University Manor Health & Reha

Based on observation, record review and interview, the facility did not maintain an ambient temperature in resident rooms and common areas. This finding had the potential to affect all 42 residents residing on the second floor and all 25 residents residing on the third floor. The facility census was 143.

Findings include:

Interview on 01/22/25 at 4:11 P.M. with Security #801 stated he felt it was cold in the facility the last two days.

Interview on 01/22/25 at 4:15 P.M. with the Administrator indicated the problems with the heat started with the boiler system in the basement. The Administrator indicated she was aware the temperatures were off.

Interview on 01/22/25 at 4:16 P.M. with the Director of Nursing (DON) indicated it was cold in the facility on 01/21/25. The DON stated the facility put heaters at the end of the halls.

Interview on 01/22/25 at 4:23 P.M. with Resident #38 indicated it was cold in the facility on 01/21/25 and 01/22/25.

Interview on 01/22/25 at 4:25 P.M. with Resident #110 revealed the facility had been cold. Observation of the resident at the time of the interview revealed she was in the first-floor smoking lounge with a coat and hat on at the time of the observation. Staff were observed sitting in a chair outside of the smoking lounge.

Telephone interview on 01/22/25 at 4:27 P.M. with Heating Services #802 indicated their company was in the facility on 01/08/25 because the basement flooded with sewage. Heating Services #802 stated their company cleaned the burners, repaired two circuit boards, four flame sensors, four pilot assemblies and two gas valves. He stated the compression tank was repaired and the pressure regular valve (auto fill valve) was repaired. He stated he was obtained temperatures on 01/21/25 the temperature on the second floor was 68 degrees Fahrenheit.

Observation on 01/22/25 at 4:42 P.M. with Mobile Administrator #803 who used a temperature gun and obtained a temperature near the first-floor smoke room revealed the temperature was 61 degrees Fahrenheit (first floor).

Observation on 01/22/25 at 4:45 P.M. with Mobile Administrator #803 who used a temperature gun and obtained a temperature of Residents #25 and #26's resident room revealed the temperature was 67 degrees Fahrenheit (second floor).

Observation on 01/22/25 at 4:45 P.M. with Mobile Administrator #803 who used a temperature gun and obtained a temperature of Resident #38's resident room revealed the temperature was 64 degrees Fahrenheit (second floor).

Observation on 01/22/25 at 4:47 P.M. with Mobile Administrator #803 who used a temperature gun and obtained a temperature of Residents #12 and #13's resident room revealed the temperature was 66 degrees Fahrenheit (second floor).

Interview on 01/22/25 at 5:07 P.M. with Receptionist #804 indicated the first floor was administration offices except for the smoking room.

Interview on 01/22/25 at 5:08 P.M. with Registered Nurse (RN) Assistant Director of Nursing (ADON) #805 indicated it had been cold in the facility for the last twenty-four to forty-eight hours.

Observations on 01/22/25 at 5:10 P.M. revealed three mobile air and power rental units on the 2nd floor (one on the end of each hall plus one in the common lounge).

Interview on 01/22/25 at 5:12 P.M. with LPN #807 indicated she had worked most days from 01/19/25 to 01/22/25 and the facility started getting cold 01/20/25 or 01/21/25.

Observations on 01/22/25 at 5:15 P.M. revealed three mobile air and power rental units on the third floor (one on the end of each hall plus one in the common lounge).

Interview on 01/22/25 at 5:26 P.M. with Mobile Administrator #803 confirmed the second floor did not meet the required ambient temperatures within the range of 71 to 81 degrees Fahrenheit. Mobile Administrator #803 indicated he would move one of the mobile heaters from the third floor to the second floor to increase the ambient temperature of the second floor.

Review of the Floor Plan Master Audit Sheet dated 01/21/25 at 11:00 A.M. of the second and third floor temperatures revealed the facility Residents #3 and #4's room temperature was 65 degrees Fahrenheit; Residents #8 and #9's room was 69 degrees Fahrenheit; Resident #20's room temperature was 66 degrees Fahrenheit; Residents #27 and #28's room temperature was 68 degrees Fahrenheit; Resident #33's room temperature was 67 degrees Fahrenheit; Resident #43's room temperature was 67 degrees Fahrenheit; Resident #47's room temperature was 68 degrees Fahrenheit; Resident #57's room temperature was 69 degrees Fahrenheit; Resident #66's room temperature was 69 degrees Fahrenheit; and Resident #69's room was 68 degrees Fahrenheit.

Review of the Floor Plan Master Audit Sheet dated 01/21/25 at 3:30 P.M. of the second and third floors revealed Residents #3 and #4's room temperature was 64 degrees Fahrenheit; Residents #8 and #9's room temperature was 64 degrees Fahrenheit; Resident #14's room temperature was 65 degrees Fahrenheit; Residents #18 and #19's room temperature was 64 degrees Fahrenheit; Residents #23 and #24's room temperature was 64 degrees Fahrenheit; Residents #31 and #32's room temperature was 67 degrees Fahrenheit; Resident #38's room temperature was 68 degrees Fahrenheit; Resident #43 and #44's room temperature was 65 degrees Fahrenheit; Resident #46's room temperature was 68 degrees Fahrenheit; Resident #50's room temperature was 69 degrees Fahrenheit; Resident #61's room temperature was 69 degrees Fahrenheit; Resident #65's room temperature was 68 degrees Fahrenheit; Resident #68's room was 69 degrees Fahrenheit; and Resident #70's room temperature was 66 degrees Fahrenheit.

Review of the Floor Plan Master Audit Sheet dated 01/21/25 at 9:15 P.M. of the second and third floors revealed Residents #1 and #2's room temperature was 65 degrees Fahrenheit; Residents #6 and #7's room temperature was 66 degrees Fahrenheit; Residents #12 and #13's resident room was 64 degrees Fahrenheit; Residents #15 and #16's room temperature was 64 degrees Fahrenheit; Resident #17's room temperature was 65 degrees Fahrenheit; Resident #20's resident room temperature was 64 degrees Fahrenheit; Residents #23 and #24's room temperature was 63 degrees Fahrenheit; Residents #29 and #30's room temperature was 66 degrees Fahrenheit; Residents #34 and #35's room temperature was 67 degrees Fahrenheit; Resident #38's room temperature was 64 degrees Fahrenheit; Resident #43's room temperature was 64 degrees Fahrenheit; Residents #35's room temperature was 67 degrees Fahrenheit; Resident #47's room temperature was 68 degrees Fahrenheit; Resident #52's room temperature was 68 degrees Fahrenheit; Resident #53's room temperature was 67 degrees Fahrenheit; Resident #55's room temperature was 68 degrees Fahrenheit; Resident #59's room temperature was 65 degrees Fahrenheit; Resident #61's room temperature was 67 degrees Fahrenheit; Resident #63's room temperature was 65 degrees Fahrenheit; Resident #65's room temperature was 65 degrees Fahrenheit; Resident #68's room temperature was 66 degrees Fahrenheit; and Resident #69's room temperature was 63 degrees Fahrenheit.

Review of the Floor Plan Master Audit Sheet dated 01/22/25 at 7:15 A.M. of the second and third floors revealed Residents #1 and #2's room temperature was 64 degrees Fahrenheit; Residents #3 and #4's room temperature was 66 degrees Fahrenheit; Residents #10 and #11's room temperature was 63 degrees Fahrenheit; Residents #12 and #13's room temperature was 67 degrees Fahrenheit; Residents #18 and #19's room temperature was 68 degrees Fahrenheit; Residents #23 and #24's room temperature was 64 degrees Fahrenheit; Residents #27 and #28's room temperature was 69 degrees Fahrenheit; Residents #31 and #32's room temperature was 67 degrees Fahrenheit; Residents #34 and #35's room temperature was 66 degrees Fahrenheit; Residents #39 and #40's room temperature was 68 degrees Fahrenheit; Residents #44 and #45's room temperature was 68 degrees Fahrenheit; Resident #47's room temperature was 66 degrees Fahrenheit; Resident #50's room temperature was 63 degrees Fahrenheit; Resident #55's room temperature was 62 degrees Fahrenheit; Resident #58's room temperature was 62 degrees Fahrenheit; Resident #62's room temperature was 62 degrees Fahrenheit; Resident #67's room temperature was 64 degrees Fahrenheit; and Resident #69's room temperature was 64 degrees Fahrenheit.

Review of the Floor Plan Master Audit Sheet dated 01/22/25 at 2:15 P.M. of the second and third floors revealed Residents #1 and #2's room temperature was 68 degrees Fahrenheit; Resident #5's room temperature was 65 degrees Fahrenheit; Residents #6 and #7's room temperature was 68 degrees Fahrenheit; Residents #8 and #9's room temperature was 66 degrees Fahrenheit; Residents #10 and #11's room temperature was 68 degrees Fahrenheit; Residents #12 and #3's room temperature was 65 degrees Fahrenheit; Resident #14's room temperature was 67 degrees Fahrenheit; Residents #15 and #16's room temperature was 65 degrees Fahrenheit; Resident #17's room temperature was 67 degrees Fahrenheit; Residents #23 and #24's room temperature was 65 degrees Fahrenheit; Residents #25 and #26's room temperature was 65 degrees Fahrenheit; Residents #27 and #28's room temperature was 64 degrees Fahrenheit; Residents #31 and #32's room temperature was 65 degrees Fahrenheit; Resident #33's room temperature was 62 degrees Fahrenheit; Residents #34 and #35's room temperature was 62 degrees Fahrenheit; Residents #36 and #37's room temperature was 62 degrees Fahrenheit; Residents #38's room temperature was 62 degrees Fahrenheit; Residents #39 and #40's room temperature was 62 degrees Fahrenheit; Resident #43 and #44's room temperature was 60 degrees Fahrenheit; Resident #50's resident room temperature was 68 degrees Fahrenheit; Resident #51's room temperature was 68 degrees Fahrenheit; Resident #53's room temperature was 67 degrees Fahrenheit, Resident #54's room temperature was 68 degrees Fahrenheit; Resident #56's room temperature was 68 degrees Fahrenheit; Resident #57's room temperature was 68 degrees Fahrenheit; Resident #58's room temperature was 66 degrees Fahrenheit; Resident #62's resident room temperature was 67 degrees Fahrenheit; Resident #63's room temperature was 68 degrees Fahrenheit; Resident #65's room temperature was 66 degrees Fahrenheit; Resident #67's room temperature was 68 degrees Fahrenheit; Resident #69's room temperature was 67 degrees Fahrenheit; and Resident #70's room temperature was 64 degrees Fahrenheit.

Review of the undated facility Extreme Weather Heat or Cold policy revealed to monitor and obtain updates on weather conditions; contact the utility company for restoration of power and/or vendors for needed equipment such as heaters and coolers; monitor the situation in coordination with local response authorities; communicate with local emergency management and state survey agency regarding nursing home situation status, critical issues and resource requests; inform staff, residents and families/representatives of the situation and provides updates as needed, assess residents frequently for changes in condition; identify residents who may require a transfer; ensure continuation of resident care and essential services; distribute appropriate comfort equipment throughout the nursing home such as fans or blankets as needed, complete repairs and restoration activities.

This deficiency represents non-compliance investigated under Complaint Number OH00161830.

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

Based on record review and interview, the facility failed to ensure Resident #74 was free from physical abuse. This finding affected one (Resident #74) of four residents reviewed for abuse.

Findings Include:

Review of Resident #701's medical record revealed the resident was admitted on 09/24/24 and discharged on 01/06/25 with diagnoses including schizoaffective disorder, diabetes and vascular dementia.

Review of Resident #701's Quarterly Minimum Data Set (MDS) 3.0 Assessment dated 01/01/25 revealed the resident exhibited moderate cognitive impairment.

Review of Resident #701's progress note dated 01/04/25 at 9:30 A.M. (recorded as a late entry on 01/05/25 at 2:45 A.M.) authored by Licensed Practical Nurse (LPN) #814 revealed the writer was informed of resident involvement in a physical altercation with Resident #74. The resident was removed from the room and placed in staff view. An assessment was completed with no injuries noted to Resident #701. Upon an interview of Resident #701, she stated she informed Resident #141 of Resident #74 taking her belongings. The two then went to Resident #74's room to confront him and started a physical altercation with the resident. No new orders were obtained, and the emergency contacts were notified.

Review of Resident #701's progress note dated 01/04/25 at 9:30 P.M. (recorded as a late entry on 01/05/25 at 3:04 A.M.) authored by LPN #814 revealed the writer was informed of resident involvement in a physical altercation with Resident #74. The resident was removed from the room and placed in staff view. An assessment was completed with no injuries noted to Resident #701. Upon interview of Resident #701, she stated she informed Resident #141 of Resident #701 taking her belongings. The two then went to Resident #74's room to confront him and started a physical altercation with the resident. No new orders were obtained, and the emergency contacts were notified.

Review of Resident #701's progress note dated 01/05/25 at 4:05 A.M. authored by LPN #815 indicated Resident #701 along with another resident (Resident #141) initiated a physical altercation with a third resident (Resident #74). Resident #701 did not sustain any injuries from the altercation and an attempt was made to contact the next of kin.

Review of Resident #701's progress note dated 01/06/25 at 11:31 A.M. authored by Social Services (SS) #816 revealed the resident had a history of making false allegations. In particular, she targeted another male resident (Resident #74) and accused him of entering her room and taking some money. She was unsure how much. Staff monitors this resident and her room closely. No one was observed entering her room and staff also stated that she had no money. The resident was very delusional, paranoid and psychotic. Will continue to monitor.

Review of Resident #701's progress note dated 01/06/25 at 5:40 P.M. authored by LPN #817 indicated staff had been observing the resident on the unit. Resident #701 went into Resident #74's room yelling and screaming at him. The unit manager and staff followed the resident. Resident #701 went into Resident #74's room with an ink pen and stabbed him in the left and right arm. Both residents were immediately separated, and the family were made aware of the event. The resident continued to use inappropriate words threatening to kill Resident #74. The resident was sent to the emergency room. Resident #701 did not return to the facility.

Review of Resident #141's medical record revealed the resident was admitted on 10/15/24 and discharged on 01/30/25 to home with diagnoses including diabetes, essential hypertension and cellulitis of the lower right limb.

Review of Resident #141's Admission MDS 3.0 Assessment dated 10/22/24 revealed the resident exhibited intact cognition.

Review of Resident #74's medical record revealed the resident was admitted on 02/09/18 with diagnoses including schizophrenia, difficulty in walking and muscle weakness.

Review of Resident #74's Quarterly MDS 3.0 Assessment dated 11/05/24 revealed the resident exhibited intact cognition.

Review of Resident #74's Physical Abuse Self-Reported Incident (SRI) Form Tracking #255777 dated 01/05/25 revealed on 01/04/25 at approximately 10:00 P.M., Resident #141 and Resident #701 entered Resident #74's room accusing him of stealing from Resident #701. The confrontation resulted in both Resident #141 and Resident #701 striking Resident #74. Staff immediately separated the residents. Resident #141 had been referred for further psychiatric evaluation and would remain on one to one until further notice while in the facility. The unit nurse completed skin and pain assessments on all residents. Resident #74 was noted to have sustained multiple scratches, red eyes, and a bloody mouth. Resident #74 was refusing further medication evaluation and treatment and would continue to be monitored for any change in condition. Resident #74 would be moved to another floor to ensure continued safety. The SRI conclusion revealed the allegation was unsubstantiated as the evidence was inconclusive. Abuse, neglect or misappropriation was suspected.

Review of Resident #74's Observation Detail List Report form (skin assessment) dated 1/04/25 at 11:38 P.M. revealed two 15 cm (centimeter) scratches on the left side of the back with several small scratches on the face and blood shot red eyes.

Review of Resident #74's Physical Abuse SRI Form Tracking Number #255828 dated 01/06/25 revealed a resident-to-resident altercation took place. On 01/06/25 at approximately 5:30 P.M., Resident #701 entered Resident #74's room without permission and accused him of taking her belongings. As Resident #701 approached Resident #74, she began poking him in both the right and left arm with a pen which resulted in a break of the resident's skin. Resident #701 was pink slipped to the hospital for a psychiatric evaluation and Resident #74 was sent to the hospital for further medical evaluation and treatment. The resident returned the same day after evaluation and a tetanus shot. The conclusion revealed the allegation was substantiated.

Review of Resident #74's hospital After Visit Summary form dated 01/06/25 revealed the resident had a left penetrating forearm wound and a superficial injury of the right forearm. The medications administered included a tetanus booster vaccine.

Review of Resident #74's Observation Detail List Report form (skin assessment) dated 01/07/25 at 3:17 P.M. revealed the resident had scratches on his back and bilateral arms.

Interview on 01/30/25 at 11:51 A.M. with Security Director #810 indicated he was called up to the floor on 01/06/25 when Resident #701 had accused Resident #74 of stealing something and she stabbed him with a fork.

Interview on 01/30/25 at 11:59 A.M. with Resident #74 revealed Resident #701 came in his room and hit him with a pen in his arms. He stated he had one drop of blood in his left arm, and he went to the hospital. He did not report any other concerns.

Interview on 01/30/25 at 1:36 P.M. with Registered Nurse (RN) Unit Manager (UM) #818 indicated she was coming down the hall and heard a resident say no to Resident #701. She stated she walked into Resident #74's room and observed Resident #701 stab him with a pen.

Telephone interview on 01/30/25 at 1:42 P.M. with LPN #814 with RN UM #818 in attendance revealed Resident #701 had jumped onto Resident #74's back while Resident #141 was in front of the resident during the altercation which occurred on 01/04/25. She stated the residents were separated. LPN #814 stated she did not know why she documented the same altercation between Residents #74, #141 and #701 on 01/04/25 at 9:30 A.M. and 9:30 P.M. but confirmed the actual events occurred on 01/04/25 at 9:30 P.M.

Telephone interview on 01/31/25 at 1:51 P.M. with LPN #817 with RN UM #818 in attendance revealed on 01/06/25 at 5:11 P.M., Resident #74 walked down to his room and stayed there. LPN #817 stated she heard shouting and RN UM #818 as well as the CNA were in the resident's room. She confirmed that Resident #701 had stabbed Resident #74 in the right and left arm with a pen and Resident #701 was walked back to the common area to be monitored. Resident #74 was sent to the hospital.

Interview on 01/30/25 at 2:03 P.M. with SS #816 indicated Resident #701 had a large psychiatric history and targeted males. He also stated on the 01/04/25 incident involving Residents #74, #141 and #701, Resident #74 was the aggressor when Residents #141 and #701 went into the resident's room.

Interview on 01/30/25 at 2:09 P.M. with the Administrator and SS #816 indicated the facility investigated the allegation of abuse on 01/04/25 between Residents #701, #141 and #74 and Resident #701 definitely did not jump on Resident #74's back at any point. The Administrator stated they felt the allegation was unsubstantiated because Residents #701 and #141 went into Resident #74's room but Resident #74 was the person who started the altercation with the other two residents. The Administrator confirmed the second abuse allegation on 01/06/25 between Residents #74 and #701 was substantiated.

A second telephone interview on 01/30/25 at 2:14 P.M. with LPN #814 with the Administrator and SS #816 in attendance revealed she had heard that Resident #701 jumped on Resident #74's back but she had not witnessed the event.

Telephone interview on 01/30/25 at 2:15 P.M. with Certified Nursing Assistant (CNA) #819 revealed he was coming up the stairs and had observed Resident #74 fending off Resident #141 and Resident #701. He stated Resident #141 was in front of Resident #74 and Resident #701 was behind the resident scratching at the resident's back. CNA #819 indicated Resident #74 was bleeding from his face with blood on the wall and on the floor and blood appeared on his face near his mouth and right eye. CNA #819 revealed both Residents #141 and #701 were attacking Resident #74 when he entered the room.

Review of the Ohio Resident Abuse Policy revised 07/11/24 revealed the facility would not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone.

The deficient practice was corrected on 01/24/25 when the facility implemented the following corrective actions:

Resident #74 was sent to the hospital for evaluation on 01/06/25 and received a tetanus vaccine. The resident returned to the facility and was moved to a different floor.

Resident #701 was sent to the hospital for a psychiatric evaluation and did not return to the facility.

Resident #141 was put on a one-to-one supervision from 01/04/25 until discharge to home on 01/30/25.

From 01/06/25 to current, SS #816 began behavior huddles with the nursing staff including the nurse and CNA for all residents with any type of report behaviors. The huddles discuss a plan of action to make sure resident behaviors do not escalate and de-escalation techniques to ensure the plan succeeds.

The Abuse, Neglect and Misappropriation policy was reviewed by the Administrator on 01/07/25.

On 01/07/25 through 01/09/25, Mobile Administrator #803 educated 11 staff members on abuse and behavior management with quizzes following the education including LPNs #806, #807, #814, #884, #964; CNAs #702, #863, #875; Security #846; Environmental Services #843, #848, #874, #970; and Maintenance #878, #919.

On 01/08/25, the Administrator conducted an inservice on Abuse Education and Resident to Resident Altercations. The Inservice Sign-Off Sheet revealed LPNs #708, #814, #820, #825, #891, #895, #917, #964, #968; CNAs #827, #833, #838, #839, #841, #844, #847, #853, #863, #864, #872, #875, #883, #902, #908, #931, #933, #940, #946, #956, ##962; Food #821, #876, #885, #958, #971, #974; Environmental Staff Members #843, #879, #924, #959, #970; Security Staff Members #845, #846, #871, #912; RN UM #813; SS #869; Maintenance #919; Administration Staff Members #920, #941; SS #816; RN Assistant Director of Nursing (ADON) #805; Clinical Support #942; Receptionist #954; and RN MDS #963 received the inservice.

On 01/08/25, the Administrator emailed education to all staff members regarding abuse, neglect and behavior management. The Administrator revealed this was for all staff members, including those who did not make it to the education sessions in person.

On 01/10/25, a Quality Assurance and Performance Improvement (QAPI) meeting was held with RN MDS #963; Administration #941 (admissions); Environmental Services Director #959; Clinical Support #942 (central supply and medial records); RN ADON #805; the Director of Nursing (DON); SS #816; and the Administrator on abuse, neglect and behavior management.

On 01/16/25, Mobile Administrator #803 educated 13 staff members on abuse and behavior management with quizzes following the education including RN MDS #965; CNAs #828, #832, #833, #840, #875, #904, #906, #933, #940; Food #957; Administration #920; Social Services Designee #869 (prior); and Environment #843, #959.

On 01/24/25, Mobile Administrator #803 and the DON educated 15 staff members on abuse and behavior management with quizzes following the education including Security #892; CNAs #706, #707, #808, #841, #857, #952; Life Enrichment #850; RN UMs #813, #818; Administration #941; RN MDS #963; Office Support #954; LPN #820; and Clinical Support #942.

This deficiency represents non-compliance investigated under Complaint Number OH00161562.

Based on observation, interview, and review of facility policy, the facility failed to ensure medications were prepared and administered for one resident at a time. This had the potential to affect the 35 residents living on the fifth floor (Resident #8, #10, #13, #15, #20, #23, #25, #28, #31, #38, #40, #43, #50, #57, #59, #60, #64, #66, #71, #72, #74, #80, #82, #83, #84, #87, #90, #91, #97, #98, #107, #108, #114, #124, and #126). The total census was 144.

Findings include:

Observation on 01/02/25 at 9:06 A.M. of the fifth floor medication carts with Licensed Practical Nurse (LPN) #901 revealed LPN #901 had assembled 13 medication cups containing varying amounts of pills and wrote resident names on the cups with marker so she could later administer those pills to the respective residents. These cups were set on the high and low medication carts for the fifth floor, and LPN #901 was working at these medication carts removing the pills and placing them into the labeled cups.

Interview with LPN #901 at the time of the above observation confirmed the above findings. LPN #901 said she did this to help keep track of the medications, as she recently switched to working day shift and it was much busier than during the night. LPN #901 said was the nurse for all residents on the fifth floor.

Review of the facility's medication administration policy, revised 11/15/24, revealed medications were only to be prepared for one resident at a time.

Based on record review, interview, and policy review the facility failed to ensure Resident #198's monies from the authorized resident fund account (RFA) were dispersed timely upon the resident's death. This affected one (Resident #198) of five residents reviewed for resident funds.

Findings include:

Review of Resident #198's medical record revealed an admission date of 08/27/07 and diagnoses including other specified schizophrenia and pulmonary heart disease. Resident #198 expired in the facility on 09/08/24 at 12:28 A.M.

Review of Resident #198's medical record revealed the RFA dispersal check was dated 12/03/24.

Interview on 12/03/24 at 11:25 A.M. with Business Office Manager (BOM) #402 confirmed Resident #198's RFA monies were not dispersed timely upon the resident's death as required.

Review of the Resident Personal Funds Management Policy revised 07/29/24 revealed if the resident expired, personal funds deposited, would be refunded within 30 days with an accounting of these funds to the individual, probate jurisdiction administering the resident's estate, or other entities or individuals as required by State law or regulation.

Based on record review, interview, and review of the facility policy and procedure the facility failed to ensure advanced directives were accurate and readily available. This affected three residents (#87, #99 and #143) of four residents reviewed for advanced directives. The facility census was 148.

Findings include:

1. Review of the medical record for Resident #87 revealed an admission date of 03/24/23. Diagnoses included chronic respiratory failure, hypertension, chronic kidney disease stage three, edema, and obstructive sleep apnea.

Review of Resident #87's physician orders for December 2024 revealed an active order for code status of Do Not Resuscitate Comfort Care Arrest (DNRCC-A) dated 07/17/24.

Further review of Resident #87's medical record revealed there was not a completed and signed Do Not Resuscitate (DNR) form.

Interviews on 12/03/24 at approximately 9:20 A.M. and 3:52 P.M. with Licensed Practical Nurse (LPN) #308 verified a completed and signed DNR form was not in Resident #87's medical record. LPN #308 stated she talked with Resident #87 and asked if he wanted any changes to his advance directive as per physician order and the resident said no. LPN #308 stated she then contacted the nurse practitioner to complete a DNR form reflecting the resident's advance directives as per physician order.

Review of the facility policy titled Advanced Care Planning Protocol

Based on record review and interview, the facility failed to provide Residents #29, #43 and #47 and/or their resident representatives, at the time of transfer or in cases of emergency transfer within 24 hours, written information which explained the duration of the bed-hold and the reserve bed payment policy including the resident's return to the next available bed. This affected three (Residents #29, #43 and #47) of four residents reviewed for hospitalization.

Findings include:

1. Review of Resident #29's medical record revealed the resident was admitted on 02/18/20 with diagnoses including schizophrenia, anxiety disorder and violent behavior. Further review of Resident #29's medical record revealed the resident's insurance payor source was Medicaid. The medical record did not reveal evidence Resident #29 or the resident's representative were provided a bed hold notice upon the residents transfer to the hospital on 10/14/29.

Review of Resident #29's Minimum Data Set (MDS) 3.0 assessment dated 10/14/24 revealed the resident exhibited intact cognition.

Review of Resident #29's progress note dated 10/14/24 timed 12:00 P.M. revealed the nurse observed the resident with difficulty breathing and Resident #29 was transferred to the hospital.

Review of Resident #29's progress note dated 10/28/24 timed 4:37 A.M. revealed Resident #29 arrived from the hospital to the facility around 10:45 P.M.

Interview on 12/03/24 at 1:15 P.M. with Regional Registered Nurse #467 confirmed Resident #29 was not provided a bed-hold notice which identified the bed-hold policy with bed-hold days and included the policy for returning to the facility with the reserve bed payment policy upon transfer.

Review of the Bed Hold Letter Policy revised 09/26/20 revealed it was the policy of the facility to track Medicaid bed hold days and notify the appropriate parties via Medicaid Bed Hold Letter.

2. Review of Resident #43's medical record revealed the resident was admitted on 03/12/21 with diagnoses including bipolar disorder, epilepsy and anemia. Further review of the medical record revealed Resident #43's insurance payor source was Medicaid. The medical record did not reveal evidence Resident #43 or the resident's representative were provided a bed hold notice upon transfer to the hospital on 10/05/24.

Review of Resident #43's quarterly Minimum Data Set 3.0 Assessment dated 10/07/24 revealed the resident exhibited moderate cognitive impairment.

Review of Resident #43's progress note dated 10/05/24 timed 3:44 P.M. revealed Resident #43 approached the nurse and stated her right hand hurt. Upon assessment, the dorsal part of the right hand was edematous. Resident #43 was transferred to the hospital.

Review of Resident #43's progress note dated 10/06/24 timed 1:26 A.M. revealed Resident #43 returned from the hospital around 10:52 P.M.

Review of Resident #43's progress note dated 10/10/24 timed 2:36 P.M. revealed Resident #43 sustained a fall on 10/05/24 and was diagnosed with a right fifth metacarpal and right fifth proximal phalanx fracture.

Interview on 12/03/24 at 1:15 P.M. with Regional Registered Nurse #467 confirmed Resident #43 was not provided a bed-hold notice upon transfer to the hospital which identified the bed-hold policy with bed-hold days and included the policy for returning to the facility with the reserve bed payment policy.

Review of the Bed Hold Letter Policy revised 09/26/20 revealed it was the policy of the facility to track Medicaid bed hold days and notify the appropriate parties via Medicaid Bed Hold Letter.

3. Review of Resident #47's medical record revealed the resident was admitted on 07/14/22 with diagnoses including multiple sclerosis, vascular dementia and bipolar disorder. Further review of the medical record revealed Resident #47's insurance payor source was Medicaid. The medical record did not reveal evidence Resident #47 or the resident representative were provided a bed hold notice upon Resident #47's discharge to the emergency room on 09/15/24.

Review of Resident #47's Minimum Data Set 3.0 assessment dated 11/02/24 revealed the resident exhibited moderate cognitive impairment.

Review of Resident #47's progress note dated 09/15/24 timed 4:08 P.M. revealed Resident #47 and another resident were fighting over an orange dehydration unit and Resident #47 fell to the floor with the dehydration unit.

Review of Resident #47's progress note dated 09/15/24 timed 8:00 P.M. revealed Resident #47 had a bruise to the left shoulder which was tender to the touch. Resident #47 was discharged to the emergency room.

Review of Resident #47's progress note dated 09/17/24 timed 2:58 P.M. revealed Resident #47 sustained a fall on 09/15/24 and was diagnosed with a dislocation of the left shoulder with no surgical intervention.

Review of Resident #47's progress note dated 09/20/24 timed 7:33 A.M. revealed Resident #47 returned from the hospital.

Interview on 12/03/24 at 1:15 P.M. with Regional Registered Nurse #467 confirmed Resident #47 was not provided a bed-hold notice upon transfer which identified the bed-hold policy with bed-hold days and included the policy for returning to the facility with the reserve bed payment policy.

Review of the Bed Hold Letter Policy revised 09/26/20 revealed it was the policy of the facility to track Medicaid bed hold days and notify the appropriate parties via Medicaid Bed Hold Letter.

Based on record review and staff interview the facility failed to notify the appropriate state agency (The Ohio Department of Mental Health) of a significant change in a resident's mental health condition as required. This affected one resident (#106) of one resident reviewed for preadmission screening and resident review (PASARR). The facility census was 148.

Findings include:

Review of the medical record for Resident #106 revealed an admission date of 04/25/22 with a diagnosis of dementia. Further review of the resident's diagnosis list revealed diagnoses including bipolar disorder, current episode depressed, mild or moderate severity dated 05/21/23, bipolar disorder, current episode mixed, moderate dated 05/23/23, schizoaffective disorder dated 07/26/23, and paranoid schizophrenia dated 10/24/23.

Further review of a Notice of PASARR level II outcome dated 04/21/22 revealed Resident #106 was ruled out from further PASARR review related to dementia, Alzheimer's or other neurocognitive disorder. There were no other PASARR reviews after this date.

Interviews on 12/03/24 at 1:50 P.M. and at 2:26 P.M. with the Administrator revealed they checked the Healthcare Electronic Notification System (HENS) and there were no other PASARRs other than the one from 2022. The Administrator stated they submitted a PASARR today (12/03/24) to include the diagnoses from 2023.

3. Review of the medical record for Resident #40 revealed an admission date of 01/11/18. Diagnoses included but were not limited to bipolar disorder, suicidal ideations, altered mental status, schizoaffective disorder, panic disorder and post-traumatic stress disorder (06/29/23).

Review of Resident #40's annual Minimum Data Set (MDS) 3.0 assessment dated 09/26/24 revealed Resident #40 had mild cognitive impairment and required supervision for eating, oral hygiene, toileting hygiene and rolling 150 feet in her wheelchair. Resident #40 required moderate assistance for dressing and personal hygiene and maximum assistance from staff for bathing.

Review of Resident #40's care plan revealed it was last reviewed on 11/04/24 and revealed no evidence of a care plan or interventions for post-traumatic stress disorder (PTSD).

Interview on 12/04/24 at 9:28 A.M. with Social Services #317 confirmed there was no PTSD care plan for Resident #40.

Interview on 12/04/24 at 9:46 A.M. with Regional Nurse #467 confirmed there was no care plan addressing PTSD despite Resident #40 having a diagnosis of PTSD since 06/29/23.

Review of the facility's Comprehensive Care Planning Policy with a revision date of 03/02/21, revealed the facility must develop a comprehensive Person-Centered Care Plan for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessments.

3. Review of the medical record for Resident #13 revealed an admission date of 08/07/23. Diagnoses included but were not limited to epileptic seizures, dysphagia, flaccid hemiplegia affecting right dominant side, bipolar disorder, dementia and paranoid schizophrenia. Further review of the medical record did not reveal any documentation of a care conference being held within the past twelve months.

Review of Resident #13's annual Minimum Data Set (MDS) 3.0 assessment dated 11/19/24 revealed Resident #13 had moderate cognitive impairment and was dependent upon staff for all activities of daily living (ADLs).

Phone interview on 12/02/24 at 1:58 P.M. with Resident #13's guardian revealed she was unsure when the last care conference was held as she had not been contacted to attend.

Interview on 12/04/24 at 9:46 A.M. with Regional Registered Nurse #467, the Director of Nursing and Assistant Director of Nursing revealed they were unable to provide evidence of a care conference being held for Resident #13 in the past 12 months. Regional Registered Nurse #467 stated the facility identified the concern in October 2024 but had not held a care conference since identifying the concern.

Review of the facility's Comprehensive Care Planning Policy with a revision date of 03/02/21 revealed an interdisciplinary plan of care would be established for every resident and updated in accordance with state and federal regulatory requirements and on an as needed basis. The facility was to develop a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessments. A resident care plan conference was to be scheduled at least weekly. Residents scheduled for the resident care conference included new admissions whose MDS was completed within the previous seven days, residents who returned from the hospital in the past week, residents with a significant condition change and MDS was completed in the past week, and residents with 90-day review assessments or an annual full assessment completed within the previous seven days.

Based on medical record review, bathing/showering documentation review, facility policy review and interview, the facility failed to ensure bathing/showering was completed as required for one Resident #110 who required total assistance with activities of daily living. This affected one (#110) of one resident reviewed for bathing. The facility census was 148.

Findings include:

Review of the medical record for Resident #110 revealed an admission date of 07/22/24. Diagnoses included but were not limited to acute respiratory failure, chronic obstructive pulmonary disease, and atrial fibrillation.

Review of Resident #110's quarterly Minimum Data Set (MDS) 3.0 assessment dated 10/28/24 revealed Resident #110 had intact cognition and was dependent for all activities of daily living (ADLs) including bathing.

Review of Resident #110's care plan last reviewed on 11/18/24 revealed Resident #110 had a self-care deficit and required total assistance with ADLs. The care plan did not include specific information related to bathing type preference or frequency for bathing.

Interview on 12/02/24 at 10:32 A.M. with Resident #110 revealed he had not been offered a shower in two months, he was sometimes offered a bed bath but not consistently.

Review of the undated facility shower rotation sheet for the second floor (the floor Resident #110 resided) revealed Resident #110 was to receive a shower or bed bath on Wednesdays and Saturdays.

Review of Resident #110's shower sheets for the past 90 days revealed four shower sheets dated 08/14/24, 08/21/24, 12/02/24 and one which was undated.

Interview on 12/04/24 at 1:05 P.M. with the Director of Nursing revealed she was unable to provide any other shower sheets for Resident #110 for the past 90 days and he should have been bathed twice weekly.

Review of the facility's Resident Bath Showering Scheduling Policy with a revision date of 09/09/22 revealed each resident would be scheduled to receive bathing a minimum of two times per week unless they preferred less frequent baths. When the bath or shower was complete, the nursing assistant was to document the activity on the shower sheet or the electronic medical record.

Based on observation, record review and interview, the facility failed to ensure residents who resided on the fifth floor were provided activities as scheduled. This affected 34 residents (Residents #2, #4, #9, #14, #18, #19, #21, #22, #23, #24, #26, #27, #29, #31, #34, #38, #41, #43, #44, #46, #58, #61, #65, #68, #78, #79, #90, #91, #93, #97, #102, #107, #119 and #123) who resided on the fifth floor secured unit. The facility census was 148.

Findings include:

Observation on 12/02/24 at 2:01 P.M. revealed Activity Director (AD) #459 counting money for residents on the fifth floor. Residents were observed in their rooms and in the common area. The television was on and music was playing in the common area. No formal activities were observation the fifth floor in the afternoon.

Interview on 12/03/24 at 11:45 A.M. with AD #459 revealed she was the only activity staff member working on 12/02/24 and the afternoon/evening activities were not completed as scheduled for the fifth floor residents including the 2:00 P.M. Hydration Hour, 3:00 P.M. Griddle Goodies and 6:00 P.M. Table Games. AD #459 stated she had recently terminated an activity staff. The current activity staff consisted of AD #459, one activity staff member who worked during the week and one activity staff who worked the weekend.

Review of the Activity Calendar for 12/02/24 revealed activities including 10:00 A.M. coffee cafe, 11:00 A.M. What's in the news?, 11:30 A.M. Hidden Picture Puzzles; 1:00 P.M. room/virtual visits, 2:00 P.M. Hydration Hour, 3:00 P.M. Griddle Goodies and 6:00 P.M. Table Games.

Review of the facility census revealed 34 residents resided on the fifth floor secured unit including Residents #2, #4, #9, #14, #18, #19, #21, #22, #23, #24, #26, #27, #29, #31, #34, #38, #41, #43, #44, #46, #58, #61, #65, #68, #78, #79, #90, #91, #93, #97, #102, #107, #119 and #123.

Review of the Life Enrichment Programming Policy revised 05/04/23 revealed an ongoing resident-centered Life Enrichment Program, based on comprehensive assessments and care plans, would be provided. The program would be designed to meet the interests and abilities of each resident including their physical, mental, emotional, social, spiritual, psychosocial and leisure needs.

Based on observation, record review and interview, the facility failed to ensure assessment and monitoring of a wound to Resident #79's left great toe. This affected one (Resident #79) of four residents reviewed for wounds.

Findings include:

Review of Resident #79's medical record revealed the resident was admitted on 01/26/21 with diagnoses including Huntington's disease, acute respiratory failure with hypoxia and muscle weakness.

Review of Resident #79's annual Minimum Data Set (MDS) 3.0 assessment dated 11/27/24 revealed the resident exhibited severe cognitive impairment.

Review of Resident #79's physician orders revealed an order dated 10/22/24 to cleanse the great toe of the left foot with normal saline, pat dry, apply an abdominal dressing and wrap with a gauze roll until healed once daily on night shift.

Further review of Resident #79's medical record revealed no evidence of monitoring or assessment of Resident 79's left great toe wound.

Observation of Resident #79 on 12/02/24 at 11:50 A.M. with Licensed Practical Nurse (LPN) #364 revealed no evidence Resident #79 had a dressing on the inner aspect of the left great toe.

Interview on 12/03/24 at 9:55 A.M. with Interim LPN Wound Nurse #308 revealed the staff did not tell her that Resident #79 had a wound on the inner aspect of the great toe and wound assessments and monitoring were not completed.

Interview on 12/04/24 at 12:24 P.M. with Wound Nurse Practitioner (NP) #468 revealed Resident #79's left great toe wound was an abrasion and their first evaluation of the wound was on this date (12/04/24).

Review of the Skin and Wound Care Best Practices policy revised 11/05/24 revealed the facility would provide evidence based preventative skin care and wound treatment to prevent unavoidable skin complications.

Based on interview and record review the facility failed to ensure pre and post dialysis communication was completed. This affected two residents (#100 and #133) of two residents reviewed for dialysis. The facility census was 148.

Findings include:

1. Review of Resident #100's medical records revealed an admission date 04/07/23. Diagnoses included end stage renal disease and acute kidney failure.

Review of Minimum Data Set (MDS) assessment dated 10/15/24 revealed Resident #100 had intact cognition.

Review of the care plan dated 11/18/24 revealed Resident #100 required dialysis.

Review of physician orders for December 2024 revealed an order to complete Resident #100's dialysis observation tool prior to dialysis and print and send with resident to dialysis.

Interview on 12/04/24 at 8:05 A.M. with Licensed Practical Nurse (LPN) #425 revealed dialysis communication was to be completed prior to residents leaving for dialysis and was to be sent with the residents.

Review of dialysis communication forms for Resident #100 on 12/04/24 at 2:37 P.M. with Regional Registered Nurse (RRN) #467 revealed communication forms had not been completed with each dialysis treatment as required.

Review of the facility policy titled Hemodialysis revised 08/24/23 revealed the policy indicated to document pre-assessments on the dialysis communication tool including vital signs, pre-treatment weight, medications administered before treatment and any additional alerts or information. The policy further indicated to print the tool and send with the residents. The Post dialysis processes included received report from the dialysis provider and post dialysis information was to include vital signs, post treatment weights and any new orders.

4. Review of Resident #19's medical record revealed the resident was admitted on 07/31/13 with diagnoses including schizoaffective disorder, bipolar disorder and generalized anxiety.

Review of Resident #19's Minimum Data Set (MDS) 3.0 assessment dated 11/06/24 revealed the resident exhibited a memory problem.

Review of Resident #19's physician orders revealed an order dated 02/17/23 (discontinued 01/29/24) for Meloxicam 7.5 milligrams (mg) give one tablet one time a day for inflammation of the right leg.

Review of Resident #19's Pharmacy Consultation Report form dated 12/16/23 indicated the resident was started on Meloxicam 7.5 mg daily on 02/17/23. The recommendation indicated to please discontinue the Meloxicam and consider initiating an alternative analgesic. The form did not have a physician response.

Review of Resident #19's physician orders revealed an order dated 01/29/24 (discontinued 09/24/24) for Meloxicam 7.5 mg one tablet by mouth one time a day for inflammation of the right leg.

Review of Resident #19's Pharmacy Consultation Report form dated 02/29/24 revealed the resident was started on Meloxicam 7.5 mg daily on 02/17/23. The recommendation indicated to please discontinue Meloxicam and consider initiating an alternative analgesic. The form did not have a physician response.

Review of Resident #19's Pharmacy Consultation Report dated 06/17/24 indicated the resident was started on Meloxicam 7.5 mg daily on 02/17/23. The recommendation indicated to discontinue the Meloxicam and consider initiating an alternative analgesic. The physician response to the recommendation indicated to check a basic metabolic panel (BMP) blood level with the next lab draw.

Interview on 12/04/24 at 9:31 A.M. with Regional Registered Nurse #467 confirmed Resident #19's pharmacy recommendations were not acted upon in a timely manner.

Review of the Medication Regiment Review policy revised 06/01/24 revealed the consultant pharmacist would document medication record reviews (MRRs) and would make recommendations based on the information made available in the residents' health record. The consultant pharmacist would provide required recipients of residents' MRRs on the MRR report to the Director of Nursing and/or the attending physician, and to the Medical Director.

Based on record review and interview, the facility failed to ensure Resident #19's as-needed antipsychotic medications were limited to fourteen days until the physician evaluated the resident, and non-pharmacological interventions were attempted prior to administering as-needed antipsychotic medications. This affected one (Resident #19) of five residents reviewed for medication administration.

Findings include:

1. Review of Resident #19's medical record revealed the resident was admitted on 07/31/13 with diagnoses including schizoaffective disorder, bipolar disorder and generalized anxiety.

Review of Resident #19's Minimum Data Set (MDS) 3.0 assessment dated 11/06/24 revealed the resident exhibited a memory problem and received antipsychotic medications.

Review of Resident #19's physician orders revealed an order dated 11/11/24 for olanzapine (antipsychotic) 2.5 mg intramuscularly (IM) every six hours as needed for agitation. There was no stop date on the order.

Review of Resident #19's Pharmacy Consultation Report dated 11/15/24 revealed the resident was ordered olanzapine antipsychotic medications without a stop date. The physician response dated 11/26/24 indicated to initiate the stop date to 14 days (stop date 11/26/24).

Review of Resident #19's medication administration records from 11/04/24 to 12/04/24 revealed no evidence the resident received the olanzapine IM during this time frame.

Interview on 12/04/24 at 9:44 A.M. with Regional Registered Nurse (RN) #467 confirmed Resident #19's IM olanzapine did not have an appropriate stop date.

2. Review of Resident #19's medical record revealed the resident was admitted on 07/31/13 with diagnoses including schizoaffective disorder, bipolar disorder and generalized anxiety.

Review of Resident #19's Minimum Data Set (MDS) 3.0 assessment dated 11/06/24 revealed the resident exhibited a memory problem and received antipsychotics.

Review of Resident #19's physician orders revealed an order dated 11/27/24 (discontinued 12/09/24) for olanzapine 2.5 mg give one tablet by mouth every six hours as needed.

Review of Resident #19's medication administration records revealed the resident was administered the olanzapine antipsychotic on 11/27/24 at 1:26 P.M., 11/27/24 at 8:04 P.M. and 11/28/24 at 9:19 P.M. The medical record did not have evidence non-pharmacological interventions were implemented prior to administering the antipsychotic medication.

Interview on 12/04/24 at 9:31 A.M. with Regional Registered Nurse #467 confirmed Resident #19's medical record did not have evidence non-pharmacological interventions were implemented prior to administering Resident #19's as needed antipsychotic medication.

Review of the Psychoactive Medication Policy revised 05/10/24 revealed all residents receiving psychoactive medications would have their behaviors, effectiveness of interventions (pharmacological and non-pharmacological) and potential for a gradual dose reduction of psychoactive medications monitored and documented.

Based on observation, record review, and interview the facility failed to ensure the coordination of services to make certain residents received the correct diets. This affected two residents (#19 and #29) of seven residents (#19, #29, #31, #100, #119, #134, and #143) reviewed for nutrition. The facility census was 148.

Findings include:

Observation of lunch on 12/02/24 at 12:50 P.M. revealed Resident #29's meal ticket indicated regular double protein diet and listed beef stew, mixed vegetables, biscuit, margarine, tropical fruit cup, whole milk, and beverage of choice. Observation of Resident #29's meal revealed no double protein.

Medical record review revealed Resident #29 was to receive double protein with meals.

Interview on 12/02/24 at 12:55 P.M. with Agency Certified Nurse Aide (CNA) #500 confirmed Resident #29 did not have double protein for his meal.

Observation of lunch on 12/03/24 at 12:30 P.M. revealed Resident #19's meal ticket indicated regular, renal diet and listed cheese pizza, salad garden with dressing, fortified potatoes, chocolate chip cookie, two percent milk, hot chocolate, margarine, beverage of choice, salt, pepper, and sugar. Observation of Resident #19's meal revealed she received noodles, a plain hamburger, and milk.

Medical record review revealed Resident #19 was to receive fortified potatoes and was not ordered a renal diet.

Interview on 12/03/24 at 12:33 P.M. with CNA #347 verified the observation of Resident #29's lunch meal.

Based on record review, interview, and policy review the facility failed to ensure Resident #95 was provided education and offered the influenza and pneumococcal vaccines. This affected one (Resident #95) of five residents reviewed for immunizations.

Findings include:

Review of Resident #95's medical record revealed the resident was admitted on 09/13/24 with diagnoses including essential hypertension, other chronic pain and history of falling.

Review of Resident #95's Minimum Data Set (MDS) 3.0 assessment dated 09/20/24 revealed the resident exhibited intact cognition.

Further review of Resident #95's medical record did not reveal evidence the resident was offered or educated on the influenza and pneumococcal vaccines.

Interview on 12/05/24 at 11:03 A.M. with Registered Nurse Infection Preventionist #320 and Regional Registered Nurse #467 confirmed Resident #95 was not offered or educated on the influenza or pneumococcal vaccines.

Review of the Influenza Vaccine Policy (Resident) revised 08/19/20 revealed all residents would be offered an influenza vaccine beginning in October of each year, unless medically contraindicated or the resident had already been vaccinated. The facility would provide the most recent vaccine information statement from the Centers for Disease Control and Prevention and an opportunity to ask any questions they may have before consenting to the vaccination.

Review of the Pneumococcal Vaccine Policy (Resident) revised 08/19/20 revealed all residents would be offered the pneumococcal vaccine to aid in preventing pneumococcal infections. The facility would provide educational information regarding the significant risks and benefits of the vaccine to the resident and/or residents' representative on admission and prior to administration of the vaccine.

Based on observation and interview the facility failed to ensure the resident environment on the fourth floor was maintained in good repair. This had the potential to affect all 42 residents (#1, #3, #6, #7, #11, #12, #16, #36, #37, #39, #45, #49, #51, #52, #56, #57, #60, #64, #72, #73, #77, #80, #83, #85, #87, #89, #92, #98, #106, #108, #109, #111, #112, #114, #120, #128, #133, #137, #140, #144, #145, and #148) who resided on the fourth floor. The facility census was 148.

Findings include:

Observation on 12/03/24 at 12:04 P.M. revealed Resident #72 was in bed. The wall the bed was against was caved in and in disrepair. Interview at the time of the observation with Certified Nurse Aide (CNA) #300 verified the observation and stated the damage to the wall was from the bed. CNA #300 asked Resident #72 how long the wall had been that way and the resident responded it was like that when he moved to this room about four months ago.

Observation of the shower room on the fourth floor located to the right of the vending machine on 12/03/24 at 1:07 P.M. revealed the back of the sink was not affixed to the wall and slightly leaning forward. Interview on 12/03/24 at 1:13 P.M. with CNA #451 verified the observation and stated all the residents on the unit used the shower room.

Observation of Residents #1 and #3's room on 12/03/24 at 1:20 P.M. revealed a missing ceiling tile above the toilet exposing the pipes. The ceiling tile was on the floor near the toilet. Several missing floor tiles were observed around the toilet. There was a large white patch on the wall above the soap dispenser that needed to be painted. Interview at this time with CNAs #300 and #451 verified the observations and they stated that the bathroom had been that way greater than five months

During observation of the fourth floor on 12/05/24 from 11:03 A.M. to 11:20 A.M. with Director of Maintenance (DOM) #341 the DOM #341 verified the back side of sink in the shower room was not affixed to the wall and sightly leaning forward. During the observation of Residents #1 and #3's bathroom, DOM #341 stated he was not aware of the missing ceiling or floor tiles but stated he was aware of the patched wall and needed to get paint. DOM #341 stated he was not sure when the hole was patched because there were so many holes they had patched because of the resident population. During the observation of Resident #72's room, DOM #341 stated he was aware of wall next to bed and stated he was not sure when the damage occurred. Additional observation of Resident #72's room with DOM #341 revealed a baseball size hole in wall across from and facing the foot of the bed. DOM #341 stated he was not aware of that hole.

Review of the facility census report dated 12/02/24 revealed 42 residents (#1, #3, #6, #7, #11, #12, #16, #36, #37, #39, #45, #49, #51, #52, #56, #57, #60, #64, #72, #73, #77, #80, #83, #85, #87, #89, #92, #98, #106, #108, #109, #111, #112, #114, #120, #128, #133, #137, #140, #144, #145, and #148) resided on the fourth floor.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, facility self-reported incident (SRI) review, and facility policy review the facility failed to prevent an incident of staff to resident emotional abuse, based on the reasonable person concept, when State Tested Nurse Aide (STNA) 314 posted a video showing Resident #5 on social media. This affected one resident (#5) of six residents reviewed for abuse. The facility census was 144. Findings include: Review of the medical record revealed Resident # was admitted to the facility on 12/20/22 with diagnoses including severe intellectual disabilities, seizures, schizophrenia, and dementia The resident was discharged on 10/04/24 to a group home. Review of the Quarterly Minimum Data Set (MDS) assessment dated 09/08/24 revealed the resident had severely impaired cognition. Resident #5 had behaviors including delusions, physical behavioral symptoms directed at others, verbal behavioral symptoms directed at others, other behavioral symptoms not directed at others, rejection of care, and wandering. Review of the SRI allegation background revealed on 09/12/24 at approximately 7:10 P.M., the Director of Nursing (DON) was notified of a video that was posted on social media by STNA #314. The video was captioned Everyday it is something new with my clients. STNA # was heard on the video making the statement what the [expletive]THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.

Based on record review, interview, facility self-reported incident (SRI) review, and facility policy review the facility failed to prevent an incident of staff to resident emotional abuse, based on the reasonable person concept, when State Tested Nurse Aide (STNA) 314 posted a video showing Resident #5 on social media. This affected one resident (#5) of six residents reviewed for abuse. The facility census was 144.

Findings include:

Review of the medical record revealed Resident # was admitted to the facility on 12/20/22 with diagnoses including severe intellectual disabilities, seizures, schizophrenia, and dementia The resident was discharged on 10/04/24 to a group home.

Review of the Quarterly Minimum Data Set (MDS) assessment dated 09/08/24 revealed the resident had severely impaired cognition. Resident #5 had behaviors including delusions, physical behavioral symptoms directed at others, verbal behavioral symptoms directed at others, other behavioral symptoms not directed at others, rejection of care, and wandering.

Review of the SRI allegation background revealed on 09/12/24 at approximately 7:10 P.M., the Director of Nursing (DON) was notified of a video that was posted on social media by STNA #314. The video was captioned Everyday it is something new with my clients. STNA # was heard on the video making the statement what the [expletive]

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

Based on record review and interview, the facility did not ensure the physician and/or nurse practitioner was notified of abnormal laboratory results for Resident #113. This affected one resident (#113) of three residents reviewed for physician notification of laboratory results. The facility census was 144.

Findings include :

Review of the medical record for Resident #113 revealed an admission date of 02/22/24. Diagnoses included intracranial hemorrhage, hyperparathyroidism, cocaine abuse, hypertension, chronic kidney disease stage four, and hemiplegia.

Review of the Minimum Data Set ( MDS) 3.0 assessment dated 06/27/24 revealed cognition was intact and the resident needed substantial assistance to walk ten feet, transfer from the toilet, and transfer from bed to chair.

Review of physician orders dated 07/17/24 revealed an order for CBC ( complete blood count) with differential, Comprehensive Metabolic Panel ( CMP) and magnesium to be drawn on 07/18/24 with special instructions of monitoring for chronic kidney disease.

Review of the progress note dated 07/18/24 at 1:24 P.M. written by Licensed Practical Nurse (LPN) #527 revealed Resident #113 was compliant with blood draw.

Review of the progress note dated 07/18/24 at 1:09 P.M. revealed the Nurse Practitioner (NP) had a follow up assessment for Resident #113 regarding hypertension and chronic kidney failure stage four. The NP noted there were no recent labs to review and to monitor labs as needed.

Review of CMP specimen collected 07/18/24 final report revealed the following lab results: potassium 5.3 milliequivalent (meq) was within normal range ( 3.5 to 5.3 meq/liter), Blood Uria Nitrogen ( BUN) was 71 and high ( normal reference range was 7 to 25 milligrams/deciliter (mg/dl) and Creatinine 3.2 mg/dl was high ( normal reference range was 0.6 to 1.2 mg/dl) .

Review of a progress note dated 07/18/24 at 4:58 P.M. written by Nursing Supervisor (NS) #700 revealed Resident #113's family was notified regarding recent labs that had been ordered and CNP had been in to assess. There was nothing in the progress note to indicate the ordering physician or NP had been notified of the results.

Review of a progress note dated 07/24/24 at 11:05 A.M. written by NA #700 revealed the NP was contacted regarding labs on 07/18/24 and the NP requested new labs to be done STAT (immediately) due to chronic kidney disease.

Review of STAT CMP dated 07/24/24 final report revealed SR #113's potassium was 5.8 meq/dl and high, BUN was 81 and high, and Creatinine was high at 3.6 mg/dl.

Review of a progress note dated 07/24/24 at 6:49 P.M. written by LPN #565 revealed the lab results were reported to the NP and new orders for Lokelma was ordered and a new BMP in the morning. Resident #113 was placed on Normal Saline intravenously (IV) 100 milliliters per hour for one liter. The residents daughter was notified by LPN # 565.

Interview on 08/28/24 at 12:40 P.M. with LPN #527 revealed she faxed the labs drawn on 07/18/24 to the NP on 07/18/24 but the fax did not reach the NP's office to review the labs. LPN #527 confirmed she did not document she faxed these labs to the NP to review and there was no evidence to show the NP ever received and reviewed those labs. LPN #527 verified abnormal labs were considered a change of condition and the NP should have been notified and addressed the abnormal labs.

Interview on 08/28/24 at 1:00 P.M. with the Director of Nursing ( DON) revealed she reviewed labs every morning and if a lab was to be done it was the responsibility of the nurse supervisor to ensure the practitioner was notified at the end of each shift. The floor nurse supervisor received a facility document called Homework to review daily to ensure labs were not missed. The DON stated on 07/22/24 the DON questioned why there was no interventions for Resident #113's high BUN lab level from the lab draw on 07/18/24. After an audit was conducted, NS #700 revealed they did not ensure the NP was notified regarding the high BUN level from 07/18/24 labs.

Review of the facility policy titled Change in Condition dated 06/27/24 revealed the licensed nurse would recognize and intervene in the event of a change in condition. The Provider would be notified as soon as possible.

The deficient practice was corrected on 07/25/24 when the facility implemented the following corrective actions:

On 07/23/24 the facility identified that the lab work completed for Resident #113 on 07/18/24 was not reported to the Nurse Practitioner ( NP) .

On 07/24/24 the NP evaluated Resident #113 and ordered a STAT lab to be obtained and a STAT dose of Lokelma was administered and IV fluid was ordered after review of STAT labs.

On 07/24/24 the Director of Nursing (DON) completed audits of all current resident's medical records for validation of laboratory testing and results reported to the practitioner from the past thirty days. All labs were found to have been reported to the practitioner.

On 07/24/24 the DON educated all nursing staff in person or by phone related to immediate reporting of resident change in condition pertaining to laboratory results and timely follow up for physician orders. All education was completed by 07/25/24.

On 07/25/24 the specified nurse was placed on a Performance Improvement Plan regarding follow through with reporting of labs.

On 07/25/24 the facility conducted an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) Action Plan to review during the meeting. The Medical Director was in attendance by phone on 07/25/24.

Beginning 07/25/24 the facility implemented a plan for twice a week audits of laboratory testing documentation and reporting results to the physician. The audits will continue for four weeks then monthly times two months. Results of the audits would be submitted to the QAPI Committee for further review and recommendation.

There were no further residents experiencing a change in condition related to laboratory results not reported to the physician or documented as such in the resident records from 07/25/24 to the date of this survey 09/04/24.

This deficiency represents non-compliance investigated under Complaint Number OH00157080.

Based on observation, interview and review of facility policy, the facility did not ensure garbage was properly disposed of to prevent the harborage pests. This had the potential to affect all 144 residents. The facility census was 144.

Findings include:

Observation on 08/28/24 at 9:30 A.M. with Maintenance Director #539 revealed the three outside dumpsters near the facility kitchen doors did not have lids covering trash, a sour smell permeated around the dumpsters with wet boxes and leaf and twig debris piled up around the dumpsters.

Maintenance Director #539 verified the findings on 08/28/24 at 9:30 A.M. and stated it was difficult to get behind the dumpsters to pick up the boxes and clean the area, and there should be lids to cover the trash.

Interview with Exterminator #646 on 08/28/24 at 12:31 P.M. revealed garbage containment and sanitation was important to prevent and control pests.

Review of the facility policy titled Pest Control dated 8/12/18 revealed routine pest control would be placed to prevent pest infiltration. Maintenance of the garbage storage area to prevent harboring and feeding of pests. Outside dumpsters doors and lids would be kept shut and secure.

This deficiency represents noncompliance as an incidental finding during the investigation of Complaint Number OH00157080.