Westerwood Rehabilitation

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.

Based on medical record review, interview and facility policy review, the facility failed to ensure Resident #10 was transferred in a safe manner and as per the resident's plan of care and facility policy with two staff via a mechanical (Hoyer) lift to prevent a potential accident. This affected one resident (#10) of four residents reviewed for accident hazards. The facility census was 59.

Findings include:

Review of the medical record for Resident #10 revealed an admission date of 07/12/2023 with diagnoses including chronic obstructive pulmonary disease, spinal stenosis lumbar region, and dementia.

Review of the plan of care dated 07/26/2023 revealed Resident #10 had an activity of daily living (ADL), self-care performance deficit related to decreased mobility, weakness, memory loss/confusion, and required assistance for ADLs and mobility needs. Interventions included providing two staff assist with transfers using a Hoyer (mechanical) lift.

Review of Resident #10's quarterly Minimum Data Set (MDS) 3.0 assessment dated 04/11/2024 revealed a Brief Interview for Mental Status (BIMS) score of 08 out of 15 indicating a moderately impaired cognition for daily decision-making abilities. Resident #10 was noted to be free from bilateral upper and/or lower extremity impairment and required a wheelchair for mobility. The assessment noted the resident was dependent on staff with all transfers.

Review of the Fall Risk Assessment completed for Resident #10 dated 04/28/2024 revealed resident was alert only with one to two falls in the past three months. Resident #10 was noted to be chair bound and was noted to require the use of assistive devices for gait and balance.

Interview on 05/08/2024 at 2:00 P.M. with the Administrator revealed there was a staff member, State Tested Nursing Assistant (STNA) #335 who was still in training who transferred Resident #10 (on 05/06/24) by himself with the use of a mechanical lift. The Administrator revealed the management team was made aware of the incident by Resident #8's daughter.

Interview on 05/08/24 at 4:30 P.M. with the daughter of Resident #8 revealed she was concerned an STNA (STNA #335) was transferring Resident #10 via a Hoyer lift by himself, without a second person present on 05/06/24. The daughter indicated she asked the STNA if he needed a spotter since she stated she was aware he was a new employee. The daughter indicated the STNA replied to her he had 25 years experience, knew what he was doing, was very strong and didn't need help. The daughter indicated the STNA also reported everyone was busy right now. The daughter indicated she reported the situation to staff but continued to have concerns related to the safety of the resident without a second staff person present for the transfer with the Hoyer lift.

Attempts to reach STNA #335 during the investigation on 05/08/24 at 3:10 P.M. and 05/20/24 at 11:40 A.M. were unsuccessful. Record review/review of Resident #10's medical record revealed no written documentation of the incident/transfer on 05/06/24. There was no written statement from STNA #335 available or provided to review during the survey.

Review of an undated facility policy titled Hoyer (Sling) Lift Transfer

Based on medical record review, resident and staff interview, and observation, the facility failed to ensure residents were provided with activities to meet their needs. This affected one resident (Resident #32) of four residents reviewed for activities. The facility census was 62.

Findings include:

Review of medical record for Resident #32 revealed an admission date of 07/10/23 with diagnoses which included nuerolyptic parkinsonism, dementia, depression, bipolar II disorder, anxiety disorder, benign prostatic hyperplasia, cognitive communication deficit, drug induced movement disorder, and dorsalgia (back pain).

Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/18/24, revealed Resident #32 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status assessment. Resident #32 required a varied amount of assistance which ranged from minimal to total dependence on staff to complete Activities of Daily Living.

Review of Resident #32's Activities Assessment, dated 02/09/24, revealed the resident enjoys watching the news, watching Cleveland Browns football on television, spending time with family, spending time outside hiking, ham radio, reading, and listening to music. Resident #32 liked to do research and activity staff have been giving him a tablet to work on. Resident #32 was to receive one-to-one visits.

Review of Resident #32's Activities Log from 02/01/24 to 03/31/24 revealed the activities that were documented as having been completed for Resident #32 included reading on 20 out of 60 days, watching television on 45 out of 60 days, This Day in History & Puzzles on 40 out of 60 days, catholic communion and other religious activities on 02/06/24, 02/13/24, 02/20/24, 03/03/24, 03/05/24, 03/10/24, 03/12/24 and 03/19/24, family or friends visits on 02/06/24, 02/14/24, 02/26/24, and 03/01/24 and electronics use (Kindle which is a mobile reading device) on 13 out of 60 days. The activities log documented one to one visits occurred on 02/07/24, 02/20/24, 02/23/24, 02/25/24, 02/26/24, 03/04/24, 03/07/24, 03/11/24, 03/13/24, 03/18/24, 03/22/24, 03/24/24, and 03/27/24 with documentation which indicated the one on one visits consisted of dropping off a Kindle to Resident #32.

Review of Resident #32's Care Plan, completed on 03/26/24, revealed Resident #32 needed to maintain social interaction and stimulation, and his interests included watching the news, watching Cleveland Browns football on television, spending time with family, spending time outside hiking, ham radio, reading, and listening to music. Interventions for Resident #32 included assessing Resident #32 for response to activities and adjusting the plan, assisting the resident to the activity area per his choice, introducing Resident #32 to peers, and providing an activity calendar.

Interview on 04/01/24 at 11:03 A.M. with Resident #32 revealed he does not like to participate in group activities. Resident #32 stated he has a hard time speaking and was tired all the time. Resident #32 stated he does not really watch television and would like more things to do.

Interview on 04/02/24 at 3:25 P.M. with Resident #32 revealed he does not watch television and wished he had his computer but it was a desktop computer and he had nowhere to put it. Resident #32 stated he liked listening to music too but did not have a radio.

Observations on 04/01/24 at 3:09 P.M., on 04/02/24 at 3:25 P.M. and on 04/03/24 at 10:42 A.M., revealed Resident #32 was sitting up in his chair with no reading materials, no music, and the television was off. Resident #32 was not actively engaged in any activities.

Interview on 04/04/24 at 11:42 A.M. with State Tested Nurse Aide (STNA) #217 revealed Resident #32 liked to stay in his room and read, visit with family or listen to music. STNA #217 confirmed there was no radio or reading materials in Resident #32's room.

Interview on 04/04/24 at 1:47 P.M. with Community Life Coordinator (CLC) #192 confirmed CLC #192 was aware of Resident #32's preferred activities which included reading and listening to music. CLC #192 confirmed Resident #32 did not have a radio or reading device in his room and stated Resident #32 would be provided a radio or Kindle, but it was expected that he ask for it. CLC #192 indicated Resident #32 used to have a radio however it broke and the facility did not have enough radios available to give each resident their own radio. CLC #192 stated staff are supposed to check in every morning to ask if residents want anything but do not document requests or refusals. CLC #192 indicated the actitivity titled This Day in History & Puzzles on the activity log meant staff dropped off a packet to the resident.

Based on medical record review, observation, and staff interview, the facility failed to obtain a physician order for a right arm sling prior to use. This affected one (Resident #116) out of two residents reviewed for limited mobility. The facility census was 62.

Findings include:

Review of the medical record for Resident #116 revealed an initial admission date of 05/16/23 and a readmission date of 03/19/24. Resident #116's medical diagnoses included fracture of shaft of right humerus, laceration of part of head, difficulty in walking, lack of coordination, cognitive communication deficit, and history of falling.

Review of the Admission Minimum Data Set 3.0 assessment, dated 03/26/24, revealed Resident #116 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #116 had an impairment on one side of her upper extremity (shoulder, elbow, wrist, hand). Resident #116 required setup or clean-up assistance with eating and hygiene, and required partial to substantial assistance from staff to complete all other activities of daily living. Resident #116's active diagnoses included fractures and other multiple trauma.

Review of Resident #116's physician orders dated April 2024 revealed there was no order for a right arm sling.

Observation on 04/01/24 at 3:00 P.M. revealed Resident #116 was in her room, laying in bed, wearing a sling on her right arm.

Interview on 04/02/24 at 2:45 P.M. with the Assistant Director of Nursing (ADON) #229 confirmed there was no a physician order in place for Resident #116's right arm sling and stated there should be an order for it. ADON #229 stated Resident #116 fractured her right humerus bone and was wearing the sling while the bone healed.

Based on medical record review, resident and staff interviews, and facility policy review, the facility failed to ensure residents were provided with timely dental services. This affected one (Resident #116) out of one resident reviewed for dental services. The facility census was 62.

Findings include:

Review of the medical record for Resident #116 revealed an initial admission date of 05/16/23 and a readmission date of 03/19/24. Resident #116's medical diagnoses included fracture of shaft of right humerus, laceration of part of head, difficulty in walking, lack of coordination, cognitive communication deficit, and history of falling.

Review of a progress note, dated 03/06/24 at 8:00 A.M., revealed Resident #116 had a Medicare payer source.

Review of the Admission Evaluation, dated 03/19/24, revealed Resident #116 had broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose).

Review of Resident #116's plan of care, dated 03/20/24, revealed there were no dental or denture concerns addressed in the resident's care plan.

Review of the Admission Minimum Data Set 3.0 assessment, dated 03/26/24, revealed Resident #116 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status assessment. The assessment did not note any dental issues.

Review of Resident #116's physician orders, dated April 2024, revealed Resident #116 had an order for a regular, mechanical soft diet per the resident's request. The order was dated 03/28/24 at 2:24 P.M.

Review of a dietary progress note, dated 03/28/24 at 2:26 P.M., by Dietitian #327 revealed an oral exam showed Resident #116 had broken or loosely fitting full or partial dentures (chipped, cracked, uncleanable, or loose). The note stated, dentures do not fit. Furthermore, Resident #116 reported the dentures have caused a sore and that it is effecting her ability to eat with dentures in. Resident #116 agreed to downgrade her diet to mechanical soft until the sore healed. The diet change would allow Resident #116 to eat without dentures in at meal time and allow the gums to heal.

Review of the list of residents seen by the dentist, dated 03/28/24, revealed Resident #116 had not been seen by the dentist.

Review of a progress note, dated 03/29/24 at 6:57 A.M., by Assistant Director of Nursing (ADON) #229 revealed a new order was implemented for a mechanical soft diet per Resident #116's request related to a sore from Resident #116's dentures. The start date of the new diet was 03/28/24.

Interviews on 04/02/23 at 11:18 A.M. and on 04/03/24 at 4:40 P.M. with Resident #116 revealed the resident reported her dentures did not fit and she had sore gums. Resident #116 stated she had a canker sore on her right upper gum. The resident attempted to raise her upper lip to show the sore to this surveyor but stated, I don't think you can see it. Resident #116 placed her finger on the outside of her upper lip just under her right nostril and stated, it's right there. Resident #116 stated when she had to bite into harder foods her upper denture rubbed against the canker sore and caused pain so she had been leaving her dentures out during meals. This surveyor observed both her upper and lower dentures to be sitting on the bed side table next to the resident's bed. Resident #116 stated she had an appointment with an outside dentist scheduled in June 2024 but would like to be seen by a dentist sooner. Resident #116 stated she had not been informed of an in-facility dentist or any dental services offered by the facility.

Interview on 04/03/24 at 6:08 P.M. with Ancillary Specialist (AS) #141 revealed the facility did offer dental services to residents. The services were offered to both Medicare and Medicaid residents. AS #141 stated when a resident was admitted to the facility, ancillary services were part of the admission packet that was reviewed with the resident. A consent form was reviewed with the resident and the resident signed the form indicating whether the resident wanted to accept or decline ancillary services. AS #141 reviewed the admission packets and notified providers of the residents who wished to receive services. AS #141 confirmed the dentist visited the facility on 03/28/24 and Resident #116 was not seen at that time. AS #141 reviewed Resident #116's admission packet and ancillary services consent form and confirmed neither had been completed. AS #141 stated Dietitian #327 informed her of Resident #116's ill-fitting dentures after the dentist's visit to the facility. AS #141 stated she had not been told Resident #116 was experiencing any pain.

Interview on 04/03/24 at 6:27 P.M. with Admissions Coordinator (AC) #319 revealed he reviewed admission packets and ancillary services consent forms with new admissions to the facility. AC #319 stated the admission packet and consent forms should be completed within 72 hours of admission. AC #319 confirmed the admissions packet or ancillary services consent form for Resident #116 had not been completed yet. AC #319 stated he had not been able to connect with the resident yet in order to complete the paperwork.

Review of the facility policy titled Dental Services

Based on medical record review, review of a lunch tray ticket, observation, and staff interview, the facility failed to ensure was provided meals as preferred. This affected one resident (#4) of five residents reviewed for nutrition. The facility census was 62.

Findings include:

Review of the medical record for Resident #4 revealed an admission date of 10/21/23 with diagnoses including Alzheimer's disease, Parkinson's disease, severe protein-calorie malnutrition, vascular dementia, acquired absence of right and left leg above knee, type two diabetes mellitus, unspecified mood disorder, dysphagia, adult failure to thrive, and constipation.

Review of Resident #4's Plan of Care, dated 02/07/24, revealed Resident #4 had the potential for nutrition or hydration issues related to her diagnoses, need for mechanically altered diet, dysphagia, pocketing food, severe protein calorie malnutrition, being underweight, and increased nutrient needs related to her wound. Interventions included a consistent carbohydrate and pureed diet, offering alternates if intake is poor, assisting with meals, providing supplements as ordered, encouraging intake of meals and fluids, and per the resident's preference and daughters request the resident was to be given a bite of food with or dipped in frozen nutritional treat.

Review of Resident #4's quarterly Minimum Data Set (MDS) assessment, dated 03/21/24, revealed Resident #4 had severely impaired cognition. Resident #4 weighed 72 pounds, had no significant weight changes, and was on a mechanically altered and therapeutic diet.

Review of Resident #4's physician order, dated 04/02/24, revealed Resident #4 was to receive a frozen nutritional treat with meals.

Review of the lunch tray ticket, dated 04/04/24, revealed Resident #4 was to receive pureed cornflake chicken breast, pureed squash, carrots, and green beans, and a vanilla frozen nutritional treat.

Observation on 04/04/24 from 1:00 P.M. to 1:15 P.M. revealed STNA #77 was assisting Resident #4 with her meal. There was a plate which included two pureed foods and no supplements on Resident #4's bedside table. STNA #77 was observed feeding Resident #4 bites of pureed food and the bites of pureed food were not mixed with or dipped in frozen nutritional treat as indicated on Resident #4's care plan. The observation further revealed there was a refrigerator in Resident #4's room which contained one frozen nutritional treat and two house shakes. STNA #77 indicated he would call the kitchen to find out if Resident #4 was supposed to receive a nutritional supplement. STNA #77 verified with the kitchen that Resident #4 was supposed to receive a frozen nutritional treat with the lunch meal and the kitchen staff agreed to deliver a nutritional treat to the residents room. STNA #77 did not mix any bites of pureed food with a nutritional treat or dip the bites in a nutritional treat at any point prior to the kitchen staff bringing the nutritional treat to Resident #4's room.

Interview on 04/04/24 from 1:00 P.M. to 1:15 P.M. with STNA #77 verified there was no nutritional treat on Resident #4's bedside table or with Resident #4's meal tray. He additionally reported Resident #4 had not eaten a nutritional treat or supplement prior to the beginning of the observation and he was unsure what supplements Resident #4 was supposed to be receiving as she had just returned to the facility. STNA #77 verified the tray ticket indicated Resident #4 was to receive a frozen nutritional treat and he called the kitchen to ensure one was sent to the room. STNA #77 reported the facility staff was not supposed to take things from the refrigerator in the residents room.

This deficiency represents non-compliance investigated under Master Complaint Number OH00152690 and Complaint Number OH00152366.

Based on medical record review, review of hospital records, observation, staff interview, facility policy review, and review of Centers for Disease Control and Prevention guidance, the facility failed to staff practiced proper infection control practices while assisting residents with meals. This affected one (Resident #4) out of three residents reviewed for transmission based precautions. The facility census was 62.

Findings include:

Review of Resident #4's medical record revealed an initial admission date of 08/08/23 and a readmission date of 10/21/23. Resident #4's diagnoses included but were not limited to Alzheimer's disease, Parkinson's disease without dyskinesia (uncontrolled, involuntary muscle movement), severe protein-calorie malnutrition, adult failure to thrive, type two diabetes mellitus, and colonized clostridium difficile (C. Diff) colitis.

Review of the quarterly Minimum Data Set 3.0 assessment, dated 03/21/24, revealed Resident #4 had severely impaired cognition and was unable to complete the Brief Interview for Mental Status assessment. Resident #4 required total dependence on staff to complete all activities of daily living.

Review of Resident #4's census revealed the resident was hospitalized from 03/22/24 to 04/02/24.

Review of hospital records, dated 04/02/24, revealed Resident #4 tested positive for Clostridium difficile (C. Diff) at the hospital on 03/23/24. However, the hospital records indicated the second step of the test was negative which was indicative of a colonized infection and not an active infection. Resident #4 was noted to have watery stool on 03/28/24 and was placed under contact transmission-based precautions (TBP) during her hospitalization.

Review of a progress note dated 04/02/24 at 9:36 A.M., revealed Resident #4 ' s daughter was contacted to inform her Resident #4 ' s discharge date and time had been confirmed as today at 2:00 P.M. Resident #4's daughter was informed that Resident #4 would be readmitted to a private room due to isolation needs.

Observation on 04/04/24 from 12:45 P.M. to 1:12 P.M. of Resident #4 during lunch meal service with State-Tested Nurse Aide (STNA) #77 revealed Resident #4 was in a private room and was under contact TBP. STNA #77 was observed in the room wearing an isolation gown and gloves. Resident #4's meal tray was observed on the bedside table on the right side of the resident's bed. The resident's meal ticket was observed laying on the floor next to the bedside table. There was no nutritional supplement observed on Resident #4's meal tray and STNA #77 stated he would call the kitchen to find out if Resident #4 was supposed to receive a nutritional supplement because prior to the resident's hospitalization, she did receive a frozen nutritional treat with meals. STNA #77 walked over to corded phone in room that was sitting on the floor and picked it up with gloves on and called the kitchen. STNA #77 verified with the kitchen Resident #4 was supposed to receive a frozen nutritional treat with the resident's lunch meal and agreed to deliver one to the resident's room. STNA #77 hung up the phone and placed it back onto the floor. STNA #77 walked back over to Resident #4's bedside table where Resident #4's meal tray was sitting, picked up the spoon (with the same gloves on) and began attempting to feed the resident again. STNA #77 put the spoon up to Resident #4's lips and encouraged the resident to open her mouth. Resident #4 opened her mouth slightly and took a very small amount of food into her mouth before shutting it again. STNA #77 looked down at the floor and noticed the resident's meal ticket was laying on the floor. STNA #77 picked up the resident's meal ticket from the floor with the same gloves on and handed it to this surveyor. STNA #77 did not change gloves or complete any hand hygiene. STNA #77 walked back over to Resident #4 and lifted the resident's covers to reveal the resident's abdominal binder with his gloved hands. STNA #77 replaced the resident's covers with the same gloves on. Kitchen staff arrived at Resident #4's room with a frozen nutritional treat. STNA #77 answered the knock at the door with the same gloves on and accepted the nutritional treat from the kitchen staff. STNA #77 did not change gloves or complete any hand hygiene. STNA #77 returned to the resident's bed side table and opened the frozen nutritional treat with the same gloves in place, picked up the resident's spoon again and began mixing the nutritional treat with the resident's pureed foods. STNA #77 again put the spoon to Resident #4's lips and encouraged her to open her mouth. Resident #4 opened her mouth and accepted bites of food. STNA #77 continued feeding Resident #4 without changing his gloves or completing any hand hygiene during the observation.

Interview on 04/04/24 at 2:05 P.M. with STNA #77 confirmed the above observations. STNA #77 confirmed he had not changed his gloves or completed any hand hygiene after picking up items from the floor or answering the resident's door with gloves on and continued feeding Resident #4. STNA #77 stated Resident #4 ate approximately 25 percent of her meal at lunch and drank approximately 120 milliliters (mL) of fluids. STNA #77 stated he was not told why Resident #4 was under contact TBP and he did not ask anyone. STNA #77 stated he was not aware Resident #4 had colonized C. Diff with possible symptoms (water stools) of an active C. Diff infection.

Review of the facility policy titled Handwashing/Hand Hygiene Policy

Based on record review, resident representative and staff interviews, review of the hospice contract, and facility policy review, the facility failed to ensure hospice communication notes were available and a part of the medical record for one resident (Resident #59). The facility also failed to timely notify the hospice provider of medication changes for one resident (Resident #59). This affected one resident (Resident #59) of three reviewed for hospice services. The facility census was 61.

Findings Include:

Review of the closed medical record for Resident #59 revealed an admission date on 11/02/23 and a discharge date on 12/29/23 due to the resident passing away. Medical diagnoses included Parkinson's Disease with dyskinesia (uncontrolled, involuntary muscle movement), dementia with psychotic disturbance and anxiety, epilepsy (seizures), anxiety disorder, supraventricular tachycardia (a faster than normal heart rate beginning above the heart's two lower chambers), cognitive communication deficit, presence of neurotransmitter, and dystonia (involuntary muscle contractions that cause repetitive or twisting movements).

Review of Resident #59's census revealed the resident was admitted under a hospice payer.

Review of the Patient Information Report from the hospice provider date 09/28/23 revealed Resident #59 was admitted to hospice on 07/06/23 (prior to the resident's admission to the facility).

Review of the physician orders for Resident #59 revealed the resident had the following orders: Hospice-Transitions Hospice (dated 11/02/23 and discontinued 12/19/23), Hospice-Transitions Hospice (dated 11/03/23 and discontinued 12/04/23 with reason to add a diagnosis), Hospice-Transitions Hospice with diagnosis Parkinson's Disease (dated 12/04/23 and discontinued 12/14/23 with no reason indicated), Hospice-Transitions Hospice with diagnosis Parkinson's Disease (dated 12/13/23 and discontinued 12/17/23), and Hospice-Transitions Hospice with diagnosis Parkinson's Disease (dated 12/17/23 and discontinued 12/29/23 due to the resident being deceased).

Further review of the physician orders for Resident #59 revealed the resident had the following medication orders: Quetiapine Fumarate (Seroquel) (an antipsychotic medication) 50 milligrams (mg) with instructions to give one tablet every eight hours as needed for severe agitation dated 11/02/23 and discontinued 11/03/23, Quetiapine Fumarate 50 mg with instructions to give one tablet twice a day (BID) dated 11/03/23 and discontinued 11/07/23, Seroquel 50 mg with instructions to give one tablet in the evening for dementia with behaviors dated 11/07/23 and discontinued 12/11/23, Seroquel 100 mg with instructions to give one tablet daily for dementia with behaviors dated 11/08/23 and discontinued 12/11/23, Quetiapine Fumarate 25 mg with instructions to give one tablet in the evening for one week dated 12/11/23 and discontinued 12/18/23, Quetiapine Fumarate 50 mg with instructions to give one tablet in the morning for one week dated 12/12/23 and discontinued 12/19/23, and Quetiapine Fumarate 25 mg with instructions to give one tablet in the morning dated 12/20/23 and discontinued 12/27/23 due to hospice. Additionally, Resident #59 had an order for Trazodone Hydrochloride (HCl) 50 mg with instructions to give 25 mg by mouth at bedtime for insomnia dated 11/07/23 and discontinued 12/11/23 per the hospice Certified Nurse Practitioner (CNP).

Review of the admission Minimum Data Set (MDS) 3.0 assessment dated 11/09/23 revealed Resident #59 had severely impaired cognition and scored a zero out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #59 was dependent on facility staff to complete Activities of Daily Living (ADLs).

Review of the progress notes dated from 11/02/23 to 12/29/23 revealed on 11/02/23 at 4:41 P.M., Resident #59 admitted to the facility and was transported by the family. Vital signs were within normal limits. There was no indication of the resident receiving hospice services upon admission. The first progress note which mentioned contact with hospice was dated 11/09/23 (seven days after admission) at 7:32 P.M., Certified Nurse Practitioner (CNP) was notified of x-ray results. The nurse also left a voicemail with hospice. No new orders at this time. Resident denied pain. Power of Attorney (POA) aware.

Further review of the progress notes dated from 11/02/23 to 12/29/23 revealed on 11/07/23 at 11:02 A.M. and 11:03 A.M., notification of order change notes stated Resident #59 and the resident's representative were updated on new orders. Risk/Benefits were explained for Trazodone HCl 50 mg with instructions to give 25 mg by mouth at bedtime for insomnia, Seroquel tablet 100 mg with instructions to give one tablet by mouth daily, and Seroquel 50 mg with instructions to give one tablet in the evening for dementia with behaviors. The start dates for the medication were 11/07/23 and 11/08/23. Resident #59 and the resident's Power of Attorney (POA) were made aware. There was no indication the resident's hospice provider was notified of the medication changes.

Review of the care plan dated 11/03/23 revealed Resident #59 had a terminal prognosis related to hospice services for Parkinson's Disease with declines in condition expected. Interventions included Capital City Hospice, all care must be preauthorized: all new medications-call before contacting contracted company, all new treatments-medical equipment, labs, diagnostic tests, x-rays, transport from the facility, condition change, hospice will call the resident's physician unless other arrangements are made with hospice staff. The interventions were resolved on 11/06/23. On 11/06/23, interventions included Transitions Hospice was initiated. Additional intervention included coordinate all care with hospice and work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met (dated 11/03/23).

Review of the Encounter Summary-Progress Note completed by the facility's Certified Nurse Practitioner (CNP), CNP #150, dated 11/07/23 at 1:47 P.M. revealed Resident #59 was seen for an acute visit due to behaviors including restlessness, impulsivity, yelling out during the day and night, and difficulty with redirecting the resident. CNP #150 planned to increase Seroquel to 100 mg daily at bedtime and add Trazodone 25 mg daily at bedtime to address dementia with psychotic disturbances. The resident's instructions included the same and to continue to follow with hospice. There was no indication the hospice provider was notified of the medication changes.

Review of Plan of Care Conference, dated 11/16/23 (nine days after medication changes), revealed Resident #59's POA/spouse, the resident's daughter and son-in-law, Hospice Executive Director (HED) #105, Licensed Social Worker (LSW) #112, and the Director of Nursing (DON) attended the care conference. Nursing Services noted the current plan of care, behaviors, falls, and interventions were reviewed. Nursing agreed with the current plan and medication education was provided. Resident #59's family reported medication tweaks and environmental adjustments were still occurring. The care conference did not indicate what medications were reviewed or what medications the resident's family received educated about.

Further review of the medical record for Resident #59 revealed there were not any hospice communication notes included in the medical record.

Interview on 01/10/24 at 1:08 P.M. via telephone with CNP #103 revealed she was the on-call CNP for Resident #59's hospice provider. CNP #103 stated the facility's CNP (CNP #150) increased Resident #59's Seroquel shortly after the resident was admitted and thinks CNP #150 also adjusted or added some other medication as well that she was not notified of until she attended a care conference via telephone to discuss Resident #59 on 12/11/23 and reviewed Resident #59's medications. CNP #103 recommended Resident #59's antipsychotic medication be reduced again at that time. CNP #150 stated she did not attend a care conference on 11/16/23 for Resident #59.

Interview on 01/11/24 at 10:21 A.M. via telephone with HED #105 revealed the facility's CNP (CNP #150) adjusted Resident #59's medications, including Seroquel, without notifying the hospice provider/hospice CNP (CNP #103). HED #105 stated CNP #103 became aware of the medication adjustments/changes on 12/11/23 when CNP #103 attended a care conference via telephone to discuss Resident #59 and she reviewed the resident's medications. CNP #103 requested to have the medications reduced again at the time of the care conference. HED #105 denied medications were discussed during the care conference held on 11/16/23.

Interview on 01/11/24 at 11:12 A.M. with the DON confirmed there were some communication issues between the facility and the hospice provider for Resident #59. The DON stated the facility conducted two care conferences for Resident #59 during her stay at the facility. The DON stated one was completed in November and the other was completed in December 2023. The DON stated a hospice representative attended both care conferences and the resident's medications would have been reviewed at each care conference. The DON confirmed there was no documentation the hospice provider was notified of any medication changes for Resident #59 prior to 11/16/23 (nine days later).

Further interview on 01/11/24 at 11:52 A.M. with the Director of Nursing (DON) confirmed Resident #59's medical record only included plans of care from the hospice provider and did not include any progress/visit notes from the hospice provider.

Interview on 01/11/24 at 2:10 P.M. with LSW #112 confirmed a care conference was completed on 11/16/23 for Resident #59 (nine days after the medication changes). LSW #112 stated she was not able to remember exactly what was discussed during the care conference but the resident's medications would have been reviewed as that was standard procedure for all care conferences. LSW #112 confirmed HED #105 attended the care conference on 11/16/23 via telephone but CNP #103 did not attend. LSW #112 stated there was a family meeting held on 12/11/23 per the family's request as well but she was not able to attend that meeting and was not aware what occurred during that meeting.

Review of the facility policy, Hospice Program

Based on medical record review, observation, family interview, staff interview, and facility policy review, the facility failed to accommodate Resident #30 food preferences for meals. This affected one (Resident #30) out of one resident reviewed. The facility census was 61.

Findings include:

Review of the medical record for Resident #30 revealed Resident #30 was admitted on 08/08/23 with diagnoses which included type two diabetes mellitus, dysphagia, Parkinson's disease, and Alzheimer's disease.

Review of the significant change Minimum Data Set assessment, dated 10/28/23, revealed Resident #30 had severe cognitive impact and is dependent for eating.

Review of Nutrition/Dietary Note on 10/10/23 revealed Daughter #200 is selecting puree meals for Resident #30.

Review of Resident #30's comprehensive care plan, dated 01/08/24, revealed interventions include honor food preferences, provide and serve diet as ordered, and one person assist for eating.

Observation on 01/10/24 at 12:35 P.M. revealed a meal ticket for Resident #30 that included pureed beef stroganoff, pureed egg noodles, pureed peas and carrots, and pureed cantaloupe.

Interview on 01/10/24 at 12:35 P.M. with Daughter #200 of Resident #30, revealed she did not want the order of pureed egg noodles and pureed cantaloupe for Resident #30. Observed the pureed egg noodles pushed to the side of the plate. The daughter explained she sends a highlighted menu every Friday to the facility for what her mother will eat for the following week.

Observation on 01/11/24 at 12:45 P.M. revealed the meal ticket had lunch items scratched out and broccoli and Italian sausage with peppers and onions were handwritten.

Interview on 01/11/24 at 12:45 P.M. with state tested nursing assistant (STNA) #151, who sat down to feed Resident #30, confirmed Italian sausage with peppers and onions were handwritten on the ticket and both items were on the plate.

Observation on 01/11/24 at 12:45 P.M. revealed a small covered bowl of orange puree was on the tray. STNA #151 was asked what this was. STNA #151 revealed she did not know and would find out.

Interview on 01/11/24 at 12:45 P.M. with Lead Dietary Aide #160 revealed the item is pureed spaghetti and meatballs. Observed Lead Dietary Aide #160 reviewed the ticket and said the resident should not have received this. Observed Lead Dietary Aide #160 take the item away.

Interview on 01/11/24 at 1:48 P.M. 1/11/24 with Daughter #200 revealed she did not order spaghetti and meatballs for her mom.

Review of the Puree Food Service Policy/Procedure dated 07/01/23 revealed Prepare each resident's plate according to menu tickets.

This deficiency was an incidental finding identified during the investigation of Complaint Number OH00149626.

Based on record review, staff interviews, review of the hospice contract, and facility policy review, the facility failed to follow the hospice agreement in place for one resident's (Resident #59) hospice provider. This affected one (Resident #59) of three residents reviewed for hospice services. The facility census was 61.

Findings Include:

Review of the closed medical record for Resident #59 revealed an admission date on 11/02/23 and a discharge date on 12/29/23 due to the resident passing away. Medical diagnoses included Parkinson's Disease with dyskinesia (uncontrolled, involuntary muscle movement), dementia with psychotic disturbance and anxiety, epilepsy (seizures), anxiety disorder, supraventricular tachycardia (a faster than normal heart rate beginning above the heart's two lower chambers), cognitive communication deficit, presence of neurotransmitter, and dystonia (involuntary muscle contractions that cause repetitive or twisting movements).

Review of Resident #59's census revealed the resident was admitted under a hospice payer.

Review of the Patient Information Report from the hospice provider date 09/28/23 revealed Resident #59 was admitted to hospice on 07/06/23 (prior to the resident's admission to the facility).

Review of the physician orders for Resident #59 revealed the resident had the following hospice orders: Hospice-Transitions Hospice (dated 11/02/23 and discontinued 12/19/23), Hospice-Transitions Hospice (dated 11/03/23 and discontinued 12/04/23 with reason to add a diagnosis), Hospice-Transitions Hospice with diagnosis Parkinson's Disease (dated 12/04/23 and discontinued 12/14/23 with no reason indicated), Hospice-Transitions Hospice with diagnosis Parkinson's Disease (dated 12/13/23 and discontinued 12/17/23), and Hospice-Transitions Hospice with diagnosis Parkinson's Disease (dated 12/17/23 and discontinued 12/29/23 due to the resident being deceased).

Review of the physician orders for Resident #59 revealed the resident had the following medication orders: Quetiapine Fumarate (Seroquel) (an antipsychotic medication) 50 milligrams (mg) with instructions to give one tablet every eight hours as needed for severe agitation dated 11/02/23 and discontinued 11/03/23, Quetiapine Fumarate 50 mg with instructions to give one tablet twice a day (BID) dated 11/03/23 and discontinued 11/07/23, Seroquel 50 mg with instructions to give one tablet in the evening for dementia with behaviors dated 11/07/23 and discontinued 12/11/23, Seroquel 100 mg with instructions to give one tablet daily for dementia with behaviors dated 11/08/23 and discontinued 12/11/23, Quetiapine Fumarate 25 mg with instructions to give one tablet in the evening for one week dated 12/11/23 and discontinued 12/18/23, Quetiapine Fumarate 50 mg with instructions to give one tablet in the morning for one week dated 12/12/23 and discontinued 12/19/23, and Quetiapine Fumarate 25 mg with instructions to give one tablet in the morning dated 12/20/23 and discontinued 12/27/23 due to hospice. Additionally, Resident #59 had an order for Trazodone Hydrochloride (HCl) 50 mg with instructions to give 25 mg by mouth at bedtime for insomnia dated 11/07/23 and discontinued 12/11/23 per the hospice Certified Nurse Practitioner (CNP).

Review of the admission Minimum Data Set (MDS) 3.0 assessment dated 11/09/23 revealed Resident #59 had severely impaired cognition and scored a zero out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #59 was dependent on facility staff to complete Activities of Daily Living (ADLs).

Review of the progress notes dated from 11/02/23 to 12/29/23 revealed on 11/07/23 at 11:02 A.M. and 11:03 A.M., notification of order change notes stated Resident #59 and the resident's representative were updated on new orders. Risk/Benefits were explained for Trazodone HCl 50 mg with instructions to give 25 mg by mouth at bedtime for insomnia, Seroquel tablet 100 mg with instructions to give one tablet by mouth daily, and Seroquel 50 mg with instructions to give one tablet in the evening for dementia with behaviors . The start dates for the medication were 11/07/23 and 11/08/23. Resident #59 and the resident's Power of Attorney (POA) were made aware. There was no indication the resident's hospice provider was notified of the medication changes.

Review of the care plan dated 11/03/23 revealed Resident #59 had a terminal prognosis related to hospice services for Parkinson's Disease with declines in condition expected. Interventions included Capital City Hospice, all care must be preauthorized: all new medications-call before contacting contracted company, all new treatments-medical equipment, labs, diagnostic tests, x-rays, transport from the facility, condition change, hospice will call the resident's physician unless other arrangements are made with hospice staff. The interventions were resolved on 11/06/23. On 11/06/23, interventions included Transitions Hospice was initiated. Additional intervention included coordinate all care with hospice and work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met (dated 11/03/23).

Review of the Encounter Summary-Progress Note completed by the facility's Certified Nurse Practitioner (CNP), CNP #150, dated 11/07/23 at 1:47 P.M. revealed Resident #59 was seen for an acute visit due to behaviors including restlessness, impulsivity, yelling out during the day and night, and difficulty with redirecting the resident. CNP #150 planned to increase Seroquel to 100 mg daily at bedtime and add Trazodone 25 mg daily at bedtime to address dementia with psychotic disturbances. The resident's instructions included the same and to continue to follow with hospice. There was no indication the hospice provider was notified of the medication changes.

Review of Plan of Care Conference, dated 11/16/23 (nine days after medication changes), revealed Resident #59's POA/spouse, the resident's daughter and son-in-law, Hospice Executive Director (HED) #105, Licensed Social Worker (LSW) #112, and the Director of Nursing (DON) attended the care conference. Nursing Services noted the current plan of care, behaviors, falls, and interventions were reviewed. Nursing agreed with the current plan and medication education was provided. Resident #59's family reported medication tweaks and environmental adjustments were still occurring. The care conference did not indicate what medications were reviewed or what medications the resident's family were educated on.

Interview on 01/10/24 at 1:08 P.M. via telephone with CNP #103 revealed she was the on-call CNP for Resident #59's hospice provider. CNP #103 stated the facility's CNP (CNP #150) increased Resident #59's Seroquel shortly after the resident was admitted and thinks CNP #150 also adjusted or added some other medication as well that she was not notified of until she attended a care conference via telephone to discuss Resident #59 on 12/11/23 and reviewed Resident #59's medications. CNP #103 recommended Resident #59's antipsychotic medication be reduced again at that time. CNP #150 stated she did not attend a care conference on 11/16/23 for Resident #59.

Interview on 01/11/24 at 10:21 A.M. via telephone with HED #105 revealed the facility's CNP (CNP #150) adjusted Resident #59's medications, including Seroquel, without notifying the hospice provider/hospice CNP (CNP #103). HED #105 stated CNP #103 became aware of the medication adjustments/changes on 12/11/23 when CNP #103 attended a care conference via telephone to discuss Resident #59 and she reviewed the resident's medications. CNP #103 requested to have the medications reduced again at the time of the care conference. HED #105 denied medications were discussed during the care conference held on 11/16/23.

Interview on 01/11/24 at 11:12 A.M. with the DON confirmed there were some communication issues between the facility and the hospice provider for Resident #59. The DON stated the facility conducted two care conferences for Resident #59 during her stay at the facility. The DON stated one was completed in November and the other was completed in December 2023. The DON stated a hospice representative attended both care conferences and the resident's medications would have been reviewed at each care conference. The DON confirmed there was no documentation the hospice provider was notified of any medication changes for Resident #59 prior to 11/16/23 (nine days later).

Interview on 01/11/24 at 2:10 P.M. with Licensed Social Worker (LSW) #112 confirmed a care conference was completed on 11/16/23 for Resident #59 (nine days after the medication changes). LSW #112 stated she was not able to remember exactly what was discussed during the care conference but the resident's medications would have been reviewed as that was standard procedure for all care conferences. LSW #112 confirmed HED #105 attended the care conference on 11/16/23 via telephone but CNP #103 did not attend. LSW #112 stated there was a family meeting held on 12/11/23 per the family's request as well but she was not able to attend that meeting and was not aware what occurred during that meeting.

Review of the facility policy, Hospice Program

Based on medical record review, interview, and facility policy review, the facility failed to report an allegation of abuse to the state agency as required for one resident (#65). This affected one (Resident #65) of one resident reviewed for abuse. The facility census was 63.

Findings Include:

Review of the medical record for the Resident #65 revealed an initial admission date of 11/07/23 with diagnoses including fracture of shaft of humerus, left arm, anemia, chronic kidney disease, obstructive sleep apnea, diabetes mellitus, hypertension, hyperlipidemia, gastro-esophageal reflux disease, dysphagia, generalized muscle weakness, history of falling, pain and secondary hyperparathyroidism of renal origin. The resident discharged against medical advice (AMA) on 11/11/23.

Review of the resident's discharge Minimum Data Set (MDS) assessment dated 11/11/23 revealed the resident's cognition was not assessed. Review of the mood and behavior revealed the resident displayed verbal behaviors directed towards others and rejected care. The resident was dependent on toileting and required substantial assistance with bed mobility, bathing, and personal hygiene.

Review of the progress note dated 11/11/23 at 2:13 A.M. revealed the resident was heard yelling and the nurse went into his room to find out what was going on. Two aides were in the room trying to change the pads under the resident but the resident was verbally abusive. The nurse instructed the aides to leave the room and the resident reported he wet himself because a urinal was placed between his legs with the lid on. The nurse explained spills do occur while using a urinal in bed and offered to change the resident and also provide care for him the rest of the night. The resident refused to be changed and called his family to come and get him. The resident's family arrived at the facility at 1:30 A.M. An AMA form was given to the family to sign but they refused to sign and wrote complaints on the form. The resident and his family left the facility at 1:45 A.M. The Certified Nurse Practitioner (CNP) was notified as well as the on call nurse manager.

Review of the resident's AMA Form dated 11/11/23 revealed the resident's signature and a hand written note stating Leaving due to patient abuse. Would not come when light was on to urinate, put urinal on didn't take the lid off, urinated in bed. Insulted with smart comments and was made fun of. Two nights of abuse, had enough.

Review of the facility's Self-Reported Incidents (SRI) revealed no incident related to the allegation of abuse.

On 12/05/23 at 2:00 P.M., interview with the Director of Nursing (DON) verified no SRI was filed for the allegation of abuse documented by Resident #65 on the AMA form.

Review of the facility policy titled, Abuse Prevention Policy