to be expired as it stated on the pen date opened on 11/01/23. LPN #919 verified the insulin had been opened and used longer than 28 days.

Review of the facility policy titled, Storage and Expiration Dating of Medications

Based on observation, interview, and record review, the facility failed to ensure a clean and sanitary kitchen area. This had the potential to affect all residents who received meals from the kitchen. The facility identified 12 residents (#2, #13, #15, #41, #62, #77, #80, #88, #94, #96, #420, and #670) that had a nothing by mouth (NPO) diet. The facility census was 123.

Findings include:

Observations of the facility kitchen on 12/04/23 at 8:22 A.M. revealed a fan located by the ice machine covered in dust. The ice machine had a white colored build up at the gaskets and the down sides. There was an unidentified brown substance on the inside of the ice machine. There were juice concentrate boxes (cranberry, fruit punch, orange, and apple) on the floor in front of the juice and coffee preparation table. Observation of the dish machine area revealed the walls were splattered with dried on food debris/drips. The floor of the dish machine area had a sticky residue with food debris throughout. There was a strong odor coming from garbage disposal and observation revealed there was large amount of food blocking the drain. The dish machine had food residue down the sides and front.

Interview on 12/04/23 at 8:24 A.M. with Dietitian #817 revealed she did not typically spend much time in the kitchen. Dietitian #817 indicated she did sanitation audits and had identified issues in the past. The findings were confirmed with Dietitian #817.

Observations of the dry storage area on 12/04/23 at 8:28 A.M. revealed multiple boxes resting on the floor including bags of egg noodles, boxes of fudge rounds, cans of white potato, cans of peaches, cans of chicken noodle soup, containers of mayonnaise, cans of banana pudding, cans of mandarin oranges, cans of pear, cans of creamed corn, box of orange juice concentrate, box of lemonade concentrate, boxes of cornbread mix, bag of rice, and containers of ketchup. There was a large bin of granulated sugar that was uncovered. Kitchen staff coats and purses were on the racks containing food. The floors in the dry storage area, including under storage racks were coated in food residue and debris.

Interview on 12/04/23 at 8:31 A.M. with Dietitian #817 confirmed the findings in the dry storage area. Dietitian #817 indicated dry storage deliveries were on Thursdays.

Observations of the walk-in cooler on 12/04/23 at 8:32 A.M. revealed the floors were coated in food debris and dark sticky residue in the walkway and under the storage racks. A plastic tub of left over canned pears was covered in plastic wrap unlabeled and undated with a serving spoon resting inside, a half bag of shredded cheddar cheese was wrapped in plastic wrap with no date or label, sliced cheese was wrapped in plastic wrap with no date or label, there was an uncovered packet of sliced cheese with no open date or label, deli ham was wrapped in plastic wrap with no label or date, an onion was wrapped in plastic wrap with no label or date, a half of an onion was wrapped in plastic wrap with no label or date, there was a bag of shredded mozzarella cheese with a bag clip on top however the bag was not fully sealed with no label or date, an open bag of shredded parmesan cheese with no label or date, and a second open bag of shredded mozzarella cheese with no label or date. There was a tray of dished pudding not covered or dated. There was an unidentified white substance in an eight-quart bin with no label or date and the top of the food product was covered in mold. There was an open bin of hard-boiled eggs.

Observation of the walk-in freezer on 12/04/23 at 8:37 A.M. revealed ice buildup at the freezer condenser and a food storage rack below. There were boxes of pancakes, dinner rolls, and pizza resting on the floor.

Observation of the food preparation area on 12/04/23 at 8:38 A.M. revealed the outside of oven with drips of food debris and burnt on grease buildup. The kitchen ventilation hood grates were covered in thick layer of dust. The four-burner range had a layer of burnt on grease on grates and drips of food debris on sides of equipment. There was a preparation table with food debris on the lower rack. The can opener had dark dried on debris. The tilt skillet had dried food splatters down the front. The toaster had dark dried on food debris. The floors in preparation areas were sticky with food debris and debris under equipment.

Interview on 12/04/23 at 8:42 A.M. with Dietitian #817 confirmed the findings in the walk-in cooler, walk-in freezer, and food preparation areas.

Review of the facility Storage of Dry Food Policy dated 06/21/21 revealed dry goods would be stored in a manner to avoid contamination, optimize food safety, and protect food quality. Food would be stored a minimum of six inches above the floor. When the original packaging was opened food must be stored in a container that could be sealed or covered. Dry storage rooms would be neat and orderly.

Review of the facility Storage of Refrigerated Foods Policy dated 08/02/23 revealed perishable foods would be stored in order to maximize food safety and quality. All food and leftovers would be stored in covered approved food grade containers. Food items would be marked to indicate the date the food would be consumed or discarded by.

Review of the facilityFood Preparation Area Policy dated 06/07/21 revealed the facility would maintain clean, sanitary and safe food preparation areas. All machines and equipment would be cleaned after use.

Review of Daily Cleaning Assignments undated revealed each position had daily cleaning assignments including preparation equipment, floors, walls, dish machine area, ice machine, coolers, and freezers.

Review of facility Delivery Schedule undated revealed the facility received deliveries from US Foods on Thursdays, Prairie Farms Dairy on Tuesdays, and Nickles Breads on Saturdays.

Based on observation, interview, and record review, the facility failed to ensure the dumpster area was maintained in a clean and sanitary manner. This had the potential to affect all residents. The facility census was 123.

Findings include:

Observation on 12/04/23 at 8:45 A.M. revealed three dumpsters. One dumpster was propped open with a white post. Observation behind and around the sides of the dumpsters revealed significant debris including gloves, boxes, plastic bags, plastic cups, a gas can, a wheelchair, stack of wooden pallets, and an upholstered chair.

Interview on 12/04/23 at 8:47 A.M. with Dietitian #817 confirmed the findings. Dietitian #817 indicated she was unsure of who was responsible for keeping the area clean and clear.

Review of the facility Waste Disposal Policy dated 06/05/18 revealed trash bags would be sealed prior to removing them from the facility. Trash would be deposited into a sealed container outside the premises. Outside dumpster lids and doors would remain closed and secure when not in use.

Based on record review and interview, the facility failed to ensure Resident #10's medical record was complete and accurate. This affected one resident (#10) of two residents reviewed for antibiotic use. The facility census was 123.

Findings include:

Review of Resident #10's medical record revealed the resident was admitted on 11/03/23 with diagnoses including diabetes, neuromuscular dysfunction of the bladder and osteomyelitis.

Review of Resident #10's physician orders revealed an order dated 11/04/23 for Vancomycin intravenous solution (antibiotic) infuse 1.5 grams intravenously every 12 hours for osteomyelitis until 11/20/23 and an order dated 11/04/23 for piperacillin sod-tazobactam intravenous solution (antibiotic) 3.375 grams infuse 3.375 grams every eight hours for osteomyelitis until 11/20/23.

Review of Resident #10's Minimum Data Set (MDS) 3.0 assessment dated 11/15/23 revealed the resident exhibited intact cognition.

Review of Resident #10's medication administration records (MARS) from 11/04/23 to 11/20/23 did not reveal evidence the vancomycin antibiotic was administered as ordered on 11/07/23 at 9:00 A.M., 11/08/23 at 9:00 A.M., 11/16/23 at 9:00 A.M., 11/17/23 at 9:00 A.M. and 11/20/23 at 9:00 A.M. The MARS did did not reveal evidence the piperacillin-sod-tazobactam antibiotic was administered as ordered on 11/05/23 at 6:00 A.M., 11/06/23 at 2:00 P.M., 11/07/23 at 2:00 P.M., 11/08/23 at 2:00 P.M. and 11/20/23 at 2:00 P.M.

Interview with Registered Nurse (RN) #861 on 12/07/23 at 11:30 A.M. revealed the antibiotics were given as ordered by her. RN #861 verified the medications were not signed off as administered.

Interview with Resident #10 on 12/07/23 at 1:00 P.M. verified that all antibiotics were administered as ordered.

Review of the Medication Administration policy dated 01/01/22 revealed, After medication administration, facility staff should take all measures required by facility policy and applicable law including but not limited to the the following: Document medication administration/treatment information on appropriate forms.

Based on observation, interview and record review, the facility failed to maintain adequate infection control practices during administration of medications to residents. This affected one (Resident #6) of six residents observed during medication administration. The facility census was 123.

Findings include:

Review of the medical record for Resident #6 revealed an admission date of 12/02/22 with diagnoses including hypertension (high blood pressure), anxiety and altered mental status.

Review of the physician's orders for December 2023 revealed Resident #6 had orders for venlafaxine (medication for depression) 150 milligrams (mg), furosemide (diuretic) 40 mg, clonazepam (medication for anxiety) 1 mg and oxybutynin chloride (medication for overactive bladder) 5 mg.

Observation on 12/05/23 at 8:05 A.M. of the medication administration to Resident #6 by Licensed Practical Nurse (LPN) #917 revealed LPN #917 pulled the clonazepam medication card from the narcotic drawer, popped the pill in her hand and placed the card back in the narcotic drawer. When asked to see the medication card and pill, LPN #917 held her hand out and the medication was in her bare hand. LPN #917 then placed the medication into a medication cup. LPN #917 then continued with Resident #6's medication administration and placed oxybutynin, furosemide and venlafaxine into the medication cup. LPN #917 moved the medication cup which then spilled the medications on to the top of the medication cart. LPN #917 picked up the medications in her bare hand and placed them back in the medication cup. LPN #917 then administered the medications to Resident #6.

Review of the facility policy titled, General Dose Preparation and Medication Administration

Based on observation and interview, the facility failed to ensure space heaters were not used by residents in the facility. This affected one resident (Resident #116) and had the potential to affect an additional 28 residents (Residents #1, #10, #17, #25, #26, #39, #50, #54, #58, #63, #66, #67, #82, #84, #85, #101, #107, #110, #120, #470, #471, #472, #473, #474, #475, #476, #477 and #670) residing on the 300 hall. The census was 123.

Findings include:

Observation on 12/05/23 at 9:00 A.M. revealed a space heater in use in Resident #116's room. Interview with Resident #116's wife at the time of the observation revealed the space heater was used to keep the room warm.

An interview on 12/05/23 at 1:45 P.M. with the Administrator revealed space heaters were prohibited in the building. The administrator stated the space heater had since been removed.

Review of the Census form revealed 29 residents resided on the 300 hall including Residents #1, #10, #17, #25, #26, #39, #50, #54, #58, #63, #66, #67, #82, #84, #85, #101, #107, #110, #116, #120, #470, #471, #472, #473, #474, #475, #476, #477 and #670.

Review of policy titled Prohibition on Use of Space Heaters dated March 2020 revealed the facility prohibited the use of any portable space heating devices.

Based on observation and staff and resident interview, the facility failed to ensure all residents had the right to a dignified existence and self-determination by not providing knives on their meal trays so their food could be cut up for ease of consumption. This affected 28 residents (#11, #12, #22, #27, #36, #38, #39, #40, #42, #43, #44, #49, #53, #57, #63, #70, #75, #76, #77, #79, #83, #90, #94, #95, #97, #104, #106, #110) on the secured units and four residents (#26, #62, #81 and #112) on the unsecured units of the 102 residents receiving meals from the kitchen. The facility identified 13 residents (#8, #10, #25, #48, #50, #65, #72, #80, #92, #103, #107, #111, and #113) as receiving nothing by mouth. The facility census was 115.

Findings include:

Observation of the tray line on 05/09/23 from 11:16 A.M. to 12:40 P.M. revealed meal trays for the Jefferson (dementia) unit had a fork and spoon on their meal tray but did not have a knife. When asked why those trays were not receiving a knife, Dietary Aide #334 replied no one receives a knife on that unit. The Regional Dietitian #398, at the time of observation, confirmed all meal trays should receive a knife unless it was individually care planned not to have one, and told the dietary staff to start putting knives on the trays.

Observation of breakfast tray on 05/10/23 at 8:30 A.M. and interview with Resident #26, who did not reside on the Jefferson unit, revealed there was a fork and spoon on the tray but no knife. Resident #26 stated very seldom had she received a knife on her meal tray.

Observation of breakfast tray on 05/10/23 at 8:32 A.M. and interview with Resident #112, who did not reside on the Jefferson unit, revealed the tray had a spoon and a fork but no knife. Resident #112 stated she rarely received knives on her meal tray. Licensed Practical Nurse #351, who delivered the breakfast tray to Resident #112, confirmed there was no knife on the breakfast tray.

Interview on 05/10/23 at 8:38 A.M. with Resident #62 revealed she never received a knife on her meal tray and if she couldn't cut something up with her fork, she wouldn't eat it.

Interview on 05/10/23 at 8:45 A.M. with Resident #81 revealed when she didn't receive a knife on her tray and if she had to spread margarine, she would use a spoon.

Interview on 05/10/23 at 9:00 A.M. with Licensed Practical Nurse #265 confirmed the residents on the dementia unit (Jefferson) had not been receiving knives on their meal trays, and she had families complain to her it was hard to cut the food without knives.

Interview on 05/10/23 at 12:59 P.M. with the Administrator revealed there was plenty of knives in the facility, the only time residents should not receive a knife was if it was care planned, and she did not know why knives were not being provided on meal trays.

This deficiency was a result of incidental findings during the investigation of Complaint Number OH00141721.

Based on observation, staff and resident interviews and record review, the facility failed to ensure correct portions were served and standardized recipes were followed to ensure proper nutritional content of the meals. This had the potential to affect all residents receiving regular and mechanical soft diets excluding the 13 residents the facility identified as receiving nothing by mouth (Resident #8, #10, #25, #48, #50, #65, #72, #80, #92, #103, #107, #111, and #113) and five residents (#28, #33, #57, #74 and #83) who were ordered pureed diets. The facility census was 115.

Findings include:

Record review was conducted of the facility document titled Diet Type Report, dated 05/09/23, revealing all residents received either regular texture or mechanical soft diets except for 13 residents (#8, #10, #25, #48, #50, #65, #72, #80, #92, #103, #107, #111 and #113) who were NPO (nothing by mouth) and five residents (#28, #33, #57, #74 and #83) who were ordered pureed texture diets.

Interview on 05/10/23 at 9:02 A.M. revealed when Resident #114 received a grilled cheese sandwich, there was not enough cheese.

Interview on 05/10/23 at 8:55 A.M. with State Tested Nursing Assistant (STNA) #318 revealed food portions were not always equal.

Review of the facility recipe titled Sandwich Grilled Cheese revealed five slices of cheese would be placed between two slices of bread brushed with melted margarine and then grilled on both sides until golden brown on both sides.

Review of facility spreadsheet for 05/09/23 revealed for lunch residents would be served one six-ounce ladle of chicken and dumplings and one-half cup (one number eight scoop) of peas and pearl onions, one dinner roll with one packet of margarine, and one square of fruited gelatin.

Observation of the tray line on 05/09/23 from 11:16 A.M. to 12:40 P.M. with Regional Dietitian #398 and Food Service Director (FSD) #332 revealed the following concerns:

1. One number six scoop (5.33 ounces) of chicken and dumplings was used for the regular and mechanical soft diets instead of a one six-ounce ladle per spread sheet, and one number 12 scoop (.33 cup) of lima beans was served to the regular diets, which was the substitute for peas and pearl onions once the facility ran out, instead of one number eight (one half cup) scoop.

2. Observation of two grilled cheese sandwiches being placed on a resident's plate revealed the grilled cheese was made with two slices of American cheese between two slices of bread. Two more grilled cheeses prepared with two slices of American cheese were being prepared in a frying pan at the same time the two grilled cheese sandwiches were being placed on a plate.

At the time of observation, The FSD #332 confirmed all four grilled cheese being served for lunch had been made with two slices of American cheese. The Regional Dietitian #398 confirmed the grilled cheese should have had five slices of American cheese instead of two slices according to the grilled cheese sandwich recipe, one six-ounce ladle should have been used instead of one number six scoop for the chicken and dumplings, one number eight scoop instead of one number 12 scoop should have been used for the lima beans.

This deficiency represents non-compliance investigated under Complaint Number OH00141721.

Based on observation, staff and resident interviews, and record review, the facility failed to ensure the coffee was served at a palatable temperature. This affected seven residents (#15, #26, #71, #88, #98, #112 and #115) out of the 102 residents who received meals from the kitchen. The facility identified 13 residents (#8, #10, #25, #48, #50, #65, #72, #80, #92, #103, #107, #111, and #113) as receiving nothing by mouth. The facility census was 115.

Findings include:

Interview on 05/10/23 at 8:38 A.M. with Resident #98 revealed the coffee was always cold and because the coffee was always cold, she wouldn't drink it.

Review of 04/18/23 food committee minutes revealed Residents #15, #26, #71, #88, #112 and #115 had voiced a concern the coffee was cold.

Observation of the tray line from 11:16 A.M. to 12:40 P.M. revealed three trays full of hot beverages with lids were prepared prior to the start of tray line at 11:16 A.M, and there was no replenishment of hot beverages during the tray line.

Observation of the test tray completed on 05/09/23 revealed the coffee that was placed on the test tray that left the kitchen at 12:40 P.M. had been poured prior to the start of tray line at 11:16 A.M. and had a temperature of 120 degrees Fahrenheit at the time the test tray items were temped at 12:47 P.M. by the Regional Dietitian #398. At the time of observation, the Regional Dietitian #398 confirmed the coffee was too cold and was not palatable.

This deficiency represents non-compliance investigated under Complaint Number OH00141721.

Based on observation, staff interview and facility policy, the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect all residents who received food from the kitchen. The facility identified 13 residents (#8, #10, #25, #48, #50, #65, #72, #80, #92, #103, #107, #111, and #113) as receiving nothing by mouth. The facility census was 115.

Findings include:

Observation of the kitchen on 05/09/23 from 12:25 P.M. to 12:35 P.M. with Regional Dietitian #398 revealed the following concerns: The juice machine nozzle was observed hanging off the counter and was laying on top of a lemonade bag sitting on top of a box, the stand mixer had an accumulation of dried debris on the metal guard, the walk-in cooler on the back right hand corner floor had what appeared to be a white colored large dried-up spill of chicken and dumplings with a package of turkey lunch meat sitting on top of it, the chest freezer had a dangling seal when lid was opened and an accumulation of ice buildup, the insulated dome lid storage rack was sticky to touch and had a buildup of debris where the domes were stored, the microwave located on the stainless-steel table located behind the steam table had an accumulation on the inside walls and inside top of top, the vent located in the wall behind the steam table and above the stainless-steel table where the microwave was located had a large accumulation of black dust.

An interview was conducted with Regional Dietitian (RD) #398 during the observation of the kitchen on 05/09/23 from 12:25 P.M. to 12:35 P.M. and RD #398 verified the areas of concern.

Review of facility policy Food Preparation and Handing Policy

Based on interview, observations and review of the facility menus, the facility failed to provide food portions according to the menu. This affected Resident #2 and had the potential to affect 104 residents receiving meals prepared in the kitchen. The facility identified 10 residents who did not receive nourishment by mouth, Residents #38, #39, #40, #41, #42, 43, #44, #45, #46 and #47 . The census was 114.

Findings Include:

Interview on 01/30/23 at 9:25 A.M. with Resident #2 revealed when she ordered toasted cheese sandwiches there was a small piece of cheese in the middle and the rest was bread.

Observations on 01/30/23 at 11:30 A.M. of tray line revealed staff plating baked ham and green beans. Dietary Manager (DM) #165 was observed plating unequal portions of ham for the residents. Interview with Regional Dietitian (RD) #164, at the time of the observation, verified the varied serving sizes of ham. DM #165 stated she sliced the ham by hand because the slicer was in the back room and needed to be cleaned. RD #164 stated portions needed to be equal throughout the tray line service.

Observations on 01/30/23 at 12:07 P.M. revealed Kitchen Aide (KA) #168 making a toasted cheese sandwich using one and a half slices of cheese. Interview immediately after the observation with RD #164 revealed toasted cheese sandwiches were to have five pieces of cheese. Continued observations revealed staff plating unequal slices of cake. Staff were further observed preparing chocolate pudding to serve because they ran out of cake due to not cutting equal slices. Interview immediately after observation with RD #164 verified the observations. Review of the recipe for pineapple ham and toasted cheese sandwiches with RD #164 revealed one serving of ham was two ounces and grill cheese sandwiches were to have five slices of cheese. RD #164 confirmed the serving sizes on the menu.

Based on observation, policy review and interview, the facility failed to ensure food was stored and served in a sanitary manner. This affected all 110 residents who received meals from the kitchen except Resident #5, #6, #7, #8, #9, #10, #11, #12, #13, #14 and #15 who were ordered nothing to eat/drink by mouth. The census was 121.

Finding include:

An initial tour of the kitchen on 12/13/22 at 2:15 P.M. with Dietary Manager (DM) #1 revealed the following in the walk-in refrigerator: cheesecake filling in a three-quart container dated 11/07/22, chocolate mousse in an eight-quart container dated 11/21/22, mushroom soup in a two-quart container without a date, a brown solid substance in a two-quart container without a label or a date and a light brown substance in a two-quart container without a label or a date. Interview, during the observation, with DM #1 verified the above findings including foods not properly dated or discarded.

Observation on 12/13/22 at 5:03 P.M. of Cook #4 serving dinner revealed Cook #4 was using his right gloved hand to grab rolls from the steam table and placing the rolls on the resident dinner plates. Cook #4 grabbed the plate warmer handle then grabbed a roll to place on a resident dinner plate. Cook #4 grabbed a drawer handle then grabbed a roll to place on a resident's dinner plate.

Interview on 12/13/22 at 5:30 P.M. with Regional Director of Food and Nutrition Services #6 verified Cook #4 was not serving food in a sanitary manner as he was touching contaminated surfaces and then touching the rolls.

Review of the facility's Storage of Refrigerated Foods policy, revised on 02/19/19, revealed potential hazardous food/time-temperature controlled for safety foods that have been prepared in-house can be stored for a maximum of seven days at 41 degrees Fahrenheit (F) or lower.

Review of the facility's Food Preparation and Handling policy, revised 02/29/19, revealed in order to avoid cross-contamination of foods, single-use gloves will be used when handling food directly with hands, or a contact barrier.

This deficiency represents non-compliance investigated under Complaint Number OH00137569.

Based on observation, interview, and record review the facility failed to ensure intravenous (IV) dressings were changed per physician orders. This affected one (Resident #12) of three (Resident's #12, #48, and #100) observed for IV dressings. The facility census was 123.

Findings include:

Review of Resident #12's medical records revealed an admission date of 07/28/22. Diagnosis included adult failure to thrive, seizures, and respiratory failure.

Review of the care plan dated 07/29/22 revealed Resident #12 required total care for all care.

Review of the Minimum Data Set (MDS) 3.0 assessment dated 07/30/22 revealed Resident #12 had impaired cognition. Resident #12 required total dependence for toileting and personal hygiene.

Review of the physician orders for August 2022 revealed to change the IV dressing every seven days and as needed.

Observation on 08/19/22 at 8:33 A.M. while in the hallway awaiting on a staff member revealed Resident #12 had an IV line in her left arm that had a large amount of dried blood underneath it. Further observation with State Tested Nurse Aide (STNA) #201 revealed IV dressing was dated 08/10/22 and was not intact; Resident #12 was non-verbal.

Observation on 08/19/22 at 8:49 A.M. revealed Registered Nurse (RN) #202 was in Resident #12's room and was beginning to remove her IV dressing. RN #202 confirmed the dressing was dated 08/10/22 and had a large amount of dried blood underneath it. RN #202 stated the residents IV was to be flushed twice a day and she had flushed the IV this morning and had not noticed the dressing. RN #202 stated the IV dressing should be changed every seven days and as needed.

Interview on 08/19/22 at 2:13 P.M. with Regional Registered Nurse (RRN) #205 revealed she had obtained Resident #12's discarded IV dressing and had confirmed the dated of 08/10/22 and it had a large amount of dried blood on it.