Woods Edge Rehab and Nursing

Based on record review, observation, and interview, the facility failed to ensure a resident's compression stockings were applied as ordered to treat edema. This affected one (Resident #80) of three residents reviewed for edema. The facility census was 89.

Findings include:

Review of the medical record revealed Resident #80 was admitted on 03/27/24. Diagnoses included nerve root and plexus disorder, wernicke's encephalopathy, alcohol abuse with alcohol-induced sleep disorder, insomnia, legal blindness, depression, anxiety, and iron deficiency anemia.

Resident #80 had a physician order 05/24/24 to apply compression wraps to bilateral lower extremities, on in the morning, off at night.

During an observation on 06/03/24 at 12:27 P.M., Resident #80 had swelling in her legs and was not wearing any compression hose. During interview at the time of the observation, Resident #80 stated she asked for compression hose, however had not been provided with any.

During an observation on 06/03/24 at 5:04 P.M., Resident #80 was not wearing any compression hose.

During an interview on 06/03/24 at 5:06 P.M., Licensed Practical Nurse (LPN) #400 verified Resident #80 had an order to apply compression hose but did not have compression hose applied. LPN #400 stated Resident #80 did not ask about having them applied nor did she try to apply them, however she was told the resident sometimes refuses to have them applied. LPN #400 affirmed there was no documentation regarding Resident #80's refusal to wear the compression hose for 06/03/24. LPN #400 stated the nurse was responsible for ensuring the compression hose were applied as there was a physician's order for them to be applied.

During an observation on 06/04/24 at 12:25 P.M., Resident #80 was observed sitting on the edge of her bed. The resident had edema in her legs and was not wearing compression hose. Resident #80 stated nobody had offered to apply the compression hose.

During observations on 06/04/24 at 2:06 P.M., 2:30 P.M., and 4:00 P.M., Resident #80 was sitting up in her wheelchair in her room and in the hallways and was not wearing compression hose.

During an interview on 06/04/24 at 4:00 P.M., LPN #400 verified Resident #80 was not wearing compression hose. LPN #400 stated she talked with night shift about the compression hose and was, again, told the resident sometimes refused to have them applied, but stated she did not attempt to apply Resident #80's compression hose on 06/04/24. LPN #400 further verified she did not document anything in the medical record about Resident #80's refusal to wear the compression hose.

This deficiency represents non-compliance investigated under Complaint Number OH00153742.

Based on record review, interview and policy review, the facility failed to ensure residents were seen by the physician as required. This affected one (Resident #80) of three residents reviewed for physician visits. The facility census was 89.

Findings include:

Review of the medical record of Resident #80 revealed an admission date of 03/27/24. Diagnoses included nerve root and plexus disorder, wernicke's encephalopathy, alcohol abuse with alcohol-induced sleep disorder, insomnia, legal blindness, depression, anxiety, and iron deficiency anemia.

Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/02/24, revealed the resident had moderately impaired cognition.

Review of facility physician, physician assistant (PA), and nurse practitioner (NP) visits revealed Resident #80 was seen by the physician on 03/29/24, physician assistant on 04/05/24, and the nurse practitioner on 05/24/24 and 05/30/24.

During an interview on 06/04/24 at 10:52 A.M., the Director of Nursing (DON) verified Resident #80 was not seen by the physician as required. The DON verified residents should been seen at least every 30 days during the first 90 days of their admission.

During interview on 06/04/24 at 12:08 P.M., the DON stated the physician tried to see Resident #80 two weeks ago but she would not get off the phone The physician tried again today 06/04/24 and the resident would not get off the phone.

Interview on 06/04/24 at 2:26 P.M., Medical Director (MD) #420 verified she had not seen Resident #80 since her initial visit. MD #420 stated she attempted to see Resident #80 last month but she was on the phone and did not want to participate in a medical visit. MD #420 stated she was in the facility on the morning of 06/04/24 but did not try to see Resident #80 that day, nor had she tried to see the resident after the resident refused to participate in the medical visit during the prior month.

Review of the facility policy titled, Physician Visits

Based on observation, record review and interview, the facility failed to ensure menus were followed and residents were notified of menu changes prior to the meal. This had the potential to affect 88 of 89 residents. The facility identified one Resident (Resident #33) who did not receive food from the kitchen. The facility census was 89.

Findings include:

During observations on 06/03/24 between 10:50 A.M. and 11:10 A.M., the menus posted on each unit indicated the residents were to receive turkey and rice casserole, green peas, and a biscuit for the supper meal on 06/03/24 and were to receive a baked pork chop, stuffing, green beans, and a dinner roll for the supper meal on 06/02/24.

Review of the menu for the current week had had turkey and rice casserole, green peas, and a biscuit for the supper meal on 06/02/24.

Review of the Daily Menu for 06/02/24 listed a baked pork chop, stuffing, green beans, and a dinner roll for supper The menu for 06/03/24 had turkey and rice casserole, green peas, and a biscuit for the supper meal.

During an observation on 06/03/24 at 4:44 P.M., the tray line had shredded pork, potatoes with peas, and a roll for the supper meal.

During an interview on 06/03/24 at 4:46 P.M., Dietary Supervisor (DS) #405 stated the residents were not being served the turkey and rice casserole, green peas, and a biscuit as was on the menu. DS #405 stated she ran out of biscuits and the turkey and rice casserole meal was served on 06/02/24 because the meal scheduled for 06/02/24 had not been taken out to thaw. DS #405 stated menus are posted on all units and verified the posted menu did not match what was served on 06/02/24 and 06/03/24 at the supper meals. DS #405 verified the residents had not been notified of the menu changes prior to the meals and further verified residents should be notified of menu changes prior to the meal.

This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation, record review and interview, the facility failed to ensure recipes were followed and that the food was visually appealing. This had the potential to affect 88 of 89 residents. The facility identified one resident (Resident #33) who did not receive meals from the kitchen. The facility census was 89.

Findings include:

Review of the menu for the current week revealed the residents were to receive an open-faced turkey sandwich with gravy, roasted potatoes, and a California vegetable blend for lunch on 06/03/24.

Review of the daily menu for 06/03/24 revealed the residents were to receive an open faced turkey sandwich with gravy, mashed potatoes, and a California vegetable blend.

Review of the recipe revealed the open faced turkey sandwich was to consist of a slice of toast with three ounces of sliced turkey, mashed potatoes on top of the turkey, and turkey gravy over the sandwich.

During observations on 06/03/24 between 12:10 P.M. and 1:00 P.M., residents on all units received a piece of white bread with a chopped meat with a reddish-brown gravy served on top with mashed potatoes and mixed vegetables on the side.

During an interview on 06/03/24 at 12:19 P.M., Resident #66 stated the meal looked like dog food and she was not going to eat it.

During an interview on 06/03/24 at 12:22 P.M., Resident #71 looked at the meal she had just been served, and pushed it away and stating it looked awful and she would not eat it.

During an interview on 06/03/24 at 12:27 P.M., Resident #80 stated the meal did not look at all appetizing.

During an observation on 06/03/24 at 12:42 P.M., Resident #38 looked at the contents of the plate as staff served it. He stated it looked gross and immediately asked for a peanut butter and jelly sandwich.

During an interview on 06/04/24 at 9:00 A.M., Dietary Supervisor (DS) #405 verified the recipe for the open face turkey sandwich did not match what was served at lunch on 06/03/24. Meat was cubed instead of sliced and the gravy was dark/red in color and did not appear to be turkey gravy. DS #405 stated the correct food had not been taken out to thaw.

This deficiency represents non-compliance investigated under Complaint Number OH00153742.

Based on observation, interview and policy review, the facility failed to ensure employees wore hair nets while preparing and serving food and beverages. This had the potential to affect 88 of 89 residents. The facility identified one resident (Resident #33) who did not receive food from the kitchen. The facility census was 89.

Findings include:

During an observation on 06/03/24 at 4:28 P.M., Dietary Aide (DA) #415 was standing at the juice machine in the kitchen, pouring drinks, in preparation for the dinner meal. DA #415 was not wearing a hairnet.

During interview at the time of the observation, Dietary Supervisor (DS) #405 verified DA #415 was not wearing a hairnet and told DA #415 to go put a hairnet on.

During an observation on 06/03/24 at 4:29 P.M., DA #415 put a hairnet on, however his braids were not fully covered.

During observation on 06/03/24 at 4:34 P.M., Dietary Cook (DC) #430 was standing at the steam table stirring the food that would be served for the dinner meal. DC #430 was wearing a hairnet, however her braids were sticking outside of the hairnet, not fully covered.

During an observation on 06/03/24 at 4:42 P.M., DC #430 plated food for the meal and DA #415 placed drinks and silverware on the trays. DA #415 and DC #430 wore hairnets but their braids were not secured beneath the hairnets.

During an interview on 06/03/24 at 4:49 P.M., DS #405 verified DA #415 and DC #430 did not have their hair fully covered and affirmed all hair should be contained within the hairnet.

Review of the facility policy titled, Dietary/Food Handling

Based on observations, staff interviews, and review of facility policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This had the potential to affect all but one resident (#17) who facility identified as not receiving food from the kitchen. The facility census was 86.

Findings include:

Observation of the kitchen on 03/25/24 at 8:50 A.M. with the Admissions Director (AD) #60 revealed Kitchen Aide (KA) #55 was not wearing a hair net while working in the kitchen. Interview with AD #60 at the same time verified KA #55 was not wearing a hairnet while working in the kitchen.

Observation of the kitchen on 03/26/24 at 9:03 A.M. with Kitchen Director (KD) #56 revealed KA #54 was wearing a hairnet; however, KA #54's hair hung down and extended outside of the hair net. Interview at the same time with KD #56 verified KA #54's hair hung down and outside of the hairnet. KD #56 verified Resident #17 was the only resident who did not receive food from the kitchen.

Review of the 01/01/23 facility policy titled Dietary/Food Handling revealed clean uniforms must be worn daily and hairnets or caps must be worn in food service areas.

This deficiency represents noncompliance investigated under Complaint Number OH00151129.

Based on record review, observations, staff interviews, and review of facility policy, the facility failed to provide a clean, sanitary, and homelike environment. This affected one (#15) resident of the three residents reviewed for environment. The facility census was 86.

Findings include:

Record review for Resident #15, revealed the resident was admitted on 10/18/23. Diagnoses included, but not limited to, schizoaffective disorder, constipation, diabetes mellitus, and chronic back pain.

Review of the Minimum Data Set (MDS) assessment dated 01/31/24 for Resident #15 revealed the resident had significant cognitive deficits and required supervision with activities of daily living (ADLs).

Interview with Resident #15 on 03/25/24 at 2:00 P.M. revealed there were bugs in his room all the time. Observation at the same time revealed four roaches crawling on the floor and one roach was crawling up the wall. Resident #15 killed them all.

Interview with Licensed Practical Nurse (LPN) #66 on 03/25/24 at 2:30 P.M. reported there had been problems with roaches on the unit for a while and when the pest control company comes to treat the facility, they only spray the room with the roaches, and they seem to migrate to another room.

Review of the 07/01/22 facility policy titled Cleaning of Resident Rooms revealed staff should remain alert for evidence of rodent activity (droppings) and report such findings to the Environmental Services Director.

This deficiency represents noncompliance investigated under Complaint Number OH00151838 and Complaint Number OH00151129.

Based on review of personnel records and staffing schedules, staff interview, and review of the State of Ohio Nurse Aide Registry, the facility failed to ensure a state tested nursing assistant's (STNA) registration was not expired. This affected one (STNA #10) of three personnel files reviewed. This had the potential to affect sixteen residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16) that STNA #10 regularly cared for. The facility census was 86.

Findings include:

Review of State Tested Nursing Assistant (STNA) #10's personnel file revealed a hire date of 06/23/22.

Review of the State of Ohio Nurse Aide Registry revealed STNA #10 was not eligible to work in a long-term care facility due to not having work verification in the past 24 months. STNA #10's nurse aide registration expired on 03/01/23.

Review of the staffing schedules from 11/01/23 through 11/08/23 revealed STNA #10 worked the evening shift in the Medical Unit on 11/02/23, 11/03/23, 11/06/23, and 11/07/23. STNA #10 was scheduled to work the evening shift on 11/08/23.

During an interview on 11/08/23 at 10:45 A.M., Human Resources (HR) #60 stated she became aware in February 2023 that STNA #10's nurse aide registry was going to expire in March 2023. STNA #10 had been off due to a workplace injury from January 2023 to May 2023. HR #60 sent a letter to the State of Ohio Nurse Aide Registry per facsimile (fax) in August 2023 but had not followed-up with the letter. HR #60 had not called the State of Ohio Nurse Aide Registry.

During an interview on 11/08/23 at 10:50 A.M., the Director of Nursing (DON) confirmed the facility was responsible for submitting information to the State of Ohio Nurse Aide Registry to keep STNAs current and in good standing. At 11:13 A.M., the DON confirmed STNA #10's regular assigned work area was the Medical Unit.

Review of the resident census revealed 16 residents resided in the Medical Unit (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16).

This violation represents non-compliance investigated under Complaint Number OH00146811.

Based on record review, staff interview, and review of the policy, the facility failed to conduct a timely post-fall investigation. This affected one (#76) of three residents reviewed for falls. The facility census was 89.

Findings include:

Review of the medical record for Resident #76 revealed an admission date of 11/23/22, with diagnoses including: chronic obstructive pulmonary disease (COPD), acute kidney failure (AKF), dementia without behavioral disturbance, and hypertension. Review of the fall risk assessment for Resident #76 dated 05/28/23 revealed resident was at risk for falls.

Review of the Minimum Data Set (MDS) assessment for Resident #76 dated 07/01/23 revealed resident was cognitively impaired and required supervision and set up help with activities of daily living (ADLs.)

Review of the nurse progress note for Resident #76 dated 07/25/23 revealed the resident had an unwitnessed fall and was found in his room lying on the floor perpendicular to his bed. Resident #76 reported he had fallen but couldn't state when the event had occurred. Resident #76 was sent to the hospital via 911 for an evaluation due to hip pain.

Review of hospital notes for Resident #76 dated 07/25/23 revealed hip x-rays for resident were negative for fracture. Resident was found to have a urinary tract infection (UTI) and returned with orders for antibiotics.

Review of the care plan for Resident #76 updated 08/07/23 revealed resident was at risk for falls. Interventions included the following: call light and personal items within reach when in room, anticipate needs and encourage resident to use call light, encourage resident to wait for assistance and not risk falls, ensure assistive devices readily available, ensure clutter free walkways, and minimize environmental hazards, maintain bed in lowest position with brakes on, communicate with members of the Interdisciplinary Team (IDT) to ensure continuity of care.

Review of the facility post-fall investigation for Resident #76 dated 08/07/23 revealed the IDT met to discuss the resident's fall from 07/25/23. The facility was unable to determine root cause of the fall, but suspected UTI was a predisposing factor. The resident was treated for UTI and had no further falls since the fall on 07/25/23.

Interview on 08/11/23 at 12:43 P.M., with the Director of Nursing (DON) confirmed the facility did not conduct a post fall investigation of Resident #76's fall on 07/25/23 until 08/11/23. DON confirmed the post fall investigation should be done as soon as possible after the fall and Resident #76's fall investigation was done 13 days post-fall.

Review of the policy titled Fall Program dated January 2020, revealed the facility would identify all residents who have a high risk for falls and to ensure adequate interventions are in place to prevent injury. When a resident had a fall, the facility would complete a post fall investigation within 24 hours.

This deficiency represents non-compliance investigated under Complaint Number OH00144308.

Based on record review, observations and resident and staff interviews, the facility failed to ensure resident call lights were in reach of the resident per the plan of care. This affected two (#19 and #20) of three residents reviewed for quality of care. The facility census was 87.

Findings include:

1. Review of the medical record for Resident #19 revealed an admission date of 09/20/19 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, chronic obstructive pulmonary disease (COPD), hypertension, and generalized anxiety disorder.

Review of the Minimum Data Set (MDS) for Resident #19 dated 04/10/23 revealed the resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's).

Review of the fall care plan for Resident #19 dated 11/05/19 revealed the resident was at risk for falls related to decreased mobility, weakness, history of falls, psychotropic medication use, anemia, and stroke with left sided weakness. Interventions included the following: call light and personal items within reach when in room, anticipate needs and encourage resident to use call light, encourage resident to wait for assistance and not risk falls, ensure assistive devices readily available, communicate with members of the interdisciplinary team (IDT) to ensure continuity of care.

Review of the incontinence care plan for Resident #19 dated Care 11/05/19 revealed the resident was always incontinent of bladder and bowel. Interventions included the following: keep call light within reach and remind resident to call for assistance, provide incontinent care every two hours and as needed.

Observation on 06/23/23 at 10:00 A.M. revealed Resident #19 was in bed resting. Resident #19's call light was out of resident's reach.

Interview on 06/23/23 at 10:00 A.M. with State Tested Nursing Assistant (STNA) #625 confirmed Resident #19's call light was out of reach, and resident was non-ambulatory. STNA #625 confirmed Resident #19 did use her call light to request assistance. STNA #625 further confirmed the night shift staff had placed the call light out of resident's reach, and she had been the resident's assigned aide since 06/23/23 at 7:00 A.M.

Interview on 06/23/23 at 10:13 A.M. of Resident #19 confirmed the night shift aide had placed her call light out of her reach sometime during the night and that this happened on occasion. Resident #19 confirmed she was planning to ask the aide to hand her the call light as soon as she saw her.

2. Review of the medical record for Resident #20 revealed and admission date of 01/23/18 with diagnoses including the following: dementia without behavioral disturbance, major depressive disorder, bipolar disorder, and schizophrenia.

Review of the MDS for Resident #20 dated 04/25/23 revealed the resident was cognitively impaired and required extensive assistance of one to two staff with ADL's.

Review of the ADL care plan for Resident #20 dated 07/12/21 revealed the resident had an ADL self-care performance deficit related to dementia, impaired balance, psychosis. Interventions included the following: resident requires extensive assistance by staff for toileting, resident requires extensive assistance by staff to move between surfaces and as necessary, discuss with resident/family/care any concerns related to loss of independence, decline in function, encourage the resident to participate to the fullest extent possible with each interaction, encourage the resident to use bell to call for assistance, praise all efforts at self-care.

Review of the fall care plan for Resident #20 dated 03/22/20 revealed the resident was at risk for falls related to confusion, gait/balance problems, incontinence, poor communication/comprehension, psychoactive drug use, unaware of safety needs. Interventions included the following: bed against the wall, anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance.

Observation on 06/23/23 at 10:00 A.M. of Resident #20 was in bed resting. Resident #20's call light was out of resident's reach. Resident #20 was noninterviewable.

Interview on 06/23/23 at 10:00 A.M. with STNA #625 confirmed Resident #20's call light was out of reach, and the resident was non-ambulatory. STNA #625 confirmed she did not think Resident #20 used her call light to request assistance. STNA #625 further confirmed the night shift staff had placed the call light out of resident's reach, and she had been the resident's assigned aide since 06/23/23 at 7:00 A.M.

Observation of incontinence care for Resident #20 on 06/23/23 at 10:01 A.M. per STNA #625 revealed call light fell on the ground during care. STNA #625 placed the call light back in resident's reach after discussion with the surveyor on 06/23/23 at 10:12 A.M.

Interview on 06/23/23 at 10:12 A.M. STNA #625 confirmed the aide placed call light within Resident #20's reach after discussing the observation with the surveyor. STNA #625 confirmed she didn't think this was necessary because Resident #20 had severe dementia.

Interview on 06/23/23 at 12:41 P.M. with the Assistant Director of Nursing (ADON), Registered Nurse (RN) #630 confirmed the facility did not have a call light policy. RN #630 confirmed all residents should have call lights within reach at all times.

This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on document review and staff interview, the facility failed to ensure a registered nurse (RN) worked in the facility for eight consecutive hours daily as required. This had the potential to affect all 87 residents residing in the facility. The census was 87 residents.

Findings include:

Review of the staffing schedules for the month of June 2023 revealed the facility did not have an RN working on the following dates: 06/13/23, 06/14/23, 06/17/23, 06/18/23.

Interview on 06/23/23 at 12:41 P.M. with the Assistant Director of Nursing (ADON), Registered Nurse (RN) #630 confirmed the average daily census in the facility for every day the month of June 2023 exceeded 60 residents, and the facility did not have a RN working on the following dates: 06/13/23, 06/14/23, 06/17/23, 06/18/23. Interview with the ADON and RN #630 confirmed the facility did not have a staffing policy.

This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation, review of orders for dietary products, and staff interview, the facility failed to ensure residents were not served on disposal plates. This affected 24 (#2, #6, #12, #13, #15, #16, #21, #23, #26, #28, #34, #39, #40, #41, #49, #50, #51, #60, #61, #64, #67, #68, #69 and #75) residents out of 77 residents that received meals from the facility kitchen. The facility census was 79.

Findings include:

Observation of tray line in the kitchen on 02/08/23 at 11:32 A.M. revealed Dietary Cook #77 to serve food items on Styrofoam plates for the second floor men's unit. The plates were then covered with additional Styrofoam plates and placed on the meal cart.

Interview on 02/08/23 at 11:32 A.M. with Dietary Cook #77 and Dietary Supervisor #77 revealed the kitchen had ran out of regular plates and plate covers and had to serve the second floor men's unit their meals on Styrofoam plates with Styrofoam plates covering the top of the plates. Dietary Supervisor #77 stated the plates and plate covers were back ordered and the facility had not had enough plates to serve all resident meals since mid December 2022.

Review of the facility dietary department orders dated 02/08/23 revealed no indication the facility attempted to order regular plates and lids prior to 02/08/23.

Review of the facility's undated census sheet revealed Resident #2, #6, #12, #13, #15, #16, #21, #23, #26, #28, #34, #39, #40, #41, #49, #50, #51, #60, #61, #64, #67, #68, #69 and #75 resided on the second floor men's unit.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure residents were provided Notice of Medicare Non Coverage (NOMNC) to inform the resident of the right to an expedited review of a services termination or Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage (SNFABN) to inform the resident of the potential liability for a non covered stay. This affected three (#24, #233, and #234) out of three residents reviewed for beneficiary notices. The facility census was 79. Findings include: 1. Review of the Resident #24's medical record revealed an admission to the facility on 07/28/22. Diagnoses included iron deficiency anemia, chronic obstructive pulmonary disease, type two diabetes mellitus without complications, spondylosis, osteoarthritis, and major depressive disorder. Review of Resident #24's payer source documentation revealed Resident #24 was on Medicare Part A from 11/04/22 to 11/22/22. Resident #24's payer source was changed to Medicaid on 11/23/22. Review of the record revealed Resident #24 did not have a NOMNC or SNFABN to inform the resident of the right to an expedited review of a services termination or the potential liability for a non covered stay when Resident #24's payer source changed from Medicare Part A to Medicaid on 11/23/22. Interview with the Administrator and Social Service Designee (SSD) #60 on 02/08/23 at 10:46 A.M. verified Resident #24's last covered day of Medicare Part A services was 11/22/22. Resident #24 was not given a NOMNC or SNFABN upon Resident #29's payer change from Medicare Part A to Medicaid on 11/22/22. 2. Review of the Resident #234's medical record revealed Resident #234 admitted to the facility on 08/26/22. Diagnoses included cardiomyopathy, muscle weakness, obesity, type two diabetes mellitus, hypertension, atherosclerotic heart disease of native coronary artery with unstable angina pectoris and complete traumatic amputation at level between knee and ankle left lower leg. Resident #234 discharged from the facility on 01/06/23. Review of Resident #234's payer source documentation revealed Resident #234 was on Medicare Part A from 08/26/22 to 11/11/22. Resident #234's payer source was changed to Medicaid on 11/12/22. Review of the medical record revealed Resident #234 did not have a NOMNC or SNFABN to inform the resident of the right to an expedited review of a services termination or the potential liability for a non covered stay when Resident #234's payer source changed from Medicare Part A to Medicaid on 11/12/22. Interview with the Administrator and SSD #60 on 02/08/23 at 10:46 A.M. verified Resident #234's last covered day of Medicare Part A services was 11/11/22. Resident #234 was not given a NOMNC or SNFABN upon Resident #234's payer change from Medicare Part A to Medicaid on 11/12/22. 3. Review of the Resident #233's medical record revealed Resident #233 admitted to the facility on 10/07/22. Diagnoses included lack of coordination, urinary tract infection, emphysema, congestive heart failure, chronic kidney disease and hyperlipidemia. Resident #233 discharged from the facility on 11/08/22. Review of Resident #233's payer source documentation revealed Resident #233 was on Medicare Part A from 10/07/22 to 11/08/22. Resident #233 discharged from the facility on 11/08/22 upon the resident's Medicare Part A ending. Review of the record revealed Resident #233 did not have a NOMNC to inform the resident of the right to an expedited review of a services termination. Interview with the Administrator and SSD #60 on 02/08/23 at 10:46 A.M. verified Resident #233's last covered day of Medicare Part A services was 11/08/22. Resident #233 was not given a NOMNC upon Resident #233's Medicare Part A services ending. Review of the facility policy titled NOMNCBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure residents were provided Notice of Medicare Non Coverage (NOMNC) to inform the resident of the right to an expedited review of a services termination or Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage (SNFABN) to inform the resident of the potential liability for a non covered stay. This affected three (#24, #233, and #234) out of three residents reviewed for beneficiary notices. The facility census was 79.

Findings include:

1. Review of the Resident #24's medical record revealed an admission to the facility on 07/28/22. Diagnoses included iron deficiency anemia, chronic obstructive pulmonary disease, type two diabetes mellitus without complications, spondylosis, osteoarthritis, and major depressive disorder.

Review of Resident #24's payer source documentation revealed Resident #24 was on Medicare Part A from 11/04/22 to 11/22/22. Resident #24's payer source was changed to Medicaid on 11/23/22.

Review of the record revealed Resident #24 did not have a NOMNC or SNFABN to inform the resident of the right to an expedited review of a services termination or the potential liability for a non covered stay when Resident #24's payer source changed from Medicare Part A to Medicaid on 11/23/22.

Interview with the Administrator and Social Service Designee (SSD) #60 on 02/08/23 at 10:46 A.M. verified Resident #24's last covered day of Medicare Part A services was 11/22/22. Resident #24 was not given a NOMNC or SNFABN upon Resident #29's payer change from Medicare Part A to Medicaid on 11/22/22.

2. Review of the Resident #234's medical record revealed Resident #234 admitted to the facility on 08/26/22. Diagnoses included cardiomyopathy, muscle weakness, obesity, type two diabetes mellitus, hypertension, atherosclerotic heart disease of native coronary artery with unstable angina pectoris and complete traumatic amputation at level between knee and ankle left lower leg. Resident #234 discharged from the facility on 01/06/23.

Review of Resident #234's payer source documentation revealed Resident #234 was on Medicare Part A from 08/26/22 to 11/11/22. Resident #234's payer source was changed to Medicaid on 11/12/22.

Review of the medical record revealed Resident #234 did not have a NOMNC or SNFABN to inform the resident of the right to an expedited review of a services termination or the potential liability for a non covered stay when Resident #234's payer source changed from Medicare Part A to Medicaid on 11/12/22.

Interview with the Administrator and SSD #60 on 02/08/23 at 10:46 A.M. verified Resident #234's last covered day of Medicare Part A services was 11/11/22. Resident #234 was not given a NOMNC or SNFABN upon Resident #234's payer change from Medicare Part A to Medicaid on 11/12/22.

3. Review of the Resident #233's medical record revealed Resident #233 admitted to the facility on 10/07/22. Diagnoses included lack of coordination, urinary tract infection, emphysema, congestive heart failure, chronic kidney disease and hyperlipidemia. Resident #233 discharged from the facility on 11/08/22.

Review of Resident #233's payer source documentation revealed Resident #233 was on Medicare Part A from 10/07/22 to 11/08/22. Resident #233 discharged from the facility on 11/08/22 upon the resident's Medicare Part A ending.

Review of the record revealed Resident #233 did not have a NOMNC to inform the resident of the right to an expedited review of a services termination.

Interview with the Administrator and SSD #60 on 02/08/23 at 10:46 A.M. verified Resident #233's last covered day of Medicare Part A services was 11/08/22. Resident #233 was not given a NOMNC upon Resident #233's Medicare Part A services ending.

Review of the facility policy titled NOMNC

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide daily activities of daily living (ADL) in the form of hair care, hygiene, dressing, and getting out of bed for one (#27) out of 23 residents reviewed. The facility census was 79. Findings include: Review of the medical record for Resident #27 revealed an admission date of 12/14/21. Diagnoses included encephalopathy, gout, Alzheimer's Disease, hypertension, insomnia, dementia, and diverticulosis of intestine part. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 12/16/22, revealed the resident had severely impaired cognition. The resident was dependent for bathing and required extensive staff assistance for hygiene, dressing, and transfers. Review of the plan of care dated 08/04/22 revealed the resident had behaviors of refusing adequate personal hygiene (bathing, changing clothing, oral care, verbal, and physical aggression towards staff during care. Interventions included anticipate and meet resident's needs. Observation on 02/06/23 at 12:12 P.M., revealed Resident #27 was lying in her bed. The resident had gray hair around her lips and chin, was wearing a night gown, and had her hair uncombed. Observation on 02/07/23 at 12:00 P.M., revealed Resident #27 was lying in her bed wearing a hospital gown. Her hair was uncombed and she had hair on her face. Observation on 02/08/23 at 10:21 A.M., revealed Resident #27 was in bed in a hospital night gown. Her hair was uncombed and there was hair on her face. Review of shower sheets revealed Resident #27 received showers on Monday, Wednesday, and Friday evenings. There was no refusal of care from Resident #27 documented during the showering. Interview on 02/08/23 at 11:26 A.M., with State Tested Nursing Aide (STNA) #201 revealed the resident was combative and refuses care. STNA #201 reported staff documents when this behavior occurs. Interview on 02/08/23 at 11:39 A.M., with Licensed Practical Nurse (LPN) #80 reported Resident #27 used to be real combative but lately she has not. She can been easily directed. Interview on 02/08/23 at 12:30 P.M., the Director of Nursing (DON) reported there was no reason why Resident #27 should not be getting up. There were no restrictions for Resident #27 not to be up and dressed. The DON stated residents are to be shaved during showers and if she refused then staff will document. The DON verified there were no refusal of showers from Resident #27. Review of facility policy titled Personal Care NeedsBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide daily activities of daily living (ADL) in the form of hair care, hygiene, dressing, and getting out of bed for one (#27) out of 23 residents reviewed. The facility census was 79.

Findings include:

Review of the medical record for Resident #27 revealed an admission date of 12/14/21. Diagnoses included encephalopathy, gout, Alzheimer's Disease, hypertension, insomnia, dementia, and diverticulosis of intestine part.

Review of the comprehensive Minimum Data Set (MDS) assessment, dated 12/16/22, revealed the resident had severely impaired cognition. The resident was dependent for bathing and required extensive staff assistance for hygiene, dressing, and transfers.

Review of the plan of care dated 08/04/22 revealed the resident had behaviors of refusing adequate personal hygiene (bathing, changing clothing, oral care, verbal, and physical aggression towards staff during care. Interventions included anticipate and meet resident's needs.

Observation on 02/06/23 at 12:12 P.M., revealed Resident #27 was lying in her bed. The resident had gray hair around her lips and chin, was wearing a night gown, and had her hair uncombed.

Observation on 02/07/23 at 12:00 P.M., revealed Resident #27 was lying in her bed wearing a hospital gown. Her hair was uncombed and she had hair on her face.

Observation on 02/08/23 at 10:21 A.M., revealed Resident #27 was in bed in a hospital night gown. Her hair was uncombed and there was hair on her face.

Review of shower sheets revealed Resident #27 received showers on Monday, Wednesday, and Friday evenings. There was no refusal of care from Resident #27 documented during the showering.

Interview on 02/08/23 at 11:26 A.M., with State Tested Nursing Aide (STNA) #201 revealed the resident was combative and refuses care. STNA #201 reported staff documents when this behavior occurs.

Interview on 02/08/23 at 11:39 A.M., with Licensed Practical Nurse (LPN) #80 reported Resident #27 used to be real combative but lately she has not. She can been easily directed.

Interview on 02/08/23 at 12:30 P.M., the Director of Nursing (DON) reported there was no reason why Resident #27 should not be getting up. There were no restrictions for Resident #27 not to be up and dressed. The DON stated residents are to be shaved during showers and if she refused then staff will document. The DON verified there were no refusal of showers from Resident #27.

Review of facility policy titled Personal Care Needs

Based on observations, record review and staff interviews, the facility failed to ensure residents were provided activities. This affected two (#27 and #46) out of three residents reviewed for activities. The facility census was 79.

Findings include:

1. Review of the medical record for Resident #27 revealed an admission date of 12/14/21. Diagnoses included encephalopathy, gout, Alzheimer's Disease, hypertension, insomnia, dementia, and diverticulosis of intestine part.

Review of Resident #27's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 12/16/22, revealed the resident's cognition was severely impaired. Section F on MDS Activities revealed it was somewhat important to Resident #27 to have books, newspapers, and magazines to read, somewhat important to listen to music, somewhat important to do favorite activities.

Review of the plan of care dated 08/04/22 revealed the resident was refusing adequate personal hygiene (bathing, changing clothing, oral care, verbal, and physical aggression towards staff during care. Interventions included anticipate and meet resident's needs, as able and encourage attendance/participation in a program of activities that is of interest and accommodates resident's status.

Reviewed Resident #27's activity participation sheet from September 2022 to February 2023 revealed no participation September 2022, October 2022, December 2022, January 2023 and February 2023. The November 2022 participation sheet revealed Resident #27 participated in an activity of reading on 11/02/23, talking on 11/07/22, and attempted an activity of coloring on 11/16/22.

Observations on 02/06/23 at 12:34 P.M. revealed Resident #27 in a hospital gown lying in bed in bed awake. There was television on in the room, however it was on the roommate's side of the room.

Observation on 02/07/23 at 11:58 A.M. revealed Resident #27 was in bed awake. The roommate's television was turned on.

Interview on 02/08/23 at 3:46 P.M., the Activity Director (AD) verified there was no evidence Resident #27 was being provided any activities.

2. Review of the medical record for Resident #46 revealed an admission date of 01/23/18. Diagnoses included pseudobulbar affect, delirium due to known physiological condition, dementia, major depressive disorder, bipolar disorder, seizures, schizophrenia, and unspecified psychosis.

Review of Resident #46's comprehensive MDS 3.0 assessment, dated 01/03/23, revealed the resident's cognition was severely impaired. Section F on MDS Activities was not assessed.

Review of the plan of care dated 01/13/20 revealed the resident had potential alterations in activities and was dependent on staff for meeting emotional, intellectual, physical, and social needs due to unspecified dementia with behavioral disturbance, impaired balance, cognitive deficits, pseudobulbar affect may affect Resident #46's attendance and participation. Goals included: 1:1 sensory social visits one to three times weekly as tolerated, maintain involvement in cognitive stimulation, social activities as desired, and attend/participate in one to three activities of choice by next review.

Review Resident #46's activity participation sheet from September 2022 to February 2023 revealed no documentation of Resident #46's attendance and participation in activities.

Observation on 02/06/23 at 11:58 A.M. revealed Resident #46 was in bed sleeping with clothes on.

Observations on 02/07/23 at 11:33 A.M. revealed Resident #46 was sitting in chair in room with helmet on head.

Observation on 02/09/23 at 12:23 P.M. revealed resident is up in wheelchair with helmet on. Resident #46 was chewing on a white towel. The television was on.

Interview on 02/09/23 at 12:14 P.M., the AD reported she has been seeing Resident #46 but forgot to document. The AD stated staff have not been bringing the resident to activities. AD verified findings of no participation in activities for five months.

Based on the staffing punch detail, review of the schedule, and staff interview, the facility failed to ensure there was Registered Nurse (RN) coverage for eight consecutive hours, seven days each week. This had the potential to affect all residents. The facility census was 79.

Findings included:

Review of the staffing punch details for the two weeks prior to survey revealed there was no RN coverage on 01/28/23 and 01/29/23.

Review of the schedule during the week of survey revealed there was no RN scheduled on 02/07/23.

An interview was conducted with the Administrator on 02/09/23 at 12:40 P.M. She verified there was no RN working on the 01/28/23, 01/29/23, and 02/07/23. She stated when there was a need for a nurse at times the Director of Nursing (DON) would come in, but the DON did not work those days. The Administrator stated they had one full time RN and two as needed RNs on staff.

Based on observations, medical record, resident and staff interviews, the facility failed to ensure a resident was served a meal to accommodate her food preference. This affected one (#14) of one resident reviewed for meal preferences and allergies. The facility census was 79.

Findings include:

Review of the medical record for Resident #14 revealed an admission date of 09/23/20. Diagnoses included asthma, schizophrenia, cerebral aneurysm, hypertension, dementia, personality disorder and insomnia.

Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/13/22, revealed the resident had intact cognition. The resident required limited assistance with one person for physical assist for eating.

Review of the Admission Nutritional Assessment, dated 09/29/20, revealed the resident requests excess beverages often-prune juice, cranberry juice, and Lactaid milk. The resident was obsessed with health and bowels in the past. Likes most foods however periods of changing food preferences and dislikes. The resident drinks Lactose free milk.

Review of the plan of care dated 09/13/22 revealed the resident was at risk for nutritional deficits due to history and drinks Lactaid milk. Interventions included honor food preferences and dislikes as able.

Interview on 02/07/23 at 12:28 P.M., Resident #14 reported she has not been receiving Lactaid milk on her tray recently and has family members purchasing it for her.

Observation on 02/07/23 at 12:30 P.M., of Resident #14's lunch meal revealed the resident was served her meal without any milk or Lactaid milk. Observation of the tray card revealed the resident is to have cranberry juice, Lactaid milk and water. Interview at the time of the observation with State Tested Nurse Aide (STNA) #59 revealed Resident #14 had been complaining about not receiving Lactaid milk with her meals. STNA #59 confirmed resident did not have her food preference of Lactaid milk on lunch tray.

Observation on 02/08/23 at 11:42 A.M., revealed Resident #14's lunch meal tray contained no Lactaid milk.

Interview at the tie of the observation with Licensed Practical Nurse (LPN) #80 verified the absence of Lactaid milk on the resident's meal tray.

Interview on 02/08/23 at 12:07 P.M., Registered Dietician (RD) #14 reported Resident #14 should be receiving Lactaid milk with every meal and the facility should provide it.

Interview on 02/08/23 12:13 P.M., Dietary Manager(DM) #97 reported the supplier was out of Lactaid milk and they did not seek an alternative for Resident #14.

Review of facility policy titled Foods Likes and Dislikes with no date, revealed the facility dietary department assess each resident for their likes and dislikes. A written record shall be maintained of the resident's likes and dislikes. Such record will include how the resident prefers his/her food to be served (i.e. cut, chopped or ground).

Based on observation, review of the dishwasher manufacturer's recommendations, review of facility policy, and staff interview, the facility failed to ensure the kitchen was maintained in a sanitary manner, dishware was properly sanitized, and food was stored to prevent contamination. This affected 77 residents who received food from the kitchen. Resident #5 and #54 received no food by mouth. The facility census was 79.

Findings include:

Observation of the kitchen on 02/06/23 at 11:05 A.M. revealed lunch food items were on the steam table in the kitchen next to a wire that went from the ceiling to the steam table. The wire was observed to have a fuzzy brown debris on it. There was a red fire blanket on the wall next to the stove which had brown debris on the top of it. Observation of the ceiling above the steam table revealed the ceiling to have a large circular area where the paint was visibly chipping from the ceiling. Observation of the toaster in the kitchen revealed a fan with gray debris to be sitting on top of the toaster pointing towards the steam table area. Observation of the walk in refrigerator revealed the refrigerator to be 30 degrees fahrenheit. The fan of the refrigerator was observed leaking water onto the shelves below that contained individually packaged yogurts. There was a box of orange juices on the top shelf dated 08/17/22 and water was observed to pour out of the box when the box was removed from the shelf. The box also had a brown spotted substance on the bottom. Observation of the dishwasher revealed the facility was using a meat thermometer as the temperature gauge for the dishwasher. The meat thermometer read 60 degrees fahrenheit for both the wash and the rinse. Further observation of the kitchen revealed Dietary Aide #25 did not have a hair net applied while working in the kitchen and moving around meal carts.

Interview with Dietary Aide #25 on 02/06/23 at 11:05 A.M. verified she was not wearing a hair net. Dietary Aide #25 also verified the dishwasher had not been working properly and was not up to the proper temperature. Dietary Aide #25 did not know how long the dishwasher had been broken.

Interview with Dietary Cook #77 on 02/06/23 at 11:05 A.M. verified there was a wire with debris on it next to the steam table, there was a fire blanket with debris on it next to the stove, the paint on the ceiling above the steam table was chipping, there was a fan sitting on the toaster that had debris on it, the fan in the walk in refrigerator was leaking onto food items below, a box of orange juices were expired with a date of 08/17/22, brown spots and water were in and on the box of orange juices, and the dishwasher was using a meat thermometer to read the dishwasher temperature and the dishwasher was not up to the temperature.

Review of the facility's undated policy titled Food Storage revealed food will be stored, prepared, and transported at an appropriate temperature and by methods to prevent contamination.

Review of the dishwasher's manufacture instructions, dated February 2023, revealed the water temperature was to be a minimum of 120 degrees fahrenheit.