Mckinley Nursing

Based on record review, interview, and policy review, the facility failed to ensure a discharge summary which included a recapitulation (concise summary) of the resident's stay at the facility, was completed. This affected one (Resident #1) of three residents reviewed for discharge. The facility census was 150. Findings include: Review of Resident #1's closed medical record revealed an admission date of 02/04/20 with diagnoses that included schizoaffective disorder, anxiety, heart failure, atrial fibrillation, asthma, and the use of anticoagulant therapy. The resident was discharged to another nursing facility on 03/06/24. Review of the Minimum Data Set (MDS) quarterly assessment, dated 01/01/24, revealed the resident had intact cognition with delusions, physical and verbal behaviors, and rejection of care noted. Review of the medical record revealed no evidence that the discharge summary was completed at the time of Resident #1's discharge on 03/06/24. During interview on 03/27/24 at 10:39 A.M., the DON confirmed she could not find evidence that a discharge summary was completed for Resident #1 at the time of discharge. Review of facility policy titled, Discharge Summary and PlanBased on record review, interview, and policy review, the facility failed to ensure a discharge summary which included a recapitulation (concise summary) of the resident's stay at the facility, was completed. This affected one (Resident #1) of three residents reviewed for discharge. The facility census was 150.

Findings include:

Review of Resident #1's closed medical record revealed an admission date of 02/04/20 with diagnoses that included schizoaffective disorder, anxiety, heart failure, atrial fibrillation, asthma, and the use of anticoagulant therapy. The resident was discharged to another nursing facility on 03/06/24.

Review of the Minimum Data Set (MDS) quarterly assessment, dated 01/01/24, revealed the resident had intact cognition with delusions, physical and verbal behaviors, and rejection of care noted.

Review of the medical record revealed no evidence that the discharge summary was completed at the time of Resident #1's discharge on 03/06/24.

During interview on 03/27/24 at 10:39 A.M., the DON confirmed she could not find evidence that a discharge summary was completed for Resident #1 at the time of discharge.

Review of facility policy titled, Discharge Summary and Plan

Based on observation and staff and resident interviews, the facility failed to ensure cinnamon rolls were properly prepared to ensure palatability and an appetizing appearance. This had the potential to affect all residents residing in the facility. The facility census was 150.

Findings include:

Observation on 03/27/24 at 12:28 P.M. with State Tested Nursing Assistant (STNA) #303 revealed Resident #6 had eaten approximately 10% of his lunch tray. Observation of the uneaten cinnamon roll revealed the roll, still covered with clear plastic, was approximately the size of a 50-cent piece in diameter and the texture was hard and crunchy. During interview on 03/27/24 at 12:29 P.M., STNA #303 revealed residents had complained that they were unable to eat the cinnamon rolls because they were too hard and appeared overcooked. STNA #303 verified Resident #6's cinnamon roll appeared overcooked and was hard throughout. During interview on 03/27/24 at 12:31 P.M. Resident #6 stated he didn't eat his cinnamon roll because it was hard.

During interview on 03/27/24 at 12:34 P.M., Registered Nurse (RN) #304 stated residents had complained to her that the cinnamon rolls were too hard to eat.

During interview and observation on 03/27/24 at 12:38 P.M., Resident #7 was sitting at a table in the dining room, and stated his cinnamon roll was very hard and gross. Observation revealed the cinnamon roll was approximately the size of a 50-cent piece in diameter and the texture appeared to be hard and overcooked.

Interview on 03/28/24 at 11:17 A.M. with Dietary Manager (DM) #304 revealed she was made aware of the concern regarding the cinnamon rolls served on 03/27/24. DM #304 confirmed all the cinnamon rolls served for lunch were not properly prepared. DM #304 stated a dietary cook did not place the tray of cinnamon rolls over a steam table to allow the dough to rise before baking, which resulted in the very small size and texture. DM #304 confirmed the cinnamon rolls were not palatable nor appetizing in their appearance and should not have been served to the residents. DM #304 stated the dietary cook who prepared the cinnamon rolls, had been educated on the proper preparation of the cinnamon rolls.

This deficiency represents non-compliance investigated under Complaint Number OH00151976 and Complaint Number OH00151767.

Based on observation, interview, and policy review, the facility failed to maintain appropriate infection control precautions when Licensed Practical Nurse (LPN) #320 did not properly dispose of a used insulin syringe with needle. This had the potential to affect 31 residents (#3, #7, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40) of 31 residents residing on Harrison Hall. The facility census was 150. Findings include: Observation on 03/27/24 at 12:40 P.M. revealed a used insulin syringe, with the sheath pulled over the needle, lying on the floor approximately five feet from the nursing station. This surveyor continued observation. At 12:45 P.M., the Director of Nursing (DON) confirmed the needle was lying on the floor and then retrieved it, without donning gloves, and walked approximately 20 feet to the location of the medication cart and placed the syringe into the sharps disposal container (rigid, puncture-resistant plastic or metal with leak-resistant sides and bottom, and a tight-fitting, puncture-resistant lid with an opening to accommodate depositing a sharp but not large enough for a hand to enter). Interview on 03/28/24 at 12:46 P.M. with LPN #320 revealed she was certain the insulin syringe was used to administer insulin to Resident #3. LPN #320 stated that she must have missed the sharps disposal container and apologized. The DON and LPN #302 confirmed Resident #3 did not have any communicable diseases. Interview on 03/28/24 at 12:50 P.M., the DON confirmed all needles and sharps should be properly disposed of after use. Review of the facility's policy titled, Insulin AdministrationBased on observation, interview, and policy review, the facility failed to maintain appropriate infection control precautions when Licensed Practical Nurse (LPN) #320 did not properly dispose of a used insulin syringe with needle. This had the potential to affect 31 residents (#3, #7, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40) of 31 residents residing on Harrison Hall. The facility census was 150.

Findings include:

Observation on 03/27/24 at 12:40 P.M. revealed a used insulin syringe, with the sheath pulled over the needle, lying on the floor approximately five feet from the nursing station. This surveyor continued observation. At 12:45 P.M., the Director of Nursing (DON) confirmed the needle was lying on the floor and then retrieved it, without donning gloves, and walked approximately 20 feet to the location of the medication cart and placed the syringe into the sharps disposal container (rigid, puncture-resistant plastic or metal with leak-resistant sides and bottom, and a tight-fitting, puncture-resistant lid with an opening to accommodate depositing a sharp but not large enough for a hand to enter).

Interview on 03/28/24 at 12:46 P.M. with LPN #320 revealed she was certain the insulin syringe was used to administer insulin to Resident #3. LPN #320 stated that she must have missed the sharps disposal container and apologized. The DON and LPN #302 confirmed Resident #3 did not have any communicable diseases.

Interview on 03/28/24 at 12:50 P.M., the DON confirmed all needles and sharps should be properly disposed of after use.

Review of the facility's policy titled, Insulin Administration

Based on record review and staff interview, the facility failed to ensure the services of a registered nurse were used for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 150 residents residing in the facility.

Findings Include:

Review of facility staffing schedules revealed on 01/01/24 there was no evidence the services of a registered nurse (RN) were used for at least eight consecutive hours on this date. The schedule reflected there was no RN scheduled for, or present in the building during this entire day.

Interview with the Administrator on 03/02/24 at 3:10 P.M. confirmed the facility did not have a registered nurse scheduled or working on 01/01/24. The facility was unable to provide any evidence to support a registered nurse worked in the facility on this date.

This deficiency represents non-compliance investigated under Complaint Number OH00150409.

Based on observation, staff interview, review of the facility menu spread sheets, review of the printed tray cards, and medical record review, the facility failed to ensure proper food portions were served to meet the individual needs of Resident #143 who was ordered double portions, and failed to ensure proper food portions were served to all residents receiving meals from the kitchen. This had the potential to affect all residents receiving meals from the kitchen except Resident #37 who the facility identified as receiving nothing by mouth. The facility census was 147.

Findings include:

1. Observation of the lunch meal trayline on 12/12/23 from 11:18 A.M. to 12:55 P.M. with Dietary Cook/Supervisor (DC/S) #413 revealed Cook #419 used one number-eight, gray handled ( four ounce) scoop to dish out the regular and mechanical soft turkey divan and one number-12, green handled (two and two-third ounce) scoop to dish the puree turkey divan and the puree mashed sweet potatoes.

Review of facility Fall and Winter 2023 to 2024 spread sheet for Tuesday, week three revealed the correct portion size for the regular and mechanical soft turkey divan was one eight-ounce spoodle (portion controlled serving spoon) and the puree turkey divan was one number-six, white handled (five and one-third ounce) scoop. The puree mashed sweet potato was one number-eight (four ounce) gray handled scoop.

Review of the of facility Fall and Winter 2023 to 2024 spread sheet for Tuesday, week three and interview on 12/12/23 at 2:50 P.M. with DC/S #413 revealed she was unaware of what the color of the handle of the scoop represented. She confirmed the residents who received the regular, mechanical soft and puree turkey divan and the puree mashed sweet potatoes did not receive the full portion sizes since the residents who received regular and mechanical soft turkey divan received four ounces instead of eight ounces, the residents who received the puree turkey divan received two and two-third ounces instead of five and one third ounces, and the residents who received puree mashed sweet potatoes received two and two-third ounces instead of four ounces. DC/S #413 stated she had never seen a spread sheet. She indicated the facility had been printing out production sheets which listed the portion sizes, but since the employee who printed them out had been on leave of absence, there had not been any production sheets printed for about a month.

2. Review of medical record for Resident #143 revealed an admission date of 05/25/23. Diagnoses included fatty liver, hypo-osmolality (low levels of electrolytes in blood) and hyponatremia (low sodium levels in the blood), atherosclerotic heart disease, and essential hypertension (high blood pressure).

Review of physician orders for Resident #143 revealed an order dated 05/26/23 for mechanical soft, double portions diet.

Observation of Resident #143's breakfast tray and review of the resident's breakfast tray card on 12/13/23 at 9:21 A.M. with State Tested Nursing Assistance (STNA) #347 revealed Resident #143 received a single portion of eggs, one piece of toast, one bowl of hot cereal, and one bowl of sliced bananas. Resident #143's tray card placed on his breakfast tray did not indicate he was to receive double portions. At the time of observation, STNA #347 confirmed Resident #143 received a single portion for breakfast and his tray card had not indicated he should be receiving double portions.

Interview on 12/13/23 at 9:34 A.M. with Dietary Manager (DM) #505 confirmed Resident #143's breakfast tray card should have specified the resident was on double portions. DM #505 stated he did audits to compare tray card and physician orders, and he had no idea how that got missed.

This deficiency represents non-compliance investigated under Complaint Number OH00148558.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure food was served in a sanitary manner when a dietary staff member with artificial nails was observed not wearing gloves during tray line. This had the potential to affect 146 residents who received food from the kitchen. The facility identified one resident (#37) as not receiving anything by mouth. The facility census was 147.

Findings include:

Observation of the tray line on 12/12/23 from 11:18 A.M. to 12:55 P.M. with Dietary Cook/Supervisor (DC/S) #413 revealed Dietary Aide (DA) #432 had long, artificial nails with a three dimensional nail charm attached to the right fourth finger. DA #432 was not wearing gloves to cover the artificial nails and was setting up the trays on trayline for the lunch meal service.

Interview with the Administrator on 12/12/23 at 3:38 P.M. revealed gloves should be worn by any dietary employee who has artificial nails, and DA #432 should have been wearing gloves to cover the artificial nails while on tray line.

Review of undated facility policy Personal Hygiene revealed the food handler must wear gloves if artificial nails are worn to work in order to reduce the risk of food borne illness and food handler hazards.

This deficiency represents non-compliance as an incidental finding during the investigation of Complaint Number OH00148558.

Based on closed record review, facility policy review, and interview the facility failed to notify Resident #200's family and physician of changes in the resident's condition. This affected one resident (#200) of three residents reviewed for change in condition.

Findings include:

Review of Resident #200's hospital documentation dated 09/15/23 indicated the 70-year-old female presented with ongoing pain following a fall. The resident fell at home 09/14/23 and was evaluated in the emergency department (ER). She was diagnosed with a left superior pubic ramus fracture and possible left inferior pubic ramus fracture. The resident was neurovascularly intact, alert and oriented, and able to bear some weight but with pain.

Review of Resident #200's closed medical record revealed the resident was admitted to the facility on 09/18/23 with diagnosis including a fracture of the superior rim of the left pubis, weakness and major depressive disorder.

A plan of care, created 09/19/23 revealed Resident #200 was at risk for falls due to her history of falls prior to admission, her mental status and her general weakness. Interventions included but were not limited to, staff to report any falls to family/physician.

Review of Resident #200's progress note dated 09/18/23 at 4:15 P.M., 09/19/23 at 6:24 A.M., 09/20/23 at 3:08 P.M., 09/21/23 at 3:37 A.M., 09/22/23 at 11:38 P.M., 09/23/23 at 12:50 P.M. and 09/24/23 at 6:42 A.M. noted the resident was alert and oriented (times two to three).

Review of Resident #200's Minimum Data Set (MDS) 3.0 assessment dated 09/24/23 revealed the resident exhibited moderate cognitive impairment and required extensive two person assist for bed mobility, dressing, toilet use, personal hygiene and bathing as well as limited two person assist for transfers.

Review of Resident #200's progress note dated 09/24/23 at 2:48 P.M. revealed the resident was alert with periods of confusion. The note did not indicate if this was a change for the resident or the resident's baseline orientation.

Review of Resident #200's progress note dated 09/25/23 at 6:16 A.M. revealed the resident was agitated and confused during the shift, yelling at the State Tested Nursing Assistant (STNA) to get out of her apartment and calling the police that someone put something in her drink. Record review revealed no evidence the resident's physician or family were notified of this change in behavior.

Review of Resident #200's progress note dated 09/25/23 at 6:00 P.M. indicated the STNA reported the resident was sitting in front of the bathroom. No injuries were noted. No change in range of motion (ROM) to all extremities or neurological checks were identified and the supervisor was notified. Review of the progress note revealed no evidence the resident's physician or family were notified of incident.

A fall evaluation form completed by the facility on 09/25/23 revealed the resident had ROM of four quadrants without pain or limitation and the daughter was notified of the fall.

Review of Resident #200's progress note dated 09/27/23 at 7:29 A.M. indicated at 4:00 A.M. the resident came out of her room and thought it was morning. The resident was re-educated, and she had returned to her room. At 5:00 A.M. the resident came out of the room and stated the STNA kicked her a**. When questioned, the resident stated it happened right at the time of the interview. The resident then lowered herself to the floor and started to crawl across the floor. Staff tried to encourage the resident to return to the wheelchair. She refused and started to roll down the hall. The Registered Nurse (RN) Supervisor was notified and able to get the resident back to her room. The resident refused the 6:45 A.M. neurological check and refused lab work. Record review revealed no evidence the resident's physician or family were notified of this change in behavior.

Review of Resident #200's progress note dated 09/27/23 at 11:52 A.M. revealed the resident was sent to the hospital via the emergency technicians (EMT) per the family's request for evaluation and treatment.

Review of Resident #200's progress note dated 09/27/23 at 5:00 P.M. revealed the daughter stated they were taking the resident home from the hospital and she would not return to the facility.

Interview on 11/03/23 at 6:26 A.M. with Licensed Practical Nurse (LPN) #803 indicated she took care of Resident #200 on (09/27/23) the day that she was sent out. She confirmed around 4:00 A.M., the resident came out of the room and was observed putting herself on the ground from the wheelchair. LPN #803 indicated both herself, STNA #804 and STNA #805 picked the resident back up and put her in a wheelchair. LPN #803 indicated she had assessed her following this incident and the resident had no concerns with pain or injuries. LPN #803 indicated around five minutes later, the resident placed herself on the floor again and was screaming. LPN #803 stated the resident would not let the STNAs and the nurse pick her up to place her back in the wheelchair. LPN #803 indicated she called the nursing supervisor to come see the resident, but Central Supply #808 came to the floor first and picked the resident up and placed her back in the wheelchair.

Interview on 11/03/23 at 6:36 A.M. with STNA #805 indicated (on 09/27/23) Resident #200 threw herself on the floor and herself as well as LPN #803 and STNA #804 picked the resident up and placed her in the wheelchair. STNA #805 indicated five minutes later the resident was on the floor again and would not let the staff pick her up so Central Supply #808 came on the floor and picked her up and put her back in the wheelchair.

Interview on 11/03/23 at 7:45 A.M. with the Administrator confirmed Resident #200 had a change in mental status/falls and the physician or family were not notified timely of these changes/incidents.

Review of the Change in a Resident's Condition or Status policy revised 08/2008 indicated the facility shall promptly notify the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status, changes in the level of care, billing/payments, resident rights etc.

This deficiency represents non-compliance investigated under Complaint Number OH00147385.

Based on closed record review, hospital record review, facility policy review and interview the facility failed to implement comprehensive and individualized fall/safety interventions to prevent falls including a fall with injury for Resident #200.

Actual Harm occurred on 09/27/23 when Resident #200, who had moderate cognitive impairment and required extensive two-person assistance for bed mobility and transfers was transferred to the emergency room per family request due to changes in condition. Record review revealed the resident sustained three falls between 09/25/23 and 09/27/23 without evidence of adequate interventions being in place at the time of the falls. Following a second fall on 09/27/23, the resident was picked up off the floor by Central Supply #808, an employee who was not qualified/trained to provide direct resident care. The resident was subsequently diagnosed with non-displaced left rib fractures and re-injury of a previous pelvic fracture.

This affected one resident (#200) of three residents reviewed for falls.

Findings include:

Review of Resident #200's closed medical record revealed the resident was admitted to the facility on 09/18/23 with diagnoses including a fracture of the superior rim of the left pubis, weakness and major depressive disorder. Hospital documentation dated 09/15/23 (prior to admission) revealed the resident had presented to the hospital with pain following a fall at home on 09/14/23. The resident was diagnosed with a left superior pubic ramus fracture and possible left inferior pubic ramus fracture.

Review of Resident #200's hospital admission orders dated 09/18/23 indicated she had a primary diagnosis of left pelvic fracture with a secondary diagnosis of falls.

A fall risk assessment, dated 09/18/23 revealed the resident was at high risk for falls.

A plan of care, created 09/19/23 revealed Resident #200 was at risk for falls due to her history of falls prior to admission, her mental status and her general weakness. The goal developed was for the resident to remain free from significant injury due to her risk of falls. Interventions included the resident needed assistance with transfers, does reposition in wheelchair and does try to ambulate without assistance; staff to report any falls to family/physician and fall interventions, which may include vital signs, neurological exams, medication reviews, lab work, x-rays and any intervention that may be ordered by the physician.

Review of Resident #200's Minimum Data Set (MDS) 3.0 assessment dated 09/24/23 revealed the resident exhibited moderate cognitive impairment and required extensive two person assist for bed mobility, dressing, toilet use, personal hygiene and bathing as well as limited two person assist for transfers.

Review of Resident #200's progress note dated 09/25/23 at 6:00 P.M. indicated the STNA reported the resident was sitting in front of the bathroom. The note indicated no injuries were noted. The resident had no change in range of motion (ROM) to extremities, neurological checks were initiated and the supervisor was notified. In addition, record review revealed no evidence comprehensive or individualized fall/safety interventions were initiated following this incident. Following the fall, the resident was encouraged to call for (staff) assistance.

Review of Resident #200's progress note dated 09/26/23 at 9:15 A.M. indicated the resident was extremely confused, stated she had $25.00 under her breakfast tray for her groceries. The son indicated the resident did not have money.

Review of Resident #200's progress note dated 09/26/23 at 2:26 P.M. indicated the resident was confused and forgetful and propelled herself in the wheelchair without difficulty.

Review of Resident #200's progress note dated 09/26/23 at 4:15 P.M. indicated the police officer came to the facility due to the resident calling them and she had reported that her children were stealing her clothing and her belongings. The staff were unable to redirect the resident and the supervisor was aware.

Review of Resident #200's progress note dated 09/26/23 at 5:02 P.M. indicated the resident called the police and stated her children were taking her belongings and selling them. The resident was confused to the month but was aware of the year and that she was at the nursing facility.

Record review revealed no evidence of new fall/safety interventions being initiated following the changes in behavior/increased confusion exhibited by the resident on 09/26/23.

Review of Resident #200's progress note dated 09/27/23 at 7:29 A.M. indicated at 4:00 A.M. the resident came out of her room and thought it was morning. The resident was re-educated, and she had returned to her room. At 5:00 A.M. the resident came out of the room and stated the STNA kicked her a**. When questioned, the resident stated it happened right at the time of the interview. The resident then lowered herself to the floor and started to crawl across the floor. Staff tried to encourage the resident to return to the wheelchair. She refused and started to roll down the hall. The Registered Nurse (RN) Supervisor was notified and able to get the resident back to her room. The resident refused the 6:45 A.M. neurological check and refused lab work. Record review revealed no evidence this incident was investigated or evidence interventions were initiated to prevent additional falls/promote resident safety.

Review of Resident #200's progress note dated 09/27/23 at 11:52 A.M. revealed the resident was sent to the hospital via the emergency technicians (EMT) per the family's request for evaluation and treatment (due to the resident not acting herself). The resident did not return to the facility after being transferred to the emergency room.

Review of Resident #200's hospital documentation dated 09/27/23 indicated the resident arrived to the emergency room on 09/27/23 at 12:30 P.M. and was evaluated in the trauma bay by the physician. The resident was able to move all of her extremities but had decreased range of motion in the bilateral lower extremities secondary to pain. X-ray of the chest did show possibility of rib fractures as well as a re-injury of her known pelvic fracture. Dedicated rib x-rays were obtained which showed evidence of non-displaced left rib fractures.

Review of the hospital radiology report (one view chest x-ray), dated 09/27/23 at 12:38 P.M. indicated a slight cortical step-off of the left lateral 6th through 8th ribs. The impression included findings were suspicious for a nondisplaced left lateral 6th through 8th ribs and consider a rib series for further evaluation.

Review of the hospital radiology report (two view rib x-ray), dated 09/27/23 at 2:15 P.M. indicated the resident had a slight cortical step-off of the left lateral second rib. Subtle cortical irregularity of the left lateral 4th and 5th ribs may be overlap of adjacent ribs on the x-ray. Previously described left lateral 6th through 8th rib step-off was not appreciated on this exam. The impression was a nondisplaced left lateral second rib fracture and questionable left 4th and 5th rib fractures versus artifacts.

Interview on 11/03/23 at 6:26 A.M. with Licensed Practical Nurse (LPN) #803 indicated she took care of Resident #200 on (09/27/23) the day that she was sent out. She confirmed around 4:00 A.M., the resident came out of the room and was observed putting herself on the ground from the wheelchair. LPN #803 indicated both herself, STNA #804 and STNA #805 picked the resident back up and put her in a wheelchair. LPN #803 indicated she had assessed her following this incident and indicated the resident had no concerns with pain or injuries. LPN #803 indicated around five minutes later, the resident placed herself on the floor again and was screaming (this incident was not documented in the medical record progress note). LPN #803 stated the resident would not allow the STNAs and the nurse to pick her up to place her back in the wheelchair following the second fall. LPN #803 indicated she called the nursing supervisor to come see the resident, but Central Supply #808 came to the floor first and picked the resident up and placed her back in the wheelchair.

Interview on 11/03/23 at 6:30 A.M. with STNA #804 indicated Resident #200 had come out of her room (on 09/27/23) in her wheelchair and stated STNA #805 had beat her up. She indicated the resident then placed herself on the floor and was yelling. STNA #804 confirmed Central Supply #808 put Resident #200 back in the chair the second time the resident was on the floor (on this date).

Interview on 11/03/23 at 6:36 A.M. with STNA #805 indicated on 09/27/23 Resident #200 threw herself on the floor and LPN #803, STNA #804 and STNA #805 picked the resident up and placed her in the wheelchair. STNA #805 indicated five minutes later the resident was on the floor again and would not let the nursing staff pick her up so Central Supply #808 came and picked her up and put her back in the wheelchair.

Interview on 11/03/23 at 7:09 A.M. with Central Supply #808 indicated he went upstairs to deliver linens and observed Resident #200 on the floor screaming. He stated at that point, he observed the nursing staff standing near the resident and the resident on the floor. He stated he went over and picked the resident up and placed her in the wheelchair. When questioned, he stated he picked up Resident #200 from the floor under both arms and placed her in her wheelchair.

Interview on 11/03/23 at 7:17 A.M. with LPN Unit Manager (UM) #810 indicated she was called to the second floor because Resident #200 was crawling around on the floor. She indicated when she got to the unit, Resident #200 was already in her wheelchair, and she took the resident back to her room and completed neurological checks on the resident. She stated she did not observe any injuries. LPN UM #810 indicated later in the day, Resident #200's daughter wanted to take the resident home and requested the resident go to the emergency room for treatment. LPN UM #810 confirmed the resident did not return to the facility after being transferred to the hospital.

Interview on 11/03/23 at 7:45 A.M. with the Administrator indicated Resident #200's son came to the facility and wanted to know about the fall as well as the rib fracture that was sustained following the fall on 09/27/23 per the hospital documentation. The Administrator indicated the resident had a history of falls and he felt it was an old rib fracture.

Interview on 11/03/23 at 9:25 A.M. with the Administrator confirmed the facility did not identify the gradual change in Resident #200's mental status (following admission) and the facility did not have a fall investigation for resident falls that occurred after her admission on 09/18/23. The Administrator verified the lack of evidence of new fall/safety interventions being initiated for the resident and also indicated he was not aware Central Supply #808 had picked the resident up off the floor when she sustained the second fall on 09/27/23.

Review of the Fall Clinical Protocol policy revised 08/2008 indicated the staff and physician would continue to collect and evaluate information until either the cause of the fall was identified, or it was determined that the cause could not be found or that finding a cause would not change the outcome or the management of falling and fall risk.

This deficiency represents non-compliance investigated under Complaint Number OH00147385.

Based on closed record review, hospital record review, and interview the facility failed to identify and provide the necessary behavioral health care and services to Resident #200 related to a substance abuse disorder to assist the resident to attain or maintain her highest practicable physical, mental and psychosocial well-being following admission for rehabilitation/treatment of a fall with fracture. This affected one resident (#200) of three residents reviewed for safety/falls.

Findings include:

Review of Resident #200's hospital documentation dated 09/15/23 indicated the 70-year-old female presented with ongoing pain following a fall. The resident fell at home 09/14/23 and was evaluated in the emergency department (ER). She was diagnosed with a left superior pubic ramus fracture and possible left inferior pubic ramus fracture. She had a dog at home, and she did not want to leave the dog alone, so she had insisted on going home with pain medication and a walker. She returned with pain that she was unable to manage. She had now arranged for somebody to take care of her dog and would like placement in a facility to recover from her injury. The pain was in her left groin and was rated an 8 out of 10 (on a scale of one to 10). She was neurovascularly intact, alert and oriented, and able to bear some weight but with pain. The resident's social history included beer daily with an average of one drink per day and marijuana daily.

Review of Resident #200's hospital documentation dated 09/18/23 revealed the resident had pubic rami fractures and had a plan for (nursing home) placement. Today she indicated she was a heavy drinker and given a dose of the anti-anxiety medication, Ativan (anti-anxiety) prior to the assessment. No signs of withdrawal were noted and the note indicated would continue to monitor.

Review of Resident #200's medical record revealed the resident was admitted to the facility on 09/18/23 with diagnoses including a fracture of the superior rim of the left pubis, weakness and major depressive disorder.

Review of Resident #200's medical record did not reveal orders for alcohol withdrawal monitoring or treatment. There was no reference to the resident receiving Ativan at the hospital in relation to the resident indicating she was a heavy drinker.

Review of the resident's baseline/acute plan of care revealed no care plan had been developed for the resident's substance abuse disorder or major depressive disorder.

Review of Resident #200's progress note dated 09/18/23 at 4:15 P.M. indicated the resident arrived at the facility alert and oriented times two.

Review of Resident #200's progress note dated 09/19/23 at 6:24 A.M. indicated the resident was alert and oriented times two.

Review of Resident #200's progress note dated 09/20/23 at 3:08 P.M. indicated the resident was alert and oriented times two.

Review of Resident #200's progress note dated 09/21/23 at 3:37 A.M. revealed the resident was alert and oriented.

Review of Resident #200's progress note dated 09/22/23 at 11:38 P.M. revealed the resident was alert and oriented.

Review of Resident #200's progress note dated 09/23/23 at 12:50 P.M. revealed the resident was alert and oriented times three.

Review of Resident #200's Minimum Data Set (MDS) 3.0 assessment dated 09/24/23 revealed the resident exhibited moderate cognitive impairment and required extensive two person assist for bed mobility, dressing, toilet use, personal hygiene and bathing as well as limited two person assist for transfers.

Review of Resident #200's progress note dated 09/24/23 at 6:42 A.M. revealed the resident was alert and oriented.

Review of Resident #200's progress note dated 09/24/23 at 2:48 P.M. revealed the resident was alert with periods of confusion.

Review of Resident #200's progress note dated 09/25/23 at 6:16 A.M. revealed the resident was agitated and confused during the shift, yelling at the State Tested Nursing Assistant (STNA) to get out of her apartment and calling the police that someone put something in her drink.

Review of Resident #200's progress note dated 09/25/23 at 6:00 P.M. indicated the STNA reported the resident was sitting in front of the bathroom.

Review of Resident #200's progress note dated 09/26/23 at 9:15 A.M. indicated the resident was extremely confused, stated she had $25.00 under her breakfast tray for her groceries. The son indicated the resident did not have money.

Review of Resident #200's progress note dated 09/26/23 at 2:26 P.M. indicated the resident was confused and forgetful and propelled herself in the wheelchair without difficulty.

Review of Resident #200's progress note dated 09/26/23 at 4:15 P.M. indicated the police officer came to the facility due to the resident calling them and she had reported that her children were stealing her clothing and her belongings. The staff were unable to redirect the resident and the supervisor was aware.

Review of Resident #200's progress note dated 09/26/23 at 5:02 P.M. indicated the resident called the police and stated her children were taking her belongings and selling them. The resident was confused to the month but was aware of the year and that she was at the nursing facility.

Review of Resident #200's progress note dated 09/27/23 at 7:29 A.M. indicated at 4:00 A.M. the resident came out of her room and thought it was morning. The resident was re-educated, and she had returned to her room. At 5:00 A.M. the resident came out of the room and stated the STNA kicked her a**. When questioned, the resident stated it happened right at the time of the interview. The resident then lowered herself to the floor and started to crawl across the floor. Staff tried to encourage the resident to return to the wheelchair. She refused and started to roll down the hall. The Registered Nurse (RN) Supervisor was notified and able to get the resident back to her room. The resident refused the 6:45 A.M. neurological check and refused lab work.

Review of Resident #200's progress note dated 09/27/23 at 11:52 A.M. revealed the resident was sent to the hospital via the emergency technicians (EMT) per the family's request for evaluation and treatment (due to the resident not acting herself).

Interview on 11/03/23 at 6:26 A.M. with Licensed Practical Nurse (LPN) #803 indicated she took care of Resident #200 on (09/27/23) the day that she was sent out. She confirmed around 4:00 A.M., the resident came out of the room and was observed putting herself on the ground from the wheelchair. LPN #803 indicated around five minutes later, the resident placed herself on the floor again and was screaming. LPN #803 stated the resident would not allow the STNAs and the nurse to pick her up to place her back in the wheelchair following the second fall. LPN #803 indicated she called the nursing supervisor to come see the resident, but Central Supply #808 came to the floor first and picked the resident up and placed her back in the wheelchair.

Interview on 11/03/23 at 6:30 A.M. with STNA #804 indicated Resident #200 had come out of her room (on 09/27/23) in her wheelchair and stated that STNA #805 had beat her up. She indicated the resident then placed herself on the floor and was yelling.

Interview on 11/03/23 at 6:36 A.M. with STNA #805 indicated on 09/27/23 Resident #200 threw herself on the floor the first time and LPN #803, STNA #804 and STNA #805 picked the resident up and placed her in the wheelchair. STNA #805 indicated five minutes later the resident was on the floor again and would not let the nursing staff pick her up so Central Supply #808 came on the floor and picked her up and put her back in the wheelchair.

Interview on 11/03/23 at 7:17 A.M. with LPN Unit Manager (UM) #810 indicated she was called to the second floor because Resident #200 was crawling around on the floor. She indicated when she got to the unit, Resident #200 was already in her wheelchair.

Interview on 11/03/23 at 9:25 A.M. with the Administrator confirmed the facility did not identify the gradual change in Resident #200's mental status (following admission). There was no evidence the facility identified and implemented a comprehensive and individualized plan to address the resident's substance abuse disorder prior to admission to ensure the resident attained/maintained her highest physical, mental and psychosocial well-being.

This deficiency is an incidental finding to Complaint Number OH00147385.

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

Based on facility self-reported incident review, record review, policy review, resident interview and staff interview the facility failed to ensure Resident #1 was free from staff to resident verbal abuse. This affected one resident (#1) of three residents reviewed for abuse. The facility census was 150.

Findings include:

Review of facility self-reported incident (SRI) #237331 revealed on 07/21/23 a verbal altercation occurred between Resident #1 and Licensed Practical Nurse (LPN) #205. The incident was immediately reported to the shift supervisor who notified the facility Administrator and Director of Nursing (DON). The incident was reported to Ohio Department of Health on 07/21/23.

Further review of the facility SRI and facility investigation revealed a statement from Resident #1 was obtained on 07/24/23 which indicated LPN #205 entered her room with medications, inhaler, and cup of water. Resident #1 indicated LPN #205 brought very little water, and Resident #1 told LPN #205 with an attitude she needed additional water. LPN #205 gave the resident attitude back. Resident #1 yelled at LPN #205 to leave her room, but LPN #205 would not leave. Resident #1 stated she got up out of bed and she pushed LPN #205. Resident #1 indicated staff members entered the room to check on the incident. LPN #205 refused to provide any additional details in her statement at this time.

Review of State Tested Nurse Aide (STNA) #211's witness statement obtained on 07/21/23 indicated she was at the unit nurse's station when she heard Resident #1 screaming at the top of her lungs. STNA #211 indicated when she arrived at the room, LPN #205 and Resident #1 were arguing back and forth about water. She further indicated they called each other [expletive], fat [expletive], and kept going. She indicated LPN #205 did not walk away, she stayed and argued with Resident #1. She further indicated that LPN #205 told Resident #1 she belonged on the Taft unit (secured behavior unit).

Review of STNA #219's witness statement obtained on 07/21/23 indicated she was at the unit nurse's station when she heard Resident #1 screaming. STNA #219 indicated Resident #1 and LPN #205 were going back and forth, Resident #1 called LPN #205 a fat [expletive]. STNA #219 and STNA #211 got in between Resident #1 and LPN #205. Resident #1 got out of her bed and attacked LPN #205. LPN #205 stood there and told Resident #1 your [expletive] hits don't hurt and that [expletive] needs to be on Taft (secured behavior unit).

Review of LPN #205's undated witness statement indicated she entered Resident #1's rooms with her medications and inhaler. Resident #1 said something she couldn't hear and asked her what she said. Resident #1 then screamed at her she needed more water. LPN #205 indicated she told Resident #1 she didn't need to scream at her. Resident #1 then threw the water on LPN #205 and called her a fat [expletive]. LPN #205 asked Resident #1 if she was going to take her medications and Resident #1 threw her medications on the floor, jumped out of her bed, and started to attack LPN #205. LPN #205 indicated Resident #1 was punching and grabbing her. Resident #1 grabbed her arm and twisted it behind her telling her I'm going to break this mother [expletive]. Resident #1 called LPN #205 a fat [expletive] and continued to hit her. STNAs #211 and #219 entered the room at some point, but she was unsure of when. LPN #205 indicated she did not call Resident #1 any names until she started hitting her.

Review of Resident #1's medical record revealed an admission date of 02/13/14 with diagnoses including schizoaffective disorder, anxiety disorder, and major depression.

Further review of Resident #1's medical record including the Minimum Data Set (MDS) 3.0 annual assessment dated 05/30/23 revealed an independent cognition level.

Interview with Resident #1 on 08/11/23 at 11:08 A.M. revealed a few weeks ago she had a verbal altercation with a nurse during evening medication pass. She didn't bring in enough water and she yelled at the nurse, the nurse wouldn't leave, so she jumped out of bed and pushed her. They called each other names back and forth until the STNAs broke it up.

Interview with the facility Administrator on 08/11/23 at 10:45 A.M. verified a verbal abuse incident between Resident #1 and LPN #205.

Review of the facility policy titled Abuse Prevention Program

Based on observation and interview the facility failed to ensure call lights were within resident reach. This affected one resident (Resident #76) of 32 residents observed for call light accessibility. The facility census was 148.

Findings include:

Record review revealed Resident #76 was admitted to the facility on 04/18/19 with diagnoses including schizoaffective disorder, hypertension, type two diabetes mellitus, major depressive disorder, and chronic obstructive pulmonary disease.

Observation on 04/24/23 at 10:37 A.M. revealed Resident #76's call light was coiled up and zip tied together, hanging against the wall and out of the resident's reach. Interview at the time of the observation with Resident #76 revealed she did not know how long the call light had been hanging that way.

Interview on 04/24/23 at 10:40 A.M. with Licensed Practical Nurse (LPN) #556 confirmed Resident #76's call light was coiled up and zip tied hanging against the wall, out of Resident #76's reach. LPN #556 verified Resident #76 would not have access to the call light in an emergency and did not know how long it was coiled up and zip tied.

This deficiency represents non-compliance investigated under Complaint Number OH00135062.

Based on self-reported incident review, medical record review, policy review and staff interview, the facility failed to ensure narcotic medications were not misappropriated by staff members. This affected three residents (Residents #68, #99 and #111) of five residents reviewed for misappropriation. The facility census was 148.

Findings include:

Review of the facility Self-Reported Incident (SRI) #230289 with a created date of 12/19/22 revealed Licensed Practical Nurse (LPN) #701 alleged Registered Nurse (RN) #658 was possibly misappropriating resident narcotic medications.

Further review of SRI #230289 and the facility investigation found that RN #658 misappropriated narcotic medications from Residents #68, #99 and #111. Further review of SRI #230289 revealed RN #658 was also identified in an SRI for another facility in 2017 with the allegation of misappropriation of resident narcotics. The SRI was substantiated and RN #658 was terminated from the other facility

1. Facility investigation determined RN #658 misappropriated three narcotic medications on 12/17/22 from Resident #68.

Review of Resident #68's medical record including controlled drug receipt/record disposition form revealed misappropriation of narcotic medications on:

a. RN #658 forged the signature of LPN #701, who was not working the resident unit at the time of administration, on Resident #68's controlled drug receipt/record/disposition form. Oxycodone (narcotic opioid analgesic medication) five milligrams (mg) was administered on 12/17/22 at 10:45 (no indication A.M. or P.M.).

b. RN #658 forged the signature of LPN #604, who was not working the day of administration, on Resident #68's controlled drug receipt/record/disposition form Oxycodone five mg was administered on 12/17/22 at 4:45 (no indication of A.M. or P.M.).

c. RN #658 documented on Resident #68's controlled drug receipt/record/disposition form Oxycodone five mg was administered on 12/17/22 at 10:45 (no indication of A.M. or P.M.). Medication was previously documented as administered, see example 1 a.

2. Facility investigation determined RN #658 misappropriated narcotic medication on 12/16/22 for Resident #99. Review of the Resident #99's controlled drug receipt/record/disposition form revealed a fictitious/unknown staff member signed out Oxycodone five mg for Resident #99 on 12/16/22 at 8:00 P.M. RN #658 was working Resident's #99's unit at the time of documented administration.

3. Facility investigation determined that on 12/17/22 at 3:00 P.M. and 10:00 P.M. LPN #604 administered hydrocodone/acetaminophen (narcotic opioid analgesic medication) to Resident #111. The facility determined that LPN #604 was not working at the time of documented administration and also that Resident #111 was on a leave of absence from the facility during the time of administration. RN #658 forged the signature of a different staff member, LPN #604, when administering.

On 04/27/23 at 10:20 A.M. interview with the Administrator and Director of Nursing verified RN #658 was misappropriating resident narcotic medications by signing out resident narcotic medications using other staff names when the staff were not in the building, working the unit of the resident for administration, using a fictitious/unknown staff member name and documenting administration of narcotic pain medications to residents while on leave from the facility. Continued interview revealed RN #658 resigned before the facility could get her statement for the investigation.

Review of the facility policy Abuse Prevention Program with a revision date of 02/07/17 indicated this facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment.

Based on observation, record review and interview the facility failed to ensure residents received the assistance needed for activities of daily living (ADLs). This affected two residents (Resident #89 and #143) of three residents reviewed for ADLs. The census was 148.

Findings Include:

1. Review of the medical record for Resident #89 revealed an admission date of 09/14/22. Diagnoses included the need for assistance with personal care, vitreous hemorrhage (blood in the space between the eye's lens and retina), bilateral cataracts, bipolar disorder, anxiety disorder, major depressive disorder, and diabetes with neuropathy.

Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/31/23, revealed the resident had moderately intact cognition, severely impaired vision, and minimally impaired hearing. Behaviors included delusions and verbal behavioral symptoms directed at others. The resident required the extensive assistance of two staff for transfers. The resident was totally dependent for locomotion, dressing, and personal hygiene. The extensive assistance of one staff was needed for eating and toilet use. Bathing did not occur.

Interview on 04/24/23 at 12:07 P.M. with Resident #89 revealed he was blind, very hard of hearing, couldn't walk, and had such bad neuropathy in his hands he couldn't feel anything. The resident stated he hadn't had a shower, or had his hair washed in seven weeks.

Review of the point of Care History from 03/01/23 through 04/30/23 revealed no record of the resident receiving a shower or bath.

Review of the Bath/Shower sheets for March and April 2023 for Resident #89 revealed in March there were two days where the state tested nursing assistant (STNA) and nurse had signed. In April the was one refusal and two days with only a nurse signature and treatment in place was noted. It was not clear if Resident #89 was bathed or showered those days.

Interview on 05/01/23 at 1:22 P.M. with Registered Nurse (RN) #518 verified showers had not occurred as scheduled for Resident #89 after reviewing the Bath/Shower sheets and the point of care history.

2. Review of the medical record for Resident #143 revealed an admission date of 10/04/22. Diagnoses included cerebral infarction, polyarthritis, and the need for assistance with personal care.

Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/06/23, revealed the resident had moderately impaired cognition.

Interview and observation on 04/24/23 at 11:38 A.M. with Resident #143 revealed the resident's fingernails were long on both hands. The fingernails on the left hand were thick, long and dark colored. The resident stated he had tried to cut them with his toenail cutter but could not get through them.

Interview on 04/26/23 at 10:03 A.M. with LPN #615 verified Resident #143's fingernails on his left hand were thick and long and the fingernails on his right hand needed to be soaked and cut.

Review of the Care of Fingernails/Toenails policy and procedure dated 04/07 revealed nail care included daily cleaning and regular trimming. Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease.

This deficiency represents non-compliance investigated under Complaint Number OH00135062.

Based on medical record review, staff interview and policy review, the facility failed to monitor resident weights as ordered by the physician. This affected one (Resident #138) of three residents reviewed for weight loss. The facility census was 148.

Findings include:

Review of Resident #138's medical record revealed an admission date of 11/12/22 with diagnoses that included Alzheimer's disease with dementia, hypothyroidism and hypertension.

Review of the physician's orders dated 11/12/22 revealed to obtain weekly weights for four weeks then monthly.

Review of Resident #138's weight records revealed weights were obtained on 11/12/22 and then on 12/02/22. There was no evidence of any additional weights obtained between 11/12/22 and 12/02/22.

On 04/27/23 at 11:35 A.M. interview with the Director of Nursing verified weights were not obtained per physician's orders following admission.

Review of the facility policy Weight Assessment and Intervention with a revision date of 08/2008 indicated nursing staff will measure resident weight on admission and weekly for three weeks thereafter. If no weight concerns are noted at this point, weight will be measured monthly thereafter.

This deficiency represents non-compliance investigated under Complaint Number OH00135062.

Based on observation and staff interview the facility failed to ensure the kitchen was maintained in a clean and sanitary condition. This had the potential to affect the 147 residents receiving food from the facility. The facility identified Resident #55 as receiving no food by mouth. The facility census was 148.

Findings include:

Observation of the kitchen during the initial tour on 04/24 23 starting at 9:41 A.M. with Dietary Manager (DM) #519 revealed the following concerns:

The tiled floors were discolored with ground in dirt and wax, giving a darkened appearance. The grout between the tiles was also darkened and needing cleaned.

The microwave was dirty with food spills inside

The dish-machine needed to be wiped down. There were crumbs and dust on top with detergent spills down the sides.

The spice table had dried spills down the side.

The stove top was dusty/dirty, and the knobs of the stove were sticky to touch.

The ice machine had a pink gritty substance on the inside of the lid.

There was a large container of cereal not labeled or dated in dry storage and a bag of frozen omelets not labeled and dated in the freezer.

There were three sour cream containers and crates of individual chocolate milk cartons that were outdated.

DM #519 verified the above findings at the time of observation.

Based on observation and staff interview the facility failed to ensure the dumpster area was maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 148.

Findings include:

Observation of the facility's dumpster area on 04/24 23 at 9:41 A.M. with Dietary Manager (DM) #519 revealed the following concerns:

a. Three of six dumpster lids were not closed.

b. There was a large bag of trash outside the dumpsters with miscellaneous gloves, papers, and other trash on the ground.

DM #519 verified the above findings at the time of observation.