Laurels of Mt Vernon The

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

Based on medical record review, review of a facility investigation, review of the facility abuse policy, and interview, the facility failed to protect from abuse Resident #87, who exhibited severe cognitive impairment (with a Brief Interview for Mental Status score of two) and had the diagnoses of unspecified dementia and cognitive communication deficit. This resulted in verbal and physical abuse occurring on 04/12/24 at 7:28 P.M. by Licensed Practical Nurse (LPN) #655 when Resident #87 was yelled at and forcibly placed back into the wheelchair. This affected one resident (#87) of six residents reviewed for dementia care. The facility census was 83.

Findings Include:

Review of the medical record for Resident #87 revealed an admission date of 04/04/24 with the diagnoses including unspecified dementia, cognitive communication deficit, depression, anxiety, and difficulty in walking. Resident #87 required assistance from staff for activities of daily living (ADLs) tasks and used a wheelchair for mobility. Resident #87 was discharged to home on 04/14/24.

Review of Resident #87's comprehensive care plan dated 04/04/24 revealed Resident #87 was incontinent of both bowel and bladder and required assistance from staff for incontinence care. Resident #87 was at risk for decline in cognition and had impaired cognitive function related to dementia, short attention span, and inability to follow directions. Resident #87 had the potential for fluctuations in mood related to dementia.

Review of the progress notes for Resident #87 dated 04/12/24 at 8:05 P.M. authored by Assisted Director of Nursing (ADON) #412 revealed a head-to-toe skin assessment was completed with negative results noted.

Review of the progress notes for Resident #87 dated 04/11/24 at 10:30 P.M. to 04/12/24 at 5:15 A.M. revealed Resident #87 was exhibiting aggressive behaviors towards staff and self-harming behaviors. Resident #87 was transferred to the hospital emergency room for evaluation and treatment. Resident #87 returned to the facility with the diagnosis of urinary tract infection and order for antibiotic use.

Review of the physician orders for Resident #87 revealed an order dated 04/12/24 for the antibiotic Doxycycline 100 mg by mouth two times per day for seven days to treat urinary tract infection.

Review of the facility's completed investigation initiated on 04/12/24 revealed the following statements as part of the facility investigation included but were not limited to:

A written statement completed by ADON #412 dated 04/12/24 at 7:28 P.M. revealed, LPN #655 was witnessed by (State Tested Nursing Assistant) STNAs #486 and #499 yelling at Resident #87 using profanities and pushing her into her wheelchair very aggressively.

A verbal interview conducted by ADON #412 dated 04/12/24 at 8:20 P.M. via telephone conversation with STNA #486 revealed, I witnessed LPN #655 yell and cuss at Resident #87 in her face and aggressively shoved her down into her wheelchair. LPN #655 used profanity and was screaming at Resident #87 we are not doing this tonight.

A verbal interview conducted by ADON #412 dated 04/12/24 at 8:35 P.M. via telephone conversation with STNA #499 revealed, I witnessed LPN #655 screaming at Resident #87 after she had hit LPN #655. LPN #655 yelled profanities saying, Who do you think you are? Then said, I'm sending her out, I'm dealing with this tonight.

A verbal interview conducted by ADON #412 dated 04/13/24 via telephone conversation with STNA #480 revealed, states she didn't witness anything that would be mistreatment of Resident #87. States that STNA #486 and #499 took over trying to calm Resident #87 and the only thing she witnessed was everyone trying to calm Resident #87 down from the behaviors she was having.

A verbal interview conducted by ADON #412 dated 04/13/24 at 10:00 A.M. via telephone conversation with STNA #504 revealed, I witnessed LPN #655 being mean, using foul language, and being not nice to Resident #87. The physical interactions of Resident #87 being shoved down into her wheelchair and the way she was talking to her was very inappropriate.

Review of the in-depth analysis of how the deficiency occurred dated 04/12/24 authored by the Administrator revealed, Resident #87 was confused and trying to get out her wheelchair repeatedly and the nurse yelled at the resident.

Interview on 05/06/24 at 3:17 P.M. with ADON #412 revealed on 04/12/24 at 7:30 P.M. she was notified by STNAs #486 and #499 reporting the yelling, cussing and physical force used by LPN #655 towards Resident #87. ADON #412 revealed they went into the facility then and spoke with LPN #655 concerning the situation, notified the Administrator and then suspended LPN #655 pending investigation. ADON then assessed Resident #87 for any injuries that may have occurred during the altercation. I did not observe any injuries. Resident #87 was known for having behaviors since her admission to the facility and she was also being treated for a urinary tract infection. LPN #655 was suspended and then was terminated a couple days later.

Interview on 05/06/24 at 4:05 P.M. with Regional Nurse Consultant (RNC) #650 confirmed LPN #655 did yell at and forcibly place Resident #87 into the wheelchair. RNC #650 revealed the ADON conducted the investigation due to the Director of Nursing being on vacation. LPN #655 was reported to the Ohio Board of Nursing and was terminated from employment at the facility.

Interview on 05/07/24 at 10:31 A.M. with SS #574 revealed they attempted to follow up with Resident #87 the next day. SS #574 couldn't have a conversation with her due to her impaired cognition. Resident #87 appeared that she did not remember the incident and she did not appear in any type of distress.

Review of the facility's policy titled, Abuse Prohibition Policy dated 10/04/22 revealed, Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property.

The abuse was reported and subsequently corrected on 04/14/24 when the facility implemented the following corrective actions:

On 04/12/24 at 7:30 P.M. Resident #87 was removed from the activity lounge by STNAs #486 and #499.

On 04/12/24 at 7:40 P.M. LPN #655 was suspended from work pending investigation of the incident by the ADON #412.

On 04/12/24 at 7:50 P.M. ADON #412 conducted a head-to-toe skin assessment for Resident #87 with negative results documented.

On 04/12/24 at 8:05 P.M. all staff abuse prohibition policy review and reeducation was initiated by ADON #412 via in -person and verbal education and was completed on 04/13/24.

On 04/14/24 LPN #655 was terminated from employment at the facility by the Administrator.

On 04/16/24 a weekly audit was initiated by SS #574 for five random residents to be interviewed to ensure that they feel safe, for the next four weeks with the results to be reviewed by the facility's interdisciplinary team (IDT) and the next scheduled quality assurance and performance improvement (QAPI) meeting.

On 04/23/24 LPN #655 was reported to the Ohio Board of Nursing by the Administrator.

This deficiency represents non-compliance investigated under Complaint Number OH00153282.

Based on observation, record review, facility policy review, and interview the facility failed to ensure the use of a lap buddy was assessed to be the least restrictive device for Resident #42 and failed to identify the device as a physical restraint once the resident could no longer independently remove the device on command. This affected one resident (#42) of one resident reviewed for physical restraints. The facility census was 88.

Findings include:

Review of Resident #42's medical record revealed Resident #42 was admitted to the facility on 06/30/19 with diagnoses including Huntington's Disease, anxiety disorder, major depression, traumatic brain injury, and insomnia.

Review of Resident #42 fall history revealed Resident #42 fell while she was pushing the empty wheelchair on 10/10/22. Following the incident, the facility fall committee implemented the use of a lap buddy (a cushion which fits into to the armrests of a wheelchair and lays across a resident's upper thighs while sitting in a wheelchair) as a fall intervention.

Review of Resident #42 physician orders revealed a signed order dated 10/10/22 for a lap buddy while in wheelchair.

Review of Resident #42's fall care plan revised on 10/10/22 revealed a fall intervention for a lap buddy while Resident #42 is in the wheelchair.

Review of Resident #42's evaluation revealed a completed Physical Device Evaluation dated 10/10/22 reflecting the implementation of the lap buddy for Resident #42 while she is in the wheelchair.

Review of Resident #42 therapy notes for services on 04/27/23 and 08/11/23 revealed Resident #42 was evaluated for appropriate transfers and for activities of daily living (ADL) decline due to the disease process. The use of the lap buddy was not included in either therapy note.

Record review revealed no further evaluation of the lap buddy, a completed quarterly Physical Device Evaluation until 07/20/23 which noted the continued use of the lap buddy while Resident #42 was in the wheelchair.

Review of the Minimum Data Set (MDS) 3.0 assessment dated 07/27/23 revealed Resident #42 had impaired cognition and required extensive assistance from staff for completion of ADL tasks including bed mobility and transfers. The assessment also noted the resident used a wheelchair for mobility and had a history of falls since admission to the facility.

Observations on 10/16/23 at 9:30 A.M. and again at 12:14 P.M. revealed Resident #42 sitting in the wheelchair self-propelling in the activity area and then sitting at a dining room table during the lunch meal with the lap buddy in place. Resident #42 did not attempt to remove the lap buddy.

Observations on 10/17/23 at 7:34 A.M. and 11:50 A.M., and again at 2:49 P.M. revealed Resident #42 siting at a dining room table during the breakfast meal and self-propelling in the wheelchair throughout the hallway and lounge area with the lap buddy in place. Resident #42 did not attempt to remove the lap buddy.

Observations on 10/18/23 at 7:29 A.M., 9:30 A.M., and again at 10:16 A.M. revealed Resident #42 was self-propelling throughout the dining room and lounge area in the wheelchair with the lap buddy in place. Resident #42 did not attempt to remove the lap buddy.

Observation on 10/18/23 at 12:05 P.M. revealed Resident #42 was sitting at a dining room table during the lunch meal. The lap buddy was partially attached to the left armrest and was completely attached to the right armrest. The lap buddy was positioned in an upward angle from Resident #42's lap. Resident #42 was continually rolling forward towards the table in an attempt to reach the plate of food. The positioning of the lap buddy was prohibiting Resident #42 from getting up next to the table and the plate of food located on the table in front of her. After several attempts to get up next to the table, Resident #42 reversed the wheelchair and self-propelled out of the dining room. Observation of Resident #42's plate revealed less than 25 percent (%) of her meal was consumed.

Observation on 10/18/23 at 2:01 P.M. revealed Resident #42 was participating in activities and was eating an ice cream sundae. Resident #42 was sitting in the wheelchair with the lap buddy in place. Resident #42 did not attempt to remove the lap buddy.

Interview on 10/18/23 at 12:05 P.M. with State Tested Nursing Assistant (STNA) #228 revealed Resident #42 usually required verbal cues to eat meals. STNA #228 stated, She usually only drinks cranberry juice and eats the ice cream. Her best meal is breakfast. She always has that lap buddy in the wheelchair.

Interview on 10/18/23 at 2:49 P.M. with STNA #214 revealed the lap buddy was there to prevent the resident from standing up from the wheelchair. STNA #214 stated, She would always try to stand up from the wheelchair and several times she has fallen and hurt herself. I would remove it when I must change her or when I put her to bed.

Interview on 10/18/23 at 3:04 P.M. with Registered Nurse (RN) #204 revealed the lap buddy was in place for Resident #42 due to multiple falls when Resident #42 would attempt to stand up from the wheelchair.

Interview on 10/18/23 at 3:11 P.M. with the Director of Nursing (DON) revealed Resident #42 could remove the lap buddy from the wheelchair and if staff attempted to remove the lap buddy, Resident #42 would start to yell at the staff. The DON revealed therapy staff would evaluate Resident #42 for appropriate positioning in the wheelchair.

Interview on 10/18/23 at 3:21 P.M. with Unit Manager Licensed Practical Nurse (LPN) #219 revealed the Physical Device Evaluations were to be completed upon implementation of the device and then quarterly to ensure the device was still appropriate. LPN #219 confirmed there had been only the initial evaluation completed on 10/10/22 and a quarterly evaluation completed on 07/20/23 for the use of the lap buddy for Resident #42.

Interview on 10/18/23 at 3:36 P.M. with Therapy Staff #260 revealed Resident #42 would remove the lap buddy and transfer to the couch to lay down and watch television. Therapy Staff #42 stated, Her cognition has rapidly declined due to Huntington's Disease. She doesn't really know how to remove the lap buddy now. She seems to like having it in place, it must make her feel safe.

On 10/16/23 at 11:00 A.M. and again on 10/18/23 at 8:15 A.M. Resident #42 was asked if she was able to remove the lap buddy from the wheelchair. The resident made no attempt to remove it upon request.

Review of the facility policy titled, Restraint Management, revised date 03/07/23, revealed when a resident's condition necessitates consideration for a restraint, alternative interventions must be attempted and documented on the Physical Device Evaluation and in the care plan. During the time a restraint is in place, the restraint is periodically removed. Restraints should always be removed during supervised mealtimes and activities unless clinical contraindications are documented.

Based on record review and interview the facility failed to ensure medications were administered as ordered to treat medical conditions of Resident #59 and/or medications were administered as needed/ordered based on the resident's hemodialysis schedule. This affected one resident (#59) of six residents reviewed for unnecessary medication use. The facility census was 88.

Findings include:

Review of the medical record for Resident #59 revealed an admission date of 07/03/23 with diagnoses including end stage renal disease with dependence on renal dialysis, type two diabetes mellitus, chronic viral hepatitis C, unspecified protein-calorie malnutrition, and hemiplegia and hemiparesis.

Review of the quarterly Minimum Data Set (MDS) assessment dated 09/20/23 revealed Resident #59 had intact cognition. She was on a therapeutic diet. She was on dialysis.

Review of the physician order dated 10/10/23 revealed Resident #59 had dialysis at DaVita every Tuesday, Thursday, and Saturday.

a. Review of the physician order dated 07/03/23 revealed an order for Carvedilol (beta blocker to treat high blood pressure) oral tablet 25 milligrams (mg) one tablet by mouth two times a day for hypertension.

Review of the physician order dated 07/04/23 revealed Resident #59 was to receive Amlodipine Besylate (calcium channel blocker to treat high blood pressure) 10 mg one tablet by mouth for hypertension.

Review of the October 2023 Medication Administration Record (MAR) revealed Amlodipine Besylate 10 mg and Carvedilol 25 mg were not administered at 8:00 A.M. due to the Resident #59 being 'absent from the home' on 10/03/23, 10/05/23, 10/07/23, 10/10/23, and 10/14/23. On 10/12/23 and 10/17/23 it was indicated to see nurses' notes.

Review of the progress notes dated 10/12/23 revealed no reasoning for holding Amlodipine Besylate or Carvedilol.

Review of the progress notes dated 10/17/23 revealed only 'dialysis today.'

b. Review of the physician order dated 07/03/23 revealed an order for Sevelamer 800 mg (lowers the amount of phosphorus in the blood for residents receiving dialysis) one tablet by mouth with meals for supplement.

Review of the October 2023 MAR revealed Sevelamer was not administered due to Resident #59 being 'absent from the home' at 7:30 A.M. on 10/03/23, 10/05/23, 10/07/23, 10/10/23 and 10/15/23 and at 12:00 P.M. on 10/03/23, 10/05/23, 10/07/23, 10/10/23, 10/12/23 and 10/15/23.

c. Review of the physician order dated 07/03/23 revealed an order for Senexon-S oral tablet 50 mg two tablets to be administered twice a day for constipation.

Review of the physician order dated 07/03/23 revealed an order for Cilostazol oral tablet 100 mg (vasodilator) one tablet by mouth two times a day for atrial fibrillation.

Review of the physician order dated 07/04/23 revealed Resident #59 was to receive Aspirin low dose tablet delayed release 81 mg one tablet by mouth for preventative.

Review of the physician order dated 07/04/23 revealed an order for Topiramate oral tablet 50 mg (anticonvulsant) one tablet by mouth for migraines.

Review of the physician order dated 07/04/23 revealed an order for B-Complex oral tablet one time a day for supplement.

Review of the physician order dated 07/04/23 revealed an order for Bupropion extended-release oral tablet 150 mg (antidepressant) by mouth one time a day for depression.

Review of the physician order dated 07/04/23 revealed an order for cholecalciferol tablet 1000 units (vitamin D supplement) by mouth one time a day for supplement.

Review of the physician order dated 07/04/23 to 10/13/23 revealed an order for Omeprazole delayed release 20 mg (proton-pump inhibitor) one capsule by mouth one time a day for gastro-esophageal reflux disease.

Review of the physician order dated 07/06/23 revealed an order for liquid protein 30 milliliters (ml) two times a day.

Review of the physician order dated 09/04/23 revealed an order for Clopidogrel Bisulfate tablet 75 mg (blood thinner) one tablet by mouth one time a day for atrial fibrillation.

Review of the physician order dated 09/19/23 revealed an order for Celexa Oral Tablet 20 mg (antidepressant) one tablet by mouth one time a day for depression.

Review of the physician order dated 10/14/23 revealed an order for Omeprazole delayed release 20 mg one capsule by mouth one time a day every other week.

Review of the October 2023 MAR revealed Senexon-S 50 mg, Cilostazol 100 mg, Aspirin 81 mg, B-Complex, Bupropion, Celexa, cholecalciferol, Clopidogrel Bisulfate, Omeprazole, Topiramate, liquid protein 30 ml, were not administered at 8:00 A.M. due to Resident #59 being 'absent from the home' on 10/03/23, 10/05/23, 10/07/23, 10/10/23, and 10/14/23.

. Review of the physician order dated 09/18/23 revealed an order for Buspirone oral tablet 5 mg (antianxiety) one tablet by mouth three times a day for anxiety.

Review of the October 2023 MAR revealed Buspirone 5 mg was not administered at 12:00 P.M. due to Resident #59 being 'absent from the home' on 10/03/23, 10/05/23, 10/07/23, 10/10/23, and 10/14/23.

Interview on 10/18/23 at 10:00 A.M. with the Director of Nursing (DON) verified Resident #59 had not been given medications and supplements as ordered without hold orders. She reported some medication times had been changed on 10/17/23 but verified medications were still not administered as ordered on that day.

Based on observation, record review, interview, and facility policy review the facility failed to implement fall interventions for Resident #17. This affected one resident (#17) of two residents reviewed for fall interventions. The facility census was 88.

Findings include:

Review of Resident #17's medical record revealed Resident #17 was admitted to the facility on 12/11/21 with diagnoses including stroke, diabetes mellites type two, sleep apnea, depression, anxiety, and breast cancer.

Review of Resident #17 fall investigation dated 03/03/23 revealed Resident #17 slid out of bed and was on the floor beside the bed. Resident #17 had no injuries.

Review of Resident #17's fall care plan revised on 03/03/23 revealed the intervention for the fall out of bed was to place a perimeter mattress on Resident #17's bed.

Review of Resident #17's physician orders revealed a signed order dated 03/29/23 for a perimeter mattress to bed at all times, check every shift.

Review of the Minimum Data Set (MDS) assessment dated 07/27/23 revealed Resident #17 had impaired cognition and required extensive assistance from staff for completion of activities of daily living (ADL) tasks including bed mobility and transfers. The assessment also noted the resident used a wheelchair for mobility and had a history of falls since admission to the facility.

Observation on 10/16/23 at 11:36 A.M. revealed Resident #17 was lying in bed watching television. Resident #17 was lying on a regular flat bariatric mattress. The sides of mattress were not raised to create a perimeter to the mattress.

mattress: on 10/17/23 at 1:52 P.M. with the Director of Nursing (DON) confirmed the mattress that was currently on Resident #17's bed was not a perimeter mattress; it was a regular flat bariatric mattress.

Review of the facility's policy titled Fall Management

Based on observation, record review, and interview the facility failed to provide timely care and interventions for Resident #183 related to a urinary tract infection (UTI). The facility also failed to provide proper oversight, assessment, and follow up of urinary catheters for Resident #60 and Resident #334. This affected one resident (#183) of four residents reviewed for UTI and two residents (#60 and #334) of two residents reviewed for urinary catheters. The facility census was 88.

Findings include:

1. Resident #183 was admitted to the facility on 09/28/23 with diagnoses including displaced intertrochanteric fracture of right femur, type II diabetes, hypertension, insomnia, muscle weakness, difficulty walking, cognitive communication deficit, hypothyroidism, atrial fibrillation, chronic obstructive pulmonary disease, enterocolitis, chronic kidney disease (stage III), depression, heart failure, hyperlipidemia, edema, and anxiety disorder.

Review of the Minimum Data Set (MDS) assessment dated 10/05/23 revealed Resident #183 was cognitively intact.

Review of Resident #183's laboratory reports revealed the original urine sample was collected on 09/29/23 due to her having signs/symptoms of a potential UTI. Documentation found that the urine sample was read on 09/30/23, which had six abnormal test results, including white blood cell count, red blood cell count, and urine appearance was cloudy. Then, on 10/04/23, the lab results were read again with the gram-negative rods being abnormal. This prompted the culture and sensitively to being completed. Then, on 10/07/23, the same urine same was reviewed and it determined the urine sample was contaminated, so the sensitivity could not be performed.

Review of Resident #183's physician orders dated 10/11/23 revealed a new order for a urinalysis was to be collected to determine if the resident had a UTI. The urine sample was collected on 10/13/23, and the results of the UTI ProX results, which was read on 10/14/23, revealed she had a UTI.

Review of Resident #183 physician orders revealed she was prescribed Macrobid (antibiotic) 100 milligrams (mg) twice daily for seven days for a UTI. From the initial onset of symptoms, dated 09/29/23, to the date the treatment was ordered on 10/15/23 it was 16 days.

Review of Resident #183 progress notes, dated 09/29/23 to 10/15/23, revealed no documentation to support the facility contacted the lab to determine if there was a problem with the sample prior to a handwritten note on the lab results, dated 10/07/23, and there was no documentation to support they contacted the lab and/or physician to determine why there was a lag time in getting the actual lab results.

Interview with the Director of Nursing (DON) on 10/18/23 at 2:59 P.M. and 10/19/23 at 8:41 A.M. confirmed the initial urine sample was taken on 09/29/23, and they did not receive information from the lab that the sample was contaminated to complete the sensitivity until 10/07/23. She confirmed there was no documentation to support communication with the lab to get this information in a timelier manner. She confirmed there was 16 days between the initial urine sample was taken to determine if Resident #183 had a UTI, and when treatment finally started (09/29/23 to 10/15/23). She confirmed that is more time than desired to start treatment, which is why they are switching lab companies; she confirmed they have had multiple issues with this lab company. She also agreed the lab should have told the facility prior to 10/07/23 if the initial urine sample was contaminated, especially since they received two lab reports from them prior to getting that information.

Based on record review, interview, and facility policy review the facility failed to ensure weekly weights were obtained for Resident #46 who had significant weight loss. This affected one resident (#46) of two residents reviewed for nutrition. The facility census was 88.

Findings include:

Review of the medical record for Resident #46 revealed an admission date of 10/13/22 with diagnoses including Parkinson's disease, dementia, chronic obstructive pulmonary disease, type two diabetes, heart failure, depression, and dysphagia.

Review of the plan of care dated 10/18/22 revealed Resident #46 was at nutritional or dehydration risk related to diagnoses, and as of 09/23/23 a significant weight gain or loss in one and three months. Interventions included administering medications as ordered, encouraging choices within ordered diet, observing for signs of dehydration, obtaining labs as ordered, obtaining weight, regular diet, supplements as ordered, and referring to dietitian as needed.

Review of the quarterly Minimum Data Set (MDS) assessment dated 08/21/23 revealed impaired cognition. Resident #46 had no significant weight changes and was on a mechanically altered and therapeutic diet.

Review of Resident #46's weights revealed on 03/08/23 he weighed 127.1 pounds, on 03/10/23 he weighed 127.1 pounds, on 03/17/23 he weighed 129.4 pounds, 03/22/23 he weighed 139 pounds, on 04/13/23 he weighed 140.6 pounds, on 05/02/23 he weighed 135.4 pounds, on 06/20/23 he weighed 132.4 pounds, on 07/26/23 he weighed 131.6 pounds, on 08/03/23 he weighed 131.4 pounds, on 08/16/23 he weighed 134.6 pounds, on 09/08/23 he weighed 130.2 pounds, on 09/14/23 he weighed 130 pounds, and on 09/20/23 he weighed 125.2 pounds which was a 9.9 percent (%) loss over six months, a 7% loss over one month, and a 5.1% loss over three months. His weight was obtained again on 10/18/23 and was 133.4 pounds.

Review of the dietary progress note dated 09/21/23 revealed Resident #46 had a significant weight loss. Resident #46's intake was improving, and he was on house supplements. The dietitian recommended adding a supplement shake every day to increase caloric intake and continuing weekly weights.

Review of the resident at risk progress note dated 09/21/23 revealed Resident #46 had a significant weight loss. The facility was to continue to monitor his weight weekly.

Interview on 10/18/23 at 2:15 P.M. with Diet Technician #304 verified Resident #46 was supposed to be getting weekly weights. Diet Technician #304 reported it was against corporate policy to have orders for weekly weights; however, she made a list weekly of those who needed weighed and provided it to nursing staff. She reported she would check the list on Tuesday's, Thursday's, and Friday's and would send daily reminders of residents who had not been weighed. She was aware Resident #46's weekly weights had not been obtained and said she continued to put him on the list.

Interview on 10/19/23 at 8:30 A.M. with the Director of Nursing (DON) verified Resident #46 did not get weighed weekly as he should have.

Review of the policy titled Weight Management

Based on observation, record review, and interview the facility failed to ensure respiratory equipment was stored in a clean environment. This affected one resident (#17) of one resident reviewed for respiratory care. The facility census was 88.

Findings include:

Review of the medical record revealed Resident #17 was admitted to the facility on 12/11/21 with diagnoses including stroke, diabetes mellites type II, sleep apnea, depression, anxiety, and breast cancer.

Review of the Minimum Data Set (MDS) assessment dated 07/27/23 revealed Resident #17 had impaired cognition and required extensive assistance from staff for completion of activities of daily living (ADL) tasks including bed mobility and transfers.

Review of Resident #17's physician's orders revealed a signed physician order dated 10/09/23 for Budesonide inhalation suspension (steroid) 0.5 milligram (mg) per milliliter (ml) to be administered 2.0 ml via nebulizer machine every twelve hours for respiratory care.

Review of Resident #17's medication administration record (MAR) for October 2023 revealed Budesonide inhalation suspension was administered twice daily (at 8:00 A.M. and at 8:00 P.M.). The administration of this medication was verified and documented by the floor nurse.

Observation on 10/16/23 at 11:36 A.M. in Resident #17's room revealed a nebulizer machine located on the top of the three-drawer dresser next to Resident #17's bed. There was tubing connected to the nebulizer machine and a nebulizer mask attached to the end of the tubing which was lying on the floor on the opposite side of the three-drawer dresser from the bed. The tubing and mask were not inside a bag nor was there a barrier on the floor underneath the tubing and mask.

Interview on 10/16/23 at 12:02 P.M. with Licensed Practical Nurse (LPN) #305 revealed once the nebulizer medication was administered via the nebulizer mask and tubing, the mask should be rinsed with water and dried then placed in a bag until the next time for administration of the medication. LPN #305 confirmed Resident #17's nebulizer mask and tubing was lying on the floor beside the three-drawer dresser in Resident #17's room.

Based on record review, interview, and facility policy review the facility failed to complete pre and post dialysis assessments for Resident #59. This affected one resident (#59) of one resident reviewed for dialysis. The facility census was 88.

Findings include:

Review of the medical record for Resident #59 revealed an admission date of 07/03/23 with diagnoses including end stage renal disease with dependence on renal dialysis, type II diabetes mellitus, chronic viral hepatitis C, unspecified protein-calorie malnutrition, and hemiplegia and hemiparesis.

Review of the quarterly Minimum Data Set (MDS) assessment dated 09/20/23 revealed Resident #59 had intact cognition. She was on a therapeutic diet. She was on dialysis.

Review of the plan of care dated 09/20/23 revealed Resident #59 was at risk for complications related to dialysis due to end stage renal disease. Interventions included administering medications as ordered, not using shunted arm for blood pressure, checking bruit and thrill every shift, utilizing dialysis communication form to communicate with the dialysis center, upon return from dialysis observe resident's access site, and checking and reinforcing dressing at access site as needed.

Review of the physician order dated 10/10/23 revealed Resident #59 had dialysis at DaVita every Tuesday, Thursday, and Saturday.

Review of Resident #59's dialysis binder on 10/18/23 at 8:55 A.M. revealed the binder was empty.

Interview on 10/18/23 at 8:55 A.M. with the Director of Nursing (DON), Registered Nurse (RN) #204, and Licensed Practical Nurse (LPN) #222, verified there were no pre and post dialysis assessments for Resident #59. They reported they had problems getting dialysis to complete the assessments sent with the resident, and many residents had refused to bring the binder since dialysis was not looking at the forms anyway. However, they verified there was no documented evidence pre-dialysis assessments were being completed which would not require dialysis cooperation.

Interview on 10/18/23 at 10:00 A.M. with the DON revealed she had spoken to dialysis on that day to restart the dialysis forms, and both facility staff and dialysis staff would be educated. She reported the facility would have to make sure they were sending the forms again as residents were refusing to bring the binders at times. The DON verified there was no documentation present to indicate the resident refused to bring the binder or previous attempts to speak to dialysis about the form.

Review of the facility policy titled Hemodialysis

Based on record review, interview, and facility policy review the facility failed to comprehensively assess/provide written description of pain and provide evidence of non-pharmacological interventions prior to administering as needed pain medications for Resident #60. This affected one resident (#60) of five residents reviewed for unnecessary medications. The facility census was 88.

Findings include:

Review of the medical record for Resident #60 revealed an admission date of 08/20/21 with diagnoses including other muscle spasm, type II diabetes mellitus, lymphedema, generalized anxiety disorder, major depressive disorder, post-traumatic stress disorder, bipolar disorder, and hypertension.

Review of the plan of care dated 08/23/21 revealed Resident #60 was at risk for pain related to diagnoses, muscle spasms, and back pain. Interventions included administering medications as ordered, anticipating the residents need for pain relief, evaluating the effectiveness of pain interventions, observing for probable cause of pain and removing or limiting causes, offering non-pharmacological interventions, and reporting to the nurse any changes in activity.

Review of the quarterly Minimum Data Set (MDS) assessment dated 09/20/23 revealed Resident #60 had intact cognition.

Record review revealed Resident #60 had been hospitalized from 10/03/23 to 10/05/23 for sepsis.

Review of the physician order dated 10/06/23 (re-admission) revealed non-pharmacological pain interventions were to be documented when needed. Non-pharmacological interventions included massage, meditation, positioning, ice or cold pack, diversional activity, guided imagery, rest, social interaction, or other.

Review of the physician order dated 10/09/23 revealed Resident #60 had an order for Oxycodone HCl oral tablet (opioid pain medication) 5 milligrams (mg), one tablet by mouth every six hours as needed for pain.

Review of the Medication Administration Record (MAR) for October 2023 revealed Resident #60 received Oxycodone HCl 5 mg once on 10/07/23, twice on 10/08/23, once on 10/09/23, twice on 10/10/23, once on 10/11/23, 10/12/23, and 10/13/23, twice on 10/14/23, once on 10/15/23, and once on 10/17/23. Additional review revealed no non-pharmacological interventions were documented prior to the administration of the as needed medication.

Review of the medication administration progress notes from 10/07/23 to 10/17/23 revealed there were no descriptions or locations given for pain upon administration of Oxycodone HCL.

Interview on 10/18/23 at 12:53 P.M. with the Director of Nursing (DON) verified there was no indication non-pharmacological interventions had been attempted and no description of or location of pain. The DON verified that descriptions of pain should have been given and non-pharmacological interventions should have been attempted for every 'as needed' administration.

Review of the policy titled Pain Management

Based on medical record review and staff interview, the facility failed to have proper justification for the use of psychotropic medication for Resident #75. This affected one resident (#75) of six residents reviewed for unnecessary medications. The facility census was 88.

Findings include:

Resident #75 was admitted to the facility on 09/05/23 with diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, degenerative disease of nervous system, amnesia, aphasia, hyperlipidemia, cognitive communication deficit, major depressive disorder, insomnia, hypertension, anxiety disorder, and constipation.

Review of Resident #75's Minimum Data Set (MDS) assessment dated 09/14/23 revealed the resident had a severe cognitive impairment.

Review of Resident #75's current physician orders revealed she was prescribed Depakote (anticonvulsant used to treat bipolar disorder) 125 milligrams (mg) twice daily for dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.

Review of Resident #75's psychiatric/mental health report, dated 09/25/23, revealed the resident was prescribed Depakote 125 mg twice daily for dementia with mood disturbances. There was no other documentation to support why Resident #75 should be prescribed Depakote.

Interview with Director of Nursing (DON) on 10/18/23 at 11:05 A.M. confirmed Resident #75 was prescribed Depakote for dementia with mood disturbances. She confirmed there were no other diagnoses to support the need for Depakote.

Based on observation, record review, and interview the facility failed to ensure medications were dated and disposed of according to industry standards. This had the potential to affect all 85 residents residing at the facility. The facility census was 88.

Findings include:

1. Observation on 10/17/23 at 7:40 A.M. revealed during medication room review of the facility's second medication room refrigerator and opened multi-use vial of Aplisol Tuberculin solution without the date it was opened. The vial of Aplisol Tuberculin solution had been delivered from the pharmacy on 09/05/23 and had an expiration date of 09/2024.

Interview on 10/17/23 at 7:55 A.M. with Licensed Practical Nurse (LPN) #212 confirmed the opened multi-use vial of Aplisol Tuberculin solution did not have the date it was opened, and the vial was delivered to the facility from the pharmacy on 09/05/23.

Review of the manufacturer's information sheet for Aplisol Tuberculin solution revealed, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.

2. Observation on 10/18/23 at 11:37 A.M. of the facility's 400 Hallway medication cart revealed an open bottle of over-the-counter Artificial Tears eye drops with no resident's name or date it was opened.

Interview on 10/18/23 at 11:40 A.M. with LPN #222 confirmed the open bottle of over-the-counter Artificial Tears eye drops with no resident's name or dated it was opened in the drawer of the 400 Hallway medication cart.

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

Based on observation, record review, and interview the facility failed to maintain a safe, homelike environment. This affected two residents (#17 and #21) of 88 residents residing in the facility.

Findings include:

1. Review of the medical record revealed Resident #21 was re-admitted to the facility on 08/19/23 with the diagnoses including obesity, bipolar disorder, major depression, and anxiety.

Review of the Minimum Data Set (MDS) assessment dated 09/19/23 revealed Resident #21 had intact cognition and required extensive assistance from staff to complete activities of daily living (ADL) tasks including bed mobility and transfers.

Observation on 10/16/23 at 9:25 A.M. revealed Resident #21's half of the room was nearest the window. Resident #21 uses a large bariatric bed which was in the far corner of the room beneath the light fixture. Immediately to the left side of Resident #21's bed was a wall with multiple patched areas. The wall was blue in color, and the patched areas were white in color with rough edges located throughout the patched material. On the wall directly behind the headboard of Resident #21's bed were large, long gouges with exposed drywall material. Further observation revealed Resident #21's land line phone connection box cover was unattached to the phone connection box. The land line phone wire was protruding from the phone connection box with the connection box cover hanging from the end of the wire which was attached to the phone jack with exposed individual wires noted.

Interview on 10/16/23 at 1:35 P.M. with Licensed Practical Nurse (LPN) #305 confirmed the multiple patched areas to the wall on the left side of Resident #21's bed, the large, long gouges to the wall behind Resident #21's headboard to the bed, the unattached phone connection box cover, and the exposed wires attached to the phone jack hanging out of the phone connection box.

2. Review of the medical record revealed Resident #17 was admitted to the facility on 12/11/21 with diagnoses including stroke, diabetes mellites type two, sleep apnea, depression, anxiety, and breast cancer.

Review of the MDS assessment dated 07/27/23 revealed Resident #17 had impaired cognition and required extensive assistance from staff for completion of activities of daily living (ADL) tasks including bed mobility and transfers.

Observation on 10/16/23 at 10:26 A.M. revealed Resident #17's half of the room was nearest the window. Resident #17 uses a large bariatric bed which was in the far corner of the room underneath the light fixture. Further observation revealed approximately two feet up the wall from the floor were long large gouges in the wall with drywall material exposed. Directly above the baseboard was a linear penetration in the wall approximately twelve inches in length and at the widest section approximately four inches wide. At the widest section there was a hole approximately two inches in diameter with exposed drywall material and wood particles from the wall support structures. There was an empty rodent glue trap lying on the floor underneath Resident #17's bed and directly in front of the wall penetration.

Interview on 10/16/23 at 1:20 P.M. with LPN #305 confirmed in Resident #17's room the long, large gouges in the wall with exposed drywall material, the linear wall penetration with a hole located in the center of the penetration above the baseboard, and the empty rodent glue trap lying on the floor underneath Resident #17's bed and in front of the hole in the wall penetration.

Review of the facility resident admission paperwork booklet titled Federal & Ohio Resident Rights & Facility Responsibilities revealed in the section of Residents' rights; sponsor may protect rights. (3721.13) Safe and Clean-Living Environment. The right to a safe and clean-living environment pursuant to the Medicare and Medicaid programs.

Based on interview, record review, and policy and procedure review, the facility failed to ensure their abuse policy and procedure was implemented in regard to staff reporting an injury of unknown origin in a timely manner. This affected one resident (#24) of three residents reviewed. The facility census was 76.

Findings include:

Review of the medical record for Resident #24 revealed an admission date of 08/10/22. Diagnoses included left femur fracture, falls, muscle weakness and dementia. Review of the Minimum Data Set (MDS) assessment, dated 11/23/22, revealed Resident #24 had impaired cognition, required extensive assistance with transfers, ambulation, toileting and personal hygiene, and was incontinent of bowel and bladder.

Review of the care plan dated 11/23/22 revealed Resident #24 had self care deficits. Interventions included assist resident with care as needed. Resident #24 was at risk for bruising related to anticoagulant use. Interventions included monitor for signs of bruising and report abnormalities to the physician. Resident #24 was at risk for falls related to gait abnormalities and confusion. Interventions included maintain a safe, clutter free environment, keep call light within reach and encourage resident to call for help when needed.

Review of the progress note dated 12/01/22 timed 5:37 P.M. authored by Licensed Practical Nurse (LPN) #310 revealed LPN #310 observed a bruise near Resident #24's right eye during medication administration. The progress note stated the resident had indicated the injury had occurred during a farming accident. The nurse practitioner was notified as well as the resident's son. The resident's son indicated he had observed the bruise earlier and it may have been from Resident #24 hitting the side of his face on the wall because when the son saw Resident #24 earlier that morning he was sleeping in bed with the right side of his face against the wall.

Observation on 12/14/22 at 8:33 A.M. revealed Resident #24 was in his wheelchair in a common area. Resident #24 had a small crescent shaped bruise to the side of his right eye. Resident #24 was unable to answer questions appropriately.

Interview on 12/14/22 at 12:27 P.M. with LPN #310 revealed on 12/01/22 she worked from 7:00 A.M. to 7:30 P.M. LPN #310 did not see Resident #24 until approximately 5:30 P.M. when she administered his evening medications. LPN #310 stated during medication administration she observed Resident #24 with a bruise to his right eye which was red and purple in color. LPN #310 asked Resident #24 how the injury occurred and he had stated it was from a farming accident. LPN #310 performed a full body assessment of the resident with no other injuries observed. LPN #310 asked State Tested Nurse Aide (STNA) #311 about the bruising and STNA #311 stated she observed the bruising earlier that day. LPN #310 stated she had not been informed by STNA #311 of the injury.

Interview on 12/14/22 at 12:49 P.M. with STNA #311 revealed she worked on 12/01/22 from 7:00 A.M. to 7:00 P.M. STNA #311 stated shortly after she had started her shift she observed Resident #24 with a small red/purple colored bruise to the side of his right eye. STNA #311 stated the resident was unable to tell her how the injury occurred. STNA #311 did not inform the nurse about the bruise at that time, however when LPN #310 asked her about the injury around 5:30 P.M. she told her she saw it earlier and was unaware how it occurred.

Interview on 12/14/22 at 2:49 P.M. with Regional Registered Nurse (RRN) #400 revealed STNA #311 should have reported Resident #24's bruising to the nurse immediately upon discovery. RRN #400 stated the facility investigation did not determine how the injury had occurred.

Review of facility policy titled Abuse Prohibition revised 09/09/22, revealed staff should immediately report injuries of an unknown source.

This deficiency represents non-compliance investigated under Control Number OH00138297.

Based on observations, staff interview, and facility policy review the facility failed to provide privacy during incontinence care for Resident #1. This affected one resident (Resident #1) of three reviewed for incontinent care. The facility census is 81. Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on 12/05/15. Diagnoses included alcohol dependence, hypokalemia, Alzheimer's dementia, metabolic encephalopathy, hypertension, major depressive disorder, and edema. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated 09/21/22 revealed Resident#1 moderately impaired cognition and required extensive assistance of two staff for toileting. Observation on 10/28/22 at 4:50 P.M. State Tested Nursing Assistant (STNA) #103 provided incontinence care to Resident #1 with no issues. However, she failed to close the door to provide privacy. The resident was in the first bed and was visible from the door. The privacy curtain was not pulled in front of the door. Interview at this time STNA #103 stated she does not know why she did not shut the door. Review of the facility policy titled, Notice of PrivacyBased on observations, staff interview, and facility policy review the facility failed to provide privacy during incontinence care for Resident #1. This affected one resident (Resident #1) of three reviewed for incontinent care. The facility census is 81.

Findings include:

Review of the medical record revealed Resident #1 was admitted to the facility on 12/05/15. Diagnoses included alcohol dependence, hypokalemia, Alzheimer's dementia, metabolic encephalopathy, hypertension, major depressive disorder, and edema.

Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated 09/21/22 revealed Resident#1 moderately impaired cognition and required extensive assistance of two staff for toileting.

Observation on 10/28/22 at 4:50 P.M. State Tested Nursing Assistant (STNA) #103 provided incontinence care to Resident #1 with no issues. However, she failed to close the door to provide privacy. The resident was in the first bed and was visible from the door. The privacy curtain was not pulled in front of the door. Interview at this time STNA #103 stated she does not know why she did not shut the door.

Review of the facility policy titled, Notice of Privacy

Based on observation, staff interview, and facility policy review the facility failed to provide a shower as scheduled for a dependent resident. This affected one resident (Resident #26) of three revealed for showers. The facility census was 81.

Findings include:

Review of the medical record revealed Resident #26 was admitted to the facility on 09/15/22. Diagnoses included acute diastolic heart failure (CHF), respiratory failure, diabetes, protein calorie malnutrition, cerebral infarction, cystitis, atrial fibrillation, neuropathy, fibromyalgia, lymphedema, major depressive disorder, generalized anxiety disorder, chronic pain syndrome, insomnia, and restless leg syndrome.

Review of the plan of care dated 09/16/22 revealed Resident #26 had an activities of daily living (ADL) self-care performance deficit and required assistance with ADL and mobility related to limited mobility and muscle weakness. Interventions included dependent assistance of one staff member for bathing.

Review of the admission Minimum Data Set (MDS) 3.0 assessment dated 09/26/22 revealed Resident #26 had intact cognition, required extensive assistance of two staff members for bed mobility, toilet use, and personal hygiene extensive assistance of one staff member and total assistance of two for bathing. She was always continent of bladder and bowel. She had a stage two unhealed pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough, may also present as an intact or open/ruptured serum filled blister).

Review of the facility shower schedule revealed Resident #26 was to have a shower bath on Monday and Thursday.

Review of the September 2022 shower documentation revealed there was no documented evidence Resident #26 received a shower, bath, or bed bath on 09/19/22, 09/26/22 or 10/29/22.

Review of the October 2022 shower documentation revealed Resident #26 refused a shower on 10/06/22 and had shower on 10/10/22. There was no documented evidence Resident #26 received a shower, bath, or bed bath on 10/03/22.

Interview on 10/28/22 at 6:30 P.M., Registered Nurse #400 verified there was no documented evidence Resident #26 had all her scheduled showers/baths.

Review of the undated facility policy, Tub Baths and Showers

Based on record review, facility policy and procedure review and interview the facility failed ensure an emergent (STAT) doppler study was obtained timely Resident #146 who had symptoms of a deep vein thrombosis to the right extremity/leg. This affected one resident (#146) of four residents reviewed for x-ray and/or doppler study orders.

Findings include:

Review of the medical record for Resident #146 revealed an admission date of 07/01/17 with diagnoses including epilepsy, intracranial injury without loss of consciousness, pulmonary hypertension, muscle weakness, and personal history of cerebral infarction.

Record review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/19/22 revealed Resident #146 was cognitively intact, required extensive assistance from two staff for bed mobility and transfers and extensive assistance from one staff for locomotion.

Review of the care plan, dated 08/19/22 revealed Resident #146 was at risk for cardiac complications related to multiple cardiovascular diseases. Interventions included observe, document and report to the physician any symptoms including changes in capillary refill, color/warmth of extremities, lab values as ordered and notify physician of abnormalities as needed.

Review of a nursing progress note, dated 09/02/22 at 12:37 P.M. authored by Licensed Practical Nurse (LPN) #307 revealed the LPN was called into the resident's room room by the therapist. The therapist had concerns about Resident #146's right leg. LPN #307 assessed Resident #146's right leg and noted pitting edema (plus three) to the lower right leg. Resident #146 complained of pain in his right heel and right ankle with no redness or warmth noted. Resident #146 denied pain in his right calf. Resident #146's left leg had no edema, no redness or warmth and the resident denied any pain to the left leg. Resident #146 had normal range of motion (ROM) to the left leg. LPN #307 notified the nurse practitioner (CNP) and the CNP gave orders for a doppler to the right leg and x-ray to right foot.

A physician's order, dated 09/02/22 at 12:45 P.M. and completed by LPN #307 for Resident #146 revealed a STAT (urgent or rush) doppler to right lower leg.

Review of a nursing progress note, dated 09/06/22 at 11:48 A.M. authored by LPN #315 revealed radiologist to perform venous doppler to right lower extremity (RLE) here. LPN #315 was informed by tech, Resident #146 had a deep vein thrombosis (DVT) to the femoral and distal vein (hard copy (results) included). LPN #315 informed the CNP and was instructed to enforce bed rest for the resident for 48 hours and start the anti-coagulant medication, Eliquis 10 milligrams (mg) twice a day for seven days and five mg twice a day indefinitely.

Review of the results of the doppler to the right extremity for Resident #146 revealed non-occlusive deep venous thrombosis involving saphenofemoral junction, common femoral in the entire femoral vein.

On 09/29/22 at 1:35 P.M. interview with the Director of Nursing (DON) confirmed an order was obtained on 09/02/22 for a STAT doppler for Resident #146. However, the doppler was not obtained until 09/06/22 (four days later). The results of the doppler were positive for a DVT and additional treatment was required for the resident. There was no evidence the physician, CNP or resident were notified there would be a delay in obtaining the STAT doppler at the time it was ordered to look at other possibilities for timely testing.

Review of facility policy titled Federal and State - Guest/Resident Rights and Facility Responsibilities, dated 04/08/22, revealed the resident had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred.

The deficiency is an incidental finding to Complaint Number OH00135895.

Based on closed record review and interview the facility failed to communicate Resident #177's care needs to a contracted x-ray company to ensure the resident was provided adequate and necessary care/treatment to prevent an injury during a x-ray procedure following a left knee/joint replacement. The facility also failed to ensure the necessity of a second x-ray obtained on the same date for the resident. This affected one resident (#177) of four residents reviewed for x-ray and/or doppler study orders.

Findings include:

Review of the closed medical record for Resident #177 revealed an admission date of 12/15/21 with diagnoses including aftercare following explanation of knee joint prosthesis, subacute osteomyelitis left tibia and fibula, muscle weakness and difficulty in walking. Resident #177 was discharged from the facility on 02/02/22.

A plan of care, dated 12/15/21 revealed Resident #177 was at risk for pain and had acute pain related to osteomyelitis of left tibia and fibula, left knee osteoarthritis, and polyneuropathy. Interventions included to notify the physician if interventions were unsuccessful or if current complaint was a significant change from residents past experience of pain. The resident also had a plan of care related to potential for complications from surgical wound left knee. Interventions included to avoid tension at surgical incision site and follow up with orthopedic surgeon as ordered.

On 12/15/21 an order was noted for Resident #177 for Physical Therapy (PT) and Occupational Therapy (OT) to evaluate and treat as indicated. Orders included the resident's prognosis and rehab prognosis were good.

A PT evaluation and plan of treatment completed by Physical Therapist #304 revealed PT was initiated on 12/16/21. Resident #177's potential for achieving rehab goals were excellent as evidenced by the resident's ability to follow multi-step directions, able to make needs known, motivation to participate and motivation to return to prior level of living. The PT documentation reflected a past medical history including a hospital admission from 12/09/21 through 12/15/21. Resident #177 had a total knee replacement in March 2021 and as he was undergoing rehab, he experienced buckling of the knee as well as increased pain. A nuclear scan was consistent with loosening or infection of the area. The resident underwent removal of the hardware with implantation of a spacer as well a debridement. He was being treated with intravenous antibiotics for eight weeks. Precautions: diagnosis left knee total knee replacement, tibial and femur osteomyelitis, removal of hardware with implantation of spacer. The therapy notes indicated the resident was non-weight bearing to the left, no knee flexion and use of a knee immobilizer.

Record review revealed the facility failed to develop a plan of care related to the resident being non-weight bearing to the left leg, no knee flexion to the left leg and use of the knee immobilizer.

Review of a nursing progress note, dated 12/20/21 at 3:55 P.M. authored by Licensed Practical Nurse (LPN) #305 revealed Physician #306 was in for professional visit. A new order was received to schedule the resident's pain medication, Endocet 5-325 milligrams (mg) every four hours for ten days then resume as needed every four hours (due to left leg pain).

A Summary of Daily Skilled Services note, dated 12/21/21 (not timed) completed by Physical Therapist (PT) #304 revealed precautions: Non-weight bearing, no knee flexion, immobilizer to be worn when out of bed. Documentation included resident was complaining of increased left knee pain medially. Resident notified certified nurse practitioner (CNP) who is ordering an x-ray to rule out block displacement.

A physician order was obtained on 12/21/21 for an x-ray of the left knee due to increased pain.

A nursing progress note, dated 12/21/21 at 10:24 A.M. authored by LPN #307 revealed x-ray being done due to increased pain in the left knee.

Review of the radiology results report for Resident #177 revealed examination date 12/21/21 at 12:00 P.M. (report date 12/21/21 at 8:11 P.M.). Reporting Clinic Radiology Company #312. Findings: Post surgical changes are seen with intra-articular device in the femoral tibial joint space. There is no fracture or dislocation. The patellar is intact. Moderate prepatellar soft tissue swelling and air is noted. Multiple skin staples overlie the anterior soft tissue. Conclusion: Post surgical changes. Correlate with expected positioning of the femoral tibial intra-articular device.

Review of the x-ray pictures of the left knee revealed on 12/21/21 at 12:22 P.M. the front view of the left knee appeared to not be flexed, 12:23 P.M. the lateral view appeared to have a slight flex. An x-ray taken with a lateral view on 12/21/21 at 7:55 P.M. noted an increase in the degree the knee flexion from the x-ray taken at 12:23 P.M.

Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 12/22/21 revealed Resident #177 was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15 out of 15. The assessment revealed the resident required extensive assistance from two staff for bed mobility and limited assistance of one physical assist for transfers and ambulation.

A nursing progress note, dated 12/22/21 at 1:23 P.M. authored by the Registered Nurse (RN) revealed nursing notified of increased pain to left knee, call out to physician (Physician #309) with message left to follow up with facility.

Review of the nursing progress note, dated 12/23/21 at 3:47 P.M. authored by LPN #310 revealed Resident #177 complained of pain after he had an x-ray done by x-ray Staff #312. Resident #177 stated Staff #312 had him to bend his left knee. CNP #311 onsite and had the resident sent to the emergency room (ER) and notified Physician #309. Physician #309 called back indicating Resident #177's left knee may possibly need to have surgery due to the spacer being out of place.

A nursing progress note, dated 01/03/22 at 2:13 P.M. authored by LPN #313 revealed Resident #177 had an appointment with Physician #309 on this date at 9:30 A.M. and returned with orders for surgery to the left knee on Thursday 01/06/2022 at 2:30 P.M.

A progress note, dated 01/06/22 at 2:03 P.M. authored by LPN #313 revealed Resident #177 was having surgery to the left knee today and would be kept overnight for observation.

On 09/28/22 at 1:35 P.M. interview with Resident #177 revealed he had concerns regarding the x-rays taken of his left knee on 12/21/21. The resident revealed no facility staff had accompanied either x-ray technician into his room on this date. The resident reported the first technician obtained the x-ray without bending his leg. A second technician came into his room later that night and reported he needed to do an additional x-ray of his knee. The resident revealed the second x-ray technician removed his brace from his left leg and told the resident he needed to bend the knee 45 degree to obtain the picture. The resident reported several times he told the technician no but the insisted he had to. The resident revealed after several minutes of arguing and telling the technician he had recent surgery and was not supposed to bend the knee he agreed to allow it to be done because the technician keep insisting it was ordered by the physician. The resident revealed when the technician bent the left knee, the pain he had was unbearable and he was screaming but the technician continued to obtain the x-ray. The resident said he immediately called for the nurse, explained to the nurse what happened, and the Certified Nurse Practitioner came in the following day to see him and sent him to the emergency room where he was told he would have to have an additional surgery due to the damage, displaced spacer in the knee.

On 09/28/22 at 2:38 P.M. interview with Rehab Director #301 revealed she was the Rehab Director when Resident #177 resided at the facility. Rehab Director #301 revealed Resident #177 had knee surgery and a spacer was placed to his left knee. Resident #177 arrived at the facility for treatment for osteomyelitis and to receive therapy services. Resident #177 was doing well but after about a week, he complained his left leg felt locked, stiffer. The director revealed Resident #177 was very alert and oriented and had reported concerns to the CNP who ordered an x-ray. The x-ray company came in during the morning and did the x-ray. The x-ray company then came back in the evening and did a second x-ray. It was unknown why a second x-ray was obtained on the same date. Rehab Director #301 revealed she followed-up with Resident #177 the morning after the second x-ray was done and Resident #177 was upset the x-ray technician removed his brace and bent his knee. Rehab Director #301 confirmed Resident #177's left knee should not have been flexed (bent) due to the previous surgery on the knee and potential for injury if the knee had been bent.

On 09/28/22 at 3:28 P.M. interview with CNP #311 revealed on 12/21/21 he assessed Resident #177 for complaints of increased left knee pain (more (pain) than usual). CNP #311 revealed he told Resident #177 he would order a flat plate, which was an x-ray under the knee, the knee would not be bent. When he went back to follow up with Resident #177 after the x-ray, the resident reported a female came in and did the x-ray early in the day which was fine, she did not bend the knee. And then a male came back later that night, woke him up saying he had to re due the x-ray because the doctor re-ordered it. CNP #311 revealed he didn't reorder the x-ray. CNP #311 revealed Resident #177 was upset because he told the x-ray technician he was not supposed to bend his knee due to the type of surgery he had, and the technician bent it anyway. CNP #311 confirmed Resident #177 was correct, the left knee should not be flexed or bent at all due to the surgery procedure and restrictions. Resident #177 was wearing an immobilizer at all times to prevent bending of the knee. Resident #177 revealed the man (x-ray technician) didn't listen and he forced a pillow under the knee to bent it for the x-ray. CNP #311 revealed if the technician bent Resident #177's left knee, the technician likely would have displaced the plate in the knee. CNP #311 confirmed he sent Resident #177 to the hospital after the conversation with Resident #177 due to the concern of the potential injury caused by bending the left knee during the x-ray and the increased pain after the x-ray. Resident #177 was seen at the hospital by the orthopedic surgeon and found the plate in the left knee was displaced. Resident #177 then had an additional surgery done to replace the spacer and returned to the facility. CNP #311 revealed he had only seen one x-ray result from the two that were taken, the x-ray was timed at 12:00 P.M. on 12:21 and was normal.

On 09/29/22 at 9:52 A.M. interview with Vice President of Operations (VPO) #317 of X-ray Company #312 revealed X-ray Technician Staff #316 from the x-ray company went in the facility to obtain the x-ray of left knee for Resident #177 on 12/21/21 and either the resident had refused or was unable to bend his knee for the x-ray. The radiologist was not happy, and felt the lateral view was supposed to have the knee bent at 45 degrees. X-ray Technician Staff #318 was sent back to the facility to obtain a lateral view, arrived at 7:41 P.M. and obtained the x-ray at 8:06 P.M. A final report was completed at 8:15 P.M. VPO #317 revealed some patients who have knee surgery can bend their knee, it was hit or miss and difficult to visualize the result if the knee was straight.

On 09/29/22 at 11:35 A.M. interview with the Director of Nursing (DON) confirmed Resident #177 should have had orders obtained on admission and a plan of care initiated for to reflect the resident's non-weight bearing status of the left knee, no knee flexion, and the knee immobilizer to be on at all times when out of bed. In addition to the proper care requirements for the resident, the facility failed to ensure a second x-ray was warranted on 12/21/21 and failed to communicate to the x-ray company the resident's left leg could not be bent to obtain the x-ray.

This deficiency substantiates Complaint Number OH00135895.

Based on record review, facility policy and procedure review and interview the facility failed to implement its' abuse policy and procedure when background checks/pre-screening procedures were not implemented for newly hired staff prior to being permitted to provide care for residents. The facility identified 10 employees who were currently working in the facility, who had not had fingerprint background checks completed as required. This had the potential to affect all 80 residents residing in the facility.

Findings include:

On 08/10/22 at 6:32 A.M. interview with Registered Nurse (RN) #303 revealed she had worked as a nurse at the facility since 06/27/22. RN #303 revealed she had not submitted fingerprints for a criminal background check prior to beginning employment with the facility. RN #303 revealed upon hire, she was told by the facility, they were not sure where they were going to send newly hired employees for a background check, because the place they were using, was no longer completing background checks and the facility would follow up with her later. RN #303 revealed she had still not been given instruction regarding a background check as of the time of the survey. At the time of the interview, RN #303 was observed to be standing at a medication cart on Unit 400 preparing medications to administer to residents.

Review of the personnel file for RN #303 revealed no evidence a background check had been completed for the employee.

Review of the facility Bureau of Criminal Investigations (BCII) log revealed the log was incomplete (i.e. staff missing from log, no dates marked for fingerprint background check completions, submissions or that the facility received background checks) for all employees from September 2021 through current date.

On 08/10/22 at 3:30 P.M. interview with the Regional Administrator revealed the local sheriff's office who performed the fingerprint background checks was down for a while and they were re-routing new hires, but she was not sure where. The Regional Administrator further revealed the facility had approximately three accounts payable managers in the last several months and that was the reason the BCII log was not up to date. The Regional Administrator confirmed the BCII log and personnel file contained no evidence a BCII checks was completed for RN #303.

In addition, there was no BCII check completed for the following staff which was verified by the Regional Administrator at the time of the review:

Licensed Practical Nurse (LPN) #326 with a hire date of 07/20/22.

LPN #329 with a hire date of 06/26/22.

State Tested Nursing Assistant (STNA) #321 with a hire date of 06/16/22.

STNA #322 with a hire date of 07/07/22.

STNA #323 with a hire date of 06/03/22.

STNA #325 with a hire date of 06/13/22.

STNA #327 with a hire date of 06/03/22.

STNA #328 with a hire date of 06/02/22

Dietary Aide #324 with a hire date of 06/07/22.

Review of the facility policy titled Abuse Prohibition Policy, revised 04/28/22 revealed the facility would pre-screen employees for a history of abusive behavior with a criminal background check in states that conduct them (Indiana, Michigan, North Carolina, Virginia, and Ohio).

This deficiency substantiates Complaint Number OH00134556. This deficiency is also an example of continued non-compliance from the survey dated 07/05/2022.

Based on record review and interview the facility failed to ensure the Medical Director attended quarterly quality assessment and assurance meetings. This had the potential to affect all 80 residents residing in the facility

Findings include:

Review of the Quality Assessment and Assurance (QA) meeting sign in sheets from 2022 revealed on 02/23/22 the medical director attended a meeting by telephone. There was no evidence the Medical Director had attended any other facility QA meetings from 02/23/22 through current date.

On 08/12/22 at 2:15 P.M. interview with Corporate Administrator #399 verified the Medical Director had only attended the 02/23/22 meeting by phone and there was no evidence the Medical Director had attended any other facility QA meetings from 02/23/22 through 08/12/22.

This deficiency is an incidental finding to Master Complaint Number OH00134556.