Wyant Woods Healthcare Center

Based on record review, review of the facility's self-reported incident (SRI) and associated facility investigation, review of facility policy, and staff interviews, the facility failed to ensure staff reported allegations of abuse in a timely manner. This affected one resident (#78) of three reviewed for abuse. The facility census was 167.

Findings include:

Review of the medical record for Resident #78 revealed an admission date of 12/31/22 and re-admission date of 02/03/23. Diagnoses included hemiplegia and hemiparesis affecting right dominant side, aphasia following cerebral infarction, hypertension, vascular dementia with mood and behavior disturbance, expressive language disorder, adjustment disorder with mixed disturbance of emotions and conduct, dysphagia following cerebral infarction, impulse disorder, anxiety disorder, delusional disorders, intermittent explosive disorder, bipolar disorder, and major depressive disorder.

Review of the behavior care plan, revised 08/27/24, revealed Resident #78 had a behavior problem related to impulse disorder, dementia, bipolar disorder, verbally aggressive or threatening, touching staff inappropriately, making inappropriate comments, and refusal of care. Interventions included provide medications as ordered (01/06/23), approach and speak in a calm manner (01/06/23), consult behavioral health as needed (01/06/23), communicate with resident regarding behaviors and treatment (01/06/23), encourage resident to express feelings (01/06/23), encourage resident to maintain as much independence and control or decision making as possible (01/06/23), intervene as necessary to protect the rights and safety of others (01/06/23), minimize the potential for disruptive behaviors by offering snacks that divert attention (01/06/23), monitor behavioral episodes and attempt to determine underlying causes (01/06/23), notify medical director of increased behaviors (01/06/23), observe and anticipate resident's needs (01/06/23), praise any indication of progress in behaviors (01/06/23), psychosocial assessment completed (09/19/24), and PTSD screen completed (09/19/24).

Review of the facility submitted SRI dated 09/19/24 revealed a chemical made contact with Resident #78's eyes. Further review of the facility's SRI investigation revealed STNA #942 had sprayed oleoresin capsicum (OC) spray (also known as pepper spray) toward Resident #78. Review of the witness statements revealed Resident #81 witnessed STNA #942 spray Resident #78 with mace, STNA #919's statement indicated STNA #942 told STNA #919 that she sprayed Resident #78 with mace and STNA #919 reported it to the nurse and unit manager immediately, and Licensed Practical Nurse (LPN) #941's statement indicated Resident #78's eyes were burning and red and Resident #78 indicated he was sprayed with something. The facility's timeline of their investigation indicated the alleged incident occurred around 10:00 A.M., facility management were not notified of the alleged abuse until 1:55 P.M., and the investigation of the incident began at 1:56 P.M.

Review of the Post-Traumatic Stress Disorder (PTSD) Assessment, dated 09/20/24, indicated Resident #78 considered the event traumatic, had nightmares or thought about the event when he did not want to, had been frequently on guard or watchful or easily startled, and felt guilty or unable to stop blaming himself or others for the event. Resident #78 described the event as he got into a heated conversation with staff about the smoke break, he got agitated, and the next thing he knew was he was getting sprayed in the eyes with pepper spray.

Review of the PTSD Assessment, dated 09/21/24, indicated Resident #78 considered the event traumatic and had been frequently on guard or watchful or easily startled. He described the event as he got into an argument with staff over the smoke break, he got agitated, and the next thing he knew was he was getting sprayed in the eyes with that spray.

On 10/16/24 at 11:55 A.M., an interview with the Administrator and DON stated the Administrator was out of town at the time of the incident and the DON conducted the investigation. The Administrator and DON confirmed STNA #942 sprayed Resident #78 with pepper spray. The Administrator and DON said initially it was reported that Resident #78 got cleaning chemicals in his eyes and further investigation determined that was inaccurate.

On 10/16/24 at 2:00 P.M., an interview with Unit Manager #861 stated the management team was sitting in morning meeting around 9:30 A.M. on the day of the incident when one of the managers received a text about someone being maced on the unit and there was an odor.

On 10/16/24 at 2:50 P.M., an interview with the Administrator and DON confirmed the facility's timeline for the incident, including that management staff were not aware of the incident until 09/19/24 at 1:55 P.M.

On 10/17/24 at 10:49 A.M., an interview with STNA #919 stated she was assisting another resident with breakfast when she heard a commotion in the hallway. Upon entering the hallway, she noted Resident #78 had an orange residue dripping down his face and STNA #942 told her Resident #78 tried to hit STNA #942 and she maced him. STNA #919 stated she alerted the nurse, Resident #78's eyes were cleaned, and Resident #78 was given a shower to remove the remaining orange residue from his hair and face. STNA #919 said she texted Unit Manager #809 on 09/19/24 at 9:54 A.M. to notify her that Resident #78 had been maced on the unit. Observation of the text conversation at the time of interview confirmed the date and time the text message notification was sent from STNA #919 to Unit Manager #809.

On 10/17/24 at 11:27 A.M., an interview with Unit Manager #809 stated she was in morning meeting when someone reported an odor on the unit. Unit Manager #809 confirmed STNA #919 texted her on 09/19/24 at 9:54 A.M. notifying her that someone had been massed on the unit, STNA #919 then clarified it smelled like bear mace, and STNA #919 said Resident #78 needed help. Unit Manager #809 said she asked STNA #919 if the nurse was over there and STNA #919 said she told LPN #941 and LPN #941 was in the office. Unit Manager #809 said she texted LPN #941 on 09/19/24 at 10:34 A.M. to ask if everything was okay and LPN #941 texted back that Resident #78 must have gotten a chemical in his eyes because his eyes were burning and they flushed his eyes. Unit Manager #809 stated she went to the unit around 11:15 A.M. to assess Resident #78 with no significant findings, there was no odor of mace on the unit, and none of the residents complained of burning sensations or difficulty breathing at that time. Unit Manager #809 further stated that STNA #919 did not approach management staff until later in the day to state what really happened and that's when management began investigating the possibility of mace instead of a cleaning chemical.

Review of the facility's policy titled OHIO Abuse, Neglect & Misappropriation

Based on record review, review of the facility's self-reported incident (SRI) and associated facility investigation, review of facility policy, and staff interviews, the facility failed to remove a perpetrator of abuse from the facility immediately to ensure all residents were protected from further abuse. This affected one resident (#78) and had the potential to affect 22 additional residents (#61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #79, #80, #81, #82, and #83) who resided on the secured Hickory unit. The facility census was 167.

Findings include:

Review of the medical record for Resident #78 revealed an admission date of 12/31/22 and re-admission date of 02/03/23. Diagnoses included hemiplegia and hemiparesis affecting right dominant side, aphasia following cerebral infarction, hypertension, vascular dementia with mood and behavior disturbance, expressive language disorder, adjustment disorder with mixed disturbance of emotions and conduct, dysphagia following cerebral infarction, impulse disorder, anxiety disorder, delusional disorders, intermittent explosive disorder, bipolar disorder, and major depressive disorder.

Review of the facility submitted SRI dated 09/19/24 revealed a chemical made contact with Resident #78's eyes. Further review of the facility's SRI investigation revealed STNA #942 had sprayed oleoresin capsicum (OC) spray (also known as pepper spray) toward Resident #78. Review of the witness statements revealed Resident #81 witnessed STNA #942 spray Resident #78 with mace, STNA #919's statement indicated STNA #942 told STNA #919 that she sprayed Resident #78 with mace and STNA #919 reported it to the nurse and unit manager immediately, and Licensed Practical Nurse (LPN) #941's statement indicated Resident #78's eyes were burning and red and Resident #78 indicated he was sprayed with something. The facility's timeline of their investigation indicated the alleged incident occurred around 10:00 A.M., facility management were not notified of the alleged abuse until 1:55 P.M., and the investigation of the incident began at 1:56 P.M. The facility's timeline further indicated STNA #942 was suspended on 09/19/24 at 2:15 P.M. and LPN #941 was suspended on 09/19/24 at 3:03 P.M.

Review of the time punch detail for STNA #942 revealed she worked on 09/19/24 from 7:07 A.M. to 2:17 P.M.

Review of the time punch detail for LPN #941 revealed she worked on 09/19/24 from 6:03 A.M. to 3:06 P.M.

Review of the Post-Traumatic Stress Disorder (PTSD) Assessment, dated 09/20/24, indicated Resident #78 considered the event traumatic, had nightmares or thought about the event when he did not want to, had been frequently on guard or watchful or easily startled, and felt guilty or unable to stop blaming himself or others for the event. Resident #78 described the event as he got into a heated conversation with staff about the smoke break, he got agitated, and the next thing he knew was he was getting sprayed in the eyes with pepper spray.

Review of the PTSD Assessment, dated 09/21/24, indicated Resident #78 considered the event traumatic and had been frequently on guard or watchful or easily startled. He described the event as he got into an argument with staff over the smoke break, he got agitated, and the next thing he knew was he was getting sprayed in the eyes with that spray.

On 10/16/24 at 2:00 P.M., an interview with Unit Manager #861 stated the management team was sitting in morning meeting around 9:30 A.M. on the day of the incident when one of the managers received a text about someone being maced on the unit and there was an odor.

On 10/16/24 at 2:50 P.M., an interview with the Administrator and DON confirmed the facility's timeline for the incident, including that management staff were not aware of the incident until 09/19/24 at 1:55 P.M. and suspensions were implemented after management staff were notified.

On 10/17/24 at 10:49 A.M., an interview with STNA #919 stated she was assisting another resident with breakfast when she heard a commotion in the hallway. Upon entering the hallway, she noted Resident #78 had an orange residue dripping down his face and STNA #942 told her Resident #78 tried to hit STNA #942 and she maced him. STNA #919 stated she alerted the nurse, Resident #78's eyes were cleaned, and Resident #78 was given a shower to remove the remaining orange residue from his hair and face. STNA #919 said she texted Unit Manager #809 on 09/19/24 at 9:54 A.M. to notify her that Resident #78 had been maced on the unit. Observation of the text conversation at the time of interview confirmed the date and time the text message notification was sent from STNA #919 to Unit Manager #809.

On 10/17/24 at 11:27 A.M., an interview with Unit Manager #809 confirmed STNA #919 texted her on 09/19/24 at 9:54 A.M. notifying her that someone had been massed on the unit, STNA #919 then clarified it smelled like bear mace, and STNA #919 said Resident #78 needed help. Unit Manager #809 said she asked STNA #919 if the nurse was over there and STNA #919 said she told LPN #941 and LPN #941 was in the office. Unit Manager #809 said she texted LPN #941 on 09/19/24 at 10:34 A.M. to ask if everything was okay and LPN #941 texted back that Resident #78 must have gotten a chemical in his eyes because his eyes were burning and they flushed his eyes.

Review of a list of residents STNA #942 cared for on 09/19/24 revealed Resident #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #79, #80, #81, #82, and #83 had the potential to be affected.

Review of the facility's policy titled OHIO Abuse, Neglect & Misappropriation

Based on observation, record review and interview, the facility failed to appropriately assess and monitor Resident #80's closed reduction of the resident's left ankle fracture, a closed reduction of the resident's right first proximal phalanx fracture and a L1 inferior endplate fracture. This finding affected one (Resident #80) of three residents reviewed for quality of care.

Findings include:

Review of Resident #80's hospital progress note prior to facility admission, dated 08/08/24 at 10:36 A.M., revealed the resident had a closed reduction of the resident's left ankle fracture, a closed reduction of the resident's right first proximal phalanx fracture and a L1 inferior endplate fracture. A closed reduction of the left ankle was completed in the hospital. The left lower extremity was placed in a bulky splint and the toes had minimal edema.

Review of Resident #80's medical record revealed the resident was admitted on 08/09/24 with diagnoses including nondisplaced fracture of the medial malleolus of the left tibia, anemia and schizoaffective disorder bipolar type.

Review of Resident #80's Modified Admission Minimum Data Set (MDS) 3.0 Comprehensive Assessment dated 08/15/24 revealed the resident exhibited moderate cognitive impairment.

Review of Resident #80's history and physical form dated 08/10/24 revealed the resident was identified to have a closed left ankle fracture and a first proximal phalanx fracture and was placed in a fixed mobilization. The facility would continue her care as ordered and would work with therapy to improve the resident's function and plan for post-acute care as well.

Review of Resident #80's physician orders, medication administration records (MARS) and treatment administration records (TARS) from 08/09/24 to 10/16/24 did not reveal evidence of assessments and monitoring of the closed reduction of the resident's left ankle fracture, a closed reduction of the resident's right first proximal phalanx fracture and a L1 inferior endplate fracture.

A telephone interview on 10/16/24 at 10:56 A.M. with Hospital Scheduling #940 indicated the resident's original orthopedic appointment was on 09/12/24 and the appointment was canceled. Hospital Scheduling #940 stated on 10/01/24 a staff member called in and rescheduled the appointment for 10/31/24. She indicated their office needed the financial information for the resident.

Review of Resident #80's physician orders revealed an order dated 10/30/24 for an orthopedic follow-up appointment dated 10/31/24; and an order dated 08/09/24 for a wound consult.

Observation on 10/16/24 at 11:27 A.M. with Regional Nurse #938 of Resident #80's bilateral feet revealed the resident had wrapped her right foot in paper products and debris. No wounds were identified on the right foot when the resident removed the dressings. Further observations revealed the resident removed a plastic bag and paper on the left foot. The left foot/leg was wrapped with a soiled ace wrap and underneath of the wrap, the resident had a soft sided cast. The resident's toes appeared within normal limits and no edema or odors were identified.

Telephone interview on 10/16/24 at 11:40 A.M. with Nurse Practitioner (NP) #939 indicated she did not follow Resident #80's left lower extremity fracture, and the facility wound nurse as well as the wound NP followed this resident for the left lower extremity.

Interview on 10/16/24 at 12:02 P.M. with Licensed Practical Nurse (LPN) Unit Manager (UM) #807 (facility wound nurse) stated the resident was a surgical resident and was not being followed by her or the Wound NP on the left lower extremity fracture.

Interview on 10/16/24 at 12:10 P.M. with the Administrator confirmed Resident #80's orthopedic appointment was canceled on 09/12/24 because of insurance issues and the resident was rescheduled for an appointment on 10/31/24 with Medicaid insurance. The Administrator confirmed Resident #80's medical record did not have assessments and monitoring of the closed reduction of the resident's left ankle fracture, a closed reduction of the resident's right first proximal phalanx fracture and a L1 inferior endplate fracture.

Review of the undated Wound Care policy revealed residents/patients admitted with or develop skin integrity issues would receive treatment as indicated based on location, stage and drainage.

This deficiency represents non-compliance investigated under Complaint Number OH00158183.

Based on observation and interview, the facility failed to discard expired food items timely and appropriately label or date opened and prepared food items. This had the potential to affect all 166 of 167 resident who received food from the kitchen as Resident #151 received nothing by mouth (NPO). The facility census was 167.

Findings include:

On 10/15/24 from 6:45 A.M. to 7:00 A.M., the initial walkthrough of the kitchen revealed the reach-in refrigerator contained the following:

- One container of beans that was not labeled or dated.

- One container of mayonnaise that was not labeled with the open date.

- One container of sour cream with an expiration date of 10/12/24.

- Three plastic wrapped bundles of sliced cheese that were not labeled or dated.

- One bag of lettuce that was not labeled or dated.

- One plastic tub containing open packages of hot dogs that was not labeled or dated.

- Two small containers of a brown substance that were not labeled or dated.

- One container of Dannon Light + Fit vanilla yogurt with an expiration date of 10/03/24 and writing in black marker indicated the container had been opened on 10/14/24.

Interview at the time of observation with Culinary Supervisor #818 verified the above observations. Culinary Supervisor #818 stated all staff in the kitchen were responsible for ensuring items were appropriately labeled and dated and to check the expiration date on food items. Culinary Supervisor #818 further stated the expiration date of the yogurt should have been checked before it was opened and served to residents.

This deficiency represents non-compliance investigated under Complaint Numbers OH00158037 and OH00158183.

Based on observation, interview, record review, and policy review the facility failed to ensure Resident #165's diabetes was managed appropriately by ensuring insulin was administered according to physician orders. This affected one (#165) of four residents observed for medication administration. The facility census was 170.

Findings include:

Review of Resident #165's medical records revealed an admission date of 08/23/24. Diagnoses included diabetes, developmental delays and schizophrenia.

Review of Resident #165's Minimum Data Set (MDS) assessment dated 08/29/24 revealed Resident #165 had intact cognition and required moderate assistance with toileting, bathing and personal hygiene.

Review of Resident #165's current physician orders for September 2024 revealed Resident #165 was ordered Fiasp (fast acting insulin) 15 units before meals.

Observation of medication administration on 09/10/24 at 7:56 A.M. for Resident #165 with Registered Nurse (RN) #427 revealed RN obtained Resident #165's insulin pen and the packaging indicated to administer 12 units. RN #427 removed the Fiasp out of the package and dialed in the dosage of the insulin to be administered. Observation of the pen revealed the dosage was dialed to deliver 18 units. RN #427 took the pen back and stated Oh I was only supposed to draw up 12 units. RN #427 then dialed in 12 units of Fiasp and administered the Fiasp.

Interview on 09/10/24 at 1:08 P.M. with the Director of Nursing (DON) confirmed Resident #165's physician orders were to administer 15 units of Fiasp.

Review of facility policy titled Medication Administration undated revealed to administer medications only as prescribed by the provider.

This deficiency represents non-compliance investigated under Complaint Number OH00157395.

Based on observation, interview, record review, and policy review the facility failed to maintain proper infection control techniques during wound care and insulin administration. This affected one (#40) of three residents observed for wound care, one (#165) of one resident observed for insulin administration, and had the potential to affected 52 residents (#2, #11, #12, #19, #21, #22, #26, #27, #35, #40, #46, #55, #56, #59,#62, #64, #69, #72, #73, #81, #83,#87, #91,#98, #102, #103, #106, #110, #111, #112, #115, #120, #122, #123, #126, #128, #129, #131, #134, #137, #140, #141, #142, #147, #149, #151, #153, #156, #157, #165 #166 and #169) residing on the Oak and Walnut halls where Registered Nurses #427 and 304 were providing care. The facility census was 170.

Findings include:

1. Review of Resident #40's medical records revealed an admission date of 08/26/24. Diagnoses included diabetes and non-compliance with medical treatments.

Review of Resident #40's Minimum Data Set (MDS) assessment dated 08/22/24 revealed Resident #40 had intact cognition.

Review of Resident #40's care plan dated 09/06/24 revealed Resident #40 required Enhanced Barrier Precautions (EBP) related to a wound. Interventions included to wear appropriate Personal Protective Equipment (PPE) during high contact care.

Review of Resident #40's current physician orders for September 2024 revealed Resident #40 required EBP related to

wound.

Observation on 09/10/24 at 10:28 A.M. revealed a sign posted outside of Resident #40's room that indicated Resident #40 was on (EBP) and an isolation bin with PPE was located outside of Resident #40's room. Interview with Registered Nurse (RN) #427 at the time of observation revealed she believed Resident #40 was no longer on EBP because he had completed his course of antibiotics for an infection in his wound. RN #304 and RN #427 proceeded to enter Resident #40's room without donning PPE. RN #427 placed wound care supplies on Resident #40's bedside table without cleaning the surface of the table or placing a barrier down. RN #427 placed a soiled towel that was on the floor underneath Resident #40's left leg and then using scissors that were removed from her pocket cut the dressing covering Resident #40's wound. RN #304 and RN #427 cleansed Resident #40's wound, and while wearing the soiled gloves RN #427 proceeded to open Resident #40's dresser drawers to look for additional wound care supplies. Without changing gloves or completing hand hygiene the RNs placed a new dressing on Resident #40's wound. RN #427 returned to Resident #40's drawer and obtained a pair or socks and placed them on Resident #40's feet. After completing the wound care RN #304 and RN #427 discarded their gloves and without completing hand hygiene exited the room.

Interviews with RN #304 and RN #427 immediately after the observation revealed they did not don PPE prior to entering Resident #40's because they did not believe he required isolation; RN #304 and RN #427 confirmed they had not performed hand hygiene; RN #427 confirmed she placed a soiled towel under Resident #40's leg stating it was already dirty

Based on personnel file review, interview and review of the facility policy, the facility failed to hire staff free of disqualifying offenses including abuse. This affected three out of five personnel files reviewed and had the potential to affect all 161 residents in the facility.

Findings include:

Review of personnel files on 07/30/24 at 12:03 P.M. and 4:25 P.M. with the Administrator revealed the following areas of concern:

Review of State Tested Nursing Assistant (STNA) #356's personnel file revealed a date of hire of 03/06/23. Review of STNA #356's background check report dated 03/10/23 revealed a charge dated 03/31/04 for cruelty towards child and child neglect and a charge of aggravated child abuse and cruelty towards child with a note that charge was dropped/abandoned on 07/09/04. Both charges occurred in the state of Florida.

Review of Maintenance Technician (MT) #438's personnel file revealed a date of hire of 06/19/24. Review of MT #438's background check report dated 07/01/24 revealed a charge dated 11/05/18 for possession of drugs (2925.11).

Review of STNA #367's personnel file revealed a date of hire of 04/24/24. Review of STNA #367's background check dated 05/03/24 revealed a charge dated 05/03/21 for endangering children, a charge dated 10/21/20 for possession of drugs (2925.11) and a charge dated 08/30/21 for possession of marijuana (2925.11).

Interviews with the Administrator verified the above findings at the time of discovery. The Administrator indicated the internal facility processes regarding questionable background checks was not followed, as any applicant with findings on their background checks that Human Resources staff had questions about would have to go to the Divisional Vice President of Human Resources for further review. The Administrator also stated based on STNA #356's findings of child neglect, STNA #356 never should have been hired by the facility.

Review of the facility policy, Background Checks/Abuse Checks Under Ohio Law

Based on personnel record review, facility policy review, and interview, the facility failed to implement their abuse policy and procedure regarding checking potential applicants against the Ohio Nurse Aide Registry (NAR). This affected three out of five personnel files reviewed and had the potential to affect all 161 residents who resided in the facility.

Findings include:

Review of personnel files on 07/30/24 at 12:03 P.M. and 4:25 P.M. with the Administrator revealed the following areas of concern:

Review of State Tested Nursing Assistant (STNA) #356's personnel file revealed a date of hire of 03/06/23. STNA #356's personnel file lacked evidence she was checked against the NAR prior to 07/30/24. A copy of the NAR ran by the Administrator on 07/30/24 was on top of her personnel file.

Review of Maintenance Technician (MT) #438's personnel file revealed a date of hire of 06/19/24. MT #438's personnel file lacked evidence he was checked against the NAR.

Review of Activity Aide (AA) #307's personnel file revealed a date of hire of 06/19/24. AA #307's personnel file lacked evidence she was checked against the NAR.

Interviews with the Administrator verified the above findings at the time of discovery. The Administrator indicated she ran STNA #356 against the NAR this date for her own peace of mind and confirmed all staff regardless of position were to be ran against the NAR to ensure they do not have a finding of abuse, neglect, mistreatment, exploitation of residents or misappropriation of their property.

Review of the policy, Background Checks/Abuse Checks Under Ohio Law

Based on medical record review, review of admission documents, staff interviews, and review of facility policy, the facility failed to timely implement effective and individualized interventions to address behavioral health concerns. In addition, the facility failed to monitor the effectiveness of interventions once implemented. This affected one (#70) of three residents reviewed for behavioral health services. The facility census was 167.

Findings include:

Review of the medical record for Resident #70 revealed an admission date of 04/17/24. Further review revealed Resident #70 passed away in the facility on 04/26/24. Resident #70 had diagnoses including left non-dominant side hemiplegia and hemiparesis following cerebral infarction, type one diabetes mellitus, psychosis, anxiety disorder, major depressive disorder, delirium, and insomnia.

Further review of the medical record revealed Resident #70 was transferred from another facility. Review of admission documents, which included progress notes from the previous facility, revealed the following behaviors: 04/09/24 Resident yelling out, refused to use call light, called staff inappropriate names, used foul language, and wanted someone to stay in the room with her; 04/10/24 behaviors of yelling out; 04/11/24 Resident yells out; 04/15/24 at 12:28 A.M. Resident yells out often, almost constantly, tries to get out of bed, pulled tube feeding line apart, resident needs constant monitoring; and 04/15/24 at 9:40 A.M. Resident continues to yell out frequently and several attempts to self-transfer, interventions ineffective except sitting with resident and providing 1:1.

Review of the Nursing Admission Evaluation, dated 04/17/24, indicated Resident #70 exhibited no behaviors and included care planning for psychosocial well-being. Interventions included to observe for signs and symptoms of psychosocial issues and initiate resident specific interventions.

Review of the plan of care initiated 04/18/24 revealed no care plan interventions related to behavioral challenges. On 04/19/24, a focus area was initiated for the use of antipsychotic and antidepressant medication. Interventions included administer medications as ordered, monitor for side effects, encourage resident to voice feelings and discuss coping skills, maintain consistent daily routine when possible, provide calm environment and limit over stimulation. Further review revealed on 04/23/24 (six days after admission), a care plan focus area was initiated, which indicated Resident #70 had a behavior problem: yelling out, delusions, agitation, resistive to personal care, crawling out of bed onto fall mat, removing soft boots and dressing to left foot, and crawling and rolling on the floor. Interventions included administer medications as ordered, observe and document effectiveness and side effects of medications, educate resident/resident representative to medication effectiveness, behavioral health consults as needed, encourage active support by family/resident representative, encourage to maintain as much independence and control as possible, intervene as necessary to protect the rights and safety of others, minimize the potential for disruptive behaviors by offering tasks that divert attention, monitor behavioral episodes and attempt to identify underlying causes, notify the provider of increased episodes of behaviors, non-pharmacological interventions to include 1:1 support, reorient, redirect, and reapproach, observe and anticipate resident's needs, praise any indication of progress in behaviors, approach/speak in a calm manner, and communicate with resident/resident representative regarding behaviors and treatment.

Review of physician orders, dated 04/18/24, revealed Resident #70 was ordered quetiapine 50 milligrams (mg) one tablet via feeding tube two times daily for psychosis, venlafaxine HCI oral tablet 50 mg one tablet via feeding tube three times a day for depression, monitor for antidepressant and antipsychotic medication side effects, bed against wall per resident preference, fall mat to floor to open side of bed, and a perimeter mattress to define edges.

Review of the Medication Administration Record (MAR) from 04/17/24 through 04/26/24 revealed on 04/18/24, 04/19/24, 04/21/24, 04/22/24, 04/23/24, and 04/25/24 Resident #70 was documented to have delusions, on 04/22/24, 04/23/24, 04/24/24, and 04/25/24 Resident #70 was documented to yell out, on 04/19/24, 04/22/24, 04/23/24, and 04/24/24 Resident #70 was documented to be agitated, on 04/23/24 Resident #70 was documented to resist personal care, and on 04/23/24, 04/24/24, and 04/25/24 Resident #70 was noted to crawl onto floor mat. Interventions included one on one support, reorientation, redirection, and reapproach. There was no documentation to evaluate the effectiveness of interventions.

Review of an undated Witness Statement revealed Nursing Supervisor (NS) #802 provided one to one care for Resident #70 on 04/18/24, 04/19/24, 04/22/24, 04/23/24, 04/24/24, and 04/25/24 for two to three hours each day. NS #802 provided nail care, braided the resident's hair, listened to music, put puzzles together, colored, and attempted to do word searches. Emotional support was given, and Resident #70 was receptive. No additional information was included to determine the effectiveness of each intervention.

Review of a nursing note dated 04/18/24 at 5:00 P.M. revealed Resident #70 was observed crawling onto the floor mat. Resident #70 indicated she was stretching. Staff assisted Resident #70 back to bed. Record review revealed no documented evidence of staff interventions at this time to address the resident crawling onto the floor mat.

Review of a physician's order, dated 04/19/24, revealed to monitor every shift for behaviors of yelling out, delusions, agitation, crawling out of bed onto fall mat, and resistance to personal care. Non-pharmacological interventions included one on one support, reorientation, redirection, and reapproach.

Review of a nursing note dated 04/19/24 at 8:47 A.M. revealed Resident #70 was pulling on soft boots to remove them and had already removed a wound care treatment. Boots were properly placed back on the resident's feet and floor nurse notified of treatment needing replaced. Record review revealed no additional documented evidence of staff interventions at this time to address the resident removing the wound care treatment or information as to why the treatment was removed.

Review of a nursing note dated 04/19/24 at 4:42 P.M. revealed Resident #70 was agitated for most of the day. Resident #70 was observed trying to crawl out of bed multiple times. The note indicated Resident #70 was confused at times. Record review revealed no documented evidence of staff interventions at this time to address the resident's behavior.

Review of an attending physician progress note dated 04/20/24 revealed Resident #70 had a history of depression and staff reported Resident #70 was easily anxious. The attending physician indicated Resident #70 would likely be seen by psychological services. Further review revealed no additional information on Resident #70's behaviors or interventions implemented at that time.

Review of a Medication Administration Note dated 04/21/24 at 7:26 A.M. revealed Resident #70 refused to wear soft boots for skin integrity. Record review revealed no documented evidence of staff interventions at this time to address the resident's behavior.

Review the the Medicare Admission Minimum Data Set (MDS) assessment dated 04/22/24 revealed Resident #70 had moderately impaired cognition and moderate depressive symptoms. There were no behaviors identified on the assessment.

Additional review of a physician order dated 04/23/24 revealed Resident #70 was ordered hydroxyzine pamoate (Vistaril) capsule 50 mg one capsule every six hours as needed for anxiety.

Further review of the plan of care revealed on 04/23/24 a care plan focus area was initiated, which indicated Resident #70 had a behavior problem: yelling out, delusions, agitation, resistive to personal care, crawling out of bed onto fall mat, removing soft boots and dressing to left foot, and crawling and rolling on the floor. Interventions included administer medications as ordered, observe and document effectiveness and side effects of medications, educate resident/resident representative to medication effectiveness, behavioral health consults as needed, encourage active support by family/resident representative, encourage to maintain as much independence and control as possible, intervene as necessary to protect the rights and safety of others, minimize the potential for disruptive behaviors by offering tasks that divert attention, monitor behavioral episodes and attempt to identify underlying causes, notify the provider of increased episodes of behaviors, non-pharmacological interventions to include 1:1 support, reorient, redirect, and reapproach, observe and anticipate resident's needs, praise any indication of progress in behaviors, approach/speak in a calm manner, and communicate with resident/resident representative regarding behaviors and treatment.

Interview on 04/23/24 at 7:37 A.M. with State Tested Nursing Assistant (STNA) #809 revealed Resident #70 was on her assigned hallway. STNA #809 noted Resident #70 had challenging behaviors including rolling onto the floor, screaming, taking clothing off, and repeatedly pressing her call light, despite staff just leaving the room. STNA #809 indicated staff had to go into Resident #70's room frequently to comfort her; however, it was challenging when there were others to care for.

A telephone interview on 04/23/24 at 2:15 P.M. with Licensed Practical Nurse (LPN) #804 revealed Resident #70 was on his assigned hallway on 04/21/24. LPN #804 indicated Resident #70 was screaming a lot on his shift. LPN #804 indicated he had to go into her room several times to reassure her she was okay. LPN #804 indicated this was the first time he had worked with Resident #70 and she was making strange comments he did not understand.

Interview on 04/23/24 at 2:28 P.M. with STNA #807 revealed Resident #70 was on her assigned hallway. STNA #807 indicated Resident #70 screamed a lot during her shift. STNA #807 indicated she provided routine care for Resident #70 including dressing and incontinence care. STNA #807 reported Resident #70 was accepting of care but used inappropriate language. STNA #807 indicated Resident #70 did not have behaviors when staff were in the room talking with her; however, she had others to care for so was unable to stay in the resident's room for her entire shift.

Review of a nursing note dated 04/23/24 at 3:21 P.M. revealed Resident #70 had multiple episodes of screaming out for help and when staff respond she had no specific request. Resident #70 was not redirectable. Resident #70 was brought to the activities room and started yelling again. Resident #70 was then brought to the nursing station and offered an activity but refused. Redirection and emotional support were offered with no success.

Telephone interview on 04/23/24 at 3:06 P.M. with LPN #806 revealed Resident #70 yelled all night, despite staff checking on her. LPN #806 indicated when she checked on Resident #70 she would report she did not need anything. LPN #806 indicated Resident #70 also used the call light repeatedly. LPN #806 indicated this behavior was baseline for Resident #70.

Interview on 04/23/24 at 4:09 P.M. with the Administrator revealed Resident #70 was transferred from another facility due to behaviors. The Administrator confirmed the facility had been informed Resident #70 had behaviors of putting herself on the floor, fidgeting with the call light, yelling out and was a fall risk. However, the Administrator indicated Resident #70's behaviors were more severe than reported from the previous facility.

Review of a Behavior Note dated 04/23/24 at 9:52 P.M. revealed Resident #70 had multiple episodes of screaming and increased anxiety. The physician was notified of the behaviors and gave a new order for hydroxyzine pamoate 50 milligrams (mg) tablet as needed.

Review of a Medication Administration Note dated 04/23/24 at 10:30 P.M. revealed Vistaril was administered for increased anxiety and yelling. Review of a follow up note dated 04/23/24 at 11:30 P.M. revealed Vistaril administration was unsuccessful and Resident #70 continued to yell.

Review of a Medication Administration Note dated 04/24/24 at 3:45 A.M. revealed Vistaril was administered for uncontrolled yelling and anxiety. Review of a follow up note dated 04/24/24 at 4:42 A.M. revealed Vistaril was effective.

Review of a Medication Administration Note dated 04/24/24 at 9:45 A.M. revealed Vistaril was administered for anxiety. Review of a follow up note dated 04/24/24 at 10:44 A.M. revealed Vistaril was ineffective. Resident #70 was noted to have increased behaviors. Record review revealed no documented evidence any additional staff interventions were attempted at this time to address the resident's behaviors.

Review of a nursing note dated 04/24/24 at 1:50 P.M. revealed Resident #70 with labile moods (rapid, exaggerated changes in mood) and inappropriate affect. Resident #70 had delusions and disorganized thought process. Resident #70 had intermittent screaming out without a cause and redirection was not very effective. It was noted Resident #70 could be distracted with activities. Record review revealed no documented evidence of any specific activities provided for distraction or additional staff interventions attempted at this time to address the resident's behaviors.

Review of a Medication Administration Note dated 04/24/24 at 5:48 P.M. revealed Vistaril was administered for anxiety.

Review of a nursing note dated 04/24/24 at 5:49 P.M. revealed Resident #70 was yelling and climbing onto the floor mat. Vistaril medication was ineffective. Record review revealed no documented evidence any additional staff interventions were attempted at this time to address the resident's behaviors.

Review of a Medication Administration Note dated 04/24/24 at 11:50 P.M. revealed Resident #70 was having increased anxiety with screaming and yelling. Vistaril was administered.

Review of a nursing note dated 04/25/24 at 4:53 A.M. revealed Resident #70 had increased anxiety when her husband left. Resident #70 continued to yell out and crawl onto the floor. Resident #70 did not sleep despite administration of Vistaril. Resident #70 was brought to the nurse's station and offered ice chips. When Resident #70 was put back to bed she continued to yell out and crawl onto the floor mat. Record review revealed no documented evidence any additional staff interventions were attempted at this time to address the resident's behaviors.

Review of a nursing note dated 04/25/24 at 9:20 P.M. revealed Resident #70 had increased anxiety. Resident #70 was yelling and crawling on the floor. Education was attempted. Record review revealed no documented evidence any additional staff interventions were attempted at this time to address the resident's behaviors.

Review of a nursing note dated 04/25/24 at 11:10 P.M. revealed Resident #70 was screaming and yelling. Resident #70 was brought to the nurse's station so she could see the staff.

Interview on 04/29/24 at 12:39 P.M. with the Administrator revealed Resident #70's behaviors were addressed in the care plan. The Administrator indicated Resident #70 had one on one interactions when she was yelling or experiencing behavioral challenges. The Administrator indicated Resident #70 had an order to see psychological services on 04/26/24; however, she passed away prior to the appointment.

Interview on 04/29/24 at 1:48 P.M. with Assistant Director of Nursing (ADON) #842 and the Administrator revealed there were no set behavioral interventions for all residents and they had to test out interventions to determine what would be effective. ADON #842 confirmed there was no documentation for the effectiveness of behavior interventions attempted with Resident #70.

Review of facility policy titled Behavior Management General

Based on observation of a video recording, resident interview, staff interview, medical record review, self-reported incident (SRI) review, and policy review, the facility failed to ensure a resident's privacy was maintained, when the resident was video recorded without their permission. During the recording, a staff member was questioning the resident about their opinion on body piercing's. Subsequently the video was posted to a social media website with laughing emojis (small digital image or icon used to express an idea, emotion, etc.) at the bottom of the video. This affected one (#4) of three resident reviewed for privacy. The facility census was 163.

Findings include:

Review of Resident #4's medical record revealed an admission date of 02/14/2012. Diagnoses included paranoid schizophrenia, dementia, severe psychotic disturbances and with agitation, extrapyramidal and movement disorders, anxiety disorder, delusional disorder, and epilepsy.

Review of the quarterly Minimum Data Set (MDS) assessment dated 12/13/23 revealed Resident #4 was cognitively intact with disorganized thinking which fluctuates and changes in severity.

Review of a SRI dated 03/04/24 revealed a State Tested Nurse Aide (STNA) was scrolling through Instagram and came across familiar worker from activities and seen a video of a Resident #4 from Wyant Woods. The STNA immediately reported to the Assistant Director of Nursing (ADON)/RISK manager immediately. Resident #4 was immediately interviewed and stated she felt safe. Activities Lead #464 was suspected called immediately and suspended pending investigation. Interviews and investigation in progress.

Interview on 03/11/24 at 10:27 A.M., with Resident #4 revealed she was talkative. Resident #4 identified herself as a recruiter, a captain, and a volunteer. Resident revealed she never recalled being videotaped.

Interview on 03/11/24 at 10:30 A.M., with Registered Nurse (RN) Unit Manager #441 revealed Resident #4 identified as different people daily.

Interview on 03/11/24 at 10:33 A.M., with Administrator confirmed on 02/18/24, Activities Lead #464 recorded Resident #4 on her personal phone and posted it on social media. The Administrator revealed she was made aware of the post by another employee on 03/04/23. Administrator revealed she spoke with Activities Lead #464 on 03/04/24 who confirmed she recorded Resident #4 on her personal phone and posted it on social media. Administrator revealed she viewed the post on social media on 03/04/23 and removed the post at that time.

Observations on 03/11/24 at 10:35 A.M., with the Administrator viewed the video with surveyor which revealed Resident #4 was sitting in the dining room while being recorded. Activities Lead #464 was talking with Resident #4 while video recording her. The conversation included Resident #4 revealing she did not understand those nose rings, Activities Lead #464 laughing questioning what my nose rings. Resident #4 revealed they were like lasers in her eyes, revealed Activities Lead #464 was not working and made a threatening statement. On the bottom of the video shared by Activities Lead #464 on social media were four laughing emojis.

Review of the facility policy titled, Social Media Policy dated 10/01/19, included Site Contributors are responsible for assuring it complies with all HIPPA Privacy Policies.

This deficiency represents non-compliance investigated under Complaint Number OH00151704 and OH00151219.

Based on record review of the Payroll Based- Journal (PBJ) Staffing Data Report and staff interview, the facility failed ot meet the required minimum staffing levels to meet the needs of the residents. This had the potential to affect all 163 residents residing at the facility. The facility census was 163.

Findings include:

Review of the PBJ Staffing Data Report for quarter three 2023, dated 04/01/23 through 06/30/23, revealed a one star staffing rating and excessively low weekend staffing.

Interview on 03/12/24 at 2:51 P.M., with Administrator confirmed the PBJ Staffing Data Report for 04/01/23 through 06/30/23 was reported correctly. The facility reported less than sufficient staffing to meet the needs of the residents. The Administrator verified the facility has no evidence of corrective action to fix the low staffing situation.

This deficiency represents non-compliance investigated under Complaint Number OH00151062 and OH00151071.

Based on medical record review, observation and staff interview, the facility failed to ensure fall prevention interventions were in place as ordered by the physician and per the fall plan of care. This affected two (Residents #15 and #62) of three residents reviewed for falls. The facility census was 164.

Findings include:

1. Review of Resident #15's medical record revealed an admission date of 06/05/22 with diagnoses that include Alzheimer's disease with dementia, chronic kidney disease and hypertension.

A fall risk assessment completed on 12/28/23 indicated Resident #15 was at high risk for falls.

Review of the fall risk plan of care for Resident #15 revealed a new intervention of mat to floor beside open side of bed added on 01/06/24. Review of the physician's orders revealed an order dated 01/08/24 which identified the use of a fall mat to the bedside.

Observation on 01/09/24 at 12:00 P.M. revealed Resident #15 lying in bed on her left side with no evidence of any fall mat to the floor beside the bed.

On 01/09/24 at 12:02 P.M. Licensed Practical Nurse (LPN) #211 verified there was no fall mat to the floor next to Resident #15's bed and the care plan and physician's orders indicate a fall mat should be in use.

2. Review of Resident #62's medical record revealed an admission date of 03/05/21 with diagnoses that include schizoaffective disorder, bipolar disorder, chronic obstructive pulmonary disease and dementia.

A fall risk assessment completed on 11/26/23 indicated Resident #62 was a high risk for falls.

Review of the fall risk plan of care for Resident #62 revealed a new intervention of mat to floor open side of bed added on 11/12/22. Review of the physician's orders revealed an order dated 11/14/22 which identified the use of a fall mat to the bedside.

Observation on 01/09/25 at 11:50 A.M. revealed no evidence of any fall mat to the floor beside the bed and a fall mat was not located in the resident's room.

On 01/09/25 at 11:52 A.M. Registered Nurse (RN) #209 verified there was no fall mat to the floor next to Resident #62's bed and the care plan and physician's orders indicate a fall mat should be in use.

This deficiency represents non-compliance investigated under Complaint Number OH00149543.

Based on observation and interview, the facility failed to maintain resident rooms and common areas in a clean and sanitary manner. This affected nine residents (Residents #9, #21, #91, #117, #121, #135, #140, #142 and #165) and had the potential to affect all 166 residing in the facility.

Findings include:

1. Observation on 07/21/23 at 8:00 A.M. revealed dirty linens and old meal trays that had food from the previous evening in a common dining area on one of two secured units located on the first floor. Interview with Licensed Practical Nurse (LPN) #385 on 07/21/23 at 8:05 A.M. confirmed the observation. LPN #385 stated the linens and dirty dishes should have been removed by the previous evening shift staff.

2. Observation on 07/21/23 at 8:12 A.M. revealed dirty linens in the hallway and old meal trays that had food from the previous meal in a common dining area on the second secured unit located on the first floor. The observation was confirmed by LPN #373 at time of observation. LPN #373 stated the linens and dishes should have been removed the previous shift.

3. Observation on 07/21/23 at 8:20 A.M. revealed Resident #21's toilet had stool and urine on the toilet seat and lid. Resident #21 was not interviewable.

4. Observation on 07/21/23 at 8:22 A.M. revealed Resident #165's room had large amounts of food and debris on the floor. Further observation revealed Resident #165's bathroom had stool on the walls, and toilet seat as well as an extremely large amount of stool and various other undetermined items in the toilet. Resident #165's bedding was dirty and soiled. The observations were confirmed by State Tested Nurse Aide (STNA) #414. STNA #414 stated Resident #165 had behaviors that included placing items in the toilet and the room was to be cleaned as needed. Resident #165 was not interviewable.

5. Observation on 07/21/23 at 8:29 A.M. revealed Resident #117's bedding was dirty and soiled. The observation was confirmed with STNA #414 at the time of the observation. STNA #414 stated resident bedding was to be changed at least weekly and as needed.

6. Observation on 07/21/21 at 8:33 A.M. revealed Resident #91's bathroom had numerous soiled incontinence briefs in an overflowing trash can and on the floor. Further observation revealed stool on the toilet and toilet seat.

7. Observation on 07/21/23 at 8:35 A.M. revealed Residents #135's and #140's bathroom had a broken toilet seat that had stool on the seat and the toilet. The observation was confirmed with Housekeeper #421 who stated she did not work for the facility directly. Housekeeper #421 did not know when the bathroom had last been cleaned.

8. Observation on 07/21/23 at 9:12 A.M. revealed Resident #142's bedding had a large soiled areas and there was a large amounts of food and debris on the floor. The observation was confirmed by Registered Nurse (RN) #381. RN #381 stated resident bedding was to be changed when soiled.

Interview on 07/21/23 at 9:18 A.M. with Housekeeper #422 revealed she did not work for the facility directly; however, she had been cleaning at the facility for a few months. Housekeeper #422 stated resident rooms and common areas were to be cleaned daily and as needed.

9. Observation on 07/21/23 revealed Housekeeper #386 was cleaning Resident #165's room. Housekeeper #386 stated Resident #165 had behaviors and often had a dirty room. Housekeeper #386 stated resident rooms were to be cleaned daily and as needed. At time of interview Maintenance Director (MD) #403 was observed in Resident #165's bathroom cleaning the toilet. MD #403 stated he was not sure of the last time the toilet was cleaned out and there were numerous items in the toilet. MD #403 stated staff had been instructed to take things out of the resident's toilet.

10. Interview on 07/21/23 at 11:00 A.M. with Resident #121 revealed he had taken a shower in a shower room and there were piles of old moldy towels and clothes that appeared as if they needed to be thrown out. Observation of the shower room at time of interview revealed there were no towels or clothing; however, the toilet had a black film around the inside of the toilet bowel. The observation of the black film inside the toilet bowl was confirmed by LPN #389.

This deficiency represents non-compliance investigated under Complaint Number OH00143844.

Based on observation, record review and interview, the facility failed to ensure residents were treated with dignity and respect at all times. This affected three residents (Resident #3, #9, and #23) of 42 reviewed for dignity.

Findings include:

1. Review of the medical record for Resident #9 revealed an admission date of 03/18/15. Resident #9's diagnoses included schizoaffective disorder, dementia and gastro-esophageal reflux disease (GERD).

Review of the quarterly MDS assessment dated 10/27/22 revealed Resident #9 could not complete a mental status assessment. He required extensive assistance of two people for bed mobility, transfers, dressing, toilet use and hygiene.

Interview and observation on 12/12/22 at 9:46 A.M. revealed Resident #9's bedroom door closed. The resident was lying in bed with a sheet covering him. He stated staff often entered his room without knocking or introducing themselves and did not wear nametags. He revealed he would like to get out of bed and get dressed for the day.

Interview and observation on 12/13/122 at 1:30 P.M. revealed Resident #9's bedroom door was closed. The resident was lying in bed and wanted to get up, but he reported staff told him they did not want him getting out of bed.

Observation on 12/13/22 at 1:57 P.M. revealed State Tested Nursing Assistant (STNA) #572 entered Resident #9's room without knocking or introducing herself and began assisting him in getting out of bed.

Interview on 12/13/22 at 2:02 P.M. with STNA #572 confirmed she did not knock or introduce herself before entering Resident #9's room. She reported he liked to sleep in in the morning and preferred to get out of bed in the afternoon.

Interviews on 12/14/22 at 10:00 A.M. with STNA's #549 and #616 confirmed they did not have name tags.

2. Resident #3 was admitted on 01/10/19 with diagnoses including paranoid schizophrenia, chronic kidney disease, intermittent explosive disorder, and post-traumatic stress disorder.

Resident #3's comprehensive MDS assessment dated 10/27/22 revealed his cognition was not assessed, and required limited two person assist for bed mobility, and extensive two person assistance for transfers, dressing, and toileting.

Observation on 12/15/22 at 8:32 A.M. revealed Resident #3 in bed with a shirt on and nothing covering his bottom half. A disposable brief was at the foot of the bed around his ankle. The door to his room was open and the curtain pulled back.

Interview on 12/15/22 at 8:32 A.M. with Registered Nurse (RN) #550 confirmed Resident #3's door and curtain were open. She confirmed staff were aware the resident would remove his brief at times and as a result, his curtain and bedroom door should be closed to maintain dignity.

3. Review of the medical record for Resident #23 revealed an admission date of 11/09/11 with diagnoses including dementia, traumatic brain injury and hyperlipidemia.

Review of the comprehensive MDS dated 11/04/22 revealed Resident #23 could not complete a mental status assessment. He required extensive assistance of two people for bed mobility and toilet use and was totally dependent on two staffing for transfers, hygiene and dressing.

Observation on 12/14/22 at 9:40 A.M. revealed resident #23's door was closed. The resident was lying in bed and appeared to be sleeping. STNA #616 entered the residents' room without knocking or asking for permission to enter.

Interview on 12/14/22 at 10:00 A.M. with STNA #616 confirmed she entered Resident #23's bedroom without knocking or asking for permission to enter.

Review of the facility policy for Resident Rights, undated, revealed staff would knock before entering a resident's room and doors and privacy curtains would be closed when providing care to a resident.

Based on observation, record review and interview, the facility failed to ensure call lights were in reach. The affected two residents (Resident #19 and Resident #37) out of nine residents reviewed for accommodation of needs.

Findings include:

1. Review of the medical record for Resident #19 revealed an admission date of 06/09/2019. Resident #19's diagnoses included multiple sclerosis, dementia, epilepsy and paraplegia.

Review of the quarterly Minimum Data Set (MDS assessment dated 12/09/22 revealed Resident #19 had moderately impaired cognition. She required extensive assistance of two people for bed mobility and toilet use, extensive assistance of one person for dressing, eating and hygiene and was totally dependent on two staff for transfers.

Review of the care plan dated 09/21/22 revealed the resident had a self-care performance deficit. Interventions included assistance with locomotion and tasks that caused frustration. She also used a mechanical lift for transfers with interventions to ensure her call bell was within reach.

Observation on 12/14/22 at 10:12 A.M. revealed Resident #19 was in her power wheelchair in her room and asked for a nurse. She used her wheelchair to move toward the nurse's station at the end of the hall and asked for a nurse to help her get into bed. Licensed Practical Nurse (LPN) #548 escorted the resident back to her room. Observation at the time revealed the resident's call light wrapped up and lying against the floor at the foot of her bed. Interview with LPN #548 at the time of the observation confirmed the call light was not within the resident's reach.

2. Review of the medical record for Resident #37 revealed an admission date of 03/05/21 with diagnoses including Alzheimer's, diabetes, depression and sleep apnea. Resident #37 resided a secured unit.

Review of the comprehensive MDS dated 11/14/22 revealed Resident #37 had moderately impaired cognition. He required extensive assistance of two people for bed mobility, transfers, dressing, toilet use and hygiene.

Review of the care plan dated 10/06/22 revealed the resident had a self-care performance deficit. Interventions included assistance ambulation, bathing, dressing and hygiene. He was also at risk for falls due to impaired cognition, mobility and balance. Interventions included ensuring the call bell was within reach.

Observation on 12/12/22 at 9:05 A.M. of Resident #37 revealed his bed was against the wall with the call light attached to the wall at the foot of his bed. A sign next to his bed read use call light for assistance.

Interview on 12/12/22 at 9:05 A.M. with Registered Nurse #592 confirmed Resident #37 could not access his call light and should have a bell on his bedside table. She confirmed the bell was at the nurses' station since the resident had just moved into that room the previous weekend.

Review of the facility policy for Resident Rights, undated revealed call lights or bells would be within the residents' reach.

Based on record review and interview, the facility failed to ensure resident funds were disbursed in a timely manner for Resident #209 after death as required. This affected one resident (Resident #209) of five residents reviewed for resident funds.

Findings include:

Review of Resident #209's closed medical record revealed an admission date of 05/29/19 and diagnoses including moderate protein-calorie malnutrition, dementia without behavioral disturbance, hypertension, alcohol abuse, delusional disorders, major depressive disorder and peripheral vascular disease.

Review of an annual minimum data set (MDS) assessment dated 07/01/22 revealed Resident #209 was cognitively intact.

Review of a nurses' note dated 07/07/22 revealed Resident #209 passed away at 6:15 P.M.

Review of a closed account summary report from 06/01/22 to 12/15/22 revealed Resident #209 expired on 07/07/22.

Review of Resident #209's quarterly statement for 07/01/22 through 09/30/22 revealed a balance of $1760.36 on 08/12/22 and the account was closed on that date. A check dated 11/14/22 in the amount of $1760.36 was sent as final disbursal.

Interview on 12/15/22 at 11:42 A.M. with Business Office Manager (BOM) #593 revealed a check dated 08/12/22 was to be sent as final disbursal for Resident #209 but it was voided and BOM #593 did not know why the check was voided, when it was voided or who voided the check. BOM #593 showed the surveyor the check information for the check on 08/12/22 on her computer which indicated the check was voided but no rationale or void date was provided. BOM #593 verified the check dated 11/14/22 was the final disbursal for Resident #209 and confirmed this exceeded the 30 day limit.

Review of the policy, Resident Trust Fund

Based on observation, record review and interview, the facility failed to notify Resident #61's representative of a change in condition. This affected one resident (Resident #61) of three reviewed for notifications.

Findings include:

Review of the medical record for the Resident #61 revealed an admission date of 07/16/19. Resident #61's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), respiratory failure and dementia.

Review of the nurses notes dated 10/06/22 through 10/07/22 revealed the resident reported shoulder pain after reaching for his wheelchair and missing it. He was sent to the Emergency Department (ED) for evaluation and treatment and returned with a dislocation shoulder and his arm in a sling. There was no evidence the guardian was notified.

Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/18/22, revealed the resident had intact cognition.

Review of physician orders for October 2022 identified orders for an orthopedic appointment on 10/18/22.

Review of the plan of care dated 10/26/22 revealed the resident had a left shoulder dislocation. Interventions included completing fall evaluations, following orders from the physician and assisting with activities of daily living (ADL)'s.

Observation and interview on 12/13/22 at 2:05 P.M. of Resident #61 revealed he was lying in bed on his right side. He reported he was not feeling well since he was just getting over the flu. He had no recollection of a dislocated shoulder.

Interview on 12/14/22 at 3:34 P.M. with the Director of Nursing (DON) confirmed there was no evidence the guardian was notified of the injury, transfer to the ED or subsequent appointments.

Review of facility policy titled Resident Rights

2. Record review for Resident #33 revealed an admission date of 11/24/21. Resident #33's diagnoses included dementia moderate with agitation, impulse disorder, schizoaffective disorder, bipolar type, severe intellectual disabilities, down syndrome, and visual hallucinations.

Record review of the Minimum Data Set (MDS) dated 12/7/22 revealed Resident #33 required extensive assistants for bed mobility, transfers, toilet use, and required limited assistants for locomotion with use of a wheelchair. Resident #33 was at risk for falls.

Record review of the skin assessment for Resident #33 dated 12/13/22 at 6:31 A.M. completed by Unit Manager, Registered Nurse (RN) #634 revealed a new red area was found on the mid-lower back with redness caused by the brief rubbing. The area measured 12 centimeters (cm) by .1 cm by zero cm. Area was not open. A treatment was applied to pad and protect, cover the area with an abdominal dressing and secure the dressing with tape.

Record review revealed Resident #33 had no falls documented for the month of December 2022.

Interview on 12/13/22 at 1:56 P.M. with Resident #33's roommate, Resident #115, revealed the previous night Resident #33 had a fall, she saw her lying on the floor and assisted her back to bed.

Interview on 12/14/22 at 10:05 A.M. with Unit Manager, RN #634 revealed Resident #33 had a urinary tract infection. Resident #33 required assistance for transfers and had been trying to transfer herself. Unit Manager, RN #634 revealed Resident #33 had no recent falls.

Interview on 12/15/22 9:31 A.M. with Unit Manager, RN #634 revealed on 12/13/22 in the morning she was assisting Resident #33 to get cleaned up when she noticed a wound on Resident #33's back. Unit Manager, RN #634 revealed the wound was located where the brief was on the lower back. When the surveyor requested Unit Manage, RN #634 to describe what the wound looked like, Unit Manager, RN #634 took her forearm and quickly and firmly pulled her arm down the edge of the desktop of the nurses station then showing her arm to the surveyor revealed that was what the wound would have looked like. Unit Manager, RN #634 revealed Resident #33's brief was not tight, the brief fit appropriately, there was no elastic on the brief, Resident #33 had always worn the same type and size of brief, and there was no prior history of the brief causing a wound to Resident #33. Unit Manager, RN #634 revealed she was not sure how the brief would have caused the wound on Resident #33 but it must have been the brief because that was the only thing near Resident #33 when she (Unit Manager, RN #634) found the wound. Unit Manager, RN #634 confirmed she did not do any investigation to determine the cause of Resident #33's wound to her lower back and the wound had not yet healed. Unit Manager, RN #634 confirmed Resident #33 continued to wear the same type of brief.

Interview on 12/15/22 at 1:35 P.M. with Director of Nursing (DON) confirmed Resident #33's wound to her lower back was unwitnessed. DON confirmed there was no investigation initiated or completed on how the brief, as stated in the progress note dated 12/13/22 at 6:31 A.M. completed by Unit Manager, RN #634, would have caused the wound on Resident #33's back. DON confirmed Resident #33 continued to wear the same type of brief.

Based on observation, interview, and record review, the facility failed to provide shaving assistance to Resident #50 and nail care to Resident #103 timely. This affected two residents (Residents #50 and #103) of four residents reviewed for activities of daily living (ADL).

Findings include:

1. Review of the medical record for Resident #50 revealed an admission date of 08/31/17. Resident #50's diagnoses included metabolic encephalopathy, type two diabetes mellitus, and paranoid schizophrenia.

Review of care plan dated 05/27/21 revealed Resident #50 had a self-care performance deficit and required assistance with activities of daily living. Interventions included to provide assistance with personal hygiene and bathing.

Review of the quarterly Minimum Data Set (MDS) assessment dated 11/25/22 revealed Resident #50 had moderate cognitive impairment. Resident #50 required extensive one-person physical assistance for bed mobility, transfers, and personal hygiene; supervision of one person for dressing; supervision with set-up help only for eating; and extensive two-person physical assistance for toilet use.

Review of shower sheets for Resident #50 from 09/01/22 to 12/14/22 revealed Resident #50 received shaving assistance on 09/01/22, 09/05/22, 09/09/22, 09/15/22, 09/22/22, 09/26/22, 10/03/22, 10/07/22, 10/11/22, 10/15/22, 10/23/22, 10/27/22, 11/05/22, 11/12/22, 11/24/22, 12/01/22, 12/04/22, 12/11/22, and 12/14/22.

Interview and observation on 12/13/22 at 8:30 A.M. with Resident #50 revealed half inch chin hairs hanging from her chin. She reported she does not like the chin hairs, but the staff is too busy to take care of them and they often forget. Resident #50 reported the chin hair embarrass her.

Observation on 12/14/22 at 10:56 A.M. revealed Resident #50 sitting in the common area with chin hairs still on her chin. Interview during the observation with the resident revealed they have been busy, and she still did not like them there.

Interview on 12/14/22 at 11:02 A.M. with State Tested Nursing Assistant (STNA) #611 confirmed Resident #50 did have chin hairs. She reported Resident #50 has never asked to have them shaved. She confirmed Resident #50 does get shaved every shower day which is twice a week on Sundays and Wednesdays. STNA #611 reported this is a locked behavioral Alzheimer's unit and residents often have different stories from minute to minute.

Review of facility policy on nail and hair hygiene services, undated revealed residents will have routine nail hygiene and hair hygiene as part of the bath or shower. Hair shampooing and trimming if needed will be completed on an as needed basis but no less than weekly.

2. Review of the medical record for Resident #103 revealed an admission date of 11/30/16. Resident #103's diagnoses included Alzheimer's disease with late onset, dementia, and peripheral vascular disease.

Review of care plan dated 09/22/22 for Resident #103 revealed she had a self-care performance deficit. Interventions included to provide assistance with hygiene and praise all efforts for self-care.

Review of quarterly Minimum Data Set (MDS) assessment dated 09/23/22 revealed Resident #103 had severe cognitive impairment with a memory problem. Resident #103 required extensive one-person physical assistance for bed mobility, dressing, toileting, and personal hygiene; and limited one-person physical assistance for transfers and eating.

Review of shower sheets for Resident #103 from 09/01/22 to 12/14/22 revealed Resident #103 received nail care as part of her shower on 09/03/22, 09/11/22, 09/18/22, 10/03/22, 10/10/22, 10/13/22, 10/20/22, 10/24/22, 11/01/22, 11/12/22, 11/15/22, 11/22/22, 12/06/22, and 12/14/22.

Observation on 12/13/22 at 8:17 A.M. of Resident #103 sitting in the common area with long dirt filled fingernails.

Observation on 12/13/22 at 1:21 P.M. of Resident #103 sitting in the common area scratching her leg with long dirt filled fingernails.

Observation on 12/14/22 at 10:58 A.M. of Resident #103 sitting in the common area listening to music and her fingernails were still long and dirt filled.

Interview on 12/14/22 at 11:02 A.M. with State Tested Nursing Assistant (STNA) #611 confirmed Resident #103 had long dirt filled fingernails. STNA #611 reported this was a locked Alzheimer's behavioral unit.

Review of facility policy nail and hair hygiene services, undated revealed residents will have routine nail and hair hygiene as part of the bath or shower.

Based on observation, interview, and record review, the facility failed to change a unsecured sterile dressing utilized to prevent infection at a peripherally inserted central catheter (PICC) line site for Resident #53. This affected one resident (Resident #53) of one resident reviewed for care of PICC line dressings.

Findings include:

Record review for Resident #53 revealed an admission date of 08/24/16. Resident #53's diagnoses included dementia severe with psychotic disturbances.

Record review of the quarterly Minimum Data Set (MDS) dated 11/03/22 revealed Resident #53 had a Brief Interview of Mental Status (BIMS) score of 12 showing mild cognitive impairement. Resident #53 required limited assistance for bed mobility and extensive assistance for transfers.

Record review of the care plan for Resident #53 revealed no care plan for the care of the PICC line.

Record review of the physician orders for Resident #53 revealed an order for vancomycin hcl (antibiotic) intravenous solution reconstituted 750 milligrams (mg) intravenous (IV) every eight hours for right foot infection until 12/15/22 (vancomycin initiated 12/04/22 and adjusted by pharmacy). Orders included PICC line dressing change weekly on Mondays and as needed.

Record review of the Treatment Administration Record (TAR) for Resident #53 revealed the PICC line dressing change was completed on 12/12/22.

Observation on 12/13/22 1:33 PM of Resident #53's dressing covering the PICC line insertion site located on the right inner upper arm revealed the white border of the dressing was dingy and discolored. The edges of the dressing was partially lifted on three sides leaving the insertion site exposed to potential infection. There was one piece of dingy white paper tape securing the fourth edge of the dressing. The dressing was undated and no initials were present.

Interview on 12/13/22 at 1:44 P.M. with Licensed Practical Nurse (LPN) #539 confirmed she was Resident #53's charge nurse. LPN #539 revealed she was unsure the last time Resident #53's PICC line dressing was changed. Observation with LPN #539 of Resident #53's PICC line dressing revealed LPN #539 confirmed the white border of the dressing was dingy and discolored. The edges of the dressing was partially lifted on three sides leaving the insertion site exposed at different areas of the dressing. The piece of paper tape applied to the fourth edge was also dingy white. LPN #539 revealed it was no concern with a loose, dingy dressing as long as the line was not dislodged and was intact.

Observation on 12/13/22 at 4:44 PM with Unit Manager, Registered Nurse (RN) #634 verified Resident #53's PICC line dressing's white border of the dressing was dingy and discolored. The edges of the dressing was lifted on three sides leaving the insertion site exposed. There was a fresh piece of clear tape applied to the fourth edge since the last observation on 12/13/22 at 1:44 P.M. with LPN #539. RN #634 revealed the dressing should be fine because it was not like it was a central line.

Interview on 12/14/22 at 8:04 A.M. with Director of Nursing confirmed Resident #53 dressing to the PICC line site should be secure surrounding the site to prevent potential infection.

Based on record review and interview, the facility failed to ensure Resident #94's restorative program and splint devices were implemented to assist with range of motion. This affected one resident (Residents #94) of three reviewed for restorative services.

Findings include:

Based on observation, interview, and record review, the facility failed to residents were supervised during smoking. This affected eight residents (Resident #30, #35, #36, #54, #70, #80, #129, and #133) of nine residents reviewed for smoking.

Findings include:

1. Record review for Resident #30 revealed an admission date of 01/26/21. Resident #30's diagnoses included dementia, severe with mood disturbances, psychotic disturbances, need for assistance with personal care, muscle weakness, and nicotine dependence.

Record review of the Minimum Data Set (MDS) dated 11/08/22 revealed Resident #30 was severely cognitively impaired and required supervision with activities of daily living.

Record review of the list of residents who smoke and require supervision while smoking revealed Resident #30 required supervision during their smoking breaks.

Observation on 12/14/22 at 8:37 A.M. revealed Resident #30 was outside in the courtyard of the secured behavioral unit smoking unsupervised.

Interview on 12/14/22 at 8:40 A.M. with State Tested Nursing Assistant (STNA) #529 revealed she lit each residents cigarettes then went back inside the facility leaving residents unattended to complete breakfast trays. STNA #529 confirmed Resident #30 required supervision while smoking cigarettes. STNA #529 confirmed there were times staff did not supervise residents while smoking.

Interview on 12/14/22 at 8:42 A.M. with Licensed Practical Nurse (LPN) #621 confirmed Resident #30 required supervision while smoking cigarettes. LPN #621 revealed she was collecting breakfast trays and confirmed staff were not supervising residents during their smoking break.

Interview on 12/15/22 at 1:57 P.M. with Director of Nursing (DON) and Administrator confirmed Resident #30 required supervision during smoking breaks.

2. Record review for Resident #35 revealed an admission date of 02/09/12. Diagnosis included paranoid schizophrenia, dementia severe with other behavioral disturbances, psychotic disturbances, delusional disorder, and nicotine dependence.

Record review of the MDS dated 10/31/22 revealed Resident #35 had moderately impaired cognition. Resident #35 required supervision with activities of daily living.

Record review of the list of residents who smoke and require supervision while smoking revealed Resident #35 required supervision during their smoking breaks.

Observation on 12/14/22 at 8:37 A.M. revealed Resident #35 was outside in the courtyard of the secured behavioral unit smoking unsupervised.

Interview on 12/14/22 at 8:40 A.M. with STNA #529 revealed she lit each residents cigarettes then went back inside the facility leaving residents unattended to complete breakfast trays. STNA #529 confirmed Resident #35 required supervision while smoking cigarettes. STNA #529 confirmed there were times staff did not supervise residents while smoking.

Interview on 12/14/22 at 8:42 A.M. with LPN #621 confirmed Resident #35 required supervision while smoking cigarettes. LPN #621 revealed she was collecting breakfast trays and confirmed staff were not supervising residents during their smoking break.

Interview on 12/15/22 at 1:57 P.M. with DON and Administrator confirmed Resident #35 required supervision during smoking breaks.

3. Record review for Resident #36 revealed an admission date of 11/04/21. Diagnosis included schizophrenia, monoplegia of upper limb affecting right dominant side, dementia with severe agitation, severe with psychotic disorder and severe with mood disturbances, muscle weakness, and nicotine dependence.

Record review of the MDS dated 12/05/22 revealed Resident #36 was cognitively intact. Resident #36 required extensive assistance with bed mobility, transfers, and dressing.

Record review of the list of residents who smoke and require supervision while smoking revealed Resident #36 required supervision during their smoking breaks.

Observation on 12/14/22 at 8:37 A.M. revealed Resident #36 was outside in the courtyard of the secured behavioral unit smoking unsupervised.

Interview on 12/14/22 at 8:40 A.M. with STNA #529 revealed she lit each residents cigarettes then went back inside the facility leaving residents unattended to complete breakfast trays. STNA #529 confirmed Resident #36 required supervision while smoking cigarettes. STNA #529 confirmed there were times staff did not supervise residents while smoking.

Interview on 12/14/22 at 8:42 A.M. with LPN #621 confirmed Resident #36 required supervision while smoking cigarettes. LPN #621 revealed she was collecting breakfast trays and confirmed staff were not supervising residents during their smoking break.

Interview on 12/15/22 at 1:57 P.M. with DON and Administrator confirmed Resident #36 required supervision during smoking breaks.

4. Record review for Resident #54 revealed an admission date of 05/14/19. Diagnosis included dementia severe with agitation, behavioral disturbances, psychotic disturbances, impulse disorder, and nicotine disturbance.

Record review of the MDS dated 11/15/22 revealed Resident #54 was unable to complete a Brief Interview of Mental Status (BIMS) to assess cognition. Resident #54 required supervision with activities of daily living.

Record review of the list of residents who smoke and require supervision while smoking revealed Resident #54 required supervision during their smoking breaks.

Observation on 12/14/22 at 8:37 A.M. revealed Resident #54 was outside in the courtyard of the secured behavioral unit smoking unsupervised.

Interview on 12/14/22 at 8:40 A.M. with STNA #529 revealed she lit each residents cigarettes then went back inside the facility leaving residents unattended to complete breakfast trays. STNA #529 confirmed Resident #54 required supervision while smoking cigarettes. STNA #529 confirmed there were times staff did not supervise residents while smoking.

Interview on 12/14/22 at 8:42 A.M. with LPN #621 confirmed Resident #54 required supervision while smoking cigarettes. LPN #621 revealed she was collecting breakfast trays and confirmed staff were not supervising residents during their smoking break.

Interview on 12/15/22 at 1:57 P.M. with DON and Administrator confirmed Resident #54 required supervision during smoking breaks.

5. Record review for Resident #70 revealed an admission date of 03/01/14. Diagnosis included paranoid schizophrenia, dementia, severe with agitation, and nicotine dependence.

Record review of the MDS dated 11/15/22 revealed Resident #70 had moderately impaired cognition. Resident #70 required supervision with activities of daily living.

Record review of the list of residents who smoke and require supervision while smoking revealed Resident #70 required supervision during their smoking breaks.

Observation on 12/14/22 at 8:37 A.M. revealed Resident #70 was outside in the courtyard of the secured behavioral unit smoking unsupervised.

Interview on 12/14/22 at 8:40 A.M. with STNA #529 revealed she lit each residents cigarettes then went back inside the facility leaving residents unattended to complete breakfast trays. STNA #529 confirmed Resident #70 required supervision while smoking cigarettes. STNA #529 confirmed there were times staff did not supervise residents while smoking.

Interview on 12/14/22 at 8:42 A.M. with LPN #621 confirmed Resident #70 required supervision while smoking cigarettes. LPN #621 revealed she was collecting breakfast trays and confirmed staff were not supervising residents during their smoking break.

Interview on 12/15/22 at 1:57 P.M. with DON and Administrator confirmed Resident #70 required supervision during smoking breaks.

6. Record review of the medical record for Resident #80 revealed an admission date of 02/18/22. Diagnosis included schizoaffective disorder, bipolar type, obsessive compulsive disorder, dementia severe with psychotic disturbances and mood disturbances, muscle weakness, and nicotine dependence.

Record review of the MDS dated 11/08/22 revealed Resident #80 had intact cognition. Resident #80 required extensive assistance with bed mobility and supervision transfers, ambulation, and eating.

Record review of the list of residents who smoke and require supervision while smoking revealed Resident #80 required supervision during their smoking breaks.

Observation on 12/14/22 at 8:37 A.M. revealed Resident #80 was outside in the courtyard of the secured behavioral unit smoking unsupervised.

Interview on 12/14/22 at 8:40 A.M. with STNA #529 revealed she lit each residents cigarettes then went back inside the facility leaving residents unattended to complete breakfast trays. STNA #529 confirmed Resident #80 required supervision while smoking cigarettes. STNA #529 confirmed there were times staff did not supervise residents while smoking.

Interview on 12/14/22 at 8:42 A.M. with LPN #621 confirmed Resident #80 required supervision while smoking cigarettes. LPN #621 revealed she was collecting breakfast trays and confirmed staff were not supervising residents during their smoking break.

Interview on 12/15/22 at 1:57 P.M. with DON and Administrator confirmed Resident #80 required supervision during smoking breaks.

7. Record review for Resident #129 revealed an admission date of 07/12/21. Diagnosis included dementia moderate with behavioral disturbances, vascular dementia, moderate with agitation, delusional disorder, and nicotine dependence.

Record review of the MDS dated 10/21/22 revealed Resident #129 was severely cognitively impaired. Resident #129 required supervision with activities of daily living (ADL).

Record review of the list of residents who smoke and require supervision while smoking revealed Resident #129 required supervision during their smoking breaks.

Observation on 12/14/22 at 8:37 A.M. revealed Resident #129 was outside in the courtyard of the secured behavioral unit smoking unsupervised.

Interview on 12/14/22 at 8:40 A.M. with STNA #529 revealed she lit each residents cigarettes then went back inside the facility leaving residents unattended to complete breakfast trays. STNA #529 confirmed Resident #129 required supervision while smoking cigarettes. STNA #529 confirmed there were times staff did not supervise residents while smoking.

Interview on 12/14/22 at 8:42 A.M. with LPN #621 confirmed Resident #129 required supervision while smoking cigarettes. LPN #621 revealed she was collecting breakfast trays and confirmed staff were not supervising residents during their smoking break.

Interview on 12/15/22 at 1:57 P.M. with DON and Administrator confirmed Resident #129 required supervision during smoking breaks.

8. Record review for Resident #133 revealed an admission date of 06/25/21. Diagnosis included alcohol abuse with alcohol induced psychotic disorder, dementia with other behavioral disturbances, impulse disorder, and nicotine dependence.

Record review of the MDS dated 10/12/22 revealed Resident #133 was cognitively intact. Resident #133 required supervision with activities of daily living.

Record review of the list of residents who smoke and require supervision while smoking revealed Resident #133 required supervision during their smoking breaks.

Observation on 12/14/22 at 8:37 A.M. revealed Resident #133 was outside in the courtyard of the secured behavioral unit smoking unsupervised.

Interview on 12/14/22 at 8:40 A.M. with STNA #529 revealed she lit each residents cigarettes then went back inside the facility leaving residents unattended to complete breakfast trays. STNA #529 confirmed Resident #133 required supervision while smoking cigarettes. STNA #529 confirmed there were times staff did not supervise residents while smoking.

Interview on 12/14/22 at 8:42 A.M. with LPN #621 confirmed Resident #133 required supervision while smoking cigarettes. LPN #621 revealed she was collecting breakfast trays and confirmed staff were not supervising residents during their smoking break.

Interview on 12/15/22 at 1:57 P.M. with DON and Administrator confirmed Resident #133 required supervision during smoking breaks.

Based on record review and interview, the facility failed to ensure Resident #9 urine and bowel restorative program was implemented as ordered. This affected one resident (Resident #9) of three reviewed for restorative services.

Findings include:

Review of the medical record for Resident #9 revealed an admission date of 03/18/15. Resident #9's diagnoses included schizoaffective disorder, dementia and gastro-esophageal reflux disease (GERD).

Review of Resident #9's bowel assessment dated 03/14/22 revealed a scheduled toileting program would be initiated.

Review of Resident #9's care plan dated 10/25/22 revealed the resident was incontinent of urine and bowel. Interventions included checking for incontinence, establishing voiding patterns and referring to restorative toileting.

Review of the quarterly MDS assessment dated 10/27/22 revealed the resident could not complete a mental status assessment. He required extensive assistance of two people for bed mobility, transfers, dressing, toilet use and hygiene.

Review of Resident #9's physician's orders for December 2022 revealed an order beginning on 03/14/22 for restorative toileting. The resident was to be assisted with toileting upon rising, after breakfast, before lunch and dinner, at bedtime and twice between 12:00 A.M. and 6:00 A.M.

Interview on 12/13/22 at 1:57 P.M. with State Tested Nurses Aide (STNA) #571 revealed the resident was never assisted with a toileting program. She had no knowledge of a restorative program for toileting for the resident.

Interview on 12/15/22 at 8:22 A.M. with Registered Nurse (RN) #554 revealed she had no knowledge of changes to Resident #9's toileting needs and was on a restorative program for toileting.

Interview on 12/15/22 at 8:30 A.M. with RN #550 confirmed the resident was checked for incontinence and has never been offered a toileting program.

2. Review of the medical record for Resident #3 revealed an admission date of 01/10/19. Resident #3's diagnoses included paranoid schizophrenia, chronic kidney disease and post-traumatic stress disorder (PTSD). He weighed 153 pounds on 11/09/22 and 138 pounds on 12/07/22, which was a 9.8 % weight loss over 30 days.

Review of the comprehensive Minimum Data Set (MDS) assessment dated 10/2722 revealed the resident could not complete a mental status assessment. He required limited assistance of two people for bed mobility and extensive assistance of two people for transfers, dressing, toilet use and hygiene. He required supervision and set up help to eat.

Review of the care plan dated 10/04/22 revealed had a self-care performance deficit. Interventions included staff assistance with bed mobility, dressing, hygiene and eating. He was also at risk for nutrition issues. Interventions included providing assistance with meals and notifying nurses when feeding assistance increases and monitoring weights to include notifying nursing of any significant changes.

Interview on 12/14/22 at 10:37 A.M. with Registered Dietician (RD) #556 revealed once she received the monthly weights from the unit managers, she assessed for any significant weight losses. She confirmed Resident #3 had a significant weight loss and had not yet asked that he be reweighed.

Observation on 12/14/22 revealed RD #556 asking STNA #571 to obtain a weight on Resident #3. After doing so, RD #556 left the secured unit. STNA #571 and STNA #538 used a weight chair to obtain the weight and told the surveyor he weighed 127 pounds.

Interview on 12/15/22 at 12:30 P.M. with RD #556 revealed she was told Resident #3 refused to be reweighed. She confirmed she did not track weight loss occurring for longer than one month.

Review of the medical record on 12/15/22 at 12:45 P.M. revealed no evidence a weight had been documented as completed since 12/07/22.

3. Review of the medical record for the Resident #459 revealed an admission date of 11/02/22. Diagnoses included diabetes, dementia, sleep apnea and epilepsy.

Review of Resident #459's weights revealed he weighed 163 pounds on 11/02/22 and 142 pounds on 12/38/22, which was a 12.9 % weight loss in thirty days.

Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/05/22, revealed the resident had severely impaired cognition. He required extensive assistance of two people for bed mobility, transfers, dressing, toilet use and hygiene. He required supervision of one person when eating. There was not weight loss or gain identified.

Interview on 12/14/22 at 11:22 A.M. with Licensed Practical Nurse (LPN) #548 revealed a list of weights that needed to be obtained was provided to floor staff at the end of each month. Staff had until the sixth of the month to obtain weights. The list provided the previous months weight and if there was a five pound difference from the weight obtained, staff were to immediately reweigh the resident. If the re-weigh is accurate, the unit manager was notified and would investigate potential causes.

Interview on 12/14/22 at 11:43 A.M. with LPN #516 revealed the registered dietician (RD) put out a weight sheet monthly which included the previous months' weights and any weights which need to be obtained. After staff weighed the resident, the report was given to the unit managers and entered into the electronic medical record. If the unit manager saw a variance, they asked staff to reweigh the resident and made the RD aware.

Interview on 12/15/22 at 11:53 A.M. with RD # 556 confirmed no interventions were in place to address Resident #459's weight loss.

7. Review of the medical record for Resident #23 revealed an admission date of 11/09/11. Diagnoses included dementia, traumatic brain injury, chronic obstructive pulmonary disease (COPD) and hyperlipidemia.

Review of the comprehensive MDS dated 11/04/22 revealed the resident could not complete a mental status assessment. He required extensive assistance of two people for bed mobility and toilet use and was totally dependent on two staffing for transfers, hygiene and dressing. He has shortness of breath when lying flat.

Review of the physician's orders for December 2022 revealed the head of the resident's bed should be at 30 degrees or higher due to COPD. There was no order for oxygen therapy.

Review of the care plan dated 11/10/22 revealed the resident had occasional shortness of breath due to COPD. Interventions included oxygen as needed with tubing changed per facility policy.

Observation on 12/12/22 at 11:05 A.M. revealed the resident was using oxygen. The oxygen tubing was dated 11/20/22.

Interview on 12/12/22 at 11:07 A.M. with LPN #516 confirmed a date of 11/20/22 on resident #23's oxygen tubing. He revealed oxygen tubing should be changed weekly.

Interview on 12/15/22 at 10:44 A.M. with DON confirmed there was no order for oxygen or tubing changes for Resident #23 and tubing should be changed weekly.

8. Review of the medical record for the Resident #61 revealed an admission date of 07/16/19. Diagnoses included chronic obstructive pulmonary disease (COPD), respiratory failure and dementia.

Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/18/22, revealed the resident had intact cognition.

Review of the plan of care dated 10/26/22 revealed the resident had occasional shortness of breath due to COPD. Interventions included oxygen as needed with tubing changed per facility policy.

Review of Resident #61's physician orders revealed no orders for oxygen therapy.

Observation on 12/12/22 at 11:05 A.M. revealed the resident was using oxygen. The oxygen tubing was undated.

Interview on 12/12/22 at 11:07 A.M. with LPN #516 confirmed there was no date on resident #61's oxygen tubing. He revealed oxygen tubing should be dated when changed, and changed weekly.

Interview on 12/15/22 at 10:44 A.M. with the DON confirmed there was no order for oxygen or tubing changes for Resident #61 and tubing should be dated when changed and changed weekly.

Review of the facility policy titled, Supplemental Oxygen Using Nasal Cannula, undated, revealed oxygen is considered a medication and should be treated in a similar manner, including a physician's order. Cannula would be labeled and dated when opened.

Based on observation, interview and menu spreadsheet review, the facility failed to follow the menu as written. This affected three residents (Residents #38, #95 and #459) observed out of eight residents receiving pureed meals.

Findings include:

Review of a menu for week two, corresponding to 12/11/22 to 12/17/22 revealed the dinner meal on 12/12/22 included breaded fish on a bun with broccoli florets, tater tots and deluxe fruit salad.

Review of a spreadsheet for Dinner Day Nine, Week Two-Monday corresponding to 12/12/22 revealed residents on a pureed diet were to receive a #8-scoop of pureed breaded fish, a #10-scoop of pureed broccoli florets, a half-cup of mashed potatoes, a #16-scoop of pureed dinner roll/bread and a #10-scoop of pureed sliced peaches and pears.

Observation of the dinner trayline on 12/12/22 starting at 4:45 P.M. revealed pureed fish, pureed broccoli, mashed potatoes and gravy were noted on the steamtable. Canned fruit was noted on carts adjacent to the steamtable. No pureed bread was observed during dinner trayline. Tray service started at 5:09 P.M. for the Buckeye unit. At 5:22 P.M. trays for the Hickory unit were started. At 5:29 P.M. a pureed meal was plated for Resident #459 contained mashed potatoes, pureed fish and pureed vegetables with no pureed bread on the tray. At 5:33 P.M. trays for the Willow unit were started and a pureed meal was plated for Resident #38 which did not contain pureed bread. At 5:39 P.M. a puree tray was made for Resident #95 that had mashed potatoes, pureed fish and pureed vegetables but no pureed bread. The cart for the Willow tray was followed out of the kitchen for a separate test tray observation.

Interview on 12/12/22 at 5:56 P.M. with Dietary Manager (DM) #555 verified the menu was not followed for residents on a pureed diet as the pureed bread was not served.

A follow-up interview was conducted on 12/12/22 at 6:06 P.M. with DM #555 who stated her staff said pureed bread had been prepared and served.

Observation was made on 12/12/22 at 6:06 P.M. of Resident #38's dinner tray with DM #555 and Licensed Practical Nurse (LPN) #516 was feeding Resident #38. Resident #38's tray was observed and no pureed bread was noted. LPN #516 and DM #555 verified the lack of pureed bread at the time of observation.

Review of a facility diet list dated 12/13/22 revealed eight residents received a pureed diet, Residents #23, #38, #45, #95, #108, #123, #154 and #459.

Based on observation, interview and recipe review, the facility failed to ensure pureed foods were prepared in an appropriate manner that preserved its nutritional value. This affected eight residents (Residents #23, #38, #45, #95, #108, #123, #154 and #459) receiving a pureed diet.

Findings include:

Observation of puree preparation on 12/12/22 starting at 4:18 P.M. revealed Dietary Aide (DA) #543 placed 15 breaded fish filets into the food processor. DA #543 blended the food, then added water by the tablespoon. When DA #543 deemed the puree complete, 10 tablespoons of water had been added. The mixture was tasted and was thick, salty and lacked flavor. Interview with DA #543 at the time of observation indicated she followed the recipe by adding water. No recipe was out and available during the puree preparation observation.

Interview on 12/12/22 at 4:32 P.M. with Dietary Manager (DM) #555 revealed she would have added milk to thin the puree instead of water. DM #555 tasted the puree when requested and agreed the mixture had no flavor as prepared.

Interview on 12/12/22 at 4:34 P.M. with Director of Clinical Operations (DCO) #638 verified water should not have been added to the puree but vegetable broth or tartar sauce could have been added instead.

Review of a recipe for, Fish, Baked (tilapia) no date revealed for pureed fish, measure out desired number of servings into food processor and blend until smooth. Add liquid if product needs thinning. Add commercial thickener if product needs thickening. The recipe did not specify the liquid to be used or the amount of liquid to be added.

Review of a facility diet list dated 12/13/22 revealed eight residents received a pureed diet, Residents #23, #38, #45, #95, #108, #123, #154 and #459.

Based on observation, interview and record review, the facility failed to provide foods per preference. This affected one resident (Resident #62) of four residents reviewed for dietary preferences.

Findings include:

Review of Resident #62's medical record revealed an admission date of 06/09/21 and diagnoses including syncope and collapse, altered mental status, suicidal ideations, anxiety disorder, hypertension, unspecified dementia severe with other behavioral disturbance, unspecified dementia severe with mood disturbance, schizoaffective disorder, delusional disorders, type two diabetes and paranoid schizophrenia.

Review of Resident #62's physician's orders revealed an order dated 10/07/22 for regular diet with diabetic condiments.

Review of a food preference assessment dated 10/07/22 revealed Resident #62 received a regular diet. The assessment had food dislikes listed including scrambled eggs.

Review of a quarterly minimum data set (MDS) assessment dated 10/18/22 revealed Resident #62 was cognitively intact, had inattention that came and went but changed in severity. Resident #62 required staff supervision for ambulation and eating. No weight loss was recorded on the MDS assessment.

Review of a nutritional assessment dated 12/10/22 revealed Resident #62 was alert and oriented, able to make needs known and feeds self. No food preferences were documented on this assessment.

Nurses' notes from 10/01/22 through 12/13/22 revealed no mention of food preferences.

Interview on 12/12/22 at 10:00 A.M. with Resident #62 revealed she was upset she received scrambled eggs for breakfast. Resident #62 stated she didn't like eggs and stated they were not listed on her meal ticket either.

Observation on 12/12/22 at 10:00 A.M. of Resident #62's breakfast tray revealed a meal of cold cereal, french toast and scrambled eggs.

Observation of a diet ticket for Resident #62 for breakfast dated 12/14/22 (wrong date) revealed Resident #62 was to receive one serving of apple cinnamon french toast bake, one serving of toasted oat cereal, eight ounces of 2% milk, six ounces of hot coffee and four ounces of orange juice.

Interview on 12/12/22 at 10:05 A.M. with State Tested Nursing Assistant (STNA) #623 verified Resident #62 had eggs on her tray and it was not printed on her ticket to receive eggs. STNA #623 stated if it was not on the ticket dietary staff were not supposed to serve it.

Interview on 12/14/22 at 11:26 A.M. with Dietary Manager (DM) #555 revealed she did food preferences with residents yearly and provided the surveyor with Resident #62's food preferences which indicated she disliked eggs.

Based on record review and interview, the facility failed to ensure the resident's medical record was complete and accurate. This affected one (Resident #156) of one resident reviewed for discharge records.

Findings include:

Review of the closed medical record for Resident #156 revealed an admission date of 10/10/22 and a discharge date of 10/11/22. Resident #156's diagnoses included dementia with agitation, hypertension, and anxiety disorder.

Review of the discharge no return anticipated Minimum Data Set assessment dated 10/11/22 revealed the resident had impaired cognition and had an unplanned discharge to the community.

Review of the closed hard chart revealed a form titled Discharge: Release from Responsibility for Discharge Against Medial Advice (AMA) Form dated 10/11/22 at 4:05 P.M. and signed by Resident #156's power of attorney (POA).

Review of the progress notes revealed no documentation related to Resident #156's discharge.

Interview on 12/14/22 at 3:23 P.M. with the Director of Nursing (DON) revealed Resident #156's daughter, who was also his POA, wasn't happy with the facility and signed the resident out AMA. DON verified there was no documentation in the medical record detailing the resident's discharge.

Review of the facility policy titled Leaving Against Medical Advice (AMA) undated revealed document events, discussions, and notifications in the medical record.

Based on observation, interview, policy review, record review and guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure staff wore appropriate personal protective equipment (PPE) to prevent the further spread of COVID-19. This had the potential to affect all 16 residents (Residents #27, #29, #31, #38, #42, #59, #62, #66, #69, #90, #95, #105, #107, #120, #122 and #138) residing on the Willow unit. The facility census was 153 residents.

Findings include:

Review of Resident #42's medical record revealed an admission date of 08/22/22 and diagnoses including intermittent explosive disorders, peripheral vascular disease, unspecified dementia, constipation, quadriplegia, sepsis and schizoaffective disorder bipolar type.

Review of a quarterly minimum data set (MDS) assessment dated 11/07/22 revealed Resident #42 had severe cognitive impairment and was totally dependent on two staff for bed mobility and transfer.

Review of Resident #42's current physician's orders revealed an order dated 12/03/22 for droplet precautions for COVID-19.

Observation on 12/12/22 at 9:50 A.M. revealed Resident #42 had signage on his door and a bin with PPE outside of his room. Licensed Practical Nurse (LPN) #548 was observed in Resident #42's room with a face shield, surgical mask, gown and gloves on. LPN #548 doffed her PPE, washed her hands and exited the room.

Interview on 12/12/22 at 9:50 A.M. with LPN #548 verified she wore a surgical mask in Resident #42's room and verified Resident #42 was COVID-19 positive so she should have worn an N95 mask in the room.

Interview on 12/14/22 at 10:10 A.M. with the Director of Nursing (DON) verified staff were required to wear an N95 mask in a COVID-positive room.

Review of the facility policy, Reference Guidance for PPE - Updated 09/23/22 revealed a N95 was to be used when caring for residents while in transmission-based precautions, have symptoms or have had close contact with someone with COVID-19 and when caring for residents with COVID-19. N95's must be removed and discarded after the resident encounter and a new one will be donned.

Review of the CDC guidance, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic

Based on record review and interview the facility failed to ensure Resident #114's physician was notified timely following an acute change in condition. This affected one resident (#114) of three residents reviewed for timely notification to the physician of a medical change in condition.

Findings include:

Review of the medical record for Resident #114 revealed an admission date of 06/08/22 with diagnoses including hemiplegia and hemiparesis, metabolic encephalopathy, dysphagia following cerebral infarction, and epilepsy.

Review of the plan of care, dated 09/06/22 revealed Resident #114 had a seizure disorder and a history of cerebral vascular disease (CVA). Interventions included to observe for a change in mental status and report abnormal findings to the physician. Interventions also included to monitor vital signs as needed and report abnormal findings to the physician.

Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/14/22 revealed Resident #114 had a Brief Interview of Mental Status (BIMS) score of 13 (intact cognition). The resident's hearing was adequate and speech was clear. Resident #114 was able to understand and was usually understood.

Review of a nursing note for Resident #114, dated 10/26/22 at 2:47 P.M. and completed by Licensed Practical Nurse (LPN) #309 revealed on 10/26/22 at 7:30 A.M. Resident #114 had a low appetite and was less responsive. Resident #114's vital signs were assessed and the resident's oxygen saturation level was low (ranged 88-90 %). LPN #309 documented she referred to the Unit Manager (UM) and was advised to increase the resident's oxygen to three liters per minute. LPN #309 documented in the same note that around 2:00 P.M., Resident #114 was re-assessed. Resident #114 was still less responsive and oxygen saturation continued to range between 88-90%. LPN #309 again referred to the UM and then consulted with physician, (Physician #307), who advised the LPN to send the resident to the hospital for further assessment. Documentation included Resident #114 was sent to the emergency room around 2:40 P.M.

Review of physician's orders for Resident #114 for the month of October 2022 revealed there were no orders for oxygen use.

On 11/16/22 at 12:40 P.M. interview with the Director of Nursing (DON) confirmed Resident #114 did not have an order for oxygen use and a physician order was required when administering oxygen. The DON confirmed UM/LPN #323 instructed LPN #309 to apply oxygen to Resident #114 on 10/26/22. The DON verified Resident #114 had a change in condition on 10/26/22 at 7:30 A.M. when the resident was assessed to have a change in mental status with a decreased oxygen level. The DON confirmed the physician should have been notified when the change in condition was first observed/noted.

On 11/16/22 at 12:55 P.M. interview with Physician #307 verified he was Resident #114's primary care physician while the resident resided at the facility. Physician #307 revealed a nurse may apply oxygen without an order in an emergency when the oxygen level was below 91%, but in that situation the nurse should complete a full assessment and notify the physician as soon as possible. Physician #307 confirmed he should have been notified prior to 2:00 P.M. of the change in condition and that it was inappropriate to not notify the physician timely when the change in condition for Resident #114 first occurred.

The violation represents non compliance investigated under complaint number OH00137169.

Based on observation, record review and interview the facility failed to ensure Resident #122, Resident #120 and Resident #121 were provided clean and sanitary bed linens. This affected three residents (#122, #120 and #121) of five residents reviewed for a clean comfortable environment.

Findings include:

1. Record review revealed Resident #122 had an admission date of 04/17/22 with a diagnosis including chronic respiratory failure.

Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/04/22 revealed Resident #122 had a Brief Interview of Mental Status (BIMS) score of 14 out of 15 (cognitively intact). The assessment revealed Resident #122 required extensive assistance from one person for bed mobility and transfers.

On 11/15/22 at 1:34 P.M. Resident #122 was observed sitting up in bed. Resident #122's fitted bed sheet was observed to be frayed, with multiple food and drink dried stains, and multiple food crumbs on top of the sheet. Resident #122 had two pillows on his bed that were stained and with no pillowcases. At the time of the interview, Resident #122 revealed staff did not routinely change his linen even when requested. The resident revealed the pillowcases would slide off the pillows and staff would put the pillowcases in laundry but not replace them. Resident #122 revealed he was unable to change his own linen.

On 11/15/22 at 1:39 P.M. interview with Housekeeping/Laundry Supervisor #318 revealed the State Tested Nursing Assistant (STNA) staff were responsible to change linen and make residents beds.

On 11/15/22 at 1:45 P.M. interview with Registered Nurse (RN) #314 confirmed Resident #122's fitted bed sheet was frayed, with multiple food and drink dried stains, and multiple food crumbs on top of the sheet. RN #314 had Resident #122 stand and found he had been sitting on multiple food crumbs on top of stained sheets. RN #314 confirmed Resident #122 also had no pillowcases for his pillows and revealed she was unsure why.

2. Review of the medical record for Resident #120 revealed an admission date of 10/13/20 with diagnoses including chronic pain syndrome, need for assistance with personal care, muscle weakness and neuromuscular dysfunction of the bladder.

Review of the comprehensive MDS 3.0 assessment, dated 11/03/22 revealed Resident #120 had a BIMS score of 15 out of 15 (cognitively intact). The assessment revealed Resident #120 required (staff) supervision with transfers and ambulation with the use of a walker and required extensive assistance from one person for toilet use. Resident #120 was assessed to be occasionally incontinent of urine.

Review of the plan of care for Resident #120, dated 11/09/22 revealed Resident #120 had occasional incontinence of urine related to a history of neurogenic bladder and bowels related to irritable bowel syndrome.

On 11/16/22 at 8:05 A.M. Resident #120 was observed sitting in the activity lounge area. The resident appeared clean and dry. Observation of Resident #120's room revealed Resident #120's bed sheet was soiled with a large dark brown wet area in the mid-section of the bed. There were three colorful blankets bundled to the side and bottom of the bed that also had multiple stains including dark brown stains. Additional observations on 11/16/22 at 9:35 A.M., 10:25 A.M., 10:45 A.M., and 12:00 P.M. revealed Resident #120 had not returned to her room, the bed and linen were in the same condition (dry at this time) and location as noted at 8:05 A.M.

On 11/16/22 at 12:05 P.M. interview with the Director of Nursing (DON) revealed her expectations would be for resident beds to be made by lunch time or noon. The DON revealed beds were made on an as needed basis by STNA staff. The DON revealed beds were not on a routine schedule for linen changes. The DON also indicated the facility did not have a policy available for linen changes.

On 11/16/22 at 12:40 P.M. observation with the DON revealed Resident #120 had returned to her room. Resident #120 was sitting on her coat on her bed. Resident #120 stood, removed her coat which was covering the soiled dark brown area on the bed sheet. The remainder of the bed linen was in the same area of the bed as noted at 8:05 A.M. At the time of the observation, interview with Resident #120 revealed she was unable to make her own bed or change her soiled linen and the STNA staff did not always make it for her. During the interview, Resident #120 indicated she never refused to have her bed made because she preferred a clean bed.

On 11/16/22 at 2:55 P.M. observation and interview with the DON confirmed Resident #120's bed was in the same soiled condition as found at 12:40 P.M. with DON. Resident #120 was sitting in the activity lounge at the time of the observation.

On 11/16/22 at 3:00 P.M. interview with STNA #317 revealed she was the STNA assigned to care for Resident #120 this date for day shift. STNA #317 revealed she had been giving showers and just had not gotten to making Resident #120's bed yet. STNA #317 revealed she had enough time to complete her tasks throughout the day, but she just hadn't planned on changing the resident's linen yet.

3. Record review for Resident #121 revealed an admission date of 03/16/16 with a diagnosis including ataxic cerebral palsy.

Review of the quarterly MDS 3.0 assessment, dated 10/10/22 revealed Resident #121's cognition was moderately impaired. The assessment revealed Resident #121 required (staff) supervision with activities of daily living and required limited (staff) assistance with personal hygiene.

On 11/16/22 at 8:14 A.M. Resident #121's bed was observed to be unmade. The fitted sheet was observed to be stained and had four dime sized holes throughout the upper half of the sheet exposing the mattress.

Observation and interview on 11/16/22 at 8:18 A.M. with STNA #305 confirmed Resident #121's bed sheet had four holes and was stained. STNA #305 revealed the linen for beds were frequently tattered and or stained but would continue to be used for resident beds.

The deficiency represents non compliance investigated under complaint number OH00134614.