Harvard Gardens Rehabilitation & Care Center

Based on record review, interview, and facility policy review, the facility failed to ensure Resident #51was seen my a physician least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter. This affected one resident (#51) of the three residents reviewed for physician visits. The facility census was 92.

Findings include:

Review of the medical record for Resident #51 revealed an admission date of 02/05/24 with diagnosis including vascular dementia, depression, epilepsy, atrial fibrillation, anxiety, hypertension, heart failure, and hemiplegia.

Review of the practitioner's progress notes dated 02/07/24 revealed a New Admission History and Physical was conducted by a virtual visit by Physician #348 for Resident #51.

Review of medical record progress notes revealed no visits were made by a general practitioner after 02/07/24 until 05/08/24.

Review of practitioner's progress note revealed the last general practitioner note was written on 05/08/24. The was no evidence of a general practitioner visit for Resident #51 after 05/08/24.

Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/17/24, revealed Resident #51 was cognitively intact.

On 10/28/24 at 3:05 P.M., an interview with Resident #51 stated he had only seen the physician once during his eight months stay in the facility.

On 10/29/24 at 9:00 A.M., an interview with the Assistant Director of Nursing (ADON) #328, confirmed the facility or Physician #348 was unable to find any physician's notes for visits after May 2024 for Resident #51.

Review of the facility policy titled Physician Visits Version 1.2, dated April 2013, revealed the attending physician must visit their patients at least once every thirty days for first ninety days following the resident's admission, and then at least every sixty days thereafter.

This deficiency represents non-compliance investigated under Master Complaint Number OH00158474.

Based on observation, interview and review of cleaning schedules, the facility did not ensure residents were sitting in clean wheelchairs. This affected four residents (#14, #15, #29 and #47) out of 66 residents utilizing wheelchairs. The facility census was 94.

Findings include:

On 02/21/24 between 10:00 A.M. and 12:00 P.M. during the tour of the facility, Residents #14, #15, #29 and #47 were observed to be sitting in wheelchairs. Each chair had a buildup of dirt on the frame. Interview with the Director of Nursing (DON) verified the dirt buildup on each wheelchair at the time of the tour.

Interview on 02/21/24 during the tour, the DON stated that wheelchairs were to be cleaned two times weekly.

A review of the cleaning schedule revealed wheelchairs were to be cleaned two times weekly on Monday and Wednesday on night shift.

This deficiency represents noncompliance investigated under Complaint Number OH00151189.

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

Based on interview, schedule review, and policy review the facility did not ensure sufficient nursing staff to provide nursing and related services to assure resident safety when two of four nurses left the building for lunch at 12:00 A.M. on 02/05/24 and did not return until 4:30 A.M. (4.5 hours). This had the potential to affect 37 residents (#2, #3, #4, #7, #10, #12, #13, #11, #18, #19, #28, #30, #34, #38, #44, #47, #49, #50, #52, #54, #53, #56, #57, #60, #62, #66, #70, #71, #76, #80, #81, #86, #88, #89, #93, #91, and #97) residing on the units assigned to the two nurses. The facility census was 94.

Findings Include:

A review of the facility assessment dated 03/01/23 revealed the facility will be staffed with three to four nurses per shift.

A review of staffing sheets dated 02/04/24 revealed Licensed Practical Nurse (LPN) #234 was scheduled from 7:00 P.M. until 7:00 A.M. the following day for unit 1 North. LPN #235 was scheduled from 7:00 P.M. until 7:00 A.M. on the 60/90 unit. LPN #214 was scheduled from 7:00 P.M until 7:00 A.M. on the 70/80 unit. LPN #164 was scheduled on the 2 North unit.

On 02/21/24 at 9:24 A.M. an interview with the Director of Nursing (DON) revealed that on 02/05/24 at 7:00 A.M. she was notified that LPN #234 and LPN #235 left the building at approximately midnight and did not return to the facility until 4:30 A.M. The times were confirmed by camera. The staff is permitted to clock out and leave for 30 minutes for lunch.

On 02/21/24 at 2:36 P.M an interview with the Administrator revealed he was notified of LPN #234 and LPN #235 leaving the building from midnight to 4:30 A.M. on 02/05/24.

On 02/21/24 at 4:05 P.M. an interview with State Tested Nurse Aide (STNA) #171 revealed he was working on 02/04/24 from 11:00 P.M. until 7:00 A.M. At 3:30 A.M. on 02/05/24 he found Resident #91 on the floor and could not find LPN #234 assigned to the unit. STNA #171 stated he called for LPN #214 to assist. There were no injuries. STNA #171 revealed he did not see LPN #234 until 4:30 A.M.

The deficient practice was corrected on 02/07/24 when the facility implemented the following corrective actions:

On 02/05/24, LPN #234 and LPN #235 were terminated. A review of the employee files verified the terminations.

On 02/05/07, the DON reported LPN #234 to the Ohio Board of Nursing. A confirmation email dated 02/07/24 revealed confirmation of the filing.

On 02/07/24, the DON in-serviced all staff on elder abuse. The in-service included abandonment, leaving the unit or assigned area without proper notification and hand off of keys and reporting to covering or oncoming nurse.

This deficiency represents noncompliance investigated under Complaint Number OH00151189.

Based on observation and interview the facility failed to ensure Resident #54 received meals according to documented food preferences. This affected one resident (#54) of three residents investigated for food preferences. The facility census was 94.

Findings Include:

Record review for Resident #54 revealed an admission date of 02/05/24 with diagnoses including vascular dementia, depression, epilepsy, anxiety, diabetes mellitus type II, and hemiplegia following a cerebral vascular accident (CVA). Resident #54's diet orders included a regular diet with low concentrated sweets.

Review of a dietary admission note dated 02/15/24 included Resident #54 disliked pork and ground meat.

Review of the nurse practitioner notes dated 02/19/24 revealed Resident #54 does not eat pork or beef. The nurse practitioner instructed nursing to inform the kitchen.

Interview with the Director of Nursing (DON) on 02/22/24 at 9:00 A.M. revealed resident food preferences were honored.

On 02/22/24 at 9:30 A.M. an interview with Director of Dietary Services #118 revealed resident food preferences were honored, and that she interviews residents to know their likes and dislikes. Menu tickets were marked with dislikes and allergies. There was an at your request menu that residents can order from at any time. Director of Dietary Services #118 stated she was aware Resident #54 disliked pork.

Observation on 02/22/24 at 12:45 P.M. revealed Resident #54 eating lunch that included a plate of roasted pork, mashed potatoes, and broccoli. The menu ticket on the food tray indicated no pork. There was not an alternative noted. An interview at the time of the observation revealed Resident#54 was upset. He stated he had told multiple staff he does not eat pork.

This deficiency represents non-compliance investigated under Master Complaint Number OH00151321.

Based on observation and staff interview, the facility failed to ensure its kitchen area was maintained in a clean and sanitary manner. In addition, the facility did not ensure that food was plated to be served in a sanitary manner. This had the potential to affect all 94 residents receiving food from the kitchen. There were no residents residing in the facility not receiving food from the kitchen.

Findings Include:

Observation on 02/21/24 at 10:05 A.M. a tour of the kitchen was conducted with the Director of Nursing (DON). The floor had dirt and food buildup. There was also a buildup of dirt under the steam table where food was served from. The dirty floor was verified with the DON at the time of the tour. The inside of the drawer holding the serving and cooking utensils had dirt and grease buildup. The surface of the drawer had a greasy texture. The DON verified the dirty utensil drawer at the time of the kitchen tour. Dietary Manager (DM) #118 was observed packing brown bag lunches for dialysis residents. DM #118 did not have a hairnet on. The DON verified the absence of the hairnet.

On 02/21/24 at 12:30 P.M., observation of the tray line during lunch service revealed Dietary Aide (DA) #185 walk into the kitchen and wash her hands. DA #185 did not don a hairnet. DA #185 then walked over to the tray line. The absence of the hairnet was verified by the DON.

On 02/21/24 at 1:00 P.M. an interview with the Regional Director of Clinical Services revealed a company had been contacted to consult and clean kitchen. They were on site today. The Regional Director of Clinical Services also verified that hairnets are to be worn in the kitchen.

This deficiency represents noncompliance investigated under Complaint Number OH00151189.

Based on record review and interviews, the facility failed to provide adequate supervision to prevent the elopement of a resident. This affected one (Resident #100) of one resident reviewed for elopement. The facility census was 99.

Findings include:

Review of the medical record for Resident #100 revealed an admission date of 11/30/23 with diagnosis including diabetes mellitus, depression and COVID-19. His medical record contained a photograph so that he was identifiable to staff. He was discharged to the hospital on 01/07/24.

Review of the admission Minimum Data Set 3.0 Assessment dated 12/04/23 revealed Resident #100 had impaired cognition.

Review of Resident #100's Skilled Nursing Summary dated 12/27/23 revealed the resident's gait was unsteady, had a balance problem, and required ambulatory assistance of one.

Review of Resident #100's plan of care revealed the resident had impaired cognitive process for daily decision making and was at risk for further decline in cognitive status. Interventions included but were not limited to reorient and redirect as needed.

Review of the elopement timeline for Resident #100 revealed on 01/06/24 at 9:30 P.M. the resident was last seen by Social Services Designee #203 at approximately 9:30 P.M. in the area of his room and nurse's station. At 9:45 P.M., Receptionist #209 let Resident #100 out of the building when other visitors exited. At 10:10 P.M. nursing staff were unable to locate Resident #100 and a search was initiated. At 10:15 P.M., staff found Resident #100 outside by the building and dumpster area with his coat and shoes on.

Review of the incident report dated 01/06/24 at 10:07 P.M. revealed Resident #100 was not seen for his nighttime medication. Social services stated she had seen him on another unit visiting other residents. The nursing staff called an elopement code to look for the resident. The staff found the resident outside by the dumpster. Resident #100 had no complaints and stated he was fine. No injuries were noted.

Review of the statement dated 01/06/24 by Receptionist #209 revealed she was sitting at the reception desk when she opened the door for a resident's family and a few other visitors. She stated she accidentally let Resident #100 out of the facility. She stated she had never seen him before and he was fully dressed. She stated she was not familiar with every resident in the building by face.

Review of Resident #100's hospital History & Physical dated 01/07/24 revealed the resident was confused and had no injuries related to the elopement.

Interview on 01/18/24 at 8:57 A.M. with the Administrator revealed Resident #100 eloped out of the building on 01/06/24 at 9:45 P.M. when the receptionist let him out of the building with other visitors. She stated Resident #100 was usually in a wheelchair but at the time of him leaving the building he was ambulating unassisted and had shoes and a coat on.

Review of the facility policy titled, Elopement Risk

Based on record review, interview, and facility policy review the facility failed to timely notify the physician and dietitian of Resident #294's continued refusal of daily weights. This affected one resident (#294) of four residents reviewed for weights. The facility census was 98. Findings include: Review of Resident #294's medical record revealed an admission date of 08/31/23 with diagnoses including chronic systolic congestive heart failure, stage IV chronic kidney disease, and depression. Review of the physician's orders revealed Resident #294 had an order dated 09/05/23 for daily weights related to a diagnosis of congestive heart failure. Further review of the medical record and medication administration record (MAR) for September 2023 revealed Resident #294's weights were marked as refused on 09/05/23, 09/06/23, 09/08/23, 09/10/23, 09/11/23, 09/12/23, 09/13/23, 09/15/23, 09/17/23, 09/18/23, and 09/20/23. No response was indicated on 09/07/23, 09/14/23, and 09/19/23. Review of the electronic medical record under the weight monitoring tab for Resident #294 revealed a weight was obtained on 09/09/23 at 200 pounds and again on 09/16/23 at 197 pounds. No further weights were documented prior to surveyor intervention on 09/21/23. Review of Resident #294's weight on 09/21/23 revealed a weight of 240 pounds, with no reweight initiated by the facility. The physician was notified of the significant weight gain and ordered STAT labs since the weight gain was from 200 pounds on 09/09/23 to 240 pounds on 09/21/23. Weights obtained on 09/22/23 and 09/23/23 were also 240 pounds. Review of the lab results dated 09/25/23 revealed no critical findings and no new physician orders. Review of Resident #294's care plan initiated on 08/31/23 did not reflect any interventions for weight monitoring. Interview on 09/20/23 at 1:19 P.M. with Licensed Practical Nurse (LPN) #1133 confirmed daily weights were not recorded in the paper chart for Resident #294. Interview on 09/20/23 at 2:30 P.M. with the Director of Nursing (DON) revealed Resident #294's orders for daily weights were to be completed between 3:00 A.M. and 7:00 A.M., and Resident #294 refused to be weighed. When the DON was asked if it was a convenient agreed upon time for Resident #294, she stated it may have been towards 7:00 A.M. but agreed a later time may have been better accepted and had not discussed with Resident #294 his reason for continued refusals. Review of the physician orders for Resident #294 revealed a new order on 09/21/23 for daily weights to be obtained after 7:00 A.M. Interview on 09/20/23 at 2:33 P.M. with Resident #294 revealed staff have asked him several times about being weighed between 3:00 A.M. and 7:00 A.M. but he was sleeping and refused because he wanted to continue sleeping. Review of the nursing progress notes from 09/05/23 to 09/21/23 revealed no documented evidence of physician and dietitian notification of the refusals of daily weights and no documented evidence of education provided to Resident #294 of the importance of daily weights for monitoring his diagnosis of congestive heart failure. Interview on 09/25/23 at 12:19 P.M. with the DON confirmed she did not have further documented evidence of physician and/or dietitian notification or resident education for Resident #294's refusals of daily weights. Review of the facility policy titled Weight PolicyBased on record review, interview, and facility policy review the facility failed to timely notify the physician and dietitian of Resident #294's continued refusal of daily weights. This affected one resident (#294) of four residents reviewed for weights. The facility census was 98.

Findings include:

Review of Resident #294's medical record revealed an admission date of 08/31/23 with diagnoses including chronic systolic congestive heart failure, stage IV chronic kidney disease, and depression.

Review of the physician's orders revealed Resident #294 had an order dated 09/05/23 for daily weights related to a diagnosis of congestive heart failure.

Further review of the medical record and medication administration record (MAR) for September 2023 revealed Resident #294's weights were marked as refused on 09/05/23, 09/06/23, 09/08/23, 09/10/23, 09/11/23, 09/12/23, 09/13/23, 09/15/23, 09/17/23, 09/18/23, and 09/20/23. No response was indicated on 09/07/23, 09/14/23, and 09/19/23.

Review of the electronic medical record under the weight monitoring tab for Resident #294 revealed a weight was obtained on 09/09/23 at 200 pounds and again on 09/16/23 at 197 pounds. No further weights were documented prior to surveyor intervention on 09/21/23.

Review of Resident #294's weight on 09/21/23 revealed a weight of 240 pounds, with no reweight initiated by the facility. The physician was notified of the significant weight gain and ordered STAT labs since the weight gain was from 200 pounds on 09/09/23 to 240 pounds on 09/21/23. Weights obtained on 09/22/23 and 09/23/23 were also 240 pounds. Review of the lab results dated 09/25/23 revealed no critical findings and no new physician orders.

Review of Resident #294's care plan initiated on 08/31/23 did not reflect any interventions for weight monitoring.

Interview on 09/20/23 at 1:19 P.M. with Licensed Practical Nurse (LPN) #1133 confirmed daily weights were not recorded in the paper chart for Resident #294.

Interview on 09/20/23 at 2:30 P.M. with the Director of Nursing (DON) revealed Resident #294's orders for daily weights were to be completed between 3:00 A.M. and 7:00 A.M., and Resident #294 refused to be weighed. When the DON was asked if it was a convenient agreed upon time for Resident #294, she stated it may have been towards 7:00 A.M. but agreed a later time may have been better accepted and had not discussed with Resident #294 his reason for continued refusals.

Review of the physician orders for Resident #294 revealed a new order on 09/21/23 for daily weights to be obtained after 7:00 A.M.

Interview on 09/20/23 at 2:33 P.M. with Resident #294 revealed staff have asked him several times about being weighed between 3:00 A.M. and 7:00 A.M. but he was sleeping and refused because he wanted to continue sleeping.

Review of the nursing progress notes from 09/05/23 to 09/21/23 revealed no documented evidence of physician and dietitian notification of the refusals of daily weights and no documented evidence of education provided to Resident #294 of the importance of daily weights for monitoring his diagnosis of congestive heart failure.

Interview on 09/25/23 at 12:19 P.M. with the DON confirmed she did not have further documented evidence of physician and/or dietitian notification or resident education for Resident #294's refusals of daily weights.

Review of the facility policy titled Weight Policy

Based on record review, staff interview, self-reported incident (SRI) review, and facility policy review, the facility failed to prevent resident-to-resident abuse. This affected one resident (Resident #81) of four residents reviewed for abuse. The facility census was 98.

Findings Include:

1. Resident #81 was admitted to the facility on 06/16/23 with diagnoses including depression, bipolar disorder, psychotic disorder with delusions, and schizophrenia. The resident resides on the facility's secured unit.

Review of the comprehensive admission minimum data set (MDS) assessment dated 06/24/23 revealed Resident #81 was moderately cognitively impaired, exhibited no behaviors during the assessment period, and was non-ambulatory.

Review of Resident #81's care plans revealed he was at risk for altered cognitive function related to schizophrenia and would have alterations in behavior leading to abusive attacks on staff and residents.

Review of the nursing progress note dated 08/12/23 at 3:00 A.M. revealed Resident #81 returned from a local Emergency Department (ED) with no new orders. At 3:05 A.M. Registered Nurse (RN) #1113 notified the resident's physician had been sent to the ED for evaluation of facial injuries sustained during a resident-to-resident altercation.

2.Resident #73 was admitted to the facility on 11/15/22 with diagnoses including vascular dementia with behavioral disturbance, chronic obstructive pulmonary disease, bipolar disorder, depression, and anxiety. The resident resided on the facility's secured unit.

Review of the comprehensive quarterly MDS assessment dated 07/21/23 revealed Resident #73 was moderately cognitively impaired, wandered several days during the assessment period, and was independently ambulatory.

Review of the care plans revealed Resident #73 had newly implemented plans, dated 09/25/23, regarding impaired cognitive function, impaired thought processes, wandering, and behavior problems.

Review of the nursing progress note dated 08/12/23 revealed Resident #73 assaulted Resident #81 at approximately 11:30 P.M. on 08/11/23. Resident #73 was very aggressive, and the agency nurse called 911 but they never arrived at the facility. The resident continued to walk into other resident's rooms and threatened to hit the staff. Continued review of the nursing progress notes revealed the resident's behaviors continued to increase including his wandering and aggressiveness. Resident #73 was transferred to the ED on 08/22/23 due to increased agitation and aggression. After being evaluated the resident returned to the facility with no new orders. On 09/26/23 Resident #73 had an initial evaluation by the facility psychiatrist for his increased aggression, combativeness, and wandering.

Review of the facility's SRI #238031, dated 08/12/23, revealed Resident #73 hit Resident #81 in the face after Resident #81 told Resident #73 to stay out of his room. Resident #73 had been having increased behaviors in the previous several months, was wandering in and out of other resident's room, and was difficult to redirect. Resident #81 requested to be sent to the ED for evaluation and returned with no new orders. The police were notified while at the ED and interviewed Resident #81 who declined to file charges. When the facility attempted to talk to Resident #73 about the incident, the resident did not want to discuss the incident/did not remember the incident. The facility obtained witness statements, did skin checks on all the residents on the unit. Resident #73's room was changed to the opposite end of the unit as an intervention to prevent further abuse. All staff were educated on abuse. The facility unsubstantiated the allegation of abuse as as no abuse per definition has occurred with alleged incident.

Interview with Social Services Director (SSD) #1164 on 09/25/23 at 10:50 A.M. revealed Resident #73 has not been seen by the facility psychiatrist. The resident's primary physician is the one who orders his psychotropic medication (a psychoactive drug taken to exert an effect on the chemical makeup of the brain and nervous system to treat mental health issues). SSD #1164 confirmed the resident's behaviors had been escalating over the last few months. He was referred to a contracted mental health services company approximately three months ago, but they never assessed him until a few days ago as there was a mix up with the referral. The company uses nonpharmacological interventions for treatment.

Review of the facility's Abuse, Neglect, and Exploitation policy, last revised 10/01/22, revealed the definition of abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility's policy revealed to prevent abuse, neglect, and exploitation requires ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.

Based on record review, interview, and facility policy review, the facility failed to implement their abuse policy regarding an allegation of resident-to-resident abuse. This affected two residents (#68 and #55) of four residents reviewed for abuse. The facility census was 98. Findings include: 1.Resident #55 was admitted to the facility on 09/08/22 with diagnoses including chronic pancreatitis, anxiety, depression, Covid-19, psychoactive substance abuse, a right above the knee amputation, and schizophrenia. Review of the comprehensive annual Minimum Data Set (MDS) assessment dated 08/14/23 revealed Resident #55 was cognitively intact, exhibited no behaviors during the assessment period. Review of the nursing progress note dated 09/02/23 for Resident #55 revealed Licensed Practical Nurse (LPN) #1134 heard a loud commotion in the hallway. LPN #1134 observed Resident #55 arguing with another resident. Resident #55 said another resident had slapped and choked her. Resident #55's face was slightly red and swollen and there was a small skin alteration to the resident's left wrist and the back of her neck. Resident #55 said that during the smoke break she was passing through in her motorized wheelchair. The resident said she excused herself while passing another resident who became agitated and called Resident #55 an inappropriate name. The two residents then became involved in a verbal altercation in which they called each other inappropriate names. The second resident then started to walk away when Resident #55 called him another name. The second resident then turned around and walked back to Resident #55 and told her if she continued to call him names, he would slap her. Resident #55 called him another name and the second resident slapped her. Resident #55 then said she would report him and re-entered the building from the smoke area. The second resident also re-entered the building and began choking Resident #55. Staff immediately separated the residents. Resident #55 said she had called the local police department and filed a report. Resident #55's injuries were treated. The resident's emergency contact was notified and came to the facility. LPN #1134 notified the Administrator and Assistant Director of Nursing (ADON) #1109. Further review of the nursing progress notes revealed on 09/06/23 Social Service Director (SSD) #1164 interviewed Resident #55 who indicated she felt safe in the facility. Review of Resident #55's care plan revealed a care plan was initiated on 02/22/23 that the resident made abusive attacks on staff and/or other residents, including physically and verbally abusive behaviors. Resident #55 refused a request for an interview on 09/21/23 at 11:55 A.M. 2. Resident #68 was admitted to the facility on 07/31/23 with diagnoses including traumatic brain injury, psychoactive substance abuse, diabetes, mild cognitive impairment, Parkinson's disease, and epilepsy. Review of the comprehensive MDS admissions assessment dated 08/13/23 revealed Resident #68 was moderately cognitively impaired and exhibited no behaviors during the assessment period. Review of the nursing progress notes dated 09/02/23 revealed LPN #1134 heard a commotion in the hallway and went to investigate. Upon entering the hallway LPN #1134 observed Resident # 68 arguing with a female resident. The female resident stated Resident #68 had slapped her in the face and was choking her. Another resident who was present stated the female resident had hit him with her motorized wheelchair. LPN #1134 asked Resident #68 what happened, and he denied slapping or choking the female resident. The staff separated the residents and placed Resident #68 on 1:1 observation due to physical aggression. Resident #68 was assessed for injuries, and none were noted. Resident #68's physician was notified, and no new orders were received. The facility attempted to notify Resident #68's emergency contact without success. LPN #1134 notified the Administrator and ADON #1109 of the incident. Review of Resident #68's care plans revealed a care plan was initiated on 09/06/23 that he makes abusive attacks on staff and/or other residents, and that he was physically and verbally abusive. A new care plan was initiated on 09/22/23 that he demonstrates accusatory behavior by making false statements to gain what he wants, then retracts the statement and will state the truth. He was to be referred to psychiatric services as needed. Resident #68 refused an interview on 09/21/23 at 12:05 P.M. Interview with the Administrator on 09/20/23 at 3:40 P.M. revealed she was not aware of any resident-to-resident allegation of abuse for Residents #55 and #68 on 09/02/23. The Administrator stated no Self-Reported Incident (SRI) form was submitted as she was unaware of any abuse. The Administrator said she was on vacation when the incident was alleged to have occurred. The Administrator reviewed the nursing progress note for Resident #55 dated 09/02/23 and said the incident must not have occurred as the resident has her personal phone number and the resident would have called her immediately. The Administrator said she would go and speak with Resident #55 and then call LPN #1134 to determine what happened. A second interview with the Administrator on 09/20/23 at 4:40 P.M. revealed she had just spoken with Resident #55 who denied the incident ever happened. Resident #55 told the Administrator Resident #68 would never hurt her and she did not know why LPN #1134 would say that. The Administrator said the incident should have been on the facility's 24-hour report and does not know why the Director of Nursing (DON) would not have been made aware of the alleged altercation. The Administrator stated she would enter an investigation and close it out immediately as nothing had happened. Interview with the DON on 09/21/23 at 11:45 A.M. revealed she had seen the documentation by LPN #1134 on the 24-hour report and that she spoke with Resident #55 and Resident #68 who denied they had had an altercation. The DON confirmed she did not speak with LPN #1134 about the incident and felt LPN #1134 notified ADON #1109 as that was the first person who she thought of. The DON said she did not initiate an SRI at the time as she was not authorized to, only the Administrator was able to initiate one. A telephone call was made to LPN #1134 on 09/21/23 at 4:50 P.M. and a voice mail message was left requesting a return phone call. As of 09/26/23 at 12:10 P.M. no return call was received. Review of the facility's Abuse, Neglect, and ExploitationBased on record review, interview, and facility policy review, the facility failed to implement their abuse policy regarding an allegation of resident-to-resident abuse. This affected two residents (#68 and #55) of four residents reviewed for abuse. The facility census was 98.

Findings include:

1.Resident #55 was admitted to the facility on 09/08/22 with diagnoses including chronic pancreatitis, anxiety, depression, Covid-19, psychoactive substance abuse, a right above the knee amputation, and schizophrenia.

Review of the comprehensive annual Minimum Data Set (MDS) assessment dated 08/14/23 revealed Resident #55 was cognitively intact, exhibited no behaviors during the assessment period.

Review of the nursing progress note dated 09/02/23 for Resident #55 revealed Licensed Practical Nurse (LPN) #1134 heard a loud commotion in the hallway. LPN #1134 observed Resident #55 arguing with another resident. Resident #55 said another resident had slapped and choked her. Resident #55's face was slightly red and swollen and there was a small skin alteration to the resident's left wrist and the back of her neck. Resident #55 said that during the smoke break she was passing through in her motorized wheelchair. The resident said she excused herself while passing another resident who became agitated and called Resident #55 an inappropriate name. The two residents then became involved in a verbal altercation in which they called each other inappropriate names. The second resident then started to walk away when Resident #55 called him another name. The second resident then turned around and walked back to Resident #55 and told her if she continued to call him names, he would slap her. Resident #55 called him another name and the second resident slapped her. Resident #55 then said she would report him and re-entered the building from the smoke area. The second resident also re-entered the building and began choking Resident #55. Staff immediately separated the residents. Resident #55 said she had called the local police department and filed a report. Resident #55's injuries were treated. The resident's emergency contact was notified and came to the facility. LPN #1134 notified the Administrator and Assistant Director of Nursing (ADON) #1109. Further review of the nursing progress notes revealed on 09/06/23 Social Service Director (SSD) #1164 interviewed Resident #55 who indicated she felt safe in the facility.

Review of Resident #55's care plan revealed a care plan was initiated on 02/22/23 that the resident made abusive attacks on staff and/or other residents, including physically and verbally abusive behaviors.

Resident #55 refused a request for an interview on 09/21/23 at 11:55 A.M.

2. Resident #68 was admitted to the facility on 07/31/23 with diagnoses including traumatic brain injury, psychoactive substance abuse, diabetes, mild cognitive impairment, Parkinson's disease, and epilepsy.

Review of the comprehensive MDS admissions assessment dated 08/13/23 revealed Resident #68 was moderately cognitively impaired and exhibited no behaviors during the assessment period.

Review of the nursing progress notes dated 09/02/23 revealed LPN #1134 heard a commotion in the hallway and went to investigate. Upon entering the hallway LPN #1134 observed Resident # 68 arguing with a female resident. The female resident stated Resident #68 had slapped her in the face and was choking her. Another resident who was present stated the female resident had hit him with her motorized wheelchair. LPN #1134 asked Resident #68 what happened, and he denied slapping or choking the female resident. The staff separated the residents and placed Resident #68 on 1:1 observation due to physical aggression. Resident #68 was assessed for injuries, and none were noted. Resident #68's physician was notified, and no new orders were received. The facility attempted to notify Resident #68's emergency contact without success. LPN #1134 notified the Administrator and ADON #1109 of the incident.

Review of Resident #68's care plans revealed a care plan was initiated on 09/06/23 that he makes abusive attacks on staff and/or other residents, and that he was physically and verbally abusive. A new care plan was initiated on 09/22/23 that he demonstrates accusatory behavior by making false statements to gain what he wants, then retracts the statement and will state the truth. He was to be referred to psychiatric services as needed.

Resident #68 refused an interview on 09/21/23 at 12:05 P.M.

Interview with the Administrator on 09/20/23 at 3:40 P.M. revealed she was not aware of any resident-to-resident allegation of abuse for Residents #55 and #68 on 09/02/23. The Administrator stated no Self-Reported Incident (SRI) form was submitted as she was unaware of any abuse. The Administrator said she was on vacation when the incident was alleged to have occurred. The Administrator reviewed the nursing progress note for Resident #55 dated 09/02/23 and said the incident must not have occurred as the resident has her personal phone number and the resident would have called her immediately. The Administrator said she would go and speak with Resident #55 and then call LPN #1134 to determine what happened.

A second interview with the Administrator on 09/20/23 at 4:40 P.M. revealed she had just spoken with Resident #55 who denied the incident ever happened. Resident #55 told the Administrator Resident #68 would never hurt her and she did not know why LPN #1134 would say that. The Administrator said the incident should have been on the facility's 24-hour report and does not know why the Director of Nursing (DON) would not have been made aware of the alleged altercation. The Administrator stated she would enter an investigation and close it out immediately as nothing had happened.

Interview with the DON on 09/21/23 at 11:45 A.M. revealed she had seen the documentation by LPN #1134 on the 24-hour report and that she spoke with Resident #55 and Resident #68 who denied they had had an altercation. The DON confirmed she did not speak with LPN #1134 about the incident and felt LPN #1134 notified ADON #1109 as that was the first person who she thought of. The DON said she did not initiate an SRI at the time as she was not authorized to, only the Administrator was able to initiate one.

A telephone call was made to LPN #1134 on 09/21/23 at 4:50 P.M. and a voice mail message was left requesting a return phone call. As of 09/26/23 at 12:10 P.M. no return call was received.

Review of the facility's Abuse, Neglect, and Exploitation

Based on record review, interview, and facility policy review the facility failed to report an allegation of resident-to-resident abuse to the state agency within the required time frames. This affected two residents (#68 and #55) of four residents reviewed for abuse. The facility census was 98. Findings include: 1.Resident #55 was admitted to the facility on 09/08/22 with diagnoses including chronic pancreatitis, anxiety, depression, Covid-19, psychoactive substance abuse, a right above the knee amputation, and schizophrenia. Review of the comprehensive annual Minimum Data Set (MDS) assessment dated 08/14/23 revealed Resident #55 was cognitively intact, exhibited no behaviors during the assessment period. Review of the nursing progress note dated 09/02/23 for Resident #55 revealed Licensed Practical Nurse (LPN) #1134 heard a loud commotion in the hallway. LPN #1134 observed Resident #55 arguing with another resident. Resident #55 said another resident had slapped and choked her. Resident #55's face was slightly red and swollen and there was a small skin alteration to the resident's left wrist and the back of her neck. Resident #55 said that during the smoke break she was passing through in her motorized wheelchair. The resident said she excused herself while passing another resident who became agitated and called Resident #55 an inappropriate name. The two residents then became involved in a verbal altercation in which they called each other inappropriate names. The second resident then started to walk away when Resident #55 called him another name. The second resident then turned around and walked back to Resident #55 and told her if she continued to call him names, he would slap her. Resident #55 called him another name and the second resident slapped her. Resident #55 then said she would report him and re-entered the building from the smoke area. The second resident also re-entered the building and began choking Resident #55. Staff immediately separated the residents. Resident #55 said she had called the local police department and filed a report. Resident #55's injuries were treated. The resident's emergency contact was notified and came to the facility. LPN #1134 notified the Administrator and Assistant Director of Nursing (ADON) #1109. Further review of the nursing progress notes revealed on 09/06/23 Social Service Director (SSD) #1164 interviewed Resident #55 who indicated she felt safe in the facility. Review of Resident #55's care plan revealed a care plan was initiated on 02/22/23 that the resident made abusive attacks on staff and/or other residents, including physically and verbally abusive behaviors. Resident #55 refused a request for an interview on 09/21/23 at 11:55 A.M. 2. Resident #68 was admitted to the facility on 07/31/23 with diagnoses including traumatic brain injury, psychoactive substance abuse, diabetes, mild cognitive impairment, Parkinson's disease, and epilepsy. Review of the comprehensive MDS admissions assessment, dated 08/13/23, revealed Resident #68 was moderately cognitively impaired and exhibited no behaviors during the assessment period. Review of the nursing progress notes dated 09/02/23 revealed LPN #1134 heard a commotion in the hallway and went to investigate. Upon entering the hallway LPN #1134 observed Resident # 68 arguing with a female resident. The female resident stated Resident #68 had slapped her in the face and was choking her. Another resident who was present stated the female resident had hit him with her motorized wheelchair. LPN #1134 asked Resident #68 what happened, and he denied slapping or choking the female resident. The staff separated the residents and place Resident #68 on 1:1 observation due to physical aggression. Resident #68 was assessed for injuries, and none were noted. Resident #68's physician was notified, and no new orders were received. The facility attempted to notify Resident #68's emergency contact without success. LPN #1134 notified the Administrator and ADON #1109 of the incident. Review of Resident #68's care plans revealed a care plan was initiated on 09/06/23 that he makes abusive attacks on staff and/or other residents, and that he was physically and verbally abusive. A new care plan was initiated on 09/22/23 that he demonstrates accusatory behavior by making false statements in order to gain what he wants, then retracts the statement and will state the truth. He was to be referred to psychiatric services as needed. Resident #68 refused an interview on 09/21/23 at 12:05 P.M. Interview with the Administrator on 09/20/23 at 3:40 P.M. revealed she was not aware of any resident-to-resident allegation of abuse for Residents #55 and #68 on 09/02/23. The Administrator stated no Self-Reported Incident (SRI) form was submitted as she was unaware of any abuse allegation. The Administrator said she was on vacation when the incident was alleged to have occurred. The Administrator reviewed the nursing progress note for Resident #55 dated 09/02/23 and said the incident must not have occurred as she knew Resident #55 from another facility and the resident had her personal phone number. Resident #55 would have called her immediately had anything happened to her. The Administrator said she would go and speak with Resident #55 and then call LPN #1134 to determine what happened. A second interview with the Administrator on 09/20/23 at 4:40 P.M. revealed she had just spoken with Resident #55 who denied the incident ever happened. Resident #55 told the Administrator Resident #68 would never hurt her and she did not know why LPN #1134 would say that. The Administrator said the incident should have been on the facility's 24-hour report and does not know why the Director of Nursing (DON) would not have been made aware of the alleged altercation. The Administrator stated she would submit an SRI and close it out immediately as nothing had happened. Interview with the DON on 09/21/23 at 11:45 A.M. revealed she had seen the documentation by LPN #1134 on the 24-hour report and that she spoke with Resident #55 and Resident #68 who denied they had had an altercation. The DON confirmed she did not speak with LPN #1134 about the incident and felt LPN #1134 notified ADON #1109 as that was the first person who she thought of. The DON said she did not initiate an SRI at the time as she was not authorized to, only the Administrator was able to initiate one. A telephone call was made to LPN #1134 on 09/21/23 at 4:50 P.M. and a voice mail message was left requesting a return phone call. As of 09/26/23 at 12:10 P.M. no return call was received. The facility submitted a Self-Reported Incident (SRI) on 09/20/23. An SRI is a report a facility is required to submit to the state agency regarding any allegation of abuse, neglect, exploitation, or injury of unknown origin. Review of the SRI revealed the date of discovery of the allegation of abuse was 09/20/23. Review of the nursing progress notes for Residents #55 and #68 revealed LPN #1134 notified the Administrator and ADON #1109 were notified of the incident on 09/02/23 when it occurred. The DON confirmed on 09/21/23 at 11:45 A.M. she was aware of the incident and did not file an SRI with the state agency. Review of the facility's Abuse, Neglect, and ExploitationBased on record review, interview, and facility policy review the facility failed to report an allegation of resident-to-resident abuse to the state agency within the required time frames. This affected two residents (#68 and #55) of four residents reviewed for abuse. The facility census was 98.

Findings include:

1.Resident #55 was admitted to the facility on 09/08/22 with diagnoses including chronic pancreatitis, anxiety, depression, Covid-19, psychoactive substance abuse, a right above the knee amputation, and schizophrenia.

Review of the comprehensive annual Minimum Data Set (MDS) assessment dated 08/14/23 revealed Resident #55 was cognitively intact, exhibited no behaviors during the assessment period.

Review of the nursing progress note dated 09/02/23 for Resident #55 revealed Licensed Practical Nurse (LPN) #1134 heard a loud commotion in the hallway. LPN #1134 observed Resident #55 arguing with another resident. Resident #55 said another resident had slapped and choked her. Resident #55's face was slightly red and swollen and there was a small skin alteration to the resident's left wrist and the back of her neck. Resident #55 said that during the smoke break she was passing through in her motorized wheelchair. The resident said she excused herself while passing another resident who became agitated and called Resident #55 an inappropriate name. The two residents then became involved in a verbal altercation in which they called each other inappropriate names. The second resident then started to walk away when Resident #55 called him another name. The second resident then turned around and walked back to Resident #55 and told her if she continued to call him names, he would slap her. Resident #55 called him another name and the second resident slapped her. Resident #55 then said she would report him and re-entered the building from the smoke area. The second resident also re-entered the building and began choking Resident #55. Staff immediately separated the residents. Resident #55 said she had called the local police department and filed a report. Resident #55's injuries were treated. The resident's emergency contact was notified and came to the facility. LPN #1134 notified the Administrator and Assistant Director of Nursing (ADON) #1109. Further review of the nursing progress notes revealed on 09/06/23 Social Service Director (SSD) #1164 interviewed Resident #55 who indicated she felt safe in the facility.

Review of Resident #55's care plan revealed a care plan was initiated on 02/22/23 that the resident made abusive attacks on staff and/or other residents, including physically and verbally abusive behaviors.

Resident #55 refused a request for an interview on 09/21/23 at 11:55 A.M.

2. Resident #68 was admitted to the facility on 07/31/23 with diagnoses including traumatic brain injury, psychoactive substance abuse, diabetes, mild cognitive impairment, Parkinson's disease, and epilepsy.

Review of the comprehensive MDS admissions assessment, dated 08/13/23, revealed Resident #68 was moderately cognitively impaired and exhibited no behaviors during the assessment period.

Review of the nursing progress notes dated 09/02/23 revealed LPN #1134 heard a commotion in the hallway and went to investigate. Upon entering the hallway LPN #1134 observed Resident # 68 arguing with a female resident. The female resident stated Resident #68 had slapped her in the face and was choking her. Another resident who was present stated the female resident had hit him with her motorized wheelchair. LPN #1134 asked Resident #68 what happened, and he denied slapping or choking the female resident. The staff separated the residents and place Resident #68 on 1:1 observation due to physical aggression. Resident #68 was assessed for injuries, and none were noted. Resident #68's physician was notified, and no new orders were received. The facility attempted to notify Resident #68's emergency contact without success. LPN #1134 notified the Administrator and ADON #1109 of the incident.

Review of Resident #68's care plans revealed a care plan was initiated on 09/06/23 that he makes abusive attacks on staff and/or other residents, and that he was physically and verbally abusive. A new care plan was initiated on 09/22/23 that he demonstrates accusatory behavior by making false statements in order to gain what he wants, then retracts the statement and will state the truth. He was to be referred to psychiatric services as needed.

Resident #68 refused an interview on 09/21/23 at 12:05 P.M.

Interview with the Administrator on 09/20/23 at 3:40 P.M. revealed she was not aware of any resident-to-resident allegation of abuse for Residents #55 and #68 on 09/02/23. The Administrator stated no Self-Reported Incident (SRI) form was submitted as she was unaware of any abuse allegation. The Administrator said she was on vacation when the incident was alleged to have occurred. The Administrator reviewed the nursing progress note for Resident #55 dated 09/02/23 and said the incident must not have occurred as she knew Resident #55 from another facility and the resident had her personal phone number. Resident #55 would have called her immediately had anything happened to her. The Administrator said she would go and speak with Resident #55 and then call LPN #1134 to determine what happened.

A second interview with the Administrator on 09/20/23 at 4:40 P.M. revealed she had just spoken with Resident #55 who denied the incident ever happened. Resident #55 told the Administrator Resident #68 would never hurt her and she did not know why LPN #1134 would say that. The Administrator said the incident should have been on the facility's 24-hour report and does not know why the Director of Nursing (DON) would not have been made aware of the alleged altercation. The Administrator stated she would submit an SRI and close it out immediately as nothing had happened.

Interview with the DON on 09/21/23 at 11:45 A.M. revealed she had seen the documentation by LPN #1134 on the 24-hour report and that she spoke with Resident #55 and Resident #68 who denied they had had an altercation. The DON confirmed she did not speak with LPN #1134 about the incident and felt LPN #1134 notified ADON #1109 as that was the first person who she thought of. The DON said she did not initiate an SRI at the time as she was not authorized to, only the Administrator was able to initiate one.

A telephone call was made to LPN #1134 on 09/21/23 at 4:50 P.M. and a voice mail message was left requesting a return phone call. As of 09/26/23 at 12:10 P.M. no return call was received.

The facility submitted a Self-Reported Incident (SRI) on 09/20/23. An SRI is a report a facility is required to submit to the state agency regarding any allegation of abuse, neglect, exploitation, or injury of unknown origin. Review of the SRI revealed the date of discovery of the allegation of abuse was 09/20/23. Review of the nursing progress notes for Residents #55 and #68 revealed LPN #1134 notified the Administrator and ADON #1109 were notified of the incident on 09/02/23 when it occurred. The DON confirmed on 09/21/23 at 11:45 A.M. she was aware of the incident and did not file an SRI with the state agency.

Review of the facility's Abuse, Neglect, and Exploitation

Based on record review, interview, and facility policy review the facility failed to investigate an allegation of resident-to-resident abuse. This affected two residents (#68 and #55) of four residents reviewed for abuse. The facility census was 98. Findings include: 1.Resident #55 was admitted to the facility on 09/08/22 with diagnoses including chronic pancreatitis, anxiety, depression, Covid-19, psychoactive substance abuse, a right above the knee amputation, and schizophrenia. Review of the comprehensive annual Minimum Data Set (MDS) assessment dated 08/14/23 revealed Resident #55 was cognitively intact, exhibited no behaviors during the assessment period. Review of the nursing progress note dated 09/02/23 for Resident #55 revealed Licensed Practical Nurse (LPN) #1134 heard a loud commotion in the hallway. LPN #1134 observed Resident #55 arguing with another resident. Resident #55 said another resident had slapped and choked her. Resident #55's face was slightly red and swollen and there was a small skin alteration to the resident's left wrist and the back of her neck. Resident #55 said that during the smoke break she was passing through in her motorized wheelchair. The resident said she excused herself while passing another resident who became agitated and called Resident #55 an inappropriate name. The two residents then became involved in a verbal altercation in which they called each other inappropriate names. The second resident then started to walk away when Resident #55 called him another name. The second resident then turned around and walked back to Resident #55 and told her if she continued to call him names, he would slap her. Resident #55 called him another name and the second resident slapped her. Resident #55 then said she would report him and re-entered the building from the smoke area. The second resident also re-entered the building and began choking Resident #55. Staff immediately separated the residents. Resident #55 said she had called the local police department and filed a report. Resident #55's injuries were treated. The resident's emergency contact was notified and came to the facility. LPN #1134 notified the Administrator and Assistant Director of Nursing (ADON) #1109. Further review of the nursing progress notes revealed on 09/06/23 Social Service Director (SSD) #1164 interviewed Resident #55 who indicated she felt safe in the facility. Review of Resident #55's care plan revealed a care plan was initiated on 02/22/23 that the resident made abusive attacks on staff and/or other residents, including physically and verbally abusive behaviors. Resident #55 refused a request for an interview on 09/21/23 at 11:55 A.M. 2. Resident #68 was admitted to the facility on 07/31/23 with diagnoses including traumatic brain injury, psychoactive substance abuse, diabetes, mild cognitive impairment, Parkinson's disease, and epilepsy. Review of the comprehensive MDS admissions assessment, dated 08/13/23, revealed Resident #68 was moderately cognitively impaired and exhibited no behaviors during the assessment period. Review of the nursing progress notes dated 09/02/23 revealed LPN #1134 heard a commotion in the hallway and went to investigate. Upon entering the hallway LPN #1134 observed Resident # 68 arguing with a female resident. The female resident stated Resident #68 had slapped her in the face and was choking her. Another resident who was present stated the female resident had hit him with her motorized wheelchair. LPN #1134 asked Resident #68 what happened, and he denied slapping or choking the female resident. The staff separated the residents and placed Resident #68 on 1:1 observation due to physical aggression. Resident #68 was assessed for injuries, and none were noted. Resident #68's physician was notified, and no new orders were received. The facility attempted to notify Resident #68's emergency contact without success. LPN #1134 notified the Administrator and ADON #1109 of the incident. Review of Resident #68's care plans revealed a care plan was initiated on 09/06/23 that he makes abusive attacks on staff and/or other residents, and that he was physically and verbally abusive. A new care plan was initiated on 09/22/23 that he demonstrates accusatory behavior by making false statements in order to gain what he wants, then retracts the statement and will state the truth. He was to be referred to psychiatric services as needed. Resident #68 refused an interview on 09/21/23 at 12:05 P.M. Interview with the Administrator on 09/20/23 at 3:40 P.M. revealed she was not aware of any resident-to-resident allegation of abuse for Residents #55 and #68 on 09/02/23. The Administrator stated no Self-Reported Incident (SRI) form was submitted as she was unaware of any abuse. The Administrator said she was on vacation when the incident was alleged to have occurred. The Administrator reviewed the nursing progress note for Resident #55 dated 09/02/23 and said the incident must not have occurred ass the resident has her personal phone number, and the resident would have called her immediately. The Administrator said she would go and speak with Resident #55 and then call LPN #1134 to determine what happened. A second interview with the Administrator on 09/20/23 at 4:40 P.M. revealed she had just spoken with Resident #55 who denied the incident ever happened. Resident #55 told the Administrator Resident #68 would never hurt her and she did not know why LPN #1134 would say that. The Administrator said the incident should have been on the facility's 24-hour report and does not know why the Director of Nursing (DON) would not have been made aware of the alleged altercation. The Administrator stated she would enter an investigation and close it out immediately as nothing had happened. Interview with the DON on 09/21/23 at 11:45 A.M. revealed she had seen the documentation by LPN #1134 on the 24-hour report and that she spoke with Resident #55 and Resident #68 who denied they had had an altercation. The DON confirmed she did not speak with LPN #1134 about the incident and felt LPN #1134 notified ADON #1109 as that was the first person who she thought of. The DON said she did not initiate an SRI at the time as she was not authorized to, only the Administrator was able to initiate one. A telephone call was made to LPN #1134 on 09/21/23 at 4:50 P.M. and a voice mail message was left requesting a return phone call. As of 09/26/23 at 12:10 P.M. no return call was received. Review of the facility's Abuse, Neglect, and ExploitationBased on record review, interview, and facility policy review the facility failed to investigate an allegation of resident-to-resident abuse. This affected two residents (#68 and #55) of four residents reviewed for abuse. The facility census was 98.

Findings include:

1.Resident #55 was admitted to the facility on 09/08/22 with diagnoses including chronic pancreatitis, anxiety, depression, Covid-19, psychoactive substance abuse, a right above the knee amputation, and schizophrenia.

Review of the comprehensive annual Minimum Data Set (MDS) assessment dated 08/14/23 revealed Resident #55 was cognitively intact, exhibited no behaviors during the assessment period.

Review of the nursing progress note dated 09/02/23 for Resident #55 revealed Licensed Practical Nurse (LPN) #1134 heard a loud commotion in the hallway. LPN #1134 observed Resident #55 arguing with another resident. Resident #55 said another resident had slapped and choked her. Resident #55's face was slightly red and swollen and there was a small skin alteration to the resident's left wrist and the back of her neck. Resident #55 said that during the smoke break she was passing through in her motorized wheelchair. The resident said she excused herself while passing another resident who became agitated and called Resident #55 an inappropriate name. The two residents then became involved in a verbal altercation in which they called each other inappropriate names. The second resident then started to walk away when Resident #55 called him another name. The second resident then turned around and walked back to Resident #55 and told her if she continued to call him names, he would slap her. Resident #55 called him another name and the second resident slapped her. Resident #55 then said she would report him and re-entered the building from the smoke area. The second resident also re-entered the building and began choking Resident #55. Staff immediately separated the residents. Resident #55 said she had called the local police department and filed a report. Resident #55's injuries were treated. The resident's emergency contact was notified and came to the facility. LPN #1134 notified the Administrator and Assistant Director of Nursing (ADON) #1109. Further review of the nursing progress notes revealed on 09/06/23 Social Service Director (SSD) #1164 interviewed Resident #55 who indicated she felt safe in the facility.

Review of Resident #55's care plan revealed a care plan was initiated on 02/22/23 that the resident made abusive attacks on staff and/or other residents, including physically and verbally abusive behaviors.

Resident #55 refused a request for an interview on 09/21/23 at 11:55 A.M.

2. Resident #68 was admitted to the facility on 07/31/23 with diagnoses including traumatic brain injury, psychoactive substance abuse, diabetes, mild cognitive impairment, Parkinson's disease, and epilepsy.

Review of the comprehensive MDS admissions assessment, dated 08/13/23, revealed Resident #68 was moderately cognitively impaired and exhibited no behaviors during the assessment period.

Review of the nursing progress notes dated 09/02/23 revealed LPN #1134 heard a commotion in the hallway and went to investigate. Upon entering the hallway LPN #1134 observed Resident # 68 arguing with a female resident. The female resident stated Resident #68 had slapped her in the face and was choking her. Another resident who was present stated the female resident had hit him with her motorized wheelchair. LPN #1134 asked Resident #68 what happened, and he denied slapping or choking the female resident. The staff separated the residents and placed Resident #68 on 1:1 observation due to physical aggression. Resident #68 was assessed for injuries, and none were noted. Resident #68's physician was notified, and no new orders were received. The facility attempted to notify Resident #68's emergency contact without success. LPN #1134 notified the Administrator and ADON #1109 of the incident.

Review of Resident #68's care plans revealed a care plan was initiated on 09/06/23 that he makes abusive attacks on staff and/or other residents, and that he was physically and verbally abusive. A new care plan was initiated on 09/22/23 that he demonstrates accusatory behavior by making false statements in order to gain what he wants, then retracts the statement and will state the truth. He was to be referred to psychiatric services as needed.

Resident #68 refused an interview on 09/21/23 at 12:05 P.M.

Interview with the Administrator on 09/20/23 at 3:40 P.M. revealed she was not aware of any resident-to-resident allegation of abuse for Residents #55 and #68 on 09/02/23. The Administrator stated no Self-Reported Incident (SRI) form was submitted as she was unaware of any abuse. The Administrator said she was on vacation when the incident was alleged to have occurred. The Administrator reviewed the nursing progress note for Resident #55 dated 09/02/23 and said the incident must not have occurred ass the resident has her personal phone number, and the resident would have called her immediately. The Administrator said she would go and speak with Resident #55 and then call LPN #1134 to determine what happened.

A second interview with the Administrator on 09/20/23 at 4:40 P.M. revealed she had just spoken with Resident #55 who denied the incident ever happened. Resident #55 told the Administrator Resident #68 would never hurt her and she did not know why LPN #1134 would say that. The Administrator said the incident should have been on the facility's 24-hour report and does not know why the Director of Nursing (DON) would not have been made aware of the alleged altercation. The Administrator stated she would enter an investigation and close it out immediately as nothing had happened.

Interview with the DON on 09/21/23 at 11:45 A.M. revealed she had seen the documentation by LPN #1134 on the 24-hour report and that she spoke with Resident #55 and Resident #68 who denied they had had an altercation. The DON confirmed she did not speak with LPN #1134 about the incident and felt LPN #1134 notified ADON #1109 as that was the first person who she thought of. The DON said she did not initiate an SRI at the time as she was not authorized to, only the Administrator was able to initiate one.

A telephone call was made to LPN #1134 on 09/21/23 at 4:50 P.M. and a voice mail message was left requesting a return phone call. As of 09/26/23 at 12:10 P.M. no return call was received.

Review of the facility's Abuse, Neglect, and Exploitation

Based on record review, staff interview, and facility policy review the facility failed to ensure the state ombudsman was notified of resident transfers to the hospital. This affected two residents (#10 and #89) of two residents reviewed for hospitalization and had the potential to affect all 98 residents currently residing in the facility.

Findings include:

1. Review of Resident #89's medical record revealed admission to the facility occurred on 07/03/23, with medical diagnoses including hyperlipidemia, type two diabetes, and heart failure.

The record identified Resident #89 discharged to the hospital on 08/18/23 and had not returned as of the annual survey dated 09/18/23.

Review of the electronic medical record revealed no evidence the state ombudsman was notified of Resident #89's transfer to the hospital on 08/18/23.

2. Review of Resident #10's medical record revealed admission to the facility occurred on 10/10/21, with medical diagnoses including type two diabetes, dysfunction of the bladder, and paraplegia.

The record identified Resident #10 discharged to the hospital on 06/06/23, 06/19/23, 07/07/23, 07/15/23, and 08/14/23.

Review of the electronic medical record revealed no evidence the state ombudsman was notified of Resident #10's transfers to the hospital on 06/06/23, 06/19/23, 07/07/23, 07/15/23, and 08/14/23.

Review of the June, July, and August 2023 email correspondence between the state ombudsman and Social Services (SS) #1164 revealed notifications were not sent until 09/20/23 at 2:12 P.M. Review of the email correspondence revealed Resident #10 was not listed for discharges and transfers for the Month of June 2023.

Interview on 09/20/23 at 9:15 A.M. with SS #1164 revealed she was responsible for notifying the state ombudsman of resident discharges and transfers from the facility. SS #1164 revealed she compiled a list and sent the list once a month for the previous month.

Interview on 09/20/23 at 2:18 P.M. with the Administrator revealed the transfers and discharges for the month of June, July, and August 2023 were not submitted to the state ombudsman.

Review of the facility policy titled Facility-Initiated Transfer or Discharge

Based on record review, staff interview, and facility policy review the facility failed to develop care plans regarding behaviors and medications usage. This affected three residents (#55, #73, and #68) of four residents reviewed for behaviors and psychotropic medications. The facility census was 98.

Findings include:

1. Resident #55 was admitted to the facility on 09/08/22 with diagnoses including chronic pancreatitis, anxiety, depression, Covid-19, psychoactive substance abuse, a right above the knee amputation, and schizophrenia.

Review of the comprehensive annual Minimum Data Set (MDS) assessment dated 08/14/23 revealed Resident #55 was cognitively intact, exhibited no behaviors during the assessment period.

Review of the physician's orders for Resident #55 revealed an order for:

Acyclovir (an antiviral medication) 400 milligrams (mg) by mouth twice a day for Herpes Viral Infection dated 03/28/23.

Amitriptyline (a psychotropic medication) 75 mg by mouth twice a day for Anxiety, Depression, and Schizophrenia, dated 06/19/23.

Eliquis (an anticoagulant) 5 mg by mouth twice a day for atrial fibrillation, dated 04/04/23.

Review of the care plans for Resident #55 revealed no care plans addressing the use of the listed medication or the associated viral infection.

Interview with Registered Nurse (RN) #1167 on 09/26/23 at 1:42 P.M. confirmed care plans should have been developed for the medications Resident #55 receives.

2. Resident #73 was admitted to the facility on 11/15/22 with diagnoses including vascular dementia with behavioral disturbance, chronic obstructive pulmonary disease, bipolar disorder, depression, and anxiety. The resident resided on the facility's secured unit.

Review of the comprehensive quarterly MDS assessment dated 07/21/23 revealed Resident #73 was moderately cognitively impaired, wandered several days during the assessment period, and was independently ambulatory.

Review of the physician's orders for Resident #73 revealed an order for:

Albuterol (an inhaled respiratory medication) 2 puffs orally every six hours as needed for shortness of breath due to Chronic Obstructive Pulmonary Disease (COPD), dated 11/16/22.

Incruse Ellipta (an inhaled respiratory medication) 62.5 micrograms (mcg)/ACT aerosol Powder 1 puff daily for COPD, dated 7/21/23.

Review of the nursing progress notes for Resident #73 revealed increasing episodes of agitation, combativeness, aggressiveness, and wandering since July 2023. On 08/12/23 the resident struck Resident #80 in the face when told to get out of the resident's room.

Review of the care plans revealed Resident #73 had newly implemented plans, dated 09/25/23, regarding impaired cognitive function, impaired thought processes, wandering, and behavior problems. No care plan was found regarding the medications used for treating COPD or the risks to the resident's health for a diagnosis of COPD.

Review of the facility's Care Plans, Comprehensive Person-Centered policy, last revised December 2016, includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs are to be developed and implemented for each resident. The care plan will also describe the services that are to be provided to meet those goals.

Interview with RN #1167 on 09/26/23 at 1:42 P.M. confirmed Resident #73's care plans should have been developed for the resident's behaviors and for the resident's diagnosis of COPD and the associated medications.

3. Resident #68 was admitted to the facility on 07/31/23 with diagnoses including traumatic brain injury, psychoactive substance abuse, diabetes, mild cognitive impairment, Parkinson's disease, and epilepsy.

Review of the comprehensive MDS admissions assessment, dated 08/13/23, revealed Resident #68 was moderately cognitively impaired and exhibited no behaviors during the assessment period.

Review of the nursing progress notes dated 09/02/23 revealed Licensed Practical Nurse (LPN) #1134 heard a commotion in the hallway and went to investigate. Upon entering the hallway LPN #1134 observed Resident # 68 arguing with a female resident. The female resident stated Resident #68 had slapped her in the face and was choking her. Another resident who was present stated the female resident had hit him with her motorized wheelchair. LPN #1134 asked Resident #68 what happened, and he denied slapping or choking the female resident. The staff separated the residents and placed Resident #68 on 1:1 observation due to physical aggression. Resident #68 was assessed for injuries, and none were noted. Resident #68's physician was notified, and no new orders were received. The facility attempted to notify Resident #68's emergency contact without success. LPN #1134 notified the Administrator and Assistant Director of Nursing (ADON) #1109 of the incident.

Review of Resident #68's care plans revealed a care plan was initiated on 09/06/23 that he makes abusive attacks on staff and/or other residents, and that he was physically and verbally abusive. A new care plan was initiated on 09/22/23 that he demonstrates accusatory behavior by making false statements in order to gain what he wants, then retracts the statement and will state the truth. He was to be referred to psychiatric services as needed.

Resident #68 refused an interview on 09/21/23 at 12:05 P.M.

Interview with RN #1167 on 09/26/23 at 1:42 P.M. confirmed Resident #68's care plans should have been developed for the resident's behaviors earlier than they were.

Based on observation, record review, interview, and facility policy review the facility failed to ensure care plans were updated and accurate for Residents #7, #14, #35, #73, #80, #244 and #294. This affected seven residents (#7, #14, #35, #73, #80, #244 and #294) of 23 residents reviewed for assessments. The facility census was 98.

Findings include:

1. Review of the medical record for Resident #7 revealed an admission date of 05/21/22. Diagnoses included schizophrenia, diabetes, chronic obstructive pulmonary disease (COPD), and gastro esophageal reflux disease (GERD).

Review of the quarterly Minimum Data Set (MDS) assessment dated 07/13/23 revealed Resident #7 was moderately cognitively impaired. She required supervision for transfers and was independent with no set up help for bed mobility, dressing, toileting, eating, and hygiene. She occasionally rejected care.

Review of the elopement assessment dated 07/16/23 revealed Resident #7 resided on a secured unit.

Review of a nurse's note dated 08/28/23 revealed Resident #7 room was changed to a room on the first floor which was not a secured unit.

Review of the physician's orders for September 2023 revealed an order for a secured unit due to a diagnosis of schizophrenia.

Review of the care plan dated 09/07/23 revealed Resident #7 had a psychiatric diagnosis which required supervision on a secured unit. Interventions included meeting criteria for placement on a secured unit and quarterly reviews for continued appropriateness of placement on a secured unit.

Interview on 09/20/23 at 2:54 P.M. with the Director of Nursing (DON) confirmed the care plan for Resident #7 was not updated when the resident no longer required placement on a secured unit.

2. Review of the medical record for Resident #14 revealed an admission date of 10/05/21. Diagnoses included vascular disease, diabetes, hypertension, and paraplegia.

Review of the comprehensive MDS assessment dated 08/18/23 revealed Resident #14 was moderately cognitively impaired. He required total assistance of two people for transfers, total assistance of one person for toilet use and extensive assistance of one person for bed mobility, dressing, and hygiene. The resident did not have any behaviors or rejection of care.

Review of the care plan dated 09/07/23 revealed no evidence Resident #14 had refused care.

Review of the progress notes dated 06/29/23 through 09/25/23 revealed Resident #14 often refused personal hygiene and general care services.

Interview on 09/26/23 at 1:35 PM with Licensed Practical Nurse (LPN) #1116 reveal Resident #14 did refuse care at times.

Interview on 09/26/23 at 1:37 PM with the Administrator confirmed Resident #14 had no evidence of refusals being addressed in his care plan.

3. Review of the medical record for Resident #35 revealed an admission date of 10/29/16. Diagnoses included diabetes, asthma, and epilepsy.

Review of the quarterly MDS assessment dated 08/17/23 revealed Resident #35 was cognitively intact. She required total assistance of two people for transfers, total assistance of one person for toilet use, extensive assistance of two people for bed mobility, extensive assistance of one person for dressing and limited assistance of one person for hygiene. She was independent with eating and had no weight loss or dental issues.

Review of the care plan dated 05/22/23 revealed Resident #35 was at risk for dental or chewing problems due to some missing natural teeth. Interventions included assisting with oral hygiene including denture care, monitoring wait for any changes, and notifying the doctor if there were problems with chewing or swallowing.

Interview and observation of Resident #35 on 9/20/23 at 11:26 A.M. revealed she had all her own natural teeth.

Interview on 09/20/23 at 2:50 P.M. with the DON Confirmed the care plan for Resident #35 was inaccurate.

4. Review of the medical record for resident #80 revealed and admission date of 05/31/23. Diagnoses included diabetes, hypertension, depression, anxiety, and heart failure.

Review of the comprehensive MDS assessment dated 06/07/23 revealed Resident #80 was moderately cognitively impaired. She required supervision and set up help for bed mobility, transfers, dressing, eating, toilet use, and hygiene. She had trouble falling and staying asleep, she felt down and depressed, had little interest in doing things, had trouble concentrating and displayed no behaviors.

Review of the care plan dated 06/01/23 revealed no evidence depression and anxiety were addressed.

Interview on 09/21/23 at 9:48 A.M. with the DON confirmed there was no care plan for depression and anxiety for Resident #80.

5. Review of the medical record for Resident #244 revealed an admission date of 08/14/23. Diagnoses included diabetes, hypoxia (low oxygen levels), spinal stenosis (narrowing of the spine), and chronic obstructive pulmonary disease.

Review of the comprehensive MDS assessment dated 08/25/23 revealed Resident #244 was moderately cognitively impaired. He required limited assistance from one person for bed mobility, transfers, toilet use, dressing, and personal hygiene, and was at risk for pressure ulcers. He was on oxygen.

Review of the physician's orders for September 2023 revealed an order for Ace wraps to the lower extremities every morning.

Review of the care plan dated 08/15/23 revealed no evidence Ace wraps were addressed.

Interview on 09/21/23 at 9:47 A.M. with the DON revealed Resident #244 had an order for Ace wraps to his legs every morning for edema. She confirmed this was not addressed in the Resident's care plan.

6. Review of the medical record for Resident #294 revealed an admission date of 08/31/23 with diagnoses including chronic systolic congestive heart failure, stage IV chronic kidney disease, and depression.

Review of the admission MDS assessment dated 09/05/23 revealed Resident #294 had moderate cognitive impairment. Review of activities of daily living (ADL) revealed Resident #294 required supervision for transfers, dressing, eating, and toileting and was independent for personal hygiene.

Review of the physician's orders for Resident #294 revealed an order dated 09/05/23 for daily weights related to a diagnosis of congestive heart failure.

Review of the care plan for Resident #294 initiated on 08/31/23 did not reveal interventions related to weight monitoring and no modifications following the 09/05/23 order for daily weights.

Interview on 09/25/23 at 2:16 P.M. with the DON confirmed Resident #294's care plan did not have an intervention listed for weight monitoring and was not revised to reflect the 09/05/23 order for daily weights.

Review of the facility policy titled Care Plans, Comprehensive, Person Centered

Based on record reviews, interviews, and facility policy review the facility failed to adequately monitor Resident #90 after a significant change in condition and failed to follow physician orders for daily weights for Resident #294. This affected one resident (#90) out of three residents reviewed for death and one resident (#294) of four residents reviewed for weights. The facility census was 98.

Findings include:

1.Review of the closed medical record for Resident #90 revealed an admission date of 02/28/19 with diagnoses including diabetes, hypertension, altered mental status, and dementia.

Review of the Minimum Data Set (MDS) assessment dated 07/27/23 revealed Resident #90 was severely cognitively impaired. She required total assistance of two people for bed mobility and transfers and extensive assistance of one person for dressing, toilet use, and hygiene. She had no issues with swallowing and had one fall since the previous assessment, with no injury.

Review of the fall risk assessment dated 07/03/23 revealed Resident #90 was at moderate risk for falls.

Review of the August 2023 physician's orders revealed orders dated 04/01/21 for a regular diet with nectar thick liquids, 08/19/23 to record vital signs every four hours for 24 hours, two liters of oxygen to keep oxygen saturation level (SpO2) above 92 percent (%), a STAT (immediate) chest x-ray, to call the nurse practitioner if the resident's heart rate was 110 or higher and/or her systolic blood pressure decreased to 100 or lower every shift and ten liters of oxygen via a non-rebreather mask until her oxygen levels reached 100% with a call to the nurse practitioner if her oxygen decreased to 92% or lower per shift.

Review of the nursing note dated 08/17/23 at 11:30 A.M. revealed Resident #90 was sitting near the nurse's station when dietary staff member was transporting the breakfast cart and Resident #90 began to ambulate via wheelchair in the path of the cart and fell out of the chair. Resident #90 was assessed for injury, and an abrasion was observed to her right knee. Vital signs were assessed: temperature of 98 degrees Fahrenheit (F), pulse 91, respirations 18, blood pressure 147/82 and SpO2 100 % on room air.

Review of the neurological assessment sheet initiated on 08/17/23 at 10:30 A.M. were as follows:

08/17/23 at 10:30 A.M. blood pressure 147/92, pulse 91, respirations 18, range of motion and strength normal, pupils were equal and reactive to light.

08/17/23 at 10:45 A.M. blood pressure 145/90, pulse 88, respirations 18, range of motion and strength normal, pupils were equal and reactive to light.

08/17/23 at 11:00 A.M. blood pressure 146/88, pulse 82, respirations 18, range of motion and strength normal, pupils were equal and reactive to light.

08/17/23 at 11:30 A.M. blood pressure 142/82, pulse 78, respirations 18, range of motion and strength normal, pupils were equal and reactive to light.

08/17/23 at 12:00 P.M. blood pressure 149/66, pulse 75, respirations 18, range of motion and strength normal, pupils were equal and reactive to light.

08/17/23 at 12:30 P.M. blood pressure 141/74, pulse 78, respirations 18, range of motion and strength normal, pupils were equal and reactive to light.

08/17/23 at 1:30 P.M. blood pressure 144/78, pulse 76, respirations 18, range of motion and strength normal, pupils were equal and reactive to light.

08/17/23 at 2:30 P.M. blood pressure 141/57, pulse 82, respirations 18, range of motion and strength normal, pupils were equal and reactive to light.

08/17/23 at 7:00 P.M. blood pressure 148/60, pulse 77, respirations 18, range of motion and strength normal, pupils were equal and reactive to light.

08/18/23 at 7:00 A.M. blood pressure 144/65, pulse 84, respirations 18, range of motion and strength normal, pupils were equal and reactive to light.

08/18/23 at 7:00 P.M. blood pressure 153/73, respirations 19, range of motion and strength normal, pupils were equal and reactive to light. No pulse was assessed.

08/19/23 at 7:00 A.M. blood pressure 134/74, respirations 18, range of motion and strength normal, pupils were equal and reactive to light. No pulse was assessed.

Review of the nursing note dated 08/17/23 at 1:06 P.M. revealed the intervention for Resident #90's fall was to include transporting the resident from the dining room after meals to area of choice close to nurse's station out of the hallways.

Review of the nursing note dated 08/18/23 at 8:24 P.M. revealed staff notified the nurse that Resident #90 had medium emesis and appeared to be in respiratory distress. Upon entering the resident's room, the nurse observed emesis on the bed and floor. The emesis was pink tinged and had chunks of food in it. Resident #90 was sitting on the side of the bed breathing rapidly but was not using accessory muscles. Her blood pressure was 153/79, pulse 109, temperature 97.9 degrees F, respirations 22, and SpO2 was 78% on room air. Staff immediately administered oxygen via nasal canula and her SpO2 increased to 82%. Assessment of abdomen completed without abnormal findings. No signs and symptoms of discomfort were observed. Call placed to the on call Optum Certified Nurse Practitioner (CNP). New orders were obtained to place resident on ten liters (10 L) of oxygen via a non-rebreather mask. Administer Zofran (antiemetic) 8 milligrams (mg) by mouth times one dose. Obtain full set of vital signs every four hours for twenty-four hours and notify Optum of a heart rate greater than 110 beats per minute, systolic blood pressure less than 100, and SpO2 less than 92%. All orders were implemented. SpO2 was noted at 96% on 10 L oxygen via mask. Resident #90's Power of Attorney (POA) was notified of the situation and plan of action. All concerns were addressed at this time. Resident #90's POA also gave verbal consent to send the resident to the emergency room (ER) if health status declined any further. Shortly after, Optum nurse called this nurse back to check health status and was informed Resident #90 was improving and SpO2 was noted at 100 %. New orders were obtained for STAT (immediate) two view chest x-ray to rule out pneumonia and STAT complete blood count (CBC) w/differential and complete metabolic panel (CMP). Staff currently awaiting arrival. CNP also ordered staff to remove the non-rebreather mask and place the resident on six liters of oxygen via nasal cannula. SpO2 at 97%. No further concerns to report at this time. Staff will continue to monitor for further decline.

Review of the neurological assessment sheet revealed on 08/19/23 at 7:00 A.M. Resident #90's blood pressure was 134/74 and respirations at 19, range of motion and strength normal, pupils were equal and reactive to light. No pulse was assessed.

Review of the medical record revealed no further documented evidence of assessment of Resident #90 until a nursing note dated 08/19/23 at 10:44 A.M. authored by Licensed Practical Nurse (LPN) #1109 revealed when the CNP #1108 called the facility and spoke to this nurse regarding the resident's overall status. This nurse stated that Resident #90 was in stable condition with a temperature of 97.6 degrees F, blood pressure of 119/64, pulse of 108, respirations 18, and SpO2 of 90% on room air. Lungs were clear to auscultation. Resident #90 consumed all her breakfast without incident. No nausea or vomiting, and the lab came to the facility for STAT orders, and the chest x-ray was complete now pending results. CNP #1108 then ordered Augmentin 875 mg (antibiotic) by mouth twice daily for seven days, oxygen on two liters to keep SpO2 above 92%, and consult speech therapy for Monday (08/21/23). Resident #90's daughter was updated.

Review of the nursing note dated 08/19/23 at 12:37 P.M. stated this writer went in to continue re-assessments of Resident #90 and the resident was observed with no visible breathing. This nurse assessment revealed the resident to be absent of all vital signs. Resident #90 absent of blood pressure, pulse, temperature below 98.6 degrees F, no palpable carotid pulse, unable to auscultate apical pulse absence of breathing one full minute. Resident #90 was noted to have oxygen via nasal cannula in proper placement. Additional shift nurse in room to verify resident was absent of all vital signs. Resident #90 was noted to be clean and dry, appearing to be resting in bed with the head of the elevated upon entering the room. No change in resident's skin tone at this time of assessment. Emergency Medical Services (EMS) was contacted and noted Resident #90 to be asystole (no heartbeat) on EKG monitoring and absent of all other vital signs. EMS pronounced Resident #90 dead at 12:17 P.M. The CNP was contacted to inform of Resident #90's expiration. The family was contacted and informed of need to come immediately to the facility. Postmortem care provided by nursing staff for family viewing, the DON and Administrator were informed of Resident #90's expiration.

Interview with CNP #1108 on 09/21/23 at 12:12 P.M. revealed she was in building when Resident #90 fell on 08/17/23, but the resident wouldn't allow an assessment as she was pushing her hand away. She did have a bump on her head. CNP #1108 could not describe how the bump looked, but it might have been a little raised. I offered to send her for a CT (computerized tomography) scan, but the resident refused, and Resident #90's daughter said she would come in. I looked at her chart over the weekend. I ordered neurological assessments and a fall protocol. I didn't think she needed to go to the ER but did offer. If a resident is a Do Not Resuscitate Comfort Care (DNRCC), I would never say no, not to send them, but I didn't think she needed to go, and would send if needed. Resident #90 was stable on Friday (08/18/23), the nurse and the daughter called me but there was another CNP on call, so I didn't answer (I was not supposed to). When I came in Monday, 08/21/23, she had died. There was an on call CNP from Friday, 08/18/23 from 5:00 P.M. until Monday, 08/21/23 at 8:00 A.M. When asked if she knew the cause of death, she stated she believed it was aspiration pneumonia. If I had been on call, I would have ordered oxygen as needed, labs, and chest x-ray. Maybe breathing treatments, albuterol and depending on chest x-ray results, steroid, vital signs every four hours or every shift.

Interview with the Administrator and Director of Nursing (DON) on 09/21/23 1:35 P.M. revealed the DON did not know if Resident #90 had a head injury related to the fall, she did not see her. She stated when a chest x-ray is ordered STAT, we have to wait, it takes time for the x-ray company to get here. The Administrator stated a STAT order takes approximately six to eight hours. The Administrator stated Resident #90 had stabilized by the time they did the chest x-ray. The Administrator verified the nursing staff did not document the bump on Resident #90's head from the fall on 08/17/23 in the medical record. The DON stated she had no idea why the nurses did not assess Resident #90's vital signs every four hours as ordered by the CNP on 08/18/23.

Interview with LPN #1109 on 09/21/23 at 2:39 P.M. stated she worked 08/19/23 from 7:00 A.M. to 7:00 P.M. She stated she spoke to Resident #90 on morning rounds because heard she might have aspirated. Resident #90 denied pain not in pain and shortness of breath, was wearing oxygen, and ate breakfast. She stated she spoke to the CNP who ordered antibiotics and a chest x-ray. I checked on Resident #90 after breakfast to notify her of the blood draw, and next time I went to see her (12:17 P.M.) she had expired. She stated Resident #90 had oxygen the whole time, they were trying to wean her, and she tugged at it periodically. When asked about assessments, LPN #1109 stated when she completed resident assessments, she documented them in the electronic health record. She stated she remembers doing assessments for Resident #90, but does not recall where she documented them as they were not documented in the electronic health record until her conversation with the CNP on 08/19/23 at 10:44 A.M.

Review of the facility policy titled Notification of changes

Based on observation, record review, facility policy and procedure review and interview the facility failed to prevent an in-house acquired pressure ulcer for Resident #14. Actual Harm occurred on 05/23/23 when Resident #14, who was dependent on staff for bed mobility, was observed to have an unstageable/suspected deep tissue injury (SDTI) (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear) pressure ulcer to the left heel. Following the development of the ulcer, the area declined to a Stage IV pressure ulcer with odor noted with recommendation for hospitalization and possible amputation. This affected one resident (#14) of three residents reviewed for pressure ulcers. The facility census was 98. Findings include: Review of the medical record revealed Resident #14 was admitted to the facility on 10/05/21 with diagnoses including peripheral vascular disease, type II diabetes mellitus, hypertension, altered mental status, neuromuscular dysfunction of the bladder, and paraplegia. A plan of care, dated 10/05/21 included an intervention to encourage resident to turn and reposition every two hours and as needed. However, there was no documented evidence on the administration records of turning and repositioning being provided for the resident. Review of the Braden Scale for predicting pressure sore risk dated 03/16/23 revealed Resident #14 was at a low risk for pressure ulcer development. Review of a skin observation document dated 05/22/23 revealed the resident had no new skin areas noted. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated 05/23/23 revealed Resident #14 was cognitively intact. The assessment revealed the resident required extensive assistance from two staff for bed mobility, extensive assistance from one staff for hygiene and was dependent on two staff for transfers. The resident had an indwelling (Foley) catheter and an ostomy. The assessment also noted the resident was at risk for skin breakdown and had no behaviors, including refusal of care. Record review revealed no updates to the resident's plan of care until 08/09/23 related to risk for pressure ulcers. Review of a skin grid dated 05/23/23 revealed Resident #14 had a new area to the left heel first identified as an unstageable SDTI measuring 7.0 centimeters (cm) in length by 5.0 cm width with an undetermined depth. The ulcer was noted to have 100 percent (%) necrotic tissue. New orders were received to cleanse the left heel with wound cleanser/normal saline, pat dry, cover with abdominal pad (ABD) and wrap with Kerlix gauze, daily and as needed. Record review revealed no evidence the dietitian was notified of the development of the left heel wound to implement nutritional interventions to promote healing. Review of the skin grid dated 06/06/23 revealed the left heel was not assessed because Resident #14 was on a leave of absence (LOA) with activities. Review of the skin grid dated 06/13/23 revealed to the left heel wound measured 7.0 cm length by 6.0 cm width with an undetermined depth due to the presence of 100% necrotic tissue. The wound was now classified as an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed). There was no evidence the dietitian was notified of the presence of the ulcer at this time. Review of the skin grid dated 06/20/23 revealed the left heel wound measured 8.0 cm length by 6.0 cm width with an undetermined depth due to the presence of 100% necrotic tissue. There was no evidence the dietitian was notified of the presence of the ulcer at this time. Review of the skin grid dated 06/27/23 revealed the left heel wound measured 7.0 cm length by 4.0 cm width with an undetermined depth due to 50% necrotic tissue and 50% granular tissue. The wound was debrided sharply manually with curette at this time. There was no evidence the dietitian was notified of the presence of the ulcer at this time. Review of the skin grid dated 07/11/23 revealed the left heel wound measured 8.0 cm length by 5.5 cm width with an undetermined depth due to 50% necrotic tissue and 50% granular tissue. The wound was treated with enzymatic debridement (removal of necrotic/dead tissue), Santyl (ointment used to aid in the healing of skin ulcers), calcium alginate (dressing used to repair wounds), ABD (dressing used for wounds with heavy leakage) and Kerlix gauze. Review of the skin grid dated 07/18/23 revealed the left heel wound measured 8.5 cm length by 4.5 cm width with an undetermined depth due to 50% necrotic tissue and 50% granular tissue. The wound was debrided. There was no evidence the dietitian was notified of the presence of the left heel wound at this time. Review of the skin grid dated 07/25/23 revealed the left heel wound measured 7.5 cm length by 5.5 cm width with an undetermined depth due to 50% necrotic tissue and 50% granular tissue. There was no evidence the dietitian was notified of the presence of the left heel wound at this time. Review of the skin grid dated 08/01/23 revealed the left heel wound measured 9.0 cm in length by 7.0 cm width with an undetermined depth due to 75% necrotic tissue and 25% granular tissue. There was no evidence the dietitian was notified of the presence of the left heel wound at this time. The assessment of the wound at this time noted it was larger and had an increase in necrotic tissue. Review of a dietary progress note dated 08/09/23 revealed Registered Dietitian (RD) #1111 was notified of the left heel wound and made recommendations for a multivitamin, Vitamin C 500 milligrams (mg) twice per day (BID) for 30 days, Zinc Sulfate 220 mg every day (QD) for 14 days and liquid protein 30 milliliters (ml) QD for 30 days to promote wound healing. Review of the skin grid dated 08/15/23 revealed the left heel wound measured 6.0 cm length by 5.0 cm width with a measurable depth of 0.3 cm. The wound was assessed to continue to have 75% necrotic tissue and 25% granular tissue. The note revealed the physician was notified of a decline in the wound status. The wound was cleansed, flushed, and irrigated, and prepared for debridement/dressing. A dressing of calcium alginate, ABD pad, and kerlix gauze was applied. The wound was now classified as a Stage IV (full-thickness tissue loss with exposed bone, tendon, or muscle. Slough may be present on some parts of the wound bed) pressure ulcer. Record review revealed as of 08/15/23 there was no evidence RD #1111's recommendations (dated 08/09/23) had been implemented. Review of the skin grid dated 08/22/23 revealed the left heel wound measured 8.0 cm length by 5.0 cm width with 0.3 cm depth. The wound was noted to have 75% necrotic tissue and 25% granular tissue. The note indicated the physician was notified of a decline in wound status. Review of the wound progress note dated 08/22/23 and completed by Medical Doctor (MD) #1113 revealed the resident's left heel wound was declining and bone was exposed. MD #1113 recommended the resident be sent to the hospital for evaluation with the possible need for amputation; however, Resident #14 declined the recommendation at that time. Record review revealed as of 08/22/23 there was no evidence RD #1111's recommendations (dated 08/09/23) had been implemented. On 08/23/23 new physician orders were obtained for Vitamin C 500 mg BID for 30 days, Zinc Sulfate 220mg QD for 14 days and Pro Stat oral liquid 30 ml QD for 30 days. Review of the skin grid dated 09/05/23 revealed the left heel wound measured 9.0 cm length by 7.0 cm width with 0.3 cm depth. The wound was assessed to have 50% necrotic tissue and 50% granular tissue with bone exposed and an odor. MD #1113 was notified of the decline and recommended a hospital evaluation with the possible need for amputation; however, the resident continued to refuse to go to the hospital. The wound was treated with autolytic bone debridement (breakdown of damaged issue) and calcium alginate, ABD pad, and Kerlix gauze were applied. Review of the skin grid dated 09/12/23 revealed the left heel wound measured 9.0 cm length by 9.0 cm width with a depth of 0.3 cm. The wound was assessed to have 50% necrotic tissue and 50% granular tissue with bone exposed and odor. The wound was assessed to have declined. MD #1113 was notified of the decline and recommended a hospital evaluation with the possible need for amputation; however, the resident continued to refuse. The wound was treated with autolytic bone debridement and calcium alginate, ABD pad, and Kerlix gauze were applied. Review of the skin grid dated 09/19/23 revealed the left heel wound measured 9.0 cm length by 6.0 cm width with 0.3 cm depth and was assessed to show improvement. Interview on 09/26/23 at 8:09 A.M. with the Director of Nursing (DON) revealed when a recommendation from the RD comes in, the facility would implement the recommendation within seven days. She confirmed the orders for Resident #14 for Vitamin C 500 mg BID for 30 days, Zinc Sulfate 220 mg QD for 14 days and Pro Stat oral liquid 30 ml QD for 30 days were implemented 13 days after they were recommended, which was longer than it should have been. Interview on 09/26/23 at 11:09 A.M. with Registered Nurse (RN)/Assistant Director of Nursing (ADON)/Wound Nurse #1109 revealed she could not explain how Resident #14 developed an unstageable STDI on 05/23/23 when no new issues were reported to his skin on 05/22/23. RN #1109 revealed there was no way an injury like that could have developed in one day. Interview on 09/26/32 at 11:31 A.M. with RD #1112 (RD #1111 was not available to interview) revealed the dietician was first notified of the new heel wound for Resident #14 on 08/09/23. Observation on 09/26/23 at 1:33 P.M. of Resident #14's left heel revealed a wound was present with a moderate amount of reddish-brown drainage with no tunnelling. The wound measured 8.0 cm length by 6.0 cm width with no measurable depth. An interview with MD #1113 at the time of the observation revealed the wound was currently showing improvement. The MD did not provide any additional information as to how or why the pressure ulcer developed. Interview 09/28/23 at 9:47 A.M. with Resident #14 revealed the MD #1113 talked to him about needing to go to the hospital for his foot, but stated he never mentioned it might need to be amputated. Resident #14 said he did agree to go to the hospital, but never did because the wound started to get better. Interview with the Administrator on 09/28/23 at 10 45 A.M. revealed a wound culture and or/antibiotic was not ordered when the odor was first identified on 09/05/23 or anytime thereafter. Review of the facility policy titled Pressure Ulcers/Skin Breakdown - Clinical ProtocolBased on observation, record review, facility policy and procedure review and interview the facility failed to prevent an in-house acquired pressure ulcer for Resident #14.

Actual Harm occurred on 05/23/23 when Resident #14, who was dependent on staff for bed mobility, was observed to have an unstageable/suspected deep tissue injury (SDTI) (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear) pressure ulcer to the left heel. Following the development of the ulcer, the area declined to a Stage IV pressure ulcer with odor noted with recommendation for hospitalization and possible amputation. This affected one resident (#14) of three residents reviewed for pressure ulcers. The facility census was 98.

Findings include:

Review of the medical record revealed Resident #14 was admitted to the facility on 10/05/21 with diagnoses including peripheral vascular disease, type II diabetes mellitus, hypertension, altered mental status, neuromuscular dysfunction of the bladder, and paraplegia.

A plan of care, dated 10/05/21 included an intervention to encourage resident to turn and reposition every two hours and as needed. However, there was no documented evidence on the administration records of turning and repositioning being provided for the resident.

Review of the Braden Scale for predicting pressure sore risk dated 03/16/23 revealed Resident #14 was at a low risk for pressure ulcer development.

Review of a skin observation document dated 05/22/23 revealed the resident had no new skin areas noted.

Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated 05/23/23 revealed Resident #14 was cognitively intact. The assessment revealed the resident required extensive assistance from two staff for bed mobility, extensive assistance from one staff for hygiene and was dependent on two staff for transfers. The resident had an indwelling (Foley) catheter and an ostomy. The assessment also noted the resident was at risk for skin breakdown and had no behaviors, including refusal of care. Record review revealed no updates to the resident's plan of care until 08/09/23 related to risk for pressure ulcers.

Review of a skin grid dated 05/23/23 revealed Resident #14 had a new area to the left heel first identified as an unstageable SDTI measuring 7.0 centimeters (cm) in length by 5.0 cm width with an undetermined depth. The ulcer was noted to have 100 percent (%) necrotic tissue. New orders were received to cleanse the left heel with wound cleanser/normal saline, pat dry, cover with abdominal pad (ABD) and wrap with Kerlix gauze, daily and as needed.

Record review revealed no evidence the dietitian was notified of the development of the left heel wound to implement nutritional interventions to promote healing.

Review of the skin grid dated 06/06/23 revealed the left heel was not assessed because Resident #14 was on a leave of absence (LOA) with activities.

Review of the skin grid dated 06/13/23 revealed to the left heel wound measured 7.0 cm length by 6.0 cm width with an undetermined depth due to the presence of 100% necrotic tissue. The wound was now classified as an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed). There was no evidence the dietitian was notified of the presence of the ulcer at this time.

Review of the skin grid dated 06/20/23 revealed the left heel wound measured 8.0 cm length by 6.0 cm width with an undetermined depth due to the presence of 100% necrotic tissue. There was no evidence the dietitian was notified of the presence of the ulcer at this time.

Review of the skin grid dated 06/27/23 revealed the left heel wound measured 7.0 cm length by 4.0 cm width with an undetermined depth due to 50% necrotic tissue and 50% granular tissue. The wound was debrided sharply manually with curette at this time. There was no evidence the dietitian was notified of the presence of the ulcer at this time.

Review of the skin grid dated 07/11/23 revealed the left heel wound measured 8.0 cm length by 5.5 cm width with an undetermined depth due to 50% necrotic tissue and 50% granular tissue. The wound was treated with enzymatic debridement (removal of necrotic/dead tissue), Santyl (ointment used to aid in the healing of skin ulcers), calcium alginate (dressing used to repair wounds), ABD (dressing used for wounds with heavy leakage) and Kerlix gauze.

Review of the skin grid dated 07/18/23 revealed the left heel wound measured 8.5 cm length by 4.5 cm width with an undetermined depth due to 50% necrotic tissue and 50% granular tissue. The wound was debrided. There was no evidence the dietitian was notified of the presence of the left heel wound at this time.

Review of the skin grid dated 07/25/23 revealed the left heel wound measured 7.5 cm length by 5.5 cm width with an undetermined depth due to 50% necrotic tissue and 50% granular tissue. There was no evidence the dietitian was notified of the presence of the left heel wound at this time.

Review of the skin grid dated 08/01/23 revealed the left heel wound measured 9.0 cm in length by 7.0 cm width with an undetermined depth due to 75% necrotic tissue and 25% granular tissue. There was no evidence the dietitian was notified of the presence of the left heel wound at this time. The assessment of the wound at this time noted it was larger and had an increase in necrotic tissue.

Review of a dietary progress note dated 08/09/23 revealed Registered Dietitian (RD) #1111 was notified of the left heel wound and made recommendations for a multivitamin, Vitamin C 500 milligrams (mg) twice per day (BID) for 30 days, Zinc Sulfate 220 mg every day (QD) for 14 days and liquid protein 30 milliliters (ml) QD for 30 days to promote wound healing.

Review of the skin grid dated 08/15/23 revealed the left heel wound measured 6.0 cm length by 5.0 cm width with a measurable depth of 0.3 cm. The wound was assessed to continue to have 75% necrotic tissue and 25% granular tissue. The note revealed the physician was notified of a decline in the wound status. The wound was cleansed, flushed, and irrigated, and prepared for debridement/dressing. A dressing of calcium alginate, ABD pad, and kerlix gauze was applied. The wound was now classified as a Stage IV (full-thickness tissue loss with exposed bone, tendon, or muscle. Slough may be present on some parts of the wound bed) pressure ulcer.

Record review revealed as of 08/15/23 there was no evidence RD #1111's recommendations (dated 08/09/23) had been implemented.

Review of the skin grid dated 08/22/23 revealed the left heel wound measured 8.0 cm length by 5.0 cm width with 0.3 cm depth. The wound was noted to have 75% necrotic tissue and 25% granular tissue. The note indicated the physician was notified of a decline in wound status.

Review of the wound progress note dated 08/22/23 and completed by Medical Doctor (MD) #1113 revealed the resident's left heel wound was declining and bone was exposed. MD #1113 recommended the resident be sent to the hospital for evaluation with the possible need for amputation; however, Resident #14 declined the recommendation at that time.

Record review revealed as of 08/22/23 there was no evidence RD #1111's recommendations (dated 08/09/23) had been implemented.

On 08/23/23 new physician orders were obtained for Vitamin C 500 mg BID for 30 days, Zinc Sulfate 220mg QD for 14 days and Pro Stat oral liquid 30 ml QD for 30 days.

Review of the skin grid dated 09/05/23 revealed the left heel wound measured 9.0 cm length by 7.0 cm width with 0.3 cm depth. The wound was assessed to have 50% necrotic tissue and 50% granular tissue with bone exposed and an odor. MD #1113 was notified of the decline and recommended a hospital evaluation with the possible need for amputation; however, the resident continued to refuse to go to the hospital. The wound was treated with autolytic bone debridement (breakdown of damaged issue) and calcium alginate, ABD pad, and Kerlix gauze were applied.

Review of the skin grid dated 09/12/23 revealed the left heel wound measured 9.0 cm length by 9.0 cm width with a depth of 0.3 cm. The wound was assessed to have 50% necrotic tissue and 50% granular tissue with bone exposed and odor. The wound was assessed to have declined. MD #1113 was notified of the decline and recommended a hospital evaluation with the possible need for amputation; however, the resident continued to refuse. The wound was treated with autolytic bone debridement and calcium alginate, ABD pad, and Kerlix gauze were applied.

Review of the skin grid dated 09/19/23 revealed the left heel wound measured 9.0 cm length by 6.0 cm width with 0.3 cm depth and was assessed to show improvement.

Interview on 09/26/23 at 8:09 A.M. with the Director of Nursing (DON) revealed when a recommendation from the RD comes in, the facility would implement the recommendation within seven days. She confirmed the orders for Resident #14 for Vitamin C 500 mg BID for 30 days, Zinc Sulfate 220 mg QD for 14 days and Pro Stat oral liquid 30 ml QD for 30 days were implemented 13 days after they were recommended, which was longer than it should have been.

Interview on 09/26/23 at 11:09 A.M. with Registered Nurse (RN)/Assistant Director of Nursing (ADON)/Wound Nurse #1109 revealed she could not explain how Resident #14 developed an unstageable STDI on 05/23/23 when no new issues were reported to his skin on 05/22/23. RN #1109 revealed there was no way an injury like that could have developed in one day.

Interview on 09/26/32 at 11:31 A.M. with RD #1112 (RD #1111 was not available to interview) revealed the dietician was first notified of the new heel wound for Resident #14 on 08/09/23.

Observation on 09/26/23 at 1:33 P.M. of Resident #14's left heel revealed a wound was present with a moderate amount of reddish-brown drainage with no tunnelling. The wound measured 8.0 cm length by 6.0 cm width with no measurable depth. An interview with MD #1113 at the time of the observation revealed the wound was currently showing improvement. The MD did not provide any additional information as to how or why the pressure ulcer developed.

Interview 09/28/23 at 9:47 A.M. with Resident #14 revealed the MD #1113 talked to him about needing to go to the hospital for his foot, but stated he never mentioned it might need to be amputated. Resident #14 said he did agree to go to the hospital, but never did because the wound started to get better.

Interview with the Administrator on 09/28/23 at 10 45 A.M. revealed a wound culture and or/antibiotic was not ordered when the odor was first identified on 09/05/23 or anytime thereafter.

Review of the facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol

Based on interview, record review, and facility policy review the facility failed eliminate risk hazards when a staff member pushing a dietary cart ran into Resident #90 causing the resident to fall out of her wheelchair. This affected one resident (#90) of three residents reviewed for falls. The facility census was 98. Findings include: Review of the closed medical record for Resident #90 revealed an admission date of 02/28/19 with diagnoses including diabetes, hypertension, altered mental status, and dementia. Review of the Minimum Data Set (MDS) assessment dated 07/27/23 revealed Resident #90 was severely cognitively impaired. She required total assistance of two people for bed mobility and transfers and extensive assistance of one person for dressing, toilet use, and hygiene. Review of the care plan dated 08/17/23 revealed Resident #90 was at risk for falls due to unsteadiness on her feet and impaired cognition. Interventions included using assistive devices for ambulation and non-skin footwear when out of bed. Review of the fall risk assessment dated 07/03/23 revealed Resident #90 was at moderate risk for falls. Review of the nursing note dated 08/17/23 at 11:30 A.M. revealed Resident #90 was sitting in close proximity to the nurse's station when dietary staff member was transporting the breakfast cart and Resident #90 began to ambulate via wheelchair in the path of the cart and fell out of the chair. Resident #90 was assessed for injury, and an abrasion was observed to her right knee. Vital signs were assessed: temperature of 98 degrees Fahrenheit (F), pulse 91, respirations 18, blood pressure 147/82, and oxygen saturation (SpO2) 100 percent (%) on room air. Review of the nursing note dated 08/17/23 at 1:06 P.M. revealed the intervention for Resident #90's fall was to include transporting the resident from the dining room after meals to area of choice close to nurse's station out of the hallways. Review of the facility investigation dated 08/17/23 revealed Cook #1148 revealed he was retrieving the breakfast cart from the dining room when he ran into Resident #90 with the cart. She was assessed by the nurse, and he was educated by the Administrator to pull the cart from the front instead of pushing it from behind. Review of the pain evaluation dated 08/17/23 and timed 10:59 A.M. revealed Resident #90 complained of right knee pain, but no interventions were needed. Review of the facility policy titled Falls policyBased on interview, record review, and facility policy review the facility failed eliminate risk hazards when a staff member pushing a dietary cart ran into Resident #90 causing the resident to fall out of her wheelchair. This affected one resident (#90) of three residents reviewed for falls. The facility census was 98.

Findings include:

Review of the closed medical record for Resident #90 revealed an admission date of 02/28/19 with diagnoses including diabetes, hypertension, altered mental status, and dementia.

Review of the Minimum Data Set (MDS) assessment dated 07/27/23 revealed Resident #90 was severely cognitively impaired. She required total assistance of two people for bed mobility and transfers and extensive assistance of one person for dressing, toilet use, and hygiene.

Review of the care plan dated 08/17/23 revealed Resident #90 was at risk for falls due to unsteadiness on her feet and impaired cognition. Interventions included using assistive devices for ambulation and non-skin footwear when out of bed.

Review of the fall risk assessment dated 07/03/23 revealed Resident #90 was at moderate risk for falls.

Review of the nursing note dated 08/17/23 at 11:30 A.M. revealed Resident #90 was sitting in close proximity to the nurse's station when dietary staff member was transporting the breakfast cart and Resident #90 began to ambulate via wheelchair in the path of the cart and fell out of the chair. Resident #90 was assessed for injury, and an abrasion was observed to her right knee. Vital signs were assessed: temperature of 98 degrees Fahrenheit (F), pulse 91, respirations 18, blood pressure 147/82, and oxygen saturation (SpO2) 100 percent (%) on room air.

Review of the nursing note dated 08/17/23 at 1:06 P.M. revealed the intervention for Resident #90's fall was to include transporting the resident from the dining room after meals to area of choice close to nurse's station out of the hallways.

Review of the facility investigation dated 08/17/23 revealed Cook #1148 revealed he was retrieving the breakfast cart from the dining room when he ran into Resident #90 with the cart. She was assessed by the nurse, and he was educated by the Administrator to pull the cart from the front instead of pushing it from behind.

Review of the pain evaluation dated 08/17/23 and timed 10:59 A.M. revealed Resident #90 complained of right knee pain, but no interventions were needed.

Review of the facility policy titled Falls policy

Based on observation, interview, record review, and facility policy review the facility failed to administer oxygen as ordered. This affected two residents (#5 and #244) of three residents reviewed for respiratory care. The facility census was 98. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 05/04/22. Diagnoses included depression, dementia, arthritis, and asthma. Review of the comprehensive Minimum Data Set (MDS) assessment dated 07/03/23 revealed Resident #5 was rarely or never understood. She required total assistance of two people for bed mobility and transfers and total assistance of one person for dressing, eating, toilet use, and hygiene. She was on oxygen. Review of the physician's orders for September 2023 revealed an order for two liters of oxygen continuously. Review of the care plan dated 07/24/23 revealed Resident #5 had the potential for complications due to asthma. Interventions included assessing for difficulty breathing and administering oxygen as ordered. Observation on 09/18/23 at 10:38 A.M. revealed Resident #5's oxygen was set at three liters. Interview at the time of the observation with Licensed Practical Nurse (LPN) #1115 confirmed Resident #5's oxygen was set at three liters and the order was for it to be set at two liters. 2. Review of the medical record for Resident #244 revealed an admission date of 08/14/23. Diagnoses included diabetes, hypoxia (low oxygen levels), spinal stenosis (narrowing of the spine), and chronic obstructive pulmonary disease (COPD). Review of the comprehensive MDS assessment dated 08/25/23 revealed Resident #244 was moderately cognitively impaired. He required limited assistance from one person for bed mobility, transfers, toilet use, dressing, and personal hygiene, and was at risk for pressure ulcers. He was on oxygen. Review of the physician's orders for September 2023 revealed an order for five liters of oxygen every shift. Review of the care plan dated 08/15/23 revealed Resident #244 required five liters of oxygen due to COPD. Interventions included administering oxygen as ordered, monitoring lung sounds and observing for signs and symptoms of difficulty breathing. Observation on 09/18/23 at 10:02 A.M. revealed Resident #244's oxygen was set at 4.5 liters. Interview at the time of the observation with Registered Nurse (RN) #1114 confirmed the oxygen was not set to 5 liters as ordered. Review of the facility policy titled Oxygen AdministrationBased on observation, interview, record review, and facility policy review the facility failed to administer oxygen as ordered. This affected two residents (#5 and #244) of three residents reviewed for respiratory care. The facility census was 98.

Findings include:

1. Review of the medical record for Resident #5 revealed an admission date of 05/04/22. Diagnoses included depression, dementia, arthritis, and asthma.

Review of the comprehensive Minimum Data Set (MDS) assessment dated 07/03/23 revealed Resident #5 was rarely or never understood. She required total assistance of two people for bed mobility and transfers and total assistance of one person for dressing, eating, toilet use, and hygiene. She was on oxygen.

Review of the physician's orders for September 2023 revealed an order for two liters of oxygen continuously.

Review of the care plan dated 07/24/23 revealed Resident #5 had the potential for complications due to asthma. Interventions included assessing for difficulty breathing and administering oxygen as ordered.

Observation on 09/18/23 at 10:38 A.M. revealed Resident #5's oxygen was set at three liters. Interview at the time of the observation with Licensed Practical Nurse (LPN) #1115 confirmed Resident #5's oxygen was set at three liters and the order was for it to be set at two liters.

2. Review of the medical record for Resident #244 revealed an admission date of 08/14/23. Diagnoses included diabetes, hypoxia (low oxygen levels), spinal stenosis (narrowing of the spine), and chronic obstructive pulmonary disease (COPD).

Review of the comprehensive MDS assessment dated 08/25/23 revealed Resident #244 was moderately cognitively impaired. He required limited assistance from one person for bed mobility, transfers, toilet use, dressing, and personal hygiene, and was at risk for pressure ulcers. He was on oxygen.

Review of the physician's orders for September 2023 revealed an order for five liters of oxygen every shift.

Review of the care plan dated 08/15/23 revealed Resident #244 required five liters of oxygen due to COPD. Interventions included administering oxygen as ordered, monitoring lung sounds and observing for signs and symptoms of difficulty breathing.

Observation on 09/18/23 at 10:02 A.M. revealed Resident #244's oxygen was set at 4.5 liters. Interview at the time of the observation with Registered Nurse (RN) #1114 confirmed the oxygen was not set to 5 liters as ordered.

Review of the facility policy titled Oxygen Administration

Based on interview, record review, and facility policy review the facility failed to ensure monitoring prior to and following dialysis treatments for Resident #50. This affected one resident (#50) of one resident reviewed for dialysis. The facility census was 98.

Findings include:

Review of the medical record for Resident #50 revealed an admission date of 10/19/22 with diagnoses including diabetes mellitus with kidney complication, adult failure to thrive, paranoid schizophrenia, dependence on renal dialysis, and end stage renal disease.

Review of the physician's orders dated 08/08/23 revealed an order for dialysis communication tool under the assessment tab in the electronic medical record to be completed and printed to send to dialysis with Resident #50 every Tuesday, Thursday, and Saturday for dialysis assessment.

Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated 08/16/23 for Resident #50 revealed she was on dialysis treatments.

Review of Resident #50's care plan dated 10/19/22 revealed she is at risk for potential complications related to diagnosis of renal failure/end stage renal disease requiring renal dialysis treatment. Interventions included communicating with dialysis center staff regarding plan of care, lab values, diet, and fluid restrictions recommendations, etc. Nurse to utilize dialysis communication form for pre-dialysis assessment including obtaining vital signs.

Review of dialysis communication tool forms for Resident #50 from 08/01/23 to 09/23/23 revealed dialysis communications forms for 08/01/23, 08/03/23, 08/05/23, 08/10/23, 08/12/,23, 09/02/23, 09/07/23, 09/12/23, 09/14/23, 09/16/23, and 09/21/23 were not found.

Interview on 09/25/23 at 3:54 P.M. with the Administrator confirmed the facility did not have further evidence of dialysis communication forms for the identified missing dates to review.

Review of the facility policy titled Dialysis, Pre and Post Care

Based on record review, staff interview, self-reported incident (SRI) review, and facility policy review the facility failed to implement interventions to attain or maintain a resident's highest practicable psychosocial well-being. This affected one resident (#73) of four residents reviewed for behaviors. The facility census was 98. Findings include: 1. Resident #81 was admitted to the facility on 06/16/23 with diagnoses including depression, bipolar disorder, psychotic disorder with delusions, and schizophrenia. The resident resides on the facility's secured unit. Review of the comprehensive admission minimum data set (MDS), dated 06/24/23, revealed Resident #81 was moderately cognitively impaired, exhibited no behaviors during the assessment period, and was non-ambulatory. Review of Resident #81's care plans revealed he was at risk for altered cognitive function related to schizophrenia and would have alterations in behavior leading to abusive attacks on staff and residents. Review of the nursing progress note dated 08/12/23 at 3:00 A.M. revealed Resident #81 returned from a local Emergency Department (ED) with no new orders. At 3:05 A.M. Registered Nurse (RN) #1113 notified the resident's physician had been sent to the ED for evaluation of facial injuries sustained during a resident-to-resident altercation. 2.Resident #73 was admitted to the facility on 11/15/22 with diagnoses including vascular dementia with behavioral disturbance, chronic obstructive pulmonary disease, bipolar disorder, depression, and anxiety. The resident resided on the facility's secured unit. Review of the comprehensive quarterly MDS assessment dated 07/21/23 revealed Resident #73 was moderately cognitively impaired, wandered several days during the assessment period, and was independently ambulatory. Review of the care plans revealed Resident #73 had newly implemented plans, dated 09/25/23, regarding impaired cognitive function, impaired thought processes, wandering, and behavior problems. Review of the nursing progress note dated 08/12/23 revealed Resident #73 assaulted Resident #81 at approximately 11:30 P.M. on 08/11/23. Resident #73 was very aggressive, and the agency nurse called 911 but they never arrived at the facility. The resident continued to walk into other resident's rooms and threatened to hit the staff. Continued review of the nursing progress notes revealed the resident's behaviors continued to increase including his wandering and aggressiveness. Resident #73 was transferred to the ED on 08/22/23 due to increased agitation and aggression. After being evaluated the resident returned to the facility with no new orders. On 09/26/23 Resident #73 had an initial evaluation by the facility psychiatrist for his increased aggression, combativeness, and wandering. Review of the facility's SRI #238031, dated 08/12/23, revealed Resident #73 hit Resident #81 in the face after Resident #81 told Resident #73 to stay out of his room. Resident #73 had been having increased behaviors in the previous several months, was wandering in and out of other resident's room, and was difficult to redirect. Resident #81 requested to be sent to the ED for evaluation and returned with no new orders. The police were notified while at the ED and interviewed Resident #81 who declined to file charges. When the facility attempted to talk to Resident #73 about the incident, the resident did not want to discuss the incident/did not remember the incident. The facility obtained witness statements, did skin checks on all the residents on the unit. Resident #73's room was changed to the opposite end of the unit as an intervention to prevent further abuse. All staff were educated on abuse. The facility unsubstantiated the allegation of abuse as as no abuse per definition has occurred with alleged incident. Interview with Social Services Director (SSD) #1164 on 09/25/23 at 10:50 A.M. confirmed Resident #73 has not been seen by the facility's psychiatrist. The resident's primary physician is the one who orders his psychotropic medication (a psychoactive drug taken to exert an effect on the chemical makeup of the brain and nervous system to treat mental health issues). SSD #1164 confirmed the resident's behaviors had been escalating over the last few months. He was referred to a contracted mental health services company approximately three months ago, but they never assessed him until a few days ago as there was a mix up with the referral. The company uses nonpharmacological interventions for treatment. SSD #1164 confirmed she did not follow up with the contracted mental health services company regarding the referral to determine if the assessment had been completed. Interview with the Administrator on 09/25/23 at 5:00 P.M. revealed not all residents need to be followed by a psychiatrist. Review of the facility's Abuse, Neglect, and ExploitationBased on record review, staff interview, self-reported incident (SRI) review, and facility policy review the facility failed to implement interventions to attain or maintain a resident's highest practicable psychosocial well-being. This affected one resident (#73) of four residents reviewed for behaviors. The facility census was 98.

Findings include:

1. Resident #81 was admitted to the facility on 06/16/23 with diagnoses including depression, bipolar disorder, psychotic disorder with delusions, and schizophrenia. The resident resides on the facility's secured unit.

Review of the comprehensive admission minimum data set (MDS), dated 06/24/23, revealed Resident #81 was moderately cognitively impaired, exhibited no behaviors during the assessment period, and was non-ambulatory.

Review of Resident #81's care plans revealed he was at risk for altered cognitive function related to schizophrenia and would have alterations in behavior leading to abusive attacks on staff and residents.

Review of the nursing progress note dated 08/12/23 at 3:00 A.M. revealed Resident #81 returned from a local Emergency Department (ED) with no new orders. At 3:05 A.M. Registered Nurse (RN) #1113 notified the resident's physician had been sent to the ED for evaluation of facial injuries sustained during a resident-to-resident altercation.

2.Resident #73 was admitted to the facility on 11/15/22 with diagnoses including vascular dementia with behavioral disturbance, chronic obstructive pulmonary disease, bipolar disorder, depression, and anxiety. The resident resided on the facility's secured unit.

Review of the comprehensive quarterly MDS assessment dated 07/21/23 revealed Resident #73 was moderately cognitively impaired, wandered several days during the assessment period, and was independently ambulatory.

Review of the care plans revealed Resident #73 had newly implemented plans, dated 09/25/23, regarding impaired cognitive function, impaired thought processes, wandering, and behavior problems.

Review of the nursing progress note dated 08/12/23 revealed Resident #73 assaulted Resident #81 at approximately 11:30 P.M. on 08/11/23. Resident #73 was very aggressive, and the agency nurse called 911 but they never arrived at the facility. The resident continued to walk into other resident's rooms and threatened to hit the staff. Continued review of the nursing progress notes revealed the resident's behaviors continued to increase including his wandering and aggressiveness. Resident #73 was transferred to the ED on 08/22/23 due to increased agitation and aggression. After being evaluated the resident returned to the facility with no new orders. On 09/26/23 Resident #73 had an initial evaluation by the facility psychiatrist for his increased aggression, combativeness, and wandering.

Review of the facility's SRI #238031, dated 08/12/23, revealed Resident #73 hit Resident #81 in the face after Resident #81 told Resident #73 to stay out of his room. Resident #73 had been having increased behaviors in the previous several months, was wandering in and out of other resident's room, and was difficult to redirect. Resident #81 requested to be sent to the ED for evaluation and returned with no new orders. The police were notified while at the ED and interviewed Resident #81 who declined to file charges. When the facility attempted to talk to Resident #73 about the incident, the resident did not want to discuss the incident/did not remember the incident. The facility obtained witness statements, did skin checks on all the residents on the unit. Resident #73's room was changed to the opposite end of the unit as an intervention to prevent further abuse. All staff were educated on abuse. The facility unsubstantiated the allegation of abuse as as no abuse per definition has occurred with alleged incident.

Interview with Social Services Director (SSD) #1164 on 09/25/23 at 10:50 A.M. confirmed Resident #73 has not been seen by the facility's psychiatrist. The resident's primary physician is the one who orders his psychotropic medication (a psychoactive drug taken to exert an effect on the chemical makeup of the brain and nervous system to treat mental health issues). SSD #1164 confirmed the resident's behaviors had been escalating over the last few months. He was referred to a contracted mental health services company approximately three months ago, but they never assessed him until a few days ago as there was a mix up with the referral. The company uses nonpharmacological interventions for treatment. SSD #1164 confirmed she did not follow up with the contracted mental health services company regarding the referral to determine if the assessment had been completed.

Interview with the Administrator on 09/25/23 at 5:00 P.M. revealed not all residents need to be followed by a psychiatrist.

Review of the facility's Abuse, Neglect, and Exploitation

Based on record review, interview, and facility policy review the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of pain medication for Resident #80. This affected one resident (#80) of five residents reviewed for unnecessary medication use. The facility census was 98. Findings include: Review of the medical record for Resident #80 revealed and admission date of 05/31/23. Diagnoses included diabetes, hypertension, depression, anxiety, and heart failure. Review of the comprehensive MDS assessment dated 06/07/23 revealed Resident #80 was moderately cognitively impaired. She required supervision and set up help for bed mobility, transfers, dressing, eating, toilet use, and hygiene. She had trouble falling and staying asleep, she felt down and depressed, had little interest in doing things, had trouble concentrating and displayed no behavior. Review of the physician's orders for September 2023 revealed Resident #80 was ordered Percocet (opioid pain medication) 5-325 milligram (mg) tablet every six hours as needed (prn) for pain and Acetaminophen (analgesic) 325 mg two tablets every six hours prn for pain. Review of the Medication Administration Record (MAR) for September 2023 revealed Resident #80 received Percocet 5-325 mg for a pain level of zero on a one to ten scale with ten being the worst, two times on 09/02/23, a pain level of seven once on 09/02/23, a pain level of three once on 09/03/23, a pain level of ten once on 09/05/23, a pain level of eight once on 09/08/23, a pain level of three once on 09/09/23 and a pain level of ten once on 09/09/23, a pain level of three two times on 09/10/23, a pain level of five on once on 09/11/23, a pain level of eight two times on 09/12/23, a pain level of four one time on 09/13/23, a pain level of ten two times on 09/15/23, a pain level of three once on 09/16/23 and a pain level of ten once on 09/16/23 and a pain level of two once on 09/17/23. The resident received Acetaminophen 325mg for a pain level of ten on 09/15/23 and 09/16/23. Review of the progress notes for September 2023 revealed non-pharmacological interventions were attempted prior to Percocet administration once on 09/02/23, 09/03/23, 09/08/23, 09/09/23, 09/10/23, once on 09/12/23 and once on 09/15/23. There was no evidence non-pharmacological interventions were attempted prior to Acetaminophen administration on 09/15/23 and 09/16/23. Interview on 09/20/23 at 1:31 P.M. with Licensed Practical Nurse (LPN) #1133 revealed if non-pharmacological interventions were attempted, they would be documented in progress notes. She revealed she would use her nursing judgment to determine whether to administer Acetaminophen or Percocet. If the resident reported a pain level from one to four, she would administer Acetaminophen, if a pain level of five through ten was reported she would administer Percocet. Interview on 09/20/23 at 2:53 P.M. with the Director of Nursing (DON) confirmed the physician's order did not specify when to administer Acetaminophen versus Percocet. She revealed if nonpharmacological interventions were attempted, they would be documented in the progress notes. She also revealed she would use her judgment to determine whether to administer Acetaminophen or Percocet. Generally, if a resident reported a pain level of five or higher, she would administer Percocet. Review of the facility policy titled Pain ManagementBased on record review, interview, and facility policy review the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of pain medication for Resident #80. This affected one resident (#80) of five residents reviewed for unnecessary medication use. The facility census was 98.

Findings include:

Review of the medical record for Resident #80 revealed and admission date of 05/31/23. Diagnoses included diabetes, hypertension, depression, anxiety, and heart failure.

Review of the comprehensive MDS assessment dated 06/07/23 revealed Resident #80 was moderately cognitively impaired. She required supervision and set up help for bed mobility, transfers, dressing, eating, toilet use, and hygiene. She had trouble falling and staying asleep, she felt down and depressed, had little interest in doing things, had trouble concentrating and displayed no behavior.

Review of the physician's orders for September 2023 revealed Resident #80 was ordered Percocet (opioid pain medication) 5-325 milligram (mg) tablet every six hours as needed (prn) for pain and Acetaminophen (analgesic) 325 mg two tablets every six hours prn for pain.

Review of the Medication Administration Record (MAR) for September 2023 revealed Resident #80 received Percocet 5-325 mg for a pain level of zero on a one to ten scale with ten being the worst, two times on 09/02/23, a pain level of seven once on 09/02/23, a pain level of three once on 09/03/23, a pain level of ten once on 09/05/23, a pain level of eight once on 09/08/23, a pain level of three once on 09/09/23 and a pain level of ten once on 09/09/23, a pain level of three two times on 09/10/23, a pain level of five on once on 09/11/23, a pain level of eight two times on 09/12/23, a pain level of four one time on 09/13/23, a pain level of ten two times on 09/15/23, a pain level of three once on 09/16/23 and a pain level of ten once on 09/16/23 and a pain level of two once on 09/17/23. The resident received Acetaminophen 325mg for a pain level of ten on 09/15/23 and 09/16/23.

Review of the progress notes for September 2023 revealed non-pharmacological interventions were attempted prior to Percocet administration once on 09/02/23, 09/03/23, 09/08/23, 09/09/23, 09/10/23, once on 09/12/23 and once on 09/15/23. There was no evidence non-pharmacological interventions were attempted prior to Acetaminophen administration on 09/15/23 and 09/16/23.

Interview on 09/20/23 at 1:31 P.M. with Licensed Practical Nurse (LPN) #1133 revealed if non-pharmacological interventions were attempted, they would be documented in progress notes. She revealed she would use her nursing judgment to determine whether to administer Acetaminophen or Percocet. If the resident reported a pain level from one to four, she would administer Acetaminophen, if a pain level of five through ten was reported she would administer Percocet.

Interview on 09/20/23 at 2:53 P.M. with the Director of Nursing (DON) confirmed the physician's order did not specify when to administer Acetaminophen versus Percocet. She revealed if nonpharmacological interventions were attempted, they would be documented in the progress notes. She also revealed she would use her judgment to determine whether to administer Acetaminophen or Percocet. Generally, if a resident reported a pain level of five or higher, she would administer Percocet.

Review of the facility policy titled Pain Management

Based on medical record review, staff interview, pharmacy review, and facility policy review the facility failed to ensure attempts were made to decrease dosages of psychotropic medications. This affected one resident (#73) of five residents reviewed for unnecessary medications. The facility census was 98. Findings include: Resident #73 was admitted to the facility on 11/15/22 with diagnoses including vascular dementia with behavioral disturbance, chronic obstructive pulmonary disease (COPD), bipolar disorder, depression, and anxiety. The resident resided on the facility's secured unit. Review of the comprehensive quarterly Minimum Data Set (MDS) assessment dated 07/21/23 revealed Resident #73 was moderately cognitively impaired, wandered several days during the assessment period, and was independently ambulatory. He received antipsychotic medication seven out of seven days of the assessment period and an antidepressant seven out of seven days of the assessment period. The assessment noted no gradual dose reduction (GDR) had been attempted. Review of the physician's orders for Resident #73 revealed an order dated 11/15/22 for Seroquel (an antipsychotic medication) 300 milligrams (mg) by mouth once a day at bedtime. On 11/16/22 an order was written for Effexor XR (an antidepressant) 75 mg by mouth once a day for depression. On 08/15/23 an order was written for Depakote Sprinkles (an anticonvulsant which is also used as a mood stabilizer) 125 mg by mouth twice a day for vascular dementia. Review of the pharmacist recommendations dated 04/06/23 revealed: Seroquel 300 mg requires a GDR attempt twice within the first year and then annually unless clinically contraindicated. Resident #73's nurse practitioner responded on 04/27/23 that the resident's target symptoms returned or worsened after most recent GDR attempt and another attempt at this time is likely to impair the individual's function or cause psychiatric instability by exacerbating a medical condition or psychiatric disorder. Effexor 75 mg requires a GDR attempt twice within the first year and then annually unless clinically contraindicated. Resident #73's general nurse practitioner responded on 04/27/23 that the resident's target symptoms returned or worsened after most recent GDR attempt and another attempt at this time is likely to impair the individual's function or cause psychiatric instability by exacerbating an medical condition or psychiatric disorder. Review of the nursing progress notes for Resident #73 revealed no attempts at a GDR. Review of the Medication Administration Record (MAR) from admission through the present revealed no attempts at a GDR. Review of the care plans for Resident #73 revealed a care plan initiated on 07/25/23 that he uses Seroquel for behavior management. The resident has received Seroquel since his admission on 11/15/22. The care plan had no interventions regarding a GDR. A care plan was initiated on 07/25/23 for use of an antidepressant which the resident had been receiving since 11/16/22. The care plan had no interventions regarding a GDR. A care plan for use of Depakote Sprinkles had not been initiated as to what to monitor for or for associated lab work. Interview with Registered Nurse (RN) #1167 on 09/26/23 at 1:42 P.M. confirmed Resident #73's care plans should have been developed for the resident's behaviors and for the resident's diagnosis of COPD and the associated medications. The facility will make every effort to comply with state and federal regulations in long term care. Psychotropic medications include antianxiety/hypnotic medications, antipsychotic medication, and antidepressant classes of drugs. Interview with the Director of Nursing (DON) on 09/26/23 at 9:00 A.M. confirmed there had not been an attempt to gradually reduce the dosage of Resident #73's Seroquel or Effexor XR. The nurse practitioner addressed the pharmacy's 04/06/23 request by indicating the resident's target symptoms returned or worsened after the most recent GDR attempt within the facility and a GDR attempt at this time is likely to impair the individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder. She said the medication doses did not change because the general nurse practitioner felt it was inappropriate, so a GDR was never attempted despite marking it had been attempted previously. Review of the facility's Psychotropic MedicationsBased on medical record review, staff interview, pharmacy review, and facility policy review the facility failed to ensure attempts were made to decrease dosages of psychotropic medications. This affected one resident (#73) of five residents reviewed for unnecessary medications. The facility census was 98.

Findings include:

Resident #73 was admitted to the facility on 11/15/22 with diagnoses including vascular dementia with behavioral disturbance, chronic obstructive pulmonary disease (COPD), bipolar disorder, depression, and anxiety. The resident resided on the facility's secured unit.

Review of the comprehensive quarterly Minimum Data Set (MDS) assessment dated 07/21/23 revealed Resident #73 was moderately cognitively impaired, wandered several days during the assessment period, and was independently ambulatory. He received antipsychotic medication seven out of seven days of the assessment period and an antidepressant seven out of seven days of the assessment period. The assessment noted no gradual dose reduction (GDR) had been attempted.

Review of the physician's orders for Resident #73 revealed an order dated 11/15/22 for Seroquel (an antipsychotic medication) 300 milligrams (mg) by mouth once a day at bedtime. On 11/16/22 an order was written for Effexor XR (an antidepressant) 75 mg by mouth once a day for depression. On 08/15/23 an order was written for Depakote Sprinkles (an anticonvulsant which is also used as a mood stabilizer) 125 mg by mouth twice a day for vascular dementia.

Review of the pharmacist recommendations dated 04/06/23 revealed:

Seroquel 300 mg requires a GDR attempt twice within the first year and then annually unless clinically contraindicated. Resident #73's nurse practitioner responded on 04/27/23 that the resident's target symptoms returned or worsened after most recent GDR attempt and another attempt at this time is likely to impair the individual's function or cause psychiatric instability by exacerbating a medical condition or psychiatric disorder.

Effexor 75 mg requires a GDR attempt twice within the first year and then annually unless clinically contraindicated. Resident #73's general nurse practitioner responded on 04/27/23 that the resident's target symptoms returned or worsened after most recent GDR attempt and another attempt at this time is likely to impair the individual's function or cause psychiatric instability by exacerbating an medical condition or psychiatric disorder.

Review of the nursing progress notes for Resident #73 revealed no attempts at a GDR.

Review of the Medication Administration Record (MAR) from admission through the present revealed no attempts at a GDR.

Review of the care plans for Resident #73 revealed a care plan initiated on 07/25/23 that he uses Seroquel for behavior management. The resident has received Seroquel since his admission on 11/15/22. The care plan had no interventions regarding a GDR. A care plan was initiated on 07/25/23 for use of an antidepressant which the resident had been receiving since 11/16/22. The care plan had no interventions regarding a GDR. A care plan for use of Depakote Sprinkles had not been initiated as to what to monitor for or for associated lab work.

Interview with Registered Nurse (RN) #1167 on 09/26/23 at 1:42 P.M. confirmed Resident #73's care plans should have been developed for the resident's behaviors and for the resident's diagnosis of COPD and the associated medications. The facility will make every effort to comply with state and federal regulations in long term care. Psychotropic medications include antianxiety/hypnotic medications, antipsychotic medication, and antidepressant classes of drugs.

Interview with the Director of Nursing (DON) on 09/26/23 at 9:00 A.M. confirmed there had not been an attempt to gradually reduce the dosage of Resident #73's Seroquel or Effexor XR. The nurse practitioner addressed the pharmacy's 04/06/23 request by indicating the resident's target symptoms returned or worsened after the most recent GDR attempt within the facility and a GDR attempt at this time is likely to impair the individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder. She said the medication doses did not change because the general nurse practitioner felt it was inappropriate, so a GDR was never attempted despite marking it had been attempted previously.

Review of the facility's Psychotropic Medications

Based on observation, interviews, facility policy review, and facility invoices, the facility failed to serve hot and palatable foods. This had the potential to affect all residents. The facility identified 97 of 98 residents that received food from the kitchen. Resident #5 was identified as receiving no food by mouth. The facility census was 98.

Findings include:

Interview with Resident #14 on 09/18/23 at 10:29 A.M. revealed the facility's food was horrible.

Interview with Resident #44 on 09/18/23 at 10:41 A.M. revealed the facility's food was nasty and cold.

Interview with Resident #343 on 09/18/23 at 10:49 A.M. revealed the facility's food was poor and not much to it with taste.

During tray line service on 09/18/23 beginning at 11:45 A.M., the kitchen was noted to be without an insulated base and covers for plates while plating the second-floor unit. Observation revealed State Tested Nurse (STNA) #1146 was measuring out cling wrap and placing it over each lunch meal plate.

Interview on 09/18/23 at the time of the observation of the plating of the lunch meal, Food Service Supervisor (FSS) #1145, revealed there were multiple trays that did not have insulated tops and/or bottoms due to not having any available for use. FSS #1145 revealed the facility ordered insulated tops and bottoms a few weeks ago and were waiting for delivery. FSS #1145 revealed there were 28 plates that would be served without insulated tops and bottoms and effected whether the meals would stay warm.

Demonstration of the test tray with FSS #1145 on 09/18/23 at 1:30 P.M. revealed the tray consisted of baked pasta with Italian sausage (noodles with sliced Italian sausage), salad, and a slice of bread. The baked pasta with Italian sausage was noted to be barely warm with little seasoning and measured a temperature of 109 degrees Fahrenheit, the salad was made fresh to order, and the slice of bread was room temperature. FSS #1145 verified the findings of the test tray at the time of observation.

Review of the facility document titled WebstaurantStore Sales Invoice revealed the facility placed an order for 48 cranberry insulated meal delivery bases and 48 insulated dome plate covers. Further review of the document revealed the facility did not place an order for the insulated plate bases and covers until day of the annual survey, 09/18/23.

Review of the facility document titled Monitoring Food Temperatures for Meal Service

Based on observation and staff interview the facility failed to ensure foods were stored in a matter to prevent contamination. This had the potential to affect all residents. The facility identified 97 of 98 residents that received food from the kitchen. Resident #5 was identified as receiving no food by mouth. The facility census was 98.

Findings include:

During the initial kitchen tour on 09/18/23 between 8:30 A.M. and 9:00 A.M. the following was observed:

On 09/18/23 at 8:30 A.M. the ice machine was observed to be open with ice exposed to air and the door was broken and placed on top of the ice machine.

During the tour of the kitchen there were piles of oatmeal spilled at the entryway to the kitchen with other food, dirt, and various spills throughout the kitchen. The trashcan located near the handwashing station adjacent to the kitchen office space, was full and overflowing, the garbage dumpster was open and full of trash spilling out, and multiple small flying bugs were observed throughout the kitchen.

During the tour Dietary Aide (DA) #1137 was observed to be without hair covering.

In the dry pantry area, the following was observed:

A container holding white flour with the scoop inside.

An open bag of macaroni noodles

An open package of tortillas

An open container of ground black pepper and Montreal chicken seasonings

An open bag of powdered sugar

An open can of thick and easy thickener

In the walk-in cooler the following was observed:

A bag of salad undated and open to air

A container of orange liquid drink uncovered.

A container of yellow liquid drink uncovered.

A bag of Monterey jack cheese undated and open to air

A block of American cheese slices undated

A package of lunch meat undated

Dietary Aide (DA) #1137 verified the above findings at the time of the observations.

Observation and Interview on 09/18/23 between 9:15 A.M. and 9:45 A.M. during the second tour of the kitchen, State Tested Nurse Assistant (STNA) #1200 was observed entering the kitchen without hair covering. STNA #1200 revealed she did not know how to put a hairnet on.

Food Service Supervisor (FSS) #1145, during second tour of the kitchen, confirmed and verified the ice machine door was broken, STNA #1200 was without her hair covering, and multiple small flying bugs and/or insects identified as gnats/fruit flies were observed.

Based on observation, record review, personnel file review, job description review, interview, review of a facility Legionella water management plan documentation, review of Centers for Disease Control and Prevention (CDC) guidance, review of facility self-reported incidents (SRI), and review of the Occupational Safety and Health Standards (OSHA) standards for safe oxygen storage the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Tthe facility failed to prevent an in-house acquired pressure ulcer for Resident #14. Actual Harm occurred on 05/23/23 when Resident #14, who was dependent on staff for bed mobility, was observed to have an unstageable/suspected deep tissue injury (SDTI) (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear) pressure ulcer to the left heel. Following the development of the ulcer, the area declined to a Stage IV pressure ulcer with odor noted with recommendation for hospitalization and possible amputation. In addition, the facility failed to fully implement a complete water management program to prevent the growth of Legionella bacteria. In addition, the facility failed to maintain standard infection control protocols regarding isolation precautions. This had the potential to affect all 98 residents residing in the facility. The facility failed to timely notify the physician and dietitian of Resident #294's continued refusal of daily weights, failed to ensure care plans were updated and accurate for seven residents (Residents #7, #14, #35, #73, #80, #244 and #294), failed to develop care plans for Residents # 68, #73, and #82 regarding psychotropic meds and behaviors, failed to adequately monitor Resident #90 after a significant change in condition, failed to serve hot and palatable foods and failed to ensure food was stored in a manner to prevent contamination for all residents except Resident #5 who received nothing by mouth, the facility failed to ensure their environment was maintained in a clean and sanitary manner affecting Resident #4, #14, #18, #23, #33, #46, #68, #76, and #77, the facility failed to ensure kitchen and resident rooms were free from pests potentially affecting all residents, the facility failed to prevent resident-to-resident abuse affecting Resident #81, the facility failed eliminate risk hazards when a staff member pushing a dietary cart ran into Resident #90 causing the resident to fall out of her wheelchair, the facility failed to ensure oxygen tanks were stored and secured in a safe manner. This had the potential to affect all 98 residents residing in the facility.

Findings include:

During the annual and complaint surveys, observations, record reviews and interviews resulted in concerns including but not limited to treatment of pressure ulcers resulting in harm, infection control, care planning, environmental concerns, water management, physician and dietitian notification, monitoring residents after a significant change in condition, palatable foods, food storage, pest control, resident-to-resident abuse, risk hazards, oxygen storage.

1. A situation resulting in Actual Harm occurred on 05/23/23 when Resident #14, who was dependent on staff for bed mobility, was observed to have an unstageable/suspected deep tissue injury (SDTI) (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear) pressure ulcer to the left heel. Following the development of the ulcer, the area declined to a Stage IV pressure ulcer with odor noted with recommendation for hospitalization and possible amputation. Review of a dietary progress note dated 08/09/23 revealed Registered Dietitian (RD) #1111 was notified of the left heel wound and made recommendations for a multivitamin, Vitamin C 500 milligrams (mg) twice per day (BID) for 30 days, Zinc Sulfate 220 mg every day (QD) for 14 days and liquid protein 30 milliliters (ml) QD for 30 days to promote wound healing. Record review revealed as of 08/22/23 there was no evidence RD #1111's recommendations (dated 08/09/23) had been implemented. Interview with the Administrator on 09/28/23 at 10 45 A.M. revealed a wound culture and or/antibiotic was not ordered when the odor was first identified on 09/05/23 or anytime thereafter.

2. Upon entry to the facility, it was discovered nine residents had tested positive for COVID 19 in the last two to three days. Within an hour of our arrival to the facility, five more residents were reported as testing positive for COVID 19. During observations, it was determined staff did not practice appropriate infection control procedures while caring for COVID 19 positive residents as evidenced by staff entering and exiting both COVID 19 positive and negative rooms without the appropriate personal protective equipment (PPE), and not clearly identifying rooms with COVID part 19 positive residents. In addition, the facility did not provide influenza vaccine information and education to all residents.

3. Review of the physician's orders revealed Resident #294 had an order dated 09/05/23 for daily weights related to a diagnosis of congestive heart failure. Interview on 09/20/23 at 1:19 P.M. with Licensed Practical Nurse (LPN) #1133 confirmed daily weights were not recorded in the paper chart for Resident #294. Review of the nursing progress notes from 09/05/23 to 09/21/23 revealed no documented evidence of physician and dietitian notification of the refusals of daily weights and no documented evidence of education provided to Resident #294 of the importance of daily weights for monitoring his diagnosis of congestive heart failure. Interview on 09/25/23 at 12:19 P.M. with the DON confirmed she did not have further documented evidence of physician and/or dietitian notification or resident education for Resident #294's refusals of daily weights.

4. Care plans were not updated and inaccurate for seven residents (Residents #7, #14, #35, #73, #80, #244 and #294). Interview on 09/21/23 at 1:35 PM with the Administrator revealed she was aware there were issues with documentation in the facility, however the facility had taken no actions to correct the concern.

5. The facility failed to develop care plans for Residents # 68, #73, and #82 regarding psychotropic meds and behaviors.

6. The facility failed to adequately monitor Resident #90 after a significant change in condition. Review of the nursing note dated 08/18/23 at 8:24 P.M. revealed staff notified the nurse that Resident #90 had medium emesis and appeared to be in respiratory distress. Upon entering the resident's room, the nurse observed emesis on the bed and floor. The emesis was pink tinged and had chunks of food in it. Resident #90 was sitting on the side of the bed breathing rapidly but was not using accessory muscles. Her blood pressure was 153/79, pulse 109, temperature 97.9 degrees Fahrenheit (F), respirations 22, and oxygen saturation (SpO2) was 78 percent (%) on room air. Staff immediately administered oxygen via nasal canula and her SpO2 increased to 82%. Assessment of abdomen completed without abnormal findings. No signs and symptoms of discomfort were observed. Call placed to the on call Optum Certified Nurse Practitioner (CNP). New orders were obtained to place resident on ten liters (10 L) of oxygen via a non-rebreather mask. Administer Zofran (antiemetic) 8 milligrams (mg) by mouth times one dose. Obtain full set of vital signs every four hours for twenty-four hours and notify Optum of a heart rate greater than 110 beats per minute, systolic blood pressure less than 100, and SpO2 less than 92%. All orders implemented. SpO2 was noted at 96% on 10 L oxygen via mask. Resident #90's Power of Attorney (POA) was notified of the situation and plan of action. All concerns were addressed at this time. Resident #90's Power of Attorney (POA) also gave verbal consent to send the resident to the emergency room (ER) if health status declined any further. Shortly after, Optum nurse called this to nurse back check health status and was informed Resident #90 was improving and SpO2 was noted at 100%. New orders were obtained for STAT (immediate) two view chest x-ray to rule out pneumonia and STAT complete blood count (CBC) w/differential and complete metabolic panel (CMP). Staff currently awaiting arrival. CNP also ordered staff to remove masks and place the resident on six liters of oxygen via nasal cannula. SpO2 at 97%. No further concerns to report at this time. Staff will continue to monitor for further decline. Review of the medical record revealed no further documented evidence of assessment of Resident #90 until a nursing note dated 08/19/23 at 10:44 A.M. authored by Licensed Practical Nurse (LPN) #1109 revealed when the CNP #1108 called the facility and spoke to this nurse regarding the resident's overall status. This nurse stated that Resident #90 was in stable condition with a temperature of 97.6 degrees F, blood pressure of 119/64, pulse of 108, respirations 18, and SpO2 of 90% on room air. Lungs were clear to auscultation. Resident #90 consumed all her breakfast without incident. No nausea or vomiting, and the lab came to the facility for STAT orders, and the chest x-ray was complete now pending results. CNP #1108 then ordered Augmentin 875 mg (antibiotic) by mouth twice daily for seven days, oxygen on two liters to keep SpO2 above 92%, and consult speech therapy for Monday (08/21/23). Resident #90's daughter was updated. Review of the nursing note dated 08/19/23 at 12:37 P.M. stated this writer went in to continue re-assessments of Resident #90 and the resident was observed with no visible breathing. This nurse assessment revealed the resident to be absent of all vital signs. Resident #90 absent of blood pressure, pulse, temperature below 98.6 degrees F, no palpable carotid pulse, unable to auscultate apical pulse absence of breathing one full minute. Resident #90 was noted to have oxygen via nasal cannula in proper placement. Additional shift nurse in room to verify resident was absent of all vital signs. Resident #90 was noted to be clean and dry, appearing to be resting in bed with the head of the elevated upon entering the room. No change in resident's skin tone at this time of assessment. Emergency Medical Services (EMS) was contacted and noted Resident #90 to be asystole (no heartbeat) on EKG monitoring and absent of all other vital signs. EMS pronounced Resident #90 dead at 12:17 P.M. The CNP was contacted to inform of Resident #90's expiration. The family was contacted and informed of need to come immediately to the facility. Postmortem care provided by nursing staff for family viewing, the DON and Administrator were informed of Resident #90's expiration. Interview with the DON on 09/21/23 1:35 P.M. revealed she had no idea why the nurses did not assess Resident #90's vital signs every four hours as ordered by the CNP on 08/18/23.

7. The facility failed to serve hot and palatable foods and failed to ensure food was stored in a manner to prevent contamination for all residents except Resident #5.

8. The facility failed to ensure their environment was maintained in a clean and sanitary manner affecting Resident #4, #14, #18, #23, #33, #46, #68, #76, and #77 and the facility failed to ensure kitchen and resident rooms were free from pests potentially affecting all residents.

9. Review of the facility's SRI #238031, dated 08/12/23, revealed Resident #73 hit Resident #81 in the face after Resident #81 told Resident #73 to stay out of his room. Resident #73 had been having increased behaviors in the previous several months, was wandering in and out of other resident's room, and was difficult to redirect. Resident #81 requested to be sent to the ED for evaluation and returned with no new orders. The police were notified while at the ED and interviewed Resident #81 who declined to file charges. When the facility attempted to talk to Resident #73 about the incident, the resident did not want to discuss the incident/did not remember the incident. The facility obtained witness statements, did skin checks on all the residents on the unit. Resident #73's room was changed to the opposite end of the unit as an intervention to prevent further abuse. All staff were educated on abuse. The facility unsubstantiated the allegation of abuse as as no abuse per definition has occurred with alleged incident.

10. Review of the nursing note dated 08/17/23 at 11:30 A.M. revealed Resident #90 was sitting in close proximity to the nurse's station when dietary staff member was transporting the breakfast cart and Resident #90 began to ambulate via wheelchair in the path of the cart and fell out of the chair. Resident #90 was assessed for injury, and an abrasion was observed to her right knee. Vital signs were assessed: temperature of 98 degrees Fahrenheit (F), pulse 91, respirations 18, blood pressure 147/82, and oxygen saturation (SpO2) 100 percent (%) on room air.

11. Observation of the oxygen storage area on 09/19/23 at 9:40 A.M. revealed the facilities oxygen storage was located inside a fenced area on the back dock with a no smoking sign on the wall behind it. The area revealed large amounts of combustible leaves mixed with cigarette butts underneath and around the 22 oxygen tanks stored in the fenced area.

Review of the Administrator's personnel file revealed a hire date of 08/22/22. Review of undated facility Job Description for the Administrator revealed she was responsible for the direct the day-to-day functions of the facility in accordance with federal, state, and local standards, guidelines. The description revealed the Administrator was delegated the administrative authority, responsibility, and accountability necessary for carrying out the assigned duties including clinical and administrative activities of the facility.

This deficiency represents non-compliance investigated under Complaint Number OH00146813.

Based on interview and record review, the facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 98 residents in the facility.

Findings include:

Review of the PBJ report for Fiscal Year (FY) Quarter 2 (January 1, 2023 through March 31, 2023) revealed the facility triggered failing to submit data for the quarter and one-star staffing rating as identified areas of concerns.

Interview on 09/20/23 at 12:04 P.M. with the Administrator and Facility Owner (FO) #5500 revealed FO #5500 was responsible for the submission of data to CMS regarding the PBJ. Interview revealed PBJ staffing information for FY Quarter 2 was never reported. Interview revealed FO #5500 submitted staffing information for the PBJ to CMS on 08/14/23 for FY Quarter 3.

Review of the facility document titled CMS Submission Report PBJ Final File Validation Report dated 08/14/23 revealed the facility submitted PBJ staffing information for FY Quarter 3 and was unable to produce any other required documentation regarding the PBJ for FY Quarter 2.

Based on observation, record review, facility policy review, review of a facility Legionella water management plan documentation, staff interview, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to fully implement a complete water management program to prevent the growth of Legionella bacteria. In addition, the facility failed to maintain standard infection control protocols regarding isolation precautions. This had the potential to affect all 98 residents residing in the facility. Findings include: 1. Interview on 09/25/23 at 9:29 A.M. with the Administrator confirmed she did not have documented evidence of facility Legionella testing for 2022. Review of the facility policy titled Legionella Surveillance and DetectionBased on observation, record review, facility policy review, review of a facility Legionella water management plan documentation, staff interview, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to fully implement a complete water management program to prevent the growth of Legionella bacteria. In addition, the facility failed to maintain standard infection control protocols regarding isolation precautions. This had the potential to affect all 98 residents residing in the facility.

Findings include:

1. Interview on 09/25/23 at 9:29 A.M. with the Administrator confirmed she did not have documented evidence of facility Legionella testing for 2022.

Review of the facility policy titled Legionella Surveillance and Detection

Based on record review, interview, and facility policy review the facility failed to obtain signed consents or declinations and evidence of education for influenza vaccinations for Residents #40 and #62. This affected two residents (#40 and #62) of six residents reviewed for immunizations. Findings include: 1.Review of the medical record or Resident #40 revealed an admission dated 12/04/18 with diagnoses including dementia, diabetes mellitus, morbid obesity, and schizophrenia. Review of Resident #40's medical record under the immunization tab revealed influenza consent was refused but no date was listed. Review from 09/01/22 to 03/31/22 of nursing progress notes or under the miscellaneous tab did not reveal any documented evidence of influenza immunization being offered or education being provided for the influenza vaccine. 2. Review of the medical record for Resident #62 revealed an admission date of 01/24/20 with diagnoses including unspecified protein-calorie malnutrition, atrial fibrillation, peripheral vascular disease, and acquired absence of right leg above knee. Review of Resident #62's medical record revealed a 12/28/22 progress note stating Resident #62 declined the influenza vaccine despite education, but no signed documentation was found. Interview on 09/21/23 at 9:54 A.M. with the Director of Nursing (DON) confirmed she was unable to provide written documentation for the influenza vaccination for Residents #40 and #62. Review of the facility policy titled Influenza VaccinationBased on record review, interview, and facility policy review the facility failed to obtain signed consents or declinations and evidence of education for influenza vaccinations for Residents #40 and #62. This affected two residents (#40 and #62) of six residents reviewed for immunizations.

Findings include:

1.Review of the medical record or Resident #40 revealed an admission dated 12/04/18 with diagnoses including dementia, diabetes mellitus, morbid obesity, and schizophrenia.

Review of Resident #40's medical record under the immunization tab revealed influenza consent was refused but no date was listed. Review from 09/01/22 to 03/31/22 of nursing progress notes or under the miscellaneous tab did not reveal any documented evidence of influenza immunization being offered or education being provided for the influenza vaccine.

2. Review of the medical record for Resident #62 revealed an admission date of 01/24/20 with diagnoses including unspecified protein-calorie malnutrition, atrial fibrillation, peripheral vascular disease, and acquired absence of right leg above knee.

Review of Resident #62's medical record revealed a 12/28/22 progress note stating Resident #62 declined the influenza vaccine despite education, but no signed documentation was found.

Interview on 09/21/23 at 9:54 A.M. with the Director of Nursing (DON) confirmed she was unable to provide written documentation for the influenza vaccination for Residents #40 and #62.

Review of the facility policy titled Influenza Vaccination

Based on observation, staff interview, and facility floor plan review the facility failed to ensure its environment was maintained in a clean and sanitary manner. This affected 9 residents (#4, #14, #18, #23, #33, #46, #68, #76, and #77) with the potential to affect all residents. The facility census was 98.

Findings include:

Observation during the initial kitchen tour on 09/18/23 between 8:30 A.M. and 9:00 A.M. with Dietary Aide (DA) #1137 of the designated outside area for the garbage dumpsters (loading dock) revealed two signs attached to the building reading No Smoking. Observation revealed a black square rug, adjacent to the on and off ramp, with approximately 13 cigarette ends and multiple new and old crumbled leaves on top of the rug.

Interview during tour with DA #1137 revealed the area was not a designated smoking area; however, staff used the area to smoke often. DA #1137 verified the above findings at the time of the tour.

Observation and verification on 09/18/23 at 1:13 P.M. with Maintenance Director (MD) #1159 of Residents #4, #23, and #46 room revealed a ceiling vent exposed and hanging from the ceiling.

Observation and verification on 09/19/23 at 9:42 A.M. with MD #1159 of Residents #76 and #77 room, revealed blue wall paint bubbled up and peeling below and all around the air conditioning unit on the wall near the window. The wall adjacent to the air conditioning unit also had white paint bubbled up and peeling with various cracks and scrapes.

Observations and verification on 09/19/23 at 10:15 A.M. with Facility Owner (FO) #5500 revealed the heating vents located outside of Residents #14, #18, #33, and #68 rooms and inside of Residents #4, #46 and #23 rooms were uncovered with the heat registers exposed with significant dust, grime, dirt buildup, and rust.

Interview on 09/20/23 at 8:03 A.M. with State Tested Nurse Assistant (STNA) #1193 revealed residents had designated smoking areas and staff were to smoke in their cars. STNA #1193 revealed the outside areas near the garbage dumpsters and loading dock was not a designated smoking area.

Review of the facility floor plans revealed the designated outside area for the garbage dumpsters (loading dock) was not a designated smoking area.

This deficiency represents non-compliance investigated under Master Complaint Number OH00146903 and Complaint Number OH00146813.

Based on observation, staff interview, record review, and facility invoices, the facility failed to ensure the facility, including the kitchen and resident rooms, was free from pests (ants, flies, and gnats/fruit flies). This affected the kitchen and three residents' rooms (#4, #23, and #46). The facility census was 98. Findings include: During the initial kitchen tour on 09/18/23 between 8:30 A.M. and 9:00 A.M. approximately two to three flies and seven to eight gnats/fruit flies were noted swirling around the trashcan, food serving and preparation areas. During the second tour of the kitchen between 9:15 A.M. and 9:45 A.M., Food Service Supervisor (FSS) #1145 confirmed and verified the existence of the flies and gnats/fruit flies. FSS #1145 revealed that the facility utilized extermination services but could not confirm the date of the last visit and treatment. Observation on 09/18/23 at 10:20 A.M. of Residents #4, #23, and #46 room, revealed approximately 23 small ants crawling on the floor near the entrance to the room. Interview on 09/18/23 at 10:23 A.M. with State Tested Nurse Assistant (STNA) #1176 verified the ants crawling on the floor near the entrance of the room. STNA #1176 revealed she had not seen any treatments for pests. Interview on 09/18/23 at 10:25 A.M. with Housekeeper (HKP) #1151 verified the ants. HKP #1151 revealed she attempted to clean resident rooms and common areas clean throughout the day but revealed she had not cleaned Residents #4, #23, and #46 room at the time of the observation. Review of the facility invoice documentation titled High Rock Pest ControlBased on observation, staff interview, record review, and facility invoices, the facility failed to ensure the facility, including the kitchen and resident rooms, was free from pests (ants, flies, and gnats/fruit flies). This affected the kitchen and three residents' rooms (#4, #23, and #46). The facility census was 98.

Findings include:

During the initial kitchen tour on 09/18/23 between 8:30 A.M. and 9:00 A.M. approximately two to three flies and seven to eight gnats/fruit flies were noted swirling around the trashcan, food serving and preparation areas.

During the second tour of the kitchen between 9:15 A.M. and 9:45 A.M., Food Service Supervisor (FSS) #1145 confirmed and verified the existence of the flies and gnats/fruit flies. FSS #1145 revealed that the facility utilized extermination services but could not confirm the date of the last visit and treatment.

Observation on 09/18/23 at 10:20 A.M. of Residents #4, #23, and #46 room, revealed approximately 23 small ants crawling on the floor near the entrance to the room.

Interview on 09/18/23 at 10:23 A.M. with State Tested Nurse Assistant (STNA) #1176 verified the ants crawling on the floor near the entrance of the room. STNA #1176 revealed she had not seen any treatments for pests.

Interview on 09/18/23 at 10:25 A.M. with Housekeeper (HKP) #1151 verified the ants. HKP #1151 revealed she attempted to clean resident rooms and common areas clean throughout the day but revealed she had not cleaned Residents #4, #23, and #46 room at the time of the observation.

Review of the facility invoice documentation titled High Rock Pest Control

Based on observation, interview, facility policy review, and review of the Occupational Safety and Health Standards (OSHA) standards for safe oxygen storage the facility failed to ensure oxygen tanks were stored and secured in a safe manner. This had the potential to affect all 98 residents in the facility.

Findings include:

Observation of the oxygen storage area on 09/19/23 at 9:40 A.M. revealed the facilities oxygen storage was located inside a fenced area on the back dock with a no smoking sign on the wall behind it. The area revealed large amounts of combustible leaves mixed with cigarette butts underneath and around the 22 oxygen tanks stored in the fenced area.

Interview on 09/19/23 at 9:40 A.M. with Director of Maintenance #1150 confirmed the observation and revealed staff were not to smoke near the area.

Review of the facility policy titled Resident Smoking Policy

Based on observation, interview and record review the facility failed to ensure the second floor secured unit was clean and well maintained. This affected all 29 residents residing on the secured unit. The facility census was 81.

Findings include:

Observation on 01/11/23 at 7:15 A.M. revealed a strong odor of stale urine once exiting the elevator on the second floor. Interview on 01/11/23 at 7:20 A.M. with State Tested Nursing Assistant (STNA) #320 confirmed the area near the elevator had a strong smell of urine.

Interview on 01/11/23 at 7:26 A.M. with Housekeeper #325 revealed resident areas should be cleaned daily. Housekeeper #325 had not cleaned the common area outside of the elevator on the second floor which opened to large foyer as of yet. Housekeeper #325 had not been at the facility for a few days and could not say when the area had last been cleaned. Housekeeper #325 confirmed the strong odor of urine.

Observation of the dining room located on second floor on 01/11/23 at 9:16 A.M. revealed a large section of the ceiling in the dining room had crumbling drywall that was peeling. Crumbling and peeling drywall was observed on the couch and on the floor underneath the area.

Observation of Resident #1's and #2's room on 01/11/23 at 9:23 A.M. revealed a large area of peeling paint on the wall exposing the dry wall as well as various other areas of peeling paint underneath an air conditioning unit on a separate wall.

Interview on 01/11/23 at 9:36 A.M. with the Director of Nursing (DON) confirmed the observation in the dining area as well as in Resident #1's and #2's room. The DON stated she was aware the facility had environmental concerns and had been working toward fixing them.

Observation on 01/12/23 at 11:50 A.M. revealed a strong odor of stale urine outside of Resident #1's and #2's room. Interview with STNA #330 at time of interview confirmed the odor and stated that sometimes when residents were incontinent, the urine soaked into their mattresses causing the stale urine odor. STNA #330 stated she had smelled that same odor in other resident rooms as well. Observation at time of interview revealed STNA #330 performing incontinence care for Resident #1. Resident #1 was incontinent of a small amount of urine which would not account for the strong stale urine odor.

Review of maintenance logs from November 2022 through January 2023 revealed no work orders had been placed for damaged walls or ceilings.

The facility was asked for but did not provide a cleaning schedule for the second floor and did not provide information on when area was last cleaned prior to observation on 01/11/23 at 7:26 A.M.

This deficiency represents non-compliance investigated under Complaint Number OH00139158.

Based on observation and staff interview, the facility to ensure food was stored in a manner to prevent food borne illness, the dishwashing area was maintained in a clean and sanitary manner, and the sanitizer level of the dishmachine was maintained at the proper level. This had the potential to affect 80 out of 82 residents receiving food from the facility kitchen. Two residents (Residents #27 and #41) out of 82 residents received nothing by mouth. The facility census was 82.

Findings include:

During tour of the kitchen on 11/28/22 from 7:35 A.M. to 8:15 A.M. with Dietary Supervisor (DS) #128 revealed the following.

1. Observation of the walk-in freezer revealed a bag of breadsticks which was not closed properly and without a date as to when the bag was opened.

2. Observation in the walk-in refrigerator revealed applesauce, gravy, and spaghetti sauce that was not labeled or dated.

3. Observation of the dishwashing room revealed the side drainboard was dirty with dried food.

4. Observation of Dietary Aide (DA) #104 measuring the sanitizer level of the dishmachine revealed the sanitizer level was 25 parts per million (ppm). DA #104 did not know what the sanitizer level should be. DS #128 verified the test strip measured 25 ppm and indicated she was not sure what the proper ppm should be for the low temperature dish machine.

Interview on 11/28/22 at 11:33 A.M. with Registered Dietitian #133 revealed she audited kitchen sanitation at least monthly and tray line weekly.

Review of the undated facility policy titled, Sanitary Conditions revealed that all opened food items were to be stored properly in covered containers, labeled, and dated.

Review of the undated facility policy titled; Sanitary Conditions revealed a cold-water sanitizing system would be used with a minimum of 50 ppm of hypochlorite.

After it was determined the sanitization level of the dishmachine was not at the level required and before dishes went through the dishmachine, the dishmachine was serviced and the sanitizer level corrected by a contacted service company.

This deficiency represents non-compliance investigated under Complaint Number OH00137853.

Based on observation and staff interview, the facility failed to ensure its kitchen area was maintained in a clean and sanitary condition. This had the potential to affect 80 out of 82 residents receiving food from the facility. Two residents (Residents #27 and #41) out of 82 residents received nothing by mouth. The facility census was 82.

Findings include:

During kitchen tour of the facility on 09/06/22 from 7:35 A.M.to 8:15 A.M. with Dietary Supervisor (DS) #128 revealed in the walk-in freezer there was a bag of breadsticks not closed properly with no open date on it. In the walk-in refrigerator there were the following items not labeled and dated: applesauce, gravy, and spaghetti sauce. The dish room's clean side drainboard was dirty with dried food residue. Dietary Aide (DA) #104 took the sanitizer reading and it was reading 25 parts per million (ppm). DA #104 did not know what the correct ppm that the dish machine should be. DS #128 verified that the test strip measured 25 ppm and she was not sure what the proper ppm should be for the low temperature dish machine. Dish machine was corrected by chemical company before dishes went through the dish machine.

Interview on 11/28/22 at 11:33 A.M. with Registered Dietitian #133 revealed she audits kitchen sanitation at least monthly and tray line weekly.

Review of the undated facility policy titled, Sanitary Conditions revealed that all opened food items will be stored properly covered containers, labeled, and dated. Facility policy titled; Sanitary Conditions revealed that a cold-water sanitizing system will be used with a minimum of 50 ppm of hypochlorite.

Based on interview, observation, and record review, the facility failed to notify hospice and Resident #35's guardian regarding a change in her tube feeding orders. This affected one resident (Resident #35) out of three residents reviewed for notification of change in condition. The facility census was 79.

Findings included:

Review of closed medical record for Resident #35 revealed an admission date of 06/25/21 and that she had passed away at the facility on 10/22/22 under hospice services. Her diagnoses included altered mental status, multiple myeloma not having achieved remission, chronic kidney disease, and diabetes. Review of medical record revealed Resident #35 had a guardian of person.

Review of care plan dated 01/07/22 revealed Resident #35 was dependent on tube feeding for nutrition and hydration. She was at risk for aspiration and other complications related to the tube feeding. Interventions included administer tube feeding and flushes as ordered, check residuals as ordered, and notify physician of any complications.

Review of care plan dated 05/18/22 revealed Resident #35 and Resident' #35 family elected hospice services as Resident #35 desired to be kept comfortable and not receive life sustaining measures. Interventions included communicate to hospice regarding changes in condition, and coordinate plan of care with resident, family, and hospice.

Review of physician order dated 09/22/22 and completed by Hospice Registered Nurse (RN) #727 revealed Resident #35 was re-admitted to hospice services with a terminal diagnosis of multiple myeloma. The order revealed to contact hospice prior to initiating any treatments, after a fall, or with any change in status.

Review of Significant Change Minimum Data Set (MDS) dated 10/05/22 revealed Resident #35 had impaired cognition. She was totally dependent of one person with eating, and she had a tube feeding.

Review of physician order dated 10/13/22 and wrote by Dietician #677 revealed an order for Resident #35 to receive Diabetisource continuous at 40 milliliter (ml) per hour. There was no order discontinuing the previous tube feeding order of Diabetisource 240 ml bolus per peg tube every six hours.

Review of nursing note dated 10/18/22 at 4:00 A.M. and completed by RN #679 revealed Resident #35 had a large emesis (process of vomiting) that appeared to be tube feeding material. The nursing note revealed Resident #35 was grimacing and crying in pain when moved or when her abdomen was palpated. Hospice was notified. Primary Care Physician #725 was notified and stated he would contact hospice.

Review of nursing note dated 10/18/22 at 4:23 A.M. and completed by RN #679 revealed Resident #35 was grimacing in pain and yelling out when abdominal area was touched.

Review of Hospice Visit Note Report dated 10/18/22, untimed and completed by Hospice RN #727 revealed Resident #35 was seen earlier than scheduled due to Resident #35 was having emesis and stomach pain. The note revealed when Hospice RN #727 arrived LPN #657 had stated Resident #35 was having stomach pains, nausea, and vomiting over the last few days. Hospice RN #727 requested a printout of the current physician orders and reviewed the orders. Hospice RN #727 noted Resident #35 had a new order for Diabetisource 40 ml per hour continuous as well as she continued to have her previous tube feeding order to still receive Diabetisource 240 ml bolus every six hours. Hospice RN #727 questioned LPN #657 regarding the orders which she was not aware of the reasoning of, and that LPN #657 had stated Resident #35 had a history of not being able to tolerate continuous tube feedings and that was why she was switched to bolus feedings in the past. Hospice RN #727 questioned further LPN #657 regarding who had ordered the continuous tube feeding and was told Dietician #677 had written the order. Hospice RN #727 noted that there was no progress note or anything else in the medical record regarding why the change in order after review. Hospice RN #727 wrote a clarification order to discontinue the continuous tube feeding due to patients' current symptoms that had started on 10/16/22 after the continuous tube feeding order had been started and to continue only the bolus tube feedings as ordered. Hospice RN #727 spoke with LPN #657 regarding the new order.

Review of Prescriber's telephone order dated 10/18/22 and completed by Hospice Physician #729/ Hospice RN #727 revealed the order stated to please clarify enteral feed order that was changed on 10/13/22 due to patient's history of not tolerating continuous tube feeding and with her being hospice recommended promoting comfort. The telephone order ordered to discontinue continuous tube feeding at 40 ml per hour and to continue Diabetisource bolus 240 ml every six hours. The order was in Resident #35's medical record but was never transcribed by the facility.

Review of nursing note dated 10/19/22 at 3:39 P.M. and completed by the Director of Nursing revealed Primary Care Physician #725 was notified due to Resident #35 having a large emesis and residual. Primary Care Physician #725 ordered to place tube feeding and water flushes on hold for four hours and use as needed Zofran (medication for vomiting and nausea) to address issues with vomiting. Hospice and Resident #35's guardian was updated.

Review of nursing note dated 10/19/22 at 11:14 P.M. and completed by LPN #602 revealed Resident #35's tube feeding was held due to 60 ml of residual and severe stomach pain.

Review of nursing note dated 10/20/22 at 7:09 P.M. and completed by Agency LPN #726 revealed the tube feeding was held due to Resident #35 had increased residual of 60 ml.

Review of nursing note dated 10/22/22 at 3:01 P.M. and completed by LPN #631 revealed Resident #35 had absent of vitals and Primary Care Physician #725 was at the facility and pronounced her death. Hospice and Resident #35's guardian was notified.

Interview on 10/31/22 at 9:20 A.M. with Hospice Director of Clinical Service revealed on 10/18/22 they received a call from the facility that Resident #35 was having severe abdominal pain, vomiting, and was nauseated. She revealed Hospice RN #727 had come to the facility and verified Resident #35 had severe abdominal pain with vomiting. She revealed Hospice RN #727 had found after she completed a record review that Resident #35 was ordered on 10/13/22 Diabetisource continuous tube feeding at 40ml per hour which hospice had not been notified of the new order. She revealed it was in best practice to ensure the facility notified hospice of any order changes. She also revealed Hospice RN #727 had discovered not only was Resident #35 receiving the new continuous tube feeding order but that she was still receiving the old tube feeding order of Diabetisource 240 ml bolus every six hours and most likely the reason of the abdominal pain, emesis, and nausea. She revealed Hospice RN #727 had received an order on 10/18/22 from the Hospice Physician #729 to discontinue the continuous tube feeding order and just to continue the previous bolus tube feeding order. She revealed Hospice RN #727 had checked through the medical record and there was no documentation as to why the continuous tube feeding was ordered and that staff and Resident #35's guardian had stated that Resident #35 had a history of not being able to tolerate continuous tube feedings in the past. She verified she was not aware Resident #35 continued to receive both the continuous tube feeding and the bolus tube feeding after 10/18/22 when Hospice RN #727 had written the order to discontinue the continuous tube feeding order.

Interview on 10/31/22 at 9:43 A.M. and 11:15 A.M. with the Administrator verified the Dietician #677 had placed the order for Resident #35 into the electronic medical record to receive the continuous Diabetisource 40 ml per hour and had forgot to discontinue the previous tube feeding order of Diabetisource 240ml bolus every six hours. She verified on review of the MAR the nurses documented that Resident #35 continued then to receive both tube feedings orders. She verified on 10/18/22 Resident #35 had severe abdominal pain with nausea and vomiting requiring a call to hospice due to her symptoms. She verified Hospice RN #727 had left an order in Resident #35's medical record to discontinue the continuous Diabetisource 40 ml per hour and to continue only the Diabetisource bolus 240 ml every six hours. She verified this order was never transcribed and Resident #35 continued to receive both tube feeding orders including Diabetisource bolus 240 ml every six hours and Diabetisource 40 ml every hour continuously. She verified from 10/18/22 to 10/22/22 Resident #35 continued to have abdominal pain, nausea, vomiting and increased residuals of tube feeding when checked. She revealed she was unsure why the order was not transcribed. She verified hospice and Resident #35's guardian was not notified regarding the Diabetisource 40ml per hours continuous tube feeding order change dated 10/13/22 and that they both should have been notified.

Interview on 10/31/22 at 9:54 A.M. and 10:33 A.M. with Dietician #677 revealed she had felt Resident #35 would tolerate better from a continuous tube feeding rather than a bolus so she had changed the tube order to Diabetisource 40 ml per hour continuous on 10/13/22 but that she had forgot to discontinue the Diabetisource bolus 240 ml every six hours as both tube feeding orders should not have been administered at the same time. She verified she had not contacted Resident #35's guardian or hospice regarding the change in tube feeding order on 10/13/22 and could not remember if she had passed it along to nursing.

Interview on 10/31/22 at 12:17 P.M. with Resident #35's guardian revealed she was never contacted on 10/13/22 regarding Resident #35's tube feeding order change for continuous tube feeding. She revealed if she would have been contacted, she would have not approved the order change because Resident #35 in the past was not able to tolerate continuous tube feeding and only could tolerate bolus tube feedings. She revealed in the past on continuous Resident #35 would have severe abdominal pain, vomiting and nausea when the tube feeding was continuous and that was why it was changed to bolus. She revealed she was not notified to ensure this did not happen until 10/18/22 and then was told by hospice that the continuous tube feeding would be stopped on 10/18/22 but then she had found out that it continued despite Resident #35 having severe abdominal pain.

Review of facility policy labeled, Enteral Nutrition, dated 09/29/21, revealed the dietician with input from the physician, nurse, and resident representative would determine the calorie, protein, nutrient, fluid needs and evaluate whether the resident's current intake was adequate. The policy revealed the dietician was responsible for routinely assessing residents who received enteral feedings.

Review of undated facility policy labeled, Change in Condition Notification Protocol, revealed the facility would inform the residents legal representative when there was a need to alter treatment.

This deficiency represents non-compliance investigated under Complaint Number OH00136986.

Based on interview, record review and review of facility abuse policy, the facility failed to implement their abuse policy to ensure all employees were checked against the Nurse Aide Registry (NAR) for findings concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. This affected 27 employees: Director of Nursing #605, Assistant Director of Nursing (ADON)/ Registered Nurse (RN) #683, RN #611, RN #679, Licensed Practical Nurse (LPN) #602, LPN #603, LPN #604, LPN #657, LPN #658, LPN #665, LPN #689, LPN #674, LPN #676, LPN #678, LPN #680, LPN #685, LPN #722, Cook #600, Cook #692, Dietary Aide #609, Activities Assistant #618, Activities Assistant #640, Activities Assistant #688, Maintenance Director #639, Human Resources (HR) #645, Admission Director #648, and Dietary Manager #664 that were hired between 05/04/21 to 10/24/22 and continued to be currently employed at the facility. This had the potential to affect all 79 residents residing at the facility.

Findings included:

Review of personnel file for Registered Nurse (RN) #695 revealed her date of hire was 01/19/22 and there was no evidence in her personnel file that she was checked against the NAR prior to being employed at the facility.

Review of personnel file for Licensed Practical Nurse (LPN) #674 revealed a hire date of 04/10/22 and there was no evidence in her personnel file that she was checked against the NAR prior to being employed at the facility.

Interview on 10/24/22 at 12:03 P.M. and 3:11 P.M. with Human Resources (HR) #645 revealed she was hired on 04/01/22 and that she was not aware staff that were not State Tested Nursing Assistants (STNA's) were to be checked against the NAR to ensure they did not have a finding entered on the registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property as required as a screening process to prevent abuse. HR #645 revealed she received a one-day training that she did not feel was sufficient training and was never trained that staff that were not STNA's were to be checked against the NAR. She revealed she had to just kind of winged it as to what she was supposed to be doing regarding background checks. She verified on review of personnel files for RN #695, and LPN #674 they were not checked against the NAR prior to employment. She revealed the following employees that were hired from 05/04/21 to 10/24/22 and continued to be employed by the facility that she had no documentation in their personnel files that they were checked against the NAR prior to starting employment and that they still had not been checked against the NAR which included 27 employees: Director of Nursing #605, ADON/ RN #683, RN #611, RN #679, LPN #602, LPN #603, LPN #604, LPN #657, LPN #658, LPN #665, LPN #689, LPN #674, LPN #676, LPN #678, LPN #680, LPN #685, LPN #722, Cook #600, Cook #692, Dietary Aide #609, Activities Assistant #618, Activities Assistant #640, Activities Assistant #688, Maintenance Director #639, HR #645, Admission Director #648, and Dietary Manager #664

Interview on 10/24/22 at 12:17 P.M. with Administrator revealed she was recently hired at the facility on 08/22/22 and revealed recently she was going through personnel files and did notice employees of the facility that were non-STNA's were not checked against the NAR which was part of their screening process on abuse.

Review of facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated October 2020, revealed the facility would undertake background checks of all employees and retain on file applicable records of current employees regarding such checks. The policy revealed the facility would prior to hiring a new employee check the Ohio NAR.

This deficiency represents non-compliance investigated under Complaint Numbers OH00136176 and OH00136272.

Based on record review, facility policy review, facility self-reported incident (SRI) review, and interview, the facility failed to thoroughly investigate allegations of neglect. This affected one resident (Resident #21) of six residents reviewed for neglect. The facility census was 79 residents.

Findings include:

Review of Resident #21's medical record revealed an original admission date of 08/18/21 and diagnoses including anxiety, schizophrenia, heart failure and chronic obstructive pulmonary disease.

Review of Resident #21's quarterly minimum data set (MDS) assessment dated 10/02/22 revealed Resident #21 was cognitively intact and did not display behaviors including wandering or rejection of care. Resident #21 was independent with bed mobility, required staff supervision for ambulation and transfers and required the limited assistance of one staff for personal hygiene and toileting. No restraints or alarms were coded on the assessment. Review of profile information in Resident #21's electronic medical record revealed he had a guardian.

Review of Resident #21's assessments indicated a wandering and elopement assessment dated 08/19/21 that classified the resident as not at risk for elopement and stated Resident #21 was cognitively impaired with poor decision-making skills (i.e., intermittent confusion, cognitive deficits or disoriented), pertinent diagnoses and ambulated independently. No elopement history was noted on the assessment. A box was checked at the bottom of the assessment indicating Resident #21 was at high risk for elopement with a listed goal of remaining safe within facility unless accompanied by staff or other authorized persons through next review.

Review of Resident #21's care plan dated 09/10/21 revealed Resident #21 was at high risk for elopement and included use of a Wanderguard as an intervention in place.

Review of a nurses' note dated 10/11/22 at 9:45 A.M. and written by Licensed Practical Nurse (LPN) #623 revealed Resident #21 left for his medical appointment at 9:30 A.M. via the facility's transportation with face sheet and medication list; all parties aware.

Review of the next available nurses' note in Resident #21's medical record revealed a late entry note dated 10/16/22 at 10:39 P.M. originally for 10/15/22 for 5:30 P.M. and written by the Director of Nursing (DON) indicated Resident #21 returned to the facility on this date at 5:30 P.M. accompanied by this nurse and another staff member (not identified). Resident #21 ambulated with cane, was placed in his wheelchair and taken to his room now on the second floor's secured unit. Resident #21 was assessed and found to have no injuries.

Review of the SRI dated 10/11/22 for alleged neglect involving Resident #21 revealed the initial allegation was submitted to the State Agency (SA) on 10/11/22 at 7:28 P.M. Resident #21 had an unauthorized departure from a medical appointment in the community. The facility's investigation contained no resident interviews and two staff statements from Transportation Staff (TS) #687 and LPN #623. A police report number but no actual report was included in the file. A separate incident summary dated 10/17/22 was available but not included with the SRI investigation.

Interview on 10/24/22 at 8:58 A.M. with Registered Nurse (RN)/Assistant Director of Nursing (ADON) #683 revealed she and the DON helped to search for Resident #21 on 10/11/22 and she also searched for him after work.

Interview on 10/24/22 at 9:29 A.M. with Social Service Designee (SSD) #650 revealed on 10/11/22 during the early afternoon TS #687 called the facility and the front desk staff (not named) let her know Resident #21 could not be found from the medical center where he had had his medical appointment. SSD #650 and the DON left the facility to search the area around the medical center.

Interview on 10/24/22 at 10:36 A.M. with the DON revealed on 10/11/22 in early afternoon SSD #650 came to tell her that TS #687 told them Resident #21 was no longer at his appointment in the community and had been observed smoking then getting on a bus. She, RN/ADON #683, State Tested Nursing Assistant (STNA)/Scheduler #667 and SSD #650 went to try to locate Resident #21.

Interview on 10/24/22 at 11:15 A.M. with the Administrator revealed she was the main staff responsible for the investigation and completion of the SRI regarding Resident #21's elopement. The Administrator was asked why additional staff statements were not completed as part of the facility's SRI investigation as Resident #21's elopement occurred in a medical center in the community with multiple witnesses present and the complaint investigation also indicated that RN/ADON #683, SSD #650 and the DON were involved. The Administrator stated she felt it was not necessary to have statements that facility staff looked for Resident #21 for four days in the community.

Review of the facility policy, Abuse, Neglect, Exploitation and Misappropriation of Resident Property

Based on interview, emergency medical services (EMS) run sheet review and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate. This affected one resident (Resident #80) of seven closed records reviewed for accuracy of assessments. The facility census was 79 residents.

Findings include:

Review of Resident #80's closed record revealed an admission date of 04/14/22 and diagnoses including opioid dependence, low back pain, chronic pain, anxiety disorder, cutaneous abscess of back and fusion of spine. Resident #80's face sheet indicated he discharged to the hospital on 04/28/22.

Review of a care plan note dated 04/19/22 and authored by Social Service Designee (SSD) #650 revealed Resident #80 had an advanced directive of full code.

Review of Resident #80's nurses' notes revealed a note dated 04/27/22 at 12:12 P.M. and authored by Licensed Practical Nurse (LPN) #697 revealed the assigned state tested nursing assistant (STNA) answered Resident #80's call light and noticed he was acting differently. LPN #697 immediately came to Resident #80's room and Resident #80 was unresponsive; a code was called, cardiopulmonary resuscitation (CPR) was initiated and 9-1-1 was called. [City] medical services arrived to the facility on 04/27/22 at 12:15 P.M. and took over the critical healthcare situation, appropriate notifications were made and report was given to the local emergency room.

Review of the EMS run report dated 04/27/22 revealed Resident #80 was found unresponsive in cardiac arrest and CPR was being performed by facility staff. Resident #80 was moved to the floor for further treatment, placed onto a cot and moved out to the squad. Resident #80 was transported and turned over to [hospital name] medical staff.

Review of the physician note dated 04/27/22 revealed Resident #80 was pronounced deceased at the hospital 20 minutes after arrival.

Review of Resident #80's death in facility minimum data set (MDS) assessment dated 04/28/22 indicated Resident #80 expired in the facility.

Interview on 10/21/22 at 9:25 A.M. with LPN #697 revealed she had performed CPR on Resident #80 on 04/27/22 and confirmed EMS personnel continued CPR on Resident #80 as they exited the facility. LPN #697 verified Resident #80 was not pronounced deceased at the facility.

Interview on 10/24/22 at 8:47 A.M. with LPN/MDS Coordinator #661 revealed she was not aware Resident #80 did not expire in the facility on 04/27/22 and would need to check her notes to see why she coded the assessment as a death in facility. LPN/MDS #661 was made aware during the interview that Resident #80 expired in the hospital on 04/27/22 and the MDS assessment was not accurate.

Based on observation, interview and record review, the facility failed to develop an accurate comprehensive care plan. This affected one (Resident #21) of three residents reviewed for elopement risk. The facility census was 79 residents.

Findings include:

Review of Resident #21's medical record revealed an original admission date of 08/18/21 and a readmission date to the facility of 10/28/21 and diagnoses including anxiety, schizophrenia, heart failure and chronic obstructive pulmonary disease. Resident #21 discharged from the facility on 10/13/21 to the hospital directly from a medical appointment and readmitted to the facility on 10/28/21.

Review of Resident #21's quarterly minimum data set (MDS) assessment dated 10/02/22 revealed Resident #21 was cognitively intact and did not display behaviors including wandering or rejection of care. Resident #21 was independent with bed mobility, required staff supervision for ambulation and transfers and required the limited assistance of one staff for personal hygiene and toileting. No restraints or alarms were coded on the assessment.

Review of Resident #21's physician's orders revealed no orders for a Wanderguard (device that would alarm when approaching a door to alert staff).

Review of Resident #21's assessments indicated a wandering and elopement assessment dated 08/19/21 that classified the resident as not at risk for elopement and stated Resident #21 was cognitively impaired with poor decision-making skills (i.e., intermittent confusion, cognitive deficits or disoriented), pertinent diagnoses and ambulated independently. No elopement history was noted on the assessment. A box was checked at the bottom of the assessment indicating Resident #21 was at high risk for elopement with a listed goal of remaining safe within facility unless accompanied by staff or other authorized persons through next review. Listed interventions included BLANK intervention for editing; apply Wanderguard to reduce risk of elopement; check device for proper functioning per facility protocol; develop an activity program to divert attention and meet individual needs; discuss with resident/ Family risks of elopement/ wandering; if resident is missing from facility, follow elopement protocol, notify physician and family immediately and document; if resident is wandering in potentially unsafe area or situation, redirect to safer area; observe/ record/ report to physician or nurse practitioner risk factors for potential elopement; and take photograph of resident to maintain on file for identification purposes. No further elopement assessments were completed for Resident #21 until 10/12/22 when Resident #21 was still missing from the facility.

Review of Resident #21's care plan dated 09/10/21 revealed Resident #21 was at high risk for elopement and included use of a Wanderguard as an intervention in place also as of 09/10/21.

Observation on 10/20/22 at 12:47 P.M. of Resident #21 revealed he was seated in his wheelchair with a coat over a t-shirt and had sweatpants on with no Wanderguard noted.

Interview on 10/24/22 at 9:29 A.M. with Social Services Designee (SSD) #650 revealed she and Licensed Practical Nurse (LPN)/MDS Coordinator #661 were responsible for resident care plans which were updated quarterly and as needed. SSD #650 verified Resident #21 did not have a Wanderguard. SSD #650 was made aware during the interview that Resident #21's care plan inaccurately stated he utilized a Wanderguard as an elopement intervention.

Review of an undated document, Wanderguard List, revealed only Resident #15 was identified as having a Wanderguard in the facility.

Based on interview, observation, record review, and policy review, the facility failed to ensure appropriate interventions were implemented to prevent the development of a pressure ulcer for Resident #58. Actual Harm occurred on 10/11/22 at 2:15 P.M. when Resident #58, who was a paraplegic and required total dependence of two staff with transfers, extensive assist of one person with toileting and dressing and limited assistance of one staff with bed mobility, was found to have a Stage three (full thickness tissue loss that may include undermining, tunneling, and slough {dead skin tissue that may be white and/ or yellow in appearance} which does not obscure the depth of the tissue loss) pressure ulcer to his coccyx area during wound rounds that required debridement. No treatment to the pressure ulcer was initiated from the discovery date of 10/11/22 until 10/17/22 (six days). In addition, review of the medical record revealed the facility did not have any evidence Resident #58's coccyx pressure ulcer was re-assessed and measured after 10/11/22 once discoveed until 10/24/22. This affected one resident (Resident #58) of three residents (Resident #58, #61, and #78) reviewed for pressure ulcers. The facility census was 79.

Findings included:

Review of medical record for Resident #58 revealed an admission date of 10/05/21 with diagnoses including altered mental status, peripheral vascular disease, and diabetes.

Review of care plan dated 10/05/21 revealed Resident #58 had actual skin impairment related to his pressure areas on admission to his left heel that resolved on 12/21/21, right dorsal foot that resolved on 10/19/21, sacrum area that resolved on 12/21/21 and his current right ischium pressure ulcer. The care plan contained no evidence of the regarding new facility acquired pressure ulcer to his coccyx area that was found on 10/11/22. Interventions included initiate wound treatment and continue treatment as ordered, limit time out of bed, and skin observation on bath and shower days.

Review of Braden Score evaluation dated 08/09/22 and completed by Minimum Data Set 3.0(MDS)/ Registered Nurse (RN) #661 revealed Resident #58 was at moderate risk for skin breakdown due to his sensory perception was slightly limited, he was constantly moist, he was chairbound, his mobility was slightly limited, and he had a problem with friction and shear.

Review of annual MDS dated 09/25/22 revealed Resident #58 had intact cognition and required limited assist with bed mobility and was totally dependent of two people with transfers. He required extensive assist of two people with toileting. Resident #58 was at risk for developing a pressure ulcer and had three unstageable (full thickness tissue loss and the actual depth of the ulcer was completely obscured by slough in the wound bed) pressure ulcers that were not present on admission.

Review of October 2022 physician orders revealed Resident #58 had an order dated 10/16/22 to cleanse his coccyx area with normal saline, pat dry, apply calcium alginate to wound bed and cover with foam dressing daily and as needed.

Review of Treatment Administration Record (TAR) for October 2022 revealed Resident #58's treatment was documented as first initiated on 10/17/22 7:00 P.M. to 7:00 A.M. to cleanse his coccyx area with normal saline, pat dry, apply calcium alginate to wound bed and cover with foam dressing daily and as needed. The TAR revealed there was no treatments for his coccyx area documented as being completed from 10/11/22 when his coccyx pressure ulcer was first found to 10/17/22 (six days).

Review of physician progress note dated 10/11/22 at 2:15 P.M. and completed by Wound Physician #713 revealed on wound rounds it was identified Resident #58 had a new facility acquired Stage three pressure ulcer to his coccyx area that measured a length of 2.5 centimeters (cm), width of 1.5 cm and depth of .3 cm. The pressure ulcer contained 75 percent granular tissue, and 25 percent slough. The progress note revealed Wound Physician #713 cleaned the wound, flushed, irrigated, and prepared for debridement. The progress revealed the wound was sharply debrided manually with a curette (a surgical instrument used to remove material by a scraping action) to reduce infection and promote wound healing. The progress note revealed a treatment plan was given to the wound care nurse verbally and written.

Review of facility form labeled, Skin Grid Pressure dated 10/11/22 and completed by the Director of Nursing revealed Resident #58 had an unstageable pressure ulcer that was identified on 10/11/22 to his coccyx area that measured a length of 2.5 cm, width of 1.5 cm and depth of .3 cm. The skin grid revealed the pressure ulcer had 75 percent granular tissue, and 25 percent soft yellow slough. The skin grid revealed Wound Physician #713 debrided the wound with a curette.

Review of nursing note dated 10/18/22 at 5:44 P.M. and completed by the Director of Nursing revealed Resident #58 was not seen per the Wound Physician #713 because he was out of the facility at an appointment.

Review of facility form labeled, Skin Grid Pressure dated 10/18/22 and completed by the Director of Nursing revealed the form was opened in the electric medical record but that there was no assessment documented regarding Resident #58's wound to his coccyx including measurements, and description of his wound.

Interview on 10/24/22 at 9:00 A.M. and 10/26/22 at 10:58 A.M. with Assistant Director of Nursing (ADON/ Registered Nurse (RN) #683 revealed she completed wound rounds weekly with Wound Physician #713. She revealed on 10/11/22 during wound rounds they found Resident #58 to have a pressure ulcer to his coccyx area that was not previously reported and/ or documented. She verified Wound Physician #713 staged his coccyx pressure area as a Stage three wound and the wound had contained slough inside the wound bed that needed debrided by Wound Physician #713. She verified there was a discrepancy in documentation as the facility Skid Grid Pressure form dated 10/11/22 and completed by the Director of Nursing revealed the coccyx pressure ulcer was unstageable but Wound Physician #713's progress note revealed the wound to his coccyx area on 10/11/22 was a Stage three. She also verified Wound Physician #713 had given her a treatment order verbally for Resident #58's coccyx that included to cleanse his coccyx area with normal saline, pat dry, apply calcium alginate to wound bed and cover with foam dressing daily and as needed. She revealed there was a lot going on that week and she verified she did not initiate the physician order for Resident #58's coccyx pressure ulcer on 10/11/22 when she received the order and that she did not transcribe the order until 10/16/22. She verified the treatment was not documented on the TAR as being completed until 10/17/22 . ADON/ RN) #683 verified she had no documentation a treatment was completed to Resident #58's coccyx area from 10/11/22 to 10/17/22 (six days). She revealed wounds were to be assessed and measured weekly and that Wound Physician #713 came into the facility on 10/18/22 but Resident #58 was at an outside appointment. ADON/RN) #683 verified the documentation per the facility form, Skin Grid Pressure dated 10/18/22 was blank and that she did not have any documentation that the coccyx wound was measured and/ or documented on appearance of the wound from 10/11/22 to 10/24/22. ADON/RN) #683 verified Resident #58 was a paraplegic and required total dependence of two staff with transfers, extensive assist of one person with toileting and dressing and limited assist of one staff with bed mobility. She verified staff should have found and reported the pressure ulcer to his coccyx area prior to the wound being found as a stage three on wound rounds and stated, I really can not explain why it was not found earlier as it should have been.

Observation and interview on 10/24/22 at 1:00 P.M. of wound care for Resident #58's coccyx area completed by Wound Physician #713 and ADON/ RN #683 revealed Wound Physician #713 measured the wound as a length of 3 cm, width 2.5 cm and depth of .2 cm. He revealed the wound continued to be a Stage three and had 85 percent granulation and minimal slough. He recommended the same order to continue. Wound Physician #713 verified the wound to Resident #58's coccyx area was found on 10/11/22 during wound rounds and was discovered as a Stage three wound. Wound Physician #713 verifed the wound was larger in length and width from 10/11/22.

Review of facility policy labeled, Pressure Injury Prevention and Management dated 08/22/22 revealed the facility was committed to the prevention of avoidable pressure injuries and was to provide treatment and services to heal pressure ulcers. The unit manager and/ or designee would review relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly. The policy revealed nursing assistants would inspect skin during bath and would report any concerns to the resident's skin immediately after the task.

This deficiency represents non-compliance investigated under Complaint Number OH00136176.

Based on interview, observation, and open and closed record review, the facility failed to ensure tube feedings were ordered and implemented appropriately to prevent gastrointestinal symptoms including severe abdominal pain, nausea, and vomiting. Actual Harm occurred on 10/13/22 when Dietician #677 wrote an order for Resident #35 to receive Diabetisource (tube feeding) 40 milliliters (ml) per hour continuously but did not discontinue the previous tube feeding order of Diabetisource bolus 240 ml every six hours resulting in Resident #35 receiving both tube feeding orders. On 10/18/22 at 4:00 A.M. Resident #35 had a large emesis, and abdominal pain causing her to cry out in pain. On 10/18/22 Hospice RN #727/ Hospice Physician #729 ordered to discontinue the continuous tube feeding and only administer the bolus tube feeding order. The facility failed to transcribe the physician order and Resident #35 continued to receive both tube feeding orders (continuous and bolus) that resulted in continued abdominal pain, nausea and vomiting. Resident #35 expired on 10/22/22. In addition, the facility failed to ensure Resident #35 and #39 had an annual comprehensive nutritional assessment completed monitoring their tube feeding status. This affected two residents (Resident #35 and #39) of three residents (Resident #23, #35, and #39) reviewed for tube feedings. The facility had a total of three residents with orders for tube feedings (Resident #23, #35, and #39) residing at the facility.

Findings included:

1. Review of closed medical record for Resident #35 revealed an admission date of 06/25/21 and the resident expired on 10/22/22 under hospice services. Diagnoses included altered mental status, multiple myeloma not having achieved remission, chronic kidney disease, and diabetes. Review of medical record revealed Resident #35 had a guardian of person.

Review of facility form labeled, Comprehensive Medical Nutrition Therapy Assessment- V1 dated 06/28/21 revealed Former Dietician #724 completed the admission comprehensive nutritional evaluation. There were no other Comprehensive Medical Nutrition Therapy Assessments in the resident's medical record until 10/15/22.

Review of the care plan dated 01/07/22 revealed Resident #35 was dependent on tube feeding for nutrition and hydration. She was at risk for aspiration and other complications related to the tube feeding. Interventions included administer tube feeding and flushes as ordered, check residuals as ordered, and notify physician of any complications.

Review of care plan dated 05/18/22 revealed Resident #35 and Resident' #35's family elected hospice services as Resident #35 desired to be kept comfortable and not receive life sustaining measures. Interventions included communicate to hospice regarding changes in condition, and coordinate plan of care with resident, family, and hospice.

Review of a physician order dated 09/22/22 and completed by Hospice Registered Nurse (RN) #727 revealed Resident #35 was re-admitted to hospice services with a terminal diagnosis of multiple myeloma. The order revealed to contact hospice prior to initiating any treatments, after a fall, or with any change in status.

Review of Significant Change Minimum Data Set 3.0 (MDS) dated 10/05/22 revealed Resident #35 had impaired cognition. She was totally dependent on one person with eating, and she had a tube feeding.

Review of Medication Administration Record (MAR) for October 2022 revealed Resident #35 had a physician order with a start date of 06/30/22 for Diabetisource 240 ml per peg tube every six hours (12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M) The MAR revealed the nurses documented they administered the bolus tube feeding as ordered from 10/13/22 to 10/22/22 except on 10/18/22 at 6:00 A.M. and 12:00 P.M. due to resident being nauseated, 10/19/22 at 12:00 P.M. and 6:00 P.M. with no indication provided, and on 10/20/22 the MAR was blank for 12:00 A.M., and 6:00 A.M. and the tube feeding was held at 6:00 P.M. Resident #35 had an order that started on 10/13/22 at 11:00 P.M. for Diabetisource continuous at 40 ml per hour through peg tube. The nurses documented every shift that Resident #35 received this as ordered beginning 10/13/22 through 10/21/22 except on 10/15/22 7:00 A.M. to 3:00 P.M., 10/15/22 3:00 P.M. to 11:00 P.M., 10/16/22 from 11:00 P.M. to 7:00 A.M., 10/18/22 7:00 A.M. to 3:00 P.M., and 10/18/22 3:00 P.M. to 11:00 P.M. as the tube feeding was held.

Review of physician order dated 10/13/22 and written by Dietician #677 revealed an order for Resident #35 to receive Diabetisource continuous at 40 ml per hour. There was no order discontinuing the previous tube feeding order of Diabetisource 240 ml bolus per peg tube every six hours.

Review of nursing note dated 10/15/22 at 7:25 P.M. and completed by Licensed Practical Nurse (LPN) #657 revealed the tube feeding was held for Resident #35 because it was not continuous but there was no further documentation.

Review of facility form labeled, Comprehensive Medical Nutrition Therapy Assessment- V1 dated 10/15/22 and completed by Dietician #677 revealed the assessment was in progress and the only things completed on the assessment were name, room number, admission date, date of birth, age, physician, assessment type (significant change), diagnoses, and medications as all the other areas were left blank. There was no further documentation including meal intake, impairments, tube feeding order including calories, protein, and water flushes, body type, laboratory data, nutritional needs, nutritional risks, plan of care and how Resident #35 was tolerating the tube feeding.

Review of nursing note dated 10/18/22 at 4:00 A.M. and completed by RN #679 revealed Resident #35 had a large emesis that appeared to be tube feeding material. The nursing note revealed Resident #35 was grimacing and crying in pain when moved or when her abdomen was palpated. Hospice was notified and was refusing to come see Resident #35. Primary Care Physician #725 was notified and stated he would contact hospice.

Review of nursing note dated 10/18/22 at 4:23 A.M. and completed by RN #679 revealed Resident #35 was grimacing in pain and yelling out when abdominal area was touched.

Review of Hospice Visit Note Report dated 10/18/22, untimed and completed by Hospice RN #727 revealed Resident #35 was seen earlier than scheduled due to Resident #35 was having emesis and stomach pain. The note revealed when Hospice RN #727 arrived LPN #657 had stated Resident #35 was having stomach pains, nausea, and vomiting over the last few days. Hospice RN #727 requested a printout of the current physician orders and reviewed the orders. Hospice RN #727 noted Resident #35 had a new order for Diabetisource 40 ml per hour continuous as well as she continued to have her previous tube feeding order to still receive Diabetisource 240 ml bolus every six hours. Hospice RN #727 questioned LPN #657 regarding the orders which she was not aware of the reasoning of, and LPN #657 had stated Resident #35 had a history of not being able to tolerate continuous tube feedings and that was why she was switched to bolus feedings in the past. Hospice RN #727 questioned LPN #657 further regarding who had ordered the continuous tube feeding and was told Dietician #677 had written the order. The Hospice RN #727 noted that there was no progress note or anything else in the medical record regarding why there was a change in order. Hospice RN #727 wrote a clarification order to discontinue the continuous tube feeding due to patients' current symptoms that had started on 10/16/22 after the continuous tube feeding order had been started and to continue only the bolus tube feedings as ordered. Hospice RN #727 spoke with LPN #657 regarding the new order.

Review of Prescriber's telephone order dated 10/18/22 and completed by Hospice Physician #729/ Hospice RN #727 revealed the order stated to please clarify enteral feed order that was changed on 10/13/22 due to patient's history of not tolerating continuous tube feeding and with her being hospice recommended promoting comfort. The telephone order ordered to discontinue continuous tube feeding at 40 ml per hour and to continue Diabetisource bolus 240 ml every six hours. The order was in Resident #35's medical record but was never transcribed by the facility.

Review of nursing note dated 10/19/22 at 12:35 P.M. and completed by Director of Nursing revealed Resident #35's tube feeding was held because she had a residual of 60 ml.

Review of nursing note dated 10/19/22 at 3:39 P.M. and completed by the Director of Nursing revealed Primary Care Physician #725 was notified due to Resident #35 having a large emesis and residual. Primary Care Physician #725 ordered to place tube feeding and water flushes on hold for four hours and use as needed Zofran (medication for vomiting and nausea) to address issues with vomiting. Hospice and Resident #35's guardian were updated.

Review of a nursing note dated 10/19/22 at 11:14 P.M. and completed by LPN #602 revealed Resident #35's tube feeding was held due to 60 ml of residual and severe stomach pain.

Review of nursing note dated 10/20/22 at 7:09 P.M. and completed by Agency LPN #726 revealed the tube feeding was held due to Resident #35 had increased residual of 60 ml.

Review of nursing note dated 10/22/22 at 3:01 P.M. and completed by LPN #631 revealed Resident #35 had absence of vital signs and Primary Care Physician #725 was at the facility and pronounced her death. Hospice and Resident #35's guardian were notified.

Interview on 10/31/22 at 9:20 A.M. with Hospice Director of Clinical Service revealed on 10/18/22 they received a call from the facility that Resident #35 was having severe abdominal pain, vomiting, and was nauseated. She revealed Hospice RN #727 had come to the facility and verified Resident #35 had severe abdominal pain with vomiting. She revealed Hospice RN #727 had found after she completed a record review that Resident #35 was ordered on 10/13/22 Diabetisource continuous tube feeding at 40ml per hour and hospice had not been notified of the new order. She revealed it was in best practice to ensure the facility notified hospice of any order changes. She also revealed Hospice RN #727 had discovered not only was Resident #35 receiving the new continuous tube feeding order but that she was still receiving the old tube feeding order of Diabetisource 240 ml bolus every six hours and most likely the reason of the abdominal pain, emesis, and nausea. She revealed Hospice RN #727 had received an order on 10/18/22 from the Hospice Physician #729 to discontinue the continuous tube feeding order and just to continue the previous bolus tube feeding order. She revealed Hospice RN #727 had checked through the medical record and there was no documentation as to why the continuous tube feeding was ordered and that staff and Resident #35's guardian had stated that Resident #35 had a history of not being able to tolerate continuous tube feedings in the past. She verified she was not aware Resident #35 continued to receive both the continuous tube feeding and the bolus tube feeding after 10/18/22 when Hospice RN #727 had written the order to discontinue the continuous tube feeding order.

Interview on 10/31/22 at 9:43 A.M. and 11:15 A.M. with the Administrator verified Dietician #677 had placed the order for Resident #35 into the electronic medical record to receive the continuous Diabetisource 40 ml per hour and had forgot to discontinue the previous tube feeding order of Diabetisource 240ml bolus every six hours. She verified on review of the MAR the nurses documented that Resident #35 continued then to receive both tube feedings orders. She verified on 10/18/22 Resident #35 had severe abdominal pain with nausea and vomiting requiring a call to hospice due to her symptoms. She verified Hospice RN #727 had left an order in Resident #35's medical record to discontinue the continuous Diabetisource 40 ml per hour and to continue only the Diabetisource bolus 240 ml every six hours. She verified this order was never transcribed and Resident #35 continued to receive both tube feeding orders including Diabetisource bolus 240 ml every six hours and Diabetisource 40 ml every hour continuously. She verified from 10/18/22 to 10/22/22 Resident #35 continued to have abdominal pain, nausea, vomiting and increased residuals of tube feeding when checked. She revealed she was unsure why the order was not transcribed. She also verified that there was a comprehensive admission nutritional assessment completed on 06/28/21 but that there were no further comprehensive nutritional assessments completed as the one dated 10/15/22 was almost completely blank. She verified a comprehensive nutritional assessment should be completed at least annually and on any significant change. She verified hospice and Resident #35's guardian were not notified regarding the Diabetisource 40ml per hours continuous tube feeding order change dated 10/13/22 and that they both should have been notified.

Interview on 10/31/22 at 9:54 A.M. and 10:33 A.M. with Dietician #677 revealed she had felt Resident #35 would tolerate better from a continuous tube feeding rather than a bolus so she had changed the tube order to Diabetisource 40 ml per hour continuous on 10/13/22 but that she had forgot to discontinue the Diabetisource bolus 240 ml every six hours as both tube feeding orders should not have been administered at the same time. She verified Resident #35's last comprehensive nutritional assessment was completed on 06/28/21 and that an annual had not need completed in June 2022. She verified she had only started the comprehensive significant change nutritional assessment on 10/15/22 with basic information but had not gotten a chance to complete the assessment before the resident passed away. She verified she had not contacted Resident #35's guardian or hospice regarding the change in tube feeding order on 10/13/22 and could not remember if she had passed it along to nursing. She verified she was not aware Resident #35 was having abdominal pain, vomiting, and nausea after she had added the continuous tube feeding order and she was not notified regarding hospice consulting and recommending discontinuing the continuous tube feeding and only maintaining the bolus tube feeding order. She revealed she was not aware the order from hospice on 10/18/22 was never transcribed.

Interview on 10/31/22 at 12:17 P.M. with Resident #35's guardian revealed she was never contacted on 10/13/22 regarding Resident #35's tube feeding order change for continuous tube feeding. She revealed if she would have been contacted, she would have not approved the order change because Resident #35 in the past was not able to tolerate continuous tube feeding and only could tolerate bolus tube feedings. She revealed in the past on continuous tube feeding Resident #35 would have sever abdominal pain, vomiting and nausea that was why it was changed to bolus. She revealed she was not notified to ensure this did not happen until 10/18/22 and then was told by hospice that the continuous tube feeding would be stopped on 10/18/22 but then she had found out that it continued despite Resident #35 having severe abdominal pain.

2. Review of medical record for Resident #39 revealed an admission date of 06/22/21 and diagnoses included hypertension, dementia, peripheral vascular disease, and asthma.

Review of facility form labeled. Comprehensive Medical Nutrition Therapy Assessment dated 07/01/21 and completed by Former Dietician #724 revealed Resident #39 was evaluated upon admission and continued on tube feedings per physician orders and was tolerating them without any issues. There was no other comprehensive nutritional assessments completed in her medical record.

Review of care plan last revised 10/04/21 revealed Resident #39 had altercation in her nutrition and hydration status. She received enteral feedings and was on hospice. Interventions included collaborate with the hospice team, provide enteral nutrition per physician orders and weigh per policy.

Review of quarterly MDS dated 10/4/22 revealed Resident #39 was cognitively impaired as she was rarely and/ or never understood. She was totally dependent of one person for eating as she received tube feedings.

Observation and attempted interview on 10/31/22 at 9:06 A.M. revealed Resident #39 was receiving tube feeding per order and was unable to be interviewed due to impaired cognitive ability.

Interview on 10/31/22 at 9:54 A.M. and 10:33 A.M. with Dietician #677 verified the last comprehensive nutritional assessment for Resident #39 was completed on 07/01/21. She verified comprehensive nutritional assessment were to be completed at least annually and upon any significant change. She revealed Resident #39's comprehensive assessment must have been missed in July 2022.

Review of facility policy labeled, Enteral Nutrition dated 09/29/21 revealed the dietician with input from the physician, nurse, and resident representative would determine the calorie, protein, nutrient, fluid needs and evaluate whether the resident's current intake was adequate. The policy revealed the dietician was responsible for routinely assessing residents who received enteral feedings.

Review of facility policy labeled, Nutritional Management dated 08/22/22 revealed a comprehensive nutritional assessment would be completed by the dietician on admission, annually, and upon significant change in condition.

This deficiency represents non-compliance investigated under Complaint Number OH00136986.

Based on interview and record review, the facility failed to ensure state tested nursing assistants (STNA's) had at least 12 hours of in-service education per year. This affected two STNA's (STNA #655 and STNA #673) out of two STNA's (STNA #655 and STNA #673) personnel files that were reviewed as they were employed over a year at the facility. This had the potential to affect all 79 residents residing at the facility.

Findings included:

Review of personnel file for STNA #673 with a hire date of 10/16/89 revealed she had no in service training in her personnel file within the last year.

Review of personnel file for STNA #655 with a date of hire of 11/14/19 revealed she had no in service training in her personnel file within the last year.

Interview on 10/26/22 at 11:12 A.M. with Human Resource Director #645 verified she had no in service educations for STNA #655 and STNA #673 in their personnel file. She revealed the facility did not have a tracking form that they utilized to track the in-service educations of STNA's to ensure they met the 12-hour requirement.

Interview on 10/26/22 at 2:29 P.M. with Administrator revealed when she started at the facility on 08/22/22 she knew that training of the STNA's was an issue as there was no specific tracking form to see what training an STNA had received and that they met their 12 hours in service requirement per year. She verified she had no evidence that STNA #655 and STNA #673 met the 12 hours in service education for the year. She also revealed the facility did not have a policy regarding in service education for STNA's.

Based on interview and record review, the facility failed to be administered in a manner which enabled it to use its resources effectively and efficiently to ensure all residents attain or maintain their highest practicable physical, mental and psychosocial well-being. This had the potential to affect all 79 residents residing in the facility.

Findings include:

During the complaint and partial extended survey the following concerns were identified:

1. Review of the medical record for Resident #21 along with review of a facility self-reported incident (SRI), police report and interviews revealed concerns were identified related to the facility's lack of routine and accurate assessment and care planning related to elopement risk, a lack of obtaining and implementing instructions contained on guardianship paperwork and a lack of staff supervision for medical appointments in the community to prevent Resident #21's elopement. This resulted in Immediate Jeopardy on 10/11/22 when Resident #21 was dropped off at a medical appointment in the community without staff supervision and subsequently left the appointment at a medical center and got on a bus. The facility was unaware of Resident #21's condition and whereabouts until staff located him in the community on 10/15/22, four days later.

Interview on 10/24/22 at 8:58 A.M. with Registered Nurse (RN)/Assistant Director of Nursing (ADON) #683 verified residents were to be assessed for elopement risk quarterly and after an incident and was made aware during the interview that Resident #21 lacked evidence of routine/ quarterly elopement assessments. RN/ADON #683 also verified Resident #21 did not have a Wanderguard even though his care plan stated one was in place.

Interview on 10/24/22 at 10:36 A.M. with the Director of Nursing (DON) verified all residents were to have a Leave of Absence physician's order that would reference the need for an escort for appointments in the community and Resident #21 did not have such an order at the time of his elopement. The DON verified residents were to be assessed for elopement status quarterly. The DON confirmed the facility did not know about Resident #21's guardianship papers indicating he was a flight risk and required placement on the secured unit until these documents were pulled during this incident.

Interview on 10/24/22 at 11:15 A.M. with the Administrator revealed she was the main staff responsible for the investigation and completion of the SRI regarding Resident #21's elopement. The Administrator was asked why additional staff statements were not completed as part of the facility's SRI investigation as Resident #21's elopement occurred in a medical center in the community with multiple witnesses present and the complaint investigation also indicated that RN/ADON #683, Social Service Designee (SSD) #650 and the DON were involved. The Administrator stated she felt it was not necessary to have statements that facility staff looked for Resident #21 for four days in the community.

Interview on 10/25/22 at 12:14 P.M. with Licensed Practical Nurse (LPN) #606 verified she made the original appointment and order for Resident #21's dermatology appointment on 10/11/22. LPN #606 indicated an order would be placed by the nurse into the electronic medical record and a paper slip that for the appointment that would also indicate if a resident needed an escort or not would be placed into the schedule book on the unit. Paper copies of the form would also go to administrative staff as well as the staff scheduler so that a staff member would be scheduled to escort the resident as indicated. LPN #606 verified she had indicated Resident #21 needed to have an escort for the dermatology appointment on 10/11/22 and text-messaged the surveyor a photo of the form which did indicate Resident #21 needed an escort for this appointment. See findings at F610, F656 and F689.

2. Review of personnel file for Registered Nurse (RN) #695 revealed her date of hire was 01/19/22 and there was no evidence in her personnel file that she was checked against the NAR prior to being employed at the facility.

Review of personnel file for Licensed Practical Nurse (LPN) #674 revealed a hire date of 04/10/22 and there was no evidence in her personnel file that she was checked against the NAR prior to being employed at the facility.

Interview on 10/24/22 at 12:03 P.M. and 3:11 P.M. with Human Resources (HR) #645 revealed she was hired on 04/01/22 and that she was not aware staff that were not STNA's were to be checked against the NAR to ensure they did not have a finding entered on the registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property as required as a screening process to prevent abuse. HR #645 revealed she received a one-day training that she did not feel was sufficient training and was never trained that staff that were not STNA's were to be checked against the NAR. She revealed she had to just kind of winged it as to what she was supposed to be doing regarding background checks. She verified on review of personnel files for RN #695, and LPN #674 they were not checked against the NAR prior to employment. She revealed the following employees that were hired from 05/04/21 to 10/24/22 and continued to be employed by the facility that she had no documentation in their personnel files that they were checked against the NAR prior to starting employment and that they still had not been checked against the NAR which included 27 employees: Director of Nursing #605, Assistant Director of Nursing (ADON)/ Registered Nurse (RN) #683, RN #611, RN #679, Licensed Practical Nurse (LPN) #602, LPN #603, LPN #604, LPN #657, LPN #658, LPN #665, LPN #689, LPN #674, LPN #676, LPN #678, LPN #680, LPN #685, LPN #722, Cook #600, Cook #692, Dietary Aide #609, Activities Assistant #618, Activities Assistant #640, Activities Assistant #688, Maintenance Director #639, Human Resources (HR) #645, Admission Director #648, and Dietary Manager #664.

Interview on 10/24/22 at 12:17 P.M. with Administrator revealed she was recently hired at the facility on 08/22/22 and revealed recently she was going through personnel files and did notice employees of the facility that were non-STNA's were not checked against the NAR which was part of their screening process on abuse.

Review of facility policy titled Abuse, Neglect, Exploitation, and Misappropriation of Resident Property dated October 2020 revealed the facility would undertake background checks of all employees and retain on file applicable records of current employees regarding such checks. The policy revealed the facility would prior to hiring a new employee check the Ohio NAR. See findings at F607.

3. Review of personnel file for STNA #673 with a hire date of 10/16/89 revealed she had no in service training in her personnel file within the last year.

Review of personnel file for STNA #655 with a date of hire of 11/14/19 revealed she had no in service training in her personnel file within the last year.

Interview on 10/26/22 at 11:12 A.M. with Human Resource Director #645 verified she had no in service educations for STNA #655 and STNA #673 in their personnel file. She revealed the facility did not have a tracking form that they utilized to track the in-service educations of STNA's to ensure they met the 12-hour requirement.

Interview on 10/26/22 at 2:29 P.M. with the Administrator revealed when she started at the facility on 08/22/22 she knew that training of the STNA's was an issue as there was no specific tracking form to see what training an STNA had received and that they met their 12 hours in service requirement per year. She verified she had no evidence that STNA #655 and STNA #673 met the 12 hours in service education for the year. She also revealed the facility did not have a policy regarding in service education for STNA's. See findings at F730.

4. Review of QAA Committee meeting minutes revealed since 05/04/21 the facility only had one QAA meeting dated for 09/28/22.

Interview on 10/26/22 at 2:29 P.M. with Administrator revealed she had started 08/22/22 and she discovered that the facility QAA Committee had not been meeting on a quarterly basis like they should have. She verified she had no documentation the facility QAA Committee met from 05/04/21 to 09/28/22. She revealed she had a meeting on 09/28/22 but that was the only meeting the facility had documentation for during this time frame.

Review of facility policy labeled, Quality Assurance and Performance Improvement (QAPI), dated 10/01/22, revealed the facility would develop, implement, and maintain an effective, comprehensive, data driven QAPI program, that focused on indicators of the outcomes of care and quality of life and addressed all the care and unique services that the facility provided. The policy revealed the committee would meet at least quarterly and as needed to coordinate and evaluate activities under a QAPI program. See findings for F868.

Based on interview, record review and policy review, the facility failed to ensure resident records were complete and accurate. This affected one resident (Resident #21) of three residents reviewed for elopement. The facility census was 79 residents.

Findings include:

Review of Resident #21's medical record revealed an admission date of 08/18/21 and diagnoses including anxiety, schizophrenia, heart failure and chronic obstructive pulmonary disease.

Review of Resident #21's quarterly minimum data set (MDS) assessment dated 10/02/22 revealed Resident #21 was cognitively intact and did not display behaviors including wandering or rejection of care. Resident #21 was independent with bed mobility, required staff supervision for ambulation and transfers and required the limited assistance of one staff for personal hygiene and toileting.

Review of a nurses' note dated 10/11/22 at 9:45 A.M. and written by Licensed Practical Nurse (LPN) #623 revealed Resident #21 left for his medical appointment at 9:30 A.M. via the facility's transportation with face sheet and medication list.

Review of the next available nurses' note in Resident #21's medical record revealed a late entry note dated 10/16/22 at 10:39 P.M. originally for 10/15/22 for 5:30 P.M. and written by the Director of Nursing (DON) which indicated Resident #21 returned to the facility on this date at 5:30 P.M. accompanied by this nurse and another staff member (not identified). Resident #21 ambulated with cane, was placed in his wheelchair and taken to his room which was now on the second floor's secured unit. Resident #21 was assessed and found to have no injuries.

No nurses' notes were available indicating Resident #21 had eloped from his medical appointment in the community or that Resident #21's guardian or the physician had been notified of the elopement.

Interview on 10/21/22 at 11:27 A.M. with Legal Guardian (LG) #698 revealed he was made of Resident #21's elopement on 10/13/22 when he spoke to the Administrator and denied any other earlier voicemail messages from the facility regarding the elopement.

Interview on 10/24/22 at 10:36 A.M. with the DON verified staff were always supposed to write a progress note when the guardian/family member and physician were notified of an incident regarding a resident and verified Resident #21's nurses' notes lacked this documentation.

Interview on 10/25/22 at 3:20 P.M. with Physician #708 revealed his nurse practitioner was in the facility and had been notified of Resident #21's elopement on 10/11/22.

Review of facility policy, Documentation in the Medical Record, dated 09/01/22, revealed the medical record should contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation. Documentation should be completed at the time of service but no later than the shift in which the assessment, observation or care service occurred.

Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee met on a quarterly basis. This had the potential to affect all 79 residents residing at the facility.

Findings included:

Review of QAA Committee meeting minutes revealed since 05/04/21 the facility only had one QAA meeting dated for 09/28/22.

Interview on 10/26/22 at 2:29 P.M. with Administrator revealed she had started 08/22/22 and she discovered that the facility QAA Committee had not been meeting on a quarterly basis like they should have. She verified she had no documentation the facility QAA Committee met from 05/04/21 to 09/28/22. She revealed she had a meeting on 09/28/22 but that was the only meeting the facility had documentation for during this time frame.

Review of facility policy labeled, Quality Assurance and Performance Improvement (QAPI), dated 10/01/22, revealed the facility would develop, implement, and maintain an effective, comprehensive, data driven QAPI program, that focused on indicators of the outcomes of care and quality of life and addressed all the care and unique services that the facility provided. The policy revealed the committee would meet at least quarterly and as needed to coordinate and evaluate activities under a QAPI program.