Columbus Alzheimer'S Care Ctr

Based on record review, review of the facility Self-Reported Incidents (SRI), review of the facility investigation, review of facility policy and procedure, resident interview, and staff interview, the facility failed to ensure Resident #100 was free from resident to resident physical abuse. Actual harm occurred on 02/03/25 when Resident #57, who had a history of resident altercations and impaired cognition, pushed Resident #100 causing a fall and a right femur fracture. This affected one (Resident #100) of six residents reviewed for abuse. The facility census was 98.

Findings include:

a. Review of a facility submitted SRI dated 02/03/25 for physical abuse revealed Resident #57 pushed Resident #100 to the ground when Resident #100 wandered into Resident #57's room. Both residents were assessed for injuries. Resident #100 was left immobilized on the floor due to an obvious range of motion deficit to the right hip. Nine-one-one (911) was called for Resident #100's pain and range of motion deficit. Neurological checks were initiated but did not continue due to the transfer to the hospital. The medical provider and families were notified of the incident. Resident #57 was assessed for physical injuries with none noted. Resident #57 was placed on 15-minute checks until he retired for sleep at 11:00 P.M. the same day. The facility unsubstantiated abuse and marked that the evidence indicated abuse, neglect, or misappropriation did not occur.

Review of the medical record for Resident #100 revealed an admission date of 12/29/21. Resident #100's diagnoses included Alzheimer's disease with late onset, vascular dementia, osteoarthritis, and major depressive disorder. The resident was discharged to the hospital on 02/03/25 and did not return to the facility.

Review of the physician's order initiated 04/28/24 for Resident #100, revealed the resident had orders for Zoloft and Trazodone, and an order to monitor for side effects for antidepressants and report to physician: sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle, tremor, agitation, headache, skin rash, photo sensitivity, and excess weight gain every shift.

Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated 12/05/24 revealed Resident #100 had severe cognitive impairment. Resident #100 was independent for all mobility such as transferring and walking 150 feet.

Review of the care plan dated 12/20/24 revealed Resident #100 had the potential for mobility limitations with expected fluctuations with chronic medical conditions. Interventions included providing hands on assistance to steady him daily, as needed, when exhibiting weakness or resistance and to monitor his safety with the use of his assistive device. The care plan also identified Resident #100 had a tendency to misperceive information. Interventions included for the chair that he typically sits in, in the common area, to be labeled to reflect that the chair belonged to him and staff would also redirect him away from the West Pod if observed ambulating in that area, as this is where Resident #57's room was located.

Review of a nursing progress note dated 02/03/25 at 11:21 P.M. revealed that Resident #100 stated that another resident [Resident #57] pushed him, and he had a fall. The note also revealed that Resident #100 was in a lot of pain and he received as needed Norco 5-325 milligrams (mg) for pain. The resident was taken to the hospital for further evaluation.

Review of a nursing progress note dated 02/03/25 at 3:55 P.M. revealed Resident #100 received a fall risk assessment. The assessment indicated the resident had an unwitnessed fall that occurred in the common area and the resident was injured. The assessment note revealed another resident pushed Resident #100 and he fell. The assessment note also revealed Resident #100 had verbal complaints and facial expressions of pain. The pain was sharp and aching in the right hip and was worse with movement. Daily as needed pain medication, Norco, was administered.

Review of the Incident Report dated 02/03/25 for Resident #100, revealed Resident #100 was found lying on his back on the West Pod near Resident #57's room. Resident #100 stated that a man pushed him, and he fell. Resident #100 was in a lot of pain and was given as needed Norco 5-325 mg for pain. The incident was unwitnessed. Resident #100's vital signs were taken, he was given as needed medication for pain, and neurologic checks were initiated. Resident #100 was immobilized due to an obvious range of motion deficit to his right hip. There were no obvious outward signs of skin impairment. The resident was taken to the hospital and the injury observed at the time of the incident was determined to be a fracture of the right hip. The report also stated Resident #100 was ambulating without assistance and was very territorial about particular chairs on the unit and he sought out the whereabouts of the male resident he was accusing of pushing him down, to tell him not to take his chair.

Review of the Neurological Evaluation Flowsheet dated 02/03/25 for Resident #100 revealed neurologic (neuro) checks were completed at 3:30 P.M. and 3:45 P.M. Resident #100 was in the hospital for any further neuro checks.

Review of the Fall Risk Evaluation dated 02/03/25 at 3:55 P.M. for Resident #100 revealed he had one to two falls in the past three months, had intermittent confusion, was ambulatory, had adequate vision, and did not have a change in condition in the last 14 days.

Review of the Post Fall Evaluation dated 02/03/25 at 3:56 P.M. for Resident #100 revealed an unwitnessed fall with an injury occurred and the resident was sent to the hospital. The Certified Nurse Practitioner (CNP) #250 was notified on 02/03/25 that there was a resident to resident fall where another resident pushed Resident #100 and he fell. The evaluation noted that Resident #100 had severe right hip pain.

Review of the Hospital Transfer Form dated 02/03/25 revealed Resident #100 ambulated independently, and he was alert and disoriented, but could follow simple instructions.

Review of hospital records for Resident #100 revealed he had an X-ray on 02/03/25 that showed an acute obliquely oriented intertrochanteric fracture of the proximal right femur. Resident #100 received surgery on 02/04/25 for his right intertrochanteric hip fracture with osteopenia.

b. Review of the medical record for Resident #57 revealed an admission date of 01/22/25. Resident #57's diagnoses included dementia, depression, cognitive communication deficit, and conversion disorder with seizures or convulsions.

Review of the care plan for Resident #57 dated 01/22/25 revealed he was resistive to care related to dementia, he wandered about the facility, and he had the potential to become agitated if his routine or patterns of behavior were disrupted. The plan noted that Resident #57 liked to rearrange furniture in the common area, he had a history of aggression toward male residents that wandered into his room, and he was rigid with his room. Interventions included psychiatric services to evaluate and treat, provide consistency in care to promote comfort with activities of daily living (ADLs), and to maintain consistency in timing of ADLs, caregivers and routine as much as possible.

Review of admission Minimum Data Set (MDS) 3.0 assessment dated 01/30/25 for Resident #57 revealed he had severe cognitive impairment. Resident #57 was independent for all mobility such as transferring and walking 150 feet.

Review of the nursing progress note dated 02/03/25 at 12:00 A.M. for Resident #57 detailed his History and Physical which revealed Resident #57 transferred from another skilled nursing facility on 01/22/25. The note also revealed there were no previous facility records to review.

Review of the nursing progress note dated 02/03/25 at 3:30 P.M. for Resident #57 revealed the resident stated he made contact with another resident. Resident #57 was assessed with no injury noted and his skin was intact. The Director of Nursing (DON), CNP #250, and the residents family member were notified. Fifteen-minute checks were initiated.

Review of the incident report dated 02/03/25 at 3:30 P.M. for Resident #57 revealed Resident #57 stated I pushed that man who wandered in my room, out of the room, because I don't want anyone in my room. An assessment of Resident #57 was completed with his skin intact and no injury noted. Resident #57 received 15-minute checks through 11:00 P.M. to ensure he made no further reactive movements toward other residents. Predisposing physiological factors included Resident #57 was confused and had impaired memory. Predisposing situation factors included Resident #57 was a wanderer and he was ambulating without assistance. Resident #57 had a pattern of coming out of his room to straighten chairs and rearrange some of the chairs in the common area. Interventions included 15-minute checks through 11:00 P.M. on 02/03/25 and the activities director was to assist the resident to find activities to distract him from his patterned behavior of moving chairs around in the common area.

Review of the 15-minute check log sheet dated 02/03/25 for Resident #57 revealed sign offs every 15 -minutes from 3:30 P.M. to 11:00 P.M. were completed.

Review of the written staff statement dated 02/03/25 by Licensed Practical Nurse (LPN) #111 revealed she did not witness the incident, but walked into her shift and noticed Resident #100 was lying on the floor and in pain. LPN #111 gave the resident as needed pain medicine.

Review of the written staff statement dated 02/03/25 by Certified Nursing Aide (CNA) #112 revealed she heard a noise and saw Resident #100 laying down and observed Resident #57 standing in front of his room looking angry.

Review of the written staff statement dated 02/03/25 by Registered Nurse (RN) #14 revealed she was sitting at the nurses station and heard a scream from the common area. She saw Resident #100 on the floor on his left side. RN #14 and staff assessed Resident #100. They tried getting Resident #100 off the floor, but he was in too much pain to move around. RN #14 called 911.

Review of the written interview statement dated 02/03/25 by Resident #57 revealed Resident #57 initially denied knowledge of any interaction with Resident #100. Resident #57 then stated he pushed Resident #100 out of his room because he walked in. Resident #57 stated he didn't want strangers in his room.

Review of the nursing progress note dated 02/04/25 at 1:52 P.M. for Resident #57 revealed he had an altercation with another male resident who he indicated, wandered into his room. Resident #57 had some rigid behaviors involving repositioning chairs. The note indicated that activities staff would be working with him to find one on one activities to distract him. Resident #57 stated, I feel sorry the guy got a fracture.

Review of physician's orders dated 02/11/25 for Resident #57 revealed the resident was to be seen by psychiatric services to evaluate and treat.

An interview on 02/21/25 at 11:37 A.M. with Resident #57 revealed he had not been a part of or witnessed resident abuse. Resident #57 also revealed he had not been involved in a resident to resident altercation.

An interview on 02/21/25 at 12:08 P.M. with LPN #6 confirmed Resident #100 fractured his hip during a resident to resident altercation.

An interview on 02/21/25 at 12:25 P.M. with RN #23 revealed he was not at the facility for the altercation, but if two residents had an altercation it would be considered resident to resident abuse.

An interview on 02/21/25 at 6:17 P.M. with the DON revealed Resident #57 had ridged behaviors of moving chairs around and Resident #100 had a chair that he [Resident #100] liked. Resident #57 moved the chair and Resident #100 went into Resident #57's room and Resident #57 pushed Resident #100 resulting in a fall. The DON stated she thought Resident #100 intimidated Resident #57, but that no one knew why Resident #100 went into #57's room. The DON confirmed that Resident #100 was injured from the shove, with a right hip fracture. The DON stated it wasn't resident to resident abuse, because the residents didn't know what they were doing based on their BIMS scores. The DON revealed they were both reacting on impulse, she didn't think they were plotting to hurt each other.

An interview on 02/21/25 at 6:31 P.M. with the Administrator revealed Resident #100 liked to have his table and chair a certain way and Resident #57 liked to move chairs around the tables. Resident #100 entered Resident #57's room and Resident #57 didn't want Resident #100 in his room, so he pushed him. Resident #100 fell and was sent out [to the hospital] subsequently. The Administrator revealed she received an update after Resident #100 was sent out and he was going to have surgery. The Administrator confirmed Resident #100 had a right hip fracture when he was injured from the shove and fall. The Administrator did not claim the situation was abuse, because it was a resident to resident altercation with no intention to cause harm. The Administrator revealed the nature of the facility was dementia and they did not have an intent to harm.

An interview on 02/24/25 at 12:11 P.M. with the Administrator revealed residents did not have intent and they were reacting. The Administrator also revealed nobody could be held liable for abuse of somebody else at the facility and law enforcement had told her this in the past. The Administrator explained that the residents had to have a dementia status to be at the facility and she couldn't think of a time she had ever substantiated two residents abusing each other.

Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated October 2023, revealed residents had the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. The facility policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. If another resident was accused or suspected of abuse, the policy also stated the facility would ensure other residents were protected as determined by the circumstances, which may include but were not limited to, increased supervision of the alleged perpetrator and/or other residents, room or staffing changes, and immediate transfer or discharge, if indicated.

This deficiency represents non-compliance investigated under Master Complaint Number OH00162994 and Complaint Number OH00162478.

Based on staff interview, resident interview, family interview, review of the self-reported misappropriation incident investigation and review of the abuse policy, facility failed to ensure allegations of misappropriation were reported to the state agency in a timely manner. This affected one (Resident #89) of one reviewed for misappropriation. The facility census was 96.

Findings include

Review of the medical record for Resident #89 revealed an admission date of 09/06/24. Diagnoses included unspecified dementia, aphasia, vascular disease, diabetes, epilepsy, hemiplegia and hemiparesis, and cognitive communication deficit.

Review of the Minimum Data Set (MDS) assessment dated 12/12/24 revealed Resident #89 was cognitively impaired with a Brief Interview of Mental Status (BIMS) of 03 and required extensive assistance for bed mobility and transfers, partial/moderate assist for bathing and dressing, and substantial maximum assistance for personal hygiene.

Review of the plan of care dated 12/30/24 revealed the resident had a behavior problem and fidgets with most things including jewelry and remote. Interventions included to develop more appropriate methods for coping and interacting, monitor behaviors for delusions and paranoia.

Review of the Self-reported Incident investigation (SRI) for Misappropriation dated 12/31/24 revealed Resident #89's family member had reported her wedding ring was missing. Facility staff searched for the ring, checked laundry and could not locate the ring. Staff statement from Unit Manager #67 dated 01/03/24 revealed on 12/24/24 Resident #89's sister contacted her to report the missing wedding ring. She revealed she informed family she would look for it and follow up with them on any outcome. She searched for the ring that day without success. On 12/31/24 Director of Nursing was informed by Resident's husband of the missing wedding band and an SRI was initiated.

Review of disciplinary action dated 01/02/25 with meeting on 01/03/25 revealed Unit Manager #67 received a written warning related to not following the abuse policy. Facility management was not informed timely after a report of the missing wedding ring for Resident #89 and the SRI was therefore not reported in a timely manner.

Interview on 01/14/25 at 10:40 A.M. with Unit Manager #67 revealed she was informed of the missing ring by residents family prior to Christmas and looked for it but did not tell anyone as the typical staff she would alert were off work. She revealed she then went on vacation and did not return until after the new year. When she returned she was informed family had brought up the ring again to the Director of Nursing and an investigation was started. Unit Manager reported she received a write up for not reporting the concern to management back on 12/24/24 when it was reported to her.

Interview on 01/14/25 at 2:20 P.M. with Director of Nursing (DON) revealed Unit Manager should have reported the concern of the missing wedding ring to management on 12/24/24 when it was first reported to her. DON also confirmed this led to a delay in facility reporting the SRI to the Department of Health.

Review of facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/2023 revealed facility staff shall immediately report all such allegations to the Administrator and Ohio Department of Health in accordance with procedures in this policy. Facility shall ensure staff know how to identify Abuse, neglect and misappropriation of resident property. Events of misappropriation shall be reported to the Ohio Department of Heath (ODH) within 24 hours from the time the incident is known to a staff member.

This deficiency represents non-compliance investigated under Complaint Number OH00161067.

Based on staff interviews, review of self-reported incident investigations (SRI) and policy review, the facility failed to ensure allegations of abuse, neglect, misappropriation and injuries of unknown origin were thoroughly investigated and interventions put in place. This affected eight Residents (#20, #21, #33, #48, #52, #54, #89 and #100) of nine reviewed for abuse, neglect and misappropriation investigations. The facility census was 96.

Findings include

1. Review of the medical record for Resident #54 revealed an admission date of 10/18/24. Diagnoses included multiple rib fractures, Alzheimer's disease, dementia, aphasia, diabetes, depression, osteoporosis and restlessness.

Review of the Minimum Data Set (MDS) assessment dated 12/11/24 revealed Resident #54 was cognitively impaired with a Brief Interview of Mental Status (BIMS) of 05 and required substantial assistance for showering bathing and dressing

Review of SRI 252935 regarding an injury of unknown origin for Resident #54 dated 10/12/24 revealed no resident interviews or statements were completed and an intervention of 15-minute checks was to be initiated. The facility had no evidence of any 15-minute checks being completed for Resident #54.

Interview on 01/14/25 at 4:42 P.M. with Director of Nursing revealed the facility had no evidence of 15-minute checks being completed. She acknowledged the interventions were not typical for an injury of unknown origin but confirmed it was mentioned multiple times in the investigation.

2. Review of the medical record for Resident #89 revealed an admission date of 09/06/24. Diagnoses included unspecified dementia, aphasia, vascular disease, diabetes, epilepsy, hemiplegia and hemiparesis, and cognitive communication deficit.

Review of the Minimum Data Set (MDS) assessment dated 12/12/24 revealed Resident #89 was cognitively impaired with a BIMS of 03 and required extensive assistance for bed mobility and transfers, partial/moderate assistance for bathing and dressing, and substantial maximum assistance for personal hygiene.

Review of SRI 255726 and SRI 255654 for misappropriation involving Resident #89 dated 12/31/24 and 01/03/25 revealed no resident interviews or statements were completed. The investigation did not include the questions asked of staff and was not specific to a missing wedding ring and clothes but included information about a different ring sent home with family.

Interview on 01/14/25 at 4:42 P.M. with Director of Nursing revealed facility investigation was a mix of information related to the previous ring that was reported missing and the new ring that Resident #89's family had provided. DON also revealed facility spoke with the abuse department at Ohio Department of Health and did not include any of those interactions in the investigation steps and when new information was found, facility provided no information indicating the abuse officer was updated. The facility also agreed they did not consider staff working prior to the allegation of the ring being missing but only considered and looked at staff working after the allegation was made on 12/24/24. DON revealed the staff would have also worked prior to the allegation.

3. Review of the medical record for Resident #52 revealed an admission date of 03/21/24. Diagnoses included dementia, catatonic disorder, aphasia, depression, and muscle weakness.

Review of the Minimum Data Set (MDS) assessment dated 12/31/24 revealed Resident #52 was cognitively impaired with a BIMS of 00.

Review of the medical record for Resident #100 revealed an admission date of 09/17/24 and discharge date 01/06/25. Diagnoses included dementia, muscle weakness, bipolar disorder, and pulmonary disease.

Review of the Minimum Data Set (MDS) assessment dated 12/12/24 revealed Resident #100 was cognitively impaired with a BIMS of 10.

Review of SRI 253374 for physical abuse of a resident-to-resident altercation between Resident #52 and Resident #100 dated 10/27/24 revealed no resident interviews or statements were completed. An intervention of 15-minute checks was to be initiated for 24 hours. The facility provided evidence of 15-minute checks being completed for Resident #100 showed the incident occurred at 9:00 A.M. missing entries 10/27/24 from 9:00 A.M. to 9:30 A.M., at 3:15 P.M., 3:45 P.M. to 4:15 P.M., 6:30 P.M., 7:00 P.M., 8:15 P.M., and 9:00 P.M.

Interview on 01/14/25 at 4:42 P.M. with Director of Nursing revealed the facility had no additional evidence of 15-minute checks being completed. She acknowledged the interventions were missing multiple entries and documentation was missing several sections. DON revealed each box should be completed and confirmed staff used lines and arrows for shorthand and confirmed several sections were left with no documentation to prove 15-minute checks were completed.

4. Review of the medical record for Resident #33 revealed an admission date of 08/05/22. Diagnoses included heart disease, depression, hypertension, aphasia, chronic pain, and muscle weakness.

Review of the Minimum Data Set (MDS) assessment dated 10/08/24 revealed Resident #33 was cognitively impaired with a BIMS of 07.

Review of the medical record for Resident #48 revealed an admission date of 05/19/22. Diagnoses included dislocation of left humerus, Alzheimer's disease, malnutrition, aphasia, heart disease and vascular dementia.

Review of the Minimum Data Set (MDS) assessment dated 12/05/24 revealed Resident #48 was cognitively impaired with a BIMS of 08.

Review of SRI 254391 for physical abuse of a resident-to-resident altercation between Resident #33 and Resident #48 dated 11/22/24 revealed no resident interviews or statements were completed. An intervention of 15-minute checks was to be initiated for 24 hours. The facility provided evidence of 15-minute checks being completed for Resident #48 which showed the incident occurred at 10:39 P.M. and was missing all entries on 11/23/24 from 2:00 A.M. to 9:30 A.M.

Interview on 01/14/25 at 4:42 P.M. with Director of Nursing revealed the facility had no additional evidence of 15-minute checks being completed. She acknowledged the interventions were missing multiple entries.

5. Review of the medical record for Resident #20 revealed an admission date of 05/22/23. Diagnoses included vascular dementia, hemiplegia and hemiparesis, aphasia and diabetes.

Review of the Minimum Data Set (MDS) assessment dated 11/05/24 revealed Resident #20 was cognitively impaired with a BIMS of 08.

Review of the medical record for Resident #21 revealed an admission date of 06/27/23. Diagnoses included vascular parkinsonism, insomnia, aphasia, vascular dementia and cognitive communication deficit.

Review of the Minimum Data Set (MDS) assessment dated 12/11/24 revealed Resident #21 was cognitively impaired with a BIMS of 01.

Review of SRI 254574 for physical abuse of a resident-to-resident altercation between Resident #20 and Resident #21 dated 11/28/24 revealed no resident interviews or statements were completed. An intervention of 15-minute checks was to be initiated for 24 hours. The facility provided evidence of 15-minute checks being completed for Resident #20 showed the incident occurred at 9:00 P.M. and had two separate forms dated 11/29/24 completed by two different staff and stated resident was in two different locations for the entirety of this time period 3:00 P.M. through 3:45 P.M.

Interview on 01/14/25 at 4:42 P.M. with Director of Nursing revealed facility had no additional evidence of 15-minute checks being completed. She acknowledged the intervention was completed on different forms for the same time period and provided no reasoning for two different staff completing the checks and different information being provided for the same residents at the same times.

Review of facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/2023 revealed facility staff shall immediately report all such allegations to the Administrator. Facility shall complete an investigation into the alleged violation within five working days. The actions to be taken include interview the resident, the accused, and all witnesses including anyone who come in contact with the resident(s) the day of the incident. If there were no direct witnesses, interviews should be expanded for example all staff on the shift in question. For injuries of unknown origin facility may generally interview staff working on the shift the injury was discovered as well as shifts prior to the incident. Facility shall review all applicable medical records and document all evidence of the investigation. At the end of the investigation, facility shall make a conclusion whether to substantiate the claim vs unsubstantiated the claim. Facility shall follow up by completing any necessary staff education and implementing any other measures deemed appropriate.

This deficiency represents non-compliance investigated under Complaint Number OH00161067.

Based on observations and staff interviews the facility failed to ensure call lights were in reach and accessible for resident use. This affected two residents (#35 and #54) of two observed laying in their bed in their rooms. Facility census was 96.

Findings include:

1. Review of the medical record for Resident #35 revealed an admission date of 11/21/24. Diagnoses included dementia, osteoarthritis, aphasia, and anxiety.

Review of the Minimum Data Set (MDS) assessment dated 12/03/24 revealed Resident #35 was cognitively impaired with a BIMS of 99 (unable to determine due to lack of responses in answering) and required extensive assistance of two staff members for bed mobility and extensive assistance of one staff member for transfers.

Observation and interview on 01/14/25 at 9:35 A.M. revealed Resident #35's call light was not within reach. It was hung back behind the headboard over the clock hanging on the wall about 6 feet from the ground. Registered Nurse (RN) #53 confirmed the call light was hung up over the wall clock and was out of reach for the resident. She revealed possibly the staff feeding her hung it up then forgot to give it back. RN #53 confirmed the call light should be left in resident reach at all times, while she was in bed.

2. Review of the medical record for Resident #54 revealed an admission date of 10/18/24. Diagnoses included multiple rib fractures, Alzheimer's disease, dementia, aphasia, diabetes, depression, osteoporosis and restlessness.

Review of the Minimum Data Set (MDS) assessment dated 12/11/24 revealed Resident #54 was cognitively impaired with a BIMS of 05 and required substantial assistance for showering bathing and dressing

Observation and interview on 01/14/25 at 12:20 P.M. revealed Resident #54's call light was not within reach. It hung from the plug against the wall and under the bed at the foot board end of the bed. RN #53 confirmed the call light was on the floor under the foot board side of the bed and had to climb around the bed to retrieve it. RN #53 confirmed the call light should always be left in resident reach, while the resident was in bed.

Interview on 01/14/25 at 2:30 P.M. with Administrator and Director of Nursing revealed they did not believe the facility had a policy related to residents having access to their call light devices but would check. No policy was provided.

Based on record review, family interview, staff interviews, and policy review the facility failed to make a life insurance policy payment from a facility managed account for one resident (Resident #9) out of five residents reviewed for personal funds. The facility census was 99.

Findings include:

Review of Resident #9's record revealed the resident was admitted on 09/23/19 with diagnoses that included dementia, age-related osteoporosis, psoriasis, dysphagia, aphasia, Alzheimer's disease, history of other mental and behavioral disorders.

Review of the quarterly minimum data set (MDS) assessment dated 07/12/24 revealed Resident #9 was not interviewed for cognition because she was rarely or never understood. Resident #9 had poor short term and long-term memory and was unable to make daily care decisions on her own. Resident #9 displayed physical behaviors four to six days during the look back period. Resident #9 was unable to be interviewed for the resident screening process.

Interview on 08/19/24 at 1:03 P.M. via telephone with Resident #9's daughter revealed Resident #9 had a life insurance policy established prior to admission to the facility. The policy premiums were recently set up to be paid out of the resident's account. The previous business office manager didn't make a payment, and the policy was canceled. The current business office manager staff #700 is working with Resident #9's daughter to get the policy reinstated, and a payment has been made however th policy has not been reinstated.

Review of Resident #9's monthly funds account statements for 2023 and 2024 revealed insurance premium payments were made 05/12/23, 07/11/23, 10/16/23 and 01/19/24. There was not another payment made until 06/20/24 and this payment was twice the amount of the previous payments.

Interview 08/22/24 at 11:55 A.M. with Staff #700 confirmed, Resident #9's family had been managing payments for Resident #9's life insurance since 2002. The facility's business office manager took over making the life insurance payments as of 05/12/23 and the payments were to be made quarterly starting 07/11/23. Quarterly payments were made on 07/11/23, 10/16/23 and 01/19/24. Staff #700 confirmed the facility did not make the April 2024 quarterly payment and the policy was canceled by the insurance company. Staff #700 stated they had worked with Resident #9's daughter and called the insurance company in an effort to reinstate the life insurance policy and a double payment was made on 06/20/24 as directed by the life insurance company, but the policy has not been reinstated.

Review of policy Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property last reviewed 10/2023 revealed the facility's policy to educate all staff to prevent any abuse, neglect exploitation or misappropriation and for all staff to recognize and report any concerns.

Based on medical record review, staff interview, and review of the facility policy, the failed to ensure staff notified resident physicians of abnormal lab results in a timely manner. This affected one (Resident #72) of 25 residents sampled. The facility census was 99 residents.

Findings include:

Review of the medical record for Resident #72 revealed an admission date of 09/02/21 with diagnoses including Alzheimer's disease, venous insufficiency, open wound of the left lower leg, generalized anxiety disorder and major depressive disorder.

Review of the MDS assessment for Resident #72 dated 07/18/24 revealed the resident was cognitively intact.

Review of the physician's orders for Resident #72 revealed an order dated 08/21/24 to obtain a culture to the wound on the resident's left lower extremity.

Review of the wound culture results for Resident #72 revealed the wound culture was obtained on 08/21/24 and the results were received on 08/24/24 at 2:06 P.M. indicating the wound was infected with a heavy growth of streptococcus pyogenes (bacteria) which was susceptible to penicillin and first generation cephalosporins (antibiotic medications.)

Review of the nurse progress notes for Resident #72 dated 08/24/24 to 08/26/24 revealed the notes did not include documentation of physician notification of the abnormal wound culture obtained on 08/21/24.

Interview on 08/26/24 at 4:05 P.M. with Licensed Practical Nurse (LPN) #215 confirmed she notified the physician of Resident #72's the abnormal wound culture results on 08/26/24, but she had not heard back from the physician. LPN #215 further confirmed the results were available on 08/24/24 and the physician was not notified in a timely manner.

Review of the facility policy titled Notification of Change undated revealed the facility must immediately inform the resident, consult with the resident's physician, and if known, notify the resident's legal representative or an interested family member when there was a need to alter treatment significantly or to commence a new form of treatment.

Based on observation, interviews, and record review, the facility failed to maintain a clean and homelike environment for seven (#18, #26, #35, #44, #78, #90, and #92) residents, all residents were screened during the annual survey. The facility census was 99.

Findings include:

1. Review of Resident #44's medical record identified admission to the facility occurred on 07/18/17 with medical diagnosis including aphasia, Alzheimer's disease, and dementia.

Observation on 08/19/24 at 3:47 P.M. of Resident #44's room revealed the room was filthy, the floor was sticky causing feet to stick to the floor. The bedspread was visibly soiled and the wall behind the bed was stained with residue.

Observation on 08/22/24 at 10:31 A.M. with Maintenance Director #801 and Housekeeping Supervisor #615 of Resident #44's room revealed the floor was very sticky and there were brown and yellow stains on the wall next to Resident #44's bed.

Interview on 08/22/24 at 10:31 A.M. with Maintenance Director #801 verified the floor was sticky.

Interview on 08/22/24 at 10:31 A.M. with Housekeeping Supervisor #615 verified the stains on the wall next to the resident's bed.

2. Review of Resident #78's medical record identified admission to the facility occurred on 05/14/22 with medical diagnosis including depression, generalized anxiety disorder, and dementia.

Observation on 08/19/24 11:19 at A.M. revealed Resident #78's room includes one pink wall with patches of white where it has been repaired. There was not one single picture or photo on any wall. The floor was very sticky. There was dried residue on the bathroom floor to left side of toilet and commode.

Observation on 08/22/24 at 10:42 A.M. with Maintenance Director #801 and Housekeeping Supervisor #615 of Resident #78's room revealed the floor was very sticky and there were little black balls all over the floor.

Interview on 08/22/24 at 10:42 A.M. with Housekeeping Supervisor #615 confirmed the room floor was sticky and the bathroom floor was soiled.

Interview on 08/22/24 at 10:46 A.M. with Maintenance Director #801 confirmed there were shredded rubber pellets on the room floor.

Review of the undated Routine Cleaning and Disinfection Policy stated This facility's policy is to ensure routine cleaning and disinfection to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible.

3. Review of Resident #26's medical record identified admission to the facility occurred on 12/29/21 with medical diagnosis including depression, epilepsy, and dementia.

Observation on 08/20/24 at 8:51 A.M. of Resident #26's room revealed the walls were scuffed there were drywall patches by the bed.

Observation on 08/22/24 at 10:56 A.M. with Maintenance Director #801 and Housekeeping Supervisor #615 of Resident #26's room revealed there was nothing on the walls in room and the room was not in a homelike condition.

Interview on 08/22/24 at 10:57 A.M. with Housekeeping Supervisor #615, Maintenance Director #801, and Activity Supervisor #608 all confirmed there was nothing in the room.

4. Review of Resident #90's medical record identified admission to the facility occurred on 12/12/23 with medical diagnosis including traumatic hemorrhage of cerebrum, depression, and dementia.

Observation on 08/19/24 at 10:10 A.M. revealed Resident #90's walls were scuffed and had dry wall patches showing throughout the room.

Observation on 08/20/24 at 9:22 A.M. of Resident #90's room revealed the room was not homelike. There was nothing on the walls.

Observation on 08/22/24 at 11:13 A.M. with Maintenance Director #801 and Housekeeping Supervisor #615 of Resident #90's room revealed there was nothing on walls of the room and it was not in a homelike condition.

Interview on 08/22/24 at 11:13 A.M. with Housekeeping Supervisor #615 confirmed there was nothing on the walls.

5. Review of Resident #35's medical record identified admission to the facility occurred on 03/01/24 with medical diagnosis including depression, aphasia, and dementia.

Observation on 08/20/24 at 9:15 A.M. revealed Resident #35's wall and ceiling are patched with drywall and scuffed.

Observation on 08/22/24 at 10:59 A.M. with Maintenance Director #801 and Housekeeping Supervisor #615 of Resident #35's room revealed there is nothing on Resident #35's side of the room and it is not in a homelike condition. Also observed was a piece of coving missing which exposed valves and there was broken flooring in front of the room.

Interview on 08/22/24 at 10:59 A.M. with Housekeeping Supervisor #615 confirmed there was nothing in Resident #35's room.

Interview on 08/22/24 at 11:00 A.M. with Maintenance Director #801 confirmed there was missing coving with exposed valves and there is broken flooring in front of the room.

6. Review of Resident #92's medical record identified admission to the facility occurred on 03/14/24 with medical diagnosis including dementia, depression, and bipolar disorder.

Observation on 08/20/24 at 9:00 A.M. of Resident #92's room revealed the room was not homelike.

Observation on 08/22/24 at 10:33 A.M. with Maintenance Director #801 and Housekeeping Supervisor #615 of Resident #92's room revealed there was nothing in the room to look at. It was not in a homelike condition.

Interview on 08/22/24 at 10:33 A.M. with Housekeeping Supervisor #615 confirmed nothing was in the room. Housekeeping Supervisor #615 said there are supposed to be clocks and dressers in the room.

7. Review of Resident #18's medical record identified admission to the facility occurred on 01/10/19 with medical diagnosis including insomnia, Alzheimer's disease, and dementia.

Observation on 08/22/24 at 11:13 A.M. of Resident #18's room with Maintenance Director #801 and Housekeeping Supervisor #615 revealed there is nothing on the walls in the room and it was not in a homelike condition.

Interview on 08/22/24 at 11:13 A.M. with Housekeeping Supervisor #615 confirmed there is nothing on the walls.

Review of the Quality of Life-Homelike Environment policy dated May 2017 stated Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

2. Review of Resident #35's medical record revealed she was admitted to the facility on 03/01/24. Diagnoses included dementia, chronic obstructive pulmonary disease (COPD), depression, Rheumatoid arthritis, PVD (peripheral vascular disease), osteoarthritis (OA) and Congestive Heart Failure (CHF).

Review of the quarterly minimum data set (MDS) assessment dated 07/25/24 revealed her cognition was not intact. No impairment on either side for functional range of motion.

Review of the plan of care dated 06/27/23 revealed she had the potential to have activity of daily living self care performance deficit due to dementia, chronic obstructive pulmonary disease (COPD), rheumatoid arthritis, PVD, osteoporosis, idiopathic progressive neuropathy, CHF. She is very independent with need of assistance at times.

Observation on 08/22/24 8:13 A.M. revealed her hair appears unkept. At 10:35 A.M., 12:00 P.M., and 2:10 P.M. She still has not had her hair care completed. . On 08/26/24 at 10:33 A.M. Remains up in common area with walker, her hair remains unkept and greasy.

Interview with RN #276 at 10:39 A.M. verified Resident #35's hair was unkept and when staff asked her to go to her room so they could fix her hair, she complied and went with them.

Review of the policy Supporting Activities of Daily Living (ADLs), reviewed 08/2021, revealed residents will be provided with appropriate care and services will be provided for residents who are unable to carry out ADLs independently in accordance with the plan of care, including appropriate support and assistance with communication. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals, and recognized standards of practice.

3. Record review for Resident #45 revealed an admission date of 07/29/21. Diagnoses included dementia, other specified disorders of bone density and structure, hemiplegia and contracture of muscle right hand and left hand.

Review of the annual Minimum Data Set (MDS) assessment dated 07/01/24 revealed Resident #45 was severely cognitively impaired and dependent for activities of daily living.

Review of the care plan with the focus area of activity dated 04/08/24 revealed Resident #45 is dependent on staff for activities. Interventions included Resident #45's preferences for activities including: music, spiritual activities, and watching movies.

Observation made on 08/20/24 at 04:52 P.M. revealed Resident #45 sitting in her wheelchair by the window in the room.

Interview on 08/21/24 at 09:57 AM with Activity Supervisor #608 revealed she has worked with Resident #45. When asked what activities Activity Supervisor #608 had done with Resident #45 she said everything. Activity Supervisor #608 said Resident #45 does more sensory activities because she can't see well. Activity Supervisor #608 said she is given busy boards, has books read to her, specifically religious books. Activity Supervisor #608 also revealed Resident #45 likes to go outside and the loves the dog. Activity Supervisor #608 said Resident #45 is with the low functioning group. When asked if Resident #45 likes one on one or group activities, Activity Supervisor #608 said group activities.

Record Review for Resident #45 monthly activity sheets shows there is a blank week in May, June, and July from the 20 to the 27.

Interview on 08/21/24 at 10:45 A.M. with Activity Supervisor #608 revealed she was asked by the surveyor why are there blank weeks on Resident #45 activity sheets from May 20 to May 27, 2024, June 20 to June 27, 2024, and July 20 to July 27, 2024 each month. Activity Supervisor #608 responded that she does not have much staff at the end of the month like she does at the beginning of the month. Activity Supervisor #608 revealed that aides fill out the forms.

Interview on 08/21/24 at 2:39 P.M. with STNA #180 revealed she has worked with Resident #45. STNA #180 said Resident #45 likes to sing and she really likes strawberry ice cream. STNA #180 said Resident #45 will kick you out of any activity but she likes when we play music.

Interview on 08/21/24 at 02:51 P.M. with STNA #485 revealed sometimes physical activities are done with Resident #45 like exercises with arms, hands, and legs.

Interview on 08/21/24 at 05:48 P.M. with RN #190 revealed she works with Resident #45 and she has not seen activities with Resident #45.

Review of the August 2024 Activity Calendar for August 22 at 11:30 A.M. revealed a Nature walk is to take place.

Interview on 08/22/24 at 11:29 A.M. with Activity Supervisor #608 revealed Activity Supervisor #608 was asked when your activity and what activity is it. Activity Supervisor #608 said they are going outside right now. When asked if everyone is going, Activity Supervisor said no, just a few at a time.

Observation on 08/22/24 at 11:30 A.M. revealed Resident #45 was sitting in wheelchair in room towards window.

Interview on 08/22/24 at 11:30 A.M. with Resident #45 revealed the surveyor asked if Resident #45 would like to go outside. Resident #45 responded if she had a jacket she would.

Observation on 08/22/24 at 11:47 A.M. revealed Activity Supervisor #608 was passing out soup in the dining room.

Interview on 08/22/24 at 11:47 A.M. with Activity Supervisor #608 revealed they only did a 15 minute walk. Activity Supervisor said they go to all rooms to see ask everyone, however since there are only two activity staff they have no more than 6 people for ratio purposes. When asked how did you get everyone in 15 minutes, Activity Supervisor #608 revealed that café ended at 11:00 A.M. and the next event started at 11:30 A.M. so she had buffer room. Activity Director #608 said Resident #45 would tell us if she wanted to go out, only 10 residents wouldn't. Activity Director #608 said they get separate activities. When asked if Resident #45 went out, Activity Supervisor #608 said STNA #245 would have asked her.

Interview on 08/22/24 at 11:58 A.M. with Resident #45 revealed she was not asked to go outside.

Interview on 08/22/24 at 3:24 P.M. with Activity Supervisor #608 revealed poetry and reading is not taking place because that event is for lower functioning residents and they are all sleeping.

Observation on 08/22/24 at 3:31 P.M. revealed Resident #45 was in her room in her wheelchair singing to the radio.

Observation on 08/26/24 at 8:32 A.M. revealed Resident #45 was listening to music in her room.

Observation on 08/26/24 at 10:23 A.M. revealed Resident #45 was in her room listening to music with the door open. There was different music playing outside her room in the open area.

Observation on 08/26/24 at 11:31 A.M. revealed Resident #45 was sitting in her wheelchair listening to music.

Interview on 08/26/24 at 2:50 P.M. with STNA #245 revealed most of the time we don't have enough staff to have activities in all the areas. When asked if events are offered after three o ' clock in the afternoon, STNA #245 responded with I don't know what else they do. STNA #245 revealed that Resident #45 has not been at any event they held in the past week.

Review of the undated Activities Guidelines policy stated This facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental and psychosocial well being of each resident.

Based on personnel file review, staff interview and review of a job description, the facility failed to ensure a qualified Activity Director (AD) was in place to oversee the facility's overall activity services. This had the potential to affect all 99 resident residing in the facility. The census was 99.

Findings include:

Review of personnel files on 08/21/24 at 1:20 P.M. revealed Activities Director (AD) #608 was hired as activities aid 10/30/22 part-time. Staff #608 had a high school diploma and had attended some collage studying social work but did not graduate. Staff #608 resigned her part-time position 01/19/23 and became employed on an as needed or PRN basis. A new application to be activities aid full-time was submitted on 09/26/23 and human resources documents indicate this is when Staff #608 became a full-time activities assistant. Staff #608 was promoted to Activities Manager 04/05/2024.

Interview on 08/20/24 at 03:26 P.M. with AD #608 confirmed she is not certified yet. AD #608 stated she has worked here for three years as activity assistant; 5 months as director. AD #608 confirmed she not certified as an activities director but believes facility is going to pay for her education but they had not done that yet. AD #608 confirmed there are 9-10 activity staff members here at the facility; AD #608 confirmed so staff at the facility are certified to be an Activities Director. AD #608 stated there is no regional or corporate activity person/oversight. When asked how she decides what activities are needed; AD #608 stated she uses online resources and online groups for ideas in planning activities.

Interview on 08/21/24 at 1:35 P.M. with Human Resources Director (HRD) #775 confirmed AD #608 was hired as activities aid 10/30/22 part-time, and resigned her part-time position 01/19/23 and became employed on an as needed or PRN basis. A new application to be activities aid full-time was submitted on 09/26/23 and human resources documents indicate this is when AD #608 became a full-time activities assistant. HRD #775 stated AD #608 was promoted to Activities Manager 04/05/2024. HRD #775 confirmed AD #608 did not meet the criteria to be an activities director as she did not have an associates degree or certification and did not have two years full-time experience as an activities aid. HRD #775 stated AD #608 had just over six months experience full-time as an activities aid.

Review of the Position Description for Activities Director (created on 06/01/05) signed by AD #608 on 04/05/24 revealed the facility requirements for an Activities Director state:

1. Associates degree in recreation is required.

2. Must have two years experience in long-term care as a supervisor

3. In lieu of college degree will consider an applicant with two years experience in recreation department plus the required two years supervisory experience.

4. Certification in accordance with regulatory agencies is required.

Interview on 08/27/24 at 2:20 P.M. with HRD #775 confirmed AD #608 did not have two years experience in activities; she had one year six months experience and only six months of that was full-time. AD #608 had no supervisory experience and has no degree or certification.

Based on medical record review and staff interview, the facility failed to follow physicians orders in obtaining daily weights. This affected one (Resident #4) of 25 residents records reviewed. The census was 99.

Findings include:

Review of Resident #4's medical record revealed she was admitted to the facility on 01/28/21. Diagnoses included Alzheimer's disease with agitation, congestive heart failure (CHF), Psychotic disorder with delusions and paranoid schizophrenia. Review of the significant change minimum data set assessment dated 07/01/24 revealed her cognition was not intact.

Review of the physicians orders revealed an order on 07/18/24 weigh daily at 6:00 A.M. notify if weight gain is three pounds in a day or five pounds in a week. This weight must be done every morning and charted at 6:00 A.M. by the night shift nurse.

Review of the plan of care dated 07/17/24 revealed Resident #4 has need for cardiac assessment/potential for alteration in cardiac output..Complete cardiac assessment, as clinically indicated, and notify the physician of findings which significantly vary from her baseline, as needed. Provide follow up, as indicated, per physician order. Monitor weights as ordered notify the doctor if weight gain is three pounds in a day or five pounds in one week.

Review of Resident #4's medical record revealed there were no weights documented on 07/28/24, 08/09/24, and 08/12/24.

On 08/22/24 at 2:58 P.M. interview with Unit Manager #227 verified the weights were not obtained and documented everyday as ordered.

Based on observation, record review, resident and staff interview, the facility failed to assist Resident #78 with applying his corrective lenses. This affected one (Resident #78) of two residents reviewed for communication-sensory. The facility census was 99.

Findings include:

Review of Resident #78's medical record revealed an admission date of 05/14/22. Medical diagnoses included dementia, polyneuropathy, and hemiplegia and hemiparesis (weakness and paralysis) following a cerebrovascular accident (stroke).

Review of Resident #78's Minimum Data Set 3.0 quarterly assessment, dated 07/01/24 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 03, indicating severely impaired cognition. The assessment noted the resident's vision was adequate with no corrective lenses. Resident #78 was identified as usually able to make himself understood and usually able to understand others.

Review of Resident #78's care plan, initiated on 05/24/22 and revised 06/27/24, revealed the resident had a visual acuity deficit due to the aging process, he wears glasses some of the time to correct this issue. A listed goal stated the resident will be free from signs and symptoms of a visual acuity deficit through wearing corrective eyewear daily, as recommended, over the course of the review period. Listed interventions included to adapt his environment to meet his individual needs, and to assist him in keeping his eyeglasses clean and stored appropriately.

Review of Resident #78's optometry note, dated 07/02/24, revealed the resident was assessed to have myopic astigmatism (a refractive change that can result in blurry vision) and presbyopia (gradual loss of the eye's ability to focus on nearby objects). The plan noted the resident needed new bifocals. New glasses were recommended and noted to be delivered upon approval. The note indicated Resident #78 required glasses and encouraged full-time use for distance and reading.

Review of Resident #78's interdisciplinary progress notes revealed a note dated 08/14/24 at 1:36 P.M. which stated the resident received his new glasses today, and stated they worked good.

An observation on 08/19/24 at 11:25 A.M. revealed Resident #78 was seated up in his wheelchair in his room. He was not wearing glasses. Resident #78's glasses were observed on top of a wardrobe against the wall and next to his bed which was approximately five foot tall.

An observation on 08/20/24 at 4:44 P.M. of Resident #78's room revealed the resident was not in his room, but his glasses were observed on top of the wardrobe next to his bed.

An observation on 08/20/24 at 4:47 P.M. revealed Resident #78 was seated in the dining room table with his evening meal in front of him. He was not wearing his eyeglasses.

Subsequent observations on 08/21/24 at 9:40 A.M., 10:29 A.M., and 12:55 P.M. revealed Resident #78 was observed seated in his wheelchair and was not wearing his eyeglasses.

An interview on 08/21/24 at 12:55 P.M. with Resident #78 revealed him seated in his wheelchair in the 100 hallway near the nurse's station. The resident stated he had glasses and was supposed to wear them all the time.

An observation at 12:57 P.M. of Resident #78's room revealed the glasses were again observed on top of the wardrobe next to the bed.

An observation and interview on 08/21/24 at 12:58 P.M. with Stated Tested Nurse Aide (STNA) #345 revealed she was unsure if Resident #78 wore glasses or not. STNA #345 stated she would check the resident's room and proceeded to walk down to Resident #78's room where she retrieved his glasses off the top of his wardrobe. STNA #345 returned to where Resident #78 was seated and applied his glasses. Resident #78 thanked STNA #345 and stated now he can see great.

An observation on 08/22/24 at 10:38 A.M. revealed Resident #78 seated in his wheelchair propelling himself down the long hallway towards the 300 hallway. The resident stated he was looking for his room but was having trouble finding it. When asked where his glasses were, he stated he did not know.

An interview on 08/22/24 at 10:39 A.M. with Activity Director (AD) #608 revealed she had never seen Resident #78 wear glasses but would assist him back to his room on the other side of the building and would ask someone.

An observation on 08/22/24 at 11:57 A.M. of Resident #78 revealed him seated up in the dining room awaiting lunch. The resident was not wearing his eyeglasses.

An observation and interview on 08/22/24 at 11:57 A.M. with STNA #350 confirmed Resident #78 was not wearing his eyeglasses. STNA #350 asked Resident #78 if he wanted her to retrieve his eyeglasses, to which he responded yes while nodding his head. STNA #350 exited the dining room, walked towards the 100 hallway, and retrieved Resident #78's glasses from on top of the wardrobe in his room. STNA #350 confirmed the glasses were on top of the tall wardrobe in the resident's room, but she was able to find them. STNA #350 applied the glasses to Resident #78's face. Resident #78 thanked STNA #350 and stated he could see much better with his glasses on.

An observation and interview on 08/26/24 at 4:01 P.M. revealed Resident #78 propelling himself down the 100 hallway towards his room. Resident #78 was not wearing his eyeglasses. Licensed Practical Nurse (LPN) Unit Manager (UM) #215 was present in the hall and verified the resident did not have on his glasses. LPN UM #215 confirmed staff should be providing and assisting the resident to apply his eyeglasses when he is up.

Review of the policy Supporting Activities of Daily Living (ADLs), reviewed 08/2021, revealed residents will be provided with appropriate care and services will be provided for residents who are unable to carry out ADLs independently in accordance with the plan of care, including appropriate support and assistance with communication. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals, and recognized standards of practice.

Based on medical record review, observation and staff interview, the facility failed to maintain interventions to promote healing of pressure ulcers. This had the potential to affect three (Resident #1, #18 and #90) of four residents reviewed for pressure ulcers. The Census was 99.

Findings include:

Review of Resident #18's medical record revealed she was admitted to the facility on 01/10/19. Diagnoses included protein calorie malnutrition, pressure ulcer of the right ankle, open wound of the left lower leg, Alzheimer's disease, aphasia, anxiety and major depression. Review of the quarterly minimum data set (MDS) assessment dated 07/16/24 revealed her cognition was not intact. Resident #18 had no limitation in range of motion. Resident #18 had a Stage II pressure ulcer and an open lesion other than an ulcer coded on the assessment. Resident #18 was coded as having a pressure reducing device for her chair and the bed.

Review of the physician's orders revealed an order for a pressure reducing cushion to her chair dated 03/13/24 .

Review of the plan of care dated 03/13/24 revealed Resident #18 had the potential for skin breakdown and needs extensive assistance with care and mobility, can be resistive to care, and has a history of pressure ulcers.

Observations on 08/20/24 at 8:15 A.M., 10:20 A.M., 11:19 A.M. and 12:08 P.M. revealed Resident #18 was up in her chair without the pressure reduction cushion in place.

Interview on 08/20/24 at 2:20 P.M. with Unit Manager #227 verified Resident #18 did not have her pressure reducing cushion in place in her chair as ordered.

2. Review of Resident #90's medical record revealed he was admitted to the facility on 12/12/23. Diagnoses included traumatic hemorrhage of cerebrum, aphasia, hemiplegia and hemiparesis, hypertension, convulsions, dysphagia, vascular dementia with agitation, anxiety, depression, and insomnia. Review of the quarterly MDS assessment dated 07/30/24 revealed his cognition was not intact. It identified no functional limitation in range of motion. No pressure ulcers were coded on the assessment.

Review of the physicians orders dated 08/09/24 revealed heel elevators to bilateral heels, off for hygiene only.

Review of the plan of care date 12/15/23 revealed the resident is at risk for impaired skin integrity due hemiparesis, hemiplegia, tube feeding, dementia, hemorrhage of cerebrum,and chronic kidney disease.

Observations on 08/22/24 at 11:42 A.M. revealed no heel elevators were observed on while the resident was in bed. On 08/26/24 at 8:40 A.M. and 10:00 A.M. no heel elevators were observed on while he was in bed. On 08/26/24 at 10:17 A.M. interview with Unit Manager #227 verified during interview the resident did not have the heel elevators on.

Based on medical record review, observation, and staff interview, the facility failed to ensure tube feedings were administered at the rate ordered by the physician. This affected one (Resident #26) of two facility-identified residents with orders for tube feeding. The facility census was 99 residents.

Findings include:

Review of the medical record for Resident #26 revealed an admission date of 12/29/21 with diagnoses including dementia with agitation, dysphagia, contracture of muscles, severe protein calorie malnutrition, paranoid schizophrenia, and diabetes.

Review of the Minimum Data Set assessment for Resident #26 dated 05/22/24 revealed the resident was cognitively impaired.

Review of the physician's orders for Resident #26 revealed an order dated 05/09/24 to administer Isosource 1.5 per gastrostomy tube via pump at 55 cubic centimeters (cc) per hour continuously.

Review of the plan of care for Resident #26 dated 03/31/24 revealed the required a tube feeding related to having severe protein calorie malnutrition and dysphagia with interventions which included staff should administer the tube feeding as ordered.

Observation on 08/19/24 at 9:54 A.M. revealed Resident #26 was receiving Jevity 1.5 tube feeding via pump at 50 cc per hour.

Observation on 08/20/24 at 4:18 P.M. revealed Resident #26 was receiving Jevity 1.5 tube feeding via pump at 50 cc per hour.

Interview on 08/20/24 at 4:23 P.M. with Unit Manager (UM) #227 confirmed Resident #26 was receiving Jevity 1.5 tube feeding via pump at 50 cc per hour, but the physician's order was for Isosource 1.5 at 55 cc per hour.

Based on medical record review, observation, staff interview, policy review, and review of manufacturer's guidelines, the facility failed to ensure the medication error rate did not exceed five percent (%). The facility had four medication errors of 31 opportunities for an error rate of 12.9 %. This affected four (Residents #64, #27, #08, and #49) of five residents reviewed for medication administration. The facility census was 99 residents.

Findings include:

1. Review of the medical record for Resident #64 revealed an admission date of 05/08/23 with diagnoses including dementia, type two diabetes mellitus, paranoid schizophrenia, and hypertension.

Review of the Minimum Data Set (MDS) assessment for Resident #64 dated 07/23/24 revealed the resident had intact cognition.

Review of the physician's orders for Resident #64 revealed an order dated 09/01/23 for Namenda 10 milligram (mg) one tablet by mouth twice daily.

Observation on 08/21/24 at 8:38 A.M. revealed Licensed Practical Nurse (LPN) #470 prepared Resident #64's morning medications for administration. Namenda was not available for administration.

Interview on 08/21/24 at 8:38 A.M. with LPN #470 confirmed Namenda for Resident #64 was not available for administration. LPN #470 confirmed she would order the medication from the pharmacy, and it should arrive later in the day.

Observation on 08/21/24 at 9:30 A.M. with LPN #120 revealed the skilled hallway medication room contained the facility's emergency supply of commonly ordered and/or used medication. The supply included six Namenda 5 mg tablets.

Interview on 08/21/24 at 11:10 A.M. with the Director of Nursing (DON) confirmed she was not notified that Resident #64 did not receive his morning dose of Namenda 10 mg, and LPN #470 should have retrieved Namenda from the facility's emergency supply so he did not miss his dose of medication.

2. Review of the medical record for Resident #27 revealed an admission date of 03/14/23 with diagnoses including dementia, depression, osteoarthritis, and hypertension.

Review of the MDS assessment for Resident #27 dated 07/02/24 revealed the resident had moderately impaired cognition.

Review of the physician's orders for Resident #27 revealed an order dated 08/07/24 for Zoloft 150 mg every morning.

Observation on 08/21/24 at 9:18 A.M. revealed Registered Nurse (RN) #120 prepared Resident #27's morning medications. RN #120 checked the cards of medications and stated she only had Zoloft 100 mg tablets present in the medication cart and was missing a 50 mg tablet of Zoloft to make up the total dose of 150 mg.

Observation on 08/21/24 at 9:30 A.M. with RN #120 revealed the emergency supply of medications included six 125 mg Zoloft tablets.

Interview on 08/21/24 at 9:30 A.M. with RN #120 confirmed the doses of Zoloft in the emergency supply were 125 mg per dose and would not work to make up Resident #27's dose of Zoloft 150 mg. RN #120 confirmed she would not be able to administer Resident #27's full dose of Zoloft and would give him a partial dose of 100 mg.

Observation on 08/21/24 at 9:36 A.M. revealed RN #120 administered Zoloft 100 mg to Resident #27.

Interview on 08/21/24 at 9:52 A.M. with Unit Manager (UM), LPN #215 confirmed Zoloft 50 mg for Resident #27 had been ordered from the pharmacy and would not arrive till later in the afternoon.

3. Review of the medical record for Resident #08 revealed an admission date of 01/20/22 with medical diagnoses included glaucoma, Alzheimer's disease, depression, and aphasia.

Review of the MDS assessment for Resident #08 dated 03/14/23 revealed the resident was cognitively impaired.

Review of the physician's orders for Resident #08 revealed an order dated 07/26/22 for Senna-S 8.6-50 mg 1 tablet by mouth twice daily.

Review of the Medication Administration Record (MAR) for Resident #08 dated August 2024 revealed Senna S had been signed as given twice daily from 08/01/24 to 08/21/24's morning dose.

Observation on 08/21/24 at 9:43 A.M. revealed RN #160 administered a Senna 8.6 mg tablet to Resident #08 with his morning medications.

Interview on 08/21/24 at 10:09 A.M. with RN #160 confirmed she gave Resident #08 the wrong laxative. RN #160 confirmed she gave the resident a dose of senna 8.6 mg, because she did not have a bottle of Senna-S in the medication cart. RN #160 stated she could have checked the medication room or central supply as it was an over-the-counter medication, but the Senna 8.6 mg was close enough to the ordered Senna-S tablets.

4. Review of the medical record for Resident #49 revealed an admission date of 05/22/23 with diagnoses including type two diabetes and hemiplegia and hemiparesis following a cerebrovascular accident.

Review of the MDS assessment for Resident #49 dated 06/29/24 revealed the resident was cognitively impaired and received insulin injections.

Review of the physician's orders for Resident #49 revealed an order dated 02/23/24 for Humalog insulin two units by subcutaneous injection three times daily before meals.

Observation on 08/21/24 at 11:55 A.M. revealed Registered Nurse (RN) #190 applied a clean needle to the Humalog insulin pen, dialed the pen to 2 units, cleansed a site on Resident #49's left upper arm, and administered the Humalog to the resident. RN #190 did not prime the needle prior to administering the resident's medication.

Interview on 08/21/24 at 12:00 P.M. with RN #190 confirmed she did not prime the insulin pen for Resident #49 after applying the new clean needle.

Interview on 08/21/24 at 12:22 P.M. with the Director of Nursing (DON) confirmed the expectation of the nurse was to prime the new needle applied to an insulin pen prior to each use.

Review of the manufacturer's instructions for the Humalog insulin pen revised 07/2023 revealed the nurse should prime the insulin pen prior to each injection. Priming the pen meant removing air from the needle and cartridge that might collect during normal use and ensured that the pen was working correctly. If the nurse did not prime the pen before each injection there could be too much, or too little insulin administered.

Review of the facility policy titled Medication Dispensing System undated revealed prior to medication administration the nurse should verify each medication to ensure that the medication is the right drug, at the right dose, the right route, at the right rate, at the right time, for the right customer, and to verify that the MAR reflects the most recent medication order. Nurses should follow appropriate medication administration guidelines.

Review of the policy titled Medication Errors Reporting - Pharmacy Related undated revealed errors included medications not administered within the allowed time frame, failing to administer an ordered dose, and administration of medication which was greater/lesser than what was ordered. Medication errors should be documented on an occurrence report. All medication incident reports would be reviewed by appropriate pharmacy and long-term care facility management to ensure the appropriate action was being consistently implemented.

Review of the facility policy titled Emergency Pharmacy Service and Emergency Kits dated 03/28/18 revealed medications were only administered with a valid provider's order. A list of all medications and supplies were posted on the kit and system and should include medication, quantity, expiration date and the pharmacy name and phone number. A method of recording use of items from the emergency kit should be in place. Medications used from the emergency kit/system or entire kit shall be replaced.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure residents were free from significant medication errors related to insulin administration. This affected one (Resident #49) of five residents reviewed for medication administration. The facility identified eight residents whose medication regimens required insulin injections. The facility census was 99 residents.

Findings include:

Review of the medical record for Resident #49 revealed an admission date of 05/22/23 with diagnoses including type two diabetes and hemiplegia and hemiparesis following a cerebrovascular accident.

Review of the Minimum Data Set (MDS) assessment for Resident #49 dated 06/29/24 revealed the resident was cognitively impaired and received insulin injections.

Review of the physician's orders for Resident #49 revealed an order dated 02/23/24 for Humalog insulin two units by subcutaneous injection three times daily before meals. The order specified to hold the medication if the blood glucose level was less than 140 milligram (mg)/deciliter (dl).

Review of the Medication Administration Record (MAR) for Resident #49 dated August 2024 revealed the resident's morning dose of Humalog was administered on the following dates when the blood glucose level was less than 140 mg/dl which was outside of the parameters specified in the physician's order. Resident #49 received 2 units of insulin on the following dates when her blood glucose was too low for administration per the physician ordered parameter: 08/02/24-84, 08/03/24-67, 08/04/24-112, 08/06/24-126, 08/08/24- 77, 08/11/24-97, 08/15/24-105, 08/22/24-115.

Interview on 08/26/24 at 9:36 A.M. with the DON confirmed Resident #49's morning dose of insulin had been given outside of the parameters on 08/02/24, 08/03/24, 08/04/24, 08/06/24, 08/08/24, 08/11/24, 08/15/24, and 08/22/24.

Review of the facility policy titled Medication Dispensing System undated revealed prior to medication administration the nurse should verify each medication to ensure that the medication is the right drug, at the right dose, the right route, at the right rate, at the right time, for the right customer, and to verify that the MAR reflects the most recent medication order. Nurses should follow appropriate medication administration guidelines.

Based on observation, staff interview, medical record review, policy review, and review of manufacturer's guidelines, the facility failed to ensure medications were labeled and stored appropriately per manufacturer's guidelines and failed to ensure medication carts were secured when not in use. This had the potential to affect all residents residing in the facility. The facility census was 99 residents.

Findings include:

1.Observation on 08/21/24 at 8:52 A.M. revealed Registered Nurse (RN) #190 was at her medication cart preparing medications on the 300 unit. RN #190 had a cup of crushed medications mixed with applesauce in her hand. RN #190 turned her back to the medication cart and walked approximately 30 feet to the center of the dining room and did not lock her medication cart. RN #190 returned to the cart approximately one minute later.

Interview on 08/21/23 at 8:54 A.M. with RN #190 confirmed she had left her medication unlocked and unattended.

Observation on 08/21/24 at 2:19 P.M. revealed RN #120 at her medication cart in the Pink hall of the skilled unit. RN #120 had a cup of pills in her hand, turned her back to the medication cart and walked into a resident's room without locking her medication cart. Four residents were observed in the pink hallway of the skilled unit near the nurse's station/lounge area within 15 feet of RN #120's medication cart. RN #120 returned to her medication cart at 2:23 P.M.

Interview on 08/21/24 at 2:24 P.M. with RN #120 confirmed she left her cart unlocked and unattended and should not have done so.

Review of the policy titled Medication Dispensing System undated revealed medication carts were always to be locked when out of sight or unattended.

2. Review of the medical record for Resident #8 revealed an admission date of 01/20/22 with diagnoses including Alzheimer's disease, glaucoma, and osteoarthritis.

Review of the Minimum Date Set (MDS) assessment for Resident #8 dated 03/14/23 revealed the resident was cognitively impaired.

Review of the August 2024 physician's orders for Resident #8 revealed an order for Cosopt ophthalmic solution (eye drops used to treat glaucoma) one drop in each eye twice daily.

Review of the Medication Administration Record (MAR) for Resident #8 dated August 2024 revealed the resident's eye drops had been recorded as administered twice daily from 08/01/24 through 08/21/24.

Observation on 08/21/24 at 9:43 A.M. revealed RN #120 administered Resident #8's Cosopt ophthalmic solution. Neither the Cosopt eye drop box nor the vial contained a date the medication was opened. The vial did list 03/09/24 as the date the medication was delivered by the pharmacy.

Interview on 08/21/24 at 10:09 A.M. with RN #120 confirmed there was no date opened listed on the Cosopt eye drop vial or box. RN #120 confirmed the printed fill date from the pharmacy listed on label of the vial and box read 03/09/24. RN #120 was unsure when eye drops should be discarded after opening.

Interview on 08/21/24 at 10:18 A.M. with Licensed Practical Nurse (LPN) #215 confirmed she was unsure when eye drops should be discarded after opening.

Review of the facility policy titled Medications with Shortened Expiration Dates undated revealed medications in multiple dose-containers should be discarded 28 days after opening unless otherwise specified by the manufacturer.

Review of the manufacturer's information for Cosopt eye drops/solution dated 12/12/16 revealed Cosopt can be used for 28 days after first opening the container and then should be discarded.

3. Observation on 08/21/24 at 2:53 P.M. with LPN #227 revealed the medication room refrigerator on the 300 unit contained a box which contained an open undated vial of tuberculin testing solution and a vial of influenza vaccine which was being stored in a tuberculin testing solution box.

Interview on 08/21/24 at 2:53 P.M. with LPN #227 confirmed the tuberculin testing solution should be dated when opened and should be discarded within 30 days. LPN #227 further confirmed the influenza vial should not be stored inside a tuberculin testing solution box as a staff member could easily grab the wrong vial.

Review of the manufacturer's package insert for tuberculin testing solution dated November 2013 revealed vials in use more than 30 days should be discarded due to possible oxidation and degradation which might affect potency.

Based on observation, staff interview, and review of the facility policy, the facility failed to prevent clean equipment and utensils from contamination, failed to maintain kitchen equipment in operating condition, and failed to follow proper datemarking procedures. This had the potential to affect all residents with the exception of Residents #26 and #90 who receive nothing by mouth. The facility census was 99 residents.

Findings include:

1. Observation on 08/19/24 at 04:18 P.M. revealed there was a rectangular door on the ceiling above a storage rack for clean pots and pans with chipped paint on the door and all around the door frame.

Interview on 08/19/24 at 04:18 P.M. with Dietary Director (DD) #570 confirmed the clean pots and pans were stored underneath the ceiling door to the attic access and the chipping paint could fall on the clean pots and pans.

Review of the facility policy titled Cross Contamination Overview dated August 2008 revealed physical contaminants included foreign objects that might inadvertently enter the food.

2. Observation on 08/19/24 at 04:33 P.M. in the dish room with DD#570 revealed there was a pink pool of liquid near the drain.

Interview on 08/19/24 04:34 P.M. with DD#570 confirmed that the garbage disposal had a leak for approximately two months prior to the survey and the leak allowed fluid to pool on the floor of the dish room. DD #570 further confirmed the facility had a new garbage disposal, but the facility staff had not installed it yet.

Observation on 08/21/24 at 10:18 A.M. revealed the garbage disposal was leaking with water pooling on the floor underneath. There was red fluid dripping from the disposal.

Interview on 08/21/24 at 10:18 A.M. with DD#570 confirmed the red fluid leaking from the garbage disposal was cranberry juice.

Interview on 08/26/24 at 08:49 A.M. with DD #570 confirmed the kitchen staff performed general monitoring of the kitchen equipment every day.

Review of the facility policy titled Floor Cleaning dated August 2008 revealed all kitchen floors should be cleaned as needed or at a minimum after each meal.

Review of the work orders from the last six months revealed there were no work orders regarding the garbage disposal leaking on the floor.

Review of the facility policy titled Maintenance Records dated August 2008 revealed a work order request should be completed for all equipment in need of repair.

3. Observation on 08/19/24 at 04:52 P.M. of the walk-in cooler revealed there was a bag of sliced yellow and white cheese that was dated 08/07/24 and a bag of shredded cheese dated 08/08/24.

Interview on 08/19/24 at 04:54 P.M. with DD #570 confirmed the hold time for cheese was seven days and the bags of cheese should have been discarded.

Observation on 08/19/24 at 04:56 P.M. with DD #570 revealed the walk-in cooler contained a large half sliced log of undated bologna.

Interview on 08/19/24 at 04:56 P.M. with DD #570 confirmed there was no date on the open log of bologna, and it should be discarded.

Observation on 08/21/24 at 12:54 P.M with DD #570 revealed the walk-in cooler contained a bin of mushrooms dated 08/12/24.

Interview on 08/21/24 at 12:54 P.M. with DD#570 confirmed the mushrooms were out of date and should be discarded.

Interview on 08/26/24 at 08:49 A.M. with DD #570 confirmed the facility datemarking policy was the date opened plus 6 days out. DD #570 further confirmed the date of disposal was to be marked on the product.

Review of the facility policy titled Datemarking dated August 2008 revealed food maintained at a temperature of 41 degrees Fahrenheit (F) or less, should be marked to be used in seven calendar days.

4. Observation on 08/19/24 at 04:58 P.M. revealed the noncommercial microwave had peeling metal around the interior edge and on the inside of the microwave.

Interview on 08/19/24 at 04:59 P.M. with DD#570 revealed the microwave was not commercial grade and there was peeling metal on the edge and inside the microwave.

Interview on 08/20/24 at 03:00 P.M. with Maintenance Director (MD) #801 confirmed the microwave in the facility kitchen was not commercial grade.

Interview on 08/21/24 at 12:48 P.M. with DD #570 confirmed the microwave was not commercial grade and had peeling metal on the edge and inside the microwave. DD #570 further confirmed the local health department told the facility to get a commercial grade microwave.

Interview on 08/26/24 at 08:49 A.M. with Dietary Director #570 confirmed the kitchen staff performed general monitoring of kitchen equipment every day.

Review of the facility policy titled Microwave Cleaning dated August 2008 revealed the microwave should be cleaned and sanitized as needed or at a minimum daily.

Review of the work orders from the last six months revealed there were no work orders for the microwave.

Review of the facility policy titled Maintenance Records dated August 2008 revealed a work order request should be completed for all equipment in need of repair.

5. Observation on 08/19/24 at 05:00 P.M. of the reach-in cooler revealed there was a large amount of water pooling in the bottom.

Interview on 08/19/24 at 05:00 P.M. with DD #570 confirmed water was pooling at the bottom of the cooler. DD #570 confirmed the cooler did that every couple of weeks.

Observation on 08/21/24 at 12:04 P.M. revealed water was pooling in the bottom of the reach-in cooler.

Interview on 08/21/24 at 12:05 P.M. with the DD #570 confirmed water was pooling in the bottom of the unit again.

Review of the policy titled Refrigerator, Reach-in Cleaning dated August 2008 revealed all refrigerators should be cleaned and sanitized as needed or at a minimum monthly.

Review of the work orders from the last six months revealed there were no work orders for water pooling at the bottom of the reach in cooler.

Based on facility document review and staff interview, the facility failed to ensure the facility assessment contained all required information. This had the potential to affect all residents residing in the facility. The facility census was 99.

Findings include:

Review of the facility assessment updated 08/19/24 revealed the assessment was completed using a facility assessment tool which provided guidelines and prompts for completing a comprehensive assessment. The section prompting the facility to describe ethnic, cultural, or religious factors or personal resident preferences that could affect the care provided to the residents was blank. The section prompting the facility to list contracts, memoranda of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies, such as transfer agreements, was blank. The section prompting the facility to list their health information technology resources for electronically managing patient records and electronically sharing information with other organizations, was blank. The section prompting the facility to provide the facility-based and community-based risk assessment, utilizing an all-hazards approach, was blank. There were no attachments or addendums. The assessment listed the updated facility assessment was to be reviewed at the Quality Assurance/Performance Improvement (QAPI) meeting scheduled for 08/26/24.

Interview on 08/26/24 at 8:48 A.M. with the Administrator confirmed the facility assessment was updated 08/19/24.

Interview on 08/26/24 at 4:10 P.M. with the Director of Nursing (DON) confirmed the facility had four residents whose primary language was not English. The DON confirmed two residents spoke French Creole, one resident spoke Georgian, and one resident spoke Vietnamese. The DON shared the facility held their scheduled QAPI meeting early in the day of 08/26/24, but none of the QAPI members in attendance had time to read the multiple pages of the facility assessment. The DON confirmed the facility assessment sections regarding ethnic, cultural, or religious factors, contracts and agreements with third parties, health information technology resources, and the facility-based and community-based risk assessments were blank.

4. Review of the medical record for Resident #49 revealed an admission date of 05/22/23 with diagnoses including type two diabetes.

Review of the Minimum Data Set (MDS) assessment for Resident #49 dated 06/29/24 revealed the resident was cognitively impaired and received insulin injections.

Review of the physician's orders for Resident #49 revealed an order dated 02/23/24 for resident to receive Humalog insulin 2 units by subcutaneous injection three times daily before meals.

Observation on 08/21/24 at 11:55 A.M. revealed Registered Nurse (RN) #190 administered Resident #49's pre-lunch dose of insulin injection to the resident's left upper arm and was not wearing gloves during administration.

Interview on 08/21/24 at 12:00 P.M. with RN #190 confirmed she did not wear gloves while administering Resident #49's insulin. RN #190 confirmed she should have applied clean gloves prior to insulin administration.

Interview on 08/21/24 at 12:22 P.M. with the DON confirmed nurses should don clean gloves prior to administration of insulin injections.

Review of the facility policy titled Standard Precautions revised August 2022 revealed gloves should be worn before and removed after contact with blood or body fluid, mucous membranes, or non-intact skin.